amfAR, The Foundation for AIDS Research

The Global Fund, Remodeled

The TREAT Asia Report Interview: Dr. Mark Dybul

mark-dybul-aids-malaria-tuberculosis.jpgPhoto: The Global Fund to Fight, AIDS, Tuberculosis and Malaria Dr. Mark Dybul was appointed executive director of the Global Fund to Fight AIDS,Tuberculosis and Malaria in November2012. Since its 2002 inception, the Global Fund has supported more than 1,000 programs in 151 countries and programs it supports have provided antiretroviral therapy to 4.2 million people. Dr. Dybul was a founding architect of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and was appointed its head in 2006, earning him the titles U.S. Global AIDS Coordinator and Ambassador. He served there until early 2009 and, before joining the Global Fund, was co-director of the Global Health Law Program at Georgetown University.

TREAT Asia Report: Donors and country governments face a range of priorities in improving public health. Why is it important that they continue to focus on HIV/AIDS?

Dr. Mark Dybul: The reason is, we’re at a historic moment. Because of advances in science, epidemiology, investments over the last 10 years, and experience on the ground, we now have the capacity to completely control HIV, as well as tuberculosis and malaria.

It doesn’t mean eliminate. It means completely control, and in epidemiological terms it would mean converting HIV from a pandemic to low levels of an endemic. And if we could do that, a relatively inefficient vaccine—50 or 60 percent effective—might be sufficient to move us towards ending the epidemic. So it’s really a historic moment now that we never had before. We’ve literally come by it in the last two to three years. And we need to grab it.

If we don’t, we already have indications from places like Uganda—which has increasing incidence despite very high coverage with antiretrovirals and prevention programs—that infection rates will start to go back up. If we don’t act now, we’ll miss this opportunity and it won’t come around again.

TA Report: Are you optimistic that we’ll seize this opportunity?

"We now have the capacity to completely control HIV, as well as tuberculosis and malaria… If we don’t act now, we’ll miss this opportunity and it won’t come around again."

 Dr. Dybul: I’m always optimistic. I think one of the more encouraging things is the increase in domestic contributions to HIV/AIDS programs. As countries increase their commitment to fighting their own domestic epidemics, it encourages international contributors to increase their response.

We’re finding it’s really about getting to the ‘hot zones.’ There’s never been any such thing as a global HIV epidemic.

There’s a series of micro-epidemics. And even countries that have relatively low national prevalence or incidence rates have hot zones of high incidence. And countries with high incidence and high prevalence have areas of very high incidence and very high prevalence that are driving the national averages.

Those are people who are vulnerable, marginalized, difficult to reach, often criminalized—young women in southern Africa, men who have sex with men (MSM), people who inject drugs, sex workers, prisoners. We have to take a fundamentally different approach to how we view the response to the epidemic, then engage civil society more, deal with cultural issues, expand the human family.

And it means changing our thinking of what a health system is. Health systems don’t end at clinics. Health systems dig deep into the communities. Otherwise we have no chance of finding marginalized people, educating them, and providing them with services.

TA Report: The Global Fund has a new funding model. How will it allow for more strategic investments on HIV?

Dr. Dybul: In a lot of ways. I’ll highlight a couple. We’re moving away from a one-size-fits-all approach. So all people—the government, civil society, representatives of affected communities including vulnerable and marginalized groups, and other funders, including external funders—come together to support the country to utilize Global Fund resources through a concept note that contributes to achieving the goal of completely controlling HIV while strengthening the health system and fitting into the National Health Strategy. It means getting up-to-date epidemiology that’s district-by-district, which can be done very quickly by incidence surveys. And then using those data to triangulate with the people who are at risk in areas with high transmission.

Then we have to start looking in a very sophisticated epidemiological way at where the infections are, who is at greatest risk, and identify the interventions that are most likely to have an impact, and then to align that better with national health strategies. The whole package allows for a much higher impact.

TA Report: What can we do to encourage private industry to be more engaged?

Dr. Dybul: First of all, the private sector is more involved than just financial contributions. They’re involved with core competencies and expertise that’s not reflected in their financial donations. A good example is Coca-Cola, who we work with on supply chains. (RED), a tremendous organization has new leadership that’s really pushing the boundaries, and I think we’re going to see increased contributions there.

