International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding
Prepared for Members and Committees of Congress
The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L.
and malaria from FY2004 through FY2008. It also authorizes the Office of the Global AIDS
Coordinator (OGAC) to oversee U.S. government efforts to combat HIV/AIDS internationally.
These efforts to combat HIV/AIDS implement the President’s Emergency Plan for AIDS Relief
(PEPFAR), a program proposed by President Bush in January 2003.
President Bush requested $30 billion for the reauthorization of PEPFAR from FY2009 through
FY2013, estimating it would support HIV/AIDS treatments for 2.5 million people, the prevention
of more than 12 million new HIV infections, and care for more than 12 million HIV-affected
people, including 5 million orphans and vulnerable children.
On July 24, 2008, Congress reauthorized $48 billion for U.S. international HIV/AIDS,
tuberculosis, and malaria programs through FY2013 in H.R. 5501, the Tom Lantos and Henry J.
Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (hereafter referred to as the Reauthorization Act). The President
signed H.R. 5501 into law (P.L. 110-293) on July 30, 2008.
The Reauthorization Act makes a number of changes to U.S. international HIV/AIDS,
tuberculosis, and malaria programs. It increases funding for U.S. efforts to fight HIV/AIDS,
tuberculosis, and malaria and for U.S. contributions to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (Global Fund). It adds Vietnam to the list of PEPFAR Focus Countries;
proposes the use of compacts or framework agreements between the United States and each
country receiving HIV/AIDS funds under the reauthorization; and removes the 33% spending
requirement on abstinence prevention efforts, as well as the 20% spending recommendation on
prevention efforts overall. It establishes a Global Malaria Coordinator within the U.S. Agency for
International Development (USAID) and supports the sustainability of health care systems in
affected countries. It eliminates Immigration and Nationality Act (INA) language that statutorily
bars foreign nationals with HIV/AIDS from entering the United States.
This report discusses changes in coordination and funding for HIV/AIDS, tuberculosis, and
malaria programs as directed in the Reauthorization Act. It provides background on PEPFAR
implementation including results and funding through FY2008. It then discusses similarities and
differences between H.R. 5501 as passed by the House on April 2, 2008, and H.R. 5501 as passed
by the Senate on July 16, 2008. Finally, it details key outcomes in the legislation as enacted. This
report will be updated as events warrant.
Introduc tion ..................................................................................................................................... 1
PEPFAR: Implementation, Results, and Funding...........................................................................1
OGAC and PEPFAR Countries...........................................................................................2
Participating U.S. Agencies................................................................................................2
International Organizations and International Initiatives....................................................3
Restrictions on Spending and Programs.............................................................................3
Result s ....................................................................................................................................... 4
Funding ........................................................................................................................ ............. 4
Key Reauthorization Proposals and Debates During Consideration of H.R. 5501.........................6
Funding Authorization Increase................................................................................................7
Global Malaria Coordinator......................................................................................................8
List of Focus Countries Expansion...........................................................................................9
Compacts with Recipient Countries........................................................................................10
Role of Spending Directives...................................................................................................10
Balance Between Prevention, Treatment, and Care................................................................12
HIV/AIDS Activities and Family Planning.............................................................................13
Health Systems and the Single Disease Approach..................................................................14
HIV/AIDS Activities and Nutrition Programs........................................................................15
Immigration and Nationality Act Amendment........................................................................16
Additional Oversight Activities...............................................................................................16
Taxation of Assistance Funds by Foreign Governments Prohibited.......................................17
Prevention of Mother to Child HIV Transmission (PMTCT) Panel.......................................17
Conscience Clause Expansion.................................................................................................17
Outcomes Under H.R. 5501/P.L. 110-293.....................................................................................17
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria Appropriations by Disease,
FY2004 through FY2008.............................................................................................................5
Table 2. U.S. Contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria,
FY2004 through FY2008.............................................................................................................6
Table 3. Comparison of Proposed Reauthorization Levels from FY2009 through FY2013
in House and Senate Versions of H.R. 5501.................................................................................7
Table 4. Outcomes of Key Proposals to Change International HIV/AIDS, Tuberculosis,
and Malaria Programs Under P.L. 110-293................................................................................18
Table 5. Key Authorization Levels from FY2009 through FY2013 in P.L. 110-293, the
Reauthorization Act of 2008.......................................................................................................20
Author Contact Information..........................................................................................................21
On May 30, 2007, President Bush announced that he would request $30 billion for the
reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), which is the 1
coordinated U.S. government effort to combat HIV/AIDS globally. The President estimated
PEPFAR would support HIV/AIDS treatments for 2.5 million people, the prevention of more than
efforts to combat global HIV/AIDS, tuberculosis, and malaria from FY2004 through FY2008
with the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
(P.L. 108-25) (hereafter referred to as the Leadership Act).
On July 24, 2008, Congress authorized $48 billion for U.S. global efforts to fight HIV/AIDS,
tuberculosis, and malaria and for U.S. contributions to the Global Fund to Fight AIDS, 3
Tuberculosis, and Malaria (Global Fund) from FY2009 through FY2013 through H.R. 5501, the
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008 (hereafter referred to as the
Reauthorization Act). The Reauthorization Act (P.L. 110-293) was signed into law on July 30,
This report describes U.S. efforts to combat international HIV/AIDS through PEPFAR including
an overview of its implementation structure, key program elements, results, and funding from
FY2004 through FY2008. It also details funding for tuberculosis, malaria, and U.S. contributions
to the Global Fund during that time. This report discusses similarities and differences between
H.R. 5501 as passed by the House on April 2, 2008, and H.R. 5501 as passed by the Senate on
July 16, 2008, including proposed changes in program authorities and funding for HIV/AIDS,
tuberculosis, and malaria programs. Finally, it details key outcomes in the legislation as enacted. 4
It does not describe U.S. efforts to combat tuberculosis and malaria.
On January 28, 2003, President Bush proposed the President’s Emergency Plan for AIDS Relief
(PEPFAR) in his State of the Union address, requesting $15 billion over five years to combat 5
HIV/AIDS. Congress authorized $15 billion for U.S. efforts to combat global HIV/AIDS,
1 Office of the Global AIDS Coordinator (OGAC), U.S. Department of State, “President Bush Announces Five-Year,
$30 Billion HIV/AIDS Plan,” at http://www.pepfar.gov/ 85811.htm.
3 The Global Fund to Fight AIDS, Tuberculosis, and Malaria, headquartered in Geneva, Switzerland, is an independent
foundation that seeks to attract and rapidly disburse new resources in developing countries aimed at countering the
three diseases. The Fund is a financing vehicle, not an implementing agency. For more information on the Global Fund,
see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress Report and Issues for
Congress, by Tiaji Salaam-Blyther.
4 For more information on U.S. efforts to combat tuberculosis, see CRS Report RL34246, Tuberculosis: International
Efforts and Issues for Congress, by Tiaji Salaam-Blyther. For more information on U.S. efforts to combat malaria, see
CRS Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and Malaria Spending: FY2004-FY2008, by Tiaji
5 For more information on PEPFAR, see CRS Report RL33771, Trends in U.S. Global AIDS Spending: FY2000-
tuberculosis (TB), and malaria from FY2004 through FY2008 with the Leadership Act, which the
President signed into law (P.L. 108-25) on May 27, 2003.
The Leadership Act created the Office of the Global AIDS Coordinator (OGAC) in the 6
Department of State and outlined its role. OGAC directly approves all U.S. activities and funding
related to combating HIV/AIDS in the 15 PEPFAR Focus Countries. In addition to the Focus
Countries, OGAC has primary responsibility for the oversight and coordination of all U.S.
government resources and international activities to combat HIV/AIDS. This role extends to
ensuring program and policy coordination among the relevant executive branch agencies and non-
governmental organizations (NGOs), including auditing, monitoring, and evaluating all such 7
programs including activities conducted in non-Focus Countries.
