Jonathan Ernst/Pool Photo via AP
Secretary of State Antony Blinken speaks about the President’s Emergency Plan for AIDS Relief (PEPFAR) at the World AIDS Day event hosted by the Business Council for International Understanding in Washington, December 2, 2022.
Congress appears unlikely to reauthorize the President’s Emergency Plan for AIDS Relief, or PEPFAR, a flagship public-health program that has saved millions of lives and promoted American soft power in the developing world.
A bipartisan program created by President George W. Bush, PEPFAR is the largest global health initiative ever to address a single disease. As of last year, according to the CDC, PEPFAR had provided antiretroviral therapy to more than 20 million people around the world with HIV.
Foreign aid doesn’t always work. It can have perverse consequences—for instance, it can prioritize one disease at the expense of others, diverting care away from rival causes. But researchers have found that PEPFAR reduced the odds of death from any cause by as much as 16 to 20 percent in target countries. And PEPFAR has had positive spillover effects beyond HIV, such as raising workforce participation and reducing tuberculosis infections and deaths.
But as a September 30th deadline approaches to reauthorize PEPFAR, the once-bipartisan aid program is snarled in the U.S. culture wars.
In May, the right-wing Heritage Foundation released a report saying that the Biden administration was using PEPFAR “to promote its domestic radical social agenda overseas” on abortion and gay rights. As evidence, Heritage pointed to a White House memo that committed “to support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally.”
“On the Left, ‘sexual and reproductive rights’ and ‘reproductive health services’ are code for abortion,” the Heritage report argues.
“While PEPFAR very clearly does not go to fund abortions in any way, this [phrase on reproductive health] got taken up as code,” AIDS activist Charles King told the Prospect. “Well, if you’re talking about women who have what is largely a sexually transmitted disease, then as part of taking care of their HIV, taking care of their sexual and reproductive health is absolutely critical.”
Right-wing activists have insisted that the reference to sexual and reproductive health is concealing a secret agenda. Travis Weber, vice president for policy and government affairs at the anti-abortion group Family Research Council, said on a July podcast, “What’s changed is the Biden administration’s radical insistence on ramming abortion into our foreign policy in an aggressive manner that we’ve never seen before.”
Biden did rescind what is known as the Mexico City Policy, which prevents federal money from going to NGOs that perform, or provide counseling on, abortion. But that is separate from PEPFAR, and there is no evidence that PEPFAR funds have ever been used to pay for abortions.
Still, anti-abortion advocates are now pushing for a one-year reauthorization with explicit abortion restrictions, which would subject the program to continual renewals from a Congress that is having difficulty even completing short-term government funding. Making the program more susceptible to the funding whims of Congress could undermine the treatment plans of medical providers, since HIV patients must take antiretroviral medications long-term.
THE CONFLICT RUNS DEEPER than U.S. abortion politics. PEPFAR was born 20 years ago in a more unipolar world. Threats to the program today may signal a greater shift in American foreign-policy ambitions.
Bush announced the creation of PEPFAR in 2003, at the same State of the Union address where he detailed false intelligence claims that Saddam Hussein had sought African uranium, and urged that Iraq could distribute weapons of mass destruction to terrorists. In 2004, the program began providing antiretroviral drugs to patients in Africa.
By all accounts, PEPFAR was a priority for Bush. In a recent interview, a key architect of the program recalled that Bush had said, “Don’t tell me how much it’s going to cost, tell me what you’re going to do, how you’re going to do it, what your timelines are, and I’ll find the money. Tell me how much it’ll cost to achieve big goals.”
The former president has remained a passionate advocate of the program to take on global HIV. Last week, he penned a Washington Post op-ed defending PEPFAR.
But the COVID-19 pandemic era has brought greater skepticism toward both overseas development and public-health initiatives. Domestic AIDS funding—Trump’s “Ryan White” effort to end the HIV epidemic—is also under threat in new budget cuts. Americans may question the link between leadership on global health and sustaining an international system favorable to U.S. interests.
“If we are unable to reauthorize a consistently bipartisan, widely successful public-health program as we have over the last 20 years, it sends a message to our partners across the globe that we are less committed to achieving an AIDS-free generation,” Rep. Barbara Lee (D-CA), ranking member of the House Appropriations Committee’s Subcommittee on State, Foreign Operations, and Related Programs, told the Prospect.
Still, a bipartisan group of senators, including Mitt Romney (R-UT) and Bill Cassidy (R-LA), have defended the merits of the program. They led a call for reauthorization, citing a 2021 analysis finding that countries with a PEPFAR program “showed a significant increase in opinion of the United States.”
“The success that PEPFAR should have with implementing such a maternal care program will extend beyond the lives saved and pain ameliorated among African women and children. It will be strategically important to the United States,” the senators wrote. “40% of the world’s population will be African by the end of the century and our strategic competitors are investing comprehensively in the region. We know that the PEPFAR program remains one of our most potent soft power assets on this front.”
