Order Code RL34192
PEPFAR: From Emergency to Sustainability
September 28, 2007
Tiaji Salaam-Blyther
Global Health Specialist
Foreign Affairs, Defense, and Trade Division

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PEPFAR: From Emergency to Sustainability
Summary
The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that
HIV/AIDS, tuberculosis (TB), and malaria kill more than 6 million people each year.
At the end of 2006, about 39.5 million people were living with HIV/AIDS, 2.3
million (6%) of whom were children under 15 years. Nearly 90% of all children
infected with HIV are African. On each day of 2005, some 1,500 children around the
world contracted HIV, due in large part to inadequate access to drugs that prevent
mother-to-child HIV transmission (PMTCT). In that year, 8% of pregnant women
in low- and middle-income countries had access to PMTCT services.
In January 2003, President George Bush proposed that the United States spend
$15 billion over five years to combat the three diseases and established the
President’s Emergency Plan for AIDS Relief (PEPFAR). The President proposed
concentrating most of the resources ($9 billion) in 15 Focus Countries, where the
Administration estimated 50% of all HIV-positive people lived. The proposal
allotted $5 billion of the funds to research and other bilateral HIV/AIDS, TB, and
malaria programs, and $1 billion for contributions to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (Global Fund). The President estimated that from FY2004
to FY2008, PEPFAR would support the provision of anti-retroviral treatment (ARV)
to 2 million HIV-infected people; prevent 7 million new HIV infections; and care for
10 million people affected by HIV/AIDS, including children orphaned by AIDS.
In May 2003, Congress passed the U.S. Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (P.L.108-25) to authorize funds for PEPFAR
and create the Office of the Global AIDS Coordinator (OGAC). The newly created
office was responsible for managing the flow of U.S. funds aimed at addressing the
three diseases in 15 Focus Countries. As of March 31, 2007, PEPFAR has
supported the treatment of 1.1 billion people; and as of September 30, 2006,
supported the prevention of mother-to-child HIV transmission during more than 6
million pregnancies and facilitated care for nearly 4.5 million people, including more
than 2 million orphans and vulnerable children. From FY2004 to FY2007, Congress
provided nearly $13.5 billion for U.S. global HIV/AIDS, TB, and malaria programs.
In FY2008, the President requested $5.8 billion for global HIV/AIDS, TB, and
malaria efforts; the House proposed spending almost $6.2 billion; and the Senate
proposed nearly $6.1 billion.
On May 30, 2007, President Bush requested that Congress authorize $30 billion
to extend PEPFAR an additional five years. The President anticipates that from
FY2009 to FY2013, the plan would support treatment for 2.5 million people, prevent
more than 12 million new infections, and care for more than 12 million people,
including 5 million orphans and vulnerable children. Supporters of the
Administration’s plan applauded the President and congratulated him for leading
global efforts to address HIV/AIDS. Critics asserted that the target of treating 2.5
million HIV-infected people was not ambitious enough and that the next five years
of PEPFAR should build on the progress already made. This report focuses on some
of the key issues that Congress might consider as it faces the issue of whether, and
at what level, to reauthorize PEPFAR.

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Glossary of Abbreviations and Acronyms
ARV
Anti-Retroviral medication
DFID
Department for International Development
FAO
United Nations Food and Agriculture Organization
FDA
U.S. Food and Drug Administration
GAO
Government Accountability Office
GHAI
Global HIV/AIDS Initiative
HIPC
Highly Indebted Poor Countries
HIV/AIDS
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
IHP
International Health Partnership
IMF
International Monetary Fund
IOM
Institute of Medicine
JLI
Joint Learning Institute
MTCT
Mother-to-Child Transmission
NIH
National Institutes of Health
NGO
Non-Governmental Organization
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
WFP
World Food Program
WHO
World Health Organization

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Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Policy Options for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Define Focus of PEPFAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Revisit Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Increase Prevention of Mother to Child HIV Transmission
(PMTCT) Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Provide Contraceptives to HIV-Positive Women . . . . . . . . . . . . . 4
Address Gender Inequities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Expand Access to Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Explore the Potential Impact of Circumcision . . . . . . . . . . . . . . . . 5
Reconsider Spending Restrictions and Requirements . . . . . . . . . . . . . . . . 7
Evaluate the Impact of the Prostitution Pledge . . . . . . . . . . . . . . . 7
Evaluate the Impact of the Mexico City Policy . . . . . . . . . . . . . . . 7
Evaluate the Impact of the Abstinence-Until-Marriage
Stipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Expand Access to Generic Anti-Retroviral Medication . . . . . . . . . . . . . . 9
Improve Integration of Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . 10
Improve Food Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Support Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . 11
Address Other Diseases That Kill . . . . . . . . . . . . . . . . . . . . . . . . 11
Strengthen Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Address Health Worker Shortages . . . . . . . . . . . . . . . . . . . . . . . . 13
Consider the Impact of Disease-Specific Approach on
Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Support Global Health Efforts to Strengthen Health Systems . . . 14
Provide Support for Health Systems Research . . . . . . . . . . . . . . 15
Consider Role of International Financial Institutions . . . . . . . . . 15
Reconsider Emphasis on Focus Countries . . . . . . . . . . . . . . . . . . . . . . . . 17
List of Tables
Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations . . . . . . . . . . 18
Table 2. Number and Shortage of Doctors, Nurses, and Midwives . . . . . . . . . . 19
Table 3. Distribution of Health Workers in Africa and the United States . . . . . 19
Table 4. Spending on Health in Africa and the United States . . . . . . . . . . . . . . 20

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PEPFAR: From Emergency to Sustainability
Background
In 2003, Congress authorized $3 billion for each fiscal year from 2004
through 2008 to support the $15 billion five year President’s Emergency Plan for
AIDS Relief (PEFAR); aimed at responding to the rapid spread of human
immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) and two
other key diseases: malaria and tuberculosis (TB). Some estimate that since
HIV/AIDS was first identified in 1981, 65 million people have contracted the virus
and it has killed more than 25 million.1
The World Health Organization (WHO) estimates that by the end of 2004,
more than 14 million people were infected with TB,2 almost 9 million of whom were
newly infected.3 More than 80% of those 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 that year.
According to WHO, each year there are about 300 million acute malaria cases,4
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,5
1 Avert, an international HIV/AIDS charity, used UNAIDS data to reach its estimate. See
world AIDS statistics at [http://www.avert.org/worldstats.htm].
2 TB is a contagious disease that spreads through the air like the common cold. 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. Minimal exposure is
enough to contract the disease. Left untreated, each person with active TB will infect an
average of between 10 and 15 people every year. The TB bacilli will not necessarily sicken
people whose immune systems are intact; however the disease can lie dormant for years.
When someone’s immune system is weakened, as it can be with HIV infection, the chances
of becoming sick rise. See [http://www.who.int/mediacentre/factsheets/fs104/en/].
3 WHO Report 2006, Global Tuberculosis Control: Surveillance, Planning, Financing, at
[http://www.who.int/tb/publications/global_report/en/index.html].
4 There are four types of malaria: Plasmodium (P.) vivax, P. malaria, P. ovale, and P.
falciparum. P. falciparum, the deadliest kind, is most common in sub-Saharan Africa and
is a significant factor in the region’s high malarial mortality rate. People contract malaria
from infected mosquitos; and mosquitos can get malaria if they ingest blood from an
infected person. [http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm].
5 WHO estimates that 300 million malaria cases result in 1 million annual deaths, 90% of
which occur in sub-Saharan Africa. The World Bank estimates that there are more than 500
million malaria cases each year and that about 85% of the resulting deaths occur in sub-
Saharan Africa, 8% in southeast Asia, 5% in the Middle East, 1% in the Western Pacific,
(continued...)