In 2003, the 15 PEPFAR Focus Countries accounted for over 50% of all HIV-infected people in
the world. The 15 Focus Countries are Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya,
Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and 8
Zambia. OGAC estimates that from FY2004 through FY2008, 58% of PEPFAR funds will have 9
been spent on the 15 Focus Countries. OGAC transfers funds to PEPFAR-participating agencies
that administer HIV/AIDS programs in Focus Countries.
PEPFAR-participating agencies and departments, which receive funding transfers from OGAC,
include the U.S. Agency for International Development (USAID); the Department of State
(State); the Department of Health and Human Services (HHS) through the Centers for Disease
Control and Prevention (CDC), the National Institutes of Health (NIH), the Health Resources and
Services Administration (HRSA), the Food and Drug Administration (FDA), and the Substance
Abuse and Mental Health Services Administration (SAMHSA); the Department of Labor (DOL);
the Department of Commerce; the Peace Corps; and the Department of Defense (DoD). These
agencies may allocate their own agency funds for global HIV/AIDS, tuberculosis, and malaria
FY2008, by Tiaji Salaam-Blyther, and CRS Report RL34192, PEPFAR: Policy Issues from FY2004 through FY2008,
by Tiaji Salaam-Blyther.
6 Section 102 of P.L. 108-25, the Leadership Act.
7 OGAC, “FY 2006 Countries of the President’s Emergency Plan for AIDS Relief (PEPFAR),” at
8 These Focus Countries, except Vietnam, were specified in the Leadership Act (P.L. 108-25). Section 102(B)(ii)(VII)
of the Leadership Act also authorizes the President to designate Focus Countries. President Bush announced that
Vietnam would be added to the group of Focus Countries on June 23, 2004. See The White House, “Vietnam to
Receive U.S. Emergency HIV/AIDS Assistance,” June 22, 2004, at http://vietnam.usembassy.gov/pepfar040622.html.
9 OGAC figures do not include funding for U.S. international malaria programs. OGAC, “Making A Difference:
Funding,” at http://www.pepfar.gov/press/80064.htm.
The Leadership Act authorizes funds to support U.S. contributions to some multilateral
organizations and international research initiatives including the Global Fund to Fight AIDS, 10
Tuberculosis, and Malaria (hereafter referred to as the Global Fund), the United Nations Joint
Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI).
OGAC reports that 16% of PEPFAR funds will support the Global Fund from FY2004 through 11
Though Focus Countries receive the bulk of PEPFAR funding, individual Focus Countries may
not necessarily receive more funds than non-Focus Countries: for example, India, which is not a 12
Focus Country, receives more funding than Guyana, a Focus Country. OGAC determines annual
funding allocations for each Focus Country based on past funding allocations and provides an
initial budget estimate to U.S. staff in each PEPFAR country to help them formulate a Country
Operational Plan (COP). A COP provides data that informs OGAC’s final funding decision.
OGAC uses the COP to evaluate country-based information on the extent of the HIV/AIDS
epidemic, absorptive capacity for funding, effectiveness of PEPFAR efforts to date, and country 13
team projections of need.
In the Leadership Act, Congress outlined both funding distribution guidelines and “spending
directives” for HIV/AIDS assistance. Congress recommended that 20% of HIV/AIDS funds
should be spent on prevention. It required that from FY2006 through FY2008 at least 33% of 14
these prevention funds must be spent on abstinence-until-marriage programs. In addition,
Congress directed that from FY2006 through FY2008 not less than 55% of HIV/AIDS funds
must be spent on treatment, and of these, it recommended that 75% should support the purchase
and distribution of antiretroviral (ARV) drugs, while the remaining 25% should be spent on
related care for treatment patients. Congress also recommended that 15% of HIV/AIDS funds
should be spent on palliative care of HIV-affected people. Finally, it required that from FY2006
through FY2008 the remaining 10% of HIV/AIDS funds must be spent on orphans and vulnerable 15
children (OVC). It required that at least 50% of these OVC funds must be provided through
non-profit NGOs, including faith-based organizations (FBOs), that implement programs on the
10 For more information on the Global Fund, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-Blyther.
11 OGAC figures do not include funding for U.S. international malaria programs. OGAC, “Making A Difference:
Funding,” at http://www.pepfar.gov/press/80064.htm.
12 OGAC, “2008 PEPFAR Country Profiles: India,” and “2008 PEPFAR Country Profiles: Guyana,” at
13 For more information on the OGAC allocation process, see Government Accountability Office (GAO), Global
HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding, April 2008, at
14 OGAC defines abstinence-until-marriage activities as programs that address both abstinence and faithfulness,
according to GAO, Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding
Under the President’s Emergency Plan for AIDS Relief, April 2006, at http://www.gao.gov/new.items/d06395.pdf.
15 For more information on OVC, see CRS Report RL32252, AIDS Orphans and Vulnerable Children (OVC):
Problems, Responses, and Issues for Congress, by Tiaji Salaam-Blyther.
When President Bush proposed PEPFAR in 2003, he projected that the five-year initiative to
combat HIV/AIDS globally would prevent 7 million new HIV infections, would provide
antiretroviral treatment for 2 million people, and would support care for 10 million HIV-affected 16
As of September 30, 2007, OGAC reports that it has accomplished the following:17
• Prevention: supported over 33 million HIV counseling and testing sessions;
supported prevention of mother to child [HIV] transmission (PMTCT) services in
more than 10 million pregnancies; and prevented an estimated 157,000 infant
• Treatment: provided antiretroviral treatment for about 1.45 million people,
including 86,000 children.
• Care: supported care for more than 6.6 million HIV-affected people, including
more than 2.7 million orphans and vulnerable children (OVC).
The Leadership Act authorizes $15 billion to address HIV/AIDS, tuberculosis, and malaria
globally and to provide U.S. contributions to the Global Fund from FY2004 through FY2008.
OGAC calculates PEPFAR funding as the total of enacted funding for U.S. efforts to combat
HIV/AIDS globally, U.S. efforts to combat tuberculosis internationally, and U.S. contributions to 18
the Global Fund. Prior to FY2006, PEPFAR funding also included U.S. efforts to combat
malaria. Then in June 2005 the President introduced the President’s Malaria Initiative (PMI) to 19
expand U.S. government efforts to combat malaria globally. As a result, OGAC excluded 20
malaria funding from PEPFAR calculations beginning in FY2006. Since that time, U.S. 21
government spending on malaria has been reported separately. Since the Leadership Act
authorization included malaria programs, the funding data in this report includes malaria and PMI
funding. This report details funding separately for HIV/AIDS, TB, malaria, and U.S.
contributions for the Global Fund.
16 The White House, “Fact Sheet: The President’s Emergency Plan for AIDS Relief,” January 29, 2003, at
17 OGAC has updated some but not all of these statistics through March 31, 2008; CRS has included statistics available
through September 30, 2007, in order to provide more detailed information. Data in this section was compiled by CRS
from OGAC, “Latest Results,” at http://www.pepfar.gov/about/c19785.htm.
18 OGAC, “Making A Difference: Funding,” at http://www.pepfar.gov/press/80064.htm.
19 For more information on PMI, see CRS Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and Malaria
Spending: FY2004-FY2008, by Tiaji Salaam-Blyther.
