Dybul urges partnering with governments, communities to fight AIDS

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In honor of World AIDS Day (Dec. 1), Ambassador Mark Dybul, the U.S. global AIDS coordinator who is leading the implementation of the $48 billion President’s Emergency Plan for AIDS Relief (PEPFAR), spoke Dec. 4 in Sever Hall. The event, sponsored by the Harvard Department of Global Health and Social Medicine, the Harvard Initiative for Global Health, and the Harvard College Global Health and AIDS Coalition, drew an attentive crowd.

Dybul began with statistics. Despite advances, AIDS still kills 2 million people a year, with half of the cases clustered in just 15 countries. The disease is the leading killer in sub-Saharan Africa, and experts are concerned that the epidemic may expand, particularly in Eastern Europe and parts of Asia. Though the financial resources available for dealing with the epidemic have risen annually since 1986, the United States is providing 55 percent of the total. “I don’t say that out of pride,” Dybul said, “but out of disgust. This is a global issue. We need a global response.”

PEPFAR, which was first fully implemented in 2004, initially had three goals: to prevent 7 million new HIV infections, to treat 2 million of those who are already infected, and to care for 10 million people affected by HIV/AIDS, including orphans and vulnerable children. “We’ve met those goals and met them early,” he said.

A large part of the treatment portion of the program comes from antiretroviral therapy (ART), which was being used by about 2,000 patients in 2002, and is now being used by more than 3 million, the vast majority of whom are in sub-Saharan Africa. “Countries are achieving what we consider universal access,” Dybul maintained. The cumulative life-years gained through 2009 due to PEPFAR support for ART in focus countries is estimated to be about 3.2 million. This has a trickle-down effect on every aspect of a nation, from infant mortality to the economy, he said. “You keep people alive to keep their societies alive.”

Many programs focus on treatment and prevention, he noted, but “care is the stepchild that hasn’t been focused on enough. You need to get people in care so you can treat them in optimal time.” When parents aren’t treated in time, they leave orphaned children. The epidemic, Dybul said, has caused “more displacement and orphanhood than all the civil wars in sub-Saharan Africa. And the best way to prevent orphanhood is to prevent AIDS.”

As for prevention, Dybul said the “ABC” education campaign — promoting abstinence, being faithful, and use of condoms — has helped. Though it is often said that Africans have more partners than Europeans and Americans, the numbers don’t bear that out. They do, however, tend to have concurrent multiple partners, which can spread the disease more quickly because condom use is lower in long-term relationships.

The injunction to be faithful, Dybul added, doesn’t mean lifelong monogamy; it simply encourages reducing the number of partners. “We teach people to respect themselves,” he said, “and give people the information and let them choose.” Young people in many African countries are waiting longer to become sexually active, he pointed out, and faithfulness increases respect toward women and, therefore, gender equality.

A point Dybul returned to several times was that “country ownership” is key to containing the problem. “We still talk about aid and assistance in very paternalistic ways,” he said. “As long as we’re stuck in that mindset, we will not succeed.” Rather than going in as savior figures, he noted, those trying to help must concentrate on partnerships, not only with governments but, perhaps more importantly, with community groups. “In HIV as in everything else,” he said, “if you don’t link to the community you won’t succeed.”

However, the biggest problem, he maintained, is vision. “The economic crisis gives us opportunities to look at things in new ways. Crises are always opportunities. … We can take that opportunity or we can blow it. I would say it’s 50/50 which way we go.”