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International funding and coordination to tackle HIV/AIDS and support health systems in lower- and middle-income countries, is at risk of not being renewed by US Congress, due to demands that it should be linked to new abortion-related restrictions in recipient countries. 

This program is estimated to have saved over 20 million lives since it was launched by the Bush Administration in 2003, and even now averts over a million HIV/AIDS deaths annually. 

Since it has also helped support health systems in LMICs, and tackle malaria and tuberculosis, its impact is likely greater than this.

In my view this is the most important risk to global health we face today, and I think it isn't getting enough attention.

If anyone is interested in research, writing or advocacy on this issue, please do so. If you are interested in jointly working on this, or if you already know of ongoing efforts, please comment below or get in touch. My email: saloni@ourworldindata.org

Relevant background reading:

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest commitment in history by any single country to address a disease, is estimated to have averted 25 million deaths from AIDS and enabled 5.5 million babies to be born free from HIV infection over the past 20 years.1 

It has provided more than $100 billion in funding for HIV prevention, care, and treatment internationally, supporting 55 low- and middle-income countries that are collectively home to 78% of all people living with HIV.

Together with the Global Fund to Fight AIDS, Tuberculosis, and Malaria, PEPFAR has transformed AIDS in low-income countries, especially those in Africa, from a death sentence to a readily treatable chronic disease by deploying programs that provide antiretroviral treatment even in the most remote villages. 

Right from the start, PEPFAR was more than just an AIDS program; it partnered with countries in Africa to support the development of health systems for essential community services, trained thousands of health care workers, fostered security and stability in affected countries, and engendered hope amid a devastating global AIDS crisis.
Karim et al. (2023)

Why is it at risk?

Republican colleagues [...] accuse the Biden administration of using PEPFAR to fund abortion providers overseas and House Democrats who refuse to reinstate Trump administration rules that prohibited foreign aid going to groups that provide or counsel on abortions. Discussions about a compromise that would extend the program for more than one year but less than five, with language stressing the existing ban on federal money directly paying for abortions, have collapsed.

Now, the best hope for re-upping the $7 billion annual program is a government spending process beset by delays and divisions and slated to drag into January and February with no guarantee of success. PEPFAR can hobble along without reauthorization unless there’s a prolonged government shutdown. But its backers say that without a long-term U.S. commitment, groups fighting HIV and AIDS around the world will struggle to hire staff and launch long-term projects.

Complicating any hope for compromise is the 2024 election.

Congress passed two short-term funding patches that expire in January and February. That eliminated the possibility of the typical end-of-year omnibus bill that many on both sides of the PEPFAR fight saw as the best vehicle for its reauthorization and kicked the fight into an election year when compromise — particularly on a contentious issue like abortion — will be more challenging.
Politico [7 Dec. 2023]


The lawmakers stalling the reauthorization are seeking to impose on PEPFAR a prohibition on the disbursement of federal funding to foreign agencies and nongovernmental organizations that provide, promote, or make referrals to abortion services or give information about abortions, even if they use funding from sources other than the U.S. government to do so.

This prohibition was first introduced by President Ronald Reagan in 1984 and became known as the “global gag rule.”3 

Its proponents are now aiming to codify the global gag rule into U.S. law. Doing so would expand the abortion-related prohibitions contained in the Foreign Assistance Act, amended in 1973, which prohibits foreign-assistance funds from being used for the performance of abortion as a method of family planning or to motivate or coerce any person to perform abortions.
Karim et al. (2023)

A few relevant statistics:

  • The US is the largest contributor to HIV/AIDS efforts in LMICs – it contributes around 73% of total government donor funding. (See also.)
  • Still more than 35 million people currently live with HIV/AIDS worldwide, including 1.7 million children, and around 600,000 die annually from the disease.
  • HIV/AIDS is near-uniformly fatal without treatment. With early antiretroviral therapy, support and healthcare, patients in North America and Europe now have near-normal life expectancy.
  • Around 1.5 million deaths are now averted each year due to antiretroviral therapy.
Sorted by Click to highlight new comments since:

