Order Code RL34569
International HIV/AIDS, Tuberculosis, and Malaria:
Key Changes to U.S. Programs and Funding
Updated August 25, 2008
Kellie Moss
Analyst in Global Health
Foreign Affairs, Defense, and Trade Division

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

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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 and Debates During Consideration of
H.R. 5501 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Funding Authorization Increase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Global Malaria Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
List of Focus Countries Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Compacts With Recipient Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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 . . . . . . . . . . . . . . . . . . . . 17
HIV/AIDS Activities and Nutrition Programs . . . . . . . . . . . . . . . . . . . . . . . 18
Immigration and Nationality Act Amendment . . . . . . . . . . . . . . . . . . . . . . 19
Additional Oversight Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Taxation of Assistance Funds by Foreign Governments Prohibited . . . . . . 20
Prevention of Mother to Child HIV Transmission (PMTCT) Panel . . . . . . 20
Conscience Clause Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Outcomes Under H.R. 5501/P.L. 110-293 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
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 Fight AIDS, Tuberculosis,
and Malaria, FY2004 through FY2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Table 3. Comparison of Proposed Reauthorization Levels from FY2009
through FY2013 in House and Senate Versions of H.R. 5501 . . . . . . . . . . . 8
Table 4. Outcomes of Key Proposals to Change International HIV/AIDS,
Tuberculosis, and Malaria Programs Under P.L. 110-293 . . . . . . . . . . . . . . 21
Table 5. Key Authorization Levels from FY2009 through FY2013 in
P.L. 110-293, the Reauthorization Act of 2008 . . . . . . . . . . . . . . . . . . . . . . 24

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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 The President estimated PEPFAR would support HIV/AIDS treatments
for 2.5 million people, the prevention of more than 12 million new HIV infections,
and care for more than 12 million HIV-affected people, including 5 million orphans
and vulnerable children.2 In 2003, Congress authorized $15 billion for U.S. efforts
to combat global HIV/AIDS, tuberculosis, and malaria from FY2004 through
FY2008 with the United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 (P.L. 108-25) (hereafter referred to as the Leadership Act).
On July 24, 2008, Congress authorized $48 billion for U.S. global efforts to
fight HIV/AIDS, tuberculosis, and malaria and for U.S. contributions to the Global
Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund)3 from FY2009 through
FY2013 through H.R. 5501, the Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008 (hereafter referred to as the Reauthorization Act). The Reauthorization Act
(P.L. 110-293) was signed into law on July 30, 2008.
This report describes U.S. efforts to combat international HIV/AIDS through
PEPFAR including an overview of its implementation structure, key program
elements, results, and funding from FY2004 through FY2008. It also details funding
for tuberculosis, malaria, and U.S. contributions to the Global Fund during that time.
This report discusses similarities and differences between H.R. 5501 as passed by the
House on April 2, 2008, and H.R. 5501 as passed by the Senate on July 16, 2008,
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.

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CRS-2
including proposed changes in program authorities and funding for HIV/AIDS,
tuberculosis, and malaria programs. Finally, it details key outcomes in the legislation
as enacted. 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 evaluating 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
Africa, Tanzania, Uganda, Vietnam, and Zambia.8 OGAC estimates that from
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].
8 These Focus Countries, except Vietnam, were specified in the Leadership Act (P.L. 108-
25). 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.
(continued...)

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CRS-3
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 Fight
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
country-based information on the extent of the HIV/AIDS epidemic, absorptive
8 (...continued)
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].

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CRS-4
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,
would 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]
transmission (PMTCT) services in more than 10 million
pregnancies; and prevented an estimated 157,000 infant infections.
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.htm].

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! 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); $530 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].

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CRS-6
$915 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
2,031.0
State Global HIV/AIDS Initiative (GHAI)
10,624.0
Foreign Military Financing
6.9
CDC Global AIDS Program
754.2
CDC International HIV Research
23.0
NIH International HIV Research
1,795.8
DOL AIDS Initiative
11.8
DOD HIV/AIDS Prevention Education
25.0
Total HIV/AIDS Fundinga
15,271.7
Tuberculosis Program
Amount
USAID Tuberculosis
525.7
CDC Tuberculosis
4.3
Total Tuberculosis Funding
530.0
Malaria Program
Amount
USAID Malaria
870.3
CDC Malaria
44.9
Total Malaria Fundingb
915.2
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 Fight 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 and Debates During
Consideration of H.R. 5501
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 included $6 billion for U.S.
international HIV/AIDS and tuberculosis programs.26 Of this $6 billion, $500
million was 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
The following section focuses on key proposed changes to U.S. programs that
combat HIV/AIDS, tuberculosis, and malaria, as suggested by the April 2, 2008,
version of H.R. 5501 that was passed by the House and the July 16, 2008, version of
H.R. 5501 that was passed by the Senate and that was subsequently voted on and
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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passed by the House and enacted into law. This section highlights key proposed
requirements and funding allocations included in either version of the bill and
discusses the debate surrounding the proposals, including debates about possible
policy implementation implications.
Funding Authorization Increase
H.R. 5501 as passed by the House proposed up to $50 billion for U.S.
international efforts to combat HIV/AIDS, tuberculosis, and malaria during the
reauthorization period of FY2009 through FY2013. It would have authorized $10
billion for each of the five years.29 The Senate version proposed $48 billion in total
over the same period for these activities. Both versions also proposed authorizing
higher funding levels for U.S. contributions to the Global Fund and for U.S. efforts
to combat tuberculosis and malaria (Table 3).

