An Update on PEPFAR Reauthorization
Kellie Moss and Jennifer Kates
Published:
PEPFAR’s latest reauthorization expired on March 25, 2025, heightening the stress the program is now experiencing as the Trump administration reviews and rolls back foreign aid. It has also raised several questions about whether PEPFAR can continue in the absence of reauthorization. This policy watch provides an update on what this means for PEPFAR. As it notes, because PEPFAR operates largely under permanent authorities of U.S. law, the program continues as long as funds are appropriated by Congress (although certain time-bound requirements lapsed as of March 25, 2025). At the same time, the changes and reforms being instituted by the Trump administration are posing larger challenges for PEPFAR going forward.
Box 1: PEPFAR Background |
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What is “authorizing” legislation, and how does it differ from “appropriations” legislation?
There is an important distinction between “authorizing” and “appropriations” legislation. Authorizing (or reauthorizing) legislation, which is the purview of Congressional authorizing committees, 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. Appropriations legislation, under the purview of Congressional appropriations committees, 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.
How was PEPFAR created?
PEPFAR was created in 2003 through authorizing legislation (The Leadership Act), which established the program, its structure – including creating a new position of U.S. Global AIDS Coordinator at the Department of State (with the rank of Ambassador) and participation in the Global Fund – and other program aspects without 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 recent Continuing Resolution for FY 2025 included the same level of funding for PEPFAR as provided in FY 2024.
What is PEPFAR “reauthorization”?
Since PEPFAR was a new program when created in 2003 and because it included some time-limited provisions, Congress has passed reauthorizing legislation four times, some of which included modifications to adapt to new circumstances and others with only date changes (extensions) to allow expiring provisions to continue (see Table 1 and the KFF side-by-side of PEPFAR legislation over time.). Reauthorization has also served to demonstrate Congress’ support for the program. The first three reauthorizations of the program were each for five-year periods. The most recent was short-term, extending expiring provisions for only one year, largely due to partisan debate related to abortion. This is not the first time PEPFAR reauthorization has lapsed while Congress considered reauthorization. For example, in 2018, some provisions of the PEPFAR Stewardship Act lapsed at the end of FY 2018 (Sept. 30, 2018) until the PEPFAR Extension Act was enacted more than two months later on Dec. 11, 2018, and in 2023, some provisions of the PEPFAR Extension Act lapsed at the end of FY 2023 (Sept. 30, 2023) until the recent short-term extension was enacted nearly six months later on March 23, 2024.
Table 1 | ||||
PEPFAR Legislation |
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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 | No amount specified |
PEPFAR Extension Act of 2018 | “The PEPFAR Extension Act” |
P.L. 115-305 | FY 2019 – FY 2023 | No amount specified |
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) | No amount specified |
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. |
What happened when PEPFAR’s latest reauthorization “expired”?
Under the recent short-term reauthorization of PEPFAR, there were eight time-bound requirements that “sunset” on March 25, 2025, when they were not extended by Congress. These included requirements related to Global Fund support, a funding directive for orphans and vulnerable children (OVC), and others (see Table 2). This means that these provisions are not currently required, although the administration can choose to follow them.
Table 2 | |
PEPFAR Reauthorization’s Time-Bound Provisions |
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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: Status as of April 14, 2025. * 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. |
Does this mean that the PEPFAR program is not authorized anymore?
No. PEPFAR is a permanent part of U.S. law and will continue, provided funds are appropriated, which Congress has once again done for FY 2025, the current fiscal year.
Are there any other impacts of having a lapsed reauthorization?
If PEPFAR is not reauthorized this year or in the near future, as mentioned above, the program won’t end, but there are practical and symbolic implications for the program and the people it serves, including:
- The lack of reauthorization marks a significant departure from PEPFAR’s long-time bipartisan support, following its short-term reauthorization last year. PEPFAR had long enjoyed strong bipartisan support across multiple Congresses and administrations. Despite the fact that funding for PEPFAR could continue absent reauthorization, the program may be more vulnerable in future funding debates.
- Failure to reauthorize the program, alongside recent foreign aid developments, may further concern partner countries and the people served by PEPFAR. In light of uncertainty surrounding the future of the program under the Trump administration, the lack of reauthorization by Congress creates further uncertainty in the field. It could also weaken PEPFAR’s partnerships and diplomatic efforts, particularly regarding longer-term planning, financial sustainability, and country leadership of efforts.
What is next for PEPFAR reauthorization?
While it is unknown what Congress will choose to do regarding PEPFAR reauthorization, options include:
- Do nothing. This legally allows the program to continue, since Congress has appropriated funding for its operations in FY 2025.
- Extend the dates of the eight lapsed time-bound provisions, in a reauthorization bill or another legislative vehicle.
- Reauthorize the program with changes to address concerns raised by members of Congress and others related to abortion (which shaped congressional consideration over the past two years) and the need to better demonstrate sustainability and transition plans to scale-down the program over time (such as requiring progressive country co-financing or graduation requirements.
What is the outlook for PEPFAR more broadly?
More broadly, however, PEPFAR is, for the first time in its two-decade history, facing significant challenges that could impede its ability to fulfill its mission. Recent actions of the Trump administration, such as the foreign aid freeze, the proposed “realignment” of USAID’s functions into the State Department, and cancellation of many grant awards, have significantly affected PEPFAR services, operations, and health outcomes. This has included reduced spending on PEPFAR, below the funding levels appropriated by Congress, raising questions about whether the administration will spend all the funding that has been appropriated for this purpose. At the same time, a divided Congress is likely to mean heightened disagreements over funding levels more generally across the federal budget, particularly amid administration efforts to cut spending and dramatically reduce the U.S. government footprint in foreign aid, including for global health. The administration has already indicated that it may seek rescissions of prior year funding amounts, which could further affect PEPFAR activities and funding, should Congress agree to these. In addition, the President’s budget request for FY 2026 has included significant cuts to global health, although it specifies that PEPFAR funding “is preserved for any current beneficiaries.” Cuts to PEPFAR’s budget were proposed in the first Trump administration but were rejected by Congress. The current dynamic, however, is much less certain.