Global AIDS Coordinator Says the Fight Is On

The conversation about the global AIDS crisis with Ambassador Mark Dybul, the U.S. Global AIDS Coordinator. Dyul discusses President Bush's pledge, earlier this year, of $30 billion to combat HIV/AIDS throughout the world over the next five years.

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MICHEL MARTIN, host:

I'm Michel Martin. This is TELL ME MORE from NPR News.

Just ahead: fighting racism and violence in international sports.

But first, we're going to continue our conversation on the worldwide spread of HIV/AIDS. We've been speaking with Raphaele Dambo. She's a program officer at the Caribbean Coalition of National AIDS Program Coordinators. She's standing by.

But joining us now is Ambassador Mark Dybul. He is the U.S. Global AIDS coordinator. He's on the phone with us from California.

Ambassador, welcome. Thanks so much for speaking with us.

Ambassador MARK DYBUL (U.S. Global AIDS Coordinator): Thanks for having me on.

MARTIN: And as you - I think you heard, Raphaele was talking about the feminization…

Ambassador DYBUL: Mm-hmm.

MARTIN: …of HIV/AIDS. Is that a worldwide trend?

Ambassador DYBUL: It's certainly a significant part of the epidemic in hard-hit places, such as Sub-Saharan Africa, Latin America, Asia. So, yes, it is a worldwide problem.

MARTIN: And, ambassador, earlier this year, President Bush pledged $30 billion to combat HIV/AIDS throughout the world over the next five years. That actually doubles an initial $15 billion commitment that he announced in 2003. The U.N. report says that globally the number of cases of AIDS has actually leveled off, and the number of new infections is falling. Do you think that the president's program is in part responsible for that? And if so, why?

Ambassador DYBUL: Well, we've certainly been working awfully hard over the last four years to help turn the tide against the epidemic, and that first $15 billion made it the largest international health initiative in history for a single disease. So we've certainly been out there having an impact in prevention, care and treatment. And I think it's important that you don't just need to prevent the infections, but you need to provide care and treatment. And this initiative has supported treatment for more than a million people globally, and the president will announce new numbers on Friday.

But we've also been out there trying to affect behavior change, so that people will change their sexual behavior - something that's started before this initiative, but we've certainly supported the expansion of it. And the data are very impressive, that people are delaying sexual activity, people - young boys in particular are reducing their sexual partners, which is good for women because fewer boys are going after girls, who are going after younger men or older men who are preying on younger women. But behavior change takes time, and so it's going to take a long time, but we're doing the program starting with young children to try to change their behaviors.

MARTIN: Raphaele, from your perspective, has the U.S. commitment to fighting HIV/AIDS made a difference in your region?

Dr. RAPHAELE DAMBO (Program Officer, Caribbean Coalition of National AIDS Program Coordinators): In terms of care and treatment, definitely. I think since 2001, extensive efforts have been made in the area of care and treatment. But we know very well that care and treatment is not efficient without efficient prevention programs. Care, treatment and prevention go together hand in hand, and this is something that we have now realized in the Caribbean.

There's been a lot of information, communication programs about knowing the disease - how it works, what it does to your body, how not to get it. But we haven't seen, really, behavior change following those campaigns of communication. So the idea now is that now we have pretty decent care and treatment programs. We need to strengthen our prevention programs, and I think this is definitely a challenge for these funding agencies, especially the U.S. agencies.

MARTIN: What are you saying? Is that these public service campaigns just don't seemed to be working in your area?

Dr. DAMBO: They do work in terms of knowledge. People know. People know about the disease. People know how to get it and how to not get it. But the fact of the matter is it's not because you know something that you are going to change the way you do things, and this is the gap that we have to fill.

MARTIN: That's interesting. So despite the successes, ambassador, I want to just sort of broaden the conversation. We've seen increases in some region. I don't think it's also fair to point out that part of the reason that the statistics show a leveling off of the infection or the epidemic worldwide is that the measurement, the tools of measurement have changed. So I think that is something that is fair to mention.

But where do you think - ambassador, I wanted to ask where do you see the most success in curtailing the epidemic, and where are some regions of the world that we're still concerned about, where the epidemic seems to be increasing, or not improving?

Ambassador DYBUL: Well, it is true that a lot of the change is due to better measurement - which also, by the way, shows that health capacity is being built to do the measuring. But I think where we have seen clear change - behavior change, where we've seen documented behavior change, and I agree completely that this is one of our problems. Awareness does not lead to behavior change. Many people know smoking is harmful, but they don't change - don't stop smoking anyway. And it's the same with sexual behavior.

