Trends in U.S. Global AIDS Spending: FY2000-FY2008

Trends in U.S. Global AIDS Spending:
Updated July 16, 2008
Tiaji Salaam-Blyther
Specialist in Global Health
Foreign Affairs, Defense, and Trade Division

Trends in U.S. Global AIDS Spending: FY2000-FY2008
It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million
people each year. According to the Joint United Nations Program on HIV/AIDS
(UNAIDS), at the end of 2007, an estimated 33.2 million people were living with
HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the
course of that year. More than 2 million of those living with HIV/AIDS at the end
of 2007 were children, and some 290,000 of those who died of AIDS that year were
under 15 years old. On each day of 2007, some 1,000 children worldwide became
newly infected with HIV, due in large part to little access to drugs that prevent the
transmission of HIV from mother to child. An estimated 9% of pregnant women in
low- and middle-income countries were offered services to prevent HIV transmission
to their newborns.
UNAIDS asserts that an effective fight against the global spread of HIV/AIDS
would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in 2008. In
FY2006, Congress provided about $3.1 billion for international HIV/AIDS programs
and U.S. contributions to the Global Fund to Fight HIV/AIDS, TB, and Malaria, $4.3
billion in FY2007, and $5.7 billion in FY2008. Most recent statistics indicate that
in 2005, some $8.3 billion was spent on HIV/AIDS globally, though UNAIDS
estimated that $11.6 billion was needed. About $4.3 billion of those funds were
provided by donor governments. The Kaiser Family Foundation asserts that in 2005,
the United States provided the largest percentage of HIV/AIDS assistance in the
world, comprising some 49% of all donor spending.
Although the United States is the leading provider of international HIV/AIDS
assistance, some argue that it needs to give more, particularly to the Global Fund.
Critics of increased AIDS spending, however, question whether the most affected
region — sub-Saharan Africa — can absorb increased revenue flows. Some also
contend that additional HIV/AIDS allocations will yield limited results, as poor
health care systems and health worker shortages complicate efforts to scale up
HIV/AIDS spending. While this report describes how HIV/AIDS, TB, and malaria
are interlinked and exacerbate efforts to control each disease, it primarily addresses
funding issues related to U.S. global HIV/AIDS initiatives. It provides background
information on the key U.S. agencies that implement global HIV/AIDS programs,
analyzes U.S. spending on HIV/AIDS by U.S. agency and department, and presents
some issues Congress might consider, particularly as debate on PEPFAR
reauthorization ensues. This report will not be updated; PEPFAR authorization
expires in FY2008. Subsequent reports will analyze additional funding should the
initiative be reauthorized.

ABCAbstinence, Be Faithful, Condoms
ARVAnti-Retroviral medication
CDCU.S. Centers for Disease Control and Prevention
COPCountry Operation Plan
CSHChild Survival and Health
DODU.S. Department of Defense
DOLU.S. Department of Labor
FDAU.S. Food and Drug Administration
GAOGovernment Accountability Office
GAPGlobal AIDS Program
GHAIGlobal HIV/AIDS Initiative
HHSU.S. Department of Health and Human Services
HIPCHighly Indebted Poor Countries
HRSAU.S. Human Resources and Services Administration
IAVIInternational AIDS Vaccine Initiative
ILABBureau of International Labor Affairs
ILOInternational Labor Organization
IMFInternational Monetary Fund
I-TECHInternational Training and Education Center on HIV
JLIJoint Learning Institute
LIFELeadership and Investment in Fighting an Epidemic Initiative
MTCTMother-to-Child Transmission
NIHNational Institutes of Health
OAROffice of AIDS Research
OGACOffice of Global AIDS Coordinator
PEPFARPresidents Emergency Plan For AIDS Relief
PMIPresidents Malaria Initiative
PMTCTPrevention of Mother-to-Child Transmission
TB Tuberculosis
UNAIDSJoint United Nations Program on HIV/AIDS
USAIDU.S. Agency for International Development
USDAU.S. Department of Agriculture
WHOWorld Health Organization

In troduction ......................................................1
History of Funding for U.S. Global HIV/AIDS Efforts.....................4
LIFE Initiative................................................4
International Mother and Child HIV Prevention Initiative..............6
PEPFAR .....................................................7
PEPFAR-Participating Departments and Agencies.......................10
Department of State: Office of the Global AIDS Coordinator ..........10
U.S. Agency for International Development (USAID)................11
Department of Health and Human Services.........................13
Centers for Diseases Control and Prevention...................13
National Institutes of Health (NIH)...........................15
Health Resources and Services Administration (HRSA)...........16
U.S. Food and Drug Administration (FDA)....................16
Department of Defense (DOD)..................................18
Department of Labor (DOL) ...................................19
Peace Corps.................................................21
U.S. Department of Commerce..................................21
Issues for the Second Session of the 110th Congress......................21
Reauthorize PEPFAR..........................................21
Determine Appropriate Amount of Support for PEPFAR
Reauthorization ......................................22
Consider U.S. Contributions to the Global Fund.................22
Reconsider Abstinence-Until-Marriage Provisions...............23
Consider Impact of Abstinence-Until-Marriage Provision
on Gender...........................................24
Emphasize Other HIV Prevention Strategies....................25
Consider Access to Condoms...............................25
Integrate Family Planning Services Into PEPFAR Programs.......26
Increase Anti-Retroviral Treatments for Children................26
Expand the List of Focus Countries?..........................26
Address Infrastructure Challenges and Health Worker Shortages........27
Integrate Food and HIV/AIDS Services............................28
Boost Support for Research and Innovative Technology...............29
Appendix. Participating Agencies and Departments in U.S. Global
HIV/AIDS Initiatives: LIFE and PEPFAR.........................31
List of Figures
Figure 1. OGAC HIV/AIDS Appropriations: FY2004-FY2008.............11
Figure 2. USAID HIV/AIDS Appropriations: FY2000-FY2008............13
Figure 3. CDC HIV/AIDS Appropriations: FY2000-FY2008..............15
Figure 4. Office of AIDS Research Grants: FY2000-FY2008..............16
Figure 5. DOD HIV/AIDS Appropriations: FY2000-FY2008..............19
Figure 6. DOL HIV/AIDS Appropriations: FY2000-FY2008..............20

List of Tables
Table 1. Appropriations to Bilateral HIV/AIDS Programs and the Global
Fund: FY2000-FY2003.........................................6
Table 2. U.S. Spending on Global HIV/AIDS, TB, and Malaria:
FY2004-FY2008 ..............................................9

Trends in U.S. Global AIDS Spending:
It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million
people each year.1 According to the Joint United Nations Program on HIV/AIDS
(UNAIDS), at the end of 2007, an estimated 33.2 million people were living with
HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the2
course of that year. More than 2 million of those living with HIV/AIDS at the end
of 2007 were children, and some 290,000 of those who died of AIDS that year were3
under 15 years old. On each day of 2007, some 1,000 children worldwide became
newly infected with HIV, due in large part to little access to drugs that prevent the
transmission of HIV from mother to child. An estimated 9% of pregnant women in
low- and middle-income countries were offered services to prevent HIV transmission
to their newborns.
Although tuberculosis (TB)4 is curable, the World Health Organization (WHO)
estimates that by the end of 2005 (the year for which the most current data are
available), the disease killed 1.6 million people, including 195,000 who were also

1 World Health Organization. “2006 TB Factsheet.” At [
publications/2006/tb_facts_2006.pdf], visited on December 5, 2007.
2 Unless otherwise indicated, all data on HIV/AIDS infection rates were taken from
UNAIDS. 2007 AIDS Epidemic Update. December 2007. At [
EPISlides/2007/2007_epiupdate_en.pdf], visited December 5, 2007.
3 Estimates for HIV infection among children were revised after the publication of
UNAIDS’ report, 2007 AIDS Epidemic Update. On its website, UNAIDS indicated that an
“in-depth review of HIV estimates among children published in the 2007 AIDS Epidemic
Update report in November 2007 has revealed inaccuracies in processing some of the data.”
HIV infection estimates for children reflect those changes. See UNAIDS website:
[ en/K nowledgeCentre/HIV Data/EpiU p d a t e /EpiUpdArchive /2007/
default.asp], visited on January 29, 2008.
4 Tuberculosis is a contagious disease that is spread like the common cold through the air.
Only people who are sick with TB in their lungs are infectious. When infectious people
cough, sneeze, talk, or spit, they propel TB germs, known as bacilli, into the air. A person
needs only to inhale a small number of these to be infected. Left untreated, each person
with active TB disease will infect an average of between 10 and 15 people every year.
However, people infected with TB bacilli will not necessarily become sick with the disease.
The immune system “walls off” the TB bacilli, which, protected by a thick waxy coat, can
lie dormant for years. When someone’s immune system is weakened, the chances of
becoming sick are greater. See [].

infected with HIV/AIDS.5 Some 8.8 million people were estimated to have
contracted the disease in 2005, with about 84% of the cases having occurred in 22
countries.6 All but three of those high-burden countries were found in Africa or
Asia.7 About half of all new TB cases were in six countries: Bangladesh, China,
India, Indonesia, Pakistan, and the Philippines. More than 80% of those living with
TB in 2005 were in southeast Asia and sub-Saharan Africa, with the greatest per
capita rate found in Africa.8
According to WHO, each year there are about 300 million acute malaria cases,9
which cause more than 1 million deaths annually. Health experts believe that
between 85% and 90% of malaria deaths occur in Africa, mostly among children,10
killing an African child every 30 seconds.11
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, 90% of people living with AIDS die within four to

