PEPFAR: From Emergency to Sustainability

Prepared for Members and Committees of Congress

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

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

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

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

2006 (Table 1).

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

For example, in India, the number of sentinel surveillance sites increased to more than 1,100 in 2006 (up from 155 in
1998) and now more extensively cover at-risk populations. Since 2001, 30 countries in sub-Saharan Africa, Asia, and
the Caribbean have conducted national population-based surveys. Results from such population-based surveys have
generally indicated lower national HIV prevalence than extrapolations from sentinel site surveillance. For more
information on this process, see UNAIDS, 2007 AIDS Epidemic Update.
2 For 2006 estimates, see UNAIDS, 2006 Report on the Global AIDS Epidemic,
3 Prevalence is the total number of cases within a given time period; incidence is the number of new cases within a
given time period, such as a year.

Table 1. Adult (15-49 years) HIV Prevalence in Countries That Have Conducted
Population-Based HIV Surveys Since 2001
2001 2003 2005
Prevalence Prevalence Prevalence (%)
Population-Year (%) Reported (%) Reported Reported in
Based Survey Population-in 2002 AIDS in 2004 AIDS 2006 AIDS
HIV Prevalence Based Survey Epidemic Epidemic Epidemic
Countries Rate (%) Conducted Report Report Report
Sub-Saharan Africa
Benin 1.2 2006 3.6 1.9 1.8
Botswana 25.2 2004 38.8 38.0 24.1
Burkina 1.8 2003 6.5 4.2 2.0
Burundi 3.6 2002 8.3 6.0 3.3
Cameroon 5.5 2004 11.8 7.0 5.4
Central 6.2 2006 12.9 13.5 10.7
African Rep.
Chad 3.3 2005 3.6 4.8 3.5
Cote 4.7 2005 9.7 7.0 7.1
Equatorial 3.2 2004 3.4 Not Available 3.2
Ethiopia 1.4 2005 6.4 4.4 0.9 - 3.5
Ghana 2.2 2003 3.0 3.1 2.3
Guinea 1.5 2005 Not Available 2.8 1.5
Kenya 6.7 2003 15.0 6.7 6.1
Lesotho 23.5 2004 31.0 29.3 23.2
Malawi 11.8 2004 15.0 14.2 14.1
Mali 1.3 2006 1.7 1.9 1.7
Niger 0.7 2006 Not Available 1.2 1.1
Rwanda 3.0 2005 8.9 5.1 3.1
Senegal 0.7 2005 0.5 0.8 0.9
Sierra 1.5 2005 7.0 Not Available 1.6
South Africa 16.2 2005 20.1 20.9 18.8
Swaziland 25.9 2006-2007 33.4 38.8 33.4
Uganda 7.1 2004-2005 5.0 4.1 6.7
Tanzania 7.0 2004 7.8 9.0 6.5
Zambia 15.6 2001-2002 21.5 16.5 17.0
Zimbabwe 18.1 2005-2006 33.7 24.6 20.1

2001 2003 2005
Prevalence Prevalence Prevalence (%)
Population-Year (%) Reported (%) Reported Reported in
Based Survey Population-in 2002 AIDS in 2004 AIDS 2006 AIDS
HIV Prevalence Based Survey Epidemic Epidemic Epidemic
Countries Rate (%) Conducted Report Report Report
Cambodia 0.6 2005 2.7 2.6 1.6
India 0.28 2005-2006 0.8 0.9 0.9
Latin America and Caribbean
Dominican 1.0 2002 2.5 1.7 1.1
Haiti 2.2 2005-2006 6.1 5.6 3.8
Source: UNAIDS, 2007 AIDS Epidemic Update
Table 2. Regional HIV/AIDS Statistics, 2001 and 2007
Adults and Adults and Adult and
Children Living with Children Newly Infected Adult Child Deaths
HIV with HIV Prevalence Due to AIDS
(thousands) (thousands) (%) (thousands)
2001 2007 2001 2007 2001 2007 2001 2007
Sub-Saharan Africa 20,900 22,500 2,200 1,700 5.8 5.0 1,400 1,600
South & Southeast
Asia 3,500 4,000 450 340 0.3 0.3 170 270
Latin America 1,300 1,600 130 100 0.4 0.5 51 58
North America 1,100 1,300 44 46 0.6 0.6 21 21
E. Europe &
Central Asia 630 1,600 230 150 0.4 0.9 8 55
Western & Central
Europe 620 760 32 31 0.2 0.3 10 12
East Asia 420 800 77 92 <0.1 0.1 12 32
Middle East & N.
Africa 300 380 41 35 0.3 0.3 22 25
Caribbean 190 230 20 17 1.0 1.0 14 11
Oceania 26 75 3.8 14 0.2 0.4 <0.5 1.2
Total 29,000 33,200 3,200 2,500 0.8 0.8 1,700 2,100
Source: UNAIDS, 2007 AIDS Epidemic Update.

