This session was part of the CFR roundtable, Meeting the Challenge of HIV/AIDS in South Africa, made possible by the generous support of MSD.

MR NAVARIO:  Alright, let's go ahead and get started, Nono will join us in a moment she just had to step out.  I'd like to circle back briefly on the conversation that just completed and just reiterate what I stated that the beginning of this meeting and there were some discussion of elevating concerns and publicising the South African perspective and that's really what this is and understanding the South African perspective and that's really what this meeting is about, so I just wanted to sort of make that point.  We've also got a great round table up here, lots of expertise and so I'm just going to throw a few questions around to the people up here and then we'll throw out to - we'll open it up to general question.  And I think - I want to say - the first question I want to take things in a bit of a different direction and ask Olive about the NHI and the implications of NHI reform on ensuring people on antiretrovirals and maybe you could just give us a brief discussions thus far look like and what you know what are we look at down the road, we are talking about five and 10 years down the road here, so what implications does NHI reform have for HIV care, prevention and treatment?

MS SHISANA:  Thanks very much, clearly South Africa is looking for a solution that is sustainable in terms of funding healthcare.  We don't consider ourselves in the country as people who are going to be asking for money from foreign governments for ever, that is why the government has decided that they do want to investigate this issue of having a national health insurance which will provide universal access to healthcare for all.  That means that HIV/AIDS will also be included.  University access is to a comprehensive package of services which includes prevention treatment and care for all of the diseases including HIV/AIDS.  You all know that South Africa was terribly underfunded in terms of the number of health workers that is should have and that has created a lot of concerns about whether we can be able to deliver good HIV/AIDS services in the country.  We - for the last 10 years we are unable as a country to fund about 80 000 jobs, and those 80 000 jobs were not available at the time when the epidemic increased and the population increased, so the new plan for the national health insurance includes the question of funding those 80 000 that should have been funded before which will enable us to be able to deal with our HIV/AIDS.  So, HIV/AIDS is an important element of the national health insurance.

MR BRINK:  May I add one comment from private sector where we're used to health insurance, the beauty of health insurance is that it is population based, it requires membership and enrol of all the beneficiaries, and if you really want to tackle AIDS and you want succeed you've got to take population based approach to dealing with the problem, so we really look forward that NHI can succeed because that's the time that we'll start beating the AIDS epidemic.

MR NAVARIO:  Brian let me stick with you, you were talking about the role of the private sector and you were mentioning that - there have been several comments today about insufficient engagement with the private sector, you've - you echoed that notion, I'm curious how would you see from sort of the perspective of small to medium size enterprise and particularly I mean it's one thing to be Anglo, it's quite another to run a small business, how do you see - what do you see as the role for the small to medium enterprise and how do you see them getting engaged in supporting HIV efforts?

MR BRINK:  Well, from experience in our own workplace dealing with AIDS treatment now for some eight years we have shown quite conclusively from a business perspective that to invest in the care and support and treatment of your employees costs you a whole lot less money than if you do nothing about it.  The return on that investment is far more than the actual investment, we keep people at work, we don't lose our skills, we improve our productivity, we've just shown it over and over again, it is good for business, every sent invested in our AIDS programme for your direct employees is returned with multiples.  And so if it works within our business environment it works for every business no matter what size, and I would argue that for small and medium enterprises who are so critically dependant on their skills and cannot afford to lose one or two people here it's even more important for them that they diagnose, detect HIV infection early and ensure that those employees get the care, support and treatment that they need so that they don't get sick every, that they stay productive and those skills aren't loss.  That's what's good for business and we know that that works.

MR NAVARIO:  There's a, to follow up, there was a recent report in the papers, I don't know if it was maybe a day or two ago about private sector and I'm not sure I'm remember the context exactly, but there was a conference and there was a statement from the private sector from a variety of industries that they didn't believe that HIV was a high priority for them, I mean I don't know if you saw that report or if anybody else saw that report, it was...

MR BRINK:  Well, sadly that's often an impression that's out there because it's such a long term thing that you know this is something that we can just ignore.  People that are claiming that are simply denying the information that already exists, we know that within the working population and certainly down at the lower income levels that the prevalence of HIV infection amongst those employees is somewhere around 20%, thereabout, so to say that that's not a problem is actually just putting your head in the sand.