5 Data in this section was compiled from WHO, 2007 Global Tuberculosis Control Report,
6 The 22 high-burden countries were: Afghanistan, Bangladesh, Brazil, Burma, Cambodia,
China, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique,
Nigeria, Pakistan, Philippines, Russia, South Africa, Tanzania, Thailand, Uganda, Vietnam,
and Zimbabwe.
7 Of the high burden-countries, Afghanistan, Brazil, and Russia are not in Africa or Asia.
8 For more information on tuberculosis, see CRS Report RL34246, Tuberculosis:
International Efforts and Issues for Congress, by Tiaji Salaam-Blyther.
9 There are four types of human malaria, Plasmodium (P.) vivax, P. malaria, P. ovale, and
P. falciparum. P. vivax and P. falciparum are the most common, and P. falciparum is the
most deadly type of malaria infection. P. falciparum malaria is most common in sub-
Saharan Africa, accounting in large part for the extremely high malarial mortality in the
region. People contract malaria through bites from infected mosquitos. An infected
mosquito spreads the malaria parasite through the bloodstream. Once in the bloodstream,
the malaria parasite can evade the immune system and infect the liver and red blood cells.
Mosquitos can also contract malaria if they ingest blood from an infected person. See
[ 0/000/015/372/RBM Infosheet_1.htm] .
10 As indicated above, WHO estimates that each year, 300 million acute malaria cases cause
some 1 million deaths, 90% of which occur in sub-Saharan Africa. The World Bank
estimates that there are more than 500 million cases of malaria each year, and that at least
85% of malarial deaths occur in sub-Saharan Africa. The World Bank believes that 8% of
deaths occur in southeast Asia, 5% in the Eastern Mediterranean region, 1% in the Western
Pacific, and 0.1% in the Americas. It asserts that there is no accurate count of malaria
infections or deaths, due to weaknesses in data collection and reporting systems, inaccurate
diagnoses that may result in over- or under-reporting, and an insufficient amount of skilled
workers who can accurately make diagnoses, particularly in malaria-endemic areas.
11 WHO’s Roll Back Malaria website, [
RBMInfosheet_1.htm], accessed on August 31, 2006.

twelve months of contracting TB if they do not receive TB treatment.12 TB/HIV co-
infection is a considerable burden in sub-Saharan Africa, where 70% of the world’s
14 million co-infected people live. As many as half of all HIV-positive people in
Africa have TB (and one out of three dies of TB), and up to 80% of all African TB
patients have HIV.13 Research has demonstrated that treatment of TB or HIV in co-
infected patients has positive effects on halting the advancement of both diseases.
Studies have shown that HIV replication increases during the active phase of TB and
returns to baseline after successful TB therapy. Conversely, anti-retroviral (ARV)
treatment may decrease the progression of latent TB to active TB, allowing those
infected with HIV to live longer.14
Some research has also found that malaria contributes to the advancement of
HIV replication, greater sexual transmission of HIV, and higher mother-to-child HIV
transmission (MTCT) rates among the co-infected. For example, one study in
Malawi found that adults with acute malaria had a seven-fold increase in their HIV
viral load.15 However, HIV viral loads decreased when malaria treatment was offered
to some patients. Conversely, HIV-positive pregnant women were more likely to
contract malaria than HIV-negative pregnant women.16 Additionally, malaria-HIV
co-infection was associated with an increased risk of maternal, perinatal, and early
infant death compared to infection of either disease alone. Researchers are also
beginning to explore whether HIV-positive pregnant women who are co-infected
with malaria are more likely to transmit HIV to their children. In Uganda, co-infected
women had an HIV-transmission rate of 40%, while HIV-positive women not
infected with malaria had an HIV transmission rate of 15.4%.17
Drug resistence complicates efforts to halt the spread of TB and malaria. WHO
estimates that about 450,000 new multi-drug-resistant TB cases occur each year. In
September 2006, WHO expressed concern about an increase in treatment-resistant
TB cases, particularly in the Soviet Union, Asia, and South Africa.18 WHO found
that Extensive Drug Resistant TB (XDR-TB) is resistant not only to the two main

12 The Stop TB Partnership, “WHO Calls for Free TB Drugs for HIV Patients,” July 16,

2003; see [].

13 WHO press release, “WHO Pushing to Rapidly Scale-Up Measures to Fight TB and HIV,”
January 21, 2004, at [].
14 For more information on TB and HIV co-infection, see WHO, Frequently asked questions
about TB and HIV/AIDS. [].
15 U.S. Department of Health and Human Services, Centers for Disease Control, National
Center for Infectious Diseases, Division of Parasitic Diseases, Malaria Branch, “Interaction
of HIV and Malaria,” at [].
16 Carlo Ticconi et al.,”Effect of Maternal HIV and Malaria Infection on Pregnancy and
Perinatal Outcome in Zimbabwe,” Journal of Acquired Immune Deficiency Syndromes, vol.

34, no. 3 (November 1, 2003), at [].

17 H. Brahmbhatt et al.,”The Effects of Placental Malaria on Mother-to-Child HIV
Transmission in Rakai, Uganda,” AIDS: Official Journal of the International AIDS Society,
vol. 17 (November 21, 2003), pp. 2539-2541, at [].
18 UN News Center, “Drug-Resistant Strains of Tuberculosis Spark Concern from UN
Health Agency.” September 5, 2006, at [


first-line TB drugs — isoniazid and rifampicin — but also to three or more of the six
classes of second-line drugs.19 Health experts are particularly concerned about the
most recent outbreak of XDR-TB in South Africa, which killed 52 out of 53 patients
within 25 days on average, including those being treated with anti-retroviral
medication.20 On October 9 and 10, 2006, WHO convened a meeting of a Global
Task Force to review available data on XDR-TB incidence, and to develop an
emergency XDR-TB action plan focused on containing the deadly strain and advising
health practitioners on XDR-TB case management.21
Some experts believe that a steady rise in malarial deaths in sub-Saharan Africa
is due in large part to an increase in treatment resistance. One of the commonly used
drugs, chloroquine, is quickly becoming ineffective in treating those infected with
malaria.22 Chloroquine is affordable to many, as it costs approximately 10 cents per
course of treatment. Because it has been used for more than 50 years, however,
resistant strains of malaria are rapidly developing, rendering the drug useless in a
growing number of cases. Newer treatments that are more effective and have no
observable resistance are considerably more expensive. The new drugs, called
“artemisinin-based combination therapies” (ACTs), cost about $2 per treatment
course, which is beyond the financial reach of many in the most affected regions.
History of Funding for U.S. Global HIV/AIDS Efforts
LIFE Initiative
In July 1999, then-President Bill Clinton requested that Congress provide an
additional $100 million to fund his Leadership and Investment in Fighting an
Epidemic (LIFE) Initiative. The initiative sought to expand U.S. global HIV/AIDS
efforts and to target the funds at 13 countries with the highest number of new HIV
infections.23 Specifically, President Clinton proposed that Congress allocate $48
million to global AIDS prevention, $23 million to home- and community-based care,
$10 million to children orphaned by AIDS, and $19 million to infrastructure and
capacity development.

19 For more information on the spread of drug-resistant TB, see [
tb/pubs/mmwrhtml/mmwr_mdrtb.htm] .
20 “Drug-Resistant TB in South Africa Draws Attention from U.N.,” New York Times,
September 6, 2006, at [].
21 UNAIDS, 2006 AIDS Epidemic Update, p. 12.
22 Data in this paragraph taken from Disease News, “Malaria Mortality Rate in Africa and
Asia Could Double in a Few Decades as the Drug Used Most Frequently Is Rendered
Useless,” July 23, 2004; see [].
23 The LIFE target countries were India, Ethiopia, Kenya, Malawi, Mozambique, Nigeria,
Rwanda, Senegal, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe.

In FY2000, Congress provided more for global HIV/AIDS programs than
President Clinton requested for his LIFE Initiative, directing $189.3 million24 to
USAID for global HIV/AIDS activities; and appropriating $46.7 million25 to the
Department of Health and Human Services (HHS) for the Centers for Disease
Control and Prevention’s (CDC) Global AIDS Program (GAP), providing the first
bilateral HIV/AIDS appropriation to an U.S. agency other than the U.S. Agency for
International Development (USAID).26
In FY2001, Congress expanded appropriations for global HIV/AIDS programs
to the Departments of Agriculture (P.L. 106-387), Defense (P.L. 106-259), and Labor
(P.L. 106-554); and provided funds for the first U.S. Global Fund contribution (P.L.
106-429). Some HIV/AIDS analysts contend that the LIFE Initiative raised
congressional awareness about potential implications of a global HIV/AIDS
epidemic, led to an increase in U.S. spending on global HIV/AIDS, and enhanced
congressional receptivity to President George Bush’s Emergency AIDS Plan, which
he would announce three years later. While advocating for the LIFE Initiative, U.S.
officials argued that HIV/AIDS was more than a health issue. HIV/AIDS, the
Clinton Administration contended, threatened economic growth, political stability,
and civil society, which made it an issue of trade and investment, security and
stability, and development.27

24 This figure includes a 0.38% across-the-board rescission.
25 The $46.7 million includes $34.8 million directed to CDC through regular FY2000
appropriations, and $11.9 million provided through FY2000 emergency appropriations.
26 Although in FY2000, CDC was the only agency outside of USAID to which Congress
appropriated funds for global HIV/AIDS programs, DOD and DOL websites indicate that
each launched HIV/AIDS programs through the LIFE Initiative that fiscal year.
Additionally, Congress authorized funds to the National Institutes of Health (NIH) for
international research activities (discussed later).
27 The White House, Report on the Presidential Mission on Children Orphaned by AIDS in
Sub-Saharan Africa: Findings and Plan of Action, July 19, 1999, at [http://clinton4.nara.
gov/ media/pdf/africa2.pdf].

