Introduction
Over the past decade, the United States has recognized the human immunodeficiency virus and the acquired immune deficiency syndrome (HIV/AIDS) as a key foreign policy priority. Congressional authorization of the President's Emergency Plan for AIDS Relief (PEPFAR) in 2003 brought unprecedented attention and funding to the epidemic and established a new and central role for donor governments in the fight against HIV/AIDS, particularly regarding the provision of AIDS treatment. The United States remains the largest single donor for global HIV/AIDS efforts in the world, providing over 50% of all government donor funds. In recent years, despite the continued challenge of HIV/AIDS around the world, international funding for HIV/AIDS—including U.S. assistance—has begun to level off. This report provides information on key components of the HIV/AIDS epidemic and the U.S. response to HIV/AIDS.
Description of HIV/AIDS
HIV is an infectious disease that damages human immune cells. The final stage of HIV is AIDS, which occurs when an individual's immune system is so damaged it can no longer fight off other infections. If left untreated, AIDS is fatal. HIV is spread through contact with the bloodstream or by passing through delicate mucous membranes, including the vagina, rectum, and urethra. Transmission primarily occurs in three ways: (1) unprotected sexual intercourse with an infected partner; (2) injections with a needle, syringe, or other equipment that has been used by an infected person; and (3) between a child and an infected mother, during pregnancy, birth, or breast-feeding. High-risk groups include sex workers, men who have sex with men, and injecting drug users.
Global HIV/AIDS Statistics1
Prevalence: Prevalence measures the number of people living with a disease. Since the beginning of the epidemic, more than 60 million people have been infected with HIV. In 2010, there were an estimated 34 million people living with the virus. Women make up 50% of all adults living with HIV. The number of people living with HIV continues to rise as a combined result of new infections and improved access to antiretroviral treatment (ART) that has lowed AIDS-related mortality.
Incidence: Incidence measures the number of people who contract a disease within a given time period (usually one year). In 2010, 2.7 million people contracted HIV, including 390,000 children under the age of 15. New infections are thought to have peaked in 1996 at 3.5 million (Figure 1). Incidence has fallen by more than 25% in 33 countries between 2001 and 2009, including in 22 sub-Saharan African countries.
Mortality: HIV continues to be a leading cause of death worldwide and the number one killer in sub-Saharan Africa. In 2010, 1.8 million people died of AIDS, including roughly 250,000 children. AIDS-related deaths are thought to have peaked in 2004 at 2.2 million and declined since then due to the improved access to ART.
Regional Distribution of HIV/AIDS2
HIV/AIDS is a global phenomenon, but there are important regional and intra-regional differences in HIV prevalence, incidence, and mortality.
- Sub-Saharan Africa (SSA) is the region most affected by HIV/AIDS (Figure 2). In 2010, an estimated 22.9 million people were living with HIV/AIDS in SSA, accounting for 68% of all people living with HIV worldwide. Southern Africa is home to the nine countries with the world's highest HIV prevalence rates worldwide and was home to an estimated 11.1 million people living with HIV in 2010. Swaziland has the world's highest prevalence rate (25.9%), and South Africa has the world's largest population with HIV (5.6 million). In 2010, about 1.9 million people in SSA contracted HIV and some 1.2 million people in the region died from AIDS.
- In 2010, an estimated 4.8 million people were living with HIV in Asia, including 360,000 people who became infected in 2010. Also in 2010, approximately 310,000 AIDS-related deaths occurred in the region, the largest number of deaths outside of sub-Saharan Africa. In Asia, the rate of HIV transmission is slowing and the death toll has remained stable, while the epidemic among men who have sex with men appears to be growing.
- In 2010, an estimated 1.7 million people were living with HIV in Latin America and the Caribbean, including 112,000 people who became infected in 2010. In the region, the Bahamas has the highest prevalence rate, while Brazil has the largest population living with virus. Overall, the epidemic in Latin America has stabilized and the rates of new infections and AIDS-related deaths in the Caribbean have slowed.
