International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding

^Pr^ep^ar^{ed f}^o^r^M^e^m^b^ers^an^d^Com^mⁱ^t^t^ees^of^C^ong^r^e^ss

The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L.

108-25) authorizes $15 billion for U.S. global efforts to combat HIV/AIDS, tuberculosis (TB),

and malaria from FY2004 through FY2008. It also authorizes the Office of the Global AIDS
Coordinator (OGAC) to oversee U.S. government efforts to combat HIV/AIDS internationally.
These efforts to combat HIV/AIDS implement the President’s Emergency Plan for AIDS Relief
(PEPFAR), a program proposed by President Bush in January 2003.
President Bush requested $30 billion for the reauthorization of PEPFAR from FY2009 through
FY2013, estimating it would support HIV/AIDS treatments for 2.5 million people, the prevention
of more than 12 million new HIV infections, and care for more than 12 million HIV-affected
people, including 5 million orphans and vulnerable children.
On July 24, 2008, Congress reauthorized $48 billion for U.S. international HIV/AIDS,
tuberculosis, and malaria programs through FY2013 in H.R. 5501, the Tom Lantos and Henry J.
Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (hereafter referred to as the Reauthorization Act). The President
signed H.R. 5501 into law (P.L. 110-293) on July 30, 2008.
The Reauthorization Act makes a number of changes to U.S. international HIV/AIDS,
tuberculosis, and malaria programs. It increases funding for U.S. efforts to fight HIV/AIDS,
tuberculosis, and malaria and for U.S. contributions to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (Global Fund). It adds Vietnam to the list of PEPFAR Focus Countries;
proposes the use of compacts or framework agreements between the United States and each
country receiving HIV/AIDS funds under the reauthorization; and removes the 33% spending
requirement on abstinence prevention efforts, as well as the 20% spending recommendation on
prevention efforts overall. It establishes a Global Malaria Coordinator within the U.S. Agency for
International Development (USAID) and supports the sustainability of health care systems in
affected countries. It eliminates Immigration and Nationality Act (INA) language that statutorily
bars foreign nationals with HIV/AIDS from entering the United States.
This report discusses changes in coordination and funding for HIV/AIDS, tuberculosis, and
malaria programs as directed in the Reauthorization Act. It provides background on PEPFAR
implementation including results and funding through FY2008. It then discusses similarities and
differences between H.R. 5501 as passed by the House on April 2, 2008, and H.R. 5501 as passed
by the Senate on July 16, 2008. Finally, it details key outcomes in the legislation as enacted. This
report will be updated as events warrant.

Introduc tion ..................................................................................................................................... 1
PEPFAR: Implementation, Results, and Funding...........................................................................1
Implementation Structure..........................................................................................................2
OGAC and PEPFAR Countries...........................................................................................2
Participating U.S. Agencies................................................................................................2
International Organizations and International Initiatives....................................................3
Restrictions on Spending and Programs.............................................................................3
Result s ....................................................................................................................................... 4
Funding ........................................................................................................................ ............. 4
FY2004-2008 Appropriations.............................................................................................5
Key Reauthorization Proposals and Debates During Consideration of H.R. 5501.........................6
Funding Authorization Increase................................................................................................7
Global Malaria Coordinator......................................................................................................8
List of Focus Countries Expansion...........................................................................................9
Compacts with Recipient Countries........................................................................................10
Role of Spending Directives...................................................................................................10
Program Objectives..................................................................................................................11
Balance Between Prevention, Treatment, and Care................................................................12
HIV/AIDS Activities and Family Planning.............................................................................13
Health Systems and the Single Disease Approach..................................................................14
HIV/AIDS Activities and Nutrition Programs........................................................................15
Immigration and Nationality Act Amendment........................................................................16
Additional Oversight Activities...............................................................................................16
Taxation of Assistance Funds by Foreign Governments Prohibited.......................................17
Prevention of Mother to Child HIV Transmission (PMTCT) Panel.......................................17
Conscience Clause Expansion.................................................................................................17
Outcomes Under H.R. 5501/P.L. 110-293.....................................................................................17
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria Appropriations by Disease,
FY2004 through FY2008.............................................................................................................5
Table 2. U.S. Contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria,
FY2004 through FY2008.............................................................................................................6
Table 3. Comparison of Proposed Reauthorization Levels from FY2009 through FY2013
in House and Senate Versions of H.R. 5501.................................................................................7
Table 4. Outcomes of Key Proposals to Change International HIV/AIDS, Tuberculosis,
and Malaria Programs Under P.L. 110-293................................................................................18
Table 5. Key Authorization Levels from FY2009 through FY2013 in P.L. 110-293, the
Reauthorization Act of 2008.......................................................................................................20

Author Contact Information..........................................................................................................21

On May 30, 2007, President Bush announced that he would request $30 billion for the
reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), which is the ¹
coordinated U.S. government effort to combat HIV/AIDS globally. The President estimated
PEPFAR would support HIV/AIDS treatments for 2.5 million people, the prevention of more than

12 million new HIV infections, and care for more than 12 million HIV-affected people, including ²

5 million orphans and vulnerable children. In 2003, Congress authorized $15 billion for U.S.

efforts to combat global HIV/AIDS, tuberculosis, and malaria from FY2004 through FY2008
with the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
(P.L. 108-25) (hereafter referred to as the Leadership Act).
On July 24, 2008, Congress authorized $48 billion for U.S. global efforts to fight HIV/AIDS,
tuberculosis, and malaria and for U.S. contributions to the Global Fund to Fight AIDS, ³
Tuberculosis, and Malaria (Global Fund) from FY2009 through FY2013 through H.R. 5501, the
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008 (hereafter referred to as the
Reauthorization Act). The Reauthorization Act (P.L. 110-293) was signed into law on July 30,

2008.

This report describes U.S. efforts to combat international HIV/AIDS through PEPFAR including
an overview of its implementation structure, key program elements, results, and funding from
FY2004 through FY2008. It also details funding for tuberculosis, malaria, and U.S. contributions
to the Global Fund during that time. This report discusses similarities and differences between
H.R. 5501 as passed by the House on April 2, 2008, and H.R. 5501 as passed by the Senate on
July 16, 2008, including proposed changes in program authorities and funding for HIV/AIDS,
tuberculosis, and malaria programs. Finally, it details key outcomes in the legislation as enacted. ⁴
It does not describe U.S. efforts to combat tuberculosis and malaria.

On January 28, 2003, President Bush proposed the President’s Emergency Plan for AIDS Relief
(PEPFAR) in his State of the Union address, requesting $15 billion over five years to combat ⁵
HIV/AIDS. Congress authorized $15 billion for U.S. efforts to combat global HIV/AIDS,

¹^O^f^fⁱ^c^e^o^f^the^G^l^oba^{l A}^I^D^S^C^oor^dina^t^o^r⁽^O^G^A^C⁾^{, U}^.^{S. D}^e^pa^r^t^m^eⁿ^t^of^Sta^t^e^,^“^P^r^e^sⁱ^de^nt^B^u^s^h^A^nnou^nc^e^s^Fiv^e^-^Y^e^a^r^,
^$30^Billi^on^HIV^/^A^I^DS^P^l^aⁿ^,”^a^t^h^ttp://w^ww^.pe^p^fa^r.g^o^v^/⁸⁵⁸^11.^htm^.
²^Ibid^.
³^T^h^e^G^l^oba^{l Fun}^d^t^o^Fig^h^t^A^I^D^S^{, T}^ube^r^c^ulos^is^{, a}ⁿ^{d Ma}^la^rⁱ^a^,^he^a^d^q^u^a^r^te^r^e^{d in G}^e^ne^v^a^{, Sw}^itz^e^r^la^{nd, is}^aⁿⁱⁿ^de^peⁿ^d^eⁿ^t
^f^ounda^ti^{on t}^h^a^t^s^e^e^k^s^{to a}^ttr^a^c^t^aⁿ^{d r}^a^pi^dly^dis^bur^s^e^ne^w^r^e^s^our^c^e^s^{in de}^v^e^lopi^ng^c^o^uⁿ^tr^ie^s^aⁱ^m^e^{d a}^t^c^oun^te^rⁱ^ng^the
^t^h^{ree d}ⁱ^seases.^T^h^{e F}^uⁿ^dⁱ^s^{a f}ⁱⁿ^aⁿ^cⁱⁿ^{g veh}ⁱ^cl^e,^no^t^anⁱ^m^p^l^e^m^en^tⁱⁿ^{g agen}^c^y^.^F^o^{r m}^o^{re i}ⁿ^f^o^r^m^atⁱ^oⁿ^on^t^h^{e G}^l^o^b^a^l^F^uⁿ^d^,
^s^e^e^C^R^S^R^e^por^{t R}^L³³³⁹^6,^T^h^e^G^l^ob^{al F}^uⁿ^d^t^o^Fi^ght^AI^D^S^,^Tu^be^r^c^ulos^is^,^an^{d M}^a^l^a^rⁱ^a:^Pr^o^g^r^e^s^s^Re^por^t^an^{d I}^s^s^u^e^s^f^o^r
^C^ongr^e^s^s^,^by^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.
⁴^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^U^.^S.^e^f^f^o^r^t^s^to^c^o^m^b^a^t^tube^r^c^ul^os^is^{, s}^e^e^C^R^{S R}^e^por^t^R^L³⁴²⁴⁶^,^T^ube^r^c^ulosⁱ^s^:^Iⁿ^te^r^nat^io^nal
^Effo^rts^aⁿ^d^Issu^{es fo}^{r C}^o^ng^ress^{, b}^y^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^{. For m}^o^re^inf^o^rm^a^{tion on U.}^{S. e}^f^f^o^{rts to c}^o^m^b^a^t^m^a^la^ri^a^,^se^e
^C^R^S^R^e^por^t^R^L³³⁴^85,^U^.^S^.^Iⁿ^te^r^nati^oⁿ^a^{l H}^I^V/^AI^D^S^,^Tu^be^r^c^ulos^is^,^an^{d M}^a^l^a^rⁱ^a^Spe^ndi^ng:^FY2⁰⁰⁴^-^F^Y20⁰⁸^{, by}^Tⁱ^a^ji
^Sa^la^a^m^-Bl^y^the^r^.
⁵^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^P^E^PFA^R^,^s^e^e^C^R^S^R^e^por^t^R^L³³⁷^71,^Tr^e^ndsⁱⁿ^U^.^{S. G}^l^ob^{al AI}^D^S^S^p^eⁿ^dⁱⁿ^g^:^FY²⁰^00-
⁽^c^onti^nue^d.^..)

tuberculosis (TB), and malaria from FY2004 through FY2008 with the Leadership Act, which the
President signed into law (P.L. 108-25) on May 27, 2003.
The Leadership Act created the Office of the Global AIDS Coordinator (OGAC) in the ⁶
Department of State and outlined its role. OGAC directly approves all U.S. activities and funding
related to combating HIV/AIDS in the 15 PEPFAR Focus Countries. In addition to the Focus
Countries, OGAC has primary responsibility for the oversight and coordination of all U.S.
government resources and international activities to combat HIV/AIDS. This role extends to
ensuring program and policy coordination among the relevant executive branch agencies and non-
governmental organizations (NGOs), including auditing, monitoring, and evaluating all such ⁷
programs including activities conducted in non-Focus Countries.
In 2003, the 15 PEPFAR Focus Countries accounted for over 50% of all HIV-infected people in
the world. The 15 Focus Countries are Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya,
Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and ⁸
Zambia. OGAC estimates that from FY2004 through FY2008, 58% of PEPFAR funds will have ⁹
been spent on the 15 Focus Countries. OGAC transfers funds to PEPFAR-participating agencies
that administer HIV/AIDS programs in Focus Countries.
PEPFAR-participating agencies and departments, which receive funding transfers from OGAC,
include the U.S. Agency for International Development (USAID); the Department of State
(State); the Department of Health and Human Services (HHS) through the Centers for Disease
Control and Prevention (CDC), the National Institutes of Health (NIH), the Health Resources and
Services Administration (HRSA), the Food and Drug Administration (FDA), and the Substance
Abuse and Mental Health Services Administration (SAMHSA); the Department of Labor (DOL);
the Department of Commerce; the Peace Corps; and the Department of Defense (DoD). These
agencies may allocate their own agency funds for global HIV/AIDS, tuberculosis, and malaria
programs.

