WASHINGTON — A battle is underway in Congress over reauthorizing the lifesaving, two-decade-old President's Emergency Plan for AIDS Relief (PEPFAR) — centered on whether the program now facilitates abortions overseas.

Pro-life Rep. Chris Smith, R-N.J., previously a prime sponsor of PEPFAR, told the Register that he is opposing the program’s reauthorization unless it excludes groups that provide, promote or lobby for abortion because he sees an “existential threat to the children of Africa” in the Biden administration’s alleged inclusion of abortion within the program.

Smith told the Register that the program, which has saved 25 million lives and helped 5.5 million babies to be born HIV-free, has been “hijacked” by the Biden administration. He pointed to language in the Biden administration’s 2022 PEPFAR action plan, “Reimagining PEPFAR’s Strategic Direction,” which calls for integrating “HIV programming into strengthened public health systems to manage tuberculosis, high burden non-communicable diseases, sexual reproductive health, rights and services,” and to strengthen “coordination between PEPFAR and other U.S. government global health and development programs, including for tuberculosis, malaria, sexual and reproductive health and rights.”

Rep. Smith said that the Biden administration uses the terms “sexual and reproductive health and rights” as inclusive of abortion, noting administration guidance and executive orders where the definitions include abortion.

While the Helms and Siljander Amendments bar U.S. foreign-aid dollars from going directly to providing abortions or lobbying for abortion, Smith and these pro-life groups are calling for language that would bar organizations that provide and promote abortion from receiving U.S. taxpayer dollars at all. This was a part of the Reagan-era Mexico City Policy that was expanded under the Trump administration and renamed the Protecting Life in Global Health Assistance Policy (both policies were revoked almost immediately after Biden took office in January 2021).

In May, a coalition of 31 pro-life organizations, including Susan B. Anthony Pro-Life America, Americans United for Life and the Ethics and Public Policy Center, wrote to the heads of the House and Senate Foreign Relations Committees asking that Mexico City Policy language be added to PEPFAR so that “no grantees or subgrantees are using taxpayer funds to promote a radical sexual and reproductive health agenda.”

They wrote that “many of PEPFAR’s top grant recipients publicly support abortion as a method of family planning,” giving an example of the International Planned Parenthood Federation, one of the largest global abortion advocacy groups, announcing in March 2022 “a partnership with USAID to address ‘HIV/AIDS, family planning, and reproductive health’ in low- and middle-income countries.”

Abortion Provision and Promotion

In July, the Biden administration added a footnote in its 2022 PEPFAR document stating that sexual and reproductive health meant “education, testing and treatment for sexually transmitted infections, cervical cancer screening and care” and “prevention of mother to child transmission of HIV and access to condoms,” as well as “gender-based violence prevention.” It stated PEPFAR “does not under any circumstances provide support for abortion services.”

Smith called the footnote a “farce,” saying after attention was drawn to the language by himself and others, the administration tweaked it, but added “it’s useless,” as abortion groups still receive large amounts of funding through PEPFAR even if that taxpayer money is not specifically used to provide or lobby for abortions.

In a letter to his fellow lawmakers in June, Smith gave three examples of recipients of PEPFAR funding going to groups that provide and promote abortion. The Population Services Institute (PSI), which has received $96.5 million in PEPFAR funding in the last two years, touts on its website its provision of “comprehensive abortion and post-abortion care services in nearly 20 countries throughout the world,” including launching “misoprostol and mifepristone-misoprostol combination-pack brands in nearly 20 countries.” The site also notes work leading “the effort to create Nigeria’s first national guidelines for abortion provision.”

Another example was VillageReach, which received $10.1 million in PEPFAR funding over the past two years and worked with Planned Parenthood using PEPFAR funding through the DREAMS Innovation Challenge to create a youth health hotline and training manual in Malawi that included information on “sexual and reproductive health and rights” and “unsafe abortion,” which, according to the letter, included “the need to change pro-life laws to provide ‘services that young people need.’”

A statement on the website of Pathfinder International, which received $5 million in PEPFAR funding over the past two years, said that it works “with local partners and community leaders to achieve policy changes that reduce barriers to and provide an enabling environment for safe abortion services.”

Two of these organizations, PSl and VillageReach, have contested the letter’s characterization of their work.

“What we delivered complied with U.S. law and Malawi law,” a statement from VillageReach told the global development media outlet Devex, regarding the work on the hotline and manual. PSI said it “adhere[s] strictly to all applicable regulations to ensure compliance and to provide essential reproductive healthcare services while respecting local laws,” and asserting that “PSI’s safe abortion work remains separate from U.S. government funding due to long-standing U.S. laws and regulations.”