Table 3. Comparison of Proposed Reauthorization Levels from
FY2009 through FY2013 in House and Senate Versions of
H.R. 5501
H.R. 5501 as passed by the H.R. 5501 as passed by the
Area of Authorization
House
Senate
Overall for HIV/AIDS,
$50 billion ($10 billion each $48 billion (in total)
Tuberculosis, and Malaria
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 Fight 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 April 2, 2008, House-passed version and July 16, 2008, Senate-
passed version of H.R. 5501.
The Senate version of H.R. 5501 also proposed authorizing $2 billion for an
emergency fund for Indian health and safety from FY2008 through FY2013. The
Senate adopted S.Amdt. 5076 to S. 2731, the basis for the substitute amendment to
H.R. 5501, and S.Amdt. 5084, which amended S.Amdt. 5076. These amendments
added language that requires an emergency plan to address the law enforcement,
29 According to 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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CRS-9
water, and health care needs of Indian tribes and directs the expenditure of the funds
for particular purposes.30
Critics of the $50 billion and $48 billion authorization levels argued that it
would be fiscally irresponsible to spend such levels in light of U.S. military
operations in Iraq and Afghanistan, a near economic recession in the United States,
and questions about the absorptive capacity of recipient countries. Some analysts
suggested that increased disease-specific funding in the foreign operations
appropriations would drain available funding from other aid priorities in developing
countries, such as agriculture assistance and private sector growth. Others opposed
increased funding because they did not want to expand current PEPFAR activities to
support additional Focus Countries and to fund activities not directly related to AIDS.
Critics of high spending levels were concerned about proposals to increase the
number of Focus Countries and to extend PEPFAR funds to support health care
infrastructure as well as to enhance nutrition and feeding programs.31 For example,
Senators who placed a hold on H.R. 5501 and S. 2731 had stated that the bills would
“transform a targeted and accountable $15 billion dollar AIDS program into an
unaccountable, unspecified $50 billion development program.”32
Proponents of the authorization level argued that access to HIV/AIDS
prevention, treatment, and care for all would require greater resources. As a result,
debate among bill advocates focused on where the dollars should be spent and what
priorities the increased funding should support. Some urged Congress to consider
further definition of tuberculosis authorities and targets, improved coordination of
tuberculosis activities with HIV/AIDS activities in areas of co-infection, and
strengthened reporting requirements for tuberculosis. Backers of the increased
authorization argued that the next stage in fighting AIDS, tuberculosis, and malaria
must occur alongside the strengthening of health systems. They argued that these
activities must be integrated with related development efforts in order to ensure the
sustainability of efforts to fight the three diseases.
30 For further information, see CRS Report RL34461, Interior, Environment, and Related
Agencies: FY2009 Appropriations, by Carol Hardy Vincent, et al.; and CRS Report
RL32198, Indian Reserved Water Rights: An Overview, by Yule Kim.
31 Adam Graham-Silverman, “Despite Efforts, Senate Global AIDS Legislation Stalled Over
Cost Concerns,” CQ Today, June 13, 2008.
32 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]. An agreement to limit amendments to S. 2731
to those identified and agreed to as first degree by the bill’s managers (10 amendments) was
reached with most of the Senators. Shortly thereafter, the Senate invoked cloture on a
motion to proceed to the bill.

