 Good morning. We have some open chairs. Open seats up front. Please come on down. Good morning. I'm Steve Morrison from CSIS and thank you all for joining us here on this wonderful spring morning. At the end of an exhausting and crazy week here, I think we're really very fortunate to end this week here on this subject with Gita, Mark, Judith and Deborah. Mark will be joining us. Mark Diab will be joining us momentarily. It's a really important and pressing and timely subject. We're going to touch, I'll say a few words about that in a moment and we're really very fortunate to have these four thought leaders here to share their outlook on this. I also want to congratulate Janet Fleischman and Katie Peck on the publication today and I hope you all have a copy of that. It's a terrific piece of work and really capturing the moment and where we are in these initiatives that we will be discussing today. Special thanks, of course, to Janet and Katie, to Talia Dubovie, to Deb Derrick, Anjali Afrakar, Craig McClure and many other people who worked with us to pull all this together. We're very grateful to you. Addison Smith and Alexandra Sassoon made a lot of contributions, interns here with us, thanks to all of you. We are at a very extraordinary moment. There's very stark data on HIV in adolescent girls and young women, particularly in East and Southern Africa, we'll hear more about that, and rising global momentum to respond in new ways. This is a key challenge to achieving an AIDS-free generation and we've got exceptional leadership. We're very, very blessed with the exceptional leadership that we're seeing now, with Ambassador Birx, Ambassador Dible, Tony Lake and Gita Rao Gupta, the Pop Council, Judith Bruce. Chief among the new initiatives in the Dreams partnership, launched on World AIDS Day, the Dreams partnership, launched December 2014, PEPFAR, in partnership with the Bill and Melinda Gates Foundation and the Nike Foundation, committed to significantly reduce new HIV infections in adolescent girls and young women. As we'll hear, over $210 million committed, highly ambitious goals, the Dreams partnership aims to address HIV risk for adolescent girls and young women in very high burden hotspots in Southern and Eastern Africa. This is long overdue. This type of thing is long overdue and very welcome. The goals are quite high to reduce incidents in high burden areas by 25% in two years, 40% in three years. The challenges we'll hear about today are daunting, but they're not insurmountable. It's very imperative to show significant impact quickly within a short two-year timeline. That will be a challenge. Success rests on really working with partners in the countries that are empowered to bring about major political, social, cultural shifts in norms and practices to shift some of the economic realities. These are difficult structural issues that stand at the center of the strategy, and it requires very strong sustained host country commitment at all levels in a dynamic political strategy. The way forward is going to figure this morning in our discussions, the critical moment to begin to transform this rising consciousness, this glowing global interest in these issues, and women and girls into effective HIV programming and to highlight the results. Looking forward at the 2016 International AIDS Conference in Durban, South Africa, I think we need to sort of keep in mind that we have the opportunity to really show dramatic gains in this period and really celebrate and put further emphasis on that, as I expect we'll see in Durban in July of 2016. U.S. leadership and bipartisan support absolutely fundamental to moving ahead, public-private partnerships, private sector engagement, and obviously galvanizing the partnerships with the Global Fund, UNICEF, Pop Council, and others. So please join me in thanking everyone here. We're going to begin, Mark will jump in as he arrives, but it's over to you, Janet. Thank you and congratulations. Your leadership on this has just been remarkable and I'm very grateful to you. Thank you. Thank you all so much for coming. I'm Janet Fleischman, a senior associate here at the CSIS Global Health Policy Center. We are delighted that so many of you could come and we welcome also our audience online. We want to just dive right in and turn it over to Ambassador Birx to give us an overview of the DREAMS partnership. Great. Thank you and should I share the slides now also? That would be great. Okay, so actually looking out to you all, I see individuals who have been raising this issue for years now and have had focus on young women. So thank you for your work and thank you CSIS and Janet for putting this together and for this brilliant report. It's really, hopefully everybody got one. It's really terrific. I just flew in from South Africa yesterday morning, so I'm not sure how, and I went running to meetings, so I'm not sure how jet lagged I'm going to be, but thank goodness you did this in the morning. But it was, I was just with the caribs, with their caprices, so I'm just going to show a little bit of their data at the end. But I think all of you know where the burden of disease is and this burden of disease is very much mapped also to the risk of two young women. And when you look and you dissect the UNAID's numbers about progress, these light blue bars are the progress we've made in prevention of mother-to-child transmission. And it's really quite astounding. Every country has made extraordinary progress and we can all say we were part of it, but really the person who was part of this are pregnant women who came forward. And that's been true since the very beginning of single dose nevarapy. Pregnant women came forward to protect their babies. So women have really sacrificed much to get and help support control of this epidemic by decreasing mother-to-child transmission. And we owe it to the young women who were born then AIDS-free to figure out ways to protect them from HIV. And so this is really, I just wanted to show you really quickly, the dark blue bars and the reason they're dark and ominous is that's the impact we've had over the last eight years in these countries in transmission of adult new infections. So you can see a whole series of countries, Angola and Uganda, it's actually been increasing. But if you look at Ethiopia, Kenyan, Lesotho, no progress over the last eight years in preventing infections between adults. And this is really, I think, a very stark message to all of us that we have to do better. This was from the UN AIDS GAP report. And I think I just want to recognize both UN AIDS and Michelle Seedy Bay in raising this issue over the last two to three years. And really Ambassador Dible who's been talking about this consistently over and over again of raising this alert of these infections in young women. But that big red circle in Sub-Saharan Africa recognizes the number of new infections that are coming from young women. And this is also their graphic. And country after country, no matter what the burden of disease. So whatever your prevalence is, your prevalence in young women is always twice that of young men. And it's really quite telling to all of us. So when you break out those numbers of 7,000 new infections a week, it sounds so anonymous. But when you see that it's almost 2,400 in South Africa, that's overall, it's 1,000 new infections per day. And we're not mobilizing across all of us with having different talents and different insights to really deal with 1,000 new infections per day. But finally this is the numbers and you can't see them now. I see that quite clearly. So the under, right under 16 is 17 to 18. And then 19 to 20 and 21 to 22. This crashes the data. By 20, 30% of the women. Is your microphone on? No, it's not. Could you hear anything that I said? Yeah. That was my previous life. That command voice. So good it's on right now because this is the important slide. So 30% of women positive at age 20. And 50% by 24. This should be an outbreak. This should be mobilizing all of the resources in the same focus that we put on Ebola. This should be all of us coming together and saying this is a crisis and we can't accept our most valuable commodity, our most important human capacity on this planet. Young women and all of their opportunities that they have and the choices that we know that they'll make for the family, for the community and the leadership role that they'll play. And we have 50% HIV positive by the time they're 24. Now, of course, these numbers are quite compelling. It is a region of Southern Africa and in KZN that has very high prevalence in general. But there is a cascade like this that you could see over and over again that matches the cascade of early pregnancy. And we know how many. We just heard that number of women that are pregnant as teenagers. So I think hopefully this is a call to action. Thank you for the report and thank you for ending with opportunities and challenges. But looking at all of you, I see it's a response that we're going to be able to do together. So thank you. Thank you so much. These slides are very compelling and your leadership on this in propelling the attention forward is going to be fundamental, I think, to the U.S. government's response. So thank you so much for what you've done. And it's more than just the U.N., the U.S. The U.N. is also involved and has launched another new initiative focusing in part on this population. And we have Gita Rao Gupta here from UNICEF. And I wonder, Gita, if you can tell us a little bit more about the all-in initiative and why the UN and UNICEF in the lead has launched this now. Thank you. Thank you very much, firstly, for hosting this event and for including us. I have to say that we have failed adolescent girls for many, many years now. This is a really happy debut to hear you sort of have a can-do attitude because we must, we have to