Summary:

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.