No deal in sight for global AIDS program as deadline looms

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GOP House members and conservative advocates allege that some of PEPFAR’s nearly $7 billion annual budget flows to abortion providers — a charge the Biden administration, the program’s leaders and outside experts vehemently deny.

Rep. Chris Smith (R-N.J.), who leads the House’s global health subcommittee that controls PEPFAR, is leading the charge against renewing the program until anti-abortion restrictions the Biden administration lifted in 2021 are reinstated. Those restrictions would block groups that receive PEPFAR funds from using other sources of money to provide abortions or even discuss them as an option.

Smith told POLITICO that he partnered with Sen. Cindy Hyde-Smith (R-Miss.) and other Capitol Hill conservatives to lobby fellow Republicans in both chambers over the August recess, and said two arguments they made resonated with members. The first is that PEPFAR would have funding to operate even if the law governing the program lapses, and the second is that the Biden administration has “hijacked” the program to support abortion access overseas.

“That’s the gee-whiz moment that’s happening when I have conversations with people who do believe in the sanctity of life,” Smith said. “I’m encouraged that within two or three minutes of a conversation people would say, ‘That’s not what we signed up for. We signed up to go after HIV and AIDS aggressively and effectively, not to have a diversion of priority to abortion on demand.’”

The fight over the landmark program combating AIDS and HIV, the virus that causes it, in the developing world comes amid a broader GOP effort to draw more federal programs into the abortion wars. House Republicans have, for instance, tucked anti-abortion language into nearly every corner of the appropriations process, setting up a showdown with the Senate and White House that could lead to a government shutdown. And in the Senate, Tommy Tuberville (R-Ala.) has for months blocked senior military promotions over the Pentagon’s new policy of reimbursing service members who travel to another state to obtain abortions and other reproductive services.

A spokesperson for Sen. Jim Risch (R-Idaho), the top Republican on the Foreign Relations Committee, which oversees the program, confirmed to POLITICO that “ongoing confusion” among lawmakers about PEPFAR’s intersection with abortion makes it “unlikely” Congress will renew it before Sept. 30. The spokesperson pointed to several provisions that could expire as a result, such as a requirement that at least 10 percent of the program’s funds go to children orphaned by AIDS.

Groups who receive PEPFAR funds for projects across Africa, Asia and the Caribbean warn that Congress’ failure to act would put the program at the mercy of Capitol Hill’s precarious spending fights, send the message that the U.S. is not committed to the fight against HIV and AIDS anymore, diminish American influence in regions where it’s competing with China and Russia and bring “human consequences” on the ground. According to a report from UNAIDS, there are roughly 39 million people living with HIV worldwide, including 1.3 million newly infected last year.

“Taking the foot off the gas at this point is so incredibly ill-advised,” said Asia Russell, the executive director of the Health Global Access Project. “The Biden administration got elected asserting that it would be the administration to put the global HIV response back on track to defeat HIV as a public health threat by 2030. And this would completely derail and break that political commitment.”

Adrienne Watson, spokesperson for the National Security Council, said in an email that the administration will continue to work with both parties to “sustain the bipartisan legacy” and pass a five-year PEPFAR reauthorization before the current authorization expires at the end of September.

Some program supporters, including Senate Foreign Relations Chair Bob Menendez (D-N.J.), told POLITICO they are hoping to do so with a standalone vote on the program.

“Based on my conversations with some Republicans on the committee, they would be in support of moving PEPFAR forward,” he said in late July. “And I think if it was put up for a vote, it would have broad bipartisan support.”

But several Hill staffers and outside groups said that they anticipate this effort to fail and said the program’s best hope is to hitch a ride on an expected omnibus spending bill in December, which would give Republicans the cover of voting for it in a bigger package rather than on its own. Whether an omnibus will come together, however, remains in doubt given the impasse over abortion provisions.

With only a handful of legislative days before the Sept. 30 deadline, a lobbying frenzy has sprung up, with groups like Susan B. Anthony Pro-Life America diving into the fight for the first time and threatening to score a vote on any PEPFAR bill that doesn’t include anti-abortion restrictions.