- Eastern Europe and Central Asia (EECA) has experienced the largest regional increase in HIV prevalence, most prominently in Russia and Ukraine. Since 2001, the number of people living with HIV in the region has increased by 250%. In 2010, an estimated 1.5 million people were living with HIV in EECA, including 160,000 people who were infected in 2010. The number of AIDS-related deaths in the region has also continued to grow, reaching 83,000 in 2010.
HIV/AIDS Treatment, Care, and Prevention
Treatment: Use of ART to treat HIV/AIDS has lowered the rate of AIDS-related deaths in much of the world. ART coverage—the percentage of people on ART among those eligible for treatment—was 47% in 2010, up from 7% in 2003.3 While lowering AIDS-related deaths, access to ART has also increased HIV prevalence around the world, as infected individuals are now living longer. ART also has preventive benefits as it lowers viral loads, consequently reducing the likelihood of transmission.
Care Activities: Care for individuals infected and affected by HIV/AIDS constitutes a wide range of activities, including support for ART adherence, treatment of opportunistic infections, nutritional counseling, mental health services, prevention education, and livelihood activities, along with attention to orphans and vulnerable children.
Prevention Activities: A number of prevention efforts are being used to combat HIV/AIDS, including male circumcision, reduction of mother-to-child transmission (PMTCT), behavior change programs (including advocacy of abstinence, being faithful, and using condoms), HIV testing, blood supply safety programs, harm reduction programs aimed at high-risk groups, and increased provision of antiretroviral therapy, which can reduce the potential of transmission.
Prevention Research: Several studies published in 2010 and 2011 have demonstrated progress in developing new prevention technologies. Antiretroviral therapy has been shown to have important preventive benefits: among couples with one infected partner, early use of ART was shown to reduce transmission by at least 96%.4 Efforts to develop HIV preventive vaccines and microbicides—compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections—are also underway. Results from a 2010 study in South Africa, funded in part by the United States, showed that the use of a microbicide was 39% effective in reducing a woman's risk of contracting HIV during sex.5 Many health experts support microbicide research as it offers women vulnerable to violence and sexual coercion some degree of protection against HIV.
Key U.S. Legislation on Global HIV/AIDS, 2003-2011
- On May 27, 2003, President George W. Bush signed into law the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (Leadership Act, P.L. 108-25). The Leadership Act authorized $15 billion for global HIV/AIDS, TB, and malaria programs from FY2004 through FY2008. The act also authorized the creation of the Office of the Global AIDS Coordinator (OGAC) at the Department of State to oversee and coordinate all bilateral HIV/AIDS activities and funding.
As part of the act, Congress recommended the following distribution of HIV/AIDS funds:
- 15% of funds be used for palliative care, and
- 20% of funds be used for HIV/AIDS prevention efforts.
Congress further required the following distribution of HIV/AIDS funds for each fiscal year from FY2006 to FY2008:
- at least 55% of funds be used for AIDS treatment, of which at least 75% be used for the purchase and distribution of ART and at least 25% be used for related care;
- at least 33% of appropriated prevention funds be used for abstinence-until-marriage programs; and
- at least 10% of funds be spent on orphans and vulnerable children.
Finally, the act mandated that from FY2004 to FY2008, the United States contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, see, "Key Partners in the Response to Global HIV/AIDS") not exceed 33% of the total amount of funds contributed from all sources.
- On July 24, 2008, President Bush signed into law the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-Hyde Act, P.L. 110-293). The Lantos-Hyde Act authorized $48 billion for U.S. global HIV/AIDS, TB, and malaria efforts from FY2008 through FY2013, including $2 billion for the Global Fund in FY2008.
As part of the act, Congress removed the recommendations that 20% of funds be spent on prevention efforts and that 33% of these funds be used for abstinence-until-marriage programs, and required the following:
- for each fiscal year from FY2009 to FY2013, at least 10% of funds be spent on orphans and vulnerable children;
- for each fiscal year from FY2009 to FY2013, more than 50% of bilateral assistance be spent on treatment and care of individuals infected with HIV/AIDS;
- balanced funding for prevention activities including those that promote abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction and country-specific implementation of such activities; and
- a report to Congress should less than 50% of prevention funds go to activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in any country with a generalized epidemic.
