PEPFAR: From Emergency to Sustainability

^Pr^ep^ar^{ed f}^o^r^M^e^m^b^ers^an^d^Com^mⁱ^t^t^ees^of^C^ong^r^e^ss

The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 33.2 million people
are living with human immunodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS). The U.N. organization believes that in 2007, some 2.5 million people will contract
HIV and it will kill about 2.1 million. Sub-Saharan Africa is the most affected region, with about
68% of the world’s HIV-positive population, 90% of all HIV-infected children, and more than 11
million children who have lost one or both parents to the virus. UNAIDS anticipates that in 2007,
about 420,000 children will contract HIV, due in large part to inadequate access to drugs that
prevent mother-to-child HIV transmission; about 8% of pregnant women in low- and middle-
income countries have access to PMTCT services.
In January 2003, 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 concentrating most of the
resources ($9 billion) in 15 countries, where the Administration estimated 50% of all HIV-
positive people lived. The proposal allotted $5 billion of the funds to research and other bilateral
HIV/AIDS, TB, and malaria programs, and $1 billion for contributions to the Global Fund to
Fight AIDS, Tuberculosis, and Malaria (Global Fund). The President estimated that from FY2004
to FY2008, PEPFAR funds would support the purchase of anti-retroviral treatments (ARV) for 2
million people; the prevention of 7 million HIV infections; and care for 10 million people
affected by HIV/AIDS, including children orphaned by AIDS.
In May 2003, Congress passed the U.S. Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 (P.L. 108-25), which authorized funds for PEPFAR and created the Office of
the Global AIDS Coordinator (OGAC) to manage U.S. funds aimed at addressing the three
diseases in 15 Focus Countries. As of March 31, 2007, PEPFAR has supported the treatment of
1.1 million people; and as of September 30, 2006, supported PMTCT service provision during
more than 6 million pregnancies and facilitated care for nearly 4.5 million people, including more
than 2 million orphans and vulnerable children. From FY2004 to FY2007, Congress provided
nearly $13.5 billion for U.S. global HIV/AIDS, TB, and malaria programs. In FY2008, the
President requested $5.8 billion for global HIV/AIDS, TB, and malaria efforts; the House and
Senate proposed spending almost $6.2 billion and nearly $6.1 billion, respectively.
On May 30, 2007, President Bush requested that Congress authorize $30 billion to fund PEPFAR
an additional five years. The President asserts that from FY2009 to FY2013, the plan would
support treatment for 2.5 million people, prevent more than 12 million new infections, and care
for more than 12 million people, including 5 million orphans and vulnerable children. Supporters
of the Administration’s plan applauded the President and congratulated him for leading global
efforts to address HIV/AIDS. Critics asserted that PEPFAR could treat more than 2.5 million
HIV-infected people and that PEPFAR’s spending requirements should be eliminated. This report
focuses on some of the key issues that Congress might consider as it faces the issue of whether,
and at what level, to reauthorize PEPFAR.

Backgr ound ..................................................................................................................................... 1
H IV / AIDS ....................................................................................................................... .......... 1
Revised Epidemic Estimates...............................................................................................1
2007 Estimates....................................................................................................................1
Tuberc ulosis ................................................................................................................... ........... 4
Mala ri a ........................................................................................................................ .............. 4
Global Spending on HIV/AIDS................................................................................................5
Policy Options for Congress............................................................................................................6
Define Focus of PEPFAR..........................................................................................................7
Revisit Prevention Efforts.........................................................................................................7
Increase Prevention of Mother to Child HIV Transmission (PMTCT) Initiatives..............8
Provide Contraceptives to HIV-Positive Women................................................................8
Address Gender Inequities..................................................................................................9
Expand Access to Condoms................................................................................................9
Explore the Potential Impact of Circumcision..................................................................10
Reconsider Spending Restrictions and Requirements..............................................................11
Evaluate the Impact of the Prostitution Pledge..................................................................11
Evaluate the Impact of the Mexico City Policy.................................................................11
Evaluate the Impact of the Abstinence-Until-Marriage Stipulation..................................12
Expand Access to Generic Anti-Retroviral Medication..........................................................12
Improve Integration of Health Programs................................................................................13
Improve Food Security.....................................................................................................14
Support Maternal and Child Health..................................................................................15
Address Other Diseases That Kill.....................................................................................15
Strengthen Health Systems......................................................................................................16
Address Health Worker Shortages....................................................................................16
Consider the Impact of Disease-Specific Approach on Health Systems...........................18
Support Global Efforts to Strengthen Health Systems......................................................19
Provide Support for Health Systems Research.................................................................19
Consider Role of International Financial Institutions.......................................................20
Address the Needs of Children Affected by HIV/AIDS.........................................................21
Reconsider Emphasis on Focus Countries..............................................................................23
Table 1. Adult (15-49 years) HIV Prevalence in Countries That Have Conducted
Population-Based HIV Surveys Since 2001.................................................................................2
Table 2. Regional HIV/AIDS Statistics, 2001 and 2007.................................................................3
Table 3. U.S. Global HIV/AIDS, TB, and Malaria Appropriations.................................................5
Table 4. Number and Shortage of Doctors, Nurses, and Midwives..............................................17
Table 5. Distribution of Health Workers in Africa and the United States......................................17
Table 6. Spending on Health in Africa and the United States........................................................21

Author Contact Information..........................................................................................................24

The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 33.2 million people
are living with human immunodeficiency virus/ acquired immunodeficiency syndrome
(HIV/AIDS); some 16% fewer people than it initially estimated in 2006 (about 39.5 million).
UNAIDS asserts that the decline reflects improvements in data collection and analysis. Expanded
and improved HIV surveillance systems and household surveys reportedly provided a more ¹
precise count of HIV prevalence than earlier studies. In most of the 30 countries where
household studies were conducted, prevalence rates in 2007 were lower than those reported in

2006 (Table 1).

UNAIDS also used the expanded studies to adjust prevalence estimates of countries that had not
conducted household surveys but had similar epidemics. After retrospectively applying the
improved methodology, UNAIDS estimated that in 2006, 32.7 million people were living with
HIV (adjusted from the original estimate of 39.5 million). The revised estimates for India (2.5
million, down from 5.7 million), combined with revisions in five sub-Saharan African countries ²
(Angola, Kenya, Mozambique, Nigeria, and Zimbabwe) accounted for 70% of the reduction.
UNAIDS notes that HIV/AIDS prevalence rates have largely stabilized since 2001 and ³
HIV/AIDS incidence rates are mostly declining (see Table 2). Although prevalence rates have
stabilized and incidence rates are mostly declining, the total number of people living with
HIV/AIDS continue to rise, though at a slower rate. UNAIDS predicts that 2.5 million people will
contract HIV in 2007, compared to the estimated 3.2 million who became HIV-positive in 2001.
UNAIDS does not expect the number of HIV/AIDS-related deaths to decrease, however; in 2007,
some 2.1 are expected to die from AIDS, while 1.7 million died in 2001.

¹
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Table 1. Adult (15-49 years) HIV Prevalence in Countries That Have Conducted
Population-Based HIV Surveys Since 2001
²⁰⁰¹²⁰⁰³²⁰⁰⁵
^Prevalence^Prevalence^{Prevalence (%)}
^Population-^Year^{(%) Reported}^{(%) Reported}^{Reported in}
^{Based Survey}^Population-^{in 2002 AIDS}^{in 2004 AIDS}²⁰⁰^{6 AIDS}
^{HIV Prevalence}^{Based Survey}^Epidemic^Epidemic^Epidemic
^Countries^{Rate (%)}^Condu^cted^Report^Report^Report
^Sub-Saharan^Af^rica
^{Benin 1.2}²⁰⁰⁶^3.6^1.9^1.8
^{Botswana 25.2}²⁰⁰⁴^38.8^38.0^24.1
^Burkina^{1.8 200}³^6.5^4.2^2.0
^Faso
^Buru^{ndi 3.6}²⁰⁰²^8.3^6.0^3.3
^{Cameroon 5.5}²⁰⁰⁴^11.8^7.0^5.4
^Central^{6.2 200}⁶^12.9^13.5^10.7
^{African Rep.}
^{Chad 3.3}²⁰⁰⁵^3.6^4.8^3.5
^Cote^{4.7 200}⁵^9.7^7.0^7.1
^d’Ivoire
^Equa^torial^{3.2 200}⁴^3.4^Not^Available^3.2
^Guinea
^Ethiopia^1.4²⁰⁰⁵^6.4^4.4^{0.9 - 3.5}
^{Ghana 2.2}²⁰⁰³^3.0^3.1^2.3
^{Guinea 1.5}²⁰⁰⁵^Not^Available^2.8^1.5
^{Kenya 6.7}²⁰⁰³^15.0^6.7^6.1
^{Lesotho 23.5}²⁰⁰⁴^31.0^29.3^23.2
^{Malawi 11.8}²⁰⁰⁴^15.0^14.2^14.1
^{Mali 1.3}²⁰⁰⁶^1.7^1.9^1.7
^{Niger 0.7}²⁰⁰⁶^Not^Available^1.2^1.1
^{Rwanda 3.0}²⁰⁰⁵^8.9^5.1^3.1
^{Senegal 0.7}²⁰⁰⁵^0.5^0.8^0.9
^Sierra^{1.5 200}⁵^7.0^Not^Available^1.6
^Leone
^{South Africa}^16.2²⁰⁰⁵^20.1^20.9^18.8
^{Swaziland 25.9}²⁰⁰^6-2⁰⁰⁷^33.4^38.8^33.4
^{Uganda 7.1}²⁰⁰^4-2⁰⁰⁵^5.0^4.1^6.7
^{Tanzania 7.0}²⁰⁰⁴^7.8^9.0^6.5
^Zambia^15.6²⁰⁰^1-2⁰⁰²^21.5^16.5^17.0
^{Zimbabwe 18.1}²⁰⁰^5-2⁰⁰⁶^33.7^24.6^20.1

²⁰⁰¹²⁰⁰³²⁰⁰⁵
^Prevalence^Prevalence^{Prevalence (%)}
^Population-^Year^{(%) Reported}^{(%) Reported}^{Reported in}
^{Based Survey}^Population-^{in 2002 AIDS}^{in 2004 AIDS}²⁰⁰^{6 AIDS}
^{HIV Prevalence}^{Based Survey}^Epidemic^Epidemic^Epidemic
^Countries^{Rate (%)}^Condu^cted^Report^Report^Report
^Asia
^{Cambodia 0.6}²⁰⁰⁵^2.7^2.6^1.6
^{India 0.28}²⁰⁰^5-2⁰⁰⁶^0.8^0.9^0.9
^{Latin America an}^{d Carib}^bean
^Dominican^{1.0 200}²^2.5^1.7^1.1
^Republic
^{Haiti 2.2}²⁰⁰^5-2⁰⁰⁶^6.1^5.6^3.8
^Source:^UNAIDS,^{2007 AIDS Epidemic Update}
Table 2. Regional HIV/AIDS Statistics, 2001 and 2007
^{Adults and}^{Adults and}^{Adult and}
^{Children Living with}^{Children Newly Infected}^Adult^{Child Deaths}
^HIV^{with HIV}^Prevalence^{Due to AIDS}
^(thousands⁾^(thousands⁾^(%)^(thousands⁾
²⁰⁰¹²⁰⁰⁷²⁰⁰¹²⁰⁰⁷²⁰⁰¹²⁰⁰⁷²⁰⁰¹²⁰⁰⁷
^Sub-Saharan^A^frica^20,9⁰⁰^22,5^{00 2,20}^{0 1,70}⁰^5.8^5.0^1,40⁰^1,60⁰
^{South & Southeast}
^Asia^3,50⁰^4,00^{0 450 340}^0.3^0.3¹⁷⁰²⁷⁰
^Latin^America^1,30⁰^1,60^{0 130 100}^0.4^0.5⁵¹⁵⁸
^North^Ame^rica^1,10⁰^1,30^{0 44 46}^0.6^0.6²¹²¹
^{E. Eu}^{rope &}
^Central^Asia⁶³⁰^1,60^{0 230 150}^0.4^0.9⁸⁵⁵
^{Western & Ce}^ntral
^Europe⁶²⁰^{760 32 31}^0.2^0.3¹⁰¹²
^{East Asia}⁴²⁰⁸⁰⁰⁷⁷⁹²^<0.1^0.1¹²³²
^{Middle East & N.}
^Africa³⁰⁰^{380 41 35}^0.3^0.3²²²⁵
^Caribbean¹⁹⁰^{230 20 17}^1.0^1.0¹⁴¹¹
^Oceania²⁶⁷⁵^3.8^{14 0.2 0.4}^<0.5^1.2
^Total^29,0⁰⁰^33,2^{00 3,20}^{0 2,50}⁰^0.8^0.8^1,70⁰^2,10⁰
^Source:^UNAIDS,^{2007 AIDS Epidemic Update}^.

HIV/AIDS is contributing to rising TB prevalence in areas with high HIV/AIDS prevalence, ⁴
particularly in Africa. The weakened immune systems of HIV-positive people places them at
greater risk of contracting TB. Correspondingly, TB considerably shortens the survival of people
with HIV/AIDS. In 2005, about 80% of all HIV-positive people with TB were found in Africa.
That year, nearly 630,000 people were co-infected with HIV/AIDS and TB, some 500,000 of
whom were African. About 160,000 of the nearly 195,000 co-infected patients who died from TB
were African, representing 82% of those deaths.
Although most forms of TB are curable, the World Health Organization (WHO) estimates that in

2005 (the year for which the most current data are available), the disease killed 1.6 million ⁵

people, including 195,000 who were also infected with HIV/AIDS. Some 8.8 million people ⁶
contracted the disease in 2005, of which 84% of the cases occurred in 22 countries. All but three
of those high-burden countries were found in Africa or Asia. About half of all new TB cases were
in six countries: Bangladesh, China, India, Indonesia, Pakistan, and the Philippines.
While HIV/AIDS, TB, and malaria are preventable diseases, their impacts have been catastrophic,
particularly in sub-Saharan Africa. Researchers have found that people infected with one of the
three illnesses are more likely to contract either of the other two, and the symptoms are more
severe in people with two or more of the diseases. According to WHO, each year there are about ⁷

300 million acute malaria cases, which cause more than 1 million deaths annually. Health experts ⁸

believe that between 85% and 90% of malaria deaths occur in Africa, mostly among children, ⁹
killing an African child every 30 seconds.