MR NAVARIO:  Max, I just want to go over to you and speak about KZN a bit, one of the deficiencies has been addressing - providing care and services in rural and underprivileged areas, KZN has a number, we were talking earlier about the specific challenges in KZN prevalence aside, how - what is happening at the provincial level in order to address care and treatment in underserved areas?

MR DHLOMO:  Thank you very much for that, ja I just want to actually indicate that some of the issues that one is actually dealing with it's just not a thing that I've just thought about, but it's issues that one must recognise the provision of a strategic leadership coming from the Minister himself together with the Premier of the province who fortunately happens to be a medical doctor and he was the first MEC for Health in the democratic South African in 1994 in that province.  We are actually faced you know we are the province that has got the highest disease burden on HIV and also I mean cases we have the highest number of cases therefore we need to actually be able to indicate our readiness to deal with, but when you also look into the 11 districts that we have in the province there are certain districts that seem to be projecting much more prevalence that is (indistinct) above 40%.  Now, the Premier is saying when you mobilise resources and you mobilise everything else you need to give me a specific programme that must address those three different from the rest of the other seven because there seem to be a certain pattern that goes into those three districts.  We must actually point out that with all the support that we've got internationally and also locally KwaZulu-Natal still remains the province with the highest number of patients on ARVs.  I mean a third of patients that on ARVs in the province - in the country are coming from KwaZulu-Natal, but I mean our good work is not adequate enough we still need to do more.  One of the things that has actually helped us in that regard is because colleagues have spoken quite at length about the limitations of accreditation of service - I mean of the centre sites and therefore it takes a bit longer whilst the issue of creation of what we call roving teams, so what we have would be a nurse, a doctor and a pharmacist that will then go and initiate ARVs in a clinic that is otherwise not yet accredited, attached to centre that is accredited.  And that is allowed us to have in certain districts (indistinct) being one of them 9% waiting lists, and we learnt that and Francois was on the news of giving us a bit of (indistinct) about what happened at Edendale.  You see we noticed that Edendale as a hospital with all the attached clinics have got the highest enrolment in the country, more than 11 000 of patients are enrolled in 18 clinics around.  But their good work was not adequate enough because there was just bottlenecks patients who otherwise were 20 coming to a clinic in 2004 are now 200 or 300, now we can't manage that.  So they very - they were much behind in terms of planning to capacitate clinics, down refer patients who otherwise were stable and initiate in those other areas so that now what we then learnt from districts that have been doing well was to over and above having a centre that is actually initiating have a roving team of those professionals going to the clinic - to other clinics so that rather than to have one source per district to be initiating or attached to a hospital you have people who are initiating in one.  So, that has actually helped us (indistinct) we seem to how it's bad and to reduce the number of patients waiting to be initiated and those are the lessons that have been learnt from other districts.  We are very happy to hear that the Minister was actually saying we must come and present to the Minmec now called National Council the success stories of these roving teams because if it could work for KwaZulu-Natal then probably should have work - it should work for other parts of the country where we might have the highest number of patients waiting to be initiated on ARVs.

MR NAVARIO:  Thank you.  I want to move to this issue of alignment and harmonisation, it was a prominent theme in all of the discussion today, in anticipation of this meeting I reread the national strategic plan and one of the priorities it emphasises was improving coordination, improving coordination is also one of the priorities of PEPFAR interesting enough and so for the people up I think almost everybody on this panel can address this issue of alignment, cultural changes - what, Nono, what do you see SANAC in improving in coordination between sectors, private sectors, civil society and the public sector as well as between domestic and donor funded efforts?

