Policy Podcast: U.S. President's Emergency Plan for AIDS Relief

Ambassador Mark Dybul, U.S. Global AIDS Coordinator
Sean McCormack, State Department Spokesman

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MR. MCCORMACK: Ambassador Mark Dybul, thank you very much for joining us here. You are the Chair of the President's Emergency Plan for AIDS Relief and just last week -- or two weeks ago was World AIDS Day, November 30th. I wanted to talk to you a little bit about what current efforts the President and you have ongoing about AIDS relief. Let's start by talking a little bit about the scope of your program in terms of the dollars and the countries and some of the work that you've been doing recently.

AMBASSADOR DYBUL: Well, it's an extraordinary program. Actually, what the President did is launch the largest international health initiative in history ever for a single disease and I'm told it's currently the largest developing program in the world. And so in size, it is rather extraordinary.

MR. MCCORMACK: What, in dollar figures, how much is that?

AMBASSADOR DYBUL: $15 billion over five years, but it's had such strong bipartisan support that it's going to exceed 15, probably in the neighborhood of 18. And President Bush has called for renewal of the program in the next five years of $30 billion, so -- to double the original commitment. So it's rather extraordinary. He wants to double what was already the largest initiative in history.

And I think that what's important about it is not just the dollars, though. What's important about it is really the scope that he raised because particularly in development, all we talk about is money. What we really want to do is save lives. And so he set very specific goals to support treatment for 2 million people and to support care for 10 million, including orphans and vulnerable children and to support prevention of 7 million new infections. That's a lot of numbers. Now what it really means is when he announced this, only 50,000 people were receiving treatment in sub-Saharan Africa, so going up to 2 million, prevention -- that 7 million represents a version of 60 percent of new infections in 15 countries, 12 in sub-Saharan Africa. So really, the scope is extraordinary.

But also, and I think this is very important, it's the first time ever in development, the United States and the American people or anyone else is committed to tackling a chronic disease. We tend to do short-term immunization or -- this is the first time we've committed to supporting countries to build the infrastructure that's necessary to tackle a chronic disease. And that's a rather extraordinary thing. It's a quantum change not only in money, but in vision, and that's an extraordinary thing.

MR. MCCORMACK: Talk about the different components to the program: treating people who have AIDS, helping them, talk about the -- your prevention programs. How do you come at this? I know that there's a lot of discussion in the development community about this and people have different approaches. Tell us about the approach the United States takes and some of the controversy that exists within the community about our approach versus other approaches.

AMBASSADOR DYBUL: Yeah. Well, it's rather extraordinary, actually, the approach we take is to support the people in country to tackle their epidemic and that's kind of a shift too. We -- and the President has said this repeatedly, that we're there to support the people on the ground and he always wants to meet with the people who are doing the work on the ground because that's what we're doing. So we're supporting Africans and people in Asia and the Caribbean to tackle their epidemic. And so we follow their national strategies and support their national strategies.

The treat -- this is one of the extraordinary things about it. It's actually the first time we've integrated prevention, treatment, and care. In the past, people said do prevention or do treatment; care always gets left out.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And care is so important for the orphans and vulnerable children and people living with HIV. So you've got to do all three of them. And in terms of prevention, ultimately, what we want to do, the best treatment and care for an orphan is to prevent the orphan to begin with and to make sure someone doesn't get infected so you never have to treat them. So prevention is really the bedrock of this, but it's pretty shaky without care and treatment.

So in terms of prevention, this is a controversial issue in capitals in the United States and Europe. It's not so controversial in Africa.

MR. MCCORMACK: Right, when you get down on the ground.

AMBASSADOR DYBUL: When you get on the ground, they don't get into these arguments and the reason is because the so-called abstain, be faithful and correct and consistent condom approach --

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- is what you need to do in Africa. The highest risk groups are young people, kids who are 10 to 24 years old, especially 15 to 24. That's where most of the infections are occurring. So how are you going to turn that epidemic around?

MR. MCCORMACK: Have those infection rates gone up or have they gone down? I suppose it varies from country --

AMBASSADOR DYBUL: Yeah.

