The Ebb and Flow of Successes and Setbacks
November 30, 2009 –Some 33 million people in the world live with HIV/AIDS; 1.1 million of those people are in the United States, according to the Centers for Disease Control and Prevention. As World AIDS Day approaches, many will evaluate how far we’ve come in terms of research, funding, care and treatment. Former U.S. Global AIDS Coordinator and Ambassador Mark Dybul says there are many successes in the fight against the virus and disease, but with those successes come some setbacks. The Georgetown alumnus of the College and the School of Medicine now serves as co-director of the O’Neill Institute for National and Global Health Law and senior adviser to the university president. Dybul talked with the Blue & Gray about HIV/AIDS funding, the gains in vaccine research and the slow progress in policy changes.
Q. What kinds of trends are there in the treatment of people living with HIV/AIDS?
A.There’s a trend of treating HIV-positive people earlier in the disease as a method of prevention to reduce their viral loads so they’re less likely to transmit the virus. We also know now that male circumcision and other interventions on prevention, including behavior change and teaching life skills programs, can significantly reduce the spread of the virus and disease.
Q.Has the global economic crisis had an impact on funding for the fight against the virus?
A.Global financing is really hitting a bit of a plateau, which makes it increasingly difficult to reach global goals. I wouldn’t blame it on the global economic crisis. There is interest in other areas of global health right now -- particularly maternal and newborn child health.
So when you have countries like Norway donating $5.3 million toward the Global Fund to Fight AIDS, Tuberculosis and Malaria, it’s not entirely true that there’s new money for global health. It’s just that some areas of global health are getting increases while others are getting less. It’s very difficult to keep up the funding for treatment, research and prevention. HIV is very expensive, and there’s this shift right now in the global health community. Certainly the financial crisis is a contributor, but it’s hardly the only reason.
Q.Have there been recent gains in finding effective treatment against HIV/AIDS?
A.It’s night and day in terms of where we were. Before President Bush announced the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR), we didn’t believe antiretroviral therapy was possible on a global scale. We’ve had some good news with vaccines this year, but we also had some bad news with research on microbicides.
There was some success in an HIV vaccine trial in Thailand that showed for the first time that vaccination could protect people against infection with the virus that causes AIDS. However, there were a few studies for microbicides that didn’t show any benefit in fighting the virus or disease.
Q.How long have you been involved with HIV/AIDS research?
A.I have been involved since my fourth year in medical school. That was in 1991. Back then, we didn’t have antiretroviral drugs or the combinations that we have now. We did not have proof that male circumcision was an effective method to prevent HIV. We had no knowledge of the immune response to HIV. Now, we probably have more information about the virus and the immune response than any other disease – certainly more than any viral disease.
When I was at the National Institutes of Health, my research focused on immunology and virology, particularly therapeutic intervention. I continued that research when I went to work for the State Department. Now, I’m doing more research on policy at the O’Neill Institute.
Q.What were some of your biggest accomplishments while working on the PEPFAR?
A.One is passing two major laws and creating a $19 billion program that is now, after five years, a $40 billion program for prevention, care and treatment.
During the last presidential administration, we started a policy change to the travel ban on HIV-positive people coming into the country. We already allowed HIV-positive people into the country, but there was a special 10-day waiver for HIV-positive people that proved cumbersome and discriminatory.
We were one of the few countries in the world that had that policy left over from the early days of fear about how HIV and AIDS were transmitted.
When PEPFAR was reauthorized by the Obama administration the policy change was completed. He announced it last month during a White House ceremony, where he reinstated the Ryan White program to help people with HIV and low incomes.
Q.How does your past work relate to your current work at the O’Neill Institute?
A.The work I do now on HIV still relates to pre-exposure prophylaxis, or experimental HIV prevention strategies such as the use of antiretroviral drugs. I look at the foreign policy regulatory, legal and ethical issues as they relate to clinical trials and proof of deliverability.
Q.How much do nations spend on HIV/AIDS treatment, care and prevention, globally?
A.Globally, we’re at about $10 billion a year on HIV. The United States provides about 55 percent of the global funding.
Q.Why is it that when there’s progress made in one area of the world, there seems to be a spike in the spread of the disease in another region?
A.There is no such thing as a global HIV/AIDS epidemic. There are many, many epidemics around the world and very many epidemics within countries. Africa has one of the most mature epidemics. It’s probably where HIV/AIDS started. The transmission mode in the United States is mostly through heterosexual contact, particularly among African-Americans, particularly in the cities, particularly among women. In Eastern Europe, it’s mostly an intravenous drug and prison epidemic. So they are very different in terms of where the at-risk populations are how it gets spread. Every country has very different and multiple types of epidemics.
Q.What do you think should be on the focus for the current presidential administration?
A.I really don’t want to get into what this administration should or shouldn’t do. But some of the challenges the current administration has to face include: how to deal with financing and global funds, how to most effectively deal with prevention and how to advance the research agenda. The issues are almost limitless as they were in the last administration.
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