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Skriven 2005-11-30 23:33:24 av Whitehouse Press (1:3634/12.0)
Ärende: Press Release (051130d) for Wed, 2005 Nov 30
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Press Briefing by Conference Call with Dr. Mark Dybul, Deputy Global AIDS
Coordinator on the President's Plan for Emergency AIDS Relief
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For Immediate Release
Office of the Press Secretary
November 30, 2005

Press Briefing by Conference Call with Dr. Mark Dybul, Deputy Global AIDS
Coordinator on the President's Plan for Emergency AIDS Relief



2:30 P.M. EST

DR. DYBUL: (In progress) -- the resources. And so the programs have moved
rapidly, with money moving rapidly. And what really is happening is that,
as we say, the heart and soul of the emergency plan is to support national
strategies, to support governments at the national, provincial, state,
local level, non-governmental organization, faith-based, community-based
organizations, to move as rapidly as possible on prevention, care and
treatment to achieve the goals the President set for the initiative, which
will be achieved through supporting national strategies and approaches.

And tomorrow, President Bush will commemorate World AIDS Day and provide an
update on where we are in terms of the emergency plan support, but as you
all might remember, that in March of -- at the end of March of this year,
we were well on our way with the support that's been provided, and that
progress has continued.

I think it is important to reemphasize, again, that this is people
in-country, coming together, moving their strategies forward, and
effectively coming together as communities. It's not too dissimilar from
what we saw in the United States where communities came together and said,
enough is enough, we're going to do something about this epidemic. And what
the emergency plan has done is provide resources, both financial and
technical, to allow those people to move forward, to provide the support
for that to happen.

And it's extraordinary what's happened. And the biggest change for someone
who goes over there fairly regularly and visits the country at six-month
intervals is an extraordinary hope, a change, a fundamental change in how
people view the epidemic and what they can do about the epidemic. And
that's a remarkable, remarkable thing.

And the only other thing I would say is -- to reemphasize the strategy of
the emergency plan is to, in those $15 billion, to support through
bilateral programs, $10 billion for 15 focus countries of the 123 in which
we operate; to rapidly scale up prevention, care and treatment services on
a national level -- not pilot studies or pilot projects, which are
fundamentally different than the national rollout, what's necessary for a
national rollout.

And because we've been in some of these focus countries as a government --
with government experts and personnel working on the ground,
shoulder-to-shoulder in-country, with our many partners, we had the
greatest ability to move as rapidly as possible to fight in an emergent way
the epidemic through a larger commitment to bilateral programs.

But the Global Fund is a fundamental piece of what we do, as well, and is a
fundamental piece of the emergency plan. We are still, by far, the largest
contributor to the Global Fund. About 30 percent of all resources for the
Global Fund come from the American people, as part of President Bush's
emergency plan for AIDS relief. And so about a third of all our -- 30
percent of all grants that come out from the Global Fund come from the
American people, as well. And that's a fundamental piece of the emergency
plan.

And we think it's important that all countries look at where they can move
the most rapidly on AIDS with their support. If you have a strong bilateral
program and can move most rapidly there, put resources there. If you don't
have bilateral programs where, really, out of a handful of countries in the
world, all don't -- most countries don't, then the resources should be
going to the Global Fund.

Still, the United States is providing approximately 50 percent, or half of
all resources for HIV/AIDS among international government. And that
fundamentally needs to change. And so we need everyone in the world to step
up to the same type of leadership the American people has responded -- and
World AIDS Day is an important day to call for that. So I don't know if
that generated any questions.

Q On the world is falling substantially short of the three-by-five goals --
from our point of view, what are the big holdups in that? Is it that the
resources are there, as you have said, but national governments are not
rolling out infrastructure quickly enough and bringing in the patients, or
are there other holdups -- what's the problem?

DR. DYBUL: Well, actually, things are moving very rapidly and people are
utilizing and building capacity as they go. But I think the biggest
impediment to rapid, rapid rollout is what we would probably call capacity,
which has many components. One is human resources -- doctors, nurses,
pharmacists, technical, health professionals -- which is why we need some
policy changes to allow community health aides and community health workers
who are perfectly competent to follow antiretroviral therapy on a regular
basis into the mix.

