Mark Dybul: US Global AIDS Coordinator in charge of PEPFAR.

In August, 2006, Mark Dybul was sworn in as the new US Global AIDS coordinator to oversee the US response to the global HIV/AIDS crisis, and specifi cally to direct the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR). The plan—a 5-year US$15 billion initiative—is the largest programme ever launched to target a single disease. “The President saw tackling the HIV/ AIDS pandemic as a moral imperative, to save lives, restore hope, and to build local capacity to transform the African subcontinent. I want to make clear that the President sets the direction and the goals, and that I wouldn’t be here if it wasn’t for him”, Dybul says. Billy Pick, a USAID colleague and a friend of Dybul’s told The Lancet, “Mark is determined to make PEPFAR work but he is not big on being in the limelight. He is very passionate about science and his patients and fully embraces the embodiment of an academic researcher. Facts and evidence are what matters to him. He is not seen as a politician so there is no agenda”. A graduate from Georgetown University, Dybul completed his residency in internal medicine at the University of Chicago Hospitals and then embarked on a research career at the National Institute of Allergy and Infectious Diseases and the National Institutes of Health under the supervision of Anthony Fauci. “Mark is a compassionate physician with strong ethical values. I promoted him to be my Special Assistant for Medical Aff airs, a position in which he complemented his clinical and research skills with a manifestation of leadership, managerial, strategic, and organisation capabilities. It was very apparent to me that I was dealing with a real star.” Dybul went on to work closely with Fauci to develop PEPFAR, and still maintains an active role in research with an emphasis on HIV therapy, HIV reservoirs, and immunopathogenesis. Dybul welcomes the recent focus on prevention, but feels the care component and the needs of orphans and vulnerable people are being overlooked. He is also convinced that alcohol misuse is driving the epidemic in parts of Africa, fuelling gender inequality and domestic violence. He acknowledges the challenges in prevention are enormous. “Behavioural change is ultimately the lynch pin for all prevention and we need to keep our eye on the ball.” He refers to the rising rates of HIV in the west: “When I was in San Francisco as a young doctor, we saw radical behaviour change but in the treatment era those behavioural messages have been forgotten. There is a need to keep messages real, live, and relevant for people today. We need to look beyond just university-based behavioural change technologisies. Industry have the right idea, we need to learn from them. For example, there is a reason that people still drink both coke and pepsi. This kind of marketing is needed in prevention.” PEPFAR’s prevention programmes in Africa consist of abstinence, being faithful, and the correct and consistent use of condoms (ABC). This approach has been condemned by many, because of the emphasis on AB over C, but Dybul refutes the criticisms: “My reaction is amusement and occasional frustration. As a scientist the data tell me overwhelmingly that ABC works in a generalised epidemic, and furthermore the approach comes from Africa, not us. When I go to Africa, they thank me for giving ‘our’ approach a chance.” He dismisses the stories of condom shortages. “Facts need to have some relevance in this debate. Criticism is fi ne but disinformation is harmful to the overall fi ght.” Dybul believes that expanding local capacity will be the solution to the epidemic in Africa. National scale-up is not going to happen without locally owned and run programmes, explains Dybul. Handing programmes over to the Africans also creates a culture of accountability, “Our support are not handouts, they are partnerships.” Dybul hopes President Bush’s wider global vision will be realised—to tackle the HIV/AIDS pandemic in the context of broader development goals. “When the infrastructure for home-based HIV care and delivery is in place, why not use this opportunity to put bednets through the post? We need to partner with other initiatives to enhance leverage. That vision is not there yet”. Paul Zeitz of the Global AIDS Alliance thinks Dybul has changed the way PEPFAR does business: “He has tried to establish broader partnerships with other major fi nancing donors like the Global Fund and other agencies. Importantly, PEPFAR are now having a more constructive dialogue with activists. There was a complete block or lack of dialogue with most of the activist community when Tobias was running the place, Mark has opened up those community channels. However, that said, he isn’t going as far or as fast as most people think he should and he still defends AB on scientifi c grounds”. Last week’s Institute of Medicine (IOM) report highlighted the need to move from emergency relief to sustainable long-term planning and capacity building and to intensify evidence-based prevention eff orts. Dybul responded confi dently: “In many cases, PEPFAR has already taken action to address the recommendations made in the report. We will draw on IOM’s input to further strengthen the program. PEPFAR has sought to save as many lives as rapidly as possible. At the same time, it is essential to look to the future and sustaining an eff ective response. PEPFAR continues to build the capacity of public and private institutions in host nations to lead their own responses to HIV/AIDS.”