MS SIMELELA:  Thank you.  I mean SANAC mandate is to coordinate, I mean if you looked in the strategic plan that's the role of the Council and in how we are setting it up we've got already a manager who is appointed to do resource tracking and management and on coordinating, that's her portfolio.  So, we started by meeting development partners, we've met the EU Plus yesterday we were discussing with them, and basically what you know we're trying to get a database of who is being funded by development partners, where are they funding and what have the beneficiaries of those resources done because that's the first that will help and quantify what has gone in what return to that investment.  And in terms of coordination across other sectors you know all the sectors are represented on SANAC and you know it's a couple of months now that we're in place, I mean if you remember the Secretariat hasn't had capacity, so we're just starting to build those systems to collect the data, to coordinate, you know we're not there yet, but that's the role of SANAC and that's why I was lamenting the absence of data from the private sector we will be engaging with them to get more information.  So, we already have a study that was commissioned that has been done by KPMG for the development partners and you know it's been very difficult we're told to get all the data, but we're getting there.

MR NAVARIO:  I apologise for jumping around, but I want to come over to Helen quickly and again highlight a number - a theme that came up today and that is this issue of prevention it was possibly the prevention panel was possibly the bleakest of those that we had today and so what seemed to come out of that was that there is a need for profound social change and so my question is what catalyst is required to kick start that social change?  What are some of the key - you know how does this happen I guess is the question?  I mean these are deep seated cultural issues, where do we begin?

MS REES:  I think - I mean that it is very easy and we all talk about you know having this sort of social movement, but I think it is a very important question because I mean what are you going to say in that social movement because we tried ABC and that was a bit of flop as a social movement it never took off and the messages are quite possibly the right messages anyway.  So, I think that the first thing you'd really have to work out is if you have a social movement what is it that that is going to focus on, is it going to focus on sexual behaviour, is it going to focus on gender, it is it going to focus on poverty and rights?  Because those things are very different and if you have a social movement that's all things to all people then the message gets lost, you're in fact doing what we should be doing in this country anyway which is to say that everyone has rights and we want equity and we want poverty alleviation and that's what we should be doing anyway.  So, I think that we - part of I think of this analysis of what needs to go into prevention is to begin to understand what packages stands a chance of working and that's why I think that we need to do a much more rigorous analysis in our own setting of what the evidence is out there, what is the hard evidence, about what are the hard things we should be putting in place that we know work.  And then I think we need to say what's, as Salim said what is our best guess, and then I think we need to say in our setting in South Africa what are the big messages that you would really want to push in terms of the social movements and certainly I think that one of the things that would come very high up on that would be gender and gender relationships, because I think for much of the work that we're looking at shows that gender is really driving some of the issues there.  But I think the other thing I just want to say about prevention is that we were talking in terms of Botswana as well in the schools programme is that in terms of just prevention strategies what we've tended to do is the same old same old because that's what we've always done, so we've paid school then we continue to pay for school, the school's programme paid for by the Education Department is very expensive, there is no evidence that it has done any good, and yet we continue to do it because we continue to do it.  The counselling and testing programmes we have we talk about VCT very often in the same breath being a prevention strategy, there is no evidence in the way that we're doing it at the moment that it is a prevention strategy.  So, I think that we need to actually stand back and be much more critical about every single component and say what do we know works, what do we think should work but actually there is no evidence to shows that for all our efforts it's work and then actually sort of fundamentally rethink it.  But it terms of social movement I think that has to be part of the dialogue because I think we have to extract what we think are the major issues.

MR NAVARIO:  Olive?

MS SHISANA:  Ja, thanks.  I think this whole issue of social cultural practices it's a very complex issue, but the bottom line we have to be concerned about in my view is that it is the socio-economic conditions under which people finds themselves that make them to support those kind of unhealthy social cultural practices, let me just give an example, I said earlier on about some of the families that would allow a young girl to have a sugar daddy.  Why?  It's because they are poor, it is not so much that if they were not poor they wouldn't do what an average middle class family would do, an average middle class family would want to protect their girl from having a sugar daddy, but a poor family would eventually say if you can get money from this person to keep us alive let's do so.  So, the values themselves are actually influenced by the socio-economic conditions in which they are living.  The other thing I want to say it that even with those biomedical intervention that we have that we know are working like male circumcision, like you know the prevention of mother to child transmission and so forth you still have to consider the behavioural factors, the behavioural issues are still important because you can bring in an intervention for male circumcision, but if at all you have not dealt with those issues of prevent - gender - you know there is violence for example, if you have not brought all those other issues things are still going to be very much problematic.  So, it is important that we you look at the social cultural issues we look at them comprehensively even within the biomedical intervention strategies that we are actually trying to implement.

