U.S. International HIV/AIDS, Tuberculosis, and Malaria Spending: FY2004-FY2008
U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2008
Updated February 29, 2008
Specialist in Global Health
Foreign Affairs, Defense, and Trade Division
U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2008
On January 28, 2003, during his State of the Union Address, President George
Bush proposed that the United States spend $15 billion over five years to combat
HIV/AIDS, tuberculosis (TB), and malaria through the President’s Emergency Plan
for AIDS Relief (PEPFAR). The President proposed that most of the spending on
PEPFAR programs be concentrated in 15 countries. Of the $15 billion, the President
suggested spending $9 billion on prevention, treatment, and care services in the 15
Focus Countries, where the Administration estimated 50% of all HIV-positive people
lived. The President also proposed that $5 billion of the funds be spent on existing
bilateral HIV/AIDS, TB, and malaria programs and research, and $1 billion of
PEFPAR funds be reserved for U.S. contributions to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (Global Fund). Between FY2004 and FY2008, PEPFAR
aims to have supported care for 10 million people affected by HIV/AIDS, including
children orphaned by AIDS; prevented 7 million new HIV infections; and supported
efforts to provide anti-retroviral medication (ARV) to 2 million HIV-infected people.
From FY2004 through FY2008 Congress provided almost $20 billion to fighting
the global spread of HIV/AIDS, TB, and malaria, some $5 billion more than the
President proposed. The President’s FY2008 budget request included about $5.8
billion for global HIV/AIDS, TB, and malaria efforts. The Administration proposed
that the bulk of the funds, about $5.0 billion, be provided through Foreign Operations
appropriations and that about $800 million be provided through Labor/HHS
appropriations, of which $300 million would be reserved for a U.S. contribution to
the Global Fund. Congress exceeded the President’s request by some $560 million,
providing $6.3 billion for global HIV/AIDS, TB, and malaria efforts, including some
$840 million for a U.S. contribution to the Global Fund. This report reviews U.S.
appropriations for treatment and prevention of the three diseases from FY2004
through FY2008. The report will not be updated; PEPFAR authorization expires in
FY2008. Subsequent reports will analyze additional funding should the initiative be
reaut hori z ed.
Most Recent Developments..........................................1
In troduction ......................................................1
Appropriations for Global HIV/AIDS Efforts............................3
Prevention of Mother and Child HIV Transmission Initiative............3
The President’s Emergency Plan for AIDS Relief.....................3
Global Fund to Fight AIDS, Tuberculosis, and Malaria ................6
Global Fund Results............................................7
The President’s Malaria Initiative.....................................7
Appendix. Explanation of Data in Table 1..............................9
List of Tables
Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations...........5
Table 2. FY2001-FY2008 U.S. Contributions to the Global Fund............7
U.S. International HIV/AIDS, Tuberculosis,
and Malaria Spending: FY2004-FY2008
Most Recent Developments
On November 13, 2007, the President signed the FY2008 Department of
Defense Appropriations (P.L. 110-116) into law, which included not less than $8
million for Department of Defense global HIV/AIDS activities. On December 26,
2007, the President signed the FY2008 Consolidated Appropriations into law
(PL.110-161), which includes the State/Foreign Operations and Labor/HHS
appropriations. The act includes $6.3 billion for global HIV/AIDS, tuberculosis
(TB), and malaria initiatives, of which $5.8 billion is appropriated to international
HIV/AIDS initiatives, including $840.3 million for U.S. contributions to the Global
Fund to Fight HIV/AIDS, TB, and Malaria. Congress exceeded the President’s
FY2008 request for global HIV/AIDS, TB, and malaria programs by $570.1 million
(most of which was provided to the Global Fund) and by $4.7 billion for PEPFAR’s
entire five-year term.
