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Disappointing Version of PEPFAR Reauthorized

On July 17, the Senate voted overwhelmingly in favor of reauthorizing the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $48 billion global initiative to combat HIV/AIDS, tuberculosis, and malaria. Just one week later, on July 24, the House adopted the Senate language for the PEPFAR reauthorization bill and sent it to President Bush to be signed. Unfortunately, the reauthorization bill failed to address PEPFAR’s critical shortfalls.

Although PEPFAR provides much needed funding throughout the world, the legislation that originally authorized the bill imposed a number of ideological constraints that advocates had hoped could be rectified this time around.[i] One of the most ineffective components of the previous PEPFAR bill was a hard earmark requiring that 33 percent of prevention funds be spent on abstinence-only and be faithful (AB) programs. While the Senate’s PEPFAR reauthorization eliminated this hard earmark, the bill has left in its place a requirement that the Office of the Global AIDS Coordinator submit a report to Congress if an organization allocates less than 50 percent of its funds to non-AB programming. Advocates are concerned that this new requirement will act as a “de facto abstinence earmark” by discouraging organizations from using money for comprehensive prevention programming out of fear of losing funding.[ii]
Advocates were also hoping that the Senate would remove from the reauthorization language a provision requiring that organizations receiving PEPFAR funding publicly pledge their opposition to prostitution and sex trafficking before receiving U.S. money. The pledge makes it harder for organizations on the ground to deliver the necessary prevention, care, and treatment services to sex workers, a high risk population that is already marginalized.   Despite numerous reports detailing the failures and limitations of the pledge, the Senate maintained the provision in the bill. 
The Senate also elected to expand an existing conscience clause that applies to organizations engaging in prevention, care, and treatment services. The provision, which allows for PEPFAR-funded organizations to refuse services to someone based on moral or religious objections, sets the stage for taxpayer-funded discrimination.
Despite statistics that indicate that 80 percent of new infections occur from sexual contact, the reauthorized version of PEPFAR does not acknowledge the need to strengthen critical linkages between family planning and reproductive health services and HIV prevention efforts.  In fact, some members of congress vehemently opposed the insertion of family planning into HIV prevention services.
While the PEPFAR reauthorization fell flat in these areas, there were some important gains. The Senate bill makes critical the need to fix the healthcare worker shortage in developing countries by supporting nations in the development of long-term heath workforce plans and funding 140,000 new health workers.[iii] Additionally, the legislation includes explicit language concerning men who have sex with men (MSM), one of the groups most affected by the epidemic, which was previously absent. Perhaps most importantly, an amendment proposed by Senators John Kerry (D-Mass.) and Gordon Smith (R-Ore.) to reverse the HIV travel ban was accepted and added to the legislation. The travel ban has blocked HIV-positive persons from traveling to the United States for 20 years.
President Bush signed the reauthorized PEPFAR into law on July 30. Of the reauthorized legislation, SIECUS President and CEO Joseph DiNorcia said, “[This bill]represents the same war on evidence-based prevention that it did five years ago and will likely only continue to destroy a comprehensive approach to prevention. Provisions such as an ongoing and disproportionate emphasis on abstinence-until-marriage, a prostitution pledge which has nearly obliterated outreach to this population, a lack of common sense integration between family planning and HIV-prevention work, and a stricter conscience clause all represent the worst of our politics and dampen the positive potential of PEPFAR.  With the number of new infections outpacing existing prevention efforts, a major revelation of PEPFAR is that a prevention portfolio should be front-and-center for the new President and a new Congress.

[i] PEPFAR funding has especially helped 15 focus countries: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia.

[ii] Population Action International, “Senate Passage of Landmark HIV/AIDS Bill; Failure to Maximize Prevention Efforts,” Press Release published 16 July 2008, accessed 23 July 2008 <>.

[iii] Physicians for Human Rights, “PEPFAR: $48 Billion Landmark Bill Reauthorized; Millions of Lives to be Saved,” Press Release published 16 July 2008, accessed 23 July 2008 <>.