The Global Challenge of HIV/AIDS,
Tuberculosis, and Malaria
Alexandra E. Kendall
Analyst in Global Health
February 23, 2012
Congressional Research Service
7-5700
www.crs.gov
R41802
CRS Report for Congress
Pr
epared for Members and Committees of Congress
The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria
Summary
The spread of human immunodeficiency virus/acquired immune deficiency syndrome
(HIV/AIDS), tuberculosis (TB), and malaria across the world poses a major global health
challenge. The international community has progressively recognized the humanitarian impact of
these diseases, along with the threat they represent to economic development and international
security. The United States has historically been a leader in the fight against HIV/AIDS, TB, and
malaria; it is currently the largest single donor for global HIV/AIDS and has been central to the
global response to TB and malaria. In its second session, the 112th Congress will likely consider
HIV/AIDS, TB, and malaria programs during debate on and review of U.S.-supported global
programs, U.S. foreign assistance spending levels, and foreign relations authorization bills.
Over the past decade, Congress has demonstrated bipartisan support for addressing HIV/AIDS,
TB, and malaria worldwide, authorizing more than $52.5 billion for U.S. global efforts to combat
the diseases from FY2001 through FY2012. During this time, Congress supported initiatives
proposed by President George W. Bush, including the President’s Emergency Plan for AIDS
Relief (PEPFAR) and the President’s Malaria Initiative (PMI), both of which have demonstrated
robust U.S. engagement in global health. Through the Global Health Initiative (GHI), President
Barack Obama has led efforts to coordinate U.S. global HIV/AIDS, TB, and malaria programs
and create an efficient, long-term, and sustainable approach to combating these diseases.
In 2011, there were several significant scientific advancements in global health, including, most
notably, evidence that early HIV treatment not only saves lives but can reduce the risk of
transmission by 96%. Despite this scientific landmark, and ongoing progress in fighting
HIV/AIDS, TB, and malaria, these diseases remain leading global causes of morbidity and
mortality. Many health experts urge Congress to capitalize on recent gains and bolster U.S.
leadership and funding to combat these diseases. In contrast, some Members of Congress have
proposed cuts to these programs as part of deficit reduction efforts.
This report reviews the U.S. response to HIV/AIDS, TB, and malaria and discusses several issues
Congress may consider as it debates spending levels and priority areas for related programs. The
report includes analysis of:
• Funding Trends: Combined funding for the three diseases has increased
significantly over the past decade, from approximately $832 million in FY2001
to $7.1 billion in FY2012. The bulk of the increase over time has been targeted
toward HIV/AIDS, although in recent years funding for global HIV/AIDS has
begun to level off. When compared to FY2011, funding in FY2012 included
decreases for global HIV/AIDS, and slight increases for global TB and malaria
programs. Some health experts applaud what they see as a shift toward less
expensive efforts that maximize health impact. Other experts warn that
divestment from HIV/AIDS could significantly endanger lives of those reliant on
U.S. assistance and could reverse fragile gains made against the epidemic and
other diseases.
• Disease-Specific Issues: HIV/AIDS, TB, and malaria each present unique
challenges. Rising numbers of people in need of life-long HIV/AIDS treatment,
as well as new evidence about the preventive benefits of early treatment, have
heightened concern over the sustainability of treatment programs and incited
debate over the appropriate balance of funding between antiretroviral treatment
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The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria
(ART) and other HIV/AIDS interventions. Growing rates of HIV/TB co-infection
and drug-resistant TB strains have increased calls for escalating TB control
efforts. Finally, growing resistance to anti-malaria drugs and insecticides
threatens malaria control efforts, leading to calls for more attention to reducing
resistance and developing new anti-malaria commodities.
• Cross-Cutting Issues: Several cross-cutting issues are currently being debated,
particularly in relation to increased efficiency and sustainability of HIV/AIDS,
TB, and malaria programs under the GHI. These include
• Health Systems Strengthening;
• Country Ownership in Recipient Countries;
• Research and Development;
• Monitoring and Evaluation; and
• Engagement with Multilateral Organizations.
For details on particular characteristics of the HIV/AIDS, TB, and malaria epidemics and the U.S.
response, see the following CRS reports, by Alexandra E. Kendall.
• CRS Report R41645, U.S. Response to the Global Threat of HIV/AIDS: Basic
Facts
• CRS Report R41643, U.S. Response to the Global Threat of Tuberculosis: Basic
Facts
• CRS Report R41644, U.S. Response to the Global Threat of Malaria: Basic
Facts
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Contents
Introduction...................................................................................................................................... 1
Recent Developments ...................................................................................................................... 2
U.S. Policy Background................................................................................................................... 2
Clinton Administration .............................................................................................................. 2
Bush Administration.................................................................................................................. 3
Obama Administration............................................................................................................... 5
U.S. Funding Levels and Trends...................................................................................................... 7
Trends in Funding for HIV/AIDS, TB, and Malaria: FY2001-FY2012.................................... 9
FY2012 Funding...................................................................................................................... 11
FY2013 Budget ....................................................................................................................... 12
Progress in Combating HIV/AIDS, TB, and Malaria .................................................................... 12
Progress in Global HIV/AIDS................................................................................................. 12
Progress in Global TB ............................................................................................................. 13
Progress in Global Malaria...................................................................................................... 13
Key Disease-Specific Issues .......................................................................................................... 14
HIV/AIDS................................................................................................................................ 14
Tuberculosis............................................................................................................................. 17
HIV/TB Co-infection ........................................................................................................ 17
Drug-Resistant TB............................................................................................................. 18
Malaria..................................................................................................................................... 19
Drug and Insecticide Resistance ....................................................................................... 19
Control, Elimination, and Eradication............................................................................... 20
Key Cross-Cutting Issues............................................................................................................... 22
Health Systems Strengthening (HSS)...................................................................................... 22
Health Worker Shortages................................................................................................... 24
Country Ownership ................................................................................................................. 26
Research and Development (R&D)......................................................................................... 27
Monitoring and Evaluation (M&E) ......................................................................................... 29
Engagement with Multilateral Organizations.......................................................................... 31
Looking Forward ........................................................................................................................... 33
Figures
Figure 1. GHI Proposed Funding Distribution, FY2009-FY2014................................................... 6
Figure 2. Distribution of Funding for Global Health Programs, FY2001-FY2012 ....................... 10
Figure 3. U.S. Funding Trend Line for HIV/AIDS, TB, and Malaria FY2001-FY2012 ............... 11
Figure 4. PEPFAR Funding for Prevention, Treatment, and Care FY2006-FY2009 .................... 15
Figure 5. Phases of Malaria Control Efforts, 2011 ........................................................................ 21
Figure 6. U.S. Bilateral and Multilateral HIV/AIDS, TB, and Malaria Funding, FY2012 ........... 32
Figure D-1. U.S. Bilateral HIV/AIDS Funding, by Country, FY2009 .......................................... 44
Figure D-2. HIV Prevalence Rates and PEPFAR COP Countries, 2009 ....................................... 45
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Figure D-3. U.S. Bilateral TB Funding, by Country, FY2009....................................................... 46
Figure D-4. TB Prevalence Rates and USAID TB Countries, 2009.............................................. 47
Figure D-5. U.S. Bilateral Malaria Funding, by Country, FY2009 ............................................... 48
Figure D-6. Malaria Prevalence Rates and PMI Focus Countries, 2009 ....................................... 49
Tables
Table 1. U.S. Funding for Global HIV/AIDS, TB, and Malaria: FY2008-FY2013 ........................ 8
Table 2. HIV/AIDS, TB, and Malaria Research and Development Funding, FY2008.................. 28
Table C-1. FY2001-FY2013 Global HIV/AIDS, TB, and Malaria Funding, by Agency
and Program................................................................................................................................ 41
Table C-2. FY2001-FY2012 Global HIV/AIDS, TB, and Malaria Funding Totals in
Constant Dollars ......................................................................................................................... 42
Appendixes
Appendix A. Acronyms and Abbreviations ................................................................................... 36
Appendix B. HIV/AIDS, TB, and Malaria GHI Goals.................................................................. 38
Appendix C. HIV/AIDS, TB, and Malaria Funding...................................................................... 40
Appendix D. HIV/AIDS, Tuberculosis, and Malaria Program Maps ............................................ 43
Contacts
Author Contact Information........................................................................................................... 50
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The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria
Introduction
Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS),
tuberculosis (TB), and malaria are three of the world’s leading causes of morbidity and mortality.
Along with the direct health effects, HIV/AIDS, TB, and malaria have far-reaching
socioeconomic consequences, posing what many analysts believe are threats to international
development and security. Because of this, the United States has considered the fights against
these three diseases to be important foreign policy priorities. In FY2011, of the $7.8 billion the
United States spent on global health programs under the Global Health Initiative (GHI)—the
Obama Administration’s effort to coordinate and improve U.S. global health programming—
approximately 83% was on bilateral and multilateral HIV/AIDS, TB, and malaria combined, with
bilateral HIV/AIDS programs accounting for 63% of all funding. The United States is currently
the single largest donor for global HIV/AIDS and has played a key role in generating a robust
international response to TB and malaria.1
Despite growing international support for global health programs over the last decade and
progress made in controlling HIV/AIDS, TB, and malaria in much of the world, significant
obstacles remain in fighting the three diseases. In many countries, HIV infection rates are
outpacing access to treatment, rates of drug resistance are increasing for TB and malaria, and
health systems in resource-poor settings are under increasing pressure to address these diseases
while struggling to provide basic health care.
Over the last few years, Congress has debated the U.S. strategy to confronting these diseases,
including how to best support a long-term approach to these diseases that generates positive
outcomes for global health in general. In response, implementing agencies have begun to make
programmatic changes, and the Obama Administration has called for a revised U.S. approach to
HIV/AIDS, TB, and malaria in the hopes of making related efforts more effective and efficient.
This process has led to a broader discussion on how best to allocate global health funding, both
within and between programs. The financial crisis and economic recession, and consequent calls
to reduce the U.S. budget deficit, have led to decreased funding for these diseases in recent years,
and have heightened the urgency of reevaluating U.S. global health investments. This report
highlights some of the current challenges posed by HIV/AIDS, TB, and malaria, as well as
several cross-cutting policy issues that the 112th Congress may consider as it determines U.S.
global health funding for these three diseases, including
• Health Systems Strengthening,
• Country Ownership,
• Research and Development,
• Monitoring and Evaluation, and
• Engagement with Multilateral Organizations.
1 For more information on the HIV/AIDS, TB, and malaria epidemics, and the U.S. response to each disease, see CRS
Report R41645, U.S. Response to the Global Threat of HIV/AIDS: Basic Facts, by Alexandra E. Kendall; CRS Report
R41643, U.S. Response to the Global Threat of Tuberculosis: Basic Facts, by Alexandra E. Kendall; and CRS Report
R41644, U.S. Response to the Global Threat of Malaria: Basic Facts, by Alexandra E. Kendall.
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Recent Developments
• In May 2011, results from a study demonstrated that early HIV treatment in
couples with one infected partner reduced the risk of transmission by 96%.2 This
finding indicated the preventative benefits of HIV treatment and has been hailed
by many as a “game-changer” in the fight against global HIV/AIDS.
• In November 2011, the Board of the Global Fund to Fight AIDS, Tuberculosis,
and Malaria (Global Fund) announced that due to the current fiscal environment
and resulting inadequate funding, it was canceling its 11th round of funding.
While it has put a “transitional funding mechanism” in place to avoid disruption
of existing services, it will not be offering any new funding until 2014.
• On December 23, 2011, the President signed into law the Consolidated
Appropriations Act, 2012 (P.L. 112-74). Congress appropriated $7.3 billion for
HIV/AIDS, TB, and malaria programs in FY2012, including slightly decreased or
level funding for HIV/AIDS, and slightly increased funding for malaria and TB
programs.
• On February 13, 2012, the President released the FY2013 budget request. The
request included approximately $7.1 billion for HIV/AIDS, TB, and malaria
programs, which included further decreases in funding for bilateral HIV/AIDS,
TB, and malaria programs. At the same time, the request included a considerable
increase in funding for the Global Fund. Despite the proposed decrease in
bilateral HIV/AIDS funding, the budget request affirmed the Administration’s
commitment to treating 6 million HIV-positive people by the end of 2013, a
target announced on World AIDS Day in 2011.
U.S. Policy Background
U.S. efforts to address HIV/AIDS, TB, and malaria have grown significantly over the last few
decades, as successive Administrations and Congresses have increasingly recognized the severity
and impact of these diseases.
Clinton Administration
An expansive U.S. government response to HIV/AIDS began under President Bill Clinton. In
1999, President Clinton launched the Leadership and Investment in Fighting an Epidemic (LIFE)
Initiative to address HIV/AIDS in 14 African countries and India, marking the first interagency
response to the epidemic. The following year, President Clinton signed into law the Global AIDS
and Tuberculosis Relief Act of 2000 (P.L. 106-264), boosting funding for both HIV/AIDS and TB
activities.
2 Myron Cohen et al., “Antiretroviral treatment to prevent the sexual transmission of HIV-1: results from the HPTN
052 multinational randomized controlled trial,” 6th International AIDS Society Conference on HIV Pathogenesis,
Treatment and Prevention (IAS 2011), Rome, July 17-20, 2011.
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Bush Administration
The George W. Bush Administration greatly elevated the fight against HIV/AIDS, TB, and
malaria in the U.S. foreign policy agenda. In 2001, President Bush contributed the “founding
pledge” to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), a public-
private financing mechanism for the global response to HIV/AIDS, TB, and malaria.3 Shortly
thereafter, in 2002, President Bush launched the International Mother and Child HIV Prevention
Initiative, supporting prevention of mother-to-child transmission (PMTCT) activities in 12
African and 2 Caribbean countries.
In 2003, the Bush Administration announced the establishment of the President’s Emergency Plan
for AIDS Relief (PEPFAR), pledging $15 billion over the course of five years to combat
HIV/AIDS, TB, and malaria. This pledge represented the largest commitment ever by a single
nation toward an international health issue, and established a new and central role for donor
governments in the fight against HIV/AIDS. Of the $15 billion, the President proposed spending
$9 billion on HIV/AIDS prevention, treatment, and care services in 15 focus countries.4 The
President also proposed spending $5 billion of the funds on existing bilateral HIV/AIDS, TB, and
malaria programs in roughly 100 other countries and $1 billion of the funds for U.S. contribution
to the Global Fund.
