WASHINGTON — A few days before the United States Congress was set to vote on legislation to authorize the largest investment in fighting a single disease in history, Shepherd Smith, a well-connected evangelical Christian, found himself in a meeting at the White House with President George W. Bush and a group of faith leaders.
Smith, who together with his wife Anita had been working for years to draw the Christian church into the fight against HIV and AIDS, had been watching the bill that would create the U.S. President’s Emergency Plan for AIDS Relief very closely.
Smith was worried about one specific provision — which he had worked behind the scenes to support — offered as an amendment by Rep. Christopher Smith from New Jersey. The congressman had proposed that PEPFAR include a “conscience clause,” which would allow organizations to opt out of activities they felt conflicted with their values or beliefs. For many church groups, the prospect of distributing condoms to schools was a nonstarter, and requiring them to do so “would effectively eliminate faith participation” in PEPFAR, Shepherd Smith said.
His efforts to build support for the provision seemed to be hitting a wall.
“We were pretty careful on counting the votes in the committee and felt that we were going to end up short on this amendment,” Smith said.
At the White House meeting, Smith told the president about a recent experience he had in Uganda, where faith leaders from different denominations in the country had expressed concern about not being able to get U.S. grants because they required recipients to distribute condoms, something these faith leaders were not willing to do. Smith had visited the U.S. embassy and asked if they would give an award to a faith group that only wanted to give a message of faithfulness to adults and abstinence — or “delayed sexual debut” — to children. They told him, “No,” Smith recalled. They would require condom distribution to promote the U.S. government’s comprehensive approach — dubbed “ABC” for “abstinence, be faithful, use a condom.”
When Smith asked the embassy team if they would require an organization that only wanted to distribute condoms to also promote abstinence and faithfulness, they seemed much less certain.
“The mindset ... was clearly a strong bias toward condoms and a strong bias against abstinence and faithfulness,” Smith said.
After he related his experience in Uganda to then-President Bush, he “gained an appreciation for the importance of the amendment … turned to his staff and said, ‘look we’ve got to get this through,’” Smith said. “When the final vote came in, we won by one vote in committee.”
PEPFAR remains a rare and remarkable story in American politics, a multibillion dollar government foreign assistance program that has survived 15 years of starkly opposed administrations — and that counts both Hillary Clinton and Mike Pence as true believers.
See more on the future of PEPFAR:
Republican support for the unprecedented foreign aid program is due, in large part, to the role Christian evangelicals played in pointing conservative lawmakers toward their moral obligation. In turn, PEPFAR’s authorizing legislation recognized their contribution, requiring that one-third of PEPFAR funds be spent on abstinence-until-marriage programs.
While many conservative Christians initially interpreted the HIV and AIDS crisis as God’s punishment for sinful behavior, a wide network of evangelical leaders and organizations has since come to hold significant sway over the flagship PEPFAR initiative, as well as other U.S. global health programs. While the relative influence of these groups and individuals has waxed and waned with changing presidential administrations, Donald Trump’s presidency has presented the evangelical community with an opportunity to reassert its role, both in setting U.S. global health policy and in ensuring that faith-based organizations in America and around the world are positioned to receive government money to implement that policy.
PEPFAR’s leaders have set about trying to reinvigorate the initiative’s relationship with churches and communities of faith in the countries where U.S. HIV and AIDS programs operate, while some of PEPFAR’s most influential evangelical backers still face questions about how they draw the lines between faith, science, and human rights.
When AIDS first erupted into American consciousness, Christian evangelicals were not the most compassionate responders. In some cases, evangelical leaders were openly hostile to the idea of extending treatment to AIDS patients, blaming those who contracted the virus — mostly gay men in the early years of the epidemic — for living sinful lifestyles that invited “the wrath of a just God,” as prominent televangelist Jerry Falwell put it.
Messages of sin and responsibility have persisted. Ken Isaacs, a vice president at Samaritan’s Purse who recently lost a bid to lead the United Nations International Office of Migration, wrote in 2003, “that when we choose to act outside of God’s mandate for sexual purity, we should be prepared to deal with the consequences.”
The virus demanded a message of “the redeeming love of Christ and the eternal life they can have through him,” Isaacs wrote, concluding that, “AIDS has created an evangelism opportunity for the body of Christ unlike any in history.”