Table 1. Appropriations to Bilateral HIV/AIDS Programs and the
Global Fund: FY2000-FY2003
(current U.S.$ millions)
P r ogram F Y 2000 F Y 2001 F Y 2002 F Y 2003
USAID HIV/AIDS assistance 189.3318.0424.0523.8
(excluding Global Fund)
USAID contributions to the Global Fund0.0100.050.0248.4
Foreign Military Financing0.
Foreign Operations Appropriations Subtotal189.3418.0474.0772.2
CDC Global AIDS Program46.8104.5143.8182.5
Global Fund Contribution from HHS0.00.0125.099.0
Department of Labor AIDS in the Workplace
Labor/HHS Appropriations Subtotal46.8114.5278.8291.4
Department of Defense HIV/AIDS Prevention
Total 236.1 542.5 766.8 1,070.6
Source: Prepared by CRS from appropriations legislation and interviews with Administration officials.
Note: The data includes supplemental appropriations. This table reflects appropriated figures, which
may differ from actual spending. Agencies and departments might spend additional funds on
global HIV/AIDS efforts that were not specifically appropriated. For example, though Congress
does not specifically appropriate funds to NIH’s global HIV/AIDS research efforts, the Office
of AIDS Research reports that it has allocated some $160 million, $218 million, and $279
million in grants in FY2001, FY2002, and FY2003, respectively.
International Mother and Child HIV Prevention Initiative
In FY2002, President Bush requested that Congress provide $500 million to
fund a new initiative he called the International Mother and Child HIV Prevention
(PMTCT) Initiative.28 The initiative sought to prevent the transmission of HIV from
mothers to infants and to improve health care delivery in Africa and the Caribbean.
Congress provided that up to $100 million (excluding rescissions) be made available
to USAID for the initiative in FY2003. In FY2004, Congress provided $150 million
(excluding rescissions) to CDC for PMTCT programs. Conferees also expressed an
expectation that $150 million would be made available for the initiative from the
newly established Global HIV/AIDS Initiative (GHAI; H.Rept. 108-401). Since the
initiative expired in FY2004, Congress has included funds for PMTCT programs in
the GHAI account.

28 See [].

On January 28, 2003, during his State of the Union Address, President Bush
proposed that the United States spend $15 billion over the next five fiscal years to
combat HIV/AIDS through an initiative he called the President’s Emergency Plan for
AIDS Relief (PEPFAR). The President proposed channeling $10 billion through the
Global HIV/AIDS Initiative (GHAI) to 15 Focus Countries (9 of the 11 LIFE Focus
Countries are also PEPFAR Focus Countries); directing $4 billion to global TB
programs, international HIV/AIDS research, and bilateral HIV/AIDS programs in
more than 100 additional non-Focus Countries; and reserving $1 billion for U.S.
Global Fund contributions.29 In May 2003, Congress authorized sufficient funds to
support the initiative through P.L. 108-25, the U.S. Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act (the Leadership Act).
Each fiscal year since the inception of PEPFAR, Congress has allocated more
than the Administration has requested for global HIV/AIDS programs. Congress
exceeded the President’s five-year spending proposal for PEPFAR by nearly $5
billion. From FY2004 through FY2008, Congress provided almost $20 billion to
fight the global spread of HIV/AIDS, TB, and malaria, of which $18.3 billion was
appropriated for global HIV/AIDS programs and the Global Fund (Table 2). The
President’s FY2008 budget request included about $5.8 billion for global HIV/AIDS,
TB, and malaria efforts. Congress exceeded the President’s request by some $570
million, providing $6.3 billion for global HIV/AIDS, TB, and malaria efforts,
including $5.8 billion for global HIV/AIDS programs and a U.S. contribution to the
Global Fund.
Between FY2004 and FY2008, PEPFAR programs aimed to support care for 10
million HIV-affected people, including children orphaned by AIDS; to support the
prevention of 7 million new HIV infections; and to support the provision of ARVs30
to 2 million people. The Office of Global AIDS Coordinator (OGAC) reports that
as of September 30, 2007, PEPFAR-participating U.S. agencies and departments
have supported
!the provision of prevention of mother-to-child HIV transmission
(PMTCT) services during more than 10 million pregnancies, of
whom over 827,000 have received ARV treatment, leading to the
prevention of an estimated 157,000 new HIV infections;
!the purchase and distribution of ARV medication for an estimated
1.44 million people, 1.35 million of whom lived in Focus Countries
and 86,000 of whom were children;
!care for more than 6.6 million people in the Focus Countries, of
whom 2.7 million were orphans and vulnerable children; and

29 White House Fact Sheet, “The President’s Emergency Plan for AIDS Relief,” January 29,

2003, at [], visited on January 29, 2008.

30 Ibid.

!HIV counseling and testing services for over 33 million people.31
PEPFAR programs, led by OGAC at the U.S. Department of State and
implemented by various U.S. agencies and departments, are authorized to support
initiatives that prevent HIV/AIDS, TB, and malaria transmission, as well as care and
treatment for people affected by the three diseases. Meanwhile, U.S. agencies and
departments implement additional international HIV/AIDS, TB, and malaria
programs not funded through PEPFAR. In each fiscal year since PEPFAR was
launched, appropriators have included a chart in the foreign operations appropriations
conference reports that itemizes how global HIV/AIDS, TB, and malaria funds are
authorized to be spent (see Table 2). Most public documents refer to this chart as
“PEPFAR appropriations.”
Since FY2007, however, Congress has not included appropriations to global
malaria efforts in the “PEPFAR appropriations.” Instead, global malaria funds are
provided through the President’s Malaria Initiative (PMI). In June 2005, President
Bush launched PMI to increase support for U.S. international malaria programs by
more than $1.2 billion between FY2006 and FY2010 in 15 countries. Since launching
PMI, the Administration has requested that all support for bilateral malaria efforts be
provided to USAID as the coordinating agency for the initiative. When the
Administration shifted leadership for bilateral malaria programs to USAID in
FY2005, it determined that the Office of the Global AIDS Coordinator (OGAC)
would no longer include malaria spending in its annual PEPFAR reports to Congress
and that budgetary requests for the disease would be made separately from
HIV/AIDS and TB requests.
While authorizing legislation for PEPFAR requires the President to submit to
appropriators an annual report that describes how U.S. funds support the prevention
of HIV/AIDS, TB, and malaria, as well as care and treatment for those affected by
the three diseases, the annual reports that OGAC has submitted have reported only
on U.S. global HIV/AIDS activities and services provided to those co-infected with
HIV/AIDS and TB. There is some debate about whether malaria should be included
in PEPFAR spending estimates. U.S. spending on international malaria activities are
included herein, because in the first two fiscal years that PEPFAR was implemented,
the Administration included spending on HIV/AIDS, TB, and malaria in its reports
to Congress; the Leadership Act authorized support for all three diseases; and the act
required that the President report on progress made in addressing HIV/AIDS, TB, and

31 PEPFAR website, “Latest Results.” At [],
visited January 29, 2008.

Table 2. U.S. Spending on Global HIV/AIDS, TB, and Malaria: FY2004-FY2008
($ millions, current)
P r ogram F Y 2004Ac t u al F Y 2005Ac t u al F Y 2006Ac t u al F Y 2007Ac t u al F Y 2008Estimate F Y 2008
1. USAID HIV/AIDS (excluding Global Fund)555.5384.7373.8345.9371.12,031.0
2. USAID Tuberculosis85.192.091.594.9162.2525.7
3.USAID Malaria79.990.8102.0248.0349.6870.3
3. USAID Global Fund Contribution397.6248.0247.5247.50.01,140.6
4. FY2004 Global Fund Carryoverb(87.8)87.8n/an/an/a0.0
5. State Department GHAI488.11,373.51,777.02,869.04,116.410,624.0
6. GHAI Global Fund Contribution0.00.0198.0377.5545.51,121.0
7. Foreign Military Financingc1. — 6.9
8. Subtotal, Foreign Operations
Appropriations 1,519.9 2,278.7 2,791.7 4,184.4 5,544.8 16,319.5
9. CDC Global AIDS Programd266.9123.8122.6 121.5119.4754.2
10. CDC Tuberculosis2.
11. CDC Malaria9.
12. CDC International Research9.
13. NIH International Researche317.2370.0373.0372.0363.6 1,795.8
14. NIH Global Fund contribution149.
15. DOL AIDS in the Workplace Initiative9.91.9 0.0
16. Subtotal, Labor/HHS Appropriations763.3620.3603.6601.4786.53,375.1
17. DOD HIV/AIDS prevention education4.37.55.2
18. Total HIV/AIDS and Global Fund2,111.32712.33,198.04,434.05,818.818,274.4
19. GRAND TOTAL2,287.52,906.53,400.54,785.86,339.319,719.6
Sources: Prepared by CRS from appropriations bill figures and interviews with Administration officials.
Note: Agencies and departments might obligate more funds to global HIV/AIDS, TB, and malaria efforts than were appropriated.
All figures are at appropriated levels and include rescissions.
a. Although the Administration asserts operations for PMI began in FY2006, Congress did not appropriate funds to the initiative until
FY2007. That fiscal year, it provided $250.9 million for global malaria programs, including $149.0 million to expand PMI.
b. In FY2004, $87.8 million of U.S. contributions to the Global Fund was withheld per legislative provisions that prohibit U.S.
contributions to the Fund to exceed 33% of all contributions. The FY2005 Consolidated Appropriations act released these funds
to the Global Fund, subject to the 33% proviso.
c. Appropriations for Foreign Military Financing are used to purchase equipment for DOD HIV/AIDS programs.
d. Lower spending levels after FY2004 reflect the shift of funds initially reserved for the International Mother and Child HIV
Prevention Initiative to the Global HIV/AIDS Initiative account. When the initiative expired in FY2004, these changes were
made permanent and were applied to subsequent fiscal years.
e. Although appropriations bills do not specify funding for NIH’s international HIV research initiatives, sufficient funds are provided
to the Office of AIDS Research (OAR) to undertake such efforts. The figures used in Line 11 reflect those amounts reported
by OAR in its congressional budget justifications.