MR BRINK:  Helen mentioned that for a lot of these prevention strategies we are lacking the evidence that they work and that more analysis needs to be done, and off course that has to be done, but that doesn't mean analysis paralysis.  What we also have to do is look at some of the obvious facts and the intuitive response to those, so you look at our burden of disease, you look at the burden of disease on young women and girls and you know there is something dreadfully wrong there, and so Helen mentioned gender issues how those need to be tackled.  She also mentioned that there is no evidence that these sexuality education programmes in schools are working, but I would ask has anybody gone and had a good look at the curriculum?  Has anybody looked to see who is teaching it and how effectively it's being done?  Because to me it's intuitive that we need a whole new generation of adolescents who understand sexual rights particular of girls, who understand relationships between men and women, girls and boys when it comes to sex and how as a society we need to change.  It is absolutely intuitive to me that our reproductive health services for women and girls are deficient, that our family planning services are simply not as good as they should be.  There is so much that we can do right now that will make a huge prevention difference whilst we do the analysis as well.

MS REES:  I mean I wasn't saying that we sit and we pause and we do not do detailed research, what I'm saying - but I think it's very important what you've just said and that's the problem, if you look at the school's programmes and you look at all of the evaluations of interventions in schools as they are currently constructed they are not making a difference, they might make a difference in some cases to self reported behaviour change, but there is very little evidence that it made a difference to teenage pregnancies, to SDIs or to HIV where that has been looked at.  So, the question is that absolutely morally and ethically we want to keep school's programmes, but there is no point in doing what we've done if we now know that it is not looking, then we have to look again and say we have to do something fundamentally different.  So, it's not saying pause, stop it, do - you know that's not the issue, the issue is that we actually need to be much more self critical because as is in the counselling and testing as Olive was saying increased numbers of people who are counselling and testing but they are falling out of the system, so instead of just saying yes you've got a tick in the box of counselling and tested because more people are being tested we have to be much more critical about and then what happens to people because if they are falling out of the system then we're also not achieving what we want to achieve.  So, I think that that would be what I would - what I'm arguing is unlike male circumcision there is no - schools programmes they need to be there but they need to actually be meaningful and if we're wasting everybody's time by putting in things that are have not been proven to do anything we need to re-evaluate.

MS SIMELELA:  I just get a sense that you know we need to go back to understanding or appreciating how people live their lives, you know I think, I don't know how to express this, it's more like - for me there is always a disconnect between his sort of meeting you know where we're talking about interventions in a very scientific way and how we actually get communities to talk about what is really happening, I mean one of the issues that we meant was dialogue or community dialogues and there is a lot of things that are coming up and all of them social and cultural determinacy, you know the issue of poverty, drinking you know people - lot of alcohol abuse that is coming up in some of the discourses that we're having and it's almost like there needs to be a parallel, I wanted to the comment you made about government doing business differently and really I think we need better inter-sectoral (sic) planning, better ways of ensuring that investments in education benefit health, investments in health benefit everybody else.  At the moment I think in all department plan on their own and you know are sent to somebody there is one person (indistinct) in government who is trying to coordinate the whole government's response, it is not sustainable.  So, you know I think there are many things that we can do now you know in how we do business you know and I think the more - the service delivery model I think is wrong in a way in that there is a lot of time - opportunities for waste, you know I think we really need to relook, I want to speak to Olive and those that can influence policy, this awarding tenders and not taking responsibility, so you actually have managers managing the tender and the service providers rather than managing the system and there's an opportunity to take away a lot of those resources because they leak.  I know there is a strategy for economic development and providing people with jobs, but I think there is a time now for government to balance you know those things in terms of you know what is the socio-economic development agenda and what are the immediate health issues that need to be addressed.  You know and that affects everything, the way try to procure drugs, the way we deliver services and how we do it, but at the end of the day I think if we are able to deal with people's day to day live circumstances and how they arrive at the choices they make given the example that Olive has given, that is how people live.  If you go to Soweto you know people's lives are not sophisticated, people are living the same way they have lived for 20 years you know and how do we influence that level of just despair to be become energised about preventing HIV infection.  I think that's...