The 108th Congress authorized the establishment of PEPFAR in May 2003 through the U.S.
Leadership Against HIV/AIDS, TB, and Malaria Act of 2003 (Leadership Act, P.L. 108-25). The
act authorized $15 billion for U.S. efforts to combat global HIV/AIDS, TB, and malaria from
FY2004 through FY2008, including $1 billion for the Global Fund in FY2004. The act also
authorized the creation of the Office of the Global AIDS Coordinator (OGAC) at the Department
of State to oversee all U.S. global HIV/AIDS activities. Beyond increasing the scope of U.S.
HIV/AIDS programs, the Leadership Act also shifted the focus of U.S. HIV/AIDS activities. In
particular, while past U.S. global HIV/AIDS programs had primarily supported prevention
activities, the Leadership Act set targets for extending anti-retroviral therapy (ART) and required
that 55% of PEPFAR funds be spent on HIV/AIDS treatment.
Building on the success of PEPFAR in harnessing resources to combat a disease, President Bush
announced the establishment of the President’s Malaria Initiative (PMI) in 2005, which
significantly increased U.S. funding for global malaria programs. PMI was a five-year, $1.2
billion commitment to halve the number of malaria-related deaths in 15 sub-Saharan African
countries5 by 2010 through the use of four proven techniques:
1. indoor residual spraying (IRS),
2. insecticide-treated bed nets (ITNs),
3 For more information on the Global Fund, see CRS Report R41363, The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Issues for Congress and U.S. Contributions from FY2001 to the FY2012 Request, by Tiaji Salaam-
Blyther.
4 The original PEPFAR focus countries included Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya,
Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. Vietnam was added as a focus
country in June 2004.
5 The original 15 PMI focus countries were added over the course of three fiscal years. PMI began operations in
Angola, Tanzania, and Uganda in FY2006, in Malawi, Mozambique, Rwanda, and Senegal in FY2007, and in Benin,
Ethiopia, Ghana, Kenya, Liberia, Madagascar, Mali, and Zambia in FY2008. Nigeria and the Democratic Republic of
the Congo were added as PMI focus countries in FY2011.
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3. artemisinin-based combination therapies (ACTs) to treat malaria, and
4. intermittent preventative treatment for pregnant women (IPTp).
PMI represented a significant shift from past United States Agency for International Development
(USAID) malaria programs. Until then, USAID’s malaria programs provided primarily technical
assistance. Under PMI, a minimum of 50% of the budget was devoted to the purchase and
distribution of malaria-fighting commodities. The design of PMI also took into account some of
the criticism levied against PEPFAR in its first two years, including the need to strengthen the
alignment of programs with country priorities and better integrate programs into national health
systems.
No analogous initiative was established for global TB. However, in 2007, the 110th Congress
enacted the Consolidated Appropriations Act of 2008 (P.L. 110-161), which markedly increased
funding for TB control efforts. The act provided unprecedented funding to expand USAID TB
programs in high-burden countries. The act also recognized the growing threat of HIV/TB co-
infection and directed OGAC to spend at least $150 million of its funds for PEPFAR on joint
HIV/TB activities.
In July 2008, the 110th Congress enacted the Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-
Hyde Act, P.L. 110-293), authorizing $48 billion for bilateral and multilateral efforts to fight
global HIV/AIDS, TB, and malaria from FY2009 through FY2013. Of the $48 billion, $4 billion
was for bilateral TB programs, $5 billion was for bilateral malaria programs, and $2 billion was
for U.S. contributions to the Global Fund in FY2009. The act also authorized the establishment of
the Global Malaria Coordinator at USAID to oversee and coordinate all U.S. global malaria
activities.
U.S. HIV/AIDS, TB, and malaria programs under the Bush Administration received strong
bipartisan congressional support. At the same time, Congress and the global health community
debated several aspects of PEPFAR, including
• the relationship between HIV/AIDS activities and other global health activities;
• the effectiveness of abstinence-only education;
• the integration of family planning into HIV/AIDS activities;
• the use of branded versus generic drugs;
• the role of recipient countries in setting assistance priorities; and
• the balance of funding between prevention, treatment, and care activities.
Many critics argued that PEPFAR was overly unilateral, relied too heavily on U.S.-based
organizations, and did little to strengthen national health systems or country capacity to cope with
the epidemic in the long run. The Lantos-Hyde Act was intended to respond to a number of these
criticisms and support the transition of PEPFAR from an emergency plan to a sustainable,
country-led program.6
6 For an example of congressional discussion of these issues, see U.S. Congress, House Committee on Foreign Affairs,
PEPFAR Reauthorization: From Emergency to Sustainability, 110th Cong., 1st sess., September 27, 2007, Serial No.
110-116 (Washington: GPO, 2007), http://internationalrelations.house.gov/110/37971.pdf.
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Obama Administration
Partly in response to the above-mentioned debates, on May 5, 2009, President Barack Obama
announced a six-year, $63 billion Global Health Initiative (GHI). The GHI is a comprehensive
U.S. global health strategy that brings together a number of existing global health funding streams
and programs managed by USAID and the Centers for Disease Control (CDC), as well as
HIV/AIDS programs managed by the State Department and the Department of Defense (DOD).
The initiative calls for the coordination and integration of established HIV/AIDS, TB, and
malaria programs with one another and with other, broader health activities to maximize
effectiveness, efficiency, and sustainability of U.S. global health programs. It also encourages
increased efforts to strengthen underlying health systems and support country ownership. Finally,
the GHI supports woman- and girl-centered approaches to global health, recognizing that women
and girls often suffer disproportionately from poor health.7
HIV/AIDS, TB, and malaria programs are core components of GHI. The Obama Administration
proposes spending 81% of all GHI funding on the three diseases from FY2009 through FY2014
(Figure 1). Since 2009, implementing agencies have produced multi-year HIV/AIDS, TB, and
malaria strategies, which each articulate goals and strategies to support an integrated, long-term,
and country-led approach to global health, in accordance with the GHI principles (see the
“HIV/AIDS, TB, and Malaria GHI Goals” section). In a demonstration of his commitment to the
fight against global HIV/AIDS, on World AIDS Day in 2011, President Obama announced an
increased target of providing treatment to 6 million people infected with HIV by 2013.8
7 Implementation of the Global Health Initiative, Consultation Document, USAID, http://www.usaid.gov/our_work/
global_health/home/Publications/docs/ghi_consultation_document.pdf.
8 The White House, “Remarks by the President on World AIDS Day,” press release, December 1, 2011,
http://www.whitehouse.gov/photos-and-video/video/2011/12/01/president-obama-world-aids-day#transcript.
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Figure 1. GHI Proposed Funding Distribution, FY2009-FY2014
(U.S. billions)
Source: CRS Analysis of GHI Consultation Document, Implementation of the GHI, February 2010.
In the three years since the launch of the GHI, the Administration has released a number of key
documents demonstrating how the GHI principles are beginning to be implemented in the field.
As of November 2011, 29 “GHI Plus” countries have been chosen to receive additional resources
and technical assistance to accelerate implementation of the GHI and to serve as “learning
laboratories” for best practices (the GHI will ultimately be implemented in every country
receiving health assistance).9
In March 2011, the Administration released the “United States Government Global Health
Initiative Strategy Document” as well as GHI Country Strategies outlining high-level priority
areas and targets for country programs.10 These multi-year strategies also serve as guidelines for
new coordination efforts between PEPFAR, USAID, and CDC, as they aim to reduce duplication
between programs, integrate services where appropriate, and better align programs with the
priorities of partner governments. Several outside studies have documented early signs of
progress toward a more cohesive and coordinated approach to global health, including in relation
9 In July 2011, the first eight “GHI Plus” countries were named. They included Bangladesh, Ethiopia, Guatemala,
Kenya, Mali, Malawi, Nepal, and Rwanda. In November 2011, a second round of 21 “GHI Plus” countries were
named. They are Burundi, Democratic Republic of Congo, Georgia, Indonesia, Lesotho, Liberia, Sierra Leone,
Tanzania, Ukraine, Vietnam, Botswana, Cambodia, Mozambique, Benin, South Africa, Namibia, Nigeria, Senegal,
Dominican Republic, Philippines, and Swaziland.
10 These resources are available at the Global Health Initiative website, http://www.ghi.gov/.
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to HIV/AIDS, TB, and malaria programs.11 Questions remain over how GHI will lend itself to
significant innovation, whether early progress in coordination can be brought to scale, and
whether efforts to better integrate global health activities can be sustained without significant
additional resources. Also, despite the Administration’s stated commitment to existing initiatives
like PEPFAR and PMI, some experts have expressed concern that a new focus on coordination
and integration will lead to decreasing support for touchstone disease-specific programs.
U.S. Funding Levels and Trends
Congress provides funds for HIV/AIDS, TB, and malaria assistance through several
appropriations vehicles, including State and Foreign Operations; Labor, Health and Human
Services, and Education; and the Department of Defense. Funds are appropriated to a number of
U.S. agencies including the Department of State, USAID, CDC, and DOD. Congress also
provides sufficient resources to the Office of AIDS Research at the National Institutes of Health
(NIH) to support international HIV/AIDS research efforts. The agencies use the funds for
bilateral HIV/AIDS, TB, and malaria programs and for contributions to multilateral organizations
that address these diseases, including the Global Fund.
Since FY2001, U.S. funding in support of global HIV/AIDS, TB, and malaria programs has
significantly increased. Funding for FY2012, as signed into law by the President on December
23, 2011, demonstrates continued congressional commitment to global HIV/AIDS, TB, and
malaria programs, although it does not support the increased funding for these programs included
in the President’s FY2012 budget request. For a snapshot of recent years, Table 1 includes U.S.
actual, enacted, and requested funding for global HIV/AIDS, TB, and malaria from FY2008
through FY2013. Appendix C includes all U.S. actual and estimated funding for global
HIV/AIDS, TB, and malaria from FY2001 through FY2012, as well as the President’s FY2013
budget request.
11 For example, see Center for Strategic and International Studies (CSIS), The Global Health Initiative in Malawi: New
Approaches and challenges to Reaching Women and Girls, December 2011, http://csis.org/publication/global-health-
initiative-malawi, CSIS, On the Ground with the Global Health Initiative: Examining Progress and Challenges in
Kenya, March 2011, http://csis.org/publication/ground-global-health-initiative and Kaiser Family Foundation, The U.S.
Global Health Initiative: A Country Analysis, February 2011, http://www.kff.org/globalhealth/8140.cfm.
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Table 1. U.S. Funding for Global HIV/AIDS, TB, and Malaria: FY2008-FY2013
(current U.S. $ millions)
% Change
% Change
FY2011
FY2012
Actual
Estimate
Agency or
FY2008
FY2009
FY2010
FY2011
FY2012
– FY2012
FY2013
– FY2013
Programa
Actual
Actual
Actual
Actual
Estimate
Estimate
Request
Request
USAID
HIV/AIDS
(GHCS/GHP)b
347.2 350.0 350.0
349.3 350.0 0.2% 330.0 -5.7%
USAID
HIV/AIDS
(Other
Accounts)c
24.8 0.0 0.0
0.0 0.0 0.0% 0.0 0.0%
State
HIV/AIDS
4,116.4 4,559.0 4,609.0
4,585.8 4,242.9
-7.5% 3,700.0 -12.8%
CDC
HIV/AIDS
118.9 118.9 119.0
118.7 117.1 -1.3% 117.2 0.1%
NIH Global
AIDS
Research
411.7 451.7 485.6
375.7 364.5 -3.0% 388.9 6.7%
DOD
HIV/AIDS 8.0
8.0
10.0
10.0
8.0
-20.0%
8.0
0.0%
FMF
HIV/AIDS
1.0 0.0 0.0
0.0 0.0 0.0% 0.0 0.0%
HIV/AIDS
Subtotal
5,028.0 5,487.6 5,573.6
5,439.5 5,082.5
-6.6% 4,544.1 -10.6%
USAID TB
(GHCS/GHP) 148.0 162.5 225.0
224.6 236.0 5.1% 224.0 -5.1%
USAID TB
(Other
Accounts)
15.2 14.1 18.2
13.8 13.8 0.0% 8.0 -42.0%
TB Subtotal
163.2 176.6 243.2
238.4 249.8 4.8% 232.0 -7.1%
USAID
Malaria
(GHCS/GHP) 347.2 382.5 585.0
618.8 650.0 5.0% 619.0 -4.8%
USAID
Malaria
(Other
Accounts)
2.4 2.5 0.0
0.0 0.0 0.0% 0.0 0.0%
CDC
Malaria 8.7 9.4 9.4
9.4 9.3 -1.1% 9.4 1.1%
Malaria
Subtotal
358.3 394.4 594.4
628.2 659.3 5.0% 628.4 -4.7%
USAID Global
Fund
Contribution 0.0
100.0 0.0
0.0 0.0 0.0% 0.0 0.0%
State Global
Fund
Contribution
545.5 600.0 750.0
748.5
1,300.0 73.7% 1650.0 26.9%
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% Change
% Change
FY2011
FY2012
Actual
Estimate
Agency or
FY2008
FY2009
FY2010
FY2011
FY2012
– FY2012
FY2013
– FY2013
Programa
Actual
Actual
Actual
Actual
Estimate
Estimate
Request
Request
HHS Global
Fund
Contribution 294.8 300.0 300.0
297.3 0.0 -100.0%
0.0 0.0%
Global Fund
Subtotal
840.3 1,000.0 1,050.0
1,045.8 1,300.0 24.3% 1650.0 26.9%
HIV/AIDS,
TB, and
Malaria
Total
6,389.8 7,058.6 7,461.2
7,351.9 7,291.6
-0.8% 7,054.5
-3.3%
Source: Compiled by CRS from appropriations legislation, congressional budget justifications, and the
President’s budget request.
Note: n/s = not specified.
a. Centers for Disease Control and Prevention (CDC); National Institutes of Health (NIH); Department of
Labor (DOL); Department of Defense (DOD); Department of Health and Human Services (HHS), United
States Agency for International Development (USAID), Foreign Military Financing Account (FMF).
b. Global Health and Child Survival Account (GHCS). In FY2013, the GHCS account was renamed the Global
Health Programs (GHP) Account.
c. This includes funding from the Development Assistance Account (DA), the Economic Support Fund
Account (ESF), and the Assistance for Europe, Eurasia, and Central Asia Account (AEECA).