maintain that can-do attitude. And thanks to people like Janet and Judith and others who've been in many of you in the audience, as Debbie said, who have been persistent in keeping this issue on the agenda. But ultimately, we knew, and in fact, as I was saying to Judith earlier, this was a tsunami that hit us a while ago. It's just persisted since then. And we have failed adolescent girls by not coming up with a strategy or by directing targeted resources to them. And that's what Dreams is now trying to fix, what All-In is trying to do. All-In is really a platform for collaboration and action. It's bringing together a range of partners within the UN, so UNAIDS, UNICEF, UNFPA, UNFPA and WHO, as well as the Global Fund, PEPFAR, MTV and the Global Youth Movement. And it's focused on trying to mobilize young people to be agents of change themselves. It's trying to use data and sharpen programs by making them evidence-based so that we really target the places that need the most resources with the interventions that will work. It's intended to foster innovation and it's intended to advocate for this issue and mobilize more resources. The good news is that we now have resources. We have the commitment from PEPFAR and from Nike Foundation and the Bill and Melinda Gates Foundation. And that's terrific because that was a missing piece for many, many years, is that they weren't targeted resources for this issue. So I think we have come a long way in that sense and there's an opportunity now to make a difference. And I think the UN agencies certainly want to do their bit. We have in UNICEF our country offices in over 130 countries that can work with governments and with civil society partners and the private sector. We're trying to mobilize resources from our national committees which are independent nonprofits and industrialized nations that raise money for specific issues. So this is now high on their agenda. So we're really hoping that all in will mobilize and support dreams and other country programs and governments to really make a difference for adolescents now. And of course there are groups like the Population Council that have been working on this population for a long time and certainly Judith Bruce has been a pioneer in that work. Can you tell us, Judith, what are some of the steps that you have developed over the years to reach the most vulnerable girls who are at risk of HIV infection? Well, I'm delighted. And again, congratulations on this effort. And Janet, you have been a persistent advocate all the way through. Very appreciative. The Council began its work with adolescent girls really around 1995. And our problem statement, and I think it's a useful beginning point, was to build the health, social, economic, and cognitive assets of girls, protective assets of girls in ways that help them prevent, mitigate the effects of, or leave unsafe sexual relationships. At that time we identified as the core drivers of a lot of bad outcomes including HIV, persistent social isolation of girls from their own core authenticity as well as from friends and their communities. And then the economic dependence which I would venture is actually rising and the role of sexual transaction in entering economies I believe is rising. The countries in which this initiative is dedicated, I checked last night, between 50% and 75% of the girls who are adolescents will be single mothers. Most of them will arise from after they've had a child which will, talking about the vicious versus the virtuous cycle. So addressing social isolation and economic resilience is first of all one of the ways to stop this train. In terms of the council's program, using the data and actually using maps and so forth, we overlaid data on vulnerabilities of key populations, what proportion of girls 10 to 14 are living apart from parents and not in school, what proportion of girls believe in all five scenarios of beating, what proportion of girls are married under age 15 and so forth. And we came to basically the formula was we wanted to prevent the worst human right, the worst human rights abuses in the youngest populations. So we prioritized the places where there are high levels of child marriage, which unfortunately has that word marriage there because there's nothing very sacred about what's happening there. And HIV and that led us to Ethiopia, for example, where child marriage and HIV were not only both comorbid conditions but both present, South Africa, Kenya, Uganda and so forth. The features of the programs are that in those geographies, you pick program locales, in those program locales you do a listing of households and now we've got a new app which is much simpler and fast, but basically so you have a denominator and you say, okay, what proportion of girls fall in each of these cells? I know there's some girls 10 to 14 living apart from parents and not in school, but I didn't know that there are 137,000 of them. You get the figures like that. And then look at those, that arrangement. So on this axis are the segments of girls. What are the numbers? What are the groups we really have to reach? And within those groups, in other words, the peers we're talking about are girls who are like each other, similar age out of school, similar age in school. And of course the epidemic, all those girls are at risk but the risks, the degree of risk and the types of risks. And then build programs that anchor safe and supportive spaces available at least once a week, at least once a week for at least a year because they have to get through all the seasons of risk, the scenarios of risk. And mentored with local mentors who are often role models, girls who've survived this. And then content which is benchmark to core assets they all need to live, lead their lives. What can you give to a girl that no one can take away? And the last but certainly not least step is very careful linking of those girls to the existing entitlements and facilities and resources which is where I think dreams can come in really well which is that those linkages have been weak, they can be stronger and those platforms cannot only deliver some of this stuff but they can make the specific vouchering and other systems which mobilize the investment on the ground for HIV that hasn't reached the girls yet. And that leads directly back to dreams. Ambassador Brooks, can you tell us a little bit more about the core package that dreams is trying to develop? And what that will look like in terms of programming on the ground? What's different? Well, I think both our children's initiative and the dreams initiative took a different approach in that we didn't come into this with any preconceived notions. And so at the very beginning we brought all of the countries together to start planning together. And fortunately people were so generous of their time and we had the world experts that talked about the impact of education and all of the studies that have been done there, the impact of violence against girls and gender-based violence and the impact that that has had and the programs that could mitigate that impact. The work done in cash transfers, the work done in family planning. And so we had experts in the field come and present in South Africa and then the teams which included UNICEF and UNAIDS and all of our multilateral partners and Global Fund, the Ministry of Health and Civil Society, they sat down with teams that said, and we had models all there so they could run scenarios. If you have coverage of this, what impact do you have if you put this together? Now what we found was there were very few studies that combined what you just described that combined the different things that we know are impactful together. And look to see is 1 plus 1 plus 1 is not 3. See, this is the problem about being chat lag. Or does it equal 6? And if you ask my team who are still panicked about these targets, we're saying it has to equal 10. So that is a big leap forward. But Dreams is about these, what we now call the Dreams teams, on the ground looking to see what kind of program can they build and then what are the wrap-around and ongoing daily almost monitoring of incidents of infection with using surrogate of prevalence in young women and young age groups. Are we having an impact? Because we feel compelled that this is really an emergency and needs to be approached in an emergency. So I can't tell you exactly what Dreams is going to look like because it's going to be a community by community country by country plan developed from the ground up with all of the stakeholders around the table on time. Those plans are coming in as we speak. I haven't seen any of them. What I do know is we're going to need more resources. I know that countries have put amazing work into this and really have a plan of how to move forward. But even with targeting, and we're targeting this to only the highest burden districts right now. So targeting this in a very granular way, there's still not enough funding. And so I think we think of the Bill and Melinda Gates Foundation as founding partners in Dreams. And I think once we have the plans, we're going to work very comprehensively with other multilaterals and bilaterals to make this really a village that's going to respond to the young girls' needs. So that's... I can't tell you precisely what it is, but I can tell you it includes all those different sectors, including probably some new biomedical interventions that we will try with some careful monitoring around it because we think an emergency requires risk-taking. And we're going to put together a very aggressive programming and see if we have an impact. And Gita, I think the added value of the UN is looking at this in terms of multi-sectoral interventions and some of the policy reform. Maybe you can tell us a little bit more about how you see all in complementing the work of Dreams in this way and anything