 Hello, and welcome to the Center for Strategic and International Studies. My name is Catherine Bliss, and I'm a senior fellow and deputy director within the Global Health Policy Center here. And it's great to see so many people out on this cold, windy day. And I am very pleased to welcome you to the third in our debate series, Fault Lines in Global Health. Now, our first, we launched Fault Lines last summer in order to stimulate constructive debate in exchange of perspectives on some of today's most compelling global health topics. In our first session on August 6th, we hosted a lively debate regarding the sustainability of the United States bilateral HIV AIDS programs. And at our second, on September 14th, we had a discussion about the nature, character, and future of the global fund to fight AIDS, tuberculosis, and malaria. So the positive response to these events, both in person and online, convinces us that there is significant room for dialogue and the airing of differences of opinion on some of the most pressing international health concerns. So we're fortunate today to count on Susan Denser, editor of Health Affairs as our moderator for this session. And Susan, I want to thank you for your commitment of time and your extraordinary skill in bringing us together and facilitating dialogue on these important topics. And so before I turn the session over to Susan, let me announce that our next Fault Lines debate will be on February 1st. So please continue to check your inboxes and to look at our website, www.smartglobalhealth.org for more details. And now let me turn over to Susan to open our discussion. Thank you. Great. Thank you so much, Catherine. Good afternoon to all of you. It's great to be back with you at CIS for another vigorous discussion. Also welcome to those of you who tuned in on the live webcast. As Catherine mentioned, some of you were able to join us for the first two debates in August and September. And if you miss them, they're still available at smartglobalhealth.org slash fault lines. Those events, I think, really very much underscored the goals for this series, which is that unlike cable television news, we attempt here to have open, civil, and reasonable debate, not to mention debate in which people can speak a complete sentence and more than one at a time in this case on difficult global health controversies. And today we have two people completely tailored, tailor made to those specifications who are going to be able to engage on a very important topic we'll discuss today. Let me go ahead and introduce them at this point. On my right is Phil Nieberg, who's a medical doctor as well as a master of public health. He's a pediatrician by specialty. He's trained in infectious diseases and preventive medicine. Began his career in the US Public Health Service at the Centers for Disease Control and Prevention in 1977, was there until 2003 and then served for several years as the first associate director for science at the National Center for HIV, STD, and TB Prevention. Much of his work at CDC involved famine, refugees, child nutrition, the training of epidemiologists in developing countries, tuberculosis, and HIV AIDS. He's been a senior associate here at CSIS since 2003, first with the HIV AIDS Task Force and now with the Global Health Policy Center. And also we're very delighted to have with us Chris Collins who's been vice president and director of public policy for AMFAR, the Foundation for AIDS Research since 2009. Chris has spent about 20 years in HIV AIDS policy and advocacy before going to AMFAR. He was a consultant on policy and communications for several organizations, including the Coalition for National AIDS Strategy and the Bill and Melinda Gates Foundation where he helped coordinate the global HIV prevention working group. He is co-founder of the AIDS Vaccine Advocacy Coalition. He served as its executive director for two years. He led the advocacy and development efforts of that organization. Also he served on the staff of Congresswoman Nancy Pelosi where he developed the first congressional legislation designed to provide incentives for the development and delivery of vaccines against AIDS, malaria, and TB. Our topic today or I should say our resolution today is that the United States should withhold future increases in HIV AIDS assistance from countries that have laws or policies in place that actually work to impede effective HIV prevention. And conversely, the United States should expand its HIV AIDS assistance to countries that do the opposite, that reform their laws or their policies to reduce stigma and enhance protection. Bill is going to take the statement in the affirmative and Chris will argue the contrary. We're going to start with a 10 minute opening statement from Bill, Chris will then ask some follow-up questions. Then Chris will make an opening statement in the negative and we'll switch gears and Bill will ask the questions. We'll then have a Q and A period where I'll quiz them both, mercilessly of course, and then we'll offer some closing statements and close out what I'm sure again will be a terrific discussion. So with that, Bill, let's turn things right over to you. Well, thank you, Susan. And thanks to Chris for agreeing to participate in this and to the CSIS staff for helping arrange this, especially Seth who might have been discussing this issue for a few months. The one page handout that most of you got with this graphic on it provides some sense of the frequency of this issue of structural impediments to HIV-AIDS programs in globally. So the major focus in this discussion will be prevention of HIV transmission, although the concerns that you'll hear, my concerns could apply to AIDS care and treatment as well. And I want to begin by telling you about some situations that have occurred in several unnamed countries that are examples. They're examples of the generic kind of situation that I'm concerned with. If for those of you who keep up with global HIV issues, you may recognize some of the countries, although the names and exact details are not important to today's discussion, to the generic discussion. So country A, the first example, has incarcerated tens of thousands of injection drug users and has actually had that number incarcerated for a long time. Those incarcerated people have no access to any effective treatment for opiate addiction, no access to HIV care and treatment for those who are already infected with HIV. And although sex and drugs are available in many of the incarceration facilities, condoms and clean injection equipment are not. Country A also has a small opiate substitution therapy program, but recent data indicate that the number of drug users incarcerated nationally was more than 30 times the number of people who with access to the opiate substitution program. As a result of this policy, more HIV transmission is obviously occurring among drug users than would be with better prevention methods. Some people in the incarcerated population needing antiretroviral treatment are not getting it. And fewer drug users are in comprehensive treatment programs than might be with a different approach to drug use. In contrast to the situation in example Country A, a number of nearby countries make access to comprehensive drug treatment, a high national priority. Another example of Country D already has a law criminalizing homosexual behavior that is MSM behavior, even if it's consensual and is considering making such behavior punishable by life imprisonment or in some cases death. The result of that, of the current and proposed law would likely be reluctant to those practicing MSM behavior to seek access to helpful information and resources, and therefore, consequence, another consequence would be reduced uptake of HIV testing and counseling and to the education and condoms that would go along with that and help reduce HIV transmission. So a third consequence might then be more HIV transmission. And then because of delays in identifying HIV infections and delay in beginning antiretroviral