 Good morning. Thank you all for being here this morning. I'm Steve Mawrson from CSIS. We're thrilled to be able to pull together such a distinguished group to talk about global tuberculosis this morning. Let me just quickly say a few words about what we're going to try and do today. And then I'm going to take a moment to thank a bunch of people who contributed to this effort. I'll say a little bit about the process that generated some of these results. And a few comments around some of the things that came into play. Summarize a few of the key conclusions that are contained in the report that we're issuing today, this report. And then ask my colleague and close friend, Phil Nyberg, to share some of his observations around some of the more contested and difficult issues that surfaced in this process. First of all, we're pulling everyone here today together to celebrate the release of the final report and recommendations that you have, the Strategic U.S. Leadership Report. And the six companion policy papers that are available at the moment online. We've put a placard together for you that gives you the links to those. This project started March of last year, so it's been underway for some time. It started, in a way, as a response to suggestions that came to us from a couple of different directions after we had completed. At the end of 2012, into the first month of 2013, we had done a multi-sectoral review of the Obama administration's first term and the performance and goals, outstanding business across multiple sectors in global health. And a couple of astute people said, why haven't you put more focus on TV? And I thought that was a pretty valid criticism and filled it as well. So out of that grew this rather long and complicated process. So one lesson is be careful what you agree to do in response to suggestions, but I think this was very, very worthwhile. You'll see we've got a piece that tries to look at what a strategic approach would look like and what are the national interests that come into play. And we've got six papers that look at the linkage between the U.S. and global epidemic, look at international collaborations, look at the HIV-TB interface, looks at the R&D agenda, looks at the brawl of the bricks and other emerging powers, looks at how you might rationalize spending. So that's the spectrum of work. We're also here today to pull together some of the best thinkers on tuberculosis to have a conversation that uses this body of work as a jumping off point for forward-looking conversations that we could have. And we've chosen to organize those conversations around how the U.S. key agencies can better organize and better lead in using their assets and their expertise and voice. And we'll be joined on that panel by Tom Kenyon, Robert Clay and Julia Martin. And we're very grateful that you've agreed to do that. We've tried to put a focus over the lunch hour around the international dimension, the dimension of collaboration and leadership and orchestration of multiple different actors. And we're delighted that Mario Riviglioni from WHO and his colleague Diana Weil agreed to come and be with us today and that Mario would do a presentation to kick off that discussion. And we're delighted that Joanne Carter from Results has agreed to come and be a discussant there. And then in the afternoon we're going to look at the research and development agenda looking forward. And Tony Fauci has agreed from NIH, Peter Small from the Bill and Melinda Gates Foundation, Eric Gooseby at UCSF, former director, former coordinator of the Office of Global AIDS Coordinator, three remarkable people who have huge insights into what that R&D agenda looks like. So I think it's a rich and great day and I'm grateful to all of you for coming and being part of that. I want to offer a few special thanks here. Phil Nyberg has made a prodigious effort over the many months here at pulling these papers together and helping us think this through and we could not have done it without his expertise and his commitment and his indefatigable efforts there. Alicia Kramer, who many of you know, was the partner with us on this. She is departed to go off to a medical school in Atlanta at Emory in this fall, but she made a huge commitment. Lindsay Hammergren has stepped into the breach in the last couple of months and done a wonderful job. Seth Gannon helped us enormously in the writing and editing. The report, as did Vinka Laflora. There is a video that we will show you, a small short two and a half minute video that will run in a clip at lunchtime. Beverly Kirk and her colleagues, Johnny Harris put this together. This is a tool that we are intending to use to try and reach a broader, more popular audience to convey the realities around global tuberculosis and certainly welcome you looking at that and letting us know what you think. It is for a different kind of audience. It is not for an expert audience. It is for an interested audience that is going to use the social media to think about these things. Other people have contributed a great deal logistically. Travis Hopkins, Carolyn Schrout, a number of people here. Talia Dubovie, Katie Peck and Sahil Angelo from our staff, some interns that we have that have joined us from various places. Allison Roberts, Kaleem Hawa and Lauren Hartel. I want to thank them. Our authors in the papers gave very generously. Peter Small, Nellie Bristol, Amanda Glassman and Victoria Fan, Susan Maloney and Brittany Moore and other colleagues at CDC. Katherine Bliss. And as we organized ourselves, we put together a working group. It was a mix of independent people. It was a mix of people from U.S. agencies. And one of the important things in this process is we are very reliant upon the expertise of our U.S. government friends and colleagues. But we don't hold them to account. We make that very clear in the text that we are not implying that they are standing with us necessarily with the conclusions and recommendations. But we have had to rely very heavily upon their expertise. And we are very grateful to Ariel Pablos-Mendez from USAID, from Bill Coggin at OGAC, Sherry Vincent-Namey Bloom from USAID, Christine Seismore from NIH, and as I mentioned our friends from CDC, Susan Maloney, Brittany Moore and others. There are many other people that came in as independent experts to contribute. Todd Summers, Erica Arthoon from Bill and Melinda Gates Foundation, Jen Gates, Kaiser Family Foundation, David Briden and John Fawcett from results and Christine Lubinsky from IDSA, Richard Chason from Hopkins, Heidi Ross from Congressman Angle, the ranking minority in House Foreign Affairs Committee and Democrat from New York City who is very familiar with what TV can mean. Sharon Stash, who is our former deputy director, helped instigate this and get this moving and we're very grateful to her for that. As we proceed, as we proceeded in this effort to pull this together, we began to see many of the paradoxes of TV and we'll talk about that. That it's a mix. TV brings forward a mix of hope and a mix of fear. There's been an enormous progress. There's great cooperation that happens. There's a determined and dedicated cadre of people across a spectrum of institutions who are working these issues. There's been technological gains. There's much to be very proud of. We've tried to convey that fully and fairly in the work. We've also tried to convey the flip side, which is the very real problems that we face, the problems of guaranteeing high-level adequate political leadership, conveying in both the executive in our government and executive in Congress what's at stake and what's needed in terms of resources and leadership. One of the big mega conclusions that comes across in this report is that very worthy goals do not align with the resources available. In the R&D agenda, we still lag behind in having the adequacy of tools and that high-level U.S. leadership is something we need to work, strive hard to engineer and to cultivate and encourage. Another big mega conclusion that we have here is that this is a shared agenda. This is something that relies on the well-performing key multilateral organizations in international bodies, WHO, Global Fund, the Stop TV partnership, the commitments of key governments that carry large burdens of TV that need to be there. We've tried to make the case that, and you'll see it in the video, that TV is an unusual disease and that it's a somewhat quiet, indolent and insidious disease that it's sneaky in some ways, but that we're arguing that it strikes U.S. interests in an increasing way that we need to acknowledge and that is the power of the argument for getting higher levels of U.S. leadership. We need to talk about how it impacts us at home and how globalized the epidemic at home has become. We need to talk about the degree to which we are missing the boat in not diagnosing those 3 million cases per year that go unreported and undiagnosed. We need to acknowledge the threat that MDR TV poses and mobilize at a higher level for that. And we need to see the way in which the amazing PEPFAR legacy is itself, the integrity of that, the sustainability of that legacy requires a better effort at dealing with HIV, TB, co-infection. We will talk a little more about the real and legitimate fears that run through this community of people about making missteps. People do not want to have a false dawn in terms of commitments that are empty commitments. People, we've heard this over and over again, people want real commitments. They want guarantees. They want to feel that if we're going to take U.S. approaches to a higher level that it's backed sufficiently by resources and empowerment. We can talk a little bit more about that. We put forward 4 key recommendations in the report. One is put somebody in charge and make sure that person, that office, has true authority to advocate, to lead, to set priorities, to muster higher levels of resources, to renew a vision and to lead in higher levels of international orchestration of efforts. That's a big order. That's a tall order. We're saying that we need to increase TB resources and improve their use to align them to close the gap to address