In the clinic where I work, I met a patient the other day whom I might not have 20 years ago.
He was from Uganda. Recently, he had moved to my small university town a few hours outside of Toronto. He was eager and bright. As we spoke, I was struck by how coolly he handled himself in the face of a great adversity. He told me that during an emergency medical procedure, in a rural village where he was doing fieldwork, he contracted HIV. Doctors gave him medicine — antiretrovirals that suppressed the virus for years. Sitting across from me, he said that he hoped we could extend his supply.
What made our interaction possible, I later thought, was a remarkable program called PEPFAR. In the early 2000s, therapies for HIV were widely available in Western countries but scarce in the developing world — in places like Botswana, one-third of the adult population was infected. Millions of people were dying from AIDS. In response, George W. Bush created the President’s Emergency Plan for AIDS Relief — PEPFAR, for short. Over time, it would blossom into the largest global health initiative ever dedicated to a single disease.
Scaling the once unscalable AIDS epidemic is the narrow and noble mission around which most of the public consciousness of PEPFAR has been wrapped. Yet PEPFAR is about more than that. The program — which has operated largely within Africa, saving over 25 million lives and sustaining the antiretroviral treatments for more than 20 million others — is as much about steering the world away from the grips of AIDS as it is about elevating the health of women.
Now, on the eve of its renewal, PEPFAR has been ensnared in the inescapable gravity of abortion politics. Congress may not renew PEPFAR for its typical five-year term. The problem with PEPFAR is not one of cost — it is one of ideology.
The humanitarian project’s purported support of nongovernmental organizations that prop up the practice of abortion is what has drawn the ire of its conservative opponents. Lawmakers, even those who once endorsed the program, are flexing a baseless traditionalist mettle. Christopher Smith, a Republican from New Jersey, authored the PEPFAR Extension Act in 2018 and drafted a key amendment to the original act in 2003. Yet in June, he penned a letter citing language around integrating and promoting women’s sexual reproductive health rights laced with a sort of doublespeak for condoning an abortion movement abroad. “President Biden has hijacked PEPFAR … to promote abortion on demand,” it opens.
At first blush, it may be perceived as another maligned symptom of the current moment that aims to thwart abortion rights. But PEPFAR’s mandate is rigorously monitored and has never included the funding of abortions. The U.S., in fact, has not allowed foreign aid to be allocated toward abortion care for half a century.
In the wake of the Roe vs. Wade decision, in 1973, Congress retributively passed the Helms Amendment to the Foreign Assistance Act, prohibiting appropriating an American dollar to an abortion under any circumstance. The Siljander Amendment, eight years later, disallowed U.S. funding being funneled to any form of lobbying related to an abortion.
What anti-abortion activists are now angling for, however, is the restitution of a more repressive (and regressive) promise. The Mexico City Policy is a decree that blocks American-backed NGOs from using funds from any source to advocate to liberalize, counsel around, or provide abortion services altogether — even in countries where it is legal to do so. Only under President Trump was it imposed on PEPFAR and its partners; the Biden administration rescinded it.
Scholars have scrutinized the Mexico City Policy closely. When it was in effect during the Trump years, a pivotal study found that abortion rates rose. (A similar repercussion was observed in countries where NGOs were subject to the policy by earlier Republican governments.) How laws that aim to curtail abortions in turn foster them is complex. But it is an outcome that stems, in part, from NGOs that organize family planning and reproductive health services being denied a vital financial lifeline. Health clinics shutter. Programs cancel. A twisted irony takes root: To prevent unintended pregnancies, women substitute abortions for modern means of contraception. Unsafe abortions flourish; and become a prominent cause of maternal mortality where abortion laws are the most restrictive. In sub-Saharan Africa, research has found they account for almost half of maternal deaths.
PEPFAR has been a grand undertaking. Naturally, its bounty has spilled over. The long arms of its legislation have contributed to helping test and treat people with tuberculosis and to reducing malarial deaths. During the worst of the Covid-19 pandemic, PEPFAR-funded networks were harnessed to surveil, report, and contain outbreaks, and to improve the uptake of vaccines. Though some studies have questioned its reach, countries that receive aid from PEPFAR have a 20% lower mortality than would be expected without it. For women and children, that number is lower still.
This is because women are the greatest beneficiaries of PEPFAR. HIV disproportionately affects women. Various factors — from poverty and gender inequality, to lower levels of educational attainment and intimate partner violence — are implicated. Women and girls represent around 60% of new infections in sub-Saharan Africa; those ages 15 to 24 are three times more likely to be infected with HIV than their male counterparts. AIDS — along with complications related to pregnancy — remains a leading cause of death among women of reproductive age.
Part of the fallacy is staking HIV and abortion care as forces isolated from social and economic circumstance. To prevent HIV in women, PEPFAR has focused on fostering their autonomy by ensuring access to reproductive services while taking a deeper chisel at harmful societal norms by helping women become educated and employed. PEPFAR also folds its organizational structures into the national ones that already exist, as bolstering public health systems offers a shared benefit. Investments — into a health care workforce, laboratory services, and information systems — help etch an infrastructure that uplifts not just the well-being of women, but of communities as a whole.
Now that Congress has returned from its summer recess, key PEPFAR advocates are slated to begin a “lobbying blitz” for its renewal in the House. Every five years PEPFAR has sought a clean reauthorization. That bipartisan blessing, which it has received across 10 Congresses and four presidencies, would allow the program to operate in its current form and for its standard term until 2028.
If a renewal doesn’t happen before the Sept. 30 deadline, major functions of the program will not immediately cease. But certain time-bound provisions, like the care extended to millions of orphans and children affected by HIV, may expire. Revisiting the reauthorization of PEPFAR on an annual basis is what has been proposed by those who are in opposition. It will in all likelihood open PEPFAR to a veiled scheme of irrational GOP scrutiny, and further cuts in the years ahead.
If a hobbled PEPFAR is all what we are left with, it will change how we respond to global health threats today, and to come. It will dent a vision of ending the AIDS epidemic by 2030. And it will hamper the chance women get at living their fullest lives, unbound by the unsympathetic and obtuse politics from half a world away.
Arjun V.K. Sharma is a writer and clinical fellow in infectious diseases at Western University.