else you wanted to add to that? Before I go into that, I just wanted to share with the audience and perhaps Judith will remember this, but many years ago we had come up with how do you define power in society? What are the sources that give you power to control your own destiny, which is what young girls don't have and which is what you're talking about and Judith is talking about, that we need to give them somehow. And we came up with a very simple framework. It was access to information and education, whether that's about your body services and technology, having access to those, having access to income and employment, some access to economic resources, social capital, social networks, not feeling isolated, not being alone, security, so not living constantly in fear of violence or being beaten and a voice, an ability to participate in decision making that affects your life. Those were six ingredients we came up with and if you take each one of them and you look at something like child marriage when girls are being married underage, often to men much older than them, you can see how their access to each of those resources gets depleted, because they have no voice, they have no real security, they're socially isolated, et cetera, et cetera. So in order to design a program then for adolescent girls, we need to have interventions or policies that support them and enable them to either protect the assets that they have in each of these categories or to give them those assets when they don't have access to them. And that's why this multi-sectoral approach is incredibly important and I think UNICEF has an advantage in that regard because we work across many sectors to be able to bring that together. But it also is an opportunity for us to collaborate as UN agencies, not just within the UN, but with the Global Fund, for example, with PEPFA, for example, with the Population Council, to see what are the different advantages, what is the comparative advantage of each of these institutions, organizations, and initiatives, and how can we lend our comparative advantage to that to make this happen as a whole. Because I think that's where we've failed. We've tried to take one piece, you go to Congress and you're often asked by congressmen or women, tell me the three things I must do. I remember being very frustrated by that because three things are not going to do it for girls. It's not going to do it. You're going to have to give them more than those three things, six things simultaneously, in order to see the impact. So I couldn't agree more that you need to make the investment on multiple fronts. And to do that, we have to leverage each other. And I think one of the things that UNICEF is doing pretty successfully at the country level, through our country offices, is leveraging the global fund assets and monies that countries are applying for by making sure that the proposals that they develop have in fact are informed by this understanding and can target those resources then to adolescent girls by making sure that the resources that are spent on malaria or on HIV, in fact are sort of provided on a platform that's a broader maternal nutrition and child health platform. So to be able to leverage the resources that exist to benefit adolescent girls from many different fronts. The trick, though, is to be able to work within countries across ministries. That's the challenge. That's the challenge that we have not been able to address very successfully. How do you get the HIV folks to work with the education folks to work with the Ministry of Rural Development to work with agriculture to be able to provide those assets together. And I think one way perhaps, Judith, is to focus on the hotspots, to really target those efforts in a particular way. Judith, I wanted to ask you, because you've done so much thinking on this, how do you measure this? How do you measure the impact? How do you measure the change? Well, I'm going to take off from Gita's point, because I think that's where we, you know, we will all say act, think globally, act locally. And this is the place to do it. If a girl can't walk to it, she can't get to it. That's maybe true of a lot of us. So I think the geographies you're talking, get within the hotspot geography, and that can be a very large place. And within that, you have program catchment areas. And the test, I think, is, I often call it multiple content, because I'm not always sure when can get the ministries to collaborate. But we have largely collaborated with local delivery systems, often government, by the way. But the youth ministry of Amhara is living in the middle, wasn't living in the middle of that HIV epidemic. They were very responsive. They had very little resources. At the subnational level, it's where we have focused, in terms of even developing delivery systems. It's very good to have, obviously, the imprimatur of approval at higher levels. But delivery is local. The cavalry is there. The personnel is recruited there. The mentors are those who come from those places who have done something exceptional, because one of the, what are your assets? Once you've done a household listing, you will also discover there are 30 girls here who actually have finished school. They're just lying on the shelf. They can be part of our program. Anyway, the delivery system is local, almost always, but scalable. So, for instance, one of the programs in Ethiopia is now reaching 250,000 married girls and married girls clubs. Measuring, and sort of where we start. The domains that Gita outlined show measurable differences at baseline, not only between boys and girls, but among girls. So when you lay out girls, you'll find girls with much higher levels of capital than others in many programs, in many current programs. Unless they do dedicated recruitment, we'll have elite capture that's actually quite severe. Fewer girls than boys, in many cases, and I don't want to say the wrong girls because they're no wrong girls, but the more advantage girls. So you want to devote one measure, I would have a quality of a program, is an intentional plan. Who are you reaching and why? How many of them are? And where are they at time one and where are they at time two? And the time one, time two assets per segment, so let's say I've got girls 10 to 14 living apart from parents and not in school, will be knowledge assets like, obviously we begin with their body, health, resources in the community, social capital issues like whether they ever visited it, they know it's there, whether they have identity cards, or anything that actually makes them feel like a person, it's not just a, it's both symbolic to them, it's practical. So within these domains that Dida mentioned, per segment, where are they at time one, where are they at time two, and what do we need to do? The next analysis is what do we do through the platform? And the platform for the girls, the safe space works best if the community and the girls understand that she has to go there every week at least a couple of times. Savings is great because not only does everyone like savings, but it's a regularly occurring activity. So regular, a regularly occurring opportunity, and that's how her social capital is built. So if in the first year, or the first four months even in many cases, you hit core competencies per segment. They know about HIV, they know where to get tested, some may already have been tested. The risk assessment is more accurate, which is an important one. By six months to 18 months, or again, sometimes before, they've got established relationships, they have established safety nets, a place to spend the night in an emergency, money to access an emergency, someone to turn to. Financial literacy is, I think, a fantastic intervention. Our colleague Kelly Holman and her partners in South Africa showed that just having a financial goal changed your calculus around risk. You were much more likely to get tested. And then I think after about 18 months, you might even be able to move into some of the biological markers, HSV. And in terms of technologies, which I know there's an interest in, if these are foregoing steps are laid down, you then have a group of girls you can say, and here's another option on the menu for you. But then you have the trust for the girl, first of all, to know she's making a choice. And you have the environment that you're going to need for adherence and studies of adherence. So I think there's a, I think we can measure at each level, but it's a sequence of, sequence of, these are not oppositional. It's not either or it's sort of ESM. And we build up to some of the demanding settings that I think, Ambassador, you're speaking about, that we're going to need if we're going to introduce technologies. Ambassador Birx, you're trying to get things done quickly and differently. Can you tell us how dreams is engaging governments and civil society early on in this process in a way that's different than PEPFAR has operated before? Let me just say, so I just, Judith, I loved what you just said. I love that you said focus granularly. We have to really know what the issues are on that ground for that girl and then meet the needs of that girl in that community, which I think is so powerful. And then saying that we need to have outcome impact measures, not just girls reach, but truly impact measures around those girls. And I think that is revolutionizing how we're thinking about it. So thank you for laying the groundwork for that. It really did inform us. We were very fortunate a year ago and we met with many groups who really gave us their best insights and opinions. And it's really helped format how we're thinking about this. And it was because of those interactions that I was privileged to have with many of you in the audience and hear your insights from years, months, even sometimes days of programming on the ground, but