It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million1
people each year. According to the Joint United Nations Program on HIV/AIDS
(UNAIDS), at the end of 2007, an estimated 33.2 million people were living with
HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the
course of that year.2 More than two million of those living with HIV/AIDS at the end
of 2007 were children and some 330,000 of those who died of AIDS that year were
under 15 years old. Nearly 90% of all children infected with HIV reside in sub-
Saharan Africa, which is home to 2.2 million of the estimated 2.5 million children
living with HIV worldwide. On each day of 2007, some 1,000 children worldwide
became newly infected with HIV, due in large part to little access to drugs that
prevent the transmission of HIV from mother to child. An estimated 9% of pregnant
women in low-and middle-income countries were offered services to prevent HIV
transmission to their newborns.
1 World Health Organization. “2006 TB Factsheet.” At [http://www.who.int/tb/
publications/2006/tb_facts_2006.pdf], visited on December 5, 2007.
2 Unless otherwise indicated, all data on HIV/AIDS infection rates were taken from
UNAIDS. 2007 AIDS Epidemic Update. December 2007. At [http://data.unaids.org/pub/
EPISlides/2007/2007_epiupdate_en.pdf], visited December 5, 2007.
The World Health Organization (WHO) estimates that at the end of 2004, more
than 14 million people were infected with TB,3 of whom almost 9 million were newly
infected.4 More than 80% of those living with TB in 2004 were in southeast Asia and
sub-Saharan Africa, with the greatest per capita rate found in Africa. According to
WHO, each year there are about 300 million acute malaria cases,5 which cause more
than one million deaths annually; in 2004, the disease killed about 2 million people.
Health experts believe that between 85% and 90% of malaria deaths occur in Africa,
mostly among children,6 killing an African child every 30 seconds.7
3 Tuberculosis is a contagious disease that is spread like the common cold through the air.
Only people who are sick with TB in their lungs are infectious. When infectious people
cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into the air. A person
needs only to inhale a small number of these to be infected. Left untreated, each person
with active TB disease will infect an average of between 10 and 15 people every year.
However, people infected with TB bacilli will not necessarily become sick with the disease.
The immune system “walls off” the TB bacilli which, protected by a thick waxy coat, can
lie dormant for years. When someone’s immune system is weakened the chances of
becoming sick are greater. For more information, see WHO, “Tuberculosis.” Fact Sheet.
March 2007. At [http://www.who.int/mediacentre/factsheets/fs104/en/], visited on
December 3, 2007.
4 WHO. Global Tuberculosis Control: Surveillance, Planning, Financing. 2007. At
[http://www.who.int/tb/publications/global_report/2007/pdf/full.pdf], visited on December
5 There are four types of human malaria, Plasmodium (P.) vivax, P. malaria, P. ovale and
P. falciparum. P. vivax and P. falciparum are the most common, and P. falciparum is the
most deadly type of malaria infection. P. falciparum malaria is most common in sub-
Saharan Africa, accounting in large part for the extremely high malarial mortality in the
region. People contract malaria through bites from infected mosquitos. An infected
mosquito spreads the malaria parasite through the blood stream. Once in the blood stream,
the malaria parasite can evade the immune system, and infect the liver and red blood cells.
Mosquitos can also contract malaria if they ingest blood from an infected person. For more
information, see Roll Back Malaria, “What is Malaria.” RBM Info Sheet. March 2007. At
[http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm]. Roll Back
Malaria (RBM) is a global partnership initiated in 1998 by WHO, UNDP, UNICEF and the
World Bank to reduce the human and socio-economic costs of malaria.
6 WHO estimates that each year, there are 300 million acute malaria cases that cause some
1 million deaths, 90% of which occur in sub-Saharan Africa. The World Bank estimates
that there are more than 500 million cases of malaria each year, and that at least 85% of
malarial deaths occur in sub-Saharan Africa. The Bank believes the remaining 8% of deaths
occur in southeast Asia, 5% in the Eastern Mediterranean region, 1% in the Western Pacific,
and 0.1% in the Americas. The Bank asserts that there is no accurate count of malaria
infections or deaths, due to weaknesses in data collection and reporting systems, inaccurate
diagnoses that may result in over- or under reporting, and an insufficient amount of skilled
workers who can accurately make diagnoses, particularly in malaria-endemic areas.