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UNAIDS asserts that it would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in ¹⁰
2008 to effectively fight HIV/AIDS. In FY2006, Congress provided $3.4 billion for global
HIV/AIDS, tuberculosis (TB), and malaria programs (Table 3). Most recent statistics indicate that ¹¹
in 2006, global spending reached nearly $9 billion, $6 billion less than UNAIDS advocated.
Table 3. U.S. Global HIV/AIDS, TB, and Malaria Appropriations
^{($U.S. current, mi}^llions)
^FY20⁰⁸^FY20⁰⁴^FY20⁰⁵^FY20⁰⁶^FY20⁰⁷
^PROGRAM^Actual^Actual^Actual^CR
^Request^House^Senate^Enacted
^{1. USAID HIV/AIDS}
^{(excluding Global}^549.^{2 382.}⁸^373.⁸^346.³^382.⁰^350.⁰^NYE^464.⁵
^Fund)
^{2. USAID Tuberc}^ulosis^100.⁴^87.8^91.5^89.9^313.⁵^a^200.⁰^NYE
^{3. USAID Malaria}^b^100.⁹^98.2^102.⁰^248.⁰^387.⁵^352.⁵^357.⁵^NYE
^{4. USAID Global Fund}^397.^{6 247.}⁹^247.⁵^247.⁵^0.0^250.⁰^250.⁰^NYE
^Contribution
^{5. FY200}^{4 Global Fu}^nd^{-87.8 87.8}^n/a^n/a^n/a^n/a^n/a^NYE
^Carryover^c
^{6. State Departmen}^t^488.^{1 1,37}^3.5¹⁷⁷^5.1^2,86^9.0^4,15^0.0^4,15^0.0^4,15^0.0^NYE
^GHAI
^{7. GHAI}^{Global Fund}^{0.0 0.0}^198.⁰^377.⁵^0.0^300.⁰^340.⁰^NYE
^Contribution
^{8. Foreign Military}^d^{1.5 1.9}^1.9^—^0.0^0.0^0.0^NYE
^Financing
^{9. Subtotal, Foreign}
^Operations¹⁵⁴^{9.9 227}^9.9^2,78^9.⁸^4,20^6.⁵^4,97^3.⁷^5,74^8.⁰^5,64^7.⁵
^Appr^opriations
^{10. CDC Global AIDS}^e^291.^{8 123.}⁸^122.⁷¹²^0.8^121.²^122.⁷^122.⁷^NYE
^Program
^{11. NI}^{H I}^nter^national^f^317.^{2 370.}⁰^373.⁰^372.⁰^373.⁰^—^—^NYE
^Research
^{12. NI}^{H Global Fu}^nd^149.^{1 99.2}^99.0^99.0^300.⁰^300.⁰^300.⁰^NYE
^contribution

¹⁰
^UNA^IDS^,^Tow^a^r^d^s^Uⁿ^iv^e^r^s^a^l^Ac^c^e^s^s^:^As^s^e^ss^m^e^{nt by}^the^J^oⁱⁿ^{t U}ⁿⁱ^t^e^d^N^a^ti^ons^Pr^ogr^am^oⁿ^H^I^V/AI^D^S^oⁿ^Sc^ali^{ng U}^p
^HIV^P^r^even^tⁱ^oⁿ^,^T^r^ea^t^m^en^t^,^Ca^re^aⁿ^d^Su^pp^o^r^t^{, Ma}^r^c^h²⁰⁰⁶^{. h}^ttp:^/^/^d^a^t^a^.^unaⁱ^d^s^.^or^g^/^pub^/^I^nf^or^m^a^tionN^ote^/²⁰⁰⁶^/
²⁰⁰⁶⁰³²^4_^hlm^_^g^a^_a⁶⁰⁷³⁷^_e^n.^pd^f^.
¹¹^Fin^ancⁱⁿ^{g t}^h^e^Re^s^p^ons^e^to^AI^D^S^{in L}^o^w^-^aⁿ^d^Mⁱ^dd^le^-^Iⁿ^c^o^me^Co^uⁿ^trie^{s: Inte}^rn^atio^na^{l Assista}ⁿ^c^e^{from the}^G⁸^,
^Eur^ope^{an C}^o^m^mⁱ^s^sⁱ^oⁿ^a^{nd O}^t^he^r^D^oⁿ^o^r^G^o^v^e^r^nm^eⁿ^ts^{, K}^a^is^e^r^Fa^m^ily^Founda^ti^on^{, 2}⁰⁰⁶^,^htt^p^://w^w^w^.^k^f^f^.^org^/^hiv^a^ids^/
^upl^oa^d/⁷³⁴⁷^_03^.p^df^.

^FY20⁰⁸^FY20⁰⁴^FY20⁰⁵^FY20⁰⁶^FY20⁰⁷
^PROGRAM^Actual^Actual^Actual^CR
^Request^House^Senate^Enacted
^{13. DOL AIDS in t}^he^{9.9 1.9}^0.0^—^0.0^0.0^0.0^NYE
^{Workplace Initiative}
^{14. Subtotal}^,
^Labor/HHS^768.^{0 594.}⁹^594.⁷^591.⁸^794.²^—^—
^Appr^opriations
^{15. DOD HIV/AIDS}
^preve^ntion^{4.2 7.5}^5.2^—^0.0^10.0^—^8.0
^education
^{16. Section 41}^{6(b) Food}^{24.8 24.8}^24.8^—^0.0^—^—^NYE
^Aid
^{17. TOTAL}²³⁴^6.9²⁹⁰^7.1^3,41^4.⁵^4,79^8.³^5,76^7.⁹^—^—
^Sources:^Prepa^{red by CRS from}^appro^{priations legislati}^{on figures}^{and interviews with Administrati}^{on staff.}
^Note:^{This chart does not include discretionary spe}^{nding on globa}^{l HIV/AIDS, TB}^{, and malaria programs, suc}^{h as}
^{CDC’s international HIV researc}^{h and its global TB and malaria initiatives. “—” indicates that funds}^{were not}
^{earmarked, but}^{could be}^{provided at the Administration’s discretion. “NYE” means}^{that t}^he^{bill has not yet be}^en
^enacted.
^a.^{Includes $}¹⁵^{0.0 million provided to the Global HIV/AIDS Initiative for global TB efforts.}
^b.^{House and Senat}^{e ap}^propriations^{committees began}^reporting^out^{global malaria funds sepa}^{rately fr}^om
^{those su}^{pporting global HIV/AID}^{S and TB initiatives after President Bush lau}^nch^{ed the President’s}^Malaria
^{Initiative (PMI) in June}²⁰⁰^{5. The}^{Administration reports that}^PMI^{became ope}^{rational in FY200}^{6 th}^ough
^{Congress first a}^p^p^{ropriated fu}^nds^{to PMI in FY20}^{07. That}^{fiscal year, Congress p}^{rovided $24}^{8.0 milli}^{on for}
^{international malaria programs, in}^{cluding $1}^{49.0 million to expand}^PMI.
^c.^{In FY20}^{04, Congre}^{ss with}^{held $8}^{7.8 million of the U.S. contributio}^{n to the}^{Global Fund, beca}^{use leg}^islative
^{provisions prohibit U.S. contribut}^{ions from exceeding}³³^{% of all donor contributions to t}^{he Fu}^{nd. FY2005}
^Consolidate^{d Appropriations res}^{tored the fu}^nds.
^d.^{Foreign Military Financing fu}^{nds a}^{re used to p}^urc^{hase e}^quip^ment^f^{or DOD HIV/AIDS programs (Li}^{ne 1}^5).
^e.^{In FY20}^{04, t}^{he I}^nterna^{tional Mother a}^{nd Child HIV Prevention I}^{nitiative expired. In s}^ubse^que^{nt fisc}^{al years,}
^{Congress ap}^prop^{riated funds}^for^{PMTCT activities to the Global}^{HIV/AIDS Initiative account, thou}^{gh CDC}
^{continues related}^efforts.
^f.^{The figures}^{used in Li}^{ne 1}¹^re^{flect the amou}^{nt the}^{Office of A}^{IDS Research (OAR) re}^{ports it spe}^{nds on}
^{international HIV/AIDS researc}^h.^{Congress does not sp}^{ecify how}^{much t}^{he O}^{ffice s}^{hould spend on}^this
^effort.

In 2003, Congress authorized $3 billion for each fiscal year from 2004 through 2008 to support
the President’s Emergency Plan for AIDS Relief (PEFAR). The 5-year initiative was created to
aid the millions of people sickened and killed by HIV/AIDS, malaria, and tuberculosis (TB).

Some estimate that since HIV/AIDS was first identified in 1981, 65 million people have ¹²
contracted the virus and it has killed more than 25 million.
PEPFAR provided an unprecedented amount of assistance for global HIV/AIDS efforts. The
United States remains the largest single donor for global HIV/AIDS efforts in the world, ¹³
providing nearly 50% of all donor funds. As Congress prepares to consider whether, and at what
level, to reauthorize PEPFAR, there has been considerable debate about the effectiveness of
PEPFAR. Some health experts contend that the life-saving intention of PEPFAR is weakened by
the single-disease approach. Other critics contend that ideological factors lessen the effectiveness
of the plan. A number of HIV/AIDS advocates urge the United States to harmonize its anti-
HIV/AIDS efforts with other donors to boost the impact of PEPFAR. Some of the key policy
prescriptions are discussed below.
As Congress considers reauthorizing PEPFAR, there may be some debate on how many diseases
the initiative should address. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Act of 2003 (P.L. 108-25), requires the President to submit annual reports to appropriation
committees that describe how U.S. funds support efforts to prevent HIV/AIDS, TB, and malaria
and provide care and treatment for those affected by the three diseases. However, since President
Bush launched the President’s Malaria Initiative (PMI) in June 2005, the Office of the Global
AIDS Coordinator (OGAC) determined that it would no longer include malaria spending in its
annual reports to Congress and that budgetary requests for the disease would be made separately ¹⁴
from HIV/AIDS and TB requests. The Administration requests support for PMI through the
U.S. Agency for International Development (USAID) as the coordinating agency. For
comparability, and because P.L. 108-25 considers efforts to combat malaria as a critical part of
PEPFAR, Table 3 includes appropriations to malaria programs. As Congress considers whether to
authorize funds to extend PEPFAR, Members might decide whether to define it as solely an
HIV/AIDS initiative or one that includes the three diseases.
As Congress considers reauthorizing PEPFAR, there is likely to be considerable debate on how
much funding to allocate to prevention. Consensus is growing among health experts that greater
emphasis needs to be placed on HIV prevention in global HIV/AIDS programs. The international
community has supported a tremendous increase in the number of people receiving HIV/AIDS
treatment. In 2001, about 240,000 people had access to anti-retroviral treatment (ARVs); in 2006, ¹⁵
more than 2 million were treated. Nonetheless, WHO estimated that in 2006, an additional 5.1

¹²
^A^v^ert^,^anⁱⁿ^t^e^rn^atⁱ^oⁿ^a^l^HIV^/^A^I^DS^ch^ari^t^y^,^u^s^ed^UNA^IDS^d^a^t^a^t^o^r^eachⁱ^t^s^estⁱ^m^at^e.^S^{ee w}^o^rl^d^A^I^D^S^st^atⁱ^s^tⁱ^c^{s at}
^http:^//www^.a^ve^rt.org^/w^orldsta^t^s.htm^.
¹³^Ibid^.
¹⁴^P^M^{I a}ⁱ^m^s^{to inc}^r^e^a^s^e^{U.S. su}^pp^o^r^{t f}^o^{r g}^l^oba^{l m}^a^la^ria^prog^ra^m^s^b^y^m^o^re^thaⁿ^$1.²^billi^on^be^tw^e^eⁿ^FY200^{6 a}ⁿ^d
^FY²⁰¹⁰ⁱⁿ¹⁵^c^o^uⁿ^tr^ie^s^.^F^o^r^m^o^r^e^inf^o^r^m^a^{tion on}^PMI^,^s^e^e^h^ttp:^/^/^w^w^w^.p^mⁱ^.g^ov^/.
¹⁵^S^t^atⁱ^s^tⁱ^c^{s on}^{access t}^o^A^I^DS^t^r^eat^men^t^w^a^{s co}^m^pⁱ^l^e^d^f^r^o^m^UN^A^I^D^S^,^T^o^wa^rd^{s U}ⁿ^iversa^{l Access: S}^c^a^ling^u^p^p^r^io^rity
^{HIV/AIDS i}ⁿ^te^rv^eⁿ^tio^{ns in}^the^he^alth^se^c^t^or^,^A^p^rⁱ^l²⁰⁰⁷^.
⁽^c^onti^nue^d.^..)

million people who needed treatment received none. In sub-Saharan Africa, more than 1.3 million
people received treatment, reaching some 28% of those in need; three years prior, 100,000 were
treated and coverage amounted to 2%. In spite of these advances, the rate at which individuals
become infected with HIV far outpaces the rate at which they are treated. In 2006, 4.3 million
people contracted HIV, 2.8 million of whom were African (65%), and 2.9 million people died of
AIDS, 2.1 million of whom were African (72%).
Many health experts advocate greater spending on PMTCT initiatives.¹⁶ Advocates of greater
PMTCT spending argue that providing ARVs during pregnancy is a well-documented way to
avert millions of HIV infections in a cost-efficient and effective manner, including in low-
resource settings. UNAIDS estimates that 1,800 children worldwide become infected with HIV ¹⁷
each day, the vast majority of whom are newborns. More than 85% of children infected with
HIV live in sub-Saharan Africa, although mother-to-child transmission (MTCT) rates are rapidly ¹⁸
rising in Eastern Europe and Central Asia. UNAIDS estimates that in 2005, just less than 8% of
pregnant women in low- and middle-income countries had access to services that could prevent ¹⁹
the transmission of HIV to their babies. Two-thirds of all women who lack access to PMTCT ²⁰
interventions come from 10 countries, all but one of which are in Africa; India is the exception.
Some reproductive health experts want HIV/AIDS and family planning services to be better
integrated should PEPFAR be reauthorized. Supporters of this idea contend that women who
receive PMTCT services should be subsequently offered contraceptives to lessen the likelihood
that they might give birth to HIV-positive children. Additionally, women who fear being