This legislation will be up for reauthorization in FY2013.
U.S. Global HIV/AIDS Programs
In 1999, the 106th Congress authorized resources to support a proposal by the Clinton Administration to broaden U.S. activities related to global HIV/AIDS through the Leadership and Investment in Fighting an Epidemic (LIFE) initiative. LIFE sought to address HIV/AIDS in 14 African countries and in India and represented the first time agencies other than the United States Agency for International Development (USAID) were included in the U.S. response to HIV/AIDS. President George W. Bush launched two initiatives that built on the LIFE initiative. In 2002, President Bush announced the International Mother and Child HIV Prevention Initiative, which focused on preventing mother-to-child transmission of HIV in 12 African countries and in 2 Caribbean countries. In 2003, President Bush announced PEPFAR, proposing that the United States spend $15 billion over the course of five years to combat global HIV/AIDS. Both the LIFE initiative and the International Mother and Child HIV Prevention Initiative were replaced by PEPFAR.
PEPFAR significantly increased attention to and funding for global HIV/AIDS. The President proposed that the majority of the funds ($9 billion) be concentrated in 15 focus countries, including 12 in sub-Saharan Africa. The proposal also allocated $5 billion to research and to other bilateral HIV/AIDS programs and $1 billion for contributions in FY2004 to the Global Fund.
PEPFAR represents the largest commitment by any country toward an international health issue. At the time it was established, health experts were debating whether the international community had a responsibility to provide ART to HIV-positive people in developing countries and whether they could be safely administered in such environments. PEPFAR responded to calls from those advocating treatment for the world's poor and demonstrated that ART could be effectively provided in low-resource settings.
Through the Leadership Act, Congress authorized the establishment of the Office of the Global AIDS Coordinator (OGAC), at the Department of State. OGAC oversees and coordinates all U.S. spending on bilateral global HIV/AIDS activities implemented by various agencies (see "PEPFAR Implementing Agencies"), as well as contributions to multilateral organizations.
President Barack Obama has committed to continued support for PEPFAR, while working to transition PEPFAR from an emergency plan to a long-term and sustainable approach to global HIV/AIDS. On May 5, 2009, the President announced the Global Health Initiative (GHI), a new six-year effort to develop a comprehensive U.S. global health strategy. The GHI calls for a more integrated U.S. response to global health issues and for a shift in U.S. global health strategy from one focused on specific diseases to a more comprehensive approach to health. PEPFAR is the central component of the GHI and accounts for approximately 75% of the President's FY2013 budget proposal. As part of the GHI, PEPFAR has committed to supporting the following goals from FY2010 through FY2014:
- prevention of more than 12 million new HIV infections;
- treatment of more than 6 million people living with HIV/AIDS;
- care for more than 12 million people, including 5 million orphans and vulnerable children; and
- training and retention of more than 140,000 new heath care workers.6
PEPFAR Implementing Agencies
PEPFAR programs are led by OGAC at the State Department and implemented by various U.S. agencies and departments, including the following:
- U.S. Agency for International Development: USAID supports HIV/AIDS programs in nearly 100 countries. These programs focus on providing treatment, care, and support to people infected with HIV/AIDS; strengthening primary health care systems; providing training, technical assistance, and commodities that reduce HIV transmission; reducing high-risk behaviors; and supporting international partnerships.
- Centers for Diseases Control and Prevention (CDC): CDC's Global AIDS Program (GAP) operates in 38 countries and four regional programs. CDC HIV/AIDS programs assist ministries of health and local implementing organizations to implement HIV/AIDS prevention programs, analyze program impact and cost effectiveness, and build the capacity of public workforce, as well as public health information, laboratory, and management systems.
- National Institutes of Health (NIH): NIH supports HIV/AIDS research and training in approximately 100 countries. This research focuses on tools to prevent HIV transmission, such as vaccines and microbicides; strategies to prevent mother-to-child transmission; and approaches to treating HIV and its associated opportunistic infections and co-infections in resource poor settings.