MR. MCCORMACK: -- to country, but looking worldwide and in Africa and some of the countries in Africa where you've seen either positive or negative results.

AMBASSADOR DYBUL: Well, it's too early to tell in a lot of places. Unlike treatment, where we can easily measure the number of people receiving treatment and the number of people in care, prevention's much harder. You have to depend on demographic health surveys every couple of years, but the trends are very promising. What we're seeing is changing -- changes in behavior. And UN AIDS has reported on this, so we've seen real reductions in Kenya, 30 percent reduction in prevalence rates, the percent of HIV-positive people, 23 percent in Zimbabwe. Botswana is turning the corner. Cote d'Ivoire has turned the corner.

So we're starting to see very positive things and when you look at the data, they show that what's happening is kids are delaying when they become sexually active or people who were sexually active refrain from sexual activity. That's the A. People are reducing their partners, 50 percent reduction, young men, in terms of casual partnerships. That's the B, reduce your partners or be faithful to the single partner, and correct and consistent condom use.

I think what's misunderstood is, we understand treatment and care is lifelong, something you got to -- once you start, you've got to do it. So is prevention. You've got to stay with a five-year-old till the time they're very old -- we hope that they live long enough -- and change what you do with them. You know, it's not a one-off thing. So our approach is to start with very young kids, do what's called life skills, teach them to respect themselves and respect others and if you respect yourself and respect others, there is a couple consequences. One is, boys don't abuse girls. That's a very important piece of this, to teach gender equality. And that's a fundamental part of what we're trying to do.

MR. MCCORMACK: So why is that important? Why do you -- why, in this context? I mean, obviously, it adds up to an objective good, it's important, but why in this context is that important?

AMBASSADOR DYBUL: The reason it's important in this context is young girls are far more likely to be infected, sometimes five times as much as the young boys. The reason for that is young boys can prey on young girls and older men can prey on younger girls. And there is an unequal relationship, sexual relationship often in sub-Saharan Africa, often in this country as well, where the girl doesn't have the opportunity to say, I don't want to.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And so if you teach boys to respect girls, teach them that it's being manly to refrain from abusing girls, teach them that you're equals, that has a lot of implications, societal implications, but also for HIV. And then part of that personal responsibility we're teaching is you delay sexual activity. So if you're teaching all of this, it's good for gender equality, but it's ultimately good for HIV.

And that's why Africans think our discussions here are crazy about, you know, this or that or use this letter or that letter, it's -- ABC's a catch-phrase. This is a much deeper societal issue, cultural issue, changing people's behavior and that takes a long time, but we're seeing the positive trends. We're seeing the trends that are showing the education. Some people say, oh, people will always have sex, so what are you going to do? You can't do -- that's nonsense. The data show it's not true. It's the (inaudible) of saying, why teach people not to smoke, because some people will continue to smoke. Well, of course, some people will not follow the message, but a lot will and that's public health.

MR. MCCORMACK: Let me ask you a little bit about -- try to get a picture of the costs of HIV/AIDS. What's our current estimate in Africa? And we're talking about Africa just because that's where the great majority of cases worldwide are. What's the total number of people in Africa now infected with HIV or who have full-blown AIDS?

AMBASSADOR DYBUL: Globally, it's about 33 million people and I included the United States and Europe. Africa is about 68 percent of the infections, so around 23 million people in Africa are infected. That's why we're heavily concentrated on Africa.

What people don't understand is we actually have bilateral programs in 120 countries, but a heavy concentration in Africa, 15 focus countries, all of them in Africa, two in the Caribbean, one in Asia. And then we also support the Global Fund. We're the largest contributor of the Global Fund, so we support -- 30 percent of every grant to every country from the Global Fund comes from the American people. So it's a very global presence, but we're heavily concentrated in Africa.

We talk about the cost in lives, because that's why the President said we're going to do this. And if I can sidestep -- well, I think that's why we have such strong bipartisan support because this initiative reflects who the American people are. It reflects our generosity and compassion. And when policymakers are reflecting who the American people are and you get bipartisan support and it's been rather extraordinary and the President always says: To whom much is given, much is required. And I think that's a basic instinct of the American people. And in Africa, people don't have as much as we do, so we are required, because we have much to contribute to their fight against HIV/AIDS.

