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Welcome to "Ask the State Department" -- an online interactive forum where you can submit questions to State Department officials.

Dr. Mark Dybul discussed the progress of President Bush's Emergency Plan for AIDS Relief, the largest international health initiative any nation ever has undertaken directed at a single disease.  The event took place Thursday, April 13 at 4:00 PM.

Dr. Mark Dybul, U.S. Deputy Global AIDS Coordinator
Dr. Mark Dybul, U.S. Deputy Global AIDS Coordinator Biography

April 13, 2006

Dr. Dybul:

To all those who are reading this chat, thank you for taking the time to participate, and thank you for your interest in the global HIV/AIDS emergency. There is a great deal that governments can do to combat this pandemic, but we can never do it all - we need ordinary people involved too, both in the U.S. and around the world. So thank you for your interest.

Let me begin with a few comments on the U.S. President's Emergency Plan for AIDS Relief, also known as PEPFAR or the Emergency Plan. In 2003, President George W. Bush launched the Emergency Plan, a five year, $15 billion initiative - in fact, it's the largest international health any government has ever undertaken focused on a disease in history. The Emergency Plan aims to support treatment for 2 million HIV-infected people, support prevention of 7 million new infections, and support care for 20 million people infected and affected by HIV/AIDS, including orphans and vulnerable children.

America has followed through on the President's commitment to lead the fight against HIV/AIDS and now leads the world's nations in its level of support for the fight. With the strong support of Congress and the American people, the United States committed approximately $2.4 billion to the Emergency Plan in fiscal year 2004, $2.8 billion in 2005, and $3.2 billion in 2006, and the President has requested over $4.1 billion for 2007.

With these resources, PEPFAR is implementing the most complex and diverse prevention, treatment, and care strategy in the world - and achieving remarkable results. During this hour we'll have a chance to discuss some of those results. If you'd like more information, have a look at Action Today, a Foundation for Tomorrow, our second annual report to the U.S. Congress on the results achieved by PEPFAR and its partners in host nations in its first two years of implementation. You can read the report, or a brief highlights document, here: http://www.state.gov/s/gac/

With that, I'll turn to your questions.

Melanie writes:

Given that TB is the biggest killer of people living with AIDS, how much money is being spent to support TB-HIV collaborative activities in 2006 through PEPFAR - and is this separate from USAID spending?

Dr. Dybul:

Your question makes an excellent point. Tuberculosis is a deadly airborne disease and, as you note, a leading cause of death in those living with HIV/AIDS.  Of those infected, approximately 10% per year develop active TB.  It is vital to treat people with TB to prevent illness and death, as well as to prevent its spread to others. Over 50 percent of HIV-infected people in many areas of the 15 focus nations of PEPFAR are co-infected with TB. The Emergency Plan thus monitors activities dedicated to people living with HIV/AIDS-TB co-infection.

The Emergency Plan supported TB care and treatment for approximately 369,000 co-infected people in the 15 focus countries during fiscal year 2005.  The priority is diagnosis and treatment of active TB (including directly observed therapy, or DOTS), with support also provided for diagnosis and treatment of latent TB infection to prevent the development of active disease, and for general TB-related care.

From Emergency Plan funds in the 15 focus countries alone, I believe approximately $40 million is devoted to TB/HIV care in fiscal year 2006. This is in addition to sizable U.S. Government TB programs, conducted by USAID and others, beyond the TB/HIV programs that are part of PEPFAR. Thanks for your question.

Elliot writes:

AIDS/HIV is a worldwide issue, so why is PEPFAR only working in 15 countries?

Dr. Dybul:

I particularly appreciate this question because it gives me a chance to clear up a common misconception. PEPFAR is the single umbrella program for all existing and new U.S. Government (USG) international HIV/AIDS activities, including HIV/AIDS programs of all USG agencies and departments in over 120 countries. Within those countries, PEPFAR includes dramatically ramped-up bilateral programs in 15 severely affected nations that account for approximately one-half of the world's HIV infections - we refer to these as "focus countries." So it's true that we are placing great emphasis on these 15 countries - 12 in Africa, as well as Vietnam, Haiti, and Guyana. And our intensive efforts in these nations are producing valuable lessons learned that we are using in the over 100 other countries where we have programs. Over time, we're gradually expanding our management and reporting systems, for example, to a growing number of these countries.