Push for Pro-Life Protections

Smith is backing the fiscal year 2024 appropriations bill from Rep. Mario Diaz-Balart, R-Fla., that would extend PEPFAR — which has provisions that are set to expire Sept. 30 — through 2024 with the full “Protecting Life in Global Health Assistance” policy protections and other pro-life protections. He called funding programs through appropriations a “common practice,” pushing back against claims, including from Tom Hart, president of the nonprofit ONE campaign, who told The Washington Post that some PEPFAR provisions could be lost in the battle over reauthorization.

Bishop Michael Burbidge of Arlington, Virginia, the chairman of U.S. Conference of Catholic Bishops’ pro-life committee, along with Sean Callahan, president of Catholic Relief Services, and Bishop David Malloy of Rockford, Illinois, chairman of the USCCB’s international justice and peace committee, wrote to Congress in July urging that pro-life language be a part of the PEPFAR reauthorization

“We strongly urge bipartisan cooperation in efforts to ensure that the lifesaving work of PEPFAR will continue and that the program fully respects the inherent dignity of all people, including preborn children,” they wrote. “The life-saving work of PEPFAR should never be entangled with the promotion of abortion, a grave evil and the opposite of lifesaving care.”

“Consistent with this principle,” they wrote, “we strongly appeal to you that the Protecting Life in Global Health Assistance policy be applied to this program.”

White House Stance

The push for pro-life protections has stalled progress on reauthorizing PEPFAR on Capitol Hill. The White House did not respond to the Register’s inquiries about its response to claims of abortion promotion and provision by PEPFAR grant recipients.

An anonymous senior White House official told The Washington Post, “We are not ‘injecting’ abortion into PEPFAR in any way, shape, or form or seeking to make changes in law related to abortion.” However, the official rejected the addition of Mexico City Policy language, claiming “the Mexico City Policy significantly inhibits our ability to confront health challenges, not only HIV/AIDS, but also tuberculosis and malaria, and also to support programs that prevent and respond to gender-based violence when it comes to women’s health.”

Max Primorac, director of the Douglas and Sarah Allison Center for Foreign Policy at The Heritage Foundation, which was one of the signers of the May letter, told the Register that “the president has expressed in black and white, through presidential directives, to the agencies to finance, in every aspect of foreign aid, including HIV, AIDS, the inclusion of sexual and reproductive health, including abortion.” He said the inclusion of expanded Mexico City language is a “very simple fix,” with respect to PEPFAR, and wondered why those on the other side of the issue would abandon the reauthorization of a billion-dollar, lifesaving program “in order to reject a pro-life paragraph.” Rebecca Oas, the associate director of Research for the Center for Family and Human Rights (C-Fam), which also signed on to the May letter, told the Register that taking a stand on the issue is important because “abortion is not health care and we want it kept separate.”

She pointed out that compliance was high with the expanded Mexico City Policy under the Trump administration when “grantees based overseas had to certify that they were going to be compliant, i.e., they weren’t going to be promoting or providing abortions.” The vast majority of organizations complied, while a few prominent abortion groups like Marie Stopes International and the International Planned Parenthood Federation declined the funding.

Addressing Pushback

Not all pro-life faith leaders back the push to add Mexico City Policy language to the PEPFAR reauthorization.

Former Pennsylvania Sen. Rick Santorum recently wrote for Newsmax that, while he understood why pro-life groups would like to see the pro-life language put into PEPFAR, “with Democrats controlling the Senate and the Biden administration the pen, it won’t happen during this Congress.”

Consequently, a “five-year, clean extension that carries us into the next administration may be the best outcome for everyone concerned,” given “the millions of people living with — not dying from — AIDS, and who thank Americans for keeping them alive daily.” Santorum also highlighted the existing protections against taxpayer funding going to abortions.

Primorac, of the Heritage Foundation, noted that the money the groups are getting is fungible, meaning that funding going to an organization for a specific purpose like an AIDS-relief project still frees up money in other parts of that organization for other uses like the provision of abortion.

“They can say, ‘we don't use PEPFAR money to support abortion,’ but then they have their private money that goes ahead and does it,” he said. He emphasized that “the physical platform, the infrastructure, the ability to be operating out of Africa, which is very expensive, was paid for by the taxpayers; and, without it, many of these organizations would have been unable to use private money for abortion.”

Primorac also pointed to concerns from faith leaders within the countries receiving aid, highlighting a June letter to Congress from faith-based African groups, which included Catholic bishops from Kenya, Tanzania and Zambia.

The African religious groups wrote to express their collective “concerns and suspicions that this funding is supporting so-called family planning and reproductive health principles and practices, including abortion, that violate our core beliefs concerning life, family, and religion.” And they asked that PEPFAR grant recipients “not cross over into promoting divisive ideas and practices that are not consistent with those of Africa.”