Anyone hoping for a bold change in US global AIDS leadership has had plenty of news to keep up with in the past few weeks. First, Mark Dybul, the current and controversial occupant of the Office of the Global AIDS Coordinator, submitted his resignation in anticipation of being replaced. Soon after, he sent around an email saying he had been asked by the Obama Administration to stay on board. Now, rumors are circulating that his days as the US AIDS Ambassador are in fact numbered. The Global AIDS Coordinator works under the Secretary of State, and with the confirmation of Hillary Clinton–a committed woman’s rights advocate–as Secretary of State today, the question of whether Dybul stays or goes is of keen interest to all of those concerned about an effective U.S. response to the global HIV and AIDS epidemic.

To the chagrin of some global
AIDS advocates, and to the qualified approval of others, Dybul announced last week that he had been
asked to rescind his resignation and stay on as Global AIDS Coordinator
for the start of the Obama administration – or indefinitely. In the latter case, advocates are divided on what Dybul’s "second term" means
for the future of a program that has focused on treatment but been riddled
with ideological requirements that have hamstrung efforts to prevent
new infections.

No question, Dybul’s work is not universally applauded. During the Bush
administration, he did not fight his boss’s ideological restrictions on
global AIDS funding. Many argue that the Obama Administration would be best served by appointing someone new.

On Rewire, Jodi Jacobson
has argued that the limitations embedded in PEPFAR, the President’s
global AIDS relief bill, can only be addressed with a Global AIDS Coordinator
who "gets it." "For too long, PEPFAR has been driven by
a highly medicalized approach to an epidemic fueled by gender, social
and economic disparities and by stigma and discrimination. A critical
first step for the new Administration is to appoint a Coordinator who
clearly understands these dynamics, who embraces both the public health
and human rights dimensions of risk and disease and who recognizes that
sex and sexuality are normal attributes of being human," Jacobson
writes. And for Jacobson, that Coordinator is not Mark Dybul.
"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."

"Nominating someone new is
a necessary first step to signaling that changes needed in US global
AIDS policy will be a high priority," said Jacobson.

PEPFAR‘s ideological restrictions date
from the original 2003 act, in which Congress required that only 20%
of total PEPFAR funding could be spent on prevention, and that fully
a third had to be spent on abstinence-until-marriage programs. Under
the tenure first of Randall Tobias and then Dybul after Tobias departed
in scandal, the Office of the Global AIDS Coordinator interpreted the
one-third stipulation as narrowly as possible, claiming that one-third
of all prevention funding, not just the funding spent to prevent
sexual transmission, must be spent on abstinence programs. Moreover,
while the law said abstinence-until-marriage, the implementation focused
on abstinence-only. For example, rather than counting every
dollar of a comprehensive program focused on promoting delay of sexual
debut toward the earmark while ensuring each individual received all
the information, training and methods needed, OGAC instead insisted
on funding stand-alone abstinence, or abstinence and faithfulness programs
that ignored–and in some cases denied–the possibility of practicing
safer sex.

The 2008 reauthorization lacks the specificity
of the original act, but requires that at least half of all money directed
towards preventing sexual transmission of HIV must be spent on "activities
promoting abstinence, delay of sexual debut, monogamy, fidelity, and
partner reduction" in countries with generalized HIV epidemics or
a report must be made to congress. While some argue this langauge
is less directive than the original earmark, most implementers disagree.
The requirement of a report to Congress on specific program activities
such as these on a yearly basis not only creates more bureaucratic hurdles,
but also provides the authors of this language–such as Rep. Chris
Smith of New Jersey–the fodder for harassing program providers who
are seeking to meet the needs of the populations at risk, not ideological
politics in Washington. Only programs working to prevent sexual
transmission of HIV are subject to such reporting requirements.

Taking leadership of PEPFAR
presents both opportunities and challenges for the incoming Obama administration.
The 2008 reauthorization gave a green light to spending of up to $48
billion from 2009 through 2013 that could dramatically increase funding
of key programs like those providing treatment and prevention of maternal-to-child
transmission. But Obama will also need to
address the many controversial Bush administration policies that remain
in place, both in law and in guidance, policies that hinder the fight
against the spread of HIV/AIDS. Selecting the right person as
Global AIDS Coordinator is a critical step. Given that the retention
of Dybul may be stopgap measure, President Obama still has an
opportunity to bring about real change.

But if Dybul stays on is this an indication
Obama won’t make bold and necessary changes to the global AIDS program?

Not necessarily, argues long-time
AIDS activist Gregg Gonsalves, currently of the International Treatment
Preparedness Coalition. For Gonsalves, a little more Dybul now,
with the possibility of the nomination of a strong leader later –
someone who is a "leader on global public health, who is good on
reproductive rights, needle exchange, and generic drugs, with a lot
of seniority and credibility" – is preferable to nominating an unqualified
candidate now. Candidates
that have been mentioned in the press
are CEO of the Global Health Council Dr.
Nils Daulaire,
professor and former director of the World
Health Organization HIV/AIDS department
Dr. Jim Yong Kim, and President
and CEO of CARE Dr.
Helene Gayle. "[The candidates being considered] are holdovers
from the Clinton administration who didn’t speak out against the ban
on needle exchange under Clinton or push for anti-retroviral therapy,"
says Gonsalves. "So we’re going to put in a bureaucratic coward from
the Clinton years and call that a victory?"

"Mark Dybul was not a
Tom Coburn, whose entree into AIDS and global health was to drive an
ideology forward. Mark’s background is appreciably different than
other Bush appointees," says Gonsalves. "I think he’s a scientist
and knows the science. Given more freedom, he very well may be
guided by the evidence. If he continues to push non-evidence based
policies for HIV prevention, then I’m wrong."

While Joseph Amon, the director
of the
HIV/AIDS program at Human Rights Watch,
also wants to see Dybul replaced, he agrees with Gonsalves that none
of candidates recently considered are right for the position.
"All of [the candidates being mentioned] have strong qualifications
and have shown dedication to working on HIV/AIDS, but none of the candidates
under consideration have really fully embraced and articulated the need
to address human rights," said Amon. "It is not enough to see a
decrease in HIV/AIDS prevalence statistics and ignore the underlying
problems. There needs to be more than just a health sector response."

This past December a letter
from leading advocacy groups, including the International
Women’s Health Coalition
and the Sexuality
Information and Education Council of the United States (SIECUS), exhorted
the Obama transition team
to "appoint a Global AIDS Coordinator who can lead the transition
from a disease-specific, medical model to one which embraces, and can
carry out, a broader vision" that rests on an "understanding of
the social and economic factors which drive the epidemic and a solid
grounding in public health and human rights frameworks." William
Smith, Vice President for Public Policy at SIECUS, said that his group
was concerned that current Global AIDS Coordinator Mark Dybul would
stay on. "I’m willing to give the Bush administration credit
for scaling up treatment and care but it has been a disaster on prevention
and Mark Dybul has overseen that," says Smith.

Questions remain as to whether
the position will remain an Ambassadorship, what role the State Department
will have and whether the office will be integrated into USAID.
It’s possible that Dybul will stay on until OGAC is integrated into
a larger office to address international humanitarian and development
issues. The latest rumors suggest that Dybul’s tenure may well be briefer than indicated by his own open-ended email to staff.

When Obama spoke of creating
change in Washington, many in the HIV/AIDS community clearly were thinking
about the Global AIDS Coordinator position. Now that Clinton is formally in charge at State, many hope she will quickly turn to appointing a new coordinator who will, to paraphrase Obama’s inauguration speech, get the job done — without compromising either our ideals or the rights- and evidence-based programs needed to stop the spread of HIV.