Kaiser Family Foundation Town Hall with Ambassador Eric Goosby, U.S. Global AIDS Coordinator


December 4, 2009

Kaiser Family Foundation
Washington, D.C.
December 4, 2009

Transcript provided by the Kaiser Family Foundation1

JEN KATES: Good morning everyone. My name is Jen Kates and on behalf of the Kaiser Family Foundation, I welcome you all here today. Today's event, A Town Hall Discussion with Ambassador Eric Goosby, the U.S. Global AIDS Coordinator, is part of our ongoing effort to help inform policy discussions about the U.S. role in global health.

The focus of today's event is PEPFAR - specifically PEPFAR's future directions in light of the release of the much anticipated five-year strategy earlier this week. The strategy, as mandated by Congress.

We have all been waiting for the strategy. PEPFAR means many things in many people's lives particularly the lives of the millions it has helped to save, extend, and improve.

PEPFAR has achieved a reach and success many thought not possible just a few years ago. It has had political support not generally seen in most other areas and during times when all else was well, fairly rancorous. From its launch by President Bush, its ongoing bipartisan support in Congress, and now being described as a key part of President Obama's global health initiative, we see that PEPFAR has had a unique place.

Indeed what happens with PEPFAR will, in many ways, determine what happens with the U.S. government's response to global health. PEPFAR is the largest part of the U.S. government's global health portfolio and in your packet, you'll have a new policy brief that we did where we look at the GHI budget and you can see the role that PEPFAR plays in it.

PEPFAR's the single largest program of its kind in the world but the context has shifted too. For PEPFAR itself - the strategy, for those of you who looked at it and as we'll hear today, represents a real shift in emphasis and approach; a broader shift for the U.S. government in terms of approaching global health and development; and for the global economy. From an emergency response to sustainability emphasis, from a disease-focus to a broader lens, from an era of dramatic scale-up of resources to one of a global economic crisis and a recession.

So we know from the email questions that have been submitted by email and the close to 300 people who RSVP'd and from recent news reports and other events, there's much buzz about PEPFAR, including concerns, anxieties, questions, hopes, complex issues, and all the rest.

That is why we are so pleased that Ambassador Goosby has agreed to be here today and spend the morning discussing the strategy and future with the community in this first public discussion of the strategy. Many of us know Ambassador Goosby. I have known him since I began working in the field of HIV/AIDS.

His commitment to HIV, as a physician, an implementer, an innovator, and now the U.S. Global AIDS Coordinator, is long indeed. You have his bio in your packet and I'll just say it's a bit modest for all of his accomplishments. I want to thank him for being here and also thank Ann Gavaghan and Jenny Peterson in the Office of the Global AIDS Coordinator for working with us on this, and my team, Kim Boortz and the Kaiser communications and media machine that makes all of this go on the Web and come together.

I'm now going to turn this over to Ambassador Goosby who's going to frame the big take-home points of the strategy for us. He and I will then begin with a few questions from me to him and then we're going to open it up to you because the bulk of the time will be spent taking your questions. We do have a pretty hard end time of 10:30. So we'll respect that. Thank you very much. Ambassador Goosby. [applause]

AMBASSADOR ERIC GOOSBY: Thanks. Well thank you Jen. It's always a pleasure to see you and have an opportunity to speak to everyone today. It's an honor, really, to participate in a Kaiser Family Foundation activity. The role they've played in keeping the lines of communication open and clarity in discussion has been, for many years, something that we've all benefited from, and it's really a pleasure to participate.

In my first few months as the Global AIDS Coordinator, I've seen the dedication of those who have made PEPFAR what it is, a reality around the world both within the United States and Washington and the implementing agencies -USAID, and CDC, HHS, HRSA, NIH, FDA, our SAMHSA involvement with Peace Corps, Department of Defense. It's really a huge conglomerate of implementing agencies across the entire government and is really one of the few examples of true coordination in an attempt to use and access the talent that is already present in the U.S. government's kind of toolbox of response.

It's equally true that the global AIDS emergency is very dependent on our implementing partners moving these resources to programs in country. The implementing countries have played a critical role in embracing these continuums of care in both prevention and treatment. It really speaks to an extraordinary partnership from (appropriation around the dialogue on the Hill to the actual government's appropriation, implementation through partners right down to country and to program on the ground.

The American people can really be proud and after having seen a good number of countries in the first few months of my tenure, they can be proud of that whole chain of responders that make this a reality for the people who need these services.

It's equally true that the global AIDS emergency is not over. Countries still struggle with vast unmet needs. There are an estimated 33.4 million people living with HIV and estimated 2.7 who have come in with new infections each year with about two million deaths. For every two people we put on treatment, four to five move into the infected realm, seroconvert. It's clear we need to work harder. We need to be smarter at what we do, and we need to look at every opportunity to converge and identify a diversification of resources to allow us to move to meet that unmet need.