the fact that we are falling short. We're falling short chronically of what even Congress admits is required in the earlier authorizations. And there are various ways in which we've said that USAID would benefit from having more resources at its disposal. We should not declare victory and be cutting budgets at USAID. That OGAC can do better. That the Global Fund can do better. We're saying that we should lay out a renewed vision that focuses on several top priorities. MDR, expand control over drug-sensitive TB and close that 3 million gap, create long-term research and development partnerships, elevate and set concrete targets on the prevention diagnosis and control of TB among persons living with HIV. Lastly, we're calling for a higher level of diplomatic engagement. This is not meant to create any new heavy structure. This is not meant to displace or offset the Stop TB partnership or the many other very worthy efforts that are undertaken. In a routine basis by WHO and others that keep things moving forward. We're saying that there needs to be a new high level and very focused concentrated injection of interest and energy. And we'll hear more about that at lunch. Let me just close by saying we need your help. Please read this report. Please give us your feedback. Please help us to connect to broader interested audiences. We'll probably be producing an iTunes course. We'll probably be producing a reader. We will have hard copies. We'll have consolidated disc copies. Tell us how we can do this work better in the future and tell us what you think might be of value in terms of next steps. We're not going to close this book, close this chapter and just move on to other priority issues. We're going to continue a stream of work in this area and we would welcome your advice. Some of this will involve logical next steps at looking at these issues in greater depth with delegations, with travel missions, with other conferences and the like that we'll pull together. But we really would love to hear from you in the coming weeks around what you think should be priority steps. Let me turn to Phil and hear from you. Phil, thank you. Okay, well thanks Steve. I just want to add my welcome to Steve's welcome to the group. So I'm Phil Nyberg. I'm a senior associate at the Global Health Policy Center at CSIS. Let me start by saying that there was a small dinner last night and we heard from some people who were in the working group and from some of today's presenters about the history of their involvement in tuberculosis. And the stories were varied, but all of them portrayed a sense of intensity and passion about their involvement in TB control that was truly inspiring. So I was co-chair of the CSIS TB working group where I have been, I guess it's still going on. And I want to begin by following up on what Steve said and acknowledging the critical work of Sharon Stash who was the other co-chair of this group. She's really the one who got this working group up and rolling while she was still at CSIS. I want to make a couple of macro level observations before mentioning some of the specific challenges that we encountered in putting this report together. So first was that we were not really focusing on the epidemiology of tuberculosis, the global tuberculosis. So there are a number of important TB issues, global TB issues that are not addressed in this report and I just wanted to mention them. One is tuberculosis in women and children. It's a very large issue and a bigger deal than you might think based on the amount of space in this report that's occupied by it. Another is a pair of links between tuberculosis and malaria, sorry, tuberculosis and diabetes on one hand and tuberculosis and smoking on the other. Those are both critical issues for future attention. And finally we didn't pay a lot of specific attention in this report to the critical underlying societal issues related to tuberculosis. That is issues of poverty and inequity and marginalization of populations. Okay and I guess the last macro comment was that I just want to acknowledge what became increasingly clear to me is the difficult challenges facing World Health Organization and the Stop TB Partnership and USAID and other US government organizations working on global TB. And in particular the challenge is that these organizations have, they're both external expectations and their own expectations that really, as Steve pointed out, exceed the resources available to meet the challenges. Okay well Steve has already alluded to a number of the global TB issues that produce some energetic responses from our group and from readers. People who were either supportive of or pushed back on some of these suggestions through the various drafts and up to the final report. One concern was comments that were made various times about US government interagency coordination and cooperation and there was a sense that there was implied criticism of that. In the end we all agreed that while there are some tensions the specific interactions between the agencies are good in most respects. Another concern was a series of, I guess it was a tone problem. There were comments that we needed to include more acknowledgement and credit for the progress made in both US and global TB control efforts. And that was discussed in the context of the threats and challenges that need to be faced now. The threat of MDR TB, the threat of HIV TB, the potential cuts in funding and actually the overall low level of funding. And I just want to say that this report has not been attended as a critique of strategies of any organizations. In fact the WHO post-2015 TB control strategy is a true step forward. There was a handout about that today and as you look through that you'll get a sense of a new horizon on TB control. And the other recent change that will be very helpful is the global funds insistence on a unitary application for funding that involves from countries both national TB control programs and HIV control programs. Another concern raised was that in terms of US problems the lack of adequate resources, the lack of money is really the number one issue. And the implication in some of the conversations was that if that problem, the funding problem could be solved nearly everything else would solve itself. And I think we all agreed that the lack of US resources is a very large problem that could potentially in fact be exacerbated by the proposed cuts in USAID's TB funding this coming year. There were concerns expressed in that regard that those of us who were involved in writing the drafts were that we had accepted the status quo that we've given up. And I guess that was in the context of the discussions that you'll see in the text about the need to prioritize. We got the impression that people were telling us that we had accepted the idea that there would not be new resources. And I guess we ended up with a difference of opinion on that issue in terms of the tone issues. And in part because one of the reasons cited in congressional testimony for the ability to make funding cuts was the fact that the 2015 Millennium Development Goals for TB would be reached. So there was clearly a difference of opinion about progress versus risk. There were some pushback on suggestions and recommendations. The recommendation was made about having a global TB coordinator. And I guess, first I guess we should acknowledge that the initial suggestion made, the suggestion in the initial draft that such a person should be at OGAC clearly didn't pass muster. I mean we, I think within an hour of that draft going out we had heard that pretty clearly. I guess and one of the comments made about the concept of coordinator in general was that the coordinator would include but would be just harmonizing U.S. government interests. But in our view the coordinator would actually do a lot more than harmonize the government interests. And I actually just want to read a line from the congressional, from the legislation about the malaria response coordinator. In general the malaria coordinator has primary responsibilities, this is for the PMI, the coordinator for PMI. The malaria coordinator has primary responsibilities for the oversight and coordination of all resources and all international activities of the U.S. government relating to efforts to combat malaria. And the legislation for the global AIDS coordinator is analogous to that. It's a unitary situation, clearly one person in charge. And actually those are the roles that the, that's the role that the PEPFAR, the OGAC coordinator and the PMI coordinators play now. There was pushback on some of the initial draft material discussing TB HIV, the TB HIV relationship that is TB in people who live with HIV. That we are somehow exaggerating the importance of TB HIV in the big picture. And there was a need to keep, focus on TB in places where HIV is not a big problem. And we're clearly supportive of the need to maintain the focus on the missing 3 million people. And the need to address, to continue the successful progress toward addressing drug sensitive TB. I'm not sure we came to agreement about the overall importance of HIV in the TB world, especially where U.S. supports involved. So it's true that, for example, 13% of, only 13% of new TB cases were people living with HIV. But other numbers that you could look at are much higher, or progressively higher actually. So 20% of global AIDS deaths were from tuberculosis. In autopsy studies that were done, 32 to 45% was a range of fatal AIDS cases were found to have disseminated tuberculosis. A higher number, 40%, is the proportion of bilateral U.S. tuberculosis funding that actually is focused on TB HIV coming through PEPFAR. And then, the other thing, well, the other number I guess was the 41 countries that are listed as high co-infection burden in the WHO and Global Fund documents that are, they actually collectively hold more than half of the world's population. So people are clearly concerned about the future of this set of issues. Okay, and there are two issues I wanted to, well, actually, one more, okay, one more issue in that area is the linkage between global and domestic TB concerns. And Steve has alluded