MR NAVARIO:  Helen, will you play prognosticator for us and tell us where South Africa is going to be in terms of prevention in five years in 2015 what will be the status quo with reverse prevention do you thing?

MS REES:  Well, I think if we assume that with the new political leadership that there is - that what we're seeing which is a new wave of enlightenment and commitment let's take that as the scenario which is think is a fair scenario to take.  I think we can also assume that SANAC is going to rebuild itself again with strong political leadership.  The - and against that background there is a lot of interest anyway about looking at prevention because of the non sustainability of increasing.  So, those are all sort of an upbeat scenario in which we should then look at this.  I think that what we would be seeing is and I think that we are going to see a very strong strengthening of PMTC programmes, a strong roll out eventually of circumcision which I think will start in certain provinces and will delay and eventually catch on, but I think in five years we will have circumcision available for HIV prevention in all the provinces.  I think that the treatment programme what is going to be interesting is that if we can continue to scale up the treatment programme whether in fact this the impact of treatment for prevention is going to be seen as a national natural experiment and that in fact what we see is - but that assumes that all these people who are starting treatment continue on treatment and I think that's a big assumption.  So, I think those are the biomedical, I think the real challenge is the behavioural chance and that is going to be related to what happens to the economy and it is going to be related again very strongly to political leadership, but if I were to say what I think - I think that we are going to see much more relevance in terms of campaigns, I think we've all realised we wasted loads of states funds on meaningless campaigns, and so I think that we are going to see a chance in context in terms of behaviour change campaigns, and I think that we might see certain things that might make a difference, so one thing I'll just highlight here in terms of structural issues is the issue of keeping girls in school.  There is now a new regulation that not many people know about that means that the social grant is tied to keeping children in school till the age of 18 years.  So, if these sorts of things start to creep in which is about poverty alleviation that directly impacts on HIV, I think that we will see a quite an interesting prevention package and I think we would definitely see a decline in incidents in a five year period.

MS SIMELELA:  Ja, I just want to say that I think in terms of clear indicators we are going to be seeing a decrease in HIV infection among children, we are beginning to see it over the last three surveys, we are going to begin to see or to continue to see the decrease in incidence among teenagers, it's beginning to happen and let's ensure that we continue to implement those programmes that help them to do that.  And then we are also going to see an increase is condom use among HIV positive young men, that's going to happen, it's happening already on the basis of data and I think it is going to continue that trend.  And then finally I think we are going to see a decrease in HIV prevalence among young men age 15 to 24, the data is showing that.  So, there are some good indications out there, what is going to be difficult in terms of prevention will be the older people, 25 to 49, that's where things are going to be much more complex mainly because of ARVs, with more people taking ARVs they are going to continue you know having an increase in the proportion of those people that are HIV positive simply because they live longer.  So, I think there is a glimmer of hope for me as a South African that something is happening you know and I think that's what we need to do to look for this examples of what is happening, we cannot keep saying that things aren't working, aren't working even when they are working, we need to identify areas where things are working and say they are working what more do we need to do to accelerate you know that positive change that we are seeing.

MR NAVARIO:  Great, one - Maxwell one last comment and then I want to open it up to the floor and we can - everybody can join in an we can address some issues that were raised earlier.

