U.S. Response to the Global Threat of
HIV/AIDS: Basic Facts
Alexandra E. Kendall
Analyst in Global Health
February 22, 2011
Congressional Research Service
7-5700
www.crs.gov
R41645
CRS Report for Congress
P
repared for Members and Committees of Congress
U.S. Response to the Global Threat of HIV/AIDS: Basic Facts
Summary
The human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is one
of the world’s most pressing global health challenges. Since the beginning of the epidemic, more
than 60 million people have been infected with HIV, approximately 30 million of whom have
died of HIV-related causes. As of 2009, there were 33.3 million people living with the virus, the
vast majority of whom live in sub-Saharan Africa. Expanded access to antiretroviral therapy
(ART) over the past decade, due in large part to U.S. support, has contributed to declines in
deaths among people living with HIV. Nonetheless, new infections continue to outpace access to
treatment. The 112th Congress will likely be faced with determining how, and to what extent, the
United States should respond to the continued challenge of global HIV/AIDS.
The United States has recognized HIV/AIDS as a key foreign policy priority. Congress has passed
several pieces of legislation related to global HIV/AIDS prevention, treatment, and care. In
particular, in 2003, Congress enacted the U.S. Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 (P.L. 108-25), authorizing $15 billion to combat global HIV/AIDS,
tuberculosis (TB), and malaria through the President’s Emergency Plan for AIDS Relief
(PEPFAR), an initiative proposed by the George W. Bush Administration. In 2008, Congress
enacted the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), authorizing $48 billion for
HIV/AIDS, TB, and malaria programs from FY2009 through FY2013. From FY2004 through
FY2010, the United States spent a total of $26,348 million on bilateral HIV/AIDS programs.
PEPFAR is the largest commitment in history by any nation to combat a single disease and makes
up the majority of donor funding for global HIV/AIDS. When PEPFAR was announced, health
experts were debating whether the international community had a responsibility to provide ART
in developing countries and whether they could be safely administered in such environments.
PEPFAR responded to calls from those advocating treatment for the world’s poor and
demonstrated that ART could be effectively provided in low-resource settings.
PEPFAR is coordinated by the Office of the U.S. Global AIDS Coordinator (OGAC) at the
Department of State and is implemented by a range of U.S. agencies that include, among others,
the United States Agency for International Development (USAID) and the Centers for Disease
Control and Prevention (CDC). The United States also supports several multilateral organizations
responding to HIV/AIDS, including the Global Fund to Fight AIDS, Tuberculosis and Malaria
(Global Fund) and the United Nations Joint Program on HIV/AIDS (UNAIDS).
Due in part to the global response to HIV/AIDS, progress has been made in combating the
epidemic. New HIV infections fell by more than 25% in 33 countries between 2001 and 2009,
and AIDS-related deaths have declined significantly. At the same time, major challenges remain
in the fight against HIV/AIDS. For example, the number of people in need of treatment has
continued to grow, straining available resources. Global health experts have increasingly debated
the sustainability of expanded access to HIV/AIDS treatment, and many argue that efforts to
reduce new infections should become the central focus of donor assistance. This report outlines
basic facts related to global HIV/AIDS, including characteristics of the epidemic and U.S.
legislation, programs, funding, and partnerships related to global HIV/AIDS. It concludes with a
brief description of some of the major issues that might be considered by the 112th Congress as it
responds to the disease. The report will be updated as events warrant.