^(...c^on^tin^ue^d)
^FY20⁰⁸^{, by}^Tⁱ^a^{ji Sa}^la^am^-^B^l^y^the^r^,^a^{nd C}^R^S^R^e^por^{t R}^L³⁴¹⁹²^,^PEP^{FAR: P}^o^lic^y^Issue^s^{from FY}²⁰⁰⁴^throu^g^h^FY²⁰⁰⁸^,
^by^Tⁱ^a^ji^Sa^la^a^m^-Bl^y^the^r^.
⁶^Se^c^tion¹⁰²^of^P.L^.¹⁰^8-²⁵^{, t}^h^e^L^e^a^d^e^r^s^h^{ip A}^c^t.
⁷^O^G^A^C^,^“^F^Y²⁰⁰⁶^C^o^uⁿ^tr^ie^s^of^the^P^r^e^s^ideⁿ^t’^s^Em^e^r^g^e^ncy^P^l^aⁿ^f^o^r^A^I^D^S^R^e^lief⁽^P^E^PFA^R⁾^,”^a^t
^http:^//w^w^w^.pe^p^f^a^r^.^g^o^v^/^c^ountrⁱ^e^s^/⁸⁴³⁶²^.htm^.
⁸^T^h^{ese F}^o^cu^{s Co}^un^t^rⁱ^e^s,^excep^t^Vi^etⁿ^a^m^,^w^e^{re sp}^eci^fⁱ^edⁱⁿ^t^h^{e L}^ead^ershⁱ^p^A^c^t⁽^P^.^L^.¹⁰⁸^-²⁵⁾^.^S^ectⁱ^oⁿ¹⁰²⁽^B)(iⁱ^)(V^I^I)
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^Receiv^e^{U.S. Em}^erg^eⁿ^c^y^HIV^/^A^I^DS^A^ssistan^{ce,” Ju}ⁿ^e²²^,²⁰⁰⁴^,^{at h}^t^t^p^://v^ietn^am^.u^se^m^b^ass^y^.^g^o^v^/p^ep^f^a^r⁰⁴⁰⁶^22.^htm^l^.
⁹^O^G^A^C^fⁱ^g^u^r^e^s^{do not}^inc^l^ude^f^u^ndi^ng^f^o^r^U^.^{S. i}ⁿ^te^rⁿ^a^tⁱ^ona^{l m}^a^la^rⁱ^a^pr^og^r^a^m^s^{. OG}^A^C^{, “}^M^a^k^ing^A^Dⁱ^f^f^e^r^eⁿ^c^e^:
^Fun^d^ing^,^”^a^t^htt^p^://w^ww^.pe^p^fa^r.gov^/pre^ss/80⁰⁶^4.h^t^m^.

The Leadership Act authorizes funds to support U.S. contributions to some multilateral
organizations and international research initiatives including the Global Fund to Fight AIDS, ¹⁰
Tuberculosis, and Malaria (hereafter referred to as the Global Fund), the United Nations Joint
Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI).
OGAC reports that 16% of PEPFAR funds will support the Global Fund from FY2004 through ¹¹
FY2008.
Though Focus Countries receive the bulk of PEPFAR funding, individual Focus Countries may
not necessarily receive more funds than non-Focus Countries: for example, India, which is not a ¹²
Focus Country, receives more funding than Guyana, a Focus Country. OGAC determines annual
funding allocations for each Focus Country based on past funding allocations and provides an
initial budget estimate to U.S. staff in each PEPFAR country to help them formulate a Country
Operational Plan (COP). A COP provides data that informs OGAC’s final funding decision.
OGAC uses the COP to evaluate country-based information on the extent of the HIV/AIDS
epidemic, absorptive capacity for funding, effectiveness of PEPFAR efforts to date, and country ¹³
team projections of need.
In the Leadership Act, Congress outlined both funding distribution guidelines and “spending
directives” for HIV/AIDS assistance. Congress recommended that 20% of HIV/AIDS funds
should be spent on prevention. It required that from FY2006 through FY2008 at least 33% of ¹⁴
these prevention funds must be spent on abstinence-until-marriage programs. In addition,
Congress directed that from FY2006 through FY2008 not less than 55% of HIV/AIDS funds
must be spent on treatment, and of these, it recommended that 75% should support the purchase
and distribution of antiretroviral (ARV) drugs, while the remaining 25% should be spent on
related care for treatment patients. Congress also recommended that 15% of HIV/AIDS funds
should be spent on palliative care of HIV-affected people. Finally, it required that from FY2006
through FY2008 the remaining 10% of HIV/AIDS funds must be spent on orphans and vulnerable ¹⁵
children (OVC). It required that at least 50% of these OVC funds must be provided through
non-profit NGOs, including faith-based organizations (FBOs), that implement programs on the
community level.

¹⁰^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^the^G^l^o^b^a^l^Fu^nd^{, s}^e^e^C^R^S^R^e^p^o^r^t^R^L³³³^96,^The^G^l^ob^{al F}^uⁿ^d^t^o^Fi^ght^AI^D^S^{, T}^ube^r^c^ulos^is^,
^aⁿ^d^Ma^la^ri^a^:^Pr^o^g^r^{ess Rep}^o^r^t^and^Issu^{es fo}^{r C}^o^ng^ress^{, by}^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.
¹¹^O^G^A^C^fⁱ^g^u^r^e^s^{do not}^inc^l^ude^f^u^ndi^ng^f^o^r^U^.^{S. i}ⁿ^te^rⁿ^a^tⁱ^ona^{l m}^a^la^rⁱ^a^pr^og^r^a^m^s^{. OG}^A^C^{, “}^M^a^k^ing^A^Dⁱ^f^f^e^r^eⁿ^c^e^:
^Fun^d^ing^,^”^a^t^htt^p^://w^ww^.pe^p^fa^r.gov^/pre^ss/80⁰⁶^4.h^t^m^.
¹²^O^G^A^C^,^“²⁰⁰⁸^PE^P^F^A^R^C^o^uⁿ^tr^y^P^r^of^ile^s^:^Iⁿ^dⁱ^a^,^”^a^{nd “}²⁰⁰⁸^PE^P^F^A^R^C^ountr^y^P^r^of^ile^s^:^G^u^y^a^na^,”^a^t
^http:^//www^.pe^p^f^a^r.g^o^v^/^pre^ss/c¹⁹⁵⁵⁸^.htm^.
¹³^{For m}^o^re^inf^o^rm^a^{tion o}ⁿ^the^OG^A^C^a^lloc^a^{tion pr}^oc^e^{ss, se}^e^G^o^v^e^rⁿ^m^e^{nt Ac}^c^ounta^b^ili^ty^O^f^fⁱ^c^e⁽^GAO),^G^l^ob^al
^{HIV/AIDS: A M}^o^re^C^o^uⁿ^try^-^Base^{d Ap}^pro^a^c^h^C^oul^{d Impr}^ov^e^Alloc^a^tioⁿ^{of PE}^PFAR^Fun^dⁱⁿ^g^,^A^p^r^il²⁰⁰^{8, a}^t
^http:^//w^w^w^.g^a^o^.g^ov^/ⁿ^e^w^.item^s^/^d⁰⁸⁴⁸^0.^pdf^.
¹⁴^OGA^{C de}^fⁱ^ne^{s a}^b^stineⁿ^c^e^-^unti^l^-^m^a^rria^g^e^a^c^tiv^itie^{s a}^s^prog^ra^m^s^tha^t^a^ddre^{ss bo}^{th a}^b^stineⁿ^c^e^aⁿ^{d f}^a^ithf^u^lne^ss,
^acco^rdⁱⁿ^{g t}^o^G^A^O^,^G^l^{obal H}^e^a^lth^:^Speⁿ^dⁱ^ng^Re^quir^e^m^e^nt^Pr^e^s^eⁿ^ts^C^halleⁿ^g^e^s^for^Alloc^a^ti^{ng Pr}^eventⁱ^o^{n F}^uⁿ^dⁱⁿ^g
^Unde^{r the}^Pre^s^ideⁿ^{t’s Eme}^r^ge^nc^y^Plaⁿ^for^AIDS^Re^lie^f^{, A}^p^{ril 2}⁰⁰⁶^,^a^t^htt^p^://w^ww^.ga^o^.g^ov^/ne^w^.ite^m^s^/d06³⁹^5.^pdf^.
¹⁵^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^O^V^C^,^s^e^e^C^R^S^R^e^por^{t R}^L³²²⁵^2,^AI^D^S^O^r^pha^ns^a^nd^Vulⁿ^e^r^able^C^h^il^dr^eⁿ⁽^O^VC⁾^:
^Pr^oble^m^s^,^Re^s^p^ons^e^s^,^an^{d I}^s^s^u^e^s^for^C^o^ngr^e^s^s^{, by}^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.

When President Bush proposed PEPFAR in 2003, he projected that the five-year initiative to
combat HIV/AIDS globally would prevent 7 million new HIV infections, would provide
antiretroviral treatment for 2 million people, and would support care for 10 million HIV-affected ¹⁶
people.
As of September 30, 2007, OGAC reports that it has accomplished the following:¹⁷
• Prevention: supported over 33 million HIV counseling and testing sessions;
supported prevention of mother to child [HIV] transmission (PMTCT) services in
more than 10 million pregnancies; and prevented an estimated 157,000 infant
infections.
• Treatment: provided antiretroviral treatment for about 1.45 million people,
including 86,000 children.
• Care: supported care for more than 6.6 million HIV-affected people, including
more than 2.7 million orphans and vulnerable children (OVC).
The Leadership Act authorizes $15 billion to address HIV/AIDS, tuberculosis, and malaria
globally and to provide U.S. contributions to the Global Fund from FY2004 through FY2008.
OGAC calculates PEPFAR funding as the total of enacted funding for U.S. efforts to combat
HIV/AIDS globally, U.S. efforts to combat tuberculosis internationally, and U.S. contributions to ¹⁸
the Global Fund. Prior to FY2006, PEPFAR funding also included U.S. efforts to combat
malaria. Then in June 2005 the President introduced the President’s Malaria Initiative (PMI) to ¹⁹
expand U.S. government efforts to combat malaria globally. As a result, OGAC excluded ²⁰
malaria funding from PEPFAR calculations beginning in FY2006. Since that time, U.S. ²¹
government spending on malaria has been reported separately. Since the Leadership Act
authorization included malaria programs, the funding data in this report includes malaria and PMI
funding. This report details funding separately for HIV/AIDS, TB, malaria, and U.S.
contributions for the Global Fund.