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CRS-2
killing an African child every 30 seconds.6 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.7
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 2008.8 In
FY2006, Congress provided $3.4 billion for global 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 (Table1).
Most recent statistics indicate that in 2006, some $8.9 billion was spent on
HIV/AIDS globally ($5.3 billion of which was provided by donors), $6 billion less
than UNAIDS advocated.9
Policy Options for Congress
PEPFAR provided an unprecedented amount of assistance for global
HIV/AIDS efforts. The United States remains the largest single donor for global
HIV/AIDS efforts in the world, providing nearly 50% of all donor funds.10 As
Congress prepares to consider whether, and at what level, to reauthorize PEPFAR,
there has been considerable debate about the effectiveness of PEPFAR. Some health
experts contend that the life-saving intention of PEPFAR is weakened by the single-
disease approach. Other critics contend that ideological factors lessen the
effectiveness of the plan. A number of HIV/AIDS advocates urge the United States
to harmonize its anti-HIV/AIDS efforts with other donors to boost the impact of
PEPFAR. Some of the key policy prescriptions are discussed below.
5 (...continued)
and 0.1% in the Americas. The World Bank maintains that the actual number of malaria
infections and deaths is uncertain as data collection and reporting systems are weak and
diagnoses may be over- or under-reported.
6 WHO’s Roll Back Malaria website, [http://malaria.who.int/cmc_upload/0/000/015/372/
RBMInfosheet_1.htm].
7 For more information on the impacts of co-infection see CRS Report RL33771, Trends in
U.S. Global AIDS Spending: FY2000-FY2007, by Tiaji Salaam-Blyther.
8 Towards Universal Access: Assessment by the Joint United Nations Program on HIV/AIDS
on Scaling Up HIV Prevention, Treatment, Care and Support, UNAIDS, March 2006.
[http://data.unaids.org/pub/InformationNote/2006/20060324_hlm_ga_a60737_en.pdf].
9 Financing the Response to AIDS in Low- and Middle- Income Countries: International
Assistance from the G8, European Commission and Other Donor Governments, Kaiser
Family Foundation, 2006, [http://www.kff.org/hivaids/upload/7347_03.pdf].
10 Ibid.

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Define Focus of PEPFAR
As Congress considers reauthorizing PEPFAR, there may be some debate on
how many diseases the initiative should address. The U.S. Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L.108-25), requires the
President to submit annual reports to appropriation committees that describe how
U.S. funds support efforts to prevent HIV/AIDS, TB, and malaria and provide care
and treatment for those affected by the three diseases. However, since President
Bush launched the President’s Malaria Initiative (PMI) in June 2005, the Office of
the Global AIDS Coordinator (OGAC) determined that it 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.11 The
Administration requests support for PMI through the U.S. Agency for International
Development (USAID) as the coordinating agency. For comparability, and because
P.L. 108-25 considers efforts to combat malaria as a critical part of PEPFAR, Table
1, at the end of this report, includes appropriations to malaria programs. As Congress
considers whether to authorize funds to extend PEPFAR, Members might decide
whether to define it as solely an HIV/AIDS initiative or one that includes the three
diseases.
Revisit Prevention Efforts
As Congress considers reauthorizing PEPFAR, there is likely to be
considerable debate on how much funding to allocate to prevention. Consensus is
growing among health experts that greater emphasis needs to be placed on HIV
prevention in global HIV/AIDS programs. The international community has
supported a tremendous increase in the number of people receiving HIV/AIDS
treatment. In 2001, about 240,000 people had access to ARVs; in 2006, more than
2 million were treated.12 Nonetheless, WHO estimated that in 2006, an additional 5.1
million people who needed treatment received none. In sub-Saharan Africa, more
than 1.3 million people received treatment, reaching some 28% of those in need;
three years prior, 100,000 were treated and coverage amounted to 2%. In spite of
these advances, the rate at which individuals become infected with HIV far outpaces
the rate at which they are treated. In 2006, 4.3 million people contracted HIV, 2.8
million of whom were African (65%), and 2.9 million people died of AIDS, 2.1
million of whom were African (72%).
Increase Prevention of Mother to Child HIV Transmission
(PMTCT) Initiatives. Many health experts advocate greater spending on PMTCT
11 PMI aims to increase U.S. support for global malaria programs by more than $1.2 billion
between FY2006 and FY2010 in 15 countries. For more information on PMI, see
[http://www.pmi.gov/].
12 Statistics on access to AIDS treatment was compiled from UNAIDS, Towards Universal
Access: Scaling up priority HIV/AIDS interventions in the health sector, April 2007.
[http://www.who.int/hiv/mediacentre/univeral_access_progress_report_en.pdf].

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initiatives.13 Advocates of greater PMTCT spending argue that providing ARVs
during pregnancy is a well-documented way to avert millions of HIV infections in a
cost-efficient and effective manner, including in low-resource settings. UNAIDS
estimates that 1,800 children worldwide become infected with HIV each day, the vast
majority of whom are newborns.14 More than 85% of children infected with HIV live
in sub-Saharan Africa, although mother-to-child transmission (MTCT) rates are
rapidly rising in Eastern Europe and Central Asia.15 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.16 Two-thirds
of all women who lack access to PMTCT interventions come from 10 countries, all
but one of which are in Africa; India is the exception.17
Provide Contraceptives to HIV-Positive Women. Some reproductive
health experts want HIV/AIDS and family planning services to be better integrated
should PEPFAR be reauthorized. Supporters of this idea contend that women who
receive PMTCT services should be subsequently offered contraceptives to lessen the
likelihood that they might give birth to HIV-positive children. Additionally, women
who fear being stigmatized if they visit an HIV center could receive PMTCT services
while receiving standard prenatal care. Members who endorsed the Ensuring Access
to Contraceptives Act (H.R. 2367) demonstrated their support for expanding access
to family planning and contraceptives. The bill would authorize $150 million for
such services in each of fiscal years 2008 and 2009. Some in Congress also support
the United Nations Population Fund Women’s Health and Dignity Act (H.R. 2604),
which would provide financial and other support to UNFPA’s activities that save
women’s lives, limit the incidence of abortion and maternal mortality associated with
13 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.
14 UNAIDS 2006 Global AIDS Report, p. 132, [http://www.unaids.org/en/HIV_data/2006
GlobalReport/default.asp].
15 UNAIDS 2006 Global AIDS Report, p. 132.
16 Ibid., p. 133.
17 Data from countries in sub-Saharan Africa indicate that the proportion of HIV-infected
pregnant women receiving ARVs in 2005 varied from under 1% to 54% and that the average
regional coverage rate was 11%. In East, South, and Southeast Asia, the average regional
coverage rate was 5%, with individual country rates ranging from 3% to 10%. On average,
in Latin America and the Caribbean, 24% of HIV-infected mothers had access to ARVs; the
coverage rate ranged from 13% to 46%. It is estimated that overall coverage amounted to
75% in Eastern Europe and Central Asia with coverage rates ranging from 38% to 95%.
ARV coverage for HIV-infected pregnant women in North Africa and the Middle East
averaged less than 1%.