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U.S. Response to the Global Threat of HIV/AIDS: Basic Facts
Contents
Introduction ................................................................................................................................ 1
Description of HIV/AIDS ........................................................................................................... 1
Global HIV/AIDS Statistics ........................................................................................................ 1
Regional Distribution of HIV/AIDS ............................................................................................ 2
HIV/AIDS Treatment, Care, and Prevention................................................................................ 3
Key U.S. Legislation on Global HIV/AIDS, 2003-2011............................................................... 4
U.S. Global HIV/AIDS Programs................................................................................................ 5
PEPFAR Implementing Agencies ................................................................................................ 6
U.S. Global HIV/AIDS Assistance Funds .................................................................................... 7
Key Partners in the Response to Global HIV/AIDS ................................................................... 11
Key Issues in Global HIV/AIDS ............................................................................................... 12
Figures
Figure 1. Number of People Newly Infected with HIV, 1990-2009 .............................................. 2
Figure 2. Global Prevalence Rates of HIV, 2009.......................................................................... 3
Figure 3. PEPFAR Organizational Chart: Appropriations............................................................. 8
Figure 4. U.S. Funding for Bilateral Global HIV/AIDS Programs in Constant Dollars:
FY2004-FY2010...................................................................................................................... 9
Figure 5. Donor Government HIV/AIDS Assistance, as Share of Total Disbursements,
2009 ...................................................................................................................................... 11
Tables
Table 1. U.S. Bilateral Funding for Global HIV/AIDS: FY2004-FY2012..................................... 9
Table 2. U.S. Appropriations for the Global Fund: FY2004-FY2012.......................................... 10
Contacts
Author Contact Information ...................................................................................................... 13
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U.S. Response to the Global Threat of HIV/AIDS: Basic Facts
Introduction
Over the past decade, the United States has recognized the human immunodeficiency virus and
the acquired immune deficiency syndrome (HIV/AIDS) as a key foreign policy priority.
Congressional authorization of the President’s Emergency Plan for AIDS Relief (PEPFAR) in
2003 brought unprecedented attention and funding to the epidemic and established a new and
central role for donor governments in the fight against HIV/AIDS, particularly regarding the
provision of AIDS treatment. The United States remains the largest single donor for global
HIV/AIDS efforts in the world, providing over 50% of all government donor funds. In recent
years, despite the continued challenge of HIV/AIDS around the world, international funding for
HIV/AIDS—including U.S. assistance—has begun to level off. This report provides information
on key components of the HIV/AIDS epidemic and the U.S. response to HIV/AIDS.
Description of HIV/AIDS
HIV is an infectious disease that damages human immune cells. The final stage of HIV is AIDS,
which occurs when an individual’s immune system is so damaged it can no longer fight off other
infections. If left untreated, AIDS is fatal. HIV is spread through contact with the bloodstream or
by passing through delicate mucous membranes, including the vagina, rectum, and urethra.
Transmission primarily occurs in three ways: (1) unprotected sexual intercourse with an infected
partner; (2) injections with a needle, syringe, or other equipment that has been used by an infected
person; and (3) between a child and an infected mother, during pregnancy, birth, or breast-
feeding. High-risk groups include sex workers, men who have sex with men, and injecting drug
users.
Global HIV/AIDS Statistics1
Prevalence: Prevalence measures the number of people living with a disease. Since the beginning
of the epidemic, almost 60 million people have been infected with HIV. As of 2009, there were
33.3 million people living with the virus. Women make up 52% of those living with HIV. The
number of people living with HIV continues to rise as a combined result of new infections and
improved access to antiretroviral treatment (ART) that have lowed AIDS-related mortality.
Incidence: Incidence measures the number of people who contract a disease within a given time
period (usually one year). In 2009, 2.6 million people contracted HIV—7,100 new infections per
day—including 370,000 children under the age of 15. New infections are thought to have peaked
in 1996 at 3.5 million (Figure 1). Incidence has fallen by more than 25% in 33 countries between
2001 and 2009, including in 22 sub-Saharan African countries.
Mortality: HIV continues to be a leading cause of death worldwide and the number one killer in
sub-Saharan Africa. By 2009, more than 26 million people had died of AIDS worldwide. In 2009,
1.8 million people died of AIDS, including roughly 260,000 children. AIDS-related deaths are
1 All data in this section is from Joint United Nations Program on HIV/AIDS (UNAIDS), Report on the Global AIDS
Epidemic, 2010, http://www.unaids.org/documents/20101123_GlobalReport_em.pdf.
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thought to have peaked in 2004 at 2.2 million and declined since then due to the improved access
to ART.
Figure 1. Number of People Newly Infected with HIV, 1990-2009
(Millions per year)
Source: UNAIDS, Report on the Global AIDS Epidemic, 2010, p. 16.
