 Good morning and welcome to CSIS, happy new year, I'm Steve Morson from CSIS, we call the Health Policy Center and we're thrilled today to be able to welcome Eric Busby and our other guests for the round table here. Before we launch into introductory remarks, I want to make one announcement. Since April of last year, we've had here at CSIS a commission on Smart Global Health Policy, 25 eminent individuals who joined us in this effort will be releasing the report and recommendations from that commission on February 10th at 10 a.m. at the Mayflower Hotel. Many of you will have received a Save the Date notice for that, but please put that in your calendar, a one from 10 a.m. to noon on February 10th at the Mayflower Hotel. Please join us for that. In putting this event together, a number of people have put an enormous amount of effort in getting us organized and I just want to acknowledge them. Emily Poster, Daniel Porter, Lisa Cardi, Elizabeth Morehouse, Seth Gannon, Russ Oates from here at CSIS, from Ogack and Gavigan. Welcome and thank you so much for being with us and Tom Walsh. Special thanks to my colleague Andrew Schwartz from CSIS, the head of our external affairs. This is a partnership that he has engineered over the last six months with the University of Miami Night School of Communications. We're very proud of that and very proud to be working here with the University of Miami and we're joined today by Sonjaya Kenya, a member who will be introduced momentarily by our moderator who has come up from Miami. I want to add that Donna Shalala, former HHS Secretary and President of the University of Miami, has been a very active member of our Commission on Smart Global Health Policy for which we're very grateful. Thanks to Mariam Atashnawabi, anchor of American Abroad Media for agreeing to be here today and moderating and very much thanks to my colleague at CSIS, Phil Nyberg who Mariam will introduce in a moment. We're very excited here today to hear from Eric Goosby, the U.S. Global AIDS Coordinator, to hear really about current thinking on U.S. prevention approaches on HIV. Early on during his confirmation, as he entered his office in August, as he launched the new five-year strategy, Eric's made very clear that prevention occupies a new higher priority place in U.S. policy approaches and for many of us this is a very welcome change and many of us are eager to hear his thinking and more details on the strategy and approaches looking forward. We know that prevention is innately a very difficult and complex issue. We also know that a great deal about what works and what does not work. We at CSIS have for a long time given priority to prevention. We had for six years had an active working group on HIV prevention as part of our CSIS Task Force on HIV AIDS and over the past year with the leadership of Lisa Cardi and Phil Nyberg, we assembled in the summer an expert group to examine U.S. approaches on prevention. We've issued a report. I hope you've had a chance to get it. It's been distributed here today. There are a couple of big themes that come out of that work. One is making full use of U.S. leadership at the national and global levels and engaging other political leadership of partner governments as well as international bodies to take up prevention in a new and different way. To leverage our future commitments and that gets us into a difficult terrain of conditionality and I'm sure we'll hear more about that. What do you do as resources get tighter and as prevention becomes a higher priority? What do you do when you run into obstacles in terms of malgovernance or resistant governments in taking on the challenge of reducing stigma and improving access by men who have sex with men, injection drug users, commercial sex workers when you have a repressive legal environment that is not being reformed? We've put a big focus in our work on concentrating resources where most needed to focusing prevention efforts and knowing the epidemic and lastly in investing in greater metrics, better evidence base and research and perhaps we should consider this may come up in the course of the discussion today expanding the advisory network to bring in more systematically advice from non-official experts on prevention into this. This morning what we're going to do is I'm going to in just one moment introduce Eric. Eric's going to come and do a presentation. Upon completion of that, our other guests, Mariam, Sonjai and Phil will come forward here and we'll move into a round table portion of our morning and that'll be an interactive conversation for 20 or 30 minutes followed by opening for the last portion of our program opening to the audience for questions and comments from you. Please just come forward to the microphones here. So my honor to introduce Eric Guzby. He's known to many, if not all of you, for his work over the years since August he has been the U.S. Global AIDS Coordinator responsible for overseeing the President's Emergency Plan for AIDS Relief and the U.S. Engagement in support of the Global Fund. Obviously also he is playing a pivotal role in this next phase in the launch of the President's Global Health Initiative. Eric is a friend to many of us. He's a leader. He's compassionate and committed in somebody who's been committed to HIV. His commitment stretches back to the early 80s in San Francisco when he began treating patients at San Francisco General Hospital when AIDS first emerged and came to our attention. In the Clinton era he served as Deputy Director of the White House National AIDS Policy, Shop Policy Office and Director of the Office of HIV AIDS Policy at Health and Human Services. These were pivotal moments in both of those offices with respect to domestic policy and later with respect to international. From 2001 to 2009 he served as the CEO and Chief Medical Officer at the Pangea Global AIDS Foundation in San Francisco. A highly innovative group that has put down in this last phase new programs on treatment and care and prevention in South Africa, Rwanda, China, Ukraine, among others. He has vast experience with international treatment guidelines, development of local models of care and prevention strategies for high-risk populations and we're very honored to have him here and thrilled that he's taken on this duty in service of this administration. So please join me in welcoming Eric Goosby. I'm CSIS for the beginning of truly kind of dialogue and hope that this is the beginning of what will be an ongoing relationship over the course of kind of that virus that moves into our new phase. I think that our ability to think through this what has been a beautiful problem for really everybody in terms of prevention response is effective and sustainable. It's a big part of the challenge and a big welcome and I would embrace really all thoughts on it. I wanted to kind of place this in context of the 33.4 million people who are living on the planet with HIV and 2.7 million new infections that are estimated to occur annually. We still are predominantly looking at a burden of disease that falls in Sub-Saharan Africa as you can see and the figure that just repeatedly... Sorry. Sorry, I hope you could have heard from me before that. But for only two people on ARVs, there are five that become newly infected. My problem with this juxtaposition is that they're not related to each other but people look at that as some kind of a balancing. It's not an equation, it's just two separate facts there that I think we should think about, have real implications for how we think about it but cause and effect is not there. The National Intelligence Council estimated that by 2025 there could be as many as 50 million, 25 to 30 million of whom would require treatment at any given time. Our prevention efforts, if scaled up, could dampen that trajectory but we still are looking at a large number of patients expanding from both those who are engaged in the treatment and both for opportunistic infections and the initiation of antiretrovirals adding to the total number of living in addition to the influx of the 2.7 million annually. PEPFAR's goals over the