Order Code RL33771
Trends in U.S. Global AIDS Spending:
FY2000-FY2007
December 26, 2006
Tiaji Salaam-Blyther
Analyst in Foreign Affairs
Foreign Affairs, Defense, and Trade Division
Trends in U.S. Global AIDS Spending: FY2000-FY2007
Summary
According to the Joint United Nations Program on HIV/AIDS (UNAIDS), since
AIDS was identified in 1981, about 65 million people have been infected with HIV,
and more than 25 million people have died from AIDS. At the end of 2005, some 40
million people were living with HIV/AIDS worldwide, more than 4 million of whom
were newly infected; almost 3 million died of AIDS-related illnesses in 2005. More
than 2 million of those living with HIV/AIDS at the end of 2005 were children, and
some 570,000 of those who died of AIDS that year were under 15 years old.
UNAIDS estimates that in each day of 2005, some 1,500 children worldwide became
infected with HIV, due in large part to inadequate access to drugs that prevent the
transmission of HIV from mother to child. Only 9% of pregnant women in low- and
middle-income countries were offered services to prevent HIV transmission to their
newborns.
UNAIDS asserts that an effective fight against the global spread of HIV/AIDS
would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in 2008. In
FY2006, Congress provided almost $3.4 billion for international HIV/AIDS,
tuberculosis (TB), and malaria programs, which included U.S. contributions to
international partnerships, such as the Global Fund to Fight AIDS, TB, and Malaria
(Global Fund). Most recent statistics indicate that in 2005, some $8.3 billion was
spent on HIV/AIDS globally, though UNAIDS estimated that $11.6 billion was
needed. About $4.3 billion of those funds were provided by donor governments. The
Kaiser Family Foundation asserts that in 2005, the United States provided the largest
percent of HIV/AIDS assistance in the world, comprising some 49% of all donor
spending.
Although the United States is the leading provider of international HIV/AIDS
assistance, some argue that it needs to give more, particularly to the Global Fund.
Critics of increased AIDS spending, however, question whether the most affected
region — sub-Saharan Africa — can absorb increased revenue flows. Some also
contend that additional HIV/AIDS allocations will yield limited results, as poor
health care systems and health worker shortages complicate efforts to scale up
HIV/AIDS spending. While this report describes how HIV/AIDS, TB, and malaria
are interlinked and exacerbate efforts to control each disease, it primarily addresses
funding issues related to U.S. global HIV/AIDS initiatives. It provides background
information on the key U.S. agencies that implement global HIV/AIDS programs;
analyzes U.S. spending on HIV/AIDS by U.S. agency and department; and presents
some issues Congress might encounter in the 110th Congress. This report will be
updated to reflect the final decision on FY2007 appropriations.
Glossary of Abbreviations and Acronyms
ABC
Abstinence, Be Faithful, Condoms
ARV
Anti-Retroviral medication
CDC
U.S. Centers for Disease Control and Prevention
COP
Country Operation Plan
CSH
Child Survival and Health
DOD
U.S. Department of Defense
DOL
U.S. Department of Labor
FDA
U.S. Food and Drug Administration
GAO
Government Accountability Office
GAP
Global AIDS Program
GHAI
Global HIV/AIDS Initiative
HHS
U.S. Department of Health and Human Services
HIPC
Highly Indebted Poor Countries
HRSA
U.S. Human Resources and Services Administration
IAVI
International AIDS Vaccine Initiative
ILAB
Bureau of International Labor Affairs
ILO
International Labor Organization
IMF
International Monetary Fund
I-TECH
International Training and Education Center on HIV
JLI
Joint Learning Institute
LIFE
Leadership and Investment in Fighting an Epidemic Initiative
MTCT
Mother-to-Child Transmission
NIH
National Institutes of Health
OAR
Office of AIDS Research
OGAC
Office of Global AIDS Coordinator
PEPFAR
President’s Emergency Plan For AIDS Relief
PMI
President’s Malaria Initiative
PMTCT
Prevention of Mother-to-Child Transmission
TB
Tuberculosis
UNAIDS
Joint United Nations Program on HIV/AIDS
USAID
U.S. Agency for International Development
USDA
U.S. Department of Agriculture
WHO
World Health Organization
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
History of Funding for U.S. Global HIV/AIDS Efforts . . . . . . . . . . . . . . . . . . . . . 4
LIFE Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
International Mother and Child HIV Prevention Initiative . . . . . . . . . . . . . . 7
PEPFAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
PEPFAR-Participating Departments and Agencies . . . . . . . . . . . . . . . . . . . . . . . 10
Department of State: Office of the Global AIDS Coordinator . . . . . . . . . . 10
U.S. Agency for International Development (USAID) . . . . . . . . . . . . . . . . 11
Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . . . . 13
Centers for Diseases Control and Prevention . . . . . . . . . . . . . . . . . . . 13
National Institutes of Health (NIH) . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Health Resources and Services Administration (HRSA) . . . . . . . . . . . 17
U.S. Food and Drug Administration (FDA) . . . . . . . . . . . . . . . . . . . . 17
Department of Defense (DOD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Department of Labor (DOL)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
U.S. Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Peace Corps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
U.S. Department of Commerce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Issues for the 110th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Consider Outstanding Appropriations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Reauthorize PEPFAR? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Decrease, Maintain, or Increase HIV/AIDS Funding Levels? . . . . . . . 24
Retain U.S. Contributions to the Global Fund? . . . . . . . . . . . . . . . . . . 25
Alter Abstinence-Until-Marriage Stipulation? . . . . . . . . . . . . . . . . . . 26
Emphasize Other HIV Prevention Strategies? . . . . . . . . . . . . . . . . . . . 26
Expand the List of Focus Countries? . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Address Infrastructure Challenges and Health Worker Shortages . . . . . . . . 28
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
HIV/AIDS Bills Not Enacted in the 109th Congress . . . . . . . . . . . . . . . . . . 30
Legislation Related to Strengthening Health Systems . . . . . . . . . . . . . 30
Legislation Related to Integrating Health Services . . . . . . . . . . . . . . . 30
Legislation Related to HIV/AIDS Treatments and Vaccines . . . . . . . . 31
Legislation Related to Care for those Affected by HIV/AIDS . . . . . . . 31
Legislation to Amend P.L. 108-25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
List of Figures
Figure 1. OGAC HIV/AIDS Appropriations: FY2004-FY2007 . . . . . . . . . . . . . 11
Figure 2. USAID HIV/AIDS Appropriations: FY2000-FY2007 . . . . . . . . . . . . 13
Figure 3. CDC HIV/AIDS Appropriations: FY2000-FY2007 . . . . . . . . . . . . . . 15
Figure 4. Office if AIDS Research Grants: FY2000-FY2007 . . . . . . . . . . . . . . 16
Figure 5. DOD HIV/AIDS Appropriations: FY2000-FY-2007 . . . . . . . . . . . . . 19
Figure 6. DOL HIV/AIDS Appropriations: FY2000-FY2007 . . . . . . . . . . . . . . 20
List of Tables
Table 1. Global HIV/AIDS, TB, and Malaria Appropriations:
FY2000-FY2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Table 2. Global HIV/AIDS, TB, and Malaria Appropriations:
FY2004-FY2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Table 3. USAID Global Health Programs:
FY2000-FY2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Table 4. Participating Agencies and Departments in U.S. Global
HIV/AIDS Initiatives: LIFE and PEPFAR . . . . . . . . . . . . . . . . . . . . . . . . . 29
Trends in U.S. Global AIDS Spending:
FY2000-FY2007
Introduction
It is estimated that HIV/AIDS, tuberculosis (TB), and malaria together kill more
than 6 million people each year.1 According to the Joint United Nations Program on
HIV/AIDS (UNAIDS), at the end of 2005, an estimated 38.6 million people were
living with HIV/AIDS, of whom 4.1 million were newly infected, and 2.8 million
died in the course of that year.2 More than 2 million of those living with HIV/AIDS
at the end of 2005 were children, and some 570,000 of those who died of AIDS that
year were under 15 years old. Almost 90% of all children infected with HIV reside
in sub-Saharan Africa, which is home to 2 million of the estimated 2.3 million
children living with HIV worldwide. UNAIDS estimates that on each day of 2005,
some 1,500 children worldwide became newly infected with HIV, due in large part
to inadequate access to drugs that prevent the transmission of HIV from mother to
child. Only 9% of pregnant women in low- and middle-income countries were
offered services to prevent HIV transmission to their newborns.
1 See [http://www.who.int/tb/publications/2006/tb_facts_2006.pdf].
2 Unless otherwise indicated, all data on HIV/AIDS infection rates are taken from UNAIDS,
2006 Report on the Global AIDS Epidemic, at [http://www.unaids.org/en/HIV_data/
2006GlobalReport/default.asp]. In November 2006, UNAIDS released its 2006 AIDS
Epidemic Update report. However, statistics from the 2006 full report are used, because the
full report is more detailed, provides regional data, and reports on HIV infection among
children, while the update does not. The update can be found at [http://data.unaids.org/pub/
EpiReport/2006/2006_EpiUpdate_en.pdf].
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The World Health Organization (WHO) estimates that by the end of 2004, more
than 14 million people were infected with TB,3 of whom almost 9 million were newly
infected.4 More than 80% of those living with TB in 2004 were in southeast Asia and
sub-Saharan Africa, with the greatest per capita rate found in Africa. Although most
forms of TB are curable, WHO estimates that the disease killed 2 million people in
2004.
According to WHO, each year there are about 300 million acute malaria cases,5
which cause more than 1 million deaths annually. Health experts believe that
between 85% and 90% of malaria deaths occur in Africa, mostly among children,6
killing an African child every 30 seconds.7
While HIV/AIDS, TB, and malaria are preventable diseases, their impacts have
been catastrophic, particularly in sub-Saharan Africa. Researchers have found that
people infected with one of the three illnesses are more likely to contract either of the
other two, and the symptoms are more severe in people with two or more of the
diseases. According to WHO, 90% of people living with AIDS die within four to
3 Tuberculosis is a contagious disease that is spread like the common cold through the air.
Only people who are sick with TB in their lungs are infectious. When infectious people
cough, sneeze, talk, or spit, they propel TB germs, known as bacilli, into the air. A person
needs only to inhale a small number of these to be infected. Left untreated, each person
with active TB disease will infect an average of between 10 and 15 people every year.
