Anyone hoping for a bold change in US global AIDS leadership has had plenty of news to keep up with in the past few weeks. First, Mark Dybul, the current and controversial occupant of the Office of the Global AIDS Coordinator, submitted his resignation in anticipation of being replaced. Soon after, he sent around an email saying he had been asked by the Obama Administration to stay on board. Now, rumors are circulating that his days as the US AIDS Ambassador are in fact numbered. The Global AIDS Coordinator works under the Secretary of State, and with the confirmation of Hillary Clinton--a committed woman's rights advocate--as Secretary of State today, the question of whether Dybul stays or goes is of keen interest to all of those concerned about an effective U.S. response to the global HIV and AIDS epidemic.

To the chagrin of some global AIDS advocates, and to the qualified approval of others, Dybul announced last week that he had been asked to rescind his resignation and stay on as Global AIDS Coordinator for the start of the Obama administration - or indefinitely. In the latter case, advocates are divided on what Dybul's "second term" means for the future of a program that has focused on treatment but been riddled with ideological requirements that have hamstrung efforts to prevent new infections.

No question, Dybul's work is not universally applauded. During the Bush administration, he did not fight his boss's ideological restrictions on global AIDS funding. Many argue that the Obama Administration would be best served by appointing someone new.

On RH Reality Check, Jodi Jacobson has argued that the limitations embedded in PEPFAR, the President's global AIDS relief bill, can only be addressed with a Global AIDS Coordinator who "gets it." "For too long, PEPFAR has been driven by a highly medicalized approach to an epidemic fueled by gender, social and economic disparities and by stigma and discrimination. A critical first step for the new Administration is to appoint a Coordinator who clearly understands these dynamics, who embraces both the public health and human rights dimensions of risk and disease and who recognizes that sex and sexuality are normal attributes of being human," Jacobson writes. And for Jacobson, that Coordinator is not Mark Dybul. "When given the opportunity in Congressional hearings and other fora, Dybul failed to unequivocally support removal of the abstinence-until-marriage restrictions in the original PEFPAR legislation despite mounting evidence that this restriction was undermining efforts to stop the spread of HIV. He did not speak out publicly against other restrictions such as that on syringe exchange. His office failed to use its own leverage in writing guidance that would have supported a comprehensive approach to prevention of sexual transmission of HIV or would have greatly alleviated the adverse effects of the so-called prostitution pledge. In short, even as a medical doctor he supported ideology over evidence, serving his own interests and the interests of politicians rather than those of people at risk."

"Nominating someone new is a necessary first step to signaling that changes needed in US global AIDS policy will be a high priority," said Jacobson.

PEPFAR's ideological restrictions date from the original 2003 act, in which Congress required that only 20% of total PEPFAR funding could be spent on prevention, and that fully a third had to be spent on abstinence-until-marriage programs. Under the tenure first of Randall Tobias and then Dybul after Tobias departed in scandal, the Office of the Global AIDS Coordinator interpreted the one-third stipulation as narrowly as possible, claiming that one-third of all prevention funding, not just the funding spent to prevent sexual transmission, must be spent on abstinence programs. Moreover, while the law said abstinence-until-marriage, the implementation focused on abstinence-only. For example, rather than counting every dollar of a comprehensive program focused on promoting delay of sexual debut toward the earmark while ensuring each individual received all the information, training and methods needed, OGAC instead insisted on funding stand-alone abstinence, or abstinence and faithfulness programs that ignored--and in some cases denied--the possibility of practicing safer sex.

The 2008 reauthorization lacks the specificity of the original act, but requires that at least half of all money directed towards preventing sexual transmission of HIV must be spent on "activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction" in countries with generalized HIV epidemics or a report must be made to congress. While some argue this langauge is less directive than the original earmark, most implementers disagree. The requirement of a report to Congress on specific program activities such as these on a yearly basis not only creates more bureaucratic hurdles, but also provides the authors of this language--such as Rep. Chris Smith of New Jersey--the fodder for harassing program providers who are seeking to meet the needs of the populations at risk, not ideological politics in Washington. Only programs working to prevent sexual transmission of HIV are subject to such reporting requirements.