¹⁶^T^h^{e W}^hⁱ^t^e^Ho^u^s^e,^“F^act^S^h^eet^:^T^h^e^P^r^esi^d^en^t^’^s^E^m^er^gen^c^y^P^l^an^f^o^{r A}^I^DS^Relⁱ^e^f^,^{” Jan}^u^a^r^y²⁹^,²⁰^03,^at
^http:^//w^w^w^.^w^hite^hous^e^.^g^o^v^/^ne^w^s^/r^e^l^e^a^s^e^s^/²⁰⁰^3/^01/²⁰⁰³⁰¹^29-^1.^ht^m^l^.
¹⁷^O^G^A^C^ha^s^upda^te^{d s}^o^m^e^but^no^t^a^{ll of}^the^s^e^s^t^a^tis^tic^s^thr^oug^h^Ma^r^c^{h 31}^{, 2}⁰⁰⁸^{; C}^R^{S ha}^sⁱⁿ^c^l^u^d^e^d^s^t^a^tis^tic^s^a^v^a^ila^ble
^thr^o^ug^{h Se}^p^t^e^m^be^r^{30, 2}⁰⁰⁷^,ⁱⁿ^o^r^de^r^to^pr^ovⁱ^d^e^m^o^r^e^de^ta^ile^{d inf}^o^r^m^a^{tion. D}^a^taⁱⁿ^th^is^s^e^c^{tion w}^a^s^c^o^m^p^ile^{d by}^C^R^S
^f^r^o^m^OG^A^C^{, “L}^a^t^e^s^{t R}^e^s^u^lts^,”^a^t^http:^//w^w^w^.pe^p^f^a^r^.^g^o^v^/^a^bout/^c¹⁹⁷⁸⁵^.htm^.
¹⁸^OGA^{C, “}^M^a^k^ing^A^Di^ff^e^r^eⁿ^c^e^:^Fun^d^ing^,^”^a^t^htt^p^://w^ww^.pe^p^fa^r.gov^/pre^ss/80⁰⁶^4.h^t^m^.
¹⁹^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^P^M^I^,^s^e^e^C^R^S^R^e^por^t^R^L³³⁴^85,^U^.^S^.^Iⁿ^te^r^nati^oⁿ^a^{l H}^I^V/AI^D^S^,^Tu^be^r^c^ulosⁱ^s^{, an}^{d M}^a^l^a^rⁱ^a
^S^p^e^ndⁱⁿ^g^:^FY²⁰⁰⁴^-^F^Y2⁰⁰⁸^,^by^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.
²⁰^O^G^A^C^,^“A^ppe^ndix^{1: T}^h^e^P^r^e^s^id^eⁿ^t’^s^Em^e^r^ge^ncy^P^l^aⁿ^f^o^r^A^I^D^S^R^e^lie^f^Sour^c^e^s^of^Fundi^ng^,”^The^Powe^r^of
^Partne^rshi^p^{s: Th}^{ird A}ⁿⁿ^u^a^l^Re^p^o^r^{t to C}^oⁿ^g^re^{ss on P}^EPFAR⁽²⁰⁰⁷⁾^{, a}^t^htt^p^://w^ww^.pe^p^f^a^r.^g^o^v^/^doc^u^m^eⁿ^ts/org^aⁿ^iz^a^tion/
⁸¹⁰¹⁹^.p^df^.
²¹^US^A^I^D,^Re^por^{t to}^C^o^ngr^e^s^s^:^U^S^AI^D^FY²⁰⁰^{6 M}^a^l^a^rⁱ^a^Pr^o^g^r^a^m^m^ing^Re^por^t^N^o^.¹^{, a}^t^htt^p^://^pdf^.us^a^id.g^ov^/^pdf^_doc^s^/
^P^D^A^C^H^688.^pdf^.^R^e^po^rt^to^C^oⁿ^g^r^ess:^US^A^I^{D F}^Y²⁰⁰⁶^Ma^la^ri^{a P}^r^og^ra^mmi^ng^R^e^po^rt^N^o^.²^{, a}^t^http^://^pdf^.usa^id.g^ov^/
^pdf^_d^oc^s/P^D^A^C^H689^.p^df^{. Pre}^s^id^eⁿ^{t’s Ma}^la^ria^Initia^tⁱ^v^e^{(PMI), US}^A^I^D,^PM^I^Fir^s^t^Annu^{al Re}^por^t:^S^a^vⁱ^ng^the^Liv^e^s^of
^M^o^the^{rs an}^{d Ch}^ildreⁿⁱⁿ^Afric^a^,^Ma^rc^{h 20}⁰⁷^{, a}^t^http^://w^w^w^.p^mⁱ^.gov^/re^s^ourc^e^s^{/ pm}^i_a^nnua^l^_^re^por^t.^pdf^.^P^M^I,^U^S^A^I^D^,
^PM^I^Se^c^ond^An^nu^{al Re}^por^t:^Pr^og^r^e^s^s^Thr^oug^{h P}^a^r^t^ne^r^s^hⁱ^p^s^:^S^a^vⁱⁿ^g^Liv^e^sⁱⁿ^Afrⁱ^c^a^,^htt^p^://w^ww^.p^mⁱ^.g^ov^/re^s^ourc^e^s^/
^pm^i_a^nnua^l_r^e^por^t⁰⁸^.^p^d^f^.

From FY2004 through FY2008, Congress appropriated $15.3 billion to U.S. programs to combat
global HIV/AIDS, of which $10.6 billion was spent in the 15 PEPFAR Focus Countries through
the Global HIV/AIDS Initiative (GHAI); $530 million to U.S. programs to combat TB; and $915 ²²
million to U.S. programs to combat malaria (Table 1). Congress also appropriated $3.0 billion ²³
to the Global Fund (Table 2).
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria Appropriations by Disease,
FY2004 through FY2008
^{(Current U.S. $ Millions)}
^{AIDS Prog}^ram^Amou^nt
^{USAID HIV/AIDS}^2,03^1.0
^{State Global HIV/AIDS Initiative (}^GHAI)^10,6^24.0
^{Foreign Military Financing}^6.9
^{CDC Global AIDS Program}^754.²
^{CDC International HIV Resear}^ch^23.0
^{NIH I}^nter^{national HIV Researc}^h^1,79^5.8
^{DOL AIDS Initiative}^11.8
^{DOD HIV/AIDS Prevention Educ}^ation^25.0
^{Total HIV/AIDS Funding}^a^15,2^71.7
^{Tuberculosis Pr}^og^ram^Amou^nt
^{USAID Tuberculosis}^525.⁷
^{CDC Tuberculosis}^4.3
^{Total Tuberculosis Funding}^530.⁰
^{Malaria Progr}^am^Amou^nt
^{USAID Malaria}^870.³
^{CDC Malaria}^44.9
^{Total Malaria Funding}^b^915.²
^Source:^{Derived from data p}^res^{ented in CRS Report RL33}⁴⁸^5,^U^{.S. International HI}^{V/AIDS, Tu}^bercul^{osis, and}
^{Malaria Spend}^{ing: FY2004-FY2008}^,^{by Tiaji Salaam-}^Blyther.
^a.^{Includes UNA}^{IDS, International}^{AIDS Vaccine Initiative (IAVI), and international microbicide research}
^{contributions.}
^b.^{Includes President’s}^{Malaria Initiative (PMI).}

²²^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^G^H^A^I^{, P}^E^PFA^R^,^T^B^{, a}^{nd m}^a^la^rⁱ^a^a^ppr^o^p^rⁱ^a^tio^ns^{, s}^e^e^C^R^S^R^e^p^o^r^t^R^L³³⁴^85,^U.^S^.
^Iⁿ^te^r^nat^io^{nal H}^I^V^/^AI^D^S^,^Tu^be^r^c^u^l^os^is^{, a}ⁿ^d^M^a^larⁱ^a^Speⁿ^dⁱⁿ^g:^F^Y²⁰⁰⁴^-^F^Y2⁰⁰⁸^,^by^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.
²³^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^the^G^l^o^b^a^l^Fu^nd^{, s}^e^e^C^R^S^R^e^p^o^r^t^R^L³³³^96,^The^G^l^ob^{al F}^uⁿ^d^t^o^Fi^ght^AI^D^S^{, T}^ube^r^c^ulos^is^,
^aⁿ^d^Ma^la^ri^a^:^Pr^o^g^r^{ess Rep}^o^r^t^and^Issu^{es fo}^{r C}^o^ng^ress^{, by}^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.

Table 2. U.S. Contributions to the Global Fund to Fight AIDS, Tuberculosis, and
Malaria, FY2004 through FY2008
^{(Current U.S. $ Millions)}
^{Global Fund C}^ontributions^Amou^nt
^{USAID 1,14}^0.6
^{State GHAI}^1,12^1.0
^{NIH 741.}¹
^{Total Global Fund Contribution}^3,00^2.7
^Source:^{Derived from data p}^res^{ented in CRS Report RL33}⁴⁸^5,^U^{.S. International HI}^{V/AIDS, Tu}^bercul^{osis, and}
^{Malaria Spend}^{ing: FY2004-FY2008}^,^{by Tiaji Salaam-}^Blyther.

On May 30, 2007, President Bush urged Congress to extend PEPFAR from FY2009 through ²⁴
FY2013 with an additional $30 billion authorization. The Administration estimates that $30
billion would support treatment for 2.5 million people, the prevention of more than 12 million
new infections, and care for more than 12 million people, including 5 million orphans and ²⁵
vulnerable children.
The Administration’s FY2009 budget request included $6 billion for U.S. international ²⁶
HIV/AIDS and tuberculosis programs. Of this $6 billion, $500 million was requested for a U.S. ²⁷
contribution to the Global Fund. The President also separately requested $385 million for the ²⁸
President’s Malaria Initiative (PMI) for U.S. global malaria eradication efforts.
The following section focuses on key proposed changes to U.S. programs that combat HIV/AIDS,
tuberculosis, and malaria, as suggested by the April 2, 2008, version of H.R. 5501 that was passed
by the House and the July 16, 2008, version of H.R. 5501 that was passed by the Senate and that
was subsequently voted on and passed by the House and enacted into law. This section highlights
key proposed requirements and funding allocations included in either version of the bill and
discusses the debate surrounding the proposals, including debates about possible policy
implementation implications.

²⁴^OGA^{C, “}^P^re^side^{nt Bus}^h^A^nno^un^c^e^s^Fiv^e^-Ye^a^{r, $30}^Billi^on^HIV^/^A^I^DS^P^l^aⁿ^,”^a^t^htt^p^://w^ww^.pe^p^fa^r.g^o^v^/⁸⁵⁸^11.^htm^.
²⁵^Ibid^.
²⁶^Dⁱ^r^e^c^t^or^of^U^.^S.^For^e^ig^{n A}^s^sⁱ^s^t^anc^e^,^U^.^{S. D}^e^pa^r^t^m^e^{nt of}^Sta^t^e^,^F^Y²⁰⁰^{9 I}ⁿ^te^rⁿ^a^tⁱ^ona^{l A}^f^f^a^ir^s⁽^F^unc^tion¹⁵⁰⁾
^Cong^re^ssiona^{l B}^udg^e^t^Justif^ic^a^tio^{n f}^o^{r Fore}^ig^{n O}^p^e^r^a^tio^{ns: A}^nne^x^A^{- P}^r^e^s^ideⁿ^{t’s Em}^e^r^g^e^nc^y^P^l^aⁿ^f^o^{r A}^I^{DS Re}^lie^f^,^a^t
^http:^//w^w^w^.s^ta^te^.g^ov^/^doc^um^eⁿ^ts^{/ or}^g^a^niz^a^tion/¹⁰¹⁴⁵⁸^.p^df^.
²⁷^Ibid^.
²⁸^Dⁱ^r^e^c^t^or^of^U^.^S.^For^e^ig^{n A}^s^sⁱ^s^t^anc^e^,^U^.^{S. D}^e^pa^r^t^m^e^{nt of}^Sta^t^e^,^F^Y²⁰⁰^{9 I}ⁿ^te^rⁿ^a^tⁱ^ona^{l A}^f^f^a^ir^s⁽^F^unc^tion¹⁵⁰⁾
^C^ong^r^e^s^sⁱ^ona^{l B}^udg^e^t^J^u^s^tif^ic^a^tio^{n f}^o^r^For^e^ig^{n O}^p^e^r^a^tio^ns^{: R}^e^que^s^t^by^A^ppr^op^rⁱ^a^tio^{n A}^c^c^ount—^E^x^-^I^m^B^a^nk^{, O}^P^I^C^,
^UST^D^A^,^{CSH, DA}^{, ID}^A^,^a^{nd T}^I^{, a}^t^http^://w^ww^.^s^ta^te^.g^ov^/^doc^um^eⁿ^ts/org^aⁿ^iz^a^tion/¹⁰¹⁴^17.^pdf^.