treatment, another consequence would be more severe illness among those people already infected with HIV in the MSM population. In contrast, nearby countries have recently decriminalized consensual MSM behavior and encourage prevention program outreach into the gay communities. Country J has some serious issues with gender inequity. For example, neither, no one under 18 can have HIV testing and counseling without parents permission. After the 18th birthday, people can consent for the medical care for themselves. However, once women are married, the husband's consent is required for women to access any health facilities, including for HIV testing and counseling and antiretroviral treatment. And parenthetically, married women are allowed to consent for the care of their children, even though not for themselves. As a result of that law, fewer people are being tested and counseled to know their HIV status, leading to fewer HIV infected women receiving antiretroviral treatment and programs to prevent mother-child transmission and leading to delays in those women receiving treatment for themselves. In many other countries impacted by HIV AIDS, anybody over the age of consents can give consent for their own health care regardless of their gender. As a final example, Country K has numerous antiretroviral treatment programs. Many of them have little or no active effort to involve wives, spouses, or other long-term sexual partners in partner notification programs or HIV testing and counseling programs. Although, probably, many of the people in those programs who receive antiretroviral treatment are parts of discordant couples. The lack of programs involving couples, involving family approaches, probably results in many otherwise preventable HIV infections. And in some nearby countries, countries close to that one, couples testing is the norm. If one infected person is found in the family, other entire families are tested and untreated when appropriate. So the basic issues, those are four different examples. The basic issues that US policymakers are faced with in terms of global HIV AIDS is that there are insufficient resources in terms of both money and staff to meet all of the outstanding global HIV AIDS needs. And while nearly everyone agrees, probably, well, many people agree that there should be more resources. That's a debate for another time. The reality is that there are not sufficient resources available that policymakers can control. Obviously, there are many countries that could benefit from more resources. There are also many individuals who are infected or at risk who could benefit in HIV AIDS programs if they had access to additional resources. So the challenge faced by US government officials in charge of program implementation is to set priorities among those various unmet needs using the scarce resources in an equitable way. And I guess my sense is that with a fixed amount of resources, one could probably prevent more HIV infection or treat or care for larger numbers of people in countries with fewer structural obstacles. So for public health officials or anyone implementing public programs with scarce funds they need to necessarily apply those scarce resources where they're likely to have the largest benefit that has to help the most people. Now when I talk about withholding future increases, what do I not mean? Well, I don't mean that resources should be reduced for any individuals now receiving care or treatment or prevention with interventions that have been documented to be effective. I do not mean privileging HIV prevention over AIDS care or antiretroviral treatment. I do not mean having the US government act unilaterally on culturally determined obstacles as opposed to structurally determined obstacles. So for example, in other countries with large amounts of stigma among large population groups so those kinds of issues are outside of the government's the host government's immediate control and need to be addressed in other ways over the longer term. Although I guess I would say that in some circumstances the absence of or the lack of enforcement of anti-discrimination laws might fit into the category of something that in my mind impedes HIV prevention or AIDS care. I also do not mean cutting off countries from resource increases without clear and direct warnings ahead of time about what the US policy is. And finally, I do not mean diverting any withheld resources away from the US global HIV AIDS control efforts. Any withheld resources should be allocated to other countries that do not have the same structural obstacles to effective HIV prevention. I mean, there are obviously some potential arguments against such a new policy. One might be, what about the additional people who are either infected or unaffected at risk in a country that where this policy is applied are those who could be deprived of important services because resources are cut. And I guess the answer might be if you think about the example, one of the example countries we talked about which is gonna have new resources withheld because it's laws or policies impede HIV prevention. In terms of individuals who need program services people in nearby countries who also need those services may well, from an ethical perspective, may have the same claim on global HIV AIDS resources that people in that example country have. Not receiving services in one country may not be any different in terms of outcome or ethical concern than people in another country. And put another way, the same issue for a policymaker who's faced with a decision about where or how to invest scarce resources. How much sense does it make for her or him to want to invest those resources in a situation where it's clear that fewer infections can be prevented or clear that fewer people can be treated because of the impediments in place. And I think I'll stop there. All right, Chris, have that up. Okay, well, first I want to thank everybody at CSIS for inviting me to be here today. Thanks to everybody for coming. Phil, I guess I'd ask, the first question would be, to what degree in your vision is this approach about changing the policy in governments that have high HIV infection and prevalence rates? Obviously some of the places where there are these negative counterproductive policies, there are a lot of people in need. There's a big job ahead to do. And the degree to which it is about trying to incentivize change in those heavily impacted countries, can you comment on the relative influence of the proposal I think I'm hearing from you, which is the marginal difference between current dollars and future dollars, so that marginal difference of not getting an increase versus investing in change within the country to make those laws different? Well, I guess my sense is that, although what I'm talking about might result in policy change in those host country governments, that change or that incentivization, to me, is really secondary. It's secondary to the issue. The need for US policymakers to use resources in a way that helps the largest number of people, regardless of which country they are in. There obviously are a number of ways that the US or other countries could incentivize those kind of changes in other government's policies, but that's really a secondary issue for me. Let me follow up on that, if I might, just quickly. Phil, if your argument as a policymaker should use resources in ways that help the most people, why do you stop at just withholding increases? Why not cut the funding altogether? What doesn't, isn't that more consistent with your approach? I think in some days I would probably, I might advocate that. I think that over the long run, that does need to be an approach that we think about, both for practices in other countries that are either not helpful or potentially harmful, and also for interventions that we might want to use that don't, for interventions on this side that are advocated by US sources that don't have, that are not shown to be effective. And just to go one step further, I think the same set of issues