really your insights on how we could do things better. Let us to really believing that if the planning started multi-sectorial from the beginning, that we have a potential to have a different outcome. And so this is really granularly planned with support round models around utilizing best available data that says if we do these six things together, what can we expect? And again, not knowing what the synergy is, so we didn't put any synergy into the model. So we're hoping that these six things together, as you outlined and you spoke of so eloquently, Judith, together we'll have this impact of 10% and 40%. Now people, I will tell you, I see some of the individuals from our program. This 25% impact and this 40% impact, they look at me every day and say, that is highly risky. And it is risky. But look at what our options are. The slide I didn't show shows the youth bulge, the demographic diffident in Sub-Saharan Africa. We know 50% of the population is extraordinarily young, mostly under 25. But in South Africa, if you look in every country, we're doing these demographic profiles. We have anywhere between 30% and 60% more girls at risk today than we did at the beginning of the epidemic. And so the very essence of the AIDS epidemic, the very control of the AIDS epidemic will happen on what we do together for young women. And we're really at that nexus because we don't have an extra $2.5 billion a year for the projected number of 28, 25 million new infections. We don't have that. No one has that money. No one can come up with an extra $2.5 billion a year for services. So we're hoping, approaching this planning in a very granular level, a very focused level, and multi-sectorial, and bringing in our multilateral partners from the very beginning, bringing Global Fund. Global Fund has been there every step of the way and every piece of the planning, from the portfolio managers all the way up to the regional directors to Mark Dible himself has been engaged in this to really try to do something differently together and also to show that we're all in alignment to support this, which I think is also a very key message because the only way to get the ministries to talk to one another will be have all of the multilateral and donor space talking to one another across those ministries where everyone wants to then join the bandwagon and be part of the solution. So we're hoping the planning leads to a different outcome, but I think, as Judith said, we're constantly going to monitor for impact so that we can see whether these programs, we believe if we do, we will find, Mark always talks about positive deviants, finding, as you described, where the positive, the 30 girls are and finding out those programs that are successful so they can be translated and replicated because we had years now of data and it never, I love data, many of you know me, I'm a total geeky, nerdy person who couldn't be more excited about making a graph. I mean, that to me is better than many things in life, but it doesn't help to have, I know, doesn't help to have that data if you don't make it actionable, if you don't make it understandable, if you don't compel people to translate that data into programs as Judith, thank you to have described. So we're hoping we have a different outcome, we believe that we've set the platform to look at this differently and also to create a sense of an emergency, we really believe it is, that the very, the very progress that we made in HIV-AIDS over the last 20 years is at risk right now because of our lack of engagement with young women. And it's not that we haven't spoken about the challenges, but Gita, I'd like to talk to you a little bit more about some of the ways that all in might be able to address some of the issues, some of the policy issues, some of the age of consent, age of marriage, how do you reach the 10 to 14 year olds who are often sort of beyond the reach of much programming. Can you speak to some of those issues and some of the early thinking that all in, how all in wants to address that? So let me begin with where Debbie left off, which is about the data and the granular data. I think for one of the things that all in is doing that we've begun to do at UNICEF is to give country offices and local governments the tools they need to be able to do the kind of analysis at a granular level, at the local level that is necessary to be able to design and plan for programs and then implement them. Because what we're finding not just in HIV but in across the health sector overall and the Ebola outbreak for certain showed this to us that we do not have the analytical capacity or the data available to local district officials as they're trying to decide where best to put their resources and how to target those. So I think that that's one critical tool just in terms of what all in is hoping to get out there. In terms of policies, I can say to you that on the child marriage front, UNICEF has put together last year a new gender action plan that has one of its targeted areas of priority is child marriage because it is so disempowering to girls and is so prevalent across so many countries now and there's so many girls at risk but the point is on that particular issue policy alone we're finding won't do it. So just having a law that says this is the age of marriage is clearly not making a change happen. There are social norms that presume that girls are safer, should be married younger. There is pressure within communities to follow that social norm. The social sanctions associated with not keeping up with that social norm are quite severe and so there's a sort of social normative side to it. There's a poverty angle to it. Child marriage occurs in many instances because families are poor. It's very expensive to delay the age of marriage but there's some interesting research on the impact of cash transfers for example to delay the age of marriage. So there are social protection policies that can be put in place to help adolescent girls get the little sort of push they need to be able to stay in school for example. So cash transfers that accrue to the family or to the girl ideally to the girl if she stays in school and remains unmarried. There have been programs that have successfully done that. So we're looking at that. There's a lot of work and analysis of evaluations of cash transfer programs and the outcomes that they have achieved. They have achieved significant impact on HIV preventive behaviors for example. I don't think we use them enough as a way to trigger social change because social normative change takes a long time to do. You can make it happen. We've shown in UNICEF through working with UNFPE on our female general mutilation and cutting programs prevention programs that norms can change at the community level and people do take leadership in changing their own norms to protect their girls but it takes time. You have to do it one step at a time a few people at a time before you begin to see the tipping point happen and the momentum build. But you can put a few things in place policies and programs that can trigger that change and I certainly think that cash social protection programs are one way in which to trigger that kind of social change and we are certainly looking to that in particular for adolescent girls. The other piece you talked about is the disaggregation of data by age. Adolescent girls are the sort of the perilous intersection of both the inequities caused by age and by gender and we talk about 15 to 19 but we rarely talk about 10 to 14 and as Judith said many, many, many years ago if the trajectory for girls' life changes in a negative direction at the age of 12 it's very difficult to get her back on course. But we don't have the data to tell us how those 10 to 14 year olds are doing and for us in UNICEF that second generation now that second decade of life is increasingly our focus because we feel that we can bring something to that 10 to 14 age group in particular not just to the 15 to 19 year olds and the first step in that is to disaggregate the data and through our mixed surveys our multi-indicator cluster surveys household surveys that we do we are beginning to disaggregate by those age groups so that that data will be available to do the analysis in their mark. I'd like to welcome Ambassador Diable thank you so much for joining us we've been talking about the Global Fund already so we've prepared the ground for you saying all sorts of good things not only about the engagement of the Global Fund but particularly about your own passion for this issue and getting this at the most high level attention that you can can you talk to us for a minute about how the Global Fund sees the issue of adolescent girls and young women and HIV as part of what it has to do for its own mission. Sure, thanks Dan and I'm very sorry for being late I also think my microphone is on probably because I was going to the toilet and they were smart enough not to leave it on I'm very sorry I'm late I think we all know never trust a multilateral's timeline for high level meetings so I ran a little bit late Tony even put his flag down at one point it was a good going so long but it actually is not as essential I'd be here because I know that we are so aligned with PEPFAR and where Deb's going on this and I really want to acknowledge the US leadership on this as well as UNICEFs and both of their personal commitment to this so I don't have to be here as much because we're so aligned and I know what Deb covered you know this might be a little bit severe but we have we have gotten so far in so many areas of HIV but we have fundamentally failed adolescent girls in particular and that means we failed young women because if you lose the adolescent girl you've lost the young woman and there are a lot of reasons for that the data I heard Gita talking about we're actually now doing age