 There's a particular burden on this panel because we're the panel right before lunch. So that means we need to be extra interesting. And I promise you that we are going to rise to that challenge this morning. So thanks to you all for being here. Special thanks to Steve for convening this conversation. I don't know how the rest of you feel, but whenever I get an email from CSIS about an event here, I know I'm going to be coming to something that's very well planned, where there's going to be lots of good information, where it's going to be thought provoking, and where I'm going to leave the room feeling a lot richer for having been here. So Steve, whether it's this discussion today or everything you've been doing on a bowl over many months or the many other issues the Center has taken up, thank you for giving us this opportunity. So we've got a great panel here this morning, and you have their full bios, but I am just going to take a minute to say a word about each of them because they're special people and we're very fortunate to have them with us today. So here on my immediate right is Dr. Doyen Alawale. Dr. Alawale is the Executive Director of Pink Ribbon Red Ribbon. She is a pediatrician by training with 25 plus years of experience working in Africa on child health, family health, reproductive health, the gamut of issues. She joined Pink Ribbon Red Ribbon about five, six months after it got started in sort of early 2012, and she's really been guiding the effort ever since. So with Doyen is Dr. Kennedy Lashimpi. Dr. Kennedy is the Director of the National Disease Cancer Hospital in Lusaka, which is the premier cancer treatment center in Zambia. I've actually had the privilege of visiting there, and I can tell you that it is very much on the front lines of doing what we're talking about today, that Dr. Lashimpi has been very innovative in looking for partners in different ways of doing business that can really improve the kind of service he can provide to the clients at his hospital. So Dr. Lashimpi, thank you. You've come a very long way. You're in Texas anyway this week, but you've come here today, which is great. And your perspective is really very critical to the conversation. And then we also have Sandy Thurman with us this morning, who I know many of you know. Sandy's the Chief Strategic Information. I didn't get that right. Sorry. Chief Strategy Officer. Chief Strategy Officer at the Office of the U.S. Global AIDS Coordinator. And has also had a very distinguished career with the Director of the White House Office of National AIDS Policy in the White House, founded the International AIDS Trust. Is a professor at Emory University and has done many other significant and important contributions to both the global and the domestic AIDS epidemic. So we want to get started with the panel. But I did think I'd just say a word or two as we move from the discussion of the prior panel to this one, which is a little bit of a different focus, about some of the things I think we need to keep in the back of our mind as we talk this morning. And I think there are issues that have sort of percolated to the service already, but I think it's just good to be reminded of them. And they've really struck me in the time that I've been engaged with Pink Ribbon, Red Ribbon. I've been a part of the group since the start in 2011 and have had the opportunity to work closely with Doyin and the Pink Ribbon, Red Ribbon team and to travel and visit almost all the sites where Pink Ribbon, Red Ribbon is working. And there's four or five kind of key impressions that have really stuck with me. You know, the first is, this is a disease and we've heard this in the Q&A already, that in Africa it's still very much a silent killer. You know, too many women are being diagnosed much too late for this to be able to make a difference to them. Secondly, it's very highly stigmatized. There is a lot of fear and a lot of misconception about cervical cancer and other cancers, certainly in Africa. I make it a practice when I travel to ask women that I meet with what is more difficult for them to hear, a diagnosis of HIV or a diagnosis of cancer. And I'm always amazed by the number of people that answer cancer. So I think that actually says a lot, you know. We know that this is a condition that affects HIV positive women much more than anyone else, if you're HIV positive and you're a woman, you're four to five times more likely to develop cervical cancer. We know that it's a condition that's infecting young women ever more acutely and in a much more serious way than I think over the prior five or 10-year period. And we know that the burden of the disease is growing. And I think according to WHO statistics, I think in 2013 for the first time, the number of deaths due to cervical cancer exceeded the number of deaths due to maternal-related conditions. So that's a very important fact I think for us to keep in the back of our mind. And that trend is projected to grow and expand at an alarming rate, actually. So I think to start this morning, we actually have a short clip, just two minutes, that we want to share with you all. It's from a video that was developed by the Pink Ribbon, Red Ribbon Secretariat. And I think it will help us think a little bit about those issues I just flagged and also understand a little bit the human dimension of what we're talking about today. So if we could just start with that clip, that would be great. I'm sure it's coming. So this is not the right clip. So why don't we... Good morning. Good morning. Good morning. We're in the same place. I'm coming. I'm coming. Come on. Come on. Come on. Come on. Come on. Come on. Come on. This is a good life, because I want to live with my wife. I don't live in the water. It's a good life. I want to live with my wife. I don't want to live with my wife. As a mother, I want to live with my wife. When you live with your husband, you can't have a husband. We can't have a husband. We can't have a husband. I feel like I'm going to die. I feel like I'm going to die. 34. 