Ambassador Mark Dybul, U.S. Global AIDS Coordinator

On May 30th President Bush urged Congress to reauthorize PEPFAR with a $30 billion commitment for the next five-year period (October 1, 2008 to September 30, 2013). Most recently, on August 2nd, Senator Dick Lugar, introduced S.1966, the HIV/AIDS Assistance Reauthorization Act of 2007 stressing that Americans are providing crucial support to fighting the global AIDS pandemic. Given this endorsement, what is your assessment of reauthorization prospects? Do you have any concerns about renewal funding or do you anticipate any criticism from skeptics who question how fighting AIDS abroad benefits the United States? 

Just a few years ago, the new hope that the American people and the people of the developing world have been able to achieve in partnership against HIV/AIDS was unthinkable. Today, the question is no longer whether any success is possible; the question is how rapidly we can bring the successful programs we have pioneered to national scale. PEPFAR has always received solid bipartisan support, and Members of Congress across the board have been deeply impressed by the results we have achieved together.

In addition to the humanitarian impact of the President’s Emergency Plan, I also see growing awareness of the central role of our HIV/AIDS response to ensuring development, especially in Africa. PEPFAR programs recognize that HIV/AIDS is deeply connected to the other challenges people in these nations face, from economic growth, to education, to nutrition, to gender, to protection of children, to overall health. Success against HIV/AIDS fosters success on these other issues – and helps dispel the hopelessness that breeds instability and security concerns that can affect us here at home.

Thanks in large part to the efforts of outside organizations such as the members of GBC, I think Congress understands these realities, and thus I am very hopeful about reauthorization. We are working to have PEPFAR reauthorized as quickly as possible so we can continue to save lives.

It’s obvious that the United States can’t fight AIDS alone. The European Union, other G8 countries and the private sector all play important roles. How do you and your colleagues encourage contributions from other countries? 

As noted, on May 30, President Bush proposed a $30 billion U.S. commitment for the next phase of the Emergency Plan. Challenged by President Bush’s commitment, in June the G-8 leaders committed to a total of $60 billion dollars for HIV/AIDS, tuberculosis and malaria programs over the next few years. And just as importantly, in another first, the G-8 made a commitment to support country-owned, national programs to meet specific, numerical goals: treatment for 5 million, prevention of 24 million new infections, and care for 24 million people living with or affected by HIV, including 10 million orphans and vulnerable children.

These landmark commitments are based squarely on the success of courageous people in nations devastated by HIV/AIDS who are saving the lives of their countrymen and women. The results achieved in the fight against HIV/AIDS are inspiring a growing commitment from international partners, national governments, and the private sector.

One of PEPFAR’s most impressive attributes is that its 2-7-10 performance targets for 15 focus countries enumerate clear goals: treatment for two million people living with HIV/AIDS; prevention of seven million new HIV infections; and care for 10 million HIV-positive persons and OVCs. Recognizing that one year remains before full evaluation can occur, how would you describe progress thus far and what challenges are still being addressed?

Thanks to the generosity of the American people and strong bipartisan support of Congress, PEPFAR is on track to meet its 2-7-10 goals. For example, as of March 31, 2007 – after three years of the initiative -- PEPFAR supported 1.1 million men, women and children on antiretroviral treatment, All along, we have focused on building the capacity needed for dramatic scale-up in these final years of the initial phase of the Emergency Plan. Thanks to the President’s growing requests for resources and Congress’ bipartisan support for those requests, there has been an accelerating rate of program expansion over time.

In terms of challenges, one issue is uncertainty among partners as to funding levels beyond 2008, which has led some partners to indicate a reluctance to add large numbers of new people to treatment and care programs in 2008. Thus I believe reauthorization of the program in 2007 would bolster our efforts to achieve the goals, by giving our partners in the field the assurance they need as to future resources that will encourage them to scale up aggressively in 2008.

On August 11, 2006 you became the second U.S. Global AIDS Coordinator. How has the role evolved since it was first created four years ago?

I have to say that I think President Bush’s vision for this role is one that continues to be validated. He proposed creation of the role of the U.S. Global AIDS Coordinator in order to lead a unified U.S. Government response to the global pandemic, focusing a diverse array of resources to save as many lives as possible. The creation of this role was a real innovation in government, and I hope the role will continue long after I have moved on. In the early days, there was a need for leadership to create new structures for the varied U.S. agencies that work on global HIV/AIDS to cooperate together. My predecessor, Ambassador Randall Tobias, came from the private sector, and drew on best practices from that world to build a successful "virtual organization."

Now those structures are established and work well, due to the tremendous commitment of the people of the PEPFAR implementing agencies. So the challenge now is ensuring that the interagency approach continues to be strong even with vastly increased resources -- as many GBC members will understand, greater size can create centrifugal forces. So the challenges of a start-up are somewhat different from that of an established organization, but our mission to save lives has remained constant, and so has our strong support from the President and Congress – which are essential to the success of this model.

