 I'm Steve Horst from CSIS. We're thrilled to be able to come together this afternoon with this very distinguished panel to talk about the implications looking forward of this very important Institute of Medicine's evaluation study of PEPFAR. I want to draw your attention here to a small survey that's on your seat. This is a tool that the inimitable Todd Summers has developed, which we are now going to use here to try and get to capture your candid opinion of how we did today. So as Todd said yesterday, you've got to give the speaker extra high marks, or the coordinator, the moderator, extra high marks. This is a joint effort of ourselves in the Kaiser Family Foundation. I want to thank Craig Pulaski. I want to thank Jen Cates from the Kaiser Family Foundation. We've been collaborating fruitfully and very positively for over a decade together on multiple events. And we're really proud of that relationship. And it's been among our most valuable relationships here in Washington. And so we were delighted to be able to pull this together today. And it was even more important because Jen's played such a leadership role in this panel and is so knowledgeable and conversant with it. And we'll be able to hear from her today. So we're doing this jointly. The panel doesn't have Kaiser's logo on it, but I want you all to imagine that, in fact, it is there because they are a partner in this event. I want to thank also my colleagues from CSIS, Matt Fisher in particular, Alicia Kramer, have been very active in helping us pull this event together. And I want to welcome those of you who are online. We have many online. And we will also be posting this on our websites in the coming days so you'll be able to view that again. We, as I said, we've been collaborating on these types of reflections for some time. At the time of the last IOM study of PEPFAR, we pulled together a session up in the Senate, as I recall with Senator Feingold. Barbara Lee joined us. Mike Merson, who is on that IOM panel, joined us. It was a very exciting moment, that review. It laid down a lot of very important reflections around what had happened in the first phase and setting course in the direction. And I think IOM should be very proud and all the members of that of the impact that it did have. And in the current setting, when reauthorization by Congress seems less likely in this next cycle, I think the IOM study becomes even that much more important in thinking about the course that we'll be taking in the coming years. And I think it's going to be a very, very important reference point, and already has become that. And it's interesting, when we decided to do this particular event, Jen and I were discussing it, and we were recruiting the speakers. And we were really wondering what kind of response we were going to get, because there had been many very, very good events staged around town to talk about the report. And we deliberately framed this as looking ahead and looking at the implications and thinking of where does this point us to? And I do think that that has not been treated with sufficient attention or depth. And the fact that all of you are here today, and many of you are online, I think, is testimony that there's an appetite for that particular issue, and it's ground that is very important ground that's still to be covered. What we're going to do, I'll do the quick introductions. These speakers are all familiar to you. I'm not going to give exhaustive introductions. And then what we're going to do is do two quick rounds. Ask each of them in a very short, succinct fashion to comment on two questions. And the first one really is looking at the report itself. What are the two to three top priorities? Looking forward, if you were advising a member of Congress or a senior member of the administration, what does it point us to as the two to three top priorities for the next coming years? And harvest those quick opinions from folks and have a short discussion around that. And then we'll move to a second question, which is what outside of the domain of this report that might not have been possible could not be covered because of data limitations, time limitations, politics, policy choices, congressional mandates, whatever those are. But there are things, there are big issues that we might have wished could have been covered more. And let's talk about those and what that means. We'll try to move through those so that there's maximum of time to hear from you because there's so many very informed folks here. And we really do want to maximize the amount of time that you have, an opportunity you have to weigh in. So please think about your questions. And when we get to that point, we'll try and get there quickly. We'll come to you and ask you to step forward. There'll be microphones. And just try and keep your interventions succinct and very clear. So let me just start with our quick introductions. Jen Cates, you are all probably very familiar with her. She's played this very premier role in the policy world here in Washington as a vice president and director of the global health and HIV policy at the Kaiser Family Foundation. And that has very broad remit in the quality of the work and the centrality of their products that she has pioneered over many years, which have become the kind of common anchors for many of our discussions across a wide range of issues. She comes to this also with, I would guess, at least 15 years, if not longer, of sustained commitment around HIV-AIDS policy issues. And the role at the IOM was among the most activist and committed of those IOM members and I think had profound impact on the outcome and the shape. And somehow, in the midst of all of this creation of this program, she also completed her PhD at George Washington University, which I still haven't figured out how that happened. But congratulations, and it did. And Chris Collins, Amtfar, as vice president, director of public policy, joined there in April of 2009. Again, over 18 years of leadership role in HIV policy and advocacy has published very broadly, was very integral to the very important global HIV prevention working group of the last decade, co-founded AVAC, the AIDS Vaccine Advocacy Coalition, many other achievements. To my left, Kimberly Scott, senior program officer and the guiding light from the IOM, the Institute of Medicine on the Board on Global Health for this particular study, and many others, came to this role as a field coordinator, manager, and leader in North Carolina on HIV-AIDS programs over several years at the Duke Center for Health policy thereafter at the Government Accountability Office, really a quite remarkable and sustained and consistent background on these matters and has been with IOM since 2005. Julia Martin, on my far left, Julia is the deputy global AIDS coordinator at the Office of the US Global AIDS Coordinator here in Washington, familiar to many of you. Over 18 years of service and commitment in HIV-AIDS and public health, much of it, I'd say probably most of it, ground level, programmatic and policy leadership in Uganda, work, very important fieldwork in China, Ukraine, residential field-based work in Zambia, and has been really a pillar of OGAX leadership in this last phase. So thank you all, thank all four of you for joining us here. Julia, I'm going to ask you as the senior person representing OGAX here today, Julia, if you could start us off with that first question, just a quick, some quick bullet points on the two or three top line conclusions that, or recommendations that you would make pointing us to what you think this report tells us should be the priorities over this next period. So thank you. Thank you. And I'll try and turn this way as well, so I acknowledge the room. And I just want to begin by saying thank you for this report. It isn't, not every program has the opportunity to receive an evaluation, which you can then use and work to improve that, which we're here to do and that people are here to serve. So it's been a great opportunity. So I'll start with that. There are many things in the report that are worth noting, if not all of it. So it is difficult to hone in on just a few. But in the desire to be in bullet form, I will say that there are three top ones and then say a couple of words about each one. And the first is care and treatment. It is one of the lead recommendations or lead sections. And it's really essential to an age-free generation in being able to achieve that. Issues of retention, quality, service, models of service delivery that are most efficacious or effective and really cost effective. And looking at defining the highest impact interventions and how those are prioritized in programs. So that's a collection of thoughts under care and treatment. The second would be program sustainability and transition. And I think we're grappling very seriously with the word transition, defining that clearly, defining it in context, and understanding what it means for the country that we're operating in and supporting and what it looks like in the pace of transition. And the third area I would like to highlight is knowledge management. This was a large section in the report, a very important one for understanding how we represent the successes and achievements of PEPFAR, as well as really understanding how you use data to inform program improvement and change. And so issues around measurement, the quality of data, and then how we get that data out, how we make it accessible and usable to others. So those are my sort of top priorities. Thank you. Kimberly. Thank you all for everyone here. It's CSIS and Kaiser Family Foundation for inviting us to participate today. As people know, Ms. Julia has alluded, the report is very lengthy. It's over 700 pages, so we hope that we're gonna be able to talk about it in snippets and invite further conversation in your questions. I think that some of the high level messages that I would like to present from the committee's perspective, and I would like to say that when I am talking about the