Report: 4th Pre-Meeting on HIV and Health Systems by Tegan Culler

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

IAC Pre‐Conference, 20‐21 July 2012, Washington, DC Conference Report

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Funding for this conference was made possible (in part) by the Centers for Disease Control and Prevention. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

IAC Pre‐Conference, 20‐21 July 2012, Washington, DC Conference Report

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation IAC Pre‐Conference, 20‐21 July 2012, Washington, DC

HIV and Health Systems Pre‐Meeting Series The fourth annual “HIV and Health Systems” IAC/IAS pre‐meeting took place on July 20‐21, 2012, immediately prior to the International AIDS Conference in Washington, DC. The meeting agenda was developed by a planning group of global experts (see page 44), who graciously contributed their time and effort to ensuring an outstanding event. The pre‐meeting was hosted by ICAP Columbia University, the International AIDS Society, the World Bank, UNICEF and the World Health Organization, with additional support from the U.S. National Institutes of Health, the Office of the U.S. Global AIDS Coordinator (OGAC) and the President’s Emergency Plan for AIDS Relief (PEPFAR).

This report provides a brief summary of the meeting; slides, video, transcripts and a complete webcast are available at: http://www.iasociety.org/Default.aspx?pageId=671

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Table of Contents Background

Page 8

Conference agenda

Page 12

Session summaries

Page 14

Planning group

Page 44

Speaker biographies

Page 48

Participant list

Page 72

Slide presentations

Page 82

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Background The International AIDS Conference (IAC) and International AIDS Society (IAS) meeting, held in alternate years, are among the premier gatherings for those working in the field of HIV, as well as policymakers, persons living with HIV, and other individuals committed to ending the pandemic. In recent years, new conference tracks have been added to reflect growing interest in implementation science, health systems, and health economics. In addition, increased attention to the linkages between HIV scale‐up and health systems has brought into sharp focus the common goals underpinning programs to improve health outcomes in resource‐limited settings, as well as the need to translate HIV scale‐up into broader health systems benefits. In 2009, ICAP at Columbia University, the International AIDS Society (IAS), and the Global Fund to Fight AIDS, TB and Malaria convened a pre‐conference meeting in advance of the IAS 2009 meeting in Cape Town, with support from the Rockefeller Foundation. Informed by a 2008 Bellagio conference hosted by ICAP Columbia University, the 2009 meeting was entitled “Accelerating the Impact of HIV Programming on Health Systems Strengthening.” It convened 100 researchers and implementers to explore the impact of HIV scale‐up on health systems, including those who had never before attended an international AIDS meeting. The Bellagio and Cape Town conferences resulted in a special issue of JAIDS, dedicated to the topic of HIV scale‐up and global health systems, and to a second Bellagio conference in 2010.

In July 2010, ICAP partnered with IAS and the Global Fund to host a two‐day meeting prior to AIDS 2010 in Vienna. Entitled “Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems,” the pre‐conference meeting was intended to foster new partnerships amongst a wide range of global experts. The following year, ICAP partnered with IAS, the Global Fund, the NCD Alliance, the National Institutes of Health, the U.S. Office of the Global AIDS Coordinator (OGAC), the Rockefeller Foundation, and other partners to host a pre‐ meeting at IAS 2011 in Rome. The meeting, “HIV and Health Systems: Leveraging HIV Scale‐ up to Strengthen Chronic Disease Services,” focused on the intersection between HIV and non‐communicable chronic diseases, convening a diverse audience of HIV, NCD, and health systems experts. A second JAIDS supplement, entitled “Bridging the Divide,” was published in July 2011. In 2012, this series of successful HIV and Health Systems pre‐conference meetings continued, with a focus on health systems barriers to HIV scale‐up: this year’s meeting is entitled “Strengthening Health Systems for an AIDS‐Free Generation.”

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Recent research has confirmed the efficacy of antiretroviral therapy for prevention of HIV transmission in HIV serodiscordant couples, and the potential impact of “treatment as prevention” has raised a wide range of policy questions. Many countries are now changing treatment guidelines to include patients with higher CD4+ cell counts, markedly expanding the numbers of people eligible for care and treatment and necessitating new approaches to decentralized diagnosis, support for adherence and retention, laboratory monitoring, and program design. At the same time, the global financial crisis has limited the availability of additional resources for HIV scale‐up, and HIV programs are being asked to do more with less. What are the health systems implications of expanding treatment criteria? How can country programs define prevention and treatment priorities in 2012? How can health systems be strengthened so that programs and services are positioned to ensure an AIDS‐ free generation? How can the use of modeling and economic data assist countries to effectively prioritize interventions? Are there optimal ways to approach the issues of ethics and equity raised by the dual use of antiretroviral therapy for both treatment and prevention? As WHO develops new guidelines for HIV prevention, care, and treatment, exploration of these key questions will be an important and complimentary endeavor.

Goals and Objectives: The goal of the 2012 pre‐conference was to contribute to both HIV scale‐up and health systems strengthening in low‐ and middle‐income countries (LMIC) by:  Facilitating productive discussions between policymakers, front‐line implementers and technical experts in HIV and health systems;  Highlighting key health systems barriers to the expansion of HIV prevention, care and treatment services needed to ensure an AIDS‐free generation;  Identifying policy‐relevant questions about HIV scale‐up, with particular attention to the policy needs of partner country Ministries of Health, Finance and Planning;  Discussing the challenges of decentralization, integration, and the expansion of HIV counseling and testing services required to engage a broader range of patients; considering the implications for laboratory and diagnostic systems;  Fostering professional relationships, partnerships and communities of practice between experts in the HIV community and health systems community, in order to strengthen health systems, enhance HIV services, and catalyze implementation science.

Participants:

The HIV and Health Systems pre‐conference series has been particularly successful in its ability to attract a truly interdisciplinary group of participants. The 2012 meeting similarly engaged a wide range of participants, including high‐level policymakers, experts in health systems and HIV program implementation, and leaders in HIV and health systems research.

As with earlier pre‐conferences in this series, special attention was paid to ensuring representation from the global South, and to supporting the costs of researchers, implementers, and policymakers from LMIC. A list of participants can be found on page 68.

Pre‐Meeting Agenda: The over‐arching goal of the pre‐meeting was to bridge the divide between country‐level policymakers, implementers, and technical experts in HIV and health systems, identifying the policy‐relevant information required by key Ministries and other implementers in order to strengthen health systems and expand HIV prevention, care, and treatment services to achieve the goal of an AIDS‐free generation. A detailed agenda can be found on page 12.

Further Information:  



“High‐level ICAP Meeting in Bellagio Addresses Impact of HIV Program Scale‐Up on Health Systems in Africa”: http://www.mailman.columbia.edu/news/article?article=669 Accelerating the Impact of HIV Programming on Health Systems Strengthening: Pre‐ Conference Meeting of Health Systems Experts, HIV Researchers and Implementers ‐ Cape Town, South Africa, 17 ‐ 18 July 2009, http://www.iasociety.org/Default.aspx?pageId=344 Journal of Acquired Immune Deficiency Syndromes: November 2009 ‐ Volume 52 ‐ Supplement 1, HIV Scale‐Up and Global Health Systems: http://journals.lww.com/jaids/toc/2009/11011 Bridging the Divide: Inter‐Disciplinary Partnerships for HIV and Health Systems: HIV and Health Systems Pre‐Conference Meeting, 16th‐17th July, Vienna, Austria: http://www.iasociety.org/Default.aspx?pageId=405 HIV and Health Systems: Leveraging HIV Scale‐up to Strengthen Chronic Disease Services, HIV and Non‐Communicable Diseases Pre‐Conference, 15th ‐ 16th July, Rome, Italy: http://www.iasociety.org/Default.aspx?pageId=555 Journal of Acquired Immune Deficiency Syndromes: August 1, 2011 ‐ Volume 57 ‐ Supplement 2, Bridging the Divide: http://journals.lww.com/jaids/toc/2011/08012

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Meeting Agenda Friday, July 20 (opening reception) Welcome and introductions ‐ Dr. Elly Katabira, President, International AIDS Society Keynote speakers: ‐ Ambassador Eric Goosby, United States Global AIDS Coordinator ‐ Dr. J. Stephen Morrison, Director, Center on Global Health Policy, Center for Strategic and International Studies Wrap‐up/concluding remarks: ‐ Dr. Wafaa El‐Sadr, Director, ICAP Columbia

Saturday, July 21 (morning session) Welcome, opening remarks: ‐ David Wilson, Director, Global AIDS Program, World Bank Framing presentations: ‐ Dr. Rifat Atun, Imperial College: Investing for sustained scale‐up of HIV services ‐ Dr. John Blandford, CDC: Using modeling and forecasting to inform planning and policy Panel Presentations: Planning for Sustained Scale‐up: Where is the Evidence? ‐ Moderators: Dr. Till Bärnighausen, HSPH/Africa Centre, Ms. Sharonann Lynch, MSF ‐ Panelists: “lightning” panel: 5 minutes each, followed by discussion and Q&A 1. Dr. Charles Holmes, CDC: How an empirical costing model influenced USG policy and targets

2. Dr. Jan Hontelez, Africa Centre: Human resources modeling for ART scale up in South Africa

3. Dr. Emmanuel Njeuhmeli, USAID: How VMMC modeling & costing studies influenced USG policy

4. Mr. Leonard Nkosi, MSH Malawi:

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Assessment of Malawi’s emergency hiring project

5. Dr. Claudes Kamenga, UNICEF: Planning and costing of PMTCT in Francophone Africa

Panel Discussion: Key questions from the policy‐maker perspective: ‐ Moderators: Dr. Estelle Quain, USAID and Dr. Wafaa El‐Sadr, ICAP Columbia ‐ Panelists: 1. Honorable Minister Benedict Xaba, Minister of Health, Swaziland

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

2. Dr. Faustine Ndugulile, Tanzania parliament 3. Dr. Kesetebirhan Admasu, State Minister for Health, Ethiopia 4. Dr. Ibrahim Mohamed, Director of Kenya’s National AIDS/STI Control Programme (NASCOP) 5. Dr. Yogan Pillay, Deputy Director General of Strategic Health Programmes, South Africa Department of Health

Saturday, July 21 (afternoon session): Welcome, opening remarks: ‐ Dr. Gottfried Hirnschall, Director, HIV/AIDS Department, WHO

Panel presentations: Decentralization ‐ examples/case studies: ‐ Moderators: Dr. Anita Asiimwe, Rwanda Biomedical Center, Dr. Eric Goemaere, MSF ‐ Panelists: “lightning” panel: 5‐7 minutes each, followed by discussion and Q&A 1. Dr. Tom Decroo, MSF Mozambique: Community‐based ARV groups in Tete, Mozambique

2. Dr. Connie Celum, University of Washington: Home‐based testing in Kwa‐Zulu Natal, South Africa

3. Dr. David Hoos, ICAP Columbia: Decentralization of PMTCT and HIV care and treatment services in Tanzania

Panel presentations: Integration of HIV programs into health systems: What do and don’t we know about the tradeoffs? ‐ Moderators: Mr. Craig McClure, UNICEF and Dr. Miriam Rabkin, ICAP Columbia ‐ Panelists: “lightning” panel: 5 minutes each, followed by discussion and Q&A 1. Ms. Stephanie Topp, CIDRZ Zambia: Integration of HIV into PHC in Lusaka

2. Dr. Karl Dehne, UNAIDS: Costs and efficiencies of integration

3. Ms. Bertha Katjivena, MOH Namibia: Challenges of HRH integration in Namibia

4. Dr. Sanjana Bardwaj, UNICEF South Africa: Integration of PMTCT & MNCH in South Africa

Facilitated audience discussion: Key questions from the implementer perspective: Moderators: Dr. Anthony Harries, International Union against TB & Lung Disease and Dr. Nancy Padian, University of California, Berkeley Closing comments: Next steps /priorities: Discussants: Dr. Estelle Quain, Dr. Jean‐Paul Moatti, Dr. Anita Asiimwe, Dr. Charles Holmes, and Dr. Miriam Rabkin

Session Summaries

Session # : Opening Reception and Keynote Addresses Friday

July

Welcoming remarks from Dr. Elly Katabira, President of the International AIDS Society: I want to begin by thanking Wafaa El‐Sadr and ICAP Columbia for organizing this meeting. This is the fourth in a series of annual meetings on HIV and health systems which ICAP and the International AIDS Society have co‐ hosted prior to our International AIDS conference. The main reason behind these meetings has been to bridge the divide between different disciplines. This year, we are focusing on the potential divide between researchers, policymakers, and program implementers. As you know, there are many different disciplines involved in HIV prevention, care and treatment, including the communities working in the field towards actually scaling up services to reach an AIDS‐free generation. Now, when we talk about the AIDS‐free generation, many people become skeptical and say, “What is he talking about?” But I have been working in this same field for 27 years and I can tell you from my experience that we now have the tools. The tools are before us to make it happen. One of the ways to make it happen is to address health systems. This topic and this meeting become extremely important. Many of us do research, in addition to clinical work. In Uganda, for example, many people ask me, “We hear about your research results in conferences, but it doesn’t help us. Why are you doing it?” So we want to see that we close that divide between the researchers and the policymakers in order to achieve the real change we know is possible. We want researchers to work together with policymakers so that they can implement the findings – and to encourage the policymakers to fund the right things, things which will make a difference to our HIV‐infected patients and their communities. It is important to address this issue of translating knowledge to practice, not only in our own clinics, but at the national and international levels.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

For example, we now have HIV 2.0 and we have Option B for PMTCT. All these are new things and those of you who come from resource limited settings are asking yourselves: Should we go for option B when we haven’t even done option A? And then there is option B+. Does it make sense? You say: we talk about treatment as prevention. We can’t even put people in treatment and now we are talking of preventing patients by treating them. Is this possible? All these questions, of course, are addressed by modellers. But our modellers need to work together with the policymakers and the implementers. How can modellers and researchers assist policymakers and implementers? We’re going to discuss this. How can implementers and the policymakers provide the appropriate inputs for these modellers who are becoming important in our day‐to‐day life because they predict where we want to be? As you know, with modeling, the details in the assumptions and the assumptions are based on what we give them as data. So this is what we hope we’ll discuss over the next two days. I’m sure, at the end of it all, you will make a difference where it matters – that is in the community with our patients. Thank you very much.

