Speaking to the U.N. General Assembly on Tuesday, President Biden appealed to lower-income countries in Africa, Latin America and Asia to work together. To illustrate the power of collaboration, he pointed to the success of PEPFAR, or the President’s Emergency Plan for AIDS Relief, an enormous $100 billion U.S.-led program to fight HIV and AIDS that is credited with saving more than 25 million lives over two decades.
“It’s a profound testament to what we can achieve when we act together, when we take on tough challenges,” Biden said, “and an admonition for us to urgently accelerate our progress so that no one is left behind because too many people are being left behind.”
The annual top diplomatic event in New York City comes just weeks before PEPFAR’s looming Sept. 30 reauthorization deadline in Congress. There, it is now the center of an unexpectedly fierce domestic battle due to pro-life groups who say PEPFAR indirectly funds abortion, a charge its supporters flatly deny.
As a U.S.-led program, PEPFAR is not officially a topic of discussion at this week’s U.N. meetings. Yet the program’s fraught future hangs in the conference’s backdrop, heightened by the number of leaders in town from recipient nations, the range of high-level talks on global health, and the U.S. push to find common ground with Global South nations on issues including the war in Ukraine and Washington’s ongoing rivalry with Beijing.
In New York, global health figures told me that the disconnect between what is being asked of Global South countries and the prospect of PEPFAR defunding is creating confusion that hurts both Washington and its prospective partners.
“I think from the outside, advocates are saying, well, what is going on here? Is this a leader?” said Dilly Severin, executive director of the Universal Access Project, an initiative of the U.N. Foundation that works to strengthen U.S. funding for global sexual and reproductive health and rights.
Yun Sun, an expert on Chinese foreign policy at the Stimson Center, said that Beijing was likely watching closely. “If the U.S. does decide to drop or reduce PEPFAR funding, I bet the Chinese will pick up on it and criticize the U.S. loss of leadership and commitment to the African countries,” Sun said.
Even for Americans, the battle over PEPFAR is confusing. The program is not supposed to have anything to do with abortion (laws prohibit the use of federal funding for abortion services). Spearheaded by President George W. Bush in 2003, it has long been considered a bipartisan win that flew through its previous authorizations with little opposition.
It is a rare program praised by almost everyone, credited with stemming the spread of HIV across Africa and a key to hopes that the AIDS epidemic could be ended by 2030.
But this year, the program has become enwrapped in America’s domestic battle over abortion, coming after the Supreme Court struck down Roe v. Wade. The conservative Heritage Foundation published a May report saying the Biden administration had reshaped the program to implement a “domestic radical social agenda overseas.” Pro-life groups have warned Republicans that if they vote in support of PEPFAR they could be docked on their scorecards.
Rep. Christopher H. Smith (N.J.), a Republican who once praised PEPFAR but now has become one of its most vocal critics, told my colleague Dan Diamond that he felt the program had been “hijacked” and pointed to efforts around the world to expand access to abortion in Africa and elsewhere. “Every single statute protecting life in Africa is under siege right now,” he said.
PEPFAR officials and others have strongly refuted the idea that the program has anything to do with abortion. “As members of faith-based organizations in Africa, some of whom have a long history with PEPFAR, we write to state that we have no knowledge of PEPFAR funding or promoting abortions,” one group of African church leaders wrote in a recent letter to Congress.
Advocates argue that some Republicans are pressuring the program with the hope that they can effectively reinstate the Mexico City Policy — a rule that bars foreign organizations that receive U.S. funding from supporting abortion access. Asia Russell, executive director of nonprofit Health GAP, said that Smith’s proposal for a one-year authorization with caveats, rather than a five-year reauthorization, showed that this was about politics.
“Everyone can agree it has nothing to do with the HIV response. It is holding out for a Republican president,” she said. “It’s not a compromise. It’s a ploy.”
Those who work with PEPFAR funds in recipient countries agree that a one-year reauthorization would create huge uncertainty in long-term planning. Some community organizations receive almost all of their funding from PEPFAR, according to Robin Gorna, executive director of Frontline AIDS.
“It will be a real disaster” for Ukraine if PEPFAR is not reauthorized, said Andriy Klepikov, executive director of Kyiv-based Alliance for Public Health, adding that the program’s swift response to the disruption caused by Russia’s invasion had saved “thousands, tens of thousands” of lives.
Peter Njane, a director of Ishtar MSM, said that his organization, which provides services to men who have sex with men in Nairobi, would cease to exist if PEPFAR folded. “Being an openly gay man in Kenya, I can’t be employed anywhere else,” he said.
In New York, global health leaders have called on Congress to reauthorize the program. “The world needs PEPFAR to be reauthorized to finish the job of ending AIDS,” Winnie Byanyima, the Ugandan leader of UNAIDS, said at one event.
However, with so many ongoing global crises, world leaders have been quieter. Even advocates said they understood why governments may be worried about wading into America’s domestic debates. “Would you want to take on the Americans?” Gorna said.
Peter Pham, a distinguished fellow with the Atlantic Council who served as an envoy to East Africa, said he had moral qualms about not reauthorizing a program that had saved so many lives. But he also noted that many African nations supported by PEPFAR had failed to take their own commitment to public health seriously, relying on the U.S. program instead.
“I don’t buy the argument that doing so might hurt America’s influence insofar as the empirical evidence from two decades of paying for the program does not show much appreciation on the part of those who govern many African countries,” Pham wrote in an email, pointing to South Africa as a country that “rarely misses an opportunity to oppose U.S. foreign policy objectives and align with America’s foes” despite its gains from PEPFAR.
It is not clear if any other nation could take America’s place in the global fight against AIDS. “Beijing might try to pick up the opportunity and fill the void,” Sun said, but “depending on China’s technical capacity on this issue, it may not be able to do so effectively even if it wants to.”
Other multilateral institutions, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, could pick up some slack. But those who worked with PEPFAR say that even if the funding hole could be filled, the U.S.-led program provides benefits including access to Centers for Disease Control and Prevention experts that could be impossible to replicate.
With U.S. leadership needed in a variety of areas from climate to pandemic preparedness, if PEPFAR is not reauthorized it will send “symbolic shock waves through the system,” said Solange Baptiste, executive director of the South Africa-based International Treatment Preparedness Coalition.
