PEPFAR’s been saved—for now. What’s next?

Advocates breathed a sigh of relief when Congress agreed to save $400 million for PEPFAR, the U.S. global HIV/AIDS assistance program, from a “rescissions” package meant by President Donald Trump to claw back money that had already been approved. It was the same measure, after all, that defunded PBS and NPR.

First off, what’s a “rescission”?

A rescission is a request from the executive branch to Congress to cancel or take back funds that Congress had already agreed to appropriate and spend, so unspent monies. That’s why it’s referred to as a clawback.

This is a potentially controversial tactic because it goes around the normal bipartisan appropriations process that Congress goes through. It unbalances the constitutional separation of powers between Congress, holding the power of the purse, and the executive, which just sort of advises and provides input into budget decisions. If you have a presidential administration that has a very strong, discrete agenda that they’re trying to push, they’re going to use every tool in their toolbox to push that agenda, and rescissions are part of that.

The original rescissions package was $9.4 billion—the bulk of it is somewhere north of $8 billion of cuts, rescissions, to the State Department budget, specifically USAID [the U.S. Agency for International Development]. The intent of this rescission was to codify, or make lawful, the chaotic and abrupt dismantling of USAID by DOGE [Elon Musk’s self-described “Department of Government Efficiency”] and by the administration, which advocates were challenging in the courts.

The administration and [Russell] Vought, the director of the Office of Management and Budget [OMB, the White House’s budget-setting department], were trying to make their actions legal; by passing this rescissions package, any and all court challenges to DOGE’s dismantling of USAID are terminated.

[Vought is credited as one of the chief authors of Project 2025, the policy blueprint for a conservative federal government. He wrote the chapter detailing how the presidency should be restructured and empowered, making the case for a sweeping expansion of presidential authority.]

This rescissions package and process were somewhat unique. The administration presented its argument to Congress with no detail. OMB director Vought went to testify before Congress, and despite multiple questions, was not able to specify which programs or projects were going to be impacted by these cuts.

They basically presented two paragraphs stating that, “we’re going to cut these amounts because they don’t align with the interests of America and our America First agenda.” In response to questions demanding details about what was being cut, Vought defended the cuts by claiming that PEPFAR funds were being used to perform abortions in Russia, among other claims. That is simply not true. Not only has PEPFAR had no funding and no programs in Russia since 2012, but there are multiple laws on the books that bar federal funding for abortions, both abroad and domestically. [Known as “the Mexico City rule” or the “global gag rule,” this is a federal policy that bans international organizations from receiving U.S. funding if they perform abortions, advocate for abortion access or refer patients to abortion services, even if they do so using their own non-U.S. funds. Instituted by President Reagan in 1984, the policy has been rescinded by Democratic presidents only to be re-instated by Republican administrations.] 

[I think that] these 20-year-old DOGE soldiers were empowered to go into U.S.  government data. They did word searches and looked for things that the administration doesn’t like—like LGBTQ, reproductive health, women, equity. Whatever they pulled up—they either didn’t read it or didn’t understand it when they read it and then copied and pasted it into a document to send to OMB—Vought then used it out of context to try to justify these broad and vague cuts.

So, is HIV funding threatened because the administration is against abortion and contraception, or against LGBTQ+ people?

I think the administration has made it very clear—although they’ve singled out trans people as a part of the community that they want to target most explicitly and most relentlessly —that they are opposed to any and all programs that serve LGBTQ+ people at large. That’s going to include HIV programs. But in my opinion HIV and sexual health programs can’t really be separated from other programs related to reproductive health, including contraception and prenatal and antenatal care. All those healthcare needs are deeply related. In the real world, you’re going to go to some of the same providers for these services, whether you need help to treat an STI, to prevent HIV or help with contraception or other things related to pregnancy. In the context of the global gag rule, it means if you are receiving any money from the U.S. government you can’t make referrals to any place that provides abortions as part of family planning.

Personally, I don’t think you can separate the attacks on reproductive health from attacks on the LGBTQ community and the programs that serve us, including HIV programs. It’s all part of the same thing, because all those health needs are interrelated.

What about domestic programs—namely HOPWA (Housing Opportunities for People with AIDS)?

Any domestic HIV program, including HOPWA, is also under threat from potential and future rescissions by this administration, now that they’ve broken the seal and achieved the precedent of passing a rescissions package for the first time in 25 years. And it’s been done with very little to no justification or data on who’s going to be impacted and what projects and programs are going to be terminated by the rescission. I believe they’re going to go after domestic programs that serve the same communities and provide the same or similar services—so, none of us is safe. They deliberately and purposefully did this first to foreign assistance, because foreign assistance can seem abstract and far away—it’s going to affect those people over there, and it’s not going to impact me. But now that they’ve successfully done it to those [foreign aid] programs and those communities, they’re going to do it domestically. This is part of a process of getting closer and closer to domestic programs and the programs that your readers may depend on.

HIV prevention has already been negatively impacted by this administration, separate from and before this rescission package ever went to Congress. As part of that executive order [cutting foreign aid], the State Department restricted access to PrEP [HIV prevention] in PEPFAR programs only to pregnant and breastfeeding women. That means male partners can’t get PrEP, whether oral or injectable, through PEPFAR programs. That means key populations—men who have sex with men, sex workers, people who use drugs, incarcerated people—can’t get PrEP through PEPFAR-funded programs, and that’s been the case since this administration came into power.