However, people infected with TB bacilli will not necessarily become sick with the disease.
The immune system “walls off” the TB bacilli, which, protected by a thick waxy coat, can
lie dormant for years. When someone’s immune system is weakened, the chances of
becoming sick are greater. See [http://www.who.int/mediacentre/factsheets/fs104/en/].
4 WHO Report 2006, Global Tuberculosis Control: Surveillance, Planning, Financing, at
[http://www.who.int/tb/publications/global_report/en/index.html].
5 There are four types of human malaria, Plasmodium (P.) vivax, P. malaria, P. ovale, and
P. falciparum. P. vivax and P. falciparum are the most common, and P. falciparum is the
most deadly type of malaria infection. P. falciparum malaria is most common in sub-
Saharan Africa, accounting in large part for the extremely high malarial mortality in the
region. People contract malaria through bites from infected mosquitos. An infected
mosquito spreads the malaria parasite through the bloodstream. Once in the bloodstream,
the malaria parasite can evade the immune system and infect the liver and red blood cells.
Mosquitos can also contract malaria if they ingest blood from an infected person. See
[http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm].
6 As indicated above, WHO estimates that each year, 300 million acute malaria cases cause
some 1 million deaths, 90% of which occur in sub-Saharan Africa. The World Bank
estimates that there are more than 500 million cases of malaria each year, and that at least
85% of malarial deaths occur in sub-Saharan Africa. The World Bank believes that 8% of
deaths occur in southeast Asia, 5% in the Eastern Mediterranean region, 1% in the Western
Pacific, and 0.1% in the Americas. It asserts that there is no accurate count of malaria
infections or deaths, due to weaknesses in data collection and reporting systems, inaccurate
diagnoses that may result in over- or under-reporting, and an insufficient amount of skilled
workers who can accurately make diagnoses, particularly in malaria-endemic areas.
7 WHO’s Roll Back Malaria website, [http://malaria.who.int/cmc_upload/0/000/015/372/
RBMInfosheet_1.htm], accessed on August 31, 2006.
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twelve months of contracting TB if they do not receive TB treatment.8 TB/HIV co-
infection is a considerable burden in sub-Saharan Africa, where 70% of the world’s
14 million co-infected people live. As many as half of all HIV-positive people in
Africa have TB (and one out of three dies of TB), and up to 80% of all African TB
patients have HIV.9 Research has demonstrated that treatment of TB or HIV in co-
infected patients has positive effects on halting the advancement of both diseases.
Studies have shown that HIV replication increases during the active phase of TB and
returns to baseline after successful TB therapy. Conversely, anti-retroviral (ARV)
treatment may decrease the progression of latent TB to active TB, allowing those
infected with HIV to live longer.10
Some research has also found that malaria contributes to the advancement of
HIV replication, greater sexual transmission of HIV, and higher mother-to-child HIV
transmission (MTCT) rates among the co-infected. For example, one study in
Malawi found that adults with acute malaria had a seven-fold increase in their HIV
viral load.11 However, HIV viral loads decreased when malaria treatment was offered
to some patients. Conversely, HIV-positive pregnant women were more likely to
contract malaria than HIV-negative pregnant women.12 Additionally, malaria-HIV
co-infection was associated with an increased risk of maternal, perinatal, and early
infant death compared to infection of either disease alone. Researchers are also
beginning to explore whether HIV-positive pregnant women who are co-infected
with malaria are more likely to transmit HIV to their children. In Uganda, co-infected
women had an HIV-transmission rate of 40%, while HIV-positive women not
infected with malaria had an HIV transmission rate of 15.4%.13
Drug resistence complicates efforts to halt the spread of TB and malaria. WHO
estimates that about 450,000 new multi-drug-resistant TB cases occur each year. In
September 2006, WHO expressed concern about an increase in treatment-resistant
TB cases, particularly in the Soviet Union, Asia, and South Africa.14 WHO found
8 The Stop TB Partnership, “WHO Calls for Free TB Drugs for HIV Patients,” July 16,
2003; see [http://www.stoptb.org].
9 WHO press release, “WHO Pushing to Rapidly Scale-Up Measures to Fight TB and HIV,”
January 21, 2004, at [http://www.who.int/mediacentre/news/releases/2004/pr5/en/].
10 “TB-HIV Fueling Each Other.” The Stop TB Partnership. June 2001.
11 U.S. Department of Health and Human Services, Centers for Disease Control, National
Center for Infectious Diseases, Division of Parasitic Diseases, Malaria Branch, “Interaction
of HIV and Malaria,” at [http://www.cdc.gov/malaria/pdf/Malaria_HIV_Rick_website.pdf].
12 Carlo Ticconi, Monica Mapfumo, Maria Dorrucci, Neela Naha, Elizabeth Tarira, Adalgisa
Pietropolli, and Giovanni Rezza, “Effect of Maternal HIV and Malaria Infection on
Pregnancy and Perinatal Outcome in Zimbabwe,” Journal of Acquired Immune Deficiency
Syndromes, vol. 34, no. 3 (Nov. 1, 2003), at [http://www.jaids.com/].
13 H. Brahmbhatt, G. Kigozi, F. Wabwire-Mangen, D. Serwadda, N. Sewankambo, T.
Lutalo, M. J. Wawer, C. Abramowsky, D. Sullivan, and R. Gray, “The Effects of Placental
Malaria on Mother-to-Child HIV Transmission in Rakai, Uganda,” AIDS: Official Journal
of the International AIDS Society, vol. 17 (Nov. 21, 2003), pp. 2539-2541, at [http://www.
aidsonline.com].
14 UN News Center, “Drug-Resistant Strains of Tuberculosis Spark Concern from UN
(continued...)
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that Extensive Drug Resistant TB (XDR-TB) is resistant not only to the two main
first-line TB drugs — isoniazid and rifampicin — but also to three or more of the six
classes of second-line drugs.15 Health experts are particularly concerned about the
most recent outbreak of XDR-TB in South Africa, which killed 52 out of 53 patients
within 25 days on average, including those being treated with anti-retroviral
medication.16 On October 9 and 10, 2006, WHO convened a meeting of a Global
Task Force to review available data on XDR-TB incidence, and to develop an
emergency XDR-TB action plan focused on containing the deadly strain and advising
health practitioners on XDR-TB case management.17
Some experts believe that a steady rise in malarial deaths in sub-Saharan Africa
is due in large part to an increase in treatment resistance. One of the commonly used
drugs, chloroquine, is quickly becoming ineffective in treating those infected with
malaria.18 Chloroquine is affordable to many, as it costs approximately 10 cents per
course of treatment. Because it has been used for more than 50 years, however,
resistant strains of malaria are rapidly developing, rendering the drug useless in a
growing number of cases. Newer treatments that are more effective and have no
observable resistance are considerably more expensive. The new drugs, called
“artemisinin-based combination therapies” (ACTs), cost about $2 per treatment
course, which is beyond the financial reach of many in the most affected regions.
History of Funding for U.S. Global HIV/AIDS Efforts
LIFE Initiative
In July 1999, then-President Bill Clinton requested that Congress provide an
additional $100 million to fund his Leadership and Investment in Fighting an
Epidemic (LIFE) Initiative. The initiative sought to expand U.S. global HIV/AIDS
efforts and to target the funds at 13 countries with the highest number of new HIV
infections.19 Specifically, President Clinton proposed that Congress allocate $48
million to global AIDS prevention, $23 million to home- and community-based care,
$10 million to children orphaned by AIDS, and $19 million to infrastructure and
capacity development.
14 (...continued)
Health Agency.” Sept. 5, 2006, at [http://www.un.org/apps/news/story.asp?NewsID=19727].
15 For more information on the spread of drug-resistant TB, see [http://www.cdc.gov/nchstp/
tb/pubs/mmwrhtml/mmwr_mdrtb.htm].
16 “Drug-Resistant TB in South Africa Draws Attention from U.N.,” New York Times,
September 6, 2006, at [http://www.nytimes.com].
17 UNAIDS, 2006 AIDS Epidemic Update, p. 12.
18 Data in this paragraph taken from Disease News, “Malaria Mortality Rate in Africa and
Asia Could Double in a Few Decades as the Drug Used Most Frequently Is Rendered
Useless,” July 23, 2004; see [http://www.news-medical.net].
19 The LIFE target countries were India, Ethiopia, Kenya, Malawi, Mozambique, Nigeria,
Rwanda, Senegal, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe.
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In FY2000, Congress provided more for global HIV/AIDS programs than
President Clinton requested for his LIFE Initiative, directing $189.3 million20 to
USAID for global HIV/AIDS activities; and appropriating $46.8 million21 to the
Department of Health and Human Services (HHS) for Centers for Disease Control
and Prevention (CDC) global AIDS activities, providing the first bilateral HIV/AIDS
appropriation to an agency other than USAID.22
In FY2001, Congress expanded appropriations for global HIV/AIDS programs
to the Departments of Agriculture (P.L. 106-948), Defense (P.L. 106-754), and Labor
(P.L. 106-1033); and provided funds for the first U.S. Global Fund contribution (P.L.
106-997 and P.L. 106-1033). Some HIV/AIDS analysts contend that the LIFE
Initiative raised congressional awareness about potential implications of a global
HIV/AIDS epidemic, led to an increase in U.S. spending on global HIV/AIDS, and
enhanced congressional receptivity to President George Bush’s Emergency AIDS
Plan, which he would announce three years later. While advocating for the LIFE
Initiative, U.S. officials argued that HIV/AIDS was more than a health issue.
HIV/AIDS, the Clinton administration contended, threatened economic growth,
political stability, and civil society, which made it an issue of trade and investment,
security and stability, and development.23
20 This figure includes a 0.38% across-the-board rescission.
21 The $46.7 million includes $34.8 million directed to CDC through regular FY2000
appropriations, and $11.9 million provided through FY2000 emergency appropriations.