Taking leadership of PEPFAR presents both opportunities and challenges for the incoming Obama administration. The 2008 reauthorization gave a green light to spending of up to $48 billion from 2009 through 2013 that could dramatically increase funding of key programs like those providing treatment and prevention of maternal-to-child transmission. But Obama will also need to address the many controversial Bush administration policies that remain in place, both in law and in guidance, policies that hinder the fight against the spread of HIV/AIDS. Selecting the right person as Global AIDS Coordinator is a critical step. Given that the retention of Dybul may be stopgap measure, President Obama still has an opportunity to bring about real change.

But if Dybul stays on is this an indication Obama won't make bold and necessary changes to the global AIDS program?

Not necessarily, argues long-time AIDS activist Gregg Gonsalves, currently of the International Treatment Preparedness Coalition. For Gonsalves, a little more Dybul now, with the possibility of the nomination of a strong leader later - someone who is a "leader on global public health, who is good on reproductive rights, needle exchange, and generic drugs, with a lot of seniority and credibility" - is preferable to nominating an unqualified candidate now. Candidates that have been mentioned in the press are CEO of the Global Health Council Dr. Nils Daulaire, professor and former director of the World Health Organization HIV/AIDS department Dr. Jim Yong Kim, and President and CEO of CARE Dr. Helene Gayle. "[The candidates being considered] are holdovers from the Clinton administration who didn't speak out against the ban on needle exchange under Clinton or push for anti-retroviral therapy," says Gonsalves. "So we're going to put in a bureaucratic coward from the Clinton years and call that a victory?"

"Mark Dybul was not a Tom Coburn, whose entree into AIDS and global health was to drive an ideology forward. Mark's background is appreciably different than other Bush appointees," says Gonsalves. "I think he's a scientist and knows the science. Given more freedom, he very well may be guided by the evidence. If he continues to push non-evidence based policies for HIV prevention, then I'm wrong."

While Joseph Amon, the director of the HIV/AIDS program at Human Rights Watch, also wants to see Dybul replaced, he agrees with Gonsalves that none of candidates recently considered are right for the position. "All of [the candidates being mentioned] have strong qualifications and have shown dedication to working on HIV/AIDS, but none of the candidates under consideration have really fully embraced and articulated the need to address human rights," said Amon. "It is not enough to see a decrease in HIV/AIDS prevalence statistics and ignore the underlying problems. There needs to be more than just a health sector response."

This past December a letter from leading advocacy groups, including the International Women's Health Coalition and the Sexuality Information and Education Council of the United States (SIECUS), exhorted the Obama transition team to "appoint a Global AIDS Coordinator who can lead the transition from a disease-specific, medical model to one which embraces, and can carry out, a broader vision" that rests on an "understanding of the social and economic factors which drive the epidemic and a solid grounding in public health and human rights frameworks." William Smith, Vice President for Public Policy at SIECUS, said that his group was concerned that current Global AIDS Coordinator Mark Dybul would stay on. "I'm willing to give the Bush administration credit for scaling up treatment and care but it has been a disaster on prevention and Mark Dybul has overseen that," says Smith.

Questions remain as to whether the position will remain an Ambassadorship, what role the State Department will have and whether the office will be integrated into USAID. It's possible that Dybul will stay on until OGAC is integrated into a larger office to address international humanitarian and development issues. The latest rumors suggest that Dybul's tenure may well be briefer than indicated by his own open-ended email to staff.

When Obama spoke of creating change in Washington, many in the HIV/AIDS community clearly were thinking about the Global AIDS Coordinator position. Now that Clinton is formally in charge at State, many hope she will quickly turn to appointing a new coordinator who will, to paraphrase Obama's inauguration speech, get the job done -- without compromising either our ideals or the rights- and evidence-based programs needed to stop the spread of HIV.