Because we don’t have a lot of detail and only some vague language that’s protecting “lifesaving” interventions or programs under PEPFAR, we really don’t know what additional harm the recissions package is going to do to HIV prevention or related programs, like STI testing, that may also refer people to where else they can get PrEP or get tested for HIV, et cetera. In terms of lenacapvir [the six-month injectable for PrEP], PEPFAR had made a commitment a couple of years ago to purchase and to rapidly scale up lenacapavir through PEPFAR programs. With the removal of [Ambassador-at-Large Dr. John N. Nkengasong] as head of PEPFAR, replacing him with someone who does not have expertise on Africa—where the majority of people living with HIV who are served by U.S. government-funded programs live, and who does not have expertise in HIV—we don’t have a strong voice with experience and expertise to negotiate and prioritize lenacapavir procurement through PEPFAR, so that is completely stalled. 

[The day after taking office in January, Trump appointed Jeffrey Graham as acting U.S. global AIDS coordinator—effectively the head of PEPFAR. A career senior Foreign Service officer who’s been posted to Ethiopia and Ghana, both PEPFAR recipient countries, his most extensive experience has been in China and Mongolia.]

The Global Fund also joined PEPFAR in that commitment. The goal is to have 2 million people receiving lenacapavir within three years. In fact, they recently announced that they have agreed to a price with [drugmaker Gilead Sciences, the manufacturer of lenacapavir], and they are starting to do procurement and are working with nine priority partner countries to get them to also do contribute towards these purchases so they can get it into those countries and scale it up as quickly as possible. 

[Separately, HIV advocates have taken issue with the Global Fund and Gilead Sciences for keeping secret the drug’s price under the agreement.]

It’s ambitious, but without additional PrEP procurement and support, it will fall short of what we really need. The U.S. contribution to the Global Fund and to all multilateral health institutions is precarious and is under threat by the current administration. [In late February, the administration announced it was terminating funding to UNAIDS effective immediately. In 2023, U.S. funding had accounted for 40% of UNAIDS’ budget.] We have to watch very closely what commitments the U.S. makes around Global Fund contributions and push them hard to see if we can get the maximum.

We’re not meeting the moment. At the very time that we should be doubling down with all speed on new technologies that are coming online, the U.S. is retreating and abandoning the promises that it made 20 years ago [when PEPFAR was established], to lead and to help end the HIV epidemic globally.

What about domestically?

I’m not a domestic expert, but I think the community recognizes that in the first Trump administration, he made some very big promises about ending HIV in the United States that were backed up by significant funding, and we are not hearing that rhetoric from this second Trump administration. We are not seeing any additional commitments to funding from this administration; in fact, we’re seeing the opposite. We’re seeing wholesale cuts to programs that a lot of people with HIV depend on—in particular, Medicaid. If you are hollowing out a core pillar of our health infrastructure, how are you going to be able to keep Americans with HIV living healthy, happy, thriving lives?

So, what’s next?

What’s supposed to happen, now that these monies are going to stay in the PEPFAR account, it’s important that they get committed to specific grants and specific projects and programs and then get out the door to those projects and programs so that they can deliver the services that they’ve agreed to—that 

There is another problem with the rescissions process: it is not transparent. We’re going to have to be working very, very hard to push Congress to make sure it uses its oversight powers so that those dollars that were “spared” in this first round of rescissions actually do get spent. There’s other ways, procedural maneuvers, that the administration and—frankly, hostile—congressional offices can do to delay or obstruct funds from actually being spent as they were intended. Advocates are going to have to be on our toes and watch very closely and work with congressional allies to make sure that this does not happen and that money gets spent and people receive services.

What can someone do in the face of all of this?

I can only speak for myself, but I think what you can do is don’t allow yourself to be overwhelmed. Try to follow the news, but keep your eye on the big picture and get in the habit of consistently communicating with your elected representatives. I set aside a little time every day for making phone calls, sending emails, signing petitions on the issues that I care about; that consistent communication lets them know that you’re watching what they do and lets them hear what you care about. That’s what’s going to break through. You can also join coalitions and campaigns like the Save HIV Funding campaign so that you get regular updates and have a calendar of things so you know when you need to react and respond to a specific call to action.

This is a long fight. We need to stay informed and stay aware, but pace ourselves. And I think we all have to get better at rapidly responding to misinformation and unfounded attacks with clear, concise, factual information.

Where do you go for factual information?

I go to the Kaiser Family Foundation—kff.org. If you go there and search PEPFAR, they have a lot of great, easy-to-read information about the history of PEPFAR, about funding, the different provisions and legislation that guide the program. For all things HIV prevention, I invite people to go to avac.org, which is my home organization. If you're a D.C.-based organization that works with PEPFAR or Global Fund-related efforts, especially abroad, you can join the Global AIDS Policy Partnership, the GAPP: globalaidspolicy.org. We have monthly calls and do a lot of work on [Capitol Hill], building and maintaining relationships with congressional offices, educating staff and trying to move things forward. 

Find an organization, check in with reliable sources and ask questions.