22 Although in FY2000, CDC was the only agency outside of USAID to which Congress
appropriated funds for global HIV/AIDS programs, DOD and DOL websites indicate that
each launched HIV/AIDS programs through the LIFE Initiative that fiscal year.
Additionally, Congress authorized funds to the National Institutes of Health (NIH) for
international research activities (discussed later).
23 The White House, Report on the Presidential Mission on Children Orphaned by AIDS in
Sub-Saharan Africa: Findings and Plan of Action, July 19, 1999, at [http://clinton4.nara.
gov/media/pdf/africa2.pdf].
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Table 1. Global HIV/AIDS, TB, and Malaria Appropriations:
FY2000-FY2003
($ millions)
Program
FY2000 FY2001 FY2002 FY2003
USAID HIV/AIDS assistance (excluding Global
189.3
280.0
485.0
587.6
Fund)
USAID contributions to the Global Fund
0.0
120.0
200.0
248.4
USAID HIV/AIDS appropriations from other
0.0
15.0
40.0
38.3
accounts
Foreign Military Financing
0.0
0.0
0.0
0.0
Foreign Operations Appropriations Subtotal
189.3
415.0
725.0
874.3
CDC Global AIDS Program
46.8
104.5
143.8
182.5
Global Fund Contribution from HHS
0.0
0.0
100.0
99.3
Department of Labor AIDS in the Workplace
0.0
10.0
10.0
9.9
Labor/HHS Appropriations Subtotal
46.8
114.5
253.8
291.7
Department of Defense HIV/AIDS Prevention
0.0
10.0
14.0
7.0
Section 416(b) Food Aid
0.0
25.0
25.0
25.0
TOTAL
236.1
564.5
1017.8
1198.0
Source: Prepared by CRS from appropriations legislation.
Note: The data includes supplemental appropriations. This table reflects appropriated figures, which
may differ from actual spending. Agencies and departments might spend additional funds on
global HIV/AIDS efforts that were not specifically appropriated. For example, though Congress
does not specifically appropriate funds to NIH’s global HIV/AIDS research efforts, the Office
of AIDS Research reports that it has allocated some $160 million, $218 million, and $279
million in grants in FY2001, FY2002, and FY2003, respectively.
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International Mother and Child HIV Prevention Initiative
In FY2002, President Bush requested that Congress provide $500 million to
fund a new initiative he called the International Mother and Child HIV Prevention
(PMTCT) Initiative.24 The initiative sought to prevent the transmission of HIV from
mothers to infants and to improve health care delivery in Africa and the Caribbean.
Congress provided $100 million to USAID for the initiative in FY2002 supplemental
appropriations (P.L. 107-206); $100 million to USAID and $40 million to CDC for
the initiative in FY2003 (P.L. 108-7); and $150 million to CDC for the initiative in
FY2004 (P.L. 108-199).
In addition to the $150 million provided to CDC in FY2004, conferees
expressed an expectation that $150 million would be made available for the initiative
from the newly established Global HIV/AIDS Initiative (GHAI; H.Rept. 108-401).
Since the initiative expired in FY2004, following the administration’s request,
Congress has continued to include funds for programs that prevent the transmission
of HIV from mother to child in the GHAI account.
PEPFAR
On January 28, 2003, during his State of the Union Address, President Bush
proposed that the United States spend $15 billion over the next five fiscal years to
combat HIV/AIDS through an initiative he called the President’s Emergency Plan for
AIDS Relief (PEPFAR). The initiative, authorized in May 2003 by P.L. 108-25, the
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, anticipates
channeling $10 billion through the Global HIV/AIDS Initiative (GHAI) to 15 focus
countries (nine of the eleven LIFE focus countries are also PEPFAR focus countries);
directing $4 billion to global TB programs, international HIV/AIDS research, and
bilateral HIV/AIDS programs in more than 100 additional non-focus countries; and
reserving $1 billion for U.S. Global Fund contributions.25 Between FY2004 and
FY2008, PEPFAR programs aim to support care for 10 million HIV-affected people,
including children orphaned by AIDS; to support the prevention of 7 million new
HIV infections; and to support the provision of ARVs to 2 million people.26
Each fiscal year since the inception of PEPFAR, Congress has allocated more
than the Administration has requested for global HIV/AIDS programs. Between
FY2004 and FY2006, the United States spent some $8.6 billion on global HIV/AIDS,
TB, and malaria efforts, $8.3 billion of which was spent on bilateral HIV/AIDS
initiatives. During this time period, an estimated $3.6 billion of the $8.3 billion was
spent on HIV/AIDS programs in the 15 focus countries through GHAI. The
remaining amount, which totaled nearly $5 billion, was spent on U.S. contributions
to global partners like the Global Fund, pre-existing programs in 108 additional
countries, international HIV/AIDS research, and global TB efforts. The Office of
24 See [http://www.whitehouse.gov/news/releases/2002/06/20020619-1.html].
25 White House fact sheet on PEPFAR, [http://www.state.gov/p/af/rls/fs/17033.htm].
26 White House Fact Sheet, “The President’s Emergency Plan for AIDS Relief,” Jan. 29,
2003, at [http://www.state.gov/p/af/rls/fs/17033.htm].
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Global AIDS Coordinator (OGAC) reports that in FY2004 and FY2005, PEPFAR-
participating U.S. agencies and departments have supported:
! the provision of prevention of mother-to-child HIV transmission
(PMTCT) services to approximately 3.2 million women, of whom
over 248,000 have received ARV treatment, leading to the
prevention of an estimated 47,100 new HIV infections;
! the purchase and distribution of ARV medication for an estimated
471,000 people, of whom 401,000 were in the 15 focus countries;
! care for nearly 3 million people in the focus countries, of whom 1.2
million were orphans and vulnerable children; and
! HIV counseling and testing services for over 9.4 million people in
the focus countries.27
PEPFAR programs, led by OGAC at the U.S. Department of State and
implemented by various U.S. agencies and departments, support initiatives that
prevent the contraction of HIV/AIDS, TB, and malaria, as well as care and treatment
for people affected by the three diseases. Meanwhile, U.S. agencies and departments
implement additional international HIV/AIDS, TB, and malaria programs not funded
through PEPFAR. In each fiscal year since PEPFAR was launched, appropriators
have included a chart in the foreign operations appropriations conference reports that
itemizes how global HIV/AIDS, TB, and malaria funds are authorized to be spent
(see Table 2). Press accounts of U.S. global HIV/AIDS spending are usually derived
from this chart, though it does not include all U.S. global HIV/AIDS, TB, and
malaria funds. In FY2007, however, the charts in House and Senate subcommittee
reports do not include funding for global malaria efforts. Instead, language indicates
that global malaria funds are authorized under the President’s Malaria Initiative.
While authorizing legislation for PEPFAR requires the President to submit to
appropriators an annual report that describes how U.S. funds support the prevention
of HIV/AIDS, TB, and malaria, as well as care and treatment for those affected by
the three diseases, the two reports submitted by OGAC have only reported on U.S.
global HIV/AIDS activities.
27 OGAC, Second Annual Report to Congress on PEPFAR, 2006, at [http://www.state.gov/s/
gac/rl/c16742.htm].
CRS-9
Table 2. Global HIV/AIDS, TB, and Malaria Appropriations:
FY2004-FY2007
($ millions)
FY2007
Program
FY2004 FY2005 FY2006
Actual
Actual
Actual Request House
Senate
1. Child Survival Assistance for HIV/AIDS
513.4
347.2
346.5
325.0
346.6
342.5
(excluding Global Fund)
2. Child Survival Assistance for TB & Malaria
183.9
168.6
178.2
305.0
257.6
305.0
3. Child Survival Assistance for Global Fund
397.6
248.0
247.5
100.0
200.0
300.0a
4. FY2004 Global Fund Carryover b
-87.8
87.8
n/a
n/a
n/a
n/a
5. Other USAID accounts c
53.2
53.1
42.6
40.4
33.8
34.1
6. State Department GHAI
488.1 1,373.5 1,775.0 2,794.0 2,528.0 2,494.9
7. GHAI for the Global Fund
0.0
0.0
198.0
100.0
244.5 300.0a
8. Foreign Military Financing d
1.5
2.0
1.9
1.6
— e
— e
9. Subtotal, Foreign Operations
1549.9
2280.2 2,789.7 3,666.0 3,610.5 3,776.5
Appropriations
10. CDC Global AIDS Program (GAP)
291.8f
123.8
122.7
121.9
121.9
121.3
11. NIH International Research
317.2
370.0
371.1
368.0
— e
— e
12. Global Fund contribution NIH
149.1
99.2
99.0
100.0
0.0
100.0
13. DOL AIDS in the Workplace Initiative
9.9
1.9
— e 0.0
0.0
—
14. Subtotal, Labor/HHS Appropriations g
768
594.9
592.8
589.9
15. DOD HIV/AIDS prevention education,
4.2
7.5
5.2
0.0
—
— e
primarily in Africa
16. Section 416(b) Food Aid
24.8
24.8
24.8
10.0
— e
— e
17. TOTAL
2346.9
2907.4 3,412.5 4,265.9
Source: Prepared by CRS from appropriations legislation figures and interviews with Administration staff.
a. S.Rept.109-277, the Senate report to the FY2007 Foreign Operations appropriations, proposes contributing
$600 million to the Global Fund, though it only appropriates $300 million to the Child Survival and
Health ( CSH) account. The additional $300 million U.S. Global Fund contribution on Line 7 should be
considered a placeholder. There is no certainty that the funds will be appropriated to this account.
b. In FY2004, $87.8 million of the amount provided to the Global Fund was withheld per legislative provisions
limiting U.S. contributions to the Global Fund to 33% of the amount contributed by all donors. The
FY2005 Consolidated Appropriations legislation provided these withheld funds to the Global Fund,
subject to the 33% proviso, like the remainder of the U.S. contribution.
c. Other USAID accounts include Development Assistance (DA), Economic Support Fund (ESF), Assistance
for Eastern Europe and the Baltic States (SEED), and Assistance for the Independent States of the Former
Soviet Union (FSA).
d. Appropriations for Foreign Military Financing are used to purchase equipment for DOD HIV/AIDS
programs. DOD HIV/AIDS initiatives are referred to in Line 15.
e. Not congressionally designated, though funds could be provided at the Administration’s discretion.
f. The funding level for FY2004 GAP activities is significantly higher than subsequent fiscal years because
funds for the PMTCT Initiative were included in overall CDC global AIDS funds. However, after
FY2004, funds for the Initiative were appropriated to GHAI.
g. FY2005 was the last year that OGAC tracked spending by CDC on HIV/AIDS research spending,
international malaria, and global tuberculosis initiatives. CRS has followed this practice and no longer
reports spending on these efforts, though they and other programs contribute to U.S. efforts to curb the
global spread of these diseases.