20 OGAC, “Appendix 1: The President’s Emergency Plan for AIDS Relief Sources of Funding,” The Power of
Partnerships: Third Annual Report to Congress on PEPFAR (2007), at http://www.pepfar.gov/documents/organization/
21 USAID, Report to Congress: USAID FY 2006 Malaria Programming Report No. 1, at http://pdf.usaid.gov/pdf_docs/
PDACH688.pdf. Report to Congress: USAID FY 2006 Malaria Programming Report No. 2, at http://pdf.usaid.gov/
pdf_docs/PDACH689.pdf. President’s Malaria Initiative (PMI), USAID, PMI First Annual Report: Saving the Lives of
Mothers and Children in Africa, March 2007, at http://www.pmi.gov/resources/ pmi_annual_report.pdf. PMI, USAID,
PMI Second Annual Report: Progress Through Partnerships: Saving Lives in Africa, http://www.pmi.gov/resources/
From FY2004 through FY2008, Congress appropriated $15.3 billion to U.S. programs to combat
global HIV/AIDS, of which $10.6 billion was spent in the 15 PEPFAR Focus Countries through
the Global HIV/AIDS Initiative (GHAI); $530 million to U.S. programs to combat TB; and $915 22
million to U.S. programs to combat malaria (Table 1). Congress also appropriated $3.0 billion 23
to the Global Fund (Table 2).
Table 1. Global HIV/AIDS, Tuberculosis, and Malaria Appropriations by Disease,
FY2004 through FY2008
(Current U.S. $ Millions)
AIDS Program Amount
USAID HIV/AIDS 2,031.0
State Global HIV/AIDS Initiative (GHAI) 10,624.0
Foreign Military Financing 6.9
CDC Global AIDS Program 754.2
CDC International HIV Research 23.0
NIH International HIV Research 1,795.8
DOL AIDS Initiative 11.8
DOD HIV/AIDS Prevention Education 25.0
Total HIV/AIDS Fundinga 15,271.7
Tuberculosis Program Amount
USAID Tuberculosis 525.7
CDC Tuberculosis 4.3
Total Tuberculosis Funding 530.0
Malaria Program Amount
USAID Malaria 870.3
CDC Malaria 44.9
Total Malaria Fundingb 915.2
Source: Derived from data presented in CRS Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2008, by Tiaji Salaam-Blyther.
a. Includes UNAIDS, International AIDS Vaccine Initiative (IAVI), and international microbicide research
b. Includes President’s Malaria Initiative (PMI).
22 For more information on GHAI, PEPFAR, TB, and malaria appropriations, see CRS Report RL33485, U.S.
International HIV/AIDS, Tuberculosis, and Malaria Spending: FY2004-FY2008, by Tiaji Salaam-Blyther.
23 For more information on the Global Fund, see CRS Report RL33396, The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-Blyther.
Table 2. U.S. Contributions to the Global Fund to Fight AIDS, Tuberculosis, and
Malaria, FY2004 through FY2008
(Current U.S. $ Millions)
Global Fund Contributions Amount
State GHAI 1,121.0
Total Global Fund Contribution 3,002.7
Source: Derived from data presented in CRS Report RL33485, U.S. International HIV/AIDS, Tuberculosis, and
Malaria Spending: FY2004-FY2008, by Tiaji Salaam-Blyther.
On May 30, 2007, President Bush urged Congress to extend PEPFAR from FY2009 through 24
FY2013 with an additional $30 billion authorization. The Administration estimates that $30
billion would support treatment for 2.5 million people, the prevention of more than 12 million
new infections, and care for more than 12 million people, including 5 million orphans and 25
The Administration’s FY2009 budget request included $6 billion for U.S. international 26
HIV/AIDS and tuberculosis programs. Of this $6 billion, $500 million was requested for a U.S. 27
contribution to the Global Fund. The President also separately requested $385 million for the 28
President’s Malaria Initiative (PMI) for U.S. global malaria eradication efforts.
The following section focuses on key proposed changes to U.S. programs that combat HIV/AIDS,
tuberculosis, and malaria, as suggested by the April 2, 2008, version of H.R. 5501 that was passed
by the House and the July 16, 2008, version of H.R. 5501 that was passed by the Senate and that
was subsequently voted on and passed by the House and enacted into law. This section highlights
key proposed requirements and funding allocations included in either version of the bill and
discusses the debate surrounding the proposals, including debates about possible policy
24 OGAC, “President Bush Announces Five-Year, $30 Billion HIV/AIDS Plan,” at http://www.pepfar.gov/85811.htm.
26 Director of U.S. Foreign Assistance, U.S. Department of State, FY2009 International Affairs (Function 150)
Congressional Budget Justification for Foreign Operations: Annex A - President’s Emergency Plan for AIDS Relief, at
28 Director of U.S. Foreign Assistance, U.S. Department of State, FY2009 International Affairs (Function 150)
Congressional Budget Justification for Foreign Operations: Request by Appropriation Account—Ex-Im Bank, OPIC,
USTDA, CSH, DA, IDA, and TI, at http://www.state.gov/documents/organization/101417.pdf.
H.R. 5501 as passed by the House proposed up to $50 billion for U.S. international efforts to
combat HIV/AIDS, tuberculosis, and malaria during the reauthorization period of FY2009 29
through FY2013. It would have authorized $10 billion for each of the five years. The Senate
version proposed $48 billion in total over the same period for these activities. Both versions also
proposed authorizing higher funding levels for U.S. contributions to the Global Fund and for U.S.
efforts to combat tuberculosis and malaria (Table 3).
Table 3. Comparison of Proposed Reauthorization Levels from FY2009 through
FY2013 in House and Senate Versions of H.R. 5501
Area of Authorization H.R. 5501 as passed by the House H.R. 5501 as passed by the Senate
Overall for HIV/AIDS, Tuberculosis, and $50 billion ($10 billion each fiscal $48 billion (in total)
Malaria year over five years)
U.S. Contribution to Global Fund to Up to $2 billion for U.S. Up to $2 billion for U.S.
Fight AIDS, Tuberculosis, and Malaria contributions in each of FY2009 and contributions in FY2009;
FY2010; such sums as may be necessary
such sums as may be necessary from from FY2010 through FY2013.
FY2011 through FY2013.
Tuberculosis $4 billion (in total) $4 billion (in total)
Malaria $5 billion (in total) $5 billion (in total)
Source: Compiled by CRS from April 2, 2008, House-passed version and July 16, 2008, Senate-passed version of
The Senate version of H.R. 5501 also proposed authorizing $2 billion for an emergency fund for
Indian health and safety from FY2008 through FY2013. The Senate adopted S.Amdt. 5076 to S.
2731, the basis for the substitute amendment to H.R. 5501, and S.Amdt. 5084, which amended
S.Amdt. 5076. These amendments added language that requires an emergency plan to address the
law enforcement, water, and health care needs of Indian tribes and directs the expenditure of the 30
funds for particular purposes.
Critics of the $50 billion and $48 billion authorization levels argued that it would be fiscally
irresponsible to spend such levels in light of U.S. military operations in Iraq and Afghanistan, a
near economic recession in the United States, and questions about the absorptive capacity of
recipient countries. Some analysts suggested that increased disease-specific funding in the foreign
operations appropriations would drain available funding from other aid priorities in developing
countries, such as agriculture assistance and private sector growth. Others opposed increased
funding because they did not want to expand current PEPFAR activities to support additional
Focus Countries and to fund activities not directly related to AIDS. Critics of high spending levels
29 According to Congressional Quarterly, the funding level for PEPFAR programs in H.R. 5501 is the result of a
compromise reached the night before introduction. Adam Graham-Silverman, “Lawmakers Push Bipartisan Deal on
Global AIDS Bill,” CQ Today, February 26, 2008.