34. To discuss today, and the full clip, it's only about 10 minutes, is available on the Pink Ribbon, Red Ribbon website. I really urge you all to try to see if there's an awful lot of very good information there. But Dwayne, I want to turn to you now to ask you to tell us a little bit more about what Pink Ribbon, Red Ribbon is doing to help women like Evelyn, and then also to tell us a little bit about how President and Mrs. Bush came to be engaged with the effort. Thank you very much, Lisa, and thanks to CSIS for inviting us to this meeting. Let me just say that within a month of the diagnosis, Evelyn died. She left behind six children and an aged mother. Every year, there are approximately 60,000 Evelyn in South Saharan Africa. And because of this magnitude of the problem and the association with HIV, we actually kept President and Mrs. Bush thinking back on what they had started in 2003. You all recall that in 2003, President Bush signed the bill that established the U.S. President's Emergency Plan for AIDS Relief. It was a $15 billion Congress approval, which of course has now grown to $59 billion. But it started and provided access to treatment for people who were suffering from HIV. As a result of the work of PEPFA and the generosity of the American people, 7.7 million people today have access to anti-retrovirals. The downside to that is that HIV wears the face of a woman, and therefore women who are now living with HIV surviving and the children that were born and have access to ARTs are now getting to adolescent becoming adults, but they are now very much susceptible to HPV infection. So what we are seeing is women who are HIV positive in their 20s, 30s coming down with cervical cancer. I'll give a typical story of a 19-year-old girl who presented in one of the Pink Ribbon Red Ribbon countries with stage 4 cervical cancer. She was found to be HIV positive. When I was in medical school in the 70s, if you diagnosed a case in a 19-year-old as cervical cancer, my professor would probably give you a straight F because this was a disease of the elderly. So now that we are having a lot of women surviving HIV, 4 to 5 times more susceptible to HPV infection and cervical cancer, this led President and Mrs. Bush to say we must not lose all of the investments that we have made into HIV. And he said it is unacceptable to save a woman from dying from HIV, only to have her die from a preventable cervical cancer. That is the raising death of Pink Ribbon Red Ribbon in September 2011. And therefore this Pink Ribbon Red Ribbon is a public-private partnership that catalyzes the global community to reduce deaths from cervical cancer and breast cancer. Why did we add on breast cancer? Because the two are the two leading causes of cancer deaths in women in Sub-Saharan Africa. And in order to make sure that this does not become another epidemic on us, Pink Ribbon Red Ribbon is working with countries in developing countries of Sub-Saharan Africa and Latin America to raise awareness of the disease, as well as provide access to early detection treatment to make sure that women do not die from these diseases. And that's how Pink Ribbon Red Ribbon came to be. Dwayne, can you say a word or two about how the partnership works? The partnership engages with countries. We select our countries deliberately using certain criteria. The country has to be one that has prioritized women's cancer, that has high political commitment right up to the First Lady, the President or Prime Minister, and of course is ready to put its own resources into it. It's a country that welcomes Pink Ribbon Red Ribbon's engagement and identifies us as partners, not as a substitute for government, and is willing to of course work hand in hand with us to make things happen, to make a difference in the lives of the women. It's a country that is secure and safe, and finally it's a country that has at least one cancer treatment center. We do this because we believe it is not appropriate for us to screen women, find those who may have disease. Yes, you can treat some with cryotherapy, with lip, but those who have suspicious cancer and you say, sorry, there is nothing we can do. Or you have to go to another country. A woman who does not have money to travel from a rural area to the capital city is unlikely to be able to make it to the next country. And so we make sure there is at least one cancer treatment center. So when we get into the country, we engage with them and align with the country's own plan. We do not come from the United States with a plan of our own to hand over to governments. We ask for their national policy, strategy, their plan. We identify who the partners are, what is government doing in this area, and we identify what the gaps are. From the gaps, we are able to say these are the ones that pink-ripping red-ripping will fulfill. We do promote the entire continuum of cancer care, from prevention to palliative care, or what you can say from vaccine to morphing, to make sure that we provide a comprehensive cervical cancer, breast cancer programming. We leverage existing HIV platforms because again HIV positive women are more prone to HPV and cervical cancer, and therefore they are the most susceptible and we go for them first. But we also use all points of contact, family planning clinics, outpatient clinics, maternal health clinics to access women. We work within the existing health structures and we are helping countries to ensure that data concerning cervical and breast cancer are also incorporated into their health management information system. We help to build capacity right from prevention, from community-level health workers, right through to cancer diseases hospital where capacity is required for pathology, for surgery, for oncology. We have to build capacity across the continuum of care, just to make sure that the country is able to provide quality services to its women. Thanks, thanks, Dwayne. And Kennedy, of course, you were one of the first countries, Ambio is one of the first countries and you are one of the first partners to work with pink-ripping red-ripping, and you're on the front lines of this issue every day. So I wonder if you could maybe tell us about two things. First, just your experience. What are the daily challenges like that you face and your colleagues face in dealing with cervical cancer and diagnosis and the continuum of care in Lusaka and the hospital that you're involved with. And then maybe also a little bit about what pink-ripping red-ripping has meant, what it has brought to you in terms of added value. Right. May I also say thank you very much for having invited me to come and be part of this discussion this morning. I come from Zambia. It's in the southern central parts of Africa and we are a population of 14 million people and about 52% of that population is women. And 60% of this population is under 15 years of age. So we are a growing population. And our HIV prevalence rate is at 