^(...c^on^tin^ue^d)
^h^t^t^p^:^/^/^www^.^w^h^o^.ⁱⁿ^t^/^hⁱ^v^/^m^edⁱ^acen^t^r^e/^uⁿⁱ^veral^_^access_^p^r^o^g^ress_^rep^o^r^t^_^en.^p^d^f^.
¹⁶^M^o^st^chi^l^d^reⁿ^lⁱ^vⁱⁿ^{g w}ⁱ^t^h^HI^V^acq^uⁱ^{re t}^h^{e d}ⁱ^{sease t}^h^r^o^u^g^h^m^o^t^h^er-^t^o^-^chⁱ^l^d^t^r^an^smⁱ^ssi^oⁿ^(M^T^C^T⁾^,^whⁱ^c^h^can^o^ccu^r
^durⁱⁿ^g^pr^e^g^na^nc^y^,^la^bor^aⁿ^d^de^liv^e^r^y^,^or^br^e^a^s^tf^e^e^d^ing^.^Iⁿ^the^a^b^s^eⁿ^c^e^of^aⁿ^y^inte^r^v^eⁿ^tion,^the^rⁱ^s^k^of^s^u^c^h^tr^aⁿ^s^m^is^sⁱ^on
ⁱ^s¹⁵^%^-30^%ⁱⁿⁿ^oⁿ^-^b^r^east^f^eedⁱⁿ^{g p}^o^p^u^l^atⁱ^oⁿ^s^.^Breast^f^eedⁱⁿ^{g b}^y^anⁱⁿ^f^ect^ed^m^o^t^h^{er can}ⁱⁿ^{crease t}^h^{e ri}^{sk t}^o⁴⁵^%.^T^h^e
^rⁱ^s^k^of^MT^C^T^c^aⁿ^be^r^e^duc^e^d^t^o^u^nde^r^2%^by^inte^r^v^eⁿ^tions^t^h^a^tⁱⁿ^c^l^ude^t^h^e^pr^ov^is^ion^of^A^R^{V tr}^e^a^t^m^e^nts^.^Ele^c^tiv^e
^caesar^ean^d^e^lⁱ^v^er^y^an^d^co^m^p^l^e^t^e^avoⁱ^d^aⁿ^{ce o}^f^b^r^east^f^e^e^dⁱⁿ^g^can^al^so^red^u^{ce t}^h^{e ri}^{sk o}^f^HIV^t^r^an^smⁱ^ssi^oⁿ^.^Iⁿ^m^aⁿ^y
^reso^u^r^ce-coⁿ^s^train^e^d^settin^g^s^{, electiv}^{e cae}^sarean^d^e^liv^er^y^is^seld^o^m^f^e^asib^{le, an}^d^m^o^th^{ers o}^f^ten^lack^acce^{ss to}^en^o^u^g^h
^cl^ean^w^a^t^e^{r o}^r^f^o^rm^u^l^{a t}^o^ref^r^aiⁿ^fro^m^b^r^east^f^eedⁱⁿ^g.^Researchⁱ^s^o^ngoⁱⁿ^{g t}^o^eval^u^a^t^e^severalⁿ^e^w^ap^p^r^o^ach^{es t}^o
^p^r^even^tⁱⁿ^{g HIV}^t^r^an^smⁱ^ssi^oⁿ^d^u^rⁱⁿ^{g b}^r^east^f^eedⁱⁿ^g.
¹⁷^U^N^A^ID^{S 2006 G}^l^oba^{l A}^I^D^S^Re^port,^p.¹^32,^htt^p^://w^w^w^.una^ids^.^or^g^/^eⁿ^/H^IV^_^d^a^t^a^/²⁰^06G^loba^lRe^p^or^t/de^f^a^u^lt.a^s^p.
¹⁸^U^N^A^I^D^{S 2006 G}^l^oba^{l A}^I^D^S^R^e^por^t,^p.¹^32.
¹⁹^I^b^id^{., p. 13}^3.
²⁰^D^a^ta^f^r^o^m^c^ountrⁱ^e^sⁱⁿ^s^ub-^Sa^ha^r^a^{n A}^f^rⁱ^c^a^indic^a^t^e^tha^t^the^pr^o^por^tⁱ^on^of^H^I^V-ⁱⁿ^f^e^c^t^e^d^pr^e^g^na^{nt w}^o^m^e^{n r}^ecei^viⁿ^g
^A^R^Vs^{in 2}⁰⁰⁵^v^a^rⁱ^e^d^f^r^om^unde^r^1%^to^54%^aⁿ^{d t}^h^a^t^the^a^v^e^r^a^g^e^r^e^gⁱ^ona^{l c}^o^v^e^r^a^g^e^r^a^te^w^a^s^11%^{. I}ⁿ^Ea^s^t^{, S}^o^u^t^h,^a^nd
^Sout^he^a^s^{t A}^s^ia^{, the}^a^v^e^r^a^g^e^re^gⁱ^oⁿ^a^l^c^o^v^e^ra^g^e^ra^te^w^a^{s 5%}^{, w}^{ith in}^divⁱ^dua^{l c}^o^uⁿ^try^ra^te^{s ra}^ng^ing^f^r^om^3%^{to 10%}^{. On}
^avera^g^e,ⁱⁿ^L^a^tⁱⁿ^Ameri^{ca an}^d^t^h^e^Cari^b^b^ean^,²⁴^{% o}^f^HIV^-ⁱⁿ^f^ect^ed^m^o^t^h^{ers h}^a^d^{access t}^o^A^R^V^s^;^t^h^e^co^verag^e^rat^e
^r^a^ng^e^d^f^r^o^m^13%^to^46%^{. I}^t^is^e^s^tⁱ^m^a^t^e^{d tha}^t^ov^e^r^a^{ll c}^o^v^e^r^a^g^e^am^o^unte^d^to⁷⁵^%^{in Ea}^s^t^e^rⁿ^Eur^ope^a^{nd C}^eⁿ^t^r^a^{l A}^s^ia
^w^{ith c}^o^v^e^r^a^ge^r^a^te^s^r^a^ng^ing^f^r^o^m^38%^to⁹⁵^%^.^A^R^{V c}^o^v^e^r^a^g^e^f^o^r^H^I^V-^inf^e^c^t^e^d^pr^e^g^na^{nt w}^o^m^e^{n in}^N^o^r^t^{h A}^f^rⁱ^c^a^a^nd
^t^h^{e M}ⁱ^d^d^l^{e E}^a^st^averaged^l^e^{ss t}^h^an¹^%^.

stigmatized if they visit an HIV center could receive PMTCT services while receiving standard
prenatal care. Members who endorsed the Ensuring Access to Contraceptives Act (H.R. 2367)
demonstrated their support for expanding access to family planning and contraceptives. The bill
would authorize $150 million for such services in each of fiscal years 2008 and 2009. Some in
Congress also support the United Nations Population Fund Women’s Health and Dignity Act
(H.R. 2604), which would provide financial and other support to UNFPA’s activities that save
women’s lives, limit the incidence of abortion and maternal mortality associated with unsafe
abortion, promote universal access to safe and reliable family planning, and assist women,
children, and men in developing countries live better lives.
Women’s rights advocates also assert that the lower status of women in many of the most affected
countries must be better addressed in order to prevent new HIV infections. In many countries,
legal and social structures leave women feeling as though they have little control over their own
bodies and do not have the option to reject their husbands’ sexual advances; even when they are
aware of their husbands’ extramarital relationships. Research has shown that in Africa, married ²¹
girls and women are more likely to contract HIV than their single counterparts. For example,
30% of married adolescents’ spouses were HIV-positive in Kenya, while 11.5% of the partners of
their unmarried counterparts were infected with HIV. Similarly, in Zambia, 31.6% of married
girls’ partners were found to carry HIV, while 16.8% of unmarried girls’ boyfriends were HIV-²²
positive. Societal forces also weaken women’s options, rights advocates contend, because in
many countries, health workers require women to obtain their husbands’ permission before ²³
providing them contraception.
Global health activists also insist that OGAC’s policy of limiting condom distribution to “high ²⁴
risk groups” ignores gender inequities and limits the effectiveness of prevention programs. U.S.
condom distribution strategies do not include married women, unless their husbands test positive
for HIV. Supporters of U.S. condom distribution guidelines counter that the definition of “high
risk” individuals is broad enough to include the most vulnerable groups. Some HIV/AIDS
proponents advocate that Congress expand the definition of “high risk” individuals to include
married young people. Advocates hope that an expanded definition might enable young married
people to access condoms through U.S.-supported programs.

²¹
^“E^arl^y^M^a^rri^a^g^{e an}^d^HIV^Ri^{sks i}ⁿ^S^u^b^-^S^a^h^a^ran^A^f^ri^ca.^”^Studie^sⁱⁿ^Fam^ily^Pl^anⁿⁱ^ng^,^V^o^l.³⁵^{, N}^o^{. 3}^,^Se^pte^m^be^r
²⁰⁰^{4. htt}^p^://w^ww^.bla^c^k^we^ll-s^y^ne^rgy^.^c^o^m^/^link^s^/^doi/^10.¹¹^11/^j.1⁷²⁸^-⁴⁴^65.²⁰^04.⁰⁰⁰¹^9.x^/^pdf^?^c^ook^ie^Se^t=^1,^“^P^rote^c^ting
^Y^oung^W^o^m^e^{n f}^r^o^m^H^I^V/A^I^D^S^{: T}^h^e^C^a^s^e^A^g^aⁱ^ns^{t C}^h^ild^a^{nd A}^dol^e^s^c^eⁿ^{t Ma}^r^rⁱ^a^g^e^.^”^Inte^rnatio^nal^F^a^mily^Plaⁿⁿⁱⁿ^g
^P^e^rsp^ectⁱ^ves^{, Vol.}³²^{, N}^o^{. 2}^,^J^u^ne²⁰^06.^ht^tp:/^/w^w^w^.js^t^or^.or^g^/jo^urⁿ^a^ls^/016²²⁷⁴^9.^htm^l^.
²²^The^Imp^lic^ati^ons^{of E}^a^rly^M^a^rria^g^e^{for HIV/}^{AIDS P}^o^lic^y^{. Pop}^u^la^ti^on^C^o^uⁿ^c^{il, 20}^04.^ht^tp:/^/w^w^w^.popc^ou^nc^il.or^g^/
^pdf^s^/^C^M^.p^df^.
²³^Violeⁿ^c^e^A^gai^ns^{t G}ⁱ^r^l^s^an^{d W}^o^m^e^n:^Effe^c^t^s^oⁿ^Se^x^u^al^an^{d Re}^pr^od^uc^tiv^e^H^e^{alth D}^e^cⁱ^sⁱ^oⁿ^M^a^kⁱⁿ^g^{. U}^N^F^P^A^w^e^bs^ite^,
^acces^sed^oⁿ^M^a^y¹⁴^,²⁰⁰⁷^h^t^t^p^:^/^/^www^.^uⁿ^f^p^a^.^o^rg/ⁱⁿ^t^ercen^t^e^r/^vi^o^l^en^ce/^e^f^f^ect^s2^a.^h^t^m^.
²⁴^Hⁱ^g^h^rⁱ^s^k^g^r^oups^a^r^e^de^fⁱ^ne^{d a}^s^s^e^x^w^o^r^k^e^r^s^a^{nd the}ⁱ^r^c^lie^nts^;^s^e^x^u^a^lly^a^c^tiv^e^dis^c^or^da^{nt c}^o^u^p^le^s⁽^w^he^{n o}ⁿ^e^pa^r^t^ne^r^is
^HIV^-^p^o^sitiv^e^a^nd^the^othe^{r is}^no^t^inf^e^c^t^e^d^{) or c}^o^u^p^le^{s w}^{ith u}ⁿ^k^now^{n HIV sta}^t^{us; s}^ubsta^nc^e^a^b^use^r^{s; m}^obile^m^a^le
^pop^ula^tⁱ^ons^{; m}^e^{n w}^{ho ha}^v^e^s^e^x^w^{ith m}^e^{n; a}^nd^pe^op^le^liv^ing^w^{ith H}^I^V/A^I^D^S^.

Health experts have begun to debate the role that circumcision could play in HIV prevention
efforts. Three randomized trials conducted in South Africa, Kenya, and Uganda demonstrated that
male circumcision reduced the risk of acquiring HIV by more than half. Some believe that if mass
circumcision was to be conducted in areas of high transmission, the procedure could avert about

5.7 million new HIV infections and 3 million deaths over 20 years among both men and ²⁵

women. WHO and UNAIDS have endorsed the practice to be added to HIV prevention ²⁶
initiatives. The organizations warn, however, that the practice should not be seen as a “magic
bullet,” as it does not prevent men from acquiring the virus, it only reduces the risk of infection.
As a result, health experts urge those who perform the surgeries to counsel the men and explain
that they must maintain other protective practices, such as abstaining from sex, reducing their
number of sexual partners, and using condoms.
Some observers argue that the studies should not yet be widely embraced, particularly since only
a few trials have been conducted. A number of scientists question the validity of the studies since ²⁷
they were terminated early; a practice, critics contend, that skews the results. Dissenters argue
that there may be other explanations for the drop in transmission. Skeptics contend that
circumcision reduces the incidence of genital symptoms, allowing men to receive fewer unsafe
injections and other blood exposures during treatment. Also, in sub-Saharan Africa, circumcised
virgins and adolescents are reportedly more likely to be HIV-infected than their uncircumcised
counterparts. Researchers suspect that unhygienic circumcision procedures might be a large factor ²⁸
in this phenomenon.
Critics and advocates of the practice agree that additional studies need to be conducted and a ²⁹
number of precautions must be taken should the practice be implemented on a larger scale.
Additional research is needed to determine how the procedure might impact HIV transmission to
women, the most affected population in Africa. There is consensus that male circumcision must
be considered part of a comprehensive HIV prevention package, which includes treatment for
sexually transmitted infections; the promotion of safer sex practices; and the provision of male
and female condoms and promotion of their correct and consistent use. HIV/AIDS advocates
maintain that men and their sexual partners must also be counseled to prevent them from
developing a false sense of security and engaging in high-risk behaviors that could undermine the
partial protection provided by male circumcision. Health experts agree that African health
systems need to be strengthened in order to ensure safe and clean operations. Circumcision must
be done under hygienic conditions by trained personnel with access to sterile surgical instruments

