The New Realism Needed to Secure PEPFAR’s Future
As World AIDS Day opens on December 1, the prospects for a successful bipartisan congressional reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR) remain grim. As of October 1, the 2018 reauthorization lapsed and will likely remain in that status indefinitely. It is time to admit that harsh reality. It is time to think hard about why this happened: responsibility for this debacle is decidedly bipartisan. And it is time to acknowledge the serious risks of regression and put forth a credible strategy to secure PEPFAR’s future in the absence of a five-year reauthorization.
A new, realist strategy to defend PEPFAR’s future should, as the first order of business, restore coherent, committed, and reliable White House leadership. The White House needs to shake off its lethargy and regularly engage with congressional leaders at a high level to reaffirm PEPFAR as a presidential program and forcefully make the case that this critical tool advances U.S. national security—not abortion access—and that PEPFAR’s future rests on the preservation of its bipartisan foundation. The White House needs to up its game and communicate what is at stake far more often and effectively to Americans. In the absence of reauthorization, the annual appropriations process should be used to spotlight program achievements, secure financing, and advance U.S. policy on PEPFAR. And any strategy should insist on a far more muscular and accountable U.S. diplomacy with African heads of state and the leadership of the African Union and the Africa Centres for Disease Control and Prevention. In the meantime, there should be a prioritized, sustained focus on advancing scientific discoveries to control HIV while documenting the emerging threat of a regression in global HIV control.
Since the PEPFAR program was launched by President George W. Bush in 2003, it has benefited from three consecutive five-year authorizations. In each instance, the legislation was backed by bipartisan Congressional leadership and a coalition encompassing persons living with HIV, the faith and scientific research communities, industry, foundations, advocates, implementers, and the national security community. African heads of state and other prominent African voices played a critical role. The most recent reauthorization, in 2018, received unanimous approval in both chambers of Congress.
In recent months, President George W. Bush, current and former PEPFAR directors, and other supporters have rallied behind reauthorization. They have detailed how this monumentally historic U.S. global health achievement has invested over $110 billion, saved over 25 million lives, and today supports over 20 million people on life-sustaining antiretroviral therapy. 5.5 million children have now been born free of HIV, while the program has brought the HIV/AIDS epidemic under effective control in many countries and can be expected to achieve that result in several additional countries by 2030. PEPFAR delivers profound health and humanitarian benefits to the countries where it operates, among them bolstering national capabilities to detect and respond to dangerous emerging pathogens, such as Covid-19. The largest beneficiaries are in eastern and southern Africa, whose health infrastructure has been upgraded by PEPFAR over two decades. While PEPFAR advances the economic prosperity of local communities, it also advances U.S. national security and foreign policy interests by strengthening diplomatic ties and countering Russian and Chinese influence.
In 2023, these worthy arguments are simply no longer working.
The political ground in America has shifted fundamentally, to PEPFAR’s deep disadvantage. In the 2022 elections, Republicans gained a thin margin of control in the House of Representatives that has given rise in 2023 to leadership instability and startling moments of dysfunction and uncertainty. In June of 2022, the Supreme Court struck down abortion rights in Dobbs v. Jackson Women’s Health Organization. In post-Dobbs America, the hunt for new anti-abortion opportunities charges forward, aided by pervasive disinformation.
These shifts opened the door for Representative Chris Smith (R-NJ) to allege, without any evidence, that PEPFAR advances abortions overseas. He rapidly assembled an anti-PEPFAR coalition—the Heritage Foundation, Susan B. Anthony Pro-Life America, the Family Research Council, Fox News, and others—which has united behind the erroneous position that a vote for PEPFAR reauthorization should be scored as a vote for abortion, despite the fact that U.S. law already prohibits PEPFAR from funding abortion. Smith will only relent if what is known as the Mexico City Policy is reimposed on PEPFAR, as was the case during the Trump administration. Under the Mexico City Policy, there would be a ban on funding to any overseas partners that, separate from U.S. programmatic support, advocate or deliver abortion services. It would roll back the administration’s policy commitments to women’s reproductive rights and to reaching the most vulnerable populations, particularly men who have sex with men, sex workers, and transgender people. These are conditions that congressional Democrats and the Biden administration will not countenance. The result is a hardened standoff with little hope of compromise.
These steps have outflanked key Republican stalwarts of PEPFAR. Congressman Michael McCaul (R-TX) and Senator Lindsey Graham (R-SC) remain active in seeking a solution, but their margin for success has nearly vanished. The ardent abortion opponent Congressman Mike Johnson’s (R-LA) ascent to Speaker of the House is hardly good news for PEPFAR. Indeed, it is a thunderclap. In the meantime, support for PEPFAR among evangelicals and Catholic bishops—key PEPFAR constituencies over the past two decades—has weakened amid the abortion controversy that now surrounds PEPFAR. On the Democratic side, the indictment of PEPFAR stalwart Senator Robert Menendez (D-NJ), former chair of the Senate Foreign Relations Committee, only adds to the chaos in Congress.
Time has not been helpful for PEPFAR’s future. Success in controlling HIV has reduced the perceived threat it poses. PEPFAR is far less well understood and actively embraced in Congress today than it was in 2003.
The Biden White House also bears responsibility for the PEPFAR debacle. It has been slow to respond to the threats to PEPFAR reauthorization, distracted by conflict in Ukraine and Israel and Gaza, fraught relations with China, and a difficult 2024 presidential campaign. While its policy obligation is to defend the PEPFAR legacy, which started and remains in the president’s office, its engagement with Republicans and Democrats in Congress has been lax, intermittent, and ineffectual. At the same time, the White House has a strong campaign incentive to exploit evidence that Republican extremists are destroying women’s reproductive rights, at home and abroad, regardless of the consequences.
Though PEPFAR is embedded at the State Department, U.S. diplomacy has been lackluster. PEPFAR was without a Senate-confirmed leader for 27 months, from March 2, 2020—when then Director Deborah Birx moved to the White House Covid-19 Task Force—until June 13, 2022, when John Nkengasong became the current director. In 2023, the State Department has not yet been seriously focused on mobilizing African state leaders to step forward and defend PEPFAR. As the newly launched State Department Bureau of Global Health Security and Diplomacy finds its feet, more progress in this area is possible.
An indefinite lapse of reauthorization will have consequences. Gone will be the five-year bipartisan protection that removed PEPFAR from year-by-year budgetary and policy debate, and that in turn infused confidence in multiyear planning for PEPFAR’s overseas partnerships with national governments and civil society organizations. PEPFAR will now become subject to continuous political challenges to its budget and policies, from both the Office of Management and Budget and budget cutters in Congress. That in turn will erode the confidence of key partners and increasingly pit yearly appropriations for PEPFAR against other worthy foreign assistance priorities. Ironically, the lapse will eliminate earmarks and thereby provide the Biden administration with greater flexibility to invest in evolving priorities.
The end of PEPFAR’s five-year reauthorizations is very disturbing and perilous, but not the end of the world. For example, the U.S. domestic HIV program, the Ryan White Act, has been without a reauthorization for 11 years, and survived, though with several budgetary setbacks along the way. The White House, the State Department, congressional stalwarts, and others need to look inward, reset their thinking, and recommit to what it is going to take to sustain PEPFAR into the future, in the absence of a five-year reauthorization. This is the message on World AIDS Day: a new realism is in order.
J. Stephen Morrison is senior vice president and director of the Global Health Policy Center for Strategic and International Studies in Washington, D.C.