Finding New Solutions to Africa's AIDS Crisis

But, a question came in from Gertrude Carpenter, of Schenectady, New York, who asked, "Are condoms being distributed through the program? Is there education among males about preventing transmission to their partners?"

And another questioner, Joyce, from Tiburon, California, also wanted to know about the administration's policy on the use of condoms.

Ambassador?

MARK DYBUL: Well, that one's easy. President Bush, every time he speaks about prevention, talks about the need for the use of condoms, but in the context of, as you said, ABC. But, ABC is a lot more complicated than those letters suggest. ABC includes teaching children, when they're very young, to respect themselves and respect others, and that has an impact on how the young boys view young girls as they grow older. We're beginning to see some tremendous impact, although it's very difficult to quantify, on shifting gender norms of the results of these programs. We teach young boys and young middle-aged boys about the fact that it's not okay to abuse women, that it's actually manly to respect girls and to reduce your partners and to not be aggressive in sexual encounters. We teach older men that it -- and younger girls that transgenerational sex or an older man with a younger woman is not appropriate. We're trying to change deep-seated gender norms and cultural norms, and that takes a long time.

But, in terms of condoms, as I mentioned, President Bush always talks about condoms. Condoms are a very important part of this program. Since the program began, the American people provided 1.67 billion condoms. And as Peter Piot, the head of U.N. AIDS has said, that's more than all other international partners, combined. So, the U.S. has been very aggressive in the provision of condoms, but we do it in the context of changing behaviors in a way that will impact this epidemic, because we know that condoms alone can't turn the epidemic around; but they're an important piece, and it's a piece that we are pursuing in the context of what we think the data indicate -- well, we -- what -- in what -- in terms of what the data indicate will be successful. But -- condoms have to be a piece of it, but they can't do it alone.

SUSAN DENTZER: Another question on prevention came in from Celeste, who's a high school student from Merion, Pennsylvania, and she wrote, "If abstinence-until-marriage programs are widely viewed as ineffective, why then is a third of the prevention money of PEPFAR going toward abstinence-only-until-marriage spending?"

And, Paul Zeitz, this has been a controversial area. What's your -- what's your view on how rigidly that set-aside, in effect, is being met or whether, as the Ambassador says, it's really a much more -- broader set of concerns about prevention that are attempting to be conveyed?

PAUL ZEITZ: Thanks, Susan.

Well, when President Bush launched his initiative with a Republican Congress in place, they imposed this requirement of one-third of the prevention money for abstinence-until-marriage programming, which was a huge shift in the way the U.S. had been programming a science-based -- evidenced-based ABC balanced approach.

When I was in Zambia, we were doing national programming to promote abstinence, and also national population-based programming on condom social marketing. With PEPFAR, many countries that had national programs in that way have subsequently collapsed. And, while they are giving some condoms out -- and Mark cites the billions that have gone out, 1.6 billion condoms, he doesn't talk about, you know, how many condoms would really be needed for those that are sexually active.

And we've seen this ideological push on abstinence-until-marriage have a real negative effect. It's reawakened some hyper-ideological forces in Africa that had been more science-based. We've seen a big reversal, for example, in President Museveni, who was an evidenced-based leader in the '90s and until the Bush administration. Recently, he was talking about condoms being only good for high-risk groups. He -- his wife has been equating condoms with theft and murder. So, they've re-stigmatized an appropriate approach to prevention, and -- in Uganda -- and we've heard, from activists on the ground, over and over again how this program is great on treatment, but has actually set the ball backwards on prevention.

SUSAN DENTZER: Ambassador --

MARK DYBUL: I have to --

SUSAN DENTZER: -- Dybul, would --

MARK DYBUL: Yes.

SUSAN DENTZER: -- do you want to comment on that?

MARK DYBUL: Yeah, I have to jump in there. I mean, you -- the United States Government is not responsible for the position of the heads of state. And our programs have had no impact on that. And if you look at Uganda -- I mean, you just have to look at the facts. We've increased condoms from 7 million to 45 million condoms. Now, it's true that there aren't enough condoms in the world right now. There aren't enough people learning about abstinence and fidelity, either. Currently, the American people are providing as much money as the rest of the world, combined, for HIV/AIDS. As long as that's the case, we will be short on everything, and we need the rest of the world to step up. But our programs are firmly rooted in the evidence-based.