As the epidemic expanded, and as churches were forced to confront the reality of AIDS inside their own congregations, a desperate need for better information and greater moral clarity emerged. Shepherd and Anita Smith were among the early voices who sought to fill that vacuum and point the church toward a more constructive approach. Shepherd worked as a political strategist for Pat Robertson, a former Southern Baptist minister who ran for U.S. president in 1988. Anita, now president of the Children’s AIDS Fund, served as co-chair of the Presidential Advisory Council on HIV and AIDS under President George W. Bush, after the couple’s attention turned to HIV.
“It was a tough time for the conservative faith community, because there were mixed messages. Our approach was that we were focused strictly on HIV/AIDS. We were not focused on the gay community. We were not focused on any specific population. We were dealing with the disease itself,” said Anita Smith.
In 1991, the Smiths co-authored a book, “Christians in the Age of AIDS,” which sought to combine medical information about the virus and epidemic with a moral case for the church’s involvement in HIV treatment and prevention.
“We were known to be evangelical Christians, and all of a sudden there was a need to have evangelical Christians reach out to a global church that was divided on how to respond. Was this a response to sin? How do we treat people? Do we allow them to be in our congregations?” Shepherd Smith said. “It was quite a chaotic time when we entered this. We felt we were being helpful.”
Anita worked through her connections in the extensive network of faith media groups, including the Evangelical Press Association, to help change the messaging around AIDS emanating from these outlets. The couple also developed deep relationships in Washington, D.C., with conservative lawmakers who needed to develop a politically palatable stance on the AIDS crisis and what to do about it.
“There were a lot of people that looked to us for information rather than to a lot of folks in the AIDS community, because they were either uncomfortable, or politically not in synch, or for whatever reasons we became a primary resource for conservatives on the Hill,” Shepherd said.
The Smiths became involved in supporting U.S. domestic initiatives such as the Ryan White HIV/AIDS Program and extending Americans with Disabilities Act protections to people living with HIV.
“That was really all kind of in preparation for our involvement in PEPFAR, as we look back on it,” Shepherd said.
The Smiths took their first trip to Africa in 1995, sponsored by a pharmaceutical company that was developing a new treatment. They visited a Salvation Army children’s hospice in Johannesburg, South Africa — their driver dropped them off several blocks away for fear of contracting AIDS — and began to recognize both the immensity of need in Africa and the scarcity of services. In March 2002, they returned alongside about 20 U.S. government officials — many of whom would end up being key architects of President George W. Bush’s groundbreaking HIV initiative — led by then-Secretary of Health and Human Services Tommy Thompson. Their mission was to “assess the health assets that existed at the time” in a handful of African countries, Shepherd said.
“My only clue that it was being done essentially for PEPFAR was that several times, a friend on the trip was saying, ‘we really want to know what sort of programs could be supported here,’” he added. “PEPFAR was kept under wraps very well by a very small number of people.”
“The faith community easily, easily offered the most substantial health assets that we saw … Faith-based clinics and hospitals … they were the ones that were responsible for the funerals, and they were burying their congregation members. They were counseling people dying.”— Shepherd Smith, co-founder of the Children's AIDS Fund
For Shepherd and Anita, the U.S. government trip reinforced their view that faith-based organizations offered the deep community ties, the networks, the infrastructure, and the commitment to carry the load of an expanded HIV and AIDS treatment effort.
“The faith community easily, easily offered the most substantial health assets that we saw. Yes, government had some facilities, but when you compared those facilities to faith-based clinics and hospitals, there really wasn’t much of a comparison,” Shepherd said. “They were the ones that were responsible for the funerals, and they were burying their congregation members. They were counseling people dying. These folks, their commitment, is unparalleled.”
Faith-based organizations provide a significant portion of health care services in developing countries, many of them with their historic roots in mission societies that spread throughout Africa, Asia, and Latin America in the 18th and 19th centuries. The extent of faith involvement in African countries’ health service delivery systems is debated. A 2006 study commissioned by the World Health Organization found that 70 percent of health assets in Zambia were owned or provided by faith organizations. A 2012 study supported by the Bill & Melinda Gates Foundation questioned such high figures, finding the highest percentages of faith-owned hospitals in Rwanda and Tanzania at 40 percent, with lower percentages in other countries and for other components of the health care system.
“So a lot of what was needed was to figure out how to structure a program that didn’t funnel money through the government but could get money to some of these groups already functioning throughout these countries. I think that’s one of the unique aspects of the legislation. It didn’t parallel the Global Fund structure, which is really kind of government to government, but here went directly to the providers,” Shepherd said.
In the meantime, the Smiths had opened four clinics in South Africa, Malawi, Uganda, and Zambia, mostly partnering with faith-based groups, who they believed offered the best chance for long-lasting interventions. Three of them would ultimately be rolled into PEPFAR.
