What is Pepfar and why is it in the news? Pepfar is an acronym for the US “president’s emergency plan for Aids relief”. It was set up two decades ago by George W Bush to address the HIV epidemic. It’s the biggest government-run fund of its kind. Since 2003, the project has donated about $110bn (£90.5bn) to governments, universities and nonprofits in 50 countries, either directly or through agencies such as USAid. Until now Pepfar has been funded in five-year cycles. In the past the programme has had virtually unanimous support from Republicans and Democrats. But the next funding cycle (from 2023 to 2028) became ensnared in US abortion politics and the fallout contributed to Congress missing the 30 September deadline to allow another five-year funding cycle for the initiative. What’s the link between Pepfar and abortion? US laws already prevent Pepfar (or any state agencies) from paying for abortion services, according to the California-based policy research group, Kaiser Family Foundation (KFF). But in May, a coalition of conservative thinktanks and lawmakers began to make waves with arguments that Joe Biden’s administration has “hijacked” Pepfar to promote abortion instead of treating and preventing HIV. That’s where the risk to Pepfar’s five-year budget emerged – because the Republican lawmakers then refused to sign off on a spending bill for Pepfar if there weren’t stricter rules in place to stop Pepfar funds from overlapping with abortion services in any way. According to Brian Honermann, deputy director of public policy at the US-based Foundation for Aids Research, the allegations that Pepfar has been usurped to push a “radical social agenda” overseas are “baseless” and “stitched together from unrelated policy speeches, documents and assertions about how those apply to Pepfar”. What will happen to Pepfar now? The multibillion-dollar health programme is a permanent part of US law. That means Pepfar funding will continue, but it will lose its favoured position of receiving five years of funding at a time. The failure to reauthorise Pepfar will mean some of its built-in rules will expire, including a guideline that requires 10% of Pepfar money to go to orphans and children in need. Will organisations and governments lose their Pepfar grants? The fund has enough money to pay governments and civil society organisations until September 2024 (about $6.8bn), but a state department spokesperson warns that Pepfar won’t escape unscathed in the long term. Moreover, getting funding for only one year at a time will make it harder for Pepfar to plan ahead and to source crucial HIV tools, such as condoms or medicine, at the best prices. This could ultimately imperil the people that rely on the fund’s support, the spokesperson warned. The symbolic power of a five-year commitment will also be lost, says Honermann. “It shows partner countries that the US is invested for a significant period of time and that Pepfar won’t just disappear.” The threat of a permanent ‘gag rule’ Another factor has swirled around Pepfar’s funding drama: some lawmakers have said they’ll only agree to restart the five-year funding regime if the fund is once again subject to the “Mexico City policy”, also called the “gag rule”. The gag rule bans organisations and governments from providing or promoting termination of pregnancy services regardless of whose money they’re using to do it. It was expanded to apply to Pepfar for the first time in 2017. It is only ever enforced when there’s a Republican president in the White House, so is not currently in effect. And while there is no finalised legislation that would make a permanent gag rule a reality (and Honermann argues it would be unlikely to get past the Democrats), the threat of it may already have done some damage. Research conducted by Fòs Feminista, a global alliance that advocates for sexual and reproductive rights, found that the 2022 decision to roll back the national right to an abortion in the US had a contagious impact in a number of countries. In Nigeria, for instance, respondents told Fòs Feminista that local lawmakers were using the change in US abortion laws to push back on a more liberal law in their country. Terminations are legal in Nigeria only if carrying the foetus to term threatens the mother’s life. Recipients of US government funding are often so worried about losing it that they enforce abortion laws more harshly than is necessary. Research shows that confusion about whether the gag rule had been revoked at the start of the Biden administration resulted in the policy – and its harms – being in place for much longer in practice. And the Pepfar wrangling and attendant media coverage has already resulted in mixed messages reaching health advocates in Africa. Some South African activists told the Guardian they were concerned that the news would be calamitous for civil society in the country. Such organisations receive the most Pepfar dollars (44%) in South Africa according to 2020 tracking data. The government gets just under 1.5% of the money. Honermann says that there is an intentional political strategy to keep communication about the changes in restrictions vague. “It’s a way to encourage over-enforcement for fear of falling on the wrong side of this.” He adds: “For now, Pepfar will continue as long as funding is made available. But these political threats to the programme are ultimately playing with the lives of millions of people worldwide who rely on this programme.” What has the reaction been in Africa? Dave Clark is the chief operating officer at the Aurum Institute, a non-profit that works on HIV and tuberculosis (TB) projects in South Africa, Mozambique, Ghana, Lesotho and Eswatini. Aurum is a partner for Pepfar’s Dreams project which works towards an Aids-free future for girls and women aged 10 to 24 by providing HIV services, contraception and violence prevention support for women, adolescents and their sexual partners. One of the major strengths of Pepfar, Clark says, is that it’s a sure-fire source of carefully planned funding for global health in a world that is often more talk than action. He explains: “The debate in America should not throw us off saving lives. Pepfar is what it says on the label: president’s emergency plan for Aids relief. That’s its extraordinary power and legacy.”