14% on average in the country. There are some areas that are higher and there are some areas that are lower. In terms of how we came to start a cancer service in our country, we all started by noticing an increase in the number of cancer diagnosis that were being made in our pathology labs in our country. And by 2004, we had about 5,000 confirmed cancer cases waiting to go for radiotherapy abroad. And for each of these, we needed to spend something close to $10,000 equivalent to send one patient for radiotherapy to South Africa. And the government only managed to send about 350 patients in that year. And you can imagine what could have happened to the rest of those patients. And the majority of these patients were cervical cancer patients at about 35%. And if you really imagine this is a disease that can easily be prevented and can easily be treated and curable if diagnosed early. So because of all this, government had to make a decision to start screening services and to start treatment services for cancer in Zambia. And so in 2006, this year marked a turning point for Zambia in the sense that we did establish a screening program and we established a treatment center for patients with cancer in Zambia. The cervical cancer screening program started with one American professor of gynecology, Bruce Beck-Paham, who came from UAB and visited the country to just come and see Victoria Falls. And at that time, he made some of us and he saw the idea of trying to establish a cervical cancer screening program. And we agreed and that started. We used the next lead based screening program, AC and treat. You see the patient, if you find they have problems, you treat with cryotherapy. And for those that have a bigger lesion that cry, these are the ones we try as for lip. And as soon as you do lip, you send it for histopath and we confirm whether this is just CIN3 or there is an invasive component with which if you find the invasive component, they are then referred to our clinic. So when we started, it was quite small and it was supported, of course, by PEPFA fans and we targeted only HIV positive women. By the year it was 2008, 2009, the pressure from HIV negative women was increasing to get screening. And by the time 2010 came, our clinics had to be opened up for HIV negative women to come for screening as well. And this is where Pink Ribbon, Red Ribbon came and made it such a significant difference because in 2011, President Bush came and launched the initiative in Zambia in our hospital. And we had such a boost that we now started looking forward to spread to make available the screening services in all the provinces of Zambia. Zambia has 10 provinces and when we started running in Lusaka and from these nine provinces at the current moment, we now have about 40 clinics and we have screened over 200,000 women for cervical cancer and we have treated over 40,000 women with proven cervical cancer at our center in Zambia. So these are some of the things that we're doing. Despite all this, we have a lot of challenges that we face on a daily basis and the greatest challenge sitting in Zambia and seeing patients is late presentation. Something that probably advanced countries don't see that often but our patients, when you diagnose them with cancer today in Zambia, 60% of them already are stage three and four because the screening program is just starting and this of course brings down the survival rate to very low figures and we fortunately have already created a very good palliative care program in the HIV era which is now benefiting the cancer patients that have been seen. The next thing is the high mortality from the cancer that we have. Both breast and cervical cancer in Zambia have very high mortality rates so we need to actually think more clearly on how to reduce the mortality from these and then we have very few in terms of trained personnel that are able to actually recognize cancer in Zambia and be able to treat whether the pre-malignant lesions or the invasive cancers themselves. Then of course we are struggling to make these services available at national level so that we make meaning and we make sense to the communities that we serve with the assistance of the international community. International Atomic Energy Agency was the first to step in and assist Zambia to create the treatment programs and train a few staff to actually manage cancer. With the coming in of the pink ribbon, red ribbon, this has had a multiplier effect. The IAEA, WHO, pink ribbon, red ribbon have all assisted Zambia to actually come up now with a National Cancer Control Strategic Plan which has prioritized cervical cancer as one of the cancers that we need to pay attention to and I'm sure by next week our Minister of Health will be signing this National Cancer Strategic Plan for Zambia. And this through the years that we've been trying to build it it has increased a lot of awareness amongst the Zambians and women have actually accepted these services. They are now beginning to come voluntarily for screening. Our clinics see not less than 40 patients in one day. You know, and the nurses are so overwhelmed and we have recently, last two years, been doing the HPV demonstration project thanks to the pink ribbon, red ribbon alliance that provided the free vaccines for 50,000 girls and we completed that. When I was looking at the data from UK, we had 90% coverage. First dose, second dose around 86. The third dose dropped about 65% for several reasons and which we are now beginning to look at to learn a few things. We also did a school based vaccine program and we are now, like I've already said, scaling up these services so that they are accessible to the population in Zambia. People to do all this is the involvement of the president and the First Lady, the Minister of Health. In Zambia we have a unique situation where the First Lady was a gynecologist, Minister of Health gynecologist, permanent secretary for Minister of Health gynecologist, the permanent secretary and the Minister for Community Development were both gynecologists. So it was quite easy for us to put these things together from community to, you know, so we were in a unique situation and I think that's why President Bush identified along with a piece that we have in Zambia, stable elections and transparency to actually launch these programs in Zambia along with the Zambian government. I think that's what I would say. Thank you, Kenney. That's a great overview and I think maybe we'll come back to this issue