“They were established in their communities. They were respected. They already had networks. They had an infrastructure,” Anita said of their faith-based partners.
On Jan. 28, 2003, President Bush issued his State of the Union address in Washington, D.C. At the time, nearly 30 million people in Africa were infected with HIV, while only 50,000 were receiving treatment, Bush said. He called for “a work of mercy beyond all current international efforts to help the people of Africa” and proposed the Emergency Plan for AIDS Relief. Bush asked the U.S. congress to commit $15 billion over five years to the effort, a scale his own advisers had considered impossible when Bush directed them to design the program.
After the announcement, Shepherd and Anita Smith began to organize faith groups to help build conservative support for the initiative.
“We were able to affect the thinking of the Republicans who, for two counts, were not excited about this initially: One, because of the amount of money — $15 billion was just a very large sum of money that was pretty much out of the blue. The other aspect was it was a disease they were not familiar with, by and large,” Shepherd said.
“In that process, we saw that for the faith community to be involved, they needed to be able to participate in government grants that did not deny them the opportunity to participate,” he said, referring to a tendency, “particularly at [the U.S. Agency for International Development],” to insert provisions into requests for proposals that would make it impossible for faith groups to be part of the initiative, like the requirement to distribute condoms. Shepherd described his and Anita’s efforts on behalf of Rep. Smith’s “conscience” amendment as, “maybe the largest role we played in this.”
As more of their attention turned to the AIDS epidemic in Africa, the Smiths became interested in one country in particular: Uganda. While others struggled to make significant inroads against the spread of the virus, Uganda showed early success. In 1990, Uganda recorded an estimated 96,000 new HIV infections, according to the Joint United Nations Programme on HIV/AIDS, and in 1998, that number had dropped to 66,000. Uganda’s early success seemed to demonstrate the potential for a behavior change message — as opposed to a strategy that favored condom distribution — in fighting the epidemic, a message that fit neatly with the evangelical view that abstinence and faithfulness should be central to a global response.
“Political leadership made a huge difference in how a country responded to HIV/AIDS. It was hands down the most important element in the reduction in infections. Plus, the messages that the Musevenis were giving were very consistent and very smart,” Shepherd said.
“They learned that this was a contagious disease that would be passed through people having multiple partners, so they encouraged what they called ‘zero grazing,’ for people to stick with one person,” he said. The phrase — “zero grazing” — derives from the image of an animal tethered to a post, limited to a circular perimeter that traces the shape of a zero.
“Yes, our government, Western countries encouraged condom use, and there was some, but they really didn’t have the impact, as we saw from data there, that partner reduction did — and delaying sexual debut,” Shepherd said.
The question of what enabled Uganda’s early success is hotly contested — and complicated by the fact that the good-news story didn’t last as long as many had hoped it would. After the early decrease in new infections, the numbers started to climb again, reaching a new high of 110,000 in 2009, according to UNAIDS. Some health experts pinned the blame on the very strategy that the Smiths claim enabled Uganda to stand out among other countries struggling to contain the virus.
“We have messages confusing what is right with what is safe,” Canon Gideon Byamugisha, a religious leader and AIDS activist in Uganda, told the New York Times in 2012. “If you have an environment that stigmatizes them, then don’t expect people to use condoms.”
Uganda’s social conservatism — and the strong behavioral messaging emanating from the country’s top leadership — while useful for advancing an agenda of faithfulness, also contributes to an environment of stigmatization and persecution of gay people. In 2009, a Ugandan member of parliament introduced the Anti-Homosexuality Act, and President Yoweri Museveni signed it into law in 2014, drawing criticism from then-President Obama and the State Department. Other donors withheld funding from Uganda in response to the legislation. The bill, which has now been annulled on a technicality, made gay sexual activity by HIV-positive people punishable by life in prison — a reduced punishment from the previous version of the original bill, which called for the death penalty.
Many have placed some of the blame for Uganda’s crackdown against homosexuality on the influence American evangelicals have had in the country. Writing in the Los Angeles Times, Kapya Kaoma, an Anglican priest and researcher at Political Research Associates, blamed prominent American evangelicals for using “their influence and credibility to contribute to a culture war in Uganda much more intense and explosive than anything seen in the United States.”
Some of the most troubling messages emanating from Ugandan preachers echoes messages propagated in the early days of the American evangelical response to the epidemic, Shepherd Smith said.
“This idea that this was the result of sin from churches here kind of bled over to churches there, and there was some of that that we needed to deal with. Even today, there are issues in some different denominations or faiths that God can cure this, you don’t need to take medicines. So we’re still working to make sure that those messages are clarified, because they’re incorrect,” he said.