7 RBM. “Children and Malaria.” RBM Info Sheet. At [http://www.rollbackmalaria.org/
cmc_upload/0/000/015/367/RBMInfosheet_6.htm], visited on December 3, 2007.
Appropriations for Global HIV/AIDS Efforts
Appropriations for combating the global spread of HIV/AIDS have grown8
considerably since President Bush entered office. U.S. contributions to the Global
Fund and the launching of two initiatives — the Prevention of Mother and Child
Transmission Initiative and the President’s Emergency Plan for AIDS Relief
(PEPFAR) — have contributed to this growth.
Prevention of Mother and Child HIV Transmission Initiative
In FY2002, the President requested that Congress provide $500 million to fund
a new initiative he called the International Mother and Child HIV Prevention
Initiative.9 The Initiative sought to prevent the transmission of HIV from mothers to
infants and to improve health care delivery in Africa and the Caribbean. Congress
provided that up to $100 million (excluding rescissions) be made available to USAID
for the initiative in FY2003. In FY2004, Congress provided $150 million (excluding
rescissions) to CDC for PMTCT programs. Conferees also expressed an expectation
that $150 million would be made available for the initiative from the newly
established Global HIV/AIDS Initiative (GHAI; H.Rept. 108-401). Since the
initiative expired in FY2004, Congress has included funds for PMTCT programs in
the GHAI account.
The President’s Emergency Plan for AIDS Relief
On January 28, 2003, during his State of the Union Address, President Bush
proposed that the United States spend $15 billion over the next five fiscal years to
combat HIV/AIDS through PEPFAR. The President proposed channeling $10 billion
to prevention, treatment, and care services in the 15 Focus Countries through
GHAI,10 $4 billion to existing bilateral HIV/AIDS, TB, and malaria programs and
research conducted in more than 100 non-Focus Countries, and $1 billion to the
Global Fund. In May 2003, Congress authorized sufficient funds to support the
initiative through P.L. 108-25, the U.S. Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Act (the Leadership Act). Between FY2004 and FY2008, PEPFAR
programs aim to support care for 10 million HIV-affected people, including children
orphaned by AIDS; support the prevention of 7 million new HIV infections; and help
8 For more information on U.S. appropriations for global AIDS programs, see CRS Report
RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2007, by Tiaji Salaam-Blyther.
9 The White House. “President Bush’s International Mother and Child HIV Prevention
Initiative.” Fact Sheet. June 2002. At [http://www.whitehouse.gov/news/releases/2002/06/
10 The 15 PEPFAR Focus Countries are Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti,
Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam,
11 The White House. “The President’s Emergency Plan for AIDS Relief.” Fact Sheet.
January 29, 2003. At [http://www.state.gov/p/af/rls/fs/17033.htm], visited November 27,
Congress appropriates the bulk of PEPFAR funds to the GHAI account. The
account was established to streamline funds for global HIV/AIDS, TB, and malaria
programs to the 15 Focus Countries. The Office of the Global AIDS Coordinator
(OGAC) at the U.S. Department of State transfers funds from GHAI to implementing
agencies and departments. The funds that Congress appropriates directly to U.S.
agencies and departments are utilized in the non-Focus Countries. U.S. agencies and
departments might also allocate additional resources to international HIV/AIDS, TB,
and malaria programs not funded through PEPFAR. In each fiscal year since
PEPFAR was launched, appropriators have included a chart in the foreign operations
appropriations conference reports that itemizes how global HIV/AIDS, TB, and
malaria funds are authorized to be spent (Table 1). Press accounts of U.S. global
HIV/AIDS spending are usually derived from this chart, though it does not include
all U.S. global HIV/AIDS, TB, and malaria support.
