Order Code RL34569
International HIV/AIDS, Tuberculosis, and Malaria:
Key Changes to U.S. Programs and Funding
Updated July 14, 2008
Kellie Moss
Analyst in Global Health
Foreign Affairs, Defense, and Trade Division

International HIV/AIDS, Tuberculosis, and Malaria:
Key Changes to U.S. Programs and Funding
Summary
The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Act of 2003 (P.L. 108-25) authorizes $15 billion for U.S. global efforts to combat
HIV/AIDS, tuberculosis (TB), and malaria from FY2004 through FY2008. It also
authorizes the Office of the Global AIDS Coordinator (OGAC) to oversee U.S.
government efforts to combat HIV/AIDS internationally. These efforts to combat
HIV/AIDS implement the President’s Emergency Plan for AIDS Relief (PEPFAR),
a program proposed by President Bush in January 2003.
President Bush has requested $30 billion for the reauthorization of PEPFAR
from FY2009 through FY2013, estimating it would support HIV/AIDS treatments
for 2.5 million people, the prevention of more than 12 million new HIV infections,
and care for more than 12 million HIV-affected people, including 5 million orphans
and vulnerable children.
Congress is considering reauthorization of U.S. international HIV/AIDS,
tuberculosis, and malaria programs through FY2013 for $50 billion. H.R. 5501, the
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008, and S. 2731, a similar bill
with the same title, would increase funding for U.S. efforts to fight HIV/AIDS, U.S.
contributions to the Global Fund to Combat AIDS, Tuberculosis, and Malaria
(Global Fund), and U.S. global efforts to combat tuberculosis and malaria.
H.R. 5501 and S. 2731 propose a number of changes to U.S. international
HIV/AIDS, tuberculosis, and malaria programs. The bills would: add Vietnam to
the list of Focus Countries; remove the 33% spending requirement on abstinence
prevention efforts; establish a Global Malaria Coordinator within the U.S. Agency
for International Development (USAID); set targets for coverage of pregnant women
and the care of HIV-infected children; and support the sustainability of health care
systems in affected countries.
There are some differences between the two bills. H.R. 5501 inserts family
planning program language, maintains prevention and care spending directives, and
adds 14 countries in the Caribbean and three countries in sub-Saharan Africa to the
list of Focus Countries. S. 2731 proposes the use of compacts or framework
agreements between the United States and each country receiving HIV/AIDS funds
under the reauthorization. It eliminates Immigration and Nationality Act language
that bars foreign nationals with HIV/AIDS from entering the United States.
This report will discuss changes in coordination and funding for HIV/AIDS,
tuberculosis, and malaria programs proposed in H.R. 5501 and S. 2731. Some
questions remain about whether programs to combat tuberculosis and malaria should
be further defined and if additional reporting requirements, distinct leadership
authorities, funding and program guidelines, project timetables, and coordination
requirements with HIV/AIDS programs are needed. This report will be updated as
events warrant.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PEPFAR: Implementation, Results, and Funding . . . . . . . . . . . . . . . . . . . . . . . . . 2
Implementation Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OGAC and PEPFAR Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Participating U.S. Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
International Organizations and International Initiatives . . . . . . . . . . . . 3
Restrictions on Spending and Programs . . . . . . . . . . . . . . . . . . . . . . . . 3
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
FY2004-2008 Appropriations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Key Reauthorization Proposals in H.R. 5501 and S. 2731 . . . . . . . . . . . . . . . . . . 7
Funding Authorization Increase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Global Malaria Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
List of Focus Countries Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Compacts With Recipient Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Role of Spending Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Program Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Balance Between Prevention, Treatment, and Care . . . . . . . . . . . . . . . . . . . 14
HIV/AIDS Activities and Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . 15
Health Systems and the Single Disease Approach . . . . . . . . . . . . . . . . . . . . 16
HIV/AIDS Activities and Nutrition Programs . . . . . . . . . . . . . . . . . . . . . . . 18
Immigration and Nationality Act Amendment . . . . . . . . . . . . . . . . . . . . . . 18
Additional Oversight Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Taxation of Assistance Funds by Foreign Governments Prohibited . . . . . . 19
Prevention of Mother to Child HIV Transmission Panel . . . . . . . . . . . . . . . 19
Conscience Clause Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
List of Tables
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria Appropriations by
Disease, FY2004 through FY2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Table 2. U.S. Contributions to the Global Fund to Combat AIDS, Tuberculosis,
and Malaria, FY2004 through FY2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Table 3. Comparison of PEPFAR Funding Reauthorization Levels from
FY2009 through FY2013 in H.R. 5501 and S. 2731 . . . . . . . . . . . . . . . . . . . 8


International HIV/AIDS, Tuberculosis, and
Malaria: Key Changes to U.S. Programs
and Funding
Introduction
On May 30, 2007, President Bush announced that he would request $30 billion
for the reauthorization of the President’s Emergency Plan for AIDS Relief
(PEPFAR), which is the coordinated U.S. government effort to combat HIV/AIDS
globally.1 He estimated it would support HIV/AIDS treatments for 2.5 million
people, the prevention of more than 12 million new HIV infections, and care for
more than 12 million HIV-affected people, including 5 million orphans and
vulnerable children.2 In 2003, Congress authorized $15 billion for U.S. efforts to
combat global HIV/AIDS, tuberculosis (TB) and malaria from FY2004 through
FY2008 with the United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 (P.L. 108-25) (hereafter referred to as the Leadership Act).
Congress is considering reauthorization of these efforts through FY2013 through
two legislative proposals before the 110th Congress. H.R. 5501, the Tom Lantos and
Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Reauthorization Act of 2008, and S. 2731, a similar bill with the same
title, would increase the funding authorization to $50 billion for U.S. efforts to fight
HIV/AIDS, U.S. global efforts to combat tuberculosis and malaria, and U.S.
contributions to the Global Fund to Combat AIDS, Tuberculosis, and Malaria
(Global Fund).3 When considering the reauthorization, Congress may wish to
consider whether programs to combat tuberculosis and malaria should be further
defined and if additional reporting requirements, distinct leadership authorities,
funding and program guidelines, project timetables, and coordination requirements
with HIV/AIDS programs are needed.
1 Office of the Global AIDS Coordinator (OGAC), U.S. Department of State, “President
Bush Announces Five-Year, $30 Billion HIV/AIDS Plan,” at
[http://www.pepfar.gov/85811.htm].
2 Ibid.
3 The Global Fund to Fight AIDS, Tuberculosis, and Malaria, headquartered in Geneva,
Switzerland, is an independent foundation that seeks to attract and rapidly disburse new
resources in developing countries aimed at countering the three diseases. The Fund is a
financing vehicle, not an implementing agency. 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.