committee's messaging, I will be talking in my role of an IOM staff person. When I'm talking in the role of a private citizen of the world, then I'll take off that hat and have to own whatever perspectives I can offer. But I think that starting at the very highest level message is that the committee recognizes and believes that a pathway to sustainable and resilient responses in countries is the appropriate activity and focus of OGAC now and going forward. In a very large umbrella, I think that the committee concluded that PEPFAR has been a very transformative, play a very transformative role in terms of the global HIV response, in terms of services that could be scaled up, delivered, planned, monitored, evaluated. Certainly looking across all technical areas, there've been accomplishments in prevention, in care and treatment, in services for children and adolescents, in terms of health system strengthening, all of which sort of lead to the conclusions and recommendations about sustainability, which is critically and intricately linked to prevention and I'm sure we're gonna be talking more about that. In terms of care and treatment, it's very important, not just in terms of the programmatic targets that have been achieved, but also understanding more about attention and adherence and how to keep people in treatment and how to follow them over a period of time to really understand who is really being maintained on therapy and being able to address the questions of who is currently being covered, what's the trajectory of need, what might be the expansion of need with the adoption of changing treatment guidelines. A particular focus is improved treatment for and care and treatment for infants and children from the cascade of testing to the initiation of therapy remains a persistent challenge. I think in terms of health system strengthening, there have been some incredibly positive leveraging effects that PEPFAR has had in its efforts in capacity building from the district level and sub-national levels to the national levels and an increased use and focus on public-private partnerships and it truly being multi-sectoral responses that include civil society in the various roles that it can have and of course, leading up to knowledge management in terms of the collection of data, better collection, more strategic, measuring what matters, really focusing and shifting from activities to outcomes, not only in terms of what might be helpful for independent evaluations, but also for OGAC as a program or PEPFAR as an initiative or partner countries and various other partners to be able to do country level studies, everything doesn't sort of have to rise to the headquarters level, but to know what information is needed and at what level to be able to focus on whether it's operational research, whether it is management of information and sharing of best practices, but understanding and being able to trace and show outcomes and impact. The last thing I would say is that this is a remarkable story that the American people should know about and there's actually a legislative requirement that the goodwill of the American people that this be communicated to people abroad, but I am wondering as a private citizen of the world whether this is a story that the American people know about and how the money is being used, how it is being accounted for and the absolute progress that is being made in so many countries in which PEPFAR is operating. Thank you, Chris. Well, I wanna thank the IOM committee for producing this report. I think it's a very important assessment of PEPFAR's work and has a lot of great recommendations in it. My comments today will reflect my thought that this report really needs to be read with its companion piece, the PEPFAR blueprint for an AIDS-free generation. I think the IOM report has great assessment and recommendations. The blueprint draws on the latest science and shows us what can be achieved if we go to scale with programs we know work. The IOM report, I think one of the great things about it is it emphasizes the need to focus on outcomes and the blueprint talks about what some of those outcomes can be if we invest strategically. In this first round, the two areas I'd like to highlight are key populations and transition or what we used to call country ownership. But I think I'm not supposed to say that anymore. On the point of key populations, the report points out that these populations are core to tackling the epidemic, that there's been improvements in terms of PEPFAR's approach here, particularly around gay men and other MSM and people who inject drugs. That being said, there's enormous unmet need in quote for these populations. There's a dearth of data about programming and epidemiology for these groups, particularly for sex workers. There are almost nothing to say because there's just not any data on them. The real question is what do we do next? I think we've got to get to scale and set the priority to get to scale with services for key populations and we need to measure that. Harm reduction, condoms, lube, information, policy interventions. We need to increase the funds for these populations and we need to be able to see that. So we need more transparency from PEPFAR on the funds that are going to key populations. And I think there's room in terms of being clear with other donors that they need to be supporting syringe services programs since the US government's prohibited from doing that. On the transition issue, the second one, I think it's really good that the report says that the speed needs to vary by country setting and that the transition needs to be gradual. The report notes that several of their sources, multiple sources, said that they're worried that transition is too accelerated right now and I would also cite the CSS report from several months ago looking at the transition in for PEPFAR in South Africa where it said that there were, quote, legitimate fears in, quote, that the transition there is threatening ARV scale up. You know, transition is good in the long run. We all agree with that. It's very troubling, however, for key populations, right? We heard from the UNAIDS last year that 90% of funding around HIV for key populations comes from external sources. Many countries just aren't dealing with their key populations groups and I'm concerned about a line in the report that says the transition, quote, may lead to results, may not lead to results as rapidly or dramatically as in the past. That concerns me at a time of such promise in the response. I don't think we should be lowering our ambition in terms of outcomes, but instead, figure out how to get services where they have the big impact and take advantage of what we know we can do. The report calls for milestones and metrics and as we do this transition, which don't exist right now, I think those milestones need to include key populations, civil society engagement, and also the ability and willingness of country to get to scale with interventions we know work so we can achieve an AIDS-free generation. Thanks, Chris. Jen. Thanks, thanks, Steve. And on behalf of Kaiser Family Foundation, welcome and thanks to CSIS for co-hosting with us again. So I get to go last, which means I can just say what they said, but I had three things I wanted to highlight and actually I'm going to highlight them not from my role on the committee, they really are from my role sitting at Kaiser and thinking about the evaluation, which in its, as an evaluation is a very retrospective, static thing. We did an evaluation at a period of time, we were asked to look back and we ended at a certain time. And since the evaluation was done and we were wrapping up the analysis, there were a lot of other things that were being solidified. The blueprint came out, 052 had already been out by the time we were doing our analysis but we actually didn't get to focus on it as much as we could have. And so I think that the information and the data out there are pretty clear. And one of the points I wanted to make, thinking from a policy perspective with all of the reports, emphasis on sustainability which was really a main message as Kimberly summed up. I worry that the emphasis on sustainability has been equated with a false impression that we've already rapidly scaled up. That we've already run the race to the top of the hill and now we can slow down or stop. And that's not the intention of the report nor do I think the data show that that's where we are with the epidemic. So one of the key policy implications is not that sustainability equals pulling back or sustainability means we already scaled up. We actually need to scale up because that's sort of a precondition for sustainability. So that's, and help as many countries as we can reach a tipping point which is really just a point in time to get beyond. So that's one message. The second is in terms of sustainability and I agree very much with Chris and I'll say something about this later that the metrics around how we look at this and what it means are really, really critical. And one of the concepts that I wonder if we haven't yet incorporated enough is to think about resiliency. We want countries and want communities to be sustainable in their response but we also want them to be resilient as the US changes their relationship with communities as other donors do or do not come in. It's HIV is still an infectious disease and there's volatility in that at times. So I'm bringing up the idea of resiliency which has been used in ecology and psychology and now has made some kind of resurgence in development and humanitarian assistance but I wonder if we wanna keep that close because we want communities to thrive even as the response changes over time. And then lastly, just to again pick up on one thing Chris said around sustainability and transition, I also think in the report gets at this that the way that we manage the relationship with civil society, particularly civil society, organizations that are dealing with key populations that are marginalized