Keynote presentation by Ambassador Eric Goosby, U.S. Global AIDS Coordinator It is an honor to be here today at the fourth annual HIV and Health Systems pre‐conference. Thank you to ICAP Columbia University for again bringing us together to discuss this important topic – and especially to Dr. Wafaa El‐Sadr for her leadership and unwavering dedication to the fight against AIDS. Thank you also to the other co‐sponsors of this pre‐ conference: the International AIDS Society, the World Bank, UNICEF, and the World Health Organization. The success of this pre‐meeting series has been its focus on examining the critical linkages between HIV scale‐up and health systems. It’s an opportunity to highlight the common goals underpinning programs to improve health outcomes in resource‐limited settings.

This year’s meeting focuses on the health systems barriers to HIV scale‐up, concentrating on information needs of policymakers and implementers to scale‐up prevention and treatment. Today, on behalf of PEPFAR, I will outline some of these critical information needs.

But first, I think it is important to recognize what we as a global community have accomplished over the last decade and to think about how to apply the lessons to our current challenges. We have seen substantial investments in critical elements of health systems, by PEPFAR, the Global Fund, other donors, and national governments in support of HIV treatment scale‐up. These have resulted in access to life‐saving medications for over 6.6 million people with HIV in resource‐limited settings, around four million of whom are directly supported by PEPFAR programs.

Our response to the global AIDS crisis has also transformed the health sector. Our investments have focused on HIV, but they have also strengthened national health systems so these systems can more effectively deliver essential services to meet the needs of their people, including the non‐HIV needs of HIV‐positive people. Clinics and hospitals that were overwhelmed dealing with AIDS now have the capacity to address other health issues that people face. Beyond that, we have rebuilt hospitals and clinics, increased quality and numbers of trained health care workers, put in patient information systems, put in quality laboratories, and strengthened commodity procurement and distribution systems.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Our focused investments have enabled access to basic health care, often where little or none existed before. In countries with substantial PEPFAR investments, we’ve seen reductions in maternal, child, and tuberculosis‐related mortalities and wider availability of safe blood, to name just a few.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

I would like to highlight two recent studies that demonstrate this type of health impact. The first was a study done in 257 health facilities across eight countries in Africa; it was presented at CROI and published in Health Affairs this year. The investigators showed that the presence of HIV care and treatment programs was associated with increased utilization of facilities for giving birth, an important indicator linked to maternal and child health outcomes. Another recent study, including over 1.5 million people from 27 countries, showed that in PEPFAR focus countries, the adjusted risk of all cause mortality significantly decreased from 2004‐2008 – and was approximately 16% lower than in other populations without significant PEPFAR intervention. The success of PEPFAR’s investments to date and new evidence demonstrating HIV treatment as potentially powerful prevention tool, led Secretary of State Clinton to declare the historic goal of creating an AIDS‐free generation last October. Less than a month later, on World AIDS Day, President Obama underscored the importance of this goal and announced ambitious new targets for evidence‐based combination prevention, including support for six million people on treatment, antiretrovirals to prevent mother‐to‐child transmission (PMTCT) for 1.5 million mothers, voluntary male medical circumcision for 4.7 million men, and the distribution of one billion condoms. On a practical level, how will we support the health systems needed to reach these goals and achieve an AIDS‐Free Generation? We will reach these goals with an approach built on systems – and integrating what we have learned from our investments over the last eight years. Let me give you some examples. One of the principal constraints to tackling AIDS in Africa is a serious shortage of health workers. Task‐shifting is one way countries can address this issue. In task‐shifting, certain duties are delegated to less specialized health workers. Several countries are now using task‐shifting to strengthen their health systems and to scale up access to services. For instance, even in South Africa, where physicians are relatively plentiful, there are simply not enough health care workers. Task‐shifting, through the Nurse Initiation and Maintenance of Antiretroviral Therapy, or NIMART, program improves access to HIV treatment and care in a cost‐effective manner. Further, a study examining the model has shown that nurse‐based treatment can achieve similar outcomes of viral suppression, adherence, toxicity, and death as physician‐based care. Turning to male circumcision, studies – including a recent meta‐analysis with more than 25,000 circumcisions from six countries – have shown that with proper training and supervision, task‐shifting to non‐physician clinicians can be done safely. Outcomes for

doctors and non‐physicians showed comparable low rates of adverse events. Most countries with accelerated male circumcision plans are incorporating task‐shifting.

But task‐shifting alone will not meet all human resource needs. This is a familiar slide to us all, from 2006, a powerful picture of the extraordinary need in many countries. 57 countries had critical shortage of doctors, nurses, and midwives; 36 of these countries are in Sub‐Saharan Africa. A 140% increase of health care providers is required to meet the basic needs of the population. Against this backdrop, PEPFAR has embarked on bold initiatives to support governments, institutions, and other partners to strengthen and expand pre‐service training and educational programs for doctors, nurses, midwives, and other health professionals. PEPFAR’s target is to support countries in training 140,000 new health care professionals and paraprofessionals. We’re emphasizing education in country. And PEPFAR wants to help ensure that we will not only train, but retain these workers to support countries in achieving staffing levels of at least 2.3 doctors, nurses, and midwives per 1,000 population, as called for by the World Health Organization.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Let me spend a few minutes providing an update on the current status of the two initiatives supporting this goal– the Medical and Nursing Education Partnership Initiatives (known as MEPI and NEPI). Both MEPI and NEPI were awarded in 2010, and awardees represent a wide range of countries, institutions, and partners. PEPFAR is funding these jointly with other U.S. agencies. The medical initiative includes two types of awards: 11 HIV basic programmatic awards to establish key training and educational interventions, and eight non‐HIV linked and pilot awards to address other health priority areas such as maternal/child health, cardiovascular disease, and cancer. We intend to provide up to $130 million over five years to African institutions, forming a network of 30 regional partners, country health and education ministries, and more than 20 U.S. collaborators. The nursing grants were awarded to three countries—Lesotho, Malawi, and Zambia—and may expand to new countries in the future. These awards were provided to the countries to support the direct scale up of nursing and midwifery training and retention activities based on country priorities. We intend to provide up to $35 million over five years to support country efforts and to a coordinating center for curriculum model development, evaluation and information dissemination. Improving supply chains is also critical to HIV programs. One key improvement has been the transition from air transport to land‐ or sea‐based shipment. Between 2005 and 2007, the Supply Chain Management System (SCMS) established by PEPFAR decreased the percentage of antiretroviral drugs shipped by air from 91% to 28%, while increasing sea shipments from 9% to 72%. It is estimated that using sea freight for major shipments saved up to 85% in

transportation costs, and through 2010, sea transport had saved PEPFAR about $40 million in transportation costs. In support of improved financing, PEPFAR’s Impact and Efficiency Acceleration Plan is supporting expanded generation and use of economic and financial information, efficient implementation of PEPFAR programs, and coordination to maximize the impact of PEPFAR resources. Economic and financial programmatic data are fundamental to improving program planning, performance and efficiency. PEPFAR has developed a new approach known as expenditure analysis. The approach involves the collection of expenditure data covering a period of one year, by country, cost category, and program area. These expenditure data are then linked to achievements reported through PEPFAR’s monitoring and evaluation system. With these links, PEPFAR can determine the expenditure per beneficiary reached for a wide variety of services. PEPFAR has pioneered the use of outcome‐linked expenditure analysis exercises among prevention, care, and treatment partners in several countries. We are working to quickly routinize this activity PEPFAR‐wide. These data are shared with partner governments, and used in decision‐analytic and cost‐ projection modeling sponsored by PEPFAR and others to improve national program planning. Updated economic and financial data and indicators will allow for PEPFAR and governments to make rapid course corrections to improve planning and effectiveness and to avoid inefficient use of resources. Our path to creating an AIDS‐free generation requires us all to work smarter and better together, which brings me to another element that is needed: country ownership, working even more closely with the governments and civil society of the countries in a partnership. Part of this discussion is asking countries to assess what complementary resources they can bring to the table. In some cases, they have responded with strong financial commitments, such as the South African government’s impressive recent increases in investments in their HIV program. Country ownership also takes the form of leadership in prioritization, implementation, and accountability at the local level. Through the over 20 Partnership Frameworks that PEPFAR has signed with partner countries, we are working with countries to put them in the driver’s seat of their national HIV responses. For HIV, as for other development issues, countries must lead their own responses, and we must model our commitment to be supportive partners as they assume increasing responsibility for their health systems.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

But country ownership alone will not solve the AIDS crisis, let alone our broader global health systems challenges. We must also challenge the world to accept that global health remains a shared responsibility. A crucial part of this shared response is the multilateral mechanisms, including the Global Fund. The Global Fund really is an indispensable tool and remains a single conduit through which other countries that will never have a bilateral program can funnel resources to those countries in need. Part of our shared responsibility is to ensure that all resources are used as efficiently and effectively as possible. With our support and encouragement, the Global Fund has taken a number of actions in recent months to recommit itself to this goal. To support country‐owned programs, PEPFAR and the Global Fund are increasingly engaging in joint planning and now co‐finance many components of country responses. Together we can do this. Over this year we have seen exciting new evidence and guidelines, and with them new challenges. Following the release of HPTN 052 last year, the World Health Organization released guidelines on the treatment as prevention for HIV‐infected partners in sero‐ discordant couples. In addition, the World Health Organization recently released a programmatic update on PMTCT, highlighting the need to improve access to therapy for pregnant women and recognizing the potential benefits of a “test and treat” approach in this population. Supporting national programs in scaling these types of approaches will require us to push even harder to innovate, streamline, and be smarter about our investments. However, as we tackle these new challenges, we should not forget the lessons of the past and resist the temptation to re‐invent the wheel. We should take the lessons we have learned from integrating treatment into thousands of primary care clinics and hospitals across Africa to ante‐natal clinics. This is where HIV‐infected women and their partners are more likely to be identified, and in many cases, have access to treatment if it is provided. We should take the example of Malawi, where a national supervision strategy is being used to maintain the quality of the HIV response, even as the program rapidly decentralizes to the hardest‐to‐reach areas, even in the midst of an economic crisis. We must continue our investments in training health‐care workers and invest in community health workers, taking care that we are “task‐shifting” and not “task dumping.”

