PEPFAR Stewardship and Oversight Act: Expiring Authorities

Updated March 14, 2019 PEPFAR Stewardship and Oversight Act: Expiring Authorities Congress has prioritized fighting HIV/AIDS globally, having authorized related activities and appropriated over $82 billion for HIV/AIDS programs since FY2001 (Table 1). The 108th and 110th Congresses enacted two pieces of legislation that have shaped U.S. responses to these diseases: the “Leadership Act” of 2003, P.L. 108-25, and the “Lantos-Hyde Act” of 2008, P.L. 110-293. Among other things, these acts authorized appropriations for the President’s Emergency Plan for AIDS Relief (PEPFAR), a government-wide initiative to combat global HIV/AIDS. In 2013, when authorizations in the Lantos-Hyde Act were set to expire, congressional commitment to fighting HIV/AIDS remained strong, but concerns about recovering from the Great Recession had depressed support for enacting legislation that authorized the provision of billions of dollars over several years. Ultimately, the 113th Congress enacted P.L. 113-56, the “Stewardship Act” of 2013, which did not authorize a particular amount, but permitted further appropriations, extended programs, and enhanced oversight. Many of these provisions were set to expire at the end of FY2018 (Table 2). On November 13, 2018, the House passed H.R. 6651, the PEPFAR Extension Act of 2018. The bill was agreed to in the Senate and presented to the President on November 30, 2018. The President signed the bill into law on December 11, 2018. Among other things, the PEPFAR Extension Act  required the Inspectors General of the Department of State, Broadcasting Board of Governors, HHS, and USAID to jointly coordinate annual plans for oversight activities through 2023;  required the Global AIDS Coordinator to publish annually reports on HIV/AIDS spending by the U.S. government, the Global Fund, and governments in partner countries through 2024;  limited U.S. Global Fund contributions to 33% of all contributions received and permit withholding portions of those contributions through 2023;  required that more than half of U.S. international HIV/AIDS appropriations be used for treatment of HIV/AIDS and other associated opportunistic infections, as well as nutritional support and medical care for people living with HIV/AIDS through 2023; and  required that at least 10% of funds be used on care and support for orphans and vulnerable children until 2023. range of HIV/AIDS prevention, treatment, and care activities and is the largest commitment by any nation to combat a single disease. Later that year, Congress enacted the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, which authorized $15 billion to be spent from FY2004 to FY2008 on bilateral and multilateral HIV/AIDS, TB, and malaria programs. The Leadership Act (and the legislation that it amends) is the primary vehicle through which U.S. global assistance for fighting these diseases is authorized. The act included language to instruct how the funds should be spent, list program goals and targets, and establish the Coordinator of the United States Government Activities to Combat HIV/AIDS Globally (known as the Global AIDS Coordinator) at the Department of State. The Office of the Global AIDS Coordinator (OGAC) distributes the majority of the funds it receives from Congress for global HIV/AIDS programs to U.S. federal agencies and departments and multilateral groups like the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The Lantos-Hyde Act. In 2008, Congress enacted the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, which amended the Leadership Act to authorize the appropriation of $48 billion for global HIV/AIDS, TB, and malaria efforts from FY2009 to FY2013. The Lantos-Hyde Act mostly amends the Leadership Act, although it also amends some other acts, such as the Foreign Assistance Act of 1961, and includes some stand-alone authorities. The Leadership Act and the Lantos-Hyde Act (primarily through amendments to the Leadership Act) created frameworks for how the funds should be spent, established program goals and targets, and established offices for coordinating government-wide responses, among other things. PEPFAR Stewardship Act. In 2013, Congress enacted