CRS-2
This report describes U.S. efforts to combat international HIV/AIDS through
PEPFAR including an overview of its implementation structure, key program
elements, results, and funding from FY2004 through FY2008. It also details funding
for tuberculosis, malaria, and U.S. contributions to the Global Fund during that time.
This report discusses similarities and differences between H.R. 5501 and S. 2731
including proposed changes in program authorities and funding for HIV/AIDS,
tuberculosis, and malaria programs. It does not describe U.S. efforts to combat
tuberculosis and malaria.4
PEPFAR: Implementation, Results, and Funding
On January 28, 2003, President Bush proposed the President’s Emergency Plan
for AIDS Relief (PEPFAR) in his State of the Union address, requesting $15 billion
over five years to combat HIV/AIDS.5 Congress authorized $15 billion for U.S.
efforts to combat global HIV/AIDS, tuberculosis (TB), and malaria from FY2004
through FY2008 with the Leadership Act, which the President signed into law (P.L.
108-25) on May 27, 2003.
Implementation Structure
OGAC and PEPFAR Countries. The Leadership Act created the Office of
the Global AIDS Coordinator (OGAC) in the Department of State and outlined its
role.6 OGAC directly approves all U.S. activities and funding related to combating
HIV/AIDS in the 15 PEPFAR Focus Countries. In addition to the Focus Countries,
OGAC has primary responsibility for the oversight and coordination of all U.S.
government resources and international activities to combat HIV/AIDS. This role
extends to ensuring program and policy coordination among the relevant executive
branch agencies and non-governmental organizations (NGOs), including auditing,
monitoring, and evaluation of all such programs including activities conducted in
non-Focus Countries.7
In 2003, the 15 PEPFAR Focus Countries accounted for over 50% of all HIV-
infected people in the world. The 15 Focus Countries are Botswana, Cote d’Ivoire,
Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South
4 For more information on U.S. efforts to combat tuberculosis, see CRS Report RL34246,
Tuberculosis: International Efforts and Issues for Congress, by Tiaji Salaam-Blyther. For
more information on U.S. efforts to combat malaria, see CRS Report RL33485, U.S.
International HIV/AIDS, Tuberculosis, and Malaria Spending: FY2004-FY2008
, by Tiaji
Salaam-Blyther.
5 For more information on PEPFAR, see CRS Report RL33771, Trends in U.S. Global AIDS
Spending: FY2000-FY2008
, by Tiaji Salaam-Blyther, and CRS Report RL34192, PEPFAR:
From Emergency to Sustainability
, by Tiaji Salaam-Blyther.
6 Section 102 of P.L. 108-25, the Leadership Act.
7 OGAC, “FY 2006 Countries of the President’s Emergency Plan for AIDS Relief
(PEPFAR),” at [http://www.pepfar.gov/countries/84362.htm].

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Africa, Tanzania, Uganda, Vietnam, and Zambia.8 OGAC estimates that from
FY2004 through FY2008, 58% of PEPFAR funds will have been spent on the 15
Focus Countries.9 OGAC transfers funds to PEPFAR-participating agencies that
administer HIV/AIDS programs in Focus Countries.
Participating U.S. Agencies. PEPFAR-participating agencies and
departments, which receive funding transfers from OGAC, include the U.S. Agency
for International Development (USAID); the Department of State (State); the
Department of Health and Human Services (HHS) through the Centers for Disease
Control and Prevention (CDC), the National Institutes of Health (NIH), the Health
Resources and Services Administration (HRSA), the Food and Drug Administration
(FDA), and the Substance Abuse and Mental Health Services Administration
(SAMHSA); the Department of Labor (DOL); the Department of Commerce; the
Peace Corps; and the Department of Defense (DoD). These agencies may allocate
their own agency funds for global HIV/AIDS, tuberculosis, and malaria programs.
International Organizations and International Initiatives. The
Leadership Act authorizes funds to support U.S. contributions to some multilateral
organizations and international research initiatives including the Global Fund to
Combat AIDS, Tuberculosis, and Malaria (hereafter referred to as the Global Fund),10
the United Nations Joint Programme on HIV/AIDS (UNAIDS), and the International
AIDS Vaccine Initiative (IAVI). OGAC reports that 16% of PEPFAR funds will
support the Global Fund from FY2004 through FY2008.11
Restrictions on Spending and Programs. Though Focus Countries
receive the bulk of PEPFAR funding, individual Focus Countries may not necessarily
receive more funds than non-Focus Countries: for example, India, which is not a
Focus Country, receives more funding than Guyana, a Focus Country.12 OGAC
determines annual funding allocations for each Focus Country based on past funding
allocations and provides an initial budget estimate to U.S. staff in each PEPFAR
country to help them formulate a Country Operational Plan (COP). A COP provides
data that informs OGAC’s final funding decision. OGAC uses the COP to evaluate
8 These countries, except Vietnam, were specified in the Leadership Act (P.L. 108-25) as
Focus Countries. Section 102(B)(ii)(VII) of the Leadership Act also authorizes the
President to designate Focus Countries. President Bush announced that Vietnam would be
added to the group of Focus Countries on June 23, 2004. See The White House, “Vietnam
to Receive U.S. Emergency HIV/AIDS Assistance,” June 22, 2004, at
[http://vietnam.usembassy.gov/pepfar040622.html].
9 OGAC figures do not include funding for U.S. international malaria programs. OGAC,
“Making A Difference: Funding,” at [http://www.pepfar.gov/press/80064.htm].
10 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.
11 OGAC figures do not include funding for U.S. international malaria programs. OGAC,
“Making A Difference: Funding,” at [http://www.pepfar.gov/press/80064.htm].
12 OGAC, “2008 PEPFAR Country Profiles: India,” and “2008 PEPFAR Country Profiles:
Guyana,” at [http://www.pepfar.gov/press/c19558.htm].