In fiscal year 2009, PEPFAR has supported antiretroviral treatment for more than 2.4 million people, essential care for nearly 11 million people, and counseling and testing services, and referral for nearly 29 million people. And through efforts to prevent mother-to-child transmission, PEPFAR prevented transmission for nearly 100,000 babies born to HIV-positive mothers in the past year, building upon the nearly 240,000 babies born HIV-free during the first five years of the program.

I'm happy to say that over the next phase of PEPFAR, the program is committed to providing treatment to more than four million people, which is an increase of the target that PEPFAR had announced last year. This treatment target will more than double the number of people supported by PEPFAR during the first five years from 2004 to 2008. PEPFAR's increase in treatment will also help to meet the needs of more than five million people worldwide in need of treatment.

But this global need requires a global response with increased coordination and commitment from other countries and other donors. If we are to sustain the gains we've made against this epidemic, PEPFAR must work in closer collaboration with country governments to support them in taking the lead and planning a response to their epidemics and orchestrating outside resources.

PEPFAR's five-year strategy, unveiled earlier this week, will focus on sustainable responses, programs that are country-owned and country-driven, programs that address HIV/AIDS in the context of broader health needs faced by people with HIV, programs that build upon our successes and incorporate efficiencies, programs that condemn stigma and discrimination, and provide services to all regardless of sexual orientation, gender, or HIV status.

The document, the five-year strategy is a policy roadmap for where we'll be going over the next few years. Over the next year, we'll be working closely with the field, with the implementing countries to define and identify changes in guidance as we try to implement some of these new emphases that we're identifying. The guidance revision will be extensive and there will be a need for new guidance production. We'll also continue to utilize existing budget processes to work with the Administration on an annual basis around our budget requests.

With that said, let me lay out what the roadmap is going to look like. First, we're going to continue the transition from an emergency response to a sustainable one through greater engagement with, and a capacity building in governments, civil society. PEPFAR has already started this with the Partnership Frameworks, five-year strategic plans developed in collaboration with partner governments but we need to do more especially around supporting the creation of government capacity to oversee, manage, and eventually finance these programs.

Secondly, we're going to focus on prevention. We're going to scale up highly effective prevention interventions like prevention of mother-to-child transmission, introduction of male circumcision. We're going to work with countries to determine where new infections are occurring and help them realign their prevention activities to target most at-risk populations.

We're going to work to identify promising interventions and create an evidence base for some general population prevention interventions like behavior change communications that need more research and more definition, trying to concentrate a combination of prevention strategies on specific populations.

With treatment, we will continue a strategic scale-up of services to more than four million people. The focus will be on populations that are most sick, lowest T cells, pregnant women, HIV/ TB coinfected patients and, at the same time, we'll work with both our country partners and the international community to continue to lower the price of commodities and distribute the costs of treatment among multiple funders.

In addition, these numbers serve as the impetus to encourage others to do more. This will fuel our dialogue and catalyze our dialogue to multilaterals and other bilateral activities that can converge in countries to add to the pool of resources that will allow for an expansion of the response to the unmet need.

As we carry out these prevention, care, and treatment activities, we'll do so with an eye toward how these activities strengthen the broader health systems. We'll work not only to continue quality delivery of services but also to create a durable response that can continue after this program is long gone. I look forward to hearing from you and answering any questions you may have. I'll stop there [applause].

JEN KATES: Thanks. So I'm going to start with a few questions for Ambassador Goosby just to get out some issues that I think many of you have or probably will ask. We've gotten them in email. They've been in news reports, etc. I thought we might as well just put them on the table.

AMBASSADOR ERIC GOOSBY: Okay.

JEN KATES: I'm going to go right to the issue of funding because we know that there's a lot of anxiety around funding and the future of funding for PEPFAR, and the context of the broader GHI. The budget request proposed a little bit of an increase for PEPFAR. We know that the fiscal year 2011 request will be out soon and the strategies don't necessarily address funding specifically because they're broad roadmaps but is there something that you can tell us about and this issue of moral imperative around treatment as well and how that all connects.

AMBASSADOR ERIC GOOSBY: Well the strategy really attempts to define a path and an emphasis on how PEPFAR will kind of reorient to activities it has already engaged with across both prevention care and treatment services. The discussion has been robust internally. The attempt to deal with the economic situation has been a real one that the government has engaged with.

I can say in no uncertain terms that the President and the Secretary have this program and these services that this program has responsibility for as the highest priority. They are committed to it and committed to sustaining and increasing, over the six-year period as defined in the Global Health Initiative, $63 billion mark.