could come up if funding, if we're suddenly faced with cuts in funding, overall cuts in funding. So I didn't address it here, but you could think about the same kinds of issues and when trying to make priority decisions about where and how to reduce funding. You would follow that approach. Yes, I would, yes. Cut the funding for those, okay. Yeah, I mean, it's the generic issue is using whatever funding's available in the most efficient and effective way possible. Did you have another question you wanted to ask? No. Okay, well, let's move to your statement in affirmative of the negative. Affirmative of the negative. All right. I guess my argument is that, well, I understand the merits of this approach. I worry then long term, it's counterproductive to advancing global health efforts. And there's three main points I'd like to make. The first is the importance of focusing on the epidemic where it's hitting the hardest. The second is to be dedicated to playing an active role in promoting policies around the needs of the most vulnerable in those countries. And the third is the array of tools that we have at hand today, which we can use more effectively to get at some of these negative policies we've got. So on the first point, we've got to think about how the proposal would limit our ability to tackle the AIDS epidemic and health concerns generally in countries hardest hit by HIV and how that affects our overall goal of bringing down infection and bringing down mortality. An example, and what's interesting is, we'll be making in some ways drawing on the same facts here. An example is gay men and other men who have sex with men. They're highly vulnerable in the HIV epidemic all over the world. They're 19 times more likely to be living with HIV than the general population in poor countries. Only about one in 10 have access to basic services. And yet, same sex activity is criminalized in seven of the 10 top recipient PEPFAR countries, seven out of 10. And we know those laws restrict access to healthcare and prevention and that they induce stigma that drives vulnerability for people. So these are some of the highest incidence places for HIV in the whole world. In total about 79 countries criminalized same sex acts and six impose a death penalty on those acts. That's a lot of countries to turn away from in the global response to AIDS. Counterproductive laws are really more the rule than they are the exception for many populations in many countries. As the director of WHO has said, Mark O'Chan, quote, in many countries women are not entitled to own property or inherit land. Social exclusion, honor killings, female general mutilation, trafficking, restricted mobility and early marriage among others deny the right to help for women and girls, end quote. Access to proven effective harm reduction services for IDUs is prohibited in many countries and more than 50 countries worldwide mandate coercive or compulsive treatment for individuals convicted of a drug offense. And we know that IDUs of course are heavily affected in the epidemic and much of the growth in HIV in many countries is among IDUs. Some evidence-based policy issues don't have to do, they have more to do with cultural preferences than they do with some of these issues that I would argue cut along lines of human rights. Male circumcision, for example, is shown to be highly effective in HIV prevention, yet in some countries there are serious cultural concerns around scaling up, male circumcision. Do we penalize those countries with funding who happen to have that cultural value? What's needed in the global response to AIDS and global health generally I would argue is scale up of what we know works. So if we abandon scale up and all those places with negative laws, how successful can we really hope to be? I think we can be more effective with intensive efforts where the challenge is most acute rather than choosing investments based on where national policy choices align more closely with ours. My second point, the proposal we're considering represents a very principled stance, but it runs serious risk of working against the very people it's hoping to protect. A blanket decision to end new investment in countries with stigmatizing laws means abandoning the most risk at risk populations in those countries. And although PEPFAR has been incredibly successful in scaling up services, it's clear now that much more attention is gonna be needed around marginalized populations, including injection drug users, gay people, and sex workers. These programs for these vulnerable populations need to grow, not be capped. We can't abandon marginalized populations simply because their governments have. In countries where we're doing global health work and national laws marginalize whole populations, we absolutely need to be working to promote improved policy. And doing that means a lot of things, like anti-stigma campaigns, training for healthcare workers, tailored services for marginalized populations who have trouble accessing services in a general health system. We don't make progress on the complex challenges of discrimination and stigma by walking away from it. We do it by funding those individuals and organizations that can do the sometimes difficult and long-term and sometimes physically threatening work of getting the job done and advancing policy. We do it by investing in groups that are gonna provide long-term leadership for national change. Third and final point is the proposal that we're hearing isn't the only option that we've got in our arsenal in terms of more prevention-friendly and humane policy. There are a whole variety of ways we can promote that. So, a couple. Framework agreements that PEPFOR sets up with PEPF partner companies can build in agreements and incentives around moving towards more evidence-based humane policy. Diplomatic leadership. When Uganda was seriously considering passing a law that would have imposed the death penalty on gay people, the United States forcefully and successfully stepped in with a variety of diplomatic approaches to oppose that law. Secretary Clinton has been outspoken about the need for equal rights for women and girls and the close tie those rights have to advancing our diplomatic and health goals. We can induce fund research to understand better how to fight stigma and we can support epidemiologic studies that have the power to drive policy change in countries by documenting the impact of AIDS on marginalized groups. One thing I'd like to say there is we don't have to wait for all the data on marginalized groups to come in to make the case forcefully to countries that they need to be addressing the needs of those groups. We can tell our in-country partners they've got to recognize that populations like gay people exist everywhere, even where they're not counted. We can be more strategic as financiers with holding funds from ministries of health and instead investing heavily in the NGO sector and building leadership there. The focus now, the real interest among many donors on building country ownership can't just mean government ownership and it certainly can't mean exclusive funding of governments when governments have destructive laws. The another thing we could do is stop funding groups that implement or deliver services in a way that promotes stigma. And our own AIDS policies need to be reformed. For example, requiring PEPFAR grantees to sign the anti-prostitution pledge. So starting with our own policies is a great place to start. The goal here is to advance global health in a sustainable way and that certainly requires more engagement of affected countries in progress towards more humane and evidence-based laws. There's no question about that. But the mission of global health is people. It's not governments. And that's an essential point as donors increasingly emphasize country ownership. We've got to think more about how to make that transition to country ownership work for everyone and not just those favored by the governments. And we need to be willing to slow down that