CRS-4
country-based information on the extent of the HIV/AIDS epidemic, absorptive
capacity for funding, effectiveness of PEPFAR efforts to date, and country team
projections of need.13
In the Leadership Act, Congress outlined both funding distribution guidelines
and “spending directives” for HIV/AIDS assistance. Congress recommended that
20% of HIV/AIDS funds should be spent on prevention. It required that from
FY2006 through FY2008 at least 33% of these prevention funds must be spent on
abstinence-until-marriage programs.14 In addition, Congress directed that from
FY2006 through FY2008 not less than 55% of HIV/AIDS funds must be spent on
treatment, and of these, it recommended that 75% should support the purchase and
distribution of antiretroviral (ARV) drugs, while the remaining 25% should be spent
on related care for treatment patients. Congress also recommended that 15% of
HIV/AIDS funds should be spent on palliative care of HIV-affected people. Finally,
it required that from FY2006 through FY2008 the remaining 10% of HIV/AIDS
funds must be spent on orphans and vulnerable children (OVC).15 It required that
at least 50% of these OVC funds must be provided through non-profit NGOs,
including faith-based organizations (FBOs), that implement programs on the
community level.
Results
When President Bush proposed PEPFAR in 2003, he projected that the five-year
initiative to combat HIV/AIDS globally would prevent 7 million new HIV infections,
provide antiretroviral treatment for 2 million people, and would support care for 10
million HIV-affected people.16
As of September 30, 2007, OGAC reports that it has accomplished the following:17
! Prevention: supported over 33 million HIV counseling and testing
sessions; supported prevention of mother to child [HIV]
13 For more information on the OGAC allocation process, see Government Accountability
Office (GAO), Global HIV/AIDS: A More Country-Based Approach Could Improve
Allocation of PEPFAR Funding
, April 2008, at [http://www.gao.gov/new.items/d08480.pdf].
14 OGAC defines abstinence-until-marriage activities as programs that address both
abstinence and faithfulness, according to GAO, Global Health: 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].
15 For more information on OVC, see CRS Report RL32252, AIDS Orphans and Vulnerable
Children (OVC): Problems, Responses, and Issues for Congress
, by Tiaji Salaam-Blyther.
16 The White House, “Fact Sheet: The President’s Emergency Plan for AIDS Relief,”
January 29, 2003, at [http://www.whitehouse.gov/news/releases/2003/01/20030129-1.html].
17 OGAC has updated some but not all of these statistics through March 31, 2008; CRS has
included statistics available through September 30, 2007, in order to provide more detailed
information. Data in this section was compiled by CRS from OGAC, “Latest Results,” at
[http://www.pepfar.gov/about/c19785].

CRS-5
transmission (PMTCT) services in more than 10 million
pregnancies; and prevented an estimated 157,000 infant infections.
! Treatment: provided antiretroviral treatment for about 1.45 million
people, including 86,000 children.
! Care: supported care for more than 6.6 million HIV-affected
people, including more than 2.7 million orphans and vulnerable
children (OVC).
Funding
The Leadership Act authorizes $15 billion to address HIV/AIDS, tuberculosis,
and malaria globally and to provide U.S. contributions to the Global Fund from
FY2004 through FY2008. OGAC calculates PEPFAR funding as the total of enacted
funding for U.S. efforts to combat HIV/AIDS globally, U.S. efforts to combat
tuberculosis internationally, and U.S. contributions to the Global Fund.18 Prior to
FY2006, PEPFAR funding also included U.S. efforts to combat malaria. Then in
June 2005 the President introduced the President’s Malaria Initiative (PMI) to expand
U.S. government efforts to combat malaria globally.19 As a result, OGAC excluded
malaria funding from PEPFAR calculations beginning in FY2006.20 Since that time,
U.S. government spending on malaria has been reported separately.21 Since the
Leadership Act authorization included malaria programs, the funding data in this
report includes malaria and PMI funding. This report details funding separately for
HIV/AIDS, TB, malaria, and U.S. contributions for the Global Fund.
FY2004-2008 Appropriations. From FY2004 through FY2008, Congress
appropriated $15.3 billion to U.S. programs to combat global HIV/AIDS, of which
$10.6 billion was spent in the 15 PEPFAR Focus Countries through the Global
HIV/AIDS Initiative (GHAI); $524 million to U.S. programs to combat TB; and
18 OGAC, “Making A Difference: Funding,” at [http://www.pepfar.gov/press/80064.htm].
19 For more information on PMI, see CRS Report RL33485, U.S. International HIV/AIDS,
Tuberculosis, and Malaria Spending: FY2004-FY2008
, by Tiaji Salaam-Blyther.
20 OGAC, “Appendix 1: The President’s Emergency Plan for AIDS Relief Sources of
Funding,” The Power of Partnerships: Third Annual Report to Congress on PEPFAR
(2007)
, at [http://www.pepfar.gov/documents/organization/81019.pdf].
21 USAID, Report to Congress: USAID FY 2006 Malaria Programming Report No. 1, at
[http://pdf.usaid.gov/pdf_docs/PDACH688.pdf]. Report to Congress: USAID FY 2006
Malaria Programming Report No. 2
, at [http://pdf.usaid.gov/pdf_docs/PDACH689.pdf].
President’s Malaria Initiative (PMI), USAID, PMI First Annual Report: Saving the Lives
of Mothers and Children in Africa,
March 2007, at
[http://www.pmi.gov/resources/pmi_annual_report.pdf]. PMI, USAID, PMI Second Annual
Report: Progress Through Partnerships: Saving Lives in Africa
,
[http://www.pmi.gov/resources/pmi_annual_report08.pdf].

CRS-6
$916 million to U.S. programs to combat malaria (Table 1).22 Congress also
appropriated $3.0 billion to the Global Fund (Table 2).23
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria
Appropriations by Disease, FY2004 through FY2008
(Current U.S. $ Millions)
AIDS Program
Amount
USAID HIV/AIDS
2,030.5
State Global HIV/AIDS Initiative (GHAI)
10,624.0
Foreign Military Financing
6.9
CDC Global AIDS Program
753.2
CDC International HIV Research
23.0
NIH International HIV Research
1,785.5
DOL AIDS Initiative
11.8
DOD HIV/AIDS Prevention Education
25.0
Total HIV/AIDS Fundinga
15,259.9
Tuberculosis Program
Amount
USAID Tuberculosis
515.5
CDC Tuberculosis
8.4
Total Tuberculosis Funding
523.9
Malaria Program
Amount
USAID Malaria
870.9
CDC Malaria
44.9
Total Malaria Fundingb
915.8
Source: Derived from data presented in CRS Report RL33485, U.S. International HIV/AIDS,
Tuberculosis, and Malaria Spending: FY2004-FY2008
, by Tiaji Salaam-Blyther.
a. Includes UNAIDS, International AIDS Vaccine Initiative (IAVI), and international microbicide
research contributions.
b. Includes President’s Malaria Initiative (PMI).
22 For more information on GHAI, PEPFAR, TB, and malaria appropriations, see CRS
Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and Malaria Spending:
FY2004-FY2008
, by Tiaji Salaam-Blyther; and CRS Report RL33771, Trends in U.S.
Global AIDS Spending: FY2000-FY2008
, by Tiaji Salaam-Blyther.
23 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. U.S. Contributions to the Global Fund to Combat
AIDS, Tuberculosis, and Malaria, FY2004 through FY2008
(Current U.S. $ Millions)
Global Fund Contributions
Amount
USAID
1,140.6
State GHAI
1,121.0
NIH
741.1
Total Global Fund Contribution
3,002.7
Source: Derived from data presented in CRS Report RL33485, U.S. International HIV/AIDS,
Tuberculosis, and Malaria Spending: FY2004-FY2008
, by Tiaji Salaam-Blyther.
Key Reauthorization Proposals in H.R. 5501
and S. 2731
On May 30, 2007, President Bush urged Congress to extend PEPFAR from
FY2009 through FY2013 with an additional $30 billion authorization.24 The
Administration estimates that $30 billion would support treatment for 2.5 million
people, the prevention of more than 12 million new infections, and care for more than
12 million people, including 5 million orphans and vulnerable children.25
The Administration’s FY2009 budget request includes $6 billion for U.S.
international HIV/AIDS and tuberculosis programs.26 Of this $6 billion, $500
million is requested for a U.S. contribution to the Global Fund.27 The President also
separately requested $385 million for the President’s Malaria Initiative (PMI) for
U.S. global malaria eradication efforts.28
A number of bills have been introduced in the 110th Congress to reauthorize
PEPFAR. The two bills highlighted in this report have advanced the farthest and
include measures from some of the other proposed bills. H.R. 5501 (H.Rept. 110-
546, Part 2), the Tom Lantos and Henry J. Hyde United States Global Leadership
24 OGAC, “President Bush Announces Five-Year, $30 Billion HIV/AIDS Plan,” at
[http://www.pepfar.gov/85811.htm].
25 Ibid.
26 Director of U.S. Foreign Assistance, U.S. Department of State, FY2009 International
Affairs (Function 150) Congressional Budget Justification for Foreign Operations: Annex
A - President’s Emergency Plan for AIDS Relief, at
[http://www.state.gov/documents/organization/101458.pdf].
27 Ibid.
28 Director of U.S. Foreign Assistance, U.S. Department of State, FY2009 International
Affairs (Function 150) Congressional Budget Justification for Foreign Operations: Request
by Appropriation Account — Ex-Im Bank, OPIC, USTDA, CSH, DA, IDA, and TI, at
[http://www.state.gov/documents/organization/101417.pdf].