Table 1. U.S. Global HIV/AIDS, TB, and Malaria Appropriations
($ millions, nominal)
F Y 2004 F Y 2005 F Y 2006 F Y 2007 F Y 2008 F Y 2008
P r ogram Ac t u al Ac t u al Ac t u al Ac t u al Estimate Tot a l
1.USAID HIV/AIDS (excluding Global Fund)555.5384.7373.8345.9371.12,031.0
4.USAID Global Fund Contribution397.6248.0247.5247.50.01,140.6
5.FY2004 Global Fund Carryoverb(87.8)87.8n/an/an/a0.0
6.State Department GHAI488.11,373.51,777.02,869.04,116.410,624.0
7.GHAI Global Fund Contribution0.00.0198.0377.5545.51,121.0
8.Foreign Military Financingc184.108.40.206.6 — 6.9
9.Subtotal, Foreign Operations
Appropriations 1,519.9 2,278.7 2,791.7 4,184.4 5,544.8 16,319.5
10.CDC Global AIDS Programd266.9123.8122.6 121.5119.4754.2
13.CDC International Research9.014.00.00.00.023.0
14.NIH International Researche317.2370.0373.0372.0363.6 1,795.8
15.NIH Global Fund contribution149.199.299.099.0294.8741.1
16.DOL AIDS in the Workplace Initiative9.91.9 0.0 0.00.011.8
17.Subtotal, Labor/HHS Appropriations763.3620.3605.8603.3788.53,381.2
18.DOD HIV/AIDS prevention education220.127.116.11 0.08.025.0
19.Total HIV/AIDS and Global Fund2,111.32712.33,198.04,434.05,818.818,274.4
Sources: Prepared by CRS from appropriations bill figures and interviews with Administration officials.
Notes: Agencies and departments might obligate more funds to global HIV/AIDS, TB, and malaria efforts than were appropriated.
All figures are at appropriated levels and include rescissions.
a. Although the Administration asserts operations for PMI began in FY2006, Congress did not appropriate funds to the initiative until
FY2007. That fiscal year, it provided $250.9 million for global malaria programs, including $149.0 million to expand PMI.
b. In FY2004, $87.8 million of U.S. contributions to the Global Fund was withheld per legislative provisions that prohibit U.S.
contributions to the Fund to exceed 33% of all contributions. The FY2005 Consolidated Appropriations act released these
funds to the Global Fund, subject to the 33% proviso.
c. Appropriations for Foreign Military Financing are used to purchase equipment for DOD HIV/AIDS programs.
d. Lower spending levels after FY2004 reflect the shift of funds initially reserved for the International Mother and Child HIV
Prevention Initiative to the Global HIV/AIDS Initiative account. When the initiative expired in FY2004, these changes were
made permanent and were applied to subsequent fiscal years.
e. Although appropriations bills do not specify funding for NIH’s international HIV research initiatives, sufficient funds are provided
to the Office of AIDS Research (OAR) to undertake such efforts. The figures used in Line 11 reflect those amounts reported
by OAR in its congressional budget justifications.
Global Fund to Fight AIDS, Tuberculosis, and Malaria
In January 2002, the Global Fund was established in Geneva, Switzerland. The
Fund provides grants to developing countries aimed at reducing the number of HIV,
TB, and malaria infections, as well as the other illnesses and deaths that result from
such infections. The Fund is an independent foundation led by a board of directors
comprised of representatives from seven donor countries and seven developing
countries. In an effort to include all major stakeholders, each of the following
communities also has one representative on the board: developed country non-
governmental organizations (NGOs), developing country NGOs, the business
community, private foundations, and people living with HIV/AIDS, tuberculosis or
malaria. The Fund projects that by 2007, the grants it has approved will have
!provided treatment for 1.8 million HIV-positive people, 5 million
people infected with TB, and 145 million malaria patients;
!prevented the spread of HIV to 52 million people through voluntary
HIV counseling and testing services;
!financed the purchase and distribution of 109 million insecticide-
treated bed nets to prevent the spread of the malaria; and
!supported care for 1 million orphans.12
Although there appears to be strong support for the Global Fund, Congress has
placed restrictions on U.S. contributions to the Fund for various reasons. In FY2006,
due to concerns about the Fund’s spending practices, Congress required that 20% of
U.S. contributions to the Fund be withheld until the Secretary of State certified that
the Fund had undertaken a number of steps to strengthen oversight and spending
practices (P.L. 109-102).13 The act allowed the Secretary to waive the requirement
if she determined that a waiver was important to U.S. national interest. Similar
language has been included in subsequent appropriations legislation.