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Some opponents used the Congressional Budget Office’s (CBO) cost estimates
to justify a lower authorization funding level. CBO estimated that implementing
either H.R. 5501 or S. 2731, which was the bill from which language for the Senate-
passed version of H.R. 5501 was drawn, would cost $35 billion from FY2009
through FY2013 and that most of the additional amounts of authorized funding
would be spent by FY2018.33 Some argued that the CBO cost estimates assumed that
outlays will follow historical spending patterns for existing programs and did not
reflect the proposed increases in authorization levels for tuberculosis and malaria
spending and for the U.S. contribution to the Global Fund.
Global Malaria Coordinator
Both bills would have established a Coordinator of United States Government
Activities to Combat Malaria Globally (Global Malaria Coordinator) at USAID. The
Global Malaria Coordinator would oversee and coordinate all U.S. resources for
international activities related to combating malaria. The bills also would have
authorized the Global Malaria Coordinator to provide financial assistance to
multilateral efforts such as the Roll Back Malaria Partnership (RBM).34 The
proposed authorization of a Global Malaria Coordinator was 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 opposed a disease-specific approach. They argued that it
ignored the interconnected nature of health care challenges, and in resource-poor
countries, it would create competition for limited human capacity such as doctors,
public health specialists, and U.S. program managers. Supporters believed PMI
would focus attention on malaria, which is a major killer in sub-Saharan Africa and
some parts of Asia.
Others contended that directed efforts on specific diseases should occur
simultaneously with efforts to build health capacity and infrastructure. While they
applauded the initial emphasis on HIV/AIDS, which helped to build health system
capacity in resource-poor settings, observers contended that the next stage of disease
response under PEPFAR should integrate efforts to combat HIV/AIDS with the
provision of basic healthcare and the prevention of childhood illness.
Some urged Congress to consider questions related to the establishment of PMI,
including how PMI should coordinate its activities with PEPFAR; the further
definition of authorities over the three diseases in the Leadership Act; the possibility
of competing priorities between PMI and PEPFAR, especially where they operate in
33 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].
34 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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CRS-11
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 the Dominican Republic to the list of Focus
Countries. When introduced, H.R. 5501 proposed adding Vietnam as a Focus
Country as well as those countries listed in H.R. 848. Representative Betty
McCollum proposed adding Malawi, Swaziland and Lesotho to the list of Focus
Countries in H.R. 5501 through H.Amdt. 975, which was adopted. While the House-
passed version of H.R. 5501 would have added these additional Focus Countries, the
Senate version proposed adding only Vietnam as a Focus Country. Vietnam has been
a Focus Country in practice since 2004 at the direction of President Bush; this
language would have updated the list of 14 Focus Countries that was included in the
Leadership Act. The new language in the Senate-passed version also specified that
in designating additional Focus Countries priority shall be given to those countries
in which there is a high prevalence of HIV or risk of significantly increasing
incidence of HIV within the general population and inadequate financial means
within the country.
Some observers questioned why the above-named countries were selected,
particularly since OGAC did not put forth these countries for consideration.
Proponents of the addition of these new Focus Countries argued that the designation
would direct more HIV/AIDS funding to these areas. Debate about the Focus
Countries list also centered on how authorized funds in excess of the President’s $30
billion PEPFAR reauthorization proposal would be distributed across PEPFAR
countries. It was not clear whether the proposed, newly-designated Focus Countries
would have received more support than they did previously or whether they would
have been funded at higher levels than non-Focus Countries for HIV/AIDS activities.
Some would have liked the final reauthorization bill to clarify this issue.
Opponents of the proposed list argued that incidence rates — the rates of new
infections — have been growing in East Asia and Oceania, while incidence rates
appeared to have stabilized in the Caribbean. They also argued that prevalence rates
— the percentages of given populations that are infected with HIV/AIDS — have
been growing in Eastern Europe and Central Asia, while prevalence rates in the
Caribbean appeared to have stabilized and in some countries have even declined.35
As new infections worldwide continued to outpace the numbers of infected persons
placed on treatment, others asserted that a more complex analysis of need should be
used in naming Focus Countries. Still others argued that Focus Countries should no
35 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].

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CRS-12
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 expressed concern about the long-term commitment that
PEPFAR may require, particularly in the Focus Countries. As an alternative to
adding Focus Countries, some suggested using compacts between the U.S.
government and PEPFAR-recipient governments to clearly outline the scope and
terms of U.S. involvement in AIDS prevention, treatment and care and to elicit
recipient government involvement, ownership, and investment. Supporters asserted
that compacts may have been helpful in outlining expectations for broader
development efforts and investments that have been shown to have a significant
impact on health. Some compacts, for example, might have included an agreement
that aid recipient countries would reform property laws and inheritance laws. Such
reforms have been shown to reduce the vulnerability of widows and orphans to HIV
infection by providing them with greater financial security.36 The Senate-passed
version of H.R. 5501 supported this idea, stating that compacts and framework
agreements were “one mechanism to promote the transition from an emergency to a
public health and development approach to HIV/AIDS” and could be “tailored to
local circumstances to promote host government commitment to deeper integration
of HIV/AIDS services into health systems, contribute to the health systems overall,
and enhance sustainability.”37 The language required that cost-sharing assurances
from PEPFAR-recipient governments and transition strategies be included in
compacts. The House-passed version of H.R. 5501 did not include similar language.
Role of Spending Directives
H.R. 5501 as passed by the House maintained funding distribution guidelines
and spending directives of 20% for HIV prevention activities, 15% for HIV/AIDS
care activities, and 10% for orphans and vulnerable children (OVC) activities, but it
did not include the spending directive for HIV/AIDS treatment. The Senate-passed
version maintained the spending directive for OVC and modified the spending
directives for treatment and care by requiring that over half of bilateral HIV/AIDS
assistance be spent on treatment, care, and nutritional and food support for
HIV/AIDS-infected people. It did not include the funding distribution guidelines and
spending directives for HIV/AIDS prevention. Both versions required balanced
funding for HIV prevention 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.
36 U.N. Millennium Project Task Force on Education and Gender Equality, Taking Action:
A c h i e v i n g G e n d e r E q u a l i t y a n d E m p o w e r i n g W o m e n , 2 0 0 5 , a t
[http://www.unmillenniumproject.org/documents/Gender-complete.pdf].
37 See Section 310(c)(6) and Section 301(d).