30 For further information, see CRS Report RL34461, Interior, Environment, and Related Agencies: FY2009
Appropriations, by Carol Hardy Vincent et al.; and CRS Report RL32198, Indian Reserved Water Rights: An
Overview, by Yule Kim.
were concerned about proposals to increase the number of Focus Countries and to extend
PEPFAR funds to support health care infrastructure as well as to enhance nutrition and feeding 31
programs. For example, Senators who placed a hold on H.R. 5501 and S. 2731 had stated that
the bills would “transform a targeted and accountable $15 billion dollar AIDS program into an 32
unaccountable, unspecified $50 billion development program.”
Proponents of the authorization level argued that access to HIV/AIDS prevention, treatment, and
care for all would require greater resources. As a result, debate among bill advocates focused on
where the dollars should be spent and what priorities the increased funding should support. Some
urged Congress to consider further definition of tuberculosis authorities and targets, improved
coordination of tuberculosis activities with HIV/AIDS activities in areas of co-infection, and
strengthened reporting requirements for tuberculosis. Backers of the increased authorization
argued that the next stage in fighting AIDS, tuberculosis, and malaria must occur alongside the
strengthening of health systems. They argued that these activities must be integrated with related
development efforts in order to ensure the sustainability of efforts to fight the three diseases.
Some opponents used the Congressional Budget Office’s (CBO) cost estimates to justify a lower
authorization funding level. CBO estimated that implementing either H.R. 5501 or S. 2731, which
was the bill from which language for the Senate-passed version of H.R. 5501 was drawn, would
cost $35 billion from FY2009 through FY2013 and that most of the additional amounts of 33
authorized funding would be spent by FY2018. Some argued that the CBO cost estimates
assumed that outlays will follow historical spending patterns for existing programs and did not
reflect the proposed increases in authorization levels for tuberculosis and malaria spending and
for the U.S. contribution to the Global Fund.
Both bills would have established a Coordinator of United States Government Activities to
Combat Malaria Globally (Global Malaria Coordinator) at USAID. The Global Malaria
Coordinator would oversee and coordinate all U.S. resources for international activities related to
combating malaria. The bills also would have authorized the Global Malaria Coordinator to
provide financial assistance to multilateral efforts such as the Roll Back Malaria Partnership 34
(RBM). The proposed authorization of a Global Malaria Coordinator was related to the creation
31 Adam Graham-Silverman, “Despite Efforts, Senate Global AIDS Legislation Stalled Over Cost Concerns,” CQ
Today, June 13, 2008.
32 Seven Senators placed a hold on H.R. 5501 and S. 2731 on March 31, 2008. See Senators Tom Coburn, Jim DeMint,
Jeff Sessions, Richard Burr, Saxby Chambliss, Jim Bunning, and David Vitter, “Letter to Senator Mitch McConnell,”
March 31, 2008, at http://coburn.senate.gov/ffm/index.cfm?FuseAction=Files.View&FileStore_id=82a33c04-4833-
4a00-9895-4ff924bd9b04. Senators Coburn and Burr subsequently withdrew their objection to a motion to proceed to
S. 2731; see “Letter to Senator Mitch McConnell,” July 1, 2008, at http://coburn.senate.gov/ffm/
index.cfm?FuseAction=Files.View&FileStore_id=de6535c6-c151-4717-89ff-26c399bf3024. An agreement to limit
amendments to S. 2731 to those identified and agreed to as first degree by the bill’s managers (10 amendments) was
reached with most of the Senators. Shortly thereafter, the Senate invoked cloture on a motion to proceed to the bill.
33 Congressional Budget Office (CBO), Cost Estimate: H.R. 5501, March 5, 2008, at http://www.cbo.gov/ftpdocs/90xx/
doc9029/hr5501.pdf. CBO, Cost Estimate: S. 2731, April 11, 2008, at http://www.cbo.gov/ftpdocs/91xx/doc9126/
34 The Roll Back Malaria Partnership (RBM) is a partnership of organizations that aims to provide a coordinated global
approach to fighting malaria. RBM was launched in 1998 by the World Health Organization (WHO), the United
Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank. For
more information on RBM, see http://www.rollbackmalaria.org/.
of the President’s Malaria Initiative (PMI), which President Bush announced in June 2005 and
has been operational since FY2006. PMI is located at USAID.
Some observers opposed a disease-specific approach. They argued that it ignored the
interconnected nature of health care challenges, and in resource-poor countries, it would create
competition for limited human capacity such as doctors, public health specialists, and U.S.
program managers. Supporters believed PMI would focus attention on malaria, which is a major
killer in sub-Saharan Africa and some parts of Asia.
Others contended that directed efforts on specific diseases should occur simultaneously with
efforts to build health capacity and infrastructure. While they applauded the initial emphasis on
HIV/AIDS, which helped to build health system capacity in resource-poor settings, observers
contended that the next stage of disease response under PEPFAR should integrate efforts to
combat HIV/AIDS with the provision of basic healthcare and the prevention of childhood illness.
Some urged Congress to consider questions related to the establishment of PMI, including how
PMI should coordinate its activities with PEPFAR; the further definition of authorities over the
three diseases in the Leadership Act; the possibility of competing priorities between PMI and
PEPFAR, especially where they operate in the same Focus Countries; and the implications of
different initiative timetables for strategic planning, funding authorizations, and implementation.
On February 6, 2007, Representative Luis Fortuño introduced H.R. 848, a bill to amend the State
Department Basic Authorities Act of 1956 to authorize assistance to combat HIV/AIDS in certain
countries in the Caribbean. The bill would add Antigua and Barbuda, the Bahamas, Barbados,
Belize, Dominica, Grenada, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Vincent and the
Grenadines, Saint Lucia, Suriname, Trinidad and Tobago, and the Dominican Republic to the list
of Focus Countries. When introduced, H.R. 5501 proposed adding Vietnam as a Focus Country as
well as those countries listed in H.R. 848. Representative Betty McCollum proposed adding
Malawi, Swaziland and Lesotho to the list of Focus Countries in H.R. 5501 through H.Amdt. 975,
which was adopted. While the House-passed version of H.R. 5501 would have added these
additional Focus Countries, the Senate version proposed adding only Vietnam as a Focus Country.
Vietnam has been a Focus Country in practice since 2004 at the direction of President Bush; this
language would have updated the list of 14 Focus Countries that was included in the Leadership
Act. The new language in the Senate-passed version also specified that in designating additional
Focus Countries priority shall be given to those countries in which there is a high prevalence of
HIV or risk of significantly increasing incidence of HIV within the general population and
inadequate financial means within the country.
Some observers questioned why the above-named countries were selected, particularly since
OGAC did not put forth these countries for consideration. Proponents of the addition of these new
Focus Countries argued that the designation would direct more HIV/AIDS funding to these areas.
Debate about the Focus Countries list also centered on how authorized funds in excess of the
President’s $30 billion PEPFAR reauthorization proposal would be distributed across PEPFAR
countries. It was not clear whether the proposed, newly-designated Focus Countries would have
received more support than they did previously or whether they would have been funded at higher
levels than non-Focus Countries for HIV/AIDS activities. Some would have liked the final
reauthorization bill to clarify this issue.
Opponents of the proposed list argued that incidence rates—the rates of new infections—have
been growing in East Asia and Oceania, while incidence rates appeared to have stabilized in the
Caribbean. They also argued that prevalence rates—the percentages of given populations that are
infected with HIV/AIDS—have been growing in Eastern Europe and Central Asia, while
prevalence rates in the Caribbean appeared to have stabilized and in some countries have even 35
declined. As new infections worldwide continued to outpace the numbers of infected persons
placed on treatment, others asserted that a more complex analysis of need should be used in
naming Focus Countries. Still others argued that Focus Countries should no longer be used to
apportion funding and that distribution of funds should be based on country needs and recipient
countries’ access to other funding sources for HIV/AIDS programs.
