A key HIV/AIDS program that has enjoyed bipartisan support for more than 20 years is highlighting a post-Roe split in the Republican Party.

Eight provisions within the President’s Emergency Plan for AIDS Relief, or PEPFAR, that expire Sept. 30 are in jeopardy, entangled in an abortion debate that has some arguing the George W. Bush-crafted program could provide aid to abortion providers abroad.

Prominent anti-abortion groups are lobbying to prevent renewing the law in its current form, arguing that part of the program’s $7 billion annual budget goes to abortion providers. Supporters of the program say it does no such thing, focusing solely on HIV and AIDS.

Last week, Bush wrote an op-ed asking Congress to re-up the program. Other Republicans, including Sens. Lindsey Graham of South Carolina and John Boozman of Arkansas, and at least 14 in the House, have also called for a prompt reauthorization. 

But Rep. Christopher H. Smith, R-N.J., who sponsored the program’s last five-year authorization, is now pushing a one-year reauthorization that would reinstate some anti-abortion restrictions as part of the State Department appropriations bill. Smith is the chairman of the House Foreign Affairs Committee’s Subcommittee on Global Health, Global Human Rights and International Organizations.

His reauthorization would reinstate an administrative action known as the Mexico City policy, which prevents an international group receiving U.S. funding from using any of its own funds for promoting or providing abortions. 

President Donald Trump expanded the use of that policy in 2019 to apply it to all foreign nongovernmental organizations receiving global health assistance and their sub-recipients, even if the sub-recipients do not use U.S. dollars.

After President Joe Biden took office, he rescinded Trump’s expansion of the policy. 

“We’re pro-life, we want to protect the victims of abortion and the victims of HIV/AIDS,” said Smith, who accused the Biden administration of “casting a false narrative” that antiretroviral HIV medicine will not be issued if the program expires. “That money will continue. We’re trying to get reforms on the policy side.”

Early momentum toward a clean reauthorization of the expiring provisions has stalled as conservatives are increasingly split on the future of a key part of Bush’s legacy.

“The reauthorization is stalled because of questions about whether PEPFAR’s implementation under the current administration is sufficiently pro-life. But there is no program more pro-life than one which has saved more than 25 million lives,” Bush wrote in his Washington Post op-ed.

That mood is matched by some Senate Republicans.

Asked about House attempts to attach the Mexico City policy to PEPFAR, Graham responded, “That’s not going to happen” in the Democrat-controlled Senate. 

“I think the program on balance has been a great pro-life program and saved a lot of babies,” he said. 

Several Republicans on the Senate Foreign Relations Committee expressed support for reauthorizing the program but wouldn’t comment on the House’s plans, including John Barrasso of Wyoming, Mitt Romney of Utah, and Boozman.

“We’re very supportive. We want to get it authorized,” Boozman said.

“I don’t know what they’re trying to do,” he added when asked about the House’s plans.

Abortion lobbying beyond abortion

That a program traditionally overwhelmingly backed by conservatives and liberals alike is now mired in the abortion debate is a reflection of the aftermath of the Supreme Court’s June 2022 decision to overturn Roe v. Wade, where previously uncomplicated policy debates have become intertwined with the debate over abortion.

In May, the Heritage Foundation released a report accusing the Biden administration of using the HIV/AIDS program to benefit abortion providers — a claim Democrats and nonpartisan policy experts dispute.

The report splintered PEPFAR’s long history of overwhelming bipartisan support.

Those at the Heritage Foundation and Family Research Council argue the blame lies on the Biden administration.

“Unlike previous presidents, whether Republican or Democrat, this one has expressly directed executive orders, and policy directives that abortion will be included in all foreign aid and humanitarian assistance for HIV/AIDS,” said Max Primorac, a director at the Heritage Foundation and a former member of the Bush and Trump administrations.

Primorac argued that PEPFAR is a conservative program at its core. But as long as Biden maintains his reversal of the Trump-era Mexico City policy expansion, it’s untenable.

“No one’s saying we can’t focus on AIDS. We’re just saying let’s do it without promoting abortion,” said Travis Weber, vice president for policy and government affairs at Family Research Council.

A prominent anti-abortion group, Susan B. Anthony Pro-Life America, has said it intends to score lawmakers based on their support for PEPFAR heading into an election year. Students for Life of America sent a separate letter and met with lawmakers about the issue on Sept. 12.

This puts GOP lawmakers in a precarious position — either reauthorize PEPFAR or lose pro-life bona fides heading into an election year. 

“They don’t want to be scored. They support PEPFAR,” said Jen Kates, a senior vice president and director of the Global Health & HIV Policy Program at KFF.

PEPFAR on the global stage

PEPFAR represents the largest commitment by a country to eliminate a disease. It’s credited with major advancements in combating HIV/AIDS globally.

The program is considered one of the United States’ hallmark public health programs, and Biden touted its successes while speaking at the U.N. General Assembly in New York City on Tuesday.

“HIV/ AIDS infections and deaths plummeted in no small part because of PEPFAR’s work in more than 55 countries, saving more than 25 million lives,” Biden told world leaders.

The Biden administration has requested $4.8 billion for fiscal 2024 in direct, or bilateral, global HIV funding, consistent with what it has received since fiscal 2019. Smith’s bill, which is proposed as part of the fiscal 2024 House State-Foreign Operations funding bill, would include $4.7 billion, according to KFF. 

While much of the law is permanent, reauthorization of the eight provisions allows Congress to revisit parts of the law. Among the eight provisions up for reauthorization are measures dealing with the U.S. commitment on the world stage and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. 

But even with its permanent authorization, letting the eight provisions in question expire could make the program more vulnerable going forward, Kates said.

“There’s concerns that it could send the signal to other countries and to the recipients of PEPFAR funding and the people that depend on PEPFAR for services that the U.S. is not as committed to this program,” Kates said, noting that PEPFAR is extremely important diplomatically for the United States.

Meanwhile, Democrats are considering their options. 

Senate Foreign Relations Chairman Bob Menendez, D-N.J., is still pushing for a five-year reauthorization but said last week he would agree to a three-year compromise. He said he is counting on Graham and Sen. Jim Risch, R-Idaho, the ranking member of the committee, to gin up support for a clean reauthorization among GOP lawmakers.

“I think we could get at least a three-year reauthorization together that would be a compromise position,” Menendez said. “It’s not what I want. But we’re not there yet.”

“If we show leadership, we could get something done here. We’ll drive towards a resolution in the House,” he added. 

Still, it’s unlikely both chambers will come to an agreement by Sept. 30, Menendez said. And that’s a drastic departure from previous years. 

“One of the hallmarks of PEPFAR is conservatives have been engaged from Day One,” said Keifer Buckingham, advocacy director for the Open Society Foundations and former Capitol Hill aide who worked on previous PEPFAR policy, pointing to Bush and the late former Rep. Henry Hyde.

“What message does it send to our partners and other governments? What messages does it send to people living with HIV around the globe if PEPFAR doesn’t get reauthorized?” Buckingham said. 

“I think that’s an important nuance.”