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There was considerable debate about the effectiveness of congressional
spending directives. Some observed that the spending directives limited Focus
Country teams’ ability to tailor budgets to local HIV transmission patterns.38 Critics
contended that the spending directives also complicated efforts to address the specific
nature of the HIV/AIDS epidemic in each country. HIV/AIDS rates among the Focus
Countries ranged from 1% to over 33%. The current and proposed Focus Countries
had epidemics that varied in nature and prevalance: some epidemics were
concentrated among drug users or prostitutes while others were spread throughout the
population. Some argued that Congress might consider eliminating some or all
prevention, treatment, and care spending directives to promote operational planning
that was responsive to the nature of the epidemic in each country and reflected the
cost of implementation in that area. The Government Accountability Office (GAO)
found that the spending restrictions did not account for the costs of particular
HIV/AIDS activities that may vary from country to country or for changes in costs
over time.39
Some encouraged Congress to maintain its spending directives, particularly
those related to orphans and vulnerable children (OVC). Supporters cited a GAO
report that stated that without the spending directive, programs for OVC might not
have been protected.40 Others stressed the importance of the spending directive that
requires at least 55% of HIV/AIDS funds be spent on HIV/AIDS treatment, to
maintaining support for the purchase and distribution of antiretroviral drugs and
related care for those receiving treatment. Senator Tom Coburn introduced S. 2749,
the Save Lives First Act of 2008, on March 12, 2008, which maintains protections
for AIDS treatment funding. Senator Coburn also signed a letter that requested a
hold on H.R. 5501 and S. 2731, noting the removal of the treatment spending
directive. Congressional Quarterly subsequently reported that, after negotiating for
changes to S. 2731 — which was the basis for the Senate-passed version of H.R.
5501, Senator Coburn was “satisfied with language that would require more than half
the money go to treatment, including antiretroviral drugs.”41 Senator Coburn
subsequently withdrew his objection to a motion to proceed to S. 2731.42
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
38 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.
39 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].
40 Ibid.
41 Adam Graham-Silverman, “Deal Could Pave Way for Quick Senate Passage of Global
AIDS Aid Measure,” CQ Today, June 25, 2008.
42 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=
de6535c6-c151-4717-89ff-26c399bf3024].

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specified period. In 2003, for example, the PEPFAR five-year global program
objective for treatment was to provide antiretroviral treatment for 2 million people.43
Some suggested that one alternative to spending directives was to allow U.S. staff in
PEPFAR Focus Countries to set annual program objectives for prevention, treatment,
and care that, in turn, would be added up to become the five-year country prevention,
treatment, and care objectives. These then would have been totaled across countries
to calculate the U.S. global program objectives for these program areas. At the time
of consideration of H.R. 5501, OGAC determined five-year country prevention,
treatment, and care goals for the 15 Focus Countries, and then U.S. staff in PEPFAR
Focus Countries set annual program objectives with the goal of reaching five-year
country goals but with consideration for the challenges of the country’s HIV/AIDS
epidemic. OGAC then calculated global program objectives by adding up the five-
year country targets.44
Some supporters of program targets being determined entirely by U.S. staff in
PEPFAR Focus Countries contended that country teams have the greatest awareness
of each country’s needs and should establish prevention, treatment, and care targets.
However, some PEPFAR country team members expressed concern about difficulties
country teams might face in reaching a consensus about such targets.45 Critics of
program targets being determined this way asserted that Congress could specify
global targets as a way of guiding policy implementation and priorities without
hampering the ability of country-based teams to respond flexibly to in-country
realities and to coordinate with national health plans. They pointed to language in
both versions of H.R. 5501 as examples: both bills proposed establishing a target for
prevention of mother to child [HIV] transmission (PMTCT) activities that at least
80% of pregnant women would be reached in affected countries by 2013.46 The
Senate version also proposed setting a target that the proportion of children receiving
care and treatment would be proportionate to their numbers within the population of
HIV-infected individuals in each country by 2013, while the House-passed version
of H.R. 5501 proposed setting a target requiring that by 2013 up to 15% of those
receiving treatment and care must be children.
Balance Between Prevention, Treatment, and Care
Debate about spending directives and program targets was closely related to
debate about how to prioritize or balance HIV/AIDS prevention, treatment, and care
activities. Some experts maintained that prevention should remain a focus of global
efforts, because there is no cure for AIDS at this time and preventing new infections
43 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].
44 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].
45 Ibid.
46 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.”