desag... requiring age desaggregation as well as gender desaggregation so we can get a handle on this but it's a very complicated thing in a county you can have different risks of adolescent girls in different places whether they're in school out of school, the economic environment childhood households cultural norms it just be incredibly different difficult so there are reasons for the failure we also haven't had very good data on what we could do to make a difference I think people have cared for a long time we just haven't had the data and one of the things that's exciting on cash transfers which is a terrible word and scares donors to death so maybe incentives is the right word that fundamentally whether conditional or unconditional whether the unconditional ones actually look better if you basically use resources to keep a girl in school that's the fundamental thing keep the girl in school the adolescent girl or young woman HIV rates in three trials dropped by 30 to 60% which is pretty dramatic we don't have much that does 30 to 60% and the data but what's really exciting is the HIV rate would be the first thing we would see but I think as most people in this room now it's the other effects that are as important we know that the girl won't get married early or is far less likely to get married early far less likely to get pregnant early likely to have fewer kids because they'll have the ability to make decisions with their partner and in their society and they'll have economic opportunity and if a woman has economic opportunity and receives income we know that 92 cents of that dollar will be spent on nutrition education and health if you give that to the man maybe a third of the money 42 cents on the dollar in some studies so the long-term impact the cultural change the ability to give adolescent girls the opportunity to be a young woman with opportunity and the impact of that is extraordinary and so an investment in health and HIV AIDS can have a dramatic impact on all of the development goals on all of development and make actually probably safer healthier happy societies so we don't get many opportunities to align in this way and going into the SDGs there's a great chapeau I'm looking at people not issues I don't see a lot of specificity around this this is one area linking health and education which are the two fundamental determinants if a young girl will have a will be a young woman with opportunity and all the developmental impacts this is such a huge opportunity we don't get many of these so this is a revolutionary thing we think and that's why we're so aligned and really pushing as hard as we can around the world because this opportunity is one we just can't miss I'm going to come back to you because we've had some time to talk before you got here can you talk a little bit more specifically about how the global fund is pulling this into their discussions directly with governments with a range of ministries into the concept notes what kind of support and guidance and impact are you seeing in getting this message to the countries you're working with we're all aligned together working with the dreams initiative which is a fantastic initiative our teams are actually working together country by country looking at those opportunities and they've been meeting and really moving aggressively and UNICEF is deeply involved but what's really exciting is what's happening in the country so I was in Zambia at the beginning of the year and they are meeting and we've all been advocating for this they're meeting at the permanent secretary level and social development to look at how they do incentives because most of the cash transfers are in the education or social development field they're not in the health field so they're looking across those ministries to see how do they have a comprehensive package to address the needs of a young adolescent girl and then a young woman particularly related across the field that's hyper exciting right so then we went to Swaziland that same week and gave them the example of what was happening in Zambia those sectors and Swaziland is now moving in that same direction so we're really trying to work in a partnership country by country to say what can we do to support you collectively so that we can move on this as aggressively as possible now we're then going to need the monitoring and evaluation if we can actually see most of these studies it's a year to 18 months when you see that dramatic decline if we start seeing that and we can prove that and then continue to monitor those other social development issues I think that could flip countries rapidly especially among deep southern Africa where the adolescent girl, young woman epidemic is what's driving the epidemic as ministers and Debbie's been phenomenal on this including yesterday with ministers of finance pointing out the youth bulge potential and the risk of the epidemic getting out of control again and that if we see that I think we would see a rapid systematic move and Tony and Geeta UNICEF have been real strong advocates on this as well Michelle CDB at UNAIDS is all over this so it's really a great partnership, UNDP is hyper excited in the country so we do see this kind of alignment country by country but what's happening in the country is terribly exciting and if we support them we think we can get there what are you most concerned about what are the big challenges that you think everyone is going to really have to address in the short term given the tight time frame to show some impact what are you most concerned about a few things one is getting ministries to work together as as complicated as getting all of us to work together but they're doing it at least we have examples of that being done we have some real leadership among some ministers and heads of state to drive this agenda it's a huge I mean it's very complicated stuff a second big challenge is sustainability and the cost benefit analysis so if you're in a real high transmission area which is where we have to start certainly with HIV money you can probably show cost benefit pretty easily and there's been just around the HIV issues but you know it's pretty hard to say we're going to do this just in these counties so then how do you have a sustainable approach and some ministers are awfully worried about that you know they're saying how am I going to maintain this in my entire country for a long time we're actually collectively working with some modelers on that because if you add not just the HIV benefit you know we're starting to see some models show that that's highly cost effective so you can use HIV money to seed it but then you can bring in the other sectors and that's really exciting too because it's the other sectors that are looking at this the other pots of money that are looking at this as well so again driving those things together the other thing and we need to be looking at this is how long do you need to do it because it's not indefinite at some point you will get the societal switch the cultural shift so it's the expectation that the girl doesn't get married early doesn't get pregnant early as a smaller size family as they decide and has is expected to have an economic opportunity so we're trying to look at other sectors with some of the modelers collectively to see how long we might that take based on other experience and therefore adjust the economic modeling and the cost benefit analysis again working with ministers of finance which you know Deb brought some people together yesterday which is highly important and then the last reason we can't maintain funding and really there's going to need to be it's not just the last there's a whole lot of risk but we can't maintain the funding and that will be hugely disappointing if we're at this incredible point and we lose it I guess the last thing is the monitoring evaluation we don't really focus on the data data capture and be able to show something you know people lose interest pretty quickly because it's so complicated to do all this I could ask all of you many more questions but I feel like we should open it up to the audience because we have a very informed audience here what we're going to do is take about three questions at a time please state your name and your affiliation and please in the interest of time just one question and then we will come back to the panel everyone will answer everything but so if you have something in particular that you want to address to one panelist please be clear about that and then we will take a round of responses and do that a couple of times so questions from the audience there's one Sally and wait for the mode Mike please thanks Janet Sally Paxton IAVI published what you fund a couple of other groups all of you talked about data and talked about the time lag on data Ambassador Burks I know that you are particularly focused on data and called yourself a data nerd nerd I would say a data diva where are my children I need to point you out Twitter, Twitter quickly but tweet it out and Mark you talked about the importance of monitoring and evaluation so that making sure you identify the problem and the populations correctly in the beginning is certainly a particularly important problem but making sure that you've got current management data as you move on to make sure particularly if you're working in emergency areas where you need to make sure that what you're doing is having the impact that you need you can't wait another 18 months to get those studies so what's being done to make sure that you what are the tactical things that need to be done so that people can report back in real time on that data so that you can adjust decision making and figure out whether you're getting the impact and the results that you want and we'll go right behind Hi Jill Gay what works association my question is for Ambassador Berks in term and