Abortion politics cast shadow over PEPFAR reauthorization

An unexpected campaign by conservative and anti-abortion activists to paint PEPFAR, the U.S. global AIDS initiative, as a source of funding for abortion has some advocates worried that plans to extend its legal authorization for another five years could be derailed. Without full authorization, the President’s Emergency Plan for AIDS Relief, or PEPFAR, which has saved 25 million lives since it was founded two decades ago, would be at risk of budget cuts, deprioritization, and diminished status. Several of its provisions and requirements would also expire, including those that direct PEPFAR’s focus areas and spending, as well as authorize U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. People working behind the scenes to support PEPFAR say the attack has less to do with the reality of how the initiative operates and more to do with a broader political push against President Joe Biden’s progressive policies at home and abroad. It also comes at a time when reproductive rights, and particularly abortion, seem especially politically divisive. But PEPFAR — like all U.S. foreign assistance programs — is legally barred from funding abortion, and in many countries where it operates abortion is heavily restricted. “PEPFAR seems to be caught in the crosshairs,” a global health executive told Devex on condition of anonymity. “Having a politicized PEPFAR, a politicized global health structure like this is just not beneficial to achieving the goal of ending AIDS.” --— Anonymous official Even if PEPFAR is not reauthorized by the end of this fiscal year on Sept. 30, the U.S. Congress will likely continue to fund it and its programs through the annual appropriations process. Funding for the Global Fund, which is channeled through the office that runs PEPFAR, could also continue in the same way. While advocates say they still see a path to reauthorization this year, the sudden broadside has raised questions about the stability of political support for an initiative that has stood as a rare bipartisan bright spot since its creation by President George W. Bush in 2003. PEPFAR, which represents the largest-ever commitment by a single country to a single disease, will spend $4.8 billion in fiscal year 2023 on bilateral HIV efforts and just over $2 billion for multilateral efforts including the Global Fund. A surprisingly bumpy path Just a few months ago, it appeared that PEPFAR was on a clear path to reauthorization — a congressional process that cements its existence in law and allows lawmakers to update its policies and funding requirements if they choose. Many hoped this year would see a “clean” or “date change” reauthorization, with no changes other than granting the initiative five more years of legislative support. At a Senate Foreign Relations Committee in late April, lawmakers from both sides of the aisle said they supported a simple extension of PEPFAR’s mandate, and U.S. global AIDS coordinator John Nkengasong, who leads the initiative, made clear that he did not need any additional permissions from Congress or changes to how PEPFAR operates. Then on May 1, two documents from conservative groups appeared alleging that PEPFAR has become a vehicle for the Biden administration’s “radical” agenda overseas. The first was a report written for the Heritage Foundation, a conservative think tank, by Tim Meisburger, a former Trump administration official who was removed from his post at the U.S. Agency for International Development in early 2021 after he downplayed the Jan. 6 attack on the U.S. Capitol. The second was a letter from 31 conservative and anti-abortion groups to high-ranking Republican lawmakers overseeing PEPFAR’s reauthorization, raising concerns that PEPFAR funds are “used by nongovernmental organizations that promote abortions and push a radical gender ideology abroad.” Neither document provides any concrete evidence that the initiative has violated its legal requirements. They both point to a $38 million USAID-funded project to research the concept of individual “agency” as it relates to health, which includes the International Planned Parenthood Federation as a member of the research consortium. IPPF is a global NGO that provides abortion care and promotes sexual and reproductive health and rights. Meanwhile, a group of 20 faith-based organizations wrote their own letter to Republican lawmakers advocating for an extension of PEPFAR, highlighting a “conscience clause” that allowed faith-based organizations to compete for and win work with the federal government on PEPFAR projects. They ask for continued support for PEPFAR and a reauthorization that would maintain those current clauses and provisions, which a clean reauthorization bill would do. A third letter, from some 52 global health organizations that are part of the Global AIDS Policy Partnership, this one to senior foreign affairs lawmakers from both parties, argued that PEPFAR continues to be a “smart investment” and urged them to reauthorize the program “as simply and expeditiously as possible.” “A simple date-change reauthorization will ensure that the program does not become overly politicized and maintains the broad support necessary to finish the job it was designed to do,” the letter said. Questions over the criticism Some of PEPFAR’s expiring provisions relate to how much funding should be spent on treatment, how much funding goes to support orphans and vulnerable children, and several related to the Global Fund, including requiring that U.S. contributions not exceed 33% of what the Global Fund raises. That 33% match requirement is critical for spurring other countries to step up their support, said Chris Collins, president of Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, which works to end those epidemics. “Everything is just clearer if you can get this authorized and keep it in law,” he said. PEPFAR insiders who spoke to Devex questioned the motivations of those leveling criticisms against it. “I don’t believe the people who are making a case that PEPFAR is a source of abortion or the other charges that they've alluded to know a great deal about the developing world. Their focus is the United States,” said Shepherd Smith, co-founder of the Children’s AIDS Fund International. “It’s a mystery to me what the motivation is to do this,” added Smith, an evangelical Christian who has supported PEPFAR since it began. The Office of the Global AIDS Coordinator, which manages PEPFAR, did not respond to an inquiry from Devex. In his report for Heritage, Meisburger accuses the Biden administration of trying to “poison bipartisan support for PEPFAR by misusing it to promote abortion under the guise of sexual and reproductive health and transgenderism.” He includes a range of controversial policy proposals, including transitioning PEPFAR from an “emergency” program at the U.S. State Department to a development program housed within USAID, and renaming it the “George W. Bush Global Health Initiative.” Meisburger did not respond to an inquiry from Devex. “It’s a dangerous time because lots of people all over the place have ideas about what they’d like to see in or out of PEPFAR,” said Bill O’Keefe, an executive vice president at Catholic Relief Services, adding that “the current set of compromises that have been so instrumental to the bipartisan support of the program really need to continue.” This reauthorization is more complicated than others because a lot of lawmakers are new and unfamiliar with PEPFAR, haven’t previously approved it, and also don’t understand what a threat this kind of disease is, he said. CRS, as well as other organizations that implement PEPFAR programs, and Nkengasong himself, need to be making the case to those lawmakers, O’Keefe said. The global health executive who spoke to Devex on condition of anonymity said they still see a pathway to a clean, bipartisan reauthorization that involves educating those less familiar with PEPFAR about how it really operates and “good faith due diligence” by the conservative lawmakers in positions of authority. But PEPFAR’s supporters face an “uphill battle,” the executive added, because it’s not clear what kind of answers will satisfy people whose disagreements are with the Biden administration’s overall policy priorities. “Having a politicized PEPFAR, a politicized global health structure like this is just not beneficial to achieving the goal of ending AIDS,” the global health executive said.