PEPFAR Reauthorization is Urgent, and We Need All Hands on Deck

Headshot of Maureen Milanga

Guest Blog by Maureen Milanga, Director of International Policy & Advocacy, Health GAP

FCAA invited Health GAP to share the following blog to remind FCAA members and broader philanthropy of what’s at stake with PEPFAR reauthorization and the important role that funding for advocacy and community leadership will continue to play.

For the first time in its 20-year history, American politics have gotten in the way of a so-called ‘clean’ legislative reauthorization that simply extends the authority of the President’s Emergency Plan for AIDS Relief (PEPFAR) to continue its powerful work responding to the HIV pandemic for another five years. 

PEPFAR marked two key moments in 2023. First, the program celebrated its 20th anniversary, with elected officials from across the American political spectrum praising it for saving 25 million lives and championing reauthorization. And then, just a few months later, Congress let PEPFAR’s legislative authorization lapse, raising significant questions about the future of the program.

How did we get here?

Extremist American politicians and think tanks, led by Rep. Chris Smith and the Heritage Foundation, dragged PEPFAR into a political battle over abortion, saying the Biden administration was indirectly funding abortions via PEPFAR – despite the fact that PEPFAR, like all U.S. foreign aid programs, is explicitly banned from funding abortion care. In May 2023, the Heritage Foundation released a report claiming, without evidence, that PEPFAR was “promoting” abortion. This strategy was triggered by the Supreme Court’s decision to end the Constitutional right to abortion in the U.S. And communities did not take this lying down–the attack on PEPFAR was met with widespread condemnation by people living with HIV, religious leaders, along with conservative former politicians ranging from President George W. Bush to Senator Rick Santorum.  

In the face of these unsubstantiated attacks, administration officials, including the head of PEPFAR, Ambassador John Nkengasong, also reaffirmed PEPFAR’s strict compliance with U.S. laws, but extremists would not relent. Attacks against the flagship global AIDS program continued, Congress failed to act to reauthorize it, and months later, heading into a high-stakes federal budget cycle, the fate of PEPFAR’s reauthorization is still uncertain. Groups like Susan B. Anthony Pro-Life America have struck fear into Republican lawmakers who are on the record supporting PEPFAR because they are threatening to give a bad report card rating to Republican legislators who support clean reauthorization.  

Why does reauthorization matter?

Letting PEPFAR’s legislative authorization lapse weakens global trust in the U.S. government’s long-term commitment to the global AIDS response–and communities I work with every day on the front lines of the HIV response in PEPFAR-supported countries are taking notice. Despite President Biden’s pledge that his administration would end AIDS as a public health threat by 2030, he has allowed the most effective response to a single disease to be greatly diminished on his watch. This sends a message to the rest of the world that the U.S. is not as invested in ending AIDS as it was in the past, and that a program with overwhelming public support and 20 years of lifesaving results can be imperiled relatively easily. This is not what strong global leadership on AIDS looks like.  

For communities of people living with HIV, young people, and key populations, the stakes are high. PEPFAR is the difference between life and death.

Funding cuts would be dire

Especially in this moment, PEPFAR cannot sustain budget cuts. Now that 75% of people living with HIV are accessing treatment, it will take new strategies and investments to reach the remaining 25% who are not, and to ensure those people on treatment are retained and have suppressed viral loads. We must not waver in that commitment. After more than 10 years of flat funding, President Biden’s budget request for FY25 in March must be ambitious and make an investment that matches the President’s stated commitment to ending AIDS as a public health threat by 2030. The community has demanded a minimum of $5.14B for Fiscal Year 2025–which includes core funding as well as money contributed by the U.S. to the Global Fund replenishment that has been unmatched by pledges from other donor countries. 

Looking beyond reauthorization

PEPFAR’s lapsed authorization isn’t the only concerning development activists are fighting back against in 2024, and funders have an important role to play in supporting the activist response that keeps PEPFAR strong and delivers the results that set the program apart. Most aid programs don’t measure their effectiveness – but PEPFAR does, and that’s because communities demanded that accountability and transparency should become central to PEPFAR’s planning processes. Activists working through PEPFAR Watch and other global collaborative spaces pore over PEPFAR program data and evidence gathered via community-led monitoring to identify which interventions are or aren’t working, and then use the data to develop recommendations about how PEPFAR can better serve most affected communities.

Activists drive PEPFAR to deliver greater results by demanding implementing partners show their results and come to the table ready to tackle the questions that don’t have easy answers–something almost unheard of in bilateral health programs. These challenges require humility and continuous loops of learning that only happen when all stakeholders from the top down take this approach. Communities must not be sidelined in this process – they have the expertise needed to drive greater impact. This kind of ongoing collaboration that is ready to rapidly evaluate and iterate as needed, that is not complacent, and does not take results for granted is even more vital as we enter the last five years of the shared commitment to end AIDS by 2030. PEPFAR must continue to respect the leadership and expertise of communities, listen to us, and work with us in a meaningful way to shape country programs. We must not go back to the early days of PEPFAR when programs were shaped and decisions made behind closed doors in Washington, D.C.—but right now, PEPFAR’s new approach to country planning is raising alarms as a move that would do precisely that. 

The Way Forward

After two decades of nearly unified congressional support, it now feels like U.S. policymakers take PEPFAR and its lifesaving results for granted. But the program cannot continue to deliver the kind of results we’ve come to expect without the legislative authority it’s had since the beginning. We are in unprecedented, dangerous territory. Time is running out to secure reauthorization in 2024–but there is still a path to victory.

Activists led by the most impacted communities are working to shape a PEPFAR that meaningfully engages civil society as equal partners in the struggle to defeat HIV as a public health threat by 2030. We’re committed to the fight for a clean, five-year reauthorization for PEPFAR and a PEPFAR that is fully funded to serve those in need. It’s not too late.

Editors’s note: In April FCAA will be hosting a webinar in partnership with the Nebula Fund to examine the potential impact that Project 2025 – the Heritage Foundation’s plan to shape policies in the case of a new Republican Adminsitration in 2025 – may have on the global HIV response. Stay tuned for more details on how to stay informed and involved on this conversation.