Trends in Funding for HIV/AIDS, TB, and Malaria: FY2001-FY2012
Over the past decade, Congress has demonstrated significant support for U.S. programs targeting
global HIV/AIDS, TB, and malaria. In particular, the enactment of the Leadership Act and the
Lantos-Hyde Act raised the profile of HIV/AIDS, TB, and malaria and authorized increases in
U.S. investments for countering each disease. Congress has also held a number of hearings in
recent years to evaluate U.S. HIV/AIDS, TB, and malaria programs and to debate various
approaches to fighting the diseases. While congressional action (including legislation and
hearings) has tended to group the three diseases together, the response to each has varied widely,
with HIV/AIDS receiving considerably more funding and attention than either TB or malaria.
Funding for each of the diseases has increased drastically since FY2001. Between FY2001 and
FY2012, funding for bilateral HIV/AIDS, TB, and malaria programs in constant dollars has
increased by approximately 600%, 201%, and 656%, respectively. Despite the marked increases
in funding, particularly for global HIV/AIDS and malaria, there are significant differences in the
percentage of the global health budget that each disease receives. Since the establishment of
PEPFAR, HIV/AIDS programs have accounted for close to or over 50% of the global health
budget, while TB programs have received between approximately 1.6% and 3.8%, and malaria
programs have received between approximately 2.6% and 7.6% of global health funding,
depending on the year (Figure 2). The establishment of PMI in 2005 raised the profile of U.S.
global malaria programs, increasing its share of the global health budget from 2.8% in FY2005 to
7.6% in FY2012. U.S. support for fighting global TB has trailed that of HIV/AIDS and malaria
and, unlike the other two, global TB has no U.S. presidential initiative or designated U.S.
coordinator. Health experts continue to debate the appropriate apportionment of funding for the
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three diseases, including questions over the relative impact of and costs of treatment for each
disease.
Figure 2. Distribution of Funding for Global Health Programs, FY2001-FY2012
Source: Compiled by CRS from appropriations legislation and congressional budget justifications.
Notes: “Other Global Health” includes programs targeting Maternal, Neonatal, and Child Health (MNCH),
Family Planning/Reproductive Health (FP/RH), Neglected Tropical Diseases (NTDs), and other activities.
FY2001-FY2011 are actual funding amounts. FY2012 is an estimated funding amount.
Although absolute funding for all three diseases has increased since FY2001, specific trends for
each disease have differed (Figure 3). Funding for HIV/AIDS increased rapidly from FY2004
through FY2008, during the first phase of PEPFAR, and has largely leveled off since the initiative
was reauthorized. Funding for malaria increased significantly following the establishment of PMI
in FY2006 and has since seen further increases. Funding for TB increased most rapidly in
FY2008 and FY2010, followed by a slight decrease in FY2011 and a slight increase in FY2012.
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Figure 3. U.S. Funding Trend Line for HIV/AIDS, TB, and Malaria FY2001-FY2012
(constant U.S. $ millions)
Source: Compiled by CRS from congressional budget justifications and appropriations legislation.
Notes: This graph has a secondary axis (in red) to account for the significant differences in funding amounts for
HIV/AIDS and funding amounts for TB, malaria, the Global Fund.
FY2012 Funding
On December 23, 2011, the President signed into law the Consolidated Appropriations Act, 2012
(P.L. 112-74). The act included specific appropriations for State Department, USAID, HHS, and
DOD global HIV/AIDS programs; USAID TB and malaria programs; and U.S. contributions to
the Global Fund. While the estimated FY2012 funding level for all global health programs was
higher than the FY2011 actual level, FY2012 funding for HIV/AIDS, TB, and malaria programs
was slightly lower than in FY2011, and included a decrease in funding for global HIV/AIDS
programs, a slight increase in funding for global TB program, and larger increases in funding for
global malaria programs and the U.S. contribution to the Global Fund. Some health experts have
expressed concern about the continuing flat-lining of global HIV/AIDS funding over the past few
years. In particular, advocates have argued that any reductions in funding undermine recent
scientific breakthroughs, which demonstrate that with adequate financial support, available
prevention and treatment methods can be harnessed to significantly decrease new HIV infections
and AIDS-related deaths. Others argue that given that HIV/AIDS funding tied to continuing
lifelong treatment for people with HIV will likely be considered impervious, coupled with the
new increased targets for treatment by 2013, the cuts made to HIV/AIDS programs may affect
critical prevention and care activities, as well as broader HIV-related efforts in areas like health
systems strengthening and country ownership.
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While the FY2012 Consolidated Appropriations Act largely maintains support for programs
targeting the three diseases, its enactment occurred after prolonged congressional debate over
reducing the budget deficit through lower discretionary spending levels, with some Members
proposing cuts to global HIV/AIDS, TB, and malaria programs. Some Members of Congress
argued that these cuts could lead to important savings, while others strongly criticized any
reduction in funding, arguing that it would undermine essential programs with humanitarian,
development, diplomatic, and security implications. Compared to the President’s request of $8.7
billion for all global health programs under the GHCS Account in FY2012, the House
Subcommittee on State, Foreign Operations, and Related Programs mark-up of the FY2012 State-
Foreign Operations appropriations bill recommended $7.1 billion for global health programs
under the GHCS Account, representing an 18% decrease from the request, and the Senate
Appropriations Committee-passed bill recommended $7.9 billion for global health, a 9.2%
decrease from the request. The estimated total funding level for GHCS global health programs in
FY2012 was higher than both the House and Senate recommendations, representing a 6.9%
decrease from the Administration’s request. A number of health advocates have applauded the
relatively small reductions made in FY2012.
FY2013 Budget
On February 13, 2012, President Obama released the FY2013 budget request. When compared to
FY2012 estimated funding levels, the budget requests funding decreases for all bilateral
HIV/AIDS, TB, and malaria programs, including, most prominently, a 10.6% decrease in funding
for bilateral HIV/AIDS programs. At the same time, the budget requested significantly increased
funding for the Global Fund, representing a 26.9% increase in funding over FY2012 levels (see
Table 1).
While the proposed increase in support to the Global Fund has been applauded by some health
advocates, many express concern over the reduction in funding for bilateral programs, most
especially PEPFAR programs. These experts argue that divestment in global HIV/AIDS and TB
programs could imperil lives, reverse recent progress, undermine significant scientific findings,
and lead to decreasing levels of support from other donors.
The Lantos-Hyde Act authorized $48 billion for global HIV/AIDS, TB, and malaria programs
from FY2009 through FY2013, including contributions to the Global Fund. Current spending
trends suggest that the authorized level may exceed appropriated amounts by over $10 billion.
Progress in Combating HIV/AIDS, TB, and Malaria
In late 2011, the World Health Organization (WHO) and the Joint United Nations Program on
HIV/AIDS (UNAIDS) released new estimates of the scale of the global HIV/AIDS, TB, and
malaria epidemics. The separate reports on each disease highlighted significant progress being
made in the fight against the diseases, much of which is attributable to the leadership and support
of the United States. The reports, characterized below, also identified major obstacles that remain.
Progress in Global HIV/AIDS
The 2011 WHO/UNAIDS report on global HIV/AIDS noted advancements in combating the
global HIV/AIDS epidemic, including the landmark finding that among couples with one infected
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partner, early use of antiretroviral therapy can reduce transmission by at least 96%. The report
also noted expanded access to several HIV/AIDS interventions, including HIV testing and
counseling, anti-retroviral therapy, and drugs to prevent mother-to-child HIV transmission
(PMTCT). Partly as a result of these interventions, both HIV-related mortality and incidence rates
have declined.12 In 2010, HIV-related deaths were close to one-fifth lower than in 2004 and the
rate of new HIV infections was almost 25% lower than in 1996, the year that the HIV incidence
rate is thought to have peaked. At the same time, WHO cited several ongoing challenges.
HIV/AIDS is still without a cure or vaccine, and in 2010 alone, an estimated 2.7 million people
were newly infected. New infections, combined with expanded access to ART for those already
infected, create greater numbers of people requiring indefinite, lifelong treatment.13
Progress in Global TB
According to the 2011 WHO report on global TB, by 2008, most countries in the world had
adopted WHO’s Stop TB Strategy (the international guidance for prevention and treatment of
TB). The global adoption of WHO prevention and treatment standards has enabled more than 55
million people infected with TB to receive treatment and prevented up to 7 million deaths
between 1995 and 2010.14 Global rates of new TB infection have been declining since 2002, and
the absolute number of TB cases has been declining since 2006. The WHO report highlighted
some ongoing obstacles to TB control as well. Progress in global TB control is also challenged by
HIV/TB co-infection and new forms of drug resistant TB. Outdated tools for diagnosis and
treatment, particularly in relation to HIV/TB co-infection and resistant forms of the disease,
hamper further progress.15
Progress in Global Malaria
The 2011 WHO report on global malaria emphasized the effective scale-up of several malaria
control interventions, including greater use of the latest malaria treatments, insecticide-treated
bednets, indoor residual spraying, and drugs to reduce the transmission of malaria during
pregnancy. Since 2000, 43 countries have experienced more than a 50% reduction in reported
number of malaria cases and 8 African countries have experienced at least a 50% reduction in
either confirmed malaria cases or malaria admissions and deaths. The decreases in each of these
African countries are associated with intense malaria control activities. Despite this success, the
report also noted obstacles in the fight against malaria. In particular, coverage rates of ITNs and
IRS and access to ACTs remain low in many African countries, and increasing drug and
insecticide resistance pose new challenges.16 Finally, while WHO estimated that there were 0.7
million deaths from malaria in 2010, a study published in The Lancet in February 2012 estimated
12 Incidence measures the number of people who contract a disease within a given time period (usually one year).
Prevalence measures the number of people living with a disease at a given time.
13 UNAIDS, Global HIV/AIDS Response: Progress Report 2011, 2011, http://www.unaids.org/en/media/unaids/
contentassets/documents/unaidspublication/2011/20111130_UA_Report_en.pdf.
14 World Health Organization (WHO), Global Tuberculosis Control, 2011, http://www.who.int/tb/publications/
global_report/2011/gtbr11_full.pdf.
15 Ibid.
16 WHO, World Malaria Report, 2011, http://www.who.int/malaria/world_malaria_report_2011/
9789241564403_eng.pdf.
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that there were actually 1.1 million malaria deaths in 2010, indicating that the epidemic might
have been far more severe than previously thought.17
Key Disease-Specific Issues
HIV/AIDS, TB, and malaria overlap geographically, share risk factors, and can worsen the
symptoms of each other in instances of co-infection. Despite these common factors, each disease
presents unique challenges, which Congress may consider as it debates the U.S. response to each
disease. For more information on the particular characteristics of and U.S. response to each of the
diseases, see the following CRS reports by Alexandra Kendall: CRS Report R41645, U.S.
Response to the Global Threat of HIV/AIDS: Basic Facts; CRS Report R41643, U.S. Response to
the Global Threat of Tuberculosis: Basic Facts; and CRS Report R41644, U.S. Response to the
Global Threat of Malaria: Basic Facts.
HIV/AIDS
Sustaining the successes achieved in fighting HIV/AIDS presents new policy challenges. While
AIDS-related mortality and HIV incidence rates have declined, improved access to anti-retroviral
therapy (ART) combined with continued new infections has led to growing numbers of people
living with HIV/AIDS and requiring lifelong treatment. At the same time, the new and long-term
financial costs associated with expanded access to ART have increased concern over the
sustainability of U.S. treatment programs, and have increased calls for considerable scale-up of
prevention efforts.
The expansion of ART to treat HIV/AIDS has significantly reduced AIDS-related mortality. 2011
UNAIDS estimates suggest that 2.5 million deaths in low- and middle-income countries have
been averted since the introduction of ART in 1995.18 Treatment has been a central component of
PEPFAR programs. According to a 2010 Government Accountability Office (GAO) report, from
FY2006 to FY2009, 46% of PEPFAR funds were used to support treatment efforts, with the rest
of the funds divided between prevention and care activities (Figure 4). As of September 2011,
PEPFAR was directly supporting ART for over 3.9 million individuals in 30 countries—
representing over half of the estimated 6.7 million people on treatment around the world.19 In
2009, the Administration committed the United States to treating an additional 4 million people
infected with HIV/AIDS from FY2009 to FY2014.20 On World AIDS Day in December 2011,
President Obama announced that the United States was committing to a new target of providing
treatment to 6 million people by the end of 2013.21
17 Christopher Murray et al., “Global Malaria Mortality Between 1980 and 2010: A Systematic Analysis,” The Lancet,
vol. 379, no. 9814 (February 4, 2010). WHO disputes these findings. For WHO’s response, see Lisa Schlein, “WHO
Stands by Its Numbers on Malaria Deaths,” Voice of America, February 3, 2012.
18 UNAIDS, Global HIV/AIDS Response: Progress Report 2011, 2011.
19 Department of State, The United States President’s Emergency Plan for AIDS Relief, Using Science to Save Lives:
Latest PEPFAR Results, http://www.pepfar.gov/results/index.htm.
20 The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy, Annex: PEPFAR’s Contributions to the
Global Health Initiative, Office of the U.S. Global AIDS Coordinator, Department of State, December 2009,
http://www.pepfar.gov/documents/organization/133437.pdf.
21 The White House, “Remarks by the President on World AIDS Day,” press release, December 1, 2011,
http://www.whitehouse.gov/the-press-office/2011/12/01/remarks-president-world-aids-day.
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Figure 4. PEPFAR Funding for Prevention, Treatment, and Care FY2006-FY2009
Source: GAO, Global Health: Trends in U.S. Spending for Global HIV/AIDS and Other Health Assistance in Fiscal Years
2001-2008, Report to Congressional Committees, GAO-11-64, October 2010, p. 8.
Notes: This graph refers only to FY2006-FY2009; it does not correspond to al PEPFAR funding since its
establishment in 2004.
a. For FY2006 and FY2007, PEPFAR care program figures included funding for al pediatric AIDS programs,
including treatment. In FY2008 and FY2009, PEPFAR counted pediatric care toward overal care funding and
pediatric treatment toward overal treatment funding.
