Unexpected change

Few moves by former President George W. Bush invited praise from former President Bill Clinton. But on World AIDS Day last December, Clinton lauded Bush's HIV/AIDS program in Africa, as did President Barack Obama and Bill and Melinda Gates.

Its track record has been easy to read: Since its inception five years ago, the President's Emergency Plan for AIDS Relief (PEPFAR) has treated more than 2.1 million people living with the virus around the world. Prior to PEPFAR, only 50,000 people were receiving antiretroviral treatment for AIDS. When Bush received an award for PEPFAR's work in December, he deflected credit and instead asked Mark Dybul, who spearheaded the effort as U.S. global AIDS coordinator, to stand.

Before Obama took office, he asked the 45-year-old Bush appointee, who is a physician and also openly gay, to remain on the job. He also pledged to continue Bush's efforts, and Congress allocated $48 billion to fight AIDS, tuberculosis, and malaria. But shortly after the inauguration, Obama abruptly asked Dybul to resign. Dybul sent an email to staff in the State Department saying goodbye and left within the day.

Conservative pundits suggested the firing was a hat-tip to fringe activist groups that didn't like Dybul's emphasis on abstinence programs. But even the liberal editorial board of the San Francisco Chronicle called the move "unexpected, unceremonious and undeserved." The Obama administration has said little in response: "At the end of an administration, on Jan. 20, officials who are political appointees are required to submit their resignations and depart," said Robert Wood, spokesman for the State Department, which helps to oversee the PEPFAR program. "And that's all that was."

Eric Goosby, former head of the Clinton HIV/AIDS program, is rumored to be Obama's new pick. Currently Tom Walsh, the PEPFAR office's chief of staff, is directing the program. But a lack of clear succession leaves AIDS relief workers concerned that lack of leadership could weaken what has been a success story.

PEPFAR promotes a grassroots distribution of antiretroviral treatments through local clinics and churches in Africa and around the world. With expenditures totaling $18.8 billion over the past five years, it is the largest program focused on a single health pandemic-AIDS takes 8,000 lives daily. Since PEPFAR has a very local presence in over a dozen countries, Dybul's quick departure in Washington spread uncertainty literally around the world, leaving little chance to communicate what was happening to workers in the initiative around the world.

As a homosexual himself, Dybul has faced criticism not from religious conservatives but from some health and reproductive rights groups that have been uneasy with what they saw as an abstinence-centered program, instead of a focus on contraceptives. "Some of the policies have not been driven purely by science," said Kelly Castagnaro, spokeswoman for the International Women's Health Coalition, referring to abstinence programs that were part of PEPFAR.

Abstinence-only programs are ineffective, she said, citing research from the Government Accountability Office that has itself been called into question ("Abstinence under attack," April 29, 2006). Other groups have expressed concern that PEPFAR doesn't address the "human rights" of sex workers because federal funds were not allocated to help them.

While many working with organizations under PEPFAR don't apologize for abstinence education, they also dispute the assertion that they employ abstinence-only approaches. In fact, organizations using PEPFAR funds distributed over 2 billion condoms.

Esther Gwan, the HIV/AIDS director for World Relief who worked for two years in Rwanda through the PEPFAR program, is worried about the direction the AIDS fight will take following Dybul's resignation. The use of faith-based organizations to bring relief is critical, she said, and the decision to remove Dybul prematurely could mean that the grassroots, faith-based approach will be reworked. "His resignation-it shakes us," she told me. One change she fears is that PEPFAR money will go directly to governments. That's what hasn't worked in the past: "It would go through a lot of layers of overhead cost, and the beneficiaries would have nothing, let alone the most vulnerable."

The grassroots approach-distributing money directly through local infrastructure instead of through some global fund-is PEPFAR's strength, relief workers agree, and that basic premise is needed to keep the program effective, despite a poorly handled transition of leadership.

Dozens of activist groups called for the State Department to have an open process in the selection of the next director, writing a letter requesting Secretary of State Clinton to convene a "multi-stakeholder committee." "Instead of immediately moving to fill the position vacated by Ambassador Mark Dybul, you instead pursue a innovative, competitive, merit based process for selection of the next head of OGAC [Office of the Global AIDS Coordinator]," the letter reads. But some relief workers have said such a committee would allow fringe groups with specific agendas on AIDS to unduly influence the selection.

Kay Warren, who co-directs Saddleback Church's AIDS initiative and is the wife of pastor Rick Warren, said that "the administration had every right to appoint a new person," but the problem "was the abruptness." She praised Dybul's work and emphasized her confidence that the Obama administration can pick the right person to fill his shoes.

Elizabeth Styffe, who also co-directs the Saddleback program and has worked closely with PEPFAR, said some Christian groups refused to offer antiretroviral treatments as part of their AIDS programs, leading to the frustration some health organizations expressed toward the abstinence approach. "We have a moral mandate," Styffe said. "God by His grace has made treatment available to people."

"We definitely still believe in PEPFAR, even if some of the things I care very much about change," Warren said. "President Obama has already lifted the Mexico City [policy]-that's a worldview issue . . . I don't agree with. There will be some battles about sexuality, family planning. There are a lot of things that are going to be different."

But the fight against AIDS has never relied solely on government programs, emphasize Styffe and Warren. Because the pandemic spans the globe, groups need the help of governments, businesses and nonprofits, including churches.

The lack of transition between directors, though, means Dybul "can't give his successor insight into what is happening," Gwan said, and she worries that it will lead to "a second program that starts from zero with no reference to the past."