I think that the emphasis on trying to look for health strengthening activities for our budget, moving from what was a very rapid increase in funding in the initial phase of PEPFAR. We are now moving into a period where we need to look at efficiencies and opportunities that allow us to continue to keep the momentum but also for the first time, begin to look for opportunities to converge divergent resources from other sources on these issues that really are not going to be responded to alone by bilateral efforts.

The global responsibility to respond to these unmet needs is something that we have through the Global Fund and through other bilateral activities. Our commitment is to make sure that we have done everything we can to position these programs so they're positioned forever for the patients that we have already committed to and for those that we need to commit to in the future. We believe that we can best do that by getting countries to begin a dialogue at the country level to define the unmet needs and prioritize those unmet needs and look at divergent funding lines to make appropriate appropriations. It's a complicated shift in the way countries operate. It's also a shift in the way the U.S. government talks and partners with other countries and other organizations.

JEN KATES: Okay. This will connect back to that question. I'm sure we'll get to this question a lot during the day: targets. You started to talk about the targets and the treatment target. I know there's been some confusion around what the targets are and what the legislation said and then what the targets are going forward. Can you just reiterate particularly around the treatment target but also the others?

AMBASSADOR ERIC GOOSBY: Well the treatment target is something that the legislation has this unusual language around "as appropriations allow". We understand the relationship between the availability of treatment, how it drives the willingness to be tested and how it is the intervention that most changes the perception within the community around HIV and addresses stigma issues.

HIV is not a big kiss of death, inevitable death, with the interventions of antiretroviral treatment. Patients who receive them, moving back into life, going back to work, being responsible and capable of supporting their families is the dramatic motor to a prevention/treatment continuum. Without that treatment capability, that desire to be tested diminishes. So we understand that relationship and the momentum needs to be sustained.

The increase from the 2004 to 2008, the end of PEPFAR-1, we basically are doubling the treatment target and are committed to that. We say more than four million because we know it will be and we want to be able to ensure that we can continue to cover those who are already on treatment and then in addition to that cover the people that will be added on over the next few years.

We see this as a need that is growing with the WHO guideline change that's going, that has already occurred from 200 to 350 mark [CD4 count]. This puts us in a position where the five million now becomes nine million. I think that countries are going to have to go through a discussion around what they are, at this time, going to be able to absorb.

When we look at the patients who are coming into care, they are still largely coming in at late stage disease. So the less than 100, less than 150 is the norm. It's very rare for delivery systems, testing systems to be able to bring people in above 200. Some of the countries that have reached 85 to 95-percent of universal coverage are moving into the 250 to 300 range and the prenatal patients that are coming in but we're still mostly seeing people coming in at the initiation of opportunistic infections.

JEN KATES: Okay. It'll be interesting to see how the guideline change gets transmitted to practitioners and how that might drive differences. On the GHI, just getting to that, there's been a lot of discussion around PEPFAR and the GHI and how PEPFAR fits in. I know the President has talked about PEPFAR, and the Secretary, as the key part of the GHI but can you tell us a little bit about that process and how this release of the strategy now relates to the discussions around the GHI and information there?

AMBASSADOR ERIC GOOSBY: Well the GHI was announced in May, $63 billion over a six-year period. The idea is to take the existing programs such as PEPFAR, malaria, TB, maternal and child health, some of the development programs, family planning as well, and build on those treatment platforms to allow for an expansion of services that an individual can access through any one of those entry points.

It is trying to position the provider in the clinic or the hospital where they can respond to the needs of the patient in front of them without having to worry about funding lines paying or not paying for the service that they feel needs to be made available.

That is kind of a purse string of already existing programs and then an expansion of new areas would be linking as much as possible maternal and child health, family planning, reproductive health services to like a PEPFAR treatment platform, but also the other way, having patients and family planning settings be able to move toward HIV/TB testing and treatment.

These services are such that being able to use and focus on women as the entry point, as the target of who we're trying to identify and bring into care because studies have shown that women really lend access to both children and partners, husbands and more efficiently, more effectively, and more consistently over time.

So PEPFAR will play a central piece of that expansion of services. I think that it is from both the President and the Secretary's view, deeply linked to expanding health strengthening-type activities as well. So it is in progress. There is an active dialogue going on with it now that has taken place both at State and HHS and the National Security Council.

It is clear to us that it is a priority of both the White House and the State Department in trying to transform what are effective and proven vertical programs into a more comprehensive package for patients.

JEN KATES: You actually touched on something. We had, probably the bulk of questions that got emailed and then we're going to turn to your questions, were around women, family planning, reproductive health, and integration. Then we also had several questions around abstinence. What is the current policy and if there have been shifts, how are these going to be communicated to the field?