five-year strategy have been outlined for you, it's on our website and the annexes really have the detail of where and what we intend to engage with. We are in addition to the transition from emergencies to sustainable engaging our partner countries in a dialogue where an increasing level of responsibility and oversight management is the focus to truly focus on that and then to expand prevention care and treatment both in concentrated and generalized epidemics. The integration and investment in research and innovation become critical compliments to this core focus. The package of the biomedical, behavioral and structural interventions are the biomedical, behavioral and structural as defined here. We also have strategically strategic opportunities to so-called combine our prevention opportunities on given specific populations to overlap and synergize with the impact. This is an idea that we hope we can in the course of our PEPFAR programs better understand and demonstrate improved or added efficacy in a combination approach. So PEPFAR prevention will support countries and mapping focusing on the demographics and moving from the demographics backward to see how these populations do or do not interface with the prevention effort on a kind of geo-mapping level to use the data that we have from other studies as well as the opportunities that are presented to us in country to converge our strategies, to converge on populations as we were saying so we get combination prevention approaches to be able within any given country to compare the convergence of a specific menu of prevention interventions compared to another menu to look at so different combinations with populations and to really be positioned so we can better understand the relative impact of this approach and then to continue to link treatment and care programs in that to ignore a strategy that does not emphasize those who are already HIV positive as a central target would be a missed opportunity. The recalibration is an example in South Africa where an attempt was made over the last year a little less than a year, six months or so to re-engage the demographics and look at where the new serial conversions are mostly assumed to occur in a geo-mapping exercise and then trying to map our programs and see if we are indeed well or not well interfaced with where the new serial conversions are occurring. It has resulted in a shift of funding from the 23 million down to the 32.5 and more importantly has allowed us to better interface our prevention programs with where we think the virus is expanding through the population. So challenges to successful prevention programs is the lack of country data for planning and thinking about where the prevention effort should concentrate. A blanketing approach to the whole population that does not take that into factor into the thinking has dominated too much and we are trying to flip that where more of our planning again is based on what our understanding is of how the virus is moving. The fact of the matter that incorporating the fact that it's not just one epidemic for South Africa it's multiple epidemics indeed geographically but if you take any one of those dots for any given village, town or city you have multiple epidemics within that city. To not have a strategy that approaches your prevention effort in that way again is to miss that opportunity. So understanding that better more intimately and telling our programs to accommodate that becomes the exercise. The ability to match what we do know works with how we emphasize our allocation decisions and what we financially support is another factor becoming more rigorous around our abstinence and be faithful populations moving into and adding a capability to refer for those that are unwilling or unable to a condom family planning strategy which is the complementary piece for those who cannot remain abstinent in their personal relationships. For multiple concurrent couple populations this also becomes important to converge those two capabilities. Our understanding needs to expand. We need to document at least for sampling, sentinel sampling of these projects if not all of them an ability to show that we indeed have connected and have conveyed information that has resulted in a behavior change. Measuring that, identifying that, understanding that has been a real challenge to everybody on the planet to come up with process and programmatic outcomes to demonstrate impact is really our goal and we see this as a central piece both of our research monitoring evaluation slash research activities in PEPFAR that needs to in real time inform our projects as to what and where and who we are impacting. That will be increased. The ability to address stigma and discrimination is inherent in all prevention activities as well as our treatment activities emphasizing that, taking advantage of that engaging with discussion with political leadership policy makers not episodically but in an ongoing way both from our PEPFAR leadership but as well as our diplomatic relationship in country through the State Department and part of our strategy an expansion of our strategy with the PEPFAR issues and the issues in Uganda and Rwanda in particular. The structural conditions are pair and parcel with that looking at having less of an impact on this except indirectly but looking at how laws and institutions favor or diminish your ability to identify enter and retain patients in care becomes a central piece of that discussion understanding the relationship to what would be laws or practices that push behavior more underground being the thing we're trying to avoid. And we want to be nimble enough in our understanding of what we're doing within any given community to identify efficacy and move the machine to preferentially going down that pathway when we see something that indeed does impact. Examples of challenges as you look at this prevention strategies increasing our ability here these are all the standards that we have seen everywhere your cervical barriers, HSV2 suppressive therapy going on up to your PMTCT condom male circumcision strategies looking at this as an attempt to move through a variety of different menus that would be able to converge on any given population to increase our ability to prevent infection. We still need to move as I've alluded to to better understandings effectiveness at the population level is something that we need to be able to talk about better to be able to understand better to be able to document better the combination prevention efforts doesn't work is combination better than single there's evidence to think that it should be we are in a position as we move these programs not to pilot but to scale to answer that more definitively at least with the populations we're in front of and our hope to increase our ability to reduce incidents at least below the prenatal numbers that we're seeing throughout these countries is the kind of surrogate goal that we're putting as the marker for each of our attempts and then as something not to decide but to inform decision making we are going to be looking at cost effectiveness of different projects in relation to prevention of infection as we move forward I've never really had a cost effective analysis that wasn't used to argue against a program but it certainly is a critical piece to understand your program and your program's ability to sustain itself and we need to increase our cost effective understanding of most of our programs so the idea is to work with our multilateral partners to ensure that the interventions provided converge and are created occur in an environment that does not increase barriers to entering and retaining patients in care we want to work actively against that on our fronts we want to expand access to high quality interventions that converge on populations and hopefully will reduce the number of new serial conversions in the burden of HIV on the medical delivery system in country access to services based on principles that are equitable and non-discriminatory become a critical foundation of that discussion supporting prevention efforts for women