around scale-up because that's a huge challenge and be good to hear a little bit more about how that's moved forward in Zambia but I think hearing you talk about the political leadership and how you all very cleverly infiltrated the leadership of people who would be advocates, you know, across, you know, the various Zambian structures is quite a good strategy. And Dr. Lyshemp also himself has been a real leader on this. He won't say that, but it's good for, I think people need to know that also. But I think we should maybe go to Sandy and talk a little bit about political leadership here, you know, in this country and I was at the launch of Pink Ribbon Red Ribbon in 2011 here in Washington where former President Bush and then Secretary Clinton and a number of other leaders came together to actually launch this initiative with a high profile and a lot of commitment. And I know Secretary Kerry has also picked this up and said he wants to approach the fight against cervical cancer the same way the U.S. has led the fight against global HIV. So it would be great to hear a little bit from you, Sandy, about why Pink Ribbon Red Ribbon is so critical to PEPFAR, how you're thinking about its future support. Sure. Thank you, Lisa. Well, first of all, let me just send you all greetings from Ambassador Birx who couldn't be here today. She's in the process of completing our first rounds of country operating plans for PEPFAR and, you know, it's wonderful as it is to have a little bit of money to give away and to program as we do in PEPFAR. It's not as easy as it looks. And so she's deep in the weeds today in Atlanta at CDC trying to finish this first round. So she sends her greetings to you all. PEPFAR I think was a perfect match for Pink Ribbon Red Ribbon from the beginning because PEPFAR is the largest single-focused public health program of its kind. And it's programming about $6 billion a year. The majority of our work is in Sub-Saharan Africa. And it has enjoyed, the program has enjoyed extraordinary support and leadership politically across the board. Democrats and Republicans, sorry, with President Bush, absolutely supported enthusiastically by President Obama. And now, of course, by Secretary Clinton and former Secretary Clinton and Secretary Kerry. What we've been able to do over the life of PEPFAR is really build extraordinary infrastructure on the ground and a sound platform that supports activities like Pink Ribbon Red Ribbon and programming like Pink Ribbon Red Ribbon. And so we think it's so natural to just build on an existing platform instead of recreating the wheel to look at, you know, finding more integrated approaches and interdisciplinary approaches to cervical cancer and breast cancer, HIV and AIDS. Then we have had in the past to create a continuum of care, particularly for women, which is another reason that Pink Ribbon Red Ribbon is a great partnership for PEPFAR because the majority of people living, as you've heard living with HIV in Sub-Saharan Africa, the majority of our clients are women. And our focus and our redoubled efforts are targeting women in this next phase of PEPFAR. And we've had some extraordinary successes in the program but still challenges around reaching women and reducing new infections. And young women in particular, so our target audiences are the same, women of childbearing age and young women who we can immunize and get into a continuum of care early. The other thing is that we have common interventions and, again, priorities, women, voluntary male circumcision, you know, building, getting people into care, retaining them in care, all those kinds of things that we both need to do, addressing HIV and cervical cancer. But the other is that we've had an enormous amount of experience in HIV over the past 30 some odd years in addressing and reducing stigma and discrimination around HIV. And we've got the same challenges in cancer and cervical cancer and breast cancer in particular to, you know, reduce stigma and to get people to seek treatment early on. So we feel like we have lessons that have been learned that we can share and new opportunities to learn and do our jobs better in making our services available to people in a way that they engage more in, you know, healthcare-seeking behavior. So we think that's really, really important. I think the other thing is that it is targeting particular populations and hard-to-reach populations. We've invested a lot of time and effort in HIV and AIDS. I know we have been cancer as well and targeting people and getting them into treatment. I think there's a lot we can share and we are sharing that helps us do our work better. And the other is this idea of the continuum of care that starts very, very early on. And as we were saying from, you know, from the very beginning in preventive care all the way to the end in palliative care. And we've been doing this side-by-side for years in the HIV world and the cancer world. And so we share that need to figure out how we do both of those things more effectively. So I think it was a natural partnership. Our priorities are very, very closely aligned. And I think Pink Ribbon, Red Ribbon really is an extraordinary example of how a public-private partnership can help us reach people, engage political leadership, find resources to fill in the gaps, you know, identify gaps, work together to fill them. It's as good as any I've seen. So we love being part of it. Well, thank you. Thanks, Mandy. And I think we'll come back when we have a few minutes to what's unique about the Pink Ribbon, Red Ribbon partnership. But I think maybe first just to follow up on these issues around scale-up, which I think are so critical and so challenging. And, you know, Sandy, you mentioned the demographic cohort of young women and girls that actually, I know that Pink Ribbon, Red Ribbon Secretary has done an analysis of what that looks like in the five Pink Ribbon, Red Ribbon countries. And it's substantial and it requires careful consideration. Kennedy, you mentioned the success in Zambia of actually pushing the screening out to the nine provinces. So I actually like each of you to think a little bit and respond around this question on scale-up. You know, and what do we need to be thinking about now so that five and 10 years from now we're able to get these services, the screening, HPV out to this ever-expanding cohort of young women who are going to need that kind of care. So maybe we could start with you, Kennedy, just to give us a little more