More than $1bn in funding for the President’s Emergency Plan for Aids Relief (Pepfar) has been delayed in the US, in the latest complication facing a lifesaving HIV programme that has been ensnared in a broader political fight around abortion.
Created by President George W Bush in 2003, Pepfar has been credited with saving more than 25m lives worldwide. The nearly $7bn annual initiative, managed by the US State Department, has distributed millions of courses of medicine to treat HIV, funded testing and prevention services, and supported an array of other interventions.
Dozens of foreign governments, including in Africa, rely on Pepfar as a key partner, reports The Washington Post.
The programme has traditionally enjoyed bipartisan support in US Congress, which has reauthorised it every five years. But lawmakers this year have failed to reauthorise it by a 30 September deadline amid claims from conservative advocacy groups that the programme is inadvertently funding abortions overseas – allegations that Biden officials, Pepfar staff and public health leaders say are unfounded and threaten the programme’s mission.
Pepfar can continue to operate without congressional authorisation, with much of its current funding intact. But Republicans have been delaying notifications that the State Department is required to send to Congress before Pepfar spends any additional money, say several sources.
The Republicans’ funding delays and objections, which have not been previously reported, centre on Pepfar’s use of terms relating to abortion, transgender people, sex workers and other areas, with the committee repeatedly demanding rewrites from the State Department.
The negotiations have delayed the State Department from releasing more than $1bn in funding for Pepfar – funding that the programme is planning to use to buy medicines, pay for staff and support other essential functions, say the sources.
Pepfar officials have pushed back on some of the requested changes, including an attempt by House Republicans to change how terms such as “human rights” appear in the document.
Keifer Buckingham, advocacy director for the Open Society Foundations and a former Democratic congressional aide who worked on Pepfar’s last reauthorisation in 2018, said previous Pepfar documents used similar language and addressed the same issues.
“None of that phrasing is new … and it’s not as if policy has dramatically changed,” Buckingham said, adding that House Republicans’ complaints about Pepfar language are “ideological” and parallel their domestic political priorities around abortion and transgender issues.
The State Department confirmed the House Foreign Affairs Committee has delayed approving the notifications required for allocating funds to Pepfar.
““If the (notifications) are not approved very soon, Pepfar’s lifesaving work and gains will be threatened,” it said.
Lawmakers have placed holds on Pepfar funding in previous years in hopes of securing changes or getting answers about the programme.
But experts said the climate around the programme has shifted since last year’s Supreme Court ruling on Dobbs v Jackson Women’s Health Organisation, which effectively overturned the national right to abortion.
“Pepfar’s never been an abortion programme,” said John Nkengasong, the programme’s director, at the Centre for Strategic and International Studies, a think tank based in Washington. “It is not and will never be because there’s a law, the 1973 Helms amendment, restricting US foreign assistance programmes from funding abortion abroad.”
Public health experts have clamoured for lawmakers to swiftly reauthorise Pepfar for five years through what is known as a “clean reauthorisation” – effectively rolling over the current structure.
Current and former Pepfar officials said that a five-year reauthorisation would protect the programme from political pressures and help global partners plan their strategies.
Others have warned that Congress’s delay in reauthorising the programme is “damaging the United States’ image globally, particularly in Africa”, and threatening plans to acquire supplies, roll out innovations and take other steps that require certainty about Pepfar’s long-term viability.
But some Republicans want to reauthorise the programme for just one year, arguing that it would allow a future GOP President to make changes to it. Conservative advocacy groups also have warned lawmakers that a vote to re-authorise Pepfar in its current form will be viewed as a vote to support abortion abroad.
Letter appeals for support
The George W Bush Institute sent a letter to congressional leaders last week signed by more than 30 organisations and leaders in global health, foreign relations and faith communities, saying that a five-year “clean” re-authorisation would help fend off strategic rivals seeking influence in regions that rely on Pepfar support.
“As authoritarian China and Russia seek to increase their influence in Africa by any means possible, Pepfar has been a shining example of compassion, transparency and accountability, as well as a massive strategic success story for the United States,” the letter reads.
“Abandoning it abruptly now would send a bleak message, suggesting we are no longer able to set aside our politics for the betterment of democracies and the world.”
Deborah Birx of the Bush Institute, who led Pepfar during the Obama and Trump administrations and helped organise the letter, said the congressional debate over the programme “is bigger than Pepfar”, citing the growing political divides over foreign aid, funding the Defence Department and other areas that were traditionally bipartisan.
Lawmakers and staffers told The Washington Post it was unclear whether newly elected House Speaker Mike Johnson, who is staunchly anti-abortion and a long-time ally of conservative advocacy groups that allege Pepfar is funding abortions abroad, would favour swiftly reauthorising the programme.
Pepfar partner organisations across the globe said they are nervously watching the congressional negotiations, which have raised international questions about whether the US remains committed to its long-running HIV programme.
It is unclear what will end the logjam.
Nkengasong has called for a “dialogue” with the programme’s critics. “We have to have a forum where we have an honest conversation … and lead with facts and not misinformation and disinformation,” the Pepfar chief said.
See more from MedicalBrief archives:
‘Colossal impact’ fears as US anti-abortion lobby threatens to kill Pepfar
Pepfar changes strategy, empowers Africa in HIV battle
SA will send team to Washington to lobby PEPFAR funding cut