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Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, passed
the House by a vote of 308-116 on April 2, 2008. On April 15, 2008, the Senate
Foreign Relations Committee reported a similar bill, S. 2731 (S.Rept. 110-325), with
the same title. On July 11, 2008, the Senate reached a unanimous consent agreement
to limit the amendments to S. 2731 to those identified and agreed to as first degree
by the bill’s managers (10 amendments). It also voted 65-3 to invoke cloture on a
motion to proceed to the bill.

The following section focuses on key proposed changes to U.S. programs that
combat HIV/AIDS, tuberculosis, and malaria, as suggested by H.R. 5501 and S.
2731. It highlights key proposed requirements and funding allocations included in
these bills and discusses the debate surrounding the proposals and possible policy
implementation implications.
Funding Authorization Increase
Both H.R. 5501 and S. 2731 would authorize up to $50 billion for PEPFAR
during the reauthorization period of FY2009 through FY2013. H.R. 5501 would
authorize $10 billion for each of the five years.29 S. 2731 would authorize $50 billion
in total for the five year period. Both bills also authorize higher funding levels for
U.S. contributions to the Global Fund as well as for U.S. efforts to combat
tuberculosis and malaria (Table 3).
Table 3. Comparison of PEPFAR Funding Reauthorization
Levels from FY2009 through FY2013 in H.R. 5501 and S. 2731
Area of Authorization
H.R. 5501
S. 2731
Overall
$50 billion ($10 billion each $50 billion (in total)
fiscal year over five years)
U.S. Contribution to Global Up to $2 billion for U.S.
Up to $2 billion for U.S.
Fund to Combat AIDS,
contributions in each of
contributions in FY2009;
Tuberculosis, and Malaria
FY2009 and FY2010;
such sums as may be
such sums as may be
necessary from FY2010
necessary from FY2011
through FY2013.
through FY2013.
Tuberculosis
$4 billion (in total)
$4 billion (in total)
Malaria
$5 billion (in total)
$5 billion (in total)
Source: Compiled by CRS from H.R. 5501 and S. 2731.
Critics of the $50 billion authorization level argue that it is fiscally irresponsible
to spend so much in light of U.S. military operations in Iraq and Afghanistan, a near
economic recession in the United States, and questions about the absorptive capacity
29 According to the Congressional Quarterly, the funding level for PEPFAR programs in
H.R. 5501 is the result of a compromise reached the night before introduction. Adam
Graham-Silverman, “Lawmakers Push Bipartisan Deal on Global AIDS Bill,” CQ Today,
February 26, 2008.

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of recipient countries. Some analysts suggest that increased disease-specific funding
in the foreign operations appropriations will drain available funding from other aid
priorities in developing countries, such as agriculture assistance and private sector
growth. Others oppose increased funding because they do not want to expand current
PEPFAR activities to support additional Focus Countries and to fund activities not
directly related to AIDS. Critics of high spending levels are concerned about
proposals to increase the number of Focus Countries and to extend PEPFAR funds
to support health care infrastructure as well as to enhance nutrition and feeding
programs.30 For example, Senators who have placed a hold on H.R. 5501 and S.
2731 have stated that the bills would “transform a targeted and accountable $15
billion dollar AIDS program into an unaccountable, unspecified $50 billion
development program.”31
Proponents of the authorization level argue that access to HIV/AIDS prevention,
treatment, and care for all requires greater resources. As a result, debate among bill
advocates focuses on where the dollars should be spent and what priorities the
increased funding should support. Some urge Congress to consider further definition
of tuberculosis (TB) authorities and targets, improved coordination of TB activities
with HIV/AIDS activities in areas of co-infection, and strengthened reporting
requirements for TB. Backers of the increased authorization argue that the next stage
in fighting AIDS, tuberculosis, and malaria must occur alongside the strengthening
of health systems. They argue that these activities must be integrated with related
development efforts in order to ensure the sustainability of efforts to fight the three
diseases.
Some opponents use the Congressional Budget Office’s (CBO) cost estimates
to justify a lower authorization funding level. CBO estimates that implementing
either H.R. 5501 or S. 2731 would cost $35 billion from FY2009 through FY2013
and that most of the additional amounts of authorized funding would be spent by
FY2018.32 Some argue that the CBO cost estimates assume that outlays will follow
historical spending patterns for existing programs and do not reflect the proposed
increases in authorization levels for tuberculosis and malaria spending and for the
U.S. contribution to the Global Fund.
30 Adam Graham-Silverman, “Despite Efforts, Senate Global AIDS Legislation Stalled Over
Cost Concerns,” CQ Today, June 13, 2008.
31 Seven Senators placed a hold on H.R. 5501 and S. 2731 on March 31, 2008. See Senators
Tom Coburn, Jim DeMint, Jeff Sessions, Richard Burr, Saxby Chambliss, Jim Bunning, and
David Vitter, “Letter to Senator Mitch McConnell,” March 31, 2008, at
[http://coburn.senate.gov/ffm/index.cfm?FuseAction=Files.View&FileStore_id=82a33c0
4-4833-4a00-9895-4ff924bd9b04]. Senators Coburn and Burr subsequently withdrew their
objection to a motion to proceed to S. 2731; see “Letter to Senator Mitch McConnell,” July
1, 2008, at [http://coburn.senate.gov/ffm/index.cfm?FuseAction=Files.View&FileStore_id=
de6535c6-c151-4717-89ff-26c399bf3024].
32 Congressional Budget Office (CBO), Cost Estimate: H.R. 5501, March 5, 2008, at
[http://www.cbo.gov/ftpdocs/90xx/doc9029/hr5501.pdf]. CBO, Cost Estimate: S. 2731,
April 11, 2008, at [http://www.cbo.gov/ftpdocs/91xx/doc9126/s2731.pdf]