The data are overwhelming, in generalized epidemics in sub-Saharan Africa, that reduction in partners, reduction in the number of your partners, which is the faithful, the delay in sexual debut, or abstinence -- we're not talking -- we're not telling 25-years-olds to not have sex. What we're telling people is, "Be responsible, respect yourself, delay your sexual activity until you can be responsible. If you're going to become sexually active, which is not optimal, but if you are, use a condom" -- the high-risk group in Africa is the young person who has sex, and that's what our programs are designed around.

I have yet to have anyone who reads our guidance and goes to see our program think there's a problem here. You can tinker around the edges, but, in general, they're fine.

But there's been this sense that we're doing things that we're not actually promoting. And, to be honest, I talked to an African activist lately who had been beating us up for years; finally, she went to read our guidance and look at our programs, and said, "You know, you've been doing what I've been doing for 23 years. This isn't a problem. And we think we're kind of being used here, but these programs are fine." We had -- recently had some members of congressional staff go and say the same thing. The programs are based in common sense and in the evidence-based. And, while I'm afraid some people have misinterpreted all of that, that's never been the intent. We've been firmly rooted in the evidence-based. And if we stay that way, we'll actually have a good impact.

And we're seeing an impact. Africa is one of the few places in the world where we're seeing stabilizations and reductions in prevalence rates, which is not to say that we're responsible for that, there's a lot that goes into it, but we've got to get through these general changes in social norms and behaviors. And the data are overwhelming that condoms alone aren't going to tackle this problem. So, we've got to have a comprehensive approach, and that's what we're trying to pursue.

Paul's right, we can do a lot better at it. We can do a lot better at everything. We've only been at this for a couple of years, to tackle a massive epidemic. But the policies and practices are the right ones.

So, let's talk a bit about investment in health systems. Paul, I'd like to start with you, since you have a perspective from your days in Zambia. How is PEPFAR doing on this score?

PAUL ZEITZ: Well, I think that there's been some positive effects of the PEPFAR program, in terms of helping to catalyze change in the broader health system. We all recognize -- and Mark has been working on this intensively in many of these countries -- that to get AIDS treatment out to all the people that need it, we are going to have to strengthen the whole health system, we can't just fly in with a helicopter, drop the drugs, and fly away. We have to train local health workers at the community level, nurses, doctors, et cetera.

The PEPFAR program has been starting to innovate in trying to meet the gap by experimenting with task-shifting, bringing workers from one category into a different category of skills, so that more workers are available to deliver the program.

We think that it's the first step, and we think that much broader reform is needed in the way that the U.S. does business and in the way that the international community steps up to the plate to deal with the health system -- the health worker crisis.

The fundamental gap is that health workers aren't getting paid. And the U.S. Government puts most of its money into contracts with U.S. organizations, U.S. academic institutions, and we bring Americans over there, and they set up offices and programs, and they do in-service training, but a lot of that money could be rechanneled and directed towards really empowering the local indigenous institutions and actually providing money for workers to get paid. Other donors, like DFiD in the U.K. and the Global Fund, are starting to reform the way they do business, to really fill this fundamental gap.

SUSAN DENTZER: What's your view on that, Ambassador Dybul?

MARK DYBUL: Well, I think Paul raises some very important points. I mean, there's no question -- and I think your listener from South Africa is absolutely right -- AIDS is tearing apart the health infrastructure. And the reason is, a lot of the healthcare workers are dying. A study in Kenya just showed that the majority of nurses that were being lost were dying, and we believe it was from HIV/AIDS. And it's also tearing the system apart because so many people are sick. Half of the hospitalizations in many of these countries are directly related to HIV-positive people, so you're increasing the burden on the health system tremendously with a lot of sick people, while you're destroying -- while you're taking apart the healthcare personnel that are there because they're dying from AIDS. And that's a terrible balance.

So, first thing you need to do, obviously, is intervene and protect the lives of the people who are health workers; and that's not as easy as it sounds, because a lot of people in the health community actually don't want to get tested, and we're trying to overcome that stigma.

I think we're also seeing -- one of the things you reported on in Rwanda is, when you provide care and treatment, the burden on the hospitalizations and health systems goes down by 30 percent in the first couple of months because people aren't hospitalized anymore.

