Health Diplomacy Bulletin #25: Former PEPFAR Director Dybul Calls for Doubling-Down on Commitment to Fight HIV/AIDS as Country Partners Take More Resonsibility for Funding

In a wide-ranging interview with Global Health Diplomacy, Mark Dybul, the physician who headed both PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria said that the struggle against HIV/AIDS is at a critical stage:

“Now is the time to double-down and see it through, giving countries time to fund the programs on their own. If we do not, if we take our foot off the pedal now, the epidemic will come roaring back and then there will not be enough money to get back just to where we are today. Who wants to be responsible for that?” 

Dybul is currently Faculty Co-Director of the Center for Global Health and Quality and Professor in the Department of Medicine at the Georgetown University Medical Center. He was an HIV research fellow at the National Institute for Allergy and Infectious Diseases under Dr. Tony Fauci in 1990s and conducted the first randomized, controlled trial with combination antiretroviral therapy with HIV patients in Africa. 

Global Health Diplomacy: Ambassador Dybul, last April you had these pessimistic words to say at an event at CSIS: “We are, in my view, at highest risk ever of losing control of the [AIDS] epidemic since all of this began.” Has anything changed? 

Mark Dybul: Things have changed in two ways. The size of the young population will continue to grow because of the high birth rate. It is projected that the population of Africa will double by 2050. In many countries two-thirds to three-quarters of the population will be under the age of 35 or even 25. So, because there are more and more young people and young people are at the highest risk of acquiring HIV, every day we get closer to losing control. It’s just math. This is not a failure of HIV programs per se. It is because of population growth. 

We also have more data showing no reduction in rates of HIV among young people for the past 15 years. That is a failure of HIV programs. But such is the reality of youth. Young people generally feel invincible and do not perceive risk – whether HIV, poor dietary decisions, or smoking. 

Another change is a more widespread recognition of the problem and significant efforts to start shifting resources. PEPFAR began acting with the DREAMS program a few years ago [DREAMS focuses on adolescent girls and young women in 10 sub-Saharan Africa countries]. The Global Fund also began shifting investments several years ago. Most importantly, countries understand the problem and are trying to act quickly. So there is reason to hope. 

GHD: You were calling for a new way to invest and a new way to treat the epidemic. Can you address both? 

Dybul: In 2012, when it was very unpopular, we began beating the drum on this. At the time – and still with many “experts” today — the commonly held belief was that we just needed to increase coverage of treatment, and that would lead to control of the epidemic. In theory, that is correct because people on treatment are highly unlikely to be able to transmit the virus. 

However, people are not laboratory animals. Just because we want to reach people at high risk and we want them to take drugs every day, does not mean they will. In fact, we have far more data that the people most at risk are theleast likely to seek testing and treatment. 

To change the course of the epidemic we argued (and published in The Lancetin 2014), that we needed to focus on areas and groups of people with the highest risk of acquiring HIV. UNAIDS also published its report on location and population. PEPFAR began investing in extensive efforts to collect data at the local level confirming and extending the database showing that new infections can be highly concentrated in “hyper-epidemic” areas with other areas, even in the same district, with low levels of transmission. PEPFAR began the “pivot” to a more focused approach. 

In addition, we argued that we needed to shift what we do not just where we do it. That means engaging communities, meeting people where they are and understanding their needs and desires as people. If young people are not interested in HIV or if they feel they are not at risk, then they will not go to a health facility of any kind to get an HIV test – and that test is the entry to care and treatment. 

We have definitive proof of this. Testing rates among young people are about half those of older people. So we need to change our programs to meet them where they are – which is outside the formal health sector. And then we need to provide them with the intervention that is appropriate for seasons of life. For example, when someone is in a partnership, we know they are far less likely to use condoms. So they likely need access to pre-exposure prophylaxis (PrEP). 

We need what we have called “the kitchen sink,” making the entire array of interventions available to people in hyper-endemic areas and in settings where they will access them if we are to have any chance of bringing the epidemic under control. 

GHD: As the co-director of the new Center for Global Health and Quality at the Georgetown University Medical Center, you are focusing on country ownership. You want PEPFAR’s indigenous partners to take over a greater share of the burden in their countries. Are you optimistic about that happening? In this regard, do you see any positive developments coming out of the State Department’s Office of the U.S. Global AIDS Coordinator (OGAC), which you used to head? 

