Experts Say Failure to Fund AIDS Relief Program Will Lead to Dire Consequences

Experts fear the ongoing delay by Congress to reauthorize long-term funding for an international AIDS relief program may have already led to a significant impact on global efforts to reduce the spread of the disease and damaged trust between the U.S. and its foreign partners that may take years to repair.

The program, called the U.S. President’s Emergency Plan for AIDS Relief Program, or PEPFAR, started in 2003 by President George W. Bush. It has been credited by many as one of the most successful humanitarian initiatives of the past two decades, responsible for saving as many as 25 million lives around the world from AIDS, according to U.S. State Department estimates.

Since its inception, the program has received bipartisan support from lawmakers. In a January statement marking the 20th anniversary of PEPFAR, President Joe Biden said the program remained, “a powerful example of America’s unmatched ability to drive progress and make life better for people around the world.”

Yet the fate of PEPFAR is in question as a political fight over abortion has stalled Congress from passing a five-year reauthorization of the program. Congress missed the Sept. 30 deadline to renew funding for PEPFAR before it expired. Much of the holdup in PEPFAR’s renewal concerns a group of House Republicans who are arguing against passing a five-year reauthorization to PEPFAR unless it includes provisions that prohibit nongovernmental organizations that receive PEPFAR funding from providing or promoting abortion services.

“Regrettably, PEPFAR has been reimagined – hijacked – by the Biden Administration to empower pro-abortion international non-governmental organizations, deviating from its life-affirming work,” said Rep. Chris Smith (R-New Jersey), chair of the House Global Health Subcommittee in a statement released on Sept. 29.

Just the day before, the House passed a bill for a one-year reauthorization to PEPFAR that many believe is unlikely to pass in the Senate, where a bipartisan group of Senators have expressed support for a full five-year renewal of the program.

At the root of the debate are conservative groups who say that the Biden administration in its Sept. 2022 five-year PEPFAR strategy stated support for reproductive health and rights, which they argue includes support for abortion. Such groups also are calling for a reinstatement of the so-called, “Mexico City Policy,” which the Biden administration rescinded in January 2021. First instituted in 1984 by President Ronald Reagan, the policy requires foreign nongovernmental organizations to certify they will neither perform nor promote abortion as a method of family planning to receive funding. The policy had not been included as a part of PEPFAR funding until 2017, when the Trump administration expanded the policy to include it as a part of the program.

Advocates for PEPFAR contend the program does not directly or indirectly fund abortion services.

“PEPFAR is one of the accomplishments under President George W. Bush that Republicans have touted probably more than any other, and for them to undercut the history of their own party is really quite surprising, in particular when they would do that without any factual basis for the charges that are being leveled about how PEPFAR is being implemented,” says George Ingram, a senior fellow in the Center for Sustainable Development at the Brookings Institute, a Washington think tank.

In the short term, the delay in reauthorizing PEPFAR won’t have an impact on direct HIV relief efforts, said U.S. State Department spokesperson Matthew Miller during an Oct. 2 press briefing. Yet he expressed concern about what it signals to other countries regarding the U.S. commitment to being a global partner in the fight against HIV/AIDS.

“The fact that Congress did not reauthorize the program sends a message to partners around the world, especially in Africa, that we are backing down from our leadership in ending HIV/AIDS as a public health threat,” Miller said.

From a practical perspective, a delay in PEPFAR reauthorization could lead to disruptions in the operations of some organizations that rely on that funding when planning out their budgets moving forward, according to Ingram.

“Organizations don’t start on a dime overnight, they have long-term planning, long-term training and long-term staffing requirements,” Ingram says. “If you get to a point where it looks like there’s no funding in two or three months, they’ll have to start letting staff go and pulling back what they do. When the funding does come back, it takes months to get re-established, so the lack of certainty has a real practical impact on the ability of organizations to deliver the services that are so critical.”

Since its launch, PEPFAR has provided more than $110 billion in foreign aid to low- and middle-income countries, the largest ever commitment by a country to a single disease, according to the Kaiser Family Foundation. Program funds have been used to deliver antiretroviral medications to more than 20 million people, supported HIV testing services to nearly 65 million individuals, and funded training of more than 340,000 new health care workers, according to the U.S. State Department.

For some countries, the health benefits of the PEPFAR program go beyond its mission of reducing the spread of AIDS.

A 2021 KFF analysis of 90 countries that receive aid from PEPFAR found the program from 2004 to 2018 was associated with a 20% lower all-cause mortality rate in those nations compared to what would have been expected without the program.

“Really, a lot of the health infrastructure in many countries is sort of anchored on PEPFAR,” says Dr. Carlos del Rio, professor of medicine in the division of infectious diseases at Emory University School of Medicine, chair of the State Department’s PEPFAR Scientific Advisory Board Committee and current president of the Infectious Diseases Society of America.

In terms of its impact on foreign relations, Ingram says PEPFAR’s reputation throughout the rest of world cannot be overstated. The program has provided one of the most positive narratives for the U.S. in areas of the world like Africa, where relations with some nations within the continent have faced challenges in recent years for several reasons, including global inflation and increased competition for establishing strategic partnerships with China and Russia.

“PEPFAR is seen as a program that the U.S. is doing altruistically and that it is undertaking because of concerns for the health and the future of African countries and people,” Ingram says. “For the reauthorization to be tied up in domestic politics and the Congress to be unable to move, it undercuts that narrative of the U.S. caring about Africa.”