But Paul raises a very important point about the long-term stability of the health system. In fact, about 80 percent of our partners are local institutions. Even when they're private organizations, they're supporting the public health infrastructure. For example, in Namibia virtually everyone in the public health sector providing antiretroviral therapy and doing counseling and testing is paid for by the U.S. Government through a contract mechanism with a long-term agreement for the Namibians to assume those people into their health system, because they just couldn't absorb that many people that quickly into their health system. Or, in Zambia we're supporting a rural retention scheme of the -- of the Ministry of Health to put people in rural areas, and keep 'em there. In Ethiopia, they have a mechanism for community health workers, to get 30,000 of them out there, two in every village, to provide general healthcare. We're paying, probably, for about 25 or 30 percent of them, because that's about HIV/AIDS.

So, I think Paul is right, we need to do innovative things. I wouldn't agree with him that we're not looking at innovative or creative ways. And a lot of the infrastructure for health is out of the public specter, about 50 percent in many countries, and so, we have to support that, as well. But I do think we need much more intelligence in novel approaches. We're working with the World Health Organization, we're talking with people, like Paul and others, who have got a lot of experience and insight. We've got a long way to go. I think a lot of progress was made, but I think the bottom line on every question you're going to ask is, we have a long way to go. We're only just beginning. Great success so far, but we've got a lot of things to do, and we've got to be very creative and innovative.

SUSAN DENTZER: Well, on that theme, one viewer, Francesca, from Tallahassee, Florida, wrote in, "What is PEPFAR not doing, and where is it not succeeding?" What would you say to that, Ambassador?

MARK DYBUL: Oh, I don't think we're succeeding yet in changing what I would call the donor recipient mentality in the world. We believe in partnership. And I'm afraid even some of our own partners don't yet get that. You know, this fundamentally --

SUSAN DENTZER: This is -- you're talking about countries now, or --

MARK DYBUL: No, I -- well, I think, countries, but also a lot of the people we fund, and our partners. I mean, this is a -- this is not Americans. I think Paul's right, at the beginning, Americans go over and start programs. But I am privileged to go to sites where, in the -- the first time you walk around, you walk around by a bunch of Americans; 6 months later, it's Namibians and Rwandans and Kenyans, very proud of their programs. And that's the way it should be. It's their programs.

We've got to -- I think one of the biggest problems is vision on this stuff. We have got to change the mentality and the approach so that we are -- and President Bush says this regularly -- we are there to support the Africans, we are there to support the people of Asia. We're not there to do the work, we're there to support them, to create their system, to create their hope. And I think we've got a ways to go there.

I don't think we're being as innovative in prevention as we need to be. We're starting to talk about prevention in combination prevention, like we talked about combination treatment. We have very good programs, but they're dispersed, and so, you'll get to kids in schools in one place, and kids in a church-based system in another place, and kids out of school in another place, but kids don't all stay in one place, they move from site to site.

We're not doing as good a job on epidemiology. We're learning that discordant couples, where one person is positive and one person is negative, because we've done so well with the youth in Uganda, are actually the highest rate of new infections in Uganda. People in regular partnerships don't use condoms, and if -- and fidelity is difficult, and abstinence is impossible. So, what we're doing is trying to focus on how we deal with discordant couples. So, we've got to do better at learning our epidemics, and changing our approaches based on it.

So, I think there's nothing we couldn't be doing better, as I said. I wouldn't say that we've failed anywhere. We've only been doing this for 3 and a half years now. But what I do think is, we need to concentrate, focus, and really tackle this epidemic in an aggressive and bold way, which is what we've been trying to do. I also think we need to do better at working with our international partners so that we are coherently supporting a national strategy. It gets back to the donors and recipients. It's not us, it's them. And we need to coherently support their programs.

SUSAN DENTZER: And, Paul Zeitz, what would you add to the list of things that PEPFAR is not doing or could be doing better?

PAUL ZEITZ: Well, I mean, I think we're at an exciting time, where we have a PEPFAR reauthorization, the next 5-year cycle is being developed now, and we have a political transition that's being competed for. And we're seeing some of the presidential candidates, for example, calling for a significant continuation of the program to keep pace with the spending increases that have been achieved so far to date. So, we have seven of the leading Democratic candidates, including Senators Obama and Clinton, that have pledged [through the Global AIDS Alliance Fund] to spend at least $50 billion over 5 years in the next phase of PEPFAR. They've also committed to looking into restructuring the way that we do foreign assistance, and developing -- building on experiences from PEPFAR from the Millennium Challenge Account, from the Global Fund, and really restructuring the way U.S. foreign assistance operates.

