As the United States marks the 35th World AIDS Day on Dec. 1, domestic politics threaten the future of one of the nation's most successful global health initiatives, which is credited with keeping millions of people alive. Catholic leaders, meanwhile, are urging lawmakers to ensure that the program continues to provide life-saving care to those in need.
Earlier this year, public health leaders celebrated an important milestone: the U.S. President’s Emergency Plan for AIDS Relief, or Pepfar, a program launched in 2003 by President George W. Bush, to combat the spread of H.I.V. in under-resourced nations, was credited with saving more than 25 million lives.
The initiative has invested more than $110 billion in the fight against H.I.V., mostly in Africa, to help slow the spread of the virus, provide life-saving drugs to people living with it and care for those whose lives have been upended by the crisis, including widows and orphaned children. The program provides funding to international nonprofits and local organizations, including Catholic groups, in order to facilitate H.I.V. testing, public health campaigns and access to antiretroviral drugs, which allow people with H.I.V. to live otherwise ordinary lives.
While lawmakers in both parties have routinely voted to reauthorize the program and to fund it with billions of dollars annually, that support seems to be eroding. Some Republicans have expressed concern in recent months that the funding Congress allocates for H.I.V. treatment is being used to offset spending on abortion by some nongovernmental organizations. Critics reject those charges and say that the lives of millions hang in the balance if the United States steps back from its role as a global leader in the fight against H.I.V.
Catholic leaders want Congress to act to secure the program’s long-term viability. Catholic Relief Services, the international development arm of the U.S. bishops, has been a Pepfar partner since the program’s inception. C.R.S. continues to work with local organizations, both by making grants to provide direct services and by training local groups to seek funding directly from Pepfar.
As the United States marks the 35th World AIDS Day on Dec. 1, domestic politics threaten the future of one of the nation's most successful global health initiatives.
But Meghan Topp Goodwin, a senior policy and legislative specialist at C.R.S., told America that the possibility of an entrenched battle over the future of Pepfar makes people whose lives are directly affected by H.I.V. nervous.
“What we are perceiving is that they fear that the Pepfar program is in jeopardy,” Ms. Goodwin said. “They see the breakdown of bipartisan consensus around reauthorization and they fear that this signals that in the future, there will not be bipartisan consensus around continuing the program.”
That kind of uncertainty can lead to real-world matters of life and death.
If an individual is concerned about their H.I.V. status, they may be dissuaded from being tested if they cannot be assured that drugs will be available in the long term to treat their infection, Ms. Goodwin said.
“There’s a sense of hopelessness that comes from that,” she added.
The U.S. Conference of Catholic Bishops supports a five-year reauthorization of Pepfar, though in a letter to lawmakers this summer, Catholic leaders expressed concern about the program’s support for H.I.V. prevention programs that promote the use of condoms.
“The Catholic Church is a major provider of HIV/AIDS-related services worldwide and has long shared PEPFAR’s foundational goals of saving lives, caring for the infected and the affected, and preventing the spread of this deadly disease,” stated the letter, which was signed by Bishop David J. Malloy, the chair of the U.S.C.C.B. international justice and peace committee; Bishop Michael F. Burbidge, the chair of the pro-life committee; and Sean Callahan, the president and chief executive officer of C.R.S. “We therefore continue to strongly support these goals and their expression in Pepfar.”
The letter from bishops and C.R.S. also expressed support for provisions to ensure that funds are not used to support organizations involved in abortion.
“The life-saving work of PEPFAR should never be entangled with the promotion of abortion, a grave evil and the opposite of lifesaving care,” the letter stated. “All appropriate steps should be taken by lawmakers, along with the Administration in its implementation and oversight of PEPFAR, to support that goal.”
Debates about abortion and the use of U.S. foreign aid money have raged for decades, but various guardrails have been in place that prevent U.S. money from promoting or paying for abortion. Some Republicans want to attach further restrictions to Pepfar, which would likely doom its reauthorization.