to that. And the discussion was whether the, that linkage needs more emphasis in terms of how global TB control activities of the U.S. government could help domestic TB concerns. Or whether it was already getting an overemphasis. And that's discussed in reasonable depth in both the overview paper that you got. And online you'll find a paper that Brittany Moore wrote with CDC colleagues that addresses it very well. There are two final issues related to OGAC, OGAC specific issues. One is a concern that we raised about the need for caution during PEPFAR's transition toward country ownership. And what we had intended to say, and I thought we said, was that it's an, that transition process is an unknown. And so it's important to maintain caution to make sure that inadvertently, that things inadvertently don't go wrong during the process in terms of TB, and PEPFAR's role in TB. And finally was the issue of PEPFAR's funding. There was a, the HIV TB allocation in PEPFAR represents, it's a lot of money, but it represents only 3% of PEPFAR's total allocation. Even though 43% of the new TB cases in PEPFAR countries are HIV infected. And so it just seemed to us that there was an imbalance in those numbers. And again there's not something we came to final conclusion on. So with that I'll turn it back to Steve. And those of you who go through, who read the report in detail will find that there's a lot of discussion on those issues. And as Steve pointed out we need to have feedback from people on your sense of how they might be resolved. Thank you very much. We noticed that there's a loop that exists where people really want to see things change. They want things to improve but they also are held back by a fear of things getting worse or promises being unfulfilled. There's a lack of, there's a skepticism and lack of confidence that's built up that things could change significantly going into the future. And I think this entire day in a way and this entire effort is a way of trying to shift that to say indeed there's a lot more expertise, a lot more commitment and a lot more energy. And the U.S. national interests are in fact very substantial and that we can do more in getting the Hill to be more interested. We can do more in terms of making the case around national interests. We can do more diplomatically and the like. So thank you all for being so patient with us as we've walked through this. And what I want to do is turn, welcome our first panel which brings together the leadership from the three key agencies along with our close colleague Todd Summers. And so I'd like to invite you guys to come on up and we can jump into that panel. Thank you. Thank you and good morning everyone. My name is Todd Summers. I'm a senior advisor here at CSIS's Global Health Policy Center. Most of my work over the last few years have been focused on the Global Fund to fight AIDS, tuberculosis and malaria. So I have some familiarity with some of the issues but I'm learning like many of you where there are opportunities to do better. This panel is going to focus as Steve said on opportunities for U.S. leadership. We have representatives here from USAID, from the CDC and from the Office of the Global AIDS Coordinator, three friends of CSIS, three friends of mine. This is going to be an exciting time for us to hear a little bit more around their thoughts. Both Tom and Julia are fresh back from the PEPFIRE annual meeting so we're going to get a little insight as to what conversations happened there. You were there too so all three people just came back from South Africa so I think we're going to get a great view from their local perspective. As Phil mentioned last night we had a discussion around some of the personal interactions that brought people to focus on TB. And we heard some from Tom around his early days as a pediatrician in his time in Botswana, Robert, his engagement in India. I know from the little that I had with Global Fund walking through hospital wards in various countries only to be told afterwards that I had just walked through the MDR TB ward. That was kind of interesting. And I do when we took a congressional visit to visit Slim Karim's TB HIV program down in Durban and there on the wall is a photograph of a physician from Harvard who was spending some time at the clinic and contracted TB during her time there and has been off work for the last three years because of the devastating impact that had even though most of the workers in his clinic that were escorting us around were not wearing masks. So there's quite a bit we all have to learn here. We're going to go through each of the speakers and ask them to offer five, seven minutes of introductory comments and then we're going to come back to you for questions and answers. Any time will be up to you to engage our speakers as they finish their comment. So Robert we'll turn to you first. U.S. Agency for International Development is obviously our key bilateral agency in addressing HIV and TB and in this case you're the big donor on TB. So help us understand where you see things in terms of leadership from the U.S. Thank you Todd and Steve. Thanks for hosting this event and also for the good paper. I think Phil laid out a lot of the issues which will be sort of guiding us today. But I think it's a real service for CSIS to bring the community together to focus on key issues like TB. So it's good to be back here again. USAID has been involved in TB really since the mid-1990s. We had a lot of work in Eastern Europe and then in 1998 we actually had TB specific funding. So that we focused our attention on activities for the next 10 years until we had the reauthorization which bumped us up again. And so it's been a close to 20 years of working in this area and I'll make a small plug. If you're interested in the in our history tomorrow afternoon at four o'clock we're actually going to launch a book which is our 50 years of global health. Which talks about all of our work in global health but TB is actually mentioned in this book. Please come at four and you can get a copy of the book as well as hear about. And it's right here. You can just spend the night and enjoy the event tomorrow. But you know I was the head of the HIV AIDS office in USAID and one of the things that struck me in that role was what Phil mentioned is that there has been really good collaboration in this field. It was one of the areas that Julia and I didn't have to spend a lot of our time sorting things out and because there was really good collaboration. And I think a couple of reasons because I think it's important as we look at these these really good good good areas where we function together. One is that there's a very strong strategy that was developed for the USG 2009 to 2014. It was based on international goals and standards so I think it was aligned with the global community and that helps very much. It delineated very specifically the roles of the different agencies. And in fact if you look at the report to Congress there's a great graph or chart that shows each of the agencies and what they would be doing. So it's very clearly laid out and I think that's helped a lot to be able to coordinate. The other is that in this field we have folks that have been around for a long time and they know each other. So inevitably it's the people who make this work. And I think in this field that we've had some very dedicated and hardworking and long relationships established relationships. So I just wanted to make that point. It was noted that we've had progress in TV. We are expected to reach the Millennium goals. We've had 45 percent reduction in deaths from 1990 to 2012. 37 percent reduction in prevalence. That's great and I think we're all pleased with that work. There's still lots to be done and that's why we're here today. But partly the success that we've seen I think is because we focused our attention on those high burden countries. So in the USG we're focusing on 27 countries. They account for about 70 percent of the prevalence of TB. And so we're actually trying to get our resources working in a more effective manner. Now I know the question it's always already come up is about funding. And so I would acknowledge that there is a gap in funding. It's two billion dollars which was estimated. And then I think it's a big challenge for all of us to figure out how we can address that gap. The Lancet did mention that most of that is could be addressed or many of much of that can be addressed through the own country resources. And I think as we look at where resources are in the world today we're seeing countries in Africa and Asia growing. They're increasing their domestic resources and we're not tapping into that as well as we should. This past year USAID has been focusing a lot on the domestic mobilization of resources across the board. But I think TB is a particular area that could benefit from that. Working with some of the big countries such as India making sure that they are utilizing their resources in that regard. Despite that the U.S. government we haven't fulfilled the vision in the Reauthorization Act. It's been short. But if you look at the total funding from both the bilateral and the global fund from 2009 to now. We actually have had we've gone from a hundred and four hundred and fifty five million to five hundred and eighty one million. So there has been an increase over that period. We would like it to be more. But remember we had a grand recession. One of those small things that happened. We've also seen some major changes in the world in terms of Eastern Europe. We've had countries where we were focusing a lot have graduated. Of course Russia we were graduated very quickly from Russia. Graduated. Maybe booted out. That changed our ability to work in that country. So despite all of those we have seen an increase in resources across the board. So that's that's the good news. But we still need to do more and we acknowledge that. I would just also say that we're working very diligently on the cost effectiveness of our program. Because money is important and we all like to have more money. But it's how we use that money is really the key to getting the results. And the