CRS-10
PEPFAR-Participating Departments and Agencies
A number of U.S. departments and agencies are responsible for implementing
PEPFAR programs, though OGAC coordinates the distribution of most U.S. global
HIV/AIDS spending through the Global HIV/AIDS Initiative (GHAI). After the
State Department, USAID and HHS (NIH OAR28 and CDC GAP) receive the largest
congressional appropriations for international HIV/AIDS efforts. Other departments
that receive global HIV/AIDS funds include Labor (though Congress did not
appropriate funds to DOL in FY2006), Defense, and Agriculture. The programs and
budgets of each PEPFAR-participating department and agency are detailed below.
All budgetary figures in this section are adjusted to reflect rescissions unless
otherwise specified.
Department of State: Office of the Global AIDS Coordinator
In FY2003, P.L. 108-25 authorized the creation of OGAC. The mission of this
office is to coordinate and oversee all global HIV/AIDS spending by U.S. agencies
in the 15 focus countries. At the time of selection, these countries were among the
world’s most severely affected by HIV/AIDS, were home to approximately half of
the world’s 40 million HIV-positive people, and held almost 8 million children who
were orphaned or made vulnerable by HIV/AIDS.
As a coordinating office, OGAC transfers GHAI funds that it receives from
Congress for the 15 focus countries to implementing departments and agencies.
Figure 1 illustrates appropriations to OGAC from FY2004 through FY2007. In
FY2004, Congress provided OGAC its first appropriation, $488.1 million. Congress
provided a substantially larger amount for GHAI in FY2005, when it appropriated
$1,373.5 million to OGAC. Congress boosted appropriations to GHAI again in
FY2006, providing $1,775.0 million to the effort. In FY2007, the President
requested $2,794.0 million for GHAI, the House Foreign Operations Appropriations
Subcommittee proposed providing $2,528.0 million to GHAI, and the Senate Foreign
Relations Appropriations Subcommittee suggested appropriating $2,476.5 million
to the initiative.
28 Staff of OAR have indicated that they do not believe that OAR funds should be included
in overall PEPFAR funds, as the office does not receive funds through OGAC and its
spending decisions are independently made. Authorizing language in HHS appropriations
since FY2000 has enabled the Office of the Director at NIH to independently determine the
appropriate spending level for international HIV/AIDS research. Nonetheless, NIH
international HIV/AIDS research spending is included here as part of PEPFAR spending,
following the practice of OGAC.
CRS-11
Figure 1. OGAC HIV/AIDS Appropriations: FY2004-FY2007
($ in millions, current)
4000
3500
3000
2500
2000
1500
1000
500
0
FY2004
FY2005
FY2006
FY2007
FY2007
FY2007
(Estimate)
(Request)
(House)
(Senate)
OGAC appropriations
Global Fund
Source: Compiled by CRS from appropriations legislation.
U.S. Agency for International Development (USAID)
USAID implements global HIV/AIDS programs in 50 countries and reaches an
additional 48 countries through regional programs. The programs largely focus on
the following objectives:
! strengthening primary health care systems;
! providing training, technical assistance, and commodities, including
pharmaceuticals that reduce HIV transmission;
! providing care and support to people infected with HIV/AIDS;
! reducing high-risk behaviors; and
! supporting international partnerships, such as the International AIDS
Vaccine Initiative (IAVI), UNAIDS, and the Global Fund.
Prior to the launching of the LIFE Initiative, USAID was the sole agency
through which Congress supported bilateral HIV/AIDS programs, though other
agencies or departments might have implemented global HIV/AIDS initiatives. In
FY2000, Congress appropriated $189.3 million to USAID for its global HIV/AIDS
programs. In FY2001, appropriators provided $295 million to the agency for global
HIV/AIDS projects, and an additional $120.0 million for a U.S. contribution to the
Global Fund.29 Appropriations for USAID's bilateral programs rose in FY2002 to
$525 million, which included $100 million for the PMTCT Initiative. When the
additional $200.0 million that Congress appropriated for a U.S. contribution to the
29 In FY2000, Congress provided $20 million for a U.S. contribution to the Global Fund in
regular appropriations, and an additional $100 million in supplemental appropriations.
CRS-12
Global Fund are added, total appropriations to USAID reached $725.0 million in
FY2002.30 In FY2003, Congress slightly increased appropriations to the agency,
providing $526.5 million for its HIV/AIDS projects, including $99.3 million for the
PMTCT Initiative and an additional $248.4 million for the Global Fund.
Some analysts have asserted that since Congress began funding GHAI in
earnest, support for USAID-managed HIV/AIDS programs has declined. In FY2004,
when PEPFAR was first funded, appropriations to USAID's bilateral programs
reached $549.2 million and appropriations to GHAI for the 15 Focus Countries were
$488.1. In FY2005 and FY2006, when appropriations to GHAI were ramped up to
$1.4 billion and $1.8 billion, respectively, support for USAID's bilateral programs
fell to $382.8 million and $371.2 million, respectively.31 In FY2007, the President
requested $325.0 million for USAID's bilateral HIV/AIDS initiatives, while the
House proposed providing $346.6 million for USAID's HIV/AIDS programs, and the
Senate suggested appropriating $342.5 million to the projects. Proposed spending
levels from the administration and appropriating subcommittees are lower for
FY2007 than FY2006 appropriations.
Although appropriations for USAID HIV/AIDS programs have declined since
FY2003, overall spending by USAID on global HIV/AIDS initiatives has increased.
In FY2004 and in subsequent fiscal years, some of the funds that were appropriated
to OGAC for GHAI were transferred to USAID (see Figure 2). As a coordinating
body, OGAC does not implement HIV/AIDS programs; it transfers funds to the
implementing agencies and departments as needed. Most of the funds appropriated
to USAID are spent on global HIV/AIDS programs in non-focus countries; while the
majority of funds transferred to the agency from OGAC are spent on HIV/AIDS
efforts in the 15 focus countries. This practice has expanded USAID’s funding
streams, so that it receives support for its global HIV/AIDS programs from
congressional appropriations and from OGAC transfers. With OGAC transfers, total
USAID HIV/AIDS spending has increased substantially since FY2003.
30 In FY2002, Congress provided $100 million to USAID for a Global Fund contribution in
regular appropriations and an additional $100 million in supplemental appropriations. The
FY2002 supplemental appropriations also included $100 million for the PMTCT Initiative.
31 Includes appropriations to other accounts for USAID's bilateral HIV/AIDS programs.
CRS-13
Figure 2. USAID HIV/AIDS Appropriations: FY2000-FY2007
($ millions, current)
2 , 0 0 0
1 , 7 5 0
1 , 5 0 0
1 , 2 5 0
1 , 0 0 0
7 5 0
5 0 0
2 5 0
0
F Y 2 0 0 1
F Y 2 0 0 3
F Y 2 0 0 5
F Y 2 0 0 7 R e q u e s t
F Y 2 0 0 7 S e n a te
F Y 2 0 0 0
F Y 2 0 0 2
F Y 2 0 0 4
F Y 2 0 0 6 E s t i m a t e
F Y 2 0 0 7 H o u s e
P M T C T I n i t i a t i v e
O G A C T r a n s f e r s
G l o b a l F u n d
B il a t e r a l P r o g r a m s
Source: Compiled by CRS from appropriations legislation and interviews with
OGAC staff.
Department of Health and Human Services
Centers for Diseases Control and Prevention. A number of HHS
agencies participate in PEPFAR activities. The CDC Global AIDS Program (GAP)
operates in 25 countries32 and includes regional programs in Asia, the Caribbean,
Central America, and Southern Africa. CDC initiated its international HIV/AIDS
programs in FY2000 under the LIFE Initiative. CDC sends clinicians,
epidemiologists, and other medical experts to assist foreign governments, health
institutions, and other entities that work on a range of HIV/AIDS-related activities.
The key objectives of GAP are to help resource-constrained countries prevent HIV
infection; improve treatment, care, and support for people living with HIV; and build
health care capacity and infrastructure. Specific activities within the projects include:
! conducting HIV lab tests;
! supporting ARV drug therapy for HIV/AIDS patients;
! preventing mother-to-child transmission (PMTCT);
! supporting HIV counseling and testing;
! strengthening national blood transfusion services to ensure safe
blood supplies;
32 The 25 GAP countries (with PEPFAR focus countries italicized) are Angola, Botswana,
Brazil, Cambodia, China, Côte d’Ivoire, D.R. Congo, Ethiopia, Guyana, Haiti, India, Kenya,
Malawi, Mozambique, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania,
Thailand, Uganda, Vietnam, Zambia, and Zimbabwe.
CRS-14
! supporting medical injection safety programs; and
! building in-country surveillance, monitoring, and evaluation
capacity.
In FY2000, for the first time, Congress provided $34.8 million for CDC global
HIV/AIDS programs, and an additional $11.9 million for global HIV prevention and
research through FY2000 emergency supplemental appropriations. In FY2001,
Congress appropriated $104.5 million to CDC (of which $3 million was committed
to Health Resources and Services Administration (HRSA)'s International Training
and Education Center on HIV. In FY2002, funding increased again to $143.7
million. Congress provided about the same level of funding for GAP programs in
FY2003, providing $142.6 million for GAP programs and an additional $40 million
for the PMTCT Initiative. Funding for GAP remained about the same in FY2004;
that year the initiative received $142.7 million and an additional $149.1 million for
the PMTCT Initiative.
