Concerned about the next phase of leadership on US Global AIDS programs, representatives of the global AIDS community are calling on the Obama Administration to establish an open process to determine who gets appointed as the next Global AIDS Coordinator.
The next Coordinator will oversee the President’s Emergency Plan for AIDS Relief (PEPFAR) in the Obama Administration, and will have purview over all funding and policies concerning global AIDS flowing through the State Department, USAID, Health and Human Services, and country-level missions. The PEPFAR reauthorization bill, passed last spring, allows for spending of up to $48 billion on U.S. global AIDS prevention, treatment, and care, though these funds have yet to be appropriated.
Notwithstanding the amount of money ultimately allocated to PEPFAR, this is a huge and wide-ranging effort with funding going to over 100 countries, a vast network of programs and a large organizational footprint. The task for the Coordinator will not be easy, as much because it requires a deep understanding of public health, human rights, and the effects of social, cultural and economic disparities in the spread of HIV.
In a letter to Secretary of State Hillary Clinton, the groups state:
"US assistance on AIDS is unique in terms of scale and accomplishment. Its connectedness with a complex array of other actors both within U.S. development assistance and with among other bilateral donors and multilateral agencies mean that the Office of the Global AIDS Coordinator is a singularly important appointment.
Therefore we are writing to you as representatives of the AIDS community to request that, instead of immediately
moving to fill the position vacated by Ambassador Mark Dybul, you
instead pursue an innovative, competitive, merit-based process for
selection of the next head of OGAC. In an expedited manner, we
recommend you convene a multi-stakeholder committee comprising US
government representatives, implementers and civil society, to identify
top candidates for the position. This selection committee could
consider a range critical qualifications, for example, experience implementing
HIV prevention and treatment programs and a demonstrated commitment to
involving affected communities, including people with HIV, at all
levels of program activity."
While the majority of organizations have greeted the departure of Mark Dybul with relief, many worry that a rush to replace him may result in the rapid choice of a candidate who is more political appointee than merit-based leader with the vision necessary both to fix problems with and to lead PEPFAR in new directions. These groups, representing a diverse array of both domestic and international organizations, are seeking an open and participatory selection process modeled on similar efforts undertaken by the U.S. National Institutes of Health and by the Global Fund.
"As you know," states the letter to Clinton:
This is the manner in which NIH selected the first and second directors of the Office of AIDS Research (OAR), after the NIH Revitalization Act of 1993. Harold Varmus convened a search committee who reviewed candidates and who selected Bill Paul (in 1994) and later Neal Nathanson (in 1998).
In an editorial published yesterday, the British public health and medical journal, The Lancet, also called for a merit-based appointment through a similar process, stating:
"The incoming Coordinator should be chosen based on his experience and ability to do the job. Essential credentials for the position include: bold and visionary leadership and expertise in global health at the scientiﬁc, policy, and implementation levels; high-level global management experience in collaboration with political, technical, and civil society groups and those living with HIV/AIDS; a commitment to increase coordination with other HIV/AIDS donors, the private sector, and foundations; a proven track record of making ambitious decisions independent of political or special interest considerations; and a commitment to do more to integrate disease-speciﬁc responses with health systems
Unfortunately, as one commentor wryly noted, the Lancet used only the pronoun "he," implying perhaps inadvertently that only men should be considered for the job. In fact, the 3 current candidates whose names are most frequently mentioned are all men.
Earlier recommendations for a similar process submitted to the Obama transition team apparently were not adopted because to date the State Department has not indicated it will in fact convene a selection panel.
Sources close to Secretary Clinton contacted by RH Reality Check have suggested that putting forth specific candidates now would be a more effective route for community participation. "Recommendations for candidates with widespread support in the community would likely ensure both a smoother transition and increase the likelihood that all parties will be happy," said one source. Some contacts noted that given how presidential appointments tend to work, "This would seem a more practical approach than requesting a new process." Earlier efforts to shape the process have included sign-on letters describing the most critical qualities in an AIDS Coordinator.
Virtually all U.S.-based advocacy groups working on global AIDS policy agree new directions in PEPFAR policy and programs are needed, but not everyone emphasizes the same priorities or has the same skill-set at the top of their list for a new Coordinator.
Adrienne Germain, President of the International Women’s Health Coalition, places high priority on someone with a strong focus on prevention and an understanding of women’s needs in the epidemic. She is less concerned with a new process in this case than with the outcome, underscoring that in an epidemic in which women now make up the majority of those infected and the majority of those at greatest risk of new infections, a new Coordinator must understand and pursue strategies to address gender-disparities that leave women vulnerable.
Moreover, she states:
"We can no longer tinker with prevention or sidestep politically tough issues such as sexuality, sex work and IV drug use. The new OGAC coordinator needs to have skills, expertise and commitment to use every proven prevention tool, unbowed by ideology or politics. We need a leader who knows that we must put the power of prevention in girls’ and women’s hands and who knows how to strengthem health systems to provide comprehensive services.
There are no silver bullets for prevention – the world needs a visionary who will bring together public health, human rights, social science, medicine and common sense."
Most agree that whoever takes the helm of PEPFAR in this Administration must be someone who can build trust across a diverse community of stakeholders that includes many advocacy groups, and must be willing to listen to critics of the program. Moreover, the next Coordinator will need to simultaneously build on and strengthen successful aspects of the program, such as increasing treatment access, while fixing fatal flaws in prevention policy. Matt Kavanagh, Global Campaigns Director at Results Education Fund and one of the authors of the letter to Secretary Clinton, agrees with Germain, and says:
"As the Obama administration takes on AIDS and makes its own stamp on this hugely important foreign policy area, it is essential that we get a bold, visionary leader at OGAC to fix what didn’t work under Bush and leverage the successes on a global stage."
One of the most urgent tasks for whomever becomes the new Coordinator will be to quickly revise program guidance for prevention programs and to mitigate the harms of existing restrictions such as the prostitution pledge. Country Operational Plans and program funding allocations will soon need to be decided. In the absence of a new appointee, it would be important for Secretary Clinton to provide immediate guidance on what can and should be done to ensure we fund the most effective programs we can.