global drug facility has been a key focus of USAID to make sure that we have the resources for drug procurement. And we also at the same time have the quality of those drugs. And that's very important again to achieve the results. So things like that focusing our attention working with the international partners. Making sure that we have the way in which we can reduce prices. I think we'll we'll get us along. And then finally in terms of the future I would say that we are leading an effort right now to read for the next strategy for 2015 to 2020. And that strategy is going to be very important to look at both how we focus our attention bringing the lessons its bills on the past strategies that we've had. And so that we have a more a better program in the future and focuses on the key areas. We need to look at look more and both on technologies and I'm sure we'll hear a lot about Jean expert and how rolling that out is going to help us in terms of the quality of our program. But also on implementation science learning about how we can better implement our programs around the world and feeding that back into the design. That's going to be very important. I also would mention and Phil talked a little bit about this or maybe Steve that you know TB is not just simply a health issue. It really brings in so many different aspects of society the poverty aspect the issue of education. So looking at this through a multi sexual approach through a development lens is going to be very important as we move forward and seeing it some of the underlying efforts that we that we have. So I think it's exciting. I think our the way that we collaborate the focus on our strategy and if all of us can do a better job on advocacy and maybe we can talk about how that can happen. But to be able to fill that funding gap I think I think we'll be able to continue the type of progress and results that we've had. Great. Thanks Robert. Tom help us understand the CDC has been engaged in this for decades as well. You personally have been involved. Tom Frieden has been very much a part of the administration's new global health security agenda which includes tuberculosis. Where do you see this from the CDC's perspective. Well thanks Todd and good morning. Thanks for the opportunity to be here. It's great to be here with my colleagues from the ID and PEPFAR with whom we work very closely on this. And many other other issues. And thanks to CSIS for bringing attention to this issue. It's a report. It's important. But it also needs to be followed up by action and implementation. You know I think we've all seen major progress over the decades but also agree that much more needs to be done. Recognizing that TB remains the single leading cause of death from a curable infectious disease. WHO recognizes this and has set these ambitious goals and targets that were officially approved at the World Health Assembly last month. And that's great. However that will require leadership particularly at the country level. Implementation particularly at the country level and of course has already been alluded to backed up by a sufficient resource envelope that can make that a reality. As Robert just said TB being a deadly infectious disease is also a humanitarian issue. It is embedded in poverty but it's also a significant public health threat. We have to look at it from both angles. And while it persists in many high burdened countries worldwide we also see it as a result of migration and global mobility. That has really changed the epidemiology of TB in low incidence settings such as here in the United States. Now in the United States the majority of TB more than 60% and the majority of MDR TB approaching 90% comes from persons that were born in other countries. So without significantly reducing the global burden of TB and drug resistant TB. At CDC we recognize that our ambitious goals for TB elimination in the United States will not be reached if global TB is not addressed. So now more than ever addressing TB is a global challenge with major domestic implications. And there's not a lot of issues we can say that about. Global HIV is incredibly important but we have a very different domestic HIV epidemic. We can learn lessons but our domestic HIV isn't dependent on global HIV. That is the case with global TB. There's a clear merger and overlap that's unavoidable and inescapable. This conversion of purpose it's coming at a critical time. We've seen tremendous advances in TB control in recent years but yet some of the basics of TB control remain unimplemented. We know how to control TB. At the same time we have new opportunities with faster diagnostics. We're getting new drugs. We're getting new treatment approaches. So the challenges we face are really growing in urgency and complexity. For example the spread of XDR TB to virtually every corner of the globe now threatens to undermine the progress that we've made over the last 25 years. The persistence of the co-epidemics of HIV and TB threatened to undermine the gains we've made in Sub-Saharan Africa with TB still being the leading cause of death in people living with HIV AIDS including those on antiretroviral therapy. And we also recognize our basic TB control efforts have allowed tremendous progress against the disease but yet we fail to reach a third of cases that go undetected, untreated and continue to transmit mycobacterium tuberculosis to others in their communities and health facilities and so forth. So strategic focus and investment is needed to accelerate innovations, scale up evidence based approaches particularly in the hybrid countries that Robert referred to. So we have to really be acting now and in the near future to take advantage of these recent advances and address these complex challenges before really they grow beyond our control and I think that's a realistic possibility. We feel our efforts really need to center around three core functions of a strong TB control program being prevent, find and cure. We have to invest in basic science and locally appropriate implementation research to improve local strategies around these core functions and working in partnership with ministries of health to scale up proven solutions both globally and locally. To prevent we need to improve infection control particularly in healthcare facilities and congregate settings and protect our health workforce and other patients. To find we need to reach at risk populations and serve the three million people we fail to reach every year. This can be reached through innovative outreach and screening strategies and building rational accessible laboratory and treatment networks. And finally to cure we need to ensure that all patients diagnosed are promptly and appropriately treated with quality assured therapy at health facilities that are close to home or some other reliable community based solution while also doing the innovative research to seek better drugs and treatment regimens. So as we find and cure more cases we'll interrupt transmission. We'll reduce new infections and thereby prevent new TB disease drug resistance and deaths. And in many ways we recognize that prompt TB treatment is indeed TB prevention. So there's multiple fronts in the global fight against TB is ensuring strong basic TB control rolling back the TB HIV co-epidemics and addressing drug resistance. In our effort to be strategic though we can't lose sight of the fact that if we abandon one of these fronts of this collective endeavor we'll soon be overwhelmed by our capacity to respond. The challenges we face in high burden countries have to be met through a coordinated and focused U.S. government response to strengthen TB control capabilities and I think we've done a long way in doing that. The U.S. government through PEPFAR through AID and our partnership with CDC remains a leader in global TB control helping to meet ambitious goals to reduce the TB burden worldwide by investing in innovative research providing technical support to partner governments and scaling up locally driven solutions. We also are important in informing global guidance and policy. In light of budget realities our approach to TB control has largely emphasized collaboration and coordination with unique contributions from each agency to comprehensively address TB control. You mentioned the global health security agenda and we've recently shown through a strong one U.S. government approach in a country that we can approach MDR, XDR TB in this way through the prevent, detect, respond model. This project was spearheaded by CDC but in close collaboration with DITRA, with OGAC, with USAID and partners in Uganda and as well as the Uganda Ministry of Health. In six months by integrating efforts and building upon existing infrastructure this project strengthened Uganda's ability to quickly detect and respond to MDR TB as well as other public health threats using the same mechanism and apparatus. Now Uganda has a well functioning emergency operation center, real time communication capabilities and a rapid and responsive laboratory network for disease detection. So I think we can move forward with a one U.S.G. coordinated response. This is one example. There are many others. So optimizing these approaches we're confident the U.S. can help forge new global solutions and accelerate progress towards the world free of TB. Thanks for the chance to respond. Thanks, Tom. Julia, you are Chief Operating Officer with PEPFAR. I think you probably have read just about every country operating plan that's ever been written. So you know probably better than anyone what's actually going on in the real world with respect to the U.S. efforts on TB HIV. So help us understand where this comes from the PEPFAR perspective. Thanks very much, Tom. Thanks for inviting us to join this panel and for the comments from my colleagues already made. And that's a nice entry or entree into making a few comments about implementation. So I'll do that as a second point. But I just wanted to first start with being grateful to the report for highlighting some of the areas where PEPFAR I think has done a good job in working across HIV TB. And the parts that you've highlighted in terms of