H.R. 5501 as passed by the House proposed up to $50 billion for U.S. international efforts to
combat HIV/AIDS, tuberculosis, and malaria during the reauthorization period of FY2009 ²⁹
through FY2013. It would have authorized $10 billion for each of the five years. The Senate
version proposed $48 billion in total over the same period for these activities. Both versions also
proposed authorizing higher funding levels for U.S. contributions to the Global Fund and for U.S.
efforts to combat tuberculosis and malaria (Table 3).
Table 3. Comparison of Proposed Reauthorization Levels from FY2009 through
FY2013 in House and Senate Versions of H.R. 5501
^{Area o}^f^Auth^orization^{H.R. 5}^{501 as passed by the}^House^{H.R. 5}^{501 as passed by the}^Senate
^{Overall for HIV/AIDS, Tuberc}^{ulosis, and}^$50^{billion ($10 billion each fiscal}^$48^{billion (in total}⁾
^Malaria^{year over five yea}^rs)
^{U.S. C}^{ontribution to Global Fund}^to^{Up to $2}^{billion for U.S}^.^{Up to $2}^{billion for U.S}^.
^{Fight AIDS, Tuberculosis, and Ma}^laria^{contributions in ea}^{ch of FY2}⁰⁰⁹^and^{contributions in FY2}⁰⁰^9;
^FY2010;^{such sums}^as^{may be necessar}^y
^{such sums}^as^{may be necessar}^y^fr^om^{from FY201}^{0 t}^hroug^{h FY20}^13.
^FY2011^thro^{ugh FY2}⁰¹^3.
^Tuberc^ulosis^$4^billi^{on (in total)}^$4^billi^{on (in total)}
^Malaria^$5^billi^{on (in total)}^$5^billi^{on (in total)}
^Source:^{Compiled by CRS from}^{April 2, 20}^{08, Hou}^{se-passed ve}^{rsion and July}^16,²⁰⁰^{8, Senate-pas}^s^{ed version of}
^{H.R. 5501.}
The Senate version of H.R. 5501 also proposed authorizing $2 billion for an emergency fund for
Indian health and safety from FY2008 through FY2013. The Senate adopted S.Amdt. 5076 to S.
2731, the basis for the substitute amendment to H.R. 5501, and S.Amdt. 5084, which amended
S.Amdt. 5076. These amendments added language that requires an emergency plan to address the
law enforcement, water, and health care needs of Indian tribes and directs the expenditure of the ³⁰
funds for particular purposes.
Critics of the $50 billion and $48 billion authorization levels argued that it would be fiscally
irresponsible to spend such levels in light of U.S. military operations in Iraq and Afghanistan, a
near economic recession in the United States, and questions about the absorptive capacity of
recipient countries. Some analysts suggested that increased disease-specific funding in the foreign
operations appropriations would drain available funding from other aid priorities in developing
countries, such as agriculture assistance and private sector growth. Others opposed increased
funding because they did not want to expand current PEPFAR activities to support additional
Focus Countries and to fund activities not directly related to AIDS. Critics of high spending levels

²⁹^Ac^c^o^r^dⁱⁿ^g^to^C^o^ngr^e^s^sⁱ^o^{nal Q}^u^a^r^te^r^l^y^{, the}^f^undi^ng^le^v^e^{l f}^o^r^P^E^PF^A^R^pr^og^r^a^m^s^{in H}^.^R^.⁵⁵⁰¹^is^t^h^e^r^e^s^u^{lt of}^a
^co^m^p^ro^mⁱ^s^e^reach^ed^t^h^{e n}ⁱ^gh^t^b^e^fo^{re i}ⁿ^t^r^o^d^u^c^tⁱ^oⁿ^.^A^d^am^G^r^ah^a^m^-^Sⁱ^l^v^er^m^aⁿ^,^“L^a^w^ma^{kers P}^u^{sh Bi}^partⁱ^s^an^Deal^oⁿ
^G^l^oba^{l A}^I^{DS Bill,”}^{CQ To}^d^a^y^{, Fe}^br^ua^r^y^{26, 2}⁰⁰⁸^.
³⁰^For^f^u^r^t^he^r^inf^o^r^m^a^{tion, s}^e^e^C^R^S^R^e^por^{t R}^L³⁴⁴⁶^1,^Iⁿ^te^rⁱ^or^,^Envⁱ^r^onm^eⁿ^t,^a^nd^Re^late^d^Ageⁿ^cⁱ^e^s^:^F^Y²⁰⁰⁹
^Appr^o^p^rⁱ^a^tio^ns^,^by^C^a^r^o^{l H}^a^r^d^y^Vinc^eⁿ^{t e}^t^a^l^{.; a}^{nd C}^R^{S R}^e^p^o^r^t^R^L³²¹⁹^8,^I^ndi^an^Re^s^e^r^v^e^d^W^a^te^r^Rights^:^An
^Overvi^ew^{, b}^y^Y^u^le^Kⁱ^m^.

were concerned about proposals to increase the number of Focus Countries and to extend
PEPFAR funds to support health care infrastructure as well as to enhance nutrition and feeding ³¹
programs. For example, Senators who placed a hold on H.R. 5501 and S. 2731 had stated that
the bills would “transform a targeted and accountable $15 billion dollar AIDS program into an ³²
unaccountable, unspecified $50 billion development program.”
Proponents of the authorization level argued that access to HIV/AIDS prevention, treatment, and
care for all would require greater resources. As a result, debate among bill advocates focused on
where the dollars should be spent and what priorities the increased funding should support. Some
urged Congress to consider further definition of tuberculosis authorities and targets, improved
coordination of tuberculosis activities with HIV/AIDS activities in areas of co-infection, and
strengthened reporting requirements for tuberculosis. Backers of the increased authorization
argued that the next stage in fighting AIDS, tuberculosis, and malaria must occur alongside the
strengthening of health systems. They argued that these activities must be integrated with related
development efforts in order to ensure the sustainability of efforts to fight the three diseases.
Some opponents used the Congressional Budget Office’s (CBO) cost estimates to justify a lower
authorization funding level. CBO estimated that implementing either H.R. 5501 or S. 2731, which
was the bill from which language for the Senate-passed version of H.R. 5501 was drawn, would
cost $35 billion from FY2009 through FY2013 and that most of the additional amounts of ³³
authorized funding would be spent by FY2018. Some argued that the CBO cost estimates
assumed that outlays will follow historical spending patterns for existing programs and did not
reflect the proposed increases in authorization levels for tuberculosis and malaria spending and
for the U.S. contribution to the Global Fund.
Both bills would have established a Coordinator of United States Government Activities to
Combat Malaria Globally (Global Malaria Coordinator) at USAID. The Global Malaria
Coordinator would oversee and coordinate all U.S. resources for international activities related to
combating malaria. The bills also would have authorized the Global Malaria Coordinator to
provide financial assistance to multilateral efforts such as the Roll Back Malaria Partnership ³⁴
(RBM). The proposed authorization of a Global Malaria Coordinator was related to the creation

³¹^A^d^a^m^G^r^a^h^a^m^-Silve^r^m^a^{n, “}^D^e^s^p^ite^Ef^f^o^{rts, Se}^na^te^G^l^oba^{l A}^I^DS^Le^gⁱ^sla^{tion Sta}^lle^d^Ov^e^r^{Cost Co}^nc^e^r^ns,”^CQ
^Tod^a^y^{, J}^u^ne¹³^,²⁰^08.
³²^S^e^ven^S^eⁿ^a^t^o^rs^p^l^aced^{a ho}^l^d^on^H.^R.⁵⁵⁰¹^an^{d S}^.²⁷³¹^on^M^a^rch³¹^,²⁰⁰⁸^.^S^{ee S}^eⁿ^a^t^o^{rs T}^o^m^C^obur^n,^Jⁱ^m^D^e^Mint,
^J^e^ff^Se^s^s^ions^{, Ric}^h^a^r^d^Burr,^Sa^x^b^y^Cham^blis^s^,^Jⁱ^m^Bunni^ng^{, a}^{nd D}^a^vⁱ^{d V}^itte^r,^“^L^e^tte^{r to Se}^na^tor^Mi^tc^{h Mc}^Co^nne^ll,”
^Ma^rc^{h 31}^{, 2}⁰⁰⁸^{, a}^t^htt^p^://c^ob^urn.s^e^na^te^.g^ov^/ffm^/ⁱ^nde^x^.^c^f^m^?^Fuse^A^c^tion=^Fi^le^s.Vⁱ^e^w^&^F^ile^Store^_ⁱ^d⁼⁸^2a^33c⁰⁴^-4⁸³^3-
^4a^00-⁹⁸^95-^4f^f^924bd^9b^04.^Se^na^t^o^r^s^C^o^b^u^rⁿ^a^{nd B}^u^r^r^s^u^bs^e^que^ntly^w^ithdr^e^w^theⁱ^r^obje^c^tio^{n t}^o^a^m^o^{tion t}^o^pr^o^ceed^t^o
^{S. 2}⁷³¹^{; se}^e^“^L^e^tte^{r to Se}^na^tor^M^itc^{h Mc}^Co^nne^ll^,”^July^{1, 2}⁰⁰⁸^{, a}^t^http:^//c^o^bur^n.se^na^te^.g^ov^/ffm^/
^inde^x^.^c^f^m^?^Fus^e^A^c^tion=^File^s^.^Vie^w^&^F^ile^Stor^e^_ⁱ^d⁼^d^e⁶⁵³^5c^6-^c¹⁵¹^-⁴⁷¹^7-^89f^f^-^26c³⁹⁹^bf³⁰²^{4. A}ⁿ^a^g^r^e^em^eⁿ^{t to lim}^it
^a^m^e^ndm^eⁿ^{ts to S}^.²⁷³¹^t^o^t^hoseⁱ^d^eⁿ^tif^ie^{d a}ⁿ^d^a^g^re^e^d^to^a^s^fⁱ^{rst de}^g^r^e^e^b^y^the^{bill’s m}^a^na^g^e^{rs (10 a}^m^e^ndm^eⁿ^ts)^w^a^s
^reach^ed^wⁱ^t^h^m^o^st^o^f^t^h^{e S}^eⁿ^a^t^o^rs.^S^h^o^r^t^l^y^t^h^ereaf^t^e^r,^t^h^{e S}^eⁿ^a^t^eⁱ^nvo^ked^cl^o^t^u^r^{e on}^{a m}^o^tⁱ^oⁿ^t^o^p^r^o^c^eed^t^o^t^h^{e b}ⁱ^l^l^.
³³^C^ong^r^e^s^sⁱ^ona^{l B}^udg^e^t^O^f^fⁱ^ce⁽^C^B^O⁾^,^{Cost Estim}^ate^:^H.R.⁵⁵⁰¹^{, Ma}^rc^h^{5, 20}⁰⁸^,^a^t^http^://w^w^w^.^c^bo.g^o^v^/^f^t^pdoc^s^/^90x^x^/
^d^o^c⁹⁰²⁹^/h^r⁵⁵⁰^1.^pd^f^.^C^B^O^,^C^o^st^E^s^tⁱ^m^a^t^e:^S.²⁷³¹^{, A}^p^ril^11,²⁰⁰⁸^,^a^t^htt^p^://w^w^w^.c^bo.g^o^v^/^f^t^pdoc^s^/⁹¹^x^x^/^doc⁹¹²⁶^/
^s²⁷³^1.^pdf^.
³⁴^T^h^e^R^o^{ll B}^a^c^k^Ma^la^rⁱ^a^P^a^r^t^ne^r^s^hⁱ^{p (}^R^B^M⁾^is^a^pa^r^t^ne^r^s^hip^of^or^g^a^niz^a^tions^tha^t^aⁱ^m^s^{to pr}^ov^ide^a^c^oor^dina^te^{d g}^l^oba^l
^a^ppr^oa^c^h^{to f}ⁱ^g^h^ting^m^a^la^rⁱ^a^.^R^B^M^w^a^s^la^unc^he^{d in}¹⁹⁹⁸^by^the^W^o^{rld He}^a^{lth Org}^a^niz^a^tion^(W^{HO), the}^Uni^t^e^d
^N^a^tions^C^h^ildr^e^n’^s^Fu^nd⁽^U^N^I^C^E^F)^{, the}^Uⁿ^ite^d^N^a^tions^D^e^v^e^lopm^eⁿ^t^P^r^og^r^a^m^m^e⁽^U^ND^P⁾^aⁿ^{d t}^h^e^W^o^r^l^{d B}^a^nk^{. F}^o^r
^m^o^re^inf^o^r^m^a^{tion on}^{RBM, se}^e^ht^tp://w^ww^.rollba^c^k^m^a^l^a^ria^.^org^/^.