I should note that there are other elements of PEPFAR in addition to the bilateral USG programs I've mentioned:  support for international HIV/AIDS research activities; support for the Global Fund to Fight AIDS, Tuberculosis, and Malaria and other multilateral HIV/AIDS organizations (such as UNAIDS and WHO), and more. So PEPFAR really is a multifaceted, worldwide effort.

M.G. writes:

I have been reading a lot about the number of orphans in Africa.  What is United States doing to help these children?

Dr. Dybul:

Thank you for focusing on this issue. I've spent a lot of time visiting sites that serve orphans and vulnerable children (also known as OVCs for short) in Africa and elsewhere, and the needs are immense.

Our starting point is this:  we must do all we can to strengthen families living in the shadow of HIV/AIDS by prolonging the lives of parents and caregivers. In addition to working to make the full spectrum of prevention, treatment, and care available to families, the Emergency Plan supports efforts - many by community- and faith-based organizations - to provide both immediate and long-term assistance to vulnerable households. Even the best program for an orphaned child can never be as good as having his or her parents alive and well.

It's important to remember that these are children, not numbers, but the numbers are important too -- last year the Emergency Plan supported care for over 1.2 million OVCs. Care activities under the Emergency Plan emphasize strengthening communities to meet the needs of OVCs affected by HIV/AIDS, supporting community-based responses, helping children and adolescents meet their own needs, and creating a supportive social environment to ensure a sustainable response.  The Emergency Plan supported training or retraining for approximately 75,000 people in caring for OVCs, which is essential for a response that can be sustained over the long haul.

After family, the community is the next safety net for children affected by HIV/AIDS, and we support activities that include community-based initiatives for OVCs. Linkages have been established to basic care for physical survival (including health care and nutrition), economic support, education and vocational training, emotional support, and protection (including birth registration, inheritance protection, and protection from violence and exploitation). The Emergency Plan works with its governmental and nongovernmental partners to increase awareness, seeking to foster leadership that helps to create a supportive environment for OVCs. We also seek to ensure that governments protect the most vulnerable children through improved policy and legislation and by channeling resources to community efforts to support OVCs.

There's much more to do, but it's a start. Again, many thanks for raising this issue.

Jen writes:

I've heard that AIDS is becoming a problem in Asia. What work are you doing in Asia?

B.K. writes:

I keep hearing about the fight against HIV/AIDS in Africa, but where else is the U.S. working to combat the disease?

Dr. Dybul:

Let me try to address both of these questions at once. As I mentioned earlier, the President's Emergency Plan supports programs all over the world. We actually have a neat map on our website that shows them all. Here's the link: http://www.state.gov/s/gac/countries/

After Africa, Asia is indeed the continent with the next biggest HIV/AIDS emergency. Epidemics in many countries in Asia are in a period of transition. Though rates of HIV infection are low compared to some other regions of the world, the large population of the region means that low levels of infection may still result in a large number of people infected with HIV.

We're working in partnership with an incredibly diverse group of Asian nations, from countries of the former Soviet Union in central Asia, to the very populous countries of South Asia, to the Middle East, to the Far East. The epidemics vary widely from one nation to another, and our activities are as diverse as these nations. I should note that Vietnam is one of PEPFAR's 15 focus countries and thus receives intensified support, but that's just one program among many we support in Asia. India is believed to rank second only to South Africa in terms of the absolute number of people living with HIV/AIDS, and thus our partnership with that nation is also very substantial.

Thanks to both of you for these questions.

I.M. writes:

Do programs and countries receiving PEPFAR money still have to emphasize abstinence over condom use as a means of protection from HIV/AIDS? Or have US policies realized that sex is a natural and human activity the world over?

C.G. writes:

We are all aware of the fact that there are 3 ways to face HIV/AIDS; I mean faithfulness, abstinence and condom. My question is to know, why when organizations struggling against AIDS communicate, they focus only on condoms? Are all the human beings unable to change their behaviors? Why not a "World Communication" saying: NO SEX BEFORE MARRIAGE! I think we can save many youth lives.

