Updated August 4, 2023
PEPFAR Extension Act of 2018: Expiring Authorities
Since the 108th Congress (2003-2004) enacted legislation to
how the funds should be spent and established program
authorize multiyear funding for international HIV/AIDS,
goals and targets.
tuberculosis (TB), and malaria programs, including the
President’s Emergency Plan for AIDS Relief (PEPFAR),
PEPFAR Stewardship Act. In 2013, Congress enacted the
PEPFAR Stewardship and Oversight Act of 2013, P.L. 113-
successive Congresses have debated extending some of
56. Unlike its predecessors, this act did not authorize a
those authorities. While most PEPFAR-related provisions
specific appropriation for global HIV/AIDS, TB, and
are authorized in statute without expiring authorities, the
malaria programs. It focused primarily on enhancing
118th Congress is currently considering whether to extend
oversight for related programs; preserving requirements to
PEPFAR-related provisions in the PEPFAR Extension Act
apportion 10% of HIV/AIDS funds for orphans and
of 2018 (P.L. 115-305) that are set to expire on September
vulnerable children (OVC); mandating that more than half
30, 2023.
of related funds be spent on HIV/AIDS treatment and care;
Whereas the PEPFAR program was the George W. Bush
and requiring that at least 50% of prevention funds be used
Administration’s clarion call for confronting the global
for activities that promote abstinence, delay of sexual debut,
HIV/AIDS crisis, Congress has used a series of laws, as
monogamy, fidelity, and partner reduction.
described below, to outline its vision on how the United
PEPFAR Extension Act of 2018. On November 13, 2018,
States should fight HIV/AIDS worldwide. This In Focus
the House passed H.R. 6651, the PEPFAR Extension Act of
describes how these acts shape U.S. international
2018. The bill was agreed to in the Senate on November 28
HIV/AIDS assistance, including PEPFAR.
and presented to the President on November 30. President
PEPFAR-Related Legislation
Donald J. Trump signed the bill into law on December 11,
2018. The act did not authorize specific appropriations
Authorization for PEPFAR activities is provided through a
levels, but it extended several provisions of the prior acts
number of acts, as described below. None of the acts
through September 30, 2023, including those requiring
authorize PEPFAR explicitly, rather they authorize support
for international HIV/AIDS assistance. The acts outline
• the Inspectors General of the Department of State,
congressional priorities on how this aid is to be provided.
Broadcasting Board of Governors, HHS, and USAID to
jointly coordinate annual plans for oversight activities;
The Leadership Act. In January 2003, President George
W. Bush announced PEPFAR, the largest bilateral
• U.S. Global Fund contributions not to exceed 33% of all
HIV/AIDS program in the world. Later that year, Congress
contributions received and allowing withholding
enacted the United States Leadership Against HIV/AIDS,
portions of those contributions;
Tuberculosis, and Malaria Act of 2003 (Leadership Act),
• more than half of U.S. international HIV/AIDS
P.L. 108-25, which authorized $15 billion to be spent from
appropriations be used for treatment of HIV/AIDS and
FY2004 to FY2008 on bilateral and multilateral HIV/AIDS
other associated opportunistic infections, as well as
programs under the PEPFAR umbrella, as well as
nutritional support and medical care for people living
tuberculosis (TB) and malaria programs. The act included
with HIV/AIDS; and
language that instructed how the funds were to be spent,
listed program goals and targets, and authorized the
• at least 10% of bilateral HIV/AIDS funds be used on
establishment of the Global AIDS Coordinator and the
care and support for orphans and vulnerable children.
Office of the Global AIDS Coordinator (OGAC). The
Global AIDS Coordinator determines how PEPFAR funds
In addition, a provision requiring the Global AIDS
Coordinator to publish annual reports on HIV/AIDS
are to be distributed to the implementing agencies and
certifies that congressional directives, such as those related
spending by the U.S. government, the Global Fund, and
to U.S. contributions to the Global Fund to Fight AIDS,
governments in partner countries was extended through
2024.
Tuberculosis, and Malaria (Global Fund), are followed.
The Lantos-Hyde Act. In 2008, Congress enacted the Tom
Selected Enduring Provisions
Lantos and Henry J. Hyde United States Global Leadership
The overall framework of U.S. international HIV/AIDS
Against HIV/AIDS, Tuberculosis, and Malaria
assistance, as presently provided through PEPFAR, is
Reauthorization Act of 2008 (Lantos-Hyde Act), P.L. 110-
enacted in law mostly without sunset provisions. As a
293, which amended the Leadership Act to authorize the
result, these provisions remain in effect without the need for
appropriation of $48 billion for global HIV/AIDS, TB, and
periodic reauthorization. They include the following:
malaria efforts from FY2009 to FY2013. Among other
•
things, the Lantos-Hyde Act (primarily through
Authorization of Global HIV/AIDS Assistance.
Section 104A of the Foreign Assistance Act of 1961,
amendments to the Leadership Act) created frameworks for
P.L. 87-195, as amended by the Leadership Act,
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link to page 2 PEPFAR Extension Act of 2018: Expiring Authorities
permanently authorized appropriations for bilateral and