integrated family planning reproductive health linkages and treatment programs becomes the overall kind of 30,000 foot level of orchestration and scaling up programs that really aggressively take advantage of what is a low hanging fruit opportunity that we identify, define and target our most at risk populations many of whom are marginalized and again move further and further away from entry and retention into care and I hope that we will be able to add to our understanding of both the difficulties and successes that we identify as we move these programs to scale and aggressively identify efficiencies, redundancies eliminate parallel systems of care that really are not contributing to our ability to contain the infection a much more detailed description in the annexes of our website goes into a lot of the strategies that we have teased out that we'll be implementing over the next two to three years and I would encourage you to take a look at those for more detail so Steve I'll stop it there and move to the discussion Thank you very much Dr. Gooseby for providing a overview of what the new PEPFAR strategy is with the Obama Administration I think it's very helpful in some of the questions and dialogue we have we'll pick up on what you discussed I first want to introduce our other two panelists that we have here on my left is Dr. Sonia Kenya she is a manager for health disparities at the J.Y. Center for Social Medicine and Health Equity at the University of Miami as was stated earlier this program the Global Challenges Program is a partnership with the University of Miami Nights Center for Media and we try at each session to have someone from the University come and speak with us she graduated with a degree in African American Studies from UCLA she has two masters degree and a PhD from Columbia University in health education she was a health disparities fellow at NIH from 2002 to 2006 and from 2007 she's been at the University of Miami on my right is Dr. Phillip Neiber he is a pediatrician but he has many years of public health experience from 1977 to 2003 he was at the Center for Disease Control and since then he has been at the Center for Strategic International Studies working on the Global Health Policy Center he has his degrees from the Case Western University his MD and a Masters of Public Health from Johns Hopkins University so I want to welcome both of our panelists in addition to Dr. Goosby I also want to acknowledge Sanjeev Chatterjee from the University of Miami's Nights Center for International Media he's the Vice Dean there for supporting this program we want to have this dialogue between a university and a research center and to get this information out actually to students we do have each session that's taped so that others can benefit from the information that's shared I want to first start on the issue of funding as we all know programs can't do much unless they have money to back them up and although the funding for PEPFAR has increased it wasn't what the Obama Administration initially wanted it to be do you think that there is enough funding to actually put into place all the programs that you mentioned well I think that the funding has increased and that has given us the ability not to stop our expansion strategy because we are still looking not at not a decrease in activity but actually a steep increase in prevention activity the constellation of programs that are in many of our larger countries are such that there are many efficiencies that can be identified really with not real digging going on looking for situations where programs have been funded where multiple entities have been funded for the same population so there is more than an overlap of target population their catchment areas are really the same looking for an efficiency to scale of number of those types of programs matching it with the demographics we will kind of do that in a very clear way we will match the populations up with the programs and the access points we also expect to be able to incur a lot of resource savings from a diminution in the cost of care and treatment as we move into now the sixth year of PEPFAR we are getting better at care in all aspects of the disease both treatment care as well as prevention and that economy of scale is significant the third big resource saving exercise is as we and this is what I would say is the smaller of the three and will come in over the next two to three years is as we move to more country ownership of program there will be and as our NGO community moves more toward mentoring and technical assistance there will be savings that will be identified there as well. I want to bring you into this discussion there is not a controversy but varying viewpoints from advocacy groups who is to value a life that okay it is cheaper to put money into prevention and some other treatments that actually can treat other diseases the antiretroviral medicine is expensive but if somebody needs it and we have it available then why shouldn't we fund that as well well it is certainly true that providing antiretroviral treatment to people who are infected with HIV and who have AIDS is a very dramatic way of extending lives and on the other hand the keeping people who are currently uninfected from becoming infected is also a way of saving a life so it's clearly a delicate balance I mean people who are currently on treatment obviously need to stay on treatment but I think we have yet to confront the issue of how decisions are made about allocating any resources that are extra the same is true about other interventions that save lives in situations that are beyond HIV for diarrhea and vaccine preventable diseases it's a very difficult situation to confront so this issue is out there these dollars are limited and they have to be allocated in a certain way and there is this shift then from the prior PEPFAR that was more treatment oriented to more prevention and other integrated care Dr. Kenya in terms of integrated care and how that can improve treatment you mentioned earlier to me that you had gone to Cuba and you saw where this can work can you explain how this can actually work where a country manager is a program and it does have positive impacts I think we've seen that in other countries as well Thailand has a wonderfully renowned program 100% condom program and really what both Cuba and Thailand did was they paid attention to the social norms and the behaviors that increased transmission in those countries and what they did is they created social interventions that were effective in one changing what is behaviorally considered acceptable specifically homosexual behaviors and they also when intervened at the places where they knew the highest rates of transmission were occurring regardless of their legal status so in Thailand they introduced condoms into essentially sex workers and they put laws in place and policies in place that really enforced the use of condoms with every sexual interaction they have some work to do since they have those great declines in their initial HIV transmission rates however what is particularly concerning about PEPFAR I think that we are providing treatment and we're allocating a lot of resources to the places that need it most but perhaps we're not paying enough attention to the social and the environmental conditions and the behaviors that are going on where we really have the opportunity to intervene in a meaningful way and what I've seen in my own work locally in Miami is when you do pay attention to those social norms and you intervene with modes and methods that are relevant to the population that you're targeting you can see very significant clinical outcomes and we know the medicine works it's not about the medicine and the access and all of the other sort of environmental barriers that prevent people from knowing what their status is knowing how they can either maintain their negative status or reduce the progression if they are currently positive and I think that's an area where we have a lot of opportunity to grow with PEPFAR you mentioned the social norms you know of course treatment of