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unsafe abortion, promote universal access to safe and reliable family planning, and
assist women, children, and men in developing countries live better lives.
Address Gender Inequities. Women’s rights advocates also assert that
the lower status of women in many of the most affected countries must be better
addressed in order to prevent new HIV infections. In many countries, legal and
social structures leave women feeling as though they have little control over their
own bodies and do not have the option to reject their husbands’ sexual advances;
even when they are aware of their husbands’ extramarital relationships. Research has
shown that in Africa, married girls and women are more likely to contract HIV than
their single counterparts.18 For example, 30% of married adolescents’ spouses were
HIV-positive in Kenya, while 11.5% of the partners of their unmarried counterparts
were infected with HIV. Similarly, in Zambia, 31.6% of married girls’ partners were
found to carry HIV, while 16.8% of unmarried girls’ boyfriends were HIV-positive.19
Societal forces also weaken women’s options, rights advocates contend, because in
many countries, health workers require women to obtain their husbands’ permission
before providing them contraception.20
Expand Access to Condoms. Global health activists also insist that
OGAC’s policy of limiting condom distribution to “high risk groups”21 ignores
gender inequities and limits the effectiveness of prevention programs. 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 expand 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.
Explore the Potential Impact of Circumcision. Health experts have
begun to debate the role that circumcision could play in HIV prevention efforts.
Three randomized trials conducted in South Africa, Kenya, and Uganda demonstrated
that male circumcision reduced the risk of acquiring HIV by more than half. Some
18 “Early Marriage and HIV Risks in Sub-Saharan Africa.” Studies in Family Planning, Vol.
3 5 , N o . 3 , S e p t e m b e r 2 0 0 4 . [ h t t p : / / w w w . b l a c kw e l l -s yn e r gy. c o m/
links/doi/10.1111/j.1728-4465.2004.00019.x/pdf?cookieSet=1], “Protecting Young Women
from HIV/AIDS: The Case Against Child and Adolescent Marriage.” International Family
Planning Perspectives, Vol. 32, No. 2, June 2006. [http://www.jstor.org/journals/
01622749.html].
19 The Implications of Early Marriage for HIV/AIDS Policy. Population Council, 2004.
[http://www.popcouncil.org/pdfs/CM.pdf].
20 Violence Against Girls and Women: Effects on Sexual and Reproductive Health Decision
Making. UNFPA website, accessed on May 14, 2007 [http://www.unfpa.org/
intercenter/violence/effects2a.htm].
21 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.

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believe that if mass circumcision was to be conducted in areas of high transmission,
the procedure could avert about 5.7 million new HIV infections and 3 million deaths
over 20 years among both men and women.22 WHO and UNAIDS have endorsed the
practice to be added to HIV prevention initiatives.23 The organizations warn,
however, that the practice should not be seen as a “magic bullet,” as it does not
prevent men from acquiring the virus, it only reduces the risk of infection. As a
result, health experts urge those who perform the surgeries to counsel the men and
explain that they must maintain other protective practices, such as abstaining from
sex, reducing their number of sexual partners, and using condoms.
Some observers argue that the studies should not yet be widely embraced,
particularly since only a few trials have been conducted. A number of scientists
question the validity of the studies since they were terminated early; a practice, critics
contend, that skews the results.24 Dissenters argue that there may be other
explanations for the drop in transmission. Skeptics contend that circumcision
reduces the incidence of genital symptoms, allowing men to receive fewer unsafe
injections and other blood exposures during treatment. Also, in sub-Saharan Africa,
circumcised virgins and adolescents are reportedly more likely to be HIV-infected
than their uncircumcised counterparts. Researchers suspect that unhygienic
circumcision procedures might be a large factor in this phenomenon.25
Critics and advocates of the practice agree that additional studies need to be
conducted and a number of precautions must be taken should the practice be
implemented on a larger scale.26 Additional research is needed to determine how the
procedure might impact HIV transmission to women, the most affected population
in Africa. There is consensus that male circumcision must be considered part of a
comprehensive HIV prevention package, which includes treatment for sexually
transmitted infections; the promotion of safer sex practices; and the provision of male
and female condoms and promotion of their correct and consistent use. HIV/AIDS
advocates maintain that men and their sexual partners must also be counseled to
prevent them from developing a false sense of security and engaging in high-risk
behaviors that could undermine the partial protection provided by male circumcision.
Health experts agree that African health systems need to be strengthened in order to
ensure safe and clean operations. Circumcision must be done under hygienic
conditions by trained personnel with access to sterile surgical instruments and
anaesthesia. Many facilities on the continent, however, lack sufficient supplies, such
22 “Circumcision and Circumspection.” The Lancet Infectious Diseases, May 2007, Vol. 7,
No. 5, [http://www.thelancet.com/journals/laninf/article/PIIS1473309907700877].
23 WHO, “WHO and UNAIDS announce recommendations from expert consultation on male
circumcision for HIV prevention.” March 28, 2007. [http://www.who.int/hiv/mediacentre/
news68/en/index.html].
24 “Male Circumcision in HIV Prevention.” The Lancet, Vol. 369, No. 9573, May 12, 2007,
[http://www.thelancet.com/journals/lancet/article/PIIS0140673607607375].
25 “Male Circumcision in HIV Prevention.” The Lancet, Vol. 369, No. 9573, May 12, 2007,
[http://www.thelancet.com/journals/lancet/article/PIIS0140673607607351].
26 UNAIDS, Male Circumcision: Context, Criteria, and Culture. [http://www.unaids.org/en/
mediacentre/pressmaterials/featurestory/20070226_MC_pt1.asp].