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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.”47 Some organizations, such as
the Bill and Melinda Gates Foundation and the Global AIDS Prevention Working
Group, focused their efforts on strategies and prevention research in an effort to
“prevent the HIV epidemic from becoming generalized in countries with emerging
epidemics” and to prevent millions of new infections.48
On the other hand, some contended that focusing on prevention and neglecting
treatment and care would ignore the economic and social impacts of the disease on
those already infected, on the children and families of infected persons, and on
countries with high prevalence rates. Some asserted that treatment and care were
investments in hope and stability, preventing children from being orphaned and
people from suffering the ravages of the disease when treatment to prolong life and
improve its quality is available. Some argued that treatment costs were dropping
very rapidly for not only first-line treatment regimens but also second-line
antiretroviral therapies, a trend that was expected to continue as treatment expanded
to cover more infected people in low and middle income countries and as more
international donors negotiated for lower prices.49 Others maintained that combating
HIV/AIDS required a combination of prevention, treatment, and care rather than a
choice between these strategies.
HIV/AIDS Activities and Family Planning
H.R. 5501 as passed by the House included language that addressed U.S.
HIV/AIDS activities’ links and referral to family planning and maternal health
programs. Section 101(a)(4) of H.R. 5501 proposed amending Section 101 of P.L.
108-25, the Leadership Act. It stated that a comprehensive five-year global strategy
to combat HIV/AIDS, tuberculosis, and malaria shall:

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.50
The Senate-passed version of H.R. 5501 did not include family planning
program language.
47 U.N. Document, A/RES/S-26/L.2, June 27, 2001, at [http://data.unaids.org/publications/
irc-pub03/aidsdeclaration_en.pdf].
48 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/].
49 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.
50 This language is the proposed Section 101(a)(5)(D) in P.L. 108-25.

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Opponents of the language in the House version of H.R. 5501 argued that the
language was ambiguous and might have applied the Mexico City policy to programs
that receive PEPFAR funding.51 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.52 Others opposed the language because they did not believe that it sufficiently
supported the integration of family planning services in U.S.-supported HIV
prevention programs.53 Proponents of the family planning program language in the
House version of H.R. 5501 maintained that it would limit PEPFAR funding for
family planning groups based on their compliance with the Mexico City policy.54
Other groups reserved endorsement or opposition until such as time as Congress
51 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_PEPFAR_Reauthorization_Senate08].
52 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.
53 See, for example, EngenderHealth, “Action Alert: Global Funding for AIDS, TB, and
Malaria,” March 4, 2008, at [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].
54 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
A I D S F u n d i n g , ” M a r c h 3 , 2 0 0 8 , a t [ h t t p : / / e r l c . c o m / a r t i c l e /
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].

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might further clarify the language. Some expressed concern, however, that the family
planning language might contradict their beliefs and principles.55
Health Systems and the Single Disease Approach
Section 501 of the House version of H.R. 5501 proposed the development of
five-year health workforce strategies by countries that receive assistance under the
reauthorization. It directed the Global AIDS Coordinator and the Secretary of the
Treasury to work to reform International Monetary Fund (IMF) policies that result
in limitations on national and donor investments in health. It also directed the Global
AIDS Coordinator to work with relevant stakeholders to develop effective public
sector procurement and supply chain management systems for supplies and drugs in
countries receiving assistance under the reauthorization. The Senate-passed version
of H.R. 5501 included similar language through the use of compacts and actions
required of the Administrator of USAID.
H.R. 5501 as passed by the House also would have required OGAC and USAID
to create and implement a plan to combat HIV/AIDS by strengthening health policies
and health systems of PEPFAR countries as part of USAID’s Health Systems 20/20
project.56 The plan, in part, would have aimed 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 included
collaboration with U.S. post-secondary educational institutions including historically
black colleges and universities.57 The Senate-passed version included similar
language.
The Senate version of H.R. 5501 also proposed requiring the U.S. strategy to
combat global AIDS to “situate United States efforts to combat HIV/AIDS,
tuberculosis, and malaria within the broader United States global health and
development agenda, establishing a roadmap to link investments in specific disease
programs to the broader goals of strengthening health systems and infrastructure and
to integrate and coordinate HIV/AIDS, tuberculosis, or malaria programs with other
health or development programs, as appropriate.” This language required greater
55 Concerned Women for America stated 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].
56 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
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/].
57 See H.Amdt. 976 to H.R. 5501, introduced by Representative Carson and agreed to with
a 415-10 vote in the House.