CRS-10
Global Malaria Coordinator
Both bills establish a Coordinator of United States Government Activities to
Combat Malaria Globally (Global Malaria Coordinator) at USAID. The Global
Malaria Coordinator would oversee and coordinate all U.S. resources for
international activities related to combating malaria. The bills also authorize the
Global Malaria Coordinator to provide financial assistance to multilateral efforts such
as the Roll Back Malaria Partnership (RBM).33 The authorization of a Global
Malaria Coordinator is related to the creation of the President’s Malaria Initiative
(PMI), which President Bush announced in June 2005 and has been operational since
FY2006. PMI is located at USAID.
Some observers oppose a disease-specific approach. They argue that it ignores
the interconnected nature of health care challenges, and in resource-poor countries,
it creates competition for limited human capacity such as doctors, public health
specialists, and U.S. program managers. Supporters believe PMI will focus attention
on malaria, which is a major killer in sub-Saharan Africa and some parts of Asia.
Others contend that directed efforts on specific diseases should occur
simultaneously with efforts to build health capacity and infrastructure. While they
applaud the initial emphasis on HIV/AIDS, which has helped to build health system
capacity in resource-poor settings, observers contend that the next stage of disease
response under PEPFAR should integrate efforts to combat HIV/AIDS with the
provision of basic healthcare and the prevention of childhood illness.
Some urge Congress to consider questions related to the establishment of PMI,
including how PMI will coordinate its activities with PEPFAR; the further definition
of authorities over the three diseases in the Leadership Act; the possibility of
competing priorities between PMI and PEPFAR, especially where they operate in the
same Focus Countries; and the implications of different initiative timetables for
strategic planning, funding authorizations, and implementation.
List of Focus Countries Expansion
On February 6, 2007, Representative Luis Fortuño introduced H.R. 848, a bill
to amend the State Department Basic Authorities Act of 1956 to authorize assistance
to combat HIV/AIDS in certain countries in the Caribbean. The bill would add
Antigua and Barbuda, the Bahamas, Barbados, Belize, Dominica, Grenada, Jamaica,
Montserrat, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Saint Lucia,
Suriname, Trinidad and Tobago, and Dominican Republic to the list of Focus
Countries. When introduced, H.R. 5501 proposed adding Vietnam as a Focus
Country as well as those countries listed in H.R. 848. Representative Betty
McCollum proposed adding Malawi, Swaziland and Lesotho to the list of Focus
33 The Roll Back Malaria Partnership (RBM) is a partnership of organizations that aims to
provide a coordinated global approach to fighting malaria. RBM was launched in 1998 by
the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the
United Nations Development Programme (UNDP) and the World Bank. For more
information on RBM, see [http://www.rollbackmalaria.org/]

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Countries in H.R. 5501 through H.Amdt. 975, which was adopted. S. 2731 would
add only Vietnam as a Focus Country. Vietnam has been a Focus Country in practice
since 2004 at the direction of President Bush; this language would update the list of
14 Focus Countries that was included in the Leadership Act.
Some observers have questioned why the above-named countries were selected,
particularly since OGAC did not put forth these countries for consideration.
Proponents of the addition of these new Focus Countries argue that the designation
would direct more HIV/AIDS funding to these areas. Debate about the Focus
Countries list also has centered on how authorized funds in excess of the President’s
$30 billion PEPFAR reauthorization proposal will be distributed across PEPFAR
countries. It is not clear whether newly designated Focus Countries would receive
more support than they did previously or whether they will be funded at higher levels
than non-Focus Countries for HIV/AIDS activities. Some would like the final
reauthorization bill to clarify this issue.
Opponents of the proposed list argue that incidence rates — the rates of new
infections — are growing in East Asia and Oceania, while incidence rates appear to
have stabilized in the Caribbean. They also argue that prevalence rates — the
percentages of given populations that are infected with HIV/AIDS — are growing in
Eastern Europe and Central Asia, while prevalence rates in the Caribbean appear to
have stabilized and in some countries have even declined.34 As new infections
worldwide continue to outpace the numbers of infected persons placed on treatment,
others assert that a more complex analysis of need should be used in naming Focus
Countries. Still others argue that Focus Countries should no longer be used to
apportion funding and that distribution of funds should be based on country needs
and recipient countries’ access to other funding sources for HIV/AIDS programs.
Compacts With Recipient Countries
Some observers have expressed concern about the long-term commitment that
PEPFAR may require, particularly in the Focus Countries. As an alternative to
adding Focus Countries, some have suggested compacts between the U.S.
government and PEPFAR recipient governments to clearly outline the scope and
terms of U.S. involvement in AIDS prevention, treatment and care and to elicit
recipient government involvement, ownership, and investment. Supporters assert
that compacts may be helpful in outlining expectations for broader development
efforts and investments that have been shown to have a significant impact on health.
Some compacts, for example, might include an agreement that aid recipient countries
would reform property laws and inheritance laws. Such reforms have been shown
to reduce the vulnerability of widows and orphans to HIV infection by providing
them with greater financial security.35 S. 2731 supports this idea, stating that
34 For more information on incidence and prevalence rates, see United Nations Joint
Programme on HIV/AIDS (UNAIDS), 2007 AIDS Epidemic Update, November 17, 2007,
at [http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf].
35 U.N. Millennium Project Task Force on Education and Gender Equality, Taking Action:
Achieving Gender Equality and Empowering Women
, 2005, at
(continued...)

