By Christine Mungai

NAIROBI, March 6 (Thomson Reuters Foundation) - U.S. President Donald Trump's abrupt freeze of foreign aid has crippled humanitarian relief efforts around the world, but warning signs that global health funding was at risk had already emerged with the politicization of the country's landmark HIV/AIDS initiative.

Confusion persists more than a month after Trump's executive order paused foreign aid for 90 days, even after a subsequent waiver for "life-saving assistance," leaving health care workers who rely on U.S. assistance, including from the President's Emergency Plan for Aids Relief (PEPFAR), struggling to understand which services can continue.

Credited with saving millions of lives from AIDS since its launch in 2003 under a Republican president, PEPFAR long enjoyed support from both U.S. political parties and was considered a major foreign policy success.

The uncertainty it now faces reveals how no foreign assistance program, no matter how life-saving or bipartisan, is immune to America's culture wars.

The writing may have already been on the wall for PEPFAR.

In 2023, conservative U.S. lawmakers - fueled by claims the initiative financed abortions abroad - only renewed the program for one year instead of its usual five-year authorization. The latest mandate expires this month.

Trump's focus on an "America First" foreign policy, curbing reproductive rights and rolling back LGBTQ+ protections all make PEPFAR a likely target. But these domestic disputes, especially on abortion, have always reverberated beyond U.S. borders, dictating life-and-death outcomes for millions around the world.

'POLITICAL INTERFERENCE'

That link was first entrenched in the wake of Roe v. Wade, when the U.S. Supreme Court in 1973 ruled safe access to abortion was a constitutional right. The same year, the late conservative senator Jesse Helms secured an amendment to a foreign assistance act that barred direct foreign funding of abortions, giving the Helms Amendment its name.

A decade later, the Mexico City Policy, - often called the Global Gag Rule by critics - went further. It withholds U.S. family planning funds from any foreign organization that mentions abortion as an option, provides referrals or advocates for legal reform, even in countries where abortion is legal, effectively silencing health care providers and non-governmental organizations abroad.

"This means that Helms has been an act of direct political interference on the part of the U.S. government for over 50 years," said Bethany Van Kampen Saravia, senior legal and policy advisor of U.S.-based reproductive rights organization Ipas, in an email interview.

"Yet now, since the repeal of Roe v. Wade, the chill and impact of our own domestic policies have made the situation only worse, and other streams of funding, like PEPFAR, are directly impacted."

In 2022, the Supreme Court overturned Roe v. Wade, giving legislatures the power to regulate or ban abortion.

Though the Helms Amendment bars PEPFAR from financing abortion, Republicans, led by Congressman Chris Smith of New Jersey, have accused PEPFAR of indirectly funding abortion providers, part of longstanding efforts to conflate HIV care with reproductive rights, which, according to conservative think tank Heritage Foundation, is "code for abortion."

U.S. officials told Congress on Jan. 23 that four nurses at a PEPFAR-funded clinic in Mozambique had performed 21 abortions since January 2021 in what they described as the first time a PEPFAR-funded provider was found to have provided abortions in the program's 20-year history.

Now, PEPFAR has been caught up in the broader U.S. aid freeze, with aid workers and U.N. officials reporting that clinics are closing, confusion about what medicine can be distributed and fears funding may never be restored.

A limited waiver, granted on Feb. 1, allows for some PEPFAR services to resume during the 90-day period, including services for the prevention of mother-to-child transmission.

CONSERVATIVE ALLIANCE

Conservative political and religious leaders in Africa increasingly employ anti-abortion and "family values" rhetoric to restrict reproductive rights, a strategy that could affect PEPFAR-funded health services.

The collateral damage extends to PEPFAR. A coalition of U.S. anti-abortion groups wrote to Congress in 2023 to express concern that PEPFAR funds were being used to "promote abortions and push a radical gender ideology abroad."

Lawmakers and religious leaders from several African countries that receive PEPFAR funding also sent a letter to Congress, with "concerns and suspicions" that funding was being used to support abortion.

"The letter was signed by 131 African leaders, mostly pastors and MPs trained by these (U.S.-based) conservative organizations, demanding PEPFAR's review," explained researcher and gender advocate Ngare Kariuki.

"The ultimate impact is that (PEPFAR's) review process is corrupted," Kariuki said. "The narrative that PEPFAR is 'tainted' is now embedded on the record, jeopardizing its future."

Until Trump's executive order, the understanding was that as long as Congress budgets for PEPFAR, it can continue to function even without a formal long-term reauthorization, said Jennifer Kates of KFF, a nonprofit organization based in San Francisco focused on global health policy.

"What is surprising, however, is that he also issued stop-work orders for existing projects. This is not how things normally happen,” Kates told the Thomson Reuters Foundation.

Trump's unprecedented halt of foreign aid during a review of all programs faces legal challenges, but many worry the ultimate aim is to dismantle almost all U.S. foreign aid.

"If PEPFAR is modified or discontinued, it's not because of evidence - it's because a manufactured crisis serves an ideological agenda," Kariuki said.

African health care systems are bracing for the fallout, including a looming collapse in HIV care and reproductive health access.

"There is no way to quantify the impact of this uncertainty or what cuts would ultimately mean to a program that has saved over 26 million lives since its beginning," Saravia said.

(Editing by Ayla Jean Yackley. The Thomson Reuters Foundation is the charitable arm of Thomson Reuters. Visit https://www.context.news/)