of the President’s Malaria Initiative (PMI), which President Bush announced in June 2005 and
has been operational since FY2006. PMI is located at USAID.
Some observers opposed a disease-specific approach. They argued that it ignored the
interconnected nature of health care challenges, and in resource-poor countries, it would create
competition for limited human capacity such as doctors, public health specialists, and U.S.
program managers. Supporters believed PMI would focus attention on malaria, which is a major
killer in sub-Saharan Africa and some parts of Asia.
Others contended that directed efforts on specific diseases should occur simultaneously with
efforts to build health capacity and infrastructure. While they applauded the initial emphasis on
HIV/AIDS, which helped to build health system capacity in resource-poor settings, observers
contended that the next stage of disease response under PEPFAR should integrate efforts to
combat HIV/AIDS with the provision of basic healthcare and the prevention of childhood illness.
Some urged Congress to consider questions related to the establishment of PMI, including how
PMI should coordinate its activities with PEPFAR; the further definition of authorities over the
three diseases in the Leadership Act; the possibility of competing priorities between PMI and
PEPFAR, especially where they operate in the same Focus Countries; and the implications of
different initiative timetables for strategic planning, funding authorizations, and implementation.
On February 6, 2007, Representative Luis Fortuño introduced H.R. 848, a bill to amend the State
Department Basic Authorities Act of 1956 to authorize assistance to combat HIV/AIDS in certain
countries in the Caribbean. The bill would add Antigua and Barbuda, the Bahamas, Barbados,
Belize, Dominica, Grenada, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Vincent and the
Grenadines, Saint Lucia, Suriname, Trinidad and Tobago, and the Dominican Republic to the list
of Focus Countries. When introduced, H.R. 5501 proposed adding Vietnam as a Focus Country as
well as those countries listed in H.R. 848. Representative Betty McCollum proposed adding
Malawi, Swaziland and Lesotho to the list of Focus Countries in H.R. 5501 through H.Amdt. 975,
which was adopted. While the House-passed version of H.R. 5501 would have added these
additional Focus Countries, the Senate version proposed adding only Vietnam as a Focus Country.
Vietnam has been a Focus Country in practice since 2004 at the direction of President Bush; this
language would have updated the list of 14 Focus Countries that was included in the Leadership
Act. The new language in the Senate-passed version also specified that in designating additional
Focus Countries priority shall be given to those countries in which there is a high prevalence of
HIV or risk of significantly increasing incidence of HIV within the general population and
inadequate financial means within the country.
Some observers questioned why the above-named countries were selected, particularly since
OGAC did not put forth these countries for consideration. Proponents of the addition of these new
Focus Countries argued that the designation would direct more HIV/AIDS funding to these areas.
Debate about the Focus Countries list also centered on how authorized funds in excess of the
President’s $30 billion PEPFAR reauthorization proposal would be distributed across PEPFAR
countries. It was not clear whether the proposed, newly-designated Focus Countries would have
received more support than they did previously or whether they would have been funded at higher
levels than non-Focus Countries for HIV/AIDS activities. Some would have liked the final
reauthorization bill to clarify this issue.

Opponents of the proposed list argued that incidence rates—the rates of new infections—have
been growing in East Asia and Oceania, while incidence rates appeared to have stabilized in the
Caribbean. They also argued that prevalence rates—the percentages of given populations that are
infected with HIV/AIDS—have been growing in Eastern Europe and Central Asia, while
prevalence rates in the Caribbean appeared to have stabilized and in some countries have even ³⁵
declined. As new infections worldwide continued to outpace the numbers of infected persons
placed on treatment, others asserted that a more complex analysis of need should be used in
naming Focus Countries. Still others argued that Focus Countries should no longer be used to
apportion funding and that distribution of funds should be based on country needs and recipient
countries’ access to other funding sources for HIV/AIDS programs.
Some observers expressed concern about the long-term commitment that PEPFAR may require,
particularly in the Focus Countries. As an alternative to adding Focus Countries, some suggested
using compacts between the U.S. government and PEPFAR-recipient governments to clearly
outline the scope and terms of U.S. involvement in AIDS prevention, treatment and care and to
elicit recipient government involvement, ownership, and investment. Supporters asserted that
compacts may have been helpful in outlining expectations for broader development efforts and
investments that have been shown to have a significant impact on health. Some compacts, for
example, might have included an agreement that aid recipient countries would reform property
laws and inheritance laws. Such reforms have been shown to reduce the vulnerability of widows ³⁶
and orphans to HIV infection by providing them with greater financial security. The Senate-
passed version of H.R. 5501 supported this idea, stating that compacts and framework agreements
were “one mechanism to promote the transition from an emergency to a public health and
development approach to HIV/AIDS” and could be “tailored to local circumstances to promote
host government commitment to deeper integration of HIV/AIDS services into health systems, ³⁷
contribute to the health systems overall, and enhance sustainability.” The language required that
cost-sharing assurances from PEPFAR-recipient governments and transition strategies be
included in compacts. The House-passed version of H.R. 5501 did not include similar language.
H.R. 5501 as passed by the House maintained funding distribution guidelines and spending
directives of 20% for HIV prevention activities, 15% for HIV/AIDS care activities, and 10% for
orphans and vulnerable children (OVC) activities, but it did not include the spending directive for
HIV/AIDS treatment. The Senate-passed version maintained the spending directive for OVC and
modified the spending directives for treatment and care by requiring that over half of bilateral
HIV/AIDS assistance be spent on treatment, care, and nutritional and food support for
HIV/AIDS-infected people. It did not include the funding distribution guidelines and spending
directives for HIV/AIDS prevention. Both versions required balanced funding for HIV prevention

³⁵^F^o^{r m}^o^{re i}ⁿ^f^o^rm^atⁱ^oⁿ^onⁱⁿ^ci^d^e^{nce an}^d^p^r^eval^en^{ce rat}^e^s,^{see Un}ⁱ^t^e^d^Natⁱ^oⁿ^s^Joⁱⁿ^t^P^r^o^g^{ramme o}ⁿ^HIV^/^A^I^DS
^(UNA^I^D^S⁾^,²⁰⁰⁷^AI^D^S^E^pⁱ^d^e^m^ic^U^pdate^,^N^o^v^e^m^b^e^r^{17, 2}⁰⁰⁷^{, a}^t^h^ttp://^da^ta^.u^na^ids^.^or^g^/^pu^b/^EP^I^S^lide^s^/200^7/
²⁰⁰^7_e^piu^pda^te^_e^n.p^d^f^.
³⁶^{U.N. Mille}ⁿⁿⁱ^um^P^r^oje^c^t^T^a^sk^F^o^rc^e^on^Ed^uc^a^tion^aⁿ^d^G^e^nde^{r Eq}^ua^lity^,^Takⁱ^ng^Ac^tio^{n: Ac}^hⁱ^e^vⁱ^ng^Ge^nde^{r Equ}^a^lity
^and^Em^p^o^w^e^rⁱ^ng^W^o^m^eⁿ^,²⁰^05,^a^t^htt^p^://w^ww^.unm^ille^nnium^proje^c^t^.org^/^doc^um^eⁿ^ts/Ge^nde^r-c^om^ple^t^e^.^pdf^.
³⁷^Se^e^Se^c^tion³¹⁰⁽^c⁾⁽⁶⁾^a^nd^Se^c^tio^{n 3}⁰¹⁽^d)^.

activities, stating that a report to Congress must be provided to justify any decision to spend less
than 50% of prevention funds on behavioral change programs, including abstinence and be
faithful activities, in any PEPFAR recipient country with a generalized epidemic.
There was considerable debate about the effectiveness of congressional spending directives.
Some observed that the spending directives limited Focus Country teams’ ability to tailor budgets ³⁸
to local HIV transmission patterns. Critics contended that the spending directives also
complicated efforts to address the specific nature of the HIV/AIDS epidemic in each country.
HIV/AIDS rates among the Focus Countries ranged from 1% to over 33%. The current and
proposed Focus Countries had epidemics that varied in nature and prevalance: some epidemics
were concentrated among drug users or prostitutes while others were spread throughout the
population. Some argued that Congress might consider eliminating some or all prevention,
treatment, and care spending directives to promote operational planning that was responsive to
the nature of the epidemic in each country and reflected the cost of implementation in that area.
The Government Accountability Office (GAO) found that the spending restrictions did not
account for the costs of particular HIV/AIDS activities that may vary from country to country or ³⁹
for changes in costs over time.
Some encouraged Congress to maintain its spending directives, particularly those related to
orphans and vulnerable children (OVC). Supporters cited a GAO report that stated that without ⁴⁰
the spending directive, programs for OVC might not have been protected. Others stressed the
importance of the spending directive that requires at least 55% of HIV/AIDS funds be spent on
HIV/AIDS treatment, to maintaining support for the purchase and distribution of antiretroviral
drugs and related care for those receiving treatment. Senator Tom Coburn introduced S. 2749, the
Save Lives First Act of 2008, on March 12, 2008, which maintains protections for AIDS
treatment funding. Senator Coburn also signed a letter that requested a hold on H.R. 5501 and S.
2731, noting the removal of the treatment spending directive. Congressional Quarterly
subsequently reported that, after negotiating for changes to S. 2731—which was the basis for the
Senate-passed version of H.R. 5501, Senator Coburn was “satisfied with language that would ⁴¹
require more than half the money go to treatment, including antiretroviral drugs.” Senator ⁴²
Coburn subsequently withdrew his objection to a motion to proceed to S. 2731.
Program objectives are goals that establish the number of people that U.S. HIV/AIDS activities,
such as prevention, treatment, and care, will reach within a specified period. In 2003, for
example, the PEPFAR five-year global program objective for treatment was to provide

³⁸^Instit^ute^of^Me^dicⁱ^ne^of^the^Na^ti^ona^{l A}^c^a^d^e^m^ie^{s (IOM)}^Com^m^itte^e^f^o^{r the}^Ev^a^l^ua^tion^of^the^P^r^e^sⁱ^d^eⁿ^{t’s Em}^e^r^ge^nc^y
^P^l^aⁿ^f^o^{r A}^I^{DS Re}^lie^f^(P^E^P^FA^{R) Im}^ple^m^eⁿ^ta^tion,^PEPFA^{R Imple}^m^eⁿ^tati^on:^Progre^{ss a}ⁿ^d^Promise^{, T}^h^e^Na^tiona^l
^A^c^ad^e^m^{ies P}^r^{ess: 2}⁰⁰⁷^.
³⁹^GA^O,^G^l^{obal H}^I^V/^AID^S^{: A}^M^o^r^e^Coun^tr^y^-^Bas^e^{d A}^ppr^oac^h^Cou^l^d^Im^pr^ov^e^All^o^c^a^ti^on^{of P}^EPFAR^Fun^dⁱⁿ^g^{, A}^p^ril
²⁰⁰^{8, a}^t^htt^p^://w^ww^.ga^o^.g^ov^/ne^w^.ite^m^s^/^d08⁴⁸^0.^pdf^.
⁴⁰^Ibid^.
⁴¹^A^d^am^G^r^a^h^am^-^S^ilve^r^m^a^{n, “}^D^e^a^l^C^oul^d^P^a^v^e^W^a^y^f^o^r^Q^u^ic^k^Se^na^te^P^a^s^s^a^g^e^of^G^l^oba^{l A}^I^D^S^Aⁱ^{d Me}^a^s^ur^e^,^”^CQ
^Tod^a^y^{, J}^u^ne²⁵^,²⁰^08.
⁴²^Se^na^tor^s^T^o^m^C^obur^{n a}ⁿ^{d R}ⁱ^c^h^a^r^{d B}^u^r^r^{, “}^L^e^tte^r^{to Se}^na^tor^Mitc^h^Mc^C^onne^l^l^,”^J^u^ly^{1, 2}⁰⁰⁸^{, a}^t
^http:^//c^o^bur^n.s^e^na^te^.g^ov^/f^f^m^/ⁱ^nde^x^.^cf^m^?^Fus^e^A^c^tion=^File^s^.^Vie^w^&^F^ile^Stor^e^_ⁱ^d⁼^d^e⁶⁵³^5c^6-^c¹^51-⁴⁷¹⁷^-^89f^f^-
^26c³⁹⁹^b^f³⁰²^4.

