Mark Dybul knows the ins and outs of PEPFAR, America’s long-running effort to fight AIDS in Africa, intimately. As a staffer at the National Institute of Allergy and Infectious Diseases, he was one of only two non-White House experts to help draw up the original outline of the program early in the George W. Bush administration. From 2006 to 2009, he served as the program’s chief as U.S. Global AIDS Coordinator.
Now two decades old, the program is credited with saving more than 25 million lives. Dybul, however, is worried it may not continue much longer, as misinformation peddled by opponents of abortion rights threatens congressional authorization of the program.
“It’s all basically misinformation being thrown around in a way that is damaging, that could risk millions of lives — which is not pro-life — and it’s not factual,” he told HuffPost in a recent interview.
At issue is whether the law authorizing PEPFAR will be renewed by Sept. 30, when the program expires. While missing that deadline won’t mean the program will immediately stop — it will still be funded — it would mean a massive self-inflicted diplomatic wound, Dybul said, and even a temporary renewal would likely set the stage for the program’s end. The drama shows how even wildly successful programs are at risk due to American culture war fights and the GOP’s anti-abortion rights stance.
Former President George W. Bush walks with Mark Dybul, then the U.S. Global AIDS Coordinator at the State Department, at the White House in 2007.
PEPFAR, the President’s Emergency Plan For AIDS Relief, was one of Bush’s few foreign policy successes of the early 2000s, delivering AIDS treatment and prevention tools to African countries besieged by the epidemic. It drew celebrity backing and support from across the political spectrum. (“Genius plan. Pretty crap acronym, it has to be said,” U2 lead singer Bono said at an anniversary event in February.)
While it still supports treatment for 20 million people currently, this year’s fight in Congress shows the program, in some respects, might be a victim of its own success. While two-thirds of HIV infections globally are in Africa, the infection rate on the continent has decreased by 60% from 1996 and, in some countries, has fallen by 95%, according to the United Nations. AIDS-related deaths in Africa are down 72% since 2004.
The improved picture has made PEPFAR, which has faced tricky questions in the past over things like AIDS prevention methods, an easier political target than it was during its last reauthorization in 2018
A report from the right-wing Heritage Foundation in May urged PEPFAR resources to be redirected toward other, more prevalent diseases and economic development.
It’s all basically misinformation being thrown around in a way that is damaging, that could risk millions of lives — which is not pro-life — and it’s not factual.Mark Dybul, former U.S. Global AIDS Coordinator
“Except in cases of rape or maternal transmission, HIV/AIDS in the U.S. and in developing countries is primarily a lifestyle disease (like those caused by tobacco) and as such should be suppressed through education, moral suasion, and legal sanctions,” the report said.
But the direct threat is the false idea the program promotes abortion.
Rep. Chris Smith (R-N.J.), one of the original backers of PEPFAR on Capitol Hill, echoed some of Heritage’s concerns in a letter to his fellow lawmakers in June, insisting the program had become “hijacked” by the Biden administration to promote abortion.
Smith’s letter cited favorable mentions of “sexual reproductive health” and “sexual, reproductive, and economic rights of women” in two of the program’s planning documents as evidence of his claim. (One of those documents has since been updated with a footnote noting that PEPFAR does not fund abortions.)
“Twenty years ago, PEPFAR was enacted to put a tourniquet on the HIV/AIDS pandemic — and in 2018, I was the prime sponsor of the bill enacted into law to reauthorize PEPFAR for five more years — the program has saved millions of lives,” Smith wrote.
“Yet, the noble goals of PEPFAR must not now — or ever — be compromised by integrating the promotion of abortion.”
Smith’s office did not respond to two requests for comment.
Rep. Chris Smith (R-N.J.), pictured here at a House committee hearing in 2021, sent a letter to his fellow lawmakers saying the Joe Biden administration had "hijacked" the U.S. effort to stop AIDS in Africa.
Dybul said PEPFAR renewals have long been dogged by social issue fights like abortion, but this year is different.