Asked how he would respond to charges that American evangelicals have contributed to a stigmatizing, dangerous environment for gay people in Uganda, Shepherd Smith described it as, “a complex issue regarding homosexuality in the developing world and the history of the laws there that really were created by Europeans initially.”
Asked to clarify their own position on the antigay law, given the Smiths’ long involvement with HIV treatment in the country and their relationships with Ugandan political leaders, Shepherd said, “the position that we’ve taken historically throughout the epidemic is that our obligation to other people, whether they’re gay or not, is to love them.”
“We felt that this legislation was not helpful in respect to dealing with the issues of the day and particularly the epidemic. That’s what we have focused on,” he said. “We certainly discouraged friends from participating, but many of them had already made a decision to disassociate themselves from the radical elements that were supporting this. I think that folks that know us well understood that we took a pretty responsible position in respect to that.”
Despite their relatively low public profile, the Smiths have, from time to time, popped up in media reports, many of which tend to raise concerns about the under-the-radar influence they wield over U.S. government programs — and their receipt of millions of dollars of federal funding for HIV programs. A report in The Nation described them as “vehement foes of what they see as the corrupting influence of LGBT organizations in the field of AIDS relief,” and documented their association with a variety of “right-wing pro-family” groups.
Writing in POZ, a magazine for people with HIV, activist Sean Strub raised concerns about Trump’s appointment of Robert Redfield to direct the Centers for Disease Control and Prevention, in large part because of Redfield’s longtime association with the Smiths, whom Strub wrote, “have received millions and millions to support their anti-gay and anti-PLHIV [people living with HIV] agenda.”
“The Smiths, their organizations and their ultra-right ‘Christian’ activism are largely unknown to the public, but they have been a powerful behind-the-scenes player, currying favor with HIV policy leaders in government in large part because of their ability to deliver evangelical/Christian Right votes in Congress for appropriations,” Strub wrote.
Shepherd called allegations that he and Anita are antigay or antipeople living with HIV “absolutely absurd … when you consider the tens of thousands of people we’ve helped.” He also said that much of the criticism they receive has stemmed not from any problem the Smiths have with homosexuality, but from their disagreements with HIV activists — many of them from the gay community — over how the HIV epidemic should be dealt with. Shepherd maintains that he and Anita have always taken a public-health-first approach, while others have tended to approach HIV as a civil rights or social issue.
“Because we didn’t go along with the activist community in our view … we became either antihomosexual or abstinence-only,” Shepherd said.
The Smiths have strong views about sexual relationships, but not about sexual orientation, Shepherd said. In line with their view that the most effective means of reducing HIV risk is by reducing sexual partners, they see a behavior-change message as equally applicable to men who have sex with men.
“What we have seen is that gay men can change behaviors,” Shepherd said. “I think the message of partner reduction is not specific to orientation at all. It doesn’t really matter. Heterosexuals who have lots of partners are putting themselves at risk just as gay men are if they have large numbers of partners. Being in stable, committed relationships reduces the risk of infections.”
The Smiths are also not abstinence-only advocates, he added, but have taken a “hierarchical” view of prevention, which favors abstinence and faithfulness over condom use, the efficacy of which Shepherd still openly questions.
“That’s a risk reduction measure, probably,” he said. “It became the answer without any proof … It was more a way of people believing they were going to be safe than it was an assurance of safety.”
“I insisted. I said you're never, ever going to have a prevention program without distribution of condoms.”— Tony Fauci, director of the National Institute of Allergy and Infectious Diseases
Some of the world’s leading HIV experts believe otherwise, including Tony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health and an architect of PEPFAR, who led some of those early trips to Africa in 2002 that the Smiths took part in. Fauci described faith-based organizations as “quite helpful in getting congressional and other support for PEPFAR,” but lumped “relying a lot on abstinence” into a category of “things that we felt as scientists were not as effective in the real world.”
“I remember the discussions that I had at the White House when they're asking me, ‘do we really need to be distributing condoms, because you know there's an aversion to that, because of the conservative wings of the party and the people who are faith-based considering that that shouldn't be done,” Fauci said. “And I insisted. I said you're never, ever going to have a prevention program without distribution of condoms.”
“And we won that battle,” he said.
See more on the origins of PEPFAR:
Asked how President Bush, a born-again Christian, grappled with conflicts between faith and what his medical advisers were telling him, Fauci said, “he was critically and firmly interested in saving lives. He is a conservative, there's no doubt about that. He's a man of faith, there's no doubt about that. But whenever we got involved in discussions about it, it was always about saving lives.”