insights into in Zambia, how you actually managed to go for a fairly small number of centers that actually do the IA screening to a much more expansive network and what that required. I think the most important thing is to ask as clinicians to ensure that we have put our case properly to the decision-maker, meaning the politicians and the people with money in the country and the people who assist us to look for money. The most powerful thing that we have used is to look at women as the economic drivers of the economy of Zambia because today in Zambia most of the households depend on women actually and when you lose a woman, even if the male parent is there, there is a negative effect on that family that begins to be seen. So you package these sort of things to those who can understand economics so that they help you to look for the money and more so to ensure that we don't lose the focus on the effect of mortality that the cervical cancer is creating and that we have come this far from the time we started the antroproviral in 2000 up to now and we keep on losing so many women and when you put it in numbers, in absolute numbers you find that the people who look at the problem begin to see it differently and so this helped us and then we had a very strong awareness program that started and we trained quite a number of community health workers to actually spread the information and spread the news into the communities and this created demand from the community-based NGOs to try and now force the government to begin to establish these services in the communities where they live and it came also with the change of governments in 2011 where a community-based approach was now emphasized by the new government that took over so you see we were just at the right time in time for these services to start getting scaled up so we used the political will that was there and we used the partners that came on board that provided financing for us to scale up but we knew what we wanted to do as a country so we had a map but we needed to have somebody come in with money so that we can begin to actually scale up these programs and the most important was to emphasize that this is a low-cost intervention, low-cost but very effective and when we believed in that and we agreed this is what we are going to do, we then designed the courses that will go with this, we identified the sort of equipment that we need, we costed the plan and when Pink Ribbon, Red Ribbon came these things were already there and when they brought the money it was easy for us then to go and we had already even identified where we are going to go next if money was available so this is something that other countries should actually look at and begin to prepare just in case you have somebody coming and say what do you want to do, here is the money so where do you want to go, then you begin to say okay, no, let's discuss that sort of thing is not nice for people bringing you help so you need to actually plan yourself as a country and begin to understand what is the next step that you need to do in case money is available so this is the most important I think is the planning Absolutely, Doine maybe you could say a few words about how in countries other than Zambia Pink Ribbon is thinking about the sustainability and the scale-up issues and trying to work with those governments on similar kinds of challenges Yes, when we did the analysis if we were to go by the fixed facilities that wait for women to seek care it would take us more than two decades to be able to reach the 80% goal that WHO says every country should attend and therefore we had to think innovatively the first thing was we need to begin to take services out to the women so we started promoting in all our countries not only fixed facilities but out-reaches mass screening campaigns take for example last year during the International Women's Day we supported Tanzania with the leadership of the first lady who went ahead and mobilized the communities over 12,000 men, women and adolescents turned up in Wanzha region just in one day because Mama Kikwete was present and within a two-day period the Medical Women's Association of Tanzania were able all hands-on to screen over 3,800 women on site and to screen over 5,200 women for breast cancer and subsequently the services continued in the nearby facilities for those who could not be attended to so getting services out there rather than waiting for the women to come and even that approach we have tried to sustain with one of our partners Project Consent International, PCI that is working in Zambia with the help of Airborne Lifeline one of our partners they go on out-reaches they are air freighted by Airborne Lifeline to different military positions and to the villages around and they actually take services out on a regular basis the second thing is we are also considering innovative treatment approaches it's become very cumbersome working with the conventional crowd therapy machine and gas cylinders not only have they become expensive but cumbersome they also leak because you transport them by road and therefore we are working closely with a company in Texas, Cryopane to develop gasless cryotherapy we are happy that NCI has given them the empowerment to go ahead and develop this gasless crowd therapy machine that can use electricity but even when electricity is not available can use three car batteries to operate and they are now developing a very robust model of it that can be portable and carried out to different locations one of our partners, Cryogen has developed HPV DNA testing and this is something that will reduce the load on visual inspection with aesthetic acid and so we are ready in discussions with Zambia with Botswana and Tanzania to first of all screen this women using HPV DNA as a triage because we know that 80 to 85% of the women will be negative so you are only left with 15 to 20% of the women that would need to go through VIA possibly cryolive and subsequent treatment once this is in place we know that we will be able to reach more women more rapidly mobile technology is something else that we are looking at to remind women of appointments to send out messages in Tanzania we are working with the Tanzania Youth Alliance in the past year they sent out 800,000 SMS messages to 40,000 subscribers out of these 18,000 women were actually referred for screening so these are methods that we are getting out there to be able to reach more women more rapidly but at the end of the day