IDSA Media Briefing: Scientific and Economic Impacts of HIV Research Funding Delays

Dr. Jeanne Marrazzo: [00:00:00] Good morning everyone. Thanks for joining us. I'm Jeannie Marrazzo, the chief executive officer of the Infectious Diseases Society of America. And I represent more than 13,000 physicians, scientists and public health experts whose focus is the prevention, treatment and cure of infectious diseases. This morning's briefing is about delays in notices of funding for the research of HIV, specifically for NIH's National Institute of Allergy and Infectious Diseases, or NIAID, HIV clinical Trials networks, and the consequences of those delays, specifically for study participants, scientific progress and the communities where research is conducted. Not to mention all of the scientists who have dedicated many years to studying these devastating infections and consequences. So this morning, we're joined by two experts. First is Doctor Aadia Rana. Doctor Rana is the director of the Implementation and Community Sciences Core for the center for AIDS research, or CFAR at the University of Alabama at Birmingham. She's also a fellow of the IDSA. Next, you'll hear from Doctor Carlos Malvestutto. Doctor Malvestutto is the clinical research site leader for the infectious diseases clinical trials at The Ohio State University. He's also a member of the HIV Medicine Association's board of directors. After the speakers remarks, we'll open the floor to questions. To ask a question, please click the Raise My Hand button. Or for those on the phone, select star nine and you'll be added to the queue. I'll now turn it over to Doctor Rana.

Dr. Aadia Rana: [00:01:50] Good morning. Thank you Doctor Marrazzo from the for that introduction. So I'm speaking today as an independent academic expert in my field and not as a representative of the University of Alabama at Birmingham's administration or policies. So the NIH funded HIV clinical trials networks are really one of the most consequential examples of sustained, publicly supported clinical research infrastructure in modern medicine. And this began with the AIDS Clinical Trials Group, or the ACTG, in 1987. And that was a time where HIV was a rapidly fatal disease for which virtually no effective treatment existed. The NIH built a permanent clinical research infrastructure, including which developed into specialized treatment prevention, vaccine and maternal and pediatric networks that are capable of answering questions that individual institutions or pharmaceutical or industry companies could not answer alone. And these networks have helped help transform HIV from an almost uniformly fatal disease into a manageable chronic infection. They established antiretroviral therapy, which is the treatment both for treatment and prevention. They advance the science of HIV vaccines and established approaches for pregnancy, children and adolescents. And these networks also pioneered sustained community involvement in clinical research, which are modeled by many other research fields today. And I think it's important to note that these networks do work alongside commercial clinical trials. But the commercial clinical trials follow individual products. NIH networks follow scientific questions, and this distinction is enormously important in HIV. For example, a successful HIV cure strategy may involve multiple components um products to decrease the reservoir where HIV sort of hides in the body, and then products that will activate the immune system and a therapeutic vaccine and potentially, um, treatment interruptions that have to be personalized testing.

Dr. Aadia Rana: [00:04:10] These types of combinations really require enormous clinical laboratory, statistical and regulatory capabilities. And the capacity to test this across large swaths of the population. The networks create a capacity for long term follow up for decades, where even key questions related to aging, chronic inflammation, malignancies, cardiovascular disease, and long-term treatment toxicities could be answered. And these networks can also help to study marginalized or rare populations pregnant during pregnancy infants, children, adolescents, people with acute HIV infection or multi multi-drug resistant HIV and challenges with adherence. People with unusual comorbidities. These are populations that are quite difficult to study in your conventional commercial trials, and the network is large. It supports 35 clinical trials units and 101 clinical research sites, including 45 here in the United States. And that includes a site here in Alabama, which is where I practice. This is one of the seven priority states of the National Ending the HIV Epidemic Initiative. At my institution, the University of Alabama at Birmingham. The NIH funded clinical trials supports six faculty, 20 staff, and through both direct funding and infrastructure support, bring about $3 million of research funding to UAB annually. And over the past five years, we've been able to enroll over 400 Alabamians across 56 studies into these network trials, and the networks importance goes beyond individual discoveries. A durable global clinical research platform includes investigators, community advisory boards, clinical sites, labs, statisticians, data systems, and relationships with communities in the United States and around the world. And this was exemplified during the Covid 19 pandemic, where the networks and other NIAID supported infrastructure were brought together to create the Covid 19 Prevention Network that really demonstrated that decades of investment in HIV clinical research ended up creating actually a broader infectious disease trial capability.