In FY2005, when the PMTCT Initiative expired, Congress stopped including
funds for the effort in CDC GAP appropriations. Nonetheless, preventing mother-to-
child HIV transmission remains a critical part of CDC GAP activities. Funds for the
PMTCT Initiative are included in GHAI appropriations, and OGAC transfers funds
to CDC to continue PMTCT activities. GAP funding fell slightly in FY2005 and
FY2006, when Congress provided $123.8 million and $122.6 million, respectively.
The Administration requested $121.9 million for CDC HIV/AIDS programs in
FY2007. The House Labor, HHS, Education Appropriations Subcommittee proposed
fully funding the President’s request, while the Senate subcommittee did not indicate
a specific amount for CDC global HIV/AIDS programs.
Although appropriations to CDC GAP have declined since FY2004, when
OGAC transfers are included, as was the case for USAID, total provisions have
increased (Chart 3).33 In FY2004, OGAC transferred $230.6 million to CDC for
GAP programs. In FY2005 and FY2006, OGAC transferred $573.5 million and
$734.0 million to CDC, respectively.34
33 This chart does not include funding for other HHS global HIV/AIDS efforts, such as
CDC overseas applied HIV prevention research, and National Institutes of Health (NIH)
international HIV/AIDS research. The chart also does not include U.S. Global Fund
contributions, as the contribution is not funded through the CDC bilateral programs.
34 Correspondence with OGAC staff in June 2006.
CRS-15
Figure 3. CDC HIV/AIDS Appropriations: FY2000-FY2007
($ in millions, current)
1000
900
800
700
600
500
400
300
200
100
0
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
FY2007
FY2007
Estimate Request
House
Senate
GAP
HRSA
OGAC Transfers
PMTCT Initiative
Source: Compiled by CRS from appropriations legislation and interviews with
CRS-16
OGAC.
National Institutes of Health (NIH). NIH has long implemented
international HIV prevention efforts. In 1984, NIH initiated its global HIV research
in Haiti; today NIH’s global HIV research is conducted in 90 countries around the
world. NIH-sponsored international research includes efforts to:
! develop an HIV vaccine;
! develop chemical and physical barrier methods for HIV prevention,
including microbicides;
! prevent sexually transmitted diseases, including HIV;
! encourage behavior change to lessen risky behaviors;
! identify drug and non-drug strategies to prevent mother-to-child HIV
transmission;
! develop therapeutics for HIV-related co-infection; and
! strengthen approaches to treating HIV in resource-poor settings.
NIH staff assert that although PEPFAR draws on expertise from NIH’s Office
of AIDS Research (OAR) international HIV/AIDS research activities, OAR spending
on global AIDS research is not determined by PEPFAR priorities.35 OAR’s
international HIV/AIDS research spending is driven by research activities conducted
in the field. NIH staff explain that its program spending fluctuations represent the
funding phases of multi-year grants that support the research activities. Through
competitively bid grants, OAR directs most of its funds to U.S.-based investigators
who conduct HIV/AIDS research in collaboration with international scientists.
However, some investigators based in foreign research institutions have also received
OAR grants. In FY2007, OAR estimates that it will award $368 million in grants for
global AIDS research activities (see Figure 4); and, as in previous fiscal years,
neither chamber appropriated a specific amount for NIH international HIV/AIDS
research.
35 CRS interview with OAR staff, July 5, 2006.
CRS-17
Figure 4. Office if AIDS Research Grants: FY2000-FY2000
($ in millions, current)
400
350
300
250
200
150
100
50
0
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
Estimate
Request
OAR Research Grants
Source: NIH, Office of the Director.
CRS-18
Health Resources and Services Administration (HRSA). HRSA, which
has experience expanding HIV/AIDS and other health services in resource-poor
settings in the United States, helps PEPFAR focus countries to develop HIV care and
treatment plans.36 Much of the training is conducted through International Training
and Education Centers on HIV (I-TECH). In 2002, HRSA and CDC established I-
TECH to share lessons learned from U.S. domestic AIDS education and training
efforts. I-TECH programs offer health experts in PEPFAR focus countries and other
resource-poor countries technical assistance on effective HIV/AIDS program
expansion. The assistance focuses on developing training programs, advising health
managers, producing health education materials, and providing guidance on HIV
awareness and education messages.
U.S. Food and Drug Administration (FDA). As OGAC began to establish
guidelines for the purchase of HIV treatment, the Bush Administration expressed
skepticism about broad-based use of generic ARV medication. The Administration
asserted that WHO’s prequalification process was not sufficient, and that generic
drugs purchased with PEPFAR funds had to pass FDA inspection.37 The
Administration’s position was that the WHO is not a regulatory body, and thus its
adherence to stringent FDA standards was uncertain.38 Observers contended that the
U.S. position was shaped by then-Global AIDS Coordinator, Randall Tobias. When
President Bush selected Randall Tobias as the Global AIDS Coordinator in July
2003, some had opposed his appointment, fearing that he would oppose the use of
generic ARV medications in PEPFAR programs because of his long-standing
relationship with the pharmaceutical industry.39 The Bush Administration responded
that Mr. Tobias’s experience in the private sector was what made him a good
candidate.
Debate about the use of generic ARVs in PEPFAR-supported programs
continued — though it was somewhat muted — after the FDA approved the first
generic ARV for use in PEPFAR programs in December 2004. Although the generic
drug was approved less than a year after FDA launched an expedited review process,
critics contended that the process was unnecessary and delayed the distribution of
ARVs.40 The FDA contended that the process was necessary to ensure that ARV
36 For more on HRSA’s global HIV/AIDS training efforts, see [http://www.go2itech.org/].
37 The WHO prequalifying process includes an assessment of product files (lasting
approximately two to four months); site inspections; and the procurement of data on all
active pharmaceutical ingredients, specifications, product formulas, and manufacturing
methods. After the products and manufacturing sites meet the required standards, the
medicine is added to the list of prequalified products. For more information, see
[http://www.who.int/3by5/publications/briefs/amds/en/].
38 Interviews with staff at the Office of the AIDS Coordinator, April 1, 2004.
39 Randall Tobias is no longer the U.S. Global AIDS Coordinator. For a summary of the
debate on his selection for the position, see the Kaisernetwork website at [http://www.
kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=18625].
40 David Brown and Ellen Nakashima, “U.S. Rule on AIDS Drugs Criticized,” Washington
Post, July 14, 2004. Steve Sternberg, “Bush’s AIDS plan could be tough to implement,”
USA Today, July 14, 2004. “The end of the beginning? AIDS,” The Economist, July 17,
(continued...)
CRS-19
treatments used in the PEPFAR programs were safe, effective, and of high quality.41
The expedited review process can take between two and six weeks. Since FDA began
reviewing generic drug applications, more than 30 generic versions of patented ARVs
have been approved or tentatively approved for use in PEPFAR treatment plans.42
Department of Defense (DOD)
The Department of Defense also joined the U.S. global fight against HIV/AIDS
under the LIFE initiative. DOD HIV prevention programs develop and implement
military-specific HIV prevention activities. DOD efforts:
! help foreign militaries to establish HIV/AIDS-specific policies for
their personnel;
! assist foreign militaries in adapting and providing HIV prevention
programs;
! train foreign military personnel to implement, maintain, and evaluate
HIV prevention programs;
! assist foreign countries in developing military-specific interventions
that address high-risk HIV attitudes and behaviors; and
! integrate with and make use of foreign military contacts, other U.S.
government programs, and those managed by allies and the United
Nations.
In FY2000, the department received $10.0 million through the LIFE Initiative,
though Congress did not appropriate funds to the department.43 In FY2001, Congress
provided $10.0 million to DOD for its HIV prevention efforts. In FY2002, Congress
provided $14.0 million. Appropriations to the department fell in FY2003 to $7.0
million. In FY2004, Congress did not provide any funds for DOD HIV prevention
activities. However, through FY2005 appropriations, Congress amended FY2004
Defense appropriations to add $4.2 million for FY2004 DOD global HIV programs,
and provided $7.5 million for FY2005 DOD HIV prevention efforts. Finally, in
FY2006, Congress appropriated $5.3 million to DOD for global HIV prevention
activities. The FY2007 budget request did not include funds for DOD global
HIV/AIDS efforts, and the FY2007 Defense appropriations did not include funds for
DOD global HIV/AIDS programs. As with other U.S. agencies and departments,
DOD spending on global HIV prevention has been significantly boosted by OGAC
transfers (see Figure 5).
40 (...continued)
2004. For more on the debate about the FDA review process, see the Kaisernetwork website
at [http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=27788].
41 HHS Press Release, “HHS Proposes Rapid Process for Review of Fixed Dose
Combination and Co-Packaged Products,” May 14, 2004, at [http://www.hhs.gov/news/
press/2004pres/20040516.html].
42 For more information on FDA’s role in reviewing ARVs, see [http://www.fda.gov/oia/
pepfar.htm].
43 DOD HIV Prevention website, [http://www.nhrc.navy.mil/programs/dhapp/background/
background.html].
CRS-20
Figure 5. DOD HIV/AIDS Appropriations: FY2000-FY2007 ($ in millions,
current)
60
50
40
30
20
10
0
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
FY2007
Estimate
Request Appropriations
Bilateral Programs
OGAC Transfers
Source: Compiled by CRS from appropriation legislation and interviews with
OGAC staff.
Department of Labor (DOL)
DOL HIV/AIDS-in-the-workplace programs are implemented through the
Bureau of International Labor Affairs (ILAB). Key activities include:
! guiding the development of comprehensive workplace-based
prevention and education programs;
! assisting governments, employers, and trade unions to develop and
disseminate national workplace policy statements that counter
stigma and discrimination; and
! supporting the formation of tripartite advisory committees
(government, business, and labor).