MR DHLOMO:  I think what Shisana has also alluded to is that the starting point is that if every South African were to know whether he or she is HIV positive or negative that is a beginning of a programme of therefore dealing with those decisively especially those because even the prevent - I mean programmes are very critically important, so that takes us a step further because then you could (indistinct) deal with even those who are HIV positive at a particular level and you know that now I'm pregnant and I know I tested last week therefore I can actually start engaging and be treated much more earlier.  But I think again for our side we are very positive about the male circumcision programme because we are going to do it medically, but again more than that we want to see it not as a separate preventative tool, but part of a total package according the strategic plan where we are saying it's an add on therefore people will also be counselled and also be motivated for HIV testing and besides that we are going to be scaling up in hospitals and clinics, we are seeing a situation where we are going to have large marquees put up and that's why we are very positive when invited them (indistinct) chips is a donor and we spoke to them and they began to prepare for themselves to say we will be putting up a big marquee in a particular area and call and actually the headman in the Amakozi will be the people to be saying there is 40 people in my district to go for circumcisions and they will be prepared to that and they will be talked we will probably be doing circumcision on a Friday afternoon and then keep them there on that marquee or next door marquee for the whole weekend and we can help men we have people to speak to all our men about how to respect women, integrity of men, manhood and all those issues, values that we see disintegrating are the issues that we would like to bring onboard and all for saying this is actually a very preventative measure, but in our province again there is another problem, I could to speak to it at length I mean later, but I'll give maybe the other members of the audience, but will be a flagship problem where we are saying every South African lives in a particular ward and therefore we can account for who lives where and we are coordinating a team which is at a level where we could be able to tell who is these South African on (indistinct) treatment, but not collecting treatment because people will be then be marshalled to go to particular areas and then to identify that people are not committing treatment who are those people let's get them and collect them.  I mean the same way we've done in the military because in the military one of the things I was actually talked of they have the roll out in the military you could told whether the soldier is at home, is at work or is deployed somewhere else, so there is nobody who can hide, so we want to say there is no South African who can hide you can tell where they are by being known by their village people that they life with, in that way you can actually deal with this issues of prevention and other scaling up of treatment.

MR NAVARIO:  Great Alright, so let's open it up to the floor if anybody has questions or comment they would like to raise at this stage please put your card on its end, I'll start with a question that I'll just throw out, anybody who cares to answer, one of the - another one of the discussion themes today was a lack of data and evidence base and I'm wondering where South Africa is going to be in five years with regards to better let's start with specifically care and treatment date, I know one of the struggles has been data management systems and there is a whole bureaucracy in selecting you know companies and nobody seems again to use the same - nobody seems to want to pull the trigger on that one and I'm just wondering where we're going to be in terms of data management and evidence base in five years?  And how we'll get there?

MS SIMELELA:  No, the Minister has already pulled the trigger on that one you know without saying much you know there is a concerted effort and a new plan to get us into a system that will allow us to collect that data.  I think the problem has been you know provinces went off and did whatever and even outside of the provinces you know other partners who are implementing have brought their own systems and this is where we as SANAC are pleading you know that if you are out there providing services whatever your are using if it is working share you know bring it to the table let's see if it is applicable, let's see if it can be done, you know I think we are a country that knows how to document and count people you know given the past system and everything.  I think we should use those experiences positively and I think it is getting better you know I want to reaffirm what this is what all of us is saying that you know five you know being away and coming back I've just seen there is a new - HIV is not that scary as it used to be, you hear young people you know that's the energy that we need to reaffirm, young people in this country are responding to this epidemic very differently, you know they are empowered, they've got information, they're using networks, they are on Facebook and they are really so open some of them about this, and I think if we re-infuse this openness as adults you know you are sexual being you know celebrate it and share that with your children.  I think we've just made this whole issue so difficult and it's us, I don't think it's young people, young people talk about sex they have sex you know it's us I think we're not providing the good role models that we should be, but I think things are positive you know I really think we shouldn't really criticise so much you know and feel that South Africa is not making progress I think we are.

MR BRINK:  This lack of information is surely the single biggest efficiency we have in having an effected management response to AIDS, actually for the entire of the health service delivery we need health information systems, we need a common platform really across the country which allows us to collect the data as we go along and to be able to measure so that we can manage.  A man doesn't try and run a bank without computers, you'd get absolutely nowhere and we're trying to run a health service where we just systematically don't have information, it's a hopeless situation, it's going to be another benefit of MHI I think Olive that may lead us to have information systems which work for the entire population.

MS SHISANA:  Ja, perhaps it's really to take all the information system that are there and harmonise them because data is there it's just not used, it's not used for management, it's used for analysis by someone else but really not for management and that's we need to do.

