Order Code RL33485
U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2008
Updated March 6, 2007
Tiaji Salaam-Blyther
Specialist in Foreign Affairs
Foreign Affairs, Defense, and Trade Division

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U.S. International HIV/AIDS, Tuberculosis, and Malaria
Spending: FY2004-FY2008
Summary
On January 28, 2003, during his State of the Union Address, President George
Bush proposed that the United States spend $15 billion over five years to combat
HIV/AIDS, tuberculosis (TB), and malaria through the President’s Emergency Plan
for AIDS Relief (PEPFAR). The President proposed that most of the spending on
PEPFAR programs be concentrated in 15 countries in Africa, Asia, Latin America,
and the Caribbean. Of the $15 billion, the Plan proposed spending $9 billion on
prevention, treatment, and care services in the 15 Focus Countries, where the
Administration estimated 50% of all HIV-positive people lived. The President also
proposed that $5 billion of the funds be spent on existing bilateral HIV/AIDS, TB,
and malaria programs and research, and $1 billion of PEFPAR funds be reserved for
U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria
(Global Fund). Between FY2004 and FY2008, PEPFAR aims to have supported
care for 10 million people affected by HIV/AIDS, including children orphaned by
AIDS; prevented 7 million new HIV infections; and supported efforts to provide anti-
retroviral medication (ARV) to 2 million HIV-infected people.
Between FY2004 and FY2007 Congress provided almost $13.5 billion to
fighting the global spread of HIV/AIDS, TB, and malaria. Through the FY2007
Continuing Appropriation Resolution, P.L. 109-289, as amended by P.L. 110-5,
Members demonstrated strong support for global HIV/AIDS, TB, and malaria
programs. Although most accounts were funded at the least of FY2006 enacted,
FY2007 House-passed, or FY2007 Senate-passed levels, appropriators increased
support for global HIV/AIDS programs by about $1.4 billion over FY2006 levels.
The year-long continuing resolution appropriation provided nearly $4.8 billion to
U.S. international HIV/AIDS, TB, and malaria initiatives, including $724.0 million
for a U.S. contribution to the Global Fund — the largest single U.S. contribution to
date.
The President’s FY2008 budget request includes about $5.8 billion for global
HIV/AIDS, TB, and malaria efforts. The administration proposes that the bulk of the
funds, about $5.0 billion, be provided through Foreign Operations appropriations.
If Congress fully funds the President’s FY2008 request, the United States will have
exceeded the $15 billion originally sought for PEPFAR; some $19.2 billion would
be spent on fighting the three diseases from FY2004 to FY2008. This report will
review U.S. appropriations to the three diseases between FY2004 and FY2007, and
will be updated to include further congressional actions in FY2008.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Appropriations For Global HIV/AIDS Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Prevention of Mother and Child HIV Transmission Initiative . . . . . . . . . . . . 2
The President’s Emergency Plan for AIDS Relief . . . . . . . . . . . . . . . . . . . . . 3
Global Fund to Fight AIDS, Tuberculosis, and Malaria . . . . . . . . . . . . . . . . 5
The President’s Malaria Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Explanation of Data in Table 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
List of Tables
Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations . . . . . . . . . . . 4
Table 2. FY2001-FY2007 U.S. Contributions to the Global Fund . . . . . . . . . . . . 6

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U.S. International HIV/AIDS, Tuberculosis,
and Malaria Spending: FY2004-FY2008
Introduction
It is estimated that HIV/AIDS, 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 two 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 little
access to drugs that prevent the transmission of HIV from mother to child. An
estimated 9% of pregnant women in low-and middle-income countries were offered
services to prevent HIV transmission to their newborns.
The World Health Organization (WHO) estimates that by the end of 2004, more
than 14 million people were infected with tuberculosis (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
1 [http://www.who.int/tb/publications/2006/tb_facts_2006.pdf]
2 All data on HIV/AIDS infection rates taken from UNAIDS 2006 Report on the Global
AIDS Epidemic unless otherwise indicated. [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].
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. [http://www.who.int/mediacentre/factsheets/fs104/en/]
4 WHO 2006 Global Tuberculosis Control Report. [http://www.who.int/tb/publications/
global_report/en/index.html]