and will be marginalized is really a critical, critical factor and that has to be a key part of policy focus going forward. Thank you. I'm gonna interject just a couple of thoughts based on what we just heard in my read of this report. One of the things that jumped out that I found very surprising was that just how in disturbing was just how problematic data is. I mean, when the first IOM study was done, the committee decided that it was too early to make very strong conclusions because the data didn't exist yet. And this second study five years later basically reached the same conclusion. I mean, it's the, throughout it, it is making the case that it cannot make very categorical, reach very categorical conclusions because of data problems. So one of the questions that that raises is on a program that's expended over $44 billion. What does that, why is that? And what do you do about it? What do you do about it looking forward? Is it an endemic problem because of the scope of programs in countries? Is it the nature, is it something that we just need to work around or is it something that can be fixed? On the transition issues, there is no discussion here about what's the vision for the future. It's very vaguely defined as to where does this all go? And when we go from year 10 to year 15, is that with an expectation that this is a permanent program that goes along like that? Or is there some vision that says this to Congress or to others, this is not permanent or it's something, there is no clear visions for where this goes. And in terms of expectations of partner governments, there's no indicators or markers around how to structure those relationships according to ability to pay but which there will be quite variation in terms of what's realistic expectations. But it doesn't communicate a vision around what are we going to really put in place in terms of expectations of the partner governments going forward, which is also I would think in year 10 to 15 a very important consideration. From year 10 to 15, the future starts, the long-term futures would seem to become important. Fixing endemic and rather pervasive data problems would seem to be a problem, a concern. But also trying to figure out what is it you're communicating to your partner governments in terms of expectations. Is a 2% budget commitment sufficient? Is a 5% health budget contribution sufficient? Where do we begin to make some judgments? Because I think over time inevitably, as we look at this as now in the second decade, people are going to begin asking these big macro questions and it may not have been possible here, but I think we need to think about that. Kimberly, do you wanna speak to some of that? Certainly, Steve. I would like to speak to two issues. One is the data issues and whether there's some indemnicity of capacity of data and use of data and the other about future vision. I would like to say that, and as a survivor of the first PEPFAR evaluation of IAM staff, as an IAM staff member, that was very critically clear that at the time that the program had been operating and by the time that the evaluation was done, it really needs to be a process evaluation. And I think drew the strongest conclusion that it could draw. Simultaneously, I think for this evaluation, there is something to be said about the questions that are asked to the evaluator. Sort of look at outcome and impact evaluations and try to break that down on what's important. That was critically important for the IOM and how the IOM operates. People come to the IOM, they want independence, they want scientific expertise from around the globe. So there are some operational things that the Institute of Medicine has to appear to. I would say that the data, the issue about the lack of data, which you will see throughout the report, throughout technical areas, is the lack of data for the committee to conduct its evaluation to answer the specific questions of the state and the task. There is a difference. And we talk about this in the Knowledge Management Chapter. We also talk about another technical area chapters where we recommend that there can either be special country level studies, particular cohort studies, using data that has already been collected to be able to look at for OGAC, for partner country governments, for implementing partners to look within countries, to look across countries with similar epidemics and similar characteristics. We do think that there may be data available to inform that process and to learn best practices and to make evidence informed as well as decisions to support evidence informed or evidence-based interventions. The fact still remains, however, is that there is very little outcome and impact data. And so we do make recommendations about how to collect better data, what it should measure, and how that can be used and at what level it can be used. In terms about the future and is the revision, I do wanna say something about the metrics. Chapter 10, and you'll hear me talk, I'm gonna be a walking table of contents for you if you haven't, if you wanna figure out how to tackle this really big report. Chapter 10 talks about the issue of sustainability. And there are two things, one I think to reinforce what Jen said earlier is that there are several models of USG assistance that people need to understand to have a rational reason discussion about the issue of pathways to sustainability. They're very different. They don't mean abandoning direct service delivery. They range from, and they do, they take into account whether a country has resources and has demonstrated country ownership and management of its own response. In that instance, the collaboration is around technical assistance and research that even OGAC and PEPFAR can learn from in terms of applying to other countries. But in the report specifically, we use the example of South Africa and its partnership framework implementation plan. There are targets and metrics within that plan. So how much, for example, might be based on the parameters of the targets within the plan if the country, for example, is supposed to assume the cost for ART. If they're supposed to reduce their new infections by at least 50%, see, I have to actually go to the report because I can't retain this information. Using combination prevention that at least 80% of people who are eligible on ART or on ART with 70% still being on treatment five years later, those are some proxy measures to be able to determine how much we're talking about in terms of joint financing, joint planning, ownership, who has primary ownership, the Republic of South Africa is supposed to be paying for ART. In terms of key populations at elevated risk, that includes not only some of the traditional populations, but also transient populations, mobile populations, zero-discording couples, young people. There are foci of activities of who is to be responsible for what, with some metrics that can be intermediate outcomes and probably more digital outcomes because the duration of the plan is five years. So I think there's something in there that we can begin to talk about, what is to be measured, but more specifically, what is to be done by whom and by when, and that those need to be a part of the discussion in terms of the vision going forward. If South Africa is the oldest, one of the oldest, most mature epidemics or at least programs within PEPFAR, if this works, then that should be informative about how PEPFAR and OGAC move forward. So the committee really gave PEPFAR credit for the content of the plan with the incorporation of all the principles in terms of aid effectiveness. All of those things are there, the critical components are there, but to me, part of the issue is when people start paying attention to that data collection, not waiting until the end of the partnership framework implementation plan and use that data for course corrections for South Africa as well as OGAC. Steve, can I have one thing on data from your first question? And we do know a lot of limitations throughout the report and there's recommendations to OGAC about how to improve data collection, use of data, reduction of burden of data, all of that. But there are two broad types of data missing data or data that we couldn't access. It was PEPFAR specific data, but then there's the world of HIV data and the world of other data like financial data from other countries. And so part of it, it wasn't just the challenge of what PEPFAR could do a better job of is really the challenge of our field and that we're still struggling to get the data that we need to really manage as effectively as we can. And that's just an ongoing challenge. Julia, how would you imagine changing the way that data in practical terms? What would the top line changes be in the next three to five years in the way that data is sourced and collected? In order to avoid the next IOM study saying we can't reach many conclusions on these vital areas, we just don't have the ability to reach solid conclusions because we don't have the data. What would you say should be the, we should point to as the top priorities in the data area? It's a hard question because this is a very complex area that you very quickly became tangled up in. But I would come back to something you said about levels of data and what you want it for and why. And to not, all data is just not one big ball. Data has to be broken down. So are you doing it for program monitoring? Can you roll that up? Are you doing it for an evaluation? Is that specific to a country? Program within a country? Can you generalize that? Can you roll that up? Are you looking at national level data? Can you roll that up and have discussions about coverage globally? So having distinct levels of data and working on improvements in the quality of those levels will be really important. And it's not to say that there isn't quality in those levels or they're not divided like that at the moment but you, we have output data. Do we have outcome data? Yes. If you dig, if you go to a specific country