MS REES:  I mean I totally agree that we need better information, but I think we've said repeatedly we also do have a lot of information already and so I think that one of the things just listening to the discussion today and I was interested in the comments that came out in the finance is that in a sense we need to decide what we're dealing with because you know the Minister now has once again said we - this should be - we should be on a war fitting look at these figures it's terrible we should be on a war fitting.  On the other hand we're now we've moved ourselves and perceptively into a chronic disease approach, we want to roll out services, we want to get quality there, we want to get coverage, it's not a war fitting kind of thing it's a different footing and I think that we do need to decide now in a way strategically is what are we doing, are we trying to really sort of urgently scale up with that sense of urgency and franticness or are we saying we know what works we want to actually systematically go and make sure we have got quality and rollout and systematic coverage because these things are different and I think that the issues about whether it is a chronic disease and it's part of our mentality we have to live with it as a country therefore we approach how many healthcare workers we train differently etcetera, etcetera, I think that that is a philosophical sort of a almost I think we're in a transition, I suspect we were never of a war footing which was a bit of a problem, but I think that we really have moved into - we're moving towards a sort of chronic disease model where we're starting to really sort of integrate this into our thinking and how we saturate our society with interventions that will respond to that.

MR NAVARIO:  Any other comments from the floor?  I think we've lost a little bit of steam here.  It's at - we're at 5 o'clock so I think if nobody has any further comments then I think maybe we'll just go ahead and wrap, Max do you want to make some final comments?

MR DHLOMO:  No, colleagues I just thought maybe I should take this opportunity firstly to thank the team that invited me as the MEC for one province and therefore just share with you some of the things that probably might give you some comfort, in September last year I was privileged to be invited by the Minister of Health to go with him to the WHO original committee meeting in Rwanda then I asked him specifically but Minister are you inviting me then he did - actually he was very honest you are in the province that has got the highest prevalence of HIV/AIDS and TB you also have a lot of patients I mean besides the prevalence being high and therefore if you could actually have a system that could work and they work for us in KwaZulu-Natal and you turn around this pandemic the statistics of the whole country will shift positively.  Now, one is actually sitting with that understanding therefore that there is this expectation that KwaZulu-Natal should be able to really scale up far more better than other provinces who probably do not have this burden that we do have.  I might as well share with you that in November last year, you probably picked up in the news, the Minister addressed all provinces per hospital he had invited the CEO, the Medical Manager, the Nurses Services Manager, the Finance Manager and Human Resource Manager, so there were five people per hospital, five provinces met in Gauteng and the next day the other four provinces met in KwaZulu-Natal, the whole day long he spoke about one of the 10 point plan of the 10 point plans that are there he spoke of just one, the one that talks about the quality of care.  Colleagues you probably know some of you that actually work in public sector that the very same doctors who support us in the public sector have other interest in the private sector so in terms of the quality of the clinic care we are very comparable to the private sector, the thing that we lack significantly of course besides probably being short staffed here and there, the thing that we lack significantly is the customer care, people come to a (indistinct) you haven't been having a blanket over yourself are you feeling comfortable can I give you one more cup of water there is some tea, that we don't have it's gone.  Now, the Minister was very emphatic addressing that part and he actually coined it he says gone are the days when you'd come to a hospital and even don't want to go in the floor because the floor is signing it's clean and spotless, we don't have such hospital, of course we do have here and there, but we should be meeting as health workers and talk about the cleanliness of hospitals because that is one of the issues that we are really interested in.  So, I'm just trying to indicate the man who is actually driving this programme how actually important it is, he says accessibility.  Of course we are talking about here accessibility of care to say probably it is time now that we intergrade TB and HIV that people can actually say I have collected my TB treatment but I don't have to take a bus another 100 kilometres and get it somewhere else, that is actually very important.  Infection control are key issues in hospitals because those are the things that we have actually previously done and we are addressing those things very significantly.  One of the things that actually was raised was on that whole list as availability of sort of product and drugs, I mean it's just not going to be acceptable for a maternal and child care hospital to say there is a labour ward but they prefer not to order plugs in case there is emergency, I mean you need to have those basic things, so we were just addressing very basic things that should be there in any place that looks like a hospital.  He has therefore tasked all MECs to actually have what he calls a look like a hospital campaign, so now I mean look I would love all the 62 hospital in KwaZulu-Natal to really look like a hospital but I must start somewhere, so I've started with 11 and those 11 are - there are certain things that we expect them they must look like a hospital and you can build up there and most of those things we are really asking are not issues that we need so much finance, but it is a bit of quality, improving attitudes, changing attitudes and behaviour.  So, I just thought I should share with you that we are not moaning and complaining about the system that is falling apart but we are actually arranging fixing some of those things that probably a lot of them do not cost a lot of money to fix, the attitude of staff and just making sure that there is (indistinct) in a clinic, I've been to clinic where I said how do you ever resuscitate your cardiac failures when they come to the clinic because you don't have IV (indistinct), I mean people just say we just don't know.  So, those are basic things that we're really trying to get on, so I just thought I should mention those things that we are very confident with the leadership that we have and a lot of us I mean there is a lot of expectations that we should be delivering and we should say with you colleagues a lot of you are involved in research and a lot of work in the country we would really be looking forward as government to work very closely with you, give us our advice, give us your support, let's work together and learn how to create better because I think we are actually (indistinct) expected to do that.  Let me just end with this part, one of the things that I learned from the WHO meeting was a painful reality, I mean based on what I've just said we are doing very well, you know if you had to need a kidney transplant, a heart transplant, even Africa know that you must come - they must come to South Africa that will be fixed.  What they do then in their countries they concentrate on what they do they do it better, they do proper maternal and child care.  So, I don't want to actually say we are not doing that well, we know that one of the things that have actually affected us here was the issue HIV we can be on top of that, we can actually do significant on maternal and child health in terms of mortality and we can actually improve on that part.  So, with all the other factors included we can really move a bit, so this is being recognised by our Minister that the common denominator in terms of maternal mortality, children mortality, infant mortality is the age of HIV.