Dr. Dybul:

Here are two questions on the same topic, so I'll try to address them both together.

Today, the U.S. supports the most diverse portfolio of HIV/AIDS prevention strategies of any international partner: the ABC strategy to prevent sexual transmission, the expansion of programs that focus on mother-to-child transmission, on blood safety and safe medical injections, on intravenous drug users, on HIV-discordant couples, on women, on men, and on alcohol abuse, among other key issues.

ABC (Abstain, Be faithful, correct and consistent use of Condoms) is good public health, based on respect for local culture - it is an African solution, developed in Africa, not in the U.S. It provides comprehensive information so people can decide how to protect themselves. The national strategies of many host nations included the ABC approach, delivered in culturally-sensitive ways, even before the advent of the Emergency Plan.

New evidence shows that in a growing number of nations in Africa and the Caribbean, people have changed their behavior to avoid HIV, causing infection rates to drop. Here's a summary of the new data from two countries:

Zimbabwe: Science reported in February 2006 that among men aged 17 to 29 years in eastern Zimbabwe, HIV prevalence fell by 23% from 1998 to 2003. Even more impressively, the prevalence among women aged 15 to 24 dropped by a remarkable 49%, as a result of:

  • Abstinence (delay in sexual debut): Among men aged 17 to 19, the percentage who had begun sexual activity dropped from 45% to 27%, and among women aged 15 to 17, it dropped from 21% to 9%.
  • Being faithful: Among those men who were sexually experienced, the proportion reporting a recent casual partner fell by 49%.
  • Condoms: The proportion of women reporting an increase in condom use with casual partners rose from 26% to 36%; however, the proportion of men reporting condom use with casual partners remained essentially unchanged, as did the proportion among both sexes reporting condom use with regular partners.

Kenya: The Kenyan Ministry of Health estimates that HIV prevalence has dropped markedly from 1998 to 2003, approximately from 10% to 7%. The data point to:

  • Abstinence: delayed sexual debut, with median age for first sex among women rising from 16.7 to 17.8, and high levels of both primary and secondary abstinence (people who were sexually active who have been abstinent for at least one year) in teenagers of both sexes.
  • Being faithful: among 20-24 year old men, the percentage who reported more than one sexual partner dropped from over 35% to 18%.
  • Condoms: increased condom use among women who engage in risky activity.

Here's a link to the Zimbabwe study (accessible only to subscribers to Science, but hopefully that includes most of the HIV/AIDS implementers in the audience): http://www.sciencemag.org/cgi/content/summary/311/5761/620

It's clear: all three elements have important roles to play in a comprehensive response. The US is proud to offer strong support to the ABC strategies of our partner nations. Thank you both for raising this important issue.

Randy writes:

How do mothers pass HIV to their babies? What can be done to prevent mother to child transmission of HIV?

Dr. Dybul:

Your question highlights one reason for PEPFAR's family-centered approach. It is estimated that over 90% of childhood HIV infections result from transmission from mothers to their children during labor, childbirth, and through breastfeeding after birth.Preventing childhood infections through programs to prevent mother-to-child transmission (PMTCT, for short) has been one of the highest priorities of the USG in the fight against AIDS.

PMTCT programs offer preventive antiretroviral drugs to mothers and infants to prevent HIV transmission to their babies during labor and delivery. While short course single-drug prophylaxis to mothers and infants beginning during the onset of labor can reduce transmission by over 40%, more effective combination regimens have now been developed which can reduce transmission from around 30% to as low as 2% in a non-breastfeeding population.The Emergency Plan has been working with countries to help them incorporate these more effective regimens and develop plans to scale up implementation in coming years.

We are supporting national strategies to expand PMTCT programs as well as antiretroviral treatment for pregnant women and their families.This requires strengthening health care systems, including infrastructure and human capacity, and improving monitoring of PMTCT programs.  Through September 2005, the Emergency Plan provided support for PMTCT services for approximately 3.2 million pregnant women.Approximately 248,100 HIV-positive pregnant women in the focus countries have received short-course preventive antiretroviral drugs.Under internationally accepted standards for calculating infections averted, the Emergency Plan has supported programs that have prevented the infection of approximately 47,100 estimated newborns.In addition to short-course preventive drugs, PEPFAR-supported PMTCT services include follow-up after birth to ensure that exposed children receive adequate diagnosis and treatment for opportunistic infections.