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compacts and framework agreements are “one mechanism to promote the transition
from an emergency to a public health and development approach to HIV/AIDS” and
could be “tailored to local circumstances to promote host government commitment
to deeper integration of HIV/AIDS services into health systems, contribute to the
health systems overall, and enhance sustainability.”36 H.R. 5501 does not include
similar language.
Role of Spending Directives
H.R. 5501 maintains funding distribution guidelines and spending directives of
20% for HIV prevention activities, 15% for HIV/AIDS care activities, and 10% for
orphans and vulnerable children (OVC) activities, but it does not include the
spending directive for HIV/AIDS treatment. S. 2731 maintains the spending
directive for OVC, but it does not include the funding distribution guidelines and
spending directives for HIV/AIDS prevention, treatment, and care. Both bills require
balanced funding for HIV prevention activities, stating that a report to Congress must
be provided to justify any decision to spend less than 50% of prevention funds on
behavioral change programs, including abstinence and be faithful activities, in any
PEPFAR recipient country with a generalized epidemic.
There has been considerable debate about the effectiveness of congressional
spending directives. The Institute of Medicine (IOM) observed that the spending
directives limit Focus Country teams’ ability to tailor budgets to local HIV
transmission patterns.37 Critics contend that the spending directives also complicate
efforts to address the specific nature of the HIV/AIDS epidemic in each country.
HIV/AIDS rates among the Focus Countries range from 1% to over 33%. The
current and proposed Focus Countries have epidemics that vary in nature and
prevalance: some epidemics are concentrated among drug users or prostitutes while
others are spread throughout the population. Some argue that Congress might
consider eliminating some or all prevention, treatment, and care spending directives
to promote operational planning that is responsive to the nature of the epidemic in
each country and reflects the cost of implementation in that area. The Government
Accountability Office (GAO) found that the spending restrictions do not account for
the costs of particular HIV/AIDS activities that may vary from country to country or
for changes in costs over time.38
Some encourage Congress to maintain its spending directives, particularly those
related to orphans and vulnerable children (OVC). Supporters cite a GAO report that
stated that without the spending directive, programs for OVC might not have been
35 (...continued)
[http://www.unmillenniumproject.org/documents/Gender-complete.pdf].
36 See Section 310(c)(6) and Section 301(d).
37 Institute of Medicine of the National Academies (IOM) Committee for the Evaluation of
the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation, PEPFAR
Implementation: Progress and Promise
, The National Academies Press: 2007.
38 GAO, Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of
PEPFAR Funding
, April 2008, at [http://www.gao.gov/new.items/d08480.pdf].

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protected.39 Others stress the importance of the spending directive that requires at
least 55% of HIV/AIDS funds be spent on HIV/AIDS treatment, to maintaining
support for the purchase and distribution of antiretroviral drugs and related care for
those receiving treatment. Senator Tom Coburn introduced S. 2749, the Save Lives
First Act of 2008, on March 12, 2008, which maintains protections for AIDS
treatment funding. Senator Coburn also signed a letter that requests a hold on H.R.
5501 and S. 2731, noting the removal of the treatment spending directive.
Congressional Quarterly recently reported that, after negotiating for changes — that
have not been formally offered yet — to S. 2731, Senator Coburn was “satisfied with
language that would require more than half the money go to treatment, including
antiretroviral drugs.”40 Senator Coburn subsequently withdrew his objection to a
motion to proceed to S. 2731.41
Program Objectives
Program objectives are goals that establish the number of people that U.S.
HIV/AIDS activities, such as prevention, treatment, and care, will reach within a
specified period. In 2003, for example, the PEPFAR five-year global program
objective for treatment was to provide antiretroviral treatment for 2 million people.42
Some have suggested that one alternative to spending directives is to allow U.S. staff
in PEPFAR Focus Countries to set annual program objectives for prevention,
treatment, and care that, in turn, will be added up to become the five-year country
prevention, treatment, and care objectives. These would then be totaled across
countries to calculate the U.S. global program objectives for these program areas.
Currently, OGAC determines five-year country prevention, treatment, and care goals
for the 15 Focus Countries, and then U.S. staff in PEPFAR Focus Countries set
annual program objectives with the goal of reaching five-year country goals but with
consideration for the challenges of the country’s HIV/AIDS epidemic. OGAC
calculates global program objectives by adding up the five-year country targets.43
Some supporters of program targets being determined entirely by U.S. staff in
PEPFAR Focus Countries contend that country teams have the greatest awareness of
each country’s needs and should establish prevention, treatment, and care targets.
However, some PEPFAR country team members expressed concern about difficulties
39 Ibid.
40 Adam Graham-Silverman, “Deal Could Pave Way for Quick Senate Passage of Global
AIDS Aid Measure,” CQ Today, June 25, 2008.
41 Senators Tom Coburn and Richard Burr, “Letter to Senator Mitch McConnell,” July 1,
2008, at
[http://coburn.senate.gov/ffm/index.cfm?FuseAction=Files.View&FileStore_id=de6535c
6-c151-4717-89ff-26c399bf3024].
42 The White House, “Fact Sheet: The President’s Emergency Plan for AIDS Relief,”
January 29, 2003, at [http://www.whitehouse.gov/news/releases/2003/01/20030129-1.html].
43 GAO, Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of
PEPFAR Funding
, April 2008, at [http://www.gao.gov/new.items/d08480.pdf].

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country teams might face in reaching a consensus about such targets.44 Critics of
program targets being determined this way assert that Congress could specify global
targets as a way of guiding policy implementation and priorities without hampering
the ability of country-based teams to respond flexibly to in-country realities and to
coordinate with national health plans. They point to language in S. 2731 and H.R.
5501 as examples: both bills establish a target for prevention of mother to child
[HIV] transmission (PMTCT) activities that at least 80% of pregnant women would
be reached in affected countries by 2013.45 S. 2731 also sets a target that the
proportion of children receiving care and treatment would be proportionate to their
numbers within the population of HIV-infected individuals in each country by 2013,
while H.R. 5501 sets a target requiring that by 2013 up to 15% of those receiving
treatment and care must be children.
Balance Between Prevention, Treatment, and Care
Debate about spending directives and program targets is closely related to
debate about how to prioritize or balance HIV/AIDS prevention, treatment, and care
activities. Some experts maintain that prevention should remain a focus of global
efforts, because there is no cure for AIDS at this time and preventing new infections
is the only way to stop the epidemic in the long term. In 2001 the U.N. General
Assembly adopted the Declaration of Commitment on HIV/AIDS, which stated that
“prevention must be the mainstay of our response.”46 Some organizations, such as
the Bill and Melinda Gates Foundation and the Global AIDS Prevention Working
Group, focus their efforts on strategies and prevention research in an effort to
“prevent the HIV epidemic from becoming generalized in countries with emerging
epidemics” and to prevent millions of new infections.47
On the other hand, some argue that focusing on prevention and neglecting
treatment and care would ignore the economic and social impacts of the disease on
those already infected, on the children and families of infected persons, and on
countries with high prevalence rates. Some argue that treatment and care are an
investment in hope and stability, preventing children from being orphaned and people
from suffering the ravages of the disease when treatment to prolong life and improve
its quality is available. Some argue that treatment costs are dropping very rapidly for
not only first-line treatment regimens but also second-line antiretroviral therapies, a
trend that is expected to continue as treatment expands to cover more infected people
in low and middle income countries and as more international donors negotiate for
44 Ibid.
45 In the Leadership Act, Congress required that the U.S. government strategy to combat the
global HIV/AIDS pandemic must “provide for meeting or exceeding the goal to reduce the
rate of mother-to-child transmission of HIV by 20 percent by 2005 and by 50 percent by
2010.”
46 U.N. Document, A/RES/S-26/L.2, June 27, 2001, at
[http://data.unaids.org/publications/irc-pub03/aidsdeclaration_en.pdf].
47 Bill and Melinda Gates Foundation, “Grantmaking Priorities for HIV/AIDS,”
[http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/HIVAIDS/HIV_Grantmaki
ng.htm]. Global HIV Prevention Working Group, [http://www.globalhivprevention.org/].