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CRS-7
as gloves, clean needles, and antiseptics. Some health experts fear that greater
investment in circumcision might disrupt other health care programs. Global health
advocates urge Congress to ensure that male circumcision services are integrated
with other services, particularly in areas with severe shortages of skilled health
workers, should it include support for the practice in PEPFAR.
Reconsider Spending Restrictions and Requirements
Evaluate the Impact of the Prostitution Pledge. A number of global
health experts contend that some current U.S. AIDS-related spending restrictions and
requirements are ideologically based, negatively impact the effectiveness of PEPFAR
programs, and complicate implementing partners’ efforts. The U.S. Leadership
Against HIV/AIDS, TB, and Malaria Act (P.L.108-25) mandates that no funds made
available to carry out the act may be used to assist any group or organization that
does not have a policy explicitly opposing prostitution and sex trafficking. This
policy has become widely known as “the prostitution pledge.” Critics of the pledge
contend that the restriction should be eliminated, because it limits implementing
partners’ HIV/AIDS prevention efforts.27 Opponents argue that groups serving sex
workers fear that by signing the pledge and openly opposing prostitution, they may
isolate the very group that they are attempting to help.
Evaluate the Impact of the Mexico City Policy. The “Mexico City
Policy”28 has also come under considerable scrutiny. The policy prohibits
reproductive health organizations from providing information about abortion.
Critics contend that, in some countries, this policy has had devastating effects,
because reproductive health services is the only form of health care that many women
27 USAID’s policy directive on the prostitution pledge can be found at
[http://www.usaid.gov/business/business_opportunities/cib/pdf/aapd05_04.pdf]. Criticisms
of PEPFAR spending requirements include AIDS Taskforce of Greater Cleveland, Is
PEPFAR Working? A Response to the Recent Annual Report Issued by the President’s
Emergency Plan for AIDS Relief, May 2006. [http://www.aidstaskforce.org/
ASSETS/72BF3DD44B1E4B93A1077EC95C655E81/PEPFAR.pdf]; Health Gap, U.S.
Global AIDS Initiative, Round 2: From Emergency to Sustainability. May 29, 2007.
[http://www.healthgap.org/PEPFAR-Renewal.doc]; Center for Health and Gender Equity
Policy Brief, Implications of U.S. Policy Restrictions for Programs Aimed at Commercial
Sex Workers and Victims of Trafficking Worldwide, November 2005.
[http://www.genderhealth.org/pubs/ProstitutionOathImplications.pdf]; “The US Anti-
Prostitution Pledge: First Amendment Challenges and Public Health Priorities.” PLoS
M e d i c i n e , V o l . 4 , N o . 7 , [ h t t p : / / m e d i c i n e . p l o s j o u r n a l s . o r g /
perlserv/?request=get-document&doi=10.1371/journal.pmed.0040207&ct=1]; Advocates
for Youth, Improving U.S. Global AIDS Policy for Young People, 2007,
[http://www.advocatesforyouth.org/publications/pepfar.pdf]; and Open Society Institute,
“Anti-Prostitution” Materials, June 2007 [http://www.soros.org/initiatives/health/
focus/sharp/articles_publications/publications/pledge_20070612].
28 The “Mexico City” policy denies U.S. funds to foreign non-governmental organizations
(NGOs) that perform or promote abortion as a method of family planning, even if the
activities are undertaken with non-U.S. funds. For more information on the policy, see CRS
Report RL33250, International Population Assistance and Family Planning Programs:
Issues for Congress, by Luisa Blanchfield.

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CRS-8
receive. The House and Senate included language in their reports (H. Rept.110-197
and S. Rept.110-128) for FY2008 Foreign Operations appropriations (H.R. 2764) that
prevented the “Mexico City Policy” from being the sole reason that U.S. funds could
not be used to provide contraceptives. A conference is pending. Opposing Members
expect the President to veto any bill that repeals the “Mexico City Policy.”
Evaluate the Impact of the Abstinence-Until-Marriage Stipulation.
Some health experts assert that congressional HIV prevention stipulations are not
well-balanced, place too much emphasis on abstinence until marriage, and limit
countries’ ability to use 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, 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. In 2006, the Government Accountability Office
(GAO) found that PEPFAR’s spending requirements limited the flexibility with
which prevention funds could be spent.29 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. In its congressionally mandated report, the
Institute of Medicine (IOM) reached similar conclusions.30
Some health specialists argue that these policies consume limited resources
and time, as they place additional reporting requirements on implementing partners.
Britain’s Department for International Development (DFID) reports that from 2003
to 2004 and 2006 to 2007, the Ugandan government was reporting on 684 different
aid instruments and associated agreements.31 Critics suggest that if Congress
reauthorizes PEPFAR, it should eliminate these spending restrictions, coordinate
reporting requirements and funding processes with other donors, and urge the United
States to sign on to the International Health Partnership. Some in Congress have
supported legislation that was introduced to remove the spending provisions. The
HIV Prevention Act (S. 1553) and the Protection Against Transmission of HIV for
Women and Youth Act (H.R. 1713) would strike the 33% abstinence-until-marriage
spending requirement from P.L.108-25. The FY2008 House Foreign Operations
Appropriations would allow the Administration to determine whether to apply the
33% abstinence-until-marriage provision to global HIV/AIDS programs.
29 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].
30 Section 101 (c)(1) of P.L.108-25 mandated that not later than three years after its
enactment, the Institute of Medicine (IOM) would “publish findings comparing the success
rates of the various programs and methods used under the [PEPFAR] strategy.” In March
2007, IOM released, PEPFAR Implementation: Progress and Promise. IOM concluded that
“PEPFAR has made a promising start, but the need for U.S. leadership in the effort to
control the HIV/AIDS pandemic continues.”
31 DFID, Millennium Development Goals: Health Facts and Figures
[http://www.dfid.gov.uk/mdg/health-facts-figures.asp#The_donor_coordination_challenge].

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CRS-9
Expand Access to Generic Anti-Retroviral Medication
Access to generic HIV/AIDS treatments is another possible issue to arise in
reauthorization debates. Shortly after PEPFAR was launched, the Bush
Administration expressed skepticism about broad-based use of generic ARV
medication. The Administration asserted that WHO’s prequalification process was
inadequate, and that generic drugs purchased with PEPFAR funds had to be first
inspected by the U.S. Food and Drug Administration (FDA).32 The Administration
argued that since WHO is not a regulatory body, its adherence to stringent FDA
standards could not be ensured.33 This policy sparked a debate with critics
contending that the process was unnecessary and delayed the distribution of ARVs.34
In January 2005, GAO reported that the policy limited the selection of ARV products
available, did not fully support the treatment strategies of the focus countries, and
was not optimally coordinated with other multinational initiatives. GAO indicated
that “better coordination with the Focus Countries and with other treatment initiatives
could facilitate more rapid implementation of the Emergency Plan. Moreover, given
the intended scale of the plan, lower prices for ARVs could result in savings of
hundreds of millions of dollars, which could be used to treat additional patients or to
support other aspects of the program.”35
In March 2007, IOM found that in many of the Focus Countries, a number of
those implementing HIV/AIDS programs complained that the U.S. treatment policy
complicated national treatment efforts.36 The Institute recommended that OGAC
work to support WHO prequalification as the accepted global standard for assuring
the quality of generic medications and work with other donors to support
strengthening the process. According to OGAC’s third annual report to Congress,
OGAC has strengthened its coordination with WHO, by sharing information on the
WHO-approved generics. OGAC estimates that in FY2006, 27% of all ARVs
purchased under PEPFAR were generic.37 Since FDA began reviewing generic drug
32 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/].
33 Interviews with staff at the Office of the AIDS Coordinator, April 1, 2004.
34 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; and “The end of the beginning? AIDS,” The Economist, July 17,
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].
35 GAO, Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications Provided
Under U.S. Emergency Plan Is Limited, January 2005. [http://www.gao.gov/
new.items/d05133.pdf].
36 [http://www.iom.edu/CMS/3783/24770/41804.aspx].
37 OGAC, The Power of Partnerships: The President’s Emergency Plan for AIDS Relief,
(continued...)

