The irony of the PEPFAR stalemate

For 20 years the bi-partisan program to fight HIV/AIDS has saved millions of lives. Now it is being held hostage to the debate over abortion.

President Bush in 2007 in Rose Garden urging Congress to fund PEPFAR. He is holding a child from South Africa whose mother is HIV-positive. PHOTO : George W Bush Presidential Center

This week Congress could make a decision on whether to reauthorize funding for the President’s Emergency Plan for AIDS Relief (PEPFAR).

Created in 2003 under President George W. Bush, PEPFAR stands as a rare testament to bipartisan unity and international cooperation in combating one of the most challenging health crises of our time.

Twenty years since its inception, PEPFAR stands as the largest commitment in history by any country to combat a single disease. Over the years, the program has not only saved 25 million lives in the developing world but also supported treatment for approximately 20 million people and facilitated the birth of 5.5 million HIV-free infants to mothers living with HIV.

At the US-Africa Leaders Summit in Washington in December 2022, African leaders emphasized the program's vital role in combating HIV/AIDS and have called for its continued support.

For two decades PEPFAR has garnered support across the political spectrum, with religious conservatives, liberals, and bipartisan members of Congress rallying behind its life-saving mission. But like so many other bipartisan initiatives, the program's unique ability to bridge political divides and unite diverse stakeholders is eroding amidst polarization and political maneuvering that has held up reauthorization for funding since last year’s September 30 deadline.

This past World AIDS Day on December 1st marked a critical juncture, as Congress had yet to pass a new five-year statutory authorization governing PEPFAR's policy and programs—a historic first since its establishment.

Republican lawmakers' assertions that President Joe Biden is leveraging PEPFAR to advocate for abortion rights have strained the bipartisan coalition that has long championed the program. They point to a PEPFAR strategy document about integrating HIV programs with “sexual health and reproductive rights,” which Republicans interpret as code for promoting abortion rights.

The Biden administration, along with Democratic lawmakers and public health advocates, vehemently denies these allegations, emphasizing that PEPFAR funds have not been directed toward promoting or providing abortion services and stressing that U.S. law already bars foreign aid from funding abortion services. Moreover, African political and religious leaders, who have expressed strong support for PEPFAR's continuation, strongly refuted any connection in the program to abortion.

“As members of faith-based organizations in Africa, some of whom have a long history with PEPFAR, we write to state that we have no knowledge of PEPFAR funding or promoting abortions,” one group of African church leaders wrote in a letter to Congress last June.

However, anti-abortion factions within Congress have launched a concerted campaign of misinformation, harassment, and misrepresentation regarding the use of PEPFAR funds for abortion-related activities. They have resorted to tactics like congressional holds to block funding and demand concessions related to sexual reproductive health, gender issues, and human rights, maneuvers that extend beyond the HIV/AIDS domain.

Claims by the conservative-leading Heritage Foundation accusing the Biden administration of using PEPFAR as a “vehicle to promote its domestic radical social agenda overseas” and demands for language barring support to abortion rights advocacy groups have intensified the political standoff and further complicated bipartisan efforts to secure PEPFAR's future.

It's kind of ironic, isn't it? How a program designed to fight a deadly virus and save lives has become entangled in the web of ideological battles about a pro-life agenda.

Exploiting PEPFAR's widespread popularity to advance an anti-abortion campaign s a dangerous politicization of a program that has historically transcended ideological divides. It’s also self-defeating because PEPFAR has also served as a public relations asset for Republicans for decades.

The repercussions of this political discord extend far beyond domestic debates. While PEPFAR can technically continue without congressional reauthorization, the absence of policy changes and additional funding would hamper its effectiveness in the global fight against AIDS.

These actions not only impede PEPFAR's ability to fulfill its mission effectively but also affect broader health programs critical to the global health security agenda, with the State Department's new Global Health Security Bureau playing a crucial role in coordinating these efforts. PEPFAR's significance also extends beyond public health, intersecting with national security imperatives and bolstering U.S. diplomatic efforts.

There is a ton of nail-biting among PEPFAR-funded partners and recipient countries about the potential slowdown in progress against HIV/AIDS and the accessibility of critical health services.

Without action, there's a tangible risk of setbacks in the fight against the epidemic, posing a threat to millions of lives globally. Using FY2023 results in 12 high-disease countries, PEPFAR projects from 2024-2030 to prevent at least 5.2 million AIDS-related deaths and 6.4 million new HIV infections.

U.S. officials and PEPFAR figures say if funding were to dry up and the program was halted, AIDS-related deaths in these countries are projected to increase by more than 400% by 2030. The potential ripple effects could embolden other major donors to retract support, impeding progress toward ending the AIDS epidemic.

Advocates of the program argue some Republicans, like Representative Chris Smith of New Jersey, are proposing a one-year authorization with caveats, rather than a five-year reauthorization in the hopes President Trump will reinstate the Mexico City Policy—a rule that bars foreign organizations that receive U.S. funding from supporting abortion access.

U.S. officials say that anything other than a five-year authorization would create uncertainty that would diminish U.S. leadership in this fight against AIDS, but would potentially jeopardize the nearly $5 billion in annual funding crucial for achieving the international goal of ending the AIDS epidemic by 2030.

Not only would such a scenario undermine a successful global health initiative, but it would also be a bad look for US efforts to spearhead international cooperation and foster partnerships critical for addressing broader global health challenges. (Is anyone seeing the parallels with the showdown over Ukraine funding here?)

At its core, PEPFAR symbolizes the best of what can be achieved through bipartisan collaboration and a shared commitment to saving lives, something that was once an easy sell.

Who would have thought that saving lives could be such a contentious issue? But here we are, with the absurdity of politicizing a critical global health program where the stakes are measured in human lives. While we grapple with the complexities of governance, let's not lose sight of the fundamental goal shall we? It’s ending the AIDS epidemic and saving lives, something pro-life advocates should be able to get behind.