And we must move to enhance our laboratory networks, quality control, and investments in point of care testing to support decentralized sites. In terms of implementation science, we should focus more on the “how” and less on the “if” in improving retention and adherence in challenging populations, including pregnant women, especially in the context of a “test and treat” approach. And as the global HIV response moves from an emergency to a sustained response, we will also need to think more about cross‐cutting programs, such as pharmacovigilance, in future programming to ensure that the antiretroviral drug regimens and monitoring approaches we use are as safe and effective as possible, over both the short and long‐term. Challenging? Yes. Insurmountable? No. In reality, if there is anything I have learned, it is that PEPFAR has proved that we can take a situation with little hope and turn it around. It challenges all of us to raise the bar for what our global programs are expected to achieve. I look forward to working with you to raise that bar still higher. Thank you very much.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Keynote presentation by Dr. J. Stephen Morrison, Director, Center on Global Health Policy, Center for Strategic and International Studies (CSIS) Thank you all – it is a real pleasure to be here. I am going to speak very rapidly to several topics, starting with the environment here in Washington and how that relates to what you are going to be debating People in Washington have been extremely busy getting ready for the International AIDS Conference. What has that revealed to us, that process and preparation that’s relevant to the subjects that you’re going to address here? One is the enormous pride that people bring to this task of talking about PEPFAR nine years on. There is this sense of a great moment that has arrived here. In terms of being able to come on U.S. soil and reflect about the achievements, about the difficulties that were faced, about the value of the investment, about the partnerships that were created, about the science and the administration and the political leadership that was brought to this task. It’s also brought home that we are in the midst of a very mixed opinion climate. This program was launched with enormous bipartisan support and enormous leadership from the Bush White House, and has been carried forward by the Obama White House. It was launched with enormous support from the faith community, from the business sector, from universities, from the foundation world. That marvelous coalition still persists, but there is an aging and thinning process going on and we were up on the hill last week briefing on this. It was interesting to see that first of all, there’s a core of folks there that understand and identify and are very, very warmly and immediately connected – but there is also the need to continue to educate and engage and bring about very forcefully and in very clear terms what these achievements have been. Many of the people that were there at the creation of PEPFAR are no longer there in Congress, and we’re in a period of considerable angst about budgets. We’re in a period of great contestation politically, and polarization, and the uncertainty and difficulty there bring forward new skepticism as well. The work that you do in terms of demonstrating to policymakers, the translation from the kind of very dense applied research you do into intelligible forms that can be acted upon, becomes that much more valuable in this climate. We have seen in the course of deliberations around U.S. policy a recurrent message which is that people return to the notion that PEPFAR has become the fundamental reference point,

the vital platform in which we build off of, and that moving forward and protecting that becomes very important. What do policymakers need to hear in this particular period? The AIDS‐free generation concept has emerged as the defining concept. I think that that brings both opportunity and a certain amount of risk. First of all, it’s going to beg, ultimately, the question of what we are talking about in terms of concrete priority investments. How do we begin to measure and know as we move forward that we’re getting progress? How do we calibrate those goals to be realistic and feasible and not be captured by any runaway hubris or enthusiasm in this period? Because people are going to push back on that in this climate, I think. I believe we’ve seen this with the health systems debate that people can turn it off or they can change the subject if they believe that it’s too broad or it’s too imprecise as a concept. Helping through research in terms of identifying how to talk about this, how to talk about the AIDS‐free generation in very clear and intelligible terms to a policymaker or a lay audience that’s interested in this, I think that still remains as one of our key, one of our really key challenges. Modeling in particular is problematic. I’m a political scientist. The field of political science was captured by modellers about 30 years ago and it’s been a big internal debate around have the political science modellers become too arcane and too insular in their own world that others that are outside of that domain have great difficulty understanding what it is. The translation issue becomes very important. I know that there’s been enormous effort undertaken by CDC and OGAC to begin using modeling in order to project cost and understand how to shift resources and investments. This has been one of the great successes, I believe, in the last period in reengineering programs in order to make the case that we’re getting much higher returns. But it’s still a process that for many people is hard to understand. That complexity hasn’t been fully conveyed, I don’t think. We have to guard against the risk of not having the comprehension levels where they really need to be and focusing on that as something where you can test it. You can test it outside to people who are interested and engaged in important positions of shaping opinion and making decisions on allocations but who may not understand the terminology terribly well. They may find this too abstruse at different points. I think that’s one of the challenges. It’s not just the modeling that you’re undertaking, I think this is true for economists and it’s true for political scientists and we’ve seen that problem in cross disciplinary translation of knowledge and impact into policy making in many ways. Thank you all for coming and thank you for the chance to be here.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Opening remarks from Dr. Wafaa El‐Sadr, Director of ICAP Columbia Thank you Eric, thank you Stephen. What a wonderful start to our pre‐meeting. I wanted to take a moment to put this gathering into context, and to say a little bit about where we have been and where we hope to go. As many of you are aware, the conversation about HIV programs and health systems is not a new one. Even in the early days of HIV scale‐up, important questions were being asked. People both within and without HIV programs wondered: How has HIV scale‐up impacted the broader health system? Has it resulted in enhancement of health systems, expansion of the opportunities for people with HIV, and also improvements in services for people without HIV? Or has it offered risks? Has it taken away from the ability to respond to other major health threats? These kinds of conversations and discussions prompted this series of meetings, conferences and academic endeavors, as we attempted to bring a wide range of disciplinary expertise to try to tackle this central issue. Our first pre‐meeting was in Cape Town, before the IAS meeting in 2009. That meeting was called “Accelerating the Impact of HIV Programming on Health Systems Strengthening.” We brought together experts and individuals across the board to talk about this central issue: as we work to accelerate access to robust and durable HIV services, how can we enhance the health system to respond to other health threats as well as HIV? Our next pre‐meeting was in 2010, before the International AIDS Conference in Vienna. That meeting was called “Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems.” You will hear us use this term a lot – bridging the divide. It stems from the realization that, often, we each work within our own discipline area, with people who do what we do. There’s very little opportunity for people from different disciplines to come together and try to solve the problem together or to work together or to do research together or to do programming together. The idea was that we needed to convene people across different disciplines to actually plan the work together and learn from each other. In 2011, we had another pre‐meeting before the IAS meeting in Rome. At that meeting, we focused on the links between HIV and non‐communicable diseases, and on leveraging HIV scale‐up to strengthen chronic disease services. Participants spent a lot of time discussing the fact that, actually, for many countries around the world, the HIV response is really the very first large‐scale response to a chronic disease. There are exciting opportunities to build

on this experience to provide services for other chronic diseases – the non‐communicable diseases. We also need to think carefully about how to provide NCD services – prevention, care and treatment – to people living with HIV. Now, we’re here in Washington. The unifying theme across all of these meetings has been an attempt to foster a new dialogue and bring together a diverse community of researchers and implementers and policymakers and modelers as well as the affected communities in order to work together and to learn from each other. What has been the result of prior meetings? I think it’s heartening to know that the pre‐ meetings that we’ve had over the years have been followed often by joint projects, where people have met each other for the first time through these meetings and developed joint initiatives, embarked in joint research. Other outputs include several journal supplements, which enabled us to share the meeting contents, and to allow for interdisciplinary collaboration on guidelines and policies and priority‐setting. As you heard from both Ambassador Goosby and Stephen Morrison, it’s a very exciting moment in time in the history of the HIV response, but it’s also a fragile moment in time. There’s lots of excitement, but there is also a bit of trepidation and anxiety about what’s ahead of us. There’s also a commitment and a true belief that we can achieve an AIDS‐free generation. That excitement is based on new science that has spurred a lot of optimism, new science in terms of concern for people living with HIV, but also for prevention of HIV. In this moment in history, there’s a lot of new science and evidence that’s emerging, and that offers opportunities to actually make a dent to stem this epidemic. But there are also complexities – of prioritization and implementation and effective scale‐up. There’s an appreciation of the sciences, but also an appreciation of what we need to do in order to scale up and to implement programs with fidelity and with success. Lastly, of course, is the realization that achieving an AIDS‐free generation is going to require a whole new collaboration to truly bridge the many divides. The focus of our meeting today and tomorrow is to explore the potential divide between researchers, policymakers and implementers. There are not always divides and dissociations amongst these groups, but when they do occur, they can really prevent us from achieving our goals. We certainly heard this loud and clear in many settings and from many people like you in this room who felt that there’s something missing, and that there is an opportunity to bring

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

these two or three groups together and to come up with a joint agenda, a common future, a common response to the challenges.

For example, how often do researchers engage policymakers before selecting a research question? It’s not common, is it? In some cases, researchers only go to policymakers when their research is complete, expecting successful interventions to be adopted into policy – and funded – irrespective of national priorities. But researchers are also asking questions, like: “What data do policymakers need in order to design and deliver effective health services? What are the important questions they have?” They want to listen to those questions, but may not have access to the right people to ask. Implementers also have questions – and these may not always be evident to researchers, modellers or policymakers. How can we facilitate this dialogue? Lastly, what are the data that modelers need in order to answer these questions? Those inputs, those data – they come from implementers. Clearly, in order to move forward, we need to be listening to each other. We need to be listening to the questions that each group has, but we also need to be trying to derive the answers that are truly meaningful and that can drive policy and can drive implementation forward so that we can meet the goal of an AIDS‐free generation. How can we build these bridges? We’re hoping that through the conversations that we’ll have tomorrow throughout the day we can tackle this issue and bring groups together and try to articulate those questions both from the policymakers’ and implementers’ perspective as well as from the modelers and researchers’ perspective and find a way to move the field forward in order to reach our collective goals. What does our agenda look like? For tomorrow, Saturday morning, we’ll have two framing presentations. The first one will be by Rifat Atun and he’ll be talking about “Investing for Sustained Scale‐Up of HIV Services.” As you know, Rifat is a professor at Imperial College and we’re very thrilled to have him here with us.

The second framing presentation will be given by John Blandford. John is the director of the Health Economics, Systems and Integration Branch at CDC, and is also well‐known to many of you. He’ll be talking about “Using Modeling and Forecasting to Inform Planning and Policy.” Then, we have two panel discussions. The first one is “Planning for Sustained Scale‐Up: Where is the Evidence?” That will be co‐moderated by Till Bärnighausen and Sharonann Lynch. It will be an interesting conversation. The second panel is focused on “Key Questions from the Policymaker’s Perspective.” I will co‐moderate this with Estelle Quain from USAID. Then, in the afternoon, we’ll start with two panels. The first panel will focus on “Decentralization and Policy Priorities.” That will be moderated by Anita Asiimwe from the Ministry of Health in Rwanda and Eric Goemaere from MSF, followed by the second panel entitled “Integration of HIV Programs Into Health Systems: What Do and Don’t We Know About the Tradeoffs?” The moderators are Miriam Rabkin from ICAP Columbia and Craig McClure from UNICEF. And lastly, we will end by facilitated audience discussion. We’ll hear from all of you. This discussion will be focusing on key questions from the implementer’s perspective. The moderators will be Tony Harries from The Union and Nancy Padian from OGAC. We will then have closing comments by Jean‐Paul Moatti from ANRS, Anita Asiimwe from the Rwanda Ministry of Health, John Blandford from the CDC, and Estelle Quain from USAID. So that’s what’s ahead of us tomorrow. We have a very ambitious agenda, but a very exciting agenda. We are very excited to have you here and are looking forward to a wonderful meeting tomorrow. Thanks again.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Session #2: Welcome and Framing Presentations Saturday

July

The Saturday morning session started with opening remarks from Dr. David Wilson, Director of the World Bank’s Global AIDS Program: Welcome to the World Bank. Last night, we had an excellent reception here, and then I went to a reception of the Global Forum of Men Having Sex with Men and the Global Network of People Living with HIV. We heard talks and we heard marvelous songs from the Washington Gay Men’s Choir. What struck me most is that I was fortunate to be at the last AIDS Conference held in the U.S., in San Francisco in 1990, where the San Francisco Gay Men’s Choir also sang. After their song, they put up a picture of the choir three years before, but with the faces of people who had died of AIDS blank—and at least half were blank. In contrast, standing in our auditorium last night, there was so much levity in the room that speakers could hardly be heard. To me it reflected the remarkable transition of a period of 20 years. Yet the job isn’t complete; it’s not finished. We still have immense challenges. That was the dilemma before me. Kevin De Cock, in a very nice blog for this conference, said that we have to overcome forgetfulness and fatigue. We’ve forgotten what the face of AIDS was like in Africa 20 years ago when hospitals overflowed with emaciated patients; it was the leading cause of adult death. Coffin making was the fastest growing business, lining miles of highways for cemeteries. This group will look at some of the critical issues before us. In my framing remarks, I’d just like to talk about the three I’s that are going to be so important for today. I think the first one is one we’ve already heard: implementation. I think many of us could agree, and you will discuss this in greater detail. If we can implement the best proven interventions; get as close to 15 million people on treatment as possible; get as many people in the 14 priority eastern and southern African countries circumcised as possible; implement intervention for key populations; for pregnant mothers and for most at‐risk populations. If we can do all this, we can perhaps reduce new infections by about half. You will decide whether we can do more, or whether that will be our best. This brings me to the second I: innovation. In a panel on Monday with Ambassador Goosby and our President, Jim Kim, Bill Gates is going to argue that we don’t have the tools to do the job, that we have the tools do about half of the job. We need further innovation to do the rest. You’ll have your own views on that. I personally think he’s right to pose it that way. I think the danger of the phrase we’re using – “ending AIDS” – is that, in the public mind, it

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

basically equates to AIDS has ended, it’s ending, this is an end, and this conference is a valedictory conference – which it isn’t. I think the third critical I – and that’s why this group is so beautifully poised to address it – is integration. Not in an abstract way, not in a confrontational way; but I think rallying around the fact that PEPFAR is the largest single global health initiative in history. We have the largest health platform we’ve had and what we need to do is look at how we can use AIDS platforms for wider health delivery and wider health outcomes. No one’s been looking at it longer and harder than Wafaa El‐Sadr and ICAP. You’ve helped to bridge this important divide. I think before us at this conference, we need to balance implementation, innovation and integration. Let me conclude by simply saying that the World Bank is very proud you have chosen to come to us for this meeting. We’re proud to host you. We’re very keen to strengthen our partnerships with academic institutions. We’re very keen to bring epidemiology and economics closer together. This is a great group to do it. Have a great conference! Following Dr. Wilson’s remarks, Dr. Rifat Atun of Imperial College and Dr. John Blandford of CDC gave framing presentations, addressing the twin themes of HIV and health systems. Their slides begin on pages 86; slides, transcripts, and a webcast of the morning presentations are available on the meeting website. Dr. Atun’s presentation, entitled “Scaling up for Sustainable Impact,” began with a call to build upon existing success, and a review of the economic returns to investments in HIV/AIDS services. Dr. Atun then discussed key challenges to scale‐up, including weak health systems, declining health ODA, ongoing challenges in retaining patients on care and treatment, and the emergence of drug resistance. He briefly reviewed the vital need to enhance the data, information and knowledge required to assess impact and inform policy as HIV scale‐up continues, and highlighted the importance of analyzing and modeling complex adaptive systems in order to understand the factors influencing the adoption of innovations.