HPV vaccination is the way to go and we are already working with Zambia and Botswana to make sure that this happens thanks to the generosity of Merck vaccine we were able to supply to donate vaccines to Botswana they have been able in the first two years to vaccinate over 8,000 girls and together with Zambia the two countries have vaccinated over 42,000 girls and this year Botswana has now assumed responsibility with its own budget with its own implementation services to deliver nationwide rollout HPV vaccination so these are some of the methods that we are looking at not forgetting data management we are working with each of the countries to make sure that right from community level right through to cancer centers we have data that would exactly tell us how many women we are reaching how many we are missing who is there, who needs care and who needs to be followed up Thanks Dwayne, that was a great and very concrete answer because you really helped us kind of see what's going on and I think it also speaks a little bit to the value of these kinds of public-private partnerships working very closely with national governments with civil society leadership in countries is that you have this mix of perspectives that collectively is going to problem solve differently than anybody would do individually and I think we've seen that in some of these more innovative approaches now that the Pink Ribbon Red Ribbon Partnership is exploring so I want to come back to the panel and even go to lunch but I think it would be good maybe to open the floor for questions for the next 10 or 15 minutes we'll see what's good but just for the panelists I think just to follow up on where Dwayne just left us I think if you could just think about public-private partnerships this is the opportunity this panel to speak about them in this space today if you could say a little bit about why you think this is a unique and effective way to work why this kind of partnership can really help move the agenda forward in a way that we can if we're just working alone I think that might be a good just last question to come back for a few minutes on but let's open the floor and hear from some of you and as folks have asked before if you could just please identify yourself and why don't we start right here and we'll do maybe three questions at a time so we can go here and then over here and then to the gentleman in the back thank you Lisa, I appreciate it I just wanted to go back to this question of scale my name is Sarah Goltz I'm here representing cervical cancer action we've had a chance to work with many of you over the last eight years how have you handled the issue of quality because you've certainly tackled the question of scale and pace which is a huge challenge for us but we know from many of our other colleagues that particularly with visual inspection it's not just a question of getting the program going but making sure over a period of time that those who are applying the services are doing so as effectively as possible in some really challenging setting so what would you say to others who are establishing programs in order to monitor those and to really assume that we're having the impact that we have the intention of having thank you and let's take the question right here please I'd like to echo the same question about quality and quality control with the current screening approaches but also we know that with some of these cost effective screening approaches there is a caveat which is that there perhaps will be more cryotherapy done than is potentially needed and how do you deal with that in terms of programmatic success because that too, as you scale can have implications on the overall cost of the program and the gentleman in the back here my name is Joe Mendo from the American Cancer Society first I just want to commend Zambia for doing such a great job as it always does in many other areas but my question is for Sandra I want to build on your sentiment that Ambassador Bex is facilitating the CARP process which is the country operating plans and as part of that I think countries are having to strategically refocus their resources to where the epidemic is and part of that means prioritizing their interventions with the ones that have the most impact on the epidemic into cold, near-cold and non-cold and subsequently or consequently cervical cancer is being categorized as non-cold because it does not directly impact HIV epidemic could you speak to the future of the PEP contribution to cervical cancer given that? Great, so let's take those three questions first and then I know there are others so we'll come back to them in the next round so I think the first two questions were a bit similar about quality and issues around maybe false positives and cost implications there so I don't know who would like to take that first So how do we handle quality control? One of the first things that Pink Ribbon Red Ribbon did when we first engaged in Zambia was to provide resources to develop what we call an electronic hub room within Lusaka it's based within the Center for Infectious Diseases Research in the early days before we came on board Center for Diseases Control would bring together all of the nurses that were in the Lusaka district every Friday and walk through all of the pictures that they have taken of the cases of the services that they had seen in the course of the week and go through like a grand round type of thing and say which one was correct which patient needed to be called back as we scaled up and people were further away from Lusaka it was important to do something of a tele medicine, tele quality control and so there's this room in Lusaka where we have four screens computers and they are connected to all of the centers that are providing see and treat so if a health worker in a distant location saw a patient and was unsure of what to do is this really eligible for crowd therapy or is it too big or is this suspicious of cancer they take the picture and they send it to the e-hub room and send a text message to the headquarters to the people managing the room to say can you help and in real time the e-hub staff would give advice because they see the photo they use cervical graft they see the photo they are able to give advice to the health worker to say yes this is cryo-eligible go ahead and treat no this is much bigger refer for leave no this is suspicious of cancer and we're told that in real time within 30 minutes the health worker in that distant location