Dr. Aadia Rana: [00:06:37] So when an important scientific hypothesis emerges with regards to infectious disease, NIH does not have to build another international clinical trial system from scratch. And with these successes, there still remain key questions to be answered. The remarkable success of antiretroviral therapy has really changed the nature of the HIV research problem. We increasingly know how to control HIV, but we don't know how to eliminate it or to make its control effortless for everyone, you know. So we need to answer can we achieve HIV cure or durable remission? Can we make prevention and treatment easier, longer lasting, more accessible? And perhaps the biggest unanswered question is why do effective interventions fail to reach everyone? And this is where HIV research and the networks are moving towards implementation science. We already possess highly effective tools, and yet the global epidemic persists. How do we deliver it to the right person at the right time, in a way that they can and want to use? And so this requires studying health systems. Transportation, stigma, medication supply, social networks, and the other factors that that inform these decisions. The Clinical Trials Network's biggest strength is exactly that. Its ability to start from basic science through the range of clinical studies and finally to implementation science, really allowing the opportunity to rapidly translate discoveries into improved outcomes nationally and globally. And this really works across the extraordinarily biological and social diversity of the global HIV epidemic. Thank you.

Dr. Jeanne Marrazzo: [00:08:30] Great idea. Thank you so much for that really compelling overview of what makes the HIV Clinical Trials Network special and really, really notable. I'm going to ask Doctor Malvestutto to go ahead and give us some comments now.

Dr. Carlos Malvestutto: [00:08:48] Thank you Doctor Marrazzo. Good morning. I am speaking today on my own behalf as a clinician investigator and as a member of the Board of directors of the HIV Medical Association. The immediate issue is straightforward. The NIH funded HIV clinical trials networks, the ACTG, the HPTN, DHPTN and impact need a timely renewal notice so clinical research sites can prepare strong applications, retain skilled staff, protect ongoing studies, and sustain the clinical research infrastructure that has helped transform HIV from a fatal disease into a manageable chronic condition. As my colleague Doctor Rana described, the scientific contributions of these networks in HIV prevention, treatment and the management of HIV associated conditions have improved the lives of countless people and communities in the United States and around the world. Some of my own patients are long term survivors who have been living with HIV for close to 40 years and participated in the earliest ACTG trials evaluating AZT as a treatment for HIV. Because of robust clinical investigation conducted through hundreds of NIH funded clinical trials over the past four decades, many people living with HIV no longer have to fear dying of AIDS and can expect to live long, productive lives. Current HIV Clinical Trials Network studies are now evaluating promising innovative strategies to achieve HIV remission without lifelong antiretroviral therapy. The expertise, partnerships, community trust and infrastructure required to support this scientific enterprise are unparalleled and have taken decades to build. Unfortunately, ongoing delays in the release of the renewal notice threaten to erode these achievements and increase uncertainty about the United States commitment to lead biomedical research to eliminate HIV as a public health threat.

Dr. Carlos Malvestutto: [00:10:48] HIV Clinical Trials Networks are renewed in seven year cycles under the Notice of Funding Opportunity. Multiple clinical research sites affiliated with at least one network and offering complementary resources, expertise and access to varied patient populations come together to form clinical trials units. Typically, notices are released about six months before the application deadline, so clinical trial unit principal investigators have adequate time to prepare competitive applications. The forecast for this renewal was announced in April with an expected posting date of August 25th, but the notice still has not been released. With the application deadline set for January 22nd, 2027, even in the best-case scenario, now leave sites with far less time than usual to prepare strong applications. This uncertainty makes it very difficult for clinical research sites to plan ahead and ensure adequate staffing for the next application cycle. Hiring and training research staff takes time, and although these staff are deeply committed to their work, uncertainty about future funding makes it harder to retain highly trained personnel. The same is true with regards to training and mentoring young clinical investigators. Developing a proposal into a full study protocol requires review by multiple scientific and regulatory committees, and many trials take years to implement and complete without assurance that network resources and funding will be available. Young investigators may choose not to invest their time and effort in careers in HIV clinical investigation at US institutions.