Some observers expressed concern about the long-term commitment that PEPFAR may require,
particularly in the Focus Countries. As an alternative to adding Focus Countries, some suggested
using compacts between the U.S. government and PEPFAR-recipient governments to clearly
outline the scope and terms of U.S. involvement in AIDS prevention, treatment and care and to
elicit recipient government involvement, ownership, and investment. Supporters asserted that
compacts may have been helpful in outlining expectations for broader development efforts and
investments that have been shown to have a significant impact on health. Some compacts, for
example, might have included an agreement that aid recipient countries would reform property
laws and inheritance laws. Such reforms have been shown to reduce the vulnerability of widows 36
and orphans to HIV infection by providing them with greater financial security. The Senate-
passed version of H.R. 5501 supported this idea, stating that compacts and framework agreements
were “one mechanism to promote the transition from an emergency to a public health and
development approach to HIV/AIDS” and could be “tailored to local circumstances to promote
host government commitment to deeper integration of HIV/AIDS services into health systems, 37
contribute to the health systems overall, and enhance sustainability.” The language required that
cost-sharing assurances from PEPFAR-recipient governments and transition strategies be
included in compacts. The House-passed version of H.R. 5501 did not include similar language.
H.R. 5501 as passed by the House maintained funding distribution guidelines and spending
directives of 20% for HIV prevention activities, 15% for HIV/AIDS care activities, and 10% for
orphans and vulnerable children (OVC) activities, but it did not include the spending directive for
HIV/AIDS treatment. The Senate-passed version maintained the spending directive for OVC and
modified the spending directives for treatment and care by requiring that over half of bilateral
HIV/AIDS assistance be spent on treatment, care, and nutritional and food support for
HIV/AIDS-infected people. It did not include the funding distribution guidelines and spending
directives for HIV/AIDS prevention. Both versions required balanced funding for HIV prevention
35 For more information on incidence and prevalence rates, see United Nations Joint Programme on HIV/AIDS
(UNAIDS), 2007 AIDS Epidemic Update, November 17, 2007, at http://data.unaids.org/pub/EPISlides/2007/
36 U.N. Millennium Project Task Force on Education and Gender Equality, Taking Action: Achieving Gender Equality
and Empowering Women, 2005, at http://www.unmillenniumproject.org/documents/Gender-complete.pdf.
37 See Section 310(c)(6) and Section 301(d).
activities, stating that a report to Congress must be provided to justify any decision to spend less
than 50% of prevention funds on behavioral change programs, including abstinence and be
faithful activities, in any PEPFAR recipient country with a generalized epidemic.
There was considerable debate about the effectiveness of congressional spending directives.
Some observed that the spending directives limited Focus Country teams’ ability to tailor budgets 38
to local HIV transmission patterns. Critics contended that the spending directives also
complicated efforts to address the specific nature of the HIV/AIDS epidemic in each country.
HIV/AIDS rates among the Focus Countries ranged from 1% to over 33%. The current and
proposed Focus Countries had epidemics that varied in nature and prevalance: some epidemics
were concentrated among drug users or prostitutes while others were spread throughout the
population. Some argued that Congress might consider eliminating some or all prevention,
treatment, and care spending directives to promote operational planning that was responsive to
the nature of the epidemic in each country and reflected the cost of implementation in that area.
The Government Accountability Office (GAO) found that the spending restrictions did not
account for the costs of particular HIV/AIDS activities that may vary from country to country or 39
for changes in costs over time.
Some encouraged Congress to maintain its spending directives, particularly those related to
orphans and vulnerable children (OVC). Supporters cited a GAO report that stated that without 40
the spending directive, programs for OVC might not have been protected. Others stressed the
importance of the spending directive that requires at least 55% of HIV/AIDS funds be spent on
HIV/AIDS treatment, to maintaining support for the purchase and distribution of antiretroviral
drugs and related care for those receiving treatment. Senator Tom Coburn introduced S. 2749, the
Save Lives First Act of 2008, on March 12, 2008, which maintains protections for AIDS
treatment funding. Senator Coburn also signed a letter that requested a hold on H.R. 5501 and S.
2731, noting the removal of the treatment spending directive. Congressional Quarterly
subsequently reported that, after negotiating for changes to S. 2731—which was the basis for the
Senate-passed version of H.R. 5501, Senator Coburn was “satisfied with language that would 41
require more than half the money go to treatment, including antiretroviral drugs.” Senator 42
Coburn subsequently withdrew his objection to a motion to proceed to S. 2731.
Program objectives are goals that establish the number of people that U.S. HIV/AIDS activities,
such as prevention, treatment, and care, will reach within a specified period. In 2003, for
example, the PEPFAR five-year global program objective for treatment was to provide
38 Institute of Medicine of the National Academies (IOM) Committee for the Evaluation of the President’s Emergency
Plan for AIDS Relief (PEPFAR) Implementation, PEPFAR Implementation: Progress and Promise, The National
Academies Press: 2007.
39 GAO, Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding, April
2008, at http://www.gao.gov/new.items/d08480.pdf.
41 Adam Graham-Silverman, “Deal Could Pave Way for Quick Senate Passage of Global AIDS Aid Measure,” CQ
Today, June 25, 2008.
42 Senators Tom Coburn and Richard Burr, “Letter to Senator Mitch McConnell,” July 1, 2008, at
http://coburn.senate.gov/ffm/ index.cfm?Fuse Action=Files.View&FileStore_ id =d e6535c6-c151-4717-89ff-
antiretroviral treatment for 2 million people.43 Some suggested that one alternative to spending
directives was to allow U.S. staff in PEPFAR Focus Countries to set annual program objectives
for prevention, treatment, and care that, in turn, would be added up to become the five-year
country prevention, treatment, and care objectives. These then would have been totaled across
countries to calculate the U.S. global program objectives for these program areas. At the time of
consideration of H.R. 5501, OGAC determined five-year country prevention, treatment, and care
goals for the 15 Focus Countries, and then U.S. staff in PEPFAR Focus Countries set annual
program objectives with the goal of reaching five-year country goals but with consideration for
the challenges of the country’s HIV/AIDS epidemic. OGAC then calculated global program 44
objectives by adding up the five-year country targets.
Some supporters of program targets being determined entirely by U.S. staff in PEPFAR Focus
Countries contended that country teams have the greatest awareness of each country’s needs and
should establish prevention, treatment, and care targets. However, some PEPFAR country team
members expressed concern about difficulties country teams might face in reaching a consensus 45
about such targets. Critics of program targets being determined this way asserted that Congress
could specify global targets as a way of guiding policy implementation and priorities without
hampering the ability of country-based teams to respond flexibly to in-country realities and to
coordinate with national health plans. They pointed to language in both versions of H.R. 5501 as
examples: both bills proposed establishing a target for prevention of mother to child [HIV]
transmission (PMTCT) activities that at least 80% of pregnant women would be reached in 46
affected countries by 2013. The Senate version also proposed setting a target that the proportion
of children receiving care and treatment would be proportionate to their numbers within the
population of HIV-infected individuals in each country by 2013, while the House-passed version
of H.R. 5501 proposed setting a target requiring that by 2013 up to 15% of those receiving
treatment and care must be children.
