Republicans delay more than $1 billion in HIV program funding
"Life-saving PEPFAR program has been ensnared for months in a broader political fight around abortion
Republicans have delayed more than $1 billion in funding for the President’s Emergency Plan for AIDS Relief, better known as PEPFAR, the latest complication facing a lifesaving HIV program that has been ensnared in a broader political fight around abortion.
Created by President George W. Bush in 2003, PEPFAR has been credited with saving more than 25 million lives around the world. The nearly $7 billion annual initiative, which is managed by the State Department, has distributed millions of courses of medicine to treat HIV, funded testing and prevention services, and supported an array of other interventions. Dozens of foreign governments rely on PEPFAR as a key partner.
The program has traditionally enjoyed bipartisan support in Congress, which has reauthorized it every five years. But lawmakers this fall failed to reauthorize PEPFAR by a Sept. 30 deadline amid claims from conservative advocacy groups that the program is inadvertently funding abortions overseas — allegations that Biden officials, PEPFAR staff and public health leaders say are unfounded and threaten the program’s mission.
PEPFAR can continue to operate without congressional authorization, with much of its current funding intact. But Republicans have been placing holds on notifications that the State Department is required to send to Congress before PEPFAR spends any additional money, according to four people with knowledge of the funding delays, three of whom spoke on the condition of anonymity to discuss private negotiations.
The GOP-led House Foreign Affairs Committee in August began objecting to language in PEPFAR’s country and regional operational plan, which offers guidance to partners around the globe about how to administer the aid program, according to the people with knowledge of the dispute.
The Republicans’ funding delays and objections, which have not been previously reported, center on PEPFAR’s use of terms relating to abortion, transgender people, sex workers and other areas, with the committee repeatedly demanding rewrites from the State Department. The negotiations have delayed the State Department from releasing more than $1 billion in funding for PEPFAR — funding that the program is planning to use to buy medicines, pay for staff and support other essential PEPFAR functions, several of the people said. PEPFAR officials have pushed back on some of the requested changes, including an attempt by House Republicans to change how terms such as “human rights” appear in the document.
Keifer Buckingham, advocacy director for the Open Society Foundations and a former Democratic congressional aide who worked on PEPFAR’s last reauthorization in 2018, said that prior PEPFAR documents used similar language and addressed the same issues.
“None of that phrasing is new … and it’s not like policy has dramatically changed,” Buckingham said, adding that House Republicans’ complaints about PEPFAR language are “ideological” and parallel their domestic political priorities around abortion and transgender issues.
The State Department confirmed that the House Foreign Affairs Committee has delayed approving the notifications that are required for allocating funds to PEPFAR.
“The delays in approval are straining PEPFAR country operations and threatening PEPFAR’s ability to continue implementation,” the State Department said in a statement. “If the [notifications] are not approved very soon, PEPFAR’s lifesaving work and gains will be threatened.” The department did not specify the amount of funding at stake.
Lawmakers have placed holds on PEPFAR funding in prior years in hopes of securing changes or getting answers about the program. But experts noted that the climate around the program has shifted in the wake of last year’s Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization, which effectively overturned the national right to abortion.
“If the current [funding] delay is based on these larger issues that have also stymied reauthorization, it would be a potentially serious situation,” said Jennifer Kates, director of global health and HIV policy at the health policy nonprofit KFF.
The House Foreign Affairs Committee referred questions to the State Department.
Republicans’ hold on PEPFAR funding comes as lawmakers continue to debate whether to reauthorize the program for one year, five years or not at all. In the wake of the Dobbs ruling, Republicans have alleged the Biden administration is using PEPFAR and other programs to support abortion access, a claim that public health experts roundly deny.
“PEPFAR’s never been an abortion program,” John Nkengasong, the program’s director, said in remarks Monday at the Center for Strategic and International Studies, a think tank based in Washington. “It is not and will never be because there’s a law, the 1973 Helms amendment,” which restricts U.S. foreign assistance programs from funding abortion abroad, he added.
Public health experts have clamored for lawmakers to swiftly reauthorize PEPFAR for five years through what is known as a “clean reauthorization” — effectively rolling over the current structure. Current and former PEPFAR officials said that a five-year reauthorization would protect the program from political pressures and help global partners plan their strategies.
Asking Congress to vote every year to reauthorize PEPFAR “is basically asking for the appropriations over time to dwindle down and [in] an irrevocable way,” Mark Dybul, a former head of the program, said at the CSIS event.
