Lifesaving HIV program faces a new threat: U.S. abortion politics
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For two decades, the United States has pursued a far-reaching global agenda to fight HIV and AIDS, an initiative credited with saving more than 25 million lives. But the President's Emergency Plan for AIDS Relief, better known as PEPFAR, has been abruptly bogged down in a domestic political fight, with Republicans citing allegations that the program's funding is being used to indirectly support abortions - claims that health advocates, Democrats and PEPFAR officials say are baseless.
As a result, lawmakers have spent months wrangling over whether Congress will reauthorize the program for five years, for one year or not at all - a decision that experts warn has both practical and symbolic consequences.
"If PEPFAR doesn't get reauthorized, the program can continue - but it could send some pretty chilling messages to people in the field who depend on PEPFAR for life support," said Jennifer Kates, director of global health and HIV policy at KFF, a health policy organization that has tracked the provisions set to expire Sept. 30.
Treasured by medical professionals and praised by foreign leaders, PEPFAR is the world's largest health program devoted to a single disease - a status that officials say achieves the dual goal of strengthening U.S. diplomatic ties and boosting public health. Since the program's inception in 2003, spearheaded by President George W. Bush, PEPFAR has spent in excess of $100 billion across more than 50 countries; distributed millions of courses of medicine to treat and prevent HIV; collected data that shed new light on the virus's spread; and forged durable partnerships with local governments and organizations.
Experts have credited PEPFAR for helping stabilize health systems in regions including sub-Saharan Africa, which was devastated by the spread of HIV in the 1990s, and for building global capacity for future crises.
But the program is now dogged by accusations that its funds are helping prop up abortion providers, a charge first publicly leveled in a report from the conservative Heritage Foundation in May and amplified by Rep. Christopher H. Smith (N.J.), an antiabortion Republican who chairs a key House panel.
"It's just dumbfounding to me that the charge has been taken seriously," said Shepherd Smith, a co-founder of the Children's AIDS Fund International who has worked closely with PEPFAR since its start and is among the advocates urging Congress to reauthorize the program before key provisions expire later this year.
The Biden administration had sought a "clean" five-year reauthorization of the HIV program, with no new policy restrictions, allowing Congress to quickly update the existing PEPFAR legislation without opening it back up to a lengthy debate.
Antiabortion advocacy groups insist that is a nonstarter. Heritage, Family Research Council and Susan B. Anthony Pro-Life America have warned lawmakers that if they vote for the Biden-backed bill, they will be docked on the organizations' scorecards - a key metric that many antiabortion Republicans rely on when campaigning for reelection.
"What's changed is the Biden administration's radical insistence on ramming abortion into our foreign policy in an aggressive manner that we've never seen before," Travis Weber, vice president for policy and government affairs at Family Research Council, said on a July 24 podcast, calling for more controls on the program. "Anyone who wants to be pro-life in their political voting record, we have to say, PEPFAR cannot go as it has been, it has to be amended."
"As it stands under the Biden administration . . . this will be a very dangerous piece of legislation," agreed Tony Perkins, the group's president.
Instead, antiabortion advocates and Republicans have pushed for a one-year reauthorization that adds explicit abortion restrictions to PEPFAR. They also argue that the shorter extension buys time in the event a Republican returns to the White House in 2025, potentially ushering in changes to PEPFAR and the United States' broader global health strategy.
Biden officials have said the claims about PEPFAR being used to support abortions are baseless, and that forcing annual votes on the program will inevitably create opportunities to weaken it.
As a result, negotiations over PEPFAR's future have stalled on Capitol Hill.
The fight is "broader than PEPFAR - it's really about the larger politics around abortion, electoral politics and the partisan divide," said KFF's Kates. "Those issues have come up in the past . . . it's just that the bipartisan alliance has been able to withstand them in the past."
David P. Fidler, a senior fellow for the Council on Foreign Relations, singled out Republican attacks on public health policies in a CFR report last month, warning that "populism, nationalism, and polarization have undermined domestic collective action and solidarity" on global health priorities such as PEPFAR.
The logjam over the HIV program has angered Democratic leaders such as Sen. Robert Menendez (D-N.J.), chairman of the Senate Foreign Relations Committee, who has been negotiating for months to reauthorize PEPFAR and attempted to include it in the armed services bill that passed the Senate on Thursday. In an interview, Menendez singled out the public health and foreign policy implications of the program, including its geopolitical role at a time when rival nations such as China seek to curry favor with African countries.
PEPFAR "helps us in a continent where China is all over the place," Menendez said. "The one place they're not all over the place is on helping to save people's lives. We are, and we are known for that."
Menendez recalled traveling to Africa this year where he met children and parents whose families were affected by HIV.
"None of the people I met would likely be alive today, but for PEPFAR," he said.
If lawmakers fail to reauthorize PEPFAR, most of the program's funding would remain intact, but some of its provisions are set to expire soon - including measures that conservatives originally fought to include, said Tom Hart, president of the ONE Campaign, a nonpartisan advocacy and campaigning organization. That includes a provision ensuring that a certain amount of PEPFAR funding would go to treatment, which was backed by conservative former senator Tom Coburn (R-Okla.), and another conservative-backed provision that ensures funds are set aside for orphans and vulnerable children.
"Ironically . . . several provisions important to conservatives will be lost," Hart said.
Smith's office pointed to a separate House Republican appropriations bill that would extend the expiring provisions.
PEPFAR's overseas partners say they are alarmed by any potential retreat from the program's historic five-year reauthorizations. Robinson Ogwang, who sits on the board of The AIDS Support Organization, a PEPFAR partner in Uganda, said "a lot of time is being wasted" as Congress debates the program's future, sparking confusion on the ground for organizations trying to plan their own operations.