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CRS-10
applications, more than 50 generic versions of patented ARVs have been approved
or tentatively approved for use in PEPFAR treatment plans.38
Improve Integration of Health Programs
In considering whether to extend PEPFAR, HIV/AIDS experts encourage
Congress to stipulate stronger integration of PEPFAR-supported programs with other
health programs that save lives. Many health experts contend that PEPFAR’s
disease-specific approach threatens to supplant support by the United States and
recipient countries for other health areas, including nutrition, maternal and child
heath, and other infectious diseases.
Improve Food Security. Malnutrition and lack of food may heighten
exposure to HIV, raise the likelihood of engaging in risky behavior (e.g.,
transactional sex), increase susceptibility to infection, and complicate efforts to
provide anti-retroviral (ARV) medication. Furthermore, those sickened by
HIV/AIDS are often too ill to till the land, lessening agricultural productivity. The
United Nations’ Food and Agriculture Organization (FAO) estimates that food
consumption drops by 40% in homes affected by HIV/AIDS, due in large part to
diminished capacity to farm.39
In communities struggling with food security, decreased food production can
complicate efforts to maintain treatment regiments. If patients do not consume
adequate amounts of nutritious food, they can suffer significant side effects while
taking ARVs and the drugs can be less effective. At the 2006 International AIDS
Conference, one AIDS advocate cited a study that showed that patients who were
malnourished when they started ARV therapy were six times more likely to die than
well-nourished patients, and were more likely to suffer side-effects, which often
caused them to stop taking the treatments.40 These issues are particularly acute in
rural communities, where AIDS incidence is rapidly increasing and access to care is
usually more limited than in urban areas. In the 25 most AIDS-affected countries in
Africa, more than 2/3 of the population live in rural areas and rely on agriculture for
their livelihoods.41
37 (...continued)
2007. [http://www.pepfar.gov/documents/organization/81019.pdf].
38 PEPFAR website, FDA Grants Tentative Approval for 50th and 51st Anti-Retroviral Drugs
Under President’s AIDS Relief Plan, August 13, 2007. [http://www.pepfar.gov/
press/91018.htm.] For more information on FDA’s role in reviewing ARVs, see
[http://www.fda.gov/oia/pepfar.htm].
3 9 FAO factsheet, HIV/AIDS, food security, and rural livelihoods
[http://www.fao.org/worldfoodsummit/english/fsheets/aids.pdf].
40 Statement made by Stuart Gillespie at the 2006 International AIDS Conference, “Breaking
the Vicious Cycle of HIV/AIDS and Hunger.” [http://www.ifpri.org/PRESSREL/
2006/20060813.asp].
41 FAO, The Impact of HIV/AIDS on Agriculture and Food Security, 2003,
[http://www.fao.org/docrep/005/Y8331E/Y8331E00.htm].

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CRS-11
In April 2007, the House Foreign Affairs Committee held a hearing on the
progress of PEPFAR. At the hearing, Global AIDS Coordinator Mark Dybul testified
that PEPFAR funds provided “limited food assistance for specific, highly vulnerable
populations,”and cited support for a pilot program that enables a local food
manufacturer to distribute nutrient-dense food to orphans and vulnerable children,
clinically malnourished HIV-positive people, and HIV-positive pregnant and
lactating women enrolled in PMTCT programs. He also indicated that in FY2006,
OGAC had contributed $2.45 million contribution to the World Food Program
(WFP) and would contribute an additional $4.27 million in FY2007. Ambassador
Dybul conceded that PEPFAR’s engagement in food insecurity is limited. He
contended, however, that efforts are intentionally limited, because OGAC prefers to
remain focused on HIV/AIDS. At the hearing, Ambassador Dybul testified that
PEPFAR supports other “wrap around” programs that support HIV-affected
populations, such as clean water programs, education initiatives, and gender projects.
Support Maternal and Child Health. According to the United Nations,
maternal and neonatal42 mortality rates could be significantly reduced if more
women, particularly in Africa, had sufficient access to skilled health personnel who
are trained to detect problems early and can effectively provide or refer women to
emergency obstetric care. The United Nations has found that regions with the lowest
proportions of skilled health attendants at birth also have the highest number of
maternal deaths.43 In sub-Saharan Africa, 1 of every 16 women who becomes
pregnant will die from complications arising during her pregnancy or childbirth. For
comparison, the rate in industrialized countries is one in 3,800.44 Experts have also
found that child survival rates are higher in areas with ample numbers of health
workers to administer immunizations, clean water, controlled mosquito populations,
and sufficient access to nutritious food.45
Address Other Diseases That Kill. Those who support integrating
PEPFAR into other health programs contend that disease-specific programs like
42 Neonatal refers to the first four weeks of life.
43 United Nations, The Millennium Development Goals Report: 2007,
[http://www.un.org/millenniumgoals/pdf/mdg2007.pdf]. While the greatest shortage of
health care workers in absolute terms are in southeast Asia (mostly in Bangladesh, India, and
Indonesia), sub-Saharan Africa suffers from the greatest proportional shortage of health care
workers in the world. WHO estimates that there are 57 countries with critical shortages of
health care workers, 36 of which are in Africa and none of which are in industrialized
nations. Globally, WHO estimates that an additional 4.3 million health workers are needed,
and that Africa would need to increase its number of health workers by about 140% in order
to meet the minimum threshold of 2.5 health care professionals per 1,000 people. WHO,
2006 World Health Report, [http://www.who.int/whr/2006/en/].
44 United Nations, Africa and the Millennium Development Goals: 2007 Update,
[http://www.un.org/millenniumgoals/docs/MDGafrica07.pdf].
45 Laurie Garrett, “The Challenge of Global Health,” Foreign Affairs, New York:
J a n u a r y / F e b r u a r y 2 0 0 7 , V o l . 8 6 , I s s u e 1 ,
[ h t t p : / / w w w . f o r e i g n a f f a i r s . o r g / 2 0 0 7 0 1 0 1 f a e s s a y 8 6 1 0 3 / l a u r i e -
garrett/the-challenge-of-global-health.html].

