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Updated March 14, 2019
PEPFAR Stewardship and Oversight Act: Expiring Authorities
Congress has prioritized fighting HIV/AIDS globally,
range of HIV/AIDS prevention, treatment, and care
having authorized related activities and appropriated over
activities and is the largest commitment by any nation to
$82 billion for HIV/AIDS programs since FY2001 (Table
combat a single disease. Later that year, Congress enacted
1). The 108th and 110th Congresses enacted two pieces of
the United States Leadership Against HIV/AIDS,
legislation that have shaped U.S. responses to these
Tuberculosis, and Malaria Act of 2003, P.L. 108-25, which
diseases: the “Leadership Act” of 2003, P.L. 108-25, and
authorized $15 billion to be spent from FY2004 to FY2008
the “Lantos-Hyde Act” of 2008, P.L. 110-293. Among
on bilateral and multilateral HIV/AIDS, TB, and malaria
other things, these acts authorized appropriations for the
programs. The Leadership Act (and the legislation that it
President’s Emergency Plan for AIDS Relief (PEPFAR), a
amends) is the primary vehicle through which U.S. global
government-wide initiative to combat global HIV/AIDS.
assistance for fighting these diseases is authorized. The act
included language to instruct how the funds should be
In 2013, when authorizations in the Lantos-Hyde Act were
spent, list program goals and targets, and establish the
set to expire, congressional commitment to fighting
Coordinator of the United States Government Activities to
HIV/AIDS remained strong, but concerns about recovering
Combat HIV/AIDS Globally (known as the Global AIDS
from the Great Recession had depressed support for
Coordinator) at the Department of State. The Office of the
enacting legislation that authorized the provision of billions
Global AIDS Coordinator (OGAC) distributes the majority
of dollars over several years. Ultimately, the 113th Congress
of the funds it receives from Congress for global HIV/AIDS
enacted P.L. 113-56, the “Stewardship Act” of 2013, which
programs to U.S. federal agencies and departments and
did not authorize a particular amount, but permitted further
multilateral groups like the Global Fund to Fight AIDS,
appropriations, extended programs, and enhanced oversight.
Tuberculosis and Malaria (Global Fund).
Many of these provisions were set to expire at the end of
FY2018 (Table 2).
The Lantos-Hyde Act. In 2008, Congress enacted the Tom
Lantos and Henry J. Hyde United States Global Leadership
On November 13, 2018, the House passed H.R. 6651, the
Against HIV/AIDS, Tuberculosis, and Malaria
PEPFAR Extension Act of 2018. The bill was agreed to in
Reauthorization Act of 2008, P.L. 110-293, which amended
the Senate and presented to the President on November 30,
the Leadership Act to authorize the appropriation of $48
2018. The President signed the bill into law on December
billion for global HIV/AIDS, TB, and malaria efforts from
11, 2018. Among other things, the PEPFAR Extension Act
FY2009 to FY2013. The Lantos-Hyde Act mostly amends
the Leadership Act, although it also amends some other
required the Inspectors General of the Department of
acts, such as the Foreign Assistance Act of 1961, and
State, Broadcasting Board of Governors, HHS, and
includes some stand-alone authorities. The Leadership Act
USAID to jointly coordinate annual plans for oversight
and the Lantos-Hyde Act (primarily through amendments to
activities through 2023;
the Leadership Act) created frameworks for how the funds
required the Global AIDS Coordinator to publish
should be spent, established program goals and targets, and
annually reports on HIV/AIDS spending by the U.S.
established offices for coordinating government-wide
government, the Global Fund, and governments in
responses, among other things.
partner countries through 2024;
PEPFAR Stewardship Act. In 2013, Congress enacted
limited U.S. Global Fund contributions to 33% of all
P.L. 113-56, the PEPFAR Stewardship and Oversight Act
contributions received and permit withholding portions of
of 2013. Unlike its predecessors, this act did not authorize a
those contributions through 2023;
particular total amount for global HIV/AIDS, TB, and
required that more than half of U.S. international
malaria programs. It primarily focused on enhancing
HIV/AIDS appropriations be used for treatment of
oversight for related programs; preserving requirements to
HIV/AIDS and other associated opportunistic infections,
apportion 10% of HIV/AIDS funds for orphans and
as well as nutritional support and medical care for people
vulnerable children (OVC); mandating that more than half
living with HIV/AIDS through 2023; and
of related funds be spent on HIV/AIDS treatment and care;
and requiring that at least 50% of prevention funds be used
required that at least 10% of funds be used on care and
for activities that promote abstinence, delay of sexual debut,
support for orphans and vulnerable children until 2023.
monogamy, fidelity, and partner reduction.