Dr. Blandford’s presentation was entitled “Bridging the Divide (redux): Using Modeling and Forecasting to Inform Planning and Policy.” He focused on the policy challenge facing PEPFAR following the release of the HPTN 052 study, which demonstrated the impact of ART on prevention amongst serodiscordant couples. By 2011, PEPFAR was directly supporting nearly 4 million patients on ART. At the same time, funding resources had plateaued – but the new data suggested that expanding access to ART might have dramatic effects on prevention. Dr. Blandford summarized three key questions facing PEPFAR policy‐makers at that time: is treatment sustainable? What does treatment buy/what are the societal benefits? How do the HPTN052 data change projection models? He described PEPFAR’s ART costing model and its inputs, including field‐based primary data collection, analysis of procurement and budget trends, and expenditure analysis. He also described PEPFAR’s analysis of societal benefits; both the direct health impact of HIV services on patients and the indirect benefits to others, including averted secondary infections. For every 1,000 patient‐years of treatment, PEPFAR found that 228 patient deaths are averted, 449 children are not orphaned, 61 sexual transmissions of HIV are averted, 29 mother‐to‐child infections are averted, 9 TB cases are averted amongst HIV patients, and 2,200 life‐years are gained. Dr. Blandford briefly describing the modeling involved in projecting the impact of accelerated treatment scale‐up, and concluded by describing how the ability to use modeling and forecasting to answer these three questions influenced a change in USG policy, prioritization, and targets.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Session # : Morning Panel Presentations Saturday

July

PANEL 1: Planning For Sustained Scale‐up: Where is the Evidence? The first panel of the morning focused on examples of policy‐focused modeling and research. Moderated by Dr. Till Bärnighausen from Harvard University and the Africa Centre and Ms. Sharonann Lynch from Médecins Sans Frontières, the “lightning panel” format required presenters to describe their research in no more than five minutes (for slides, see page 96ff). Dr. Charles Holmes, the Chief Medical Officer and Director of the Office of Research and Science at the Office of the U.S. Global AIDS Coordinator (OGAC), discussed ways in which research influenced USG policy and treatment targets. Following the HPTN 052 trial findings, which showed the dramatic impact of treatment on prevention amongst serodiscordant couples, PEPFAR’s Scientific Advisory Board recommended acceleration of ART scale up to all individuals with CD < 350, and to selected populations with CD4 > 350. Impact projections and cost analyses were used to support reallocation of resources to treatment, and to increase PEPFAR treatment targets. Dr. Jan Hontelez, from the Erasmus University Medical Center and the Africa Center for Health and Population Studies, described a time‐motion study conducted in HIV clinics in rural South Africa. Extrapolating the results under various assumptions enabled his team to describe the number of health workers needed to provide universal access to HIV care and treatment in South Africa. Sharing these projections with health workforce policymakers will be a key next step. Dr. Emmanuel Njeuhmeli, the Senior Biomedical Prevention Advisor at the Office of HIV/AIDS at USAID Washington, described the value of modeling and costing studies for voluntary medical male circumcision (VMMC). Following recommendations from WHO and UNAIDS on VMMC, the project aimed to describe the importance of VMMC within the prevention portfolio of PEPFAR partner countries, to determine how much money is required for VMMC scale‐up, to identify drivers of the unit cost, and to project the impact of VMMC scale up in each country. The initiative

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

combined facility‐based costing studies, modeling, funding gap analysis, and technical support, leading to inclusion of the strategy in each of the 14 countries, and to allocation of PEPFAR resources to VMMC scale‐up. Mr. Leonard Nkosi, Project Director at Management Sciences for Health for the AIDSTAR‐Two Malawi Project, described a collaborative analysis of Malawi’s Emergency Human Resources Project. The EHRP used five strategies – incentives, increased intake of health workers, use of volunteers, central‐level technical assistance, and an enhanced HRIS – in order to address Malawi’s HRH crisis. The analysis was designed to evaluate the strategy, and found dramatic impact on outputs, outcomes, and impact. Over the period of the EHRP strategy, Malawi saw a 49% increase in OPD attendance, a 15% increase in safe deliveries, a 7% increase in ANC visits, a 10% increase in immunization coverage, and an 18% increase in PMTCT coverage. Dr. Claudes Kamenga, UNICEF Regional Advisor for HIV/AIDS in West and Central Africa, described a six‐country PMTCT bottleneck analysis, designed to identify key barriers to expansion of PMTCT services. The results showed widespread similarities in the types but not the significance of bottlenecks amongst and between study countries. Frail policy and management environments, weak procurement and supply chain management, scarcity of human resources and weak monitoring and evaluation systems contributed to low coverage, inequitable access, and high dropout rates.

PANEL 2: Key Questions from the Policy‐Maker Perspective

The second morning panel was hosted by Dr. Wafaa El‐Sadr, Director of ICAP Columbia, and Dr. Estelle Quain, Senior Technical Advisor for Human Resources for Health and Team Leader for Health Systems Strengthening in the Office of HIV/AIDS at USAID. Panelists included Mr. Benedict Xaba, the Honorable Minister of Health of Swaziland, Dr. Faustine Ndugulile, Vice‐Chairman of the Parliamentary Social Services Committee in Tanzania’s Parliament, Dr. Kesetebirhan Admasu, State Minister for Health Programs for the Federal Democratic Republic of Ethiopia, Dr. Ibrahim Mohamed, Director of Kenya’s National AIDS/STI Control Programme in the Ministry of Medical Services, and Dr. Yogan Pillay, Deputy Director General of Strategic Health Programmes at South Africa’s Department of Health. The discussion revolved around the need to align research and modeling with policy and national contexts, and the challenges of fostering early dialogue between national policymakers and researchers. Each of the speakers gave examples of health Ministry information needs and priorities, from health workforce modeling to cost projections to questions about optimizing service delivery models. (A webcast of the proceedings is available on the meeting website).

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Session # : Afternoon Panel Presentations Saturday

July Dr. Gottfried Hirnschall, Director of the HIV/AIDS Department at the World Health Organization, opened the afternoon session, and welcomed participants to the afternoon session on behalf of WHO.

PANEL 3: Decentralization – Examples and Case Studies The afternoon’s first panel was moderated by Dr. Anita Asiimwe from the Rwanda Biomedical Center and Dr. Eric Goemaere of Médecins Sans Frontières. It was a “lightning panel,” in which presenters were limited to a mere five minutes to describe examples of decentralization of HIV prevention, care and treatment programs. Presenters focused on the challenges of geographic decentralization; subsequent discussion also included the issue of decentralizing management and governance. Slides are available on page 105. Dr. Tom Decroo, who leads MSF’s HIV project in the province of Tete, Mozambique, described the community ART groups (CAGs) which he developed in partnership with patients and communities. The CAGs are designed to bring care and treatment to the community level; group members meet monthly in the community, verify members’ adherence to treatment, complete a group card, and designate one member to travel to the ART clinic on behalf of the entire group, which can be no larger than six people. That member reports to the clinic staff and receives refills for each group member, which s/he brings back to the community. MSF has enrolled nearly 5,000 patients in the CAGs, which are completely voluntary; results are excellent, and more than 96% of patients are retained in care.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Connie Celum is Professor of Medicine and Global Health, Adjunct Professor of Epidemiology, and Director of the International Clinical Research Center in the Department of Global Health at the University of Washington. She described a home‐based HIV counseling and testing program piloted in South Africa, which demonstrated the acceptability and effectiveness of home‐based HIV testing and point‐of‐care CD4 testing. The study enrolled 282 households, testing 673 adults (91% uptake). Of these, 201 were found to be HIV‐positive, 30% of whom were diagnosed for the first time; 95% had visited an ART clinic at six months. The point of care CD4 testing had good agreement with flow‐ cytometry‐based CD4 testing. The pilot project will be followed by larger Phase 2 studies in South Africa and Uganda. Dr. David Hoos, Senior Implementation Director at ICAP Columbia and Assistant Professor of Clinical Epidemiology at the Columbia University Mailman School of Public Health, discussed ICAP’s experience supporting decentralization of HIV services in Tanzania. In the four ICAP‐supported regions, the number of sites providing HIV care and treatment services has grown from 78 in end‐2008 to 127 in end‐2011, including a mix of hospitals and primary health centers (PHC). Most PHC offer PMTCT services, which are geographically accessible to most pregnant women. ART, however, is less accessible. Of the 595 facilities offering PMTCT services, only 118 (20%) have on‐site access to ART, requiring women to travel for ART services. Dr. Hoos highlighted the fact that while PMTCT uptake and coverage is high, only 13% of newly‐ diagnosed HIV‐positive pregnant women in Tanzania initiate therapeutic ART (i.e., life‐long ART for their own health). If all currently‐eligible pregnant women initiated treatment, ART enrollment would increase by 40%, raising policy questions regarding the location of that care. Dr. Hoos discussed the implications of these data for the Option B+ strategy, in which all pregnant HIV‐positive women are intended to initiate therapeutic ART, noting the substantial systems challenges in providing lifelong ART to so many women during and after pregnancy, particularly as most of these women will initiate services at PHC and other clinical sites which do not currently provide ART.

PANEL 4: Integration of HIV Programs into Health Systems – What Do and Don’t We Know About the Tradeoffs? The final “lightning panel” of the day was moderated by Dr. Miriam Rabkin of ICAP‐ Columbia and Mr. Craig McClure from UNICEF. The moderators emphasized the panel’s focus on the integration of HIV programs into broader health systems, rather than on the integration of clinical services at the point of care. This type of integration, or “mainstreaming,” of HIV programs is often assumed to be the solution to challenges of both access and efficiency – but the evidence base to support these assumptions is limited. The panel focused on what is (and is not) known about the tradeoffs implied in moving from “vertical” HIV programs to “diagonal” or fully‐integrated programs. What is the impact of integration on the broader health system – on quality, coverage, equity, and efficiency? What is the impact of integration on the HIV programs themselves? And what is the priority research agenda as HIV initiatives evolve from highly vertical “siloes” to services integrated into national planning, financing, and service delivery programs? As before, presenters were limited to five minutes each; their slides are available on page 110 ff. Ms. Stephanie Topp, former Integration Program Manager at the Centre of Infectious Disease Research in Zambia (CIDRZ) and a current doctoral candidate at the Nossal Institute for Global Health at the University of Melbourne, discussed the Zambian experience with integrating HIV services into primary health care. Between 2008 and 2011, the Lusaka District Health Management Team with support from CIDRZ, piloted and then scaled‐up a model that integrated HIV and general outpatient (OPD) services. She reviewed the advantages of integrated services in areas such as staff scheduling, supervision and work culture, as well as disadvantages, including increased waiting times for both HIV and OPD patients and a slight worsening in some indicators of the quality of HIV care. Ms. Topp concluded by asking the audience to consider three key questions: where is there greatest resistance to the idea of integrated programming, and why? What indicators are important when considering whether and how integration can help strengthen health systems? And finally, what research methods are most appropriate for studying a phenomenon that is both complex and context‐specific?