In spite of the strides made in HIV treatment, the number of individuals newly infected with HIV
exceeded the number of individuals placed on treatment by almost a 2 to 1 margin in 2010. At the
end of that year, the 6.7 million people receiving treatment represented 47% of those in need.22
The number of people newly infected with HIV and requiring treatment is projected to grow
significantly in coming years.23 Expanding access to ART for new patients who will require
lifelong treatment will increase long-term treatment costs.24 Compounding this challenge is the
potential for increased rates of drug resistance and consequent need for second-line therapies,
which cost 5 to 10 times more than first-line drugs.25
22 UNAIDS, Global HIV/AIDS Response: Progress Report 2011, 2011.
23 Moreover, in July 2010, WHO published new guidance on ART for individuals in low-resource countries, advising
that treatment begin at an earlier stage of illness, thereby increasing the number of people eligible for treatment.
24 One model produced by aids2031, a UNAIDS-commissioned group of experts, estimated that total treatment costs
would be between $11 billion and $18 billion per year in 2020. See, Aids2031, Costs and Choices: Financing the
Long-Term Fight Against AIDS, Results for Development Institute, Costs and Financing Working Group, 2010.
25 Anil Soni and Rajat Gupta, “Bridging the Resource Gap: Improving Value for Money in HIV/AIDS Treatment,”
Health Affairs, vol. 28, no. 6 (November 2009), pp. 1617-1628.
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The logistical and fiscal challenges of scaling up treatment have led some experts to argue that
prevention efforts must be rapidly scaled up so that HIV incidence can be reduced. In 2001, the
results of an HIV prevention trial indicated that early initiation of ART in discordant couples26
reduced HIV transmission by 96%, by lowering the viral loads of infected people and therefore
reducing the possibility of transmission.27 These findings have confirmed the preventative
implications of HIV treatment and have reduced what was previously seen by some as a
dichotomous choice between increasing funds for treatment versus increasing funds for
prevention. At the same time, these findings raise new questions related to the appropriate
distribution of limited—or decreasing—funding for global HIV/AIDS, including how funds
should be divided between ART as treatment, ART as prevention, and other non-treatment-based
forms of prevention. Some also argue that the United States must consider how to make more
efficient use of available treatment resources, including in relation to earlier versus later initiation
of treatment and the distribution of resources between first-line and second-line drugs.28 The
President’s FY2013 budget request, which proposed decreased funding for bilateral global
HIV/AIDS programs while also reaffirming the Administration’s commitment to the new goal of
treating 6 million HIV-positive individuals by 2013, demonstrated the importance of evaluating
how to best allocate global HIV/AIDS funds.
Many HIV/AIDS experts stress that ART, as a tool of both treatment and prevention, must not
only be used increasingly, but also in tandem with other increased support for “combination
prevention” options, including biomedical, behavioral, and structural interventions (efforts to
address the social, political, and economic factors impacting vulnerability to HIV).29 In 2009,
prevention-specific activities accounted for 22% of HIV/AIDS spending in low- and middle-
income countries by all sources.30 According to UNAIDS, several methods of prevention have
demonstrated clear success. Prevention of mother-to-child transmission (PMTCT) has led to
reductions in children infected with HIV, and male circumcision has led to reduced likelihood of
uninfected men acquiring HIV from HIV-infected female partners.31 At the same time, UNAIDS
has argued that global prevention interventions are often not adequately directed at the
populations most in need, including people who inject drugs, sex workers and their clients, and
men who have sex with men (MSM).32 A major factor limiting the success of ART-based
prevention efforts, including early initiation of ART and PMTCT, is that more than 60% of people
living with HIV are unaware of their HIV status.33 Many experts argue that to improve the
effectiveness of HIV prevention, there must also be efforts to expand HIV testing and counseling.
26 An HIV-serodiscordant couple is one in which one partner is HIV-positive and the other HIV-negative.
27 National Institutes of Health, National Institute of Allergy and Infectious Diseases, “Treating HIV-infected people
with antiretrovirals protects partners from infection: Findings result from NIH-funded international study,” press
release, May 12, 2011, http://www.niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspx.
28 Institute of Medicine (IOM), Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility, November
29, 2010, http://www.iom.edu/Reports/2010/Preparing-for-the-Future-of-HIVAIDS-in-Africa-A-Shared-
Responsibility.aspx.
29 See, for example, Carl Dieffenbach and Anthony Fauci, “Thirty Years of HIV and AIDS: Future Challenges and
Opportunities,” Annals of Internal Medicine, vol. 154, no. 11 (June 7, 2011); Reuben Granich et al., “ART in
Prevention of HIV and TB: Update on Current Research Efforts,” Current HIV Research, vol. 9, no. 6 (2011); and
Mead Over, Achieving an AIDS Transition: Preventing Infections to Sustain Treatment (Washington, DC: Center for
Global Development, 2011).
30 UNAIDS, Report on the Global AIDS Epidemic, 2010, p. 63.
31 Ibid.
32 Ibid.
33 Ibid.
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In recent years, PEPFAR has placed new emphasis on prevention. For example, it committed to
preventing more than 12 million new infections from FY2009 to FY2014.34 PEPFAR’s five-year
strategy emphasizes scaling up combined interventions tailored to the key drivers of individual
country epidemics, and puts particular emphasis on PMTCT and male circumcision activities.
Despite this commitment, many health experts call for increased U.S. support of HIV/AIDS
prevention efforts in general, and efforts targeting high-risk groups in particular. Many experts
also urge the United States to increase its support for new methods to measure and evaluate
infection trends and prevention program impact, in order to effectively tailor prevention programs
to specific country epidemics and better assess the efficacy of various prevention programs.
While many Members of Congress agree that prevention must be a priority of HIV/AIDS
programs, there is less congressional consensus over which prevention activities are most
effective and should receive support.35 In particular, some in Congress express reservation at U.S.
support for prevention activities that they feel could be seen as supporting sex work or that may
be integrated with family planning and reproductive health services that could be connected to
abortion provision.36 Many health experts argue that in order for prevention efforts to be
successful, programs must be driven by data that indicate the needs of specific countries.37
Tuberculosis
Tuberculosis is the second-leading cause of infectious disease mortality around the world,
following HIV/AIDS, yet it receives less funding than either HIV/AIDS or malaria. Gains in
global TB control are challenged by growing occurrences of HIV/TB co-infection and drug-
resistance, as both strain already-dated tools used for TB diagnosis, treatment, and surveillance.
HIV/TB Co-infection
TB is the leading cause of death for people with HIV. Of the 8.8 million new cases of TB in 2010,
an estimated 1.1 million were HIV-positive. Along with HIV testing of TB patients, provision of
HIV and TB treatment to those infected with both diseases, and general HIV prevention services
for TB patients, WHO recommends three activities, known as the “Three I’s,” to address HIV/TB
co-infection: the provision of a prophylaxis, known as Isoniazid Preventative Therapy (IPT), for
HIV-positive people with latent TB; intensified case finding for active TB; and TB infection
control for HIV-positive people. Some argue that WHO’s “Three I’s” have been unevenly applied
34 The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy, Annex: PEPFAR’s Contributions to the
Global Health Initiative.
35 HIV prevention activities, particularly sex education, condom use, and interventions with sex workers, have been
politically divisive in Congress. The Leadership Act recommended that 20% of HIV/AIDS funds be spent on
prevention and required that 33% of prevention funds be spent on abstinence-until-marriage programs. A number of
health experts argued that these spending directives limited PEPFAR’s ability to address local prevention needs. The
Lantos-Hyde Act removed the spending stipulations, but mandated that OGAC report to Congress should “activities
promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction” amount to less than 50% of
spending on programs aimed at reducing sexual transmission of HIV in countries with generalized epidemics.
36 For more information on this issue, see CRS Report RL33250, International Family Planning Programs: Issues for
Congress, by Luisa Blanchfield, and CRS Report R41360, Abortion and Family Planning-Related Provisions in U.S.
Foreign Assistance Law and Policy, by Luisa Blanchfield.
37 Lisa Carty, Philip Nieburg, and Suzanne Brundage, Prevention of New HIV Infection: Priorities for U.S. Action,
Center for Strategic and International Studies, Washington, DC, January 2010, http://csis.org/publication/prevention-
new-hiv-infections.
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and that the global response to co-infection has been slow and uncoordinated, leading to limited
access to diagnostic, prevention, and treatment services.38 Compounding the uneven
implementation of joint TB/HIV programming, WHO reports that among the 63 high TB/HIV
burden countries, less than half reported treatment outcomes disaggregated by HIV status, making
it difficult to assess the success of any existing programs.39
U.S. HIV/TB collaborative activities are coordinated and led by PEPFAR. In FY2008, Congress
directed OGAC to provide at least $150 million for joint HIV/TB activities. As a result, PEPFAR
has scaled up its HIV/TB activities in recent years, most notably with regards to HIV screening,
testing, and counseling for TB patients.40 Nonetheless, PEPFAR’s FY2010 operational plan
explains that integrating HIV and TB services remains challenging, in part due to operational
differences between HIV and TB programs and programming that developed separately.
Advocates of increased attention to HIV/TB co-infection argue that implementation of WHO’s
“Three I’s” should be mandated as a core element of PEPFAR programming in settings with high
co-infection rates. Similarly, while PEPFAR sets annual targets for HIV/TB activities for each
focus country, some call for the creation of aggregate targets for joint HIV/TB activities.
Drug-Resistant TB
The past two decades have seen the emergence of multi-drug resistant (MDR) TB41 and
extensively drug resistant (XDR) TB.42 Drug resistance primarily arises from poor treatment
adherence or incorrect drug usage. In 2010, there were 650,000 cases of MDR-TB, and 58
countries had confirmed cases of XDR-TB.43 In January 2012, India reported several cases of TB
that seemed to be resistant to all available treatment.44 Diagnosis and treatment of MDR/XDR-TB
in low-resource countries has been limited,45 due to shortages of sufficiently equipped
laboratories and poor surveillance systems. Treatment for drug-resistant TB is more time-
intensive and costly than for basic TB and many resource-poor countries are ill-equipped to
adhere to WHO guidance that MDR-TB patients be treated in separate facilities from those with
HIV. In the absence of a scaled-up response, MDR- and XDR-TB are expected to result in
increased TB-related mortality rates.
The United States has begun to respond to the problem of mounting drug resistance, but there is
not consensus over the extent to which U.S. programs should target these particular threats. Some
38 Anthony D. Harries et al., “The HIV-associated Tuberculosis Epidemic—When Will We Act?,” The Lancet, vol. 375
(May 29, 2010), pp. 1906-19.
39 WHO, Global Tuberculosis Control, 2011.
40 Advocacy to Control TB Internationally (ACTION), Living With HIV, Dying of TB, March 2009,
http://c1280432.cdn.cloudfiles.rackspacecloud.com/ACTION-Report-Living-With-HIV,-Dying-of-TB-March-
2009.pdf.
41 MDR-TB is caused by bacteria that are resistant to at least two of the most effective anti-TB drugs. MDR-TB results
from either primary infection with resistant bacteria or improper use of treatment.
42 XDR-TB is caused by bacteria that are resistant to at least two of the most effective first-line treatments as well as
any of the second-line anti-TB drugs.
43 WHO, Global Tuberculosis Control, 2011.
44 “Indian TB cases ‘can't be cured’,” BBC , January 17, 2012, pp. http://www.bbc.co.uk/news/health-16592199.
45 According to WHO, in 2010 less than 5% of new and previously treated patients with TB were tested for MDR-TB.
Likewise, the reported number of patients on treatment for MDR-TB represented only 16% of the estimated cases of
MDR-TB among notified TB patients in 2010. See WHO, Global Tuberculosis Control, 2011, p. 2.
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argue that in the absence of increased investment for drug-resistant TB interventions, MDR- and
XDR-TB could become the dominant strains of the disease. Others argue that basic TB control
efforts reduce the potential for drug-resistant TB, and that a shift in resources to MDR- and XDR-
TB activities could threaten gains made in controlling basic TB.46 A particular area of concern for
TB advocates is a divergence in U.S. targets for TB and MDR-TB control between the Lantos-
Hyde Act and the 2010 U.S. TB Strategy. While the Lantos-Hyde Act recommends that by 2013
the United States support treatment of 4.5 million TB cases and at least 90,000 new MDR-TB
cases, the 2010 U.S. TB Strategy states that by 2014 the United States will support treatment of
2.6 million TB cases and 57,200 new MDR-TB cases. Advocates have urged Congress to support
the fulfillment of the original Lantos-Hyde goals.
Malaria
Recent data suggest significant reductions in global malaria cases and deaths, due in part to anti-
malaria efforts. However, new drug-resistant forms of malaria and insecticide-resistant
mosquitoes threaten these gains. At the same time, the success in the control of global malaria to
date has led policy makers to consider renewing efforts to eliminate and possibly even eradicate
malaria, raising questions over the appropriate distribution of malaria funds.
Drug and Insecticide Resistance
Resistance to artemisinin-based malaria drugs—the most effective treatment currently
available—has been identified in Asia, most prominently along the Thai-Cambodian border.
Along with the challenge of drug resistance, 27 African countries and 41 countries worldwide
have reported mosquito resistance to the insecticides used in Indoor Residual Spraying (IRS), and
increasingly to the insecticide used in insecticide-treated bed nets (ITNs).47 Factors leading to
increased drug and insecticide resistance have included misdiagnosis of malaria, improper use of
medications and insecticides, use of counterfeit malaria drugs, and lack of resistance surveillance.
Drug and insecticide resistance pose clear threats to U.S. malaria efforts, which support the use of
artemisinin-based combination therapies to treat malaria, IRS, and ITNs. The United States has
taken a number of steps to respond to drug and insecticide resistance. For example, the United
States is working with WHO to monitor insecticide resistance and assist countries with the
judicious use of insecticides, promoting a regular rotation of insecticides from different classes to
reduce resistance to IRS, and supporting surveillance networks and drug resistance monitoring
systems in Southeast Asia and the Americas.48 Some experts call for an expanded commitment to
reducing drug and insecticide resistance, particularly with regard to support for better surveillance
systems. Others call for U.S. efforts to preemptively monitor for drug resistance in Africa.