Dybul: Yes, I am optimistic for two reasons. First, as countries experience significant economic growth, they are funding more and more of their HIV response. As IHME research last year showed, upper-middle income countries do significantly increase their expenditures on health and HIV. Currently, low- and middle-income countries are paying for more than 50% of the bill for HIV, but most of that is in upper-middle income countries. 

When I was at PEPFAR, we required CDC and USAID to turn over very large HIV care and treatment programs to local organizations within three years. That succeeded at CDC. Now 60% of CDC’s PEPFAR programs are local organizations. It took an investment in capacity building, but it succeeded. And the Global Fund invests heavily in local organizations, in particular governments. So we know it works. 

Deb Birx was running the CDC’s HIV program when we did that, and Bill Steiger [now chief of staff at USAID] was very involved. USAID did not want to do what CDC did back then. Now Bill is at USAID [as chief of staff] and Deb is running PEPFAR. And Mark Green [the USAID Administrator] is leading across USAID with his push on country “Journey to Self-Reliance.” But it doesn’t happen overnight. And as we knew at the Global Fund and learned with the CDC transition, it requires an investment in capacity building. 

GHD: Last year, Uganda’s Minister of Health announced a new tax on sodas and alcohol to raise money for Ugandan HIV/AIDS treatment. What are some of the ways that you’re seeing countries develop promising forms of non-donor revenue sources? 

Dybul: First, just let me say I really don’t like the words “donor,” “aid,” “graduation,” etc. That is the language of paternalism, not partnership. I prefer “external partner.” Sorry to be pedantic, but words matter. And I can tell you that Africans don’t like those words either – nor did Mexico, China, Brazil and other countries when they were in a different socio-economic position. If we want strong trading and geo-political partners for the long-term, we need to change our mind-set, and therefore our language. 

Which is very relevant for this topic. The greatest innovations in health financing are occurring in the countries. The Uganda “sin” tax is an example. Fortunately, cigarette use is not yet high in much of Africa, but high taxes on cigarettes should be imposed now not just to discourage use but also to generate revenue to fund health. 

But the most important and sustainable ways to fund health – and education, and so on – is to grow a tax base and to develop strong insurance schemes, public and private. The international community is so focused on its innovative funding schemes, but they just cannot raise the resources that are needed. They can be supplemental, but right now they consume so much time. 

We need to support countries in their efforts to develop progressive taxation and health insurance premiums. The countries know this and are working on it. We need to support their efforts and stop designing mechanisms of marginal benefit to them and dumping them in their lap. 

The African Union has developed a scorecard on domestic health financing, and under the year-long chairpersonship of President Paul Kagame of Rwanda, the African Union is developing key steps to go to the next level to work together to take very concrete steps to increase domestic finance in an accountable way. We all need to get behind them and their example is a good one for the rest of the world to learn from. I am hopeful the G-20 will pick up on what Africa is doing and run with it.  

GHD: You are in the unique position of having led the world’s two largest organizations battling infectious disease. Do you think the Global Fund and PEPFAR are coordinating well? What can be improved? 

Dybul: The coordination and collaboration has never been better. PEPFAR includes the Global Fund when it reviews the country plans for funding, and PEPFAR and the U.S. Government are at the table in-country as the Country Coordinating Mechanisms develop their plans. Deb Birx has invested a lot of time into making the relationship work, as has the leadership of the Global Fund. 

However, resources are too limited for what needs to be done because of the demographics mentioned above. So it is becoming more difficult to ensure primary prevention is funded. 

GHD: On the subject of the Global Fund: France will be hosting the next replenishment conference this October. Do you think it will be successful? 

Dybul: Absolutely. The Global Fund delivers huge impact. More than 22 million lives saved. 

Peter Sands is doing a fantastic job as executive director [he is Ambassador Dybul’s successor] and is exactly what is needed right now – a former banker who can navigate increased domestic finance along the journey to self-reliance. And many countries are contributing more to their fight against HIV — more than half of all funding for HIV programs in low- and middle-income countries. 

The Global Fund is the multilateral arm of PEPFAR. We always saw it that way at the beginning. Swaziland (now Eswatini), Malawi and Zimbabwe were not among the initial focus countries of PEPFAR because they had very large Global Fund grants. And as recent PEPFAR reports have shown, those countries have done very well. 