coordination, emphasis, importance, we appreciate that call out. Because it is indeed TB HIV dominates any discussion that PEPFAR leadership either at headquarters or at the country level has about clinical services. It begins and ends with TB often in the conversation. And so it's important to say that in a public forum like this, how much we believe that we have a responsibility to address and the TB HIV co-infection. I think that was highlighted in the blueprint, which came out a couple of years ago now. Time moves quickly. And for the leadership that Ambassador Gooseby gave to that document and to emphasizing the role of TB. It's in the second roadmap, which is go where the epidemic is and it's the number one piece in that particular section. TB control is essential to controlling the improving the outcomes for HIV infected individuals. And so to that end, we also feel that treating individuals with ART, raising the policy from WHO policy from CD4 350 to 500 is an important step in controlling TB HIV. And I, and enrolling persons on therapy and keeping them on therapy is the most important tool we have in our TB HIV world. And so I think the incredible strides and advances we've really made collectively with the countries in which we operate and are supporting to enroll more persons on ART has been an incredible step forward for controlling HIV TB as well. So I wanted to underscore the importance there. The third thing I wanted to mention in terms of how we prioritize TB HIV is with the global fund and it hasn't been mentioned yet. I really actually feel it's an honor to sit on the strategy committee for the global fund board for the USG and I represent all three diseases on that board. While I work for PEPFAR, I work for Malarian TB when I sit on that committee and I am supported, I'm given positions, I'm educated and prompted and I hope that I've been able to carry the voice of TB in those strategy discussions. And in that forum as the new funding model has been developed and more recently a decision that the board endorsed and that is the TB HIV concept note development, the joint concept note for certain countries where the epidemics occur together. It's an important step I think for the strategy committee under Todd's leadership and for those of us that pushed that and then wrote the language for the decision point it was a good win. What is unsettling and now I'm going to move into implementation and some of the real challenges we have is to hear countries not wanting to submit joint concept notes. Having just come back from the PEPFAR annual meeting where we invited our global fund colleagues and senior colleagues to join that internal annual meeting, it is uncomfortable to hear countries, the leadership in countries say that they don't want to submit the joint concept notes for reasons that are unclear and certainly are not driven by epidemiology and need. And so we still have quite a lot of work to do when it comes to even working with leadership in country to understand the benefits of putting those concept notes in together and to having a very integrated plan. And so three very quick points about what I think are significant implementation challenges. The first is integration. The siloed nature of a national TB control program versus an ART program is still in the way of real progress being made. And we've moved along in some countries, notably Kenya, Tanzania and South Africa. But our work is not done in convincing the national TB control program to allow drugs to be dispensed where ART is being dispensed. And as ART programs have been pushed out to lower and lower level facilities that becomes incredibly important that we keep up with that piece of work. The second thing around integration that I would like to focus on is experts. So we've been incredibly encouraged by the rollout of gene experts, but it has been focused on MDR TB, that's fine. But we need to be quite smart about where those machines are placed in terms of where there is heavy HIV TB co-infection. The ability to diagnose accurately is limited. In fact, it's really poor. And that gets in the way, obviously, and why we have people dying. And on autopsies done, you have disseminated TB, untreated, undiagnosed, untreated, and persons dying from that. And the last thing is the incredible burden of treating HIV and TB on staff in the facilities. So the incredible volume of persons that are seen in facilities on a daily basis to 300 people, individuals who tasks have been shifted to them, and while they've been supported in that, they are not continually supported. Things are missed. Diagnosis is not made. Treatment is incomplete, lost to follow-up. These are burdensome challenges that we all have a role to support the caregivers that are out there doing the real hard work. So while there are many other issues, those are the three that I'd like to highlight that I hope we'll have some discussion with today this morning. Thanks, Julia. We're going to turn to you shortly for questions and answers. Let me just start with a quick one. Well, you and I and Joanne Carter were sort of sitting through these strategy discussions and the board meetings. One of the refrains that was quite common was from a number of the donors to evacuate Eastern Europe, and in particular, middle-income countries out of the perception that they ought to be carrying more for their own. I think we have some reports, including the Lancet study that you mentioned, Robert, showing that a lot of those middle-income countries are covering their own burdens. The bricks are covering something like 95% of their own TB costs. But in many of the countries where rates are on the rise, the populations that are being affected are not ones that garner political support. And without that political support, they don't get money. So we're in this dilemma where donors are leaving or they're being graduated. And the rates are rising and there's a lot of pressure on donors to get out. So how do we mesh our need to put more responsibility on those countries with the need to address populations that aren't being served and to achieve our elimination strategy? So how do we square those circles? And I think it would be helpful to hear from each of you around where do you see opportunities for us to raise the volume globally? It's one of the recommendations Steve mentioned, kind of building global leadership on this. How do we build more energy around TB globally? Robert, can you start? Sure. I'm glad you're focusing on the countries because I think in many ways getting information at the country level so that civil society in various different countries can use that for advocacy is going to be very, very important. So the first point is that we do need to strengthen civil society. I think we've seen in many different health areas that civil society has been very important both for advocacy but also holding people accountable when they make pledges. I'm on the Gavi board and there's actually now an immunization card for donors to see how they're doing in terms of their scorecard blank. And that's actually quite effective when you see how you're doing with other donors. So that kind of role for civil society. So in the TB world I think we have some nascent efforts but it's not been as organized and as robust as in other areas. The second point I would make is a lot of times the information about the work that we've done, some of the successes, is really buried within the community. We are not getting that out in a user friendly way so that people can take it and use it and really pass it on and be strong advocates. So I think we need to translate our work in a more user form, get it out to people and strengthen the civil society so that they can utilize that to hold people accountable. Great. Tom. Those are great comments. I think we also have an opportunity to make greater use of our global health diplomacy in this regard. We have a new office of global health diplomacy in the State Department that's educating our ambassadors as they go out to countries on the health issues unique to that country, not just in general. And I think our diplomats are better equipped with that knowledge and the need for advocacy with countries to invest in their own epidemics or health issues as we co-invest. Our investments are really there to meet the gap that they have, not the other way around. Using data, too, to drive these points, using epidemiology to tell them who is most affected, often marginalized populations. Excuse me. Coughing during a TV event, isn't it? Yes. Dramatic. Any great gene expert out there? I don't need the criteria. But anyhow, I think using data and impressing on people how huge this problem really is, just being in South Africa last week I was doing the math. They have 400,000 cases per year. If the United States had that epidemic, we'd have 2.4 million TB cases in the United States. We would be crushed. Our health system would be absolutely smothered and overwhelmed. Yet they're going through this on a daily basis, so people need to understand how big this problem really is in order to adequately address it. Julia. Well, a question around how to deal with finite resources and an infinite amount of need across many countries. And I would say that the discussion within the global funds will be a difficult one in the next two years. And I don't think that there is an easy nor a good answer nor a straightforward answer to how you deal with large epidemics and not enough money to go around. Certainly the domestic spending countries where it can increase is incredibly important. So if we focus on Eastern Europe for a moment, I think that the TB, increasing resources for TB may be more likely than for HIV. So the economic arguments around TB can be made for the general population. They cannot be made as easily for HIV. And while it's difficult to say that, it is reality. I'm not sure that we've exhausted economic positions for countries around what an investment in TB would mean in terms of the growth of their economies and the preservation of their populations and the good for public health as a whole. That would in fact help individuals who suffer