Also, physical infrastructure, a lot of places need to be renovated and
moved forward; laboratory support and, fundamentally, systems. And this is
why the strategy of the emergency plan we believe is so important, because
it's supporting national scale-up. You can do local small projects without
developing systems that will support national scale-up -- communication
systems, logistic systems, management systems, financial systems, supply
chain management systems. These are the things that need to be developed
that aren't there, and -- but they are being developed and things are
moving. So I think the rapid progress of the emergency plan demonstrates
that, in fact, the capacity can be built rapidly as you go. But we need
some concentration on that, and actually, about a third of the resources we
provide go towards supporting the buildup of capacity.

Q Good afternoon. Could you slowly go over some of the financial numbers,
including the Global AIDS Fund? And also, could you address the issue that
some AIDS activists complain that some of the money that comes from the
United States has strings attached -- i.e., the heavy reliance on programs
that promote abstinence, and not enough funding or interest by the United
States in programs that focus on other prevention measures, particularly
condoms?

DR. DYBUL: In terms of -- let me go slowly through the numbers again -- it
is a $15-billion, five-year initiative. In 2004, the first year of the
initiative, was $2.4 billion. The second year was $2.8 billion. And in
2006, the President's request is $3.2 billion. And that's actually exactly
what the President promised to do with that scale-up, getting to Don's
question, that you have to -- there is a scale-up that's necessary. It's
not just putting resources in.

In terms of the Global Fund, the United States is still far and away the
largest contributor to the Global Fund. For resources available to the fund
now, we're about 30 percent of the resources available to the fund.

Q What is that in terms of dollars?

DR. DYBUL: I will have to look while I'm answering the second part of the
question. The notion that there's an excessive focus on abstinence is just
untrue. The policy both in the guidance we issue and in the programs we
support is fully A-B-C -- abstain, be faithful, and correct and consistent
use of condoms. And one of the things that, as a public health official for
17 years, is disturbing to me is that there's a gross neglect of public
health and data in these arguments that go back and forth.

Africa, where 12 of the 15 focus countries we're working are, and Haiti,
for example, are generalized epidemics. In certain countries we're working
in and supporting, more than a third of the adult population is infected
with HIV/AIDS. In certain districts of some of these countries, 75 percent
of pregnant women are infected. Young kids are at high risk. All age groups
in the entire spectrum of society is at risk. You can't look at areas of
concentrated epidemics like Thailand, Brazil, and apply their prevention
programs to generalized epidemic. Awful public health.

In a generalized epidemic, you need a broader approach. And that's why
Africans -- not the United States -- Africans came up with A-B-C. And the
data are crystal clear on A-B-C and the effectiveness of A-B-C, which makes
perfect sense, if you look at it from a public health perspective. Uganda
is clear -- a 50-percent reduction or more in the infection rate. But I
think importantly - and Peter Piat highlighted this last week when the U.N.
AIDS Report came out -- and by the way, Peter also spoke about A-B-C, which
is the same thing as the U.S. government policy, and the effectiveness of
that.

Kenya now is reporting a reduction in infection rate from 10 percent to 7
percent. And when they looked at what occurred during that time period,
what they saw was an increase in faithfulness among young men -- so,
significant reduction in partners; an increase in the age of sexual debut,
from 16 to 17, so a later onset of sexual activity. Remarkably, we now have
solid data for a significant increase in both primary and secondary
abstinence, people who had been sexually active no longer were, over the
last period of time -- smashing the myth that it's impossible to have
secondary abstinence -- and also an increase in condom use among young
women who engaged in risky activity. So it's all three of those things, and
that's precisely what we support.

I'll add one other note to that because, again, as a public health
official, this just drives me a little crazy. What we are responsible for
in our duty as public health officials are to provide facts and information
to people so that they can make their choices for their healthy lives. We
didn't, in 1965 or the mid '70s, say, people are going to smoke no matter
what; why they tell them about the risks of smoking. The only 100-percent
way to avoid HIV/AIDS is to abstain, or to have a single, HIV-uninfected
partner. But if someone, knowing that -- and condom use -- correct and
consistent condom use, I would add, has about a 90-percent protective rate.
If you don't correctly and consistently use condoms, the protection is
rather low. So with that information, people should be allowed to make
their own choices.