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Karl Dehne, acting Chief of the Economics, Evaluation and Program Effectiveness Division at UNAIDS, presented the results of a systematic review on the costs and efficiencies of integrating HIV/AIDS services with other health services. The review included 46 studies (and 666 citations); Dr. Dehne noted that most of the research explored the integration of clinical services, not integration into health systems. The review concluded that HIV counseling and testing is less expensive when integrated into primary health care or family planning than when provided as a stand‐alone service. The authors also highlighted the fact that there is very limited evidence on the cost of integrating HIV care and treatment services with other programs, despite the frequent assumption that this approach will provide cost‐savings compared to stand‐alone ART clinics. They also noted that there is hardly any costing data on above‐facility costs, e.g., integration of supply systems, training, supervision or monitoring and evaluation. Dr. Dehne concluded that while integration can lead to efficiencies, not every model in every setting will do so. Ms. Bertha Katjivena, Director of Policy, Planning and Human Resource Development for the Namibian Ministry of Health and Social Services, shared Namibia’s experience with re‐integrating donor‐funded HIV project staff into Health Ministry structures. She noted that Namibia has had a rapid and largely successful HIV/AIDS response. However, one consequence of robust donor support and the rapid scale‐up of highly vertical programs is that by 2012, the salaries of 1,455 clinical and non‐clinical health workers were funded by donors, in a country whose total public‐sector workforce totals 4,400 health workers. Ms. Katjivena described the daunting financial, legal, and operational challenges of absorbing donor‐funded HIV staff into existing government structures without disrupting HIV programs. Dr. Sanjana Bardwaj, Senior PMTCT and Pediatric HIV Specialist at UNICEF South Africa, presented a brief overview of South Africa’s efforts to fully integrate PMTCT services into the country’s maternal, neonatal and child health programs. She highlighted progress on three levels: policies, programs, and practice. At the policy level, she noted the complexities of changing not only the national Action Framework, but 9 provincial and 52 district Action Frameworks, and the need to harmonize plans across multiple domains, including the country’s MCH Strategy, its National Strategic Plan for HIV/AIDS, STI and TB, its National Health Insurance initiative, its Primary Health Care Reengineering strategy and its Campaign on

Accelerated Reduction of Maternal and Child Mortality in Africa (CARMA), among others. At the program level, she described the use of Data for Action reports and a robot dashboard, showing progress at the national, province, district, sub‐district, and facility levels. At the practice level, Dr. Bardwaj highlighted the challenge of synergized messaging, joint accountability, and the need to maintain focus on both HIV and MCH outcomes.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Planning Group Wafaa El-Sadr (Chair) Director, ICAP Columbia University Professor of Epidemiology and Medicine Columbia University Mailman School of Public Health New York USA Rifat Atun Professor of International Health Management Imperial College Business School and Faculty of Medicine London UK Till Bärnighausen Assistant Professor of Global Health and Population Harvard University School of Public Health Boston USA Paulin Basinga Lecturer, School of Public Health National University of Rwanda Kigali Rwanda Stephen Becker Affiliate Associate Professor of Global Health University of Washington Bill & Melinda Gates Foundation Seattle Washington

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Deborah Birx Director, CGH Division of Global HIV/AIDS Centers for Disease Control and Prevention Atlanta USA John Blandford Chief, Health Economics, Systems & Integration Branch CGH Division of Global HIV/AIDS

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Centers for Disease Control and Prevention Atlanta USA

Chris Duncombe Senior Program Officer Bill and Melinda Gates Foundation Seattle USA Gottfried Hirnschall Director, HIV Department World Health Organization Geneva Switzerland Charles Holmes Chief Medical Officer, Office of the U.S. Global AIDS Coordinator Washington, DC USA Elly Katabira President, International AIDS Society and Associate Professor of Medicine Makerere Medical School Kampala Uganda Sharonann Lynch Senior HIV/AIDS Policy Advisor Treatment Action Campaign Médecins sans Frontières Craig McClure Chief, HIV/AIDS Section Associate Director, Programmes UNICEF New York USA Paulo Miotti Senior Scientist Office of AIDS Research National Institute of Health

Bethesda USA

Jean-Paul Moatti Professor of Health Economics University of the Mediterranean Marseilles France Faustine Ndugulile Regional Representative, IAS Governing Council Director, HealthConsult Tanzania Ltd Dar es Salaam Tanzania Estelle Quain Team Leader, Health Systems Strengthening Office of HIV/AIDS USAID Washington, DC USA Miriam Rabkin Associate Clinical Professor of Medicine & Epidemiology Director for Health Systems Strategies, ICAP Columbia Columbia University Mailman School of Public Health New York USA Pratima Raghunathan Acting Country Director, CDC Rwanda Centers for Disease Control and Prevention Global AIDS Program Kigali Rwanda David Wilson Director, Global AIDS Program The World Bank Washington, DC USA

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Speaker and Panelist Biographies

Kesetebirhan Admasu, MD, MPH is currently serving as the State Minister for Health Programs of the Federal Democratic Republic of Ethiopia. Prior to his appointment as State Minister in October 2010, Dr. Kesetebirhan served as Director General of Health Promotion and Disease Prevention General Directorate in the Ministry. In his capacity as DG, Dr. Kesetebirhan oversaw health sector reform and led the implementation of Ethiopia’s flagship health program, the health extension program. He is a champion of innovation, task‐shifting, and implementation at scale. Dr. Kesetebirhan has dedicated his entire career to public service and scientific research, focused on major public health problems in Ethiopia. A medical doctor by training with Master’s in Public Health, Dr. Kesetebirhan has served in a number of clinical and public health positions. He has worked as a public‐private partnership team leader, the CEO of a tertiary hospital and DG, before assuming his current ministerial portfolio. Anita Asiimwe, MD, MPH specializes in public health strategies, tackling the HIV/AIDS epidemic and other health conditions. A medical doctor by profession, she holds a Master’s degree in Public Health from Dundee University (UK). Currently, Dr. Asiimwe is the Deputy Director General of the Rwanda Biomedical Center and Head of the Institute of HIV, Disease Prevention and Control (IHDPC) where she is the overall coordinator of the national response to all disease conditions. While she was the Executive Secretary of the Rwanda National AIDS Control Commission, Dr. Asiimwe was also an overseer of the Global Fund Projects Monitoring Unit in Rwanda. Prior to this, she served as the Deputy Director General of TRACPlus, the Director of HIV/AIDS and IST’s Unit at TRACPlus, and the advisor to the State Minister in charge of HIV/AIDS and other

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

epidemics in the Ministry of Health, among other responsibilities. Dr. Asiimwe is presently a member of the Eastern and Southern Africa region’s high‐level task force for women, girls, gender equality, and HIV. During Rwanda’s Chairmanship of the GLIA (Great Lakes Initiative on AIDS), she chaired the GLIA Executive Committee, composed of the Heads of National AIDS Control Commissions of Burundi, the Democratic Republic of Congo, Kenya, Rwanda, Tanzania, and Uganda. She is also a research scientist, and the principal investigator for several studies of the Rwandan HIV/AIDS program. Rifat Atun, MBBS, MBS, DIC, FRCGP, FFPH, FRCP is Professor of International Health Management at Imperial College Business School and Faculty of Medicine Imperial College London. He heads the Health Management Group at Imperial College Business School. Between 2008 and 2012, he was a member of the Executive Management Team at the Global Fund to Fight AIDS, Tuberculosis and Malaria in Switzerland as the Director of Strategy, Performance, and Evaluation Cluster. Since 2009, he has been the Chair of the Stop TB Partnership Coordinating Board. Professor Atun has worked globally with the UK Department for International Development, the DFID Resource Centre for Health Systems, the World Bank, World Health Organization, and other international health agencies to design, implement, and evaluate health systems reforms and communicable and non‐ communicable disease programs. His research focuses on innovation in health systems. Professor Atun was a member of the Strategic Technical Advisory Group of the World Health Organization for Tuberculosis, and the Advisory Committee for WHO Research Centre for Health Development in Japan. He is a member of the Scientific Advisory Board for PEPFAR, the Global Health Group at the UK Medical Research Council, and the Global Task Force for Expanding Cancer Care and Control in Developing Countries. He has published extensively on health systems, communicable disease control, and innovation in health and biopharmaceutical sectors.

Professor Atun studied medicine at the University of London as a Commonwealth Scholar, and completed his postgraduate medical studies and Master’s in business administration at University of London and Imperial College London. He is a Fellow of the Faculty of Public Health of the Royal College of Physicians (UK), a Fellow of the Royal College of General Practitioners (UK), and a Fellow of the Royal College of Physicians (UK). Till Bärnighausen, MD, PhD, MSc, ScD is Senior Epidemiologist at the Africa Centre for Health and Population Studies and Assistant Professor of Global Health in the Department of Global Health and Population at the Harvard School of Public Health. He received his MD and PhD (in the History of Medicine) from the University of Heidelberg, an MSc in Health Systems Management from the London School of Hygiene and Tropical Medicine, an MSc in Financial Economics from the University of London and a ScD in international health (economics) from the Harvard School of Public Health.

Sanjana Bhardwaj, MBBS, MD, MPH is the Senior PMTCT and Pediatric HIV Specialist at UNICEF South Africa, responsible for technical support to the government and partners for scaling up PMTCT and pediatric AIDS programs integrated with maternal and child health programs. She has 17 years of experience as a clinician, researcher, trainer, and program manager and has been involved in policy development work in public health, particularly HIV/AIDS and maternal and child health. Since 2004, Dr. Bhardwaj has worked with UNICEF, providing technical assistance and supporting systems strengthening, evidence‐based planning and policy development for Governments in India, Papua New Guinea, and South Africa. Dr. Bhardwaj has designed and led programs on HIV prevention, focused on the most at‐risk and especially vulnerable adolescents and youth; PMTCT and Pediatric AIDS; and protection, care, and support of children affected and made vulnerable by HIV/AIDS.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Bhardwaj has a Master’s degree in Public Health in Health Behavior from the University of Alabama at Birmingham, and is an alumni fellow of the AIDS International Training and Research program of the National Institutes of Health, USA. She has medical degrees from India. She graduated from the Leadership Development Initiative UNICEF and completed the ‘Health Policy and Financing: Achieving Results for Children’ course at the London School of Tropical Medicine and Hygiene. Deborah Birx, MD has been the Director of the Division of Global HIV/AIDS in CDC’s Center for Global Health since 2005. Dr. Birx oversees all of CDC’s global HIV/AIDS activities in support of the President’s Emergency Plan for AIDS Relief (PEPFAR), which includes nearly 400 staff at headquarters, over 1,200 staff in the field, and more than 43 country offices in Africa, Asia, the Caribbean, and Latin America. With her specialized knowledge and decades of international experience in the field of HIV/AIDS, coupled with her dedication for enhancing prevention, care and treatment programs, she has greatly expanded CDC’s role and impact in achieving the goals of PEPFAR. Beginning her career in 1985 in immunology, Dr. Birx focused on HIV/AIDS vaccine research. From 1985 to 1989 she served as the Assistant Chief of the Allergy Immunology Service at Walter Reed Army Medical Center, earning the U.S. Meritorious Service Medal for her leadership in refining, validating, and standardizing cell‐mediated immunity testing in HIV‐infected patients. She was also recognized with the U.S. Meritorious Service Medal for her groundbreaking work in organizing and implementing a vaccine therapy efficacy trial from 1990‐1995. She served as the Director of the U.S. Military HIV Research Program at the Walter Reed Army Institute of Research from 1996‐2005 and received the Legion of Merit award for her leadership. Dr. Birx received her medical degree from the Hershey School of Medicine, Pennsylvania State University. She trained in basic and clinical immunology at the National Institutes of Health/Walter Reed Army Medical Center and is board certified in internal medicine, allergy and immunology, and diagnostic and clinical immunology.