Debate about spending directives and program targets was closely related to debate about how to
prioritize or balance HIV/AIDS prevention, treatment, and care activities. Some experts
maintained that prevention should remain a focus of global efforts, because there is no cure for
AIDS at this time and preventing new infections is the only way to stop the epidemic in the long
term. In 2001 the U.N. General Assembly adopted the Declaration of Commitment on HIV/AIDS, 47
which stated that “prevention must be the mainstay of our response.” Some organizations, such
as the Bill and Melinda Gates Foundation and the Global AIDS Prevention Working Group,
focused their efforts on strategies and prevention research in an effort to “prevent the HIV
43 The White House, “Fact Sheet: The President’s Emergency Plan for AIDS Relief,” January 29, 2003, at
44 GAO, Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding, April
2008, at http://www.gao.gov/new.items/d08480.pdf.
46 In the Leadership Act, Congress required that the U.S. government strategy to combat the global HIV/AIDS
pandemic must “provide for meeting or exceeding the goal to reduce the rate of mother-to-child transmission of HIV by
20 percent by 2005 and by 50 percent by 2010.”
47 U.N. Document, A/RES/S-26/L.2, June 27, 2001, at http://data.unaids.org/publications/ irc-pub03/
epidemic from becoming generalized in countries with emerging epidemics” and to prevent 48
millions of new infections.
On the other hand, some contended that focusing on prevention and neglecting treatment and care
would ignore the economic and social impacts of the disease on those already infected, on the
children and families of infected persons, and on countries with high prevalence rates. Some
asserted that treatment and care were investments in hope and stability, preventing children from
being orphaned and people from suffering the ravages of the disease when treatment to prolong
life and improve its quality is available. Some argued that treatment costs were dropping very
rapidly for not only first-line treatment regimens but also second-line antiretroviral therapies, a
trend that was expected to continue as treatment expanded to cover more infected people in low 49
and middle income countries and as more international donors negotiated for lower prices.
Others maintained that combating HIV/AIDS required a combination of prevention, treatment,
and care rather than a choice between these strategies.
H.R. 5501 as passed by the House included language that addressed U.S. HIV/AIDS activities’
links and referral to family planning and maternal health programs. Section 101(a)(4) of H.R.
5501 proposed amending Section 101 of P.L. 108-25, the Leadership Act. It stated that a
comprehensive five-year global strategy to combat HIV/AIDS, tuberculosis, and malaria shall:
include specific plans for linkage to, and referral systems for non-governmental
organizations that implement multisectoral approaches, including faith-based and
community-based organizations, for ... access to HIV/AIDS education and testing in family 50
planning and maternal health programs supported by the United States Government.
The Senate-passed version of H.R. 5501 did not include family planning program language.
Opponents of the language in the House version of H.R. 5501 argued that the language was
ambiguous and might have applied the Mexico City policy to programs that receive PEPFAR 51
funding. The Mexico City policy denies U.S. funds to foreign non-governmental organizations
(NGOs) that perform or promote abortion as a method of family planning—even if the activities
48 Bill and Melinda Gates Foundation, “Grantmaking Priorities for HIV/AIDS,” http://www.gatesfoundation.org/
GlobalHealth/Pri_Diseases/HIVAIDS/HIV_Grantmaking.htm. Global HIV Prevention Working Group,
49 First-line treatment regimens are initial drugs used to treat infected people. When patients become resistant to these
drugs they may require second-line and third-line drugs.
50 This language is the proposed Section 101(a)(5)(D) in P.L. 108-25.
51 For example, the Center for Health and Gender Equity states, “The bill restricts funding to U.S.-funded family
planning programs—ensuring that restrictive U.S. policies such as the Mexico City Policy could extend to PEPFAR-
funded programs that seek to link family planning and HIV prevention.” Center for Gender Health and Equity, “U.S.
Congress Introduces New PEPFAR Bill: Two Steps Forward, Three Steps Back,” February 27, 2008,
http://www.genderhealth.org/pubs/PR2008BermanPEPFAR.pdf. Pathfinder International, an NGO, states that the bill
“adopts an ambiguous provision stating that only family planning organizations ‘supported by the U.S. government’
will be eligible for PEPFAR funds for HIV/AIDS testing and education purposes,” which “potentially paves the way
for the Mexico City Policy ... to be applied for the first time to the receipt of global HIV/AIDS funds.” Pathfinder
International, “Pathfinder International’s Response to Recent Senate PEPFAR Reauthorization,” March 19, 2008,
are undertaken with non-U.S. funds.52 Others opposed the language because they did not believe
that it sufficiently supported the integration of family planning services in U.S.-supported HIV 53
prevention programs. Proponents of the family planning program language in the House version
of H.R. 5501 maintained that it would limit PEPFAR funding for family planning groups based 54
on their compliance with the Mexico City policy. Other groups reserved endorsement or
opposition until such as time as Congress might further clarify the language. Some expressed
concern, however, that the family planning language might contradict their beliefs and 55
Section 501 of the House version of H.R. 5501 proposed the development of five-year health
workforce strategies by countries that receive assistance under the reauthorization. It directed the
Global AIDS Coordinator and the Secretary of the Treasury to work to reform International
Monetary Fund (IMF) policies that result in limitations on national and donor investments in
health. It also directed the Global AIDS Coordinator to work with relevant stakeholders to
develop effective public sector procurement and supply chain management systems for supplies
and drugs in countries receiving assistance under the reauthorization. The Senate-passed version
of H.R. 5501 included similar language through the use of compacts and actions required of the
Administrator of USAID.
H.R. 5501 as passed by the House also would have required OGAC and USAID to create and
implement a plan to combat HIV/AIDS by strengthening health policies and health systems of 56
PEPFAR countries as part of USAID’s Health Systems 20/20 project. The plan, in part, would
have aimed to encourage post-secondary institutions in host countries, especially in Africa, to
52 For more information on the Mexico City policy, see CRS Report RL33250, International Population Assistance and
Family Planning Programs: Issues for Congress, by Luisa Blanchfield.
53 See, for example, EngenderHealth, “Action Alert: Global Funding for AIDS, TB, and Malaria,” March 4, 2008, at
http://engenderhealth.org/media/press-releases/ 2008-03-04-hiv-funding.php. Physicians for Human Rights, “PHR’s
Position on PEPFAR Reauthorization Bills,” March 27, 2008, at http://physiciansforhumanrights.org/ library/news-
2008-03-27.html. Nandini Oomman, Center for Global Development, “PEPFAR Reauthorization Responds to Some
Evidence from First Five Years,” March 19, 2008, at http://blogs.cgdev.org/globalhealth/2008/03/
pepfar_reauthorizati_1.php. Health GAP, “Comparison of House and Senate PEPFAR Legislation and Suggested
Changes,” March 24, 2008, at http://www.pepfar2.org/ legislationsuggestions.html#FP.
54 The Southern Baptist Convention’s Ethics & Religious Liberty Commission, for example, is “encouraged by the
changes that have taken place in the [House Foreign Affairs] committee that would keep funding from going to pro-
abortion organizations.” Southern Baptist Convention’s Ethics & Religious Liberty Commission, “House Panel OKs
Revised AIDS Funding,” March 3, 2008, at http://erlc.com/article/ house-panel-oks-revised-aids-funding. The Family
Research Council states, “Unlike previous versions, this House bill doesn’t fund ‘family planning’ services, although
there’s no explicit ban preventing it.” Tony Perkins, Family Research Council, “Washington Update: FRC’s PEP Talk
Improves AIDS Bill,” April 3, 2008, at http://www.frc.org/get.cfm?i=WA08D15.
55 Concerned Women for America stated that it “must watch carefully as funding is implemented” due to the “risk
posed by the ‘family planning’ language in the bill.” Sarah Griffith, Concerned Women for America, “A Series of
Positive Events for AIDS Relief,” March 28, 2008, at http://www.cwalac.org/article_670.shtml.