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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 one 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
Appropriations For Global HIV/AIDS Efforts
Appropriations for combating the global spread of HIV/AIDS have grown
considerably since President Bush entered office.8 U.S. contributions to the Global
Fund and the launching of two initiatives have contributed to this growth: the
Prevention of Mother and Child Transmission Initiative and the President’s
Emergency Plan for AIDS Relief (PEPFAR).
Prevention of Mother and Child HIV Transmission Initiative
In FY2002, the President requested that Congress provide $500 million to fund
a new initiative he called the International Mother and Child HIV Prevention
Initiative.9 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 appropriated $150 million to CDC for the
Initiative in FY2004 (P.L. 108-199).
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 blood stream. Once in the blood stream,
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.
[http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm]
6 WHO estimates that each year, there are 300 million acute malaria cases that 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 Bank believes the remaining 8% of deaths
occur in southeast Asia, 5% in the Eastern Mediterranean region, 1% in the Western Pacific,
and 0.1% in the Americas. The Bank 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, accessed on August 31, 2006. [http://malaria.who.int/
cmc_upload/0/000/015/372/RBMInfosheet_1.htm]
8 For more information on U.S. appropriations for global AIDS programs, see CRS Report
RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2007, by Tiaji Salaam-Blyther.
9 [http://www.whitehouse.gov/news/releases/2002/06/20020619-1.html]

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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.
The President’s Emergency Plan for AIDS Relief
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 PEPFAR. The Initiative, authorized in May 2003 by the
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (P.L. 108-25),
anticipates channeling $9 billion to prevention, treatment, and care services in the 15
Focus Countries through GHAI,10 $5 billion to existing bilateral HIV/AIDS, TB, and
malaria programs and research conducted in more than 100 non-Focus Countries, and
$1 billion to the Global Fund. Between FY2004 and FY2008, PEPFAR programs
aim to support care for 10 million HIV-affected people, including children orphaned
by AIDS; support the prevention of 7 million new HIV infections; and help 2 million
people receive ARVs.11
Congress appropriates the bulk of PEPFAR funds to the GHAI account. The
account was established to streamline funds for global HIV/AIDS, TB, and malaria
programs to the 15 Focus Countries. The Office of the Global AIDS Coordinator
(OGAC) at the U.S. Department of State transfers funds from GHAI to implementing
agencies and departments. The funds that Congress appropriates directly to U.S.
agencies and departments are utilized in the non-Focus Countries. U.S. agencies and
departments might also allocate additional resources to 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 (Table 1). 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 support.
10 The 15 PEPFAR Focus Countries are: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti,
Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam,
and Zambia.
11 White House Fact Sheet, “The President’s Emergency Plan for AIDS Relief.” January
29, 2003. [http://www.state.gov/p/af/rls/fs/17033.htm]

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Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations
($ millions)
FY2004 FY2005 FY2006 FY2007 FY2008
Program
Actual Actual Actual
CR
Request
1.
USAID HIV/AIDS (excluding Global Fund)
549.2
382.8
373.8
346.3
464.5
2. USAID
Tuberculosis
100.4
87.8
91.5
89.9
3. USAID
Malaria
a
100.9
98.2
102.0
248.0
387.5
4.
USAID Global Fund Contribution
397.6
247.9
247.5
247.5
0.0
5.
FY2004 Global Fund Carryover b
-87.8
87.8
n/a
n/a
n/a
6.
State Department GHAI
488.1 1,373.5 1775.1
2,869.0 4150.0
7.
GHAI Global Fund Contribution
0.0
0.0
198.0
377.5
0.0
8.
Foreign Military Financing c
1.5
1.9
1.9
—
0.0
9.
Subtotal, Foreign Operations
1549.9 2279.9 2,789.8
4,206.5 4,973.7
Appropriations
10. CDC Global AIDS Program d
291.8
123.8
122.7
120.8
121.2
11. NIH International Research e
317.2
370.0
373.0
372.0
373.0
12. NIH Global Fund contribution
149.1
99.2
99.0
99.0
300.0
13. DOL AIDS in the Workplace Initiative
9.9
1.9
0.0
—
0.0
14. Subtotal, Labor/HHS Appropriations
768.0
594.9
594.7
591.8
794.2
15. DOD HIV/AIDS prevention education
4.2
7.5
5.2
—
0.0
16. Section 416(b) Food Aid
24.8
24.8
24.8
—
0.0
17. TOTAL
2346.9 2907.1 3,414.5
4,798.3 5,767.9
Sources: Prepared by CRS from appropriations legislation figures and interviews with Administration staff.
Note: Participating U.S. agencies and departments might spend additional funds on international HIV/AIDS,
TB, and malaria assistance not included in this chart. For example, CDC engages in international HIV
prevention research and global TB and malaria initiatives, though Congress does not earmark funds for
these efforts. “ — ” indicates that the funds were not earmarked, but could be provided at the
Administration’s discretion.
a. After President Bush launched the President’s Malaria Initiative (PMI) in June 2005, House and Senate
appropriations committees reported out funds supporting global malaria efforts separately from those
supporting HIV/AIDS and TB initiatives. Although the President announced the operations for the
initiative began in FY2006, Congress did not appropriate funds to the initiative until FY2007. That fiscal
year, it provided $248.0 million for international malaria programs, including $149.0 million to expand
PMI.
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 act provided these withheld funds to the Global Fund, subject
to the 33% proviso.
c. 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.
d. Lower spending levels in FY2005 and FY2006 reflect the shift of funds initially reserved for the
International Mother and Child HIV Prevention Initiative to the Global HIV/AIDS Initiative account.
When the initiative expired in FY2004, these changes were made permanent and were applied to
subsequent fiscal years.
e. Although appropriations legislation does not specify funding for NIH’s international HIV research
initiatives, sufficient funds are provided to Office of AIDS Research (OAR) the support those efforts.
The figures used in Line 11 reflect those amounts reported by OAR.