Notes: The dotted line represents high and low estimates of new infections each year.
Regional Distribution of HIV/AIDS2
HIV/AIDS is a global phenomenon, but there are important regional and intra-regional
differences in HIV prevalence, incidence, and mortality.
• Sub-Saharan Africa (SSA) is the region most affected by HIV/AIDS (Figure 2).
As of 2009, an estimated 22.5 million people were living with HIV/AIDS in
SSA, accounting for 68% of all people living with HIV worldwide. Nearly 90%
of the estimated 16.9 million children who had lost one or both of their parents
from AIDS-related deaths by the end of 2009 were in SSA. Southern Africa is
home to the nine countries with the world’s highest HIV prevalence rates
worldwide and was home to an estimated 11.3 million people living with HIV in
2009. Swaziland has the world’s highest prevalence rate (25.9%), and South
Africa has the world’s largest population with HIV (5.6 million). In 2009, about
1.8 million people in SSA contracted HIV and some 1.3 million people in the
region died from AIDS.
• As of 2009, an estimated 4.9 million people were living with HIV in Asia,
including 360,000 people who became infected in 2009. Also in 2009,
approximately 300,000 AIDS-related deaths occurred in the region. Since 2000,
the epidemic has remained somewhat stable in Asia, with HIV incidence
peaking in the mid-1990s.
• As of 2009, an estimated 1.6 million people were living with HIV in Latin
America and the Caribbean, including 109,000 people who became infected in
2009. In the region, the Bahamas has the highest prevalence rate, while Brazil
2 All data in this section is from UNAIDS, Report on the Global AIDS Epidemic, 2010.
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has the largest population living with virus. Overall, the epidemic in Latin
America has stabilized as has the rate of new infections in the Caribbean.
• Eastern Europe and Central Asia (EECA) has experienced the largest regional
increase in HIV prevalence, most prominently in Russia and Ukraine. Since
2000, the number of people living with HIV in the region has almost tripled. As
of 2009, an estimated 1.4 million people were living with HIV in EECA,
including 130,000 people who were infected in 2009.
Figure 2. Global Prevalence Rates of HIV, 2009
Source: UNAIDS, Report on the Global AIDS Epidemic, 2010, p. 23.
Notes: Prevalence rates measure the percentage of people living with HIV in each country.
HIV/AIDS Treatment, Care, and Prevention
Treatment: Use of ART to treat HIV/AIDS has lowered the rate of AIDS-related deaths in much
of the world. ART coverage—the percentage of people on ART among those in need—was 36%
in 2009, up from 7% in 2003.3 While lowering AIDS-related deaths, access to ART has also
increased HIV prevalence around the world, as infected individuals are now living longer. ART
also has some preventive benefits as it lowers viral loads, consequently reducing the likelihood of
transmission.
Care Activities: Care for individuals infected and affected by HIV/AIDS constitutes a wide range
of activities, including support for ART adherence, treatment of opportunistic infections,
nutritional counseling, mental health services, prevention education, and livelihood activities,
along with attention to orphans and vulnerable children.
3 UNAIDS, Report on the Global AIDS Epidemic, 2010.
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Prevention Activities: A number of prevention efforts are being used to combat HIV/AIDS,
including male circumcision, reduction of mother-to-child transmission (PMTCT), behavior
change programs (including advocacy of abstinence, being faithful, and using condoms), HIV
testing, blood supply safety programs, and harm reduction programs aimed at high-risk groups.
Prevention Research: Efforts to develop HIV preventive vaccines and microbicides—
compounds that can be applied inside the vagina or rectum to protect against sexually transmitted
infections—are underway. Results from a 2010 study in South Africa, funded in part by the
United States, showed that the use of a microbicide was 39% effective in reducing a woman’s risk
of contracting HIV during sex.4 Many health experts support microbicide research as it offers
women vulnerable to violence and sexual coercion some degree of protection against HIV.
Key U.S. Legislation on Global HIV/AIDS,
2003-2011
• On May 27, 2003, President George W. Bush signed into law the United States
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
(Leadership Act, P.L. 108-25). The Leadership Act authorized $15 billion for
global HIV/AIDS, TB, and malaria programs from FY2004 through FY2008.
