Confirming month-old rumors, a high-level source reported last night that President-Elect Obama’s transition team has asked Ambassador Mark Dybul to remain in place as Global AIDS Coordinator, despite strong opposition by treatment access, HIV prevention, and women’s rights advocates across the global HIV and AIDS community, many of whom signed letters calling for a change in PEPFAR leadership at this crucial time. While keeping Dybul on may be a stopgap measure for a new Administration dealing with huge problems across the board, it is a decision that signals we may not be getting "the change we need" in global AIDS policies.
Dybul, a medical doctor, is strongly associated with the failed policies of the President’s Emergency Plan for AIDS Relief (PEPFAR), including those that flout both evidence and human rights, and that neglect the role of stigma, discrimination and gender equity in the spread of HIV. Under his tenure and that of his predecessor Ambassador Randall Tobias, for example, the Office of the Global AIDS Coordinator (OGAC) has funded abstinence-only until marriage programs that fail to provide all individuals with the basic information, skills and methods for practicing safer sex, supported policies that prohibit US funding of syringe and needle exchange programs despite evidence that such programs are the best means of preventing the spread of HIV among injecting drug users, and perpetuated restrictions on organizations conducting HIV prevention among sex workers. All of these policies have been shown ineffective by government agencies, such as the Government Accountability Office and the Institutes of Medicine, as well as by numerous independent studies conducted by non-governmental organizations.
As Global AIDS Coordinator, Dybul obviously works at the pleasure of the current Administration and is responsible for carrying out the law. However, he also is morally and ethically responsible for speaking out when taxpayer funding is being used to perpetuate ideology over evidence, and is leaving people at risk of new infections, as has been the case with PEPFAR prevention programs since day one. When given the opportunity in Congressional hearings and other fora, Dybul failed to unequivocally support removal of the abstinence-until-marriage restrictions in the original PEFPAR legislation despite mounting evidence that this restriction was undermining efforts to stop the spread of HIV. He did not speak out publicly against other restrictions such as that on syringe exchange. His office failed to use its own leverage in writing guidance that would have supported a comprehensive approach to prevention of sexual transmission of HIV or would have greatly alleviated the adverse effects of the so-called prostitution pledge. In short, even as a medical doctor he supported ideology over evidence, serving his own interests and the interests of politicians rather than those of people at risk.
Moreover, Dybul is very close to the religious right, including Pastor Rick Warren, and supported the positions of the US Conference of Catholic Bishops and Catholic Relief Services in maintaining restrictions on funding for prevention in the recent reauthorization of PEPFAR. Lobbying by these groups resulted in the retention of restrictions on funding for prevention of sexual transmission, needle exchange, and sex worker organizations. It also resulted in an expanded "conscience clause" which unconscionably allows groups to discriminate as to who will receive prevention, treatment, and care under programs funded by the U.S. taxpayer. Under Dybul’s tenure, tens of millions of dollars have been given to ideologically-driven faith-based organizations under the controversial New Partners Initiative.
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And after passage of PEPFAR 2 in 2008, Dybul acted quickly to mollify religious conservatives by writing program guidance not required by law which forbids purchase of contraceptive commodities using PEPFAR funds. This step greatly undermines integration of HIV prevention with reproductive health programs, limiting efforts to slow the rapid spread of new infections among women in sub-Saharan Africa and denying HIV-positive women in prevention of maternal-to-child transmission programs support they need to space or limit births. The guidance flouts recommendations by global bodies such as the World Health Organization and UNAIDS, and by OGAC itself, that integration of programs is an urgent priority. Dybul also tends to take a very defensive stance in regard to problems with PEPFAR. He holds grudges against critics and does not welcome vigorous debate on or critique of PEPFAR policies, a problem in a new Administration that has promised transparency and access and for a program which obligates nearly $50 billion in taxpayer funding.
The extension of Dybul’s tenure may well be an interim measure until the new Administration can get its bearings and make decisions about the reorganization of foreign assistance, a process that is in the early stages. In one scenario, for example, OGAC will become part of a more integrated and revitalized effort to deliver aid abroad while also changing the nature and scope of our assistance policies and strategies. Dybul has also worked Congress to his advantage, and built political connections that strengthen his hand. It is quite possible that keeping Dybul until things were more settled represented the course of least resistance.
This decision is nevertheless not likely to make many in the global AIDS community happy. Appointing a new Global AIDS Administrator, even if only for an interim period, somone with the ability to start a fresh dialogue on global AIDS policy would have signaled the Administration’s intention to make changes more clearly than keeping the old guard in place. And if Dybul is in for the long haul, this Administration will have failed to do what is necessary to ensure confidence in PEPFAR and to make the changes necessary to replace ideology with evidence in US global AIDS policy.