In FY2008, the President proposed that the United States contribute $300
million to the Global Fund through Labor/HHS Appropriations. Congress provided
that amount through Labor/HHS Appropriations (excluding rescissions) and
appropriated an additional $550 million through Foreign Operations Appropriations
(excluding rescissions). After deducting rescissions, in FY2008, Congress provided
a total of $840.3 million; since PEPFAR was launched in FY2004, appropriators
provided about $3 billion, and nearly $3.8 billion since making the first appropriation
in FY2001 (Table 2).14
12 Global Fund Webpages about HIV/AIDS, TB, and malaria. At
[http://www.theglobalfund.org], visited on December 10, 2007.
13 The required steps are to (1) establish clear progress indicators upon which to determine
the release of incremental disbursements; (2) release such incremental disbursements only
if progress is being made based on those indicators; and (3) provide support and oversight
to country-level entities, such as country coordinating mechanisms, principal recipients, and
local Fund agents.
14 Funding levels include supplemental appropriations. For more information on the Global
Fund, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis, and
Table 2. FY2001-FY2008 U.S. Contributions to the Global Fund
FY2001-FY2003 FY2004 FY2005 FY2006FY2007FY2008FY2008PEPFAR TotalFY2001-
FY2002 Actua l Actua l Actua l Actua l Actua l Request Est i ma t e FY2004-FY208 FY2008
a bo r/HHS $125.0 $99.3 $149.1 $99.2 $99.0 $99.0 $300.0 $294.8 $741.1 $965.4
OTAL $275.0 $347.7 $458.9 $435.0 $544.5 $724.0 $300.0 $840.3 $3,002.7 $3,625.4
Compiled by CRS from appropriations bill and interviews with Administration officials.
Global Fund Results
According to the Global Fund’s website, the organization has approved15
proposals totaling $10 billion and disbursed about half of those funds. The funds
have been used to support ARV treatment for an estimated 1.4 million people (about16
75% of whom were in Africa), treatment for almost 3 million people infected with
TB, and distribution of some 30 million insecticide-treated bed nets to prevent17
The President’s Malaria Initiative
In June 2005, President Bush launched the President’s Malaria Initiative (PMI),
a plan to increase support for U.S. international malaria programs by more than $1.2
billion between FY2006 and FY2010 in 15 countries. Since launching PMI, the
Administration has requested that all support for bilateral malaria efforts be provided
to the U.S. Agency for International Development (USAID) as the coordinating
agency for the initiative. When the Administration shifted leadership for bilateral
malaria programs to USAID in FY2005, it determined that OGAC would no longer
include malaria spending in its annual reports to Congress and that budgetary
requests for the disease would be made separately from HIV/AIDS and TB requests.
For comparability, and because P.L. 108-25 considers efforts to combat malaria as
a critical part of PEPFAR, Table 1 includes appropriations to malaria programs.
Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-Blyther.
15 Global Fund. “Current Grant Commitments and Disbursements.” June 8, 2008. At
[http://www.theglobalfund.org/en/funds_raised/reports/], visited January 8, 2008.
16 Global Fund. “Global Fund ARV Fact Sheet.” December 1, 2007. At
[ h t t p : / / www.t h egl obal f und.or g/ en/ f i l e s/ publ i cat i ons/ f act sheet s/ ai ds/ ARV _Fact sheet _
17 Global Fund. “Monthly Progress Update — October 31, 2007.” At
[ h t t p : / / www. t h e gl o b a l f und.org/ en/files/publications/basi c s / p r o gr e s s _update/
progressupdate.pdf], visited January 8, 2008.
