PEPFAR Extension Act of 2018: Extended Authorities

PEPFAR Extension Act of 2018: Extended Authorities

Updated March 29, 2024
PEPFAR Extension Act of 2018: Extended 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 an expiration date, several
malaria programs. It focused primarily on enhancing
provisions do expire if not regularly reauthorized. These
oversight for related programs; preserving requirements to
provisions were most recently extended, through March
apportion 10% of HIV/AIDS funds for orphans and
2025, in the Further Consolidated Appropriations Act, 2024
vulnerable children (OVC); mandating that more than half
(P.L. 118-47).
of related funds be spent on HIV/AIDS treatment and care;
and requiring that at least 50% of prevention funds be used
Whereas the PEPFAR program was the George W. Bush
Administration’s clarion call
for activities that promote abstinence, delay of sexual debut,
for confronting the global
monogamy, fidelity, and partner reduction.
HIV/AIDS crisis, Congress has used a series of laws, as
described below, to outline its vision on how the United
The PEPFAR Extension Act. In 2018, Congress enacted
States should fight HIV/AIDS worldwide. This In Focus
the PEPFAR Extension Act of 2018, P.L. 115-305. The act
describes how these acts shape U.S. international
did not authorize specific appropriations levels, but it
HIV/AIDS assistance, including PEPFAR.
extended several provisions of the prior acts through
September 30, 2023, including those requiring
PEPFAR-Related Legislation
Authorization for PEPFAR activities is provided through a
• the Inspectors General of the Department of State,
number of acts, as described below. None of the acts
Broadcasting Board of Governors, HHS, and USAID to
authorize PEPFAR explicitly, rather they authorize support
jointly coordinate annual plans for oversight activities;
for international HIV/AIDS assistance. The acts outline
• U.S. Global Fund contributions not to exceed 33% of all
congressional priorities on how this aid is to be provided.
contributions received and allowing withholding
The Leadership Act. In 2003, President George W. Bush
portions of those contributions;
announced PEPFAR, the largest bilateral HIV/AIDS
• more than half of U.S. international HIV/AIDS
program in the world. Later that year, Congress enacted the
appropriations be used for treatment of HIV/AIDS and
United States Leadership Against HIV/AIDS, Tuberculosis,
other associated opportunistic infections, as well as
and Malaria Act of 2003 (Leadership Act), P.L. 108-25,
nutritional support and medical care for people living
which authorized $15 billion to be spent from FY2004 to
with HIV/AIDS; and
FY2008 on bilateral and multilateral HIV/AIDS programs
• at least 10% of bilateral HIV/AIDS funds be used on
under the PEPFAR umbrella, as well as tuberculosis (TB)
care and support for orphans and vulnerable children.
and malaria programs. The act included language that
instructed how the funds were to be spent, listed program
A provision requiring the Global AIDS Coordinator to
goals and targets, and authorized the establishment of the
publish annual reports on HIV/AIDS spending by the U.S.
Global AIDS Coordinator and the Office of the Global
government, the Global Fund, and governments in partner
AIDS Coordinator (OGAC). The Global AIDS Coordinator
countries was also extended through 2024.
determines how PEPFAR funds are to be distributed to the
implementing agencies and certifies that congressional
Global HIV/AIDS Provisions in the FY2024 Further
directives, such as those related to U.S. contributions to the
Consolidated Appropriations. On March 23, 2024,
Global Fund to Fight AIDS, Tuberculosis, and Malaria
Congress enacted and President Joe Biden signed into law
(Global Fund), are followed.
the Further Consolidated Appropriations Act, 2024, which
included an extension of the above-mentioned PEPFAR-
The Lantos-Hyde Act. In 2008, Congress enacted the Tom
related provisions through March 25, 2025.
Lantos and Henry J. Hyde United States Global Leadership
Selected Enduring Provisions
Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (Lantos-Hyde Act), P.L. 110-
The overall framework of U.S. international HIV/AIDS
293, which amended the Leadership Act to authorize the
assistance, as presently provided through PEPFAR, is
appropriation of $48 billion for global HIV/AIDS, TB, and
enacted in law mostly without sunset provisions. As a
malaria efforts from FY2009 to FY2013. Among other
result, these provisions remain in effect without the need for
things, the Lantos-Hyde Act (primarily through
periodic reauthorization. They include the following:
amendments to the Leadership Act) created frameworks for
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• Authorization of Global HIV/AIDS Assistance.
Key debates related to reauthorization include questions on
Section 104A of the Foreign Assistance Act of 1961,
• whether current restrictions on PEPFAR-related funds
P.L. 87-195, as amended by the Leadership Act,
are sufficient to prevent them from being used to