I'm not the first person to post this, but, if you're an American, calling your senator or representative is probably a good idea. Here's roughly how calls have gone when I do them:

  • Find the DC office number of your two senators and one representative and dial it 
  • If it's during weekday hours, a staffer will probably answer the phone. If it's on the evening, holidays, or weekends, you'll probably be talking to an answering machine
  • A staffer or an answering machine message will ask you to say who you are and what you're calling for
  • I usually give my first name, zip code, and say that I'm calling to express my opinion on an issue or a piece of legislation. If you're talking to an answering machine, you usually have to press a button about what you're calling for (constituent services, expressing opinions, and some other stuff)
  • Then they'll ask you to say your comment
  • I begin by briefly saying what PEPFAR is (a bill that funds efforts to fight AIDS around the world) 
  • I mention that it needs reauthorization to continue being funded
  • I then give my main reason for supporting it (it's a very effective way that the US saves lives cheaply around the world)
  • I might also give some side reasons, especially if there's a person saying things like mm-hmm on the other end of the line (it's boosted America's reputation abroad, the program isn't actually related to abortion, yada yada yada)
  • I say what I have to say in under a minute
  • I don't have a personal or professional connection to the issue, but, if I did (i.e. doctor, nurse, AIDS patient, immigrant from a country with PEPFAR funds), I'd probably try to mention it
  • Some advice online says it's good to make it more of a conversation and less of a speech, but that's never worked well for me
  • You can adjust it a little for Democrats vs. Republicans as long as you're saying true statements; usually I emphasize the boosting America's reputation abroad with Republicans and maybe throw in a George W. Bush mention. But I'd definitely caution against saying things you don't believe in to signal membership with one party or another
  • If there's somebody on the line, they'll say thanks and let you know that they'll pass along your concern. 
  • Occasionally they'll ask a follow-up question (the only one I got about PEPFAR was whether this was a matter needing an individual response, but I've received actual questions about details when calling about other issues before).
  • Then I tell them thanks for listening and hang up. 
  • This takes at most 2 minutes per call in my experience. I try to call my senators and reps about something (lately it's usually PEPFAR) most weeks; I wouldn't recommend going over once a week.

    All this comes from a mix of reading some online articles, my own experience, talking with people who have been calling about other causes, and a bit of speculation.

    Conclusion: Calling senators and representatives is easy and a good way to support PEPFAR reauthorization

Edit: found an earlier comment at https://forum.effectivealtruism.org/posts/ebGwTM2FAQcp8aMNH/francis-s-quick-takes#7cQuwprYi9AiAjjK4 that talks more about effectiveness.

Thank you, that's really helpful – will share it with friends since I'm not American. I wonder if this is something we could coordinate on as a community, with people from different states, if that could be more impactful?

It would be helpful to know who the key members of Congress to persuade are. The value of contacting your rep/senators likely varies a lot depending on where you live. 

Thanks for this update, its almost unthinkable that there's any chance of this program being cut, or even drastically trimmed down. Here in Uganda I don't like to think what could happen

In most countries PEPFAR operates, abortion is illegal so I would have thought that it might be a reasonable trade-off to give that up to continue the program?

Or is that just a smokescreen and it's mainly just a partisan issue now without much substance to argumebts?

I'm also unsure about how much substance there is to it, but what I've read so far agrees with your impression. From this Foreign Policy article last month:

In a statement, Rep. Chris Smith, chair of the House global health subcommittee, cited a letter signed by 131 African religious leaders and lawmakers in countries with some of the harshest laws around abortion including Nigeria and Uganda. Quoting the letter, he urged that PEPFAR “not cross over into promoting divisive ideas and practices that are not consistent with those of Africa.”

Yet there is no consensus coming from Africa on restricting PEPFAR. In September, more than 350 African church leaders asked for PEPFAR to be reauthorized. They wrote that the assertions that PEPFAR was being used in Africa to fund or promote abortion were “unfounded and grossly unfortunate” and that they were “not aware of any such instance.”

African civil society groups argue that, given the restrictive abortion laws in many African nations, the chances of PEPFAR money being used to fund or promote abortion in those states are slim to none.