- Health Resources and Services Administration (HRSA): HRSA provides education and training HIV/AIDS programs in more than 25 countries that increase rapid roll-out of ART, support health system strengthening and improvements in human resources for health, and facilitate innovative approaches to health data collection and evaluation.
- U.S. Food and Drug Administration (FDA): FDA ensures the availability of safe and effective AIDS treatment. Since 2004, FDA has supported an accelerated review process for ARTs, including generic drugs and fixed dose combination drugs (FDCs)—multiple antiretroviral drugs combined into a single pill—for PEPFAR programs. As of 2011, 136 ART formulations had been approved or tentatively approved by FDA.
- Department of Defense (DOD): DOD operates HIV/AIDS programs in 73 countries. DOD's primary role under PEPFAR is to support military-to-military HIV/AIDS prevention, treatment, and care efforts; assist in the development of military-specific HIV/AIDS policies; and provide HIV/AIDS counseling, testing, and care for military families. DOD also provides HIV prevention scientific and technical assistance to non-military PEPFAR programs. The DOD HIV/AIDS Prevention Program (DHAPP) manages DOD's HIV/AIDS programs for foreign militaries and oversees the use of PEPFAR funds by DOD.
- Department of Labor (DOL): DOL implements HIV/AIDS programs in over 23 countries that facilitate the development of comprehensive workplace-based HIV prevention and education programs; assist governments, employers, and trade unions to develop and disseminate workplace policy countering stigma and discrimination; and support collaboration between government, business, and labor in countering HIV/AIDS.
- Peace Corps: Peace Corps volunteers support community-based HIV/AIDS care and prevention efforts over 66 countries. A number of Peace Corps volunteer projects related to HIV/AIDS received direct PEPFAR funding, while other Peace Corps posts benefited from activities organized by the headquarters using central PEPFAR funding.
- U.S. Department of Commerce (DOC): DOC creates and disseminates sector-specific strategies to inform HIV trade advisory committees on how the private sector can help combat HIV/AIDS. The U.S. Census Bureau also contributes to PEPFAR by assisting with data management and analysis, estimating infections averted, and supporting mapping of country-level activities.
U.S. Global HIV/AIDS Assistance Funds
Congress provides funds for global HIV/AIDS assistance to several U.S. agencies through a number of appropriations vehicles: State-Foreign Operations (State-Foreign Ops); Labor, Health and Human Services and Education (Labor-HHS); and Department of Defense (Defense) (Figure 3). Table 1 details all U.S. funding for global HIV/AIDS since FY2004.
|
Figure 3. PEPFAR Organizational Chart: Appropriations |
Source: CRS analysis. |
- State-Foreign Operations Appropriations: The majority of PEPFAR funds are appropriated through State-Foreign Operations to the Department of State. In FY2012, Congress appropriated over 85% of all global HIV/AIDS funds to the Department of State. As the coordinator of global HIV/AIDS activities, the Department of State transfers the bulk of these funds to implementing agencies, including USAID and CDC, in support of bilateral HIV/AIDS programs. Per congressional proviso, the department also uses some of these funds to make contributions to other organizations that combat global HIV/AIDS, including the Global Fund. Congress also appropriates funds to USAID for bilateral HIV/AIDS activities through State-Foreign Operations appropriations.
- Labor, Health and Human Services, and Education Appropriations: Congress appropriates funds for global HIV/AIDS activities to HHS agencies, including CDC and NIH, through Labor-HHS appropriations. Historically, Congress has provided a second portion of the U.S. contribution to the Global Fund through Labor-HHS, although it did not do so in FY2012 or the FY2013 budget request. Congress used to appropriate funds to DOL for bilateral HIV/AIDS activities, but it has not done so since FY2005.
- Department of Defense Appropriations: Congress also appropriates funds to DOD for bilateral HIV/AIDS programs through DOD appropriations.