gets guidance on what to do the second is supportive supervision it builds into the training and so people go back every quarter to work with the team on ground and just make sure that hands-on correction on the job training on the job and improvement of skills in terms of too many crowd therapy procedures being done it's actually been proven that it is protective of the woman if you do it and she doesn't need it that it is protective of her service and therefore for a woman who may never have another opportunity of a pelvic examination it is not a disadvantage but what we have also found is the more the health workers practice and see patients the more up they are in making those kinds of diagnosis and with the telemedicine support they get better at it do you like to hear anything Kelly? Yes the issue of quality was very pivotal in the program and when we started thinking of scaling up the program it became very clear to us that we needed to think a little bit outside the box to see what we can do to ensure that remember we are using nurses not gynecologic oncologists so these nurses were supposed to be doing the same thing throughout the country wherever whichever site you open and what Doena said is what exactly happened we I think the people who developed are the young students from Harvard two young Harvard students who helped design the EHUB program and it's got qualitative information built in on where to best decision on how to treat but we want to take it to the next step we want to put a quantitative scoring system on this if you look at the program that has been developed by the Swedish doctors there is a score that they use if they are doing VIA and it guides on who gets cryotherapy, who is negative on VIA and who needs a leap so this sort of quantitative scoring will be important to add to what we have currently so we are beginning to look at how best we can introduce this in that environment to make it even better but the good thing with us is that in Zambia today internet is available in most of the districts today in Zambia and FIBA is beginning to reach almost all districts of Zambia so here is an advantage that we can take so that we begin to ensure that the quality remains the same the over treatment issues I think she said what I needed to say and this being demonstrable using telemedicine from a very remote location those days we were having difficulties to comprehend that this can work but we have demonstrated that it works so therefore it means that even our centralized pathology can also be decentralized and these are some of the things that we put in our national cancer control strategic plan to ensure that we reduce the turnaround of those having histopathological specimens being examined and we want to also utilize the same platform provide histopath labs at lower levels with technologies that can actually produce slides and these are the slides that are going to be sent to the central location for interpretation and we are going to reduce on the time to make early diagnosis much more sensible in Zambia so these are the things about quality and how it can change the entire service and we have already demonstrated that it works and so we want to build more things on it using cervical cancer as a casing disease and then strengthening the whole system of delivering the cancer service in Zambia Sandy anything on this question or to the question that was put more to you directly not to this question but to the one that was put to me more directly is about prioritization and we are certainly refocusing and re-prioritizing inside of PEPFAR to make sure that we are investing to get the maximum impact and the maximum return on our investments however that is not to say that while we define some of our activities as core near core and non-core and our deliberations it doesn't mean we are abandoning or not appreciating how important those near core and non-core for our particular HIV AIDS work so we are not leaving those. I think what this speaks to for us is that we are going to have to be much more aggressive and creative in building partnerships so if we are pivoting our PEPFAR activities over here we don't want to leave anything behind that is undone here and we are committed to doing that certainly cervical cancer is a big part of our work because the majority of people we serve are women of child bearing age so we are not abandoning our work and are more dedicated to pink rip and red ribbon in our work in cervical cancer than ever before but it speaks to I think scale up to what happens now that we are beginning to integrate some of these programs using and leveraging existing platforms not just PEPFAR's platform but others to be more creative and outreach to places that are hard to reach and people that are hard to reach it is forcing us to change but there is a real evolution in how we are looking at public health and healthcare delivery not just in HIV but in cancer and many other areas and malaria and tuberculosis and I think it is a time in our fields that we really have to take more interdisciplinary approaches that we have to have partnerships that we have never had before we have to look at creative solutions and innovative solutions that Doine was talking about and so I think the onus is upon all of us to work together to figure out how we address these issues collaboratively it is when you look at what is happening in PEPFAR and I think it is a really good example we are almost a victim of our own success in a time where we have decreasing budgets we put more people on treatment than we ever have had or done in history but at some point in time the money gets tight and so we are going to have to get more people to the table and be more efficient than we have ever had to be and all of the time that we have been doing this in the last 35 years so I just want to leave you with we are pivoting we are taking much more solid public health approaches we are driving all of our decisions based on data that we really did not have access to in the past years of PEPFAR and do now we are doing the way we do business I think there is good news and some challenges in that but I think we are all committed to making sure that we do not leave anybody behind in the process Thanks Sandy I think PEPFAR is still the largest single financial contributor but has supported in so many other ways at country level with technical advice and support and sometimes the need to get things done I think everybody understands how hard