MS SHISANA:  Ja, just one thing to say that I'm encourage now that this interest in government to use evidence that is being generated from scientists several years ago we as scientists we were outside government was the other side, now at least we are able to work together and I think with that you know cooperation between the two we ought to be able to beat this epidemic.

MR BRINK:  I just want to say you know right now we sit with an extraordinary opportunity which we have not had before in this country where government, private sector, NGOs, donors we're all aligned in what needs to be done, we have enormous capacity in this country which has not yet been tapped, just look at the private sector, we have not engaged those thousands of doctors in the private sector who could come and join in this fight.  So, to talk about we haven't got what we need to do the job is simply not true, we simply need to get it in our minds that we are going to stop AIDS, that can be done, nobody who is HIV infected today needs to progress to AIDS and if we set ourselves that target we can do it and that will be getting through the big hump and once we get through that we can start thinking long and hard about how we're going to stop the new HIV infections as well.  And if we believe we can do it we will do it, we've had what have seen to be insurmountable problems in this country before and we have broken through those why can't we rise up and do the same for HIV/AIDS as well?

MS REES:  I think just my very last sentence again with our colleagues from the US here it goes back to what Francois said in his slide at the beginning which I think we shouldn't really forget and that is that South Africa has just an enormous number of people living with HIV, we have an enormous problem and what everyone has said here is by ourselves we can't fix this, we can't fund this, so with the optimism that's now been shared and this changing environment I think that the idea if it's needed to have a high level delegation going to the US and arguing for this and explaining why if South Africa fails then it has a massive impact not only on the region but on Sub-Sahara and Africa as a whole, we're meant to be a financial powerhouse, if that fails that has a knock on.  So, I think that I would just like to sort of say that South Africa is not the same and we've got to make this work and we will continue to need that partnership and I would appeal that we perhaps do look for an opportunity for a high level delegation to go and do our own personal lobbying in Washington.

MR NAVARIO:  Well with that I think those are great concluding remarks I'd like to thank everybody on behalf of the Global Health programme and the Council on Foreign Relations for their thoughts and their contributions I think it's been a hugely illuminating conversation for me personally and I think that you know this is - the work that we do at the Council tries to advance these very issues in South Africa and to echo what Helen just said as I said in my opening remarks South Africa was a strategic choice, I mean it is a regional and continental leader and even sort of within the sort of middle, low middle income countries and I think it is a bit of a bell weather in terms whether it if it succeeds or fails and there is knock on affect and so it was - holding this meeting has been excellent and it was chosen for that very reason.