The act also authorized the creation of the Office of the Global AIDS
Coordinator (OGAC) at the Department of State to oversee and coordinate all
bilateral HIV/AIDS activities and funding.
As part of the act, Congress recommended the following distribution of HIV/AIDS funds:
• 15% of funds be used for palliative care, and
• 20% of funds be used for HIV/AIDS prevention efforts.
Congress further required the following distribution of HIV/AIDS funds for each fiscal
year from FY2006 to FY2008:
• at least 55% of funds be used for AIDS treatment, of which at least 75% be
used for the purchase and distribution of ART and at least 25% be used for
related care;
• at least 33% of appropriated prevention funds be used for abstinence- until-
marriage programs; and
• at least 10% of funds be spent on orphans and vulnerable children.
Finally, the act mandated that from FY2004 to FY2008, the United States contribution to
the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, see, “Key
Partners in the Response to Global HIV/AIDS”) not exceed 33% of the total amount of
funds contributed from all sources.
4 Center for the AIDS Program of Research in South Africa (CAPRISA), Study of Microbicide Gel Shows Reduced
Risk of HIV and Herpes Infection in Women, July 20, 2010, http://www.caprisa.org/joomla/index.php/component/
content/article/1/226.
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• On July 24, 2008, President Bush signed into law the Tom Lantos and Henry J.
Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (Lantos-Hyde Act, P.L. 110-293). The Lantos-Hyde
Act authorized $48 billion for U.S. global HIV/AIDS, TB, and malaria efforts
from FY2008 through FY2013, including $2 billion for the Global Fund in
FY2008.
As part of the act, Congress removed the recommendations that 20% on funds be spent
on prevention efforts and that 33% of these funds be used for abstinence-until-marriage
programs, and required the following:
• for each fiscal year from FY2009 to FY2013, at least 10% of funds be spent
on orphans and vulnerable children;
• for each fiscal year from FY2009 to FY2013, more than 50% of bilateral
assistance be spent on treatment and care of individuals infected with
HIV/AIDS;
• balanced funding for prevention activities including those that promote
abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction
and country-specific implementation of such activities; and
• a report to Congress should less than 50% of prevention funds go to activities
promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner
reduction in any country with a generalized epidemic.
U.S. Global HIV/AIDS Programs
In 1999, the 106th Congress authorized resources to support a proposal by the Clinton
Administration to broaden U.S. activities related to global HIV/AIDS through the Leadership and
Investment in Fighting an Epidemic (LIFE) initiative. LIFE sought to address HIV/AIDS in 14
African countries and in India and represented the first time agencies other than the United States
Agency for International Development (USAID) were included in the U.S. response to
HIV/AIDS. President George W. Bush launched two initiatives that built on the LIFE initiative.
In 2002, President Bush announced the International Mother and Child HIV Prevention Initiative,
which focused on preventing mother-to-child transmission of HIV in 12 African countries and in
two Caribbean countries. In 2003, President Bush announced PEPFAR, proposing that the United
States spend $15 billion over the course of five years to combat HIV/AIDS. Both the LIFE
initiative and the International Mother and Child HIV Prevention Initiative were replaced by
PEPFAR.
PEPFAR significantly increased attention to and funding for global HIV/AIDS. The President
proposed that the majority of the funds ($9 billion) be concentrated in 15 focus countries,
including 12 in sub-Saharan Africa. The proposal also allocated $5 billion to research and to other
bilateral HIV/AIDS programs and $1 billion for contributions in FY2004 to the Global Fund.
PEPFAR represents the largest commitment by any country toward an international health issue.
At the time it was established, health experts were debating whether the international community
had a responsibility to provide ART to HIV-positive people in developing countries and whether
they could be safely administered in such environments. PEPFAR responded to calls from those
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advocating treatment for the world’s poor and demonstrated that ART could be effectively
provided in low-resource settings.