perhaps also for for Global Fund UNICEF we know that it's important to scale up comprehensive sex education particularly in a way that addresses issues of gender based violence and gender norms yet none none of the lower and middle education countries have scaled this up and we haven't done it in the US either as well as needing to reach the young adolescents and the girls out of school how do we move forward Julia Royal NIH I think we all agree that it's important to bring the ministers the various ministers and ministries together one of you give me a specific example of the minister of finance being brought into the mix and what happened as a result of that thanks thank you okay why don't we start with those three questions would you like to start with the data diva wow hopefully that will catch on as a cultural norm working with data or divas this would be great for all of us so let's just start with the data piece so we've been in very close because I think this is really a core value issue and we've been working with the multilateral space but also very specifically with Mark and launched these we've obviously been using data internally but that doesn't help when it needs to be actioned locally and externally so we've launched a data hubs for countries that will bring data together and allow this that age disaggregation gender disaggregation and a very granular level so that they can hold local government units accountable for progress because we know there will be progress as Mark described and then it creates that healthy competition between different communities to really have that same impact and progress but it has to be very granular and it has to include the numbers that you describe down to the 157,000 women where are the 30 and all of these issues around data disaggregation thank you for what works and having that available always for us in a transparent and open manner for all of us to read and have that data and have that information I think in that space of really figuring out how to work together across ministries and how to translate what we've known has worked in isolated vertical programs together in the synergistic way is really what we're trying to do and then monitor it really quarterly now this is going to be the level of reporting around this is another area I get pushed back on the ambitious goals and the level of reporting but if we don't have that level of reporting we're not going to be able to see the translation of the what's works best practices into reality and the impact so that's been very key I'm glad you brought up the ministers of finance question mark and I had this great meeting yesterday with ministers of finance from some of the most heavily burdened countries and they said very interestingly the minister of health never talks to me about HIV so I thought it wasn't a problem so are you telling me it is a problem and it was really astounding all of them said basically the same thing we thought this was fine we heard about it 20 years ago we haven't really heard about it recently and when we went through the data they were actually quite shocked because all of them said well I thought we were doing everything right and we're making great progress what's the problem and then we showed them that the current rate of progress is going to result in these 25 million 2.5 million new infections a year and that there's not 2.5 billion dollars on the continent per year additional every year over and over again 2.5, 5, 7.5 just in a three year period who's going to pay that house that's going to be so we don't really have a choice but I thought their responses were very insightful I thought their responses were very clear but they were really actually surprised that the problem is a significant and I think it really opens a window for Mark and I in tandem with Michelle and Unicef and all of the teams to have these talking points around these key issues Department of Treasury has come in as an absolute core partner with us and they have been providing that fiscal space discussion because I'm a health person but having a treasury person beside you that understands copper prices has been hugely helpful so I think bringing this subject to the table to have that conversations in the words that they get and understand the fiscal space argument the impact of young women and then we went to another great meeting that Margaret Chen held yesterday World Bank talked about translating the data need and our community needs into potentially employment opportunities for young women where they can participate in the community for either the data collection around these pieces and learn that incredible talent but also working in the community to really develop that respect so it's really I think it's really an exciting time I think we make the assumptions that ministries of finance didn't care I think ministries of finance haven't been aware and now we have that space again Mark would you like to come in on this in terms of the other ministries and how do you bring them in and what have you seen in your own discussions and I can give some specific examples Deb covered the meeting yesterday with the ministers and we find that but we do find some very engaged ones for example in Kenya because the president involved in Tanzania because the president's involved and while we haven't seen the ships yet because we're just beginning these conversations the energy around a lot of the stuff because we have data and that is a key point because you can't go into ministry of finance and just say this is a really good thing to do you actually have to show them what can happen they need to hold their folks accountable and that was a really great part of the conversation yesterday we have to present things in different ways because they have a thousand things that can save lives tick off things they have a lot to worry about and one of the things they said yesterday is look we think that HIV is just one of many things now it's not the crisis it was 20 years ago so we have to balance it with everything else and that really comes down to data and how you manage the data and present the data not just the funds but an impact and that's where I think this education and health piece is so critical because it comes together in a way that makes sense for them because education and health are dual priorities for most of the heads of state so in a very specific example I'll focus on Kuala Zulu Natal because in South Africa you know the parts of the country are very divided there's a lot of autonomy among the chief ministers so we met with the chief minister he actually met with us just before he left at the airport in Durban actually and I thought we'd just meet with the chief minister who was the former minister of education he brought his minister of education, social development, health and finance and he sat at the finance one right next to him and said this is what we need to do now they need our support to do that the same thing happened by the way in Swaziland was the prime minister and he ensured that the minister of finance was sitting there as we had these conversations in Zambia again it was the head of state getting to the minister of finance and so when you do that we think we'll see opportunity now we can't do it everywhere because not everyone has that kind of energy and focus so what we're doing is really, really in dreams provides that template focusing on getting those countries are parts of countries to move as rapidly as possible so that then we'll have the rest of the data and that gets kind of back to the monitoring and evaluation piece and the importance of that we actually can do this particularly if you focus in specific areas I mean it's not so you know I remember in 2004 when we said we're going to do gender disaggregation at PEPFAR and everyone said that's impossible you can't possibly get gender disaggregated data now we have gender disaggregation for everything just like when we're not putting an age disaggregation at the global fund everyone's telling me that's impossible well it is impossible if you never start but when you start and that's a requirement people start actually collecting those data and it's not going to be tomorrow that they have it but if we don't start we're not going to get there so what I'm monitoring and evaluation of me will be can we get the girls to stay in school you know the out of school young people whether they're men or women the risk of their HIV infection is huge huge so we just need to get them in that's what the data are telling us the quality of the education actually isn't relevant there's some interesting data from South Africa you can actually muck around with the health benefit if you focus too much on the quality of education with the transfers just to keep them in school and we've known these for a long time in school versus out of school the risk is very high then education people can make sure the education is good because that's really important too but you know making sure we're not losing them so we could show really good results of the girls we have access to but what about all the ones we're losing and aren't in there and how are we that's going to be really tricky and that's really a cohort or case-controlled design in areas so you're not just looking at the kids in school you're actually looking more broadly which is actually what the studies tried to do to be looking for silver bullets right I mean these transfers are incentives are not a silver bullet you have to do the gender-based violence work you have to do a lot of other you have to do a lot of stuff but we this the interesting thing about this we can start with something and perhaps see really dramatic results that will allow you then to build on that so you know it's complicated and you have to talk about this with all the ministers because if they