²⁵
^“^C^ir^c^u^m^c^is^{ion a}^{nd C}ⁱ^r^c^um^s^p^e^c^tion^.^”^T^h^{e L}^aⁿ^cet^Iⁿ^f^ectⁱ^o^u^s^Di^sea^s^es^{, Ma}^y^2007,^V^o^l.^{7, N}^o^.^5,
^http:^//w^w^w^.the^la^nc^e^t^.c^om^/^j^our^na^l^s^/la^ninf^/a^r^tic^le^/P^I^I^S1⁴⁷³³⁰⁹⁹⁰⁷⁷⁰⁰⁸⁷⁷^.
²⁶^W^HO,^“^W^H^O^{and U}^N^AI^D^S^anⁿ^ounc^e^r^e^c^o^m^m^e^nd^ati^ons^fr^om^e^x^p^e^r^{t c}^ons^ult^a^ti^on^on^m^a^le^cⁱ^r^c^um^cⁱ^sⁱ^{on f}^o^r^H^I^V
^p^r^even^tⁱ^oⁿ^.^”^M^a^rch²⁸^,²⁰⁰⁷^.^ht^t^p^:^/^/^www^.^w^h^o^.ⁱⁿ^t^/^hⁱ^v/^medⁱ^acen^t^r^e/ⁿ^e^w^s⁶⁸^/^en^/ⁱⁿ^d^e^x.^h^t^m^l^.
²⁷^“M^al^{e Ci}^rcu^m^ci^si^oⁿⁱⁿ^HI^V^P^r^ev^en^tⁱ^oⁿ^.^”^T^h^{e L}^aⁿ^cet^,^V^o^l^.³⁶^9,^No.⁹⁵⁷³^,^M^a^y¹²^,²⁰⁰⁷^,^h^t^tp^:/^/www.^th^elan^cet.^c^o^m^/
^jour^na^ls^/^l^aⁿ^c^e^t/a^r^tic^le^/^P^I^I^S⁰¹⁴⁰⁶⁷³⁶⁰⁷⁶⁰⁷³⁷⁵^.
²⁸^“M^al^{e Ci}^rcu^m^ci^si^oⁿⁱⁿ^HI^V^P^r^ev^en^tⁱ^oⁿ^.^”^T^h^{e L}^aⁿ^cet^,^V^o^l^.³⁶^9,^No.⁹⁵⁷³^,^M^a^y¹²^,²⁰⁰⁷^,^h^t^tp^:/^/www.^th^elan^cet.^c^o^m^/
^jour^na^ls^/^l^aⁿ^c^e^t/a^r^tic^le^/^P^I^I^S⁰¹⁴⁰⁶⁷³⁶⁰⁷⁶⁰⁷³⁵¹^.
²⁹^UNA^IDS^,^M^a^le^Cⁱ^r^c^um^cⁱ^sⁱ^on:^C^onte^x^t^{, C}^r^ite^rⁱ^a,^an^{d C}^u^l^t^ur^e^.^http^://www^.una^ids.org^/^eⁿ^/m^e^d^ia^c^e^ntre^/pre^ss^m^a^te^ria^l^s/
^f^e^a^t^ur^e^s^tor^y^/²⁰⁰⁷⁰²²^6_^MC^_^p^t1^.a^s^p^.

and anaesthesia. Many facilities on the continent, however, lack sufficient supplies, such as
gloves, clean needles, and antiseptics. Some health experts fear that greater investment in
circumcision might disrupt other health care programs. Global health advocates urge Congress to
ensure that male circumcision services are integrated with other services, particularly in areas
with severe shortages of skilled health workers, should it include support for the practice in
PEPFAR.
A number of global health experts contend that some current U.S. AIDS-related spending
restrictions and requirements are ideologically based, negatively impact the effectiveness of
PEPFAR programs, and complicate implementing partners’ efforts. The U.S. Leadership Against
HIV/AIDS, TB, and Malaria Act (P.L. 108-25) mandates that no funds made available to carry
out the act may be used to assist any group or organization that does not have a policy explicitly
opposing prostitution and sex trafficking. This policy has become widely known as “the
prostitution pledge.” Critics of the pledge contend that the restriction should be eliminated, ³⁰
because it limits implementing partners’ HIV/AIDS prevention efforts. Opponents argue that
groups serving sex workers fear that by signing the pledge and openly opposing prostitution, they
may isolate the very group that they are attempting to help.
The “Mexico City Policy”³¹ has also come under considerable scrutiny. The policy prohibits
reproductive health organizations from providing information about abortion. Critics contend
that, in some countries, this policy has had devastating effects, because reproductive health
services is the only form of health care that many women receive. The House and Senate included
language in their reports (H.Rept. 110-197 and S.Rept. 110-128) for FY2008 Foreign Operations

³⁰
^USA^I^{D’s polic}^y^dire^c^tiv^e^{on the}^prostit^uti^on^ple^d^g^e^c^aⁿ^be^f^o^uⁿ^d^a^t^htt^p^://w^ww^.usa^id.g^ov^/busine^ss/
^busine^ss_^op^port^uⁿ^itie^s/^cⁱ^b/pdf^/a^a^pd0^5_⁰⁴^.p^df^{. Critic}^ism^s^of^P^E^P^F^A^R^spe^nding^re^quire^m^e^{nts inc}^l^u^d^e^A^I^DS^T^a^s^k^f^o^rc^e
^o^f^G^r^eat^{er Cl}^ev^el^an^d^,^{Is PEPF}^AR^W^o^rkin^g^?^{A Resp}^oⁿ^s^{e t}^o^t^h^{e Recen}^{t An}ⁿ^u^a^l^Re^p^o^r^{t Issu}^e^d^b^y^th^e^Presid^en^t’s
^Eme^r^ge^nc^y^Plan^{for AID}^S^Re^lie^f^,^Ma^y^{2006. htt}^p^://w^w^w^.a^ids^t^a^s^kf^orc^e^.^org^/^A^SSET^S^/
^72B^F³^D^D^44B^1E^4B⁹³^A¹⁰⁷⁷^EC⁹⁵^C⁶⁵⁵^E^81/^PE^P^F^A^R^.pdf^{; H}^e^a^lth^G^a^p,^U^.^{S. G}^l^o^bal^AI^D^S^Iⁿ^iti^ativ^e^,^Rouⁿ^d^2:^Fr^om
^Em^e^r^ge^nc^y^{to S}^u^s^t^ai^na^bili^ty^.^Ma^y^29,²⁰⁰⁷^.^htt^p^://w^ww^.he^a^lthg^a^p.^org^/^PE^P^F^A^R^-Reⁿ^e^w^a^l^.doc^{; Ce}^nt^e^r^f^o^{r He}^a^{lth a}^nd
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^P^rⁱ^o^ritie^s.”^P^L^o^S^M^e^dicⁱ^ne^,^Vol.^{4, No}^{. 7}^,^ht^tp:/^/m^e^d^ic^ine^.^plosj^our^na^ls.org^/^p^e^r^lse^r^v^/^?^r^e^que^st=^g^e^t^-
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^pub^lic^a^tio^ns^/^p^le^dg^e^_20⁰⁷⁰⁶^12.
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^pr^om^ote^a^bor^ti^on^a^s^a^m^e^{thod of}^f^a^mⁱ^l^y^pla^nning^{, e}^v^eⁿ^if^the^a^c^tiv^it^ie^s^a^r^e^unde^r^t^a^k^eⁿ^w^{ith n}^on-^U^.^S^.^f^unds^{. F}^o^r^m^o^r^e
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appropriations (H.R. 2764) that prevented the “Mexico City Policy” from being the sole reason
that U.S. funds could not be used to provide contraceptives. A conference is pending. Opposing
Members expect the President to veto any bill that repeals the “Mexico City Policy.”
Some health experts assert that congressional HIV prevention stipulations are not well-balanced,
place too much emphasis on abstinence until marriage, and limit countries’ ability to use
prevention funds in a manner that is most relevant to local conditions. P.L. 108-25, which
delineates how PEPFAR funds should be allocated, stipulates that between FY2006 and FY2008,

20% of global HIV/AIDS funds are to be used for prevention efforts, of which at least 33%

should be expended for abstinence-until- marriage programs. In 2006, the Government
Accountability Office (GAO) found that PEPFAR’s spending requirements limited the flexibility ³²
with which prevention funds could be spent. GAO estimated that in order to meet the 33%
proviso, between FY2004 and FY2006, OGAC increased spending on prevention by almost 55%
and mandated that country teams spend half of prevention funds on sexual transmission
prevention and two-thirds of those funds on abstinence/faithfulness (AB) activities. In its ³³
congressionally mandated report, the Institute of Medicine (IOM) reached similar conclusions.
Some health specialists argue that these policies consume limited resources and time, as they
place additional reporting requirements on implementing partners. Britain’s Department for
International Development (DFID) reports that from 2003 to 2004 and 2006 to 2007, the ³⁴
Ugandan government was reporting on 684 different aid instruments and associated agreements.
Critics suggest that if Congress reauthorizes PEPFAR, it should eliminate these spending
restrictions, coordinate reporting requirements and funding processes with other donors, and urge
the United States to sign on to the International Health Partnership. Some in Congress have
supported legislation that was introduced to remove the spending provisions. The HIV Prevention
Act (S. 1553) and the Protection Against Transmission of HIV for Women and Youth Act (H.R.

1713) would strike the 33% abstinence-until-marriage spending requirement from P.L. 108-25.

The FY2008 House Foreign Operations Appropriations would allow the Administration to
determine whether to apply the 33% abstinence-until-marriage provision to global HIV/AIDS
programs.
Access to generic HIV/AIDS treatments is another possible issue to arise in reauthorization
debates. Shortly after PEPFAR was launched, the Bush Administration expressed skepticism

³²
^GA^O,^S^p^eⁿ^dⁱⁿ^g^R^e^q^uⁱ^remen^t^P^r^esen^t^s^Ch^a^l^l^e^ng^{es f}^o^r^A^l^l^o^c^a^tⁱⁿ^g^P^r^even^tⁱ^oⁿ^F^u^ndⁱⁿ^g^Uⁿ^d^e^{r t}^h^{e P}^r^esi^d^en^t^’^s
^Eme^r^ge^nc^y^Plan^{for AID}^S^Re^lie^f^,^A^p^{ril 200}^{6, a}^t^htt^p^://w^ww^.ga^o^.g^ov^/ne^w^.ite^m^s^/d06³⁹^5.p^d^f^.
³³^Se^c^tion¹^{01 (c}⁾⁽^{1) of}^P^.^L^.¹^08-²⁵^m^a^nda^te^{d tha}^tⁿ^o^{t la}^te^{r t}^h^aⁿ^t^h^re^e^y^e^a^r^{s a}^f^te^{r its e}ⁿ^a^c^t^m^e^{nt, the}^Iⁿ^stitute^of
^Me^dicⁱ^ne⁽^I^O^M)^w^oul^{d “}^p^ub^lis^{h f}ⁱ^ndi^ng^s^c^o^m^p^a^r^ing^the^s^u^c^c^e^s^s^r^a^te^s^of^the^v^a^rⁱ^ous^pr^og^r^a^m^s^a^{nd m}^e^thods^us^e^d^un^de^r
^th^e^[P^E^PFA^R]^strateg^y^{.” In}^March²⁰⁰⁷^{, IOM}^released^,^PEPFA^{R I}^m^ple^m^eⁿ^tati^on:^Progre^{ss a}ⁿ^d^Pro^m^ise^.^IOM
^coⁿ^c^l^u^d^e^d^t^h^at^“^P^E^P^F^A^{R h}^a^{s ma}^d^e^{a p}^r^o^mⁱ^sⁱⁿ^{g st}^art^,^bu^t^t^h^{e n}^eed^f^o^{r U.}^S^.^l^ead^ershⁱ^pⁱⁿ^t^h^{e ef}^f^o^rt^t^o^coⁿ^t^r^o^l^t^h^e
^H^I^V/A^I^D^S^pa^nde^mⁱ^c^c^ontin^ue^s^.^”
³⁴^D^F^ID^,^M^illenⁿ^iu^{m Develo}^p^m^en^t^Go^a^l^{s: Hea}^l^t^h^F^a^{cts a}ⁿ^d^Fig^u^res^http:^//www^.dfⁱ^d.g^o^v^.^uk^/m^dg^/^h^e^a^lth-f^a^c^t^s-
^fⁱ^g^u^r^e^s^.^as^p#T^he^_do^nor^_c^o^o^r^dⁱⁿ^a^t^ion^_^c^h^a^lle^ng^e^.

about broad-based use of generic ARV medication. The Administration asserted that WHO’s
prequalification process was inadequate, and that generic drugs purchased with PEPFAR funds ³⁵
had to be first inspected by the U.S. Food and Drug Administration (FDA). The Administration
argued that since WHO is not a regulatory body, its adherence to stringent FDA standards could ³⁶
not be ensured. This policy sparked a debate with critics contending that the process was ³⁷
unnecessary and delayed the distribution of ARVs. In January 2005, GAO reported that the
policy limited the selection of ARV products available, did not fully support the treatment
strategies of the focus countries, and was not optimally coordinated with other multinational
initiatives. GAO indicated that “better coordination with the Focus Countries and with other
treatment initiatives could facilitate more rapid implementation of the Emergency Plan.
Moreover, given the intended scale of the plan, lower prices for ARVs could result in savings of
hundreds of millions of dollars, which could be used to treat additional patients or to support ³⁸
other aspects of the program.”
In March 2007, IOM found that in many of the Focus Countries, a number of those implementing
HIV/AIDS programs complained that the U.S. treatment policy complicated national treatment ³⁹
efforts. The Institute recommended that OGAC work to support WHO prequalification as the
accepted global standard for assuring the quality of generic medications and work with other
donors to support strengthening the process. According to OGAC’s third annual report to
Congress, OGAC has strengthened its coordination with WHO, by sharing information on the
WHO-approved generics. OGAC estimates that in FY2006, 27% of all ARVs purchased under ⁴⁰
PEPFAR were generic. Since FDA began reviewing generic drug applications, more than 50
generic versions of patented ARVs have been approved or tentatively approved for use in ⁴¹
PEPFAR treatment plans.
In considering whether to extend PEPFAR, HIV/AIDS experts encourage Congress to stipulate
stronger integration of PEPFAR-supported programs with other health programs that save lives.