Through the Leadership Act, Congress authorized the establishment of the Office of the Global
AIDS Coordinator (OGAC), at the Department of State. OGAC oversees and coordinates all U.S.
spending on bilateral global HIV/AIDS activities implemented by various agencies (see
“PEPFAR Implementing Agencies”), as well as contributions to multilateral organizations.
President Barack Obama has committed to continued support for PEPFAR, while working to
transition PEPFAR from an emergency plan to a long-term and sustainable approach to global
HIV/AIDS. On May 5, 2009, the President announced the six-year, $63 billion Global Health
Initiative (GHI), a new effort to develop a comprehensive U.S. global health strategy. The GHI
calls for a more integrated U.S. response to global health issues and for a shift in U.S. global
health strategy from one focused on specific diseases to a more comprehensive approach to
health. PEPFAR is the central component of the GHI and accounts for over 60% of the
President’s FY2012 budget proposal. As part of the GHI, PEPFAR has committed to supporting
the following goals from FY2010 through FY2014:
• prevention of more than 12 million new HIV infections;
• treatment of more than 4 million people living with HIV/AIDS;
• care for more than 12 million people, including 5 million orphans and
vulnerable children; and
• training and retention of more than 140,000 new heath care workers.5
PEPFAR Implementing Agencies
PEPFAR programs are led by OGAC at the State Department and implemented by various U.S.
agencies and departments, including the following:
• U.S. Agency for International Development: USAID supports HIV/AIDS
programs in nearly 100 countries. These programs focus on providing treatment,
care, and support to people infected with HIV/AIDS; strengthening primary
health care systems; providing training, technical assistance, and commodities
that reduce HIV transmission; reducing high-risk behaviors; and supporting
international partnerships.
• Centers for Diseases Control and Prevention (CDC): CDC’s Global AIDS
Program (GAP) operates in 38 countries and three regional programs. CDC
HIV/AIDS programs assist ministries of health and local implementing
organizations to implement HIV/AIDS prevention programs, analyze program
impact and cost effectiveness, and build the capacity of public workforce, as
well as public health information, laboratory, and management systems.
• National Institutes of Health (NIH): NIH supports HIV/AIDS research and
training in 90 countries. This research focuses on tools to prevent HIV
5 The President’s Emergency Plan For AIDS Relief, The U.S. President’s Emergency Plan for AIDS Relief: Five-Year
Strategy, Office of the Global AIDS Coordinator, Department of State, 2009, http://www.pepfar.gov/strategy/.
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transmission, such as vaccines and microbicides; strategies to prevent mother-
to-child transmission; and approaches to treating HIV and its associated
opportunistic infections and co-infections in resource poor settings.
• Health Resources and Services Administration (HRSA): HRSA’s HIV/AIDS
strategy focuses on health system strengthening and improvements in human
resources for health. HRSA runs HIV/AIDS programs in more than 25 countries
that support rapid roll-out of ART, education and training for health workers,
and innovative approaches to health data collection and evaluation.
• U.S. Food and Drug Administration (FDA): FDA ensures the availability of
safe and effective AIDS treatment. Since 2004, FDA has supported an
accelerated review process for ARTs, including generic drugs and fixed dose
combination drugs (FDCs)—multiple antiretroviral drugs combined into a
single pill—for PEPFAR programs. As of 2008, 80 generic ART formulations,
including 16 FDCs, had been approved or tentatively approved by FDA.
• Department of Defense (DOD): DOD operates HIV/AIDS programs in 73
countries. DOD’s primary role under PEPFAR is to support military-to-military
HIV/AIDS prevention, treatment, and care efforts; assist in the development of
military-specific HIV/AIDS policies; and provide HIV/AIDS counseling,
testing, and care for military families. DOD also provides HIV prevention
scientific and technical assistance to non-military PEPFAR programs. The DOD
HIV/AIDS Prevention Program (DHAPP) manages DOD’s HIV/AIDS
programs for foreign militaries and oversees the use of PEPFAR funds by other
DOD organizations.
• Department of Labor (DOL): DOL implements HIV/AIDS programs in over
23 countries that facilitate the development of comprehensive workplace-based
HIV prevention and education programs; assist governments, employers, and
trade unions to develop and disseminate workplace policy countering stigma
and discrimination; and support collaboration between government, business,
and labor in countering HIV/AIDS.