The Biden administration has also warned that Congress’s delay to reauthorize the program is “damaging the United States’ image globally, particularly in Africa,” and threatening plans to acquire supplies, roll out innovations and take other steps that require certainty about PEPFAR’s long-term viability.
But some Republicans want to reauthorize the program for just one year — arguing that it would allow a future GOP president to make changes to it. Conservative advocacy groups also have warned lawmakers that a vote to reauthorize PEPFAR in its current form will be viewed as a vote to support abortion abroad.
House Republicans last month advanced a measure that would extend PEPFAR funding for one year while reinstating a Trump-era policy, Protecting Life in Global Health Assistance, that explicitly bars global assistance funds from being used for abortion.
Rep. Michael McCaul (R-Tex.), the chairman of the House Foreign Affairs Committee, said that he had “high hopes” that lawmakers could reach a compromise to reauthorize PEPFAR.
“Time is running out and it’s critical to find a path forward and get PEPFAR reauthorized. I know all parties involved in this discussion care about PEPFAR’s success,” McCaul said in a statement. “But that means they also all need to be willing to come to the negotiating table — and everyone needs to be prepared to give a little.”
Having failed to sway holdout Republicans by focusing on PEPFAR’s public health accomplishments, advocates are increasingly touting the program’s national security implications. The George W. Bush Institute sent a letter to congressional leaders Wednesday, signed by more than 30 organizations and leaders in global health, foreign relations and faith communities, saying that a five-year “clean” reauthorization would help fend off strategic rivals seeking influence in regions that rely on PEPFAR support.
“As authoritarian China and Russia seek to increase their influence in Africa by any means possible, PEPFAR has been a shining example of compassion, transparency and accountability, as well as a massive strategic success story for the United States,” the letter reads. “Abandoning it abruptly now would send a bleak message, suggesting we are no longer able to set aside our politics for the betterment of democracies and the world.”
Deborah Birx of the Bush Institute, who led PEPFAR during the Obama and Trump administrations and helped organize Wednesday’s letter, said the congressional debate over the program “is bigger than PEPFAR,” citing the growing political divides over foreign aid, funding the Defense Department and other areas that were traditionally bipartisan.
“There are places where this country has compromised across the aisle for issues that transcend any specific party,” Birx added. “That’s what PEPFAR was about — translating the best of America.”
PEPFAR’s fate has been further clouded by uncertainty in Congress, as House Republicans spent most of October without a speaker, paralyzing legislative efforts in the chamber. Lawmakers and staffers told The Washington Post that it was unclear whether newly elected Speaker Mike Johnson (R-La.), who is staunchly antiabortion and a longtime ally of conservative advocacy groups that allege PEPFAR is funding abortions abroad, would favor swiftly reauthorizing the program.
Johnson’s office did not immediately respond to a request for comment.
The Senate’s PEPFAR efforts have also been disrupted. Sen. Bob Menendez (D-N.J.), who was steering Democrats’ efforts and working with Republicans to find a deal, stepped down last month as Senate Foreign Relations Committee chair after he was indicted over allegations he accepted bribes in exchange for exerting political influence. Sen. Ben Cardin (D-Md.), who had not been closely involved in the PEPFAR negotiations, is now serving as committee chair.
Lawmakers in both parties have discussed attempting to attach PEPFAR’s reauthorization to a larger bill to fund the government at the end of this year, but congressional staffers and experts have said they remain cautious about its prospects.
“If the only conversation is abortion, we’re not going to have a reauthorized bill,” Dybul said this week, calling on public health experts “to stand up, to speak, and not allow the misinformation to win.”
PEPFAR partner organizations across the globe said they are nervously watching the congressional negotiations, which have raised international questions about whether the United States remains committed to its long-running HIV program.
“The anxiety we are causing to patients and health workers is unfair,” Nkatha Njeru, the coordinator and CEO of Nairobi-based African Christian Health Associations Platform, wrote in an email.
It is unclear what will end the logjam. Former president Bush appealed to Congress to reauthorize the program for five years in an op-ed in The Post published last month, and senior officials from both parties have increasingly issued their own pleas.
“I can’t think of another thing like PEPFAR until I go back to the Marshall Plan,” said Bob McDonald, who served as secretary of Veterans Affairs during the Obama administration and who co-signed the letter sent by the Bush Institute on Wednesday. “Imagine if we had been against the Marshall Plan.”
Asked how to break the political stalemate, Nkengasong called for a “dialogue” with the program’s critics. “We have to have a forum where we have an honest conversation … and lead with facts and not misinformation and disinformation,” the PEPFAR chief said."