AIDS is an issue that's bipartisan and I think both parties want to address it but there are some interesting shifts that are taking place with respect to party lines in the prior PEPFAR there was this element of not providing as much funding for those programs that dealt with family planning and that provided care for sex workers and homosexuals in terms of the guidelines I was reading that some of them are written into law so it may take some congressional changes but some are policy and some of them may be policies that you could actually impact and I'm just wondering in terms of the new guidelines in how this money can be spent we have this part of money but then it's how can it be spent there's this whole issue of opting out that some of the faith-based organizations were able to opt out of those requirements but that if these requirements are in place that this will cause faith-based organizations guidelines that you think will be implemented in terms of how the money can be spent and what restrictions there may be well we are aggressively focused on looking at our guidelines and matching it up with new perspectives around appropriateness need we are committed to positioning the provider so they can respond to the needs of the patient that's in front of them not have an ideological belief system interface or get between that provider's ability to respond to those needs and that is requiring a dialogue both internally and externally with our implementing partners around the ability to identify once these needs have been identified to acknowledge a need to move that patient in front of someone then if they are unwilling or unable to address that need so these referral consultative relationships which we do all over the world in the United States right here in Washington DC can accommodate a different philosophical, ideological, religious belief system as a barrier to that but we are keen on making sure that that patient's needs are met where do the guidelines require let's say a faith-based organization who doesn't agree with distributing condoms would it require them if they accept the funding to provide that service or can they opt out? well we will have to have a way for that patient to get the service they may not deliver it and we accept that but the ability for that person to be referred to someone who can address that need is a basic medical, ethical requirement that we are in clean discussion now to try to address I also want to say that our faith-based organizations are very effective at what they do they are some of our better implementers indeed are in settings that are not only are they better implementers but they are also in settings where there is no one else we need them to blanket the population needs in every country we are in they are frequently not in urban settings but they are in the rural setting so a way and a desire to find a way to keep them working for us and with us for the patient populations that they have been responding to for many years before PEPFAR and hopefully many years after is the goal and I am confident we will be able to figure this out and related to that there is issues of countries who have various laws that might discriminate against certain patient groups and that's been an issue with respect to getting the funding to the patients who need it I want to ask in terms of that restriction the CSIS report on this topic made recommendations that these country partnerships should be resourced more that they will provide for more sustainability but what recommendations are made for countries that may have those restrictions and not reach those populations that's a yet to be addressed issue as well in the introduction Steve Morrison mentioned the issues of conditionality and I think that's an issue that the US government in general is going to increasingly have to confront so since resources are scarce and since there are lots of populations that need help it makes sense to allocate resources to places that can use most effectively and efficiently and to and to not think about putting fewer resources in places where HIV risk behaviors are criminalized or where forced detoxification for example goes on in prisons so there are a number of issues there are also ethical issues in the way that Dr. Goosby was mentioning that have yet to be confronted but are coming closer and closer so obviously there are complications the science of it in what can be done to help a patient but we deal with restrictions and guidelines based on ideological issues here that you mentioned Dr. Goosby as well as country laws that may also come into play with respect to the country partnership Dr. Kenya you mentioned you've seen examples where having the country manage the program has worked well you mentioned Thailand and Cuba but some advocates would also argue that there are some countries that have problems with corruption and some ministries do not perform well so if we allocate more money through those ministries do we think that the money will then reach the patient has CSIS in your report looked into this issue well I think that's we didn't deal with it directly in that report but it's part of the same conditionality issue for example it's the kind of principles that the Millennium Challenge Corporation has used or is using to allocate resources and ultimately because resources are limited I think it's the same concern that resources should go to places where the lives can be extended the most or where the most people could be kept unaffected from HIV and so to the extent that issues like corruption become a drag on the system that has to be taken into account and Dr. Goosby following up on that you know part of the new strategy is to shift these programs from a lot of these NGOs it's been multi-tiered with different kinds of organizations providing the service and receiving the funding from this part of US money there's obviously other sources from multilateral would you say that capacity building for the public health ministries is going to be part of that effort to ensure that the money will be spent wisely yes it will be a central part of it no one is talking about moving the effort just to the public sector we're talking about engaging the public sector in a dialogue around increasing their current role around management definition of unmet need especially the prioritization of the unmet need and then the allocation decisions none of that necessarily means movement of money to public systems that will not happen until we are sure that transparency also moves with it it's not rocket science we'll be able to figure that out and know if those resources are being used or not being used there will be transgressions for sure and we'll respond to them but not to remove the entire pool of resources because of one transgression but to find the bad guys and get them stop the transgression and redirect those resources back to program I'm confident that we can do that in doing that we will create a cadre of capability in the country that will serve our programs and the entire country's constellation of programs and needs for the future and indeed is a central piece of the contribution we want to make so this will be a phase strategy it might be different for one country there's 15 countries in PEPFAR versus another one but that is one option that is being sought for sustainability reasons and Dr. Kenya I want to ask you you've analyzed the new PEPFAR strategy for over 15 years if you could make one recommendation to Dr. Goosby and the Obama administration of what are some areas that should require more attention or could be more helpful what would you recommend? An abstinence only strategy has never worked it's never done anything and I may be very ignorant it's never done anything but increase the rates of disease and unwanted sexual consequences so I think when we talk about encouraging abstinence and even giving our resources to organizations that will only promote abstinence I think it's a huge mistake and I think it really ignores our current science and I think that we have many examples of this in our own country when