The President’s Emergency Plan for Aids Relief (Pepfar) is widely viewed as the most successful US development programme.

Its supporters claim that it has invested more than $100-billion in fighting Aids in the past 20 years, saving 25 million lives and preventing 5.5 million babies from being born with HIV.

The programme funds global healthcare to the tune of $7-billion a year. It was championed by President George W Bush and is a rarity in Washington in that it has always won bipartisan support in Congress. It expires at the end of September.

However, influential right-wing groups such as the Heritage Foundation, Susan B Anthony List and the Family Research Council have put pressure on the Republican majority in Congress to vote against reauthorisation unless abortion-related restrictions are included.

They have warned Republican members of Congress who vote for a “clean” reauthorisation without the abortion restrictions that they will get a “demerit” — which would count against them when they face re-election next year.

The New York Times described these moves as the “latest example of how Republicans are using their majority in the House of Representatives to impose their conservative views on social policy throughout the federal government”, focusing particularly on abortion.

The lobbying on this issue has grown ever more strident since the Supreme Court overturned Roe v Wade and women’s right to choose a year ago.

“The symbolism of such a move would be devastating, [Pepfar’s] backers say — a signal to other nations that the United States is abandoning its bipartisan commitment to end the [Aids] epidemic by 2030, and that Washington is truly broken,” the Times reported.

The Right to Care Aids clinic in Johannesburg. (Photo: Gallo Images / Foto24 / Cornel van Heerden)

Immense cost to SA healthcare

The cost to South African healthcare of any reduction in the programme would be immense: One source said that up to 15 % of the South African health budget is supplemented by Pepfar and the infectious disease management is overwhelmingly dependent on the programme.

Bulelani Kuwane, the CEO of Youth Health Africa, who spent years working in the Pepfar programme through the Aurum Institute, said the withdrawal of Pepfar would have a colossal impact and reverse the gains made in the fight against HIV/Aids in South Africa in the last 20 years.

He said Pepfar supported 27 of the 52 health districts in SA. These were the most highly burdened with HIV, carrying 80% of the cases. The programme provides antiretrovirals to about four million people.

“Pepfar is an important complement to the South African government’s health programme,” he said. “The programme also provides additional resources and staff to health clinics, taking the burden off an already stretched system suffering from shortages of staff.

“There are already long queues for treatment in clinics — they are just going to get longer. Withdrawal of Pepfar would cost thousands of jobs in South Africa, further increasing unemployment.”

Pepfar also funds community programmes, including safe male circumcision programmes and programmes with female sex workers.

Veteran Washington policy framer Tony Carroll, who has been involved in Pepfar since its inception and is deeply engaged with southern Africa, said the vast majority of Pepfar funds to the country go into infectious disease management. If reduced, they would put strain on the entire system. 

The effects might even be more devastating in lower-income countries such as Botswana, Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, where Pepfar has created networks of clinics that provide a number of services including Covid-19 testing and vaccines.

‘Clean reauthorisation’

Democrats and many conservative Republicans support a “clean reauthorisation” with no added restrictions, which is how it’s been done for this highly successful programme for the past 20 years.

The Biden administration has offered to include language that Pepfar does not fund abortions, but the right wingers are not buying it.

The anti-abortion groups insist that the programme’s funds are being used to indirectly support abortions.

Representative Christopher Smith of New Jersey, an evangelical Christian, is leading the charge to get the funding coupled with language that blocks any partnership with organisations that provide abortion services, which is a non-starter for the Democrats.

There is also pushback from religious conservatives aligned with a clean renewal for Pepfar who point out that not only is there no evidence that Pepfar has been used to directly or indirectly support abortions but there are already multiple laws that prevent US agencies from funding or promoting abortions.

They say the programme has always been guided by “conservative values” and that it should remain focused on “care for those who are sick and supporting orphans and children made vulnerable by Aids”.

The ultra-conservative former Pennsylvania senator Rick Santorum has also called for a clean extension, describing Pepfar as “a great thing for our country, and it’s been a great thing for humanity”.

Irish rock star and activist Bono described the impasse as “madness” and has been lobbying members of Congress to get the authorisation across the line.

Even if an agreement is reached now, however, time is running out to meet the deadline. The US House of Representatives is on recess until the middle of September and, given the dysfunction in Washington, there are a number of other combat-heavy items on the agenda, including the possibility of a US government shutdown.

Princeton historian Kevin Kruse remarked: “In my opinion, Pepfar was the single greatest accomplishment of George W Bush’s administration and, indeed, one of the greatest contributions the US has made on the world stage. The fact that Republicans are now trying to kill it is yet another sign of how far gone they are.”

One conservative Republican remarked that it was shocking that organisations calling themselves pro-life were prepared to use people’s lives as a political bargaining chip. DM 

Phillip van Niekerk is the editor of Africa Unscrambled, a newsletter covering the continent in a way you won’t read anywhere else. He is also the editorial director of Scrolla.Africa. Get Unscrambled by signing up here.