from HIV TB as well in those countries and injection drug use. And so we could make gains across all three. So that is one area that I think warrants further exploration. Great. And I think we're going to hear during a later session on research. Dr. Goosby and others are going to talk about some of the work that's going on in implementation research. All three of you mentioned some of the lingering questions around how to do this better, how to integrate better, but also how to drive the cost of delivering both first and second line TB treatment to lower levels. We've got first line down to 1 to 500 hours per patient according to the Lancet paper, but second line TB is quite a bit more expensive because of the drugs and the way that the care is provided. So opportunities there maybe to also drive down the cost so that it's easier for those countries to cover their needs. So if folks have questions, we're going to try to gather two or three of them at a time and then let our panelists respond. Just throw your hands up. We have people with microphones because we are webcasting this. So we want people online to be able to hear your questions so if you could wait until we have a microphone available. So questions for our panelists? David up here. Yeah, David Briden with Results. I want to thank CSIS for this report. I think it really strikes the right tone. This is a matter of great urgency. And I think, you know, I want to thank to the Martin too for just being real about that the major challenges these countries are facing. And I just wanted to ask Dr. Kenyon in particular, you know, when we look at technical assistance and we want to get the most bang out of the buck so to speak. What I'm excited to hear about is that sort of more long term approach where someone is placed in health ministry over a long period of time. Rather than just simply relying on, you know, short term missions, now they're over 700 a year. Short term technical assistance missions, most of them not filing reports afterwards so you can't really assess the impact of those missions. So I just wanted to hear you talk a little bit about that because I think that's a really interesting way of trying for the US to have more of an impact over time. Now thank you for that question and I think that's our preferred mode of operation is to be co-located in health ministries, co-located with, in this case, national TV control programs, particularly using epidemiology to help them understand what are the drivers behind their epidemic, how are they performing and where can they take corrective action. Our challenges doing that in the countries that are affecting us the most are kind of following off the development agenda. Mexico, Vietnam, Philippines, China, where many of our immigrants are foreign born cases so to speak, I don't like the word foreign born but anyhow that's a quick way of saying it. And we would like to find ways to work with those programs more constructively so that we can help them address their epidemic which indirectly will benefit us down the road. But that's still something we haven't done yet and haven't found creative ways to do yet but it's something, it's a priority that we do have. But you're right, it's those long term partnerships. A lot of this is building trust and long lasting relationships that can affect change because otherwise we're not there if we're not going to change and improve the program. That's the purpose of being there. But it has to be a partnership and we can also learn things from their program that we can apply here domestically as well. Robert. No, I appreciate the question because I think our approach is that the most important way to address health issues is to have an in-country presence. So 84% of our funds actually go to the field so through the bilateral programs where they actually have a long term relationship. But inevitably you find that there are some gaps in your programs where you need experts to come in to provide assistance. You can't have, you know, 60 countries with all the experts around the world in those countries. So we look at it as sort of a dual model where you have the bulk of your resources at the country level through your bilaterals. Where you have gaps and you bring in the best of the world to come in and to provide assistance both to your in-country field staff as well as to the host country government. So that they benefit from that expertise that really, you know, very few people have. But then they're held accountable and you have people on the ground who can follow up and continue to work on that. Just a quick add on, I think that after just reviewing many country operating plans under PEPFAR, a reoccurring theme is lack of focus on the TB portfolio. So while we do have long-standing relationships with ministries of health and good integration and really good outcomes, how they hang together in a country and what you're wanting to achieve in this next year, in the next two years is sometimes missing. Not uniformly so in all countries, but there are some countries that have been at it for a long time. And when asked the question, what are you getting at a year from now? It was difficult to hear a response. So that's okay. It means that individual programs have been operating with good effect, but you do need to have a vision. So it's incredibly important to remind ourselves always and to support our teams that are in the field to always orientate towards a point of focus. That sounds like I'm stating the obvious, but when you're very busy, when you have a very large program and a lot of money to move, and a lot of partners to work with, some of these core parts can just be overlooked at times. So it's one of the roles that headquarters has within the interagency space is to just provide a reorientation or to help spur that reorientation on. Question in the back over here and then Mario up front. Good morning. Thank you. My name is T.I.G. Salam Blytham with Congressional Research Service. This is a PEPFAR specific question related to PEPFAR transitioning. PEPFAR has been wonderful in terms of both building political will for TB programs within countries as well as leveraging of resources for TB programs. In countries where we're looking at transitioning particularly like South Africa, to what extent could you talk about the plans are for the countries to be able to continue to use the resources for TB once our resources start to decline. We've seen recently, South Africa ramping up its investments in TB, but is there some concern that national investments may start to decline as they try and shift resources around? Thanks T.I.G. There's a question up here with Mario, why don't we do a couple and then we'll get with you. So Mario, we're from WHO, so well thank you very much actually for all what was said. I think it's very useful and very constructive. One of the key words of the report is leveraging. And so I was wondering particularly in the TB HIV area of integration of services and integration of planning if you like, now even pushed by the Global Fund with the policy that we know about. So how can PEPFAR really in the future leverage more towards that direction understanding that you have situations in countries which are quite imbalanced. You have an AIDS commission that command on everything for what concerns the world of HIV AIDS. And you have in some countries very little, you know, small national TB programs headed by someone who is under someone on communicable disease who is under someone that is director Genoese, under someone that is a minister of health. So we are talking about a very imbalanced type of situation. So is there anything that as PEPFAR strategically you can do to leverage better conversation and discussion between the two? Because it's bilateral, you know, in our understanding it's very clear it's bilateral, you know, some of the interventions are purely, if you like, the prerogative of TB programs. Some others are purely the prerogative of HIV programs. And so if these two don't talk or don't talk enough then you risk to have this sort of slow progress in implementation of the various interventions. Great. So first a question from Tiaji around the potential for maintaining domestic support when the U.S. starts to graduate itself. Julia, certainly this has been a key conversation with South Africa. CSIS has written two reports on the transition efforts there and the complexities involved. To help us understand how you see the conversation with South Africa about TB and their ability to maintain and even increase their efforts even as the U.S. starts to move out. One of the real pleasures about sitting on a panel with two colleagues that are PEPFAR as well is that I'm just not PEPFAR, we're all PEPFAR. So I also defer comments from colleagues in the PEPFAR family. We're all PEPFAR. I'm glad South Africa was the one pick as an example because I was going to make a comment about transition and that word that has become difficult for a lot of us. Probably everyone in this room at some point in time. I just wanted to make a plug that there are very few countries in which there's a financial transition happening. And it's only in those countries where we like to talk about transition as a word in isolation because we don't want to give the impression that by continuing to support civil society and government to completely own, lead, direct, manage the HIV and TB responses in the country that PEPFAR is backing away financially or technically. That as long as we're supported with strong appropriations we want to remain in good supportive roles. And our focus when we are transitioning anything whether it be a program or in a financial is to ensure quality. And so for South Africa the real emphasis is on money and on quality. So we're working closely with the leadership in South Africa to ensure that they're building their budgets. It's why the five-year transition, financial transition plan was over five years explicitly to allow the South African government to put money on budget. We were multiple years ahead here in the U.S. as does the South African government. To date they have met their own requirements for