• Peace Corps: Peace Corps volunteers support community-based HIV/AIDS
care and prevention efforts in 77 countries. In FY2009, 21% of Peace Corps
volunteer projects were related to HIV/AIDS and 25 Peace Corps posts received
direct PEPFAR funding, while other posts benefited from activities organized by
the headquarters using central PEPFAR funding.
• U.S. Department of Commerce (DOC): DOC creates and disseminates sector-
specific strategies to inform HIV trade advisory committees on how the private
sector can help combat HIV/AIDS. The U.S. Census Bureau also contributes to
PEPFAR by assisting with data management and analysis, estimating infections
averted, and supporting mapping of country-level activities.
U.S. Global HIV/AIDS Assistance Funds
Congress provides funds for HIV/AIDS assistance to several U.S. agencies through a number of
appropriations vehicles: State-Foreign Operations (State-Foreign Ops); Labor, Health and Human
Services and Education (Labor-HHS); and Department of Defense (Defense) (Figure 3). Table 1
details all U.S. funding for global HIV/AIDS since FY2004.
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Figure 3. PEPFAR Organizational Chart: Appropriations
Source: CRS analysis.
• State-Foreign Operations Appropriations: The majority of PEPFAR funds are
appropriated through State-Foreign Operations to the Department of State. In
FY2010, Congress appropriated approximately 81% of all global HIV/AIDS
funds to the Department of State. As the coordinator of global HIV/AIDS
activities, the Department of State transfers the bulk of these funds to
implementing agencies in support of bilateral HIV/AIDS programs. Per
congressional proviso, the Department also uses some of these funds to make
contributions to other organizations that combat global HIV/AIDS, including
the Global Fund. Congress also appropriates funds to USAID for bilateral
HIV/AIDS activities through State-Foreign Operations appropriations.
• Labor, Health and Human Services, and Education Appropriations:
Congress appropriates funds for global HIV/AIDS activities to HHS agencies,
including CDC and NIH, through Labor-HHS appropriations. Congress
provides a second portion of the U.S. contribution to the Global Fund through
Labor-HHS. Congress used to appropriate funds to DOL for bilateral HIV/AIDS
activities, but it has not done so since FY2005. DOL’s HIV/AIDS programs are
now supported through transfers from the Department of State.
• Department of Defense Appropriations: Congress also appropriates funds to
DOD for bilateral HIV/AIDS programs through DOD appropriations.
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Table 1. U.S. Bilateral Funding for Global HIV/AIDS: FY2004-FY2012
($ millions, current)
FY2004-
FY2004 FY2005 FY2006 FY2007 FY2008 FY2009
FY2010
FY2010
FY2011
FY2012
Program/Agency
Actual
Actual
Actual
Actual
Actual
Actual
Estimate TOTAL Request Request
USAID
555.5 384.7 373.8 345.9 371.1 350.0 350.0 2,731.0 350.0 350.0
State
488.1 1,373.9 1,777.1 2,869.0 4,116.4 4,559.0 4,609.0 19,792.5 4,800.0 4,641.9
Of
which,
UNAIDS
0.0 27.0 29.7 30.0 35.0 40.0 43.0 204.7 45.0 45.0
FMFa
1.5 2.0 2.0 1.6 1.0 n/s
n/s n/s n/s n/s
CDC
266.9 123.8 122.6 121 118.9 118.9 119.0 991.1 118.1 118.0
NIH
317.2 369.5 373.0 361.7 411.7 451.7 485.6 2,770.4 470.6 489.4
DOL
9.9 2.0 0.0 0.0 0.0 0.0 0.0 11.8 0.0 0.0
DOD
4.3 7.5 5.2 0.0 8.0 8.0 10.0 43.0 0.0 n/s
TOTAL
1,643.4 2,263.4 2,653.7 3,699.2 5,027.1 5,487.6 5,573.6 26,348.0 5,738.7 5,599.3
Bilateral
HIV/AIDS
Source: Compiled by CRS from Congressional Budget Justifications and appropriations legislation.