56 According to USAID’s Health Systems 20/20 website, “health system weaknesses are among the most important
factors contributing to the suboptimal use of priority health services. Health Systems 20/20 applies new and proven
interventions in financing, governance, operations, and capacity building to strengthen health systems in order to
increase use of priority services. . . . Health Systems 20/20 is working at the country level to conduct comprehensive
analysis of available and required human resources to scale up and sustain HIV/AIDS services and to facilitate
solutions to address human resource shortages.” For more information please see USAID Health Systems 20/20, “What
We Do,” at http://www.healthsystems2020.org/section/topics/.
develop human and institutional capacity to support the health care system in those countries.
This included collaboration with U.S. post-secondary educational institutions including 57
historically black colleges and universities. The Senate-passed version included similar
The Senate version of H.R. 5501 also proposed requiring the U.S. strategy to combat global AIDS
to “situate United States efforts to combat HIV/AIDS, tuberculosis, and malaria within the
broader United States global health and development agenda, establishing a roadmap to link
investments in specific disease programs to the broader goals of strengthening health systems and
infrastructure and to integrate and coordinate HIV/AIDS, tuberculosis, or malaria programs with
other health or development programs, as appropriate.” This language required greater strategic
planning across U.S. global health and development programs to coordinate efforts across
Some health experts were concerned about the single disease approach to global health and how it
focused limited resources in high burden countries on one disease while, they contended, the
overall health infrastructure and workforces in resource-poor countries minimally improved.
Some also were concerned about the possible long term implications of the increased funding
levels if the funds were spent on treatment and care of individuals who are infected with AIDS.
One study pointed out that treatment of infected individuals is a lifelong commitment and that
treatment itself prolongs that length of time; it estimated that if scale-up of treatment continued at
the historical rate since FY2004 and drug prices and treatment costs remained the same,
maintenance of treatment funding levels would necessitate either a 20% increase in total U.S.
overseas development assistance by FY2016 or a reallocation of 20% of the current overseas
development assistance budget of $23 billion to AIDS treatment funding alone. It argued this
might raise questions about how funding for other global health programs and development 58
efforts might be adversely affected.
Supporters of language that addressed issues of coordination of U.S. global health and
development programs with disease-specific initiatives like PEPFAR and PMI argued that the
more comprehensive development of health infrastructure and training of health workforces in
these areas would increase the effectiveness of PEPFAR and other single-disease programs and
decrease the need for disease-specific efforts in the future by building local capacity to address
disease and basic health. Critics argued that such investment was outside the scope of PEPFAR
and would distract from the program’s focus on HIV/AIDS.
Both versions of H.R. 5501 encouraged the integration of HIV/AIDS activities with nutrition
programs through linkages and referrals to ensure that treated individuals receive the needed daily
caloric intake to support effective treatment. Where such linkages and referrals were not possible,
the Senate-passed version of H.R. 5501 proposed establishing additional services to provide
nutritional support directly, and it also encouraged support for programs that address the
intersections between food insecurity and health problems like HIV/AIDS. The House version of
57 See H.Amdt. 976 to H.R. 5501, introduced by Representative Carson and agreed to with a 415-10 vote in the House.
58 Mead Over, “Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and
What To Do About It,” Center for Global Development Working Paper 144, April 2008, at http://www.cgdev.org/
H.R. 5501 included similar language that authorized the direct provision of food and nutritional
support to HIV/AIDS-infected individuals receiving antiretroviral treatment through PEPFAR
where referrals were not possible. Both bills encouraged providing food and nutritional support
for children affected by HIV/AIDS.
Language in both versions of H.R. 5501 addressing health system infrastructure and nutrition did
not differ greatly from language included in the Leadership Act. The new language in both
versions went into greater detail about the nature of the infrastructure and nutrition challenges in
certain regions. Both encouraged greater integration of U.S. HIV/AIDS efforts with broader pre-
existing and parallel efforts by U.S. agencies and others, such as non-governmental organizations
(NGOs), and promoted linking affected individuals through referrals with such services.
Programs that might have been coordinated with or linked to include those that strengthen health
care infrastructure, nutrition programs, safe drinking programs, income security programs, and
programs that offer technical assistance in health care capacity building and public finance
H.R. 5501 as passed by the Senate proposed eliminating the language in the Immigration and
Nationality Act (INA) that statutorily bars foreign nationals with HIV/AIDS from entering the 59
United States. The House-passed version of H.R. 5501 did not include similar language.
Supporters of the amendment argued that maintaining the restrictions on entry into the United 60
States of AIDS-infected people was “discriminatory and unnecessary.” They also argued that
major international conferences on health and AIDS should not be held in countries that have
laws restricting the entry of people living with AIDS. Opponents to the amendment contended
that the amendment would add too many costs by increasing U.S. spending on health programs
for HIV/AIDS-infected people. Others disputed this would be a significant amount.
The Senate version of H.R. 5501 proposed requiring additional reporting, including a report by
the Comptroller General that would discuss the coordination of U.S. global AIDS efforts and the
impact of global HIV/AIDS funding and programs on other U.S. global health programming. It
also required the dissemination of an annual report by OGAC on best practices that might be
replicated or adapted by other AIDS programs. In addition, it provided for the Inspectors General
of the Department of State, the Broadcasting Board of Governors (BBG), HHS, and USAID to
jointly develop five coordinated annual plans for oversight activity in each of the fiscal years
59 See Section 305 of S. 2731 (Reported in Senate) for further information and referral to information about current
U.S. law. Immigration and Nationality Act of June 27, 1952, ch. 477; 66 Stat. 163; codified as amended at 8 U.S.C.
§§1101 et seq. The INA is the basis of current immigration law. For further information, see CRS Congressional
Distribution Memorandum, U.S. Immigration Policy on Foreign Nationals with HIV/AIDS, by Ruth Ellen Wasem, July
11, 2008, available from author.
60 United Nations News Center, “UN programme to work toward elimination of HIV travel restrictions,” March 5,
2008, http://www.un.org/apps/news/ story.asp?NewsID=25860&Cr=hiv&Cr1=unaids.
H.R. 5501 as passed by the House prohibited funds appropriated under the legislation from being
made available to a foreign country unless the agreement provided that such assistance funds 61
were exempt from taxation or otherwise reimbursed by the foreign government. The Senate-
passed version of S. 2731 did not include similar language.
H.R. 5501 as passed by the Senate directed the Global AIDS Coordinator to establish an advisory
panel of experts on prevention of mother to child HIV transmission (PMTCT) that would be
known as the PMTCT Panel. The panel would review PMTCT efforts and make
recommendations to OGAC and Congress on how to scale-up PMTCT services to ensure that, by
of pregnant women in those countries most affected by HIV/AIDS in which the United States has
HIV/AIDS programs. The House version of H.R. 5501 did not include similar language.
Both versions of H.R. 5501 expanded “conscience clause” language included in the Leadership
Act. The conscience clause in the Leadership Act stated that organizations that receive funding to
prevent, treat, or monitor HIV/AIDS shall not be required, as a condition of receiving the
assistance, to endorse or utilize a multisectoral approach to combating HIV/AIDS, or to endorse,
utilize, or participate in a prevention method or treatment program to which the organization has a
religious or moral objection. The new language in each version of H.R. 5501 referred to any
HIV/AIDS program or activity to which an organization may have a religious or moral objection,
whereas language in the Leadership Act referred only to any HIV/AIDS prevention method or
treatment program to which the organization has a religious or moral objection. It further stated
that organizations who opt-out of the above activities for religious or moral reasons shall not be
discriminated against in the solicitation or issuance of grants, contracts, or cooperative
On July 24, 2008, the House passed the Senate version of H.R. 5501, the Tom Lantos and Henry
J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (hereafter referred to as the Reauthorization Act). The
Reauthorization Act (P.L. 110-293) was enacted on July 30, 2008. The outcomes of key proposals
are described in Table 4. These key proposals and debates surrounding them are discussed in
more detail in the previous section of this report. The funding levels authorized from FY2009
through FY2013 for U.S. programs to combat HIV/AIDS, tuberculosis, and malaria
internationally are described in Table 5.
