PEPFAR Limps into Uncertain Future after Failure of US Congress to Authorise Five-Year Plan
HIV-positive children can grow up healthy, thanks to the pioneering treatment interventions funded by PEPFAR and partners.

The failure of the US Congress to reauthorise a five-year budget for the world’s largest aid programme for global health, the US President’s Emergency Plan for AIDS Relief (PEPFAR), by its 30 September deadline doesn’t mean that it will automatically end – but without broad bipartisan support, it limps into an uncertain future. 

“In the short term, PEPFAR will be able to continue providing the lifesaving prevention, care, and treatment services in partnership with PEPFAR-supported countries,” said US State Department spokesperson Matthew Miller this week

“However, the fact that Congress did not reauthorize the program sends a message to partners around the world, especially in Africa, that we are backing down from our leadership in ending HIV/AIDS as a public health threat.”

Miller added while the Biden administration supported a five-year, “clean” PEPFAR reauthorization, the authorisation of certain programs has expired. 

“We’re still figuring out exactly what that means. There are some appropriations that have continued, so we’re going to work through it.  But the program can continue for now,” Miller told a press briefing.

As long as funds for PEPFAR are appropriated annually by Congress, the programme could continue without formal authorisation, according to Kaiser Family Foundation (KFF).

But this means that grantees would have to submit annual budgets rather than the more sustainable five-year programmes.

“Some requirements would ‘sunset’ if a reauthorisation bill is not passed,” according to KFF, which has identified seven requirements that would end after the 2023 financial year, and one that would end after the 2024 financial year.

A casualty of anti-abortion campaigning

PEPFAR was started by Republican president George W. Bush in 2003 and has enjoyed bipartisan support from both Republicans and Democrats until recently.

But in the past few months, there has been a concerted campaign to link PEPFAR grantees with the promotion and provision of abortion, despite US legislation making it unlawful for PEPFAR to fund or support abortion, and abortion being illegal in most African countries where it operates.

In May, a group of US influential right-wing groups claimed in a letter sent to Senate and Congress leaders that PEPFAR grantees “are using taxpayer funds to promote a radical sexual and reproductive health agenda”. Signatories include the Center for Family and Human Rights (C-FAM), the influential rightwing think-tank Heritage Foundation and the Dr James Dobson Family Institute.

A similar letter was sent on 6 June to the same US politicians by a group of conservative African politicians and religious leaders, mainly Catholics, claiming that PEPFAR “is supporting so-called family planning and reproductive health principles and practices, including abortion, that violate our core beliefs concerning life, family, and religion”.

Amongst the signatories were 10 Kenyan Members of Parliament, but last week the Speaker of Kenya’s Parliament distanced his institution from them, stating that the letter “is not the official position of the National Assembly”.

US Representative Chris Smith, who co-sponsored PEPFAR’s refinancing in 2018, has also joined its critics, claiming that the programme is being used to “promote abortion on demand”. 

Instead of reauthorising PEPFAR for five years, Smith proposed a one-year reauthorization of PEPFAR in the State, Foreign Operations, and Related Programs Appropriations Bill that was narrowly passed by the House of Representatives last Thursday night. 

The Bill adds strict anti-abortion clauses, slashes the foreign aid budget and is unlikely to be passed by the Democrat-dominated Senate.

US Congressional Representative Barbara Lee and PEPFAR head John Nkengasong.

‘Greatest act of humanity’

Dr John Nkengasong, who heads PEPFAR as the US Global AIDS Coordinator in the State Department’s Bureau for Global Health Security and Diplomacy, described PEPFAR as “the greatest act of humanity in the history of infectious diseases that has transformed the ugly face of HIV/ AIDS in Africa from hopelessness and helplessness to hopefulness”.

PEPFAR is estimated to have saved the lives of 25 million people since it was set up 20 years ago. According to UNAIDS, new HIV infections are almost 60% lower than their peak in 1995, while AIDS-related deaths are almost 70% lower since the peak in 2004 – and PEPFAR has played a major role in achieving this.

Around 30 million people now have access to antiretroviral treatment, while nine million still need access. In some African countries, over 90% of people living with HIV depend on PEPFAR funding for their treatment.

Nkengasong has also stated categorically that  “PEPFAR has never, will not ever, use that platform in supporting abortion”.

Dr Uche Ralph-Opara, Deputy Chief Health Officer for Project HOPE, an international organisation addressing global health crises, said that “lives are hanging in the balance”.

“As a public health expert and clinician who has witnessed the transformative power of PEPFAR on the ground, I can attest that without its continued authorization, we risk losing our hard-won gains in the fight against HIV/AIDS,” Ralph-Opara warned.

“From the global health perspective, PEPFAR is not just a program, it’s a lifeline for millions. Its absence would result in increased mortality rates, strained health systems, and certainly a setback in our collective efforts to achieve health for all.”