ILAB initiated its HIV prevention programs under former President Clinton’s
LIFE Initiative. Although Congress did not appropriate funds to the bureau in
FY2000, ILAB reports that it spent $900,000 on international HIV/AIDS efforts in
that fiscal year. In FY2001, ILAB received its first global HIV/AIDS appropriation,
$10 million (excluding rescissions). From FY2001 to FY2004, Congress maintained
funding for DOL HIV-prevention in the workplace programs at $10 million
(excluding rescissions). Conference report language to FY2004 Labor, HHS, and
Education Appropriations stated that ILAB was to transfer the full balance of its
global HIV/AIDS funds to the International Labor Organization’s (ILO’s) global
AIDS programs. In FY2005, appropriations to ILAB HIV programs fell to $1.9
million; conference report language again included the statement that the funds were
to be transferred to the ILO. In FY2006, Congress did not provide any funds to DOL
CRS-21
for HIV-in-the-workplace programs.44 The Administration did not request funds for
DOL HIV programs in FY2007, and neither House nor Senate subcommittee bills
appropriate funds for the programs (see Figure 6).45
Figure 6. DOL HIV/AIDS Appropriations: FY2000-FY2007
($ in millions)
20
15
10
5
0
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
Estimate
Request
Bilateral Programs
OGAC Transfers
Source: Compiled by CRS from appropriation legislation and interviews with
OGAC staff.
Some speculate that the Bush administration’s opposition to the rapid growth
and breadth of ILAB’s technical assistance programs led to a decline in congressional
support for the bureau’s HIV-in-the-workplace programs. Since the administration
submitted its first budget request in FY2002, Secretary of Labor Elaine Chao has
attempted to minimize the scope of activities undertaken by ILAB. At an FY2002
hearing on DOL’s budget, the Secretary asserted that the increase in appropriations
from FY2000 to FY2001 was made too quickly and that the bureau was not able to
absorb the rapidly increased funding.46 At a subsequent budget hearing in FY2003,
the Secretary argued that ILAB needed to return its focus to improving core labor
44 OGAC transferred some funds to DOL in FY2004, FY2005, and FY2006, providing
$400,000, $1,600,000 and $800,000, respectively.
45 The $900,000 illustrated in FY2002 of Figure 6 was not appropriated. DOL reports that
it spent that amount on international HIV/AIDS efforts in that fiscal year.
46 Senate Labor, HHS, Education Subcommittee hearing on DOL’s FY2002 budget request,
May, 2, 2001.
CRS-22
standards and combating child labor abuses.47 Other activities that the bureau
engaged in — including combating HIV/AIDS — the Secretary contended, strayed
from the bureau’s core mission and duplicated the efforts of other U.S. agencies.
Finally, in FY2005, Secretary Chao complained that ILAB spent too much of its
budget on overhead through grants to other organizations.48
U.S. Department of Agriculture (USDA)
In FY2001, and in each subsequent fiscal year, Congress committed USDA to
donate commodities valued at up to $25 million to foreign countries struggling to
counter the effects of HIV/AIDS. Although the funds are appropriated to USDA,
USAID manages the provision of the food aid. Neither the House nor the Senate
FY2007 Agriculture appropriations bills would provide funds for USDA food
assistance.
Peace Corps
The Peace Corps uses its volunteers to support community-based HIV/AIDS
care and prevention initiatives in 77 countries around the world, nine of which are
PEPFAR focus countries. Currently, some 20% of Peace Corps volunteers are
involved in HIV/AIDS and health projects worldwide, and some 800,000 people have
benefited from Peace Corps HIV/AIDS training.49 In 2003, about 1,000 volunteers
worked on HIV/AIDS programs, and in 2004, about 3,100 volunteers engaged in
HIV/AIDS activities.50 While some of the Peace Corps’ HIV/AIDS activities were
highlighted in OGAC’s Second Annual Report to Congress, no agency-specific
spending information was included in the report. Appropriations legislation has not
provided a specific amount for Peace Corps global HIV/AIDS initiatives since
PEPFAR was launched.51
U.S. Department of Commerce
The Department of Commerce provides in-kind support to PEPFAR aimed at
fostering public-private partnerships. The activities focus on informing industry HIV
trade advisory committees on how the private sector can help to combat HIV/AIDS;
and on creating and disseminating sector-specific strategies for various industries
(e.g., consumer goods, oil, and health care). The U.S. Census Bureau, within the
Department of Commerce, also contributes to PEPFAR by assisting with data
47 House Labor, HHS, Education Subcommittee hearing on DOL’s FY2003 budget request,
February 13, 2002.
48 House Labor, HHS, Education Subcommittee hearing on DOL’s FY2005 budget request,
February 12, 2004.
49 See [http://www.peacecorps.gov/index.cfm?shell=learn.whatlike.interactivefeatures.hiv].
50 See [http://www.peacecorps.gov/index.cfm?shell=learn.Whatvol.healthhiv].
51 In FY2004, appropriators authorized OGAC to transfer up to $15 million of GHAI funds
to the Peace Corps for global HIV/AIDS efforts. OGAC staff reported in an interview
conducted on June 29, 2006, that the office transferred $1.2 million, $4.7 million, and $7.8
million to the Peace Corps for global HIV/AIDS programs in FY2004, FY2005, and
FY2006, respectively.
CRS-23
management and analysis, estimating infections averted, and supporting mapping of
country-level activities.
Issues for the 110th Congress
Consider Outstanding Appropriations
HIV/AIDS advocates are closely watching how Congress will ultimately fund
global HIV/AIDS programs. In FY2007, Congress did not enact any of the
outstanding appropriations measures that would provide funds for global HIV/AIDS,
TB, and malaria activities. Instead, it amended P.L. 109-289 (Division B), which
provides funding at the lesser of FY2006 enacted, FY2007 House-passed, or FY2007
Senate-passed levels until February 15, 2007. H.R. 5522, the FY2007 House Foreign
Operations appropriations, would provide some $3.61 billion for the three diseases,
about $47 million less than the Administration requested for FY2007. H.R. 5647,
the FY2007 House Labor, HHS, Education appropriations, would provide $121.9
million for CDC’s Global AIDS Program (GAP), meeting the President’s request.
For the first time, the House Labor, HHS, Education Appropriations Subcommittee
did not propose additional funds for a U.S. Global Fund contribution through Labor,
HHS, Education appropriations. Instead, it deemed the $445 million included in its
FY2007 Foreign Operations appropriations proposal to be a sufficient amount for a
U.S. Global Fund contribution. With no additional funds provided in H.R. 5647, the
House appropriations subcommittees proposed contributing less to the Fund in
FY2007 than the preceding fiscal year for the first time since Congress began
appropriating contributions to the Global Fund.
The Senate report on FY2007 Foreign Operations appropriations, S.Rept. 109-
277, provided much less detail on how global HIV/AIDS, TB, and malaria funds
should be spent, but proposes appropriating a larger amount for the three diseases.
The Senate Foreign Relations Appropriations Subcommittee proposed nearly $3.8
billion for global HIV/AIDS, TB, and malaria efforts. Of that amount, the
subcommittee wanted to commit $600 million for a U.S. contribution to the Global
Fund, though the bill did not specify to which account $300 million of the funds
would be appropriated. Where specified, the Senate subcommittee proposal meets
or exceeds the Administration’s requests for the three diseases. S. 3708, FY2007
Labor, HHS, Education appropriations, does not provide a specific amount for global
HIV/AIDS, TB, and malaria programs.
While considering the appropriate level to provide for global HIV/AIDS
programs, some Members expressed concern that requests for complementary health
programs had fallen from FY2006 appropriated levels. Congresswoman Nita Lowey
questioned the effectiveness of increasing spending on the Millennium Challenge
Corporation (MCC) and PEPFAR, while proposing a reduction or no change in
spending for other development assistance and non-AIDS programs. Representative
Lowey stated, “I have serious concerns that as resources to these two programs have
increased, funding for traditional development initiatives managed by USAID have
either flatlined or decreased. [It] makes no sense to put money into ARV therapy for
HIV/AIDS patients if they are so malnourished that they cannot absorb the drugs. A
budget that addresses one aspect of the problem while neglecting another related
CRS-24
aspect will not achieve the desired impact.”52 Global health experts argue that the
skewed investment in HIV/AIDS is pulling in-country resources and health workers
away from government-run health clinics and toward foreign-funded HIV/AIDS
programs. This movement, health analysts argue, exacerbates the current health
worker shortage and limits the number of health professionals capable of treating
other afflictions.
Although some Members in both chambers criticized the Administration’s
proposal to lower funding for most global health programs, appropriations
subcommittees in the House and Senate suggested spending less than the President
requested in some areas (see Table 3).53 The House Foreign Operations
subcommittee sought less than was requested for USAID’s child survival and
maternal health programs and for initiatives that address other infectious diseases.
However, it proposed more than requested for USAID vulnerable children initiatives,
HIV/AIDS programs, and family planning/reproductive health efforts. The Senate
Foreign Relations subcommittee allocated less than requested for USAID bilateral
HIV/AIDS programs and other infectious diseases initiatives. Nonetheless, the
Senate proposed more than requested for the remaining programs.
52 FY2007 House Foreign Operations Appropriations Subcommittee hearing on USAID’s
FY2007 budget request, April 26, 2006.
53 Data in this table is meant for comparative purposes only. The figures were compiled by
USAID budget office, and differ somewhat from appropriated figures.
CRS-25
Table 3. USAID Global Health Programs: FY2000-FY2007
($ millions)
Program
FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2007 FY2007
Enacted Enacted Enacted Enacted Enacted Enacted Enacted Request
House
Senate
CS/MH
$461.5
$361.1
$391.7
$389.7
$442.9
$450.7
$461.4
$421.8
$356.4
$468.4
VC
$0.0
$36.7
$32.3
$34.3
$36.0
$35.3
$37.7
$13.4
$25.0
$30.0
HIV/AIDS
$200.0
$417.8
$501.3
$871.9
$972.9
$634.5
$625.9
$453.9
$546.6
$443.9
Other ID
$70.4
$140.2
$182.0
$173.1
$200.5
$216.0
$310.2
$396.6
$287.6
$367.3
FP/RH
$372.5
$424.0
$446.5
$443.6
$429.5
$437.0
$435.0
$357.3
$350.0a $465.3
TOTAL
$1,104.4 $1,379.7 $1,553.9 $1,912.5 $2,081.8 $1,773.5 $1,870.2
$1643.0 $1565.6 $1774.9
Source: USAID, Bureau for Policy and Program Coordination. FY2007 House, and Senate columns prepared by CRS
from appropriations legislation.
