On Tuesday, something odd happened in Washington: A bill became a law. It passed by unanimous consent in the Senate and voice vote in the House (typically taken when a measure faces no significant opposition), and was signed by President Donald Trump.
This wasn’t a trivial, “let’s rename a post office” bill either. The bill reauthorized PEPFAR — the President’s Emergency Plan for AIDS Relief — through 2023. PEPFAR provides billions in annual funding and technical support for antiretroviral treatment, HIV-preventing male circumcisions, and other efforts to treat and prevent HIV.
PEPFAR is one of the best government programs in American history, probably the best since the Great Society. Studies examining its impact on the AIDS crisis abroad suggest that the programs saved the lives of at least a million people, and has done so cost-effectively.
Shockingly, PEPFAR is a major government program that is mostly uncontroversial. Religious conservatives and faith leaders love it; it was originally launched by President George W. Bush, and Chris Smith, perhaps the most passionately anti-abortion Republican member of the House, sponsored the reauthorization.
But progressives and in particular the Congressional Black Caucus have been among its strongest champions as well. Barbara Lee, the famously left-wing House member for Oakland and Berkeley who cast the only vote in Congress against the resolution authorizing Bush to use military force after the 9/11 attacks, also worked with the Bush administration to create PEPFAR, and cosponsored the reauthorization with Smith.
“Bipartisanship is not dead,” Jennifer Kates, the vice president and director for global health and HIV Policy at the Kaiser Family Foundation, told me. “This is one of those rare examples in Washington. There’s been an incredible history of bipartisanship around PEPFAR that stands outside the rancor we hear about.”
What PEPFAR does
PEPFAR is the federal government’s anti-HIV/AIDS foreign aid program, established by the Global AIDS Act of 2003 and renewed in 2008 and 2013. It is the single-largest global health initiative targeting a single disease in history. It currently provides support for antiretroviral treatment for 14.6 million people, both directly and through technical support to partner countries.
”PEPFAR has helped changed the equation on what was once — not too long ago — seen as an insurmountable plague,” the Center for Global Development’s Amanda Glassman and Jenny Ottenhoff write.
The results have been nothing short of extraordinary. A 2009 study by Stanford medical professors Eran Bendavid and Jayanta Bhattacharya, comparing HIV mortality in African countries receiving PEPFAR support between 2004 and 2007 and countries that did not, found that the program reduced the HIV death rate by 10.5 percent — preventing 1.2 million deaths, at a startlingly low price of only $2,450 per death averted.
If you extrapolate out that figure for subsequent years, that’s some 6 million lives saved so far. But given that the study only focused on 12 African countries rather than every PEPFAR partner, and that PEPFAR’s funding and reach have grown dramatically since, that’s likely an underestimate. The true number saved could be significantly higher.
The benefits are particularly big for children and parents. A later 2015 paper estimated that in its first decade, PEPFAR prevented 8.9 million children from becoming orphans and generated 11.6 million years of additional life.
Though some critics have argued that programs like PEPFAR that focus on one disease damage efforts to combat other public health problems, subsequent research by Bendavid, Bhattacharya, Charles Holmes, and Grant Miller found that PEPFAR reduced overall adult mortality in affected African countries by 16 to 20 percent.
That’s the direct evidence, but there are plenty of less direct reasons to think PEPFAR is saving millions of lives. We know antiretroviral treatments are effective at expanding lifespans, and particularly effective when used to prevent transmission by pregnant women to children (a focus of PEPFAR). PEPFAR also provides funding for male circumcision, which is a cost-effective way of reducing the risk of HIV transmission.
Evaluations of local antiretroviral treatment rollouts backed by PEPFAR (but not solely by PEPFAR) have been promising. There’s evidence that antiretrovirals increase workforce participation and employment, improving development prospects and improving well-being apart from any effects on mortality. A 2013 paper even found that PEPFAR was reducing tuberculosis infections and deaths in focus countries.
PEPFAR is not perfect. It has funded abstinence-only programs that have proven ineffective at reducing infection rates, though the 2008 reauthorization removed that requirement. Until the Supreme Court struck it down, PEPFAR had a requirement that partner organizations commit to opposing sex work. Insofar as the Bush administration tried to inject social conservatism into the program’s operations, it made PEPFAR less effective. But these are relative quibbles next to the millions of lives saved.
A 2013 Institute of Medicine evaluation sums it up well:
PEPFAR’s efforts have saved and improved the lives of millions of people by supporting HIV prevention, care, and treatment services; meeting the needs of children affected by the epidemic; building capacity; strengthening systems; engaging with partner country governments and other stakeholders; increasing knowledge about the epidemic in partner countries; and ensuring that attention be paid to vulnerable populations in the response to HIV.
The reauthorization, and Trump’s record on PEPFAR
When PEPFAR was launched in 2003 and reauthorized in 2008, the authorization legislation included dollar amounts. Starting the 2013 reauthorization, which extended the program to the end of 2018, the actual dollar amounts go through the appropriations process.
What that means is that PEPFAR reauthorization itself doesn’t affect budgeting. And because of that, PEPFAR’s bilateral support to other countries’ HIV/AIDS programs would have continued if the reauthorization had not passed. (That said, according to Kates, failure to reauthorize would have endangered the US’s contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria, a huge nonprofit funded by various governments and foundations to which the US government contributes $1.35 billion a year.).
The dollar amount spent on the bilateral contributions in PEPFAR has been roughly stagnant in nominal terms, and thus decreasing after accounting for inflation. Most concerning of all, the Trump administration has proposed very large cuts to the program (as seen in the below chart):
Due to bipartisan opposition and pressure from groups working on HIV/AIDS, the administration failed to achieve cuts in 2018 and appears unlikely to do so in 2019 either.
The administration has, however, weakened the program through its Mexico City Policy. That’s the executive order, typically made by every incoming Republican administration, that requires NGOs the US works with abroad to certify that they do not perform or promote abortions. Historically, under Presidents Reagan, Bush I, and Bush II, the policy applied to funds from the US Agency for International Development (USAID), but Bush II was very clear in starting PEPFAR that the rule would not apply to the program.
Trump expanded the policy to include PEPFAR as well. The effects of this will probably be negative — the Mexico City Policy in general appears to increase the number of abortions by reducing access to contraceptives — but just how negative, and what the effect will be on the number of lives PEPFAR can save, is less clear.
More generally, Kates says, there remains a big gap in funding for HIV/AIDS efforts. Reauthorization was a great, bipartisan effort. But more funding would be useful too. When PEPFAR started, she explains, “hardly anyone was on antiretroviral treatment. Thanks primarily to PEPFAR and the Global Fund, about half of people with HIV are on treatment, around the world.”
But half of people with HIV is, obviously, not everyone with HIV. “The data says there’s still a huge funding gap for HIV just as there’s a huge funding gap for malaria and child and maternal health and other areas,” Kates says. “The question is: How do you maintain momentum around HIV?”
Reauthorization is a step in maintaining that momentum. But more funding (or at the very least a commitment by the Trump administration to stop trying to cut funding) would go a long way.