Statement for the Record by the Bush Institute’s David J. Kramer, for the Senate Appropriations Committee regarding PEPFAR and Proposed Rescissions
Dear Chairwoman Collins, Ranking Member Murray, Members of the Committee:
Thank you for the opportunity to comment on the Administration’s rescission proposals for the Department of State, the U.S. Agency for International Development (USAID), and other foreign investment programs. The Bush Institute’s particular interest in this relates to any impact on the President’s Emergency Plan for AIDS Relief (PEPFAR), which President George W. Bush signed into law 22 years ago.
Since its inception in 2003, the President’s Emergency Plan for AIDS Relief, or PEPFAR, has changed the trajectory of the HIV/AIDS pandemic. Through community partnerships, political will, data-driven programming, and the generosity and compassion of the American people, PEPFAR has saved 26 million lives and allowed nearly 8 million babies to be born HIV-free.
This incredibly successful life-saving program has benefitted from consistent bipartisan support through twelve Congresses and four reauthorizations.
As we understand it, the proposed rescissions would return a total of $900 million of funding for global health programs to the Treasury. This includes $400 million of the $6 billion appropriated in fiscal year 2025 for global health programs like PEPFAR.
There have been concerns that the program in recent years strayed from its core mission. That mission should be the same today as it was 22 years ago: providing life-saving treatment; retaining patients on treatment; and targeting prevention including preventing mother-to-child transmission to ensure no child is born with HIV. PEPFAR has done this since its inception by emphasizing measurement of quantifiable results. The law that authorized PEPFAR, the Tom Lantos and Henry Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, called for reporting on progress every six months. Using data in real time has been what sets PEPFAR apart from many other global health programs. This use of data enables the program to target geographic areas and populations where it can achieve the greatest impact and continuously evaluate the effectiveness of the work while removing barriers to care and treatment. Its collection and visualization of data continue to evolve based on the unique programmatic needs in each country, and, within each country, each region and population.
This methodology has permitted PEPFAR to adjust its funding and geographic focus to find people the program had previously missed and achieve efficiencies to expand treatment, care, and prevention services even without budget increases. Accordingly, PEPFAR and its partners must continue to collect and validate data in a timely fashion from all sites, broken down by gender, age, and geographic location, to improve programs and increase their impact.
As PEPFAR moves toward country ownership and self-sustainability, granular data can continue to inform tailored, needs-based programming with host governments as well as faith-based organizations and local community-based organizations that are delivering on the promise of PEPFAR and are particularly vulnerable to any major withdrawal or suspension of funding.
Rather than rescinding FY25 funds, these funds should be used to strengthen the data systems and independent community surveys that measure progress and trigger needed adjustments. Details on what exactly would be affected by the proposed rescissions remain unclear, but should they weaken the core mission of PEPFAR, or its ability to collect necessary data, they would place lives in danger and jeopardize the tremendous progress made over more than two decades.
PEPFAR was never intended to go on forever, with the goal of ending HIV/AIDS as a public health threat by 2030. As countries that have been beneficiaries of the program assume ownership for their respective programs, some nations already are in a position to do so, while others will take longer. Concentrating resources on those places that remain in need will be the most efficient way to ensure proper use of taxpayer dollars. Transitioning PEPFAR programming to country ownership will produce cost savings, but these need to be managed carefully, reflecting each country’s needs and capabilities. Support for the Global Fund will remain important as well as a sign of sustained commitment from the United States.
Terminating PEPFAR prematurely or significantly cutting the program’s operations and resources, however, would endanger access to lifesaving treatment for over 20 million people and could put babies at risk of contracting HIV or losing their parents to the disease. Drug-resistant strains of the virus that are more expensive and difficult to treat could spread across borders and negatively impact the United States. Individuals who survive HIV, a disease without a vaccine or a cure, could die from preventable diseases like cervical cancer or tuberculosis. Diluting or shifting PEPFAR’s mission would put decades of progress and potentially millions of lives at risk.
Remaining laser-focused on treatment, prevention, and data collection and analysis are key to the program. We are grateful that in February, Secretary of State Marco Rubio extended a waiver to PEPFAR and other lifesaving programming. As Secretary Rubio has testified, roughly 85 percent of PEPFAR programming is up and running following some disruptions earlier this year. It remains vital that those receiving anti-retroviral medications do not experience any interruptions in their treatment, that babies can continue to be born HIV-free, and people living with HIV don’t die from preventable – or even curable – diseases. It is truly a matter of life and death.
For over 20 years, PEPFAR has trained and supported thousands of healthcare workers, strengthened democratic values abroad, and helped build public health infrastructure and community networks that address challenges beyond HIV. Because of this, the average life expectancy for countries with longstanding partnerships has increased by as much as 18 years.
PEPFAR supports local communities by dedicating over half of its funding to grassroots and community-based organizations. For over 20 years, the program has ensured that people living with HIV not only survive but thrive. The program prevented countries across Africa from economic collapse, which is now home to more than half of the world’s 20 fastest growing economies. By midcentury, nearly a quarter of the world’s working- age population will reside in Africa.
PEPFAR remains a great way to promote U.S. soft power. China and Russia are waiting to take advantage should the United States falter or forgo its commitment. The global population of people living with HIV – now at nearly 40 million – is expected to keep increasing over the next several years, and a growing number of young people across the globe are at great risk of contracting HIV. Without consistent access to low-cost antiretroviral drugs, people living with HIV risk developing AIDS or a resistant strain of HIV that is more difficult and expensive to treat. Whereas PEPFAR focuses on saving lives, Chinese lending structures and health programming lack accountability, transparency, and long-term sustainability. Russia has expanded its influence on the continent – breeding instability and violence and destroying infrastructure along the way.
PEPFAR’s goal of defeating HIV/AIDS as a public health threat is within sight, and the United States should finish the lifesaving work started more than 20 years ago. It can do so by ensuring that countries reach their goals and can sustain them through effective programming with clear metrics and measurable outcomes – allowing partner countries to fund much more of the cost of prevention, treatment, and care over the next few years.
As President Bush has said, every life is precious, and no program is more pro-life than PEPFAR. The generous investments of the American people through PEPFAR offer renewed hope for millions of men and women while moving countries closer to ending AIDS as a public health threat. We can’t quit now. That’s why we thank this Committee and the Congress, working with the Administration, for ensuring that the life-saving work of PEPFAR is sufficiently funded.
Thank you for permitting us to enter this statement into the record.