46 Lee B. Reichman, “Unsexy Tuberculosis,” The Lancet, Correspondence, vol. 373 (January 3, 2009).
47 Armel Djènontin, Joseph Chabi, and Thierry Baldet, et al., “Managing Insecticide Resistance in Malaria Vectors by
Combining,” Malaria Journal, vol. 8 (October 20, 2009), p. 233.
48 President’s Malaria Initiative, Lantos-Hyde United States Government Malaria Strategy: 2009-2014, April 25, 2010,
http://www.fightingmalaria.gov/resources/reports/usg_strategy2009-2014.pdf.
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Control, Elimination, and Eradication
In October 2007, the Bill and Melinda Gates Foundation issued a call for a renewed global
commitment to the eradication of malaria.49 Malaria eradication had been widely abandoned as a
viable option in 1969, after a WHO-sponsored eradication campaign failed to gain traction in
much of sub-Saharan Africa. Since the Gates announcement, key global health actors have
compared and debated the merits and practicality of malaria control, elimination, and eradication
efforts. The three levels of anti-malaria efforts can be classified as:
• Malaria control: reduction of the malaria disease burden to a level at which it no
longer poses a major public health problem, with adequate surveillance and
monitoring to address ongoing and emergent cases.
• Malaria elimination: interruption of local mosquito-to-human malaria
transmission, and reduction to zero of new human cases in defined geographic
areas, with continued measures to prevent reestablishment of transmission.
• Malaria eradication: permanent reduction to zero of worldwide malaria
incidence, requiring no further public health action.50
WHO has categorized countries into the following malaria stages: control, pre-elimination,
elimination, prevention of reintroduction, and malaria free (Figure 5). The United States and its
WHO partners have endorsed the long-term goal of universal malaria eradication and are
increasingly supporting elimination activities in eligible countries.51 While the majority of PMI
activities are focused in countries in the “control” stage, PMI has begun to support pre-
elimination activities, such as intensified case detection and surveillance, in several specific areas
within Zanzibar, Rwanda, and Senegal.52 At the same time, PMI embraces the goal of malaria
elimination in the Greater Mekong Region and the Amazon Basin by 2020, primarily through
support for improved surveillance and monitoring systems.
Despite the widespread enthusiasm for eradication as a long-term objective, many health experts
contend this goal is not feasible with existing malaria prevention and treatment tools, and will
require new medications, prevention strategies, and a vaccine.53 Many experts argue that malaria
elimination presents a more realistic option, although some posit that a shift toward elimination
activities may pose new challenges as well. For instance, some argue that over-emphasizing and
investing in elimination activities in areas with fewer cases of malaria could divert funds away
from basic malaria control in high burden countries.54 Others argue that mass treatment in support
of malaria elimination without the appropriate monitoring and surveillance capacity could lead to
drug resistance. Finally, some warn that even if elimination is achieved, governments and donors
must ensure that disease surveillance systems are in place to detect a resurgence of the disease.55
49 Bill and Melinda Gates Foundation, Malaria Forum, October 17, 2007.
50 WHO, World Malaria Report, 2010, p. 6.
51 President’s Malaria Initiative, Lantos-Hyde United States Government Malaria Strategy: 2009-2014, p. 5, 10.
52 Personal correspondence with PMI Senior Policy Advisor.
53 Leslie Roberts and Martin Enserink, “Did They Really Say ... Eradication?,” Science, vol. 318 (2007), pp. 1544-5
and Marcel Tanner and Don de Savigny, Malaria Eradication Back on the Table, Bulletin of the WHO, 2007, p. 82.
54 J. Lines, A. Schapire, and T. Smith, “Tackling Malaria Today,” British Medical Journal, vol. 337 (2008), pp. 435-
437.
55 Richard Feachem, “Shrinking the Malaria Map: Progress and Prospects,” The Lancet, October 29, 2010.
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Figure 5. Phases of Malaria Control Efforts, 2011
Source: WHO, World Malaria Report, 2011.
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Key Cross-Cutting Issues
Along with the challenges specific to HIV/AIDS, TB, and malaria, a number of issues extend to
all three diseases. This section looks at the following issues as they relate to all three of the
diseases:
• health systems strengthening, including health worker shortages;
• country ownership;
• research and development;
• monitoring and evaluation; and
• engagement with multilateral organizations.
Health Systems Strengthening (HSS)
In recent years, weak health systems, including limited availability of health facilities, equipment,
laboratories, and personnel, have been a critical obstacle to scaling up HIV/AIDS, TB, and
malaria interventions. For example, shortages of ART have been reported in a number of African
countries due to inadequate forecasting and information sharing systems.56 Also, by 2010, only a
handful of the 36 high-burden TB and MDR-TB countries had met the WHO recommendation of
having at least one laboratory per 5 million people capable of culturing samples, the most
definitive method for detecting TB.57 USAID documents also cite inadequate clinical
management and unavailability of drugs as common causes of fatality among hospitalized malaria
patients.58 These concerns have led many in the global health community to assert that health
systems strengthening (HSS) must be considered an essential ingredient of a long-term approach
to HIV/AIDS, TB, and malaria. HSS is one of the GHI target areas and has been integrated as a
key goal in the U.S. HIV/AIDS, TB, and malaria strategies (Appendix B). At the same time,
there is a lack of clarity over what HSS means and how it can be put into practice.
While there is widespread recognition of the need for stronger health systems, no international
consensus exists on the operational definition of HSS. The clearest direction comes from WHO,
which maintains that six “building blocks” are critical for a health system: service delivery, health
workforce, health information systems, access to essential medicines, financing, and
leadership/governance.59 The GHI consultation document cites the following goals in the U.S.
approach to HSS:
• Improve financial strategies that reduce financial barriers to health care (for
example, increase government and/or private sector funding for health services);
56 IOM, Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility.
57 WHO, Global Tuberculosis Control, 2011, p. 56.
58 USAID, Global Health Initiative and the President’s Malaria Initiative: Build sustainability through health systems
strengthening, 2009, http://www.fightingmalaria.gov/about/ghi/build.html.
59 WHO, Health Systems Topics, http://www.who.int/healthsystems/topics/en/.
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• Decrease disparities in health outcomes by providing essential health services,
such as skilled birth attendance and voluntary family planning;
• Increase the number of trained health workers and community workers and
ensure their appropriate use throughout the country; and
• Improve the health management, information, and pharmaceutical systems to
reduce stock-outs.60
Despite identifying these components for HSS, the Administration has not yet identified specific
indicators for meeting these goals. The GHI consultation document states that specific HSS
targets will vary according to country-specific needs, demographics, epidemiology, and structural
conditions (such as the socioeconomic and political environment). GHI agencies including the
Department of State, USAID, and CDC are working on producing indicators for HSS; however,
as of February 2012 these have not been released. While some applaud the plan to align HSS
activities with individual country needs, others argue that in the absence of more precise targets
and ways to measure impact, the concept of HSS has the potential to be more rhetoric than
reality.61
PEPFAR, PMI, and USAID TB programs have been integrated into national health systems to
varying degrees. Since its establishment, PEPFAR has been progressively integrated into national
health systems, but it has also supported the establishment of many stand-alone systems and has
funded a number of activities through international nongovernmental organizations (NGOs),
rather than local networks (including government, private, faith-based, and NGO groups). For
example, PEPFAR has supported country health information systems for some of its programs,
but has also set up some of its own information systems to collect data. Similarly, while PEPFAR
has used some national distribution systems for AIDS treatment, it has also financed its own
supply chain systems to procure antiretrovirals in a number of countries.62
Given that PMI was established after PEPFAR, it was able to learn a number of lessons from
PEPFAR’s first few years in operation, including its relationship to the broad functioning of
national health systems. As a result, PMI activities have historically been better integrated than
PEPFAR into established clinics and laboratories. PMI services have also been frequently
combined with other maternal and child health care services. Like PMI, USAID’s TB programs
have largely been integrated into general health services. USAID’s TB programs are often
implemented by local groups and USAID works closely with WHO TB initiatives to support the
implementation of WHO’s strategy for detection and treatment of TB known as “directly
observed treatment, short-course for TB” (or DOTS), which emphasizes involvement of national
governments in TB control.
Over the past several years, debate about the impact of single disease initiatives on health systems
has intensified. Some have argued that U.S. single disease initiatives, particularly PEPFAR, have
had a detrimental impact on national health systems. For example, some critics argue that such
initiatives have led to duplicative planning, operations, and monitoring systems that have often
60 Implementation of the Global Health Initiative, USAID, p. 13.
61 Bruno Marchal, Anna Cavalli, and Guy Kegels, “Global Health Actors Claim To Support Health System
Strengthening—Is This Reality or Rhetoric? ,” PLoS Med, vol. 6, no. 4 (2009).
62 Nandini Oomman, Michael Bernstein, and Steven Rosenzweig, Seizing the Opportunity on AIDS and Health
Systems, Center for Global Development, August 4, 2008, http://www.cgdev.org/content/publications/detail/16459/.
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bypassed existing public institutions, doing little to strengthen country capacity.63 Likewise, some
maintain that single disease programs have usurped resources and personnel out of general health
services, leading to reduced care in other health areas.64 On the other hand, some argue that single
disease initiatives have had a positive impact on broader systems. Advocates point to the role of
HIV/AIDS, TB, and malaria funding in increased training of health care workers and
improvements in health supply chain mechanisms, equipment, information systems, and health
facilities.65 Some experts further argue that the implied dichotomy between single disease
programs and systems strengthening is a false one, and that support for one should not preclude
support for the other.66
Health Worker Shortages
A particular challenge for health systems strengthening (HSS) is the shortage of health care
workers in countries confronting HIV/AIDS, TB, and malaria. According to WHO, only 5 out of
the 49 low-income countries meet its minimum recommendation of 2.3 doctors, nurses, and
midwives per 1,000 people.67 Sub-Saharan Africa, home to the majority of HIV/AIDS, malaria,
and HIV/TB co-infection cases, boasts only 1.3% of the world’s health workforce.68 Shortage of
health workers limits the number of HIV/AIDS, TB, and malaria patients that can receive testing,
counseling, treatment, and care. Health worker shortages lessen the likelihood of proper diagnosis
and supervision once a patient is receiving medication, increasing the potential for poor
adherence and eventual drug resistance. The reasons for the limited workforce are myriad, but
experts point to factors such as “brain drain”; chronic underinvestment in health workforces,
including frozen recruitment and salaries; and work environments with few supplies and limited
support.69 Resource-poor countries with the highest disease burdens also suffer from widespread
lack of educational and training opportunities.
In light of these challenges, U.S. HIV/AIDS, TB, and malaria programs have supported a range of
efforts to build health worker capacity. Between FY2004 and FY2009, PEPFAR supported 5.2
million training and retraining encounters for health care workers.70 These efforts have largely
addressed health worker shortages through HIV/AIDS-specific training for existing health
workers and “task-shifting” through which less technical tasks are transferred to others, including
community health workers. In FY2009, USAID-funded programs provided training to an
63 Roger England, “The Dangers of Disease Specific Aid Programmes,” British Medical Journal, vol. 335, no. 565
(2007).
64 Bunnan Men et al., “Key Issues Relating to Decentralisation at the Provincial Level of Health Management in
Cambodia,” International Journal of Health Planning and Management, vol. 20, no. 1 (January-March 2005), pp. 3-19.
65 Jessica E. Price et al., “Integrating HIV Clinical Services into Primary Health Care in Rwanda: a Measure of
Quantitative Effects,” AIDS Care, vol. 21, no. 5 (2009), p. 608-614, and David Walton et al., “Integrated HIV
Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti,” Journal of Public Health Policy,
vol. 25, no. 2 (2004), pp. 137-158.
66 Marco Vitoria, Reuben Granich, and Charles Gilks, et al., “The Global Fight Against HIV/AIDS, Tuberculosis, and
Malaria: Current Status and Future Perspectives,” American Society for Clinical Pathology, vol. 131 (2009), pp. 844-
848.
67 WHO web page on health workforces, Achieving the Health Related MDGs: It Takes A Workforce!,
http://www.who.int/hrh/workforce_mdgs/en/index.html.
68 Institute of Medicine, Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility.
69 Ibid.
70 OGAC, Celebrating Life: The U.S. President’s Emergency Plan for AIDS Relief, Fifth Annual Report to Congress,
2009, p. 25.
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estimated 63,000 health care works in DOTS and other TB interventions.71 These efforts have
included pre-service and in-service training on TB to health care professionals and training of
community health workers. According to the U.S. TB Strategy, support is provided to health-
related academic institutions in partner countries to ensure that TB is a standard component of
health worker curriculum. In FY2010, PMI reported the training more than 36,000 health workers
in the diagnosis and treatment of malaria with ACTs.72 PMI programs sponsor malaria-specific
trainings for health workers, particularly those working in maternal and child health, and for
community health workers.
As with the general question of health systems strengthening, there has been debate over the
impact of single disease initiatives, particularly PEPFAR, on the health workforce capacity.
Critics argue that PEPFAR’s role in workforce development has primarily benefited HIV/AIDS
programs, with little impact on broader health systems. Moreover, observers maintain that in
some countries compensation to health workers through PEPFAR programs has drawn staff away
from other public health needs.73 Several experts also assert that the short-term contractual
agreements that PEPFAR programs often used to hire health workers can cause disruptions in
treatment and care. Finally, some argue that the use of short-term contacts and “task-shifting” do
not address the underlying constraints on creating a stable workforce.
In response to concerns about health worker shortages, the Lantos-Hyde Act recommends that
PEPFAR support the training and retention of more than 140,000 new health workers by 2013.
The act also specifies that these health workers should be trained to deliver primary health care
rather than HIV/AIDS-specific skills. The GHI consultation document includes the goal of
training 140,000 new workers through HIV/AIDS programs, but extends the time period to 2014.
To meet this goal, PEPFAR launched the Medical Education Partnership Initiative (MEPI) and
the Nursing Education Partnership Initiative (NEPI), which provides support through grants to
foreign institutions in African countries to expand or enhance models of medical education.
Advocates applaud the new attention to health workers, although many argue that the United
States should adopt a much higher goal for training new health workers if it is to adequately
confront shortages. Some also argue that while the Lantos-Hyde goal of training new workers
was directed specifically to PEPFAR programs, increased efforts by malaria and TB programs are
also necessary, with the ultimate goal to train workers in broad-based primary health care skills.
