High-level support for PEPFAR, with budget cut proposals looming

WASHINGTON — The United States Congress passed a bill to reauthorize the President’s Emergency Plan for AIDS Relief and its mandate will be extended through 2023 when President Donald Trump signs the legislation into law, which is expected to happen soon.

Despite a busy end-of-year schedule, the U.S. Senate passed the bipartisan PEPFAR Extension Act of 2018 late Wednesday. The 3 ½-page, straightforward bill amends the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 to extend its end date from 2018 to 2023.

Vice President Mike Pence, speaking at a White House event commemorating World AIDS Day, which is Saturday, and marking the passage of the bill, said that President Trump would soon sign the bill into law.

“We’re grateful for the strong and bipartisan support in the Congress for this extraordinary humanitarian effort by the American people,” he said. “President Trump believes this reauthorization is a critical component of our administration’s commitment to combat AIDS and it will build on the renewed energy and focus that the president … and our entire administration have brought to this critical issue.”

While the legislation passed easily, there were concerns earlier this year that the reauthorization would be politicized, which would have stalled the process and perhaps led to a situation where the program’s mandate would have been extended through the annual appropriations process rather than through legislation.

At the heart of the tension was whether the legislation would include changes related to the Mexico City policy, or “global gag rule,” and otherwise seek to change how PEPFAR can work with organizations that discuss abortion or with vulnerable populations including sex workers.

The bill that passed Wednesday avoided those issues and is the kind of “clean” extension bill many advocates had said they were hoping for.

However, it does appear there will be changes for PEPFAR. In his speech Thursday, Pence announced a new commitment to increasing funding through PEPFAR to faith-based organizations. The new investment of $100 million will increase funding by one-third to faith-based organizations working on the treatment and prevention of HIV/AIDS, he said.

“The truth is this is a sound investment because faith-based organizations, like those in this room and so many others around the world, have been a cornerstone of PEPFAR’s success,” Pence said.  “From its very inception it has been these organizations that have made the greatest difference.”

He went on to say that the administration is proud to partner with faith-based organizations and that “every dollar invested in faith-based organizations pays dividends in the fight against this crisis.”

Some global health leaders found this message difficult to square with the Trump administration’s repeated attempts to cut PEPFAR’s annual budget by roughly $1 billion — a tactic they expect to see repeated in the president’s budget request for fiscal year 2020.

“No one is under the impression that it’s going to be flat-funded or increased. All indications have been that it’s not only going to be a cut, but a bigger cut, if not the biggest cut yet that the president has proposed,” said Keifer Buckingham, senior policy adviser for international public health at the Open Society Foundations.

“While it’s exciting that we’re seeing high-level engagement for World AIDS Day … it doesn’t seem to really fit with the reality of what we kind of know is coming in the spring,” Buckingham added.

It was also not clear from the vice president’s comments where an additional $100 million for faith-based organizations would come from, given the administration’s overall push for less funding. In its statement describing the pledge, the U.S. Department of State wrote that the new resources would be “subject to the availability of funds and final congressional notification.”

“As someone who used to work for an appropriator, whenever we hear ‘new resources,’ our ears kind of perk up and say, ‘huh, what do you mean by new,’” said Buckingham, who previously worked for Representative Barbara Lee on the House of Representatives’ committee that funds PEPFAR.

If the administration is not planning to increase funding for PEPFAR — and, on the contrary, intends to seek further cuts — “the question then is, is someone else losing out on that $100 million,” Buckingham added.

The administration’s global health leaders have not been shy about their desire to push more HIV funding to faith-based organizations.

“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,” U.S. Global AIDS Coordinator Deborah Birx told a gathering of faith organizations in July.

Birx, who leads PEPFAR, told the same gathering that she has set a goal of directing 70 percent of the initiative’s more than $6 billion in yearly funding to “indigenous” organizations by the end of 2020, which many see as aligned with the effort to partner with faith groups.

The PEPFAR chief has faced repeated questions about how the Trump administration’s proposals to cut money for global HIV funding show the sustained commitment to controlling the epidemic that she and other officials — including Pence — continue to profess. Birx, including in interviews with Devex, has argued that increasing efficiency and effectiveness through better data and program targeting presents opportunities to improve PEPFAR’s impact, even in the face of a flat or decreasing budget picture.

On Wednesday, speaking at an event with the magazine The Atlantic, Birx said: “I feel very secure, because I came out of the military, so when someone doesn’t like your program, you don’t get cut, you get zeroed.”

“Are we confident that our foreign assistance programs are as effective and efficient in having the outcomes and impacts that they were designed to have? And I think anybody who runs a big program can’t answer that ‘yes.’ They need to answer it, ‘I don’t know,’ and then get the information to be able to prove to the administration or Congress. I think we’re in a position now where we’re proving that,” Birx said.

In his remarks at the White House, Pence highlighted PEPFAR’s successes and pointed to its latest progress report, released earlier this week, which said the program has now saved more than 17 million lives, supports more than 14.6 million people with antiretroviral treatment and helped more than 2.4 million babies be born HIV-free.

About 11 of the 53 countries that receive PEPFAR support are funding the majority of their HIV response themselves, Pence said, adding that the administration will “continue to empower ever more countries to mobilize domestic resources to share more of this burden.”

“We’ve made great progress but our work is far from over,” he said. “And as evidenced by the Congress’ action and the President’s renewed leadership, that work will continue until we end the scourge of HIV/AIDS once and for all.”