Dr. Carlos Malvestutto: [00:12:26] Clinical trials also depend entirely on the trust that study participants place in investigators. Participants enroll in clinical trials with the expectation that studies will have the resources needed to answer important scientific questions and keep them safe throughout the process. If funding and support remains uncertain, it may not be feasible to open a study that may never be completed. If funding for HIV Clinical Trials Networks is disrupted, even for a few months, it can begin to dismantle infrastructure that has taken decades to build. Already due to funding delays in the past year, many clinical research sites have lost personnel and expertise as investigators have taken new jobs or pursued other areas of investigation. Even the data management and statistical support staff in the ACTG network are not yet back to the staffing levels required for current studies. At my own institution, funding delays forced us to pivot to different projects to support personnel salaries, and some highly experienced long-term staff chose to leave for jobs they perceived as more stable and long term. The NIAID funded HIV Clinical Trials Networks have made enormous contributions to medicine and public health, securing and building on this legacy is essential to achieving the next generation of transformative advances, advances that can continue to improve the health of Americans, strengthen US leadership in biomedical research, and move us closer to ending HIV as a public health threat. Thank you.

Dr. Jeanne Marrazzo: [00:14:02] Thank you so much, Doctor Malvestutto, for, again, that really eloquent explanation. I think one of the interesting things about this is that this unfortunate series of events has opened people's eyes to the reality of what it takes to do high quality research in representative populations, especially those who are challenging to enroll in studies. So overall, as you've heard, many of us are deeply concerned about the long term impacts that delays in this type of research network funding could have both Scientifically, economically and for the future of researchers as. As Doctor Malvestutto pointed out, if funding lapses and institutions doing this vital research lose staff, lose faculty, lose their participants and their capacity, the consequences will be felt for generations. It took decades to build this network. It took decades to invest in the kind of discovery that these networks have generated. And if this falls, it will take decades more to rebuild. And this is happening in a time, of course, when infectious diseases are re-emerging and threatening us even more than in the past. So the researchers, the patients or the participants and the communities who rely on the HIV Clinical Trials Networks deserve better. The American people deserve better. Better. So it's vital that notices of funding opportunities be released without any further delay so that we can take care of the people we've committed to already. We're now going to move on to questions as a reminder. Uh, please click the Raise My Hand button. Or for those on the phone, please select star nine and you will be added to the queue. So the first question we have, um is about whether um, if the funding networks or if the networks, sorry, lose funding or experience an even longer delay. What's the first thing that stops? How quickly will patients feel the effect? Um, and either of you can start with that discussion.

Dr. Aadia Rana: [00:16:19] I can start off. Um, so the, you know, the effects by patient patients or potential participants in studies are felt immediately. Um, and how that usually, um, demonstrates itself is that any participant who is in screening for potential enrollment into a study. All enrollment halts because we don't know what's going to happen after a participant enrolls in terms of funding. And so that's an immediate effect. Um, subsequently then, um, from a safety perspective, we have to look to see, um, of the participants that are enrolled in studies. You know, what can we continue to do or what can't we continue to do? Um, in terms of therapeutics or, or, you know, um, sample collection, um, with the funds that are remaining. So participants feel the effect immediately. And, and I think it's important to also indicate the long term, um, impact, um, and not that much longer in that when we tell a participant they can't, um, enroll or that their study is halted, um, for these types of reasons. Um, we alluded to the long, that how long it takes to develop these trials and these networks. And the other thing that takes a lot to build is the trust with the communities, with the participants, particularly when you work with marginalized, vulnerable populations, as we do in the HIV Clinical Trials Network. And I think that effect can also be almost as immediate as that going. So, so we, we are very, um, you know, anxiety all around us in many and many facets, not just about the unit itself, but the impact in the community.

Dr. Jeanne Marrazzo: [00:18:14] Thanks, Doctor Rana. I'm going to go to a reporter from the New York Times first and then Carlos. We may come back to you for additional comments on that. But Apoorva go ahead. Please unmute your line to ask your question.

Caller 1: [00:18:25] Hi. Thanks for taking my question. Is there any reason for you to believe that this is beyond a delay and that these NOFOs won't be issued at all, that there's there are plans to just phase out these clinical trial networks.