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CRS-12
PEPFAR fail to address adequately the intersection of diseases.46 Research has
demonstrated that since HIV weakens the immune systems of those infected, they are
more susceptible to a range of illness, including malaria. HIV-positive people are
more likely to be hospitalized and sickened by malaria than those not carrying the
virus. According to WHO, Africa is the only region in the world where incidence of
new TB infections continues to rise, due in large part to HIV/AIDS co-infection.47
In 2004, more than 740,000 people who contracted TB were co-infected with
HIV/AIDS.48 Some 600,000 of those co-infected with TB and HIV/AIDS were found
in sub-Saharan Africa, representing more than 80% of all co-infected cases. About
205,000 of the more than 248,000 co-infected patients who died from TB were
African, representing 83% of those deaths. Most poorly equipped health systems in
Africa are unable to contain TB, as they have limited case detection capacity; meager
financing; too few health workers in numbers and who are sufficiently trained;
inconsistent drug supplies; and little means to monitor and evaluate TB control
programs.
Strengthen Health Systems
PEPFAR critics urge Congress to consider not only the degree to which
resources are skewed towards HIV/AIDS initiatives, but also what impact such
unbalanced spending has on health systems overall. Many global health experts
maintain that the generous salaries and other incentives (such as housing stipends)
offered by donor-supported HIV/AIDS programs draw health workers from public
health facilities and threaten other life-saving interventions offered at those clinics,
such as maternal and child survival health initiatives.49
46 See UNAIDS, 2006 AIDS Epidemic Update, and CDC, Interaction of HIV and Malaria,
[http://www.cdc.gov/malaria/pdf/Malaria_HIV_Rick_website.pdf].
4 7 W H O , 2 0 0 6 G l o b a l T u b e r c u l o s i s C o n t r o l R e p o r t ,
[http://www.who.int/tb/publications/global_report/2006/en/]. People living with HIV/AIDS
are at greater risk of becoming infected with TB because of their weakened immunity. Each
disease speeds up the progress of the other, and TB considerably shortens the survival of
people with HIV/AIDS. HIV/AIDS is the most potent risk factor for converting latent TB
into active TB, while TB bacteria accelerate the progress of AIDS. Many people affected
by HIV/AIDS in developing countries develop TB as the first manifestation of AIDS. In
HIV/AIDS-positive people, TB is harder to diagnose, progresses faster, is almost always
fatal if undiagnosed or left untreated, and kills up to half of all AIDS patients worldwide.
People with HIV/AIDS are up to 50 times more likely to develop TB in a given year than
HIV/AIDS-negative people. About 90% of people living with AIDS die within four to
twelve months of contracting TB if not treated.
48 Information in this paragraph summarized from WHO, 2006 Global Tuberculosis Control
Report, [http://www.who.int/tb/publications/global_report/2006/en/].
49 Child mortality refers to the death of children younger than five years,
[http://www.who.int/healthinfo/statistics/mortchildmortality/en/index.html]. “The
Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86, Issue 1,
[http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-
global-health.html]. “Lack of money can no longer be blamed for the poor world’s health
problems,” The Economist, July 5, 2007.
(continued...)

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Address Health Worker Shortages. According to WHO, the global
shortage of health care workers is the single most important health issue facing
countries today.50 While the greatest shortages of health care workers in absolute
terms are in southeast Asia (mostly in Bangladesh, India, and Indonesia), sub-
Saharan Africa suffers from the greatest proportional shortage of health care workers
in the world (Table 2). WHO estimates that there are 57 countries with critical
shortages of health care workers; 36 are in Africa and none are in industrialized
nations. Globally, WHO estimates that an additional 4.3 million health workers are
needed, and that Africa would need to increase its number of health workers by about
140% in order to meet the minimum threshold. None of the countries in Table 3
have enough doctors to meet the most basic health care needs; though when nurses
and midwives are included, some do meet the minimum standard. The amount and
quality of health worker numbers are positively associated with immunization
coverage, outreach of primary care, as well as infant, child, and maternal survival.
After the release of the World Bank’s report, International Migration,
Remittances, and the Brain Drain, a number of articles in the press featured the issue,
and highlighted some of the data provided in the work.51 It is estimated that 20,000
skilled professionals leave Africa each year.52 Erik Schouten, the HIV Coordinator
for the Malawi Ministry of Health announced that over the last five years, the
government had lost 53% of its health administrators, 64% of its nurses, and 85% of
its physicians — mostly to foreign NGOs, largely funded by Britain, the United
States, and the Gates Foundation.53 According to Mr. Schouten, the Ministry is now
implementing a program, supported by PEPFAR, to attract Malawi health workers
back to the country. Their tasks, however, will be to distribute antiretoriviral
medication. There is reportedly no support for programs to attract health workers to
treat malaria, diarrhea, and other common killers, such as dysentery and respiratory
infections.
Consider the Impact of Disease-Specific Approach on Health
Systems. Ambassador Dybul asserted at the April 2007 House hearing that
PEPFAR strengthens health systems and expands the health workforce. This
assertion counters the findings that the Institute of Medicine published in its March
49 (...continued)
[http://www.economist.com/world/international/displaystory.cfm?story_id=9441391].
50 WHO, 2006 World Health Report: Working Together for Health,
[http://www.who.int/whr/2006/en/]. The Joint Learning Initiative (JLI), a network of global
health leaders, defines a shortage as less than 2.5 health care professionals per 1,000 people;
the minimum proportion it deemed necessary to provide 80% of a country’s population with
basic health care (e.g., deliveries by skilled birth attendants and immunizations).
51 [http://www.worldbank.org].
52 “Brain drain deprives Africa of vital talent.” Reuters, April 24, 2006
[http://www.alertnet.org].
53 “The Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86,
Issue 1
[http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-
global-health.html].

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CRS-14
2007 report, PEPFAR Implementation: Progress and Promise.54 Though IOM
concluded that “PEPFAR has made a promising start,” it found PEPFAR might
further limit health care options for those not suffering from HIV/AIDS.
PEPFAR’s HIV/AIDS activities have sometimes negatively affected other
aspects of public health systems and exacerbated resource constraints,
particularly those related to national human resource settings. If Focus
Countries’ national plans for expanding their health workforce are not
supported, PEPFAR might worsen national shortages by shifting a
disproportionate share of the workforce to HIV/AIDS activities, which
might cause other health areas to be neglected.... PEPFAR’s initial
emergency approach to meeting personnel needs has been to focus on HIV-
specific training of existing clinicians and other health care workers.
Support for expansion of the professional clinical workforce has been
limited, even when such expansion is an explicit part of the country’s
HIV/AIDS plan, and the effort is endorsed and supported by other donors...
PEPFAR Country Teams often expressed concern that they were not
allowed to fund activities unless those activities were specifically part of
the HIV/AIDS effort and so could not support, for example, the training of
new clinical officers, who in some countries are the mainstay of the
treatment efforts.55
IOM recommended that OGAC work more closely with governments to
analyze the impact that PEPFAR-supported programs might have on public health
systems, particularly in areas related to maternal and child health and immunizations.
IOM suggested that the analysis consider whether PEPFAR’s incentives and salaries
draw workers out of public systems and shift a disproportionate share of the
workforce to HIV/AIDS efforts. The report also asserted that PEPFAR should
increase support to the education of new health professionals.
Support Global Health Efforts to Strengthen Health Systems.
There is a growing consensus that health systems, including those that address
HIV/AIDS, must be strengthened in order for health interventions to be effective. On
August 22, 2007, British Prime Minister Gordon Brown and German Chancellor
Angela Merkel announced their intention to launch an International Health
Partnership (IHP) aimed at accelerating progress towards reducing child and maternal
mortality, combating infectious diseases, including HIV/AIDS, TB, and malaria, and
strengthening health systems.56 The leaders acknowledged in their statement that the
fragmented method of applying global health aid has reduced the effectiveness of
aid, in large part because donors compete for limited trained staff and implement the
projects without considering the countries’ priorities and structures.57 According to
DFID, there are more than 40 bilateral donors and 90 global health initiatives each
maintaining their own reporting requirements and most focusing on specific health
54 [http://www.iom.edu/CMS/3783/24770/41804.aspx].
55 Ibid.
56 10 Downing Street, PM announces International Health Partnership, August 22, 2007,
[http://www.number-10.gov.uk/output/Page12903.asp].
57 Ibid.