“Abortion was publicly raised as one of the discussion points in PEPFAR reauthorization in early May after a coalition of organizations opposed to abortion rights, a conservative think tank’s report, and a member of Congress raised their concerns that PEPFAR may be supporting abortion,” the Kaiser Family Foundation reported in September. According to the foundation, “There has been no evidence produced that PEPFAR has supported any prohibited abortion activities.”
Pepfar has been reauthorized three times since its inception, often with little or no opposition from either party. President Biden urged Congress to pass another five-year reauthorization earlier this year, but a key deadline passed in September and Congress failed to act. Some Republicans are pushing for a one-year reauthorization, arguing that an annual review of contracts will ensure that no money is supporting abortion abroad.
But nonprofit organizations say that reauthorizing the program for five years at a time allows for better planning.
“We need to be able to plan five years out,” Ms. Goodwin said. “We need to know that if we’re going into a community, that we’re still going to be able to be there in five years. And that is what a five-year authorization would afford us.”
Ms. Goodwin said that C.R.S. receives less money today than it did in the early years of the program, in part because Pepfar announced in 2018 that it aimed to direct 70 percent of its grants toward local organizations. C.R.S. still receives money from Pepfar, but it has also been working with local organizations to help train them to apply for grants directly.
In some places, especially in several African countries, access to life-saving medications is possible because of the investment made by the United States.
“There are fewer people getting H.I.V. and AIDS today,” Ms. Goodwin said, “but everybody knows someone who is kept alive by antiretroviral treatments that the United States is providing to the Pepfar program.”
The involvement of faith-based organizations in fighting H.I.V. has been integral to Pepfar’s success since its earliest days.
In its 2022 annual report, Pepfar described faith-based organizations as “essential partners” and wrote that they “remain key partners to accelerate and sustain epidemic control.” The report notes that in places where Pepfar operates, the population attends religious services at rates of 65 to 70 percent and says that “communities of faith are deeply embedded regionally, with national structures, and often have unique institutional capacity and established, durable relationships of trust.”
Faith-based organizations can be especially helpful in reaching individuals who do not regularly interact with the medical system, including boys, men and non-pregnant women, the report states.
In an interview with America, Ambassador John N. Nkengasong, the U.S. Global AIDS Coordinator, praised the work of faith-based groups, including C.R.S., in helping people with H.I.V.
“They are really key players on the ground…because they are really embedded in the community, they have the trust of the community,” Dr. Nkengasong said. “They call it the ‘megaphone of trust’ of the community.”
Dr. Nkengasong also said a multiyear reauthorization is vital in order to show that the United States is a trusted partner.
“We should always remember that if we do not reauthorize Pepfar, then we are signaling a kind of withdrawal,” he said. “Then the question becomes, what happens to all the investments that we’ve put into Pepfar over the years? That is extremely important.”
Opposition to Pepfar’s reauthorization seems to go back to a report published this spring by the Heritage Foundation, a conservative think tank in Washington.
That report praises Pepfar for saving millions of lives, but it also claims that “the Biden Administration misused Pepfar” as “a well-funded vehicle to promote its domestic radical social program overseas.” It cited a memo from the White House that said the U.S. government should work with groups that promote “institutional reforms in law and policy regarding sexual, reproductive and economic rights of women” at home and abroad.
Describing H.I.V. as a “lifestyle disease,” the Heritage Foundation suggested that Congress halve Pepfar funding and that recipient countries make up the balance.
Following the publication of the report, the chair of the U.S. House Foreign Affairs subcommittee, Rep. Chris Smith, a New Jersey Republican, said that he would not move to reauthorize Pepfar for five years. Instead, he suggested a one-year reauthorization while maintaining current funding levels. That way, he said, lawmakers could review contracts in order to ascertain whether organizations that provide or promote abortion services were receiving Pepfar money.
While politics threatens the future of Pepfar, the program manager at a Catholic orphanage in Nairobi told The Associated Press that he has a plea for Congress.
“Let them know that the lives of these children we are taking care of are purely in their hands,” Paul Mulongo said.
Material from the Associated Press was used in this report.