There are a couple of things in the private sector that I think are important. The world’s a lot different than it was 12 years ago. There are a lot of companies—either multi-branches or multilaterals or new companies from Africa, Asia, Latin America—living in an environment in which HIV is epidemic. So they’re much more likely to want to be engaged.

We’re also looking at high net worth individuals who started those companies and are more interested in contributing to their community. It’s not the old approach of multilaterals with hat in hand—it’s much more sophisticated. And we’re looking at what can be contributed that’s not purely financial.

The last thing is innovative financing, which we’re very excited about. We are working on things like health insurance—bringing in insurance companies from high-income countries to develop insurance schemes in low-income countries, which is ultimately going to be a sustainable tool for health systems.

Dr. Mark Dybul visits Wuse General Hospital in Abuja, Nigeria, with Professor John Idoko, General Director of the National Agency for the Control of AIDS (NACA). Photo: The Global Fund to Fight, AIDS, Tuberculosis and Malaria 

TA Report: How are the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR) coordinating their efforts more closely to achieve greater combined impact?

Dr. Dybul: We’ve always been very well integrated. A third of the money in the Global Fund comes from the American people so it’s incumbent upon the Global Fund and PEPFAR to be closely integrated. But national health strategies have evolved, governments have taken greater leadership, and countries have taken greater leadership financially. It’s a different landscape—not an emergency response any more.

TA Report: In 2011, coverage of services to prevent mother-to- child transmission (PMTCT) in South and Southeast Asia was just 18 percent compared to the global average of 57 percent. Why do you think the region is faring so poorly with regard to PMTCT services?

Dr. Dybul: First of all, like Africa, Southeast Asia is not monolithic. Some countries in the region have had a very vibrant or robust response, others haven’t. There are a lot of different reasons for this. Some of them have to do with the landscape of the country. Some have to do with political leadership. Some have to do with the investment of the countries themselves.

The Global Fund remains very active in Southeast Asia and is fully committed to remaining engaged there, but some countries in that region have a lot of money on their own and need to be committing more of their resources if there’s going to be an effective response.

TA Report: As you’ve said, gay men, other MSM, and transgender individuals are at high risk of HIV worldwide. What can be done to end the discrimination that so often obstructs access to health services for this high-risk group?

“We have to take a fundamentally different approach to how we view the response to the epidemic, then engage civil society more, deal with cultural issues, expand the human family.” 

Dr. Dybul: Again, you have to look at the world not as a world but as regions. There are particularly high rates of infection among transgenders in Central and South America, and Southeast Asia. We actually have a program that was dedicated to the military in Central America for the uniformed police services to deal with stigma and discrimination against transgenders.

We are also financing programs in Central America and Southeast Asia that allow us to address the inequality and the structural issues that make it very difficult to protect transgender people from HIV infection. So it’s a mix of political change, cultural, structural change, and financing programs that begin to address these issues.

MSM are at great risk in many places and are often a key population with high prevalence, so we’re working to ensure that data are used to develop programs that will protect them from infection and increase access to services. For both people who are transgendered and MSM, that will mean addressing stigma and discrimination. We are partnering closely with UNAIDS and others to address these fundamental, structural issues.

TA Report: As international development aid transitions to a model of country ownership of AIDS programs, do you think there’s a danger that this may lead some countries to abandon some of these marginalized populations?

Dr. Dybul: First of all, country ownership doesn’t mean government ownership. The Eurasian Harm Reduction Regional Network initiative is entirely conducted through civil society. In other places, like Central America, there are governments that want to work with these issues because they see the epidemiology.

It doesn’t mean walking away from these important issues. It actually means working together in a more fundamental way, beginning with using the data to develop strategies and plans. Ultimately, that’s the only way to do it.

A lot of these issues we’re talking about are not only in low-income countries—they are also in middle- and upper-income countries. We will never be able to fund national programs in higher-income countries, so we are working to catalyze change and push some of these envelopes based on the data.

TA Report: You’ve been with the Global Fund now for five months. How would you characterize your experience thus far?

Dr. Dybul: It’s been incredibly exciting. It’s a tremendous organization. It’s going through a significant evolution in its business model at the same time that we’ve had an evolution in science, epidemiology, and 10 years of knowledge implementation, a lot of which the Fund helped to drive.

I have no doubt that collectively—using the current scientific tools, using the epidemiology, and focusing on the most at-risk groups and highest transmission areas, geographically and by risk group—we can completely control this infection. It’s a tremendous opportunity and a historic moment.