Abbreviations:
CS/MH = Child Survival and Maternal Health
VC = Vulnerable Children
Other ID = Other Infectious Diseases
FP/RH = Family Planning and Reproductive Health
Note:
a. The committee proposed the provision of additional funds for this program through other accounts, bringing the total
for reproductive health and family planning to $432 million.
Reauthorize PEPFAR?
In the 110th Congress, Members might decide whether to reauthorize PEPFAR,
which expires in FY2008. While there appears to be strong support for the
reauthorization of the initiative, a number of Members and advocates have proposed
some changes to the authorizing legislation. Still other HIV/AIDS analysts suggest
that health infrastructure challenges and health worker shortages in many countries
will have to be resolved if the United States is to effectively combat the global spread
of HIV/AIDS. Some global health advocates are urging Congress to reintroduce bills
similar to those that were not enacted in the 109th Congress, but sought to address a
range of issues related to the global HIV/AIDS pandemic (see Appendix).
Decrease, Maintain, or Increase HIV/AIDS Funding Levels? P.L. 108-
25 authorized the appropriation of $15 billion to fund PEPFAR through FY2008. If
current trends continue, it appears that appropriations will exceed that amount. Some
are concerned that competing domestic and international priorities might threaten
future congressional spending on foreign assistance, which includes global
HIV/AIDS efforts. In June 2006, Representative Jim Kolbe, Chair of the Foreign
Operations Subcommittee, warned that the growth in spending on domestic
entitlement programs could squeeze out foreign aid allocations.54 From FY2003 to
FY2004, Congress increased global HIV/AIDS appropriations by about $700 million,
54 Cited from a speech Representative Kolbe gave at the Center for Global Development on
June 26, 2006, at [http://www.cgdev.org/content/article/detail/8495].
CRS-26
and between FY2004 and FY2006 by about $500 million per fiscal year. If Congress
fully funds the Administration’s request, global HIV/AIDS spending in FY2007 will
exceed FY2006 spending levels by about $800 million, reaching approximately $4.3
billion. Though the virus continues to spread, some proponents of greater HIV/AIDS
spending believe that congressional support for global HIV/AIDS programs may
soon peak, as suggested by the House Foreign Operations Appropriations
Subcommittee’s decision not to exceed the President’s request for global HIV/AIDS
funding for the first time.
Retain U.S. Contributions to the Global Fund? Some HIV/AIDS
analysts predict that debate on PEPFAR reauthorization might include whether to set
spending limits for U.S. contributions to the fund and at what levels. P.L. 108-25
stipulates that U.S. contributions to the fund for FY2004 through FY2008 may not
exceed 33% of contributions from all sources. U.S. Representatives instituted the
contribution limit to encourage greater global support for the Global Fund. Some
supporters of the fund argue that the 33% should represent the amount the United
States contributes annually. Others argue that the statute serves as a ceiling and does
not commit the United States to providing 33% of all contributions.55 Senate-passed
S.Amdt. 3052 to S.Con.Res. 83, the FY2007 Senate budget bill, supported the 33%
provision and increased the U.S. FY2007 Global Fund contribution by $566 million.
Some question whether U.S. contributions to the fund are provided at the
expense of U.S. bilateral programs. At an FY2005 Senate Appropriations Committee
hearing, then-Global AIDS Coordinator Randall Tobias argued that the “incremental
difference between what the Administration requested and what was appropriated to
the Fund is money that might have been available” for use in U.S. bilateral
programs.56 While proposing PEPFAR, the Administration announced that it would
seek $1 billion for the Global Fund over the five-year term of the initiative. Congress
has already exceeded that proposal, providing more than $2 billion to the fund from
FY2004 to FY2006. The House Foreign Operations Subcommittee proposed an
additional $444.5 million for the fund in FY2007, while the Senate Foreign Relations
Subcommittee proposed $600 million.
55 For more on the Global Fund, see CRS Report RL33396, The Global Fund to Fight AIDS,
Tuberculosis, and Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-
Blyther.
56 Senate Appropriations Committee hearing on FY2005 Appropriations, May 18, 2004.
CRS-27
Alter Abstinence-Until-Marriage Stipulation? Some health experts assert
that PEPFAR’s HIV prevention stipulations are not well-balanced, place too much
emphasis on abstinence until marriage, and limit countries’ ability to utilize
prevention funds in a manner that is most relevant to local conditions. P.L. 108-25,
which delineates how PEPFAR funds should be allocated, stipulates that between
FY2006 and FY2008:
! 55% of global HIV/AIDS funds are to be used to treat people
infected with HIV/AIDS, of which 75% should be spent on the
purchase and distribution of ARV medication;
! 15% of global HIV/AIDS funds are to be used for palliative care;
! 20% of global HIV/AIDS funds are to be used for prevention efforts,
of which at least 33% should be expended for abstinence-until-
marriage programs; and
! 10% of global HIV/AIDS funds should be reserved for children
orphaned or affected by HIV/AIDS.
Opponents of the 33% abstinence-until-marriage provision cite an April 2006
Government Accountability Office (GAO) report, which concluded that the
stipulation places a burden on prevention spending. GAO found that PEPFAR’s
spending requirements limit the flexibility with which prevention funds could be
spent.57 GAO estimated that in order to meet the 33% proviso, between FY2004 and
FY2006, OGAC increased spending on prevention by almost 55% and mandated that
country teams spend half of prevention funds on sexual transmission prevention and
two-thirds of those funds on abstinence/faithfulness (AB) activities. Additionally,
GAO found that OGAC applied the 33% spending requirement to all PEPFAR
prevention funding, even though P.L. 108-25 specifies application to the 15 focus
countries funded through GHAI. Some expect that in the 110th Congress Members
might introduce legislation that amends the 33% provision, as was proposed in the
109th Congress (H.R. 5674 and S. 3656).
Emphasize Other HIV Prevention Strategies? Some HIV advocates
argue that since a disproportionate percentage of prevention funds are spent on
abstinence-only programs, spending on other HIV prevention strategies is limited.
Many health experts advocate for greater spending on the prevention of mother-to-
child HIV transmission PMTCT.58 UNAIDS estimates that 1,800 children worldwide
become infected with HIV each day, the vast majority of whom are newborns. More
57 GAO, Spending Requirement Presents Challenges for Allocating Prevention Funding
Under the President’s Emergency Plan for AIDS Relief, April 2006, at [http://www.gao.gov/
new.items/d06395.pdf].
58 Most children living with HIV acquire the disease through mother-to-child transmission
(MTCT), which can occur during pregnancy, labor and delivery, or breastfeeding. In the
absence of any intervention, the risk of such transmission is 15%-30% in non-breastfeeding
populations. Breastfeeding by an infected mother can increase the risk to 45%. The risk of
MTCT can be reduced to under 2% by interventions that include the provision of ARV
treatments. Elective caesarean delivery and complete avoidance of breastfeeding can also
reduce the risk of HIV transmission. In many resource-constrained settings, elective
caesarean delivery is seldom feasible, and mothers often lack access to enough clean water
or formula to refrain from breastfeeding. Research is ongoing to evaluate several new
approaches to preventing HIV transmission during breastfeeding.
CRS-28
than 85% of children infected with HIV live in sub-Saharan Africa, although MTCT
rates are rapidly rising in Eastern Europe and Central Asia.59 UNAIDS estimates that
in 2005, just less than 8% of pregnant women in low- and middle-income countries
had access to services that could prevent the transmission of HIV to their babies.60
Advocates of greater PMTCT spending argue that while proposed bills such as H.R.
5674, H.R. 4188, and S. 2765 support PMTCT initiatives by calling for greater
coordination of women’s health and HIV/AIDS programs, they could be strengthened
by specifying how much HIV/AIDS funding should be spent on PMTCT activities.
A number of HIV/AIDS advocates argue that if PEPFAR is reauthorized, the
guidelines on condom usage should be expanded. Critics contend that targeting
condom distribution in PEPFAR programs to “high risk groups”61 limits the
effectiveness of the strategy. Other observers complain that although research has
demonstrated that married women are particularly at risk of contracting HIV in
Africa and India, U.S. condom distribution strategies do not include married women,
unless their husbands test positive for HIV. Supporters of U.S. condom distribution
guidelines counter that the definition of “high risk” individuals is broad enough to
include the most vulnerable groups. Some HIV/AIDS proponents advocate that
Congress should introduce legislation that includes language similar to that in S.
3656, which expands the definition of “high risk” individuals to include married
young people. Advocates hope that an expanded definition might enable young
married people to access condoms through U.S.-supported programs.
Expand the List of Focus Countries? On June 22, 2004, the White House
belatedly selected Vietnam to be the last of the 15 focus countries. According to a
White House press release, U.S. officials chose the country in part because they
believed that Vietnam was facing an HIV/AIDS explosion, though the country had
about 130,000 infected people at the time. Additionally, U.S. officials decided that
Vietnam had demonstrated significant commitment to fighting the disease, as it was
spending about $36 per person for HIV/AIDS care, prevention, and treatment.
Some HIV/AIDS analysts argued that India might have been a better selection,
because at the time, it shared the distinction with South Africa of having the highest
number of HIV-positive people (about 5.3 million). Some theorized that India was
not chosen because at the time it had threatened to develop and distribute generic
versions of patented ARVs. The White House responded that India was not chosen
for a number of reasons. First, the United States was already providing the country
more than $20 million in HIV/AIDS assistance. Officials also asserted that India was
reluctant to accept the gravity of the HIV problem in the country, had invested a
relatively small amount of its own resources on HIV/AIDS care, prevention, and
59 UNAIDS 2006 Global AIDS Report, p.132.
60 Ibid, p.133.
61 High risk groups are defined as sex workers and their clients; sexually active discordant
couples (when one partner is HIV-positive and the other is not infected) or couples with
unknown HIV status; substance abusers; mobile male populations; men who have sex with
men; and people living with HIV/AIDS.