antiretroviral treatment for 2 million people.⁴³ Some suggested that one alternative to spending
directives was to allow U.S. staff in PEPFAR Focus Countries to set annual program objectives
for prevention, treatment, and care that, in turn, would be added up to become the five-year
country prevention, treatment, and care objectives. These then would have been totaled across
countries to calculate the U.S. global program objectives for these program areas. At the time of
consideration of H.R. 5501, OGAC determined five-year country prevention, treatment, and care
goals for the 15 Focus Countries, and then U.S. staff in PEPFAR Focus Countries set annual
program objectives with the goal of reaching five-year country goals but with consideration for
the challenges of the country’s HIV/AIDS epidemic. OGAC then calculated global program ⁴⁴
objectives by adding up the five-year country targets.
Some supporters of program targets being determined entirely by U.S. staff in PEPFAR Focus
Countries contended that country teams have the greatest awareness of each country’s needs and
should establish prevention, treatment, and care targets. However, some PEPFAR country team
members expressed concern about difficulties country teams might face in reaching a consensus ⁴⁵
about such targets. Critics of program targets being determined this way asserted that Congress
could specify global targets as a way of guiding policy implementation and priorities without
hampering the ability of country-based teams to respond flexibly to in-country realities and to
coordinate with national health plans. They pointed to language in both versions of H.R. 5501 as
examples: both bills proposed establishing a target for prevention of mother to child [HIV]
transmission (PMTCT) activities that at least 80% of pregnant women would be reached in ⁴⁶
affected countries by 2013. The Senate version also proposed setting a target that the proportion
of children receiving care and treatment would be proportionate to their numbers within the
population of HIV-infected individuals in each country by 2013, while the House-passed version
of H.R. 5501 proposed setting a target requiring that by 2013 up to 15% of those receiving
treatment and care must be children.
Debate about spending directives and program targets was closely related to debate about how to
prioritize or balance HIV/AIDS prevention, treatment, and care activities. Some experts
maintained that prevention should remain a focus of global efforts, because there is no cure for
AIDS at this time and preventing new infections is the only way to stop the epidemic in the long
term. In 2001 the U.N. General Assembly adopted the Declaration of Commitment on HIV/AIDS, ⁴⁷
which stated that “prevention must be the mainstay of our response.” Some organizations, such
as the Bill and Melinda Gates Foundation and the Global AIDS Prevention Working Group,
focused their efforts on strategies and prevention research in an effort to “prevent the HIV

⁴³^T^h^{e W}^hⁱ^t^e^Ho^u^s^e,^“F^act^S^h^eet^:^T^h^e^P^r^esi^d^en^t^’^s^E^m^er^gen^c^y^P^l^an^f^o^{r A}^I^DS^Relⁱ^e^f^,^{” Jan}^u^a^r^y²⁹^,²⁰^03,^at
^http:^//w^w^w^.^w^hite^hous^e^.^g^o^v^/^ne^w^s^/r^e^l^e^a^s^e^s^/²⁰⁰^3/^01/²⁰⁰³⁰¹^29-^1.^ht^m^l^.
⁴⁴^GA^O,^G^l^{obal H}^I^V/^AID^S^{: A}^M^o^r^e^Coun^tr^y^-^Bas^e^{d A}^ppr^oac^h^Cou^l^d^Im^pr^ov^e^All^o^c^a^ti^on^{of P}^EPFAR^Fun^dⁱⁿ^g^{, A}^p^ril
²⁰⁰^{8, a}^t^htt^p^://w^ww^.ga^o^.g^ov^/ne^w^.ite^m^s^/^d08⁴⁸^0.^pdf^.
⁴⁵^Ibid^.
⁴⁶^In^t^h^{e L}^ead^ershⁱ^p^A^c^t^,^Coⁿ^g^{ress req}^uⁱ^red^t^h^at^t^h^{e U.}^S^.^go^vern^m^eⁿ^t^st^rat^e^g^y^t^o^co^m^b^at^t^h^{e gl}^o^b^a^l^HI^V^/^A^I^DS
^p^aⁿ^d^e^mⁱ^c^m^u^st^“p^ro^vi^d^e^f^o^{r m}^eetⁱⁿ^{g o}^r^exceedⁱⁿ^{g t}^h^{e go}^al^t^o^redu^{ce t}^h^{e rat}^e^o^f^m^o^t^h^er-t^o^-^chⁱ^l^d^t^r^an^s^mⁱ^s^si^oⁿ^o^f^{HIV b}^y
²⁰^pe^r^c^eⁿ^{t by}²⁰^{05 a}ⁿ^d^by^{50 pe}^r^c^eⁿ^{t by}²⁰¹^0.”
⁴⁷^U^.^N^.^D^o^c^u^m^e^{nt, A}^/^R^E^S/S-²⁶^/L^{.2, J}^u^ne²⁷^,²⁰^01,^a^t^h^ttp:/^/da^t^a^.^uⁿ^a^ids^.^or^g^/^public^a^tⁱ^ons^/^ir^c^-^pu^b0^3/
^ai^d^s^d^ecl^aratⁱ^o^n_^en^.^p^d^f^.

epidemic from becoming generalized in countries with emerging epidemics” and to prevent ⁴⁸
millions of new infections.
On the other hand, some contended that focusing on prevention and neglecting treatment and care
would ignore the economic and social impacts of the disease on those already infected, on the
children and families of infected persons, and on countries with high prevalence rates. Some
asserted that treatment and care were investments in hope and stability, preventing children from
being orphaned and people from suffering the ravages of the disease when treatment to prolong
life and improve its quality is available. Some argued that treatment costs were dropping very
rapidly for not only first-line treatment regimens but also second-line antiretroviral therapies, a
trend that was expected to continue as treatment expanded to cover more infected people in low ⁴⁹
and middle income countries and as more international donors negotiated for lower prices.
Others maintained that combating HIV/AIDS required a combination of prevention, treatment,
and care rather than a choice between these strategies.
H.R. 5501 as passed by the House included language that addressed U.S. HIV/AIDS activities’
links and referral to family planning and maternal health programs. Section 101(a)(4) of H.R.
5501 proposed amending Section 101 of P.L. 108-25, the Leadership Act. It stated that a
comprehensive five-year global strategy to combat HIV/AIDS, tuberculosis, and malaria shall:
ⁱⁿ^c^l^ud^e^sp^e^cⁱ^fi^c^p^l^aⁿ^s^fo^r^lⁱ^nka^ge^t^o^,^aⁿ^d^r^e^fe^r^r^a^l^s^y^s^t^e^m^s^fo^r^noⁿ^-^go^ve^rⁿ^m^e^nt^a^l
^org^aⁿⁱ^zatioⁿ^s^t^h^{at i}^m^ple^m^eⁿ^t^m^u^l^tis^ectoral^approach^es^,ⁱⁿ^cl^u^d^ing^f^a^ith-^b^as^{ed a}ⁿ^d
^com^m^unit^y^-^b^as^ed^org^a^nization^s^,^f^o^{r ... acces}^s^to^HIV/^A^I^DS^edu^cation^aⁿ^{d te}^s^tⁱⁿ^{g i}ⁿ^f^a^mⁱ^l^y⁵⁰
^pl^anⁿⁱ^ng^an^d^m^a^t^e^rn^al^h^eal^t^h^prog^ram^s^su^pport^e^{d by}^t^h^{e U}ⁿⁱ^t^e^{d S}^t^at^es^G^o^v^e^rⁿ^m^eⁿ^t^.
The Senate-passed version of H.R. 5501 did not include family planning program language.
Opponents of the language in the House version of H.R. 5501 argued that the language was
ambiguous and might have applied the Mexico City policy to programs that receive PEPFAR ⁵¹
funding. The Mexico City policy denies U.S. funds to foreign non-governmental organizations
(NGOs) that perform or promote abortion as a method of family planning—even if the activities

⁴⁸^{Bill a}ⁿ^{d Me}^li^nda^G^a^te^s^Foun^da^ti^{on, “}^G^ra^ntm^a^kⁱ^ng^P^rⁱ^o^ritie^s^f^o^{r H}^I^V^/^A^I^D^S^,”^htt^p^://w^w^w^.^g^a^t^e^s^f^ounda^tio^n.org^/
^G^l^oba^lH^e^a^lth/P^rⁱ^_D^is^e^a^s^e^s^/H^I^V^A^I^D^S^/H^I^V^_G^r^a^ntm^a^kⁱ^ng^.ht^m^{. G}^l^o^b^a^l^H^I^V^P^r^e^v^eⁿ^tio^{n W}^o^r^k^ing^G^r^oup,
^http:^//www^.g^loba^lhiv^pre^v^eⁿ^tion^.^o^r^g^/^.
⁴⁹^First-li^ne^tre^a^t^m^e^{nt re}^gⁱ^m^e^{ns a}^r^e^initia^l^drug^{s use}^d^to^tre^a^t^inf^e^c^t^e^d^pe^op^le^{. W}^h^eⁿ^pa^tⁱ^eⁿ^{ts be}^c^o^m^e^re^sistaⁿ^{t to}^the^s^e
^dr^ug^s^the^y^m^a^y^r^e^quir^e^s^e^c^ond-^li^ne^a^nd^thir^d-^li^ne^dr^ug^s^.
⁵⁰^T^h^is^la^ng^ua^g^e^is^the^pr^op^os^e^d^Se^c^tion¹⁰¹⁽^a⁾⁽⁵⁾⁽^D⁾ⁱⁿ^P.L^.¹⁰^8-²⁵^.
⁵¹^{For e}^x^a^m^ple^,^the^Ce^nte^r^f^o^{r He}^a^{lth a}ⁿ^{d G}^e^nde^{r Eq}^uity^st^a^t^e^s^{, “}^T^he^{bill re}^stric^t^{s f}^uⁿ^d^ing^t^o^U.S^.^-f^und^e^d^f^a^mⁱ^l^y
^plaⁿⁿⁱ^ng^pr^og^ra^m^s^—e^nsuring^tha^t^re^stric^tiv^e^{U.S. p}^o^lic^ie^{s suc}^h^a^s^t^h^e^Me^xⁱ^c^o^City^P^o^lic^y^c^{ould e}^x^te^{nd t}^o^PE^P^F^A^R^-
^f^unde^{d pr}^og^r^a^m^s^tha^t^s^e^ek^{to link}^f^a^mⁱ^l^y^pla^nning^a^{nd H}^I^V^pr^e^v^eⁿ^tion.”^C^e^nte^r^f^o^r^G^e^nde^r^H^e^a^{lth a}ⁿ^{d Eq}^uity^{, “}^U^.S.
^Cong^re^{ss Intro}^duc^e^s^Ne^w^P^E^P^F^A^R^{Bill: T}^w^{o Ste}^p^{s Forw}^a^r^{d, T}^h^re^e^Ste^p^{s Ba}^c^k^,”^Fe^brua^ry^{27, 2}⁰⁰⁸^,
^http:^//www^.g^e^nde^rhe^a^lth.org^/^pub^s/P^R²⁰^08Be^r^m^a^nP^E^PFA^R.pdf^{. Pa}^thfⁱ^nde^{r Inte}^rna^tⁱ^ona^l^,^aⁿ^NG^{O, sta}^t^e^s^tha^t^the^b^ill
^“^a^dopts^aⁿ^a^m^big^uous^pr^ov^is^ion^s^t^a^ting^tha^t^only^f^a^mⁱ^l^y^pla^nning^o^r^g^a^niz^a^tions^‘^s^u^p^p^o^r^t^e^d^by^the^U^.^{S. g}^o^v^e^rⁿ^m^e^nt’
^w^{ill be}^e^lig^ible^f^o^{r PE}^P^F^A^R^f^und^{s f}^o^{r HIV}^/^A^I^{DS te}^sting^a^{nd e}^d^uc^a^tion^p^u^rp^ose^s^,”^w^h^ic^{h “}^poteⁿ^tia^ll^y^pa^v^e^{s the}^wa^y
^f^o^{r th}^{e Mex}ⁱ^co^City^P^o^licy^{... to}^b^e^ap^p^lied^f^o^{r t}^h^{e f}ⁱ^{rst tim}^{e to}^th^{e r}^eceip^t^o^f^g^l^o^b^a^{l HIV/A}^I^{DS f}^unds^.”^P^a^t^h^fⁱ^nde^r
^In^t^e^rn^atⁱ^oⁿ^a^l^,^“^P^at^h^fⁱⁿ^d^e^{r In}^t^e^rⁿ^atⁱ^oⁿ^a^l^’^{s Respo}ⁿ^s^{e t}^o^Recen^t^S^eⁿ^a^t^e^P^E^P^F^A^{R Reau}^t^h^o^rⁱ^zatⁱ^oⁿ^,^”^M^a^rch¹⁹^,²⁰⁰⁸^,
^http:^//www^.pa^t^hf^ind.org^/^site^/
^P^a^geS^e^rver?p^agen^a^m^e=N^e^w^s_^P^a^t^h^fⁱⁿ^d^e^r_^Respoⁿ^s^e_P^E^P^F^A^R^_^R^eau^t^h^o^rⁱ^zatⁱ^o^n_^S^eⁿ^a^t^e⁰⁸^.