see an investment that's not yielding a result within a year they'll just move the ministers to find it Judith I wonder if you could speak to this question of the comprehensive sex education because we know that is so important around the world and I wonder if you can speak a little bit to the importance of that in this space I'm going to speak about comprehensive because as much as a defender as I am of sex education the broader reservoir is social isolation economic dependence so you know what is a what is a 12-year-old girl need particularly in the countries the high HIV burden countries you're speaking about she has a 50 to 75 percent chance of being a single parent that's so what does she need she needs five friends she found five non-family friends she needs a place to meet them at least once a week she needs a mentor someone to turn to an emergency she needs a specific safety plan which is benchmark to the scenario she will face you know it's not just about the age marriage it's the kind of scenarios it's both trafficking and being pressured out of school and there we often don't give girls enough information or negotiation skills she needs a personal identification she needs a savings account and she needs age-graded sex education financial literacy and so forth and that's kind of a that's kind of a kit and I think that kit I think we're in the same place because we're knowing also about cash or material and we've got numbers of experiments in the field with different arms now every time you pair it with this group of group process that's its sustainability you want to you can get the finance minister's attention and they allocate it but how do you turn that one time potentially one time benefit into a lifetime asset early enough enough things early enough the enough girls so the tipping points you reframe markets right now in Tanzania when my colleagues Annabelle Realcar was we were talking about she's in an area which in Ethiopia we'd use material which was goats to anchor a child marriage program and in this environment which is a little less cohesive socially in the first round they were offered either school supplies or two chickens they did this is kind of the shadow value for the girl 80% signed up in the first round six months later over 90% and there were two things going on one was you were sort of saying your girl is valuable this opportunity is valuable the next thing was happening is if my neighbor is getting a chicken and I'm not getting a chicken so the idea of threshold saturation comes up at threshold levels we're repricing girls as a class I'm sorry to use this word but we are they're in a sexual marketplace per segment but within within that space so four girls in each of these categories in school girls out of school girls and so forth there needs to be a package of core basic protective assets that are transmitted ideally in an all girl space and certainly the issue of integration of reproductive health family planning and HIV is fundamental to all this in both directions family planning reproductive health into HIV and HIV into family planning reproductive health one more thing people are thinking about potentially the relationships between technology and group the Mary girls clubs in Ethiopia and we're talking young are achieving double the rates of family planning use double with no new technologies and no new services social capital mentoring sometimes bouchering and rising proportion are delaying a first birth so two things are happening the age of marriage has been moved up two years measurably in the communities and obviously we all want longitudinal data to look at the future of this but that's part one stop the train and slow the train and the normative age of first birth appears to be moving up to about 18 or beyond so that the girl who's married at 16 which is where the new bulge is then can delay for and she's using it with depot it's a beginning something better there's some better things than depot but this is a start but she has to do it secretly she's not this is not a public declaration that space is a place where organizations get support and you know and the social density is important look I'm married but I'm not pregnant yet this is this synergistic effect all of these take place within that the group dynamic I think that can I just add to that point because I think we don't recognize how difficult it is to be a social pioneer in a poor community where you're dependent on social capital you're dependent on your neighbors to do things to buck the norm and say you'll do things differently is hugely expensive to a poor household and so to have you know the programs that provide that support to a family to do sometimes what they really want to do but feel so nervous about the negative sanctions that they can't so just providing that space and for young girls that's particularly important but we've known this about women for years you know the benefits of microcredit programs was not just the microfinance it was that women met in a group and went somewhere other than the home that they had a reference point other than the family that they could that their horizon then was that much larger I remember I did a study many years ago in northern Nigeria where we found very conservative households but for the women who stepped out of the home on a regular basis to participate in a religious organization was radically socially different from what that society required but they just belong to a group that conducted some religious activities together and came back home regularly had greater participation in household decision making than those who did not have that external reference point so that's why going to school even if the quality of education is low makes a difference there's a different reference point families can be quite progressive for women and girls in terms of what they can do and what they're allowed to do and what they should do etc they are the ones who keep the norms in place so I just wanted to make that point it's important to understand these dynamics in order to shift things and I just want to go back to the data point to say that the point you're making is that the monitoring has to happen in real time and it has to happen in a way that's iterative with program planning and what we at UNICEF have developed is something that I don't have the time to describe now if my boss was here at the lake he would have done it nevertheless but just to tell you it's called monitoring of results for equity system or mores which is precisely our solution that we have developed in house and are now sharing with all UN agencies of what we call level 3 monitoring so level 1 is the inputs you provide level 2 is the activities you measured whatever money you got did you do the activities you promised level 4 is the impact level data which you have to wait 3 years in order to get but what if your strategy was wrong based on the analysis you did at the beginning you have to wait 3 years to rectify it no so you need a level 3 monitoring and that level 3 monitoring is the piece where you analyze upfront what are the barriers and bottlenecks that stand in the way of success what are the immediate barriers and bottlenecks is it that the supply of a commodity is not there when it should be there and that you can check in a quick and dirty way if those barriers and bottlenecks are not being reduced and that's what you check at the level 3 then you know you're not on the path to success and you're not going to get the data you want in 3 years so it's time for the feedback loop to go back to the top and say we have to do something differently because what we're doing is not reducing that barrier or bottleneck that's the methodology essentially so it's like a cup it's like a mug with a handle the handle is going from level 3 back to level 1 to say let's do things differently and to train district officials to do that on a regular basis and to value that for the program investments we're making is a critical piece and that's the piece that we have to achieve and I couldn't agree more with Judith on her response to the comprehensive sex education I think that's one piece of a much broader package of things that we used to call life skills education that needs to be provided to young girls in order for them to succeed because I go back to my 6 point framework they need it all in some places they need some pieces more in other places other pieces more that requires the granular local analysis but you can't just provide one and hope that that will be the magic bullet let's take one last round of questions over here we'll start thank you I'm Michael Moraine from Savin Vaccine Institute and I want to talk about another aspect of this problem and that is that millions of children in Africa particularly in East Africa suffer from something called schistosomiasis and a neglected tropical disease and half of those children are girls in a girls case they often end up with female genitals schistosomiasis which are lesions that leave them three times as susceptible to HIV once they become sexually active so for the lack of an intervention in childhood your prevention efforts are being undermined and my comment and question is is there a way of including this kind of effort in your focus on young girls next question I think we have in the back Shepard Shepard Smith Institute for Youth Development most programs that start focusing on young girls and women ultimately include young boys and men in respect to giving messages and so I'm curious what you're going to do in regard to boys and men and the other aspect if you look globally at the biggest influence on kids and sexual behavior it's parental involvement what emphasis will you place on that and one last question we'll give it to Craig here in the front you're going to ask your boss a question ask my boss