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CRS-15
issues, such as HIV/AIDS.58 DFID asserts that few global health efforts focus on
activities that would strengthen struggling health systems, such as training doctors
and nurses, building clinics, or supporting basic health services. Parties59 of the IHP
commit to improving donor coordination, focusing on health systems rather than
specific diseases or health issues, and supporting the health plans of recipient
countries. The leaders did not indicate how much would be allocated towards this
initiative or how it would be implemented, though seven countries were identified
as “first wave” partner countries.60
Provide Support for Health Systems Research. Some health experts
would like Congress to boost support for health systems research if it were to extend
PEPFAR.61 The Global Health Council estimates that less than 1% of research
dollars are spent on health systems research, though it could identify where health
systems failures exist, make health interventions more effective and affordable, and
improve the accessibility of health care.62 In HIV/AIDS programs, health systems
research could help administrators develop effective forecasting and distribution
systems for drugs and other commodities and make stock-outs and shortages of
contraceptives, ARVs, and other commodities less frequent. Advocates assert that
health systems research could improve retention of health personnel, because they
would have sufficient tools to perform their jobs. Data from health systems research
would reveal which sort of care, prevention, and treatment programs are needed for
the target population, and which would make the programs more effective and
efficient, proponents contend.
Consider Role of International Financial Institutions. Some have
argued that structural adjustment programs mandated by international financial
institutions have led to a decline in public sector employment and limited investment
in health worker education.63 In many of the countries with health worker shortages,
58 DFID, The International Health Partnership Launched Today, September 5, 2007,
[http://www.dfid.gov.uk/news/files/ihp/default.asp].
59 Bilateral donors include Britain, Canada, France, Germany, Italy, the Netherlands,
Norway, and Portugal. Foundations and international organizations include Africa
Development Bank, Bill and Melinda Gates Foundation, European Commission, The Global
Fund to Fight AIDS, TB, and Malaria, the Global Alliance for Vaccines and Immunization
(GAVI) Alliance, UNAIDS, UNICEF, United Nations Population Fund (UNFPA), WHO,
and the World Bank.
60 The seven countries are Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal, and
Zambia.
61 “Health systems” encompasses the personnel, institutions, commodities, information, and
the financing of health care delivery.
62 Global Health Council, Promoting Investments in Research to Strengthen Health Systems:
Why and How, May 2006 [http://www.globalhealth.org/images/pdf/publications/
research_investments.pdf].
63 For debate on this issue, see “A Critical Analysis of the Brazilian Response to HIV/AIDS:
Lessons Learned for Controlling and Mitigating the Epidemic in Developing Countries,”
American Journal of Public Health, July 2005, Vol. 95, No. 7,
(continued...)

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CRS-16
there are thousands of unemployed health workers. While Kenya has a shortage of
some 10,000 nurses in the public sector, for example, thousands of unemployed
nurses are leaving for Britain to find jobs, as the Kenyan government is under a
recruitment freeze due to World Bank and International Monetary Fund (IMF)
stipulations.64 Health sector reform, critics argue, has led to a decline in the quality
of education and training opportunities for medical students, a perpetual shortage of
health supplies and equipment (e.g., sanitation gloves and hyperdermic needles),
insufficient medicine and vaccine stocks, and “brain drain” of African health
workers. According to WHO, on average each year, the 57 countries with severe
shortages of health workers spend an average of about $33 per person on health
(Table 4). The entire continent of Africa spends about 1% of the world’s
expenditure on health, the WHO contends. Comparatively, each year the United
States spends approximately $5,711per capita on health.
Some analysts have expressed concern about the extent to which countries
rely on the World Bank to fund their health programs. The Bank estimates that it has
lent $15 billion in health, nutrition, and population funds from 1997 to 2006; an
average of about $1.5 billion per year.65 Observers worry that the loans add to
significant debt loads that many countries already face and to which they commit
considerable portions of their annual gross national products.66 In some countries,
governments are reportedly paying more on debt service than public health programs.
Oxfam estimates that of the 26 countries participating in the Highly Indebted Poor
Countries (HIPC) Initiative, half are still spending 15% or more of government
revenues on debt payments.67 Some health advocates urge Congress to use its vote
to encourage the IMF to maintain its debt relief commitments and accelerate its
plans.
In the 110th Congress, legislation has been introduced in the House and Senate
that authorizes additional funds to voluntary family planning activities, improves
coordination of HIV/AIDS and other health initiatives, and strengthens supply chain
logistics. The Focus on Family Health Worldwide Act (H.R. 1225) would provide
63 (...continued)
[http://www.ajph.org/cgi/reprint/95/7/1162.pdf]; “Toward Ethical Review of Health System
Transformations,” American Journal of Public Health, March 2006, Vol. 96, No. 3,
[http://www.ajph.org/cgi/content/abstract/96/3/447]; and Center for Global Development,
Does the IMF Constrain Health Spending in Poor Countries, June 2007,
[http://www.cgdev.org/content/publications/detail/14103/].
64 “Nurse Exodus Leaves Kenya in Crisis,” The Guardian Unlimited, May 21, 2006.
[http://www.guardian.co.uk/kenya/story/0,,1779821,00.html].
65 World Bank, Health Development: The World Bank Strategy for Health, Nutrition, and
Population Results. April 2007. [http://www.worldbank.org].
66 “The Global HIV//AIDS Pandemic, Structural Inequalities, and the Politics of
International Health,” American Journal of Public Health, March 2002, Vol. 92, No. 3,
[http://www.ajph.org/cgi/reprint/92/3/343.pdf].
67 Oxfam, Debt Relief and the HIV/AIDS Crisis in Africa: Does the Heavily Indebted Poor
Countries (HIPC) Initiative Go Far Enough?, June 2002, [http://www.oxfam.org/
en/files/pp0206_no25_debt_relief_and_the_HIV_crisis.pdf].