PEPFAR-Participating Departments and Agencies
A number of U.S. departments and agencies are responsible for implementing
PEPFAR programs, though OGAC coordinates the distribution of most U.S. global
HIV/AIDS spending. After the State Department, USAID, and HHS (which includes32
NIH’s Office of AIDS Research [OAR] and CDC’s GAP) receive the largest
congressional appropriations for international HIV/AIDS efforts. The Departments
of Defense (DOD) and Labor (DOL) also receive global HIV/AIDS funds, though
Congress has not appropriated funds to DOL since FY2006. The section below
itemizes obligations by each PEPFAR-participating department and agency to global
HIV/AIDS programs. All figures in this section are adjusted to reflect rescissions
unless otherwise specified.
Department of State: Office of the Global AIDS Coordinator
In FY2003, the Leadership Act authorized the creation of OGAC. The mission
of this office is to coordinate and oversee all global HIV/AIDS spending by U.S.
agencies in the 15 Focus Countries. At the time of selection, these countries were
among the world’s most severely affected by HIV/AIDS, were home to
approximately half of the world’s 40 million HIV-positive people, and held almost

8 million children who were orphaned or made vulnerable by HIV/AIDS.

As a coordinating office, OGAC transfers GHAI funds that it receives from
Congress for the 15 Focus Countries and other bilateral HIV/AIDS programs to
implementing departments and agencies. Figure 1 illustrates funds appropriated to
OGAC from FY2004 through FY2008. In FY2004, Congress provided OGAC its
first appropriation, $488.1 million. Congress provided a substantially larger amount
for GHAI in FY2005, when it appropriated $1,373.5 million to OGAC. Congress
boosted appropriations to GHAI again in FY2006 and FY2007, providing $1,777.0
million and $2,869.0 million, respectively.
In FY2008, Congress funded GHAI through a newly established account entitled
“Global Health and Child Survival.” The account consolidates the GHAI account
and USAID’s Child Survival and Health Account. The President’s FY2008 budget
request included $4,150.0 million for GHAI; Congress provided slightly less,
$4,116.4 million. From FY2004 to FY2008, total appropriations to GHAI reached
$10.6 billion, some $1.6 billion more than the Administration proposed for
PEPFAR’s five-year term.

32 Staff of OAR have indicated that they do not believe that OAR funds should be included
in overall PEPFAR funds, as the office does not receive funds through OGAC and its
spending decisions are independently made. Authorizing language in HHS appropriations
since FY2000 has enabled the Office of the Director at NIH to independently determine the
appropriate spending level for international HIV/AIDS research. Nonetheless, NIH
international HIV/AIDS research spending is included here as part of PEPFAR spending,
following the practice of OGAC.

Figure 1. OGAC HIV/AIDS Appropriations: FY2004-FY2008

50 00
40 00
30 00illio
t M
20 00rren
10 00
FY2004FY2005FY2006 FY2007 FY2008
OGAC AppropriationsGlobal Fund
Source: Compiled by CRS from appropriations legislation.
U.S. Agency for International Development (USAID)
USAID implements global HIV/AIDS programs in 50 countries and reaches an
additional 48 countries through regional programs. The programs largely focus on
the following objectives:
!strengthening primary health care systems;
!providing training, technical assistance, and commodities, including
pharmaceuticals that reduce HIV transmission;
!providing care and support to people infected with HIV/AIDS;
!reducing high-risk behaviors; and
!supporting international partnerships, such as the International AIDS
Vaccine Initiative (IAVI), UNAIDS, and the Global Fund.
Prior to the launching of the LIFE Initiative, USAID was the sole agency
through which Congress supported bilateral HIV/AIDS programs, though other
agencies or departments might have implemented global HIV/AIDS initiatives. In
FY2000, Congress appropriated $189.3 million to USAID for its global HIV/AIDS
programs. In FY2001, appropriators provided $318.0 million to the agency for
global HIV/AIDS projects, and an additional $100.0 million for a U.S. contribution
to the Global Fund.33 Appropriations for USAID’s bilateral programs rose in
FY2002 to $424.0 million, which included $100 million for the PMTCT Initiative.
When the additional $50.0 million that Congress appropriated for a U.S. contribution
to the Global Fund are added, total appropriations to USAID reached $474.0 million
33 In FY2000, Congress provided $20 million for a U.S. contribution to the Global Fund in
regular appropriations, and an additional $100 million in supplemental appropriations.

in FY2002.34 In FY2003, Congress slightly increased appropriations to the agency,
providing $523.8 million for its HIV/AIDS projects, including $99.3 million for the
PMTCT Initiative and an additional $248.4 million for the Global Fund.
In FY2004, when PEPFAR was first funded, appropriations to USAID’s
bilateral programs reached $555.5 million and appropriations to GHAI for the 15
Focus Countries were $488.1million. In FY2005 and FY2006, when appropriations
to GHAI were ramped up to $1,373.5 million and $1,777.0 million, respectively,
support for USAID’s bilateral programs fell below FY2004 levels to $384.7 million
and $373.8 million, respectively.35 In FY2007, appropriations to USAID bilateral
HIV/AIDS programs fell again to $345.9 million, but nearly reached FY2006 levels
in FY2008 with Congress providing an estimated $371.1 million; the President
requested $346.3 million.
Although appropriations for USAID’s HIV/AIDS programs have declined since
FY2004, overall obligations to USAID for global HIV/AIDS efforts have increased.
In FY2004 and in subsequent fiscal years, some of the funds that were appropriated
to OGAC for GHAI were transferred to USAID (see Figure 2). As a coordinating
body, OGAC does not implement HIV/AIDS programs; it transfers funds to the
implementing agencies and departments as needed. Most of the funds appropriated
to USAID are spent on global HIV/AIDS programs in non-Focus Countries; while
the majority of funds transferred by OGAC are sent to USAID for HIV/AIDS efforts
in the 15 Focus Countries. This practice has expanded USAID’s funding streams,
so that it receives support for its global HIV/AIDS programs from congressional
appropriations and from OGAC transfers. With OGAC transfers, total USAID
HIV/AIDS spending has increased substantially since FY2003.
OGAC transferred $230.0 million to USAID for HIV/AIDS projects in36
FY2004. In FY2004, USAID received a total of $785.0 million for its HIV/AIDS
projects ($230.0 million from OGAC and $555.0 million from Congress), some
$258.5 million more than in FY2003. Transfers to USAID continued to increase
with each fiscal year. In FY2005, OGAC obligated $743.0 million to USAID, $900.0
million in FY2006, and $1,552.0 million in FY2007.

34 In FY2002, Congress provided $100 million to USAID for a Global Fund contribution in
regular appropriations and an additional $100 million in supplemental appropriations. The
FY2002 supplemental appropriations also included $100 million for the PMTCT Initiative.
35 Includes appropriations to other accounts for USAID’s bilateral HIV/AIDS programs.
36 Data in this paragraph was compiled from correspondence with Karin Fenn, Program
Support Officer, OGAC on January 23, 2008.

Figure 2. USAID HIV/AIDS Appropriations: FY2000-FY2008

n $
t M
50 0
FY2000FY2001FY2002FY2003FY2004FY2005FY2006 FY2007FY2008
USAID AppropriationsGlobal FundOGAC TransfersPMTCT Initiative
Source: Compiled by CRS from appropriations legislation and interviews with OGAC staff.
Department of Health and Human Services
Centers for Diseases Control and Prevention. A number of HHS
agencies participate in PEPFAR activities. The CDC’s Global AIDS Program (GAP)
operates in 25 countries37 and includes regional programs in Asia, the Caribbean,
Central America, and Southern Africa. CDC initiated its international HIV/AIDS
programs in FY2000 under the LIFE Initiative. CDC sends clinicians,
epidemiologists, and other medical experts to assist foreign governments, health
institutions, and other entities that work on a range of HIV/AIDS-related activities.
The key objectives of GAP are to help resource-constrained countries prevent HIV
infection; improve treatment, care, and support for people living with HIV; and build
health care capacity and infrastructure. Specific activities within the projects include:
!conducting HIV lab tests;
!supporting ARV drug therapy for HIV/AIDS patients;
!preventing mother-to-child transmission (PMTCT);
!supporting HIV counseling and testing;
!strengthening national blood transfusion services to ensure safe
blood supplies;
!supporting medical injection safety programs; and
!building in-country surveillance, monitoring, and evaluation
37 The 25 GAP countries (with PEPFAR Focus Countries italicized) are Angola, Botswana,
Brazil, Cambodia, China, Côte d’Ivoire, D.R. Congo, Ethiopia, Guyana, Haiti, India, Kenya,
Malawi, Mozambique, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania,
Thailand, Uganda, Vietnam, Zambia, and Zimbabwe.

In FY2000, for the first time, Congress provided $34.8 million for CDC’s global
HIV/AIDS programs, and an additional $11.9 million for global HIV prevention and
research through FY2000 emergency supplemental appropriations. In FY2001,
Congress appropriated $104.5 million to CDC (of which $3 million was committed
to Health Resources and Services Administration (HRSA)’s International Training
and Education Center on HIV. In FY2002, funding increased again to $143.7
million. Congress provided about the same level of funding for GAP programs in
FY2003, providing $142.6 million for GAP programs and an additional $40 million
for the PMTCT Initiative. Funding for GAP dropped slightly in FY2004; that year
the initiative received $124.9 million and an additional $142.0 million for the
PMTCT Initiative.
In FY2005, when the PMTCT Initiative expired, Congress stopped including
funds for the effort to CDC. Funds for the PMTCT Initiative are included in GHAI
appropriations, and OGAC transfers funds to CDC to continue PMTCT activities.
GAP funding fell slightly in FY2005 and FY2006, when Congress provided $123.8
million and $122.6 million, respectively. In FY2007, Congress provided $121.0
million to GAP. The Administration requested $121.2 million for CDC HIV/AIDS
programs in FY2008; Congress appropriated $118.7 million.
Although appropriations to CDC GAP have declined since FY2004, when
OGAC transfers are included, as was the case for USAID, total provisions have
increased (Figure 3).38 In FY2004, OGAC transferred $231.0 million to CDC for
GAP programs, $574.0 million in FY2005, $753.0 million in FY2006, and $1,147.039
million in FY2007.