³⁵
^T^h^e^W^H^O^pr^e^qua^lif^yⁱ^ng^pr^oc^e^s^s^inc^l^u^d^e^s^aⁿ^a^s^s^e^s^s^m^e^{nt of}^pr^oduc^t^f^ile^s⁽^l^a^s^ting^a^ppr^ox^im^a^t^e^l^y^t^w^{o to f}^our^m^onths⁾^;
^s^ite^ins^p^e^c^tio^ns^{; a}ⁿ^{d t}^h^e^pr^oc^ur^e^m^eⁿ^{t of}^da^ta^on^a^{ll a}^c^tiv^e^pha^r^m^ac^e^u^tic^a^l^ing^r^e^d^ie^nts^,^s^p^e^cⁱ^fⁱ^c^a^tions^{, pr}^o^duc^{t f}^o^r^m^ula^s^,
^a^{nd m}^a^nuf^a^c^t^ur^ing^m^e^thods^{. A}^f^ter^the^pr^od^uc^ts^aⁿ^{d m}^a^nuf^a^c^t^ur^ing^s^ite^s^m^e^e^t^the^r^e^quir^e^{d s}^t^a^nda^r^d^s^,^the^m^e^dicⁱ^ne^is
^a^dde^{d t}^o^t^h^e^lis^t^of^pre^qua^lif^ie^{d pr}^oduc^ts^.^For^m^o^re^inf^o^rm^a^{tion, s}^e^e^htt^p^://w^w^w^.^w^ho.int/^3by^5/pub^lic^a^tions^/^b^rie^f^s^/^am^ds^/
^en^/^.
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^be^gⁱⁿⁿⁱ^ng^?^A^I^D^S^,”^The^Ec^onomⁱ^s^t^{, J}^u^ly^17,²⁰^04.^For^m^o^r^e^{on t}^h^e^de^ba^te^a^b^o^u^t^the^FD^A^r^e^vⁱ^ew^pr^oc^e^s^s^,^s^e^e^the
^K^a^is^e^r^ne^t^w^or^k^w^e^bs^ite^a^t^http:^//w^w^w^.^k^aⁱ^s^e^rⁿ^e^t^w^o^r^k^.or^g^/^d^a^ily^_r^e^p^o^r^ts^/r^e^p_i^nde^x^.^c^f^m^?^hint=¹^&^D^R^_^I^D⁼²⁷⁷^88.
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^doc^um^eⁿ^ts^/or^g^aⁿ^iz^a^tion/⁸¹⁰¹^9.^pd^f^.
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^re^vⁱ^e^w^ing^A^R^V^s^{, se}^e^http:/^/www^.^f^da^.g^ov^/^o^ia^/^p^e^p^f^a^r.htm^.

Many health experts contend that PEPFAR’s disease-specific approach threatens to supplant
support by the United States and recipient countries for other health areas, including nutrition,
maternal and child heath, and other infectious diseases.
Malnutrition and lack of food may heighten exposure to HIV, raise the likelihood of engaging in
risky behavior (e.g., transactional sex), increase susceptibility to infection, and complicate efforts
to provide anti-retroviral (ARV) medication. Furthermore, those sickened by HIV/AIDS are often
too ill to till the land, lessening agricultural productivity. The United Nations’ Food and
Agriculture Organization (FAO) estimates that food consumption drops by 40% in homes affected ⁴²
by HIV/AIDS, due in large part to diminished capacity to farm.
In communities struggling with food security, decreased food production can complicate efforts to
maintain treatment regiments. If patients do not consume adequate amounts of nutritious food,
they can suffer significant side effects while taking ARVs and the drugs can be less effective. At
the 2006 International AIDS Conference, one AIDS advocate cited a study that showed that
patients who were malnourished when they started ARV therapy were six times more likely to die
than well-nourished patients, and were more likely to suffer side-effects, which often caused them ⁴³
to stop taking the treatments. These issues are particularly acute in rural communities, where
AIDS incidence is rapidly increasing and access to care is usually more limited than in urban
areas. In the 25 most AIDS-affected countries in Africa, more than 2/3 of the population live in ⁴⁴
rural areas and rely on agriculture for their livelihoods.
In April 2007, the House Foreign Affairs Committee held a hearing on the progress of PEPFAR.
At the hearing, Global AIDS Coordinator Mark Dybul testified that PEPFAR funds provided
“limited food assistance for specific, highly vulnerable populations,” and cited support for a pilot
program that enables a local food manufacturer to distribute nutrient-dense food to orphans and
vulnerable children, clinically malnourished HIV-positive people, and HIV-positive pregnant and
lactating women enrolled in PMTCT programs. He also indicated that in FY2006, OGAC had
contributed $2.45 million contribution to the World Food Program (WFP) and would contribute
an additional $4.27 million in FY2007. Ambassador Dybul conceded that PEPFAR’s engagement
in food insecurity is limited. He contended, however, that efforts are intentionally limited,
because OGAC prefers to remain focused on HIV/AIDS. At the hearing, Ambassador Dybul
testified that PEPFAR supports other “wrap around” programs that support HIV-affected
populations, such as clean water programs, education initiatives, and gender projects.

⁴²
^F^A^O^f^act^sh^eet^,^{HIV/AIDS, fo}^od^se^c^u^rity^{, an}^{d rur}^a^{l liv}^e^lⁱ^h^o^ods^http^://w^w^w^.^f^a^o^.or^g^/w^or^ldf^oods^um^mⁱ^t^/^eⁿ^g^lis^h/^f^s^he^e^t^s^/
^aⁱ^ds^.pdf^.
⁴³^Sta^t^e^m^eⁿ^t^m^a^de^b^y^Stua^{rt G}^ille^spie^a^t^the²⁰⁰⁶^Inte^rna^t^io^na^{l A}^I^D^S^Conf^e^r^eⁿ^c^e^,^“^B^rea^kⁱⁿ^g^t^h^{e V}ⁱ^ci^o^u^s^Cycl^{e o}^f
^HIV/AIDS^an^{d Hun}^g^e^r.^”^htt^p^://w^w^w^.i^f^p^ri.org^/P^R^E^SSREL^/²⁰⁰^6/²⁰⁰⁶⁰⁸¹³^.a^s^p^.
⁴⁴^FA^O^,^The^I^m^pac^t^{of H}^I^V^/^AI^D^S^oⁿ^Agrⁱ^c^u^ltur^e^an^{d F}^o^o^d^Se^c^u^r^ity^,²⁰⁰^{3, htt}^p^://w^w^w^.^f^a^o^.org^/doc^re^p/⁰⁰⁵^/^Y⁸³³¹^E/
^Y⁸³³^1E^00.^htm^.

According to the United Nations, maternal and neonatal⁴⁵ mortality rates could be significantly
reduced if more women, particularly in Africa, had sufficient access to skilled health personnel
who are trained to detect problems early and can effectively provide or refer women to
emergency obstetric care. The United Nations has found that regions with the lowest proportions ⁴⁶
of skilled health attendants at birth also have the highest number of maternal deaths. In sub-
Saharan Africa, 1 of every 16 women who becomes pregnant will die from complications arising
during her pregnancy or childbirth. For comparison, the rate in industrialized countries is one in ⁴⁷
3,800. Experts have also found that child survival rates are higher in areas with ample numbers
of health workers to administer immunizations, clean water, controlled mosquito populations, and ⁴⁸
sufficient access to nutritious food.
Those who support integrating PEPFAR into other health programs contend that disease-specific ⁴⁹
programs like PEPFAR fail to address adequately the intersection of diseases. Research has
demonstrated that since HIV weakens the immune systems of those infected, they are more
susceptible to a range of illness, including malaria. HIV-positive people are more likely to be
hospitalized and sickened by malaria than those not carrying the virus. According to WHO, Africa
is the only region in the world where incidence of new TB infections continues to rise, due in ⁵⁰
large part to HIV/AIDS co-infection. In 2004, more than 740,000 people who contracted TB ⁵¹
were co-infected with HIV/AIDS. Some 600,000 of those co-infected with TB and HIV/AIDS

⁴⁵
^Ne^ona^ta^{l re}^f^e^{rs to the}^fⁱ^{rst f}^{our we}^e^k^{s o}^f^lif^e^.
⁴⁶^Unite^{d Na}^ti^ons,^Th^{e M}^illenⁿⁱ^u^m^Develo^p^m^en^{t Go}^a^l^{s Rep}^o^r^t:²⁰⁰⁷^{, htt}^p^://w^ww^.un.org^/^m^ille^nnium^goa^ls/pdf^/
^m^d^g^2007.p^d^f^.^W^h^ile^the^g^r^e^a^t^e^s^{t s}^hor^ta^g^e^of^he^a^{lth c}^a^r^e^w^o^r^k^e^r^s^{in a}^b^s^o^lu^te^te^r^m^s^a^r^e^{in s}^outhe^a^s^{t A}^s^ia⁽^m^os^tl^yⁱⁿ
^B^a^ng^la^de^s^h^{, I}ⁿ^dia^,^aⁿ^{d I}ⁿ^do^ne^sⁱ^a⁾^{, s}^ub-^Sa^ha^r^a^{n A}^f^rⁱ^ca^s^u^f^f^e^r^s^f^r^o^m^the^g^r^e^a^t^e^s^{t pr}^op^or^ti^ona^{l s}^hor^ta^g^e^of^he^a^{lth c}^a^r^e
^w^o^rker^{s i}ⁿ^t^h^{e w}^o^rl^d^.^W^{HO est}ⁱ^mat^e^{s t}^h^at^t^h^{ere are 5}⁷^co^un^t^rⁱ^e^{s w}ⁱ^t^h^cri^tⁱ^cal^sho^r^t^a^{ges o}^f^h^eal^t^h^{care w}^o^rkers,³⁶^o^f
^w^h^ic^{h a}^r^e^{in A}^f^rⁱ^c^a^a^{nd no}^ne^of^w^h^ic^{h a}^r^e^{in in}^dus^tr^ia^liz^e^d^na^ti^on^s^.^G^l^oba^lly^{, WH}^O^e^s^ti^m^a^tes^tha^t^aⁿ^a^dditⁱ^oⁿ^a^l^4.³
^m^{illion he}^a^lth^w^o^rk^e^r^s^a^r^e^ne^e^d^e^d^{, a}^nd^tha^t^A^f^ric^a^w^{ould ne}^e^d^t^oⁱⁿ^c^r^e^a^s^e^its^num^be^{r of}^he^a^{lth w}^o^rk^ers^by^a^{bout 1}^40%
^{in or}^de^r^t^o^m^e^e^t^the^mⁱⁿⁱ^m^u^m^thr^e^s^hold^of^2.5^he^a^lth^c^a^r^e^pr^of^e^s^sⁱ^ona^ls^pe^r^1,⁰⁰^{0 pe}^ople^.^W^H^O^,²⁰^{06 W}^o^r^l^{d H}^e^alt^h
^Re^por^t^{, htt}^p^://w^ww^.^w^ho.int/^w^h^r/²⁰⁰^6/^eⁿ^/.
⁴⁷^Unite^{d Na}^ti^ons,^Africa^aⁿ^d^t^h^{e M}^illenⁿⁱ^u^m^Develo^p^m^en^{t G}^o^a^l^s:²⁰⁰⁷^U^p^d^a^te^{, h}^ttp:^//w^w^w^.un.or^g^/^mⁱ^lleⁿⁿⁱ^um^g^o^a^l^s^/
^doc^s^/^MD^G^a^f^r^ic^a^07.pdf^.
⁴⁸^L^a^urie^Ga^rre^{tt, “}^The^C^hal^le^nge^o^f^G^l^ob^{al H}^e^a^lth^,”^For^e^ig^{n A}^f^f^a^ir^{s, N}^e^w^Y^o^r^k^{: J}^a^nua^r^y^/Fe^b^r^u^a^r^y^2007,^V^o^l.⁸⁶^,
^Is^s^u^e^1,^http^://w^w^w^.^f^oreⁱ^gⁿ^aff^a^irs^.^or^g^/²⁰⁰⁷⁰¹^01f^a^e^s^s^a^y^86103/^la^uri^e^-g^a^rre^tt/^the^-^c^h^a^lle^ng^e^-^of^-g^loba^l-he^a^lth.h^tm^l.
⁴⁹^S^{ee UNA}^IDS^,²⁰⁰⁶^AI^D^S^Epi^d^e^m^ic^U^pdate^,^an^d^CDC,^In^te^rac^tio^{n of}^{HIV a}ⁿ^d^M^a^lari^a^{, htt}^p^://w^ww^.c^dc^.g^ov^/^m^a^l^a^r^ia^/
^pdf^/Ma^l^a^r^ia^_H^I^V^_R^ic^k^_^w^e^bs^ite^.pdf^.
⁵⁰^W^HO,²⁰⁰^{6 G}^l^o^b^a^l^T^ube^r^c^ulos^is^C^ontr^o^{l Re}^p^o^r^t^{, htt}^p^://w^w^w^.^w^ho.int/^tb/^publ^ic^a^tions^/^g^loba^l_re^port/²⁰⁰^6/^eⁿ^/^.^P^e^ople
^lⁱ^vⁱⁿ^{g w}ⁱ^t^h^HIV^/^A^I^DS^{are at}^grea^t^e^{r ri}^{sk o}^f^b^eco^mⁱⁿ^gⁱⁿ^f^e^ct^ed^wⁱ^t^h^T^B^b^ecau^{se o}^f^t^h^ei^{r w}^e^aken^edⁱ^m^m^uⁿⁱ^t^y^.^E^ach
^dis^e^a^s^e^s^p^e^e^d^s^{up t}^h^e^pr^og^r^e^s^s^of^the^ot^he^r^,^aⁿ^{d T}^B^c^onsⁱ^d^e^r^a^b^ly^s^hor^te^ns^t^h^e^s^u^r^v^iv^a^l^of^pe^ople^w^ith^H^I^V/A^I^D^S^.
^HIV^/^A^I^DSⁱ^s^t^h^{e m}^o^st^p^o^t^eⁿ^t^ri^sk^f^act^o^r^f^o^{r co}ⁿ^v^ertⁱⁿ^{g l}^a^t^eⁿ^t^T^Bⁱⁿ^t^o^actⁱ^v^{e T}^B^,^w^hⁱ^l^e^T^B^b^act^eri^a^a^ccel^erat^{e t}^h^e
^pr^og^r^e^s^s^of^A^I^D^S^{. Ma}ⁿ^y^pe^ople^a^f^f^e^c^t^e^d^by^H^I^V/A^I^D^S^{in de}^v^e^lopi^ng^c^oun^tr^ie^s^de^v^e^{lop T}^B^a^s^the^fⁱ^r^s^{t m}^aⁿⁱ^f^e^s^t^a^{tion of}
^A^I^D^S^{. In H}^I^V^/^A^I^D^S^-pos^itiv^e^pe^o^p^le^{, T}^B^is^ha^rde^r^t^o^dia^g^nos^e^,^pr^o^g^r^e^s^s^e^s^fa^s^t^e^r^{, is}^a^l^m^o^s^t^a^l^w^a^y^s^f^a^ta^{l if}^undia^gⁿ^o^s^e^d
^{or le}^f^t^untre^a^t^e^d^,^a^{nd k}^ills^u^p^to^h^a^lf^of^a^ll^A^I^{DS pa}^tie^{nts w}^o^rldw^ide^.^P^e^ople^w^{ith HI}^V^/^A^I^{DS a}^r^e^{up t}^o⁵⁰^tim^e^s^m^o^re
^lik^e^l^y^{to de}^v^e^{lop T}^B^{in a}^gⁱ^v^e^{n y}^e^a^r^thaⁿ^H^I^V/A^I^D^S^-ⁿ^e^g^a^tiv^e^pe^ople^.^A^{bout 9}⁰^%^of^pe^o^p^le^liv^ing^w^{ith A}^I^D^S^die
^w^{ithin f}^our^t^o^tw^e^l^v^e^m^onths^of^c^ontr^a^c^ting^T^B^if^not^tr^e^a^t^e^d^.
⁵¹^Iⁿ^f^o^r^m^a^{tion in t}^h^is^pa^r^a^g^r^a^{ph s}^u^m^m^a^rⁱ^z^e^d^f^r^om^W^H^O^,^{2006 G}^l^ob^{al T}^ube^r^c^ul^os^is^C^o^ntr^o^l^Re^por^t^,
^http:^//w^w^w^.^w^ho.int^/^t^b/pu^blic^a^tio^ns^/g^loba^l_^r^e^por^t^/²⁰⁰^6/^eⁿ^/.

