PEPFAR’s Short-Term Reauthorization Sets an Uncertain Course for Its Long-Term Future

After months of partisan negotiations and wrangling over the federal budget, Congress finally agreed to spending levels for the remainder of fiscal year 2024, passing an omnibus funding bill on March 23, 2024, that was then signed by President Biden. Tucked into this agreement was a short-term reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR, the U.S. government’s global HIV response), its fourth reauthorization. Widely regarded as one of the most successful global health programs in history and credited with saving millions of lives, PEPFAR had been caught up in the broader U.S. political debate over abortion, which had effectively stalled its reauthorization for the first time in what has otherwise been a long, bipartisan history of support. With the new omnibus bill, PEPFAR has been reauthorized until March 25, 2025, without the inclusion of any controversial provisions or changes related to abortion, sought by some. Still, while this latest step provides the program with some short-term certainty, including signaling bipartisan support (albeit limited), it marks a significant departure from PEPFAR’s past. The outcome of the presidential election and Congressional races determining control of the House and Senate could have significant implications for PEPFAR and the millions of people it serves.

Why PEPFAR Reauthorization Was Stalled

As we explored in an earlier analysis, the latest reauthorization of PEPFAR was drawn into the broader U.S. debate about abortion, even though U.S. law prohibits the use of U.S. foreign assistance, including PEPFAR funding, for abortion. The Biden administration and a wide range of stakeholders had been seeking a five-year, “clean” reauthorization of PEPFAR (an extension of the dates of expiring provisions without any changes to program language or requirements), but abortion was first publicly raised in PEPFAR reauthorization discussions in early May. A coalition of organizations opposed to abortion rights, a conservative think tank’s report, and a member of Congress raised concerns that PEPFAR may be supporting abortion, and they criticized the Biden administration’s support for global sexual and reproductive health and rights, including in PEPFAR’s latest strategy document. There was also a call for Congress to reinstate and apply the “Mexico City policy” to PEPFAR (see box).

In response, PEPFAR stated that it does not provide a platform for abortion, sent official communication to its implementers regarding current law and policy in this area, and revised its strategy to clarify that “sexual and reproductive health services” has a specific meaning in the PEPFAR context and reiterated that “PEPFAR does not fund abortions, consistent with longstanding legal restrictions on the use of foreign assistance funding related to abortion. In addition, no evidence was produced to indicate that PEPFAR supported any prohibited activities. Despite the lack of evidence, however, reauthorization of the program was effectively stalled, and there was uncertainty about whether the program would be reauthorized again.

What the Omnibus Bill Does, and the Difference Between Authorizing and Appropriations Legislation

The omnibus funding bill that passed on March 23, 2024, funds the government for the remainder of the current fiscal year and also included a short-term reauthorization of PEPFAR, marking the fourth time PEPFAR has been reauthorized (although each prior time, it was reauthorized for five-year periods; see Table 1). The language in the bill extended eight time-bound requirements in PEPFAR’s legislation through March 25, 2025 (essentially, halfway through FY 2025). These included seven provisions that had “sunset” or expired at the end of FY 2023 (September 30, 2023) and one provision that would have sunset at the end of FY 2024 (see Table 2). These requirements will “sunset” again if not addressed through a future PEPFAR reauthorization or another legislative vehicle.

More generally, there is an important distinction between “authorizing” and “appropriations” legislation. Authorizing (or reauthorizing) legislation establishes programs and policies, oversight and reporting requirements, and provides guidance to appropriators on funding amounts and conditions. It may include time-bound provisions or may provide no end date for programs to operate, which they can do as long as they are funded. Such legislation can be put forward as a standalone bill or attached to another legislative vehicle, such as appropriations legislation (which is the case with this latest omnibus bill). Appropriations legislation provides budget authority, allowing funding to be provided to an agency or program; absent an authorization (or reauthorization), an appropriations bill can have the effect of allowing the continued operation of an existing program by providing funding. PEPFAR was created in 2003 through authorizing legislation (The Leadership Act), which established the program, its structure, and other program aspects without including any end date or sunsetting of the program (with the exception of some provisions). This means that PEPFAR largely operates under permanent authorities of U.S. law that allow for the program to continue as long as Congress appropriates funding. The omnibus bill also appropriated bilateral funding for PEPFAR at the same level as the prior year.