it is PEPFAR teams have been great in helping move that agenda forward so we are coming up on noon Steve can we do one more quick round or what is your advice maybe five more minutes I promised this lady over here and then this gentleman and why don't we just stop maybe with those two questions but I know Doi and Ken will be around throughout the rest of the day so if there are other questions people can of course come up to them during the coffee breaks and then we will have questions from PAHO Foundation Hi Sandy quick question in the beginning Doi and reference Latin America and the Caribbean and taking this program there we will have new challenges because we don't have the strong PEPFAR platform there so could you just say a little bit more about that plan gentlemen here please I want to thank CSIS this has been amazing but what is next what do you want what do you expect us to do to amplify all these things that are happening because this is not it's a great lecture but I want to go into how we can amplify where you are doing thank you to the first question Doi by the way Twitter has gone crazy with you so so the plans for Latin America well the questioner is also a potential partner to us we are in conversations with PAHO Foundation and we are going to be exploring Latin America in the next 2 to 3 months and the Caribbean will first of all go to Peru and to Jamaica and as our first step always is we scope the country to do a quick assessment of the situation in the country the health systems the partners that are there and just identify what the gaps are we are very conversant that the situation in Latin America will be different from what it is in Sub-Saharan Africa but we are ready for that because as we have partners who promote VIA cryotherapy in Sub-Saharan Africa so we also have partners who are willing to work with us if it's cytology, pub smears histopathology we have American society for clinical pathology if it's advanced cancer care we have MD and D�C and so on and so forth so we are going in with an open mind and we would apply the same kinds of principles looking at what the gaps are which ones we can fill and then come back to our partners and say this is what we have found on ground who is willing to do what and this is the way we work we have a very good slide that shows us from prevention right through to palliative care and you can see where each partner fits along the continuum and we would do exactly the same thing for Latin America so all eyes just out there looking for Latin America and waiting to see what the next steps would be so you are asking us what is next I need money because one of the things that we are trying to do right now is how do we transition our support as Pink Ribbon Red Ribbon full national government responsibility and to be able to do that we want to get to a comfortable position with the country where he as the senior medical superintendent is comfortable with saying now you have catalyzed action to this point we have merged what you are doing and we are comfortable that we can sustain it but for us to go from where we are now to the point of transitioning to government we need to infuse a lot more resources to just fill in some gaps within the health system and make sure that we get the country to a comfortable position where it is a program we never project ourselves as project we say we are a program because we want to sustain it so whatever it takes in terms of advocacy in terms of resources in terms of connecting us to people who are interested in women in Africa in girls that can help us to sustain this program that's what we are for. Thank you and I think you also answered the second question but let me see if either Sandy or Kennedy maybe just in terms of a quick 30-45 seconds sort of closing thought that would respond both to the question of kind of what's next and my question that I put before kind of the single thing that's most important about this partnership and then we'll wrap up and let everybody go to lunch. I just think that all of the work that we are talking about anywhere in the world is going to require new kinds of partnerships these kinds of public-private partnerships really are the key to being able to bring all of our work to scale and the wonderful thing is that they're different in every region they're different in every neighborhood they're different in every country every place in the world and our ability to understand that our work has to be done not on a one-size-fits-all basis but very very tailored to the specific challenges and opportunities in places where we're working and I think that's what's going to help us bring all of this to scale. What makes this country level for Zambia it would be interesting for you to note that the government of Zambia is busy investing in the healthcare system at this current moment we have 650 clinics being built they are all under construction at the same time in Zambia and these are the clinics where they will be in the community and these are the clinics that will carry some of these screening services and if you ask me what next, what would you want to do we will require assistance in terms of making sure that equipment is available and some of the things that we require for training are made available to us so that the whole program becomes successful I think that with the strides that government has done to ensure that we scale up the partners and the rest must actually see it as an opportunity a low-hunging fruit where we've already done at least so much so that we cover the whole country so we shall require as she said a lot of resources to do it. Do I need 30 seconds? Oh, okay I think what we need is to wage war against cervical cancer and it's obvious that no single organization institution, entity has all that it takes to wage this war and so all hands have to be on deck working together in a public-private partnership model to defeat cervical cancer. Thank you. I just say from the point of view of my own organization, UNAs, it's been one of the founding partners of Pink River Revenue from the beginning. This is a fight we are committed to 150% and I think some of the other panels mentioned the importance of actually moving this forward and making sure it's included and what comes after the Millennium Development goals and using every single platform is done. But thank you all very much. You were great questions and thanks for being with us and I guess on to lunch is that right, Steve? Yes, thank you.