were found in sub-Saharan Africa, representing more than 80% of all co-infected cases. About

205,000 of the more than 248,000 co-infected patients who died from TB were African,

representing 83% of those deaths. Most poorly equipped health systems in Africa are unable to
contain TB, as they have limited case detection capacity; meager financing; too few health
workers in numbers and who are sufficiently trained; inconsistent drug supplies; and little means
to monitor and evaluate TB control programs.
PEPFAR critics urge Congress to consider not only the degree to which resources are skewed
towards HIV/AIDS initiatives, but also what impact such unbalanced spending has on health
systems overall. Many global health experts maintain that the generous salaries and other
incentives (such as housing stipends) offered by donor-supported HIV/AIDS programs draw
health workers from public health facilities and threaten other life-saving interventions offered at ⁵²
those clinics, such as maternal and child survival health initiatives.
According to WHO, the global shortage of health care workers is the single most important health ⁵³
issue facing countries today. While the greatest shortages of health care workers in absolute
terms are in southeast Asia (mostly in Bangladesh, India, and Indonesia), sub-Saharan Africa
suffers from the greatest proportional shortage of health care workers in the world (Table 4).
WHO estimates that there are 57 countries with critical shortages of health care workers; 36 are in
Africa and none are in industrialized nations. Globally, WHO estimates that an additional 4.3
million health workers are needed, and that Africa would need to increase its number of health
workers by about 140% in order to meet the minimum threshold. None of the countries in Table 5
have enough doctors to meet the most basic health care needs; though when nurses and midwives
are included, some do meet the minimum standard. The amount and quality of health worker
numbers are positively associated with immunization coverage, outreach of primary care, as well
as infant, child, and maternal survival.
After the release of the World Bank’s report, International Migration, Remittances, and the Brain
Drain, a number of articles in the press featured the issue, and highlighted some of the data ⁵⁴⁵⁵
provided in the work. It is estimated that 20,000 skilled professionals leave Africa each year.
Erik Schouten, the HIV Coordinator for the Malawi Ministry of Health announced that over the

⁵²
^Chil^{d m}^o^rta^lity^ref^e^r^s^{to the}^de^a^t^{h of}^c^h^il^dreⁿ^y^oung^e^r^thaⁿ^fⁱ^v^e^y^e^a^r^s^,^http^://w^w^w^.^w^ho.int/^he^a^lthinf^o^/^s^ta^tis^tic^s^/
^m^o^rtc^h^ildm^o^rta^lit^y^/^eⁿ^/inde^x^.^htm^l^{. “}^T^he^Cha^lle^ng^e^of^G^l^oba^{l He}^a^lth^,”^Fore^ig^{n Aff}^a^irs^{, J}^aⁿ^u^a^r^y^/^Fe^br^ua^r^y²⁰⁰⁷^,^Vol^.⁸⁶^,
^Is^s^u^e^1,^http^://w^w^w^.^f^oreⁱ^gⁿ^aff^a^irs^.^org^/²⁰⁰⁷⁰¹^01f^a^e^s^s^a^y^86103/^la^uri^e^-g^a^rre^tt/^the^-^c^h^a^lle^ng^e^-^of^-g^loba^l-he^a^lth.h^tm^{l. “}^L^ac^k
^of^m^one^y^ca^{n no l}^ong^e^r^be^bla^m^{ed f}^o^r^the^po^or^w^o^r^l^d’^s^he^a^{lth p}^r^o^b^l^e^m^s^,^”^The^Ec^on^om^is^t^{, J}^u^ly^{5, 20}^07.
^http:^//w^w^w^.e^c^onom^is^t.c^o^m^/^w^o^r^l^d/inte^rⁿ^a^tⁱ^ona^l/^dis^p^la^y^s^tor^y^.cf^m^?^s^t^o^r^y^_id=⁹⁴⁴¹³⁹¹^.
⁵³^W^HO,²⁰⁰^{6 W}^o^r^l^d^H^e^alth^Re^p^o^r^t^:^W^o^r^k^ing^To^ge^the^r^for^H^e^alth^{, h}^ttp://w^ww^.^w^ho.int/^w^h^r/200^6/^eⁿ^/.^T^h^e^Joint
^L^e^a^r^ning^Initia^tiv^e^(JL^{I), a}^ne^tw^o^r^k^of^g^l^oba^{l he}^a^{lth le}^a^d^e^r^s,^de^fⁱ^ne^{s a}^shorta^g^e^a^s^le^{ss tha}ⁿ²^.⁵^he^a^l^t^h^c^a^r^e^prof^e^ssiona^ls
^pe^r^1,⁰⁰^{0 pe}^ople^;^the^mⁱ^nim^u^m^pr^op^or^tio^{n it}^de^e^m^e^d^ne^c^e^s^s^a^r^y^{to pr}^ov^ide^80%^of^a^c^o^uⁿ^tr^y^’^s^pop^ul^a^{tion w}^ith^ba^sⁱ^c
^he^a^{lth c}^a^r^e⁽^e^.g^{., de}^liv^e^r^ie^s^by^s^kⁱ^lle^{d bir}^t^{h a}^tte^nda^nts^a^nd^im^m^uniz^a^tions⁾^.
⁵⁴^htt^p^://w^ww^.^w^orldba^nk^.org^.
⁵⁵^“^B^ra^{in dra}ⁱⁿ^de^pr^iv^e^s^Af^ric^a^of^vita^{l ta}^le^nt.”^Re^ute^r^{s, A}^p^ril²⁴^{, 2}⁰⁰⁶^ht^tp:/^/www^.a^le^rtne^t.org^.

last five years, the government had lost 53% of its health administrators, 64% of its nurses, and

85% of its physicians—mostly to foreign NGOs, largely funded by Britain, the United States, and ⁵⁶

the Gates Foundation. According to Mr. Schouten, the Ministry is now implementing a program,
supported by PEPFAR, to attract Malawi health workers back to the country. Their tasks,
however, will be to distribute antiretoriviral medication. There is reportedly no support for
programs to attract health workers to treat malaria, diarrhea, and other common killers, such as
dysentery and respiratory infections.
Table 4. Number and Shortage of Doctors, Nurses, and Midwives
^{Number of}^Cou^ntries^{In Cou}^{ntries with Shortages}
^With^Total^Estimated^Increase
^{WHO Region}^Total^Shortages^Workf^or^ce^Shortage^Required
^{Africa 46}³⁶^590,¹⁹⁸^817,⁹⁹²¹³⁹^%
^{Americas 35}⁵^93,6⁰³^37,8⁸⁶^40%
^{Southeast Asia}¹¹⁶^2,33^2,05⁴^1,16^4,00¹^50%
^Europe⁵²⁰^{not applicable}^{not applicable}^{not applicable}
^Easterⁿ^{21 7}^312,⁶¹³^306,⁰³¹^98%
^Mediterraneaⁿ
^{Western Pacific}²⁷³^27,2⁶⁰^32,5⁶⁰¹¹⁹^%
^{World 192}⁵⁷^3,35^5,72⁸^2,35^8,47⁰^70%
^Source:^{WHO, 2}⁰⁰⁶^{World He}^{alth Report.}
Table 5. Distribution of Health Workers in Africa and the United States
^{Physicians Nurses}^Midwives
^Number^Number^Number^Year
^Population^per^per^per^Data
^Country⁽²⁰⁰⁵⁾^Number^1,00⁰^Number^1,00⁰^Number^1,00⁰^Collected
^Angola^15,9^41,0⁰⁰^{881 0.08}^13,1^{35 1.15}^{492 0.04}¹⁹⁹⁷
^Cameroon^16,3^22,0⁰⁰³¹²^{4 0.19}^26,0^{42 1.60}^{45 0.00}²⁰⁰⁴
^Ethiopia^77,4^31,0⁰⁰¹⁹³^{6 0.03}^14,8^{93 0.21}^1,27^{4 0.02}²⁰⁰³
^Ghana^22,1^13,0⁰⁰³²⁴^{0 0.15}^19,7^{07 0.92}^3,91^{0 0.18}²⁰⁰⁴
^Mozambique^19,7^92,0⁰⁰^{514 0.03}^3,95^{4 0.21}^2,23^{6 0.12}²⁰⁰⁴
^Nigeria^131,⁵³^0,00⁰^34,9^{23 0.28}^210,³⁰^{6 1.70}^6,34^{4 0.05}²⁰⁰³
^South^Africa^47,4^32,0⁰⁰^34,8^{29 0.77}^184,⁴⁵^{9 4.08}^82,7^{26 0.67}²⁰⁰³
^Uganda^28,8^16,0⁰⁰^2,20^{9 0.08}^16,2^{21 0.61}^4,16^{4 0.16}²⁰⁰⁴

⁵⁶
^“^T^he^C^h^a^lle^ng^e^of^G^l^oba^{l H}^e^a^lth^,”^Fore^ig^{n Aff}^a^irs^{, J}^aⁿ^u^a^r^y^/^Fe^br^ua^r^y²⁰⁰⁷^,^Vol^.⁸⁶^{, I}^s^s^u^e¹
^http:^//w^w^w^.f^oreⁱ^gⁿ^a^ffa^irs^.^org^/²⁰⁰⁷⁰¹^01f^a^e^s^s^a^y^86103/^la^ur^ie^-g^a^rre^tt/the^-^c^h^a^lle^ng^e^-^of^-g^loba^l-he^a^lth.^h^t^m^l.

^{Physicians Nurses}^Midwives
^Number^Number^Number^Year
^Population^per^per^per^Data
^Country⁽²⁰⁰⁵⁾^Number^1,00⁰^Number^1,00⁰^Number^1,00⁰^Collected
^Tanzania^38,3^29,0⁰⁰^{822 0.02}^13,2^{92 0.37}^not^available²⁰⁰²
^Zimbabwe^13,0^10,0^{00 2,08}⁶^{0.16 9,35}⁷^0.72^not^available²⁰⁰⁴
^Afric^a^738,⁰⁸^6,0⁰⁰^150,⁵⁶^{1 0.22}^663,⁵⁷^{2 0.96}^125,¹⁴^{2 0.25}^variable
^Total
^United^295,⁴¹^0,00⁰^730,⁸⁰^{1 2.56}^2,66^9,60^{3 9.37}^not^available²⁰⁰⁰
^States
^Source:^WHO,^{2006 W}^{orld Health Report}^.
Ambassador Dybul asserted at the April 2007 House hearing that PEPFAR strengthens health
systems and expands the health workforce. This assertion counters the findings that the Institute
of Medicine published in its March 2007 report, PEPFAR Implementation: Progress and ⁵⁷
Promise. Though IOM concluded that “PEPFAR has made a promising start,” it found PEPFAR
might further limit health care options for those not suffering from HIV/AIDS.
^P^E^P^F^A^R^’s^HIV/^A^I^{DS acti}^v^iti^es^h^a^v^e^s^o^m^e^ti^m^e^sⁿ^e^g^a^tiv^e^l^y^af^f^e^c^t^{ed oth}^e^{r as}^pects^of^p^u^b^lⁱ^c
^h^ealt^h^s^y^s^t^e^m^s^an^{d e}^x^{acerbated res}^o^u^r^{ce con}^s^traints^,^particularl^y^t^h^os^{e related to n}^a^tioⁿ^a^l
^hu^ma^{n r}^e^so^ur^c^e^se^t^tⁱⁿ^g^s.^I^f^F^o^c^u^{s Co}^un^t^rⁱ^e^s^’^na^tⁱ^o^na^l^p^l^aⁿ^{s fo}^r^e^x^p^a^ndⁱⁿ^{g t}^h^eⁱ^r^he^a^l^t^h
^w^o^rkf^o^{rce are}ⁿ^o^t^su^pport^e^{d, PEPF}^A^R^mⁱ^gh^t^w^o^r^s^{en n}^a^tⁱ^on^al^sh^ort^a^g^e^s^b^y^shⁱ^f^tⁱ^ng^a
^dⁱ^sp^r^o^p^o^r^tioⁿ^a^{te s}^h^ar^{e o}^f^t^h^e^w^o^r^k^f^o^r^{ce to}^HI^V/^A^I^{DS act}^iv^ities,^w^h^ic^h^mⁱ^g^h^{t ca}^u^s^e^o^t^h^e^r
^h^ealt^h^areas^{to be n}^e^g^l^ected....^P^E^P^F^A^R^’sⁱⁿ^it^{ial e}^m^erg^eⁿ^c^y^a^pproach^to^m^eetiⁿ^{g pers}^onn^el
ⁿ^eeds^h^a^s^been^{to f}^o^c^u^s^on^HIV-^s^p^eci^fⁱ^{c training}^of^exⁱ^s^tiⁿ^g^clin^iciaⁿ^s^aⁿ^{d oth}^e^{r h}^ealth^care
^w^o^rk^ers^.^Su^pport^f^o^{r ex}^pan^sⁱ^oⁿ^of^t^h^{e prof}^es^si^on^al^clⁱⁿⁱ^cal^w^o^rk^f^o^rc^e^h^a^s^b^e^eⁿ^lⁱ^mⁱ^t^e^d^,^e^v^en
^w^h^eⁿ^su^c^h^e^x^pansⁱ^oⁿⁱ^s^aⁿ^explⁱ^cⁱ^t^part^{of t}^h^e^coun^t^r^y^’^s^H^I^V^/^A^I^D^S^pl^aⁿ^{, a}ⁿ^{d t}^h^{e e}^f^f^o^rtⁱ^s
^en^dors^e^{d an}^{d s}^u^pport^e^d^by^ot^{her don}^ors^...^PE^PF^A^R^C^o^uⁿ^t^r^y^Te^a^m^s^o^f^t^eⁿ^e^x^p^r^e^s^s^e^d^c^oⁿ^c^e^rⁿ
^th^{at t}^h^e^y^w^e^r^eⁿ^o^{t allo}^w^e^d^to^f^uⁿ^d^acti^v^itie^{s u}ⁿ^le^{ss t}^h^o^s^{e acti}^v^itie^s^w^e^r^e^sp^ecifⁱ^ca^ll^y^p^a^r^t^o^f
^t^h^{e H}^I^V^/^A^I^D^S^e^f^f^o^rt^an^{d s}^o^cou^l^{d n}^o^t^s^u^pport^,^f^o^{r ex}^a^m^pl^e^,^t^h^{e t}^r^aiⁿⁱ^ng^ofⁿ^e^w^clⁱⁿⁱ^c^a^l⁵⁸
^of^fⁱ^cers^,^w^{ho in}^s^o^m^e^coun^trie^s^{are th}^e^m^aⁱⁿ^s^t^a^y^o^f^th^{e treat}^m^e^{nt eff}^o^rts^.
IOM recommended that OGAC work more closely with governments to analyze the impact that
PEPFAR-supported programs might have on public health systems, particularly in areas related to
maternal and child health and immunizations. IOM suggested that the analysis consider whether
PEPFAR’s incentives and salaries draw workers out of public systems and shift a disproportionate
share of the workforce to HIV/AIDS efforts. The report also asserted that PEPFAR should
increase support to the education of new health professionals.