are undertaken with non-U.S. funds.⁵² Others opposed the language because they did not believe
that it sufficiently supported the integration of family planning services in U.S.-supported HIV ⁵³
prevention programs. Proponents of the family planning program language in the House version
of H.R. 5501 maintained that it would limit PEPFAR funding for family planning groups based ⁵⁴
on their compliance with the Mexico City policy. Other groups reserved endorsement or
opposition until such as time as Congress might further clarify the language. Some expressed
concern, however, that the family planning language might contradict their beliefs and ⁵⁵
principles.
Section 501 of the House version of H.R. 5501 proposed the development of five-year health
workforce strategies by countries that receive assistance under the reauthorization. It directed the
Global AIDS Coordinator and the Secretary of the Treasury to work to reform International
Monetary Fund (IMF) policies that result in limitations on national and donor investments in
health. It also directed the Global AIDS Coordinator to work with relevant stakeholders to
develop effective public sector procurement and supply chain management systems for supplies
and drugs in countries receiving assistance under the reauthorization. The Senate-passed version
of H.R. 5501 included similar language through the use of compacts and actions required of the
Administrator of USAID.
H.R. 5501 as passed by the House also would have required OGAC and USAID to create and
implement a plan to combat HIV/AIDS by strengthening health policies and health systems of ⁵⁶
PEPFAR countries as part of USAID’s Health Systems 20/20 project. The plan, in part, would
have aimed to encourage post-secondary institutions in host countries, especially in Africa, to

⁵²^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^the^Me^xⁱ^c^o^C^ity^polic^y^,^s^e^e^C^R^S^R^e^por^t^R^L³³²⁵^0,^Iⁿ^te^r^nat^io^nal^Po^pul^ati^{on As}^sⁱ^s^t^anc^e^aⁿ^d
^Fam^ily^Pl^anⁿⁱⁿ^g^Pr^ogr^am^s^:^I^s^s^u^e^s^for^C^o^ngr^e^s^s^,^b^y^L^uⁱ^s^{a Bl}^an^ch^fⁱ^el^d^.
⁵³^Se^e^,^f^o^r^e^x^am^ple^,^Eng^e^nde^r^H^e^a^{lth, “}^A^c^{tion A}^l^e^r^{t: G}^l^oba^{l Fun}^dⁱⁿ^g^f^o^r^A^I^D^S^{, T}^B^{, a}^{nd Ma}^la^rⁱ^a^,^”^Ma^r^c^{h 4,}²⁰⁰⁸^{, a}^t
^http:^//e^ng^e^nde^r^h^e^a^l^t^h^.or^g^/^m^e^d^ia^/pr^e^s^s^-^r^e^le^as^e^s^/²⁰^08-^03-^04-^hiv^-^f^uⁿ^d^ing^.^p^h^p^.^Phy^s^ic^ia^ns^f^o^r^H^u^m^a^{n R}ⁱ^g^h^ts^{, “}^P^H^R^’^s
^Positi^{on on}^P^E^PFA^R^Re^a^u^thoriz^a^tion^B^ills,”^Ma^rc^h²⁷^,²⁰^08,^a^t^htt^p^://p^hy^sicⁱ^aⁿ^s^f^orhum^aⁿ^rig^h^ts.org^{/ libra}^ry^/ⁿ^e^w^s-
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develop human and institutional capacity to support the health care system in those countries.
This included collaboration with U.S. post-secondary educational institutions including ⁵⁷
historically black colleges and universities. The Senate-passed version included similar
language.
The Senate version of H.R. 5501 also proposed requiring the U.S. strategy to combat global AIDS
to “situate United States efforts to combat HIV/AIDS, tuberculosis, and malaria within the
broader United States global health and development agenda, establishing a roadmap to link
investments in specific disease programs to the broader goals of strengthening health systems and
infrastructure and to integrate and coordinate HIV/AIDS, tuberculosis, or malaria programs with
other health or development programs, as appropriate.” This language required greater strategic
planning across U.S. global health and development programs to coordinate efforts across
program areas.
Some health experts were concerned about the single disease approach to global health and how it
focused limited resources in high burden countries on one disease while, they contended, the
overall health infrastructure and workforces in resource-poor countries minimally improved.
Some also were concerned about the possible long term implications of the increased funding
levels if the funds were spent on treatment and care of individuals who are infected with AIDS.
One study pointed out that treatment of infected individuals is a lifelong commitment and that
treatment itself prolongs that length of time; it estimated that if scale-up of treatment continued at
the historical rate since FY2004 and drug prices and treatment costs remained the same,
maintenance of treatment funding levels would necessitate either a 20% increase in total U.S.
overseas development assistance by FY2016 or a reallocation of 20% of the current overseas
development assistance budget of $23 billion to AIDS treatment funding alone. It argued this
might raise questions about how funding for other global health programs and development ⁵⁸
efforts might be adversely affected.
Supporters of language that addressed issues of coordination of U.S. global health and
development programs with disease-specific initiatives like PEPFAR and PMI argued that the
more comprehensive development of health infrastructure and training of health workforces in
these areas would increase the effectiveness of PEPFAR and other single-disease programs and
decrease the need for disease-specific efforts in the future by building local capacity to address
disease and basic health. Critics argued that such investment was outside the scope of PEPFAR
and would distract from the program’s focus on HIV/AIDS.
Both versions of H.R. 5501 encouraged the integration of HIV/AIDS activities with nutrition
programs through linkages and referrals to ensure that treated individuals receive the needed daily
caloric intake to support effective treatment. Where such linkages and referrals were not possible,
the Senate-passed version of H.R. 5501 proposed establishing additional services to provide
nutritional support directly, and it also encouraged support for programs that address the
intersections between food insecurity and health problems like HIV/AIDS. The House version of

⁵⁷^Se^e^H^.^A^m^{dt. 976}^to^H^.^R^.⁵⁵^01,ⁱⁿ^tr^o^duc^e^d^by^R^e^pr^e^s^eⁿ^ta^tiv^e^C^a^r^s^{on a}ⁿ^{d a}^g^r^e^e^d^{to w}^{ith a}⁴¹^5-¹⁰^v^o^teⁱⁿ^the^H^o^us^e^.
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^c^onteⁿ^t/^p^ublic^a^tⁱ^ons^/^d^e^t^a^il/¹⁵⁹⁷³^.

H.R. 5501 included similar language that authorized the direct provision of food and nutritional
support to HIV/AIDS-infected individuals receiving antiretroviral treatment through PEPFAR
where referrals were not possible. Both bills encouraged providing food and nutritional support
for children affected by HIV/AIDS.
Language in both versions of H.R. 5501 addressing health system infrastructure and nutrition did
not differ greatly from language included in the Leadership Act. The new language in both
versions went into greater detail about the nature of the infrastructure and nutrition challenges in
certain regions. Both encouraged greater integration of U.S. HIV/AIDS efforts with broader pre-
existing and parallel efforts by U.S. agencies and others, such as non-governmental organizations
(NGOs), and promoted linking affected individuals through referrals with such services.
Programs that might have been coordinated with or linked to include those that strengthen health
care infrastructure, nutrition programs, safe drinking programs, income security programs, and
programs that offer technical assistance in health care capacity building and public finance
management.
H.R. 5501 as passed by the Senate proposed eliminating the language in the Immigration and
Nationality Act (INA) that statutorily bars foreign nationals with HIV/AIDS from entering the ⁵⁹
United States. The House-passed version of H.R. 5501 did not include similar language.
Supporters of the amendment argued that maintaining the restrictions on entry into the United ⁶⁰
States of AIDS-infected people was “discriminatory and unnecessary.” They also argued that
major international conferences on health and AIDS should not be held in countries that have
laws restricting the entry of people living with AIDS. Opponents to the amendment contended
that the amendment would add too many costs by increasing U.S. spending on health programs
for HIV/AIDS-infected people. Others disputed this would be a significant amount.
The Senate version of H.R. 5501 proposed requiring additional reporting, including a report by
the Comptroller General that would discuss the coordination of U.S. global AIDS efforts and the
impact of global HIV/AIDS funding and programs on other U.S. global health programming. It
also required the dissemination of an annual report by OGAC on best practices that might be
replicated or adapted by other AIDS programs. In addition, it provided for the Inspectors General
of the Department of State, the Broadcasting Board of Governors (BBG), HHS, and USAID to
jointly develop five coordinated annual plans for oversight activity in each of the fiscal years

2009 through 2013. The House version of H.R. 5501 did not include similar language.

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^11,²⁰⁰⁸^{, a}^v^a^ila^ble^f^r^om^a^u^thor^.
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H.R. 5501 as passed by the House prohibited funds appropriated under the legislation from being
made available to a foreign country unless the agreement provided that such assistance funds ⁶¹
were exempt from taxation or otherwise reimbursed by the foreign government. The Senate-
passed version of S. 2731 did not include similar language.
H.R. 5501 as passed by the Senate directed the Global AIDS Coordinator to establish an advisory
panel of experts on prevention of mother to child HIV transmission (PMTCT) that would be
known as the PMTCT Panel. The panel would review PMTCT efforts and make
recommendations to OGAC and Congress on how to scale-up PMTCT services to ensure that, by

2013, such programs would provide access to counseling, testing, and treatment for at least 80%

of pregnant women in those countries most affected by HIV/AIDS in which the United States has
HIV/AIDS programs. The House version of H.R. 5501 did not include similar language.
Both versions of H.R. 5501 expanded “conscience clause” language included in the Leadership
Act. The conscience clause in the Leadership Act stated that organizations that receive funding to
prevent, treat, or monitor HIV/AIDS shall not be required, as a condition of receiving the
assistance, to endorse or utilize a multisectoral approach to combating HIV/AIDS, or to endorse,
utilize, or participate in a prevention method or treatment program to which the organization has a
religious or moral objection. The new language in each version of H.R. 5501 referred to any
HIV/AIDS program or activity to which an organization may have a religious or moral objection,
whereas language in the Leadership Act referred only to any HIV/AIDS prevention method or
treatment program to which the organization has a religious or moral objection. It further stated
that organizations who opt-out of the above activities for religious or moral reasons shall not be
discriminated against in the solicitation or issuance of grants, contracts, or cooperative
agreements.

On July 24, 2008, the House passed the Senate version of H.R. 5501, the Tom Lantos and Henry
J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (hereafter referred to as the Reauthorization Act). The
Reauthorization Act (P.L. 110-293) was enacted on July 30, 2008. The outcomes of key proposals
are described in Table 4. These key proposals and debates surrounding them are discussed in
more detail in the previous section of this report. The funding levels authorized from FY2009
through FY2013 for U.S. programs to combat HIV/AIDS, tuberculosis, and malaria
internationally are described in Table 5.

⁶¹^T^h^is^pr^o^h^ibi^tio^{n a}^p^plie^s^to^f^unds^be^ing^m^a^de^a^v^a^ila^ble^{to a}^f^o^r^e^igⁿ^c^ountr^y^un^de^r^a^ne^w^bila^te^r^a^{l a}^g^r^e^em^eⁿ^t.