“I’m more concerned than I ever have been because there is this element of politically driven misinformation that’s not based on concern with the program. And that’s new, and that’s very dangerous, especially in the current environment,” he said.
Gary Edson, who worked as the deputy National Security Adviser in the Bush administration, was even more blunt: “PEPFAR has now become something of a pawn in the culture wars,” he told a podcast affiliated with the Center for Strategic and International Studies, a centrist think tank.
PEPFAR is bound by what’s called the Helms Amendment, named after the late archconservative Sen. Jesse Helms, which bars U.S. foreign aid from being used to promote or perform abortions abroad. Dybul said the money is tracked very closely — “literally down to the village level” — and challenged critics to show specific examples of misuse.
An additional complication: Some abortion foes hope to put PEPFAR back under the so-called Mexico City policy, an executive branch directive that forbids U.S. money from going to non-profits performing or advocating for abortion. It has long applied to family planning programs, but former President Donald Trump’s administration extended it to PEPFAR.
The Biden White House reversed Trump’s order. A provision reinstating it was included in the appropriations bill funding the State Department approved by the House Appropriations Committee in July.
PEPFAR has now become something of a pawn in the culture wars.Gary Edson, early architect of the PEPFAR anti-AIDS program
Rep. Michael McCaul (R-Texas), chairman of the House Foreign Affairs Committee, said he’s working to get the issue unsnagged even as time is running out.
“I continue to work with stakeholders and my colleagues on both sides of the aisle in the House and Senate. Our common ground is that all parties deeply care about this critical program,” McCaul said in a statement provided by his office.
Prior to leaving for the six-week summer break, McCaul said: “This has got to be bipartisan. It’s got to be bicameral. It’s the only way it’s going to work.”
PEPFAR remains popular on the Hill, even as many lawmakers were unaware of the details of the reauthorization fight. They were reminded of it, however, on Monday, when a group of activists were arrested for temporarily occupying the personal House office of Rep. Kevin McCarthy (R-Calif.), the House speaker.
“It’s saved a lot of lives, maybe one of the most signature accomplishments of President Bush. And I’m surprised anybody would oppose it at all. They should just stand up and salute and thank George Bush for what he did,” Rep. Steve Cohen (D-Tenn.), who resides firmly in the House Democrats’ liberal wing, said in July.
In urging a relatively clean renewal in April, conservative Sen. Jim Risch (R-Idaho), the top Republican on the Senate Foreign Affairs Committee, called it “an undeniable expression of the values and interests that make us uniquely American.”
That aspect, Dybul said, makes it important to reauthorize the program for another five years, not temporarily and not with controversial conditions attached, such as the Mexico City language.
The late Wagner Group head Yevgeny Prigozhin, pictured here in 2022 attending the funeral of a fighter who died in Ukraine at the Beloostrovskoye cemetery outside St. Petersburg. The Wagner Group has been active in Africa, raising concerns it is being used by Russia to extend its influence on the continent.
A one-year reauthorization like that won’t pass the Democratic-held Senate, he said. If enacted, it would only encourage Democrats to take a similar hostage, like stripping PEPFAR’s “conscience clause” that allows groups with religious objections not to offer certain services or deny services to some individuals in the future.
“Then it becomes death by 1,000 cuts,” Dybul said.
“Anyone who knows anything about how Washington works knows that if you don’t do five years [of reauthorization] if you attach things to it that are politically toxic to the other side, you’re killing the program because the next time they’re in power, they’ll do the same thing.”
Failing to do a full five-year reauthorization would also be what Dybul called a “seismic” event in Africa. With China and Russia making inroads in the continent, the former by offering aid and loans and the latter using its Wagner Group mercenaries, it would cause African leaders to doubt the U.S. commitment to the continent at a critical time, Dybul explained.
“That diplomatic cost is massive, and only two countries benefit from that: China and Russia,” Dybul added.
When American officials visit Africa, they portray the competition as “basically a war of values, whose values more align with you in Africa,” Dybul said. “And what speaks more about our values than PEPFAR? And what would speak more about our retraction of those values than to not reauthorize PEPFAR? So, this is a massive issue.”