To this end, some experts argue that the United States should employ performance incentives for
a variety of health service responsibilities, rather than just disease-specific ones. Some experts
also urge the United States to increase steps to reduce the attrition and migration of health
workers from resource-poor countries, such as through health workforce strategic planning,
health workforce needs analysis, increases in health worker remuneration, and improvement to
workplace policies.74
71 USAID, Building Partnerships to Control Tuberculosis, Fiscal Year 2009 Report to Congress, October 2010,
pdf.usaid.gov/pdf_docs/PDACQ888.pdf.
72 PMI, The President’s Malaria Initiative, Fifth Annual Report, April 2011, http://www.pmi.gov/resources/reports/
pmi_annual_report11.pdf.
73 Oomman, Bernstein, and Rozenzweig, Seizing the Opportunity on AIDS and Health Systems, p. 6.
74 Paula O’Brien and Lawrence O. Gostin, “Health Worker Shortages and Inequalities: The Reform of United States
Policy,” Global Health Governance, vol. 2, no. 2 (Spring 2009).
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Country Ownership
In recent years, the international community, including the United States, has placed growing
emphasis on “country ownership” of HIV/AIDS, TB, and malaria programs. Country ownership
refers to strengthening the capacity of recipient governments and local civil society to develop
and manage their own health programs, including the ability to develop health plans, forecast
monetary and infrastructural needs, and ensure financial support of programs. Congress has
demonstrated its support for country ownership through several mechanisms, including the
Lantos-Hyde Act, which called on the Administration to better harmonize U.S. HIV/AIDS, TB,
and malaria efforts with the national health strategies of recipient countries. The Administration
also includes country ownership among its seven GHI goals. Despite this, a number of concerns
have been raised over the feasibility of this goal, including whether countries will be willing and
able to progressively “own” U.S.-supported HIV/AIDS, TB, and malaria programs.
The Lantos-Hyde Act authorized PEPFAR programs to develop strategic agreements with
national governments to promote host government commitment to and ownership of HIV/AIDS
programs. Since enactment, PEPFAR has implemented “Partnership Frameworks” with a number
of countries. Partnership Frameworks are nonbinding five-year joint strategic planning documents
that outline the goals, objectives, and commitments of the U.S. and recipient government. Over
the five years, the United States is expected to shift increasing portions of aid from direct service
provision to technical assistance, with the goal of the recipient government assuming primary
responsibility for the management and funding of the programs to the fullest extent possible. As
of 2011, the United States has signed 21 PEPFAR partnership framework agreements.75
Unlike PEPFAR, PMI and USAID TB programs do not include a formal process of establishing
agreements with recipient countries. Nevertheless, U.S. malaria and TB efforts have historically
been better aligned with recipient country national plans than PEPFAR. According to PMI
documents, malaria needs assessments and planning visits are carried out in conjunction with
National Malaria Control Programs (NMCPs). Annual PMI Malaria Operational Plans directly
support national malaria control strategies and PMI program targets are typically aligned with
those of the host country. Likewise, U.S. TB support is generally provided to fill financing gaps
identified in recipient country National Tuberculosis Plans (NTPs).
There is widespread support within the international community for countries assuming greater
control over efforts to fight the three diseases. At the same time, a number of questions about the
realization of this goal remain, particularly in relationship to HIV/AIDS. Some experts question
whether recipient countries are in fact ready and willing to assume greater responsibility when
few African countries spend 15% of their national budgets on health care, as they committed to
do at the 2001 Abuja Summit.76 Alternatively, some analysts doubt Congress will prefer to have
recipient countries manage the substantial resources aimed at addressing these diseases, given the
possibility that funds may not be spent as efficiently or effectively as possible, along with the
75 PEPFAR website, Partnering in the Fight Against HIV/AIDS, April 2011, http://www.pepfar.gov/press/121652.htm.
76 In April 2001, African Union (AU) Heads of States met in Abuja, Nigeria, for the “African Summit on HIV/AIDS,
Tuberculosis, and Other Related Infectious Diseases.” At the summit, African leaders signed the “Abuja Declaration on
HIV/AIDS, Tuberculosis and Other Related Infectious Diseases,” pledging to allocate at least 15% of their annual
government budgets to their health sectors. This pledge was reiterated in May 2006 at a “Special Summit of the African
Union on HIV and AIDS, Tuberculosis and Malaria,” in Abuja, Nigeria.
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potential for misuse of funds by government officials. The legally nonbinding nature of
Partnership Frameworks has also led some to question how effective they are in practice.
A September 2010 Institute of Medicine (IOM) report focused on PEPFAR’s country ownership
efforts and found that activities were generally aligned with national HIV/AIDS strategies and
helped to achieve national goals; however, the study raised a number of operational challenges to
effective in-country management and control of global health programs.”77 Challenges included
• weak in-country capacity, including in technical expertise;
• significant U.S. funding for HIV/AIDS, TB, and malaria programs for
international contractors and private organizations rather than recipient
governments;
• indicators used by the United States to evaluate HIV/AIDS, TB, and malaria
program performance often differed from those used by host countries; and
• limitations in PEPFAR’s willingness to share information about its programs and
funding with recipient governments.
Research and Development (R&D)
Research and development (R&D) of diagnostic, preventative, and treatment tools is a key
component of any long-term response to HIV/AIDS, TB, and malaria. Currently, these diseases
are the top three targets of funding for global health R&D and, together, account for close to
three-quarters of all investments in global health R&D. In 2008, of all global funds spent on
global health R&D, 34.9% went to HIV/AIDS, 15.1% to TB, and 18.3% to malaria. (Table 2).78
The United States is the largest government donor for these efforts. Within the U.S. government,
NIH leads a range of basic and clinical research activities on global HIV/AIDS, TB, and malaria,
while CDC, USAID, and DOD each conduct field research related to these diseases. As the
United States reforms its HIV/AIDS, TB, and malaria programs to better support sustainable
approaches to health, spending levels for R&D and the areas of R&D priority are up for debate.
77 U.S. Government Accountability Office (GAO), President’s Emergency Plan for AIDS Relief: Efforts to Align
Programs with Partner Countries’ HIV/AIDS Strategies and Promote Partner Country Ownership, 10-836, September
2010, http://www.gao.gov/new.items/d10836.pdf.
78 The George Institute for International Health, Neglected Disease Research & Development: New Times, New Trends,
December 2009, http://www.ghtcoalition.org/files/gfinder_dec2009.pdf.
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Table 2. HIV/AIDS, TB, and Malaria Research and Development Funding, FY2008
(current U.S. $ millions)
U.S. Funding
Total Global
% of all R&D
as % of Global
Disease
Funding
Investments U.S.
Fundinga
Funding
HIV/AIDS
1,164.9 39.4%
736.1 63.2%
Tuberculosis 541.7
15.1% 128.2
28.2%
Malaria
445.9
18.3%
143.5
26.2%
Al Diseases
2,956.0
n/a
1,258.3
42.6%
Source: The George Institute for International Health, Neglected Disease Research & Development: New Times,
New Trends, December 2009.
a. This includes funding from NIH, USAID, CDC, and DOD.
Existing R&D investments in HIV/AIDS, TB, and malaria have led to some progress in the tools
available to combat the three diseases, such as the development of simpler HIV/AIDS drug
regimens and long-lasting insecticide-treated bed nets (LLINs) for malaria control. There have
also been several important recent R&D accomplishments. In 2011, results from an HIV
prevention study found that early use of ART in discordant couples led to a 96% reduction in HIV
transmission.79 A 2010 trial also demonstrated that HIV treatment used as prophylaxis reduced the
risk of HIV infection by 44% in men who have sex with men.80 Results from another 2010 study
in South Africa, funded in part by the United States, showed that a microbicide gel was 39%
effective in reducing a woman’s risk of contracting HIV during sex.81 In December 2010, WHO
endorsed the rollout of a new rapid diagnostic test for TB and MDR-TB, funded in part by NIH.
The test provides a diagnosis within 100 minutes, while existing tests can take as much as three
months to produce results.82 Finally, while no vaccine for malaria exists, research has been
promising. There are currently over a dozen vaccine candidates in clinical development and one,
produced by GlaxoSmithKline, is in clinical trial. If these are successful, the vaccine could be
available as early as 2014.83
In many cases, however, the impact of these advances have been compromised by outdated or
inadequate technologies. Despite progress made in AIDS treatment, even the most recent forms of
ART include potentially severe side effects and many of the newer drugs, particularly second- and
third-line therapies, are prohibitively expensive for many developing countries. Likewise,
available HIV/AIDS treatment requires increased nutritional intake, which is often challenging
for poor individuals and families. Many of the current TB diagnosis and treatment tools were
79 National Institutes of Health, National Institute of Allergy and Infectious Diseases, “Treating HIV-infected people
with antiretrovirals protects partners from infection: Findings result from NIH-funded international study,” press
release, May 12, 2011, http://www.niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspx.
80 Robert M. Grant et al., “Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex With Men,” New
England Journal of Medicine, November 23, 2010.
81 Quarraisha Abdool Karim, Salim S. Abdool Karim, and Janet A. Frochlich, “Effectiveness and Safety of Tenofovir
Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women,” Science, vol. 329, no. 5996
(September 3, 2010), pp. 1168-1174.
82 WHO, WHO Endorses New Rapid Tuberculosis Test, New Release, December 8, 2010, http://www.who.int/
mediacentre/news/releases/2010/tb_test_20101208/en/.
83 Rebecca Voelker, “As Trials Advance for a Malaria Vaccine, Policy Makers Urged to Plan for Its Use,” JAMA, vol.
304, no. 21 (2010), p. 2348.
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developed decades ago and have had uneven success. The most common method of TB diagnosis,
sputum smear microscopy, is labor intensive and does not consistently detect TB. Also, current
treatment regimens require people with active TB to take medicines for a period lasting 6 to 12
months and to be monitored during their entire treatment cycle. The emergence of drug-resistant
forms of TB and malaria highlight the need for even more advanced diagnostic and treatment
tools, appropriate for resource-poor environments. Treatment of MDR- and XDR-TB is
considerably more expensive than basic TB treatment and can take up to two years, including
significant time spent in a hospital with special facilities. Growing malaria drug and insecticide
resistance threaten the success of the most effective available methods to control the disease.
Many health experts believe that U.S. funding for HIV/AIDS, TB, and malaria research and
development lags behind what is needed. In particular, experts point to the need for increased
R&D related to basic TB diagnostics and treatment, new drugs to tackle TB and malaria drug
resistance, and an AIDS vaccine. Some argue that the long-term nature of R&D complicates
efforts to raise financial support for the work, and the low incomes in the most affected countries
provide little incentive for private companies to invest in expensive research. In recent years, the
international community has taken some innovative steps to address this challenge. For example,
in the absence of viable commercial markets for some health technologies for developing
countries, a number of new nonprofit ventures, known as Product Development Partnerships
(PDPs), have begun to support research and the development of drugs, vaccines, microbicides,
and diagnostics. PDPs working on HIV/AIDS, TB, and malaria includes groups like the
International AIDS Vaccine Initiative, the TB Alliance, and the Medicines for Malaria Venture.
Similarly, in 2008, WHO supported the establishment of the African Network for Drugs and
Diagnostics Innovation (ANDI), an initiative that aims to build Africa-based research capacity to
respond to diseases on the continent. The United States is one of the largest public financiers for
these efforts, but many experts advocate increased support of innovative approaches to R&D.
Many also argue that the United States should significantly increase its support for what is known
as operations, or implementation, research. Operations research is the study of how technology is
used in the field, and aims to identify factors that affect service delivery and impact
implementation or scale-up of interventions. Advocates applaud the support for operational
research in the GHI consultation document and argue that it should be seen as necessary for
improving prevention and treatment outcomes and for addressing strategies in support of more
sustainable HIV/AIDS, TB, and malaria programs.84 The recent evidence in support of early use
of ART as a prevention method has increased calls for innovative approaches to testing the
impact, feasibility, and acceptability of this approach in the field.85
Monitoring and Evaluation (M&E)
In recent years calls have increased within the global health community for more monitoring and
evaluation (M&E) to track health activities, determine progress in meeting targets, and evaluate
the activities’ impact on health outcomes. M&E is a key component of the GHI and is
emphasized in the United States’ HIV, TB, and malaria strategies (Appendix B). The United
States has recognized the need to make its HIV/AIDS, TB, and malaria programs increasingly
84 Implementation of the Global Health Initiative, Consultation Document, USAID, p. 8.
85 Reuben Granich et al., “ART in Prevention of HIV and TB: Update on Current Research Efforts,” Current HIV
Research, vol. 9, no. 6 (December 2011).
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results-based, yet these efforts remain nascent and experts have expressed a number of concerns
over how to meet these goals for each of the diseases.
While a systematic, quantitative evaluation of PEPFAR’s impact has not yet been published, the
Lantos-Hyde Act mandated a comprehensive assessment of U.S. HIV/AIDS programs and their
impact on health, to be submitted to Congress in 2012. In 2010, IOM released a consensus report
outlining its strategic approach for conducting this evaluation. Congress has also required several
targeted evaluations from GAO and IOM. In 2007, IOM conducted a short-term evaluation of
PEPFAR, focusing largely on its ability to meet its outlined targets for delivery of prevention,
treatment, and care services in its focus countries.86 GAO has released reports in July 2011,
analyzing PEPFAR’s program planning and reporting processes,87 and in September 2010,
analyzing efforts to align PEPFAR programs with partner countries’ HIV/AIDS strategies.88
Neither the IOM nor the GAO evaluation included assessments of PEPFAR programs in relation
to long-term health-related outcomes such as HIV incidence, prevalence, or mortality.89 Congress
has not mandated a systematic review of either PMI or USAID TB programs beyond annual
reports that include progress on meeting predetermined targets. The U.S. malaria strategy
indicates that a large external evaluation will be conducted and published in 2015 that assesses
progress on all U.S. malaria activities undertaken through 2014.