Table 4. Outcomes of Key Proposals to Change International HIV/AIDS,
Tuberculosis, and Malaria Programs Under P.L. 110-293
^{Key Proposals}^{P.L. 1}^10-2⁹³
^{Funding Aut}^horization^{Authorizes $4}⁸^billi^{on for HIV/AI}^{DS, tuberculosis, and malaria from FY200}^{9 t}^hrough
^Increase^{FY2013; a}^{uthorizes $}²^billi^{on for Indian Health a}^{nd Safety}^Emergeⁿ^{cy Fund f}^rom
^FY2009^thro^{ugh FY2}⁰¹^3.
^{Global Malaria Coordinator}^{Established within USAID to over}^{see and coordinate U.S. government efforts}^to
^{combat malaria globally.}
^{List of Focus Countries}^{Vietnam added as Focus Country}^{in U.S. government efforts}^{to combat HIV/AIDS}
^Expa^nsion^globally^.
^{Compacts With Recipient}^{Promotes the use of}^compacts^b^{etween th}^{e U.S. government a}^{nd country a}^nd
^Countries^{regional programs on H}^{IV/AIDS in order to promote}^{host govern}^{ment commitment}
^{to deeper integration of H}^{IV/AIDS services into health sy}^{stems, co}^ntribute^{to health}
^{systems overall, and enha}^{nce s}^ust^ainability.
^{Role of Spending Directives}^{OVC: Requires 1}^{0% of H}^{IV/AIDS funds to}^{be s}^{pent on}^orp^{hans a}ⁿ^d^{other children}
^{affected by}^{or vulne}^{rable to HIV/}^{AIDS (OVC).}
^{Prevention: Requires t}^{he Global}^{AIDS Coordinator to provide bal}^{anced fu}^{nding for}
^preve^{ntion activities for sexual tr}^{ansmission of HIV/AIDS; and to e}^nsur^{e that ac}^tivities
^{promoting abstine}^{nce, delay of se}^{xual deb}^{ut, monogamy, fidelity, a}^{nd part}^ner
^{reduction are impleme}^{nted and f}^{unded in a mea}^ningf^{ul and eq}^{uitable way in the}
^{strategy for eac}^h^{host count}^{ry ba}^{sed on objective epidemiolog}^ical^{evidence as to the}
^{source of infec}^{tions and in cons}^ul^{tation with the gover}^{nment of}^ea^{ch host co}^unty
^{involved in HIV/AIDS prevention}^{activities. A}^{lso requires a re}^port^{to the ap}^propriate
^{congressional committees within}^{30 days to justify a}^{decision to pr}^{ovide less than 5}⁰
^perce^{nt of the}^sex^{ual trans}^{mission pr}^{evention f}^unds^{for activities p}^romoting
^{abstinence, delay of se}^{xual deb}^{ut, monogamy, fidelity, and partner}^reduction.
^{Treatment and Ca}^{re: For each of}^{the fiscal years}²⁰⁰⁹^thro^ugh²⁰^{13, more t}^han^half
^{of the amou}^{nts ap}^prop^{riated for bilateral global HIV/AIDS assistance pu}^rsua^{nt to}
^{section 40}^{1 s}^{hall be ex}^{pended fo}^{r antiretroviral treatme}^{nt for}^HI^{V/AIDS; cl}^inical
^{monitoring of HIV-seropositive people not in need of a}^{ntiretroviral treatment; care}
^{for associated opportunistic infe}^c^{tions; nutrition and food sup}^port^{for people living}
^{with HIV/AIDS; and other es}^senti^{al HIV/AIDS-related medica}^{l care for people living}
^{with HIV/AIDS.}

^{Key Proposals}^{P.L. 1}^10-2⁹³
^{Program Objectives}^{Prevention Goal: To prevent}¹²^mill^{ion new HIV infections world}^wide.
^{Treatment Goal: To support}^the^{increase in t}^{he n}^u^m^{ber of individuals with HIV/AIDS}
^{receiving antiretroviral treatme}^nt^{above the}^{2 million person goal previously}
^{established unde}^{r the}^Leaders^hip^{Act for achieveme}^nt^{by the}^end^{of FY200}^{6 and}
^{increased p}^urs^{uant to t}^{he followi}^{ng: for each of t}^{he fiscal year}^{s 2}⁰^{09 t}^hroug^{h 2}⁰¹^3,
^{the treatme}^{nt goal shall be inc}^rea^{sed above 2 million people by at l}^{east the}
^perce^{ntage increa}^{se in th}^{e amou}^{nt ap}^{propriated for}^{bilateral global HIV/AIDS}
^{assistance for s}^uch^{fiscal year co}^{mpared with FY2}⁰⁰^8.
^Additi^{onally, any increase in the t}^{reatment goal above t}^{his specifie}^{d level shall be}
^{based on long-term re}^quirem^ents^{, epidemiol}^ogica^{l evidence, the sh}^{are of treatme}^nt
^{needs being}^{met b}^y^par^tner^governme^{nts and othe}^{r sour}^{ces of tre}^{atment f}^{unding, and}
^{other ap}^{propriate fa}^ctors.
^{The treatme}^{nt goal also shall be increased a}^{bove the}^nu^mber^calcu^{lated above by the}
^{same per}^{centage t}^{hat t}^{he average}^{U.S. government cost per}^patien^{t of providing}
^{treatment in}^count^{ries receiving}^{bilateral HIV/AIDS assistance has}^decreased
^{compared with FY2}^008.
^{Care Goal: To support care}^{for 1}²^{million indiv}^{iduals infected with or affected b}^y
^{HIV/AIDS, including 5 milli}^{on orphans a}^{nd vulne}^{rable c}^{hildren affec}^{ted by HIV/AIDS}
^{(OVC), with an emphasis on}^pro^{moting a compreh}^{ensive, coordinated system of}
^{services to be integ}^{rated th}^rough^{out the contin}^uu^{m of care.}
^{The Reauthorization Act also states that t}^{he p}^{revention a}^{nd care}^{goals described}
^{above shall be inc}^{reased consiste}^{nt with e}^pidemiol^{ogical evi}^{dence and available}
^resources.
^{Balance Between Preve}^ntion,^Prioriti^{zes prevention w}^{hile pres}^{erving and inc}^{reasing t}^{he treatme}^{nt compone}^{nt of}
^{Treatment, and Care}^{HIV/AIDS efforts as}^{bilateral fund}^{ing for HIV/AIDS increases}^{relative to FY200}^{8 levels.}
^{HIV/AIDS Activities and}^{Does not mention family planni}^ng^.
^{Family Planning}
^{Health Systems a}^{nd the}^{Provides for helping part}^ner^cou^{ntries to train a}^{nd su}^{pport t}^{he re}^{tention of health}
^{Single Disease Approach}^{care profe}^{ssionals and para}^profes^{sionals. It sets a target of training}^{and retaining at}
^{least 140,0}⁰⁰^new^{health ca}^{re p}^r^{ofessionals and parap}^{rofessionals with an em}^phasis
^{on training and in-cou}^{ntry de}^{ployment of critically needed doctors and n}^urses.
^{This assistance is intended to str}^engthe^{n the}^{capacity of developin}^{g countries,}
^{especially in sub-Sahara}^{n Af}^{rica, to deliver primary health ca}^{re. It h}^{as an objective to}
^{help cou}^{ntries achieve}^{staffing lev}^{els of at least 2.3 doctors, nur}^{ses, and midwives per}
^1,00^{0 pop}^{ulation, as called for by the World Health Orga}^{nization (WHO).}
^{Required OGAC a}^{nd USAID to create and impleme}^{nt a plan}^{to combat HIV/AIDS by}
^strengt^hening^health^{policies and health system}^{s of PEPFAR count}^r^{ies as part of}
^{USAID’s Health Systems 20/}²⁰^p^{roject. The plan, in part, would aim to encourage}
^{post-secondary institutions in}^{host countries, es}^{pecially in Africa, to develop human}
^{and institutional capacity to su}^pp^{ort the health}^{care s}^{ystem in t}^h^o^{se countries. This}
^{includes collaboration with U.S}^{. post-secondary educational institu}^{tions including}
^{historically black colleges and universities.}
^{Required the U.S. strategy to co}^{mbat global AIDS to situate United States efforts to}
^{combat HIV/AIDS, tube}^{rculosis, and malaria within the}^{broader Un}^{ited States global}
^{health and developme}^{nt agenda,}^{establishing a roadmap to link inv}^{estments in}^specific
^{disease programs to the}^broader^{goals of strengthe}^{ning health}^syst^{ems and}
^infrastr^uctu^{re and to integrate}^an^{d coordinate HIV/AIDS, tubercul}^{osis, or malaria}
^{programs with ot}^her^{health or d}^{evelopment p}^{rograms, as ap}^prop^{riate. This language}
^requires^greater^{strategic plan}ⁿⁱⁿ^{g across U.S. global health and development}
^{programs to coordinate efforts}^{across program}^areas.

^{Key Proposals}^{P.L. 1}^10-2⁹³
^{HIV/AIDS Activities and}^{Provides for linkages between}^HI^{V/AIDS activit}^{ies and nut}^{rition pr}^ograms.
^{Nutrition Programs}
^{Immigration and Nationality}^{Amends the}^{INA to stat}^{utorily all}^{ow foreigners infected with}^HIV/^{AIDS to enter the}
^{Act (INA) Amendme}^nt^{United States.}
^Additi^{onal Oversight}^{Requires additional reporting, including a report}^{by th}^{e Comptroller Ge}^{neral that}
^Activities^{would discuss the coordination of U.S. gl}^{obal AIDS efforts and the}^{impact of global}
^{HIV/AIDS funding a}^{nd program}^s^{on other U.S. global health progr}^amming.
^{Requires t}^{he dissemination of an}^{annual r}^eport^{by O}^{GAC on b}^est^{practices t}^hat
^{might be re}^{plicated or adapted b}^y^{other AIDS p}^rograms.
^{Provides for the Ins}^pectors^Gen^e^{ral of the Depart}^{ment of State, t}^{he Broadcasting}
^{Board of Governors (BBG), HHS, and USAID to jo}^{intly develop five coordinated}
^annual^{plans for over}^{sight activity in each of t}^{he fiscal years}²⁰⁰⁹^t^hrough²⁰¹^3.
^{Taxation of Assistance Fu}^nds^{Language not}^included.
^{by Foreign Gover}^nme^nts
^Prohibited
^{Prevention of Mothe}^{r to}^{Establishes a}^15-^person^ex^pert^pa^{nel to review PMTCT activities a}^{nd to provide}
^{Child HIV Transmission}^{recommendations for PMTCT sc}^{ale-up to the}^{Global AIDS Coord}^inator.
^{(PMTCT) Panel}
^{Conscience Clause}^Expa^{nds definition to state that o}^{rganizations that receive}^fu^{nding to prevent, tr}^eat,
^Expa^nsion^{or monitor HIV/AIDS shall not b}^e^req^{uired, as a condition of receiving the assistance,}
^{to endorse or utilize a multisectoral approac}^{h to combating H}^{IV/AIDS, or to endorse,}
^utilize,^{or participate in any}^HIV/^{AIDS program or activity to whic}^{h an orga}^nization
^{may have a}^{religious or moral obj}^ection.
^Source:^{Compiled by CRS from}^{P.L. 110-2}^{93, the Tom La}^{ntos an}^{d Henry}^{J. Hyde United States Gl}^obal
^{Leadership Against}^{HIV/AIDS, Tuberc}^{ulosis, and Malaria Reauthorization Act of 200}^8.
Table 5. Key Authorization Levels from FY2009 through FY2013 in P.L. 110-293,
the Reauthorization Act of 2008
^{Area o}^f^Auth^orization^{P.L. 1}^10-2⁹³
^{Overall for HIV/AIDS, Tuberc}^{ulosis, and Malaria}^$48^{billion (in total}⁾
^{U.S. C}^{ontribution to Global Fund}^{to Fight AIDS,}^{Up to $2}^{billion for U.S}^{. contribu}^{tions in FY200}^{9; and}
^Tuberc^{ulosis, and Malaria}^such^sums^{as may}^be^necessar^{y fr}^{om FY2010}^thro^ugh
^FY2013.
^Tuberc^ulosis^$4^billi^{on (in total)}
^Malaria^$5^billi^{on (in total)}
^{Indian Health a}^{nd Safety}^Emergeⁿ^{cy Fund}^$2^billi^{on (in total)}
^Source:^{Compiled by CRS from}^{P.L. 110-2}^{93, the Tom La}^{ntos an}^{d Henry}^{J. Hyde United States Gl}^obal
^{Leadership Against}^{HIV/AIDS, Tuberc}^{ulosis, and Malaria Reauthorization Act of 200}^8.

^{Kellie Mo}^ss
^An^al^y^s^{t i}ⁿ^Glo^b^a^{l Healt}^h
^km^o^s^s@^crs^.^l^o^c.g^o^v^,⁷^-⁷³¹⁴