Why Congress Must Reauthorize a Lifesaving Program To Fight HIV/AIDS

The President’s Emergency Plan for AIDS Relief (PEPFAR), uniformly cited as one of the United States’ most successful foreign assistance initiatives, has saved more than 25 million lives throughout the world and ensured care for millions of children orphaned by the disease. Over PEPFAR’s 20-year history, Congress has reauthorized and fully funded the initiative on a bipartisan basis every five years; but 2023 has been different. Now, what should be another routine five-year reauthorization of PEPFAR has become an anti-abortion soapbox: A small group of extreme right-wing members of Congress are holding captive PEPFAR’s reauthorization—and the welfare of millions of adults and children in Africa and other parts of the world—to advance a radical anti-abortion agenda.

By preventing reauthorization before the September 30, 2023, deadline, these members brought the program into uncharted territory. Their actions undermine progress in improving the lives and livelihoods of women and girls of reproductive age—the exact group extremists claim to be concerned about—as the initiative’s success is connected to the low cost of antiretroviral medicines, which are affordable because, in exchange, pharmaceutical companies are assured five-year contracts for millions of doses. Furthermore, these members are undermining the United States’ reputation globally as the nation competes with China, in particular, for leadership and influence in the Global South.

Arguments against PEPFAR reauthorization rely on false claims

Rep. Chris Smith (R-NJ), who led a bipartisan effort to reauthorize PEPFAR in 2018, is now leading the 2023 opposition to PEPFAR’s reauthorization because, he asserts, it is indirectly connected to abortion care. This, of course, is not true. PEPFAR opponents have not produced any evidence to back up this assertion, and ironically, noted opponents of abortion strongly endorse PEPFAR reauthorization. Still, right-wing extremists are insisting on one-year funding cycles without reauthorization unless the program reinserts redundant Trump-era anti-abortion restrictions. Unfortunately, the recent election of House Speaker Mike Johnson (R-LA) casts further shadow on PEPFAR negotiations; while Johnson has yet to weigh in on the program, he boasts an anti-abortion track record and is an ally of the extremists falsely alleging that PEPFAR funds abortions.

For most policymakers across party lines, these are nonstarters because the certainty of five-year reauthorizations and funding cycles is core to PEPFAR’s success. This predictability facilitates longer-term investments that build resilience in health systems at the heart of eliminating HIV and battling other infectious diseases, such as COVID-19, malaria, tuberculosis, and Ebola. Annual contentious fights over PEPFAR funding would lead to erratic and disjointed programs that are less effective because they are too precarious, too limited in scope, and, most importantly, unaffordable because pharmaceutical companies can negotiate lower antiretroviral medication prices based on five-year, large-scale contracts.

Currently, PEPFAR programs remain operational through surplus fiscal year 2023 funding, but these funds will run out. Additionally, the House Committee on Foreign Affairs—led by Rep. Michael McCaul (R-TX)—is preventing the release of remaining funds to buy medicines and pay health care workers, among other costs, unless the administration changes long-standing terms in PEPFAR. These include terms related to human rights, transgender people, and sex work—a survival mechanism for many women, girls, men, and boys in fragile countries.

Thanks to PEPFAR, eliminating HIV/AIDs is within grasp

Since PEPFAR’s inception in 2003, the incidence of HIV infections in recipient countries has stabilized and continues to steadily decline. AIDS-related death rates are down by 68 percent since 2004, new HIV infections are down by 42 percent, and 5.5 million babies at high risk of exposure have been born HIV-free. Indeed, PEPFAR is critical to achieving the global target of eliminating HIV/AIDS by 2030. Already, five countries in Africa have achieved their objectives, and another 16 countries—including eight in sub-Saharan Africa, where 65 percent of all people living with HIV reside—are close.*

Moreover, through PEPFAR investments in health infrastructure, health care professionals, and health care delivery, diagnostic, and pandemic response systems, PEPFAR-supported countries have greater capacity to identify, treat, and stop the spread of other infectious diseases, such as Ebola, cholera, tuberculosis, and COVID-19. PEPFAR is also credited with reducing “the odds of death from any cause by as much as 16 to 20 percent in target countries.”