Table 1
PEPFAR Legislation
Full Title	Common Title	Public Law #	Years	Funding Authorization Level
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003	“The Leadership Act”	P.L. 108-25	FY 2004 – FY 2008	$15 billion
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008	“The Lantos-Hyde Act”	P.L. 110-293	FY 2009 – FY 2013	$48 billion
PEPFAR Stewardship and Oversight Act of 2013	“The PEPFAR Stewardship Act”	P.L. 113-56	FY 2014 – FY 2018	Did not specify authorization for funding
PEPFAR Extension Act of 2018	“The PEPFAR Extension Act”	P.L. 115-305	FY 2019 – FY 2023	Did not specify authorization for funding
Department of State, Foreign Operations, and Related Programs Appropriations Act, 2024	“Extension of Certain Requirements of PEPFAR”	P.L. 118-47	FY 2024 – March 25 of FY 2025 (March 25, 2025)	Did not specify authorization for funding
Note: Current law is reflected in the consolidation of PEPFAR authorizing legislation in U.S. Code: 22 USC Chapter 83: United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria. Source: KFF analysis of PEPFAR legislation.

Table 2
Current Status of PEPFAR Reauthorization’s Time-Bound Provisions
Topic of Provision	Description
1. HIV Bilateral Funding Allocation: Treatment, Care, Nutrition and Food Support	Requires that more than half of funds appropriated or otherwise made available for bilateral HIV be expended for treatment, care, and nutrition and food support for people living with HIV (through March 25, 2025)
2. HIV Bilateral Funding Allocation: Orphans and Vulnerable Children (OVC)	Requires that not less than 10% of funds appropriated or otherwise made available for bilateral HIV be expended for programs targeting orphans and other children affected by, of vulnerable to, HIV (through March 25, 2025)
3. Global Fund Contribution: 1/3 Cap	Limits U.S. contributions to the Global Fund to not exceed 33% of all funds donated to the Global Fund during a specified period (“1/3 cap”) (through March 25, 2025, calculated from FY 2004)
4. Global Fund Contribution: Use of Funds Withheld Due to 1/3 Cap	Authorizes that any of the U.S. contribution to the Global Fund withheld due to the 1/3 cap may be used for bilateral HIV, TB, and malaria programs (through March 25, 2025)
5. Global Fund Contribution: Withholding Obligation of 20% Pending Certification	Requires withholding 20% of annual U.S. contribution to the Global Fund pending certification of certain accountability and transparency benchmarks by the Secretary of State* (through March 25, 2025)
6. Global Fund Contribution: Withholding Portion if Funds Expended to Certain Governments	Requires withholding a portion of the U.S. contribution to the Global Fund, the next fiscal year, equal to the amount expended by the Global Fund to country governments determined by the Secretary of State to have “repeatedly provided support for acts of international terrorism” (through March 25, 2025)
7. Annual Treatment Providers Study	Directs the Global AIDS Coordinator to annually complete a study of treatment providers for HIV programs, including spending by the Global Fund and partner countries (through March 25, 2025)
8. Oversight Plans of Inspectors General	Directs various agencies’ inspectors general to jointly develop coordinated annual plans for overseeing HIV, malaria, and TB programs (through March 25, 2025)
Note: As of March 23, 2024. * In certain years, Congress directed the withholding to be 10%, rather than 20%. Source: KFF analysis of Further Consolidated Appropriations Act, 2024 (P.L. 118-47) and KFF, PEPFAR Reauthorization: Side-by-Side of Legislation Over Time.

Looking Ahead

After months of uncertainty surrounding reauthorization, which had created confusion and other challenges for the program, this latest step provides the program with some certainty for the time being. The short-term reauthorization signals a demonstration of bipartisan support, including by Congressional leadership – albeit limited – allowing it to move forward without any changes or controversial provisions around abortion (despite those sought by some). It also extends the program’s authorities past the next presidential election, thereby taking PEPFAR somewhat out of the direct line of sight of presidential politics for now. Finally, the bill also included funding for PEPFAR through the end of FY 2024 (which ends September 30, 2024).

At the same time, this latest development marks a departure from PEPFAR’s long-term history of strong support across party lines through multiple Congresses and administrations. It is possible that there will be more polarized debates over PEPFAR and its funding in the future, particularly as March 2025 and the end of the short-term reauthorization draws closer. Moreover, despite the latest reauthorization extending beyond the election, the outcome itself could have significant consequences for PEPFAR, beyond the debate about reauthorization. If President Trump is elected once again, he will almost certainly reinstate the Mexico City policy to apply to PEPFAR (and global health more generally), and it’s possible its reach could be expanded even further, including to encompass all U.S. foreign aid rather than just global health, as recommended in the Heritage Foundation’s Project 2025 report, intended as a blueprint for a Trump administration. While President Biden’s reelection would mean the Mexico City policy would remain rescinded, Republican control of one or both houses in Congress could result in continued controversy over PEPFAR and abortion. Regardless of electoral outcomes, the ground upon which PEPFAR sits has already shifted, potentially changing the political and programmatic calculus for PEPFAR in the years ahead.