The graves on the edge of the orphanage tell a story of despair. The rough boards in the cracked earth are painted with the names of children, most of whom died in the 1990s. That was before that HIV Drugs arrived.
Today, the orphanage in Kenya’s capital is a happier and more hopeful place for children living with HIV. But a political battle in the United States is threatening the program that helps keep them and millions of others around the world alive.
The reason for the threat? Abortion.
The AIDS The epidemic has killed more than 40 million people since the first recorded cases in 1981, tripled child mortality and reduced life expectancy by decades in the hardest-hit areas of Africa, where treatment costs were prohibitive. Horrified, Republican President George W. Bush and Congress two decades ago made the largest commitment by a nation in history to combat a single disease.
The program, known as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), works with nonprofit groups to provide HIV/AIDS medications to millions of people around the world. It strengthens local and national health systems, cares for AIDS orphans and provides vocational training for people at risk.
Now a small number of Republican lawmakers are threatening the stability of the program that officials say has saved 25 million lives in 55 countries from Ukraine to Brazil to Indonesia. This includes the lives of 5.5 million children born without HIV.
At the orphanage in Nairobi, program manager Paul Mulongo has a message for Washington.
“Let them know that the lives of these children we care for are in their hands alone,” Mulongo said.
The issue of abortion has been a sensitive issue since PEPFAR was introduced in 2003. Yet each time the program has been brought up for renewal in Congress, Republicans and Democrats have been able to put their partisan politics behind them and support a program that has long been considered a frontrunner in global aid.
“Most eras in countries are measured by the loss of life from war, famine and pandemic,” said Tom Hart, president of the ONE Campaign, a nonpartisan organization that worked with Bush to develop the program. “This era was measured by lives saved.” The campaign released a letter to Congress from dozens of faith leaders calling PEPFAR “a story of medical miracles and mercy.”
But bipartisan support from lawmakers is enormous as the program is set to expire at the end of September. The problems began in the spring when the Heritage Foundation, an influential conservative Washington think tank, accused the Biden administration of using PEPFAR “to advance its domestic radical social agenda abroad.”
The group pointed to new language from the State Department that calls on PEPFAR to work with organizations that advocate for “institutional reforms in law and policy related to women’s sexual, reproductive and economic rights.” Conservatives argued this was code for trying to link abortion to HIV/AIDS prevention, a claim the administration has rejected.
In language reminiscent of the early, harsh years of the epidemic, Heritage called HIV/AIDS a “lifestyle disease” that should be suppressed through “education, moral suasion and legal sanctions.” It recommended that U.S. funding for PEPFAR be cut in half, with poor countries bearing a greater share of the cost.
Shortly afterwards, the Republican representative said. Chris Smith, a long-time supporter of PEPFAR who authored the reauthorization bill in 2018, said he would not advance reauthorization this time unless it bans NGOs that use funds to provide or promote abortion services. His threat carries weight because he is chairman of the House Foreign Affairs subcommittee, which is responsible for funding the program.
But with that proposal facing stiff opposition from Democrats in Congress, Smith, with the support of prominent anti-abortion groups, wants to cut PEPFAR’s usual five-year funding to one year if that ban is not included. He said this would allow lawmakers to annually review contracts with partners they believe could support or provide abortion services.
“It’s a false narrative that says you can’t run (the program) year after year while we’re trying to protect the unborn child,” Smith told The Associated Press.
Proponents of the program say partners are already prohibited under current U.S. law from using the program’s funds for abortion services. The head of PEPFAR, John Nkengasong, said AP He knew of no instances in which the program’s funds were used, directly or indirectly, to fund abortion services.
He warned that any instability in the flow of U.S. funding for PEPFAR could have dangerous health implications worldwide, including in the United States. The key to fighting AIDS is the certainty that infected people can take a pill every day, he said.
Otherwise, the virus could come back “and about 20 million people could lose their lives in the coming years,” he said. “The fragile successes we have achieved will be lost.”
In Africa, too, many PEPFAR partners and recipients in largely conservative countries do not support abortion on religious grounds. But the idea that the program, which relies on a steady supply of HIV drugs, could be subject to political winds is cause for concern.
“If PEPFAR goes, who will cover these costs?” asked Josephine Kaleebi, who runs an organization in Uganda that helped the program’s first recipient with HIV treatment drugs.
“We are proud to say that the first recipient is alive,” Kaleebi said.
The group Reach Out Mbuya Community Health Initiative was founded by members of Uganda’s Catholic Church, which opposes abortion. In the reception area, portraits of priests line the walls.
But Reach Out helps anyone who needs HIV medication, Kaleebi said. About 6,000 people are being cared for, many of them “the most vulnerable” from one of the capital’s poorest areas, Kampala.
Mark Dybul, who helped found and lead PEPFAR under Bush, warned that weakening PEPFAR would also damage the diplomatic goodwill the U.S. has created in developing regions.
“It is no secret that we are in a geopolitical battle for influence in Africa with Russia and China,” he said. “And our greatest influence, visible and impactful, is PEPFAR.” A spokesman for former President Bush declined to comment.
In neighboring Kenya, Bernard Mwololo believes he is still alive because of the medicine PEPFAR supplies. “Sometimes it’s so crazy when you hear people saying that these HIV drugs should be bought by the local government,” he said. “I’m telling you, they can’t do it.”
The 36-year-old, now an HIV activist, spent most of his life in an orphanage in Nairobi after his parents died of AIDS. He remembered his arrival and the realization that he might have hope. He was enrolled in a better school, got a bicycle and ate a balanced diet.
The number of children in sub-Saharan Africa orphaned by AIDS peaked at 1.6 million in 2004, the year PEPFAR began rolling out HIV drugs, researchers wrote in a defense of the program, published last month in the medical journal The Lancet. In 2021, the number of new orphans fell to 382,000.
And deaths of infants and young children from AIDS have fallen by 80% in the region.
Now the orphanage is being remodeled. Children have fun playing football or swinging in the colorful play area. Some are among the 1.4 million children and adults living with HIV in Kenya, according to UNAIDS. More than a million have received free HIV medication thanks to PEPFAR.
Stopping PEPFAR would amount to “global genocide,” said Mulongo, the orphanage’s program manager.
He remembered how helpless he felt watching children die before HIV drugs were available. Nearly two decades ago, they were losing at least 30 children a month to AIDS.
Elsewhere in Nairobi, 16-year-old Idah Musimbi is part of a generation that grew up without the fear that an HIV diagnosis could mean a likely death sentence.
She showed off the pills that made her feel normal. She was infected with HIV at birth.
“I don’t think I would live long if these drugs stopped. My grandparents can’t afford to buy groceries every day, let alone these ARVs,” she said.
Her grandfather David Shitika, a pastor, said he owes his granddaughter and her mother’s life to PEPFAR. His daughter was diagnosed with HIV in 1995, when many people were dying.
“It was called the slimming killer disease,” he said. “No one wanted to live with an infected person, and the deceased were wrapped in nylon bags before burial” for fear of infection.
Now he hopes that the Republican threat to PEPFAR will subside and that his granddaughter can go to law school and pursue her dream of becoming a judge.
“I want to say to the American people: God bless you,” Shitika said. “I don’t know why you decided to help us.”
Amiri and Knickmeyer reported from Washington. AP writer Rodney Muhumuza contributed in Kampala, Uganda.