How ‘unauthorized status’ is threatening US global HIV initiative

The reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), America’s global initiative to combat HIV, was one of the casualties of the fight to circumvent a government shutdown, with certain authorizations for the program expiring last month. 

The program can continue to operate into next year with preapproved funding, but advocates worry the damage has already been done to the U.S.’s reputation as a leader in the fight against the HIV epidemic.

Rep. Chris Smith (R-N.J.), chairman of the House subcommittee on global health, is refusing to allow a five-year reauthorization on the basis he believes the program is funding pro-abortion groups overseas.

While House Republicans passed a one-year extension of PEPFAR authorization in a bipartisan spending bill, it was not part of the stopgap deal that extended government funding into next month. 

HIV and AIDS advocates and Democratic lawmakers say the politicization of PEPFAR risks the integrity of the program and pulls focus away from the crucial work it supports. 

“I’m concerned that they’re politicizing it,” Rep. Barbara Lee (D-Calif.), who co-authored the original legislation for PEPFAR in 2003, told The Hill. “We’re trying to keep it bipartisan. Probably just 20 [percent], 25 percent of members serving today were here when we first authorized it, and they’re trying to find every which way to derail it.”

Brian Honermann, deputy director of the public policy office Brian Honermann, deputy director of the public policy office at ​​the amfAR, The Foundation for AIDS Research, said Smith’s rationale was based on bad information. 

“Smith is just wrong in his assertion that PEPFAR has been converted into an entity that is funding abortion work,” said Honermann. “It’s just not true. I have been involved in all — I’m deeply involved in participating in meetings that involve the development of the strategies, the development of the work plans and things like that.”

What expired Sept. 30 were funding provisions for PEPFAR, rules directing how and where the money for the program — $6.9 billion for fiscal 2023 — is spent. Honermann said the immediate impact on the operation of the initiative’s partner programs would be limited. 

“Nothing really changes for the immediate moment, there are some expiring provisions,” he said. “PEPFAR will just go into an unauthorized status.”

According to Lee, negotiations to reauthorize PEPFAR are still ongoing.

Speaking on the House floor last month, Smith called on PEPFAR to “remain true to its original mission and respect our norms, traditions, and values.” And he called for its programs to be “cognizant and respectful of our beliefs and not cross over into promoting divisive ideas and practices that are not consistent with those of Africa.”

In its 20-year existence, PEPFAR has been both a rare area of consistent bipartisan consensus and one of the U.S.’s most impactful foreign public health programs. PEPFAR estimates it has saved about 25 million lives through its efforts. 

The majority of PEPFAR’s funding is derived from the State Department, and it can continue operating even without authorization, as long as the next budget bill sets aside funds for the HIV initiative.

Honermann noted PEPFAR has briefly gone unauthorized once before in the past, but the current situation stands apart in that it was blocked for political reasons, a first for the program started by the George W. Bush administration. 

While there are already statutory limitations blocking federal funds from going toward abortions overseas, like the Helms Amendment, Smith has argued those measures are not enough. The Republican congressman has requested that the Mexico City Policy — a federal rule barring foreign aid from going to nongovernmental organizations that provide abortion counseling, referrals or other expanded services — be added to any reauthorization of PEPFAR.

Honermann said this move would be highly disruptive to trusted community organizations helping to fight HIV in other countries because many of them also provide abortion-related services, but do so with separate funds. The Mexico City Policy would cut these groups out of PEPFAR participation.

“When we shift partners that becomes very costly and it’s disruptive for the patients themselves. And we are in a stage of this fight on HIV where keeping people enrolled for the long term is the critical piece,” he said.

According to Annette Gaudino, advocacy coalition manager for the Global AIDS Policy Partnership, even though PEPFAR continues to operate independently of reauthorization for the short term, Smith’s obstruction signals an “existential threat” to the program in the long term.

“It puts PEPFAR into the annual appropriations process and potentially opens it up every year to amendments on the right and on the left,” Gaudino said. “There’s no natural constituency for foreign aid in the United States, like no one’s getting primaried if they don’t support foreign aid, despite the fact that PEPFAR is a very popular, very successful program. And so it politicizes it and risks the broad bipartisanship that’s protected PEPFAR for 20 years.”

The regular five-year authorizations have protected PEPFAR from partisan bickering. A possible move toward annual appropriations has the potential to erode the support for PEPFAR as well as damage its efficacy.

As Gaudino put it, a program like PEPFAR that supports health infrastructures internationally needs to be planned and have confirmed funding years in advance in order to be effective, something that annual reauthorization fights would undermine. 

She also noted that while the State Department will continue abiding by the expired funding provisions for the time being, the lack of authorization may undermine oversight provisions, without a mechanism for enforcement from Congress. 

One provision for PEPFAR authorization directs the inspectors general for the State Department, the Department and Health and Human Service, USAID and other agencies to coordinate oversight over HIV, malaria and tuberculosis programs.

If the gridlock in Washington does start to impact PEPFAR’s impact in places like Africa — where the vast majority of PEPFAR’s investments are made — it would damage a key diplomatic conduit for the U.S., said Gaudino.

“Africans themselves … they are very cognizant of the fact that this is an American program, and American tax dollars are supporting this life saving program. So the soft power impact of it again cannot be matched.”