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lower prices.48 Others maintain that combating HIV/AIDS requires a combination
of prevention, treatment, and care rather than a choice between these strategies.
HIV/AIDS Activities and Family Planning
H.R. 5501 includes language that addresses U.S. HIV/AIDS activities’ links and
referral to family planning and maternal health programs. Section 101(a)(4) of H.R.
5501 amends Section 101 of P.L. 108-25. It states that a comprehensive five-year
global strategy to combat HIV/AIDS, tuberculosis, and malaria shall:

include specific plans for linkage to, and referral systems for non-governmental
organizations that implement multisectoral approaches, including faith-based and
community-based organizations, for ... access to HIV/AIDS education and testing
in family planning and maternal health programs supported by the United States
Government.49
S. 2731 does not include family planning program language.
Opponents of the language in H.R. 5501 argue that the language is ambiguous
and may apply the Mexico City policy to programs that receive PEPFAR funding.50
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.51 Others oppose the language
because they do not believe that it sufficiently supports the integration of family
planning services in U.S.-supported HIV prevention programs.52 Proponents of the
48 First-line treatment regimens are initial drugs used to treat infected people. When patients
become resistant to these drugs they may require second-line and third-line drugs.
49 This language is the proposed Section 101(a)(5)(D) in P.L. 108-25.
50 For example, the Center for Health and Gender Equity states, “The bill restricts funding
to U.S.-funded family planning programs — ensuring that restrictive U.S. policies such as
the Mexico City Policy could extend to PEPFAR-funded programs that seek to link family
planning and HIV prevention.” Center for Gender Health and Equity, “U.S. Congress
Introduces New PEPFAR Bill: Two Steps Forward, Three Steps Back,” February 27, 2008,
[http://www.genderhealth.org/pubs/PR2008BermanPEPFAR.pdf]. Pathfinder International,
an NGO, states that the bill “adopts an ambiguous provision stating that only family
planning organizations ‘supported by the U.S. government’ will be eligible for PEPFAR
funds for HIV/AIDS testing and education purposes,” which “potentially paves the way for
the Mexico City Policy ... to be applied for the first time to the receipt of global HIV/AIDS
funds.” Pathfinder International, “Pathfinder International’s Response to Recent Senate
PEPFAR Reauthorization,” March 19, 2008,
[http://www.pathfind.org/site/PageServer?pagename=News_Pathfinder_Response_PEPF
AR_Reauthorization_Senate08].
51 For more information on the Mexico City policy, see CRS Report RL33250, International
Population Assistance and Family Planning Programs: Issues for Congress
, by Luisa
Blanchfield.
52 See, for example, EngenderHealth, “Action Alert: Global Funding for AIDS, TB, and
Malaria,” March 4, 2008, at
(continued...)

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family planning program language in H.R. 5501 maintain that it would limit
PEPFAR funding for family planning groups based on their compliance with the
Mexico City policy.53 Other groups reserved endorsement or opposition until
Congress further clarifies the language. Some have expressed concern, however, that
the family planning language might contradict their beliefs and principles.54
Health Systems and the Single Disease Approach
Section 501 of H.R. 5501 provides for the development of five-year health
workforce strategies by countries that receive assistance under the reauthorization.
It directs the Global AIDS Coordinator and the Secretary of the Treasury to work to
reform International Monetary Fund (IMF) policies that result in limitations on
national and donor investments in health. It also directs the Global AIDS
Coordinator to work with relevant stakeholders to develop effective public sector
procurement and supply chain management systems for supplies and drugs in
countries receiving assistance under the reauthorization. S. 2731 does not include
similar language.
H.R. 5501 also requires OGAC and USAID to create and implement a plan to
combat HIV/AIDS by strengthening health policies and health systems of PEPFAR
countries as part of USAID’s Health Systems 20/20 project.55 The plan, in part,
52 (...continued)
[http://engenderhealth.org/media/press-releases/2008-03-04-hiv-funding.php]. Physicians
for Human Rights, “PHR’s Position on PEPFAR Reauthorization Bills,” March 27, 2008,
at [http://physiciansforhumanrights.org/library/news-2008-03-27.html]. Nandini Oomman,
Center for Global Development, “PEPFAR Reauthorization Responds to Some Evidence
from First Five Years,” March 19, 2008, at
[http://blogs.cgdev.org/globalhealth/2008/03/pepfar_reauthorizati_1.php]. Health GAP,
“Comparison of House and Senate PEPFAR Legislation and Suggested Changes,” March
24, 2008, at [http://www.pepfar2.org/legislationsuggestions.html#FP].
53 The Southern Baptist Convention’s Ethics & Religious Liberty Commission, for example,
is “encouraged by the changes that have taken place in the [House Foreign Affairs]
committee that would keep funding from going to pro-abortion organizations.” Southern
Baptist Convention’s Ethics & Religious Liberty Commission, “House Panel OKs Revised
AIDS Funding,” March 3, 2008, at
[http://erlc.com/article/house-panel-oks-revised-aids-funding]. The Family Research
Council states, “Unlike previous versions, this House bill doesn’t fund ‘family planning’
services, although there’s no explicit ban preventing it.” Tony Perkins, Family Research
Council, “Washington Update: FRC’s PEP Talk Improves AIDS Bill,” April 3, 2008, at
[http://www.frc.org/get.cfm?i=WA08D15].
54 Concerned Women for America states that it “must watch carefully as funding is
implemented” due to the “risk posed by the ‘family planning’ language in the bill.” Sarah
Griffith, Concerned Women for America, “A Series of Positive Events for AIDS Relief,”
March 28, 2008, at [http://www.cwalac.org/article_670.shtml].
55 According to USAID’s Health Systems 20/20 website, “health system weaknesses are
among the most important factors contributing to the suboptimal use of priority health
services. Health Systems 20/20 applies new and proven interventions in financing,
governance, operations, and capacity building to strengthen health systems in order to
(continued...)