in a specific program, can you ever want to be able to generalize that? Not necessarily. So I, we really liked the idea of looking at what we have, what, picking out specific evaluation studies, linking evaluation and monitoring together to try and create a story. Rather than trying to figure out one master plan for data, coming back to a point you've made, Jen, just about national data systems and real improvements need to be made there. If we are really going to get behind country, I'll still use the word country ownership. This would become a bad word or two words but if we're really going to support country ownership then a country has to know where it stands in addressing its epidemic. We need to have improved systems, national systems, where we know how they're doing their coverage rates on key interventions and supporting those systems. Then how do you use that system as a hub to have program monitoring that feeds into that but is perhaps separate from that? It doesn't have to be fully connected so you don't need to create an entire system that is so cumbersome that it's not workable. So I think starting at the country and what the country needs to inform its response, to inform its decision making and how we can support that is one key aspect for the future. And then I think separating that from program data that we need to, one, tell us how we're doing to be accountable and to feed into that, national data set I think are too separate and important and linking those will be important and you can add expenditure to that. You can look at national health expenditure and at the national level at health accounts you can look at it at program level and you can start to make some links there both about how you're being cost effective at the programmatic level but also what you're spending at the national level so you can get a sense of what it is that you spent and what outcomes you achieved for that, outputs and outcomes. And lastly a comment on impact, I haven't avoided it but we see it as being distinctly different and choosing where you want to measure impact and the key questions of where you want to determine how we had an impact and really resourcing robust studies in those areas is the direction that we started to take in the last couple of years, incredibly important. They're very expensive, you cannot get impact data from for the most part from doing monitoring or from program evaluation so really looking at impact studies but choosing them very carefully because the investment is significant and so we've separated that out and I think that'll be an important trend. Why don't we move to our second question and start at this end with Jan and the second question really is what outside of the mandate or the orbit for this particular study do you see as terribly important priority for looking forward for Congress and administration? Jan? There were a couple of things that we didn't do that we either couldn't do or ran into whatever their constraints were and we've already started to hear it. One thing that we didn't do that I wish we had done was while we reviewed what OGAC has done in terms of trying to assess how to think about country ownership, beginning to look at metrics, looking at how to categorize countries, we didn't validate those, we didn't actually seek to develop metrics that could be used nor did we seek to assess countries and where they are and I really wish we had, I think that's a very critical next step and I know OGAC's moving in that direction but that was something I wish the committee had done because I've been asked about it since the report came out and yeah, it's not in the report, it wasn't really in our scope but I think that's a real critical need going forward. Second was something that I don't know if it's a critical need but it was something that, going forward, but it was something that I wished we could have done and we ran into some real methodological challenges and I think it speaks to this issue of how you evaluate going forward. I thought coming into this report after the first evaluation, I was really excited that we'll probably be able to do a population level impact analysis. We, contrary to what we said about the data challenges, we actually did get more data than probably anyone has amassed outside of OGAC on the program. So we had all of these data and some of us on the committee really wanted to look at a population level impact, what the impact might be on health systems, what the impact might be on mortality and we just couldn't do it. We couldn't get the data from some of the other places, actually not PEPFAR really, from some of the other data sources that would help us make that assessment and that was unfortunate. We were, I just want to give a shout out to Iran Ben-David in San Francisco who does that kind of work and his study has shown an association with PEPFAR reduction in HIV mortality. There was a study that came out in Jades by Cohen and others on health systems impact and they looked at a more narrow way than we were trying to. So we were very ambitious and in the end we felt we couldn't do it. So those would be two things. Thank you. Chris. Well, you cannot blame the IOM committee for not being able to have anticipated what President Obama said in his State of the Union address this year which was the goal of this country is to achieve an AIDS-free generation. It followed Secretary Clinton saying that's a policy priority for the United States in November 2011. And I think that's the frame for my comment right now about what's not on the report. I know that there were time constraints in terms of the writing and preparation of the report. That said, I think all of us in this room know that an earthquake happened in the middle of this report, right? 052 came and it changed the entire conversation and our sense of what is doable. So I was disappointed, I would have to say that I didn't see more about 052 in the report which again came out in the middle of 2011. The three core interventions needing to go to scale with three core interventions that Secretary Clinton talked about in November 2011. Again, really only mentioned in this report. The report calls for a balanced approach between prevention and treatment which I think we all want that but it strikes me as dated language frankly. That's not what, you know, what we're talking about is targeted effective interventions in combination and an era when we know that treatment is prevention. So I don't, I think this who's on, you know, who's ahead, who's behind kind of language, I don't think makes sense anymore. I think it drives a divide between prevention and treatment when the science is pointing us a different direction. And it's also interestingly problematic within the report itself because the IOM report itself acknowledges the real challenges with the outcomes data on behavioral interventions. So it kind of says more on prevention but the outcomes data we have on the behavioral pieces are not entirely clear. So I didn't quite understand that. We're in an era where the head of NIAID has said we can begin to end this epidemic where the administration has issued a blueprint for an AIDS-free generation that says if we go to scale with what we know works we will see incidents fall at an accelerated rate. So, you know, I didn't agree with the comment in the report that we should, the US supports to concentrate on long-term development of infrastructure and improving capacity in partner countries. I think the president had it right when he said we're heading towards an AIDS-free generation let's get there as quickly as possible. I think we need to use the science we have to get to that goal as quickly as we can. The second issue that I would pull out that isn't in the report and again it shouldn't be, probably, is money. You know, there's a huge mismatch right now between the rhetoric of what we want to do in this country in terms of ending AIDS and what the science tells us is doable and what the money is doing, okay? PEPFAR has been cut, now it's 12% lower than it was if you look at the State Department bilateral line than it was in 2010. You know, a lot of people will say, well we're getting more efficient but that's not an answer, right? When we're heading towards an AIDS-free generation the goal should be to use the efficiencies we've had, we have and move along those charts that are in the blueprint to scale up what we know works and achieve an AIDS-free generation. So the efficiency argument, I say great for PEPFAR, I know it's true and I applaud the program but that is no excuse to be cutting the program. That means that we need to reinvest in the program and get to the goal the president outlined. Cutting PEPFAR doesn't make sense when the IOM itself says there is a, quote, substantial remaining un-net need for all services. It doesn't make sense at a time when we know WHO is issuing guidelines that's gonna mean more than 20 million people now are gonna be eligible for AIDS treatment. It doesn't make sense at a time when the administration's own blueprint says we need to scale up things we know work rapidly and then see incidents fall. It doesn't make sense when we know there's every chance that if we pull away from countries too quickly or transition, the key populations are going to be in deep, deep jeopardy. Cutting PEPFAR fails to capitalize on what the IOM says is, quote, a unique platform for innovation to get it right on providing aid services and cutting PEPFAR is inconsistent with the politics, right? This is one of the most famously bipartisan programs we've got, so on a political level, I don't get it. So it isn't just about can we make the six million treatment target, which I love and I applaud the president for making the target and I know we're gonna get there soon because PEPFAR is such a darn good program but it isn't just about the six million target. It's about beginning to end the epidemic and achieving what the president said he wanted to do in his State of the Union address. For