How ‘unauthorized status’ is threatening US global HIV initiative

The reauthorization of the US global effort to combat HIV, the President’s Emergency Plan for AIDS Relief (PEPFAR), is one of the casualties of the fight to avoid a government shutdown, with parts of the program approved last month. It has expired.

The program could continue into next year with pre-approved funding, but supporters worry it has already damaged America’s reputation as a leader in fighting the HIV epidemic.

Rep. Chris Smith, R.N.J., chairman of the House Subcommittee on Global Health, called for a five-year reinstatement of the program because of his belief that it funds pro-abortion groups overseas. is refusing approval.

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

HIV/AIDS advocates and Democratic lawmakers argue that politicizing PEPFAR jeopardizes the program’s integrity and diverts focus from the important work it supports.

“I’m concerned that they’re politicizing it,” Rep. Barbara Lee (D-Calif.), who co-authored PEPFAR in 2003, told The Hill. “We’re trying to maintain a bipartisan relationship. We’re probably only about 20 years old. [percent], 25 percent of the members serving today were here when we first chartered it, and they’re trying to find every way to derail it. ”

Brian Hornerman, deputy director of the Office of Public Policy at the Foundation for AIDS Research, said Smith’s rationale is based on bad information.

“Mr. Smith’s assertion that PEPFAR has turned into an organization that funds abortion activities is simply false,” Hornerman said. “That’s not true. I’m involved in everything and I’m very involved in participating in meetings that involve developing strategies, developing work plans, etc.”

What expired on September 30 were funding provisions for PEPFAR, rules that dictated where and how the program’s funds ($6.9 billion in fiscal year 2023) would be spent. Hornerman said the initiative will have limited immediate impact on partner program operations.

“Nothing really changes for the time being. There are some clauses that have expired,” he said. “PEPFAR will only fall into an unauthorized state.”

Negotiations to reauthorize PEPFAR are still ongoing, Lee said.

Speaking on the House floor last month, Smith called on PEPFAR to “remain true to its original mission and respect its norms, traditions and values.” He called on the program to “recognize and respect our beliefs and not promote divisive ideas and practices that are inconsistent with the African way of thinking.”

For two decades, PEPFAR has been a rare area of ​​consistent bipartisan agreement and one of the United States’ most influential foreign public health programs. PEPFAR estimates that its efforts have saved approximately 25 million lives.

Most of PEPFAR’s funding comes from the State Department, which allows it to continue operating without authorization as long as funding for the HIV initiative is secured in the next budget bill.

Hornerman said PEPFAR has been temporarily unauthorized in the past, but the current situation is unique in that it is blocked for political reasons, starting with the George W. Bush administration. He pointed out that this was the first such program ever to be undertaken.

Although legal restrictions already exist, such as the Helms Amendment, that prevent federal funds from being used for abortions abroad, Smith argued that those measures do not go far enough. Republican lawmakers called for the Mexico City Policy, a federal rule that prohibits foreign aid to nongovernmental organizations that provide abortion counseling, referrals, and other expanded services, to be added to PEPFAR’s reauthorization.

Hornerman said the movement is highly disruptive because many of the trusted community organizations that help fight HIV in other countries also provide abortion-related services, but are funded separately. He said it would be something similar. The Mexico City Policy would exclude these groups from PEPFAR participation.

“Changing partners can be very costly and disruptive for patients themselves. And we are at a stage in the fight against HIV where keeping people enrolled long-term is critical.” ” he said.

Annette Gaudino, advocacy coalition manager at the Global AIDS Policy Partnership, said that while PEPFAR continues to operate independently of reauthorization in the short term, Smith’s obstruction could have a negative impact on the program in the long term. It poses an existential threat.

“This would bring PEPFAR into the annual appropriations process, potentially allowing right- and left-wing amendments to be accepted each year,” Gaudino said. “Despite the fact that PEPFAR is a very popular and very successful program, just as no one wins a primary if they don’t support foreign aid, the United States does not support foreign aid. There is no natural constituency to support it, so it becomes politicized and the broad bipartisan bonds that have protected PEPFAR for 20 years are at risk.”

The standard five-year authorization has shielded PEPFAR from partisan conflict. A possible move toward annual spending could not only undermine PEPFAR’s effectiveness, but also undermine support for PEPFAR.

As Gaudino says, programs like PEPFAR that support global health infrastructure require planning and funding commitments years in advance to be effective; A reauthorization fight would undermine that.

He also noted that while the State Department will continue to comply with expired funding provisions for the time being, the lack of authorization could undermine oversight provisions without a Congressional enforcement mechanism.

One of the provisions of PEPFAR’s authorization directs the inspector generals of the Departments of State, Health and Human Services, USAID, and other agencies to coordinate oversight of HIV, malaria, and tuberculosis programs.

Gaudino said that if traffic congestion in Washington begins to affect PEPFAR’s influence in places like Africa (where the majority of PEPFAR’s investments are made), it will damage key diplomatic channels for the United States. He said it would happen.

“Africans themselves…are well aware of the fact that this is an American program and American tax dollars are supporting this life-saving program. So the impact of that soft power is again unmatched.”