we promote these types of policies with our programs and not providing accurate sex education to populations in need of it we see the dire consequences we've seen it here we've seen men on the down low and how that's contributed to HIV disparities racial disparities in the United States and we see where these racial these ideologies contribute to very very disturbing outcomes all over the world and we should be a leader in advocating that science-based programs that have proven outcomes that's what we support we don't support ideological I mean we have a problem with that in our own country and I think the last that was a very very motivating question about why we change the administration so Doctor, this will be a response to that isn't the Obama administration actually opening it up more to not focus on more of an abstinence strategy as the prior administration did Yes much of our attention is looking at a way to expand the service constellation for the providers that had been just based dialogue to include condo men referral into family planning and other health services that response is a critical piece of what is needed and we hope that working again with the entire community that's already engaged in this work to look at the services that we are able to put in front of patients as the primary goal Dr. Nuber I have a CSIS report that I read on this topic it's very helpful provides recommendations now that the new PEPFAR strategy just came out last month in analyzing that what would you say could be done more that was into CSIS recommendations that may be perhaps not included in the new strategy I actually think that the new strategy does a good job of hitting the same kinds of issues that we were focused on it in terms of certainly the appendices or annexes I guess they're called that cover in detail most of the issues I think one thing that might be interesting to think about it might be useful to think about is having indicators that are more population based than individual patient based so for example the president's malaria initiative has an explicit goal of reducing malaria infection malaria deaths in the population by 50 percent the PEPFAR goals up to now have been focused on the population the medical model people who come into the programs rather than a population based and I think that's one of the reason there are obviously large differences between controlling malaria and controlling HIV AIDS but it might be easier to help target resources if there were population based goals like that and picking up on that one of the shifts with the new strategies I understand it is to integrate the treatment of HIV AIDS with malaria and TB and in your prior role at CDC you actually let a department that did all three so you're well versed with this do you think that that is possible with the limited resources that are available that if it has to be allocated in certain areas do we have enough money to do that well for tuberculosis which is probably the bigger problem of those other two I think it is possible and that's because in general TB programs are already well resourced in most places the issue is really integrating the programs so that people HIV infected people can have their TB detected and treated and reverse making sure that new or current TB patients have their HIV infections detected so I think that integration which took a long time to get started is now moving along pretty well and I think that will go pretty well. Malaria may be a little tougher we have it we're not very far down that road yet but we'll see. Picking up on that prevention versus treatment America actually just recently did a whole one hour radio piece on this topic having gone to different countries to assess this and the you know the findings were again that the treatment has been effective for those patients who received it but that the problem just keeps outgrowing the solution as you said earlier there's just more patients who keep getting HIV than are being treated as part of the new PEPFAR strategy you mentioned some of the numbers that are being targeted how much more money will it take to actually achieve those goals given this problem that's multiplying more than the solution we have. So it's that's a that's a difficult one to respond to because it kind of depends on how you cut the pie up but if you look at the number of patients on antiretrovirals now look at the 200 to 350 change the WHO recommendation change has created you know you're still looking at 33.4 million people who eventually at some point in time sooner or later are going to need antiretroviral therapy. So watching as aggressive a response as was mounted for treatment with prevention is the goal here and we need to turn the volume up on every aspect of that and take advantage of every component of that but at the same time not ignore those already infected to abandon them stops the murder that puts people in queue to get tested for a reason and to not understand the disease to be the kiss of death which is really how it is largely perceived and is a huge motor for stigma. So I've never seen a destigmatization program work without a robust treatment capability both within the health profession as health doctors and nurses where there's a huge amount of stigma in many of these instances as well as in the larger civil society without that in place you are not positioned to effectively diminish the stigma. I think that what needs to change is who we call to the table. We were not through a bilateral effort successfully treat the burden of disease that we already know is out there. We need to aggressively change the discussion to include a call of responsibility to the larger global community to look at what is the need that you are capable of responding to or contributing to the response. Activities such as the Global Fund, other bilateral Unitade type efforts there are a number of emerging strategies around kind of basketting of resources all of these need to be looked at probably convened by multilaterals but then thought through and made real through a country-based lead discussion where these multiple divergent resources are then looked at and added up at the country level to address their desire to move to universal coverage and address that large unmet need. We will not be able to do it alone. We need to admit that and engage with our colleagues on the planet to converge resources. Picking up on that obviously is a global problem. The U.S. historically has been the largest donor of these programs still remains. In addition to many other programs and with the economy here being a challenge it will be difficult as you said to fund this. What do you think needs to happen for other countries to get on board and to provide more funding to these programs? Does the administration plan on convening any international conferences or summits issued to kind of call other countries to action? Well, I've been charged with starting this conversation and it is well along the road of beginning discussion at both the UNWHR levels, Global Fund as well. We need to prime the pump with that discussion. We need to engage bilateral who are capable of identifying resources that can go toward this to do it. That will be in some convening discussions and also kind of private discussions as well. All of that has started. The UNWHO are planning to convene at the country level a robust discussion on the 200 to 350 challenge for universal coverage. We will participate and support that actively. But I think that this will require leadership on the president, the secretaries level to challenge our colleagues in countries at the G8 level in particular to look at this differently and to commit differently to it. Countries that can need to be challenged, why not? That discussion needs to happen. I think that both the secretary and the president are in a position to actually put that challenge out. What's interesting is obviously the Global Challenges series that we have focuses on these millennium development goals and the prevention and treatment of HIV AIDS is one of those eight segments of that program. Dr. Kenya, have