CRS-29
treatment (about $6 per person), and had a larger economy that was capable of
allocating more to fighting the virus.62
HIV/AIDS analysts are beginning to advocate that other countries where the
virus is rapidly spreading be included in GHAI. Since Vietnam was selected, India
has become the country with the largest number of HIV-infected people in the world
(some 5.7 million HIV-positive people), compared to South Africa’s 5.5 million. In
other areas, HIV has become more entrenched, particularly in Eastern Europe and
Central Asia. According to UNAIDS, the number of people living with HIV in those
regions has increased by more than 26% since 2003, when about 1.1 million people
were living with the virus. At the end of 2005, about 1.5 million people were living
with HIV in the two regions, 90% of whom were in Ukraine and Russia. Ukraine has
the highest HIV rate in all of Europe (1.4%), with some 410,000 people living with
the virus. Some 80% of the estimated 940,000 people living with HIV in Russia are
believed to be between 15 and 30 years old.
Address Infrastructure Challenges and
Health Worker Shortages
Global AIDS Coordinator Ambassador Mark Dybul testified at a March 2006
hearing on PEPFAR that ill-equipped health systems compromise the ability of the
United States to implement its PEPFAR programs efficiently. Ambassador Dybul
stated that building health infrastructure and strengthening health systems are critical
components of PEPFAR programs. According to OGAC, in FY2005, an estimated
25% of all PEPFAR-supported activities had components directly related to
strengthening health systems, such as quality assurance, financial management and
accounting, health networks and infrastructure, and commodity distribution and
control. In FY2006, OGAC allocated $44.8 million to policy analysis and system
strengthening. Although OGAC reports that it is allocating funds to strengthen
health systems, in a July 2004 report, GAO criticized some aspects of PEPFAR’s
health system strengthening efforts.63 GAO found that some of OGAC’s strategies
aimed at increasing the quality and quantity of health care workers in Africa might
not be cost-effective or practical for long-term implementation.64 Some analysts
project that as HIV/AIDS continues to spread, more legislation might be introduced
in the 110th Congress to support failing health systems (similar to S. 3775 and S. 850,
introduced in the 109th Congress).
Appendix
62 For more on this discussion, see the White House press release at [http://www.whitehouse.
gov/news/releases/2004/06/20040622-12.html].
63 GAO, U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment,
but Others Remain, July 2004, at [http://www.gao.gov/new.items/d04784.pdf].
64 The Institute of Medicine of the National Academies also reviewed PEPFAR health
system strengthening strategies and made some recommendations on strengthening African
health care systems; see [http://www.nap.edu/catalog/11270.html]. Some of the criticisms
that GAO made about PEPFAR health strengthening strategies were motivated by the
institute’s recommendations.
CRS-30
Table 4. Participating Agencies and Departments in U.S. Global
HIV/AIDS Initiatives: LIFE and PEPFAR
LIFE
ROLE
PEPFAR
INITIATIVE
INITIATIVE
Implementing
Implementing
Agency or
Agency or
Department
Department
Encourage public-private partnerships, inform the
Department of
private sector on how to counter HIV/AIDS,
Commerce
provide HIV/AIDS data
DOD
Provide technical assistance in the development
DOD
and implementation of HIV/AIDS policies and
programs for military personnel
DOL
Provide technical assistance in the development of
DOL
comprehensive workplace-based HIV-prevention
and -education programs, and national workplace
HIV policy statements
HHS:
HHS:
CDC
Work with health experts, governments, and
CDC
health institutions to provide care and treatment
for those infected with HIV; and to prevent new
infections
Review and approve generic ARV drugs for use in
FDA
PEPFAR programs
Help countries to develop HIV care and treatment
HRSA
plans
Conduct NIH international research activities
NIH
Coordinate implementation of the $9 billion
OGAC
GHAI
Support community-based HIV/AIDS care and
Peace Corps
prevention initiatives
USAID
Implement programs that provide care and
USAID
treatment to those affected by HIV/AIDS, and
prevent new infections.
Note: NIH is not included in the column for LIFE Initiative, because the Clinton administration did
not include the institute in its proposal. Though the institute does not consider itself part of
PEPFAR, the administration does and includes it in its reports to Congress.
CRS-31
HIV/AIDS Bills Not Enacted in the 109th Congress
Legislation Related to Strengthening Health Systems. H.R. 4222 and
S. 2765, the Child Health Investment for Long-term Development (CHILD and
Newborn) Act, would have authorized $660 million for FY2007 and $1.2 billion for
each fiscal year from 2008 through 2011 to support activities that strengthen the
capacity of health systems in developing countries; improve health care access among
under-served and marginalized populations; enhance the supply, logistics, and
distribution of essential drugs, vaccines, commodities, and equipment; integrate and
coordinate HIV/AIDS, malaria, TB, and child spacing programs; and expand access
to safe water and sanitation. The bills also would have required the President to
develop a strategy that improves the health of newborns, children, and mothers, and
reduces their mortality. The bills would have established a task force to assess,
monitor, and evaluate the progress and contributions of relevant U.S. departments
and agencies toward achieving the Millennium Development Goals to reduce the
mortality of children under the age of five by two-thirds and to reduce maternal
mortality by three-quarters in developing countries by 2015. H.R. 4222 was
introduced and referred to the House Committee on International Affairs (HIRC) on
November 3, 2005. S. 2765 was introduced and referred to the Senate Foreign
Relations Committee (SFRC) on May 9, 2006.
S. 3775, African Health Capacity Investment Act, would have provided $100
million for health systems strengthening in FY2007, $150 million in FY2008, and
$200 million in FY2009. The bill was introduced and referred to the SFRC on
August 2, 2005.
S. 850, the Global Health Corps Act, would have established at HHS an Office
of the Global Health Corps to expand the availability of health care personnel, items,
and related services to improve the health, welfare, and development of communities
in select foreign countries and regions. The office would have been responsible for
recruiting a volunteer health corps to serve in foreign countries, and for coordinating
the implementation of related efforts by participating U.S. agencies and departments.
The bill was introduced and referred to SFRC on April 19, 2005.
Legislation Related to Integrating Health Services. H.R. 4188, the
Focus on Family Health Worldwide Act, would have amended the Foreign
Assistance Act by expanding the activities that the President is authorized to furnish,
which include the coordination of HIV/AIDS and family planning programs, the
training of health care providers, and improving supply chain logistics. To support
the activities, the bill would have authorized $600 million for FY2007, $700 million
for FY2008, $800 million for FY2009, $900 million for FY2010, and $1 billion for
FY2011. The bill was introduced and referred to HIRC on November 1, 2005.
H.R. 4736, the Ensuring Access to Contraceptives Act, would have amended the
Foreign Assistance Act of 1961 to authorize the appropriation of $150 million in
FY2007 and FY2008. The bill proposed that the funds be used to purchase and
distribute contraceptives in developing countries that could help prevent unintended
pregnancies, abortions, and the transmission of sexually transmitted infections,
including HIV/AIDS. The bill was introduced and referred to HIRC on February 8,
2006.
CRS-32
Legislation Related to HIV/AIDS Treatments and Vaccines. H.R.
3854 and S. 550, the Microbicide Development Act, would have amended the Public
Health Service Act (42 U.S.C. 300cc-40 et seq.) by directing the Office of AIDS
Research to expedite the implementation of a federal microbicide research and
development plan; annually review the plan, and prioritize related funding and
activities. The bills also would have directed the Director of the National Institute
of Allergy and Infectious Diseases to establish within the Division of AIDS, a clearly
defined organizational unit charged with carrying out microbicide research and
development. At USAID, the bills directed the head of the Office of HIV/AIDS to
develop and implement a program to support the development of microbicides
products for the prevention of the transmission of HIV and other diseases, and
facilitate wide-scale availability of the products. H.R. 3854 was introduced on
September 21, 2005, and referred to Health Subcommittee of HIRC on October 7,
2005. S. 550 was introduced and referred to the Senate Health, Education, Labor,
and Pensions (HELP) Committee on March 8, 2005.
H.R. 3781 and S. 1698, the Vaccines for the New Millennium Act, proposed
implementing a number of strategies to accelerate the development of vaccines for
diseases primarily affecting developing countries, including HIV/AIDS. Proposed
strategies include encouraging public-private partnerships, supporting research,
development, and manufacturing incentives, and providing tax credits for
participating researchers and manufacturers. Both bills were introduced on
September 14, 2005. H.R. 3781 was referred to the House Subcommittee on
Domestic and International Monetary Policy, Trade, and Technology on October 17,
2005. S. 1698 was introduced and referred to the Senate Finance Committee on
September 14, 2005.
Legislation Related to Care for those Affected by HIV/AIDS. H.R.
164, the International Pediatric HIV/AIDS Network Act, would have amended the
Foreign Assistance Act of 1961 to provide for the establishment of a network of
pediatric centers in certain developing countries that treat and care for children with
HIV/AIDS. The centers would have been developed and staffed by U.S. and local
professionals, and would be modeled after international pediatric HIV/AIDS care and
treatment centers already established and operating in Romania and Botswana. The
bill was introduced and referred to HIRC on January 4, 2005.
Legislation to Amend P.L. 108-25. H.R. 5674, the Protection Against
Transmission of HIV for Women and Youth Act, would have stricken the 33%
provision from P.L. 108-25. The bill also required the President to formulate and
submit to Congress a comprehensive, integrated, and culturally appropriate global
HIV prevention strategy that addresses the vulnerabilities of married and unmarried
women and girls to HIV infection and seeks to reduce the factors that lead to gender
disparities in the rate of HIV infection. The bill was introduced and referred to HIRC
on June 22, 2006. There has been no subsequent action on the legislation.
CRS-33
S. 3656, the HIV Prevention for Youth Act, would have amended P.L. 108-25
so that the 33% provision was limited to preventing the sexual transmission of HIV
in FY2006 through FY2008. Currently, P.L.108-25 applies the 33% stipulation to
all HIV prevention funds. The draft also proposed adding a definition for
“abstinence-until-marriage” to the act. The bill added a definition of a generalized
epidemic to the Foreign Assistance Act of 1961, and included married and unmarried
sexually active young people in the “high risk” group to be targeted in HIV
prevention programs. The bill was introduced and referred to SFRC on July 13,
2006.