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would aim to encourage post-secondary institutions in host countries, especially in
Africa, to develop human and institutional capacity to support the health care system
in those countries. This would include collaboration with U.S. post-secondary
educational institutions including historically black colleges and universities.56
S. 2731 similarly requires the U.S. strategy to combat global AIDS to “situate
United States efforts to combat HIV/AIDS, tuberculosis, and malaria within the
broader United States global health and development agenda, establishing a roadmap
to link investments in specific disease programs to the broader goals of strengthening
health systems and infrastructure and to integrate and coordinate HIV/AIDS,
tuberculosis, or malaria programs with other health or development programs, as
appropriate.” This language would require greater strategic planning across U.S.
global health and development programs to coordinate efforts across program areas.
Some health experts are concerned about the single disease approach to global
health and how it has focused limited resources in high burden countries on one
disease while the overall health infrastructure and workforces in resource-poor
countries minimally improves. Some are also concerned about the possible long term
implications of the increased funding levels if the funds are spent on treatment and
care of individuals who are infected with AIDS. One study points out that treatment
of infected individuals is a lifelong commitment and that treatment itself prolongs
that length of time; it estimates that if scale-up of treatment continues at the historical
rate since FY2004 and drug prices and treatment costs remain the same, maintenance
of treatment funding levels would necessitate either a 20% increase in total U.S.
overseas development assistance by FY2016 or a reallocation of 20% of the current
overseas development assistance budget of $23 billion to AIDS treatment funding
alone. It argues this might raise questions about how funding for other global health
programs and development efforts might be adversely affected.57
Supporters of language that addresses issues of coordination of U.S. global
health and development programs with disease-specific initiatives like PEPFAR and
PMI argue that the more comprehensive development of health infrastructure and
training of health workforces in these areas would increase the effectiveness of
PEPFAR programs and decrease the need for disease-specific efforts in the future by
building local capacity to address disease and basic health. Critics argue that such
55 (...continued)
increase use of priority services. . . . Health Systems 20/20 is working at the country level
to conduct comprehensive analysis of available and required human resources to scale up
and sustain HIV/AIDS services and to facilitate solutions to address human resource
shortages.” For more information please see USAID Health Systems 20/20, “What We Do,”
at [http://www.healthsystems2020.org/section/topics/].
56 See H.Amdt. 976 to H.R. 5501, introduced by Representative Carson and agreed to with
a 415-10 vote in the House.
57 Mead Over, “Prevention Failure: The Ballooning Entitlement Burden of U.S. Global
AIDS Treatment Spending and What To Do About It,” Center for Global Development
Working Paper 144, April 2008, at
[http://www.cgdev.org/content/publications/detail/15973].

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investment is outside the scope of PEPFAR and distracts from the program’s focus
on HIV/AIDS.
HIV/AIDS Activities and Nutrition Programs
H.R. 5501 and S. 2731 encourage the integration of HIV/AIDS activities with
nutrition programs through linkages and referrals to ensure that treated individuals
receive the needed daily caloric intake to support effective treatment. Where such
linkages and referrals are not possible, S. 2731 establishes additional services to
provide nutritional support directly, and it also encourages support for programs that
address the intersections between food insecurity and health problems like
HIV/AIDS. H.R. 5501 includes similar language that authorizes the direct provision
of food and nutritional support to HIV/AIDS-infected individuals receiving
antiretroviral treatment through PEPFAR where referrals are not possible. Both bills
encourage providing food and nutritional support for children affected by HIV/AIDS.
Language in H.R. 5501 and S. 2731 addressing health system infrastructure and
nutrition does not differ greatly from language included in the Leadership Act. The
new language in H.R. 5501 and S. 2731 goes into greater detail about the nature of
the infrastructure and nutrition challenges in certain regions. Both bills encourage
greater integration of U.S. HIV/AIDS efforts with broader pre-existing and parallel
efforts by U.S. agencies and others, such as non-governmental organizations (NGOs),
and promote linking affected individuals through referrals with such services.
Programs that might be coordinated with or linked to include those that strengthen
health care infrastructure, nutrition programs, safe drinking programs, income
security programs, and programs that offer technical assistance in health care capacity
building and public finance management.
Immigration and Nationality Act Amendment
S. 2731 would eliminate the language in the Immigration and Nationality Act
(INA) that statutorily bars foreign nationals with HIV/AIDS from entering the United
States.58 H.R. 5501 does not include similar language.
Supporters of the amendment argue that maintaining the restrictions on entry
into the United States of AIDS-infected people is “discriminatory and unnecessary.”59
They also argue that major international conferences on health and AIDS should not
be held in countries that have laws restricting the entry of people living with AIDS.
Opponents to the amendment contend that the amendment would add too many costs
58 See Section 305 of S. 2731 (Reported in Senate) for further information and referral to
information about current U.S. law. Immigration and Nationality Act of June 27, 1952, ch.
477; 66 Stat. 163; codified as amended at 8 U.S.C. §§1101 et seq. The INA is the basis of
current immigration law. For further information, see CRS Congressional Distribution
Memorandum, U.S. Immigration Policy on Foreign Nationals with HIV/AIDS, by Ruth Ellen
Wasem, July 11, 2008, available from author.
59 United Nations News Center, “UN programme to work toward elimination of HIV travel
restrictions,” March 5, 2008,
[http://www.un.org/apps/news/story.asp?NewsID=25860&Cr=hiv&Cr1=unaids].

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by increasing U.S. spending on health programs for HIV/AIDS-infected people.
Others dispute this would be a significant amount.
Additional Oversight Activities
S. 2731 requires additional reporting, including a report by the Comptroller
General that discusses the coordination of U.S. global AIDS efforts and the impact
of global HIV/AIDS funding and programs on other U.S. global health programming.
S. 2731 also requires the dissemination of an annual report by OGAC on best
practices that might be replicated or adapted by other AIDS programs. In addition,
it provides for the Inspectors General of the Department of State, the Broadcasting
Board of Governors (BBG), HHS, and USAID to jointly develop five coordinated
annual plans for oversight activity in each of the fiscal years 2009 through 2013.
H.R. 5501 does not include similar language.
Taxation of Assistance Funds by Foreign Governments
Prohibited

H.R. 5501 prohibits funds appropriated under the legislation from being made
available to a foreign country unless the agreement provides that such assistance
funds shall be exempt from taxation or otherwise reimbursed by the foreign
government.60 S. 2731 does not include similar language.
Prevention of Mother to Child HIV Transmission Panel
S. 2731 directs the Global AIDS Coordinator to establish an advisory panel of
experts on PMTCT that would be known as the PMTCT Panel. The panel would
review PMTCT efforts and make recommendations to OGAC and Congress on how
to scale-up of PMTCT services to ensure that, by 2013, such programs will provide
access to counseling, testing, and treatment for at least 80% of pregnant women in
those countries most affected by HIV/AIDS in which the United States has
HIV/AIDS programs. H.R. 5501 does not include similar language.
Conscience Clause Expansion
Both H.R. 5501 and S. 2731 expand “conscience clause” language included in
the Leadership Act. The conscience clause in the Leadership Act states that
organizations that receive funding to prevent, treat, or monitor HIV/AIDS shall not
be required, as a condition of receiving the assistance, to endorse or utilize a
multisectoral approach to combating HIV/AIDS, or to endorse, utilize, or participate
in a prevention method or treatment program to which the organization has a
religious or moral objection. The new language in H.R. 5501 and S. 2731 refers to
any HIV/AIDS program or activity to which an organization may have a religious or
moral objection, whereas language in the Leadership Act refers only to any
HIV/AIDS prevention method or treatment program to which the organization has
60 This prohibition applies to funds being made available to a foreign country under a new
bilateral agreement.

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a religious or moral objection. It further states that organizations who opt-out of the
above activities for religious or moral reasons shall not be discriminated against in
the solicitation or issuance of grants, contracts, or cooperative agreements.