Without certainty about PEPFAR's fate, "you start cutting the long-term strategic interventions into midterm and short-term," Ogwang said in a call Thursday from Kampala, Uganda. "You are not confident because you don't know whether funding is going to be continuous, whether it will be reduced."
The former Republican president who launched PEPFAR has quietly stumped for it.
"I don't really come to Washington often . . . but I'm here to remind people that American taxpayers' money is making a huge difference," Bush said at a February 2023 event marking PEPFAR's 20-year anniversary. "This program needs to be funded. And for the skeptics, all I ask is look at the results, if the results don't impress you, nothing will impress you."
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How abortion ensnared HIV program
PEPFAR's defenders say they remain mystified that a program that has long enjoyed bipartisan support, with Congress voting three times to reauthorize it, has been drawn into a political miasma.
But they say they're clear on how it happened: the shifting position of Rep. Smith, who chairs a key foreign affairs panel overseeing PEPFAR legislation. He touted the program for years, working to reauthorize it under the antiabortion Trump administration, and signaled he would do so again.
"PEPFAR is widely viewed as the most successful U.S. foreign aid program since the Marshall Plan," the congressman said in January.
But by June, after the Heritage report, Smith was publicly circulating a letter saying that President Biden had "hijacked" the program to promote abortion abroad, citing examples of organizations that had received PEPFAR funding while separately supporting access to abortion. The effort effectively froze progress on the bill.
In a one-hour interview in his office Friday, the congressman defended his stance, arguing that while he remains a passionate supporter of PEPFAR, the broader battle over abortion around the world took precedence over immediately reauthorizing the program.
"Every single statute protecting life in Africa is under siege right now," the congressman said, citing efforts to expand access to abortion in Liberia and other nations. "The children are worth the fight."
Smith said he began to grow concerned that PEPFAR was being "hijacked" after reading the program's September 2022 strategic direction document and February 2023 guidance to local partners, which make brief mention of improving "sexual and reproductive health" - shorthand for abortion access, the congressman said - and encouraging local reforms.
"I reached out to every group possible, including Heritage, to take a look at this," he said. "It wasn't the groups telling me what to do, you know, with all respect."
A congressman for 42 years, Smith repeatedly cited examples of prior legislative fights in which he claimed Democrats attempted to ensure abortion access through "subterfuge," such as a long-running battle over whether the 2010 Affordable Care Act funded abortion.
"They claimed, as they're claiming now, 'Oh, no, don't look here. It's nothing to see.' And it's just one example of many," he said, arguing that the White House could win over Republicans by reinstating the Mexico City Policy, a GOP-backed measure barring foreign organizations that receive U.S. funding from supporting abortion access. Beginning with Ronald Reagan, Republican presidents have enacted that policy while successive Democratic administrations have rolled it back.
The congressman's claims about PEPFAR have been flatly rejected by the Biden administration.
"We are not 'injecting' abortion into PEPFAR in any way, shape, or form or seeking to make changes in law related to abortion," said a senior White House official who spoke on the condition of anonymity given ongoing discussions with Congress.
The White House also rebuffed Smith's suggestion that Biden reinstate the Mexico City Policy.
"The Mexico City Policy significantly inhibits our ability to confront health challenges, not only HIV/AIDS, but also tuberculosis and malaria, and also to support programs that prevent and respond to gender-based violence when it comes to women's health," the official said.
PEPFAR updated its strategic direction document to stress that the program does not support abortion.
"In the context of PEPFAR, [sexual and reproductive health] services refers to four areas," reads a recently added footnote. It lists prevention of mother-to-child transmission of HIV and access to condoms; education and care around sexually transmitted infections; cervical cancer screening and treatment; and prevention of gender-based violence. "PEPFAR does not fund abortions, consistent with long-standing legal restrictions on the use of foreign assistance funding related to abortion."
Meanwhile, the program's partners overseas said they were not aware of U.S. funding being used to support abortions.
"I've talked to a number of implementing partners and I can tell you, there is nothing like that in Uganda," said Ogwang, whose organization treats more than 100,000 HIV patients with PEPFAR support.
He added that controls and transparency around PEPFAR funding are strict.
"If there is a program funded by United States government that is highly regulated, and demands the highest degree of compliance, it's PEPFAR," said Ogwang, a professional accountant who chairs his HIV organization's audit committee.
Health GAP, an international organization working on access to HIV medication, has urged supporters to call Congress and oppose "one zealot politician and the extremist think tanks . . . lying about PEPFAR and blocking reauthorization." Fellow lawmakers have been unsparing in their criticism of Smith, too.
"It took some members like Chris Smith of New Jersey to start spreading what I think is absolute misinformation that PEPFAR is somehow producing abortion issues," said Menendez, who added that he had been working with Sen. Lindsey O. Graham (R-S.C.) to try to assuage Republican concerns. Menendez said his goal remained reauthorizing the program this year, at least from the Senate.
Antiabortion advocates insist that Smith is right and Democrats have it backward.
"President Biden was the one who started this," said Roger Severino, vice president of domestic policy at the Heritage Foundation, blaming Biden's announcement on Jan. 28, 2021, that he was rescinding the Trump administration's policies that barred U.S. funding for organizations abroad that perform abortions or promote them as a method of family planning.
Shepherd Smith, who describes himself as a pro-life Christian, said he has investigated the allegations about PEPFAR indirectly funding abortions. "I haven't found evidence, and all the people in the faith community working on PEPFAR - overwhelmingly pro-life people - would have been the first to say, 'Hey, you know, we've got a problem here, because this is happening,' but it just hasn't," Smith said.
He added PEPFAR faces "real trouble" if it doesn't swiftly receive a five-year reauthorization.
"It'll be death by 1,000 cuts in the future, if it has to go up for reauthorization every year," Shepherd Smith said.
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