Note: FY2011 Funding is currently provided under a continuing resolution at FY2010-enacted levels until March
4, 2011. “n/s” stands for “not specified” and “n/a” stands for “not available.”
a. Foreign Military Financing (FMF) funds are used to purchase equipment for DOD HIV/AIDS Programs.
Since the establishment of PEPFAR, U.S. funding for global HIV/AIDS has increased each year,
with the largest increases between FY2004 and FY2008. U.S. funding for bilateral global
HIV/AIDS programs has been largely level since FY2008 (Figure 4).
Figure 4. U.S. Funding for Bilateral Global HIV/AIDS Programs in Constant Dollars:
FY2004-FY2010
($ millions, constant)
Source: Compiled by CRS from Congress Budget Justifications.
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The United States also supports global HIV/AIDS programs through contributions to the Global
Fund, an international financing mechanism for the response to HIV/AIDS, TB, and malaria
(Table 2). U.S. contributions to the Global Fund support grants for HIV/AIDS, TB, and malaria.
The Global Fund has historically directed approximately 61% of its funds for HIV/AIDS efforts. 6
The United States is the single largest donor to the Global Fund.
Table 2. U.S. Appropriations for the Global Fund: FY2004-FY2012
($ millions, current)
FY2004-
FY2004 FY2005 FY2006 FY2007 FY2008 FY2009
FY2010
FY2010
FY2011
FY2012
Program/Agency
Actual
Actual
Actual
Actual
Actual
Actual
Estimate TOTAL Request Request
USAID Global
397.6 248.0 247.5 247.5 0.0 100.0 0.0
1,240.6 0.0
0.0
Fund
FY2004
Carryover
-87.8
87.8 n/a n/a n/a n/a n/a n/a n/a n/a
State
Global
Fund
0.0 0.0 198.0 377.5 545.5 600.0 750.0 2,471.0 700.0 1,000.0
HHS Global Fund
149.1
99.2
99.0
99.0
294.8
300.0
300.0
1,341.1
300.0
300.0
TOTAL Global
458.9 435.0 544.5 724.0 840.3 1,000.0
1,050.0 5,052.7 1,000.0 1,300.0
Fund
Source: Compiled by CRS from appropriations legislation.
Notes: In the “FY2004 Carryover” row, “n/a” is used to reflect requirements in the U.S. Leadership Act, which
stipulates that U.S. contributions to the Fund not exceed 33% of Fund contributions from al sources. FY2005
Consolidated Appropriations (P.L. 108-447) added this amount to the 2005 contribution, subject to the same
33% limitation.
In low-income countries, 88% of total spending on HIV/AIDS is from international sources, just
over three-quarters of which is from bilateral donors, with the remaining quarter from multilateral
donors. In 2009, U.S. funds made up over half of all donor government disbursements for global
HIV/AIDS (Figure 5) and 27% of global HIV/AIDS funds from all sources, including donor and
domestic governments, multilateral organizations, and the private sector.7 When standardized to
correspond to gross domestic product (GDP) per $1 million spent, six European countries spend
more than the United States on global HIV/AIDS.8
6 The Global Fund to Fight AIDS, Tuberculosis and Malaria, Distribution of Funding After 7 Rounds,
http://www.theglobalfund.org/en/distributionfunding/?lang=en#disease.
7 UNAIDS, Report on the Global AIDS Epidemic, 2010.
8 UNAIDS and Kaiser Family Foundation, Financing the Response to AIDS in Low- and Middle-Income Countries:
International Assistance from the G8, European Commission and Other Donor Governments in 2009, July 2010,
http://www.kff.org/hivaids/upload/7347-06.pdf.
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Figure 5. Donor Government HIV/AIDS Assistance, as Share of Total Disbursements,
2009
(Percent of $ billions, current)
Source: UNAIDS and Kaiser Family Foundation, Financing the Response to AIDS in Low- and Middle-Income
Countries: International Assistance from the G8, European Commission and Other Donor Governments in
2009, July 2010, p. 5.
Notes: EC stands for European Commission.