So Kenya and Zimbabwe and now, Côte d'Ivoire have very good evidence for reduced behavior change - delaying when to become sexually active, reducing the number of your partners, correct and consistent condom use was frequently called ABC. Uganda actually has data now for several years showing such behavior change with a decline in prevalence. One of the things UNAIDS reported is there's evidence for such behavior change in about - in many countries. And I have 35 of the hardest hit countries, and we are seeing these types of behavior change.

So it takes time. People don't just do this overnight. But we're starting to see the types of change that we think will reduce prevalence or HIV rates over time. And Africa is the area we're seeing the most stabilization and the most opportunity in terms of, right now, changes in behavior. Where we saw the greatest increase right now is in Eastern Europe, with 150 percent increase, and that's a different type of epidemic. That's mostly driven by injection drug use.

MARTIN: And what - I was going to ask you - Raphaele, let's go back to you, because I got the impression that you're kind of frustrated. In a way, you sort of feel like you're working on all cylinders, but you're still not seeing the kinds of changes that you would like to see. And that has to be frustrating. But do you have any sense of why? Is there any - do you have any sense of what might make a difference?

Dr. DAMBO: Well, as you - because (unintelligible) being able to change takes time, and sometimes when you've been working and you see for many, many years and you don't really see things changing, you tend to get frustrated. So I think we have use maybe a little patience. But in the Caribbean, we are so - what is frustrating sometimes is the fact that even at the highest level, the political level, the decision makers and policymakers, they are still some level of discomfort talking about sex and sex-related issues.

And, of course, this will be translated into programs that do not really address the issues that need to be addressed. You know, they don't address them properly. So it's sometimes frustrating not to see a really bold initiative or political leaders really not taking a stance. But…

MARTIN: Ambassador, do you find that in your dealings with world leaders? Do you find that there's still parts of the world where the sort of political leadership does not want to admit that this is happening in their countries, and is less reluctant to be as aggressive as perhaps they could be in fighting the problem?

Ambassador DYBUL: Oh, there's no question about it. We're also seeing a very important change in a number of places. You know, some of the most successful countries in Sub-Saharan Africa have been where the political leadership has been strong - President Mogae in Botswana, President Museveni in Uganda, President Kikwete now in Tanzania. So we've seen strong political leadership. We're also seeing the first ladies involved.

I think it's important, too, that political leadership can't just be the political class. You know, politicians, ministers of health can tell kids to change their behavior, but it's not very effective. We need the community leaders engaged, and this is a very important effort we're trying to support.

Really, what it comes down to is the people in the country changing their lives, and their communities coming together to transform what is occurring in their countries. And that's what we're trying to support, because we can't do that from America. We should even try to do it from America. We need to support the individuals, the communities, the nations to change and transform. We're seeing…

MARTIN: But Raphaele made the point earlier - I'm sorry, ambassador. Raphaele made the point earlier that some of this has to do with the fact that women in these countries don't feel that they have the power to negotiate their own kind of sexual choices and future, or that economically, they feel so dependent on men that they don't feel that they have the right to negotiate these issues in a way that would help protect them. So is there anything that you can do about that?

Ambassador DYBUL: Oh, absolutely. And dealing with gender inequality is a fundamental part of what we need to do and are doing. In fact, last year, we dedicated around $440 million for 830 programs that deal with gender inequality, including violence. One of the biggest areas is getting men to change their behavior, because the men change their behavior, that is freeing for the women. So to get older men not to prey on younger women, to get young men not to prey on young women, to have those sexual habits of delaying when you become sexually active, to reduce your partners, that's helpful to women.

We're also working to empower women in a number of different ways, including some economic opportunity. Although, I'll have to say there, the data don't necessarily mean we'll see a reduction in prevalence. So empowering women is important. The African first ladies have been out there in front trying to do that, but we have to do that at the community as well. We need to change community norms, which means dealing with the leaders in the community.

MARTIN: All right.

Ambassador DYBUL: There are actually - is a church in Zimbabwe, for example, that used to be a polygamous church that changed to monogamous church because of HIV/AIDS. So we're starting to see these changes, but, you know, the comments that we've made are - these are generational changes. They're not going to change overnight.

MARTIN: All right. Ambassador, I'm sorry, we're going to have to leave it there.

Ambassador Mark Dybul is the U.S. Global AIDS coordinator. He joined us on the phone from California. We're also joined by Raphaele Dambo. She's a program officer at the Caribbean Coalition of National AIDS Program Coordinators. She joined us on the phone from her office in Trinidad.

Thank you both so much for speaking with us.

Dr. DAMBO: Thank you very much.

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