PEPFAR gets a one-year reauthorization reprieve

The fight to reauthorize PEPFAR, the U.S. global AIDS initiative credited with saving 25 million lives over two decades, looks like it may have a resolution — albeit a short-term one. U.S. lawmakers are poised to give a 12-month reauthorization for the President’s Emergency Plan for AIDS Relief, extending it through late March 2025, as part of the 2024 foreign affairs budget bill, likely to be released imminently, several sources told Devex. PEPFAR’s reauthorization was derailed last year amid a campaign by conservative and anti-abortion activists to paint it as a source of funding for abortion. While those accusations are unsubstantiated, and U.S. law prevents aid dollars from supporting abortions, the issue continues to cast a shadow over the program’s long-term reauthorization. Global health advocates and lawmakers on both sides of the aisle had pushed for a five-year extension, the precedent since PEPFAR’s founding two decades ago. But the one-year compromise emerged as the path forward more recently and advocates are split on whether it’s a good or a bad thing. That any type of reauthorization passed has “reinforced that there is strong bipartisan support for the program,” Katie Coester, associate director of public policy and advocacy at the Elizabeth Glaser Pediatric AIDS Foundation, told Devex. It’s also a bit of a reprieve from being in the political spotlight, she said. But Jirair Ratevosian, a former PEPFAR chief of staff, told Devex the extension is worse than not having a reauthorization because it creates ambiguity and could set “a dangerous precedent” of short-term reauthorizations and risk “over politicizing the program.” “It brings relief in the short term but undermines PEPFAR’s ability to forge and maintain essential partnerships required for its enduring success,” Ratevosian said. The shorter authorization sets the scene for a fight next year and extends uncertainty around the program’s future, which can impact its effectiveness, its ability to operate, and how country partners perceive it, global health experts told Devex. “We can’t ignore that this is the first time PEPFAR received a reauthorization of less than five years,” Keifer Buckingham, advocacy director at Open Society Foundations, told Devex. “We’re at a point where on global HIV the major thing that we need sustained globally is political will — and money.” On the money front, it’s still unclear how PEPFAR will fare in the 2024 budget, but Politico reports that the foreign affairs budget overall will be cut by 6% from the previous year. PEPFAR often makes long-term plans and agreements with partners and countries, which is part of its success, some advocates said. So short-term reauthorizations could hurt its ability to negotiate such agreements, and influence policies and efforts to mobilize domestic resources for health, Ratevosian said. Spending time fighting for an extension or on standby also cuts critical time from PEPFAR and its partners to run the program and removes some of “the hallmarks of what makes PEPFAR the most impactful efficacious foreign assistance delivery program we’ve ever had,” he said. The goal for next year is to get that five-year extension of PEPFAR, “we do not want to be in these cycles of one-year authorizations,” Coester said, adding that while it will be “tough” advocates have a year to educate members of Congress and try to get it done.