61 This prohibition applies to funds being made available to a foreign country under a new bilateral agreement.
Table 4. Outcomes of Key Proposals to Change International HIV/AIDS,
Tuberculosis, and Malaria Programs Under P.L. 110-293
Key Proposals P.L. 110-293
Funding Authorization Authorizes $48 billion for HIV/AIDS, tuberculosis, and malaria from FY2009 through
Increase FY2013; authorizes $2 billion for Indian Health and Safety Emergency Fund from
FY2009 through FY2013.
Global Malaria Coordinator Established within USAID to oversee and coordinate U.S. government efforts to
combat malaria globally.
List of Focus Countries Vietnam added as Focus Country in U.S. government efforts to combat HIV/AIDS
Compacts With Recipient Promotes the use of compacts between the U.S. government and country and
Countries regional programs on HIV/AIDS in order to promote host government commitment
to deeper integration of HIV/AIDS services into health systems, contribute to health
systems overall, and enhance sustainability.
Role of Spending Directives OVC: Requires 10% of HIV/AIDS funds to be spent on orphans and other children
affected by or vulnerable to HIV/AIDS (OVC).
Prevention: Requires the Global AIDS Coordinator to provide balanced funding for
prevention activities for sexual transmission of HIV/AIDS; and to ensure that activities
promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner
reduction are implemented and funded in a meaningful and equitable way in the
strategy for each host country based on objective epidemiological evidence as to the
source of infections and in consultation with the government of each host county
involved in HIV/AIDS prevention activities. Also requires a report to the appropriate
congressional committees within 30 days to justify a decision to provide less than 50
percent of the sexual transmission prevention funds for activities promoting
abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction.
Treatment and Care: For each of the fiscal years 2009 through 2013, more than half
of the amounts appropriated for bilateral global HIV/AIDS assistance pursuant to
section 401 shall be expended for antiretroviral treatment for HIV/AIDS; clinical
monitoring of HIV-seropositive people not in need of antiretroviral treatment; care
for associated opportunistic infections; nutrition and food support for people living
with HIV/AIDS; and other essential HIV/AIDS-related medical care for people living
Key Proposals P.L. 110-293
Program Objectives Prevention Goal: To prevent 12 million new HIV infections worldwide.
Treatment Goal: To support the increase in the number of individuals with HIV/AIDS
receiving antiretroviral treatment above the 2 million person goal previously
established under the Leadership Act for achievement by the end of FY2006 and
increased pursuant to the following: for each of the fiscal years 2009 through 2013,
the treatment goal shall be increased above 2 million people by at least the
percentage increase in the amount appropriated for bilateral global HIV/AIDS
assistance for such fiscal year compared with FY2008.
Additionally, any increase in the treatment goal above this specified level shall be
based on long-term requirements, epidemiological evidence, the share of treatment
needs being met by partner governments and other sources of treatment funding, and
other appropriate factors.
The treatment goal also shall be increased above the number calculated above by the
same percentage that the average U.S. government cost per patient of providing
treatment in countries receiving bilateral HIV/AIDS assistance has decreased
compared with FY2008.
Care Goal: To support care for 12 million individuals infected with or affected by
HIV/AIDS, including 5 million orphans and vulnerable children affected by HIV/AIDS
(OVC), with an emphasis on promoting a comprehensive, coordinated system of
services to be integrated throughout the continuum of care.
The Reauthorization Act also states that the prevention and care goals described
above shall be increased consistent with epidemiological evidence and available
Balance Between Prevention, Prioritizes prevention while preserving and increasing the treatment component of
Treatment, and Care HIV/AIDS efforts as bilateral funding for HIV/AIDS increases relative to FY2008 levels.
HIV/AIDS Activities and Does not mention family planning.
Health Systems and the Provides for helping partner countries to train and support the retention of health
Single Disease Approach care professionals and paraprofessionals. It sets a target of training and retaining at
least 140,000 new health care professionals and paraprofessionals with an emphasis
on training and in-country deployment of critically needed doctors and nurses.
This assistance is intended to strengthen the capacity of developing countries,
especially in sub-Saharan Africa, to deliver primary health care. It has an objective to
help countries achieve staffing levels of at least 2.3 doctors, nurses, and midwives per
1,000 population, as called for by the World Health Organization (WHO).
Required OGAC and USAID to create and implement a plan to combat HIV/AIDS by
strengthening health policies and health systems of PEPFAR countries as part of
USAID’s Health Systems 20/20 project. The plan, in part, would aim to encourage
post-secondary institutions in host countries, especially in Africa, to develop human
and institutional capacity to support the health care system in those countries. This
includes collaboration with U.S. post-secondary educational institutions including
historically black colleges and universities.
Required the U.S. strategy to combat global AIDS to situate United States efforts to
combat HIV/AIDS, tuberculosis, and malaria within the broader United States global
health and development agenda, establishing a roadmap to link investments in specific
disease programs to the broader goals of strengthening health systems and
infrastructure and to integrate and coordinate HIV/AIDS, tuberculosis, or malaria
programs with other health or development programs, as appropriate. This language
requires greater strategic planning across U.S. global health and development
programs to coordinate efforts across program areas.
Key Proposals P.L. 110-293
HIV/AIDS Activities and Provides for linkages between HIV/AIDS activities and nutrition programs.
Immigration and Nationality Amends the INA to statutorily allow foreigners infected with HIV/AIDS to enter the
Act (INA) Amendment United States.
Additional Oversight Requires additional reporting, including a report by the Comptroller General that
Activities would discuss the coordination of U.S. global AIDS efforts and the impact of global
HIV/AIDS funding and programs on other U.S. global health programming.
Requires the dissemination of an annual report by OGAC on best practices that
might be replicated or adapted by other AIDS programs.
Provides for the Inspectors General of the Department of State, the Broadcasting
Board of Governors (BBG), HHS, and USAID to jointly develop five coordinated
annual plans for oversight activity in each of the fiscal years 2009 through 2013.
Taxation of Assistance Funds Language not included.
by Foreign Governments
Prevention of Mother to Establishes a 15-person expert panel to review PMTCT activities and to provide
Child HIV Transmission recommendations for PMTCT scale-up to the Global AIDS Coordinator.
Conscience Clause Expands definition to state that organizations that receive funding to prevent, treat,
Expansion or monitor HIV/AIDS shall not be required, as a condition of receiving the assistance,
to endorse or utilize a multisectoral approach to combating HIV/AIDS, or to endorse,
utilize, or participate in any HIV/AIDS program or activity to which an organization
may have a religious or moral objection.
Source: Compiled by CRS from P.L. 110-293, the Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.
Table 5. Key Authorization Levels from FY2009 through FY2013 in P.L. 110-293,
the Reauthorization Act of 2008
Area of Authorization P.L. 110-293
Overall for HIV/AIDS, Tuberculosis, and Malaria $48 billion (in total)
U.S. Contribution to Global Fund to Fight AIDS, Up to $2 billion for U.S. contributions in FY2009; and
Tuberculosis, and Malaria such sums as may be necessary from FY2010 through
Tuberculosis $4 billion (in total)
Malaria $5 billion (in total)
Indian Health and Safety Emergency Fund $2 billion (in total)
Source: Compiled by CRS from P.L. 110-293, the Tom Lantos and Henry J. Hyde United States Global
Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.
Analyst in Global Health