“PEPFAR should be solely focused on saving lives, not taking them,” said the group’s vice president of public policy, Autumn Christensen. “A ‘clean’ five-year authorization would give a stamp of approval to the administration’s partisan and divisive effort to incorporate abortion into the PEPFAR program.”

The National Right to Life Committee and Family Research Council are also lobbying against a five-year renewal, while Planned Parenthood, the Human Rights Campaign, ONE Campaign, CARE Action and UNICEF USA are trying to push it through. UNICEF hired the top lobbying firm Akin Gump Strauss Hauer & Feld, which has former Rep. Ileana Ros-Lehtinen (R-Fla.), an original PEPFAR architect, and Ed Pagano, who was President Barack Obama’s liaison to the Senate and a longtime aide to then-Sen. Patrick Leahy (D-Vt.), on the contract.

Former Sen. Bill Frist (R-Tenn.), who shepherded the program when he was majority leader in 2003 and now works for the Bipartisan Policy Center, has been working the phones to change skeptical lawmakers’ minds, hosting briefings on Capitol Hill and writing op-eds, arguing that PEPFAR has national security as well as humanitarian value.

“Allowing a significant lapse in the program would erode our international standing at a time when we are in a geopolitical competition with China and Russia,” he said. “Throughout our country’s history, no initiative has had a more profound impact or saved more lives around the world than PEPFAR.”

Though Frist said he’s confident “cooler heads will prevail as the deadline approaches,” he is spending time combating a hardening opposition within his own party.

“In response to assertions that PEPFAR supports abortion, I’ve seen no evidence to support that claim,” he said. “On the contrary, the program gives the children of HIV-positive mothers an opportunity for a life full of promise.”

There is little indication these arguments are making headway.

In the House, with the support of anti-abortion groups, Smith is leading the effort against a five-year reauthorization and in favor of a one-year funding patch to keep PEPFAR afloat until, he hopes, a future GOP president can reimpose anti-abortion restrictions.

In an interview, Smith waved away concerns that the program is in peril as a “false narrative” — pointing to several other major government programs that have continued on autopilot years after their authorizations expired. PEPFAR also briefly lapsed in 2013 and 2018, but laws to extend it ultimately passed during those calendar years.

“Some of these activists are telling members of Congress that it all ends on September 30th, but it’s just not true,” he said. “What planet are they on?”

A House appropriations committee approved the one-year funding patch for PEPFAR that Smith supports before Congress left for August recess, but it has yet to receive a floor vote or even be introduced in the Senate.

Groups that run PEPFAR services warn that a lapse — even with stopgap funding — would hamper their work, particularly the uncertainty of kicking the next renewal fight into the heat of the 2024 election.

“It’s not unlike the debt ceiling, when we’re constantly holding people hostage,” said Dr. Joia Mukherjee, the chief medical officer for the international relief group Partners in Health who has run programs in Haiti, Rwanda, Lesotho, Malawi, Sierra Leone, Liberia, Peru, Mexico, Russia, Kazakhstan and the Navajo Nation. “The successful treatment of HIV/AIDS depends on people staying on medicines for life. And so the idea that this would be put back into this political sphere over and over again is just maddening.”

Failing to renew PEPFAR would also bar Congress from increasing its budget, and could terminate several legal provisions in the program — including a rule that directs at least half of PEPFAR funds toward patient treatment and care. Presidential administrations could continue abiding by those rules or drop them.

The fight also comes amid a broader spending standoff and mounting fears of a government shutdown, which senior House Democratic staffers noted would harm PEPFAR if it lasted more than a couple days.

“No new grants or contracts would be able to be signed,” said one aide granted anonymity to discuss the delicate PEPFAR negotiations. “And a shutdown of longer duration could definitely have an impact on the ability to procure commodities and continue health services.”

Advocates also say a lapse in authorization, even a temporary one, would come at a particularly bad time in the global war on the disease. UNAIDS reported last year that Covid-19 caused widespread disruptions in health services, which reversed progress against HIV and AIDS in some regions, including eastern and southern Africa, and fueled a rise in new infections.

“AIDS is still an emergency,” said Russell. “There is more than one preventable AIDS death every minute around the world even though we have biomedical and structural interventions that could make this a thing of the past.”

Megan R. Wilson contributed to this report.

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