The United States is taking steps to strengthen its ability to effectively monitor and evaluate its
HIV/AIDS, TB, and malaria programs. In support of better M&E, PEPFAR has expanded its
tracking of outcomes and impacts of its programs in the short and long term. In 2009, PEPFAR
released its “Next Generation Indicators” (NGI), providing new indicators to track the impact of
PEPFAR activities. Through this effort, PEPFAR has attempted to better align its indicators with
those already used by many host nations and other international donors and to minimize
PEPFAR-specific reporting, allowing country teams more flexibility to design M&E plans in line
with national governments. NGI also includes new indicators related to program and population
coverage as well as program quality. This marks a shift from past practices, in which M&E
focused largely on program outputs, such as number of individuals on treatment.
Documents from the President’s Malaria Initiative state that it is working closely with the Roll
Back Malaria Monitoring and the Evaluation Reference Group to standardize data collection and
use internationally accepted indicators of progress, and will assist recipient governments in
conducting nationwide household surveys to measure changes in child mortality and malaria
prevalence. Likewise, in support of TB-related M&E, USAID works with the WHO Global TB
Monitoring and Surveillance project, the WHO body charged with leading TB M&E activities, to
standardize TB control indicators. USAID TB programs also include efforts to bolster national
M&E systems to track TB infection and mortality rates as a key component of DOTS.
86 Institute of Medicine, PEPFAR Implementation: Progress and Promise, March 30, 2007, http://www.iom.edu/
Reports/2007/PEPFAR-Implementation-Progress-and-Promise.aspx.
87 U.S. Government Accountability Office, President’s Emergency Plan for AIDS Relief: Program Planning and
Reporting, 11-785, July 29, 2011, http://www.gao.gov/products/GAO-11-785.
88 U.S. Government Accountability Office, President’s Emergency Plan for AIDS Relief: Efforts to Align Programs
with Partner Countries’ HIV/AIDS Strategies and Promote Partner Country Ownership, 10-836, September 20, 2010,
http://www.gao.gov/products/GAO-10-836.
89 Eran Bendavid and Jayanta Bhattacharya, “PEPFAR in Africa: An Evaluation of Outcomes,” Annals of Internal
Medicine (April 6, 2009), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892894/.
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Despite these steps to strengthen U.S. capacity for M&E activities, a number of challenges
remain. M&E requires collection of a variety of data from multiple sources, including household
surveys, birth and death registration, census, and national surveillance systems. Resource-poor
countries often have limited ability to produce data that is timely, standardized, and of a high
enough quality to use for routine tracking and assessment of health programs. Malaria M&E
efforts are particularly challenged because many resource-poor countries have weak health
information systems necessary to track childhood health and many people infected with malaria,
especially children, do not seek treatment in official health facilities. Similarly, gaps in TB
coverage, treatment, and case detection impede effective and comprehensive M&E. Drug-
resistant forms of TB pose new challenges to M&E efforts, as many resource-poor countries do
not have the capacity to test for second-line drug resistance. Efforts to monitor and evaluate
HIV/TB co-infection rates and activities are also precluded by limited information sharing
between distinct TB and HIV programs.
U.S. M&E efforts are also challenged by the interaction in the field between U.S. global health
programs and those of other donors, including the Global Fund and a range of private and NGO
actors, which make it difficult to evaluate the outcomes of any one program. Finally, given the
number of factors that influence the functioning and capacity of health systems and national
governments, effective ways to measure the progress and impact of activities related to issues
such as health systems strengthening and country ownership remain contentious. Indeed,
PEPFAR has yet to develop specific indicators for measuring the effectiveness of activities
related to HSS, country ownership, and HIV prevention.
Many have called for the United States to mandate regular and comprehensive M&E of its
HIV/AIDS, TB, and malaria programs and increase support for in-country capacity to collect and
assess health data. Some have also called on the United States to improve its data transparency
and its dissemination of results to international and local partners. Experts have encouraged the
alignment of health indicators used by the United States (through programs like PEPFAR and
PMI) and those used by multilateral organizations and national governments. Some also urge the
United States to support the use of national information systems for M&E as a way to strengthen
these systems and increase country ownership of M&E. At the same time, other observers caution
that additional measurement and reporting requirements have the potential to overburden already
strained countries and programs and may reduce the time and money available for programs.
Engagement with Multilateral Organizations
The United States supports global HIV/AIDS, TB, and malaria efforts through bilateral programs
as well as partnerships with and contributions to multilateral organizations. Over the last decade,
Members of Congress have debated the appropriate balance between funding bilateral and
multilateral global health efforts. This debate frequently focuses on the extent to which the United
States should support the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), a
multilateral public-private partnership established in 2002 to provide financial support for global
responses to the three diseases.90 The Global Fund estimates that in 2009 it provided
approximately 21% of all funding for global HIV/AIDS, 65% of all funding for global TB, and
90 For more information on the Global Fund, see CRS Report R41363, The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Issues for Congress and U.S. Contributions from FY2001 to the FY2012 Request, by Tiaji Salaam-
Blyther.
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65% of all funding for global malaria.91 Donors to the Global Fund include a number of
governments as well as private and multilateral organizations. The United States is the single
largest donor to the Global Fund, though U.S. bilateral spending on HIV/AIDS, TB, and malaria
far outweighs contributions to the Global Fund and other multilateral groups (Figure 6).
Figure 6. U.S. Bilateral and Multilateral HIV/AIDS, TB, and Malaria Funding, FY2012
Source: Compiled by CRS from appropriations legislation and congressional budget justifications.
Notes: Multilateral Contributions include funding for the Global Fund, the International AIDS Vaccine Initiative
(IAVI), UNAIDS, international microbicide research, and the Global TB Drug Facility. Contributions to the
Global Fund make up the vast majority of investments in multilateral efforts. The United States also contributes
to a range of other multilateral global health organizations, such as WHO, UNICEF, and the Global Alliance for
Vaccines and Immunizations (GAVI), through non-HIV/AIDS, TB, or malaria specific appropriations.
The Obama Administration has indicated support for increased engagement with multilateral
organizations, including the Global Fund. In October 2010, the President pledged $4 billion to the
Global Fund over the course of three fiscal years—the first multi-year pledge to the Global Fund
from the United States. While requesting decreased funding amounts for all bilateral HIV/AIDS,
TB, and malaria programs, the FY2013 budget request includes a 27% increase in funding for the
Global Fund over estimated FY2012 levels, fulfilling the President’s multi-year pledge. The
Administration has also emphasized nonfinancial ways in which the United States can support
multilateral organizations, including better coordination in-country with multilateral
91 The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Making a Difference: Global Fund Results Report,
2011.
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organizations, increased technical assistance to multilaterally funded field programs, and
demonstrated leadership in shaping the policies of multilateral organizations (for instance, as a
member of the Global Fund Board).
Despite this support, in November 2011, the Global Fund announced that due to limited resources
available from donor countries, it would indefinitely postpone its 11th round of funding. In order
to prevent any gaps in services, the Global Fund has instituted a “Transitional Funding
Mechanism” (TFM), which will secure funding for programs facing disruptions in services
currently supported by the Global Fund between 2012 and 2014. Documents released by the
Global Fund have made clear that in this same time period, it will be unable to support any new
interventions, nor will it support the scale-up of services, including provision of ART.
A number of experts contend that the Global Fund’s decision demonstrates the critical need for
increased multilateral funding from donors like the United States. Some argue that a reduction—
or leveling—of funding to the Global Fund could imperil lives and cause significant losses in the
progress made against the three diseases.92 Some experts argue that the U.S. fight against the
three diseases would be better waged through increased support to multilateral organizations
rather than to bilateral programming. Specifically, advocates argue that multilaterals cede greater
control of the programs to recipient countries, which supports the goal of country ownership.
Some also argue that multilateral programs have more flexibility than bilateral programs,
allowing them to better respond to locally defined needs. Likewise, some assert that funds are
more effectively spent through multilateral mechanisms because donors can pool their resources
and achieve economy of scale. Also, multilateral groups are capable of extending multi-year
support. Some argue that this is particularly useful when addressing diseases that require long-
term funding, like HIV/AIDS. Finally, some contend that U.S. engagement in multilateral
organizations offers the United States opportunities to demonstrate its leadership in global health
and encourage other countries to share in the global fight against the three diseases. As a result,
some of these advocates applaud the President’s decision to request significantly increased
funding for the Global Fund in the FY2013 budget.93
Advocates of limited support for multilateral organizations argue that bilateral assistance
increases the United States’ ability to target health assistance to specific countries and determine
funding priorities. In addition, others assert that bilateral assistance allows for better oversight of
the use of funds by recipient governments and organizations. Some experts also contend that
bilateral assistance is easier to track and measure than multilateral assistance, allowing for more
effective monitoring and evaluation. Ongoing concerns about the capacity of multilateral groups
like the Global Fund to detect and respond to corrupt practices propel this debate.
Looking Forward
The second session of the 112th Congress will likely exercise oversight of and debate the
appropriate funding amounts for global HIV/AIDS, TB, and malaria programs and priority areas
92 Doctors Without Borders, “As Global Fund Turns Ten, Lack of Political Support to Health Threatens Gains Against
AIDS, TB, and Malaria,” press release, January 30, 2012, http://www.doctorswithoutborders.org/press/release.cfm?id=
5749&cat=press-release&ref=home-sidebar-right.
93 For example, see Amanda Glassman, GHI 2013 and the Rise of Multilateralism, Center for Global Development,
February 15, 2012, http://blogs.cgdev.org/globalhealth/2012/02/ghi-2013-and-the-rise-of-multilateralism.php.
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within these programs. Discussions may focus on a number of critical disease-specific and cross-
cutting issues, measurement of the effectiveness of the U.S. response, and tradeoffs the United
States might consider as it sets priorities. As Congress reflects on these challenges, several
overarching issues may also be considered:
• Ways to assess impact and efficiency of global HIV/AIDS, TB, and malaria
programs: As Congress debates funding the fight against these three diseases, it
will likely consider which methods to use in determining the distribution of finite
global health and overall foreign assistance resources. The United States might
face decisions over whether it should invest in the lowest-cost interventions, such
as anti-malaria bednets, versus the higher-cost interventions that high-burden
countries may be unable to afford, such as antiretroviral therapy. Similarly, the
United States might consider whether it should support programs tackling the
high-mortality issues, such as drug-resistant TB, or the more widespread and
commonplace issues, such as malaria infection. The United States may also
consider how it should balance its funding between high-impact activities, such
as ART programs, with dramatic results and areas like health systems
strengthening, which may yield few immediate results but which could result in
significant long-term progress. More broadly, policymakers may weigh support
for these programs against other foreign policy priorities.
• Role of the United States in the global fight against HIV/AIDS, TB, and
malaria: The United States is a central leader in combating HIV/AIDS, TB, and
malaria. Some Members of Congress have targeted global health funding for cuts
as a way to reduce the U.S. deficit. Many supporters of these cuts have argued
that the United States has played an overly generous role in combating issues like
global HIV/AIDS, TB, and malaria, especially since these investments do not
necessarily have direct implications for the wellbeing of U.S. citizens.
Alternatively, many supporters argue that U.S. leadership in the fight against
these diseases remains critical, particularly as new tools for treatment and
prevention become available. Many of these advocates assert that given the
prominence of the United States, any U.S. divestment could have significant
negative consequences for some of the most vulnerable people in resource-poor
countries. Some also point out that while the United States has been a key donor
for HIV/AIDS, TB, and malaria, several European countries give more for these
diseases as a share of their country’s GDP. Finally, advocates assert that U.S.
leadership is vital for sustaining the activities of the Global Fund, a key financial
player in the fight against these diseases.
Many advocates and critics of expanding U.S. global health assistance call for
other countries, including a number of European countries, as well as emerging
economies like China, India, Brazil, and Saudi Arabia, to begin playing a larger
role in combating global HIV/AIDS, TB, and malaria. Advocates argue that
increased efforts among other donors could help achieve the United Nations
(U.N.) Millennium Development (MDG) goal “to combat HIV/AIDS, malaria,
and other diseases,” a goal which to which all U.N. member states have
committed.94 At the same time, there is disagreement over the ways in which U.S.
leadership can and should motivate this kind of engagement.
94 For more information on the Millennium Development Goals (MDGs) see the U.N. MDG website at
(continued...)
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• HIV/AIDS, TB, and malaria assistance, economic development, and
security: Congressional consideration of U.S. HIV/AIDS, TB, and malaria
programs may be affected by debate over their role in the broader U.S. foreign
policy agenda. HIV/AIDS, TB, and malaria have undeniable humanitarian
consequences. At the same time, many argue that these diseases also have
important implications for economic development and security. Development
experts argue that disease can threaten political and economic stability in fragile
areas of the world, undermining U.S. interests abroad. Health experts believe that
U.S. citizens are threatened by the spread of he infectious diseases across
borders. Furthermore, foreign policy experts contend that global health efforts
like PEPFAR have become critical diplomatic tools (often referred to as medical
diplomacy) and have bolstered the image of the United States abroad, especially
in sub-Saharan Africa. Alternatively, others caution against overly emphasizing
the security and diplomatic implications of HIV/AIDS, TB, and malaria, and
warn that doing so could lead to allocation of funding according to U.S. interests
rather than human need.
(...continued)
http://www.un.org/millenniumgoals/aids.shtml.
