The President’s Emergency Plan for Aids Relief, or PEPFAR, has been a uniquely successful bipartisan effort, saving 25 million lives globally from HIV/AIDS since it was put into place 20 years ago. Congress and the White House have reauthorized it every five years, under different parties. It has been credited with sparing entire countries from demise.
Now it is in danger of succumbing to a political brawl.
The program must be renewed this fall. But domestic pro-life organizations, including Susan B. Anthony Pro-Life America and The Heritage Foundation’s action arm, Heritage Action, have said a vote in favor of PEPFAR’s five-year reauthorization would be a mark against a lawmaker in their scorecards for elected leaders. The Family Research Council told CT it will also score the vote.
The groups argue that the Biden administration is trying to use the program to fund the promotion and provision of abortions. Family Research Council’s vice president for policy and government affairs Travis Weber told CT that PEPFAR was “being used as a massive slush fund for abortion and LGBT advocacy.”
Pro-lifers working to combat HIV/AIDS overseas say that is not the case and have been surprised by the domestic pro-life opposition. Funding or promoting abortion through PEPFAR would be against US law. Abortion is also illegal or highly restricted in most countries with PEPFAR-funded programs, almost all of which are in Africa.
Pro-life organizations regularly score lawmakers’ votes on particular pieces of legislation as a way of assessing commitment to pro-life causes. Deeming a vote for a given measure as negative tends to scotch Republican votes for it.
“A five-year reauthorization to us is beyond the pale,” Ryan Walker, the head of Heritage Action, told CT. PEPFAR grantees are “promoting and helping to support abortions abroad,” Walker said.
Without adequate Republican votes, congressional sources said that an amendment that would have extended PEPFAR’s authorization another five years is now dead in the water. Negotiations are ongoing, but PEPFAR advocates used words in interviews like “pessimistic” and “not optimistic.”
Pro-life critics of PEPFAR say that funding should instead be extended by only one year. But those who have long worked on PEPFAR argue that such a move would result in the program’s death by a thousand cuts, subjecting it to the whims of the annual appropriations process and making it an easy target to trade away for other priorities. Every aspect of PEPFAR would be up for negotiation, they say, year after year.
For decades, PEPFAR’s predictable reauthorization cycle has helped keep certain boundaries in place: controls on where US funds are directed, conscience provisions, and auditing requirements—all of which prevent the program from underwriting abortions. Appropriators could include the existing parameters, but the program would be more exposed to a political process. PEPFAR advocates also say health systems can’t function with a one-year window but need more lead time for building and operating programs.
Launched by President George W. Bush in 2003, PEPFAR aims at delivering antiretroviral (ARV) drugs to people with HIV/AIDS and preventing further transmission. It has resulted in a dramatic increase in life expectancy in Africa. Absent a cure for the disease, people on ARVs generally must remain on the drugs the rest of their lives. The United States currently provides treatment for 20 million people, mostly in Africa, through the program.
PEPFAR has long had pro-life support from Catholics and Protestants, including from African faith-based health providers. But debates about terms like “family planning” and “reproductive health” in language around PEPFAR have always been sticking points.
They appear to be especially sticky now. Some pro-life groups reacted strongly to a recent PEPFAR document that said the program would integrate “sexual reproductive health” into efforts to build up local health systems for HIV/AIDS treatment.
This week, the Biden administration added a footnote in the document to clarify that reproductive health under PEPFAR meant only “HIV prevention, testing, and treatment services,” “education, testing and treatment for sexually transmitted infections,” cancer screening and treatment, and “gender-based violence prevention and care.”
The document states that PEPFAR “does not under any circumstances provide support for abortion services.”
That has not satisfied groups like Heritage or Susan B. Anthony Pro-Life America.
The abortion criticisms are coming from people who don’t have “field experience,” said Doug Fountain, the executive director of Christian Connections for International Health, a group that has supported local organizations fighting HIV/AIDS throughout Africa for decades and does not directly receive PEPFAR funding. Fountain said he has never seen promotion or provision of abortion in PEPFAR-funded projects. “If there was a concern, the faith communities in the implementing countries would have complained.”
“The way we look at it is, which is the more pro-life position: supporting a proven program that saves lives, or impeding it out of unsubstantiated fear?” he told CT. “We actually can see a situation where HIV/AIDS will come under global control in the next decade or so. But we need to keep our eye on the ball and not stop progress based on rumors.”
Republican Rep. Chris Smith has led the charge against PEFPAR’s five-year reauthorization on pro-life grounds, despite being an early PEPFAR supporter and advocate.
About pro-lifers who support the five-year reauthorization, Smith told CT, “There are and always have been some faith-based groups that are very accommodating with abortion.” He said he’s not trying to kill the program: “We are very, very committed to keeping the program going through the appropriations process.”
To earn his support, Smith said the program must have what’s known as the Mexico City Policy, which prohibits US-funded groups from using money from any source to perform or advocate for abortions overseas.
