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