AMBASSADOR ERIC GOOSBY: Well there have been shifts. We clearly want to position the provider, who's in front of the patient, in a position where they can respond to the needs of the patient as presented to them as I was saying. So if a patient comes in who's being treated for HIV that they have the ability if there are needs in family planning or reproductive health services, sexually transmitted diseases, that that provider can respond to those needs there.

In terms of "Abstinence, Be Faithful," family planning services need to be available to individuals as needed, that abstinence is a strategy that has a legitimate role in counseling, and for those that are engaged in "Abstinence and Be Faithful" dialogue with patients, that we need to have the ability also to refer to contraceptive use, if not in that setting itself, to have that referral capability readily available. Patients needs need to be responded to and that's the basic position that we're trying to support.

In terms of the ability to actually have all services in one shop, it's probably not going to be that in most settings but the linkages and referral capability will be what we'll be focused on for many.

JEN KATES: Going back to abstinence and how, I mean I guess one of the issues that came up in the emails and of dialogue in Washington is how, in the field, is how that gets communicated though to the field because I think in the last several years, there's been lack of clarity around some aspects of it and concern that if the field doesn't get clear messages from Washington... So is that part of the guidance process at this point?

AMBASSADOR ERIC GOOSBY: We're about to go into a dialogue with the field around the entire framework and through that very quickly, we will identify the need for specific guidance. Clearly this will be an area that we'll need specific guidance, yeah.

JEN KATES: Okay, it's time for your questions. What we're going to do is take three questions at a time and when you ask a question, please identify who you are. And please don't provide long statements, filibuster, grandstand. Be efficient just like PEPFAR's being asked to do and recognize that if you take a long time, you're going to take away time from others here who want to ask questions. So we will start.

MAEVE MCKEAN: Hello. My name is Maeve McKean. I'm from the International Community of Women Living with HIV and AIDS and also the Center for Health and Gender Equity. In the five-year strategy, you said that you were specifically going to incorporate people living with the virus into the strategy and into ideas for prevention. I'm wondering, given the disproportionate effect that the disease has on women, what do you see the role of women living with HIV and AIDS in the strategy?

JILL GAY: Jill Gay, a consultant, Open Society Institute. A large number of partners in Sub- Saharan Africa are sero-discordant, and how will you address that issue? And will you be encouraging male circumcision for infants?

DONALD HITCHCOCK: Hi, my name's Donald Hitchcock with Advocates for Youth. Last week, there were some statements by you in Newsweek that you wouldn't withhold PEPFAR funds if Uganda passed a bill dealing with homosexuals and execution of homosexuals that have sex if they're HIV-positive. Recently, the State Department clarified that and said that they oppose this bill. Will there be any ramifications of PEPFAR funding to Uganda if this bill passes in 2010?

AMBASSADOR ERIC GOOSBY: Okay. The first question, in terms of women and HIV, women making up such a large percent, over 60-percent of the new seroconversions in many of the countries we're in, an emphasis on bringing women, targeting women to bring them into care is clearly a priority. Having the woman as the conduit of access to the family is part of that idea. It's not just to have women's services. It's to have services for children as well as partners.

It's put us in a position where thinking about these special needs and services that will and need to be available for women to encourage and ensure that that access is engaged with has been a big part of our discussion.

Gender inequity issues has been a part of PEPFAR since the beginning but we see it as an area that we need to increase activity in, around both ownership, property, inheritance, as well as making an effort to encourage and support education of women in many of the settings to better position the woman for stabilizing through work because of the education opening up opportunities to work that will allow her to stabilize her family and her community.

We see the woman as a focal point of our outreach efforts that needs to be central and maintained throughout the entire prevention and care network. In terms of the second question was the discordant, the actual questions was the discordant?

JEN KATES: How to address issues of sero-discordant couples in?

JILL GAY: Sero-discordant and many of them are married or in long-term partnerships, how will you reach those at risk? It's traditionally not been part of prevention efforts and yet, there's a huge amount of people who are at risk because they're in a sero-discordant relationship.

AMBASSADOR ERIC GOOSBY: Well the discordant couple needs to be identified by a testing strategy that gets both partners, actively recruits and enters partners into a testing relationship. The ability to respond with condom and protective strategies to keep the negative partner negative is part of our activity. We have brought an increase, in our technical working groups, attention to discordant couples.

Nancy Padian, who has spent a lot of her career focused on discordant couples, has come into OGAC as a consultant around these issues and will really look at each of the prevention packages in each of the countries that we're in with a lens to strengthening in that area. In terms of the last question?

JEN KATES: Which we had a lot of emails about, Uganda.