Some members of the faith community have felt that, in the intervening years since PEPFAR’s launch, the church’s role as a provider of treatment and prevention messaging has been diminished.
“Along the way of our work on PEPFAR, we lost some of our engagement directly into the churches,” U.S. Global AIDS Coordinator Debbie Birx told attendees at the Christian Connections for International Health Conference in Baltimore, Maryland, earlier this month.
“We have spent the last year and a half … mapping this out and sending emissaries out into country after country to really map what is available at all the different levels of leadership of faith in the different countries, so that we can tap back in successfully,” Birx said.
She added that PEPFAR will then be “working with organizations like World Relief to really see what can be done with pastor and leadership training in each of the churches around core issues that now are affecting many in sub-Saharan Africa and other places we work in.”
One of those core issues is sexual violence against girls and women. In many of the countries where PEPFAR operates, the percentage of girls and young women whose first experience of sex is forced or coerced is between 20-35 percent, Birx said.
“Sunday morning, both the perpetrators and the victims are in that congregation,” Birx said. “This is the role that we have to have, to put that wide arm, that reckless and unending love of God around these children, and we have to stop concentrating completely on postrape care, which is what we’ve been doing. We have to get to a place where we can speak about it, and prevent it.”
Christians Connections for International Health is a global network of organizations and individuals, “committed to promoting global health and wholeness from a Christian perspective.” Representatives from major international faith-based organizations including World Vision, Samaritan’s Purse, and IMA World Health sit on CCIH’s board of directors.
As the conference opened, attendees joined in song, and committed their thoughts to a common devotional: “Our need for one another is God-given. As children of God and formed in His image, our hearts desire healthy, positive, productive relationships.”
At the conference’s close, they joined hands in prayer.
Birx was appointed to lead PEPFAR by President Obama, but she has known the Smiths for years. She previously served on CAF’s board of directors, and in the 1990s, her family would join with the Smiths and others weeks before Christmas to wrap thousands of presents for HIV-affected children, Shepherd said.
Birx has been joined during the Trump administration by a number of appointees with evangelical ties to high-level global health positions.
Robert Redfield, who Trump appointed CDC director in March, wrote the introduction to the Smiths’ “Christians in the Age of AIDS” book.
Alma Crumm Golden, now the deputy assistant administrator in USAID’s Bureau for Global Health, spoke two days after Birx at the CCIH conference this year. The Smiths drove her from Washington, D.C., to the conference in Baltimore.
On June 10, Monique Wubbenhorst became a senior adviser in the office of Family Planning and Reproductive Health at USAID. Her publications include, “Should evangelical Christian organizations support international family planning?”
See more Devex coverage of the “global gag rule” impact:
The Trump administration has taken its most controversial global health stance by reinstating and expanding the Mexico City Policy — “or global gag rule.” This policy, favored by conservative Christians, prohibits U.S. funding to organizations that provide abortion services, or any information about abortion. Previously, the policy only applied to U.S. family planning funding. Under Trump, it has been expanded to include all U.S. global health funding, meaning that PEPFAR’s $6.5 billion is affected. Numerous organizations have spoken out about the policy and argued that it endangers women’s health, while having little impact on the number of abortions.
For PEPFAR, the changing political tides offer an opportunity to reconsider and reinvigorate the relationship between U.S. HIV and AIDS programs and faith groups in developing countries.
“We are taking advantage of our administration today to really launch … a new faith-based initiation strategy and involvement strategy and a community of faith strategy — to really move resources to indigenous organizations to have this kind of reinvigoration of the communities at the level utilizing religious leaders and faith-based organizations,” Birx told attendees at the CCIH conference.
Birx continued: “In the United States, in the beginning of PEPFAR, those were the organizations that made this happen. They were the ones that made it happen, and they’ve been a little bit quiet lately.”
Birx shared the instructions she has given to agencies that allocate PEPFAR’s funding — primarily USAID and CDC — to shift more of their funding to organizations in the countries where PEPFAR operates. She has told the agencies she wants to see 40 percent of PEPFAR’s money given to “indigenous” organizations within the next 18 months, and 70 percent of funding to those organizations in the next 30 months.
Those targets are linked with PEPFAR’s effort to revitalize its engagement with churches and communities of faith. In order to direct significantly more funding to local organizations, PEPFAR’s funding agencies will have to look to the networks that exist on the ground.
In many countries where HIV remains a major public health crisis, those networks are built on faith.