Table 1. U.S. Bilateral Funding for Global HIV/AIDS: FY2004-FY2013
($ millions, current)
|
Program/Agency |
FY2004 Actual |
FY2005 Actual |
FY2006 Actual |
FY2007 Actual |
FY2008 Actual |
FY2009 Actual |
FY2010 Actual |
FY2011 Actual |
FY2012 Estimate |
FY2013 Request |
|
USAID GHPa |
513.5 |
347.2 |
346.5 |
325.0 |
347.2 |
350.0 |
350.0 |
349.3 |
350.0 |
330.0 |
|
USAID Otherb |
42.0 |
37.5 |
27.3 |
20.9 |
24.8 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
State GHP |
488.1 |
1,373.9 |
1,777.1 |
2,869.0 |
4,116.4 |
4,559.0 |
4,609.0 |
4,585.8 |
4,242.9 |
3,700.0 |
|
FMFc |
1.5 |
2.0 |
2.0 |
1.6 |
1.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
CDC |
266.9 |
123.8 |
122.6 |
121.0 |
118.9 |
118.9 |
119.0 |
118.7 |
117.1 |
117.2 |
|
NIH |
317.2 |
369.5 |
373.0 |
361.7 |
411.7 |
451.7 |
485.6 |
375.7 |
364.5 |
388.9 |
|
DOL |
9.9 |
2.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
DOD |
4.3 |
7.5 |
5.2 |
0.0 |
8.0 |
8.0 |
10.0 |
10.0 |
8.0 |
0.0 |
|
TOTAL Bilateral HIV/AIDS |
1,643.4 |
2,263.4 |
2,653.7 |
3,699.2 |
5,028.0 |
5,487.6 |
5,573.6 |
5,539.5 |
5,082.5 |
4,536.1 |
Source: Compiled by CRS from Congressional Budget Justifications, appropriations legislation, and communication with the Office of Management and Budget (OMB).
a. Global Health Programs (GHP) Account.
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. Foreign Military Financing (FMF) funds are used to purchase equipment for DOD HIV/AIDS Programs.
Since the establishment of PEPFAR, U.S. funding for global HIV/AIDS has increased each year, with the largest increases between FY2004 and FY2008. U.S. funding for bilateral global HIV/AIDS programs has been decreasing since FY2010 (Figure 4).
The United States also supports global HIV/AIDS programs through contributions to the Global Fund, an international financing mechanism for the response to HIV/AIDS, TB, and malaria (Table 2). U.S. contributions to the Global Fund support grants for HIV/AIDS, TB, and malaria. The United States is the single largest donor to the Global Fund.
Table 2. U.S. Appropriations for the Global Fund: FY2004-FY2013
($ millions, current)
|
Program/Agency |
FY2004 Actual |
FY2005 Actual |
FY2006 Actual |
FY2007 Actual |
FY2008 Actual |
FY2009 Actual |
FY2010 Actual |
FY2011 Actual |
FY2012 Estimate |
FY2013 Request |
|
USAID |
397.6 |
248.0 |
247.5 |
247.5 |
0.0 |
100.0 |
0.0 |
0.0 |
0.0 |
0.0 |
|
State |
0.0 |
0.0 |
198.0 |
377.5 |
545.5 |
600.0 |
750.0 |
748.5 |
1,300.0 |
1,650.0 |
|
HHS |
149.1 |
99.2 |
99.0 |
99.0 |
294.8 |
300.0 |
300.0 |
297.3 |
0.0 |
0.0 |
|
TOTAL Global Fund |
546.6 |
347.2 |
544.5 |
724.0 |
840.3 |
1,000.0 |
1,050.0 |
1,045.8 |
1,300.0 |
1,650.0 |
In low-income countries, the bulk of spending on HIV/AIDS is from international sources, approximately three-quarters of which is from bilateral donors, with the remaining quarter from multilateral donors. In 2010, U.S. funds made up over half of all donor government disbursements for global HIV/AIDS (Figure 5) and 24% of global HIV/AIDS funds from all sources, including donor and domestic governments, multilateral organizations, and the private sector. When standardized to correspond to gross domestic product (GDP) per $1 million spent, six European countries spend more than the United States on global HIV/AIDS.7 UNAIDS estimates the funding gap—the difference between resources available and resources needed to combat global HIV/AIDS—to be $6 billion annually.8
Key Partners in the Response to Global HIV/AIDS
The United States works with a range of partners to combat HIV/AIDS, including other national governments, multilateral organizations, non-governmental organizations (NGOs), and the private sector. Through authorizing legislation and annual appropriations, Congress provides funds to several multilateral organizations and international research initiatives that contribute to the fight against HIV/AIDS, including the Global Fund and the United Nations Joint Program on HIV/AIDS (UNAIDS).