AMBASSADOR ERIC GOOSBY: Uganda question, yes. PEPFAR clearly treats anybody regardless of sex, gender, practices, has always been an open door to treating and identifying all populations and offering treatment for it. It is an issue that the State Department has been in dialogue with Uganda around the specifics of that legislation for a number of weeks now and will continue that dialogue.

The concerns around funding, that decision will be something that we are looking at for how we would impact if indeed the law is passed. It's clear to us that we are now taking care of many HIV-positive men who have sex with men in Uganda who have not revealed themselves to either their community or to their medical delivery system as such but that we are aware of. There are many people who are receiving services. That if we withdrew those resources, would be negatively impacted.

We understand the urgency of such a legislative act and the inappropriateness of it. We also understand that this will drive behavior down in terms of visibility, make it harder for patients to reveal themselves to systems of care, make testing more remote and that to reveal yourselves to your community has such ramifications.

We have never seen this strategy be successful on any level in any country we have seen it come up in including our own and are adamantly in dialogue and have been for weeks and trying to better understand the likelihood that this will move to a law and what the ramifications of that will be. So those discussions are actively occurring in the State Department. Thank you.

GOULDA DOWNER: Goulda Downer, Howard University College of Medicine and Howard University Caribbean Clinicians Preceptorship Program. Food is sometimes the only medicine that some communities can afford. As we scale up the antiretroviral availability, what resources are you planning to make sure that food security and nutrition are tangentially linked to the medications that are going to be provided as well?

AMBASSADOR ERIC GOOSBY: Well really from the very beginning of PEPFAR, the need for food, especially for patients taking antiretrovirals and for many just, Co-trimoxizole, especially for children, does not go well on an empty stomach. We also see, as you initiate antiretroviral therapy, your nutritional requirement goes up initially and begins to really be a rate limiting factor to the ability to continue these medications.

So we have always tried to link to the World Food Program but actually took it another step by putting the World Food Program's distribution site in the clinic sites that are delivering or making antiretrovirals available, a critical component for both children and adults and pregnant women and we need to link and infuse that throughout and that is a priority for us and will continue to be.

JEN KATES: Actually I want to interject one thing on that because for those of us looking at PEPFAR and the GHI, there's the Global Hunger and Food Security Initiative. There's all the other development reviews that the Administration is engaged in. There's legislation in Congress. In a sense, it's a little bit like a mini-version of health reform, domestic health reform, going on in the global development realm. So how are these all fitting together?

AMBASSADOR ERIC GOOSBY: Well that's a great question. It has been a challenge to understand how to put a purse string around the needs, the multiplicity of needs that the patient populations present to us. Nutrition is disproportionately high in many of the populations we're interfaced with and needs to be a central piece of our response. But it really gets down to trying to aggregate resource diversity that comes into a clinic or a hospital, a service site, above the level of the service site, so the provider, the clinician who's faced with the needs of a patient, can be free to respond to them regardless of how things are being paid for. Right now you see, because of the vertical funding, people being referred out of the building to another site if they're lucky or just saying we don't do that and that's the end of it.

I think that the Global Health Initiative is very much looking at that integrative ability to make those services available in all of the sites that we are in, for whatever primary reason, to look at ways to make those other services available at the same site or to have a real referral capability that will put the patient quickly in front of the service they need. It's an integrative nightmare around how to do that logistically sometimes but is definitely where the President and the Secretary want our services to move.

JEN KATES: We're going to go the one question at a time model.

BRIAN HENNESSEY: My name's Brian Hennessey. I'm with the Vineeta Foundation. I wanted to thank Kaiser for putting on this Town Hall. As you said, it's the first one and so many of us feel like we're getting a sausage here and maybe if there had been other Town Hall-sort of venues like this where there could have been some sausage-making collaboratively, we would have known more about the process and where we are.

Jim Kim has written an open letter. He was a person who was considered for this position and apparently he feels like he doesn't really know what's going on. I think that's probably part of the pushback you're getting here. So I wondered if you could address that but also maybe commit to making this a more regular venue or even at the State Department where stakeholders can at least see this sausage-making so when it comes out, we know what's in there and how it got there.

AMBASSADOR ERIC GOOSBY: Well thanks for saying that [laughter]. I feel from, I take the challenge, as I'm sure it's given, we want to be in a dialogue, I feel that we have tried to reach out right from really the first few days of me taking this job over.

Much of my time in any given day is in talking to groups and individuals much more than I had ever thought before taking this job. But I think, as an organization, we need to think about ways to create access and dialogue that allows people to engage and think with us around what's needed.