that reason, I think it is time for the administration to start looking at new targets in its core areas. The president announced targets in December, 2011. I think we're gonna need new targets for treatment and condoms and mail circumcision and PMCCT. Those targets then can drive us towards the AIDS-free generation goal, which is the goal. Thank you, Chris, Kimberly. I would like to just respond to the committee's treatment of O5-2 in the report just to provide some clarification because the consensus statement from the committee recognized the importance of the intervention, the design and the results that were reported but also three other things and one is that even is the recognition that even though it's a biomedical intervention of ART is secondary prevention, the committee still maintains that if you want to deal with HIV prevention for concentrated and generalized epidemic that a critical focus has to be on the prevention of sexual transmission. The committee also says that there should be a balanced portfolio of behavioral intervention, structural interventions, biomedical interventions. None of them singularly is sufficient to address all of the needs for prevention in a population. However, a balanced portfolio and by balance the committee was identifying that in terms of data collected, the platform and the innovation of platform for PEPFAR of PEPFAR serves as an opportunity to add to the evidence base for behavioral science and behavior change. Given the magnitude and scope of the program, the resources that it has, it is an opportunity instead of saying let's just focus on biomedical interventions and also recognizing too with O5-2 that there were strong behavioral elements of that intervention focusing on consistent risk reduction counseling, adherence counseling and the use of condoms that even the investigators say probably contributed to the low HIV incidents. And so the committee's concerns is not that it's not enthusiastic about the results of O5-2 but the fact that there are considerations such as the cost, the complexity of the interventions, the public health and clinical health concerns about taking an intervention outside of really strictly controlled trial conditions and scaling that up on a large scale. We don't understand those very well and that was what the committee was willing to say. But it was not willing to say and it did not say that there shouldn't be excitement or enthusiasm but it is more cautious and reserved in terms of the past history of taking some evidence and scaling up programs sort of without really sitting back whether it is at the time of larger scale up. I mean, certainly there's been success of rapid scale up from PEPFAR in terms of PEPFAR-1 to PEPFAR-2 but with the success, the goalpost gets moved. So there needs to be more rapid scale up and it needs to focus on interventions for key populations at elevated risk including all of them beyond the traditional groups that we would call MARBS as well as being able to focus on preventing sexual transmission and really focusing on behavioral interventions that we know can be effective but we seem to sort of avoid contributing to the science and really figuring out how to appropriately measure the effectiveness of those interventions instead of using either assignments that are inappropriate or saying it's just too hard. And so I just wanted to be able to say that for the committee, even the blueprint is not a clear detailed plan that says how we're going to get to this age regeneration and certainly the issue of cost. We're talking about efficiencies. So what we want now and what we wanna work towards also sort of smacks up against this whole idea of country ownership and sustainability being country-led, country-driven. So where's the partnership with the country in terms of accelerating some of our activities and our expectations and what we want for our outcomes and trying to make progress along all of these dimensions and domains that are looking at transferring or increasing joint ownership for planning, financing, managing, overseeing, measuring not only the current response in maintaining gains but also what the future needs are for services including trying to work towards an age regeneration. Thanks, Julia. I'd like to say a few words about what you see is the two, maybe three top priorities that you would identify that would not, you couldn't treat these in the scope of the IOM report as you sit where you do and think about the future or things that we need to be keeping very much front and center in our mind. The global fund. So the global funds and PEPFAR are two halves in many, many countries. And I think addressing that in the future, that partnership, and in fact add the next piece to it is the country leadership. So how has PEPFAR done with country leadership and with the global fund and maximizing the resources in a very aggressive way in terms of making sure that there's no duplication of finances and of effort overall. And I think that we've taken enormous steps in the last year and a half in that direction and feel good about that. But it would be excellent to have someone, some people and in an institute looking at us and evaluating how we've done that and where we need to improve even further. That is such an important part of the future of the sustainability and the financing of the epidemic. And we are extremely dedicated and focused on seeing the global fund be as successful as possible. And the bilateral program in PEPFAR really being the complement technically to that financing entity. So that's one. The other area is stigma and discrimination. Extremely important to our work and in the way of an AIDS regeneration. And both were detailed in the blueprint, meaning both the shared responsibility is a roadmap and stigma and discrimination features in a couple of areas in the blueprint. And it just couldn't be more important to figuring out how we work effectively to reduce those barriers so that we can see programs move forward successfully. And having someone look at us and say, well, this is really working well and this is not or you've missed a huge opportunity to use your influence and your diplomacy efforts in a new way. So that's the second. So I think that we would really prioritize. And the third is an area that may seem weedy, but essential and that is human resources for health. So PEPFAR is invested in a tremendous way in backfilling ministries of health in wonderful ways in terms of being able to capacitate them, train them, walk with them. And we've seen some great instances where we've been able to back off. Namibia, for instance, has done an amazing job at stepping up, putting new positions on their books, financing them and letting PEPFAR step away. But I really think that is an area, although it seems weedy, is at the crux of sustaining just about every intervention that's either in the blueprint or in a country plan and it's essential for a country to understand how to effectively resource its public health system. Thank you. I would second everything Julie said. And I think the other area that's sort of missing that's not an in-depth discussion is the focus on capacity building and how to measure the effects of capacity building. And a lot of what we talk about in the report, the effects are probably gonna be seen years down the road, maybe even decades, but again, it sort of gets back to the issue of, how do you know what you're doing and if you're doing it successfully along the way that might require some course corrections, but knowing that you're heading in the right direction and knowing that those efforts are critical across all levels and all stakeholders and all technical areas. Thank you. Why don't we open things up here and welcome comments and questions from the audience. And we have a microphone. Just put your hand up or stand up and we'll bundle together three or four at a time and then come back to our panelists. Judy, who else is interested? Okay. Yes, Judy? Hi, I'm Judy Kopp and I'm an independent consultant. Please speak up. Oh, speak up. And this may be weedy too, but in the discussion of what- Springtime, it's okay. Yeah, my yard's got plenty of them. What wasn't in the report? The supply chain, it seems to me, also underlies a lot of what's required. And it seems to me it's an issue of sustainability and that was not addressed at all in the report and I'm curious about why and what needs to be looked at there. Thank you. Over here. And then we had another hand which I'm not sure of there. Yeah. Thank you. Tim Boyd with AIDS Healthcare Foundation. I just had a question for Ogak. I was wondering how are you gonna take these recommendations from the IOM report and incorporate them into your plan for reauthorization this year? For which? For reauthorization for the program. All right, and back here. Hi, I'm Liana and I'm a GW student. And I did some research on the integration of water sanitation and hygiene within PEPCART. One of the things that I saw in the report was that within treatment and care, these saw in countries where they initiated treatment earlier, these saw increasing rates of an ARB resistance strain, which I think leads to the quality of care and making sure that people retention of care. So I was interested whether or not, and let me know that PEPCART is going to give us a lot of talk about comprehensive care and integration but water sanitation wasn't mentioned at all. And so I was interested in just coming from that. And there wasn't an indicator on any of the water sanitation and hygiene efforts that I've been made to PEPCART. Okay, why don't we take one more and then we'll end this round and then we'll come back. Sorry, we have only one microphone, but over here, Matt. Yes, Kay Halpern from the US GAO, Government Accountability Office. And we have actually just issued several reports on PEPCART, two are still under restriction, but one is publicly available on PEPCART costs. And my question is on task shifting. On the one hand, it's something that allows