If people decide to engage in activity, knowing the risks, then they must
have the commodities like condoms available to themselves to protect
themselves. And that's what we support. But you have to give them the
information. And what bothers me most about the condom-only approach in a
generalized epidemic is you're basically saying people are too stupid, they
can't -- it reminds me of the old treatment argument that there's just no
way they can change their behaviors. And we know from Uganda and other
parts of the world -- now Kenya -- that that is absolutely incorrect. We
know it from parts of Namibia, parts of South Africa, Ethiopia, where
behavior change is possible if you give people information. And that's our
duty as public health officials.

But I'd also say that it's important to understand that A-B-C alone isn't
going to solve prevention either, because there are other ways the epidemic
is spread, which is why you have to focus on prevention of mother-child
transmission, safe blood, safe medical injections, and some broader issues
like gender inequality that contribute to infection. In certain cases, a
woman can't negotiate A, B, or C. And so we're dealing with -- we're
supporting programs on gender issues.

And then also alcohol, which is actually a problem in sub-Saharan Africa
that can drive the epidemic, including gender abuse, which fuels the
epidemic more. All of these programs -- A-B-C; gender, alcohol, safe blood,
safe medical injections, TMTCT -- this is all part of the emergency plan,
and testing -- the importance of increasing testing and decreasing stigma
also -- these are all strategies of the emergency plan. This debate in
Western and Northern capitals about A versus C just misses the point
entirely and actually misses the reality on the ground in Africa and really
ignores the African solution, which the Africans developed for themselves
and which has been proven to be effective. And it would be nice if we
started listening to Africans as they're fighting their own epidemic.

Q Hi, how are you? I'm wondering if there's one particular success story
that you would highlight from this year.

DR. DYBUL: That's incredibly hard to come up with. Can I give you two?

Q Sure.

DR. DYBUL: Or three? Peter Mugyenyi, who many of you remember, was present
at the State of the Union address next to Mrs. Bush when the emergency plan
was announced -- he is one of the most extraordinary people out there,
someone I've known, actually, for quite a while in my own clinical research
in Uganda. Peter has been fighting AIDS for a long time and actually was
probably the first person in Africa to import antiretroviral therapy in
1991 to begin treating people in his clinic. Peter is the head of a clinic
in Uganda. He, before resources were available, started planning out, as
the Chair of the Ugandan strategy for HIV/AIDS, how you would tackle the
epidemic if resources were available. And they really said, how would we
cover the country for therapy and put together a plan to roll out care and
treatment. When resources became available, they kicked it in. And in a
year, Peter opened 25 sites. He's now up into the 30s and supporting care
and treatment for tens of thousands of people.

I think that's kind of the example of what can be done. As President Bush
said before the G8, it's African leadership, African strategies and
approaches, Africans leading their fight, and the United States standing by
their side and supporting them.

That's a representative of a larger -- much larger picture.

And then, the other one I would highlight -- which I think is one you know,
Christine, is one of my favorite stories. In Rehoboth, Namibia, there is a
small community program that we're supporting. It was called Community
Action Forum. They brought together the community, their local community,
and said, what is going on here, why do we have this epidemic, why is it
spreading in our community? And for the first time, I would add,
middle-aged women were invited into the conversation. They had never been
invited in before by the community. And they brought in women and men of
all ages and talked about -- and came up with a couple of things that they
felt were driving their epidemic. And one of them was alcohol.

So they got together as a group and put pressure on the local government to
address alcohol. They got the deputy mayor to close all the illegal
shabines, or little local bars, and to station the local police into legal
shabines to make sure no one under age drank, and if they had an underage
person drink, closing them down. They organized with the national shabine
organization to put pressure on them, to do prevention education in all the
shabines in the country. And that's actually going on now.