We also feel that our ability to engage and think with our implementers in the field needs to be strengthened. Those who are out there putting programs in place, both in civil society, NGOs need to be strengthened. I think the biggest area that we need to strengthen is our implementing countries, our partner countries. We need to be in a very different dialogue with them.

I think that the partner country's in a position where it is best positioned to understand the needs of its people. We need to acknowledge that and nurture that dialogue so we can be strategic, efficient, but also responsive to what is often a difficult and moving target.

So I would embrace an ongoing active process that would encourage you to help us think through what that might look like to increase the ability for us to hear from you and more importantly, think with you.

ADEEB MAHMUD: Adeeb Mahmud. I work for FSG, which is a non-profit consulting firm working on global health issues. You mentioned increased engagement with country governments and other donors, multi- and bilaterals. Do you have plans for additional engagement and coordination with the private sector as well namely foundations and corporations that are working on HIV/AIDS issues?

AMBASSADOR ERIC GOOSBY: PEPFAR has one of the most active, in the U.S. government, private/public partnerships, PPPs. We have activities with much of the private sector, McKinsey, Coca-Cola, Heineken, a lot of organizations and multi-nationals that have distribution networks that move into many of the areas that we have treatment sites in.

Our ability to engage with multi-nationals is a big part of what our OGAC office is involved with. We have activity in about 13 different countries that is large, large partnerships with private/public partnerships. But clearly see it as an area where technical assistance and mentoring strategies can be tapped to partner with governments, implementing governments, partner governments to better position them to play that orchestrating role for pulling together both the process that defines unmet need, prioritizes it, and makes allocation decisions, monitoring, and evaluation, distribution procurement skills.

We are trying to tap all of those. BD, which is a CD4 viral load manufacturer, has been extraordinary in giving us the ability to train and mentor technicians who can repair CD4 machines and viral load machines and all of the countries that we're engaged in. Those types of partnerships we are actively looking for and increasing. It's my hope that we will have one or more in every country that we're engaged in because we need the help.

B.J. STILES: Good morning. We miss you in San Francisco. I'm B.J. Stiles, a board member of the Global AIDS Alliance. I'm particularly interested in what you foresee as areas to be exploited in civil society, particularly in those private sector agencies that already have troops on the ground, faith-based organizations, service clubs, etc. In your future, what do you envision as the additional broader expansion of civil society's active participation as donors, volunteers, etc.?

AMBASSADOR ERIC GOOSBY: That's great. It's good to see you and it's an interesting question. We need to be aggressive at nurturing civil society, our NGO community, and continuing the roles that they play because those roles are still needed, implementing roles.

The role of an implementer remains central to the PEPFAR model but we need to add to that the capability of implementer in our NGO colleagues but also the ability to respond to technical assistance needs to have the additional model within their portfolio of activity to not put people on the ground that are actually going to be running or managing projects only but also to put people on the ground who can work with ministries of health at both national, provincial, and district levels, individual mid-level managers in clinics and hospitals, procurement distribution system, management systems, financial budget development that moves into a strategic planning strategy, all of those skills that are very common in kind of the private sector in many parts of civil society. Those needs to be tapped and put to play. So I see the NGO community as adding to their expertise another model that they can be tapped to deploy of mentoring and technical assistance.

In terms of the faith-based organizations, I see them in the same way but I would also add that because of the role, many of our faith-based organizations play in rural health care, many studies, WHO studies and the UN, have identified faith-based organizations as making up 60, 70, 80-percent, sometimes 90-percent of your rural health care that is often identified by the partner government as part of their health care delivery system getting designated as district or regional hospitals, district clinics, district health centers, etc.

That role is acknowledged. We've clearly taken advantage of it in PEPFAR. We'll need to continue to take advantage of that looking for a public counterpart to move services and to, is often not available. Our intention is to really continue and complete a continuum of care but not to give up the quality of the services delivered. So I would say that.

JEN KATES: I actually have a civil society question too that is coming at it from a different perspective and gets a little bit at Global Fund issues. But the thinking that might be going on around engaging civil society and the country ownership move and model, not necessarily the CCM model, but how PEPFAR can more actively engage civil society on the ground in designing programs.

AMBASSADOR ERIC GOOSBY: Yes. Well I think the Global Fund's CCM process was the right idea. It is the right idea to have people making allocation decisions close to the populations that are using the services. It allows for a proximity, a feedback that will allow the decision-makers to make corrections in the program as the service needs change or it becomes clear are not working. To have that decision in Geneva or in the United States, dilutes the ability to be responsive and held accountable.

I think the Global Fund had that right. Those are always messier processes as we've seen in our own domestic Ryan White activities with Planning Councils. But in the long run, it's the correct positioning of decision making and policy making. PEPFAR needs to move closer to that type of a model where country decision making and prioritization is allowed a clearer voice and role in how the resources move.