38 This chart does not include funding for other HHS global HIV/AIDS efforts, such as
CDC overseas applied HIV prevention research, and National Institutes of Health (NIH)
international HIV/AIDS research. The chart also does not include U.S. Global Fund
contributions, as the contribution is not funded through the CDC bilateral programs.
39 Data in this paragraph was compiled from correspondence with Karin Fenn, Program
Support Officer, OGAC on January 23, 2008.

Figure 3. CDC HIV/AIDS Appropriations: FY2000-FY2008

1000 $
FY2000FY2001FY2002FY2003FY2004FY2005FY2006 FY2007FY2008
HRSAGAP AppropriationsMother-to-child PreventionOGAC Transfers
Source: Compiled by CRS from appropriations legislation and interviews with OGAC.
National Institutes of Health (NIH). NIH has long implemented
international HIV prevention efforts. In 1984, NIH initiated its global HIV research
in Haiti; today NIH’s global HIV research is conducted in 90 countries around the
world. NIH-sponsored international research includes efforts to:
!develop an HIV vaccine;
!develop chemical and physical barrier methods for HIV prevention,
including microbicides;
!prevent sexually transmitted diseases, including HIV;
!encourage behavior change to lessen risky behaviors;
!identify drug and non-drug strategies to prevent mother-to-child HIV
!develop therapeutics for HIV-related co-infection; and
!strengthen approaches to treating HIV in resource-poor settings.
NIH staff assert that although PEPFAR draws on expertise from NIH’s Office
of AIDS Research (OAR) international HIV/AIDS research activities, OAR spending
on global AIDS research is not determined by PEPFAR priorities.40 OAR’s
international HIV/AIDS research spending is driven by research activities conducted
in the field. NIH staff explain that its program spending fluctuations represent the
funding phases of multi-year grants that support the research activities. Through
competitively bid grants, OAR directs most of its funds to U.S.-based investigators
who conduct HIV/AIDS research in collaboration with international scientists.
However, some investigators based in foreign research institutions have also received
OAR grants. In FY2007, OAR provided an estimated $372.0 million in grants for
40 CRS interview with Wendy Wertheimer, Senior Advisor, Office of the Director, Office
of the AIDS Research, on July 5, 2006.

global AIDS research activities (see Figure 4) and anticipates providing $363.6
million in FY2008.
Figure 4. Office of AIDS Research Grants: FY2000-FY2008

40 0
35 0
30 0
250lion $
200nt M
15 0urr
10 0
OAR Research Grants
Source: NIH, Office of the Director.
Health Resources and Services Administration (HRSA). HRSA, which
has experience expanding HIV/AIDS and other health services in resource-poor
settings in the United States, helps PEPFAR Focus Countries to develop HIV care
and treatment plans.41 Much of the training is conducted through International
Training and Education Centers on HIV (I-TECH). In 2002, HRSA and CDC
established I-TECH to share lessons learned from U.S. domestic AIDS education and
training efforts. I-TECH programs offer health experts in PEPFAR Focus Countries
and other resource-poor countries technical assistance on effective HIV/AIDS
program expansion. The assistance focuses on developing training programs,
advising health managers, producing health education materials, and providing
guidance on HIV awareness and education messages.
U.S. Food and Drug Administration (FDA). As OGAC began to establish
guidelines for the purchase of HIV treatment, the Bush Administration expressed
skepticism about broad-based use of generic ARV medication. The Administration
asserted that WHO’s prequalification process was not sufficient, and that generic
drugs purchased with PEPFAR funds had to pass FDA inspection.42 The
41 For more on HRSA’s global HIV/AIDS training efforts, see [].
42 The WHO prequalifying process includes an assessment of product files (lasting
approximately two to four months); site inspections; and the procurement of data on all
active pharmaceutical ingredients, specifications, product formulas, and manufacturing

Administration’s position was that the WHO is not a regulatory body, and thus its
adherence to stringent FDA standards was uncertain.43 Observers contended that the
U.S. position was shaped by then-Global AIDS Coordinator, Randall Tobias. When
President Bush selected Randall Tobias as the Global AIDS Coordinator in July
2003, some had opposed his appointment, fearing that he would oppose the use of
generic ARV medications in PEPFAR programs because of his long-standing
relationship with the pharmaceutical industry.44 The Bush Administration responded
that Mr. Tobias’s experience in the private sector was what made him a good
Debate about the use of generic ARVs in PEPFAR-supported programs
continued — though it was somewhat muted — after the FDA approved the first
generic ARV for use in PEPFAR programs in December 2004. Although the generic
drug was approved less than a year after FDA launched an expedited review process,
critics contended that the process was unnecessary and delayed the distribution of
ARVs.45 The FDA contended that the process was necessary to ensure that ARV
treatments used in the PEPFAR programs were safe, effective, and of high quality.46
The expedited review process can take between two and six weeks. Since FDA began
reviewing generic drug applications, more than 50 generic versions of patented ARVs
have been approved or tentatively approved for use in PEPFAR treatment plans.47

42 (...continued)
methods. After the products and manufacturing sites meet the required standards, the
medicine is added to the list of prequalified products. For more information, see
[ ht t p: / / www.who.i nt / 3by5/ publ i cat i ons/ br i ef s/ amds/ e n/ ] .
43 Interviews with staff at the Office of the AIDS Coordinator, April 1, 2004.
44 Randall Tobias is no longer the U.S. Global AIDS Coordinator. For a summary of the
debate on his selection for the position, see the Kaisernetwork website at [http://www. daily_reports/rep_index.cfm?hint=1&DR_ID=18625].
45 David Brown and Ellen Nakashima, “U.S. Rule on AIDS Drugs Criticized,” Washington
Post, July 14, 2004. Steve Sternberg, “Bush’s AIDS plan could be tough to implement,”
USA Today, July 14, 2004. “The end of the beginning? AIDS,” The Economist, July 17,
2004. For more on the debate about the FDA review process, see the Kaisernetwork website
at [].
46 HHS Press Release, “HHS Proposes Rapid Process for Review of Fixed Dose
Combination and Co-Packaged Products,” May 14, 2004, at [
press/2004pres/20040516.html ].
47 OGAC, “FDA Grants Tentative Approval for 50th and 51st Anti-Retroviral Drugs Under
President’s AIDS Relief Plan.” Press Release. August 13, 2007. At
[], visited on January 29, 2008. For more
information on FDA’s role in reviewing ARVs, see [].

Department of Defense (DOD)
The Department of Defense also joined the U.S. global fight against HIV/AIDS
under the LIFE initiative. DOD HIV prevention programs develop and implement
military-specific HIV prevention activities. DOD efforts:
!help foreign militaries to establish HIV/AIDS-specific policies for
their personnel;
!assist foreign militaries in adapting and providing HIV prevention
!train foreign military personnel to implement, maintain, and evaluate
HIV prevention programs;
!assist foreign countries in developing military-specific interventions
that address high-risk HIV attitudes and behaviors; and
!integrate with and make use of foreign military contacts, other U.S.
government programs, and those managed by allies and the United
In FY2000, the department received $10.0 million through the LIFE Initiative,
though Congress did not appropriate funds to the department.48 In FY2001, Congress
provided $10.0 million to DOD for its HIV prevention efforts. In FY2002, Congress
provided $14.0 million. Appropriations to the department fell in FY2003 to $7.0
million. In FY2004, Congress did not provide any funds for DOD HIV prevention
activities. However, through FY2005 appropriations, Congress amended FY2004
Defense appropriations to add $4.3 million for FY2004 DOD global HIV programs
and provided $7.5 million for FY2005 DOD HIV prevention efforts. In FY2006,
Congress appropriated $5.2 million to DOD for global HIV prevention activities.
The FY2007 Defense Appropriations (P.L. 109-289) did not provide funds for
DOD’s HIV/AIDS programs, though OGAC did transfer funds to the department in
that fiscal year. The President did not request funds for DOD’s HIV/AIDS
prevention efforts in FY2008, though Congress provided $8.0 million.
As with other U.S. agencies and departments, DOD spending on global HIV
prevention has been significantly boosted by OGAC transfers (see Figure 5). In
FY2004, OGAC transferred $14.0 million to DOD, $33.0 million in FY2005, $49.049

million in FY2006, and $70.0 million inFY2007.
48 DOD HIV Prevention website. At [
backgr ound/backgr ound.html ].
49 Data in this paragraph was compiled from correspondence with Karin Fenn, Program
Support Officer, OGAC on January 23, 2008.