• whether current restrictions on PEPFAR-related funds
multilateral global HIV/AIDS programs.
are sufficient to prevent them from being used to
•
support abortions;
The Global AIDS Coordinator. Section 1 of the State
Department Basic Authorities Act of 1956, P.L. 84-885,
• whether funds for children orphaned by and vulnerable
as amended by the Leadership Act, permanently
to HIV/AIDS should be (1) reallocated, given the
authorized the Global AIDS Coordinator position and
reduction in this population since it peaked at 18 million
detailed the planning, coordination, and oversight duties
in 2011 and 2012—a decline due in large part to parents
of the Coordinator, including the transfer and allocation
living longer with access to antiretroviral treatment
of funds to implementing federal agencies.
gained through PEPFAR and other global HIV/AIDS
•
programs—or (2) expanded, given the existing 13.9
The “Conscience Clause.” Section 301(d) of the
million orphans as of 2022, a number of whom have
Leadership Act specified that organizations that are
aged out (over 17 years old) and are no longer eligible
eligible to receive assistance under the FAA for bilateral
for OVC-specific programming.
HIV/AIDS assistance shall not be required to endorse or
utilize a multisectoral approach to combatting
• whether to authorize fuller flexibility of funds to allow
HIV/AIDS or to participate in a prevention method or
PEPFAR to (1) address co-morbidities such as
treatment program for which the organization has
noncommunicable diseases (as people who are HIV-
religious or moral objection. The Lantos-Hyde Act
positive continue to access antiretroviral treatment, they
amended the Leadership Act to specify that such
face increased risk of diseases associated with longer
organizations shall not be discriminated against in the
life spans, such as stroke, heart disease, and cirrhosis),
solicitation or issuance of federal funding for bilateral
and (2) provide targeted assistance aimed at future
HIV/AIDS assistance.
pandemic preparedness, response, and resilience. The
State Department and other groups have reported that
Issues Facing Congress
PEPFAR-funded clinical care platforms, laboratories,
Congress is considering whether to extend provisions in the
detection surveillance systems, supply chains, and
PEPFAR Extension Act that are set to expire (see Table 1).
health information systems were used during the peak of
the COVID-19 pandemic to detect, control, and respond
Key debates related to reauthorization include questions on
to outbreaks.
Table 1.Authorities in the PEPFAR Extension Act of 2018 Set to Expire in 2023 or 2024
Date of
Section and Title
Summary of Language
Expiration
Sec. 2 (1) Inspectors General And
Directs the Inspectors General of the Department of State and Broadcasting Board of Governors, the
September
Annual Study amends 101(f)(1) of the
Department of Health and Human Services, and the U.S. Agency for International Development to
30, 2023
Leadership Act
jointly develop annual y coordinated plans for overseeing global HIV/AIDS, TB, and malaria programs.
Sec. 2(2) amends Sec. 101(g) of the
Directs the Global AIDS Coordinator to annual y complete a study of treatment providers, including a
September
Leadership Act
description of the per-patient cost of providing treatment and care for people with HIV/AIDS, human
30, 2024
and fiscal resource requirements for HIV/AIDS programs, and spending by the Global Fund to Fight
AIDS, Tuberculosis, and Malaria (Global Fund, or the Fund) and by partner countries.
Sec. 3(1)(A)(i) Participation in the
Prohibits U.S. contributions to the Global Fund from exceeding 33% of al funds donated to the Fund.
September
Global Fund to Fight AIDS,
30, 2023
Tuberculosis, And Malaria amends
Sec. 202(d)(4)(A)(i) of the Leadership Act
Sec. 3(1)(A)(ii) amends Sec.
Requires the Department of State to withhold contributions to the Fund commensurate with the
September
202(d)(4)(A)(ii) of the Leadership Act
amount the Fund provided to a country that the President determined “repeatedly provided support
30, 2023
for acts of international terrorism.”
Sec. 3(B)(ii) amends Sec.
Permits any amounts withheld from the Global Fund to be used for bilateral HIV/AIDS, TB, and malaria September
202(d)(4)(A)(iv) of the Leadership Act
programs.
30, 2023
Sec. 3(2) amends Sec. 202(d)(5) of the
Authorizes withholding 20% of Global Fund contributions until the Secretary of State certifies that
September
Leadership Act
certain reporting and evaluation requirements are met.
30, 2023
Sec. 4(1) Allocation of Funds amends
Requires that at least 10% of funds appropriated for bilateral HIV/AIDS programs be expended for
September
Sec. 403(b) of the Leadership Act
programs supporting orphans and vulnerable children (OVC) affected by HIV/AIDS.
30, 2023
Sec. 4(2) amends Sec. 403(c) of the
Requires that more than half of funds appropriated for bilateral HIV/AIDS programs be expended on
September
Leadership Act
the provision of treatment, care, and nutritional support for people living with HIV/AIDS.
30, 2023
Source: Created by CRS from P.L. 115-305, the PEPFAR Extension Act of 2018.

Catherine L. Able-Thomas, Acting Research Assistant
Tiaji Salaam-Blyther, Specialist in Global Health

IF12463

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PEPFAR Extension Act of 2018: Expiring Authorities


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