I think the partnership framework process will enable us to move in that direction. It's not that Global Fund and PEPFAR are mutually exclusive in their intents but what needs to happen more is that both of those processes need to converge better to allow for cooperation and synergies to be identified much more than currently are.

ERIC WILLIAMS: Ambassador Goosby, good morning, and thank you for speaking with us today. My name's Eric Williams and I'm from Physicians for Human Rights. One of the things that you left out in your remarks is talking about health workforce or human resources for health. I wonder if you would just share with us some of your thoughts on the scale up of 140,000 workers as it's laid out in the legislation but particularly could you discuss for a minute retention of those health workers because I think that we all realize there are massive shortages everywhere. We are continually finding that health workers are, the push-pull factors are pushing health workers out of country. Then on a side note, the WHO's about to come out with the Code of Practice and I wonder if you could also just share some thoughts on the U.S.' position on that as well. Thank you.

AMBASSADOR ERIC GOOSBY: The 140,000 mandate and the legislatively mandated, is something that we have engaged with and are looking at as two fronts of activity. One is in health care worker training. I think the expansion of service capability, treatment capability on the part of mid-level providers, nurses in particular, as well as the creation of a health care worker with six months or more of training that results in a certification and a role in the health care delivery system is something that is well on the way.

The part that needs to compliment that so we've got health care workers increasing on the bottom of the health care delivery system, it's increased our ability to do outreach, case management to have adherence counseling, to also have lost-to-follow-up strategies that are effective, and with groups that are difficult or hidden, injection drug users, MSMs, health care worker strategies, as they move into a peer context, peer-to-peer-related context, are very effective at retaining patients, identifying and bringing back lost-to-follow-ups. That piece needs to have medical back-up at both nursing and medical doctor level is strengthened as well. For it to work well, we are not going to solve this problem by having health care workers that are not connected to through protocol and consultation referral with a higher level of medical care.

We feel that we need to look and partner with medical schools and nursing schools in Sub-Saharan Africa, in particular, where we increase the number of graduates that come out but just as importantly focus on the faculty to train, to improve their clinical ability to teach clinical medicine. This will be realized through a curriculum revision that moves more toward a problem-oriented curriculum that pops a clinician out in a shorter number of years who has a higher comfort level and a differential diagnosis and treatment plan in four years instead of six and their clinical confidence is higher. That also needs to be matched with a preceptorship that follows the nurse provider or the new doctor into their first clinical settings where they are not the only provider looking at patients.

A more senior clinician needs to be in place to look at those patients with them. We believe that the type of intellectual honesty and clinical clarity that comes out of that is critical to train physicians and nurse practitioners, nurse providers, and health care workers in a setting where they're not asked to make decisions that are beyond their ability to make in the sense that if you put any health care worker, nurse, or physician in a setting where people are dying, and they don't have enough experience to know that they are dying because of the disease or what they didn't do, you run the risk of removing that person, destroying them really for clinical care.

The years in training and the years that you've tried to put them out to train them to have them go out and practice independently are lost. So that needs to be kind of the first step. This needs to be matched with a living wage in terms of an incentive system that looks specifically at what an individual needs to live, cover their children's needs, school fees, uniforms, books.

When I talk to especially physicians and nurses who are moving, it's not to get rich that they're moving, that they're leaving their country, they're leaving where they have been grown up professionally and want to stay. They're leaving because they are not making enough money to make it. We need to work with governments to look at their civil service system to define what a living wage would be. That matched with the increased educational activity and the health care worker kind of bottom-up activity, I believe, will begin to address that longer-term haul for actually putting a cadre of providers out there who are going to stay and be stable.

JEN KATES: You can tell he's a doctor. We have time for just two more quick questions and then we really have to wrap up. So let's move on to other questions. We'll take both of them now.

CHRIS COLLINS: Thank you Ambassador Goosby for being with us today. My name's Chris Collins and I'm with amfAR. You've spoken about the need to move toward more partnership with governments in terms of governments taking responsibility for their own citizens' health care and also to build health systems and both obviously are important and laudable goals.

In light of the fact that we know that some of the groups most impacted by HIV in the world, in particular some epidemics including MSM and gay men, injection drug users, and sex workers are illegal, their behavior is illegal in the eyes of their own government. In many cases, they're not even counted in EPI that's collected by their government and they may not feel safe accessing services within their health systems. So with that in mind, I just wanted you to talk about how you address both moving towards government's responsibility in health systems while also keeping in mind those very at-risk populations.

JEN KATES: Let's take the last question and then you can answer them both.

