At a strategic moment when funding remains in limbo as unfinished business from the last Congress, the President’s Emergency Plan for AIDS Relief (PEPFAR) has significant successes to report, says recently appointed Global AIDS Coordinator Mark Dybul, M.D. Ambassador Dybul made his remarks at a January 4 Global Health Council policy forum.

According to Dybul, PEPFAR’s successes include increased numbers of the HIV-infected worldwide gaining access to life-extending antiretroviral therapies — upwards of 1 million in sub-Saharan Africa alone and expanding at a rate of roughly 50,000 per month. Also notable is progress on the prevention front, particularly with respect to women. Beyond that is greater operational implementation of what Dybul termed a “connecting the dots” philosophy: that is, stressing greater devotion to the principle that prevention, treatment, and care are intrinsically linked, work best when working in concert, and should not be viewed programmatically in isolation from each other.

Connecting the dots. Looking forward, PEPFAR’s principal challenges, according to the ambassador, emanate from “the vision thing.” By this he meant expanding application of this “connect the dots” mind-set beyond noting linkages among prevention, treatment, and care to teasing out the ways that HIV/AIDS synergizes to devastating effect with other killers such as TB and malaria. “Connecting the dots” also means forming strategic partnerships within the Bush administration through setting up interagency working groups, and with key external actors like the Gates and Rockefeller foundations. The “food for peace” program was cited as a success story stemming from such intragovernmental cooperation and public-private partnerships.

Moving from broad strokes to the specific, Dybul’s future plans for PEPFAR also include paying greater attention to deconstructing gender trends in prevention and treatment through greater evaluation and support of the “men as partners” and “changing male norms” programs, as well as through ramping up gender-based violence prevention programming. Additional future priorities include more support for strategic allocation and development of health care workforce in “focus countries,” incentivizing countries where PEPFAR operates to devote more domestic resources to health care issues, and increasing the U.S. contribution to the Global Fund.

Controversy on prevention model. The Q&A session before the attentive but no-nonsense crowd prompted Dybul to delve head first, among other things, into some of the controversy surrounding application of the “ABC” HIV prevention model, and charges that a perhaps disproportionate emphasis on abstinence crowds out other components. In defense, the ambassador made the case that form follows function when it comes to formulation and implementation of the administration’s HIV prevention strategy. That is, policy must flow from the available evidence base and should be tailored to conditions on the ground in each focus country and even regions and subpopulations within countries. “Generalized epidemics,” for example, prompt different strategic responses than do “concentrated epidemics.”

Another audience query centered on how, in policy terms, focus countries might be encouraged to spend more on health care. In response, Dybul stressed the need to move beyond the “numbers” argument and make the case for the linkages between population health status and economic development in focus countries. Interestingly, Dybul made the point that while this relationship is robust, it is also more nuanced than might be immediately apparent. He cited, for example, the finding that increased development in some situations can actually exacerbate infection rates because at-risk populations have more resources with which to engage in risky behaviors. Also touched upon was nitty-gritty discussion of funding priorities for gender-based programming.

Budget issues. Of course, current and future PEPFAR programming is largely dependent upon events currently unfolding on the Hill as the new Congress grapples with the budget. Much in this regard should come into sharper focus between now and February. In addition to his chops as a clinician and scientist, Dybul is, of course, also a political appointee and advocate for the administration position. As such, he made a reasoned pitch throughout his presentation for passage of the president’s proposed budget, which increases PEPFAR funding to roughly $4 billion. Beyond making the point that passage of this budget would permit full funding of PEPFAR’s future policy priorities, perhaps most compelling was his warning that the failure to do so would cut off thousands from life-saving treatment at critical moments, with potentially irrevocable consequences. The near future will tell whether such speaking opportunities and increased interaction with a wary HIV/AIDS advocacy community will convince stakeholders of the credibility of the administration’s PEPFAR strategy and motivate them to marshal their champions on the Hill to act accordingly.

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