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funds to expand access to voluntary family planning programs in developing
countries. The U.S. Commitment to Child Survival Act (S. 1418) would provide
assistance to improve the health of newborns, children, and mothers in developing
countries. The African Health Capacity Investment Act (S. 805) would amend the
Foreign Assistance Act of 1961 to assist countries in sub-Saharan Africa achieve
internationally recognized goals in the treatment and prevention of HIV/AIDS and
other major diseases, reduce maternal and child mortality, improve human health care
capacity, and improve the retention of medical health professionals.
Reconsider Emphasis on Focus Countries
HIV/AIDS analysts are beginning to advocate that other countries where the
virus is rapidly spreading be included in GHAI. In Eastern Europe and Central Asia,
HIV has become more entrenched. According to UNAIDS, the number of people
living with HIV in those regions has increased by more than 35% since 2003, when
about 1.1 million people were living with the virus. At the end of 2006, about 1.7
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 (1.5%), with
some 377,000 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. In
February 2007, Representative Luis Fortuño introduced H.R. 848, to Amend the State
Department Basic Authorities Act of 1956 to Authorize Assistance to Combat
HIV/AIDS in Certain Countries of the Caribbean Region.
Some caution that before Members consider expanding the number of Focus
Countries, Congress might first need to determine the extent of its commitment to
supporting global HIV/AIDS efforts. A number of HIV/AIDS advocates point out
that HIV/AIDS is a chronic disease that requires long-term care. In order for
countries to assume ownership of HIV/AIDS initiatives and expand them, this view
holds, they must first know how much support to expect from the United States and
for how long that support might last.

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Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations
($ current, millions)
FY2004 FY2005 FY2006 FY2007 FY2008 FY2008 FY2008
Program
Actual Actual Actual
CR
Request House
Senate
1. USAID
HIV/AIDS
(excluding Global
549.2
382.8
373.8
346.3
382.0
350.0
Fund)
464.5
2. USAID
Tuberculosis
100.4
87.8
91.5
89.9
313.5a
200.0
3. USAID
Malariab
100.9
98.2
102.0
248.0
387.5
352.5
357.5
4.
USAID Global Fund Contribution
397.6
247.9
247.5
247.5
0.0
250.0
250.0
5.
FY2004 Global Fund Carryoverc
-87.8
87.8
n/a
n/a
n/a
n/a
n/a
6.
State Department GHAI
488.1 1,373.5
1775.1 2,869.0 4,150.0 4,150.0 4,150.0
7.
GHAI Global Fund Contribution
0.0
0.0
198.0
377.5
0.0
300.0
340.0
8.
Foreign Military Financingd
1.5
1.9
1.9
—
0.0
0.0
0.0
9.
Subtotal, Foreign Operations
1549.9
2279.9 2,789.8 4,206.5 4,973.7 5,748.0 5,647.5
Appropriations
10.
CDC Global AIDS Programe
291.8
123.8
122.7 120.8
121.2
122.7
122.7
11.
NIH International Researchf
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
300.0
300.0
13.
DOL AIDS in the Workplace Initiative
9.9
1.9
0.0
—
0.0
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
10.0
—
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. Includes $150.0 million provided to the Global HIV/AIDS Initiative and $50.0 million for global TB efforts provided by
H.Amdt. 359 of H.R. 2764 .
b. 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.
c. 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.
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. 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.
f. Although appropriations legislation does not specify funding for NIH’s international HIV research initiatives, sufficient funds
are provided to Office of AIDS Research (OAR) to support those efforts. The figures used in Line 11 reflect those
amounts reported by OAR.

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CRS-19
Table 2. Number and Shortage of Doctors, Nurses, and Midwives
Number of Countries
In Countries with Shortages
WHO REGION
Total
With Shortages
Total Workforce
Estimated Shortage
Increase Required
Africa
46
36
590,198
817,992
139%
Americas
35
5
93,603
37,886
40%
Southeast Asia
11
6
2,332,054
1,164,001
50%
Europe
52
0
not applicable
not applicable
not applicable
Eastern
21
7
312,613
306,031
98%
Mediterranean
Western Pacific
27
3
27,260
32,560
119%
World
192
57
3,355,728
2,358,470
70%
Source: WHO, 2006 World Health Report.
Table 3. Distribution of Health Workers in Africa and the United States
Physicians
Nurses
Midwives
Year
COUNTRY
Population
Data
(2005)
Collected
Number
Number
Number
Number
Number
Number
per 1,000
per 1,000
per 1,000
Angola
15,941,000
881
0.08
13,135
1.15
492
0.04
1997
Cameroon
16,322,000
3124
0.19
26,042
1.60
45
0.00
2004
Ethiopia
77,431,000
1936
0.03
14,893
0.21
1,274
0.02
2003
Ghana
22,113,000
3240
0.15
19,707
0.92
3,910
0.18
2004
Mozambique
19,792,000
514
0.03
3,954
0.21
2,236
0.12
2004
Nigeria
131,530,000
34,923
0.28
210,306
1.70
6,344
0.05
2003
South Africa
47,432,000
34,829
0.77
184,459
4.08
82,726
0.67
2003
Uganda
28,816,000
2,209
0.08
16,221
0.61
4,164
0.16
2004
Tanzania
38,329,000
822
0.02
13,292
0.37
not available
2002
Zimbabwe
13,010,000
2,086
0.16
9,357
0.72
not available
2004
AFRICA
738,086,000
150,561
0.22
663,572
0.96
125,142
0.25
variable
TOTAL
United States
295,410,000
730,801
2.56
2,669,603
9.37
not available
2000
Source: WHO, 2006 World Health Report.

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CRS-20
Table 4. Spending on Health in Africa and the United States68
Per Capita
Per Capita
Total
General
External
COUNTRY
Population Expenditure Government Expenditure
Government
Resources for
(000)
on Health
Expenditure on Health as Expenditure as Health as % of
on Health
% of GDP
% of Total
Total
Government
Expenditure on
Expenditure
Health
Angola
15,490
$26.0
$41.0
2.8%
5.3%
6.7%
Cameroon
16,038
$37.0
$19.0
4.2%
8.0%
3.2%
Ethiopia
75,600
$5.0
$12.0
5.9%
9.6%
26.0%
Ghana
21,664
$16.0
$31.0
4.5%
5.0%
15.8%
Mozambique
19,424
$12.0
$28.0
4.7%
10.9%
40.8%
Nigeria
128,709
$22.0
$13.0
5.0%
3.2%
5.3%
South Africa
47,208
$295.0
$258.0
8.4%
10.2%
0.5%
Uganda
27,821
$18.0
$23.0
7.3%
10.7%
28.5%
Tanzania
37,627
$12.0
$16.0
4.3%
12.7%
21.9%
Zimbabwe
12,936
$40.0
$47.0
7.9%
9.2%
6.8%
United States
295,410
$5,711.0
$2,548.0
15.2%
18.5%
0.0%
Source: WHO, 2006 World Health Report.
68 All figures reflect data collected in 2003, except population, which was collected in 2004.

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