South African hospice Sister Vicky Sikhosana with a patient with AIDS in South Africa in 2007, before ARVs were available in Africa – a full decade after they were available in Western countries because of high costs.

Nkengasong also warned that PEPFAR’s gains are fragile

 “As a virologist, I will tell you this: if the 30 million people that are receiving [antiretroviral treatment] today stopped, within five weeks the virus will come back and within a couple of years they will start dying,” Nkengasong told the Annual Legislative Conference of the Congressional Black Caucus last week.

“Within a couple of years, [HIV] transmission becomes a global effect,  not just limited to Africa, and we will be all back again to 20 years ago. So the hundreds of billions we’ve invested in HIV goes into the drain and humanity suffers,” he added.

‘Not about abortion’

“PEPFAR is not about abortion but they’re trying to make it about abortion,” House of Representatives member Barbara Lee, the main negotiator for the five-year reauthorisation for the Democrats, told the Congressional Black Caucus conference.

Back in 2002, Lee was part of a group of Congressional Black Caucus members who approached Bush and urged him to address HIV and has been a PEPFAR champion since its inception a year later. 

She admitted that she had almost voted against PEPFAR initially because of some problematic elements including those related to abortion, but that ultimately the Democrats had resolved that they could work with it.

However, Lee said while working to ensure bipartisan support for PEPFAR’s current reauthorisation for another five years, “I have found pushback on the other side [amongst Republicans] big time in terms of, not only the money but also ‘why’ and for me that’s the moral disgrace of where we are right now”. 

She appealed to the faith community to galvanise support for PEPFAR: “We have to get back to some kind of sensible bipartisanship so that we can move forward and end HIV and AIDS by 2030”.

Power: ‘Manufactured controversy’

Meanwhile, USAID Administrator Samantha Power told the conference that “the manufactured controversy is making it difficult to get this clean reauthorization”, quoting a recent article in support of PEPFAR’s reauthorisation written by Bush, saying: “No programme is more pro-life than one that has saved more than 25 million lives”. 

“It’s more rare now to have things happen in a bipartisan way, but to have something stably, bipartisan for 20 years is a signal to all the countries in which we are working, that PEPFAR is here to stay,” Power added. 

She added that USAID staff had been able to go into health ministries of partner countries, confident that “bipartisanship puts [PEPFAR] on such a stable foundation that you can look beyond the next budget cycle.”

PEPFAR has invested some $110 billion in HIV prevention, treatment and care, which has had a huge impact on grantee countries’ health systems, including by increasing disease surveillance capacity, strengthening health services, and improving drug supply management. 

“I’m not sure there’s broad awareness of how much we relied on the PEPFAR infrastructure to tackle COVID-19,” added Power. 

“The PEPFAR tracing and the surveillance systems are ones that are being used for infectious diseases like Ebola and Marburg, or if there is a new COVID variant. The same individuals who transport HIV testing samples are the ones who transported COVID-19 samples. We used some of the same testing machines, some of the same laboratory capacities. When it came to the vaccination drive, it was our PEPFAR platform that was able to rapidly stand up… in getting those shots in arms.”

Goals almost within reach

UNAIDS Director Winnie Byanyima

“In many of the HIV high burden countries, which are in Africa, up to 95% of the funding for putting people on treatment and prevention is paid for by this programme,” according to Winnie Byanyima, head of UNAIDS, the United Nations agency on HIV/AIDS.

“These are countries that are so highly indebted that just the interest on their debt is four to five times as much as they are putting into their whole health systems, let alone for HIV,” Byanyima told a meeting organised by the Clinton Foundation on the sidelines of the UN General Assembly two weeks ago.

“This is not the time to stop PEPFAR. This is the time for the leadership in America to continue doing what it has done right and continue supporting countries to keep their people alive.”

Byanyima said that while the global goal of ending HIV by 2030 was achievable, “we have to have strong political leadership.”.

“It’s failing. We are in a world where the geopolitics have gone crazy and it’s hard to get leaders to stay committed to what they committed to long ago. 

“We need to follow the science to address the real epidemic in each country, not the epidemic they want to think they have, but to follow the scientific evidence,” she added, urging special attention to be paid to eliminating HIV transmission in most at-risk groups in Africa – women and girls, gay men and transgender women.

“Most people in Africa do not understand what we mean by reauthorisation and appropriation,” said Nkengasong. “These people say: ‘Well, it doesn’t mean that you will not get funding’. No, but it sends a signal and weakens our own foreign policy and diplomacy weakens our commitment to humanitarian efforts. Fighting HIV is not just a health issue for Africa. It’s a developmental issue and it’s a security issue.”

Image Credits: The Global Alliance to end AIDS in children, Kerry Cullinan.

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