you seen in the countries that you have visited and worked with a greater kind of cooperation with the multilaterals in addressing this issue, or do they want to focus on their own problem and get the assistance through their ministries? I've seen definite cooperation amongst all sectors of the communities and the countries that I've been to visit as well as my research replicates out of Paul Farmers in Haiti, and that the mode that we really work on, it's called the Community Health Worker Model, and this is not rocket science. You take people from the community, lay persons, you train them, and then you send them out to the community to provide support services, education, and increase access to care. And I see that model as being a viable opportunity for us to really encourage the countries that we work with to take ownership of their programs, the money that we save on, the money that we save on additional, you know, the additional transmissions that might be prevented can be used to pay salaries and encourage employment in those countries. And also, that's very, very effective in changing what social norms are and what's socially acceptable. You have peers on the street coming to your home telling you about what HIV is, how to take your medicines, how to access treatment, why you might want to get tested, and why you need to adhere to your medications. In doing that, you have community representatives educating people and changing what is considered acceptable, saying, hey, I'm gay, or my brother is a man who had sex with another man, and he's still a human being. And I have never seen those types of changes in a society, and I'm going to give, I'm very young in my observations of what happens in society, but I've never seen those changes occur from the top up. You know, your work is focused on urban communities in Miami, and you've said before that there are a lot of similarities between what those populations experience and what someone in an impoverished country will. Absolutely. What kind of lessons learned can domestic U.S. AIDS policy learn from the international experience? Oh, my goodness. That's a loaded question. We can learn that our resources need to be comprehensive. For example, when I went into Overtown and I was recruited to the University of Miami to do this, we had no HIV testing. So obviously you're not going to have any impact on HIV prevalence if there is no HIV testing. So, and also using our local community partners, I think that our communities are urban intercity communities, and ideally, I mean, it's ideal this conversation is happening in Washington, D.C., where our HIV rates do mirror that in many parts of many of the worst areas of the world. I haven't seen any community health worker since I've been here in Washington, D.C., telling me about HIV education, and I look like the target population, and that's what I think we need to see more of. I haven't seen any billboards, but what I do see is every time I walk down a street in D.C., and I see more than one majority, I try to estimate in my head how many are HIV positive, and it's scary as an American, in our American society, in our capital, but that's what I'm thinking about. So the lessons that I've taken from Haiti and from Cuba and from Thailand are really pay attention to the behaviors that are increasing transmission. The morality out the door. You're going to sit here and judge people, then you're going to increase poor outcomes and more racial and class disparities in HIV. Thank you very much. We'd like to have a good time for a discussion. I know there's a lot of policy folks in the audience, so if you could raise your hand and then come up to the mic closest to you and just say your name and your organization and keep it to a question and to one of the panelists. Sir? Dr. Goosby, congratulations. Good to see you. You did a great job, and I'm working in Russia, as you may know. Two questions. Sorry, your name and your organization. Harvey Sloan, I'm from the Nation Medical Education Program. Thank you. Two questions. We know that the need is far outstripping our ability to deal with this epidemic, particularly from a medical standpoint. My first question is what kind of money is PEPFAR, the Global Fund, the CDC, all the organizations that can help put on finding evidence-based information about how to protect people and prevent the spread of HIV? First question. Second question. I'm glad you were using social network and marketing, but I was surprised you didn't mention texting. Hating Today is being people are getting around by texting. Oh, taxi. Sorry. Not taxi. It's a generational threat. I got it. I have in my travels abroad, I almost feel that the best thing we could do would be distribute a cell phone to everybody, and so they can get that information. You don't, Dr. Keny, you don't go through the Missionary Hospital, you don't go through the more easy than that society. You directly hit that person who wants to get an information about that particular way of treating disease or not getting it. So thank you very much. Well, it's good to see you, Harvey. I think that the way that we are looking at our prevention shift is a way I'd say that is in each country. We're not looking, I mean, it doesn't matter what the total PEPFAR pot kind of does, prevention treatment care, unless you translate that into how it translates into program. We are trying to basically put each country that we're in, certainly the 17 focus countries, but even as you move up into our 30 country level there are prevention opportunities that present themselves, especially in Eastern Europe, Russia, the stanzas, all of those need to be addressed as prevention opportunities, where the prevention pot is going to be bigger than the treatment pot. So I mean, it's that kind of a shift. We want to be in a position where our prevention effort has engaged on every front we think affords an opportunity. In terms of taxis, I think that we, you know, I've been in this work long enough to have that kind of be something that I didn't see as an opportunity initially. I said whatever people want to do with that, great, but have come 180 degrees anyway, not full circle, but 180 degrees to wanting to test it. I want to take it to scale in one or two countries where we've already engaged in choosing the countries. We already have the resources to do it to show whether or not an aggressive kind of informatic approach, an e-med, e-health type approach to prevention and treatment from high risk populations targeted for high risk messaging recurrent kind of case management opportunities so we don't lose people to adherence and lost to follow up strategies especially where there's no addresses on the majority of the patients we're seeing. To use that as a means through which we can identify, enter and retain patients in care. We are going to take that to scale probably in Rwanda, although not finally decided because they're almost, they are very eager to do it and have put a lot of things in place to do it. And then in a country that's not ready to do it that will need a lot more infrastructure support. But I might there with you to really try to understand if this is indeed the tool that we think it might be. Thank you. This gentleman here had his hand. Thank you. David Scheer, Strategic Partnerships. We are working with the Friends of the Global Fund through the UN Foundation both in Africa, Asia and in Europe. As we pursue our work clearly the refunding of the Global Fund coming up this year obviously is a centerpiece. One we wonder if you would let us know the strategy of PEPFAR at this point in time in terms of supporting that effort. Secondly, as we work on the implementation side of this in Africa we see increasingly the importance of sustainability. And that means obviously linking with USAID the bank and other international organizations with respect to the development side and if you could talk to that a little bit too I think that would be very interesting for us. Those are two good questions. The Global Fund kind of is the future would be the short version of it. It is