San Francisco Chronicle - Friday, April 27, 2007
Sabin Russell, Chronicle Medical Writer, srussell@sfchronicle.com

Dr. Mark Dybul, an AIDS physician who spent his last year of medical school caring for patients in San Francisco in 1992, was sworn in as U.S. global AIDS coordinator in October with Secretary of State Condoleezza Rice, first lady Laura Bush and his partner, Jason Claire, by his side.

Dybul has presided over a period of impressive gains in bringing antiviral drugs to the 15 countries targeted by the Bush program, known as the President's Emergency Plan for AIDS Relief, or PEPFAR.

The program, he said in an interview, "is dead on track" to meet its goal of bringing antiviral drugs to 2 million people by the time its five-year authorization expires in 2008.

As of September, the last time numbers were officially counted, 882,000 had obtained AIDS drugs with the help of the program. "On average, that has been increasing by 50,000 per month," Dybul said. "A few years ago, there were only 50,000 on treatment in all of Africa."

Despite skepticism that the administration would distribute cheaper, generic versions of AIDS drugs to patients in the program, the lower-cost, foreign-made products now account for nearly one-third of medicines distributed through PEPFAR. Dybul said a PEPFAR-approved three-drugs-in-one pill can now be distributed for $90 a year. "We now have the lowest price in the world," he said.

Largely because Congress has appropriated more money for PEPFAR than the president has asked, the program will exceed its $15 billion price tag by $3.3 billion before its authorization expires on Sept. 30, 2008.

But despite what Dybul called a history of strong bipartisan support for the PEPFAR, the debate over reauthorization could become contentious over funding and the administration's insistence on prevention programs stressing abstinence. Congress must approve the bill extending the program for five more years before October 2008, but in practical political terms, much of the decision-making must occur this spring, well before the election season.

Democrats have been floating a commitment of $30 billion to the program -- a doubling of the current funding level. Dybul declined to speculate what figure would be proposed by the Bush administration.

The other source of friction is a requirement, set by Congress in the original authorization bill, that one-third of all prevention dollars -- amounting to about 7 percent of total spending -- be devoted to programs that promote sexual abstinence before marriage.

Last month, the Institute of Medicine in a report to Congress criticized the budget allocation system as rigid, and declared that there was no evidence "for the position that abstinence can stand alone or that 33 percent is the appropriate allocation for such activities."

Dybul's visit to the Bay Area is partly a courtesy call to the home of three powerful House members who will have a say: Speaker Nancy Pelosi, D-San Francisco; Appropriations Committee member Barbara Lee, D-Oakland; and Committee on Foreign Affairs chairman Tom Lantos, D-San Mateo.

Lee has introduced a bill that would toss out what she called "the abstinence-until-marriage earmark." She said prevention policies should be "based in science, not ideology."

Dybul, who toured San Francisco General Hospital on Thursday, will address the Commonwealth Club at noon today and will meet with Lantos at a public forum on global AIDS strategy at 2 p.m. at the San Francisco Main Library.
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