Dr. Carlos Malvestutto: [00:18:44] Um, yeah, I guess I can, I can start and it's, um, it's unclear. Um, I think also what, you know, could happen and we've seen this where, uh, novo, you know, could actually come out and then later on, then there are changes and, um, and that's part of this uncertainty that, you know, we're all dealing with. Uh, so it's certainly not, not the typical process at all. Um, we've been told by our colleagues at NIAID that, um, the expectation is that the no flows for the HIV Clinical Trials Networks, uh, will come out. Um, but, you know, we were expecting them, uh, August 25th and that, you know, that has already passed. And we're still waiting at this point. Um, we're encouraged by the fact that other networks have received NOFOs recently. Uh, so at least those were released. So we, we hope that it's a matter of time. Um, so I think the NOFOs will still come out, but even that does not guarantee, I think, in the current environment, uh, that everything will proceed as usual.

Dr. Jeanne Marrazzo: [00:20:01] Aadia, did you want to comment on that?

Dr. Aadia Rana: [00:20:03] Yeah, I agree with what, uh, Doctor Malvestutto said and I think, um, there, um, in addition, you know, we are, we are reassured that that it is coming out, um, we don't know what the scope is going to be. I think that is one of the other, um, uh, concerns, uh, that we as, as investigators, um, have is that, um, you know, What in terms of both what the science, you know, what is going to be the directive with regards to the science, um, and the program and the projects, um, the networks have historically been able to, in their application, um, help with the academic expertise to direct where that science is going based on what has been developed and input. And, um, so we don't know exactly now, um, what that scope is going to be. So that is something we're also awaiting, um, with, with the NOFO announcement.

Dr. Jeanne Marrazzo: [00:21:09] And if I could just comment on that, I think this is a really important question. And one of the reasons that everyone is so anxious is as, as Aadia and both Carlos said in the past, as you know, the generation of priorities for research were really was really generated through a synergistic discussion between the community of scientists and often the community of people affected by the infections or the diseases with NIH. And that dialogue was incredibly important because we want to study, or NIH did want to study what people thought was important, both from the community and the scientific standpoint. We have clearly seen a reversal of that right now. Where we have a lack of transparency. There's incredible opacity about how these decisions are being made, and there is a lot of top-down decision making about what is worthy of being studied. So I think all of this contributes to anxiety and frankly, fear that even if these are funded, they will be required to be directed in ways that don't reflect what the scientific or community consensus judges to be, to be important and critical.

Dr. Jeanne Marrazzo: [00:22:19] So lots of things are up in the air. And I think as we've learned from many things in this administration, anything can happen, including really undermining the scientific integrity of what we're trying to do in the first place. Um, any other questions for, um, for us from the community of reporters who are here? Um, if not, I want to ask a question for both Doctor Rana and Doctor Malvestutto. Um, you know, we have seen quite a lot less visibility on the dire consequences of people not getting life-saving antiretroviral therapy. And we've seen generally very healthy portrayals of people living with HIV, which is completely appropriate. When we have seen people who have suffered the consequences, they've often been in other countries, particularly in sub-Saharan Africa. Do you think that that's contributed to a sense of complacency from the public, who may not really be aware of what the critical nature of what you do, uh, is? And, and how can we turn that around? Um, as a professional society, how can we tell the stories of your participants in a better way?

Dr. Carlos Malvestutto: [00:23:40] Yeah, I think that's an excellent question. Um, in some ways we are victims of our own success. You know, we've made such tremendous advances. Um, and so now, you know, there's an entire generation of people who have never seen somebody with advanced AIDS or, uh, you know, don't have never met anybody who ended up, um, um, dying of AIDS. Um, whereas in the past, you know, there, uh, there were entire communities that were decimated, you know, by the AIDS epidemic. Uh, so I think that may be, that may contribute. Uh, I wouldn't say that's necessarily complacency, but, um, I mean, some of it may be the thought that, you know, we've taken care of the problem. So what? Why is there a need to do anything else? Right. Um, but, you know, there's still a lot more work to be done. And I think what the international experience is showing us, right, with the USAID, PEPFAR program cuts, um, is that how quickly those advances can be reversed? Uh, sadly so, and, you know, we're already seeing this, um, in many locations around the world where now the access to antiretrovirals, um, um, has stopped. And, you know, in many places where we were not seeing mother-to-child transmission, now we're starting to see that again. So I, I worry about what could happen, um, if we don't continue to focus on really building on what we've achieved and then, you know, to maintain, um, uh, what we have, but also to continue to, you know, build on this and move forward.