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strategic planning across U.S. global health and development programs to coordinate
efforts across program areas.
Some health experts were concerned about the single disease approach to global
health and how it focused limited resources in high burden countries on one disease
while, they contended, the overall health infrastructure and workforces in resource-
poor countries minimally improved. Some also were concerned about the possible
long term implications of the increased funding levels if the funds were spent on
treatment and care of individuals who are infected with AIDS. One study pointed out
that treatment of infected individuals is a lifelong commitment and that treatment
itself prolongs that length of time; it estimated that if scale-up of treatment continued
at the historical rate since FY2004 and drug prices and treatment costs remained the
same, maintenance of treatment funding levels would necessitate either a 20%
increase in total U.S. overseas development assistance by FY2016 or a reallocation
of 20% of the current overseas development assistance budget of $23 billion to AIDS
treatment funding alone. It argued this might raise questions about how funding for
other global health programs and development efforts might be adversely affected.58
Supporters of language that addressed issues of coordination of U.S. global
health and development programs with disease-specific initiatives like PEPFAR and
PMI argued that the more comprehensive development of health infrastructure and
training of health workforces in these areas would increase the effectiveness of
PEPFAR and other single-disease programs and decrease the need for disease-
specific efforts in the future by building local capacity to address disease and basic
health. Critics argued that such investment was outside the scope of PEPFAR and
would distract from the program’s focus on HIV/AIDS.
HIV/AIDS Activities and Nutrition Programs
Both versions of H.R. 5501 encouraged the integration of HIV/AIDS activities
with nutrition programs through linkages and referrals to ensure that treated
individuals receive the needed daily caloric intake to support effective treatment.
Where such linkages and referrals were not possible, the Senate-passed version of
H.R. 5501 proposed establishing additional services to provide nutritional support
directly, and it also encouraged support for programs that address the intersections
between food insecurity and health problems like HIV/AIDS. The House version of
H.R. 5501 included similar language that authorized the direct provision of food and
nutritional support to HIV/AIDS-infected individuals receiving antiretroviral
treatment through PEPFAR where referrals were not possible. Both bills encouraged
providing food and nutritional support for children affected by HIV/AIDS.
Language in both versions of H.R. 5501 addressing health system infrastructure
and nutrition did not differ greatly from language included in the Leadership Act.
The new language in both versions went into greater detail about the nature of the
58 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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infrastructure and nutrition challenges in certain regions. Both encouraged greater
integration of U.S. HIV/AIDS efforts with broader pre-existing and parallel efforts
by U.S. agencies and others, such as non-governmental organizations (NGOs), and
promoted linking affected individuals through referrals with such services. Programs
that might have been coordinated with or linked to include those that strengthen
health care infrastructure, nutrition programs, safe drinking programs, income
security programs, and programs that offer technical assistance in health care capacity
building and public finance management.
Immigration and Nationality Act Amendment
H.R. 5501 as passed by the Senate proposed eliminating the language in the
Immigration and Nationality Act (INA) that statutorily bars foreign nationals with
HIV/AIDS from entering the United States.59 The House-passed version of H.R.
5501 did not include similar language.
Supporters of the amendment argued that maintaining the restrictions on entry
into the United States of AIDS-infected people was “discriminatory and
unnecessary.”60 They also argued that major international conferences on health and
AIDS should not be held in countries that have laws restricting the entry of people
living with AIDS. Opponents to the amendment contended that the amendment
would add too many costs by increasing U.S. spending on health programs for
HIV/AIDS-infected people. Others disputed this would be a significant amount.
Additional Oversight Activities
The Senate version of H.R. 5501 proposed requiring additional reporting,
including a report by the Comptroller General that would discuss the coordination of
U.S. global AIDS efforts and the impact of global HIV/AIDS funding and programs
on other U.S. global health programming. It also required the dissemination of an
annual report by OGAC on best practices that might be replicated or adapted by other
AIDS programs. In addition, it provided for the Inspectors General of the
Department of State, the Broadcasting Board of Governors (BBG), HHS, and USAID
to jointly develop five coordinated annual plans for oversight activity in each of the
fiscal years 2009 through 2013. The House version of H.R. 5501 did not include
similar language.
59 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.
60 United Nations News Center, “UN programme to work toward elimination of HIV travel
r e s t r i c t i o n s , ” M a r c h 5 , 2 0 0 8 , [ h t t p : / / w w w . u n . o r g / a p p s / n e w s /
story.asp?NewsID=25860&Cr=hiv&Cr1=unaids].