In FY2006 and FY2007, appropriators provided $102 million and $248 million
for bilateral malaria efforts, respectively.18 According to the PMI website, in
FY2006, $30 million of the $99 million that USAID spent on malaria programs was
allocated to PMI, and an estimated $135 million was spent on the initiative in
FY2007. The Administration requested $387.5 million for malaria initiatives in
FY2008, of which $300 million would be for PMI; Congress appropriated $347.2
million to USAID and $36.0 million to CDC for international malaria efforts.19
According to a December 2007 press release, through September 30, 2007,
PEPFAR has supported the provision of anti-retroviral treatment for approximately
1.4 million people; prevention of mother-to-child HIV transmission services for
women during more than 10 million pregnancies and an estimated 152,000 infant
infections; care for nearly 6.7 million people, including more than 2.7 million
orphans and vulnerable children; and counseling and testing services for over 30
18 Although the President announced the operations for the initiative began in FY2006,
Congress did not appropriate funds to the initiative until FY2007. That fiscal year, it
provided $248.0 million for international malaria programs, including $149.0 million to
Appendix. Explanation of Data in Table 1
Lines 1 and 2 refer to USAID’s bilateral HIV/AIDS and TB programs in the
non-Focus Countries, which are funded through a number of accounts, including the
Child Survival and Health Account (CSH), Economic Support Fund aid (ESF),
Assistance for the former Soviet Union under the Freedom Support Act (FSA),
Assistance for Eastern Europe and the Baltics (SEED), and food aid.20
Line 3 refers to funds provided to USAID from all accounts for its bilateral
malaria programs, including the President’s Malaria Initiative (see above).
Line 4 refers to contributions to the Global Fund provided through USAID
accounts. In FY2004, $87.8 million of the amount appropriated to the Global Fund
was withheld per legislative provisions limiting U.S. Global Fund contributions to
FY2005 Consolidated Appropriations, directed that these withheld funds be
transferred to the Global Fund in FY2005, subject, like the remainder of the U.S.
contribution, to the 33% proviso.
Congress provides funds for PEPFAR’s 15 Focus Countries to the State
Department’s Global HIV/AIDS Initiative (GHAI), as indicated in Line 6. U.S.
contributions to other global AIDS efforts, such as international microbicide
research, the International AIDS Vaccine Initiative (IAVI), and the United Nations
Joint Program on HIV/AIDS (UNAIDS), are also provided through GHAI.
GHAI Funds transferred to the Global Fund are reflected in Line 7.
Line 8 refers to funds appropriated to the Foreign Military Financing (FMF)
account for equipment purchases that support the DoD’s global HIV/AIDS efforts.
DoD’s bilateral HIV/AIDS programs, referred to in Line 15, offer HIV/AIDS
prevention education, primarily to African armed forces.
Line 10 refers to the Centers for Disease Control and Prevention’s (CDC)
Global AIDS Program (GAP). CDC spends additional funds on international
HIV/AIDS, TB, and malaria activities that are not earmarked by Congress, though
they are included in the table (Lines 11- Lines 13).
Line 14 reflects grants provided by the National Institutes of Health (NIH) for
international HIV/AIDS research, which focus primarily on the development of an
AIDS vaccine. NIH also transfers funds to the Global Fund, as indicated on Line 15.
20 Such aid is in addition to the Section 416(b) food aid listed in Table 1. For a description
of food aid programs, see CRS Report RL33553, Agricultural Export and Food Aid
Programs, by Charles E. Hanrahan.
21 See P.L. 108-25, the United States Leadership against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 and P.L. 108-199, the FY2004 Consolidated Appropriations. For more
information, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis, and
Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-Blyther.
The Administration has not requested funds for the Department of Labor’s
Global AIDS in the Workplace Initiative since FY2002 (Line 16). Congress funded
the initiative, however, until FY2006. The Department received additional funds
from GHAI in support of its HIV/AIDS programs.
In FY2008, the Administration did not request funds to support DoD’s bilateral
HIV/AIDS prevention programs, as indicated in Line 18. Congress provided $8.0
million, however, for the activities.