What ‘extremism’ in US politics means for PEPFAR’s future

A small minority of hard-right Republicans have brought the U.S. House of Representatives to an unprecedented standstill and heightened fears about whether political division will overwhelm the government’s ability to function. For the flagship U.S. global AIDS initiative PEPFAR, something about that sounds familiar. For 20 years, PEPFAR was a rare bright spot of bipartisan support, holding together a diverse coalition of Christian evangelicals, AIDS activists, gay rights advocates, and politicians from across the political spectrum through successive Republican and Democratic administrations. This year that coalition — like many others in American politics — has been tested, and it has yet to prove its durability. PEPFAR’s reauthorization, the legislation that gives legal standing to its funding and policy priorities, expired on Oct. 1, and advocates are still looking for a path forward that can either mollify or circumnavigate allegations by antiabortion groups that the program has been “hijacked.” None of those efforts to move PEPFAR forward are helped by the fact that one of America’s legislative bodies is currently paralyzed and leaderless. “The ability for both parties to function, both parties to govern, for the United States House of Representatives to have a Speaker of the house — PEPFAR is relying on all of those things to be able to continue its work,” Jirair Ratevosian, PEPFAR’s former chief of staff, said at a Devex Pro Live event on Wednesday. Ratevosian, who left PEPFAR earlier this year to run for Congress as a Democrat in California, blames the rise of extreme views among Republicans for both PEPFAR’s and the rest of the U.S. government’s current predicament. “The extremism has allowed for misinformation to fester, for people to operate without real facts, and for members of Congress not to have incentives to compromise, and I think that’s what’s dangerous,” he said. “What we’re doing is we’re following the science. We’re ensuring that the program continues to deliver results,” he added. The U.S. global AIDS initiative has not been immune to debate over politically sensitive issues such as abortion, criminalization of homosexuality, and stigma. But in the past, those thorny issues have not taken precedence over securing PEPFAR’s reauthorization, as some advocates feel they have this year. “We’ve had these policy debates in the past, certainly. That’s why we consider the existing legislation to be a compromise piece of legislation,” said Katie Coester, associate director of public policy and advocacy at the Elizabeth Glaser Pediatric AIDS Foundation. “But it was at a time where we knew that all parties wanted to get us to a reauthorization,” added Coester, who also co-chairs the Global AIDS Policy Partnership. In the U.S., domestic debates over abortion and transgender rights have largely devolved into a zero-sum competition between Republicans and Democrats. Now those domestic politics have begun to “spill over” into global programs such as PEPFAR, said Lisa Bos, director of government relations at World Vision. That means the debates that used to happen “behind the scenes” are now much more public, and the criticisms are coming from individuals and organizations that were not previously part of the PEPFAR reauthorization conversation, Bos said. “They’re not coming from faith or pro-life groups that are actually working on PEPFAR,” she said. For PEPFAR — and for all organizations working to achieve the international goal of bringing HIV under epidemic control by 2030 — the politics are unavoidable. “We’re talking about things that are inherent to PEPFAR achieving its goals. You have to destigmatize sex work. You have to destigmatize gay, lesbian and bisexual relationships. You have to talk about sexual and reproductive health because you’re talking about a sexually transmitted infection,” Bos said. So how can PEPFAR follow the science when the science leads HIV programs toward issues that could alienate parts of its political coalition? For Bos, it comes back to the same overarching agreement that made PEPFAR possible two decades ago: That compassion should overcome political sensitivity. “This program started out of compassion and a recognition that we had to do something,” she said. “And I hope we can try to find a way to get back to that.”