a pot of money that everybody contributes to that goes to country and then is transformed into program. There are issues with all of that in terms of taking that pot and efficiently transforming it into programmatic responses. The presence and use of technical assistance when technical assistance is introduced how it relates to the principal recipient how the community the country coordinating committees the CCMs are convened how they deal with a kind of inherent conflicts of interest how you deal with a transgression when an error or a corruption is found how technical assistance should come before a cessation of resources. All of those things the Global Fund is acutely aware of. We sit on their board and have engaged in conversation with the leadership and the secretariat that raises my level of comfort and confidence that they are indeed moving on all of those fronts. We are having a board meeting at the end of this month that addresses all of those issues and the issue of eligible funders how do you compare unmet needs across different countries of different economic capability but it is probably the means through which rich countries can support resource poor countries and we need to look hard at the Global Fund to make it everything it needs to be to be efficient and effective at making that transition. The PEPFAR really through the appropriation gives a third of the money to the Global Fund and has really since its beginning. We are around 1.5 billion now 1.5 billion or so in the amount of money the US citizens, US Congress allocates to the Global Fund we see that as a conduit through which these resources can effectively move and we need to think about who contributes to the Global Fund and support in every way efforts to increase that contribution and the countries contributing. I think there is more room to go with that. Thank you. The woman in the third row. Hi, Nandini Uman from the Center for Global Development thanks to CSIS and the Knight Center for hosting this event and of course Ambassador Goose before sharing time with us when you have a lot more to do but I actually wanted to raise the issue you have talked a lot about and impact and I think all of us in this room are absolutely behind you in the approach that PEPFAR2 has taken but there is a lot of concern about what is meant by scale up given that successful prevention often is very much at the community-based level and so how are you thinking and I know you are working through these things but it would be useful for us to know how you're thinking about measures for success that will allow you to report both to Congress as well as to beneficiaries about how money from the US and other countries is being used effectively to actually prevent infection so to be succinct could you walk us through what you mean by scale up what are some of the measures for success and how will you incentivize countries to be able to measure those successes and report at a country level I think global measures are in the sense when we're talking about prevention given the contextual nature so that just maybe a country example like South Africa would be useful thanks well I think that it's been the million dollar question or multi-million dollar question to figure out the surrogate markers of successful prevention efforts what are the outcomes the number of preventions perverted the number of infections perverted is a difficult thing to kind of reliably quantitate our thought and we are actively working on what these markers will be and should be and we're also engaged with both UN AIDS and WHO and trying to define these same markers because the whole planet needs them we are going to move forward anyway and by scale up by taking your demographics understanding where your virus is moving within those populations not 20 years ago but in the last year where your new serial conversions are located and then backward position our programs our prevention programs so those communities are interfaced with and connected to our prevention effort first and then go to the general population so for concentrated epidemics it makes a lot of sense but it also makes a lot of sense to target communities that have generalized in the same way because there's really no other way to target them but to be smart about how we position those prevention interventions with that generalized epidemic looking for opportunities where people are convened where people are receptive where we don't have to build it from the ground up those types of efficiencies can make a big difference and then eliminating redundancies or ineffective programs and we've gotten to the point where we need to do that I think that our ability to measure this is going to be best reflected in an impact on incidents and we are hoping and that's a big statement as you know but we are hoping that we can take surrogate markers of incidents with your prenatal numbers and use that as a ballpark figure to get under and not exactly sure that that's the certainly not the only thing we'll do but that is kind of where the thinking is settling out now we've got some of our best thinkers in our country and in Europe helping us think through this and once we get an internal position we'll take it to the community to actually get a reaction but we as I said are moving forward with it aggressively now the fourth row sorry David Briden with Infectious Disease Society of America the dedication to research driven approach evidence-based approach is certainly very welcome we're extremely excited about what we're hearing about that two questions if I could squeeze them in one for Dr. Goosby if we can create pre-exposure prophylaxis if it proves efficacious changing our approaches in the nature of HIV prevention and for Dr. Nyberg I was a little concerned that among the specific recommendations in your report there isn't any recommendation for scaled up funding and when it comes to prevention itself the Futures Institute has shown with their modeling $200 million extra each year over the next five years for male circumcision would be an enormous savings over the long terms in terms of averted need for treatment what we've seen over the past couple weeks Americans willing to open their wallets for Haiti at an enormous level $200 million so far even with a tremendously difficult economic picture what we've seen so far in terms of Americans willing to donate or does that give you any hope that the US government might actually be willing to keep or able to keep its promise with the double foreign assistance and scale these programs up in the way that they need to if a compelling case is made an even emotional case is made that this needs to be done in the way that obviously Haiti has moved people thank you so let's see the first question was you took me right into that second one I was concentrating on that so what was the first issue oh prep pre-exposure proof is probably something that has reached the threshold of we need to plan for its implementation we are concerned that some of the data and the length of time that it's taken to get this control group straight has been very frustrating we have taken the step to engage in preliminary planning around what we would need to do to move that to scale if we do get data that shows efficacy we would move it to scale as a central piece of our prevention effort it would probably take the form of high risk groups and not be a general population focus injection drug users sex workers some MSM strategies should include it there are also some situations with women who are disempowered in relationships where that would also make sense I think that the ability to look at how that impacts the ARV total ARV need of a country is pretty breathtaking when you kind of do the numbers on it so we are actively looking at how we would try to move that to scale there are also a number of foundations not the least of which is an activity convened by the Gates Foundation and Steve Becker up there who is really trying to tease out the nuances of populations that indeed will benefit more than others with that strategy and to look at the implications