You’ve emphasized that men must play an integral role in undoing the feminization of HIV/AIDS. What are some of the most useful interventions for engaging men?

Men must be involved in addressing the vulnerability of women and girls to HIV infection. Practices such as rape and sexual coercion, multiple and concurrent sex partners, cross-generational sex, and transactional sex increase this vulnerability and cannot be dealt with without taking into account male norms and behaviors. To address these issues, the Emergency Plan supports such interventions as: community-based prevention programs and media messages with a focus on positive norms for boys and men; couples HIV counseling and testing as an opportunity to change gender norms and reach men; programs to prevent alcohol and substance abuse; and special programs with the armed services focusing on responsible male behavior.

As part of a special initiative on gender, we are actively working with countries to scale up programs like these to address male norms and behaviors. In South Africa, for example, the Men as Partners project tailors behavior change interventions to define masculinity and strength in terms of men taking responsible actions to prevent HIV infection and forced sex. Advertisements and public marches promote men as responsible partners. The program’s comprehensive approach has included: influencing policy and legislation; mobilizing communities; changing organizational practices; fostering coalitions and networks; educating providers; promoting community education; and strengthening individual knowledge and skills so people can decide how to protect themselves.

In 2006 and early 2007, PEPFAR invested $13.25 million in Public Private Partnerships, including innovative PPPs such as Play-Pumps, Phones-For-Health, and the Bhubezi Community Center program. We were delighted to partner with PEPFAR and the President’s Malaria Initiative on the Zambia Bednets Partnership, which brought 500,000 anti-malarial bednets to AIDS-affected families in Zambia. We look forward to doing more with PEPFAR and hope you can illuminate why PPPs are crucial to ending the world’s most challenging health epidemics and discuss some of your plans going forward? 

Public-private partnerships are essential to sustaining programs for the long term. These partnerships enable the U.S. Government and the private sector to maximize their efforts through jointly-defined objectives, program design and implementation strategies that utilize each partner’s core competencies. The keys to these relationships are the identification of on-the-ground social entrepreneurs and partnerships with local governments to ensure that the solutions make sense for, and are owned by, the communities.

Some of the greatest assets that the private sector can offer to public-private partnerships are its products, services, branding, business expertise and operational structures – core competencies that have been refined and perfected over time, and result from significant research and development.

Utilizing these core competencies enables companies to showcase what they do best and create greater utility than dollars alone can provide. In addition, by promoting core competencies, companies are often able to explore new market opportunities, test business models, build local capacity that benefits recruitment, and create basic infrastructure that supports companies’ overall operations. Public-private partnerships should be based on these competencies and grow from them.

As we look toward the future, partnerships will be a growing element of PEPFAR’s success. The private sector is diverse, and all have roles to play -- U.S. and non-U.S. private businesses, multinational corporations, small and medium-sized enterprises, business and trade associations, labor unions, foundations, and philanthropic leaders, including venture capitalists. We look forward to continuing to work with GBC and its members to explore new ways we can leverage resources.

On March 30th, The Institute of Medicine (IOM) released PEPFAR Implementation: Progress and Promise, which acknowledges PEPFAR’s success and enumerates several policy recommendations, including transitioning from an emergency response to long-term strategic planning and capacity building; accumulating better data to aid prevention efforts; addressing workforce capacity constraints; and increasing attention to marginalized populations. The IOM also advocates lifting budgetary allocations that impose strict funding requirements. How amenable is OGAC to removing the abstinence funding criteria, which has been criticized for segmenting the ABC (Abstinence, Be faithful, use Condoms) approach?

We appreciated the IOM’s thoughtful report. It described the Emergency Plan as a "learning organization," and that is high praise, because that is something we strive to be. The IOM was critical of budget allocations generally, including the allocation for programs for orphans and vulnerable children. To date, in my view budget allocations have been helpful in ensuring that programs are comprehensive and address previously underserved areas: programs for children orphaned or made vulnerable by HIV/AIDS; balanced, evidence-based behavior change programs (especially for generalized epidemics); and large-scale treatment programs.

PEPFAR supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of infection in each country. The ABC approach was developed in Africa by Africans, and is based on sound evidence. Recent data from a growing number of African countries with severe, generalized HIV epidemics have demonstrated adoption of all three of the ABC behaviors, associated with declining HIV prevalence. So the goal is comprehensive prevention programming that supports all three. As a means to that end, the allocation of 1/3 of prevention funding – or about seven percent of overall PEPFAR spending – to programs that promote the A and B components has helped us to diversify our programs from the relatively narrow pre-PEPFAR focus. Of course, application of any budget allocation has to be sensitive to local circumstances, so country teams have been able to submit justifications if meeting any allocation has not been appropriate for a particular epidemic – and all the exceptions requested so far have been granted.

In my view, some protection for a comprehensive approach to prevention will continue to be needed. I look forward to working with Congress to determine how best to accomplish that goal.

