Nancy Pelosi, the Democratic former Home speaker, and George W. Bush, the Republican former president, don’t agree on a lot. However earlier this yr, they joined a high-powered gathering in Washington — with the Irish rock star Bono on video from Dublin — to mark the twentieth anniversary of America’s largest and, arguably, most profitable overseas assist program.

Mr. Bush created that program, the President’s Emergency Program for AIDS Reduction, in 2003. Within the 20 years since, PEPFAR, as it’s identified, has saved 25 million lives and served as a robust instrument for comfortable diplomacy, an emblem of America’s ethical management on the earth. It has had extraordinary assist from a bipartisan coalition of liberals and Christian conservatives.

However now PEPFAR is in peril of changing into a sufferer of abortion politics — simply because the State Division is reorganizing to make this system everlasting.

This system is ready to run out on the finish of September. However Home Republicans usually are not transferring ahead with a invoice to reauthorize it for an additional 5 years, as a result of abortion opponents — led by a G.O.P. congressman who has lengthy been a supporter of PEPFAR — are insisting on including abortion-related restrictions.

The stalemate is the most recent instance of how Republicans are utilizing their majority within the Home of Representatives to impose their conservative views on social coverage all through the federal authorities. They’ve targeted specifically on abortion, a yr after the Supreme Court docket overturned Roe v. Wade and, with it, the proper to authorized abortion. Earlier this summer time, Home Republicans loaded up the annual navy coverage invoice that has lengthy been bipartisan with provisions to restrict abortion entry and transgender care.

The struggle over PEPFAR, a $7 billion-a-year program that operates in additional than 50 nations, is analogous, as a result of it’s a broadly bipartisan program that now seems prone to being sucked right into a partisan struggle over cultural and social points.

PEPFAR continues to have extensive assist, together with from Consultant Michael McCaul of Texas, the Republican chairman of the International Affairs Committee, which oversees this system and approve the reauthorization laws. However up to now, Mr. McCaul has not superior it due to the objections of abortion foes, together with his Republican colleague, Consultant Christopher H. Smith of New Jersey, one of many main anti-abortion voices in Congress who additionally helped draft the laws creating PEPFAR.

Mr. Smith now says he is not going to conform to renew this system until it’s topic to the so-called Mexico Metropolis coverage — enacted by Republican presidents however lifted by Democrats, together with President Biden — that may bar this system from partnering with any group that gives abortion companies, irrespective of the supply of the funding.

That may be a non-starter for Democrats, who’re demanding a “clear” five-year reauthorization — one with no added coverage restrictions.

“We’ve performed clear reauthorizations for 20 years,” mentioned Consultant Barbara Lee, Democratic of California and a chief sponsor of PEPFAR.

However there’s a substantial stumbling block: Three influential exterior teams that oppose abortion — the Household Analysis Council, the Heritage Basis’s political motion arm and Susan B. Anthony Professional-Life America — have sided with Mr. Smith and intend to “rating” the vote once they compile their annual rankings of members of Congress. A vote for renewing PEPFAR with out the anti-abortion language can be counted as a demerit, making it politically poisonous for many Republicans.

The scenario has alarmed champions of this system. In an e mail, Bono known as the deadlock “insanity,” and known as on Congress to “defend the bipartisan dedication to maintaining politics out of PEPFAR.”

Mr. McCaul mentioned he’s “speaking to supporters each inside and outdoors the federal government, and dealing with my colleagues on each side of the aisle within the Home and the Senate” to resolve the dispute. He has additionally been texting with Bono, who in flip has been in contact with congressional leaders on the matter.

A senior White Home official, talking on the situation of anonymity to explain the negotiations, mentioned on Thursday that the White Home was “participating intently with Congress at senior ranges” in pursuit of a straight five-year reauthorization.

This system is a crucial legacy for Mr. Bush and different Republicans of his period, together with Invoice Frist, the previous Senate majority chief, and Rick Santorum, a former senator from Pennsylvania.

“I look again on the issues I did as a member of Congress, and really feel like I used to be ready, because the pro-life warrior in america Senate, to forge a compromise to get conservatives to assist this,” Mr. Santorum mentioned in an interview. “It’s been a terrific factor for our nation, and it’s been a terrific factor for humanity.”

Final week, Mr. Santorum publicly pleaded for a “five-year, clear extension” in an opinion essay within the conservative outlet Newsmax. He mentioned he supposed to make use of Congress’s upcoming August recess to attempt to forge a compromise.

However in current months, Mr. Smith, the New Jersey Republican, and right-wing teams have begun accusing the Biden administration of injecting progressive politics into this system.