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Global Fund to Fight AIDS, Tuberculosis, and Malaria
In January 2002, the Global Fund was established in Geneva, Switzerland. The
Fund provides grants to developing countries aimed at reducing the number of HIV,
TB, and malaria infections, as well as the other illnesses and deaths that result from
such infections. The Fund is an independent foundation led by a board of directors
comprised of representatives from seven donor countries and seven developing
countries. In an effort to include all major stakeholders, each of the following
communities also has one representative on the board: developed country non-
governmental organizations (NGOs), developing country NGOs, the business
community, private foundations, and people living with HIV/AIDS, tuberculosis or
malaria. The Fund projects that by 2007, the grants it has approved will have:
! provided treatment for 1.8 million HIV-positive people, 5 million
people infected with TB, and 145 million malaria patients;
! prevented the spread of HIV to 52 million people through voluntary
HIV counseling and testing services;
! financed the purchase and distribution of 109 million insecticide-
treated bed nets to prevent the spread of the malaria; and
! supported care for 1 million orphans.12
Although there appears to be strong support for the Global Fund, Congress has
placed restrictions on U.S. contributions to the Fund for various reasons. In FY2006,
due to concerns about the Fund’s spending practices, Congress required that 20% of
U.S. contributions to the Fund be withheld until the Secretary of State certified that
the Fund had undertaken a number of steps to strengthen oversight and spending
practices (P.L. 109-102).13 The act allowed the Secretary to waive the requirement
if she determined that a waiver was important to U.S. national interest.
Congress has already provided more for U.S. contributions to the Fund than the
$1 billion the President originally sought. Since PEPFAR was launched in FY2004,
appropriators provided about $2.2 billion for U.S. support to the Fund and nearly
$2.5 billion since making the first appropriation in FY2001 (Table 2).14
12 Global Fund, Progress Report. January 21, 2005, at [http://www.theglobalfund.org].
13 The required steps are to (1) establish clear progress indicators upon which to determine
the release of incremental disbursements; (2) release such incremental disbursements only
if progress is being made based on those indicators; and (3) provide support and oversight
to country-level entities, such as country coordinating mechanisms, principal recipients, and
local Fund agents.
14 Funding levels include supplemental appropriations. For more information 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.