And a 20-year-old -- one of the most remarkable men you'll ever meet,
Harold, in Namibia -- told me as we was describing this program, is, what
you're fundamentally doing here is building democracy and governance; that
because resources are available, we're now pressing for accountability on
AIDS. We're looking at the problem, we're coming up with solutions, and
we're implementing them. And this accountability that's being developed is
leading to other pieces of accountability, now saying, well, why isn't my
water supply clean, or why isn't there garbage collection. It's
extraordinary. And this change, this sense that you can do something about
the epidemic, I think is reflected very well in this program, and what
Harold said. It really is a shift to hope, as I said. And it's in the shift
towards accountability that leads to governance, which is what we need to
fight this epidemic.

Q As opposed to looking at the success stories from this year, looking
forward, what would you like to see done next year, or where is a point
where you would like to see the resources focused or utilized better?

DR. DYBUL: I think there are a couple of areas. One is in prevention. We
really need to spread the prevention successes now that we know of in Kenya
and Uganda and others so that you have national A-B-C coverage and national
behavior change. One thing we do know is awareness alone doesn't change
behavior, and everyone on this call knows that. You know, we all know that
fatty foods increase our risk of heart disease and cause weight gain and
diabetes, but that doesn't -- it doesn't make us change our behavior. And
it's the same thing with prevention. It really is kind of hand-to-hand
combat, door-to-door, how do you change behavior? So spreading these
messages nationally, getting at the thought leaders, people who form
opinions, getting to people when they're young, changing behavior, massive
emphasis there.

And I would link that to one of the second things I would emphasize, which
is the need to greatly expand counseling and testing. And I'll point to a
highlight from last year that we need to look at replicating. Two districts
in Uganda decided they were just going to test the whole district. And the
way they are going to do it is by door-to-door testing. So they're going to
door-to-door, doing rapid tests in homes, giving the entire family, not
just one person, the entire family their results while they're sitting
there in a 15 to 20-minute period. They covered an entire district and got
94-percent uptake.

And you know, it smashed all the preconceived notions of, are you going to
stigmatize people if you go into their homes? It's actually the opposite,
really. You have less stigma because every home gets visited, and you don't
know what happened in there, as opposed to having to walk to a clinic to
get tested. And you get the whole family, not just one person.

So we need to push that for a couple of reasons. One, testing, when
treatment is available, reduces stigma. It becomes a medical disease. It
becomes like diabetes. And it's happened in the United States, having been
around, then, when we began care and treatment here, it really does begin
to break down stigma. But more than that, it expands the network of, and
care for people who are HIV-positive so you can follow them, so that when
they need treatment, you can initiate treatment instead of waiting until
they come in very sick when therapy is less effective.

So those are two areas we're really going to push this year -- expansion of
prevention on a door-to-door basis, and expansion of counseling and
testing, we hope also on a door-to-door basis, which requires some policy
changes and also increase of rapid testing.

Q And then, of the 15 nations that you focus on, which do you think would
be most open, or do you think -- do you expect the greatest success to
happen from this?

DR. DYBUL: Well, actually, some of the countries, again on African
leadership, are doing an extraordinary job themselves. They're doing the
work. Kenya and Tanzania recently adopted what's called -- what they call
diagnostic counseling and testing, so everyone who goes into TB clinics now
are going to be tested because it's medically sensible to do so. Fifty to
eighty percent of people who walk in the TB clinic have HIV/AIDS. So it's
important to test those people in a medical way to determine why they might
be sick.

Botswana recently has adopted a national opt-out testing approach, which is
roughly the equivalent in medical settings, mother-to-child transmission,
tuberculosis clinics, medical settings, hospital wards -- 50 percent of
people in internal medicine wards are HIV-positive, too. That's what's
driving people coming into the hospital. So doing more testing in these
areas. Other countries are looking at doing -- expanding this base on the
lessons learned from the other countries.

Q Hi. A week or two ago there was a story, I think it was on NPR, saying
that, I think it was five clinics, or some -- half a dozen or so clinics
were closed because the people operating them didn't want to comply with
various requirements. I think the suggestion was it had to do with condom
promotion, or lack of condom promotion -- certain conditions that came with
the U.S. money. I'm wondering if, A, this is true, and two, are you keeping
track, are you keeping a count of not only the success stories, but the
failures, or the places where the requirements that come with the U.S.
grants are grounds for stopping -- for closing down a facility, or reducing
treatment?