John M. Blandford, PhD is Chief of the Health Economics, Systems, and Integration Branch in the Division of Global HIV/AIDS (DGHA) of the U.S. Centers for Disease Control and Prevention. Since joining the Division of Global HIV/AIDS in 2003, he has established DGHA’s leadership in the use of economic research and financial analyses to support sustainable scale‐up and efficient operation of global PEPFAR programs. He directed the PEPFAR ART Costing Project, a multi‐ country public health evaluation to study the costs and cost drivers of PEPFAR’s treatment programs. He has grown the economics team to support PEPFAR in planning and optimization of resources in global HIV programming and has pioneered routine expenditure analyses to inform program management and efficiency. For two years, Dr. Blandford was seconded to the Office of the U.S. Global AIDS Coordinator, where he led public health evaluation activities and guided efforts to project resource needs for scale‐up of PEPFAR programs. He entered federal service as a postdoctoral Prevention Effectiveness Fellow in CDC’s Division of STD Prevention. Prior to joining CDC, he was a Social Science Research Council postdoctoral fellow at the University of Chicago. He has also worked in the philanthropic sector supporting grant review and grant‐making operations and as an adjunct instructor of undergraduate and graduate courses in economic theory and public policy. Connie Celum, MD, MPH is a Professor of Medicine and Global Health an Adjunct Professor of Epidemiology and Director of the International Clinical Research Center in the Department of Global Health at the University of Washington. She is an infectious diseases physician and epidemiologist, and her research interests include HIV‐prevention, microbicide, and vaccine trials with the objective to find effective strategies to reduce HIV acquisition and transmission. Dr. Celum was the Principal Investigator of two recently completed trials of genital herpes suppression for prevention of HIV acquisition, transmission and disease progression (the Partners in Prevention HSV/HIV Transmission Study and HPTN 039 trials) that were

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

conducted in 20 sites in the US, Peru, and eight countries in Africa (Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). She is the Principal Investigator of the Partners PrEP Study of pre‐exposure antiretroviral prophylaxis among HIV serodiscordant couples in Kenya and Uganda. She is leading studies of home‐based HIV testing and combination HIV prevention in South Africa and Uganda. After completing her BA at Stanford University (1979), she received her MD from the University of California, San Francisco (1984) and her MPH in Epidemiology from the University of Washington (1989). Tom Decroo, MD has been engaged in MSF’s HIV/AIDS projects, mainly in Mozambique, since 2003. Dr. Decroo studied medicine at the University of Gent, in Belgium, and as a clinician, he has experienced the tremendous impact of ART on people’s lives. During the years, he worked as the doctor responsible for the HIV project in Tete, Mozambique. Two questions guided him: First, how can the model of ART care be adapted to scale up ART in the resource constrained contexts in Sub‐Saharan Africa? Second, how could lessons learnt from chronic disease care be applied to involve PLWHA themselves as a resource for their own lifelong condition? In an attempt to respond to these questions, Dr. Decroo developed an innovative model of ART care, driven and owned by the community, called Community ART Groups. Karl L. Dehne, MD, PhD is the acting Chief of the UNAIDS Economics, Evaluation and Program Effectiveness Division in Geneva. This is a newly established division that provides leadership on policies and approaches for achieving the HLM goals related to efficiency and financing of HIV responses. Previously, Dr. Dehne was the Team Leader, System Integration, UNAIDS. He was also instrumental, together with colleagues in PEPFAR and UNAIDS, in developing the Global Plan for the Elimination of New Child Infection by 2015 and Keeping Their Mothers Alive. Dr. Dehne has worked on HIV prevention, treatment care and support for more than 25 years, in various positions in WHO,

UNAIDS, NGOs and the Government of Zimbabwe. From 1998 to 2000, he was a lecturer at the University of Heidelberg, Germany, where he led the UNAIDS Collaborating Centre on AIDS Strategic Planning and Operational Research. Dr. Dehne holds an MD from Heidelberg, and a PHD and MPH from Leeds. Wafaa El‐Sadr, MD, MPH, MA is the director of ICAP and the Global Health Initiative at the Mailman School of Public Health and is professor of epidemiology and medicine at Columbia University. She is a leader in global health with many contributions in HIV/TB, tuberculosis, maternal and child health, and broad health systems strengthening. Dr. El‐Sadr has been a member of the Columbia community for close to 25 years. For two decades, she led the Division of Infectious Diseases at Harlem Hospital where she successfully established a multi‐dimensional research and service program responsive to the needs of the community. Building on this experience, Dr. El‐Sadr took the lessons learned from Harlem to the global arena at a time when millions had little or no options for HIV prevention or treatment. Through ICAP, the center she founded and directs, more than a million people with HIV have received HIV‐related services in sub‐Saharan Africa and Central Asia. Dr. El‐Sadr’s work demonstrates a deep appreciation of the breadth of issues fundamental to transforming the health of populations at local and global levels—from scientific discovery to implementation science. Dr. El‐Sadr received her medical degree from Cairo University in Egypt, a Master’s of public health from Columbia Mailman School of Public Health, and a Master’s of public administration from Harvard University. She has received numerous awards for her scholarship and is a recipient of a MacArthur Genius Fellowship. Dr. El‐Sadr is a member of the Institute of Medicine of the National Academies, one of the highest honors in medicine.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Eric Goemaere, MD, DTMH, PhD is a Regional HIV/TB advisor for MSF South Africa. He has extensive humanitarian experience with MSF. For the last 13 years, he has been involved in developing HIV programs in sub‐Saharan Africa. He is associated with the Centre for Infectious diseases, Epidemiology & Research at Cape Town University, and is a technical adviser for the South African National Aids Council.

Eric Goosby, MD serves as the United States Global AIDS Coordinator, leading all U.S. Government international HIV/AIDS efforts. In this role, Ambassador Goosby oversees implementation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), as well as U.S. Government engagement with the Global Fund to Fight AIDS, Tuberculosis and Malaria. He serves on the Operations Committee that leads the U.S. Global Health Initiative, along with the heads of the U.S. Agency for International Development and the Centers for Disease Control and Prevention. Ambassador Goosby served as CEO and Chief Medical Officer of Pangaea Global AIDS Foundation from 2001 to 2009. He also previously served as Professor of Clinical Medicine at the University of California, San Francisco. Ambassador Goosby has played a key role in the development and implementation of HIV/AIDS national treatment scale‐up plans in South Africa, Rwanda, China, and Ukraine, focusing his expertise on the scale‐up of sustainable HIV/AIDS treatment capacity, including the delivery of HIV antiretroviral drugs, within existing healthcare systems. Ambassador Goosby has extensive international experience in the development of treatment guidelines for use of antiretroviral therapies, clinical mentoring and training of health professionals, and the design and implementation of local models of care for HIV/AIDS. He has worked closely with international partners on the development of successful HIV/AIDS treatment and treatment‐based

prevention strategies for high‐risk populations. Ambassador Goosby has over 25 years of experience with HIV/AIDS, ranging from his early years treating patients at San Francisco General Hospital when AIDS first emerged, to engagement at the highest level of policy leadership. As the first Director of the Ryan White Care Act at the U.S. Department of Health and Human Services, Ambassador Goosby helped develop HIV/AIDS delivery systems in the United States. During the Clinton Administration, he served as Deputy Director of the White House National AIDS Policy Office and Director of the Office of HIV/AIDS Policy of the U.S. Department of Health and Human Services. Ambassador Goosby has longstanding working relationships with leading multilateral organizations, including UNAIDS, the Global Fund, and the World Health Organization. Anthony David Harries, MD is Senior Advisor at the International Union against Tuberculosis and Lung Disease in France and an honorary professor at the London School of Hygiene and Tropical Medicine in the UK. He is a physician and a registered specialist in the United Kingdom in infectious diseases and tropical medicine.

Dr. Harries spent over 20 years living and working in sub‐ Saharan Africa, starting in North‐east Nigeria in 1983. In 1986, he moved to Malawi, where he was consecutively Consultant Physician, Foundation Professor of Medicine at the new medical school in Blantyre, National Advisor to the Malawi Tuberculosis Control Programme and National Advisor in HIV care and treatment in the Ministry of Health, responsible for scaling up antiretroviral therapy in the country. In 2008, he returned to the UK where he works for the International Union Against Tuberculosis and Lung Disease.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Harries’ main interests are in the field of TB, HIV/AIDS, tropical medicine, and operational research. He has received several awards and prizes for his work, and in 2002 was appointed Officer of the Order of the British Empire (OBE) for his services in tuberculosis in Africa.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Gottfried Hirnschall, MD, MPH is the Director of the HIV/AIDS Department of the World Health Organization. In this role, he leads the organization’s work in development and implementation of cutting‐edge normative policies and guidance for HIV prevention, treatment, care and support. Over the past twenty years, Dr. Hirnschall has contributed to WHO’s work in child, adolescent, reproductive health, and HIV, supporting numerous programs worldwide to change realities for millions of people in need of quality health services. Dr. Hirnschall has also managed several major initiatives at WHO, including the mobilization of global partners and donors for the historic “3 by 5” initiative for scaling up HIV treatment in developing countries. He also directed the Caribbean HIV program for the Pan‐American Health Organization (PAHO), subsequently leading WHO’s HIV work for the Americas based at the PAHO office in Washington D.C. Since 2010, Dr. Hirnschall has been directing the WHO’s global HIV Program, focusing on optimizing the organization’s role in improving effectiveness, impact, and sustainability of the global HIV response in the new decade. As an MD specialized in Family Health at the University of Vienna, Dr. Hirnschall holds a Diploma in Tropical Medicine from the Swiss Tropical & Public Health Institute. He completed the Epidemic Intelligence Service at the Centers for Disease Control and Prevention (CDC) in Atlanta, USA, and conducted special studies in health economics at the London School of Economics and Political Science. He has a Master’s degree in Public Health from the Johns Hopkins School of Public Health.

Charles Holmes, MD, MPH joined the Office of the U.S. Global AIDS Coordinator (OGAC) in 2008, and currently serves as Chief Medical Officer and Director of the Office of Research and Science. Following medical school at Wayne State University, and an MPH in Epidemiology from the University of Michigan, he completed clinical training in internal medicine and infectious diseases at Massachusetts General Hospital and Harvard Medical School. During his training, Dr. Holmes performed clinical work in Malawi and assisted in the development of Malawi’s Round 1 application to the Global Fund to Fight AIDS, TB and Malaria. He went on to serve on the faculty at Harvard Medical School, focusing on outcomes research and the cost‐effectiveness of antiretroviral treatment strategies in South Africa. Dr. Holmes was a member of the 2010 World Health Organization Treatment Guidelines Committee, and he remains involved in efforts to update the guidelines and to ensure their strategic adoption at the country level. In his current role at OGAC, Dr. Holmes oversees PEPFAR’s clinical and research programs and provides input into policymaking. He continues to provide patient care as an infectious diseases physician and is actively engaged as a co‐ investigator on several clinical and epidemiological studies. David Hoos, MD, MPH is Senior Implementation Director at ICAP Columbia and Assistant Professor of Clinical Epidemiology at Columbia University’s Mailman School of Public Health (MSPH). A board‐certified internist, Dr. Hoos was an initial member of the MTCT Plus Secretariat at MSPH, where he was responsible for establishing the procurement system for antiretroviral drugs and other HIV‐associated medications and diagnostics – the first multicountry, full‐formulary ARV procurement system to be established. Dr. Hoos was also the director for the Multicountry Columbia Antiretroviral Program (MCAP), an eight‐year cooperative agreement funded by the CDC, which supported the scale up of HIV prevention, care and treatment in Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa, and Tanzania. Dr. Hoos has been recognized as a technical expert in a number of areas related to HIV policy and programming. He served as a member of the Technical Review

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Panel (TRP) for the Global Fund for AIDS, TB and Malaria (GFATM). He also serves as the chairperson for the Procurement and Supply Management Advisory Panel (PSMAP), which is advisory to the GFATM on procurement related policy and country guidance. He has been a member of several WHO technical panels, and was seconded to UNAIDS in Geneva as a treatment advocacy advisor for eight months in 2011. Jan Hontelez, MPH holds two Master’s degrees, in epidemiology and public health, and works at the Erasmus University Medical Centre in Rotterdam, at the Department of Public Health. He is currently doing research on the impact of ART on HIV epidemic dynamics using mathematical models, with a focus on South Africa and sub‐Saharan Africa. Mr. Hontelez is also affiliated with the Africa Centre for Health and Population Studies in South Africa, and the Raboud University, Nijmegen (Netherlands).

Claudes Kamenga, MD is a medical doctor and a public health specialist with more than 20 years of international experience in health and HIV/AIDS programming and research. He currently serves as Regional Advisor, HIV‐AIDS, UNICEF West and Central Africa Region. In this position, he provides technical leadership, expert advice, analysis and technical support to the 24 countries in West and Central Africa on HIV and AIDS policies and programs. Before joining UNICEF, Dr. Kamenga worked for Family Health International where he last served as Senior Director, Technical Support and Research Utilization, providing oversight and leadership on technical support on HIV prevention, care and treatment, and research utilization.