for a more efficient use of resources, allowing nurses or lower level healthcare workers to perform tasks that were performed by doctors or higher level nurses. But then on the other, it seems that it may overburden the lower level staff or the community health workers with many, many tasks, including dealing with patients, dealing with supply chain issues and making sure drug stock cards, for example, are filled out and so on and so forth. And so my question is, what are your thoughts on task shifting? Thank you. So we have supply chain. How does all this figure in possible reauthorization? Water and sanitation and task shifting. Who wants to jump in on this? Which of you would like to kick this off, Julia? Don't throw things at me. Why don't I start with reauthorization? And I think that all of the recommendations that have been put forth in the IOM were taken very seriously. And I have some colleagues that are here today that have been leading in conversations about how we detail our response to them, how they then show up in our country operating guidance and other guidances that we have. And so we're taking it seriously to have a formal response to the IOM report and how we will approach the recommendations. That stands whether we are reauthorized or not. The decision that we'll rest and rest with Congress and whether we move in that direction is yet to be determined, fully determined. But PEPR will continue at the will of Congress and I think that we can move forward with these recommendations, whether in reauthorization or not. I think if there is an opportunity to reauthorize then of course they provide some path for guidance to ensure that we are responding to these kind of significant reports. Also GAO and others have put out a lot of reports that have been very helpful in guiding us for the future. So that's how I'd respond to that. Jen, on the reauthorization, please. I'll honestly say something on the reauthorization. And first, actually the day the report came out, Ambassador Goosby announced that OGAC was forming a committee to look at the recommendations. So that was what we were excited about that on the committee. We weren't asked by Congress to assess what the implications were for reauthorization. That was not part of our task. But we were really cognizant that that would be on top of mind for a lot of people. So we as a committee were able to determine that none of the recommendations in the report actually are legislative change requirements. So the actual level of what we were talking about and kind of where the program is now is really at this, the programmatic interaction with countries, interaction with programs, development of science, implementation of the science, and not at the level, very different than the first phase. So that was, even though we weren't asked, I think that was a general lead. And then secondly, I wanted to pick up on something that Chris said on AIDS-Free Generation and use my program as I was a committee member, but it was a committee of consensus. I do think the science is quite strong and that was definitely a challenge with looking at an evaluation document versus an aspirational political one based on the science. So it was a consensus of the overall committee. And unfortunately, we finished our analysis a little bit before probably it would have been made it in there. And the South Africa study came out, I think as we put it to print, which showed the correlation between tremendous treatment scale up and reduction of incidence. That's right. I'll talk about supply chain, which we do talk about in the report in chapter nine on health systems strengthening. And also in the chapter 10 on sustainability, and we talk about really sort of looking at what the country progress was and PEPFAR efforts on capacity building for all functions along the supply chain from forecasting the distribution and the types of systems, whether they're push pull systems, and where we found successes in terms of more country led, country managed systems and where they felt like that they had expertise and with an activity that they could maintain. Yet at the same time, there is fragility that all of this could come to a screeching halt if we don't have resilient supply chains, whether it's ARV commodities, commodities for malaria, tuberculosis, family planning, condoms, test kits. So we certainly talk about the need for there to be intensive focus and continue to build capacity on supply chain and have it be functioning and resilient in all countries. I'd also like to say about the water and sanitation that yes it is in care and treatment and a lot of the activities around water and hygiene and preventive services have traditionally been within the vein of care under PEPFAR. And we talk a little bit in chapter 10 about public-private partnerships where there are some partnerships beginning to be developed to focus on issues of potable water and availability and water hygiene. Activities that are being done by community health workers in terms of hygiene and preventable illness. I mean, we saw examples of a lot of that that are just sort of basic activities within a portfolio. And one of the interventions that I truly loved and had hoped to see scale up was Play Pump, which was just one of my favorites that focused on creating opportunities for exercise and recreational play for children while sort of playing around on a pump that actually has an engine in the drill and it's drilling water and pumping water. And we saw it could have been potential collaborations with more Peace Corps efforts. So there is activity there, but it's certainly in terms of continuum of care and the issue around wellness could certainly be a more integrative focus or more efforts to describe how those efforts are integrated. Can I ask, and your encyclopedic knowledge, the two of you, of what's in this report, task sifting? What would this, where would that be? Can I make, I don't know the page, you might. Can I make one comment about supply chain, though, before we move off? I can't believe how excited I've become about supply chain in the last several years. I never thought I would, but... And I just wanna say that we have work ahead of us, but what a tremendous story and the effects that the investment in supply chain in countries has had on many, many different health issues as you listed off the commodities and I'm seeing a colleague who's working in vaccine and we're talking about the DRC and the supply chain issues there and we said, well, Gavi should be at the table. We're all in this together. We're all here to support the country. We are making huge investments at the country level in terms of their supply chain and that part we have seen a lot of progress and I think there's paths to sustainability that are real at that point. Where it's probably more challenging is above the country and that is in the procurement side. So not the supply chain, but the procurement and the procurement is tough because really it makes sense to do pool procurement and bulk purchasing and you have to do that as a collection of countries and independent trying to build the capacity for procurement at the country level doesn't actually make good economic sense and so I think that it will be a challenge in the future as we look forward to how you make something stick at above the country level in bulk procurement. Just to add one thing on the supply chain side for Judith and one of the things we did find in going to countries is the impact on supply chain. I mean that came up very clearly in a lot of our interviews. So it's embedded in the report probably I think in 10 and whatever the chapter number she said. So I don't know the number page number for task shifting. Well, I can tell you the chapter would be chapter nine in health systems strengthening specifically under the discussion on workforce. We certainly look at task shifting in terms of which cadres, which activities are being shifted to which cadres? Our countries are expanding cadres of workers whether it's a formal or informal practice or adoption. There are a lot of issues in terms of scope of practice in professional organizations and even to the point of national policies and guidelines. So we do talk about task shifting in terms of health workforce. We also talk about the issue of crowd out as people have talked about sort of conditions. We talked about that in chapter nine in health systems strengthening and also chapter 10 is the same goal. Let's go to another round of comments and questions. Over here and then Paul over there. Who else is interested here so I can get. Hello. Hi, this is Catherine Connor with the Elizabeth Glazer Pediatric AIDS Foundation. I have two questions both related to children. I think one, I think pediatric treatment it was raised by Kimberly at the beginning that this was an area that was really identified as something that had been sort of lagging behind but again, my knowledge of the report not as thorough. I don't remember there being a lot of discussion about the bottlenecks challenges and the path forward. So I just wanted to get a little bit more impression on that sort of what you saw as the big issues. And the second part of this is the data question. It's been sort of a common data problem even within the US epidemic that children can get lumped together to certain age group under 15 is a popular one. However, children under 15 look very different at different ages of life, particularly when you start looking at HIV within the maternal newborn child health paradigm as well as the PEPFAR paradigm. So I'm kind of curious as to what you think to be done with the better data and de-aggregating the data and how it could better be used to target programming. There's a hand right behind you. We'll go to you first. Hello, my name is Amanigo Ufumata. Please speak up. Amanigo Ufumata with the AIDS Healthcare Foundation. Regarding transitions to country ownership and shared responsibility, was really interested to hear the gentleman from, I'm