incremental funding. But it is in a year from now or two years from now that PEPFAR will take a very large drop in the support and we will plateau out at 250 million a year. And in one year we'll drop 100 million. We're still evaluating and wanting to make sure that the South African government will have the finances on their books to do that. And then the second is around quality and putting in place those markers that would indicate when quality has dropped off. And the loss to follow up is obviously a really significant one and completion of TB treatment is another significant one related to this particular conversation. Robert. Yeah, just a couple of comments. We have the blueprint which is really focusing on a strategy on the technical aspects of PEPFAR. But I think what we haven't really done is really look at more of a financial blueprint. And so actually this past couple of months Ambassador Birx the new coordinator PEPFAR asked USA to start thinking about how do we look more carefully at this financial transition. And fortunately we've been talking with our colleagues in the economic growth area all about how do you generate domestic resources. And so there's a team of folks that have been looking both at taxation improving the not only the tax system but also the recovery of those funds and then allocation of those recoveries back into the health system. And then moving countries from basically what you know from grants which they've been receiving to more of a loan based operation we've been talking a lot with the World Bank about that. Some of these countries I think through IDA they can actually get resources that they could then utilize for some of these activities. So there's a whole group of individuals where we've presented some ideas back to the heads of PEPFAR. We're in the process of looking at that so I think we'll see a much greater focus and emphasis on this in the future. But bringing together different disciplines especially our economists to be able to help us think through this in a more systematic way. Yeah I wanted to add the transition and leveraging questions are both very important. You know again coming back to the epidemiology when we know where the epidemic is and is going it's much easier to have this discussion about transition. And as we heard last week in our PEPFAR meeting we're not we're not preparing to transition epidemics that are out of control. The priority is to get epidemics under control and then have that with that in the back of your mind. I went through that in Ethiopia where we had a very recent population based study we understood incidents was rapidly declining. We could see the light at the end of the tunnel and it's the time to have that more advanced discussion with the country. So I would link transition to where the epidemic is or isn't. On the leveraging that's always a challenge because our TV staff will work with the TV program and our HIV staff will work with the HIV program. And as Mary and the others know as well as others that's taken decades to get the two to talk to each other even though they're right down the hallway from one another. But I think we're doing better at that. But I found it very helpful at the country level where we had the TV stream and the PEPFAR stream to sit down with our colleagues and work out how one could support different aspects. Maybe you work more on the diagnostics. We'll work more on the treatment or you work more on it. So we divide up the labor so that we're not having any duplication at the same time that we're addressing gaps. Yeah the issue of transition is one that CSIS has followed. I mentioned the two reports we did on South Africa. We had an event a couple of weeks ago with folks from the Elizabeth Glazer Pediatric AIDS Foundation to talk about transitioning from an international NGO to a local NGO. So it is a theme that we're hoping to pick up on here as well because it is critically important. Not just for those countries where we're looking for more of a financial emancipation but also even earlier conversations with countries that may be grant dependent for some period of time. So there's at least a conversation started early around what is what's the trajectory of decreasing dependence on outside financing. Mario raised a little bit the question around engaging some of the national TV coordinators. Tommy touched on that Julia did that come up in the conversations in Durban. Are the PEPFAR people talking to the TV coordinators or is there a way that we can help them raise their own stature in countries so that their efforts are somehow getting more attention. It didn't specifically come up in the sessions that I was participating in but it does happen and I think we are doing better at it. But interestingly I would say the role that WHO plays in country is an important one. Important one from the perspective that governments listen to WHO. They're a good broker on the technical leadership side of responding to epidemics. And I think a more concerted effort between WHO and PEPFAR is an important one to try and accelerate this. So there is an assumption that one party is doing it but I think really being quite specific about how we can choose a few countries and have a renewed effort together around elevating the status of the national TV control program leadership is an important one. I think the joint concept notes are an opportunity where two funders can force the point and I am discouraged to hear that leadership in country are less interested in submitting joint concept notes and that just underscores that we have a problem. And understanding what those specific problems are in the countries that are resisting will be an important piece in the next six months. We don't actually have a lot of time to work on this. The moment is really right now. And the other opportunity I think PEPFAR does genuinely have is that when Secretary Kerry announced last September the country health partnership concept or framework for how to engage country leadership in planning in the long term and negotiating how funds are spent and where how epidemic control is achieved that is an opportunity to bring in different players that aren't necessarily in the HIV dialogue and that would be national TV control programs in that discussion. Giving them more opportunity to be in the discussion and a serious discussion and a decision making one. And maybe as you mentioned working in the World Bank they are also very much typically in conversation with ministers of finance. They are often involved in medium term expenditure conversations so building a partnership with them so that they are actually working with countries to put TV in the budget at a more significant rate. Robert you wanted to come in. Yeah just to make sure everyone is aware that actually we have had a lot of activity in PEPFAR of looking at bringing different elements together. So the TV family planning work I'm sorry HIV AIDS family planning has been I think very very strong and also I would highlight the work that we have done on maternal health using the PEPFAR platform under the Saving Mothers Giving Life program. So there are ways in which we can build leverage platforms and activities because we are all at the same facility and by you know just making sure that when women come in that they are able to be given multiple services and that these different elements are collaborating we make our program as much more effective as we work for. So maybe there are some more learnings that we can do on the TV HIV AIDS. I think there is one hand here one in the middle one over here and then Joanne I'm going to put you on the spot because I also want to get a quick note from Stop TV you're the vice chair of the board. It would be really interesting to hear quickly how you see USG efforts in this area and whether or not you see opportunities for improvement. I'm Deborah Dortzbach with World Relief and I have a question to piggyback from Dr. Kenyon on your three functions of prevent and find and cure. And we are working at the community level with piggybacking on child survival health grants using care group model that we've used very successfully. And I think we've discovered some interesting finds adapting it for TB and working with communities as you said in your interest in finding and curing some community viable solutions. I'm curious to know from your perspective we can find interesting cases suspects at the community level and then engage with the ministries but sometimes it's a bit frustrating. So we can rouse the community and get a lot of interest. I'd be curious to know what do we do then how can we be more effective in bringing ministries of health and communities together. Hi Jill Gay what works association and question from both the PEPFAR perspective and the Global Fund perspective. Given PEPFAR's new gender strategy and the Global Fund's new emphasis with the gender equality information note how do you and the numbers on women and TB as Gavin Churchard said to me last week TB has become a young woman's disease. It's transitioned and yet there's very little on how we outreach to women how to do the active case finding how we address the stigma issues. There's a lot of sort of literature around the problem but very little on sort of evidence based interventions about actually reaching women who are co-infected. Thanks we had one question back here and then. Elizabeth Aserifi and I'm a former WHO tobacco policy person and for the last six years or seven I worked with the Polish government so my question is much more on the Euro or Eastern European question and a comment maybe too. My question is maybe directly to PEPFAR so I guess all three of you in USAID it makes it easier in a way. Poland is considered now as less of an Eastern European country or would like to kind of portray itself more of an Eastern European but a Central European country. At the same time it is borders Russia, Belarus, a lot of the real Eastern European countries or former Soviet Union countries and it is kind of a place where a lot of the transitioning or people moving from East into the European Union are transferring into. And so the question