With Its Future in Doubt, One of the Architects Makes a Case for PEPFAR | IDWeek 2023

Mark Dybul

The ambitious U.S. program to combat AIDs and make retroviral therapy available internationally succeeded because of data-driven approach that empowered health officials and communities where it was being implemented, said one of the early architects of the program.

Mark Dybul, M.D., the keynote speaker at the closing plenary session today of the IDWeek 2023 meeting in Boston, also pushed against versions of the early history of the program, called U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), that don’t credit former George W. Bush.

“A lot of people don’t want to believe (that Bush deserves credit). They want to believe it was some faith-based organizations or Tony (Fauci) whispering in his ear that you shoulddo this. Total nonsense. It started with him giving a directive, ‘I want something big on HIV,’” said Dybul.

Dybul is a professor of professor in Georgetown University’s Department of Medicine and the co-director of the university’s Center for Global Health Practice and Impact. He was in charge of implementing the PEPFAR program during some of its early years from 2006 to 2009, and was executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is supported by multiple countries, including U.S., from 2012 to 2017.

PEPFAR and the distribution of retroviral medications it enabled, particularly in Africa, has been credited with savings 20-25 million lives during its 20-year existence. But reauthorization of U.S. funding for program has stalled in Congress because some Republicans want tighter anti-abortion restrictions on organizations receiving PEPFAR funding.

“PEPFAR reauthorization is failing right now because of abortion, astoundingly, because PEPFAR is forbidden from spending any money on abortion,” said Dybul, adding the abortion's relationship to the program had been "twisted."

Dybul’s speech was preceded by a recorded message from the Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization.Ghebreyesus praised PEPFAR and alluded to the uncertainty about reauthorization, saying that “we’re now at a critical juncture as funding for PEPFAR and other life-saving programs are under pressure.”

Dybul added that although abortion and PEPFAR have been discussed publicly, behind the scenes, transgender issues come up. “Absurd,” said Dybul. “You can’t fight HIV if you don’t deal and learn and grow and support the LBTQ community. These human rights issues are at the core of why PEPFAR might not be reauthorized. But these are not new issues. We have been meeting them for 20 years. We have to figure out a solution to this.”

Dybul suggested taking a pick-your-battles approach as he described dealing with Muslim and conservative Christian leaders in Nigeria when he was executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. “What they fundamentally said is, ‘Don’t push us on marriage or we’ll fight you. But if you are talking about treating people who are LGBTQ, they’re our brothers and sisters or daughters or sons, they must have therapy.’”

Aside from abortion debate, PEPFAR has been criticized for branching out and straying from its purpose as an AIDS effort. In addition, some experts criticize global health program that focus on a single disease as undercutting the broader development of healthcare systems in poorer countries.

Dybul said that because PEPFAR's HIV treatment and prevention programs require sustained efforts, they differ from vaccination pr ograms, and that PEPFAR wound up creating the infrastructure for healthcare systems in many countries. “You needed to build the systems that were necessary for daily therapy, the human resources systems, the logistics systems, the supply chain management systems, communications systems — everything needed to be built.”

Dybul traced the success of the PEPFAR to incorporation of principles from 2002 “Monterrey Consensus,” the guiding document that emerged from United Nations meeting on international development in that Mexcan city. Those principles included taking a results-based approach (as opposed to just measuring success by the amount of allocated funds), good governance, and giving countries where the programs and projects are being implemented control over those programs and projects.

Recently, Dybul said “we have withdrawn some of that country ownership and gone back more to dictating what happens in the country. When that happens, the countries withdraw from the program.” He credited John N. Nkengasong, who as U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy oversees PEPFAR, with working to remedy the situation.