NAOMI RUTTENBERG: Hi. My name is Naomi Ruttenberg from Population Council. We very much welcome this new emphasis and evidence-based approaches in the next five-year PEPFAR strategy. I think one thing that many of us would agree has not worked well in the previous five years are the mechanisms for generating evidence for using the PEPFAR money. Could you please speak briefly about what some of the plans are going forward for identifying research priorities, particularly applied program practical research and how you might commission that? Thank you.

AMBASSADOR ERIC GOOSBY: Both are great questions. Well Chris, the movement toward government is because I believe that we are in urgent need of positioning these programs in the best possible position to be sustained. Having just an NGO continuum of care and services has more fragility in it in terms of sustainability funding embedded or not embedded in government service sites than I feel I am comfortable with in believing that they will sustain themselves.

So it's not that we want to dismantle. We want to include a public strategy with it, a hybrid of both, and hold the government accountable to respond to their epidemic. We all know governments, in fact, many governments we've worked with, that have beliefs and practices, societal beliefs that hold patients away from entry that indeed do not create safe spaces, indeed can be the site where they're identified and brought into a legal exchange around their behavior.

We've had police forces all over Southeast Asia, in particular, wait outside of HIV clinics to find the individuals who are involved in needle exchange activity and shut down the needle exchange activity periodically and sweep everybody up and arrest them.

Those types of behaviors have to be responded to with the science as to why that [police activity] is not going to help things and address the epidemic and stop the movement of the virus through the population but we need to be willing and are to engage in an NGO strategy to create that capability when governments are unwilling to engage, and that is what we have done, and will continue to do. So that'll be the basic kind of package of response to that.

In terms of the research, a high priority that's been neglected in the first phases of PEPFAR, we are at really the cutting edge of implementation science if I can say that. Operational research is something that most of the PEPFAR activities could fit easily into. We have not taken advantage of that.

We need to, especially in the prevention arena, be aggressive about documenting more than a monitoring and evaluation level but move it into an operational research level defining the impact, looking at what we did not impact just as importantly and try to explicitly create models that may have application for scale up.

Our commitment to move to an aggressive research portfolio is a central piece of this new five-year period. We will have a structure that will allow for both our programmatic teams to ask questions and engage in operational research that's generated from the field. We will also have a portfolio of resources that are available for kind of, I would call them, external research, researchers to apply to ask larger questions that may be multi-country as opposed to related to an individual site, so a big area of priority for the next five years.

JEN KATES: So as we're just about out of time, I'm going to let you end with the final word on more of a looking forward thought. Let's say we invited you back here in a year for another Town Hall discussion like this one, what would be your vision of where we'll be with all of this at that point, the role of countries, rolling this out?

AMBASSADOR ERIC GOOSBY: Well I hope our movement to sustainable positioning in each of the countries that we're in will have moved. I hope that the dialogue with the country and the empowerment of the country leadership to take ownership of that orchestrating role that we've talked about where they are looking at these divergent funding lines and aggressively actively thinking about and prioritizing their unmet needs and making those allocation decisions.

I would also hope that we are able to increase the role of South-South Technical Assistance, that begins to increase our ability to use the expertise that has been developed over the last 20 years in these countries, to be tapped and brought to bear for them to support regionally their colleagues who are just starting the response.

I also hope that we are better at creating a package of services that meets populations that have been difficult to reach: MSMs, injection drug users, commercial sex workers. We need to intensify our ability to identify and retain these patient populations in care, that we close off the pediatric vertical transmission leakage - that really is low hanging fruit that we need to aggressively grab and stop.

So I hope I'm sitting here talking to you about PMTCT rates being up into the 85-percent rate for patients being tested in prenatal settings but also that we're in the same range for people, for women to have received antiretroviral prophylaxis.

In terms of gender-based violence, we're going to try to scale gender-based violence strategies in all of our countries that are impacted with it. I'm anxious to engage with that and move that not to that pilot or demonstration but to actually scale those activities. As our government moves into the Global Health Initiative and that becomes, as we move into an implementation period with that, I hope I can tell you specifically how this works, how the kind of aggregation of resources actually does enable the provider to respond more freely and easily to the problems in front of them.

I hope that we can have new strategies finally to move toward universal coverage for those who are without treatment who need treatment. That we have engaged in the dialogue with Global Fund and multilaterals and other bilaterals in a way that really allows us to, with country convening, define the sharing and synergies of resources that are needed, that will be needed, that are needed now to really achieve that universal coverage goal.

JEN KATES: Thank you.

AMBASSADOR ERIC GOOSBY: Yes.

JEN KATES: Well please join me in thanking Ambassador Goosby for taking time today to be here [applause].


1The Kaiser Family Foundation makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded material and the deadlines involved, they may contain errors or incomplete content.

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