Figure 5. DOD HIV/AIDS Appropriations: FY2000-FY2008

50llion $
40 M
FY2000FY2001FY2002FY2003FY2004FY2005FY2006 FY2007FY2008FY2008
(Reques t )(E s t i m at e)
DoD AppropriationsOGAC Transfers
Source: Compiled by CRS from appropriation legislation and interviews with OGAC staff.
Department of Labor (DOL)
DOL HIV/AIDS-in-the-workplace programs are implemented through the
Bureau of International Labor Affairs (ILAB). Key activities include:
!guiding the development of comprehensive workplace-based
prevention and education programs;
!assisting governments, employers, and trade unions to develop and
disseminate national workplace policy statements that counter
stigma and discrimination; and
!supporting the formation of tripartite advisory committees
(government, business, and labor).
ILAB initiated its HIV prevention programs under former President Clinton’s
LIFE Initiative. Although Congress did not appropriate funds to the bureau in
FY2000, ILAB reports that it spent $900,000 on international HIV/AIDS efforts in
that fiscal year.50 In FY2001, ILAB received its first global HIV/AIDS appropriation,
$10 million (excluding rescissions). From FY2001 to FY2004, Congress maintained
funding for DOL HIV-prevention in the workplace programs at $10 million
(excluding rescissions). Conference report language to FY2004 Labor, HHS, and
Education Appropriations stated that ILAB was to transfer the full balance of its
global HIV/AIDS funds to the International Labor Organization’s (ILO’s) global
AIDS programs. In FY2005, appropriations to ILAB HIV programs fell to $1.9
million; conference report language again included the statement that the funds were
50 Correspondence with Celeste Helm, HIV/AIDS Coordinator, Bureau of International
Labor Affairs, DOL, on June 30, 2003.

to be transferred to the ILO. In FY2006, Congress did not provide any funds to DOL
for HIV-in-the-workplace programs.51
The Administration did not request funds for DOL HIV programs in FY2007 or
FY2008, though OGAC transferred funds to the department from FY2005 to
FY2007. OGAC did not allocate funds to the department in FY2004, but provided
$2.0 million in FY2005, $1.0 million in FY2006, and $2.0 million in FY2007 (see
Figure 6).
Figure 6. DOL HIV/AIDS Appropriations: FY2000-FY2008

6nt M
FY2000FY2001FY2002FY2003FY2004FY2005FY2006 FY2007FY2008FY2008FY2008
(Reques t)(Hous e)(Senate)
DOL AppropriationsOGAC Transfers
Source: Compiled by CRS from appropriation legislation and interviews with OGAC staff.
Some speculate that the Bush Administration’s opposition to the rapid growth
and breadth of ILAB’s technical assistance programs led to a decline in congressional
support for the bureau’s HIV-in-the-workplace programs. Since the Administration
submitted its first budget request in FY2002, Secretary of Labor Elaine Chao has
attempted to minimize the scope of activities undertaken by ILAB. At an FY2002
hearing on DOL’s budget, the Secretary asserted that the increase in appropriations
from FY2000 to FY2001 was made too quickly and that the bureau was not able to
absorb the rapidly increased funding.52 At a subsequent budget hearing in FY2003,
the Secretary argued that ILAB needed to return its focus to improving core labor
standards and combating child labor abuses.53 Other activities that the bureau
engaged in — including combating HIV/AIDS — the Secretary contended, strayed
from the bureau’s core mission and duplicated the efforts of other U.S. agencies.
51 OGAC transferred some funds to DOL in FY2004, FY2005, and FY2006, providing
$400,000, $1,600,000 and $800,000, respectively.
52 U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, HHS,
Education Subcommittee, FY2002 Department of Labor Budget, May 2, 2001.
53 U.S. Congress, House Committee on Appropriations, Subcommittee on Labor, HHS,
Education Subcommittee, FY2003 Department of Labor Budget, February 13, 2002.

Finally, in FY2005, Secretary Chao complained that ILAB spent too much of its
budget on overhead through grants to other organizations.54
Peace Corps
The Peace Corps uses its volunteers to support community-based HIV/AIDS
care and prevention initiatives in 77 countries around the world, nine of which are
PEPFAR Focus Countries. Currently, some 20% of Peace Corps volunteers are
involved in HIV/AIDS and health projects worldwide, and some 800,000 people have
benefited from Peace Corps HIV/AIDS training.55 In 2003, about 1,000 volunteers
worked on HIV/AIDS programs, and in 2004, about 3,100 volunteers engaged in
HIV/AIDS activities.56 Congress has not appropriated funds to the Peace Corps for
international HIV/AIDS activities since PEPFAR was launched. OGAC reports
having transferred $1 million to Peace Corps for its international HIV/AIDS efforts
in FY2004, $5 million in FY2005, $8 million in FY2006, and $16 million in
U.S. Department of Commerce
The Department of Commerce provides in-kind support to PEPFAR aimed at
fostering public-private partnerships. The activities focus on informing industry HIV
trade advisory committees on how the private sector can help to combat HIV/AIDS;
and on creating and disseminating sector-specific strategies for various industries
(e.g., consumer goods, oil, and health care). The U.S. Census Bureau, within the
Department of Commerce, also contributes to PEPFAR by assisting with data
management and analysis, estimating infections averted, and supporting mapping of
country-level activities.
Issues for the Second Session of the
110th Congress
Reauthorize PEPFAR
Congressional debate about reauthorizing PEPFAR began in the first session ofth
the 110 Congress. One reauthorization bill has been introduced, and Members have
begun to debate at what level to fund a second five-year phase of PEPFAR. While
there appears to be strong support for the reauthorization of the initiative, a number
of Members and advocates have proposed some changes to the authorizing
legislation. Still other HIV/AIDS analysts suggest that health infrastructure

54 U.S. Congress, House Committee on Appropriations, Subcommittee on Labor, HHS,
Education Subcommittee, FY2005 Department of Labor Budget, February 12, 2004.
55 See Peace Corp’s website on HIVA/IDS. At [], visited on January 29, 2008.
56 See Peace Corp’s website, “What Do Volunteers Do?” At [
index.cfm?shell=learn.Whatvol.healthhiv], visited on January 29, 2008.

challenges and health worker shortages in many countries will have to be resolved
if the United States is to combat effectively the global spread of HIV/AIDS. The
section below analyzes some of the key issues that Congress might consider as it
debates PEPFAR reauthorization.
Determine Appropriate Amount of Support for PEPFAR
Reauthorization. The Leadership Act authorized the appropriation of the $15
billion that the President requested to fund PEPFAR through FY2008. Ultimately,
Congress supported the plan in excess of nearly $5 billion, providing $19.7 billion
for global HIV/AIDS, TB, and malaria initiatives from FY2004 through FY2008.
On May 30, 2007, President Bush requested that Congress authorize $30 billion
to extend PEPFAR an additional five years. The President anticipates that from
FY2009 through 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 (OVC). In August 2007,
Senator Richard Lugar introduced the HIV/AIDS Assistance Reauthorization Act of
2007 (S. 1966) to authorize $30 billion for FY2009 through FY2013. The bill
maintains the five-year approach to addressing HIV/AIDS, the Global AIDS
Coordinator position, and reporting requirements.
Some HIV/AIDS advocates would like Congress to provide more than the $30
billion that the President requested. On November 30, 2007, Senator Joseph Biden,
Chair of the Senate Foreign Relations Committee, issued a press release that urged57
Congress to provide $50 billion for a five-year PEPFAR reauthorization.
Representative Tom Lantos, Chair of the House Foreign Relations Committee,
announced that he intended to support efforts to increase funding for PEPFAR
“dramatically over current levels” and that the House Foreign Affairs Committee
would consider reauthorization of the initiative “as [the] first major order of business
in 2008.”58
Consider U.S. Contributions to the Global Fund. Some HIV/AIDS
analysts predict that debate on PEPFAR reauthorization might include whether to set
spending limits for U.S. contributions to the Fund and at what levels. P.L. 108-25
stipulates that U.S. contributions to the Fund for FY2004 through FY2008 may not
exceed 33% of contributions from all sources. Congress instituted the contribution
limit to encourage greater global support for the Global Fund. Some supporters of
the Fund argue that the 33% should represent the amount the United States

57 Senator Joseph Biden, “Biden Issues Statement on Eve of World AIDS Day.” Press
Release. November 30, 2007. At [
?id=bf310f9e-a173-4c46-bedd-12105bed5e61], visited January 29, 2008.
58 Representative Tom Lantos, “Observing World AIDS Day, Lantos Calls Congressional
Commitment to Ending Scourge of HIV/AIDS Higher Than Ever.” Press Release.
November 30, 2007. At [], visited
January 29, 2008.

contributes annually. Others argue that the statute serves as a ceiling and does not
commit the United States to providing 33% of all contributions.59
Some question whether U.S. contributions to the Fund are provided at the
expense of U.S. bilateral HIV/AIDS programs. At an FY2005 Senate Appropriations
Committee hearing, then-Global AIDS Coordinator Randall Tobias argued that the
“incremental difference between what the Administration requested and what was
appropriated to the Fund is money that might have been available” for use in U.S.
bilateral [HIV/AIDS] programs.60 While proposing PEPFAR, the Administration
announced that it would seek $1 billion for the Global Fund over the five-year term
of the initiative. In total, the Administration requested $1.3 billion for the Fund from
FY2004 to FY2008, $200 million in each of FY2004 and FY2005 and $300 million
in each of FY2006 through FY2008. Congress has consistently provided more to the
Fund than the Administration has requested, appropriating some $3 billion from
FY2004 through FY2008. In FY2008, Congress provided $840.3 million to the
Fund, the largest U.S. contribution in a fiscal year to date.
Reconsider Abstinence-Until-Marriage Provisions. Some health
experts assert that the spending requirements for HIV prevention activities are not
well-balanced, place too much emphasis on abstinence until marriage, and hinder
countries’ ability to utilize 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:
!55% of global HIV/AIDS funds are to be used to treat people
infected with HIV/AIDS, of which 75% should be spent on the
purchase and distribution of ARV medication;
!15% of global HIV/AIDS funds are to be used for palliative care;
!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; and
!10% of global HIV/AIDS funds should be reserved for children
orphaned or affected by HIV/AIDS.
Opponents of the 33% abstinence-until-marriage provision cite an April 2006
Government Accountability Office (GAO) report, which concluded that the
stipulation places a burden on prevention spending. GAO found that PEPFAR’s
spending requirements limit the flexibility with which prevention funds could be61
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