transition to country ownership until governments show they can treat people with dignity and equality. Let's change the conversation from capping investments to making smarter investments. There have been enormous payoffs from US investments in global health that have to do with health systems, building health systems, advancing health equity for poor people, for women, for marginalized populations. Through global health investments, we're laying a foundation for a healthier world in a more equitable one. Global health represents a quarter of one cent of each US tax dollar. But the payoff is huge and the potential here is enormous. So, Bill, your chance. Okay. Yeah, just one sentence on terminology. I don't think I was advocating abandoning most at risk people or walking away from those groups as much as shifting investments to other places where it could be more efficient for those same groups. So, I guess one question would be how would you respond to a health official in a country who says to you, hey, with that $5 million you just gave to our neighbor to prevent new HIV infections among gay men, we could prevent, with that same amount of money, we could prevent two or three times as many HIV infections because we convinced our legislature to decriminalize MSM behavior. And that other country you just gave the money to still criminalizes it. Investing with us is a smarter investment. How would you respond to that? Yeah, and to clarify, I certainly didn't mean that you personally meant abandonment of anybody. What I was saying, though, is raising a concern about if there's no growth in scale-up in the country's hardest hit, I'm not sure the marginalized populations who so far have gotten short-shrift in the response get the response they're gonna need. So, I worry about the practical effect. Well, acknowledging that the proposal you're making is certainly principled and with good intentions. In answer to the scenario, I think one thing I do is do the math. I mean, the question is, in a lot of countries where there's a lot of people living with a risk of HIV, there's terrible policies in place. I mean, if we look at a, well, I'm not gonna name a country, but let's name a country with a huge AIDS epidemic. If we say, okay, you've got several laws in place that are negative, we think that bang for the buck is gonna be better elsewhere, where there are fewer infections. I just don't understand how we bend the curve of this epidemic if we're not tackling it and scaling up services in the places where the biggest number of people. It's challenging, but in the long term, when we think about advancing the response to AIDS and global health, and this whole effort to realize in the end, countries have to take on more ownership, I think we've got to face the fact that we've got to look at how do we transform the life situations of people in the hardest hit countries. We've got to, I would say, my counter argument really is, invest in how we can make change that advances human rights and health goals in those countries hardest hit. Sometimes that costs more. In the long run, I think it's what we need to do. Chris, part of Phil's approach was going to be to give countries advanced warning that this was going to happen. And so getting to a point, I think you were driving it earlier, what was the effect of his proposal? One piece clearly was to sort of threaten a club and basically give countries some motivation to change. What's wrong with that as an approach, as of using it as a kind of pressure valve? Wouldn't that give express solidarity with groups within these countries that are working to change these policies anyway? Doesn't that essentially encourage them and give further support to their efforts? Well, the term smart sanctions comes to mind. I mean, one thing I'd ask is again, the marginal difference between today's funding and the funding possible increase next year, is that marginal difference big enough to make a country government change their policies? Ari would argue probably not, but I would also say we don't have to do it that way. The club I think is to put all the money for that country on the table and say, you know what, it's not going to the Ministry of Health as long as you've got policies that aren't working that are impeding prevention. Instead, we're gonna invest in the NGO sector. We're gonna invest in community groups that can be there for long-term change. I mean, in all these countries, there are people that are rising up, that are courageous, that wanna deliver health services for their people and are willing to in many cases put their lives at risk to make that doable. Let's invest in them. Let's give them the training they need. Let's give those organizations ongoing solid support. That to me is a bigger stick with the Ministries of Health. Let's not invest in Ministries of Health as long as they've got these negative laws. Would you buy that as an approach? I would in part, I guess my concern about that would be that for true sustainability and for true global health improvement, the governments are gonna need to have to be empowered in the end. I mean, you can temporarily use an NGO to carry out a government function, but preventing people from getting infectious diseases is clearly a government function. Let me toss out another question to Chris. If you really want to get depressed, you will develop a visual image of what investing in HIV treatment, care and prevention is currently. And given infection rates, given prevalence rates rising, you can sort of construct a mental image of a bathtub with an unplugged drain where the water is steadily leaking out of the bathtub. And so we're pouring more and more water into the bathtub and it's leaking out faster, right? I mean, truth be told, that is essentially still what's happening because we're not making an overall dent in the epidemic in that respect, the pandemic in that respect. So if you had a choice as Phil posits between pouring the water into the bathtub with the bigger drain, pulling out the water faster or the smaller drain, what makes the most sense in this environment? Why would it be wrong to approach it from that perspective? The honest truth is I got lost in the metaphors. No. I'm sorry, can you? Can I? All right, given what's happening with the ongoing rise in prevalence, right? More people are getting infected, they're getting untreated, right? So if you step back and look at our entire efforts at AIDS care treatment prevention, we're still losing, right? So why invest in countries where we're losing even faster as opposed to countries where we're losing a little less fast, I guess would be the case. Well, you know, and I think there's a question there as to whether we're losing in countries with X number of negative laws. I mean, I think that's an outstanding question. I'm not sure there's data on that. I mean, I think there's terrific examples of success in this response. I mean, way beyond what anyone imagined. I mean, the US government, people at OMB that I talked to a year ago, we're talking about how we're ahead of schedule in terms of meeting goals of the PEPFAR program. So when I look at the response to AIDS, it's mostly one of success. Now, yes, more people are getting infected faster than we're getting people on treatment. We've got to do better on prevention. There's no question about it. I think what we're talking about here is how to be strategic about doing that. And I think there's a lot of things that we can do. I think it's absolutely true that prevention planning has been poor up to now. It's great that the Office of the Global AIDS Coordinator is now doing an audit of prevention plans in all the countries they're working. They've gone through several already. They're doing it across the board. That's very positive. There are, you know, research has yielded us new approaches in the last several years. We've got to make use of the male circumcision. There's one example. We just heard about pre-exposure prophylaxis. We'll probably have a microbicide online. We're