The Emergency Plan has continued to support countries in moving toward the routine offer of voluntary diagnostic HIV testing, sometimes called the "opt-out" approach, in PMTCT and other health care settings.Progress has also been made in increasing the proportion of women who receive their results through expanding rapid testing to many USG-supported PMTCT sites. As these approaches are scaled up, they will allow the Emergency Plan to reach many more women in future years. Thanks for a great question.

S.T. writes:

How involved are religious organizations in fighting HIV/AIDS?

Dr. Dybul:

As anyone who spends much time in these hard-hit nations sees, many faith-based organizations are very involved in fighting the disease - and have been for many years.  Local community- and faith-based organizations often play critical roles as first responders to community needs, and often have access to hard-to-reach or underserved populations, such as orphans and people living with HIV/AIDS in urban slums or remote rural areas. When trained in program management and HIV/AIDS best practices, these groups often design the most culturally appropriate and responsive interventions. They often have the legitimacy and authority to implement successful programs that deal with sensitive subjects. In many of our PEPFAR focus countries, for example, more than 80 percent of citizens participate in religious institutions, and upwards of 50 percent of health services are provided through faith-based institutions, making them crucial delivery points for HIV/AIDS information and services. The Emergency Plan thus recognizes the value faith-based organizations can add to HIV/AIDS efforts -- in fiscal year 2005, approximately 25 percent of all Emergency Plan focus nation partners were faith-based. They are a big part of the success PEPFAR is having in pursuing its ambitious goals for prevention, treatment, and care.

Carrie writes:

How do you expect to reach your goals?  How are you tracking your achievements?

Dr. Dybul:

This is a great question with which to close today's conversation. The Emergency Plan has set goals of supporting prevention of 7 million new infections, supporting treatment for 2 million HIV-infected people, and supporting care for 10 million individuals, including orphans and vulnerable children as well as people living with HIV/AIDS - and doing all this in an accountable and sustainable way.

Let me share with you a quote from President Bush:  "New resources are not enough. We need new thinking by all nations. Our greatest challenge is to get beyond empty symbolism and discredited policies, and match our good intentions with good results."

Accountability is thus a hallmark of PEPFAR. Accountability depends on accurate information. The Emergency Plan is thus investing heavily in the tools needed to ensure that accurate information on results is gathered and fully utilized by the Emergency Plan and its host nations.

The test of our efforts is our results. After two years of implementation, PEPFAR has supported antiretroviral treatment for approximately 471,000 people worldwide (including 401,000 people in the 15 focus nations and 70,000 people in other nations). In two years, 3.1 million women in the focus countries have received PEPFAR-supported services to prevent mother-to-child transmission of HIV, and an estimated 47,100 infant HIV infections were prevented. In two years, 9.4 million people in the focus countries have received PEPFAR-supported HIV counseling and testing services. In FY 2005, 42 million people in the focus countries have been reached with evidence-based community outreach prevention efforts. PEPFAR supported care for nearly 3 million people in FY 2005, including 1.2 million orphans and vulnerable children and over 1.7 million people living with HIV/AIDS. For a wealth of information about the results achieved to date, see www.state.gov/s/gac.

I am convinced that U.S. leadership is making a tremendous difference in the fight against HIV/AIDS - our focused action is producing real results. But the fight against HIV/AIDS will only succeed and be sustainable with local partnerships and ownership. So just as important as the results noted above is the Emergency Plan's work with host nations to build quality healthcare networks and increase capacity while laying the foundation for nations and communities to sustain their efforts against HIV/AIDS.

Many doubted that HIV/AIDS programs could ever be successful on a broad scale in the world's poorest nations. But after two years of the President's Emergency Plan, it is clear that high-quality programs can work - and are working -- in many of the world's most difficult places. It's an exciting time.

With that, I'll close. Once again, many thanks to all of your for your interest in, and contributions to, the fight against HIV/AIDS.


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