Mark's idea of partnerships is the right one, and he has been innovating and doing that, but he would agree, I'm sure, privately, I know for sure, that, you know, there are barriers within the way the system is set up, that there are -- you know, the contracting mechanisms and the bureaucracy is very dysfunctional and outdated, and the U.S. can do better, and we should do better. And voters care about making sure that every dollar that we provide in taxpayer money is having the biggest impact possible. And I don't think we're there yet.

And I guess I would couple that with another question that came in, sort of a broader sense, from Laura Heaton, of Alexandria, Virginia, who works with an organization actively involved with PEPFAR, and she said, "With the potentially large increase in persons knowing their HIV status as a -- as a function of testing programs underway in many countries, and getting on to treatment for a lifetime, where will the increased funding come from, and is it sustainable in any realistic sense?"

Ambassador, why don't you take that one on.

MARK DYBUL: Well, I think what's -- there are multiple parts there, let me start with what's -- where we're heading. And that is, one of the extraordinary things about PEPFAR is -- I really think -- and President Bush says this all the time, "To whom much is given, much is required." It emanates from what is best in Americans and American policymakers, people coming together in compassion, generosity, and a sense of service. And that is why, because I think it is a fundamental value of the American people, it's had strong bipartisan support throughout the 4 years it's been operative. And we've seen that now with the change in the majority in Congress. So, there's strong commitment by the Members of Congress, by the President, to what is called "reauthorize" or "renew" the -- for the next 5 years of the emergency plan, and the -- and every indication is, the American people will continue to support and to serve, because that is so much a part of who we are.

And that conversation is ongoing, and it -- and it's very positive, and the Members of Congress are moving to have a reauthorization. We think sooner rather than later is a good approach, but it's a great relationship, and things are moving.

In terms of the sustainability, I mean, I think there are different types of sustainability here. One type of sustainability is where countries can pay for everything on their own. And, to be honest, except for a few countries -- and there are some who we will expect to see and are already talking with, them to increase their proportion of contribution to their epidemic, and President Bush has talked about these partnership compacts, where we're going to sit down with all countries and say, "We're going to work with you, we're going to support you. How are -- how are we going to work together?" which includes financial resources from countries themselves to their ability -- but the fact there is that many of these countries don't have the resources yet to get there, which is why ultimate development -- part of the President's bold development agenda is building trade, the Millennium Challenge Corporation, to build the ability of countries to fully develop, so that, over time, they can pick up -- these programs will be there. But, for now, we'll have to support a lot of this.

But, what "sustainability," to us, means, for now, is, countries fully own their programs, and that's what Paul was talking about, the -- that we need to get to the point where we're supporting their efforts as true partners, and then, over time, you have a more sustainable program.

So, that's probably a little bit more explanation of "sustainability" than you wanted, but "sustainability" is a very complex word, and I think we have to be careful to not be too nonspecific when we talk about it.

SUSAN DENTZER: Paul, as you noted, a number of the Democratic candidates for President have proposed spending $50 billion to fight global HIV/AIDS. The President had earlier proposed $30 billion on -- for the PEPFAR reauthorization. And Stephanie Marienau, of Nashville, Tennessee, wrote, "Do you think the pledges from these presidential candidates are affecting the PEPFAR reauthorization debate?" What do you think?

PAUL ZEITZ: Well, very much so. I think that we've -- we're seeing a bipartisan recognition that we need to go beyond the current framework of PEPFAR in order to keep America's commitment. As Mark said, we are a generous and compassionate country, but it's also in our interest to continue to invest in this -- successful parts of the program. And we expect that there will be bipartisan support for, you know, the -- a $50 billion reauthorization, and, by having these pledges come forth already from some of the Democratic candidates, there's a lot of statements that the Republican candidates are also starting to make, and we hope that they'll be making their plans known to all of us in the buildup to World AIDS Day, which is memorialized on December 1st each year.

So, we're expecting, in the next couple of weeks actually, to hear from the Republican candidates, as well, where they stand on supporting the continuation of the successful parts of President Bush's effort.