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CRS-20
Taxation of Assistance Funds by Foreign Governments
Prohibited
H.R. 5501 as passed by the House prohibited funds appropriated under the
legislation from being made available to a foreign country unless the agreement
provided that such assistance funds were exempt from taxation or otherwise
reimbursed by the foreign government.61 The Senate-passed version of S. 2731 did
not include similar language.
Prevention of Mother to Child HIV Transmission (PMTCT)
Panel
H.R. 5501 as passed by the Senate directed the Global AIDS Coordinator to
establish an advisory panel of experts on prevention of mother to child HIV
transmission (PMTCT) that would be known as the PMTCT Panel. The panel would
review PMTCT efforts and make recommendations to OGAC and Congress on how
to scale-up PMTCT services to ensure that, by 2013, such programs would provide
access to counseling, testing, and treatment for at least 80% of pregnant women in
those countries most affected by HIV/AIDS in which the United States has
HIV/AIDS programs. The House version of H.R. 5501 did not include similar
language.
Conscience Clause Expansion
Both versions of H.R. 5501 expanded “conscience clause” language included
in the Leadership Act. The conscience clause in the Leadership Act stated that
organizations that receive funding to prevent, treat, or monitor HIV/AIDS shall not
be required, as a condition of receiving the assistance, to endorse or utilize a
multisectoral approach to combating HIV/AIDS, or to endorse, utilize, or participate
in a prevention method or treatment program to which the organization has a
religious or moral objection. The new language in each version of H.R. 5501
referred to any HIV/AIDS program or activity to which an organization may have a
religious or moral objection, whereas language in the Leadership Act referred only
to any HIV/AIDS prevention method or treatment program to which the organization
has a religious or moral objection. It further stated that organizations who opt-out
of the above activities for religious or moral reasons shall not be discriminated
against in the solicitation or issuance of grants, contracts, or cooperative agreements.
Outcomes Under H.R. 5501/P.L. 110-293
On July 24, 2008, the House passed the Senate version of H.R. 5501, the Tom
Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008 (hereafter referred to as the
Reauthorization Act). The Reauthorization Act (P.L. 110-293) was enacted on July
61 This prohibition applies to funds being made available to a foreign country under a new
bilateral agreement.

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CRS-21
30, 2008. The outcomes of key proposals are described in Table 4. These key
proposals and debates surrounding them are discussed in more detail in the previous
section of this report. The funding levels authorized from FY2009 through FY2013
for U.S. programs to combat HIV/AIDS, tuberculosis, and malaria internationally are
described in Table 5.
Table 4. Outcomes of Key Proposals to Change International
HIV/AIDS, Tuberculosis, and Malaria Programs Under
P.L. 110-293
Key Proposals
P.L. 110-293
Funding Authorization
Authorizes $48 billion for HIV/AIDS, tuberculosis, and
Increase
malaria from FY2009 through FY2013; authorizes $2
billion for Indian Health and Safety Emergency Fund
from FY2009 through FY2013.
Global Malaria Coordinator
Established within USAID to oversee and coordinate
U.S. government efforts to combat malaria globally.
List of Focus Countries
Vietnam added as Focus Country in U.S. government
Expansion
efforts to combat HIV/AIDS globally.
Compacts With Recipient
Promotes the use of compacts between the U.S.
Countries
government and country and regional programs on
HIV/AIDS in order to promote host government
commitment to deeper integration of HIV/AIDS services
into health systems, contribute to health systems overall,
and enhance sustainability.
Role of Spending Directives OVC: Requires 10% of HIV/AIDS funds to be spent on
orphans and other children affected by or vulnerable to
HIV/AIDS (OVC).
Prevention: Requires the Global AIDS Coordinator to
provide balanced funding for prevention activities for
sexual transmission of HIV/AIDS; and to ensure that
activities promoting abstinence, delay of sexual debut,
monogamy, fidelity, and partner reduction are
implemented and funded in a meaningful and equitable
way in the strategy for each host country based on
objective epidemiological evidence as to the source of
infections and in consultation with the government of
each host county involved in HIV/AIDS prevention
activities. Also requires a report to the appropriate
congressional committees within 30 days to justify a
decision to provide less than 50 percent of the sexual
transmission prevention funds for activities promoting
abstinence, delay of sexual debut, monogamy, fidelity,
and partner reduction.
Treatment and Care: For each of the fiscal years 2009
through 2013, more than half of the amounts
appropriated for bilateral global HIV/AIDS assistance
pursuant to section 401 shall be expended for