DR. DYBUL: Well, in terms of the first question, that's really impossible.
U.S. guidance is clearly A-B-C, and we support a significant condom
distribution. It is impossible for a site to be told to stop distributing
condoms, or to close because of condom distribution.

We've actually heard this type of stuff from time to time. We've tracked
down every one and all have turned out to be untrue. So if anyone can
provide specifics, we'd be happy to try to track them down, because there's
lots of rumor out there with no facts behind them. And again, it would be
directly contravening the stated policy of the U.S. government to say that
because someone distributes condoms, they cannot receive resources from the
U.S. government.

We have -- you know, it's difficult to say failures in this regard because
we have no examples of it. If someone has one, we'd be happy to look into
it and rectify it. We do look very carefully at lessons learned, what's
working, what's not working, what are the best ways to expand care and
treatment and counseling and testing -- like the door-to-door testing --
what are the difficulties when you try to do it. And I'll give you an
example.

In certain places, people have begun to use rapid tests, and for those of
you who aren't familiar with them, a rapid test is a finger prick which
allows you to drop blood from a finger prick onto a sheet of paper, a
little piece of filter paper, and tell whether or not someone is
HIV-positive pretty much while they're sitting there. A huge advantage --
you don't have to send someone to a phlebotomist, there's no waiting
period. Well, unfortunately, in some settings, what we found is even though
the rapid test piece was implemented, they were still sending people to the
phlebotomist to draw the blood to do the rapid test, which is -- someone
described to me once, it's kind of like using the cell phone only when it's
plugged into the wall -- that you're kind of defeating the purpose of the
rapid test by sending someone for a blood draw.

So now, because we learned this, we're going back and working on those
policy changes to provide technical and educational assistance to -- when
you do a rapid test, you don't need to draw the blood. So we're learning
lots of things like this that are working. And we've had the door-to-door
testing, all of these examples of things that are working that we're trying
to spread, but also what needs to be done to make sure that they're
implemented well.

MR. DUFFY: Sorry to interrupt. This is Trent Duffy, at the White House.
We've got 15 more minutes, if Mark has more time. If not, we could wrap
things up and follow up with further calls.

Q Yes, thank you. I came on a little late to this and I -- there was some
sort of cut-out right at the beginning when you were introduced. I just
want to be real clear on what the ground rules are for this. Is this an
on-the-record, for writing tomorrow, or is it some sort of backgrounder --

MS. PRUETT: It's on the record. Sorry.

Q All right, but I gather you're not giving out any of the numbers --

MS. PRUETT: No, no. As most of you know, the President is announcing the
newest treatment numbers tomorrow, but we're not able to get ahead of him.

Q I would ask Mark about the policies regarding the FDA approval process
for generic drugs. I think a lot of people in the activist community have
been critical of the program for insisting on this process, and not just
getting the drugs that are available out there. Can you talk about what the
upside is for this program? Or the downside, address the criticism that if
you had just gone ahead with the available drugs, that the WHO is happy
with there would be a lot more people under treatment today?

DR. DYBUL: Yes, thanks. We have said from the beginning that we will -- the
emergency plan will support the purchase of the lowest cost drugs made
anywhere in the world as long as they're safe and effective. And that's
where we're insistent -- safe and effective.

We don't believe that drugs have two levels of quality -- one for people in
Africa and one for people in the rest of the world -- that if we wouldn't
give it to our own families, we ought not give it to anyone else. And so
the tentative approval process which actually existed before -- the FDA
tentative approval process -- basically says drugs will run through the
same testing that would be applicable to the United States market. And even
if there is patent protection in the United States, the emergency plan will
be able to support the purchase of those in resource-limited settings where
the care and treatment is essential, as rapid as possible.

And interestingly, actually, that process has led to a couple of drugs
being tentatively approved that then had the patent expire, so that those
products could then be used in the United States. And this process has
actually tentatively approved 13 true generic products -- generic products
like you or I would think about, go to the store and buy generic ibuprofen,
you're sure that that's the same thing as it was before it became a
generic. And that's what we're insistent on. We know that it's a safe and
effective drug.