Around 35 percent of PEPFAR funding in Uganda goes to civil society organizations—many of which are faith-based or affiliated with U.S. evangelical institutions. The region has one of the highest rates of unsanctioned backstreet abortions in the world due to its prohibitive laws. Lobbying by U.S.-based evangelical groups in the country has also led to restrictions on condom access, a higher burden of unwanted pregnancies, and, according to a 2021 report by the British Medical Journal, a lack of preparedness by health facilities to treat abortion complications, leading to increased maternal deaths.

FWIW, the WH after some delay put out a policy position on the Ugandan legislation, with specific language around PEPFAR.

Update – I've written an article for Vox to give more context and numbers on the issue:

Great work!

Is there a specific bill or amendment (or set of them) we should be asking ppl to support or oppose? Gonna see my Congressperson this weekend so good time to ask, but from a quick search it's not obvious what specifically I should be asking for. I'd like to be as detailed as possible. 


Second, what exactly needs to be reauthorized? The program itself, or an appropriation of funds? Or both? And if needs an appropriation, how much? Fun fact about the US system: Congress can effectively kill programs that are still technically on the  books, by just not giving them $, so you gotta be very clear in what you're demanding. 

There is no specific bill yet. There would have had to be a specific bill for a clean 5-year reauthorization before the expiration in October, but there wasn't. PEPFAR does still have a ton of supporters on both sides, and Republicans are calling for a one-year reauthorization, so it seems likely that it will be reauthorized for a year - that would take the form of being added to Congressional appropriations that happen each year. It's not clear yet how set-in-stone that is, and it would be good to ask your rep about the likelihood of a 1-year reauthorization.

The immediate problem is that, exactly as you described, previously-authorized funds of $1 billion have not been released, which is a huge strain on PEPFAR operations. Getting those funds authorized is the most important concern right now.

Anyone have a written down email they sent to their Congresspeople? I would love to share it with my friends. If not, I’ll try to make one by today. Thank you for this information, it was very informative and needs all our advocacy.

Edit: This is what I plan on saying when I call tomorrow. Feel free to copy and say the same thing to your constituent:

Greetings ______,

I am ______, a concerned constituent of yours from zip code _____. I am calling in regard to your Republican colleagues blocking the renewal of PEPFAR, the United States President’s Emergency Plan for AIDS Relief. PEPFAR is the largest commitment in history by any single country to address a disease, and is estimated to have averted 25 million deaths from AIDS and enabled 5.5 million babies to be born free from HIV infection over the past 20 years. It even now averts over a million HIV/AIDS deaths annually. It has provided funding for HIV prevention, care, and treatment internationally, supporting 55 low- and middle-income countries that are collectively home to 78% of all people living with HIV. Together with the Global Fund to Fight AIDS, Tuberculosis, and Malaria, PEPFAR has transformed AIDS in low-income countries, especially those in Africa, from a death sentence to a readily treatable chronic disease by deploying programs that provide antiretroviral treatment even in the most remote villages.

Will Congressman (or Congresswomen) _______ please fight to renew this life saving program?

The Center for New Liberalism's New Liberal Podcast (fka Neoliberal Podcast) covered the PEPFAR crisis in a November 10 episode.

Executive summary: The PEPFAR program, which has saved over 20 million lives by tackling HIV/AIDS, risks not being renewed due to new abortion-related restrictions being proposed.

Key points:

  1. PEPFAR is estimated to have averted over 25 million AIDS deaths since 2003 by funding HIV prevention and treatment.
  2. It now faces uncertainty as its reauthorization is stalled over Republican demands to ban funding for abortion providers.
  3. A long-term renewal is unsure amid political divisions, threatening HIV treatment and healthcare globally.
  4. Over 35 million people live with HIV/AIDS, with 600,000 deaths annually, showing the continued need for funding.
  5. The US contributes 73% of total government HIV/AIDS funding for lower-middle income countries.
  6. Without renewed coordination and funding, progress against HIV/AIDS globally is at risk.



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