permanently authorized appropriations for bilateral and
support abortions;
multilateral global HIV/AIDS programs.
•
• the extent to which funds provided for children
The Global AIDS Coordinator. Section 1 of the State
orphaned by and vulnerable to HIV/AIDS should be (1)
Department Basic Authorities Act of 1956, P.L. 84-885,
reallocated, given the reduction in this population since
as amended by the Leadership Act, permanently
it peaked at 18 million in 2011 and 2012 (a decline due
authorized the Global AIDS Coordinator position and
in large part to parents living longer with access to
detailed the planning, coordination, and oversight duties
antiretroviral treatment gained through PEPFAR and
of the Coordinator, including the transfer and allocation
other global HIV/AIDS programs), or (2) expanded,
of funds to implementing federal agencies.
given that 13.9 million children continue to be orphaned
• The “Conscience Clause.” Section 301(d) of the
or made vulnerable by HIV/AIDS as of 2022.
Leadership Act specified that organizations that are
• whether to authorize fuller flexibility of funds to allow
eligible to receive assistance under the FAA for bilateral
PEPFAR to (1) address co-morbidities such as
HIV/AIDS assistance shall not be required to endorse or
noncommunicable diseases (as people who are HIV-
utilize a multisectoral approach to combatting
positive continue to access antiretroviral treatment, they
HIV/AIDS or to participate in a prevention method or
face increased risk of diseases associated with longer
treatment program for which the organization has
life spans, such as stroke, heart disease, and cirrhosis),
religious or moral objection. The Lantos-Hyde Act
and (2) provide targeted assistance aimed at future
amended the Leadership Act to specify that such
pandemic preparedness, response, and resilience. The
organizations shall not be discriminated against in the
State Department and other groups have reported that
solicitation or issuance of federal funding for bilateral
PEPFAR-funded clinical care platforms, laboratories,
HIV/AIDS assistance.
detection surveillance systems, supply chains, and
Issues Facing Congress
health information systems were used during the peak of
Congress is considering whether to extend provisions in the
the COVID-19 pandemic to detect, control, and respond
PEPFAR Extension Act that are set to expire (see Table 1).
to outbreaks.
Table 1. Authorities Extended in the Further Consolidated Appropriations Act, 2024
Date of
Section and Title
Summary of Language
Expiration
Sec. 7072(a)(1) Inspectors General
Directs the Inspectors General of the Department of State and Broadcasting Board of Governors, the
March 25,
And Annual Study amends Sec.
Department of Health and Human Services, and the U.S. Agency for International Development to
2025
101(f)(1) of the Leadership Act
jointly develop annual y coordinated plans for overseeing global HIV/AIDS, TB, and malaria programs.
Sec. 7072(a)(2) amends Sec. 101(g) of
Directs the Global AIDS Coordinator to annual y complete a study of treatment providers, including a
March 25,
the Leadership Act
description of the per-patient cost of providing treatment and care for people with HIV/AIDS, human
2025
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. 7072(b)(1)(A)(i) Participation in Prohibits U.S. contributions to the Global Fund from exceeding 33% of al funds donated to the Fund.
March 25,
the Global Fund to Fight AIDS,
2025
Tuberculosis, And Malaria amends
Sec. 202(d)(4)(A)(i) of the Leadership Act
Sec. 7072(b)(1)(A)(ii) amends Sec.
Requires the Department of State to withhold contributions to the Fund commensurate with the
March 25,
202(d)(4)(A)(ii) of the Leadership Act
amount the Fund provided to a country that the President determined “repeatedly provided support
2025
for acts of international terrorism.”
Sec. 7072(b)(1)(B) amends Sec.
Permits any amounts withheld from the Global Fund to be used for bilateral HIV/AIDS, TB, and
March 25,
202(d)(4)(A)(iv) of the Leadership Act
malaria programs.
2025
Sec. 7072(b)(2) amends Sec. 202(d)(5)
Authorizes withholding 20% of Global Fund contributions until the Secretary of State certifies that
March 25,
of the Leadership Act
certain reporting and evaluation requirements are met.
2025
Sec. 7072(c)(1) Allocation of Funds
Requires that at least 10% of funds appropriated for bilateral HIV/AIDS programs be expended for
March 25,
amends Sec. 403(b) of the Leadership Act programs supporting orphans and vulnerable children (OVC) affected by HIV/AIDS.
2025
Sec. 7072(c)(2) amends Sec. 403(c) of
Requires that more than half of funds appropriated for bilateral HIV/AIDS programs be expended on
March 25,
the Leadership Act
the provision of treatment, care, and nutritional support for people living with HIV/AIDS.
2025
Source: Created by CRS from P.L. 118-47, Further Consolidated Appropriations Act, 2024

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

IF12463
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PEPFAR Extension Act of 2018: Extended Authorities

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