P.L. 113-56, the PEPFAR Stewardship and Oversight Act of 2013. Unlike its predecessors, this act did not authorize a particular total amount for global HIV/AIDS, TB, and malaria programs. It primarily focused on enhancing oversight for related programs; preserving requirements to apportion 10% of HIV/AIDS funds for orphans and vulnerable children (OVC); mandating that more than half of related funds be spent on HIV/AIDS treatment and care; and requiring that at least 50% of prevention funds be used for activities that promote abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction. PEPFAR-Related Legislation The Leadership Act. In January 2003, President George W. Bush announced PEPFAR. PEPFAR supports a wide https://crsreports.congress.gov PEPFAR Stewardship and Oversight Act: Expiring Authorities Table 1. Appropriations for Global HIV/AIDS Programs: FY2001 Enacted -FY2019 Enacted (current U.S. $ billions) State HIV/AIDS Global Fund USAID HIV/AIDS CDC HIV/AIDS NIH HIV/AIDS DOD HIV/AIDS DOL HIV/AIDS Total HIV/AIDS Bush Administration FY01-FY08 FY01-FY08 Enacted Total Average 8,663.6 1,083.0 2,858.4 357.3 2,412.7 301.6 918.4 114.8 1,935.2 241.9 42.1 5.3 30.3 3.8 16,860.9 2,107.6 Obama Administration FY09-FY16 FY09-FY16 Enacted Total Average 31,185.2 3,898.2 9,376.1 1,172.0 2,459.6 307.4 891.4 111.4 3,085.1 385.6 53.2 6.6 0.0 0.0 47,050.6 5,881.3 Trump Administration FY17 FY18 FY18 FY19 Enacted Request Enacted Enacted 4,228.5 3,850.0 4,320.0 4,370.0 1,321.4 1,125.0 1,350.0 1,350.0 323.0 0.0 330.0 330.0 125.5 69.5 128.4 128.4 a a a 422.8 8.0 0.0 8.0 8.0 0.0 0.0 0.0 0.0 a a a 6,429.2 FY2020 Request 3,350.0 958.4 0.0 n/s a 0.0 0.0 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 Section and Title Sec. 2 Inspector General Oversight amends 101(f)(1) of the Leadership Act Sec. 3(a) Annual Study amends Sec. 101(g) of the Leadership Act Sec. 4(a)(1)(A) Limitation amends Sec. 202(d)(4)(A)(i) of the Leadership Act Sec. 4(a)(1)(C)(vi) amends Sec. 202(d)(4)(A)(ii) of the Leadership Act Sec. 4(b) Withholding Funds amends Sec. 202(d)(4)(A)(iv) Sec. 4(b)(1)(A) amends Sec. 202(d)(5) of the Leadership Act Sec. 6(a)(1) Orphans and Vulnerable Children amends Sec. 403(b) of the Leadership Act Sec. 6(b)(1) Allocation of Funding amends Sec. 403(c) of the Leadership Act Date of Expiration Summary of Language Directs the Inspectors General of the Department of State and Broadcasting Board of Governors, September the Department of Health and Human Services (HHS), and the U.S. Agency for International 30, 2018 Development (USAID) to jointly develop annually coordinated plans for overseeing global HIV/AIDS, TB, and malaria programs. Directs the Global AIDS Coordinator to annually complete a study of treatment providers, including September a description of the per-patient cost of providing treatment and care for people with HIV/AIDS, 30, 2019 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. Prohibits U.S. contributions to the Global Fund from exceeding 33% of all funds donated to the September Fund. 30, 2018 Requires the Department of State to withhold contributions to the Fund commensurate to the amount the Fund provided to a country that the President has determined repeatedly provided support for acts of international terrorism. Permits any amounts withheld from the Global Fund to be used for bilateral HIV/AIDS, TB, and malaria programs. Authorizes withholding 20% of Global Fund contributions until the Secretary of State certifies that certain reporting and evaluation requirements are met. Requires that at least 10% of funds appropriated for bilateral HIV/AIDS programs be expended for programs targeting orphans and vulnerable children affected by HIV/AIDS. September 30, 2018 September 30, 2018 September 30, 2018 September 30, 2018 Requires that more than half of funds appropriated for bilateral HIV/AIDS programs be expended on September the provision of treatment, care and nutritional support for people living with HIV/AIDS. 30, 2018 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 a PEPFAR Stewardship and Oversight Act: Expiring Authorities Disclaimer This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material. https://crsreports.congress.gov | IF10797 · VERSION 13 · UPDATED