learning that treating people has an impact on their infectivity. There's a lot of reasons when you add that with getting more strategic that I think we can do a lot better. So it's a very tough problem. Resources aren't limitless. But as we're investing in this response, we've seen terrific gains. And, you know, as we're doing it, we're building health systems too. Do you want to respond to that, Phil? No, I think we'll just wait for the next one. All right. Well, I think this is a good point to just move directly to audience questions. Let's bring the audience in at this point. So if you do have a question, please come to the front and use the microphone. If you would introduce yourself by name and affiliation, that would be terrific. While we're waiting, perhaps, for someone to come forward, let's ask how this would be implemented. So, Phil, now the onus is on you. We appoint you, acting aid czar, for the moment. And you have to go to some of these countries and make this pitch to them. So we send you to speak to the Molas and you say, what? Well, that there are not enough resources to go around. And so we're being faced with very difficult choices. And starting next year, we are gonna be forced to restrict any increases in funding to countries that do not have laws that impede HIV prevention programs. And for example, and then we'd give maybe examples depending on what the epidemiology is locally. But the examples would be the criminalization of various behaviors that then restrict the access of governments and NGOs to those populations who are at risk. And I think you would have to go beyond the ministries of health in having these discussions because they're usually not the true resistors in countries. And I guess I would also say that that part of this argument could be made or should be made by the US ambassador in the country and somebody who would consistently begin sending the same message. And again, to a point that Chris made earlier since we're a country where our fundamental religious beliefs are that we would not condone MSM activity. We don't want to encourage injection drug use. It would destabilize our society to invest more power in women. This is just completely contrary to our cultural sense of who we are. What business is it of the United States to force your cultural norms on us? Well, and I understand your concerns and it isn't any business of ours. It's just because we have to ration our resources and we need to ration them in a way that will provide the best outcome for people who are at risk from various, either at risk of acquiring HIV or at risk because they already have HIV. And again, I understand your point and it isn't any business of ours to tell you what to do. It's just that we must invest wisely. And then you go back to the hotel and somebody slips you a note and it's from an injection drug user who's locked up in a prison who says, don't condemn me to death because my country is doing the wrong thing. What do you say? Well, it's an interesting discussion because that person in the prison next to the hotel is actually not much different than the people who are in prison in the country next door. And it's a difference between a humanitarian approach and a public policy approach. And I think in terms of disease control, we've done much better on public policy approaches than humanitarian approaches. I'm not sure I follow the... Well, humanitarian approaches and not just infectious disease, but humanitarian approaches consist of responding to individuals or responding to news stories, responding to sudden disasters that might have been anticipated as opposed to thinking ahead and understanding what's gonna be necessary next year or next week to minimize or mitigate the kind of problems that... So you write back to this person and say, sorry, it's just not strategic to save your life. No, no, I... Realistically, that's what it's just saying. Right, we hope we are able to change the mind or the policies of your government and now we're working on that. I have a question here, it looks like from Alan Moore. Yes, thank you. Alan Moore, Stimson Center and faculty at GW. I'm amused by the resolution in the first instance where it talks about withholding future increases in HIV AIDS funds, because I'm wondering what future increases... I was glad to hear there will be. So we probably have a little time before we really have to engage. I'm also thinking that probably the two of you guys could spend 10 minutes in a room and come to an agreement, because Phil is obviously not saying that all of these laws are equal, and if you got 90% good laws and 10% bad laws that suddenly you're gonna be penalized, and I know that you also would say, hey, we have to look at the totality of things, we have to be flexible. Now, so where I'm going with this, I'm tempted to say to you guys, what are the better laws? What are the worst laws? What are the ones that are most outrageous? And I'm happy to have you kind of think about that, because that's part of what we're talking about, is an anti-MSM law worse than an anti-Clean Needle Exchange law. And what kind of anti-MSM law? But what I really want you to think about, and you can comment about that, is who should decide, should we turn this over if we're gonna, we do this now anyway, so that we can be honest about that. We don't just say, willy-nilly whoever's got the highest rate of infection, we're gonna give them the most money. We try to look at their capacity to spend money well, and who we can talk to and get along with, and who has a system that sort of works, who has NGOs that work. So I guess who should, to the extent that we're weighing all of these factors, who should decide, and the extent to which we start moving in that direction in an obvious way, do you worry that we might be inviting congressional input? Members of Congress have their ideas too, on what are better and worse laws. So is it sort of a slippery slope? You might go down the more, it's talked about and identified. Anyway, I'll shut it. Thanks. So let's take those in two pieces. The first is can we decide, can we weight these laws differently, or some worse than others? And I guess I would throw in, does it depend on the country? Does it depend if the epidemic is concentrated? Does it depend if the epidemic is widespread, et cetera? Let's take that one first. Yeah, I'm not sure. I mean, I thought a bit about the weighting, and I think that laws that result in incarceration for various behaviors, HIV risk behaviors, probably are equal in that sense, because the outcome is equally bad. The outcome is to deprive people of either information and preventive interventions before they're infected or treatment after they're infected. So I think they're probably equal. How those would equate with bad policies, or regulations, or laws about gender issues, about marriage laws or divorce laws, or laws in that category is also not clear to me. So that would have to be sorted out, but I... Couldn't you make the point that in countries with concentrated epidemics, those laws that really target the people who are victims of the concentrated epidemics, those are really bad. But in countries with widespread epidemics, sounds to me like basically putting 52% of the population, i.e. the female part of the population in a reduced state is really, really bad. Doesn't it... Can I... Yeah, I mean, that's part of the concerns because it's going down a road of... I mean, if we accept a human right, it's an absolute. Even in an epidemic where a very small percentage, let's say, of the epidemic happens among women, well, we ought to be there standing up for women's rights. It doesn't matter that there were only two infection among women in this country. So there's an absoluteness about human rights, whatever the epidemic sitting. It's not really a public health question, really. I don't think we pick and choose our human rights that way. That's one reason I'm worried about entangling these things so closely. I think we stand up for those values wherever