really is what is USAID and PEPFAR's relationship now and outlook on the future relationship with Poland especially since we're talking right now a lot about transitioning and countries really being responsible for a lot of the budgets themselves and my experience was that yes Poland was responsible a lot more for the budget but because of it a lot less work and a lot less was really being done so on paper the budget looks good but realistically it's a lot less being performed and it is a kind of a high risk area. I wanted to just say one statement while the relationship through the State Department and USAID is really still important for you in a country like Poland which is a 99% Catholic country. The last month there was actually a kind of a policy paper that was being asked for doctors to sign which would say that any kind of diseases or not ethical diseases that people get doctors have a right not to treat them and a lot of doctors have actually signed it so now we're actually trying to kind of do a drive to say that well these doctors should actually then be removed even to be doctors because this is really unethical but it is a very strong drive so it is important to think even in countries like Eastern Europe. It will be interesting we heard last night from David that the Pope actually had TV so I wonder how he goes along with having an unethical disease whatever that is. So we had two questions here one around community and how to engage and maybe just to twist on that a little bit how are we working on community-based modes of care because particularly for second line there is a fairly clinical approach in many places which is pretty burdensome on patients and expensive to provide. So how are we doing with community and then the other was around gender how are we doing with gender and then in the comments in Eastern Europe where we have one win remaining so we'll take a few extra minutes. Steve will sell them to me cheap. If we can have quick responses that would be great. Julia can you start. I'm going to start on the gender one if that's all right and I thank you for the point and I would say that our gender strategy does not go into specifics of TV. So point taken I do think that there are overarching principles with the gender strategy for PEPFAR and what is currently under development with the Global Fund about how to access women in general where to find them how to empower them which are applicable to any disease but the specifics of TV no that's an honest response that's not where the focus is at this point in time. So I think the going where women are and understanding their prioritization is very important to understanding how to bring them into care. So they have a lot of priorities and the last of which is themselves it doesn't just doesn't work that way. So we have had quite a lot of positive gains made I would say in the last two years in the OVC world in the orphan vulnerable children world where this abuts to the community care and accessing communities and bring them into facilities and that is with how do you use programs that are directed at children to also access women and to help the needs of the children along as well or the caregiver. And so I think the integration using OVC programs to link community programs to facility programs is a new-ish effort for PEPFAR and one that is showing some rewards and I think we could swing a gender component into that as well so thank you for raising it. Tom. Well I think the community is an essential partner in a national TV program but the community can't be the national TV program it has to be backed up and so and it's very country specific the role of the community in a national TV program that may be used for case finding or sputum collection or treatment observation but the community can also be a strong advocate for services to the extent that that's allowable in a given country where you know the political dynamics are different in different countries but so I think one would want to engage the local USG team in your case to see what can we do as agencies in that country to mobilize the government to be more responsive and I'm sorry about not a more specific answer than that but I think it would be very country dependent. I think on Eastern Europe and TV and just I think we have an opportunity through the heightened awareness around global health security and the international health regulations and the concern about antimicrobial resistance to get TB in the spotlight in that sense and you know when the discussions around antimicrobial resistance it's all about bacteria but nobody in our center I've said no it has to be about malaria and TB as well because those are huge concerns as well on the global front if we have malaria resistance certainly we do have TB resistance so I think getting those on to the agenda and I would elevate MDRXDR to a global health security issue as we've done in the pilot project in Uganda it raises the profile of the concern it doesn't make it that's the only concern about TB but it raises the profile it prompts action and investigation and then people can figure out what's driving this so that they can take the appropriate action. Robert. Just so quickly on the community front it's a very important question we actually we had a evidence summit looking at the interchange between the formal health system and community workers because we noted that there's a lot of literature about both of those but not how they interact together so it seems to be a gap and so based on that we're looking at ways in which we can support more implementation science to learn how those two very important components of our program actually interact a lot of is referral but also support for both training and supervision as we look at the community based work so that's an area of ongoing. We in terms of the gender we have a lot of increased activity and gender work in the Global Health Bureau. I think we have now eight or nine individuals in our bureau working on gender. I can't say specifically on TV but there is a I know a person in the office where TV is that focuses on gender so we can get back to you on that and then on poll and I would say Tom mentioned the global diplomacy office. I think that's another area or tool that we have to interact with people and particularly when they're looking at human rights issues because we're finding more and more of health is not just at an implementation level but it's also at a policy and a diplomacy level and so using the State Department office through the ambassador through the DCM and the political officers to be able to raise health issues and have that dialogue with country has been very effective for us in many ways. Thanks I wanted to we had Jenny I think you had your hand up so we have time for one last quick round and then Joanne I want if I can put you on the spot just to get a quick feedback from Stop TV. Great that's great thank you very much so Jenny you had your hand up. I saw a hand back here where was the hand up here. I'm missing imagining. I'm not Jeannie. Hi my name is Paul Emer I'm a retired Foreign Service Officer USAID and I've had quite a bit of experience with the Global Fund as well and Global Fund 1.0. I just wanted to ask a question that follows on the question about community and it's related to stigma. I think one of the major issues in this field is the area of stigma and it's a huge political challenge I think both for us here in the United States and it's also a political challenge in the countries and I wonder if we could hear from maybe each of the panelists about the USAID CDC PEPFAR approach as to how do you deal with that important advocacy issue hitting civil society organizations you've already pointed out on that but you've got to have people who are able to bring home that message and it's a huge political problem because it's easy to measure a lot of the technical aspects of TB and HIV programs and report back to Congress so we can get more money for them but it's very hard to measure how do we deal with stigma and so I'm just wondering how you all are looking at that. Julia? We have lots of experience in the HIV world and this is just about one comment and there are other areas and pieces of work that I think we've moved the needle on stigma but that would be the response of the healthcare worker to the individual in front of them and how the person is treated so that has been a significant area of effort for HIV and I think it applies also for TB. The interaction and how the person is treated once they hit the door of the facility is incredibly important as to whether they ever return and how they feel about themselves and the illness that they have at that precise moment and it can be everything from body language to the opening questions to where you're seated you know these are self-evident things but they're not done uniformly and they're not done well and this goes back to my opening comments around staff support and the healthcare worker and how they are both trained initially and how they are supported in an ongoing way to really be mindful that they are not only the gatekeeper but they are the retainer for the person in care and treatment. Tom. In addition to that and health workers being a source of stigma I think many of the populations that we work with on these two diseases are already stigmatized and before they had these diseases the homeless, the incarcerated, the injecting drug user the alcohol abuse person and I think the origins of stigma are often ignorance about the disease in itself and so there are many approaches I think we found in HIV that we still have a lot of stigma just the hope that's been created through treatment has helped to melt a lot of that stigma but you're right it's not to where it should be and where we would hope it to be and it's something we should study more and study its origins so we can come up with appropriate solutions not just assume that we have the solutions ourselves and encourage local investigators to do that. So it sounds like we have maybe another implementation research agenda Dr. Gooseby's shop is going to be quite busy over the next coming years