Dr. Jeanne Marrazzo: [00:25:32] Yeah, thanks for that. And in fact, just a nice report, a couple of, well, maybe last week from AMFAR, uh, showing what some of the impacts have already been, uh, from reductions in USAID funding. And there's no question when you look at the statistics, it's not going to take long, particularly with regard to perinatal transmission. And when you think about that, that's condemning someone to a lifetime of chronic infection. Again, it is ideally treatable. But if you could have prevented that at birth or during pregnancy, it certainly would have been preferable. Apoorva, please go ahead and ask your follow up question.

Caller 1: [00:26:10] Thank you. Um, just to go back to the issue of timing, I know they were expected August 25th and you don't have them in hand yet, but I have spoken to some people who said, you know, if NIAID really wanted to, even if they come out late, there are things that they can do. They can sort of make the turnarounds a little faster, and it may not be dire. So in your mind, is there a time beyond which, like, is there a deadline in your mind beyond which this is unsalvageable for the next year?

Dr. Aadia Rana: [00:26:42] Yeah, that's a great question. Um, and, you know, I think the, the challenge, uh, for that or even in answering that is, is the uncertainty, um, and, and the planning that's required in maintaining a infrastructure, you know, at your own institution and how you have, we have to plan now, um, you know, well, we did before even years in advance, but that was with knowing that we had, you know, X number of years of, um, funding coming. I think what happens is, is with these grants, often the end date, um, of, you know, the study is, you know, a certain date, say November 30th, 2027. And we're not allowed to spend any more or plan for additional, you know, spending on that grant for those participants anywhere beyond that. And there previously was an expectation of no cost extension approval and all of that. That has changed actually with this administration, you know, with this recent sort of changes in the administration of grants. And so we often don't are not getting that, um, uh, guarantee or that expectation and the capacity of institutions to be able to bridge that until that approval comes, has become, has had that threshold has changed as well. And so I think any degree of uncertainty, um, makes, makes this, you know, very anxiety provoking. Um, for all of us. And so any, any delay is problematic.

Dr. Carlos Malvestutto: [00:28:32] Yeah. And I think, you know, the impact that it has. Um, and we've seen this already, even with delays that we knew were temporary, um, you know, very in just in a matter of weeks. Um, then we start to lose personnel at every level. Um, and that just makes it impossible to then sustain a, you know, some clinical trials where it just, it's just not safe to continue it. And then, uh, you can imagine, you know, many of our studies are, um, our program to really go on for several years. You know, we have, uh, and if we have to then shut down the study, it's not a matter of, uh, you know, we just continue to monitor the participants, but then the intervention may be ended. So the entire question that was being addressed by the clinical trial, then you know that the whole point of the study may we may lose that. Um, and that's, uh, you know, that I think that's, that's what, um, ultimately in a short period of time, uh, your entire agenda may be impacted, uh, in a way that is very hard to recover later on. Um, I think that's why we're particularly anxious in this case. You know, we, we want to be able to. Apply and, you know, prepare for the application to actually know what's in the NOFO and then to, uh, gather the resources and, you know, set up the right partnerships so that we have competitive units that would be participating in the network, but with very limited time, that becomes harder and harder to do. Um, so, uh, which is why I think, you know, we're raising this alert.

Dr. Jeanne Marrazzo: [00:30:29] Yeah. Thanks to you both. And I'll just add to that, that, you know, the damage has already been done and some of the damage is irreversible because every time you lose a participant, you know, because you had to cancel an appointment or because they don't trust the framework of coming back, which some people have taken a very long time to build, as we know, given the lack of trust sometimes in research, especially not just healthcare. So every participant you lose, um, and every experienced staff person, you lose. The people who do this work have been doing it for decades. They're incredibly experienced, incredibly dedicated. Every time you lose one of those people, it's an irreversible loss. It's an irreversible loss for the field and also for the data that you've invested many times, millions of dollars trying to, to build. So I think, all of these things are really important, important points to make. Um, I think, um, if there are no more questions, I want to turn it back to both of you to see if you have any closing comments or if you can give us some specific examples of studies that you have seen that have been threatened, um, by this lapse in funding or other concerns that it's raised for you at your institutions and in your communities.

Dr. Carlos Malvestutto: [00:31:53] Would you like to go first?