sorry, I apologize about your name, but your comments about what happens when transitions happen too swiftly. I'm curious to know whether in your experience with developing the report if you thought that it was country generated, that idea that they want more ownership of their age response. And if it's happening efficiently, I read a recent CSIS report on South Africa. And although it's happening there, there were some examples of where it hasn't really trickled down through to the provincial level or real local levels or it's not happening as efficiently as we'd like. So I'm curious to know what was your experience with dealing with that when developing it. Thank you. Over here, Paul, Janet, and then there's another hand. Thank you. Thank you for the panelists and a couple of questions. One question, Paul. One question. Catherine had two, so I'll do two. No, one question. One minute, one question. My question is really focused on the way forward with the implementation of the blueprint and the creation of an AIDS Regeneration. As we know, the epidemiology of the epidemic, we're getting more and more data. We do actually have good data showing that even in generalized epidemics, there are actually hot zones or concentrated epidemics within countries. And as we know, Ambassador Dible and the Global Fund are moving into a control and defeat strategy on AIDS. And I'm curious as to how PEPFAR is rethinking and reprogramming for the future in the context of a control strategy. And is that being integrated into the COPS process and what are the policy implications of the way forward? Thanks. Can you hand that to Janet right in front of you there? Thank you. Thanks, all of you. This would be a question perhaps Jen could fill us in a little bit more on the recommendations and the analysis around the gender piece as well as our colleagues from OGAC in terms of how the report was fairly strong in talking about the lack of data, the lack of a real implementation strategy on addressing the PEPFAR gender strategies calling it somewhat ad hoc and the need for really a lot more focus in this area. And I wonder, Jen, if you could talk a little bit more maybe about what the report was, what the findings were and perhaps Julie about how OGAC is gonna respond to that. Thank you. Right here. Thanks, Matt. Hi, my name is Annie from AMFAR and my question has to do with transparency and data. Recently the USAID has been charged with the Green Book and the State Department with foreignassistance.gov a reporting of US government spending for overseas projects. And so I was wondering whether or not there was any talk of using that as a springboard to connect data and important indicators, population level indicators that Jen mentioned with missing. Okay. Paul, right here. Yeah, my name is Paul Emer. I'm with Matt McDonald. I just have a question about the use of resources and I'm sorry, I haven't looked at the report. I just scanned the summary here, but and I'm very cognizant of the fact that you're recognizing that there needs to be more investment in the areas such as health systems, capacity building, human resources for health, supply chain and all of that. I think all that's true. That's very important. The reason that PEPFAR has been so important and useful to date is because they have focused on treatment and prevention. And when you've got a shrinking pot of money with more things to do, how do you actually prioritize and decide where the new money should come from if there is a new authorization and even if there isn't, how did the report make any attempt at prioritizing among all those very important things? Okay. Jen, do you want to lead off of which of those pieces you want to answer? Yes. So a couple of them. On the question about country ownership, I know you asked a few things there, but one I wanted to say and you can see this in the report, that was part of our site assessment. We went to countries and did site visits. And one of the things we were really trying to assess was what the stakeholders in country felt about the idea of country ownership, what it meant to them. And that was really, really critical. And I'd say overall, there was a few themes that came through and one is countries do want it. I mean, there's both a real appreciative sense towards what the US has done, but it also a sense of knowing that they have to be part, further part of the response going forward. And we heard that from a lot of stakeholders. Fears about how that happens, what it means, the pace. But I think you had asked, is this coming from the US? Is it coming from countries? I think it was a mix. It was definitely something that almost all the stakeholders we talked to were aware of as a new language that was being talked about in a new direction and had their own definitions of it, but recognized the importance of that from their own perspective. So that was one thing. Janet, on your question on gender, this was explicitly requested in the statement of task to look at how PEPFAR addressed the gender implications of the epidemic. So we have a whole chapter and that's chapter eight. And it was, we were looking at a 10 year, almost a 10 year period. And I think what's interesting in anyone who's focused on PEPFAR's attention to women and girls, PEPFAR's attention to gender, this would be a great chapter to look at because we look over time and we actually document the evolution and thinking and programs by PEPFAR, which really did change and expand in its view and use of resources to address the gender dynamics. But that was, looking across the years of the program, we did find that that wasn't always the case, that at times it was ad hoc, but that particularly in some areas like GBV, gender-based violence, it was a really strong response. But going forward, we felt that the way the program could do better was documenting, what was specifying outcomes and really providing a more focus for the direction and how to assess it. So that was our recommendation going forward and I would say that since this came out or when it was the ink was dry or the computer had stopped, more has even happened on the gender side. The other thing I will say is we in our, the committee decided to include in the gender chapter discussion of the impact of HIV on MSM, amend on gay and bisexual men, which we also included in other chapters, but we felt it was important to include here. So there's, we didn't define gender narrowly, we defined gender broadly, which is how OGAC has defined it as well. And then a couple other questions, one at farnassistance.gov. If anyone hasn't used farnassistance.gov, I suggest you do. It's quite a wealth of data and information. I think that the kind of study you suggest or the use of it is very doable. We do it at the Kaiser Family Foundation all the time. I think what you're asking is, have the programs considered putting their own programmatic indicators linking it with their spending? And I don't know if that's the case. I do know one of the goals for that is to get country-level, program-level data. Right now it goes down to the country. And lastly on the question of prioritization, we get asked this all the time when we were talking about the IOM report. No, we did not in the report seek to do that very hard thing that I don't know who has, but it is very important. We didn't do it. Sorry, so. And they're all equally important. And we're supposed to say they're all equally important. You're gonna say this one too. So, no, I mean, on that question, I mean I think it's just really important to call out that the idea that they're shrinking resources is a choice all of us are making, right? Our government is making a choice that they're shrinking resources. We've cut PEPFAR by 12% since 2010. If you look at the great, wonderful, needed increases, well-deserved increases to the Global Fund over that time and that about 57% of those go to fighting HIV, there's been a net loss in the US government direct investment in fighting the global epidemic at a time when our president is saying in the State of the Union that we want an AIDS-free generation. So there's a mismatch there that I think needs to be corrected. I don't see any reason why with global health in total representing one quarter of 1% of the US budget that we should be shrinking that pie for such effective programs. That said, I do think the evidence base is stronger on some services than it is on others. We have to accept that. Secretary Clinton acknowledged that on November 8th, 2011 when she spoke at the NIH and talked about focusing on core intervention. So there is a literature there, there is some evidence and there's a lot more to learn and it's certainly not just three interventions. No one would ever say that in their right mind. But certainly the evidence base does give us the ability to focus and the EPI does too. We know we need to be doing more on key populations. Ambassador Goosby himself has said key populations are gonna be core to fighting this epidemic going forward. So I think there's some pretty clear directions. I do think that a whole, I mean I would offer as a whole area of inquiry for consultants and academics and people working at OGAC and around the world is how do you pursue what the blueprint calls for which is rapidly scaling up what we know works and not take the foot off the pedal on that while you continue to build capacity. That is the challenge. The IOM report suggests that that's hard to do both at once and you sort of have to choose and I think that we need to make that not true and I think that there needs to be a science of scaling up while we build capacity and I think that's our challenge. Julia, can you? I was gonna add one thing about the prioritization which the report didn't look at but I think it's combining Paul's comment about hot zones and Chris's comment about we know what works and we know core interventions and I think that is how you begin to think about prioritizing impact. But I will say the report didn't say that you had to be a trade-off