The Mexico City Policy was not in place for PEPFAR for 16 of the program’s 20 years of existence, but Smith supported PEPFAR during those years. He said the issue was an “emergency” at the time and he agreed to “a tourniquet on this horrific problem” despite his qualms. President Donald Trump put Mexico City in place at his request, Smith said.
When president Joe Biden took office, he rescinded the policy. Even without it, other longstanding measures in US law—such as the Helms and Siljander Amendments—already prohibit any funding or advocacy of abortion overseas with US dollars.
The concerns stem from the fact that PEPFAR works through contractors, some of whom perform and advocate for abortions with non-PEPFAR money. PEPFAR has given large grants to Population Services International (PSI), a group that particularly irks pro-life critics. Those grants also happened under Trump; in 2020, PSI received $43 million in PEPFAR funding.
The biggest slice of PEPFAR’s roughly $6 billion annual budget goes to buying antiretroviral drugs and other medical supplies. The contractors’ primary role is to deliver those drugs, often through local health clinics. PEPFAR also funds prevention programs, including funding for both condoms and abstinence education.
Smith said a turning point in his position was when he recently had a two-hour lunch with the head of PEPFAR, John Nkengasong, and asked him what PEPFAR fund recipients were doing with the money in regard to abortion. According to Smith, Nkengasong told him he works at “10,000 feet” and didn’t know what local organizations were doing.
“If you tell me face to face over lunch that you have no idea what they’re doing at the local level, I have a problem with that,” Smith said. The State Department did not respond to a request for an interview, but Nkengasong recently said that “PEPFAR has never, will not ever, use that platform in supporting abortion.”
Smith says PEPFAR gives “a pot of money that empowers the abortion lobby in each and every one of these countries.”
But congressional aides who have worked on the issue for decades say they have access to information about grantees and sub-grantees of PEPFAR. When questionable actions at PEPFAR-funded clinics have been reported, congressional staffers have gone to investigate. The Bush administration designed the program with more oversight and reporting requirements than other global health programs.
“There are ways to ensure that PEPFAR funding isn’t used for abortions in program implementation without jeopardizing re-authorization,” said Perry Jansen, a physician who, with Malawian medical leaders, started a Christian health center in Malawi called Partners in Hope. It now oversees 20 percent of the country’s patients receiving antiretroviral drugs and is one of many faith-based organizations with PEPFAR contracts. Before PEPFAR, 30 percent of pregnant women in Blantyre, Malawi, were testing positive for HIV.
Catholic Relief Services, another major PEPFAR partner working throughout Africa, has objected to PEPFAR funding for condoms, but it has been able to take PEPFAR contracts thanks to the conscience clause written into the law. CRS has also supported PEPFAR reauthorization, though it has not weighed in on the specifics of the current debate.
Walker, of Heritage Action, said his group would support a short-term reauthorization, which “would allow for a potential Republican administration.”
“Post-Dobbs, we are in a different political environment,” Walker said.
Autumn Christensen, Susan B. Anthony Pro-Life America’s vice president of public policy, said her organization has supported PEFPAR for many years, but that pro-life concerns about the program were continually batted to the side.
“At every reauthorization, we have been told to just ‘trust us, don't worry, PEPFAR is not going to do anything bad,’” Christensen said. “And you see the integration with reproductive health increase over the years.”
Asked about her group holding up the five-year reauthorization, she said, “I cannot be responsible for the actions at the Biden administration in their decision to integrate reproductive and sexual health into the PEPFAR program … My job is to ensure that PEPFAR doesn’t become a funnel by which we fund the organizations that overturn pro-life laws in Africa.”
Shepherd Smith, one of the early evangelical advocates for PEPFAR who has worked on HIV/AIDS projects both in the US and abroad since the 1980s, disagrees with this assessment of the program.
“This is a huge, in my opinion, gamble, based on a rumor,” he told CT, referring to the move to a one-year appropriations process. “My level of optimism is very, very low of what the ultimate outcome would be. … It’s gone totally Washington. The truth doesn’t seem to be important now.”
“[PEPFAR] saved a generation,” said Lester Munson, who worked on foreign aid policy in the early 2000s with Republican Sen. Jesse Helms and went on to work at USAID, one agency involved in implementing PEPFAR. “It saved entire nation states from collapsing. It’s difficult to overstate the success of this program.”
During part of his time on Capitol Hill, Munson worked for Rep. Henry Hyde, responsible for the Hyde Amendment, which prohibits federal funding of domestic abortions. Munson is pro-life, and he thinks the protections against abortion in PEPFAR are “sufficient.”
There’s still a chance for the pro-life community to work through the issue, Munson said. PEPFAR’s authorization expires on September 30.
“What you have to do in the legislative process—the two sides talk to each other, work it out, be patient, be forgiving, hold hands sometimes, and not hold hands some other times,” he said. “It always takes longer than you think it will. This worked for 20 years—until now. We have to come together. It’s the only way forward.”