Dr. Aadia Rana: [00:31:55] Sure, sure I can. Yeah. No, I think, um, you know, the overall message here is that the HIV Clinical Trials Networks have, um, had tremendous impact on the outcomes for people both vulnerable to and living with HIV, both in the United States and globally. I don't think there is any other network that can say in this time frame has been able to demonstrate this degree of impact on the health of of people on this planet. If I can be a little grandiose about it in that way. At the same time, um, you know, this investment in these, in, in the, in both in the institutions, in the community, in the investigators in science has allowed us to not only build this network for HIV, but also, um, you know, can, can be utilized as has been shown for Covid 19. Um, we use this for the, for Mpox, but could also be used for any of these, the emerging infectious diseases that we are seeing, um, you know, in the news and I think we'll continue to see. And so, um, as has already been mentioned, lapses, even short-term lapses in this funding or even uncertainty in the funding has can have tremendous impact. And I think that is sometimes that's what's getting lost in oh, it you know, it's coming. It's it there will just be a short delay as it were. You know, we've had government shutdowns before. You've worked through it. I think this is a very different, um in its nature, um, and something unprecedented. And as we plan for the future and we want to make sure that, um, you know, not just the science is preserved, but, you know, public health is preserved as well. I think it's critical to prioritize this type of investment and ensure that there is both consistency and emphasis, emphasis on, on the importance of what has been built by the NIH and has been and has been the flagship has been the star, I would say, and that should be highlighted. And um, and, and um, and definitely um, prioritized, um, by, by the institution.

Dr. Carlos Malvestutto: [00:34:31] Yeah. I think I can add, um, maybe a specific example or where, um, you know, the, uh, the impact of, um, uh, these delays and also as we plan ahead, um, it could be devastating for the research agenda. Um, so in the, in our cure trials, you know, we evaluate strategies and interventions. Um, that, and then the way that we test them to see if they, um, how effective they are is we actually stop antiretroviral therapy. So participants undergo a, and what's called an analytical treatment interruption. And they're monitored very closely to see if they maintain virologic control or if there is, um, you know, rebound, at which point then we restart, uh, antiretrovirals. Um, and so these studies are very, uh, so we, uh, obviously safety is paramount. And, you know, we, we, uh, plan these studies very, very carefully. Um, but for those participants that then are able to maintain virologic suppression, we continue to follow them because we want to understand how long is this sustainable? Is this, uh, you know, an effect that we see long term? Um, so, and often, um, for example, I'm the chair of a study that is set to open in the next few weeks and where we give a combination of broadly neutralizing antibodies to a population of patients that is very difficult to identify and enroll in studies. And these are people who started antiretroviral therapy during acute or very early infection. Um, and then after they received the broadly neutralizing antibodies, then we stopped the antiretrovirals. And then we monitor, you know, how they do. But as we look to actually open the study, then we worry that, you know, um, if, uh, as we enroll participants and then they start the analytical treatment interruption, but if funding is disrupted and, uh, then we would have to, you know, again, to maintain the safety of the participants, then we would have to then restart antiretrovirals, even if, um, they're actually maintaining virologic suppression off antiretrovirals.

Dr. Carlos Malvestutto: [00:37:04] But then once we do that, then, uh, the entire point of the study, uh, you know, is done like with the question can no longer be answered. Um, and I can tell you this. Uh, so for this particular study, it's been in development for years. And then we're finally at that point, you know, where we think that, uh, you know, we're ready to open it, but it is a question that we have, you know, can we do this? Like, what's going to happen six months down the road, a year down the road? Uh, as you know, these participants are in that analytical treatment interruption. So these are very, um, you know, serious points. And if, um, you can see how that so work that has gone into developing this scientific agenda on, you know, on the cure space. Um, uh, these delays and, uh, even pauses in funding can ultimately, uh, just, uh, you know, do away with work that has taken years to, to develop and which is unfortunate because I think we're on the verge of identifying strategies that may work if not for everyone, at least for a, you know, a larger proportion of, uh, of study participants. So, um, I think that's, that's the real shame of this.

Dr. Jeanne Marrazzo: [00:38:22] Yeah. Thank you for that. Excellent example. Um, I think we'll end there. Um, it's not exactly on a positive note, but, um, it's not exactly a optimistic time. Hopefully the notice of funding opportunities will come out very soon. You'll all be able to rally. Um, and we, we can renew our commitment to, uh, the research that has made such a difference to our providers, our patients and our communities. Um, so thank you both very much for those, those really eloquent and passionate and informed comments. Um, we're going to end our session this morning. For more information on us at IDSA, please visit us at idsociety.org. And again, thanks for joining us. Thanks for covering this topic and lo