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Appendix A. Acronyms and Abbreviations
ACT Artemisinin-Combination
Therapy
AIDS
Acquired Immunodeficiency Syndrome
ART Anti-Retroviral
Therapy
CDC
Centers for Disease Control and Prevention
DOD
Department of Defense
DOTS
Directly Observed Treatment Short Course
FDC
Fixed Dose Combination
FP Family
Planning
GAO Government
Accountability Office
GHI
Global Health Initiative
Global Fund
Global Fund to Fight AIDS, Tuberculosis and Malaria
HHS
U.S. Department of Health and Human Services
HIV
Human Immunodeficiency Virus
HSS
Health Systems Strengthening
IOM Institute
of
Medicine
IPT
Isoniazid Preventive Therapy
IPTp
Intermittent Preventive Treatment of Malaria During Pregnancy
ITNs
Insecticide-Treated Bednets
IRS
Indoor Residual Spraying
Lantos-Hyde Act
Tom Lantos and Henry Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Reauthorization Act of 2008 (P.L. 110-293)
Leadership Act
U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25)
LIFE Initiative
Leadership and Investment in Fighting an Epidemic Initiative
LLINs
Long-Lasting Insecticidal Nets
M&E
Monitoring and Evaluation
MDR-TB Multidrug-resistant
Tuberculosis
MEPI
Medical Education Partnership Initiative
MNCH
Maternal, Newborn, and Child health
MSM
Men who Have Sex with Men
NEPI
Nursing Education Partnership Initiative
NIH
National Institutes of Health
NMCP
National Malaria Control Program
NTD
Neglected Tropical Disease
NTP
National Tuberculosis Plan
OGAC
Office of the Global AIDS Coordinator, Department of State
PEPFAR
President’s Emergency Plan for AIDS Relief
PMI
President’s Malaria Initiative
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PMTCT
Prevention of Mother-to-Child Transmission
R&D
Research and Development
RH Reproductive
Health
TB Tuberculosis
U.N. United
Nations
UNAIDS
Joint United Nations Program on HIV/AIDS
USAID
U.S. Agency for International Development
WHO
World Health Organization
XDR-TB
Extensively Drug-Resistant Tuberculosis
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Appendix B. HIV/AIDS, TB, and Malaria GHI Goals
PEPFAR Strategy Targets
GHI set a number of goals to be reached from FY2010 through FY2014. GHI goals and projected
targets for PEPFAR are:95
• provide direct support for more than four million people on treatment;96
• support the prevention of more than 12 million new HIV infections;
• ensure that every partner country with a generalized HIV epidemic has both 80%
coverage of testing for pregnant women at the national level, and 85% coverage
of antiretroviral drug prophylaxis and treatment as indicated, of women found to
be HIV-infected;
• double the number of at-risk babies born HIV-free, from a baseline of 240,000
babies of HIV-positive mothers born HIV-negative during the first five years of
PEPFAR;
• provide direct support for care for more than 12 million people, including 5
million orphans and vulnerable children;
• support training and retention of more than 140,000 new health care workers to
strengthen health systems; and
• ensure that in each country with major PEPFAR investment, the partner
government leads efforts to evaluate and define needs and roles in the national
response.
U.S. TB Strategy Targets
GHI goals and projected targets for U.S. TB programs are: 97
• to contribute to a 50% reduction in TB deaths and disease burden from the 1990
baseline;
• to sustain or exceed the detection of at least 70% of sputum smear-positive cases
of TB and successfully treat at least 85% of cases detected in countries with
established USG tuberculosis programs;
• to successfully treat 2.6 million new sputum smear-positive TB patients under
DOTS programs by 2014, primarily through support for need services,
95 The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy, Annex: PEPFAR’s Contributions to the
Global Health Initiative, Office of the U.S. Global AIDS Coordinator, Department of State, December 2009,
http://www.pepfar.gov/documents/organization/133437.pdf.
96 On World AIDS Day 2011, President Obama announced an increased goal of treating 6 million people by 2013.
97 USAID, et al., Lantos-Hyde United States Government Tuberculosis Strategy, 2009-2014, March 24, 2010,
http://www.usaid.gov/our_work/global_health/id/tuberculosis/publications/usg-tb_strategy2010.pdf.
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commodities, health workers, and training, and additional treatment through
coordinated multilateral efforts; and
• to diagnose and initiate treatment of at least 57,2000 new MDR-TB cases by
2014 and providing additional treatment through coordinated multilateral efforts.
U.S. Malaria Strategy Targets
GHI goals and projected targets for U.S. malaria programs are:98
• to achieve Africa-wide impact, by halving the burden of malaria (morbidity and
mortality) in 70% of at-risk populations in sub-Saharan Africa (approximately
450 million people), thereby removing malaria as a major public health problem
and promoting economic growth and development throughout the region;
• to limit the spread of anti-malaria multi-drug resistance in Southeast Asia and the
Americas;
• to increase emphasis on strategic integration of malaria prevention and treatment
activities with maternal and child health, HIV/AIDS, neglected tropical diseases,
and tuberculosis programs, and on multilateral collaboration to achieve
internationally accepted goals;
• to intensify present efforts to strengthen health systems and strengthen the
capacity of host-country workforces to ensure sustainability;
• to assist host countries to revise and update their National Malaria Control
Strategies and Plans to reflect the declining burden of malaria, and link
programming of U.S. malaria control resources to those host country strategies;
and
• to ensure a woman-centered approach for malaria prevention and treatment
activities at both the community and health facility levels, since women are the
primary caretakers of young children in most families and are in the best position
to help promote health behaviors related to malaria.
98 USAID, Lantos-Hyde United States Government Malaria Strategy, 2009-2014, April 25, 2010,
http://www.fightingmalaria.gov/resources/reports/usg_strategy2009-2014.pdf.
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Appendix C. HIV/AIDS, TB, and Malaria Funding
Table C-1 presents an overview of U.S. funding for global HIV/AIDS, TB, and malaria efforts.
The table does not include global health spending that does not correlate to specific congressional
appropriations. For instance, CDC does not receive appropriations for global TB programs
specifically, but spends a portion of its overall TB budget on international programs. Along with
CDC global TB spending, the table does not include data for NIH and DOD malaria research.
Table C-2 presents the total amounts of U.S. funding for global HIV/AIDS, TB, and malaria
efforts in constant dollars.
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Table C-1. FY2001-FY2013 Global HIV/AIDS, TB, and Malaria Funding, by Agency and Program
(current U.S. $ millions)
FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
FY2012
FY2013
Agency/Programa
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Estimate Request
USAID HIV/AIDS
305.0 395.0 587.7 513.5 347.2 346.5 325.0 347.2 350.0 350.0 349.3 350.0 330.0
(CSH/GHCS/GHP)
USAID HIV/AIDS
13.0 29.0 35.8 42.0 37.5 27.3 20.9 24.8 0.0 0.0 0.0
0.0 0.0
(Otherb)
State HIV/AIDS
n/a
n/a
n/a 488.1 1373.9 1777.1 2869.0 4116.4 4559.0 4609.0 4585.8 4242.9 3700.0
(GHAI/GHCS/GHP)
CDC
HIV/AIDS
104.5 168.7 182.6 266.9 123.8 122.6 121.0 118.9 118.9 119.0 118.7 117.1 117.2
NIH
AIDS
Research 160.1 218.2 278.5 317.2 369.5 373.0 361.7 411.7 451.7 485.6 375.7 364.5 388.9
DOL
HIV/AIDS
10.0 10.0 9.9 9.9 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
DOD
HIV/AIDS 10.0 14.0 7.0 4.3 7.5 5.2 0.0 8.0 8.0 10.0 10.0 8.0 8.0
FMF
HIV/AIDS
0.0 0.0 2.0 1.5 2.0 2.0 1.6 1.0 0.0 0.0 0.0 0.0 0.0
HIV/AIDS
602.6 834.9 1103.5 1643.4 2263.4 2653.7 3699.2 5028.0 5487.6 5573.6 5439.5 5082.5 4544.1
Subtotal
USAID TB
50.0 60.0 64.2 74.7 79.4 79.2 80.8 148.0 162.5 225.0 224.6 236.0 224.0
(CSH/GHCS/GHP)
USAID
TB
Other 12.0 12.0 12.4 10.4 12.6 12.3 14.1 15.2 14.1 18.2 13.8 13.8 8.0
TB Subtotalc
62.0 72.0 76.6 85.1 92.0 91.5 94.9 163.2 176.6 243.2 238.4 249.8 232.0
USAID Malaria
55.0 66.0 65.4 79.9 90.8 102.0 248.0 347.2 382.5 585.0 618.8 650.0 619.0
(CSH/GHCS/GHP)
USAID Malaria
0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.4 2.5 0.0 0.0 0.0 0.0
Other
CDC
Malaria
13.0 13.0 12.6 9.2 9.1 9.0 8.9 8.7 9.4 9.4 9.4 9.3 9.4
Malaria Subtotal
68.0 79.0 78.0 89.1 99.9 111.0 256.9 358.3 394.4 594.4 628.2 659.3 628.4
State
Global
Fund
0.0 0.0 0.0 0.0 0.0 198.0 377.5 545.5 600.0 750.0 748.5 1300.0 1650.0
USAID
Global
Fund 100.0 50.0 248.4 397.6 248.0 247.5 247.5 0.0 100.0 0.0 0.0
0.0
0.0
HHS
Global
Fund
0.0 125.0 99.0 149.0 99.2 99.0 99.0 294.8 300.0 300.0 297.3
0.0
0.0
Global Fund
100.0 175.0 347.4 546.6 347.2 544.5 724.0 840.3 1000.0 1050.0 1045.8 1300.0 1650.0
Subtotal
HIV/AIDS, TB,
832.6 1160.9 1605.5 2364.2 2802.5 3400.7 4775.0 6389.8 7058.6 7461.2 7351.9 7291.6 7054.5
Malaria Total
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Source: Compiled by CRS from appropriations legislation, congressional budget justifications, the President’s budget request, and interviews with U.S. officials.
Notes: n/s means not specified. n/a means not applicable.
a. Foreign Military Financing (FMF) account; Centers for Disease Control and Prevention (CDC); National Institutes of Health (NIH); Department of Labor (DOL);
Department of Defense (DOD); Department of Health and Human Services (HHS), Child Survival and Health (CSH), Global Health Programs (GHP), Global Health
and Child Survival (GHCS), Global HIV/AIDS Initiative (GHAI).
b. This includes funding from the Development Assistance Account (DA), the Economic Support Fund Account (ESF), and the Assistance for Europe, Eurasia, and Central
Asia Account (AEECA).
c. CDC does not receive appropriations for global TB programs specifically. Instead it spends portions of its TB budget on international programs.
Table C-2. FY2001-FY2012 Global HIV/AIDS, TB, and Malaria Funding Totals in Constant Dollars
(constant U.S. $ millions)
Disease/Program
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010
FY2011
FY2012
Totals
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Estimate
HIV/AIDS
761.9 1041.5 1347.1 1956.1 2608.3 2959.6 4020.5 5274.7 5720.4 5706.3 5439.5 5082.5
TB
78.4 89.8 93.5 101.3 106.0 102.0 103.1 171.2 184.1 249.0 238.4 249.8
Malaria
86.0 98.5 95.2 106.1 115.1 123.8 279.2 375.9 411.1 608.6 628.2 659.3
Global
Fund
126.4 218.3 424.1 650.6 400.1 607.3 786.9 881.5 1042.4 2075.0 1045.8 1300.0
HIV/AIDS, TB,
1052.6 1448.2 1959.9 2814.0 3229.6 3792.7 5189.8 6703.3 7358.1 7638.8 7351.9 7291.6
Malaria Total
Source: Compiled by CRS from appropriations legislation and interviews with U.S. officials.
Notes: Calculations into constant dol ars are made using the FY2011 estimate total non-defense deflator, from the U.S. Government Printing Office, “Budget of the United
States Government: Historical Tables Fiscal Year 2013,” available at http://www.whitehouse.gov/omb/budget/Historicals.
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Appendix D. HIV/AIDS, Tuberculosis, and Malaria
Program Maps
Two maps are shown for each disease. The first displays U.S. bilateral funding levels across
countries. The second highlights U.S. countries receiving assistance in relation to global
prevalence estimates for each disease.
HIV/AIDS
Figure D-1 shows U.S. bilateral HIV/AIDS funding levels across countries in FY2009. Figure
D-2 highlights U.S. countries receiving assistance in relation to global HIV prevalence estimates
in 2009.
Tuberculosis
Figure D-3 shows U.S. bilateral TB funding levels across countries in FY2009. Figure D-4
highlights U.S. countries receiving assistance in relation to global TB prevalence estimates in
2009.
Malaria
Figure D-5 shows U.S. bilateral malaria funding levels across countries in FY2009. Figure D-6
highlights U.S. countries receiving assistance in relation to global malaria prevalence estimates in
2009.
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Figure D-1. U.S. Bilateral HIV/AIDS Funding, by Country, FY2009
(current U.S. $ millions)
Source: Compiled by CRS from appropriations legislation and foreignassistance.gov.
Notes: COP countries refer to PEPFAR countries with “Country Operational Plans.” COPs document U.S. annual investments and HIV/AIDS program targets, and serve
as the basis for approval of annual U.S. bilateral HIV/AIDS funding to each country. A number of countries receiving smal er amounts of PEPFAR assistance are not required
to submit COPs.
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Figure D-2. HIV Prevalence Rates and PEPFAR COP Countries, 2009
Source: Compiled by CRS from UNAIDS, Report on the Global AIDS Epidemic, 2010, http://www.unaids.org/globalreport/Global_report.htm, appropriations legislation, and
foreignassistance.gov.
Notes: HIV prevalence measures the rate of infection among adults aged 5-49 in each country in 2009. COP countries refer to PEPFAR countries with “Country
Operational Plans.” COPs document U.S. annual investments and HIV/AIDS program targets, and serve as the basis for approval of annual U.S. bilateral HIV/AIDS funding to
each country.
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Figure D-3. U.S. Bilateral TB Funding, by Country, FY2009
(current U.S. $ millions)
Source: Compiled by CRS from appropriations legislation and foreignassistance.gov.
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Figure D-4. TB Prevalence Rates and USAID TB Countries, 2009
Source: Compiled by CRS from WHO, Global Tuberculosis Control, 2010, http://whqlibdoc.who.int/publications/2010/9789241564069_eng.pdf, appropriations legislation, and
foreignassistance.gov.
Notes: TB prevalence measures the rate of infection in each country in 2009.
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Figure D-5. U.S. Bilateral Malaria Funding, by Country, FY2009
(current U.S. $ millions)
Source: Compiled by CRS from appropriations legislation and foreignassistance.gov.
Notes: In FY2009, PMI had 15 focus countries. Several other countries were receiving bilateral malaria assistance, but were not considered PMI focus countries.
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Figure D-6. Malaria Prevalence Rates and PMI Focus Countries, 2009
Source: Compiled by CRS from WHO, World Malaria Report, 2010, http://wholibdoc.who.int/publications/2010/9789241564106_eng.pdf, appropriations legislation, and
foreignassistance.gov.
Notes: Malaria prevalence measures the rate of infection in each country in 2009.
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The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria
Author Contact Information
Alexandra E. Kendall
Analyst in Global Health
akendall@crs.loc.gov, 7-7314
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