for movement to scale so I think the question about scale-up prevention I think the answer is relatively simple which is that the intention of that paper was to sort of capture that as the major issue most of the people involved in the meeting that led to this paper including the two of us who ended up writing are involved with the Global HIV Prevention Working Group and for those of you who know that is their major issue so if that didn't come across in the paper then I should go back and look at that but obviously the scale-up on the prevention side means increasing competition for resources with the care and treatment pieces and so that has to be handled very carefully but scale-up is definitely a high priority the highest priority in the prevention area Hi, thank you so much for having this roundtable I had a question that specifically deals with young people ages 15 to 24 as we know that this is still the population of some of the highest rates of new HIV infections and I would like to pose this question to all of you about some suggestions about how your prevention strategy could be more youth-friendly and incorporate young people into specific details on how young people will tie into your prevention strategy and I'm Nikki Mangoli from Advocates for Youth Thank you Do you want to take the first part of that? I think that if we allow the demographics of the epidemic to lead how we position our prevention interventions they will not be ignored I think that youth have always presented a difficult population to identify test and enter into care and keep in care for a lot of reasons that have to do with just social maturation and self-perception those differences need to be incorporated into the strategies I think that Harvey's suggestion that texting and phone-informatic type strategies might make sense but there are very resource-poor settings for youth populations makes a lot of sense and then there's always the traditional kind of athletic for general information dissemination convening around musical stars pop music rock music or whatever local music having athletic events convene the upcoming soccer tournaments are kind of running throughout many of the countries we're in afford opportunity for that and we've already partnered with those types of organizations to saturate the World Cup activity with prevention messages that are really looking to hit youth Dr. Kenya, since you've worked with a lot of communities both outside and inside the US and specifically with minority communities. I think it's two-fold I think in order for youth to be involved we have to empower them one with the education so that they can be involved as well as the resources similar to the truth campaign which is the only thing that had any impact on tobacco and youth it was youth-led of course it was funded and still is funded by the tobacco companies perhaps that could be something that the music companies or the alcohol companies could participate in and provide the resources so that the youth with their own messages are the big proponent of community-based participatory research unless you involve the target community in your program planning you're not going to be effective one thing the youth can't do though is they're not in a position to dictate what policies provide them with what types of education and as we know the big federal funding joke whereas if you receive a certain amount of federal funding to provide certain types of health education you are not allowed to discuss condom use and things a lot of issues around that we're big in the former administration I think that we really need to actively address those and we need to look at those very seriously not as I think how do I want to frame this this has not been taken seriously in this country the way that we educate our youth and they do make up 50% of the new infections and that's the same throughout the world and in other parts of the world the youth are even less able to participate in public health efforts and I think that we need to do more for the population that does present the greatest new risk yeah just something to follow on these last two comments plus in addition to following up something that Dr. Kenya said earlier I've always been amazed that the know-your-epidemic conversation that UNAIDS and WHO have been discussing for the last five or six years includes the way it's presented only recent infections as opposed to knowing your epidemic in terms of the risk behaviors in the community looking at behavioral surveillance as well as disease surveillance and it seems to me that expanding that idea to behaviors is one way of bringing in youth and the issue with youth really is that learning things right the first time is much easier than unlearning bad practices and then relearning them the right way well because we only have a few minutes I just want to ask Dr. Gosby if he has any thoughts you'd like to share with this public policy kind of audience about what your next steps will be in terms of carrying the PEPFAR strategy forward both you know within this administration to get the funding globally well thank you you know PEPFAR has been about saving lives and that is what it will continue to be about we are going to increase our ability to be efficient at continuing that effort to save lives but also as efficient and as aggressive in our efforts to better prevent new infection we are going to move in a deliberate and specific way to challenge our program services in country to reside and embed themselves in the public sector gradually over time because we feel it is the best way to ensure that these services remain there for the populations that we have already committed to the president and the secretary are fully committed to that effort I would say it is up amongst their highest priorities and it is with that conviction that I agreed to move forward with this work thank you very much I want to thank our panelists Dr. Sunjaya Kenya from the University of Miami Dr. Gosby also Ambassador for Global AIDS Coordinator from the Obama Administration and Dr. Phillip Nyberg from CSIS for presenting these unique perspectives and the good news is that there is a strategy that this issue does have a lot of attention and priority obviously it needs more resources but it is good to see that the administration has a plan obviously this is within the larger global framework that this needs to be implemented and also funded and this series, the Global Challenge is kind of addressing some of the key challenges within that we have these Millennium Development Goals this is one of the priorities but how do we move that agenda forward with different countries sometimes who have laws that unfortunately discriminate against their own citizens and we have these guidelines on how money can be spent so it is obviously very challenging but it is good to see progress being made on some challenging issues the next session we have one every month and if you are asked you will receive it we do have a Miami series at csis.org as an e-mail address if you want to send any thoughts but we would love to see you participate in another session and I just wanted to take a moment to reflect on the prior session that we had we actually had the Haitian Ambassador with us at one of our prior sessions speaking about Haiti's goals in meeting the Millennium Development Goals and he had shared with us that a cruise line was going to be going to Haiti and that this would really help their economy and they had a really positive outlook and it was really devastating to see what happened with the earthquake and how that is going to affect the country's ability to respond to this natural disaster but also meet these goals that they already were struggling to meet so I just wanted to reflect on that and have everyone give a moment of thought to all the victims in Haiti I know all of you are probably doing something to help global issues but Haiti is definitely a country that needs all of us so I want to thank you again for your time for attending and we hope we see you at another session of the Global Challenges series thank you