Elly Tebasoboke Katabira, MBChB, FRCP Edin., is a Professor of Medicine and former Deputy Dean for Research of the Faculty of Medicine at Makerere University, Kampala, Uganda. He was trained as a medical doctor at Makerere University and later specialized in Neurology (Manchester UK; 1984). Since his return to Uganda in 1985, he has worked extensively in the field of care and support for people living with HIV. He is the Clinical Advisor at the AIDS Clinic in Mulago Hospital and at the Infectious Diseases Institute of Makerere University College of Health Sciences. In 1990, Dr. Katabira was recognized as a World AIDS Foundation International Scholar. His strength is in the development of treatment and management guidelines for HIV/AIDS and he has written several publications and chapters in various books on this topic. His research interests include clinical trials and operational research issues on various aspects of HIV/AIDS care and support, both within institutions and in the community. Dr. Katabira is also co‐founder of The AIDS Support Organization (TASO) and has been their Medical Advisor since 1987. He is a founding member of the Academic Alliance of AIDS Care and Prevention in Africa. Dr. Katabira is also the author of more than 200 published scientific articles and abstracts. In June 2000, he was elected a member of IAS Governing Council in the African Region. Since then he has actively participated in many IAS activities, including as a co‐chair of the IAS Industry Liaison Forum (ILF) and as a Co‐Editor of the Journal of the International AIDS Society (JIAS). He was elected President‐Elect of IAS in December 2007 and took office as President in July 2010.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Bertha Katjivena, MA, MHMPP is currently the Director of Policy, Planning, and Human Resource Development for the Ministry of Health and Social Services of the Republic of Namibia. In this position, Ms. Katjivena is responsible for the overall coordination of strategic planning for health services, policy formulation, development cooperation, health facility planning, management information and research, as well as the coordination of human resource development for the Ministry. Ms. Katjivena, a Registered Nurse by profession, holds a master’s degree in Health Management, Planning, and Policy (MHMPP) from the University of Leeds, United Kingdom as well as a Diploma in Health Economics from the University of Cape Town, South Africa. Sharonann Lynch is a Senior HIV/AIDS Policy Advisor for the Treatment Access Campaign at Médecins sans Frontières. A longtime activist and advocate, she has also worked with ACT‐ UP and Health GAP.

Craig McClure is the Chief of the HIV/AIDS section at UNICEF New York, where he provides leadership and coordinates UNICEF’s work on HIV and AIDS at a global level. Prior to his appointment, Mr. McClure served as Coordinator, A.I., and Senior Adviser, HIV/AIDS at the World Health Organization (WHO) in Geneva, where he coordinated the treatment and care team in the HIV Department. From 2004‐ 2009, Mr. McClure was Executive Director of the International AIDS Society (IAS), where he oversaw the staging of six major international and scientific conferences. In 2000, Mr. McClure worked for the International AIDS Vaccine Initiative (IAVI) on public policy and community‐preparedness for vaccine trials. He then joined WHO in 2002 to support partnerships for the “3 by 5” initiative. Mr. McClure has a background in political science, international relations, education, and counseling. His involvement in the fight against AIDS began in 1991 when, while teaching secondary school in the UK, he joined the activist group ACT‐UP Manchester. He returned to his native Canada in 1993 and worked for five years in the community‐based sector with the Canadian AIDS Treatment Information Exchange (CATIE) as an educator and coordinator of treatment advocacy, information, and literacy programs. After leaving CATIE, Mr. McClure co‐ founded the consulting firm Health Hounds focused on organizational development and HIV policy for government, not‐ for‐profit organizations and industry. Mr. McClure is committed to working to end the AIDS epidemic through approaches that balance investments in research with achieving and sustaining universal access to prevention, treatment and care, and promoting and protecting the rights of people living with and most affected by HIV.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Jean‐Paul Moatti, PhD obtained a doctorate in Economics in 1982 at the University of Paris, and initially worked in environmental economics for the French Atomic Energy Commission (CEA). He ultimately moved to INSERM (the French National Institute of Health) to develop research in health economics with applications in the field of prenatal diagnosis, therapeutic innovations in hematology and oncology, as well as screening and antiretroviral therapies for HIV infection. Since 2000, he has been actively involved in research about access to HIV treatment and issues related to equity in health systems of developing countries. He is currently a Professor of Health Economics at the University of the Mediterranean (Marseilles, South Eastern France), Director of the INSERM/IRD (French Public Institute for Research in Developing Countries) Unit 912 (Economic and Social Sciences, Health Systems & Societies, SE4S), Director of the Federative Research Institute on Human, Economic & Social Sciences Applied to Health of Aix‐Marseille Universities, INSERM and French National Center For Scientific Research (CNRS). He chairs the Social Science Committee of the French Agency for AIDS Research (ANRS) and is a member of the Advisory Committee on Health Research for the General Director of the World Health Organization (WHO). He is also an adviser to the Executive director of the Global Fund Against AIDS, Tuberculosis & Malaria (GFATM). He has extensively published in health economics, as well as biomedical and public health scientific journals.

Ibrahim Mohamed is a Public Health Physician with over 17 years of experience in HIV/AIDS. He has been the head of Kenya’s HIV/AIDS/STI Control Program (NASCOP) in the Ministry of Medical Services for the past eight years. Dr. Mohamed spearheaded the implementation of Kenya’s National AIDS Strategic Plan that has led to the scale‐up of HIV/AIDS interventions and the improvement of HIV indicators in Kenya, as well as the scale‐up of HIV/AIDS treatment resulting in 600,000 patients accessing antiretroviral treatment within the past eight years. Previously, Dr. Mohamed was responsible for the management and evaluation of the National HIV/AIDS surveillance program to ensure efficient monitoring and assessment of HIV/AIDS trends. Dr. Mohamed is also a researcher and was the Principal Investigator of the first‐ever Kenya AIDS indicators survey (KAIS) in 2007, the findings of which gave insights into the Kenya HIV/AIDS epidemic and subsequently informed the development of the Kenya AIDS Strategic Plan III. Dr. Mohamed has also been involved in monitoring of early warning indicators as well as HIV resistance survey studies, and developing and implementing electronic medical records systems for monitoring HIV/AIDS patients, Management, and TB HIV integration. Currently, Dr. Mohamed is involved in quality improvement in HIV/AIDS treatment outcome indicators. J. Stephen Morrison, PhD is the director of the Center on Global Health Policy and a Senior Vice President at CSIS. With support from the Bill and Melinda Gates Foundation, other foundation and corporate contributors, the Center seeks to advance a long‐ term strategic U.S. approach to global health, cultivate new global health champions, enrich understanding of the security and foreign policy dimensions of global health, and link Washington‐based work to emerging policy expertise in key developing and middle income countries. Beginning in the spring of 2009, Dr. Morrison directed the CSIS Commission on a Smart Global Health Policy, comprised of 25 diverse high‐level opinion leaders. Its findings are detailed in the final report A Healthier, Safer, and More Prosperous World: Report of the CSIS

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Commission on Smart Global Health Policy, published in 2010. Dr. Morrison writes widely, testifies often before Congress, has directed several high‐level task forces and commissions, and is a frequent contributor in major media on U.S. foreign policy, global health, Africa, and foreign assistance. He served for seven years in the Clinton Administration, four years as committee staff in the House of Representatives, and taught for twelve years as an adjunct professor at the Johns Hopkins School of Advanced International Studies. He holds a PhD in political science from the University of Wisconsin and is a magna cum laude graduate of Yale College. Faustine Ndugulile, MD, MPH is a Member of the Tanzanian Parliament and the Vice‐Chairman of the Parliamentary Social Services committee. He received his Doctor of Medicine degree from the University of Dar Es Salaam, Tanzania in 1997, a Master of Medicine in Microbiology and Immunology in 2001 from the same university, and a Master of Public Health degree from the University of Western Cape, South Africa in 2010. Between 2004 and 2006, Dr. Ndugulile was the Head of Diagnostic Services of Tanzania’s Ministry of Health, where he was instrumental in building the capacity of laboratory services to support the roll out of the HIV/AIDS Care and Treatment program. In addition, as part of the HIV/AIDS prevention strategy, Dr. Ndugulile was tasked with transforming the blood transfusion service from hospital‐based service to a centrally coordinated system that is reliant on voluntary blood donors. Between July 2007 and September 2010, Dr. Ndugulile was contracted by the U.S. Centers for Diseases Control to provide technical assistance to the South African Field Epidemiology and Laboratory Training Programme, aimed at building the capacity of South Africa in field epidemiology and diseases surveillance. Dr. Ndugulile has actively been involved in the HIV/AIDS field since 1993. He is a member of the Governing Council of the International Aids Society, a position he has held since 2008. In addition, he is a member of the American Society of Microbiologists, Tanzania AIDS Society, and Tanzania Public Health Association.

Emmanuel Njeuhmeli, MD, MPH, MBA is the Senior Biomedical Prevention Advisor at the Office of HIV/AIDS at USAID Washington and Co‐Chair of PEPFAR’s Male Circumcision Technical Working Group. He is also member of the PEPFAR HIV Prevention Steering Committee, the WHO‐UNAIDS Male Circumcision Steering Committee and the WHO Technical Advisory Group on Innovations in Male Circumcision. Dr. Njeuhmeli holds a Medical Degree from the Faculty of Medicine and Biomedical Sciences of University of Yaounde in Cameroon, a Master of Public Health from Johns Hopkins Bloomberg School of Public Health and a Master of Business Administration from John Hopkins Carey Business School. In his current role, Dr. Njeuhmeli provides high‐level technical support to all 14 countries in Eastern and Southern Africa for launch and accelerated scale up of male circumcision programs. He is a strong advocate of use of innovative service delivery models to maximize use of the limited resources available and to have the maximum public health impact on the HIV epidemic in the region. Leonard Nkosi, MA earned a Master of Arts Degree in Population Studies from the University of Ghana, Legon, in 1986; a Bachelor of Arts Degree in Sociology and English from the University of Malawi, Zomba, in 1977; a Diploma in Training of Advisors for Improvement of Human Resource Management in the Public Sector from the ILO International Training Centre, Turin, Italy, in 1994; and a Diploma in Labour, Cooperation and Development from the International Institute for Development, Cooperation and Labour Studies, Tel Aviv, Israel, in 1983. Mr. Nkosi is currently Project Director for the AIDSTAR ‐ Two Malawi Project, a component of Management Sciences for Health (MSH) in Malawi, providing capacity building technical assistance to Civil Society Organizations working in HIV and AIDS services. Prior to this, Mr. Nkosi was the Deputy Project Director for the Evaluation Project for the Emergency Human Resource Program in the Ministry of Health and the health sector in Malawi, where he led the country team in the

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

evaluation of the 5‐year program funded by DFID. Mr. Nkosi has also held positions in a number of projects of Management Sciences for Health in Malawi, including as the Human and Institutional Capacity Development Specialist for the bilateral USAID funded Child Health and Systems Strengthening Project in Malawi from 2003 to 2007. Mr. Nkosi also worked as a Senior Management Development Consultant in the Malawi Institute of Management (MIM), from 1994 to 2003, where he provided technical assistance and management consultancies to the public and private sector organizations in a number of areas, including Health Systems Planning and Management, Human Resource for Health, Project Planning and Management and Institutional strengthening and Management. Mr. Nkosi also has wide experience working in the civil service where he worked in the Ministry of Labour, where with the collaboration of the International Labour Organization, he helped improve working conditions of the working population of Malawi from 1981 to 1994. Nancy Padian, PhD, MPH is an internationally‐recognized leader in the epidemiology and prevention of sexually transmitted infections including HIV. She is a senior technical advisor at the Office of the Global AIDS Coordinator (OGAC/PEPFAR), a consultant for the Bill and Melinda Gates Foundation, and a faculty member at the University of California, Berkeley in the Department of Epidemiology. Dr. Padian is an elected member of the Institute of Medicine, the American Epidemiology Society, and the International Society for Sexually Transmitted Disease Research. She frequently consults for UNAIDS (where she is a member of the Prevention Reference Group and the Evaluation Reference Group) and also for the WHO on programs related to care, treatment and prevention of HIV. For more than two decades, Dr. Padian has developed and directed a range of research and intervention projects on HIV, sexually transmitted infections, and contraception in high‐risk populations in the U.S. and internationally. Her portfolio includes serving as the Principal Investigator on the Methods for Improving Reproductive Health in Africa (MIRA) trail which examined the effectiveness of diaphragm use in preventing acquisition of HIV

and other STDs. While focusing on HIV and other sexually transmitted diseases, Dr. Padian’s research addresses the broader context of economic development, empowerment, and gender‐based violence. In addition, she has expertise in the rigorous design and evaluation of public health interventions. Yogan Pillay is the Deputy Director General of Strategic Health Programmes in South Africa’s National Department of Health, responsible for the national HIV/AIDS, TB, and MCH programs. In addition, he is currently overseeing the strengthening of the district health system as well as communicable diseases, non‐ communicable diseases and nutrition programs. He has recently co‐authored Textbook of International Health: Global health in a dynamic world (with Drs. Anne‐Emanuelle Birn and Tim Holtz).