59 For more on this debate, see CRS Report RL33396, The Global Fund to Fight AIDS,
Tuberculosis, and Malaria: Progress Report and Issues for Congress, by Tiaji Salaam-
60 U.S. Congress, Senate Committee on Appropriations, FY2005 Appropriations, May 18,


61 GAO, Spending Requirement Presents Challenges for Allocating Prevention Funding
Under the President’s Emergency Plan for AIDS Relief, April 2006, at [
new.items /d06395.pdf].

country teams spend half of prevention funds on sexual transmission prevention and
two-thirds of those funds on abstinence/faithfulness (AB) activities. Additionally,
GAO found that OGAC applied the 33% spending requirement to all PEPFAR
prevention funding, even though P.L. 108-25 specifies application to the 15 Focus
Countries funded through GHAI.
Congress has already begun to introduce legislation to uphold, modify, or
eliminate the abstinence-until-marriage spending requirement. In the 110th Congress,
Members have enacted legislation that requires the Administration to follow the
funding guidelines of Congress for prevention activities in FY2008, notwithstanding
the 33% spending requirement for abstinence-until-marriage activities.62 Members
have also introduced the HIV/AIDS Assistance Reauthorization Act (S. 1966), which
would increase the portion of prevention funds to be spent on
abstinence-until-marriage and fidelity activities to 50%. Other bills seek to strike the
provision altogether, such as Protection Against Transmission of HIV for Women
and Youth Act of 2007 (H.R. 1713 and S. 2415) and HIV Prevention Act of 2007 (S.


Consider Impact of Abstinence-Until-Marriage Provision on Gender.
The 33% spending requirement is particularly troubling to some HIV/AIDS experts.
They contend that the provision does not consider gender dynamics in some of the
most affected countries. Research has shown that in Africa, married girls and women63
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% of64
unmarried girls’ boyfriends were HIV-positive. In response to these findings, some
Members have introduced legislation that aims to make PEPFAR responsive to
gender inequities. For example, the Protection Against Transmission of HIV for

62 Department of State, Foreign Operations and Related Programs Appropriations Act, 2008
(Division J of the Consolidated Appropriations Act, 2008; P.L. 110-161; 121 Stat. 2277),
paragraph relating to Global Health and Child Survival (121 Stat. 2292). The Senate
Committee on Appropriations reported out the House-passed foreign operations
appropriations (H.R. 2764) with language stating that funds the Act appropriated for Global
Health and Child Survival would be made available notwithstanding a requirement in the
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L.
108-25, Sec. 403(a); 22 U.S.C. 7673(a)) that “For fiscal years 2006 through 2008, not less
than 33 percent of the amounts appropriated ...shall be expended for
abstinence-until-marriage programs.”
63 “Early Marriage and HIV Risks in Sub-Saharan Africa.” Studies in Family Planning,
Volume 35, Number 3, September 2004. Also, “Protecting Young Women from HIV/AIDS:
The Case Against Child and Adolescent Marriage.” International Family Planning
Perspectives, Volume 32, Number 2, June 2006. [


64 The Implications of Early Marriage for HIV/AIDS Policy. Population Council, 2004.
[ pdfs/CM.pdf]

Women and Youth Act of 2007 (H.R. 1713 and S. 2415) requires the President to
formulate and submit to Congress a comprehensive, integrated, and culturally
appropriate global HIV prevention strategy that addresses the vulnerabilities of
married and unmarried women and girls to HIV infection and seeks to reduce the
gender disparities in HIV infection rates.
Emphasize Other HIV Prevention Strategies. Some HIV advocates
argue that a disproportionate percentage of prevention funds are spent on abstinence-
only programs, effectively limiting the amount of funds available for other HIV
prevention strategies. Many health experts advocate for greater spending on the65
prevention of mother-to-child HIV transmission (PMTCT). UNAIDS estimates that
1,800 children worldwide become infected with HIV each day, the vast majority of
whom are newborns. More than 85% of children infected with HIV live in sub-
Saharan Africa, although MTCT rates are rapidly rising in Eastern Europe and66
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 could67
prevent the transmission of HIV to their babies. The Global Pediatric HIV/AIDS
Prevention and Treatment Act of 2007 (S. 2472) amends PEPFAR authorizing
legislation to ensure that by 2013, 80% of pregnant women in the Focus Countries
receive HIV counseling and testing and all those who test positive receive PMTCT
Consider Access to Condoms. A number of HIV/AIDS advocates argue
that if PEPFAR is reauthorized, the guidelines on condom usage should be expanded.
Critics contend that the PEPFAR policy, which advises implementing partners to
distribute condoms to “high risk groups”68 has limited effectiveness. Other observers
complain that although research has demonstrated that married women are
particularly at risk of contracting HIV in Africa and India, 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 experts urge Congress to enact legislation that includes language similar

65 Most children living with HIV contract the disease through mother-to-child transmission
(MTCT), which can occur during pregnancy, labor and delivery, or breastfeeding. In the
absence of any intervention, the risk of such transmission is 15%-30% in non-breastfeeding
populations. Breastfeeding by an infected mother can increase the risk to 45%. The risk of
MTCT can be reduced to under 2% by interventions that include the provision of ARV
treatments. Elective caesarean delivery and complete avoidance of breastfeeding can also
reduce the risk of HIV transmission. In many resource-constrained settings, elective
caesarean delivery is seldom feasible, and mothers often lack access to enough clean water
or formula to refrain from breastfeeding. Research is ongoing to evaluate several new
approaches to preventing HIV transmission during breastfeeding.
66 UNAIDS 2006 Global AIDS Report, p.132.
67 Ibid, p. 133.
68 High risk groups are defined as sex workers and their clients; sexually active discordant
couples (when one partner is HIV-positive and the other is not infected) or couples with
unknown HIV status; substance abusers; mobile male populations; men who have sex with
men; and people living with HIV/AIDS.

to that proposed in HIV Prevention Act of 2007 (S. 1553), which expands the
definition of “high risk” individuals to include married and young people.
Integrate Family Planning Services Into PEPFAR Programs. A
growing number of health analysts are calling for better integration of family
planning and HIV/AIDS programs. Supporters of this strategy assert that adding
family planning services to PMTCT programs can achieve the same effect as
increasing drug coverage but at a lower cost. According to the Ensuring Access to
Contraceptives Act of 2007 (H.R. 2367) — a bill which aims to expand access to
contraceptives — at equal funding levels, family planning services can avert nearly69
30% more HIV-positive births than ARTs. The Focus on Family Worldwide Act
of 2007 (H.R. 1225) also aims to integrate family planning and HIV/AIDS activities.
Increase Anti-Retroviral Treatments for Children. According to
UNAIDS, some 2.1 million children and infants are living with HIV/AIDS
worldwide. In 2007, the virus killed an estimated 290,000 children.70 Without
treatment and care, approximately 50% of all HIV-positive children will die before
age two and 75% will die before age five.71 OGAC estimates that in FY2006, it
allocated 9% of all spending on ARVs to children.72 Some advocates for children
urge Congress to increase spending on pediatric HIV/AIDS ARVs so that funding
meets the needs of children currently without access to treatment. The Global
Pediatric HIV/AIDS Prevention and Treatment Act of 2007 (S. 2472) amends
PEPFAR authorizing legislation to require that by 2013, children account for at least

15% of those receiving treatment.

Expand the List of Focus Countries? On June 22, 2004, the White House
belatedly selected Vietnam to be the last of the 15 Focus Countries. According to a
White House press release, U.S. officials chose the country in part because they
believed that Vietnam was facing an HIV/AIDS explosion, though the country had
about 130,000 infected people at the time. Additionally, U.S. officials decided that
Vietnam had demonstrated significant commitment to fighting the disease, as it was
spending about $36 per person for HIV/AIDS care, prevention, and treatment.
Some HIV/AIDS analysts argued that India might have been a better selection,
because at the time, it shared the distinction with South Africa of having the highest

69 Ensuring Access to Contraceptives Act of 2007, H.R. 2367.
70 According to the UNAIDS website, “[an] in-depth review of HIV estimates among
children published in the 2007 AIDS Epidemic Update report in November 2007 has
revealed inaccuracies in processing some of the data. As a result, the figures used in this
paragraph reflect the corrected data and differ from those in the 2007 AIDS Epidemic
Update. At the UNAIDS homepage on the 2007 AIDS Epidemic Update:
[ en/K nowledgeCentre/HIVData/Ep iUpdate/EpiUpdArchive /

2007/default.asp], visited on January 29, 2008.