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Table 2. FY2001-FY2007 U.S. Contributions to the Global Fund
($ millions)
FY2001
FY2002
FY2003
FY2004 FY2005 FY2006
FY2007
FY2008
Actual
Actual
Actual
Actual
Actual
Actual
CR
Request
1. Foreign
Operations
120.0
200.0
248.4
397.6
248.0
445.5
625.0
0.0
2. Labor/HHS
0.0
100.0
99.3
149.1
99.2
99.0
99.0
300.0
3. FY2004
Carryover
n/a
n/a
n/a
-87.8
87.8
n/a
n/a
n/a
TOTAL
120.0
300.0
347.7
458.9
435.0
544.5
724.0
300.0
Source: Compiled by CRS from appropriations legislation.
The President’s Malaria Initiative
In June 2005, President Bush launched the President’s Malaria Initiative (PMI),
a plan to increase support for U.S. international malaria programs by more than $1.2
billion between FY2006 and FY2010 in 15 countries. Since launching PMI, the
Administration has requested that all support for bilateral malaria efforts be provided
to the U.S. Agency for International Development (USAID) as the coordinating
agency for the initiative. When the Administration shifted leadership for bilateral
malaria programs to USAID in FY2005, it determined that OGAC would no longer
include malaria spending in its annual reports to Congress and that budgetary
requests for the disease would be made separately from HIV/AIDS and TB requests.
For comparability, and because P.L. 108-25 considers efforts to combat malaria as
a critical part of PEPFAR, Table 1 includes appropriations to malaria programs.
In FY2006 and FY2007, appropriators provided $102 million and $248 million
for bilateral malaria efforts, respectively.15 The Administration requests that
Congress appropriate $387.5 million to USAID for malaria initiatives in FY2008.
According to the PMI website, in FY2006, $30 million of the $99 million that
USAID spent on malaria programs was allocated to PMI, and in FY2007, an
estimated $135 million will be spent on the initiative. The Administration requests
$300 million for PMI in FY2008 and FY2009 each, and $500 million in FY2010.16
15 Although the President announced the operations for the initiative began in FY2006,
Congress did not appropriate funds to the initiative until FY2007. That fiscal year, it
provided $248.0 million for international malaria programs, including $149.0 million to
expand PMI.
16 [http://www.pmi.gov/funding/index.html]

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Appendix
Explanation of Data in Table 1
Lines 1 and 2 refer to USAID’s bilateral HIV/AIDS and TB programs in the
non-Focus Countries, which are funded through a number of accounts, including: the
Child Survival and Health Account (CSH), Economic Support Fund aid (ESF),
Assistance for the former Soviet Union under the Freedom Support Act (FSA),
Assistance for Eastern Europe and the Baltics (SEED), and food aid.17
Line 3 refers to USAID’s bilateral malaria programs funded through all accounts
(see above).
Line 4 refers to contributions to the Global Fund provided through USAID
accounts. In FY2004, $87.8 million of the amount appropriated to the Global Fund
was withheld per legislative provisions limiting U.S. Global Fund contributions to
33% of the amount contributed by all donors, as indicated in Line 5.18 P.L. 108-447,
FY2005 Consolidated Appropriations, directed that these withheld funds be
transferred to the Global Fund in FY2005, subject, like the remainder of the U.S.
contribution, to the 33% proviso.
Congress provides funds for PEPFAR’s 15 Focus Countries to the State
Department’s Global HIV/AIDS Initiative (GHAI), as indicated in Line 6. U.S.
contributions to other global AIDS efforts, such as international microbicide
research, the International AIDS Vaccine Initiative (IAVI), and the United Nations
Joint Program on HIV/AIDS (UNAIDS), are also provided through GHAI.
GHAI Funds transferred to the Global Fund are reflected in Line 7.
Line 8 refers to funds appropriated to the Foreign Military Financing (FMF)
account for equipment purchases that support the DoD’s global HIV/AIDS efforts.
DoD’s bilateral HIV/AIDS programs, referred to in Line 15, offer HIV/AIDS
prevention education, primarily to African armed forces.
Line 10 refers to the Centers for Disease Control and Prevention’s (CDC)
Global AIDS Program (GAP). CDC spends additional funds on international
HIV/AIDS, TB, and malaria activities that are not earmarked by Congress, although
those amounts are not reflected in the table.
17 Such aid is in addition to the Section 416(b) food aid listed in Table 1. For a description
of food aid programs, see CRS Report RL33553, Agricultural Export and Food Aid
Programs, by Charles E. Hanrahan.
18 See P.L. 108-25, the United States Leadership against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 and P.L. 108-199, the FY2004 Consolidated Appropriations. For more
information, see CRS Report RL33396: The Global Fund to Fight AIDS, Tuberculosis, and
Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-Blyther.

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Line 11 reflects grants provided by the National Institutes of Health (NIH) for
international HIV/AIDS research, which focus primarily on the development of an
AIDS vaccine. NIH also transfers funds to the Global Fund, as indicated in Line 12.
The Administration has not requested funds for the Department of Labor’s
Global AIDS in the Workplace Initiative since FY2002 (Line 13). Congress funded
the initiative, however, until FY2006. The Department received additional funds
from GHAI in support of its HIV/AIDS programs.
In FY2008, the Administration did not request funds to support DoD’s bilateral
HIV/AIDS prevention programs, as indicated in Line 15.
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, as indicated in Line 16. Although the funds are
appropriated to USDA, USAID manages the provision of the food aid. The FY2007
continuing resolution did not include funds for the aid effort.

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