Estelle Quain, PhD serves as Senior Technical Advisor for Human Resources for Health and Team Leader for Health Systems Strengthening in the Office of HIV/AIDS at the U.S. Agency for International Development (USAID) in Washington D.C. In this position, she is responsible for overseeing USAID’s health systems strengthening and health workforce development activities for HIV/AIDS programs under the President’s Emergency Plan for AIDS Relief (PEPFAR). Dr. Quain serves as the co‐chair of the PEPFAR HRH Technical Working Group and the co‐chair of the PEPFAR HSS Steering Committee. She has worked on health systems and human resource issues in PEPFAR since its inception, including a one‐year assignment to the Office of U.S. Global AIDS Coordinator. Prior to joining USAID’s Office of HIV/AIDS, Dr. Quain worked in training and capacity development for reproductive health programs for almost 20 years, including 10 years in USAID’s Office of Population and Reproductive Health. She is the USG delegate to the Board of Directors of the Global Health Workforce Alliance (GHWA) and a member of the editorial board of Human Resources for Health. She holds a PhD from Harvard University.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Miriam Rabkin, MD, MPH is a senior staff member at ICAP Columbia University, where her work focuses on HIV and health systems, access to HIV services in resource‐limited settings, and the design, delivery and evaluation of chronic care programs for HIV and non‐communicable diseases (NCDs). She has supported the implementation of HIV programs in Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Thailand, and Zambia as well as health systems research and training in multiple countries in sub‐Saharan Africa. Her current research interests include the impact of HIV scale‐up on health systems and the intersection of HIV and NCDs in lower‐income countries. At Columbia University, Dr. Rabkin is an Associate Clinical Professor of Medicine and Epidemiology. She teaches at the College of Physicians and Surgeons and the Mailman School of Public Health (MSPH), and has worked with MSPH colleagues to lead a distance education course on Health Systems Strengthening for mid‐career health professionals at CDC, USAID and health ministries in Barbados, Jamaica, Kenya, Namibia, South Africa, Uganda, and Vietnam. Dr. Rabkin received her medical degree from Columbia University’s College of Physicians and Surgeons and a master’s degree in public health (epidemiology) from Columbia University’s Mailman School of Public Health. Stephanie Topp was formerly the Integration Program Manager at the Centre of Infectious Disease Research in Zambia (CIDRZ). In this role she was responsible for the development, implementation, and research efforts related to the integration of stand‐alone HIV care and treatment into routine outpatient services in primary healthcare facilities across two Zambian provinces. She successfully developed, piloted, and promoted a model of integrated HIV service delivery and is now acting as a consultant to support the Ministry‐led scale‐up Zambia‐wide. Ms. Topp trained originally in political science and modern history. She holds a dual Master’s in International Public Health and International Development Studies, the latter as a Rhodes Scholar at Oxford University. She is currently a PhD candidate

in the Nossal Institute for Global Health at the University of Melbourne Australia, where her dissertation is exploring the characteristics of primary healthcare service‐delivery systems, examining where and why differences occur between de jure (assumed) and de facto (actual) systems, and with what implications for strengthening health systems. Prior to living in Zambia, Ms. Topp was the Think Tank Coordinator at the Cape York Institute for Policy and Leadership in Northern Queensland, working directly under lawyer and academic Noel Pearson. Her job encompassed development of and advocacy for social and economic policy reform related to health, welfare, housing, and employment issues of remote and rural Indigenous Australian communities. Her eclectic training has resulted in a strong belief in multi‐disciplinarity and a professional focus on the intersection between research, policy development, and implementation. She has worked in Papua New Guinea, China, Lesotho, and Zambia. David Wilson is the World Bank’s Global AIDS Program Director and was previously the Bank’s Lead HIV Specialist. His work on HIV/AIDS spans almost 25 years. During his career he has worked as a scientist and program manager in over 50 countries and published approximately 100 scientific papers. His interests lie in HIV epidemiology, HIV prevention science, and program evaluation. He has developed prevention programs that have been recognized as best practice by the World Bank, WHO, and DFID, and have been influential in international HIV prevention science. In addition, he has served as technical consultant and adviser to many international agencies, including USAID, DFID, EU, AUSAID, SIDA, NORAD, UNAIDS, UNICEF, and WHO.

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Benedict Xaba, the Honorable Minister for Health for the Kingdom of Swaziland, is a registered professional nurse. He holds a Baccalaureate (Honours) Degree with majors in Health Care Management, Occupational Health, and HIV/AIDS Care from the University of Free State in South Africa. He also holds a Master’s Degree in Development Studies and is pursuing a Master’s degree in Business Management (UNISA). Prior to his current appointment, Minister Xaba worked as a Public Health Nurse for eight years. He then became involved in HIV/AIDS campaigns; in 2004, he formed the Nhlangano AIDS Training, Information and Counseling Centre, which focuses on HIV counseling and testing in the rural areas of Swaziland. He has also initiated a number of HIV support groups in Swaziland. Minister Xaba was elected to Parliament in 2008, and appointed by His Majesty the King to be the Minister for Health that same year. He has subsequently introduced major restructuring reforms within the Ministry of Health and a campaign for universal access to HIV services. The Minister is passionate about scaling up HIV prevention efforts, targeting universal access. With the support of PEPFAR, he recently initiated a massive campaign on male circumcision, aiming to circumcise 152,000 men within an eight‐month period. He is also championing the national efforts towards the Virtual Elimination of Mother to Child Transmission of HIV, and is a member of the Global Task Team on the Elimination of New HIV infections among children and Keeping their Mothers Alive. The Minister is also passionate about the involvement of civil society and communities in the fight against HIV, TB and Malaria, and is committed to building stronger health systems and saving lives by improving the management and leadership of priority health programs, health organizations, and multisectoral partnerships, and developing a critical mass of managers at all levels of health system who can lead and inspire teams to achieve results.

Participant List

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Aramati, Mireille Global health consultant

Asiimwe, Anita Rwanda Biomedical Center, Rwanda Ministry of Health Atun, Rifat Imperial College Business School and Faculty of Medicine, Imperial College Audoin, Bertran International AIDS Society Bärnighausen, Till Harvard School of Public Health and Africa Centre Barcikowski, Nicole Abt Associates Barr, David Fremont Center Basinga, Paulin Bill and Melinda Gates Foundation Becker, Stephen Bill and Melinda Gates Foundation Bemelmans, Marielle MSF Brussels Bennett, Sara Johns Hopkins University Berg, Roland Deutsche AIDS Hilfe Bhardwaj, Sanjana UNICEF Bilger, Catherine UNAIDS Biribonwoha, Harriet Nuwagaba ICAP Columbia

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Birx, Deborah Office of the Global AIDS Coordinator (OGAC) Blandford, John CDC Borse, Nagesh CDC Broughton, Edward University Research Co., LLC Buono, Nicole Elizabeth Glaser Pediatric AIDS Foundation Cates, Ward FHI360 Cavanaugh, Karen USAID Celum, Connie University of Washington Chamrad, Diana University Research Co, LLC Clay, Robert USAID Coovadia, Jerry University of Kwa‐Zulu Natal Culler, Tegan ICAP Columbia Davidson, Veronica CDC De Cock, Kevin CDC Decroo, Tom MSF Dehne, Karl‐Lorenz UNAIDS Dohrn, Jennifer ICAP Columbia

Driwale, Alfred Uganda Ministry of Health Drobac, Peter Partners in Health Duncombe, Chris Bill and Melinda Gates Foundation Eisenberger, Robert NIH Ekpini, Rene UNICEF El‐Sadr, Wafaa ICAP Columbia Fan, Victoria Center for Global Development

Farias, Robert Cnapsis, Inc Gaudreault, Suzanne USAID Geng, Elvin University of California, San Francisco Gloyd, Stephen University of Washington Goemaere, Eric MSF Goosby, Eric Office of the Global AIDS Coordinator (OGAC)

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Gross, Marty Bill and Melinda Gates Foundation Hall, Carolyn HRSA 74

Hallett, Timothy Imperial College, London

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Harries, Anthony The Union Hijazi, Mai USAID Hirnschall, Gottfried WHO Hirschorn, Lisa Harvard University Holmes, Charles Office of the Global AIDS Coordinator (OGAC) Hontalez, Jan The Africa Centre Hoos, David ICAP Columbia Jain, Vivek University of California, San Francisco Jarawan, Eva The World Bank Justman, Jessica ICAP Columbia Kadisia, Bernard IAS Kamenga, Claudes UNICEF Katabira, Elly IAS Katjjivena, Bertha Namibia Ministry of Health Katz, Itamar Abt Associates

Kesete, Admasu Ethiopia Ministry of Health

Koech, Emily ICAP Kenya Kurian, Manoj IAS Lazarus, Jeffrey Copenhagen HIV Program (CHIP) Leach‐Lemens, Carol NAM Legins, Kenneth UNICEF Lion, Ann Abt Associates Lueck, Renee Bill and Melinda Gates Foundation Lukas, Damali Lynch, Sharonann MSF Lyons, Charles EGPAF Maguet, Olivier Médecins du Monde Marquez, Lani USAID

Marten, Robert The Rockefeller Foundation Massoud, M. Rashad USAID

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Mastro, Timothy FHI360 McArthur, Bruce

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

McClure, Craig UNICEF McNairy, Margaret ICAP Columbia Mensah‐Abrampah, Nana University Research Co, LLC Miller, Anna Miotti, Paulo NIH Moatti, Jean‐Paul ANRS Mohamed, Ibrahim Kenya National AIDS/STI Control Programme (NASCOP) Morrison, J. Stephen Center for Strategic and International Studies Mubangizi, Deus Results for Development Muraguri, Nicholas Mwanguo, Raphael Clinical Officer, Tanzania Ndizihwe, Assay CDC Uganda Ndugulile, Faustine Tanzania Parliament and IAS Njeuhmeli, Emmanuel USAID Nkosi, Leonard MSH Malawi

Northrup, Gayle Partnership for Management Development

Ntomwa, Benson Namibia Ministry of Health Ntumy, Raphael ICAP South Africa Odlum, Michelle Okeke, Chukwudera Bridget University of Manchester Okello, Velephi Swaziland Ministry of Health Onyeizu, Ichenna Martha Iyaya Development Foundation Padian, Nancy Office of the Global AIDS Coordinator (OGAC) Palen, John Abt Associates

Papenburg, Rudolph Cnapsis, Inc Pash, Rebeen Peace Corps Pequegnat, Willo NIH Perez, Freddy PAHO Perriens, Joseph WHO Philips, Mit MSF

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Pillay, Yogan South Africa Department of Health Pluies, Julie IAS

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Pollock, John MSH Quain, Estelle USAID Pakhmanove, Nilufar FHI360 Rabkin, Miriam ICAP Columbia Rasschaert, Freya ITM Antwerp Reuben, Elan USAID Sabain, Syncia DBMI Sahabo, Ruben ICAP Swaziland Sangiwa, Gloria Management Sciences for Health Schouten, Erik Malawi Ministry of Health Shaffer, Nathan WHO Shisana, Olive Human Sciences Research Council, South Africa Sinkala, Moses CMMB Zambia Smart, Theo NAM Sulzbach, Sara Abt Associates

Timilshina, Narhari Toronto General Hospital

Topp, Stephanie CIDRZ Zambia Van Damme, Wim Institute of Tropical Medicine, Antwerp Voets, Joanna Médecins du Monde, Tanzania Wilson, David The World Bank Wuliji, Tana USAID Xaba, Benedict Swaziland Ministry of Health Zewdie, Debrework The Global Fund

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Slide Presentations Ambassador Eric Goosby, Keynote Address, Friday 20 July

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Wafaa El‐Sadr – Welcome Remarks, Friday 20 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Rifat Atun – Framing Presentation, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. John Blandford – Framing Presentation, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

HIV and Health Systems: Strengthening Health Systems for an AIDS‐Free Generation

Dr. Charles Holmes – Panel 1, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Jan Hontalez – Panel 1, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Emmanuel Njeuhmeli – Panel 1, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Mr. Leonard Nkosi – Panel 1, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Claudes Kamenga – Panel 1, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Tom Decroo – Panel 3, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Connie Celum – Panel 3, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. David Hoos – Panel 3, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Ms. Stephanie Topp – Panel 4, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Karl Dehne – Panel 4, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Ms. Bertha Katjivena – Panel 4, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Dr. Sanjana Bardwaj – Panel 4, Saturday 21 July Slides and video are also available on the meeting website, at http://www.iasociety.org/Default.aspx?pageId=671

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Pre‐Meeting Support Provided by:

ICAP Columbia University The International AIDS Society

The World Bank The National Institutes of Health The Office of the Global AIDS Coordinator (OGAC) The President’s Emergency Plan for AIDS Relief (PEPFAR) UNICEF The U.S. Centers for Disease Control and Prevention The World Health Organization

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