And until the FDA review process, no stringent regulatory authority in the
world had looked at the safety and efficacy of these drugs. No stringent
regulatory authority in the world other than the FDA had now looked at
those drugs. And so we believe that this was the right approach to take,
especially now that they're available and going out to countries. Countries
have already ordered these products. They're on the ground and moving to
the clinics.

But I want to get at your second point a little bit, had we not insisted
that the products we use and the emergency plan are as safe and effective
as anything we would give to our own families, would we have moved any
faster, would more people have been treated? Not a lot of evidence for
that. And that might be true in six months, might even be coming true now,
now we have the products available, but it wasn't true a year ago. And I
think this is an incredibly important point -- antiretroviral therapy is
not pills. Antiretroviral therapy, getting back to the question that was
asked about whether there are barriers, antiretroviral therapy is trained
personnel, laboratories, supply chain systems, logistics systems,
management systems, drugs for opportunistic infections, all of the
components that go into antiretroviral therapy, as opposed to
antiretroviral drugs. The cost of antiretroviral therapy for all of those
things is somewhere between $1,500 and $2,500, depending on where you are.
And actually, I'd refer you to an article that's going to come out in the
New England Journal tomorrow from Haiti that shows the cost of therapy
there was $1,600 overall. Of that, the cost of the drug is 20, 30, 35
percent.

So we're still pushing hard for the lowest-cost drugs at the highest safety
and efficacy. But the claims that, if you do that, you can treat two-thirds
as many people, are just untrue, because of all the other components of
therapy that need to be put in place.

So we think we did the right thing. We're absolutely certain, actually, we
did the right thing to ensure that we have the most safe and effective
products we can provide. And now that we're moving them to the ground,
we're looking forward to our rapid expansion of use of generics.

Q And just to follow up, do you have any numbers or will there be any
numbers on how much of these tentative -- I don't know quite what the term
"tentatively approved" means, but are these FDA-approved generic drugs
moving out in any numbers, and do they represent a full course of
treatment, or are they just -- I don't think there's any combination --
single pill --

DR. DYBUL: There's no combination single pill, but there are several
combination two drugs. And there's a blister pack, which, in a lot of ways,
from a public health perspective, might be more effective, which is one
combination pill of two drugs, and then a third drug in a blister pack,
which means it's in a package so that you open a container in both pills.
So it's two pills, twice a day, in a container, as opposed to, by the way,
one pill once a day. And I think you'd be pretty hard-pressed to say one
pill once a day is better than a blister pack of two pills twice a day. And
actually, there's no data from tuberculosis or other areas that blister
packs are any less effective than six-dose combinations.

But among the 13 products, pretty much every first-line drug is in there --
AZT, 3TC, D14, Nevirapine, Efavirenz -- they're all there. And we won't
have numbers tomorrow, but we will in the annual report at the end of the
year, or at the end of January, in terms of where we are with the generics.
But they've been ordered and have been on the ground now in a couple of --
in several countries.

Q Hi, Mark.

DR. DYBUL: Hi.

Q I was wondering, to what extent do you think the U.S. economy's thirst
for foreign health professionals, and particularly nurses, is contributing
to that capacity problem that you described in Africa.

DR. DYBUL: I think the data are almost unavailable on this. I don't know if
you saw -- there was actually an editorial in The Economic about a month
ago actually going back and forth saying, is the back-and-forth of doctors,
nurses and other health professionals between the developed North and West
actually contributing to or helping the development of health care
infrastructure. I can say that no one has the data on this yet, and it's
impossible to tell and it's probably pretty variable by country.

Let me just give you an example, though. We have just met with the Ministry
of Health in Kenya, and they did an evaluation of why they were losing
nurses over the last couple of years. And they looked at a variety of
things, including brain-drain. And what they found is -- and what you're
referring to is really brain-drain, educated people leaving the country --
what they found is they lost virtually no one to brain-drain. What they
lost all the nurses to was dying from AIDS. And that's one of the first
national evaluations I've seen. And so it's going to be really important to
-- because we know the health care professionals and better educated
classes can be more impacted in some countries.

So we don't really know. But we're looking at this. We're trying to get
more data on it. But I think one of the most important things is that we
need to be training people more and more in-country. And one of our largest
efforts is to train people -- doctors, nurses -- support the training of
doctors, nurses, community health aides, laboratorians, technicians, to
expand the pool of people available. So I think that's a critical point.