71 Elizabeth Glaser Pediatric AIDS Foundation, “In the Battle Against HIV/AIDS, Equal
Treatment for Children.” October 19, 2007. At [
72 PEPFAR webiste, “Pediatric Treatment and Care,” June 2007, [
pepfar/press/86524.htm] .

number of HIV-positive people (about 5.3 million). Administration critics theorized
that India was not chosen because at the time it had threatened to develop and
distribute generic versions of patented ARVs. The White House responded that India
was not chosen for a number of reasons, including the fact that the United States was
already providing the country more than $20 million in HIV/AIDS assistance.73 In
January 2007, U.S. Representative Barbara Lee introduced H.R. 175, to provide
assistance to combat HIV/AIDS in India. The bill would add India as to the list of
Focus Countries.
HIV/AIDS analysts are beginning to advocate that other countries where the virus
is rapidly spreading be included in GHAI. Some HIV/AIDS advocates would like
Congress to increase support in areas where HIV has become more entrenched,
particularly in Eastern Europe and Central Asia. UNAIDS estimates that the number
of people living with HIV in those regions has increased by 150% since 2001, when
about 630,000 people were living with the virus. At the end of 2007, about 1.6
million people were living with HIV in the two regions, 90% of whom were in
Ukraine and Russia. While Eastern Europe and Central Asia has demonstrated
significant increases in HIV prevalence, Members have introduced legislation to
boost support in other areas, namely India and the Caribbean. In February 2007,
Representative Luis Fortuno 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. Latest estimates indicate that the average
HIV/AIDS prevalence rate for the Caribbean is 1%. Nearly 75% of the 230,000
people living with HIV/AIDS in the region reside in Haiti or the Dominican
Address Infrastructure Challenges and
Health Worker Shortages
Global AIDS Coordinator Ambassador Mark Dybul testified at a March 2006
hearing on PEPFAR that ill-equipped health systems compromise the ability of the
United States to implement its PEPFAR programs efficiently. Ambassador Dybul
stated that building health infrastructure and strengthening health systems are critical
components of PEPFAR programs. According to OGAC, in FY2005, an estimated
25% of all PEPFAR-supported activities had components directly related to
strengthening health systems, such as quality assurance, financial management and
accounting, health networks and infrastructure, and commodity distribution and
control. In FY2006, OGAC allocated $44.8 million to policy analysis and system
strengthening. Although OGAC reports that it is allocating funds to strengthen
health systems, in a July 2004 report, GAO criticized some aspects of PEPFAR’s
health system strengthening efforts.74 GAO found that some of OGAC’s strategies

73 For more on this discussion, see the White House press release at [http://www.whitehouse.
gov/ news/releases /2004/06/20040622-12.html ].
74 GAO, U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment,
but Others Remain, July 2004, at [].

aimed at increasing the quality and quantity of health care workers in Africa might
not be cost-effective or practical for long-term implementation.75
The African Health Capacity Investment Act of 2007 (H.R. 3812 and S. 805)
aims to address some of these issues. The bill authorizes funds to improve health
care capacity on the continent. Related activities include training for African health
care workers, provision of incentive to encourage health worker retention, and
establishment of off-site HIV/AIDS testing and treatment facilities for health care
providers. The bill also requires the President to develop a strategy that would
coordinate health-related strategies with other donors. Some bills aim to improve
health care capacity by integrating HIV/AIDS programs with other key health
services, such as child survival and maternal health. The United States Commitment
to Global Child Survival Act of 2007 (H.R. 2266 and S. 1418) authorizes funds to
integrate and coordinate activities related to PMTCT, HIV/AIDS prevention, care and
treatment, malaria, TB, and family planning.
Integrate Food and HIV/AIDS Services
The United Nations’ Food and Agriculture Organization (FAO) estimates that in
2001-2003 there were 854 million undernourished people in the world.76 Most of the
world’s undernourished were in Asia (162 million, excluding India and China), India
(221 million), and China (142 million), though Africa (206 million) had the greatest
proportion; one in three people in Africa were undernourished. Poor nutrition in
HIV-positive people is particularly detrimental because poor nutrition weakens the
body’s immune response to the HIV virus and a number of HIV-associated
opportunistic infections. HIV-positive people with weak immune systems become
sick more frequently and develop AIDS more rapidly. Malnutrition may also be
associated with increased risk of HIV transmission from mother to child.
If patients are not well nourished, they can suffer significant side effects while
taking anti-retroviral medication (ARVs), and the drugs can be less effective. Studies
have demonstrated that a person with HIV requires 10% to 15% more energy and
50% to 100% more protein a day than a non-infected adult.77 Researchers in
Singapore found that patients who are malnourished when they start ARV therapy are

75 The Institute of Medicine of the National Academies also reviewed PEPFAR health
system strengthening strategies and made some recommendations on strengthening African
health care systems; see []. Some of the criticisms
that GAO made about PEPFAR health strengthening strategies were motivated by the
institute’s recommendations.
76 The causes of food insecurity and poor nutrition are complex, as are the range of possible
health effects. For statistics and more discussion on this issue, see FAO, The State of Food
Insecurity in the World 2006, [].
77 USAID website on HIV/AIDS and nutrition. At [
health/aids/TechAreas/nutrition/nutrfactsheet.html], visited on October 2, 2007.

six times more likely to die than well-nourished patients and are more likely to suffer
side-effects, which often caused them to stop taking the treatments.78
A growing number of HIV/AIDS advocates are urging Congress to mandate
OGAC to integrate nutritional support in PEPFAR programs. OGAC maintains that
it supports limited therapeutic feeding for malnourished AIDS patients, particularly
malnourished HIV-positive pregnant and lactating women, as well as malnourished
orphans and vulnerable children born to HIV-positive parents, who are clinically
malnourished and have no other food resources. Further, the Administration
contends that “[t]he Emergency Plan has a clear responsibility to prevent, treat and
care for people with HIV and AIDS, but comprehensively addressing issues of food
insecurity is beyond the scope of the Emergency Plan.”79 At an April 2007 House
Foreign Affairs Committee hearing on the progress of PEPFAR, Global AIDS
Coordinator Mark Dybul testified that OGAC had contributed $2.45 million to the
World Food Program (WFP) and would contribute an additional $4.27 million in
FY2007. According to the Administration, the United States provides nearly half of
all WFP’s resources, when all sources of U.S. funding are included.80
In the House report (H.Rept. 109-265) accompanying the FY2006 Foreign
Operations Appropriations (P.L. 109-102), Members urged OGAC to develop and
implement a strategy to address the nutritional requirements of those taking ARVs.
In Division J — the explanatory section for Department of State and Foreign
Operations Appropriations — of the FY2008 Consolidated Appropriations, Congress
directed that OGAC allocate no less than $100 million of PEPFAR funds to “address
short-term and long-term approaches to food security as components of a
comprehensive approach to fighting HIV/AIDS.” Additionally, in December 2007,
Representative Donald Payne introduced the Global HIV/AIDS Food Security and
Nutrition Support Act of 2007 (H.R. 4914) to amend the PEPFAR authorization to
integrate food security and nutrition activities into HIV/AIDS activities.
Boost Support for Research and Innovative Technology
Some HIV/AIDS advocates oppose congressional spending requirements, in part
because they limit the ability of implementers to explore emerging technologies. A
growing number of health experts are increasingly optimistic about the possible
development of a microbicide.81 HIV/AIDS proponents urge Congress to increase
support for microbicide research and development. Members have introduced

78 World Food Program website on HIV/AIDS. At [
food_for_hiv/nutrition.asp?section=12&sub_section=2], visited on October 3, 2007.
79 OGAC, Report on Food and Nutrition for People Living with HIV/AIDS. May 2006. At
[], visited on January 29, 2008.
80 U.S. State Department, “U.S. HIV/AIDS Program Blending Food Aid, Antiretroviral
Therapy.” Press Release. April 24, 2007. And OGAC, “Care for People Living with
HIV/AIDS,” Press Release. January 2008. At [

84749.htm], visited on January 29, 2008.

81 Microbicides are compounds that can be applied inside the vagina or rectum to protect
against sexually transmitted infections (STIs), including HIV.

legislation in support of microbicide research, such as House and Senate versions of
The Microbicide Development Act (H.R. 1420 and S. 823). The bills amend the
Public Health Service Act (42 U.S.C. 300cc-40 et seq.) and direct the Office of AIDS
Research to expedite the implementation of a federal microbicide research and
development plan, annually review the plan, and prioritize related funding and
activities. The bills also mandate the Director of the National Institute of Allergy and
Infectious Diseases to establish, within the Division of AIDS, an organizational unit
that would conduct microbicide research and development. The bills direct the head
of the Office of HIV/AIDS at USAID to develop and implement a program that
would support the development of microbicides products and facilitate their wide-
scale availability.
Some researchers recommend that Congress expand support for HIV/AIDS
vaccine research and development. Supporters of this idea argue that vaccine
identification should be an intractable part of U.S. international HIV/AIDS
assistance. A key concern for many vaccine proponents is that the cost of U.S.
international HIV/AIDS initiatives will continue to rise as more people receive
treatment. An HIV/AIDS vaccine could prevent new infections and ultimately save
the U.S. government billions of dollars. In February 2007, Senator Richard Lugar
introduced the Vaccines for the Future Act of 2007 (S. 569). The bill, and its House
companion (H.R. 1391), authorizes a number of strategies to accelerate the
development of vaccines for diseases primarily affecting developing countries,
including HIV/AIDS. Proposed strategies include encouraging public-private
partnerships; supporting research, development, and manufacturing incentives; and
providing tax credits for participating researchers and manufacturers.

Appendix. Participating Agencies and Departments
in U.S. Global HIV/AIDS Initiatives:
Life InitiativeRoleInitiative
Implementing Implementing
Agency orAgency or
Depart m e nt Depart m e nt
Coordinate implementation of the $9 billion GHAIOGAC
Support community-based HIV/AIDS care andPeace Corps
prevention initiatives
USAIDImplement programs that provide care andUSAID
treatment to those affected by HIV/AIDS, and
prevent new infections.
Encourage public-private partnerships, inform theDepartment of
private sector on how to counter HIV/AIDS,Commerce
provide HIV/AIDS data
DODProvide technical assistance in the developmentDOD
and implementation of HIV/AIDS policies and
programs for military personnel
DOLProvide technical assistance in the development ofDOL
comprehensive workplace-based HIV-prevention
and -education programs, and national workplace
HIV policy statements
CDCWork with health experts, governments, and healthCDC
institutions to provide care and treatment for those
infected with HIV; and to prevent new infections
Review and approve generic ARV drugs for use inFDA
PEPFAR programs
Help countries to develop HIV care and treatmentHRSA
Conduct NIH international research activitiesNIH
Notes: NIH is not included in the column for LIFE Initiative, because the Clinton Administration did
not include the institute in its proposal. Though the institute does not consider itself part of PEPFAR,
the Administration does and includes it in its reports to Congress.