What PEPFAR's political paralysis means for the Global Fund

Advocates for the United States global AIDS relief program PEPFAR are urging supporters not to panic about the political battle that has prevented the initiative’s reauthorization in the U.S. Congress. While that legislation is important, they say, the program will continue operating without it. “Just because it hasn't been reauthorized doesn't mean it ends,” Jennifer Kates, director of global health and HIV policy at KFF, said in a webinar on Thursday. “PEPFAR is a permanent part of U.S. law. As long as it continues to be funded by Congress, it continues.” PEPFAR’s current five-year authorization expired at the end of the fiscal year on Sept. 30 in the midst of a bitter fight over allegations from some Republicans that President Joe Biden’s administration has co-opted the initiative as part of a liberal social agenda that promotes abortion. While PEPFAR’s work continues without that legislative support in place, some of the specific policies embedded in the previous authorizing bill did expire alongside it. One of those policies governs U.S. government funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria, a multilateral organization that works alongside PEPFAR in dozens of countries. Previous PEPFAR reauthorization bills have stipulated that the U.S. government can only contribute 33% of the Global Fund’s three-year financial replenishment, which supporters view as an important policy for compelling ambitious contributions from other donors. While this provision places a limit on the United States’ contribution to the Global Fund, it has also created a norm that the U.S. will contribute the maximum allowable amount, Mark Lagon, chief policy officer at Friends of the Global Fight, said Thursday. “There's a very clear record of other countries stepping up with us because they know that they'll be leaving U.S. money on the table if they don't step up,” Lagon said. That provision is most effective when it is part of a five-year PEPFAR authorization bill that allows for long-term budgetary planning and advocacy, Lagon said. He added that a one- or two-year reauthorization — which some critics have proposed as a stopgap — would result in a “markedly weakened” ability to lean on other countries to increase their contributions — even if the U.S. government ends up contributing its full amount. “There are a lot of downsides to not having a multiyear reauthorization that's clean, that doesn't make any changes or break open earlier compromises,” Lagon said. On Thursday, the Washington Post reported that Republican lawmakers are preventing PEPFAR from spending more than $1 billion that lawmakers already approved for the initiative by placing “holds” on congressional notifications that are required for money to be released. “The delays in approval are straining PEPFAR country operations and threatening PEPFAR’s ability to continue implementation,” the State Department said in a statement to the Post. “I would posit that that is a more serious challenge right now than the fact that we passed September 30th without a reauthorization and the fact that we don't have a budget yet,” Kates said Thursday.