⁵⁷
^htt^p^://w^ww^.io^m^.e^du/CMS/³⁷⁸^3/²⁴⁷⁷⁰^/⁴¹⁸^04.a^s^px^.
⁵⁸^Ibid^.

There is a growing consensus that health systems, including those that address HIV/AIDS, must
be strengthened in order for health interventions to be effective. On August 22, 2007, British
Prime Minister Gordon Brown and German Chancellor Angela Merkel announced their intention
to launch an International Health Partnership (IHP) aimed at accelerating progress towards
reducing child and maternal mortality, combating infectious diseases, including HIV/AIDS, TB, ⁵⁹
and malaria, and strengthening health systems. The leaders acknowledged in their statement that
the fragmented method of applying global health aid has reduced the effectiveness of aid, in large
part because donors compete for limited trained staff and implement the projects without ⁶⁰
considering the countries’ priorities and structures. According to DFID, there are more than 40
bilateral donors and 90 global health initiatives each maintaining their own reporting ⁶¹
requirements and most focusing on specific health issues, such as HIV/AIDS. DFID asserts that
few global health efforts focus on activities that would strengthen struggling health systems, such ⁶²
as training doctors and nurses, building clinics, or supporting basic health services. Parties of
the IHP commit to improving donor coordination, focusing on health systems rather than specific
diseases or health issues, and supporting the health plans of recipient countries. The leaders did
not indicate how much would be allocated towards this initiative or how it would be ⁶³
implemented, though seven countries were identified as “first wave” partner countries.
Some health experts would like Congress to boost support for health systems research if it were to ⁶⁴
extend PEPFAR. The Global Health Council estimates that less than 1% of research dollars are
spent on health systems research, though it could identify where health systems failures exist,
make health interventions more effective and affordable, and improve the accessibility of health ⁶⁵
care. In HIV/AIDS programs, health systems research could help administrators develop
effective forecasting and distribution systems for drugs and other commodities and make stock-
outs and shortages of contraceptives, ARVs, and other commodities less frequent. Advocates
assert that health systems research could improve retention of health personnel, because they
would have sufficient tools to perform their jobs. Data from health systems research would reveal

⁵⁹
¹⁰^Do^wnⁱⁿ^g^S^t^r^e^e^t^,^PM^an^no^unc^e^s^Iⁿ^te^r^nati^oⁿ^a^{l H}^e^al^{th P}^a^r^t^ne^r^s^h^ip^{, A}^u^g^u^s^t²²^,²⁰^07,
^http:^//w^w^w^.num^be^r^-^10.g^o^v^.^uk^/^o^u^t^put/^P^a^g^e¹²⁹^03.a^s^p^.
⁶⁰^Ibid^.
⁶¹^D^F^ID^,^T^h^e^Iⁿ^te^rⁿ^atio^na^{l H}^e^alt^h^Par^t^ne^r^s^hⁱ^p^L^a^uⁿ^c^h^e^d^To^day^,^Se^pte^m^be^r^{5, 20}⁰⁷^,
^http:^//www^.dfⁱ^d.g^o^v^.^uk^/ne^w^s/^f^ile^s/ihp/^de^f^a^ult.a^s^p.
⁶²^Bi^l^a^t^e^ral^d^oⁿ^o^r^{s i}ⁿ^cl^ud^{e Bri}^t^aⁱⁿ^,^Can^a^d^a^,^F^r^an^ce,^G^e^r^m^an^y^,^It^al^y^,^t^h^{e Net}^h^erl^aⁿ^d^s^,^No^rw^a^y^,^an^d^P^o^rt^u^g^al^.
^Fou^nda^ti^{ons a}^{nd i}ⁿ^te^rna^tⁱ^ona^l^org^a^niz^a^{tions i}ⁿ^c^l^u^d^e^Af^ri^c^a^De^v^e^lopm^eⁿ^{t Ba}^nk^{, Bill a}ⁿ^d^Me^lin^da^G^a^te^{s Fou}^nda^ti^on,
^Eu^ro^p^ean^Co^m^mⁱ^s^s^ioⁿ^,^T^h^{e G}^l^o^b^{al Fu}ⁿ^d^t^o^Fig^h^t^A^I^{DS, T}^B^{, an}^d^M^a^{laria, th}^{e G}^l^o^b^a^{l A}^llian^{ce f}^o^{r V}^accin^e^{s an}^d
^Im^m^uniz^a^{tion (GA}^V^{I) A}^llia^nc^e^,^UN^A^I^{DS, UNICEF, Unite}^{d Na}^tio^ns^P^o^pula^t^io^{n F}^uⁿ^d^(UNF^P^A^{), W}^{HO, a}^{nd t}^h^e^W^o^rld
^Ban^k^.
⁶³^T^h^e^s^e^v^e^{n c}^ountrⁱ^e^s^a^r^e^B^u^r^u^nd^i,^C^a^m^bodia^,^Ethi^op^ia^{, K}^e^ny^a^,^Moz^a^m^b^ique^{, N}^e^pa^{l, a}^{nd Za}^m^b^ia^.
⁶⁴^“^H^e^a^{lth sy}^ste^m^s^”^eⁿ^c^o^m^p^a^s^s^e^{s the}^pe^rson^ne^l,^instit^uti^ons,^c^o^m^m^o^d^itie^{s, i}ⁿ^f^o^rm^a^{tion, a}^{nd t}^h^e^fⁱ^na^nc^ing^of^he^a^{lth c}^a^r^e
^de^liv^e^r^y^.
⁶⁵^G^l^oba^{l He}^a^{lth Co}^unc^il,^Pr^om^o^tin^{g I}ⁿ^v^e^s^tm^eⁿ^tsⁱⁿ^Re^s^e^ar^c^h^t^o^S^t^r^e^ngt^he^{n H}^e^alt^h^Sy^s^t^e^m^s^:^W^h^y^and^H^o^w^{, Ma}^y²⁰⁰⁶
^http:^//www^.g^loba^lhe^a^lth.^o^rg^/im^a^g^e^s^/pdf^/^pub^lic^a^tions^/^r^e^s^e^a^r^c^h_inv^e^s^tm^eⁿ^ts^.pdf^.

which sort of care, prevention, and treatment programs are needed for the target population, and
which would make the programs more effective and efficient, proponents contend.
Some have argued that structural adjustment programs mandated by international financial
institutions have led to a decline in public sector employment and limited investment in health ⁶⁶
worker education. In many of the countries with health worker shortages, there are thousands of
unemployed health workers. While Kenya has a shortage of some 10,000 nurses in the public
sector, for example, thousands of unemployed nurses are leaving for Britain to find jobs, as the
Kenyan government is under a recruitment freeze due to World Bank and International Monetary ⁶⁷
Fund (IMF) stipulations. Health sector reform, critics argue, has led to a decline in the quality of
education and training opportunities for medical students, a perpetual shortage of health supplies
and equipment (e.g., sanitation gloves and hyperdermic needles), insufficient medicine and
vaccine stocks, and “brain drain” of African health workers. According to WHO, on average each
year, the 57 countries with severe shortages of health workers spend an average of about $33 per
person on health (Table 6). The entire continent of Africa spends about 1% of the world’s
expenditure on health, the WHO contends. Comparatively, each year the United States spends
approximately $5,711 per capita on health.
Some analysts have expressed concern about the extent to which countries rely on the World
Bank to fund their health programs. The Bank estimates that it has lent $15 billion in health, ⁶⁸
nutrition, and population funds from 1997 to 2006; an average of about $1.5 billion per year.
Observers worry that the loans add to significant debt loads that many countries already face and ⁶⁹
to which they commit considerable portions of their annual gross national products. In some
countries, governments are reportedly paying more on debt service than public health programs.
Oxfam estimates that of the 26 countries participating in the Highly Indebted Poor Countries
(HIPC) Initiative, half are still spending 15% or more of government revenues on debt ⁷⁰
payments. Some health advocates urge Congress to use its vote to encourage the IMF to
maintain its debt relief commitments and accelerate its plans.

⁶⁶
^For^de^ba^te^oⁿ^t^h^is^is^s^u^e^,^s^e^e^“^A^Critic^a^l^Aⁿ^a^l^y^s^is^of^the^Bra^z^ilia^{n Re}^s^pons^e^to^H^I^V^/^A^I^D^S^{: L}^e^s^s^ons^L^e^a^r^ne^{d f}^o^r
^Contr^o^lli^ng^a^nd^Mitig^a^ting^t^h^e^Ep^ide^m^ic^{in De}^v^e^loping^Couⁿ^trie^s,”^Am^e^r^ic^{an J}^o^ur^na^{l of}^Pu^blic^H^e^al^th^{, J}^u^ly²⁰⁰⁵^,
^V^o^l^.⁹⁵^{, N}^o^.^7,
^http:^//w^w^w^.a^jph.or^g^/^c^g^i/^r^e^pr^int^/^95/^7/11⁶²^.p^df^{; “}^T^o^w^a^r^d^Ethic^a^l^R^e^vⁱ^ew^of^He^a^{lth Sy}^s^t^em^T^r^aⁿ^sf^or^m^a^tions^,”^Am^e^r^ic^an
^J^ourⁿ^a^{l o}^f^P^ublic^H^e^al^th^,^Ma^r^c^h²⁰⁰^6,^V^o^l.⁹⁶^{, N}^o^{. 3}^,^ht^tp:/^/w^w^w^.^a^jph.^or^g^/^c^g^i/c^onteⁿ^t/^a^b^s^t^r^a^c^t/96/³^/⁴⁴^{7; a}ⁿ^{d C}^e^nte^r
^f^o^{r G}^l^oba^{l De}^v^e^lop^m^eⁿ^t,^D^o^e^s^th^e^I^M^{F C}^ons^tr^ai^{n H}^e^alt^h^Speⁿ^dⁱⁿ^{g in}^Po^or^C^o^un^tr^ie^s^{, J}^une²⁰⁰⁷^,
^http:^//www^.c^g^d^e^v^.org^/c^onteⁿ^t/^pu^blic^a^tio^ns/^d^e^t^a^il/14¹⁰³^/.
⁶⁷^“^N^ur^s^e^Ex^odus^L^e^a^v^e^s^K^eⁿ^y^aⁱⁿ^C^r^is^is^,”^The^G^u^ar^di^{an U}ⁿ^lim^ite^d^,^Ma^y^{21, 20}⁰⁶^{. h}^ttp:^//w^w^w^.g^ua^r^d^ia^n.c^o^.^u^k^/^k^eⁿ^y^a^/
^s^t^or^y^/^0,,¹⁷⁷⁹⁸²¹^,0^0.^htm^l^.
⁶⁸^W^o^r^l^{d B}^a^nk^,^Hea^l^t^h^Devel^o^p^m^ent^:^T^h^{e Wo}^rl^d^B^aⁿ^k^S^t^ra^t^e^g^y^f^o^{r H}^e^a^l^t^h^,^Nu^t^rⁱ^tⁱ^oⁿ^,^an^{d P}^o^p^u^l^a^tⁱ^oⁿ^R^e^su^l^t^s^.^A^p^ril
²⁰⁰^{7. htt}^p^://w^ww^.^w^orldba^nk^.org^.
⁶⁹^“^T^he^G^l^oba^{l HIV//A}^{IDS P}^aⁿ^d^e^m^ic^{, Struc}^t^ura^l^Ine^qua^litie^{s, a}^nd^the^P^o^li^tic^{s of}^Inte^rna^tⁱ^ona^{l He}^a^lth^,”^Am^e^r^ic^an
^J^ourⁿ^a^{l o}^f^P^ublic^H^e^al^th^,^Ma^r^c^h²⁰⁰^2,^V^o^l.⁹²^{, N}^o^{. 3}^,^ht^tp:/^/w^w^w^.^a^jph.^or^g^/^c^g^i/r^e^p^rⁱ^nt/^92/^3/³⁴³^.p^df^.
⁷⁰^Oxfa^m^,^De^{bt Re}^lie^{f an}^{d t}^h^e^HIV/^{AIDS Crisis in}^Afric^a^{: D}^o^e^s^the^He^av^ily^Inde^bte^d^P^{oor C}^o^uⁿ^trie^{s (}^H^{IPC) Initiativ}^e
^{Go Far}^Eno^u^g^h^?^{, J}^u^ne²⁰⁰²^,^htt^p^://w^w^w^.oxf^am^.or^g^/^e^n/f^ile^s^/^pp⁰²⁰^6_n^o2^5_^de^bt^_r^e^lie^f^_^a^nd_t^he^_H^I^V^_c^rⁱ^sⁱ^s^.^pdf^.