The fact that France is hosting this replenishment — following Canada, the USA, Germany and the UK — is a great demonstration of the Global Fund’s importance. Beyond the U.S., no other countries have large bilateral programs so they can contribute only through the Global Fund. Every dollar contributed by the U.S. leverages two dollars from other countries (by U.S. law, the U.S. cannot contribute more than one-third of total Global Fund spending). Without continued U.S. leadership, the rest of the world’s engagement will rather quickly decline, and the US taxpayer will be holding the whole bag of marbles. 

So the replenishment will succeed if the USA continues its leadership and maintains its contribution of 33%. And it must – both to achieve impact and to ensure the rest of the world continues to contribute to the fight. 

GHD: Over and over, the Trump Administration has called for cutting the global health budget, including taking about $1 billion out of the global HIV/AIDS budget. Congress keeps ignoring the request for reductions. Do you believe this trend will continue, or is there a real threat of major cuts, especially with trillion-dollar federal budget deficits looming? 

Dybul: I certainly hope Congress will continue the strong bipartisan legacy PEPFAR and the Global Fund have enjoyed for more than 15 years. And we are fortunate to have some of the strongest and longest supporters of PEPFAR from both parties in key leadership positions in both chambers of Congress – across the aisle and across the Capitol. 

I understand the budget pressures and the many demands on the budget. As Vice President Mike Pence, then a member of the House Foreign Affairs Committee, said in support of the first reauthorization of PEPFAR, which included the Global Fund, of course, and an increase in funding from $15 billion to $48 billion: “You know, every so often, in this place, we have the opportunity to something for humanity and serve the American people…. I believe it is possible to be responsible to our fiscal constraints while being obedient to our moral calling….when we rise above the politics and raise up those in dire need.”  

GHD: You were present at the creation of PEPFAR. You have emphasized how the motivating factor was humanitarian. But the world has changed. Do you believe advocates now need to focus more on economic and national-security arguments to secure billions for global health? 

Dybul: Well, we’ve all been making the security argument for a while – because it is true. The first time the UN Security Council held a special session on an infectious disease, it was for HIV. Generals and commanders in Africa have spoken eloquently about it. But again, it might be useful to quote then Rep. Mike Pence: “The threat of [the HIV] pandemic poses to our security is all so real. Left unaddressed, this plague will continue to undermine the stability of nations throughout the two-thirds world, leaving behind collapsing economies and tragedy and desperation.” 

Thanks to bipartisan Presidents and Congresses, the USA has acted, and historic progress has been made. But because of the demographics, as we have discussed, now is the time to double-down and see it through, giving countries time to fund the programs on their own. If we do not, if we take our foot off the pedal now, the epidemic will come roaring back and then there will not be enough money to get back just to where we are today. Who wants to be responsible for that? 

GHD: In an op-ed on the Devex news service in October, you, Rob Mosbacher [co-chair of the Consensus for Development Reform] and John Danilovich [former CEO of the Millenium Challenge Corporation] wrote that the White House was nearing the end of its long-overdue foreign-assistance review. Can you elaborate on this point you make near the end of the piece: “We are deeply concerned by the approach to development assistance that treats its provision as a reward and the cutting of development assistance as a punishment.” But wasn’t this the idea behind the Millennium Challenge concept in the Bush 43 administration? What is the difference? 

The MCC is a remarkable program. There are benchmarks on rule of law, economic regulation and opportunity, and many others. But one qualification of MCC is not how a country votes in the UN. 

Let’s take the long view. Africa is among the fastest economically growing parts of the world. As CEOs of major US corporations have told me, “Without a growing and stable Africa, I won’t have the markets to create jobs here at home.” PEPFAR and support for the Global Fund have had tremendous diplomatic advantages. A Bipartisan Policy Center report by former Sens. Frist and Daschle showed that countries where the U.S. has contributed significantly through global health have a significantly higher opinion of the U.S.. People know what you stand for when you stand with them when they need it. 

How do you think countries will feel if we make humanitarian support contingent on UN votes? When they are deciding on companies to work with now and in the future, how do you think the U.S. will fare if we try to dictate policy to them? 

China is winning over a lot of countries by focusing on economic growth and global health in Africa. They are not forcing policy alignment. And we are losing out. Fantastic and much-needed new bipartisan efforts by Congress to create a smarter approach to business will founder if we drive a diplomatic wedge where we do not need to drive one. 

GHD: Thank you, Ambassador Dybul.