What is PEPFAR?
The President's Emergency Plan for AIDS Relief is a U.S. aid program that combats HIV/AIDS worldwide. Launched in 2003 by President George W. Bush, it has blunted the global HIV pandemic by testing hundreds of millions of people and giving those who are infected lifesaving antiretroviral drugs — medications that prevent the human immunodeficiency virus from developing into AIDS. PEPFAR has also distributed billions of condoms and prevented transmission from mothers to babies by giving women and girls reproductive education and health screenings. In just over two decades, these efforts have saved more than 26 million lives across 55 countries, reduced child mortality by 35 percent, and increased global GDP per capita by more than 2 percent.
Why did Bush set it up?
HIV/AIDS was rampant in Africa when Bush took office, infecting more than one-third of adults in some countries. While there were new drugs available, fewer than 1 percent of the 30 million HIV-positive people on the continent were getting them, and AIDS was killing 2 million Africans a year. President Bill Clinton had already declared AIDS a national security threat, fearing the 14 million kids left orphaned by those deaths would be ripe for recruitment by militias and terrorist groups. In the wake of the 9/11 terrorist attack, Bush proposed an ambitious, U.S.-funded scheme to stop the pandemic's spread, and Rep. Henry Hyde, a fiscally conservative Republican, took the lead in Congress to pass legislation establishing the program. "I'm not naïve enough to think PEPFAR was purely altruistic," said Ugandan journalist Daniel Kalinaki. "It was a defensive mechanism that turned into something good — arguably America's biggest foreign policy win." Since its passage, PEPFAR has enjoyed bipartisan support, with Congress continuously reauthorizing the program at some $25 billion every five years. But now its funding may be cut off.
Why is the program at risk?
PEPFAR was one of the initiatives halted in the blanket freeze on foreign aid President Trump declared last month. Its 270,000 doctors, nurses, and pharmacists were told not to report to work and to turn away patients who came for their antiretroviral drugs. "I was warned by my doctor not to miss a single dose because that could lead to resistance," said Milicent Muyoma, a Kenyan woman with HIV. "I don't know what will happen if I don't secure my medicines soon." Secretary of State Marco Rubio eventually issued a humanitarian waiver for PEPFAR so it could resume HIV testing and drug distribution, but the program is now in chaos. Hundreds of organizations in Africa said their access to PEPFAR-funded resources has not resumed, and they are still turning people away. Doctors Without Borders reported that none of the AIDS clinics in its network has been able to resume work. Meanwhile, even if the freeze is ultimately lifted, it's unclear whether Congress will reup PEPFAR for another five-year term when its funding expires in March.
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Why might Congress cut funding?
In 2023, the conservative Heritage Foundation put out a damning report saying that PEPFAR had become inefficient and politicized, "a subsidy program for giant contractors and NGOs" — overwhelmingly Democratic Party supporters — that were promoting a "leftist agenda" of LGBTQ ideology. Republican lawmakers began to balk at funding the program. Then, last month, U.S. officials said they had discovered that over the past four years, a small amount of PEPFAR money has gone to a health clinic in Mozambique that provides abortions in addition to HIV services. That's a violation of the Helms Amendment, which prohibits U.S. government funding of abortions. Republicans now say they won't reauthorize PEPFAR unless more oversight is added. "It is disgusting that the Biden administration has allowed taxpayer dollars to be used to perform abortions overseas," said Sen. Jim Risch (R-Idaho). "The future of the PEPFAR program is certainly in jeopardy."
That process is already underway. The U.S. has secured reimbursement from Mozambique for the salaries of the four nurses who provided abortions, and clinics receiving PEPFAR money will now be required to certify that they do not offer abortion care. Some House Republicans say they might be willing to authorize a single year of funding, rather than five, to give the Trump administration time to curb the program's bloat and "woke" excesses. But Health Secretary Robert F. Kennedy Jr. has been a vocal critic of PEPFAR as a whole. He says the fight against AIDS has been driven by pharmaceutical companies, "Africa's cruelest and most deadly colonial overlord," and he may advocate for PEPFAR to be canceled.
What effect would that have?
"We can very rapidly return to where the pandemic is exploding, like it was back in the 1980s," said Steve Deeks, an HIV expert at the University of California. More than 222,000 people pick up antiretroviral drugs through PEPFAR every day. Within a week of missing their medication, their viral load will shoot up from undetectable levels to more than 100,000 viral particles per milliliter of blood, and they can become spreaders of the disease. As with antibiotics, pausing the course of treatment makes the drugs less effective when they are resumed — which means more drug-resistant variants and less of a chance at one day developing a vaccine. HIV testing, too, would stop. "It's unlikely that we will be able to even diagnose people who need to go into treatment," said Glenda Gray, a pediatric HIV doctor in South Africa, where a PEPFAR shutdown would add more than half a million new HIV infections over the next decade. "Children who are untreated are likely to die."
A gift to China?
The end of PEPFAR would "undoubtedly rebound to China's benefit," said Jeremy Chan of the Eurasia Group. Though China currently only spends roughly $3 billion a year on aid to Africa — a fraction of the U.S.'s pre-Trump aid budget — it has established a foothold in the region through its $1 trillion Belt and Road infrastructure initiative. And last year, China signed an agreement with the U.N. agency UNAIDS to boost spending on HIV/AIDS in Africa. If the U.S. halts its own charity, China could fill the vacuum. "If we want to continue being a superpower, we need to make sure that citizens of the world continue to like us," said Dan Foote, former U.S. ambassador to Zambia. "Instead, we've started to go around and kick every ally we have in the shins. China will absolutely take advantage of the end to PEPFAR."