In late Might, a Heritage Basis scholar revealed an essay in The Hill arguing that PEPFAR had develop into “more and more politicized” and wanted an overhaul. Mr. Smith adopted in early June with “Pricey Colleague” letter asserting that Mr. Biden had “hijacked PEPFAR.”

In an interview, he pointed to new language in a PEPFAR nation and regional operational plan calling for this system to companion with organizations that advocate for “institutional reforms in regulation and coverage concerning sexual, reproductive and financial rights of ladies.” He argued that was code for a plan to “combine abortion with H.I.V./AIDS work.”

The doc additionally says PEPFAR packages ought to “advance human rights and decriminalization for lesbian, homosexual, bisexual, transgender, queer, and intersex (L.G.B.T.Q.I.+) communities.” That didn’t sit properly with the Household Analysis Council, whose chief lobbyist, Travis Weber, lately known as PEPFAR “an enormous slush fund for abortion and L.G.B.T. advocacy.” In an interview, he mentioned he stood by these phrases.

The senior White Home official mentioned that the “intentional give attention to well being fairness is new” and that it got here in response to requests from native communities for PEPFAR to “deal with boundaries to well being for youngsters, adolescent ladies and younger girls, and key populations.” The point out of ladies’s rights refers to making sure that adolescent ladies have entry to colleges, the official mentioned.

The Biden administration has added a footnote to the doc clarifying that PEPFAR doesn’t fund abortions, an assertion that Mr. Smith known as “meaningless.”

There isn’t any proof that PEPFAR or its overseas companions have used federal tax {dollars} to advertise or carry out abortions; U.S. regulation doesn’t enable it. However some PEPFAR grantees, comparable to Inhabitants Providers Worldwide, a world well being nonprofit primarily based in Washington, do present abortion-related companies with cash from different sources.

“The assertion is made by critics is that organizations like P.S.I. are working with U.S. cash and concerned in abortion — and shouldn’t that be unlawful?” mentioned Karl Hofmann, the group’s president and chief government. “I assume my reply is, these two info are true, and it’s not unlawful.”

Ms. Lee, the California Democrat, mentioned she is working to “make clear this misrepresentation” being made by Mr. Smith.

However the prospects for a five-year extension appear bleak.

“We’re in a really precarious place,” mentioned Shepherd Smith, an evangelical Christian and a co-founder of Childrens AIDS Fund Worldwide, a nonprofit. He has organized different faith-based teams to concern a letter in assist of reauthorization.

Christopher H. Smith, the New Jersey congressman, has proposed another: He persuaded fellow Republicans to insert language right into a State Division spending invoice that may enable PEPFAR to maintain working for a yr and not using a new authorization, however topic to the anti-abortion restrictions. That measure, nevertheless, like most of the spending payments making their means by the Republican-led Home, is unlikely to be acceptable to the Democratic-controlled Senate.

And the symbolism of such a transfer can be devastating, PEPFAR’s backers say — a sign to different nations that america is abandoning its bipartisan dedication to finish the AIDS epidemic by 2030, and that Washington is actually damaged. It could even be a setback for world well being; PEPFAR has created an infrastructure of clinics in poor nations that present different companies, together with Covid-19 testing and vaccines.

“This isn’t a problem that in any respect includes abortion — it’s about having well being care amenities in nations to cope with pandemic kind of challenges,” mentioned Senator Benjamin L. Cardin, Democrat of Maryland. He known as PEPFAR’s creation “one of many nice moments in American overseas coverage.”

As the controversy performs out on Capitol Hill, the State Division official who oversees PEPFAR, Dr. John N. Nkengasong, is about to get a giant promotion. On Tuesday, Secretary of State Antony J. Blinken is anticipated to announce the institution of a brand new Bureau of World Well being Safety and Diplomacy, to be led by Dr. Nkengasong. The thought is to combine PEPFAR into the division’s broader world well being work and to transition it out of emergency standing.

Since its inception, this system has invested greater than $100 billion in combating the worldwide AIDS disaster. Unbiased analyses by Okay.F.F., previously the Kaiser Household Basis, have discovered that PEPFAR has helped enhance maternal and youngster well being and is “related to massive, important declines in mortality” in nations the place it has operated.

Backers of this system are hoping that Mr. Bush will weigh in. Earlier this yr, Emily Bass, an writer and activist, despatched the previous president a signed copy of her e-book, “To Finish a Plague: America’s Battle to Defeat AIDS in Africa,” which chronicles the PEPFAR story.

Just a few weeks in the past, Ms. Bass mentioned, Mr. Bush despatched a letter thanking her.

“Laura and I’ll stay invested on this mission for the remainder of our lives,” he wrote.


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