we're acting and it becomes a diplomatic priority for us. And I think fairly to Secretary Clinton in many ways it has been. I mean, she's really stood up for human rights and she's made the connection between health and human rights. But I think it's a very slippery slope to walk down and say, well, this is the epiprofile, so here's whose rights are more important or here's whose rights we're gonna put a dollar value on. I don't know that it's doable. And I worry that, say the epidemic is 95% among heterosexuals and only 3% among MSM. Does that mean we don't use our incentive structure to get equal rights for gay people? That wouldn't be my approach. Let's bring up the second part of Alan's question which was, so who decides? Who would decide this anyway? Thoughts on that? Yeah, again, I think it would depend on how the policy was actually was written, was put into place. I think it would be a difficult call and some of which would have to be made in country by the PEPFAR country team and some here. But I think given sufficient warning and sufficient transparency and publicity within the country, I think the hard decision would be which countries to put on notice about this kind of change. And actually the easier part might be going ahead and making that change once it happened because while you're debating about that, there are an equal number or a much larger number of people with the same risk factors in other places who could use those resources and who are waiting for those resources. So I don't see this in the same punishment sense that I think we're talking about now. Again, just to go back, it's important that those resources, the scarce resources that there are and maybe even more scarce in the future, get used in a way that maximizes their benefit. Right, question here. So we had some with Open Society Foundations and I'm with Alan, but I suspect that if we all just went into a room and had a half hour long conversation that we come to an agreement and revise the resolution entirely, but I just want to pull out a piece that both of you talked about, which I think for me is the essence of this argument, which is that the promise of PEPFAR was to help countries bring programs to scale. So we were gonna move beyond pilot programs and demonstration sites and really see if we could rapidly bring programs to scale. And in that context, two things are abundantly clear to me. One is that you cannot bring programs to scale without government. Without government, supporting your efforts, you will only ever be in the pilot phase. You might be able to get large pilots, but you will never come to scale because at the end of the day, government has a large role to play in AIDS prevention, care, and treatment. And the other thing to say, because I appreciate everything you've said about vulnerable populations in most outreach groups and my own organization works almost exclusively with those populations. And what we know is that you cannot reach those populations in any meaningful manner until governments come around. You're only ever gonna be playing catch-up. You're only ever gonna be reaching a handful of people because at the end of the day, people are underground in hiding, afraid of being thrown in prison, or afraid to show up for healthcare services. And that, again, is a policy and a government problem. So I'm with you, Chris, that we should never abandon people in a country, but while we're working with those populations in a country, let's not pretend that we are solving the problem. We're putting a Band-Aid on it. And so for me, this question about what signals the US government is sending to countries, I think we have to be very clear about what we're doing in a country. So if what we're doing is putting on a Band-Aid or doing pilots or demonstrating that certain reforms could help them meet their goals, then let's say that we're doing that. But let's not pretend that we are solving their HIV problem or that we're bringing programs to scale. And in those communications, I agree with Phil, that the ambassadors and the entire USG team needs to be abundantly clear about the reforms that are necessary to solve this problem. And would you, if you were to adjourn into an adjacent room and cut a deal. I was gonna say, let's go there. Would that, in fact, be something you could agree on, which is that, regardless of threats of cutting out funding, as long as US dollars are flowing to these countries, there is every reason for USG and others to put as much pressure as possible on these countries to change these policies. Absolutely. And that maybe that's even more effective in an environment where you're still giving them money. Yeah, I mean, and I agree with everything that you said, Zoe, I mean, and that's, you know, that's, I agree, obviously. The goal here is scale and long-term impact. And governments have to be engaged for that. I guess I, with already being concerned about people wanting to backtrack a little bit on our commitment around PEPFAR, I'm concerned about capping our investment in any country, particularly the countries most affected. So I think we all agree that we've got to be pushing for policy change. And I think the question of this debate has been about tactics of doing that. But I would argue that we have to be engaged. And I said some of those things, you know, partnership agreements are an opportunity, diplomatic leverage, the relative balance between funding to governments and NGOs. I mean, I think those are all levers and I think just being leaders on the issue. So I completely agree. We, as health advocates, we have to be advocates for more humane policy. The answer about how to do that most effectively is gonna be different in different places. I worry that the particular prescription we're talking about now, capping funding in going, all funding going into a country, I don't know that that gets the job done. But I think we have to be forceful advocates on every level to change the policy. Taking a cue for, I'm sorry, go ahead. Shannon Smith with Senate Foreign Relations Committee. I wanted to base my question on the chart that was distributed at the beginning, which shows some pretty disturbing change over time. And I'm basing this on the assumption that these reflect changes in policy and not just changes in how we were measuring laws. But I wonder if y'all could comment on what are the trends, trend lines we're seeing in these policy changes, you know, what's driving them, but also what form they're taking. Is there, are there particular, you know, is it, are we talking about MSM or are we talking about drug laws as a combination of things? And some, give us some context in that sense. Bill? Yeah, and I actually am not in a good position to do that. In fact, we found this chart six weeks ago and I was surprised at the trends in it as well. So I don't have background information. And in fact, Zoe may be, Zoe may know a little more about it than anybody, but I don't know if Chris has a sense of what's changing. I, the honest truth is I'm not sure how much investment I would put in this particular chart because my understanding is this is self-reported data by governments and I don't know if the trends mean things different than reporting. That said, it may be consistent with what we're seeing. For example, on the rights of men who have sex with men and gay people, I think what we're seeing is a continental backlash against those rights in Africa. You know, in many ways, great things are happening. You know, we heard from the Secretary General of the United Nations, I guess about six weeks ago, that where cultural values are inconsistent with human rights, rights have to win out. And he was talking about the rights of lesbian, gay and bisexual and transgender people. That's pretty exciting and that's pretty amazing for the Secretary General to be saying that. At the same time, parliaments across Africa are looking at new, more negative anti-human rights laws against gay people, putting them in prison longer, seeking the death penalty. In