GOP faces pressure to reauthorize key HIV initiative held up by anti-abortion Republican 

Pressure is mounting on the GOP-majority House to pass a reauthorization of the U.S.’s long-term global HIV initiative, but the lawmaker holding up the legislation is showing no signs of moving.  

Former President George W. Bush, who launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, called on Congress to pass a five-year reauthorization in an op-ed published by The Washington Post this week, saying it would become a source of national shame if the program’s authorization was allowed to expire. 

“The reauthorization is stalled because of questions about whether PEPFAR’s implementation under the current administration is sufficiently pro-life. But there is no program more pro-life than one which has saved more than 25 million lives,” the former president wrote.  

“I urge Congress to reauthorize PEPFAR for another five years without delay,” he concluded, calling on his fellow Republicans to back one of his proudest initiatives. 

Activist groups are also raising the temperature.  

Housing Works, an HIV/AIDS advocacy organization, occupied Speaker Kevin McCarthy’s (R-Calif.) office this week, calling on him to move PEPFAR as well as domestic funding for HIV and AIDS programs. 

The obstacle to moving PEPFAR, which supports developing countries in their efforts to combat the HIV epidemic, is Rep. Chris Smith (R-N.J.), who penned the House’s last reauthorization of the program in 2018.  

Smith, who is serving his 22nd term in the House, has vowed not to advance a new reauthorization ahead of the Sept. 30 deadline, arguing that the Biden administration’s guidance on the program has led to funds going toward abortion rights movements in foreign countries. 

“Bush should be on the phone with Biden and say, ‘Why did you hijack my program?’” Smith said when asked about the former president’s op-ed. 

Advocates and lawmakers have warned that the consequences of not reauthorizing PEPFAR would be disastrous for U.S. diplomacy abroad and the health infrastructure that the program supports.  

“This commitment of funding for a five-year term is … what allows the international recipients of this aid — whether it’s countries or medical facilities — to plan for the long term,” Housing Works CEO Charles King told The Hill. “Not having that firm commitment makes that kind of planning very difficult. One of the things that we see around the world is the difficulty that low-income countries have retaining healthcare workers.” 

They also argue that Smith is wrong to say the PEPFAR program funds abortions. 

Smith told reporters this week he’s unconvinced and unmoved by the calls to allow the reauthorization to go forward. 

“If we were to support a three-year, five-year [reauthorization], we will then rubber stamp and endorse all of the radical changes that have been made by President Biden,” Smith said. “The surface of the argument that it’s a clean reauthorization — no it’s not.” 

Pushing back 

The New Jersey congressman pushed back on criticisms that his tactics will hurt PEPFAR, noting that federal agencies such as the State Department have at times operated for decades without reauthorization.  

He said he’d back an appropriations bill that added more funds to PEPFAR if it also includes “pro-life guardrails” and the Mexico City Policy — a U.S. government rule that bars federal funds from going to nongovernmental organizations (NGOs) that provide abortion services.  

President Biden rescinded the Mexico City Policy in 2021, shortly after assuming office. 

In a “Dear Colleague” letter sent in June, Smith cited PEPFAR action plans and guidance released by the Biden administration as indications of the program’s shift toward supporting abortion access. 

The PEPFAR 2023 Country and Regional Operational Plan released by the State Department said the program should work with government partners to incorporate “reforms in law and policy regarding sexual, reproductive, and economic rights of women.”  

While abortion is not mentioned in the document, Smith took this as a directive for PEPFAR to support NGOs that advocate for abortion access. 

However, the September 2022 document titled “Reimagining PEPFAR’s Strategic Direction,” also cited by Smith, explicitly notes “PEPFAR does not fund abortions, consistent with longstanding legal restrictions on the use of foreign assistance funding related to abortion.” 

Emily Bass, senior policy adviser of pandemic and outbreak activism at PrEP4All and author of a book on PEPFAR’s work in Africa, told The Hill that Smith’s claims are “absolutely baseless.” 

“They are actually legally impossible based on other legislation,” Bass said, noting the Helms Amendment in the Foreign Assistance Act of 1973 blocks foreign aid from funding abortions. 

Smith told reporters the Helms Amendment was “insufficient” and that groups would work around that requirement. 

25 million lives saved 

Begun in 2003 during the Bush administration, PEPFAR estimates it has saved 25 million lives through the prevention of HIV infections and supporting the use of viral treatments, even as the budget for the program has largely stagnated since 2009. 

In its 20-year existence, PEPFAR has been reauthorized three times before, each time with broad bipartisan support. 

PEPFAR would continue to operate without reauthorization, as KFF notes that the program works under largely permanent authorities like those of the Office of the Global AIDS Coordinator at the State Department. Reauthorization also isn’t required in order for funds to be appropriated for it. 

But some PEPFAR provisions would expire without a reauthorization, including requirements of how funds are distributed and how U.S. contributions to The Global Fund to Fight AIDS, Tuberculosis and Malaria are carried out. These lapses in requirements would disrupt global efforts in the fight against HIV, advocates say. 

“The reason to have a program like this, that’s authorized and then funded consistently over time, is you can build out those programs, maintain those programs and make sure that the services are getting to people on a consistent basis. And when you start to disrupt that, you start to disrupt the ability of folks to get the services,” said David Stacy, vice president of government affairs at the Human Rights Campaign. 

Stacy said there is still a sense of optimism in the Capitol that a clean five-year reauthorization can be passed, noting the widespread support PEPFAR continues to garner across political and ideological spectrums. 

“It seems dangerous. I don’t understand Chris Smith’s motives because really, the underlying circumstances are exactly the same. And to play games with this just seems unwise at best and really, really reprehensible,” Stacy said.