In the 110^th Congress, legislation has been introduced in the House and Senate that authorizes
additional funds to voluntary family planning activities, improves coordination of HIV/AIDS and
other health initiatives, and strengthens supply chain logistics. The Focus on Family Health
Worldwide Act (H.R. 1225) would provide funds to expand access to voluntary family planning
programs in developing countries. The U.S. Commitment to Child Survival Act (S. 1418) would
provide assistance to improve the health of newborns, children, and mothers in developing
countries. The African Health Capacity Investment Act (S. 805) would amend the Foreign
Assistance Act of 1961 to assist countries in sub-Saharan Africa achieve internationally
recognized goals in the treatment and prevention of HIV/AIDS and other major diseases, reduce
maternal and child mortality, improve human health care capacity, and improve the retention of
medical health professionals.
Table 6. Spending on Health in Africa and the United States
^General
^Government^External
^Expenditure^Resources
^{Per Capita}^Total^{as % of}^{for Health}
^{Per Capita}^Government^Expenditure^Total^{as % of}^Total
^Population^Expenditure^Expenditure^{on Health as}^Government^Expenditure
^Country⁽⁰⁰⁰⁾^{on Health}^{on Health}^{% of GDP}^Expenditure^{on Health}
^{Angola 15,4}⁹⁰^$26.0^$41.0^2.8%^5.3%^6.7%
^{Cameroon 16,0}³⁸^$37.0^$19.0^4.2%^8.0%^3.2%
^{Ethiopia 75,6}⁰⁰^$5.0^$12.0^{5.9% 9.6%}^26.0%
^{Ghana 21,6}⁶⁴^$16.0^$31.0^4.5%^5.0%^15.8%
^Mozambique^19,4²⁴^$12.0^$28.0^4.7%^10.9%^40.8%
^{Nigeria 128,}⁷⁰⁹^$22.0^$13.0^5.0%^3.2%^5.3%
^{South Africa}^47,2⁰⁸^$29^5.0^$25^8.0^8.4%^10.2%^0.5%
^{Uganda 27,8}²¹^$18.0^$23.0^7.3%^10.7%^28.5%
^{Tanzania 37,6}²⁷^$12.0^$16.0^4.3%^12.7%^21.9%
^{Zimbabwe 12,9}³⁶^$40.0^$47.0^7.9%^9.2%^6.8%
^United^295,⁴¹^{0 $5,71}^1.0^$2,54^8.0^15.2%^18.5%^0.0%
^States
^Source:^WHO,^{2006 W}^{orld Health Report}^.
^Note:^Al^{l figures reflect data collected in 20}^{03, e}^xcept^pop^{ulation, which was}^{collected in 200}^4.
UNAIDS estimates that there are 2.5 million children living with HIV around the world, up from
1.5 million in 2001. Nearly 90% of all HIV-positive children live in sub-Saharan Africa. The rate
at which children are contracting the virus is declining, however, with 460,000 having acquired
HIV in 2001 and 420,000 in 2007. AIDS is also killing fewer children. In 2001, 330,000 children
succumbed to the virus; in 2005, 360,000 died from AIDS. But in 2007, the number fell to an
estimated 330,000.
HIV/AIDS affects not only those children living with the virus, but also those who lose their
parents to the virus and who live in homes that have taken in orphans. Children who have been

orphaned by AIDS may be forced to leave school, begin working to supplement lost income,
suffer from depression and anger, or engage in survival sex, an activity that heightens their risk of
contracting HIV. Children who live in homes that take in orphans may see a decline in the
quantity and quality of food, education, love, nurturing, and may be stigmatized. Impoverished
children living in households with one or more ill parent are also affected, as health care
increasingly absorbs household funds, which frequently leads to the depletion of savings and
other resources reserved for education, food, and other basic needs. A number of HIV/AIDS
advocates call for increased spending on programs, such as skills building, microcredit lending, ⁷¹
daycare subsidization, and education, for caretakers of children orphaned by HIV/AIDS.
The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 authorizes 10%
of HIV/AIDS funds to be used to support children affected by the virus. Some of PEPFAR’s
implementing partners have reportedly suggested that in areas with high HIV/AIDS prevalence,
all children should be considered affected by or made vulnerable by HIV/AIDS; and that in high
prevalence areas, programs should allow communities to define vulnerability related to their ⁷²
contexts and to identify which children participate in programs.
In the 109^th Congress, Congress enacted the Assistance for Orphans and Other Vulnerable
Children in Developing Countries Act of 2005 (P.L. 109-95), which established a monitoring and
evaluation system to measure the effectiveness of related assistance activities; required the
Secretary of State to appoint a Special Advisor for Assistance to Orphans and Vulnerable
Children within USAID; and required an annual report on project implementation. Congress did ⁷³
not appropriate funds for these activities. A number of HIV/AIDS advocates encourage
Congress to appropriate funds to make permanent and bolster the power and influence of the
Special Advisor. Those who would like for Congress to fund such a permanent position suggest
that the advisor would report directly to the Secretary of State and have independent authority to
approve and coordinate all U.S. spending on activities related to orphans and vulnerable children.
Supporters of this idea also maintain that the Special Advisor would need appropriations for an
office that would be similar in structure to the one at USAID for the President’s Malaria
Initiative. Proponents contend that the office’s staff would: 1) devise a comprehensive U.S.
strategy to address the needs of children affected by HIV/AIDS; 2) ensure efficient use of U.S.
funds by coordinating all related U.S. programs, including those funded by OGAC, USAID, and
other U.S. Departments, international organizations like UNICEF, and public private
partnerships; and 3) monitor, evaluate, and submit reports to Congress that detail U.S. spending
on related programs. Critics of this idea counter that this position would duplicate and add to the
overhead costs of implementing U.S. global HIV/AIDS activities.
According to UNAIDS, more than 2.5 million children and infants are living with HIV/AIDS
worldwide, representing more than 7% of all cases; and some 420,000 children under 15 years are
expected to contract the virus in 2007, almost 17% of all new HIV infections. OGAC asserts that

⁷¹
^For^m^o^r^e^inf^o^r^m^a^{tion o}ⁿ^c^h^il^dr^eⁿ^a^f^f^e^c^t^e^d^by^H^I^V/^A^I^D^S^{, s}^e^e^C^R^S^R^e^por^t^R^L³²²⁵²^,^AI^D^S^O^r^ph^an^s^an^{d Vu}^lne^r^a^b^le
^Ch^ild^{ren (}^O^{VC): Pro}^b^l^ems,^Respoⁿ^s^es,^an^{d Issu}^{es fo}^{r C}^o^ng^ress^{, b}^y^Tⁱ^a^{ji Sa}^la^a^m^-Bl^y^the^r^.
⁷²^Iⁿ^te^r^v^ie^w^w^{ith G}^l^oba^{l A}^c^{tion f}^o^r^C^h^il^dr^eⁿ^{, a}^PE^P^F^A^R^im^plem^eⁿ^ting^pa^r^t^ne^r^,^on^N^o^v^e^m^b^e^r^{21, 2}⁰⁰⁷^.
⁷³^P^.^L^.¹⁰^9-⁹⁵^;²²^U^.^S.C^.²¹⁵²^f^not^e^.^T^h^e^a^c^t^am^e^nde^{d the}^F^o^r^e^ig^{n A}^s^sⁱ^s^t^aⁿ^c^e^A^c^{t of}¹⁹⁶¹⁽^P^.L^{. 8}⁷^-¹⁹⁵⁾^a^t^Se^c^tioⁿ
¹³⁵⁽²^{2 U}^.^S^.^C^.²¹^52f⁾^{to e}^s^ta^blis^{h the}^ne^w^pr^og^r^a^m^a^{nd pos}^iti^on.

children have disproportionately low access to HIV treatment and care relative to adult
populations in most developing countries. Without treatment and care, approximately 50% of all ⁷⁴
HIV-positive children will die before age two and 75% will die before age five. Some advocates
for children urge Members to increase spending on pediatric HIV/AIDS ARVs so that funding
meets the needs of children without access to treatment. OGAC estimates that in FY2006, it ⁷⁵
allocated 9% of all spending on ARVs to children.
HIV/AIDS analysts advocate that other countries where the virus is rapidly spreading be included
in GHAI. In Eastern Europe and Central Asia, HIV has become more entrenched. According to
UNAIDS, the number of people living with HIV in those regions has increased by more than
150% since 2001. An estimated 1.6 million people are living with HIV/AIDS in the region, up
from 630,000 in 2001. Nearly 90% of newly reported HIV diagnoses in this region in 2006 were
from two countries: the Russian Federation (66%) and Ukraine (21%).
A number of health experts are also concerned about the HIV/AIDS epidemic in the Caribbean.
Estimates indicate that prevalence rates have largely stabilized in the region, though they remain ⁷⁶
high in Haiti and the Dominican Republic. Nearly 75% of all people living with HIV/AIDS in
the Caribbean reside in the two countries. Some 230,000 people are HIV-positive in the
Caribbean, of whom 11,000 UNAIDS expect to die from the virus. In February 2007,
Representative Luis Fortuño introduced H.R. 848, to Amend the State Department Basic
Authorities Act of 1956 to Authorize Assistance to Combat HIV/AIDS in Certain Countries of the
Caribbean Region.
Some caution that before Members consider expanding the number of Focus Countries, Congress
might first need to determine the extent of its commitment to supporting global HIV/AIDS
efforts. A number of HIV/AIDS advocates point out that HIV/AIDS is a chronic disease that
requires long-term care. In order for countries to assume ownership of HIV/AIDS initiatives and
expand them, this view holds, they must first know how much support to expect from the United
States and for how long that support might last.

⁷⁴
^Eliz^a^b^e^t^{h G}^l^a^s^e^r^P^e^dia^t^ric^A^I^DS^Fou^nda^ti^on^{, “}^I^{n t}^h^e^Ba^ttle^A^g^aⁱ^{nst HIV}^/^A^I^{DS, Eq}^ua^{l T}^r^e^a^t^m^e^{nt f}^o^{r Chil}^dreⁿ^,”
^Oc^tobe^{r 1}⁹^,²⁰^07,^htt^p^://w^ww^.pe^d^aⁱ^ds.org^/^N^e^w^s/^Pu^blic^a^tio^ns/^F^a^c^t^%^20She^e^t^/^P^E^P^FA^R%^20Fa^c^t^%²⁰^S^he^e^t^s.a^s^px^.
⁷⁵^P^E^P^F^A^R^w^e^bis^t^e^,^“^P^e^d^ia^tr^ic^T^r^e^a^t^m^e^{nt a}^{nd C}^a^r^e^,”^J^u^ne²⁰⁰⁷^{, h}^ttp^://w^w^w^.pe^p^f^a^r^.^g^o^v^/^pe^pf^a^r^/^p^r^e^s^s^/⁸⁶⁵²^4.^htm^.
⁷⁶^Th^e²⁰⁰^{7 AI}^D^S^E^p^ide^m^ic^U^p^dat^e^did^no^{t pr}^ov^ide²⁰⁰⁷^pre^v^a^l^eⁿ^c^e^e^s^tim^a^t^e^s^f^o^{r Ha}^{iti a}^nd^the^Domⁱ^nic^aⁿ^Re^pu^blic^.
^T^h^e^re^{port di}^{d i}ⁿ^dⁱ^c^a^t^e^,^how^e^v^e^r^{, tha}^t^pre^v^a^l^eⁿ^c^e^a^ppe^a^r^{s to}^ha^v^e^d^e^c^line^dⁱⁿ^Ha^{iti sinc}^e¹⁹⁹^{6. A}^m^oⁿ^g^pre^g^na^nt
^w^o^m^e^{n a}^tte^nding^aⁿ^te^na^ta^{l c}^lⁱⁿ^ic^s^,^H^I^V^pr^e^v^a^l^eⁿ^c^e^f^e^ll^f^r^o^m^5.9%ⁱⁿ¹⁹⁹⁶^t^o³^.^1%ⁱⁿ²⁰⁰⁴^{, a}ⁿ^{d a}^p^pe^a^r^e^d^to^ha^v^e
^st^abⁱ^lⁱ^zedⁱⁿ²⁰⁰⁶^.^UNA^IDS^at^t^rⁱ^b^u^t^{es t}^h^{e d}^eclⁱⁿⁱⁿ^{g t}^r^end^t^o^d^ecreasiⁿ^{g i}ⁿ^f^ectⁱ^oⁿ^l^e^vel^sⁱⁿ^t^h^{e cap}ⁱ^t^al^,^P^o^r^t^-au^-^P^rⁱⁿ^ce,
^a^{nd o}^t^he^{r c}^itie^{s, w}^h^e^r^e^HIV^pre^v^a^l^eⁿ^c^e^a^m^ong¹⁵^–^44-y^e^a^{r-old w}^o^m^e^{n f}^e^ll^f^r^om^5.5%^{to 3%}^be^tw^e^e^{n 2}⁰⁰⁰^aⁿ^{d 2}⁰⁰⁵^.
^T^h^{e rep}^o^r^t^al^soⁱⁿ^di^cat^ed^t^h^at^p^r^e^v^al^en^{ce rat}^e^{s ap}^p^{ears t}^o^h^a^{ve st}^abⁱ^lⁱ^zedⁱⁿ^Do^mⁱⁿⁱ^can^Rep^u^b^lⁱ^c^.

Glossary of Abbreviations and Acronyms
^ARV^{Anti-Retroviral medicat}^ion
^DFID^Department^{for I}^nter^{national Development}
^FAO^{United Nations Food and Agriculture O}^rganization
^FDA^{U.S. F}^{ood and Drug Administrati}^on
^GAO^Governme^{nt Accou}^{ntability Offic}^e
^GHAI^{Global HIV/AIDS Initiative}
^HIPC^{Highly Indebted Poor Count}^ries
^HIV/AIDS^Human^Imm^{unodeficiency Virus/}^{Acquired Im}^mu^{nodeficiency Synd}^rome
^IHP^Inter^{national Health Partne}^rship
^IMF^Inter^{national Monetary F}^und
^IOM^{Institute of}^Medicine
^JLI^{Joint Learning}^Institute
^MTCT^{Mother-to-Child Transmission}
^NIH^{National Institutes of}^Health
^NGO^Non-Govern^{mental Orga}^nization
^OAR^{Office of AIDS Research}
^OGAC^{Office of Global AIDS Coordinator}
^PEPFAR^{President’s Emerge}^{ncy Plan For}^{AIDS Relief}
^PMI^{President’s Malaria Initiative}
^PMTCT^{Prevention of Mothe}^{r-to-Child T}^ransmission
^TB^Tuberc^ulosis
^UNAIDS^{Joint United Nations Program on}^HIV/AIDS
^USAID^{U.S. Agency for Inter}^{national Development}
^WFP^{World Fo}^{od Program}
^WHO^{World Health Organization}
^Tⁱ^a^j^{i Salaam}^-^B^l^y^th^er
^Sp^{ecialist i}ⁿ^Glo^b^a^{l Health}
^t^s^al^aa^m^@^crs^.^l^o^c.^g^o^v^,^7-⁷⁶⁷⁷