PEPFAR ensures health access for women and girls of reproductive age

PEPFAR has achieved remarkable public health outcomes, specifically in the context of pregnancy and breastfeeding. Largely thanks to its support, an incredible 82 percent of HIV-positive pregnant and breastfeeding women globally were able to access antiretroviral treatment in 2022. And in 2024, the Biden administration plans to launch a new multiyear Safe Births, Healthy Babies initiative, with the goal of decreasing transmission by an additional 33 percent in two years in countries with high numbers of HIV cases—but only if Congress reauthorizes and appropriates full funding for PEPFAR, as the initiative requires longer-term stability if it is to be effective.

Even with all these steady advancements, PEPFAR is still needed to support women and girls exposed to HIV/AIDs, which remains a leading cause of death in their reproductive years. Poverty and gender inequality, among other factors, heighten their risk of HIV exposure and limit opportunities for women and girls to access HIV/AIDs prevention, testing, and treatment. Notably, the risk of contracting HIV is three times higher for the one-third of women globally who experience violence in their lives.

PEPFAR’s Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative directly counters the barriers that prevent young women and girls from accessing HIV/AIDS treatment. Specifically, it supports school- and community-based HIV and violence prevention programs, post-violence care for survivors of gender-based violence, and pre-exposure prophylaxis (PrEP) HIV medications, among other measures. These interventions all increase the ability of young women and girls to seek and receive care; and they work.

In 2022, DREAMS contributed to supporting the health of almost 2.5 million young women and girls—an increase from the 1.6 million supported at the beginning of the fiscal year—and provided more than 200,000 young women and girls with education on and access to voluntary PrEP. Furthermore, more than 250,000 young women and girls received educational support, including school and exam fees, uniforms and materials, and access to basic literacy programs—critical interventions because keeping girls in school reduces their risk of contracting HIV, taking up sex work, and entering into a child marriage.

PEPFAR promotes U.S. national security and counters the influence of global competitors

The past several years of extremist political discourse and flip-flopping on global and regional commitments have contributed to a perception that the United States is an unreliable partner. Programs, such as PEPFAR, that save lives and build enduring partnerships with governments and communities have formed a cornerstone of U.S. soft power and are critical to maintaining partnerships in countries around the world. This is true both in the global fight against HIV/AIDS and in the push to advance U.S. national interests in other realms—diplomatic, economic, transboundary, security, and so on.

Many of these partnerships are under strain, however, and U.S. competition with other forces offering a different governance and development assistance model—such as China, Russia, and Saudi Arabia—is fierce. The United States’ decades-long commitment to saving lives, building strong and resilient health systems, and partnering with Global South governments on PEPFAR is a counterweight to the investment sway of China and other autocratic governments offering large-scale infrastructure and heavily debt-leveraged development financing. The United States has a compelling, if woefully underfunded, development assistance model. But by playing politics with successful U.S. international development commitments, right-wing extremists are helping the United States’ autocratic competitors further their own aims.

Conclusion

PEPFAR is among the most accomplished U.S. foreign policy initiatives in the past 25 years. The block by anti-abortion extremists is not only negligent from a global public health perspective; it also undermines U.S. influence at a critical moment globally. Importantly, American voters made clear to politicians just weeks ago that they want them to stop meddling in the right to reproductive health and women’s health.

For the 25 million individuals who are alive because of PEPFAR, the stakes are deadly serious. Holding PEPFAR captive to spurious concerns is also a distraction from the consequential national security objective of curbing the rise of pandemics and keeping U.S. goodwill and influence strong. To prove that, even with its challenges, American democracy still works, Congress must reauthorize and fully fund PEPFAR for five years.

* Author’s note: Botswana, Eswatini, Rwanda, the United Republic of Tanzania, and Zimbabwe have already reached the “95-95-95” target—meaning that 95 percent of people who live with HIV know their status, 95 percent of people who know they have HIV have access to lifesaving antiretroviral treatment, and 95 percent of people being treated for HIV are successfully suppressing the virus and reducing the risk of spreading it. Denmark, Kenya, Kuwait, Malawi, Namibia, Lesotho, Zambia, Luxembourg, Saudi Arabia, Slovenia, Thailand, Uganda, Sao Tome and Principe, Iceland, Burundi, and Togo are the 16 other countries close to achieving this target. Eight of these countries—Kenya, Malawi, Namibia, Lesotho, Zambia, Uganda, Burundi, and Togo—are in sub-Saharan Africa.