The PEPFAR Files: How Critics Put the HIV Program at Risk
*This article originally appeared in Think Global Health.
When President Joe Biden delivered the State of the Union address in March 2024, he made passing reference to a HIV/AIDS program that sat in limbo despite having saved millions of global lives.
The President’s Emergency Plan for AIDS Relief (PEPFAR) was entering its sixth month without a congressional reauthorization—an unprecedented impasse for the program founded during the George W. Bush administration to provide HIV treatment and prevention to the low-income countries with the highest rates of disease in the world. Biden said of PEPFAR, “It’s been a huge success. [Bush] thought big. He thought large. He moved! I believe we can do the same thing with cancer.”
For some advocates, the mention was a welcome sign of presidential support for the beleaguered program, whose reauthorization was derailed by spurious accusations that PEPFAR dollars paid for abortions overseas. The allegations, which began with a June 2023 report by the Heritage Foundation, persisted long after it became clear that no evidence supported the claims.
The president’s fleeting PEPFAR mention hewed close to a familiar script. Throughout the Biden administration’s first term, the White House, State Department, and the U.S. Agency for International Development (USAID) have praised PEPFAR’s achievements but not its design, strategy, or structure. When U.S. government leaders laud PEPFAR’s contributions to other outbreak and pandemic responses, including mpox, Ebola, and COVID-19, they seldom dwell on the program’s exceptional ability to serve as a springboard for urgent responses. Instead, the ends are cleaved from the methods even though the two are inextricably linked.
A strong case can be made that this omission is not accidental or incidental. Ambivalence and even animosity toward PEPFAR’s defining features have shadowed the program since its inception 21 years ago. Often, these concerns come from Democrats who favor foreign aid and soft power deployed through USAID, but the divide is bipartisan. For as long as the program has existed, some Republicans have fretted about what PEPFAR pays for, and some Democrats have fumed about how it operates.
The state of this HIV/AIDS effort will undoubtedly be front and center at the twenty-fifth International AIDS Conference kicking off on July 22. An accurate forecast of the program’s future needs to include a full reckoning of both Republican and Democratic concerns.
As described in this series’ first article, a small group of Republicans took actions and made accusations that helped botch the latest reauthorization process, which ultimately resulted in a one-year extension. By the time the abortion accusations surfaced in June 2023, the Biden administration had clearly staked out a position of praising PEPFAR’s accomplishments on HIV without substantially leveraging its potential for fighting other pandemics.
This second installment explains why this situation was no accident and how long-standing critiques of the program’s structure and modus operandi have made PEPFAR so vulnerable.
The league of Hill supporters who were present at PEPFAR’s creation has dwindled to just 13% of current members of Congress, according to Katie Coester, associate director of public policy and advocacy at the Elizabeth Glaser Pediatric AIDS Foundation and co-chair of the Global AIDS Policy Partnership.
Read the full article here.