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CRS-22
Key Proposals
P.L. 110-293
antiretroviral treatment for HIV/AIDS; clinical
monitoring of HIV-seropositive people not in need of
antiretroviral treatment; care for associated opportunistic
infections; nutrition and food support for people living
with HIV/AIDS; and other essential HIV/AIDS-related
medical care for people living with HIV/AIDS.
Program Objectives
Prevention Goal: To prevent 12 million new HIV
infections worldwide.
Treatment Goal: To support the increase in the number
of individuals with HIV/AIDS receiving antiretroviral
treatment above the 2 million person goal previously
established under the Leadership Act for achievement by
the end of FY2006 and increased pursuant to the
following: for each of the fiscal years 2009 through
2013, the treatment goal shall be increased above 2
million people by at least the percentage increase in the
amount appropriated for bilateral global HIV/AIDS
assistance for such fiscal year compared with FY2008.
Additionally, any increase in the treatment goal above
this specified level shall be based on long-term
requirements, epidemiological evidence, the share of
treatment needs being met by partner governments and
other sources of treatment funding, and other appropriate
factors.
The treatment goal also shall be increased above the
number calculated above by the same percentage that the
average U.S. government cost per patient of providing
treatment in countries receiving bilateral HIV/AIDS
assistance has decreased compared with FY2008.
Care Goal: To support care for 12 million individuals
infected with or affected by HIV/AIDS, including 5
million orphans and vulnerable children affected by
HIV/AIDS (OVC), with an emphasis on promoting a
comprehensive, coordinated system of services to be
integrated throughout the continuum of care.
The Reauthorization Act also states that the prevention
and care goals described above shall be increased
consistent with epidemiological evidence and available
resources.
Balance Between
Prioritizes prevention while preserving and increasing
Prevention, Treatment, and
the treatment component of HIV/AIDS efforts as
Care
bilateral funding for HIV/AIDS increases relative to
FY2008 levels.
HIV/AIDS Activities and
Does not mention family planning.
Family Planning

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CRS-23
Key Proposals
P.L. 110-293
Health Systems and the
Provides for helping partner countries to train and
Single Disease Approach
support the retention of health care professionals and
paraprofessionals. It sets a target of training and
retaining at least 140,000 new health care professionals
and paraprofessionals with an emphasis on training and
in-country deployment of critically needed doctors and
nurses.
This assistance is intended to strengthen the capacity of
developing countries, especially in sub-Saharan Africa,
to deliver primary health care. It has an objective to help
countries achieve staffing levels of at least 2.3 doctors,
nurses, and midwives per 1,000 population, as called for
by the World Health Organization (WHO).
Required 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.1 The plan, in
part, 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 includes collaboration
with U.S. post-secondary educational institutions
including historically black colleges and universities.
Required 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 requires greater strategic
planning across U.S. global health and development
programs to coordinate efforts across program areas.
HIV/AIDS Activities and
Provides for linkages between HIV/AIDS activities and
Nutrition Programs
nutrition programs.
Immigration and Nationality Amends the INA to statutorily allow foreigners infected
Act (INA) Amendment
with HIV/AIDS to enter the United States.
Additional Oversight
Requires additional reporting, including a report by the
Activities
Comptroller General that would discuss the coordination
of U.S. global AIDS efforts and the impact of global
HIV/AIDS funding and programs on other U.S. global
health programming.
Requires the dissemination of an annual report by OGAC
on best practices that might be replicated or adapted by
other AIDS programs.

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CRS-24
Key Proposals
P.L. 110-293
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.
Taxation of Assistance
Language not included.
Funds by Foreign
Governments Prohibited
Prevention of Mother to
Establishes a 15-person expert panel to review PMTCT
Child HIV Transmission
activities and to provide recommendations for PMTCT
(PMTCT) Panel
scale-up to the Global AIDS Coordinator.
Conscience Clause
Expands definition to state that organizations that receive
Expansion
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 any
HIV/AIDS program or activity to which an organization
may have a religious or moral objection.
Source: Compiled by CRS from P.L. 110-293, the Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.
Table 5. Key Authorization Levels from FY2009 through FY2013
in P.L. 110-293, the Reauthorization Act of 2008
Area of Authorization
P.L. 110-293
Overall for HIV/AIDS, Tuberculosis, and
$48 billion (in total)
Malaria
U.S. Contribution to Global Fund to Fight
Up to $2 billion for U.S. contributions in
AIDS, Tuberculosis, and Malaria
FY2009; and such sums as may be
necessary from FY2010 through FY2013.
Tuberculosis
$4 billion (in total)
Malaria
$5 billion (in total)
Indian Health and Safety Emergency Fund $2 billion (in total)
Source: Compiled by CRS from P.L. 110-293, the Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.

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