a question Craig McClure I have a UNICEF actually it was a two part question first a lot of talk about cash transfers UNICEF supported the work of Lucy Cleaver for many years at University of Cape Town at Oxford that looks at cash plus care and different elements of what that care looks like but the challenge is to tease out what are the core package of those care interventions in addition to cash and question about that and what's interesting is boys and girls and that's a I think one of the things about all in is that we're focusing on adolescent boys and girls and so boys in the cash and care work actually benefit more from all the additional care pieces girls seem to do quite well with the cash but this is work that still needs to be teased out so question around that teasing out from her phenomenal work the core package secondly, just to say again that all in is about adolescents and HIV overall with a big focus on girls because of the huge numbers particularly in sub-Saharan Africa but just also to say that another piece is boys and in particular gay and bisexual boys and transgender girls and recognition at UNICEF also constructions of masculinity and femininity that are driving these huge prevalence rates among young gay boys, young gay men, young transgender women and girls overall in sub-Saharan Africa and trying to get a bit better picture of the data again so countries outside of sub-Saharan Africa in particular and working with the global fund on that maybe a comment from Mark around that issue of adolescent, key populations in particular young gay men and transgender women so in the interest of time we're just going to go through the panel please be relatively brief because everyone is going to need to leave soon and answer one of these questions and any concluding remarks that you'd like to make let's start with Bester Dougal so the particular one I'll address is just so Michael we've talked about this before we actually need a trial to show that treatment makes a difference in HIV transmission that increases the risk of transmission HSV was proven for a long time we did the randomized controlled trial there was no impact on HIV infection and the only randomized controlled trial that treated in South Africa showed no impact on HIV transmission so since we have the data on transmission then we can invest in schistosomiasis but we need those data first so until that's done I don't see how HIV money is used for schistosomiasis on the broader picture and this is what I want to wrap up with is you know engagement of everyone is going to be essential just focusing on keeping a girl in school we know we'll have we think we know we'll have an impact but there's a whole village of things that happen around that and one thing we haven't talked as directly about Guido mentions the role of faith community here you know the issue of gender based violence that is it's bipartisan here and it's very non-denominational and very cross cutting across the faith community and the faith community really needs to not only be involved saying you're not doing this right but actually how are you going to deal with it and we are starting to work it's not just ministries it's actually the community and the faith community is going to be really key here and engaging them and I think there's real opportunity around this and that deals with the parents as well when you're involving the faith community and the leaders in the community you do more than just keep a girl in school and the private sector is getting involved more and more companies to say if we get a girl through secondary school or even past secondary school will you basically secure jobs they can compete for local companies and they're very willing to do that so it's involving all those pieces that will then have an impact that goes beyond the initial intervention but if we don't have the data from the initial intervention we're never going to get to those pieces and that's the key part to me and I'll end with Guido's point we talk too much I think about the situation and surveillance I was just at the Ebola meeting it's not that alone we'll get you reports it doesn't lead to real-time change and what Yid is talking about in UNICEF it's really data management and we're calling it that we're calling it data management now and management for impact because if you just report in three years you'll look back and say uh-oh we have a problem and we can't do that anymore it's just we're past the point where we can keep studying and studying so let's just go do throw the kitchen sink really at the problem and see what happens we can figure out, tease out what had the impact later but if we let this next five years go without having a significant change in the rate of infection in adolescent girls we will never catch up so we've got to go and we've got to go now and I really want to thank the people up here and Deb's personal leadership and the nice thing is we've all known each other for 15 years and Janet too, you've been pushing this for a long time now is the moment to really, really push and if we miss this opportunity you know, bad on us Judith, very quickly on data it is the use of data to design programs which we have the capability to do now at the granular level we have a tool sounds like it's a perfect match for this tool but disaggregate data before you design not afterwards because right now we have, I think, catastrophic levels of elite capture and the poorest girls in poorest communities are our priority which is my answer to the second question other populations, men and boys, parents and so forth I'm for them but our poor clients are these girls so to the extent that we involve other populations it must be in relation to a clear sense of well-being we have not built her assets what we need to do to build her assets is to design, do that analysis but that will vary by context and by segment the 10 to 14 year old girl living in the urban area has a very different set of stakeholders that need to be addressed and it's not broadcasted until we secure her tactical needs we have no business moving beyond that we have to protect her first and support her first and then figure out who else we need to involve Thank you I spent my entire professional life saying ditto to Judith Thank you I think the questions have been answered I don't want to add any more to those but just want to say what a pleasure it's been to be in this conversation I do have to admit started out this panel feeling very frustrated there's not a single data point that was mentioned today that we have not known before it was from previous years but it's exactly the same data point whether it is how women invest their money as compared to men whether it's how young girls are getting infected why are they getting infected that it's multi-sectoral and I say this not to make us feel down about it but to energize us that this is now just one and only last chance so go for it I'd say may the force be with you so quickly each of your questions showed really a broader theme that we've had this issue with so the question about comprehensive sexual education every country I go to I see the curriculum and every school I hear from the Peace Corps it's not being implemented because there's a disconnect between the highest level and the community level of engagement we've worked for years on violence against children we know what the issues are we have the surveys now we have the legal framework but it's not changing the community culture and so we have this gap between guiding principles and legal frameworks and curriculums and implementation and I think Shepard's question about the families and the community and the faith-based issue and how we are bringing this together on the ground in a real way what would happen if we do what Judith talked about this translation to the granular level so you can have that discussion at the community level and I think that's why the planning has to start at the community level engage all the way up to the ministries but the community has to feel that it's engaged in these changes because we can see that there's been this gap between frameworks and implementation because of social norms and other issues and so yes we've had the data for a long time this is true in every single field translating data into action always seems like we talked about the frameworks into the community very difficult I think making data more accessible and analytically available on a more daily basis makes it more real rather than the report and I think I believe we're at a nexus just because to collectively we're saying the same things and you all are saying the same things back to us so thank you for all of your work that continue had been tireless without always the ability to see and outcome hearing that we're not always listening but we're listening and we're very much committed to changing the framework at the community level before we close we're going to have some final remarks by Deb Derek who is the president of friends of the United States against AIDS TB and malaria just before we close up thanks thank you so much for coming I think this has been a terrific conversation thank you Janet so much for putting the oomph behind this and helping to organize it to Ambassador Birx for her energy and determination in this area and to Mark and Gita and Judith of course for taking this and making it real in the ground I just wanted to bring it back to something that Mark actually said when he first became executive director of the global fund and he was highlighting then the opportunity to move forward and to really advance human rights and listening to the conversation today it feels to me like we're at a serious inflection point where we can really help people save lives and advance human rights globally so thank you again for coming and have a great day