What’s at Stake in Global and U.S. Domestic HIV Funding

By Sarah Hamilton October 31, 2023

The U.S. government is on the brink of a shutdown. Lawmakers are politicizing the President’s Emergency Plan for AIDS Relief (PEPFAR). And the House is proposing drastic cuts to domestic HIV spending. With all of this as context, FCAA hosted a meeting in September to discuss what’s at stake, and what—if anything—funders can do in this moment of political turmoil.

What’s the current status of U.S. domestic HIV funding?

Over the summer, the Republican-led Labor, Health and Human Services, Education, and Related Agencies Subcommittee of the House Appropriations Committee released its proposed bill for fiscal year 2024.

The proposal would cut $767 million from domestic HIV funding, including:

The cuts are part of larger cuts to the Centers for Disease Control (CDC) (an 18% cut), the Department of Health and Human Services (a 12% cut), and the National Institutes of Health (an 8% cut). 

“These cuts are unparalleled. I can’t overstate how truly catastrophic it would be if they were allowed to go into effect,” says Leslie McGorman, Director of Policy and Strategy at AIDS United.

The cuts are likely to be watered down as Republicans compromise with Democrats and within their own party. In the meantime, organizations like AIDS United are reaching out to moderate Republican lawmakers to remind them that HIV has historically been a bipartisan issue, and that cutting these programs will lead to higher long-term healthcare expenses.

What’s the current status of global HIV funding?

PEPFAR is currently entangled in a domestic political fight, with Republicans alleging that the program’s funding is being used to indirectly support abortions.  Lawmakers have spent months debating over whether to reauthorize it for five years, one year, or not at all. As a result, lawmakers failed to reauthorize PEPFAR by a Sept. 30 deadline.

While the program would continue absent a reauthorization—provided the funds are appropriated—some time-bound requirements would end if a reauthorization bill isn’t passed or if Congress doesn’t address them through another legislative vehicle. Notable provisions that are expiring include a one-third threshold for Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) contributions (U.S. funding for the Global Fund cannot exceed one-third of total contributions from all donors to the Global Fund, serving as a matching challenge for other donors), as well as an allocation for orphans and vulnerable children.

Congress also shows no signs of increasing funding for PEPFAR, which has been flat-funded for over a decade. That’s a problem, says Kiefer Buckingham, Advocacy Director at Open Society Foundations and the Open Society Policy Center. “As you all know, the needs have only gotten greater…We have all the solutions, we just need to pay for them.”

Aside from PEPFAR, the House Appropriations Committee’s State, Foreign Operations, and Related Programs Appropriations (SFOPs) bill for fiscal year 2024 would cut the foreign assistance budget by nearly one-third. While this bill largely flat-funds many global health programs, it also proposes cuts to programs that support family planning, HIV testing, and maternal and child health. The bill would also slash United Nations’ funding, including funding for UN Women, the World Health Organization, and UN Development Programme.

What’s at stake?

If Congress fails to reauthorize PEPFAR and passes the House’s proposed appropriation bills in their current form, much of what’s at stake is glaringly obvious: the tremendous progress we’ve made towards ending HIV as a public health threat would backslide as resources for testing, treatment, and prevention shrink without adequate funding.

“This moment is gut wrenching for so many of us, as we think about the impact that these decisions could have. There’s no question that these reductions in investment at the federal level would lead to a worsening of the epidemic,” says Dr. Tyler Ter Meer, CEO of the San Francisco AIDS Foundation.

Speakers shared some of their most pressing concerns. At the global level, these include:

  • The risk of losing progress towards transitioning HIV programs over to local governments. If PEPFAR support is withdrawn before programs can fully transition to local ownership, those programs could see a decline in quality of care or close altogether, warns Emily Bass, author of To End a Plague: America’s Fight to Defeat Aids in Africa.
  • Compromising the U.S.’s own global health security by giving away the power it has, through PEPFAR, to partner and communicate with local governments in terms of their laboratory infrastructure and information about emerging diseases.

In the United States:

  • Community-based programs and services in areas with the highest concentrations of HIV transmission would be the most affected by federal cuts, with Black and brown communities bearing the brunt of the crisis.
  • Cutting off EHE funding would hamper the ability of HIV and sexual health clinics to reach people in the community through mobile HIV testing and at-home testing for example, in 2021, HRSA health centers administered about 1.7 million HIV tests with the help of EHE funding.
  • Community-based clinics and organizations would lose EHE funding for PrEP care and outreach to people seeking services related to sexually transmitted infections.
  • Slashing federal support for PrEP programs in places where HIV infection rates are highest would squeeze the operations of on-the-ground clinics, which are already operating on shoestring budgets. “They would have to cut services, potentially cut staff, some may even be forced to close their doors… It would inevitably lead to increasing HIV transmission, as fewer and fewer PrEP programs would exist,” says Ter Meer.
  • In some locales, cutting EHE funding would mean a decline in funds for syringe exchange or syringe service programs.

Sidebar: In this Chronicle of Philanthropy feature, Masen Davis explains what the failure to reauthorize PEPFAR means for nonprofits and philanthropy and how grant makers should respond.

How can funders meet this moment as a philanthropic community?

Multiple letters have already been sent to Congress and the White House in support and opposition of PEPFAR. To rise above the noise of what’s already been said, consider reaching out to bilateral partners who work closely with PEPFAR, and ask them to share the impact of the program in their country. Donors who fund organizations that receive PEPFAR money also have a unique message to share with The White House, embassies, and fellow donors to communicate the importance and impact of US governmental support in the HIV response.

Domestically, philanthropic organizations should use their connections to open doors that aren’t always accessible to non-funder advocates. In addition, grantmakers can direct more funding to state and local groups to help build a groundswell of support to counter the anti-LGBTQI and anti-SRHR policies and rhetoric coming from state legislatures. “When you’re doing grantmaking, remember the state-level fights—that’s where all of these attacks originate,” says McGorman. “Congress never comes up with these ideas themselves; they are something that we’ve already seen at the state level.”(Note: If you’re interested in learning more about state groups, FCAA can help you connect.)

Finally, consider rapid-response funding for organizations that can advocate for PEPFAR reauthorization and HIV-friendly legislation. With the right resources, grantees can quickly mobilize to host press conferences, organize public education events, and buy advertisements to get the message out. 

There’s no question that it’s a politically challenging time, and these conversations are alarming. Rather than feeling hopeless, we want you to feel empowered, because there are actions funders can take to ensure that we continue our progress in combatting HIV.