We talk about humanitarian costs, but it's more than that. It's much more than that. Every one of those lives is a parent, a teacher, a peacekeeper, productive members of their community. Unlike most infections, most diseases that kill the very young or the very old, this kills 15 to 40-year-olds, the most productive and reproductive people in society. And so we're developing a generation of orphans because parents are dying.

Two-thirds of new teachers in Zambia were dying from HIV/AIDS. And if two-thirds of your own teachers are dying, how are you going to educate for the future and how are you going to educate the next generation? Some estimates projected that 20 percent of the gross domestic product in the most heavily affected countries would be lost, 20 percent over a 10-year period.

MR. MCCORMACK: 20 percent?

AMBASSADOR DYBUL: 20 percent. Some countries are losing 0.5 percent of their GDP annually. Peacekeepers, something people don't -- peacekeepers are preferentially infected with this disease. South Africa tried to get a battallion for a peacekeeping effort in Sierra Leone. They had to go to three batallions to get one. So HIV has very deep implications. And just in healthcare, HIV (inaudible) kills doctors and nurses. And so how are you going to have any healthcare?

So you got to tackle all of -- we're not going to get any development right in Africa if we don't get AIDS right. And it's one of the reasons we do this. As President Bush has often said, you know, what we're fundamentally doing is building hope, create -- really restoring individuals' communities to be whole, because there's hopelessness before. And hopelessness isn't good for our security either. Hopelessness breeds extremism. And so part of this is actually to build -- recreate, build again communities that were decimated. When 30 percent of your adult population is dying, their community is decimated. So building that hope is good for us.

MR. MCCORMACK: Right. Let me ask you one final question. Because of the obvious commitment and -- of the President's program and the commitment of America to this program, not only morally but as well as with our resources, have you, in your work, been able to leverage that to get others, whether that's in the public sector or the private sector to step up and increase their contributions?

AMBASSADOR DYBUL: Both, actually. You know, after the President called for $30 billion for the renewal of this plan for the next five years, the G-8 committed to $60 million total, including half of it coming from us to fight this epidemic. It was a massive leveraging. And they committed to doubling the goals we had for the next five years in terms of prevention, care and treatment, the first time that's happened. So we got the dollar commitment and the humanitarian commitment from the G-8. The private sector is also deeply involved and we're leveraging private sector commitments. Our philosophy and the President's philosophy is this is not government-to-government. This is people-to-people. And so you need all people involved: faith, community based organizations, the private sector. And the private sector is really stepping up.

There is an initiative in Zambia that Mrs. Bush announced, extraordinary initiative, actually, where we said, look, we're sending people into the homes -- into 150,000 homes for home-based care, for orphan care, and we can take bed net, so we partnered with the President's malaria initiative, delivered 485,000 bed nets before this rainy season. They used our infrastructure, so they saved two-thirds of the cost of the bed net and we worked with the private sector. We paid for half the nets and the private sector paid for half the nets. So we saved three-quarters of the money to deliver those nets so we could deliver more nets. That's the type of thing we're doing because this is people-to-people. This is touching hand-to-hand, heart-to-heart and the American people to people in distant lands and they're touching back.

And I think one of the other things about this is people are seeing a new window into our hearts. They know what we stand for when we stand with them. I've been in rural Africa, where someone -- I asked someone what PEPFAR means, the President's Emergency Plan for AIDS Relief. He said, PEPFAR means the American people care about us. I was just with the Rwandan Ambassador to the United States. He used to be governor in Rwanda. He just went home. He said everyone in his district, his former province was talking about what the American people are doing for them around HIV/AIDS in partnership. So when we partner together as people-to-people, people know who we are and that's a very important thing too.

MR. MCCORMACK: Great. Well, I don't think I could add anything to that. Ambassador Mark Dybul, thank you very much for joining us.

AMBASSADOR DYBUL: Thank you.

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