President Bush requested $5.4 billion for PEPFAR in FY 2008. This includes money for the focus countries, The Global Fund, NIH research, TB programs, and other bilateral programs. Why does fighting HIV/AIDS now mandate increased attention to and support for fighting TB?

Today, two billion people, or 1/3 of the world’s population, are infected with tuberculosis (TB). In most cases, the bacteria remain dormant - but when a TB-infected person’s immune system is weakened, he or she can rapidly develop active TB – a serious and highly infectious disease. According to the World Health Organization, in 2005 TB killed 1.6 million people, most of them in the developing world.

People who are infected with HIV are especially susceptible to developing active TB. TB is the leading cause of death among people living with HIV/AIDS and one of the most common opportunistic infections they experience. The prevalence of HIV infection among patients in TB clinical settings is high - up to 80 percent in some countries. It is estimated that more than half of the people infected with TB in sub-Saharan Africa are co-infected with HIV. By the end of 2005, only 10% of all TB patients in Africa had been tested for HIV. Therefore, one of PEPFAR’s top priorities is to increase consistent cross-testing for TB and HIV.

PEPFAR is leading a unified U.S. Government global response to fully integrate HIV prevention, treatment and care with TB services at the country level. In fiscal year 2006, PEPFAR supported care for approximately 301,000 TB/HIV co-infected people in the 15 PEPFAR focus countries. We expect to reach even more people with TB/HIV programs this year, as we have expanded funding from $48.6 million in fiscal year 2006 to $130.9 million in funding for TB/HIV in fiscal year 2007. Additionally, the U.S. Government remains the largest contributor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, providing approximately one-third of the Fund’s resources – and through 2007, the Global Fund will have committed $1.4 billion to TB grants.

We’ve talked a great deal over the past few months about scaling up PEPFAR and private sector collaborations. What more can companies do to facilitate PEPFAR’s success and the end of the HIV/AIDS epidemic?

As I have mentioned, a central part of PEPFAR’s strategy is to deepen our partnership with GBC to support businesses in bringing their core competencies to bear on HIV/AIDS. In many ways, businesses in the developing world are on the front lines of the pandemic, facing declines in availability of skilled workers, high rates of absenteeism and turnover, increased expenses to train new workers, reduction in revenue, and soaring health care costs. Particularly in Africa, HIV/AIDS is a tremendous drag on economic development.

For corporations operating in emerging markets, corporate responsibility practices take on a heightened significance and, ultimately, can be a matter of survival. Investing in public-private partnerships can play a strategic role in managing a variety of risks often present in developing countries, including ineffective regulations, lack of skilled labor, weak infrastructure and poor health care systems. Meanwhile, establishing a strong local presence and promoting philanthropic action has been shown to play a significant role in boosting both consumer and employee loyalty.  In short, companies can do well by doing good. 

One of the most important contributions businesses can make to fighting this epidemic is to put education programs in place for their employees, employees’ families, and their communities to prevent HIV infection and make treatment available to people living with HIV/AIDS. Additionally, we have an important opportunity to change the way the business, social and public sectors work together to develop sustainable solutions to global issues like HIV/AIDS. Business in particular must take a proactive approach by partnering with host governments to address the HIV/AIDS pandemic if countries are to remain economically stable. Strong leadership by the private sector – in addition to saving lives and strengthening economies – can help governments rise to the challenge of HIV/AIDS.

Ambassador Mark R. Dybul serves as the United States Global AIDS Coordinator, leading the implementation of President Bush’s Emergency Plan for AIDS Relief. From March to August 2006, he served as Acting U.S. Global AIDS Coordinator, and prior to that he held the positions of Deputy U.S. Global AIDS Coordinator and Assistant U.S. Global AIDS Coordinator.

Before coming to the Coordinator’s Office, Ambassador Dybul served on the Planning Task Force for the Emergency Plan, and was the lead for the Department of Health and Human Services (HHS) for President Bush’s International Prevention of Mother and Child HIV Initiative.

At HHS, he also served as the Assistant Director for Medical Affairs, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), as well as Co-Executive Secretary of the HHS HIV therapy guidelines for adults and adolescents. He continues to be a Staff Clinician in the Laboratory of Immunoregulation at NIAID/NIH and maintains an active role as the principal investigator for clinical and basic research for U.S. and international protocols with an emphasis on HIV therapy, particularly those that may be applicable in resource-poor settings, including intermittent therapy and HIV reservoirs and immunopathogenesis. Ambassador Dybul is a captain in the U.S. Public Health Service Commissioned Corps, the uniformed service of HHS. He is also a former member of the World Health Organization's Writing Committee to develop global HIV therapy guidelines.

Ambassador Dybul received his A.B. (1985) and M.D. (1992) from Georgetown University before completing his residency in internal medicine at the University of Chicago Hospitals (1995) and a fellowship in infectious diseases at the National Institute of Allergy and Infectious Diseases (1998).