PEPFAR-Related Legislation
The Leadership Act. In January 2003, President George
W. Bush announced PEPFAR. PEPFAR supports a wide
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Table 1. Appropriations for Global HIV/AIDS Programs: FY2001 Enacted -FY2019 Enacted
(current U.S. $ billions)
Bush Administration
Obama Administration
Trump Administration
FY01-FY08
FY01-FY08
FY09-FY16
FY09-FY16
FY17
FY18
FY18
FY19
FY2020
Enacted Total
Average
Enacted Total
Average
Enacted Request Enacted Enacted Request
State HIV/AIDS
8,663.6
1,083.0
31,185.2
3,898.2
4,228.5
3,850.0
4,320.0
4,370.0
3,350.0
Global Fund
2,858.4
357.3
9,376.1
1,172.0
1,321.4
1,125.0
1,350.0
1,350.0
958.4
USAID HIV/AIDS
2,412.7
301.6
2,459.6
307.4
323.0
0.0
330.0
330.0
0.0
CDC HIV/AIDS
918.4
114.8
891.4
111.4
125.5
69.5
128.4
128.4
n/s
NIH HIV/AIDS
1,935.2
241.9
3,085.1
385.6
422.8
a
a
a
a
DOD HIV/AIDS
42.1
5.3
53.2
6.6
8.0
0.0
8.0
8.0
0.0
DOL HIV/AIDS
30.3
3.8
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Total HIV/AIDS
16,860.9
2,107.6
47,050.6
5,881.3
6,429.2
a
a
a
a
Source: Created by CRS from appropriations legislation and correspondence with CDC and USAID legislative affairs offices.
Abbreviations: U.S. Department of State (State), U.S. Agency for International Development (USAID), U.S. Centers for Disease Control and Prevention
(CDC), U.S. Department of Defense (DOD), National Institutes of Health (NIH), tuberculosis (TB), HIV/AIDS, TB, and malaria (HTAM), not specified (n/s).
Notes: Congress appropriated funds to the Department of Defense for global HIV/AIDS activities from FY2001 through FY2015. After FY2015, all support for
DOD HIV/AIDS activities were provided through appropriations to the State Department.
a. NIH international HIV/AIDS Research is funded through the Office of AIDS Research. Congressional budget justifications typically include annual funding
levels, but not requested funding levels. CRS did not aggregate the total since FY2018-requested and FY2019-enacted levels are not yet available.
Table 2. Authorities in the PEPFAR Stewardship Act Set to Expire in 2018 or 2019
Date of
Section and Title
Summary of Language
Expiration
Sec. 2 Inspector General
Directs the Inspectors General of the Department of State and Broadcasting Board of Governors,
September
Oversight amends 101(f)(1) of
the Department of Health and Human Services (HHS), and the U.S. Agency for International
30, 2018
the Leadership Act
Development (USAID) to jointly develop annually coordinated plans for overseeing global HIV/AIDS,
TB, and malaria programs.
Sec. 3(a) Annual Study
Directs the Global AIDS Coordinator to annually complete a study of treatment providers, including September
amends Sec. 101(g) of the
a description of the per-patient cost of providing treatment and care for people with HIV/AIDS,
30, 2019
Leadership Act
human and fiscal resource requirements for HIV/AIDS programs, and spending by the Global Fund
to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and by partner countries.
Sec. 4(a)(1)(A) Limitation
Prohibits U.S. contributions to the Global Fund from exceeding 33% of all funds donated to the
September
amends Sec. 202(d)(4)(A)(i) of
Fund.
30, 2018
the Leadership Act
Sec. 4(a)(1)(C)(vi) amends Sec. Requires the Department of State to withhold contributions to the Fund commensurate to the
September
202(d)(4)(A)(ii) of the Leadership amount the Fund provided to a country that the President has determined repeatedly provided
30, 2018
Act
support for acts of international terrorism.
Sec. 4(b) Withholding Funds Permits any amounts withheld from the Global Fund to be used for bilateral HIV/AIDS, TB, and
September
amends Sec. 202(d)(4)(A)(iv)
malaria programs.
30, 2018
Sec. 4(b)(1)(A) amends Sec.
Authorizes withholding 20% of Global Fund contributions until the Secretary of State certifies that
September
202(d)(5) of the Leadership Act
certain reporting and evaluation requirements are met.
30, 2018
Sec. 6(a)(1) Orphans and
Requires that at least 10% of funds appropriated for bilateral HIV/AIDS programs be expended for
September
Vulnerable Children amends
programs targeting orphans and vulnerable children affected by HIV/AIDS.
30, 2018
Sec. 403(b) of the Leadership Act
Sec. 6(b)(1) Allocation of
Requires that more than half of funds appropriated for bilateral HIV/AIDS programs be expended on September
Funding amends Sec. 403(c) of
the provision of treatment, care and nutritional support for people living with HIV/AIDS.
30, 2018
the Leadership Act
Source: Created by CRS from P.L. 113-56, the PEPFAR Stewardship and Oversight Act of 2013.
Tiaji Salaam-Blyther, Specialist in Global Health
IF10797
https://crsreports.congress.gov
PEPFAR Stewardship and Oversight Act: Expiring Authorities
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