between those two. Well, I don't have the chapter. But I mean it did say that it's the quote I read in the beginning that transitions may not lead to results as rapidly or dramatically as in the past. And so I think we need to work towards continued scale up while we build capacity. That's the only thing I'm saying and I think it's not going to be easy. I acknowledge that but I think we should take it on as a whole area of inquiry. Julia, could you speak to Paul's question around the hot zones issue and also to the pediatric care, the pediatric aids question that Catherine raised? So I think that we would adopt a combination approach to both controlling hot spots but in epidemics that really cut across multiple populations at a level that they really are all but generalized. It's both things. So take those countries where it's both. We look at coverage at this point, implementing the blueprint and looking for an AIDS-free generation is getting to coverage at scale on certain key interventions and the wraparounds that are required to get there. So testing is required to have scale up of male circumcision programs as well as treatment programs and PMTCT. So there are behavioral issues and agendas and interventions that must come around all of those as well. So the idea is coverage at population levels to drive down incidents generally but then in countries where we perhaps have not paid as much attention to specific populations really zoning in on those even in those generalized epidemics. It could be a drug-using issue on the coast of Kenya or down in Durban. It could be migrant workers take your pick but understanding the epidemiology and then really targeting the interventions there. So for us it's a culmination approach but it is the coverage issue. Whether it's the coverage of the target population or the general population if you're looking at big epidemics. Pediatrics. Well I think we all feel like we have a lot of work to be done. It's a population that the coverage is poor in every single country basically. Even in Botswana where there's been one of the flagship programs. What are the challenges? I think that they're understood to some degree and poorly understood in other places. You know children can't come themselves. They have to be brought by someone. That person has to prioritize that child's health. Can they prioritize that child's health? Well they also have to get food to eat. You know they're just a chain of priorities and that child comes lower and lower in the chain. Not because they're not loved but because that's life. Taking services to families, making them highly accessible is something that I'm not sure that we've spent enough time working on. We've done it more for adults interestingly in the last few years as we pushed care out into lower and lower health facilities and used community structures in increasing ways. Why we haven't done that for children is a question that should be put to all of us and we need to address it quickly. I think there are issues around drugs and really what drugs are available, pediatric drugs are available in what combinations and how user friendly they are. Some of the drug companies are working hard to improve that but I think that's another key barrier. And to your point around there are others but those are a couple of highlights. The issue around desegregation of data is incredibly important. It was discussed this morning in a country plan review where we will miss adolescents in particular if we don't desegregate into lower age groups. It is the trade off between collecting data and how much data and at what level and the burden to the field and if it's burdensome to the field the quality drops. So how do you pick ranges that you feel are not so burdensome and that you can actually get quality data? Having a lot of indicators that are poorly collected isn't going to help anything. At the moment we are going through a rethink on our indicators as a whole, our tier one indicators and pediatrics is certainly featuring as is gender. Kimberly, did you have? I would very quickly say that the committee's discussion on pediatric treatment can be found in chapter six. On care and treatment but also discussion in chapter seven in terms of children and adolescents. A lot of the issues that Julia identified to talk about and I think in terms of how the data can be used if it were aggregated differently with different strata so to speak. That there can be some focus on outcomes not only in terms of mortality and morbidity but also in terms of developmental outcomes and being able to target activities over the life course of children and being able to help countries be able to identify activities that can help them meet those selected, targeted outcomes as opposed to the other way around. We're getting towards the end here and what I would like to do is ask our panelists to reflect looking forward to the next IOM study and offer advice on what needs to happen that's gonna make the next IOM study the best possible study. Very, very, very short. Jen. Well, nothing against the IOM but I don't know if we need the next big evaluation at this point. I think we're in a different place. I think what we need potentially from an independent body could be shorter term workshops that look at specific issues such as what are the right metrics for assessing country readiness, country ability to play a different role with the US government in moving programs forward. Some of the questions that have come up here today and I think that can be done by the IOM in a quick more, I wouldn't say rapid fire because I know the IOM but more of a rapid fire type way and that doesn't need to just be the IOM but I do think there's, we're at this point where PEPFAR itself is in a much better position to look at the program level and assess what it's doing and these longer evaluations that take years are probably not, not that they're not important and some will wanna keep assessing but I think right now what we need are these quicker, more quick. How do we do the next step? How do we really get there from here? I think that's absolutely right. I mean, I just wanna repeat it. Well, I won't repeat it but that's, I think you hit it on the head. I mean, yes, maybe another five year evaluation makes sense but the science moves so fast and the politics of it moves so fast that and the implementation is so complex that I think what Jenna said makes a whole lot of sense. We need to concentrate our brain power on those implementation questions, share that information quite rapidly as if we were in business, right? If we were in business, we'd be getting the best quality information we could. It might not be at the 95% confidence level but we'd be getting useful information that would inform implementation in the field and we'd get all, everybody who's selling our product that information as quickly as possible and affect policy in the way they behave based on the latest best evidence. So I think that's a great idea. You know, in closing, I wanna say, I've said a variety of things about this report today. I think it's a really good report. I think it plays a very important role. I think it has a very positive impact. The truth is I've been quoting this report to make my case for the last couple months and so it's been very helpful to me. I pointed out some areas where I don't see it exactly that way but I think the report's very strong. Julia, what's your view of the future? What's the utility and how to go about structuring, scaling, focusing? I think much like, Jen, I think the dilemma between speed and scope gets in the way of having something very large at times but you would not want to lose the impact that a very large evaluation can have. That it can bring people together over and over again over the space of a couple of months and have people be interested and use it as a springboard for discussion. So how do you retain that? But go deep in areas, specific areas that need further attention. I think we're a mature enough program now that we know the areas that need more attention and could we do targeted studies, deploy people to do them simultaneously, come back and pull them together for a targeted yet larger evaluation. So it's not one big evaluation but it's a combination of some pieces that come together because I think the policy or the, what the report of this size just offers up so many opportunities for good dialogue, policy and programmatic that how do we retain that but bring focus. Thank you. Kimberly, maybe I can turn the question around for you since the awkward perhaps talking about the future of ILM as an ILM person. Thank you. Maybe you could comment on how do we best digest or harvest the results of this existing product in your view. There's so much there. One of the things that we are trying to do as committee and staff is to offer targeted technical briefings for USG agencies to help them digest the report and really talk about the findings and the conclusions and the recommendations and what that might mean in a similar venue. But I would say the other thing is that we would really hope that there would be an uptake on the recommendations in the knowledge management chapter which we think support this idea of faster, more nimble, maybe a little bit more complex, maybe some deeper questions really focusing on implementation, who needs to know what when. So from the committee's perspective, we think that if there is uptake of those recommendations then we could probably, it would probably support some of the ideas that people are discussing now about how do you get useful information, practical information in real time or as close to real time, certainly not four years but also what a larger evaluation can provide in terms of the value to the sponsor as well as to any stakeholder interested in HIV. Thank you. In terms of evaluations, please fill this out. Just leave it on your chair or hand it to the rear, folks in the rear. Please join me in thanking these terrific board panelists. Thank you.