Uganda, there's some talk about bringing the proposed law back. So I think there's a backlash. We see that anytime that groups win some victories in getting their rights. I think we've seen that in this country around gay rights and I think the tide is now shifting back. But when people start getting some traction, the other side will fight back. I think that's happening now on gay rights. So it's gonna be a long, long struggle. That's one reason why, I mean, to me, looking far down the road, part of the answer really is, though small NGOs won't bring services to scale and I don't think we should fool ourselves if they will, we do have to be investing in people who can stand up for the rights of people long-term. Hi, I'm Ron McInnes with the Features Group. It's a very interesting debate and I think it brings up the fact that we often try to demonize our recipient countries with these difficult laws when in a lot of ways we've sort of created the beast. Just a short five years ago, our prevention message was ABC, our official prevention message and now we're getting into a much more complex prevention message that is dangerous. And it's far more dangerous to try to provide prevention programs to the countries you're working with that it is to provide treatment programs and probably going to be more costly. And so part of what we have to do in our frameworks is understanding that as I think as you're rightfully brought forward, we have our own flaws with our own moral issues in our programs, but not to come across in a judgmental way of other countries. It's an evolutionary process, but in the meantime we need to be aware of the danger now of doing prevention programs in countries with laws where you're criminalizing the behavior of those who most need the education. And if we're coming out with a comprehensive combination prevention strategy that includes all of the tools of prevention, including outreach and education on all sexuality, including all harm reduction for needle exchange users, how do we make sure the countries we're in agreement with are either protecting the rights of those people working through the justice systems or the police programs or others to make sure that it's not just public health programs, but it's full governance programs as well that are supporting the efforts. That's I think part of the role of building good policy, but the practical elements as we look just about every few months there's someone who gets arrested for doing this work in a country. And whose responsibility is it to provide for their protection, or should we just not even do a program in a country where programs are illegal, where populations are? Comment. Yeah, and I think the fundamental question and conundrum under the resolution that we're considering today is the tectonic shift in aid now that we're talking about, which is moving towards more country ownership in all that that means, including countries designing their own programming, contributing more of the money to their own programming. As I said before, one of the things we have to watch out for is that that doesn't become, who decides doesn't just become the government in that country, but that there's a broadly inclusive way of decision making, bringing in civil society and private sector and other sorts of sectors, but also recognizing that that's not the magic bullet either. Just because you have civil society and private sector, et cetera, engaged in a country doesn't mean human rights get respected or that funding is allocated in a way that it reaches marginalized groups. You know, in our own country, this is another example about how this plays out on an operational level. We've had community planning bodies around the country in some of the epicenters of this epidemic in our country, and if you look at the way those organizations working with their health departments allocate prevention money, well, they under-invest in the needs of gay men. Now, I don't know the whys of that, but that's a fully participatory democratic, not democratic, but a fully participatory representative process, and so there has to be, there's always gonna be a role, I think, for donors to be bringing these human rights and public health values to the table, even as we wrestle with how do we engender more community or more government ownership? Can you just respond to one of Ron's comments about shifting from the earlier policy to something that's more dangerous now? I think you could use the word danger in several ways. Now you may be talking about political danger, but I guess I'd like to point out that using or advocating policies that were not very effective at stopping HIV transmission actually create, in the long term, could create true disease danger for both the at-risk population and the general population. I wanna just pick up briefly on another point that Alan Moore made, which is that isn't it the case that a more realistic discussion at this point would be assuming that the budget for HIV AIDS assistance is going to shrink, or it's certainly not gonna grow. Isn't it more realistic to talk about what are the ways we would decide how to reduce spending if the need, assuming that the need might well arise to do that, and if not reduce it in real, in absolute terms or after reduce it in real terms? Would it be at all valid in any way to take any of these arguments we've been having this afternoon into consideration as one picked and chose among the countries that we were going to continue to assist? Chris. That's a hard one, but I don't concede the point. I'm willing to have one half of one cent of my tax dollar go to global health, so that would be double. But we're gonna have to be more efficient. We're gonna have to make harder choices. There are places where our money isn't getting the bank for the buck. Absence only funding globally is one of those places. Now the funding for that is ramping down, but it's still out there being used to some degree. I think everything, both in domestic response and globally, is gonna need an audit. And I think the Office of the Lades Coordinator is in fact doing that in several ways. They've found efficiencies in providing treatment. They're doing an audit of prevention programming. I think we also have to understand the limits of being more efficient. I mean, we've heard from Ambassador Gooseby himself who runs the PEPFAR program that where they found tremendous efficiencies in the program through drug pricing and through logistics and supply chain, those efficiencies are about to run out. They're gonna run out this year. So flat funding for global aids whereas we've been able to maintain scale up for a while, flat funding really does mean cutting back and waiting lines and who knows what it means. Taking people off care, I don't know. But I think there are hard decisions. I mean, in terms of what we're discussing today, yeah. I think in the countries that are hardest hit where we know we need to go to scale if we're gonna have impact on this epidemic, I think we have to get more forceful about getting rid of laws that are standing in the way. There's no question. Again, I would argue that doesn't mean taking funds away. I would argue that it means being more forceful diplomatically and using funds differently. Bill? Yeah, it's difficult to think how cuts might be implemented. I mean, there are a series of issues. It's always been accepted that we couldn't possibly ever make any changes that would result in people being taken off of antiretroviral treatment or now on it. And I think you could make the same argument about people who are on methadone. And who are treating their opiate addiction successfully on methadone. And that's what's keeping them from getting HIV infected. Beyond that, I guess it's, we have to think about the fact that the countries that were selected as the original PEPFAR focus countries were not selected in a methodical way. Partly they were in any sub-Saharan Africa, which meant they had a lot of HIV, but partly there were convenience sample depending