Another very important piece, besides the deaths of nurses, doctors and
others from HIV/AIDS, is a burnout. As we experienced in the United States,
if you're taking care of people who are dying constantly -- and I can tell
you from my own experience in San Francisco in the mid-'80s, it was very
real. Doctors and nurses didn't survive more than a year-and-a-half because
they were just burned out from everyone dying. We are absolutely seeing a
hope coming back to life in the doctors, nurses, professional health corps,
a willingness to stay much longer in their jobs because antiretroviral
therapy is available. And anecdotally, people are going back to their home
countries to participate in this rollout as the hope is there.

So I think we need a lot more data on it. We definitely have to look at it
carefully. But in the absence of data, we need to push forward -- we have
to push forward with the training so that we can have more and more health
professionals and keep pushing the programs forward.

Q Can I ask you one slightly different question? You mentioned the
importance of tamping down on stigma. And speaking as a health
professional, what do you think of the administration's policy of requiring
NGOs that receive OGAC money to condemn prostitution?

DR. DYBUL: I actually think it's -- as a public health official -- makes a
great deal of sense in two settings. One is that -- and first, it's not
condemning prostitution and it's not condemning prostitutes. It's
opposition to prostitution and sex-trafficking as intrinsically
dehumanizing. And from women's rights or other perspectives, prostitution
and sex trafficking, or young children, is just an appalling thing. You
know, it's hard to conceive of people who are in favor of prostitution and
sex trafficking.

Q I don't think sex trafficking is really the issue in this debate, though.
It's really the prostitution question, when you're working with prostitute
groups and AIDS control rights.

DR. DYBUL: And -- but it's -- I mean, and this is another thing to me that
is very similar to A-B-C, where there is a lot of discussion back and
forth. I spent enough time on the ground that this doesn't make a whole lot
of sense, actually.

It's very important to note that immediately after the legislation talks
about the opposition to prostitution and sex trafficking, it goes on to say
that nothing in this language can be construed to prevent the provision of
services to prostitutes in prevention, care, or treatment. And, in fact, a
compassionate response requires you to do so. There is no contradiction in
being opposed to the activity while compassionately serving those who are
in that activity, oftentimes against -- for economic or other reasons.

And there is no stigmatization as a result of opposition to prostitution as
intrinsically dehumanizing that I'm aware of, and we support numerous --
many programs that work with prostitutes, both to bring prevention
activities to them, to teach them how to protect themselves, but also to
try to provide opportunities for them to get out of prostitution, to
provide income-generating opportunities for them to bring them out of this
dehumanizing activity and let them lead healthier lives. And I met with
many of these people. And I can tell you, when you ask them, does it matter
to you that your organization is opposed to prostitution, their universal
answer is, I don't like this, either, this isn't what I chose to -- this is
not what I want to be doing, and certainly not what I want my children to
be doing.

And history is pretty good on this one. Faith-based organizations -- for
example, the Catholic Church has been working with prostitutes for years
while being opposed to prostitution, with some very effective programs, and
people are very comfortable going to them. So the notion that an
organization is opposed to dehumanizing activity somehow limits the ability
to provide services or stigmatizes those, I don't see any evidence for it.

Q I wanted to address the issue of what you raised earlier, about
supporting A-B-C as an integrated response, and giving accurate information
and then letting people make the choices that work best for them, and how
that relates to requirements in many RSAs supported by the U.S. government
that say things like, "applicants are advised that grant funds may not be
used in any setting for marketing campaigns that target use and encourage
condom use as the primary intervention for HIV prevention"?

DR. DYBUL: I think you're looking at programs that are for young children.
I don't know anyone -- well, that's a little strong -- the vast majority of
people would say that a 10-year-old gets nothing but abstinence education.
And that's our policy, that young school kids, the only education they
should be getting is abstinence education. Beyond that, messaging changes
and then you get into the broader A-B-C approach, but for young children,
abstinence is the message they should be given. And I've rarely encountered
someone who disagrees with that.

Thank you all very much for participating. It's important around World AIDS
Day that everyone be conscious of the global fight and what's being done.

END 3:15 P.M. EST

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