Key Partners in the Response to Global HIV/AIDS
The United States works with a range of partners to combat HIV/AIDS, including other national
governments, multilateral organizations, non-governmental organizations (NGOs), and the private
sector. Through authorizing legislation and annual appropriations, Congress provides funds to
several multilateral organizations and international research initiatives who contribute to the fight
against HIV/AIDS, including the Global Fund and the United Nations Joint Program on
HIV/AIDS (UNAIDS).
• The Global Fund: The Global Fund was established in 2002 as a public-private
partnership to provide financial support for global responses to HIV/AIDS, TB,
and malaria. The United States contributes more to the Global Fund than any
other country. By the end of 2009, the Global Fund had committed to grant
roughly $10.8 billion for HIV/AIDS programs in 140 countries.9
• UNAIDS: UNAIDS is the main advocate for United Nations (U.N.) action on
HIV/AIDS and is responsible for coordinating HIV/AIDS activities
9 The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Innovation and Impact: Results Summary, 2010,
http://www.theglobalfund.org/documents/replenishment/2010/Progress_Report_Summary_2010_en.pdf.
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U.S. Response to the Global Threat of HIV/AIDS: Basic Facts
implemented by nine agencies, including U.N. Children’s Fund (UNICEF);
U.N. Development Program (UNDP); International Labor Organization (ILO);
U.N. Population Fund (UNFPA); U.N. Office on Drugs and Crime (UNODC);
U.N. Educational, Scientific and Cultural Organization (UNESCO); World Food
Program (WFP); World Health Organization (WHO); and the World Bank. The
United States is one of the largest contributors to UNAIDS. UNAIDS oversees a
wide range of HIV/AIDS activities, which include efforts to reduce transmission
of HIV; ensure access to ART; prevent death from HIV/TB co-infection;
empower men who have sex with men; remove punitive law, policies, and
practices that block effective responses to AIDS; reduce sexual and gender-
based violence; and empower young people to protect themselves from HIV.
Key Issues in Global HIV/AIDS
The 112th Congress will likely be faced with a number of issues regarding the U.S. response to
global HIV/AIDS, including how much assistance to provide and how to best apportion global
HIV/AIDS funds. Given the United States’ central role in the fight against HIV/AIDS, many
experts assert that the future direction of the U.S. response to HIV/AIDS will have significant
implications for the global response to HIV/AIDS as a whole. The 112th Congress may consider
the following issues as it considers the U.S. response to global HIV/AIDS:
• Treatment efforts: Without a vaccine or cure to HIV, people continue to
contract HIV and require lifelong treatment. As such, despite efforts by the
international community to expand access to treatment, the number of people in
need of ART outpaces treatment resources. Global health experts have
increasingly debated the sustainability of offering HIV/AIDS treatment and
whether treatment should continue to be the central focus of donor assistance.
• Prevention efforts: There is widespread support within the global health
community for intensifying prevention efforts, particularly in light of the
persistent need for HIV/AIDS treatments. At the same time, experts disagree on
what prevention efforts are most effective, how to measure the success of any
one prevention activity, and how to incentivize leaders of developing countries
to increase financial investment in prevention, particularly given its less
immediate and dramatic results when compared with treatment.
• Health System Strengthening: Many global health experts argue that an
effective long-term approach to global HIV/AIDS requires efforts to strengthen
health systems (HSS) in low- and middle-income countries. However, there is
little consensus within the global health community over how to define,
implement, and measure HSS activities, and over whether PEPFAR has had a
beneficial or detrimental impact on the broader functioning of health systems.
• Country ownership: Donor governments have increasingly supported the
concept of country ownership as a way to promote sustainable and country-
appropriate responses to the epidemic. To this end, PEPFAR programs have
begun to implement “Partnership Frameworks” with partner countries to clarify
joint goals and strategies. A number of issues related to country ownership are
being debated within donor governments, including how to best align donor
priorities and country priorities and how to maintain effective levels of oversight
while shifting control to host governments.
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Author Contact Information
Alexandra E. Kendall
Analyst in Global Health
akendall@crs.loc.gov, 7-7314
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