on where CDC and AID had programs. And so countries were left out for various reasons. There were heavily impacted Zimbabwe, Lesotho, I mean, there were a list of places. So we may not automatically be focusing on the most heavily impacted countries now. I think there will have to be, if there are truly cuts contemplated, then there will have to be a very serious public discussion about HIV. That sounds like you'd be more in favor of not exactly wiping the slate clean, but obviously not approaching the new reality directly from the current reality in terms of who gets funding and at what level. Right, and I think one of the things I thought about during this discussion was assuming there were additional funding as the original proposal said would be, for example, putting out an RFP request for proposal, saying we have $100 million for HIV prevention among MSM and this can be implemented in any country that doesn't criminalize MSM behavior. And so we're gonna make this available. Just please send in the proposal. So that might be the way I would have done it 10 years ago if we had thought through the process, if people have thought through the process rationally. Going backwards, cutting funding is obviously a lot more complicated. All right, well, at the risk of forcing you back to arguments that you may no longer want to defend, let me ask you to make closing statements. And in this instance, Chris will start with you. The closing statement, either on your original position in the negative or what you have now evolved to and then we'll do the same with no. Well, I haven't, you know, this has been a really interesting conversation. And I do think what's interesting is that we're citing the same concerns about the laws that are out there and the same need to be more effective with funding against the global epidemic. I think we're headed in the right place. And I do think that back room conversation would get us somewhere good. In fact, I think we're kind of pretty much there. And I, you know, again, I think this issue is very live right now because we are considering, we are in the process of changing the way we do aid, promoting country ownership, and also we've been in years now flat funding in the global response. You know, it can't be that just as the world is beginning to recognize the needs of marginalized populations in a real way, people are organizing around the HIV needs of gay people and IDUs and sex workers. That's been going on from the beginning, but it really is increasing now. And I think there's more data there. It's getting more credibility with policymakers. It can't be that just as that movement is happening that we step back. It's not just, it doesn't result in the epidemic coming to an end. So, I mean, I think we need to find, we need to keep this kind of conversation going, even more so because governments are gonna play a bigger role and we need to use every policy tool we've got to advance public health and human rights approaches. So thank you very much. Bill. Well, I don't think I have a lot to say that's different for that, interestingly. Okay, so the summary would be that we need to think hard about investing our scarce public resources where they can have the greatest impact. By which I mean, I guess, using a fixed amount of resources. Given a fixed amount of resources, we need to use it to help the largest number of people. And I suspect that after thinking about the comments and the questions, that it also means helping countries that arrange or that rearrange, in some cases, their laws and policies and regulations in a way that helps their own people, helps that reduces HIV acquisition among currently uninfected people and helps people who are already infected. The process to make that new approach happen should be as transparent as possible. It should be discussed widely within the U.S. before it's implemented. It should include all U.S. government messengers, messengers and messengers. And it should be responsive to changes in those countries if they were to happen. Changes in the laws and policies in those countries. I wouldn't exclude other approaches, public pressure of various kinds to help governments, encourage governments to change their laws. The issue of stepping on socially determined concerns is one that needs to be taken into account. But again, the issue for my perspective is we are never gonna have enough resources to do all the treatment and prevention we wanna do. And so we need to use those resources that we have in a way that's highly efficient and highly effective and maybe that means that the unit of concern needs to begin shifting from the government to the populations who need services. And that it doesn't, because we have invested in countries A, B and C, bad letter choice, but countries D, E and F for the last 10 years doesn't mean that we need to keep investing in those countries as the first choice. And the ethical issues involved in all these discussions are exceedingly complex. All right, well, I take away from this certainly to synthesize a bit of what both of these two have said is there is clear agreement, as Chris said, that the US, arguably while we still have the moral high ground by virtue of continuing to pour lots of money into HIV AIDS assistance, it is incumbent on the US to use whatever pressure moral or otherwise it can bring to bear to urge these countries to change these policies and that regardless of whether one wants to have the threat of cutting off funding or not increasing funding, that that could meaningfully and should meaningfully go forward. I guess though, I also come away with a clear sense that it probably wouldn't hurt to have a lot more data here to understand much more clearly what the effect was of these various laws and restrictions on the actual help underlying health of populations and the trajectory of the epidemic in these countries because that could only help give one a sense of what battles are the most worth fighting in this environment and particularly in the context of potentially having to shrink funding or even rethinking distribution of funding. It would be very useful to understand what the impact of these policies were so that would be a case of having more data. I guess I would also just come back to this graph. It's helpful to have a graph that shows the percentage of countries in which non-governmental sources report that there are laws or regulations that's better than not having any information like that but of course you would like to have not only a clear sense that these laws really do exist but also like to have this graph weighted for population because you want to understand the numbers of people who are affected by this. So I don't, surprisingly enough, editor of a journal calls for more of a search to be done so she can publish it but I think it probably would be incumbent on the whole community to get together and advance more of this because it could only inform policy more constructively. With that, we are going to bring today's discussion to a close and I want to thank these two participants for following all instructions to keep this as high level as possible. It certainly was that and was very informative. I also have to compliment the audience on helping us to that end and mention that there is an event starting next door at 5 p.m. with the ambassador from China so we are being urged to exit promptly and quietly as well as we leave the room today. I do hope you'll join us for the next in this series of marvelous debates and again thanks to CSIS for making these exchanges possible. Thank you very much. Thank you. Good, really good. Ladies and gentlemen just to echo that we do appreciate, excuse me, we do appreciate your efforts to keep quiet and to exit in an orderly and rapid fashion. Thank you. Thanks, thank you Chris, thank you. Thanks Phil, glad you're with us. Yes, thanks Phil. Phil Musgrove still work for you? Yes he does. He's a friend from some earlier life. He's a very smart guy. He thinks out of the box which is always fun.