- The Global Fund: The Global Fund was established in 2002 as a public-private partnership to provide financial support for global responses to HIV/AIDS, TB, and malaria. The United States contributes more to the Global Fund than any other country. The Global Fund has committed over $22.6 billion in grants in 150 countries since it was established, and was responsible for 21% of all international HIV funding in 2009.9 In November 2011, the Global Fund announced that due to limited funding available, it would postpone its 11th round of funding.10
- UNAIDS: UNAIDS is the main advocate for United Nations (U.N.) action on HIV/AIDS and is responsible for coordinating HIV/AIDS activities implemented by nine agencies, including U.N. Children's Fund (UNICEF); U.N. Development Program (UNDP); International Labor Organization (ILO); U.N. Population Fund (UNFPA); U.N. Office on Drugs and Crime (UNODC); U.N. Educational, Scientific and Cultural Organization (UNESCO); World Food Program (WFP); World Health Organization (WHO); and the World Bank. The United States is one of the largest contributors to UNAIDS. UNAIDS oversees a wide range of HIV/AIDS activities, which include efforts to reduce transmission of HIV; ensure access to ART; prevent death from HIV/TB co-infection; empower men who have sex with men; remove punitive law, policies, and practices that block effective responses to AIDS; reduce sexual and gender-based violence; and empower young people to protect themselves from HIV.
Key Issues in Global HIV/AIDS
The 112th Congress will continue to be faced with a number of issues regarding the U.S. response to global HIV/AIDS, including how much assistance to provide and how to best apportion global HIV/AIDS funds. Given the United States' central role in the fight against HIV/AIDS, many experts assert that the future direction of the U.S. response to HIV/AIDS will have significant implications for the global response to HIV/AIDS as a whole. The 112th Congress may consider the following issues as it considers the U.S. response to global HIV/AIDS:
- Treatment efforts: Without a vaccine or cure to HIV, people continue to contract HIV and require lifelong treatment. As such, despite efforts by the international community to expand access to treatment, the number of people in need of ART outpaces treatment resources. Global health experts have increasingly debated the sustainability of HIV/AIDS treatment programs and how to use limited resources to both treat those in need while also preventing new infections.
- Prevention efforts: There is widespread support within the global health community for intensifying prevention efforts, particularly in light of the persistent need for HIV/AIDS treatments. At the same time, experts disagree on what prevention efforts are most effective, how to measure the success of any one prevention activity, and how to incentivize leaders of developing countries to increase financial investment in prevention, particularly given its less immediate and dramatic results when compared with treatment. Recent scientific evidence regarding the preventive benefits of ART, as well as topical and oral antiretroviral pre-exposure prophylaxis, including microbicides, may increase support for and discussion of the use of these technologies.
- Health System Strengthening: Many global health experts argue that an effective long-term approach to global HIV/AIDS requires efforts to strengthen health systems (HSS) in low- and middle-income countries. However, there is little consensus within the global health community over how to define, implement, and measure HSS activities, and over whether PEPFAR has had a beneficial or detrimental impact on the broader functioning of health systems.
- Country ownership: Donor governments have increasingly supported the concept of country ownership as a way to promote sustainable and country-appropriate responses to the epidemic. To this end, a number of PEPFAR programs have implemented "Partnership Frameworks" with partner countries to clarify joint goals and strategies. Several issues related to country ownership are being debated within donor governments, including how to best align donor priorities and country priorities and how to maintain effective levels of oversight while shifting control to host governments.