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

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

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

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

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

Information in this paragraph was summarized from WHO, Frequently asked questions about TB and HIV/AIDS. For more information on the impacts of TB and HIV/AIDS co-
infection see CRS Report RL34246, Tuberculosis: International Efforts and Issues for Congress, by Tiaji Salaam-
5 WHO Report 2006, Global Tuberculosis Control: Surveillance, Planning, Financing, at
publications/global_report/en/index.html. For more information on TB, see CRS Report RL34246, Tuberculosis:
International Efforts and Issues for Congress, by Tiaji Salaam-Blyther.
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 There are four types of malaria: Plasmodium (P.) vivax, P. malaria, P. ovale, and P. falciparum. P. falciparum, the
deadliest kind, is most common in sub-Saharan Africa and is a significant factor in the region’s high malarial mortality
rate. People contract malaria from infected mosquitos; and mosquitos can get malaria if they ingest blood from an
infected person.
8 WHO estimates that annually, 300 million malaria cases cause 1 million deaths with 90% of the deaths in sub-Saharan
Africa. The World Bank believes average annual cases exceed 500 million and about 85% of malarial deaths are in sub-
Saharan Africa, 8% in southeast Asia, 5% in the Middle East, 1% in the Western Pacific, and 0.1% in the Americas.
9 WHOs Roll Back Malaria website,

UNAIDS asserts that it would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in 10
2008 to effectively fight HIV/AIDS. In FY2006, Congress provided $3.4 billion for global
HIV/AIDS, tuberculosis (TB), and malaria programs (Table 3). Most recent statistics indicate that 11
in 2006, global spending reached nearly $9 billion, $6 billion less than UNAIDS advocated.
Table 3. U.S. Global HIV/AIDS, TB, and Malaria Appropriations
($U.S. current, millions)
FY2008 FY2004 FY2005 FY2006 FY2007
PROGRAM Actual Actual Actual CR
Request House Senate Enacted
(excluding Global 549.2 382.8 373.8 346.3 382.0 350.0 NYE 464.5
2. USAID Tuberculosis 100.4 87.8 91.5 89.9 313.5a 200.0 NYE
3. USAID Malariab 100.9 98.2 102.0 248.0 387.5 352.5 357.5 NYE
4. USAID Global Fund 397.6 247.9 247.5 247.5 0.0 250.0 250.0 NYE
5. FY2004 Global Fund -87.8 87.8 n/a n/a n/a n/a n/a NYE
6. State Department 488.1 1,373.5 1775.1 2,869.0 4,150.0 4,150.0 4,150.0 NYE
7. GHAI Global Fund 0.0 0.0 198.0 377.5 0.0 300.0 340.0 NYE
8. Foreign Military d1.5 1.9 1.9 0.0 0.0 0.0 NYE
9. Subtotal, Foreign
Operations 1549.9 2279.9 2,789.8 4,206.5 4,973.7 5,748.0 5,647.5
10. CDC Global AIDS e291.8 123.8 122.7 120.8 121.2 122.7 122.7 NYE
11. NIH International f317.2 370.0 373.0 372.0 373.0 NYE
12. NIH Global Fund 149.1 99.2 99.0 99.0 300.0 300.0 300.0 NYE

UNAIDS, Towards Universal Access: Assessment by the Joint United Nations Program on HIV/AIDS on Scaling Up
HIV Prevention, Treatment, Care and Support, March 2006.
11 Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from the G8,
European Commission and Other Donor Governments, Kaiser Family Foundation, 2006,

FY2008 FY2004 FY2005 FY2006 FY2007
PROGRAM Actual Actual Actual CR
Request House Senate Enacted
13. DOL AIDS in the 9.9 1.9 0.0 0.0 0.0 0.0 NYE
Workplace Initiative
14. Subtotal,
Labor/HHS 768.0 594.9 594.7 591.8 794.2
prevention 4.2 7.5 5.2 0.0 10.0 8.0
16. Section 416(b) Food 24.8 24.8 24.8 0.0 NYE
17. TOTAL 2346.9 2907.1 3,414.5 4,798.3 5,767.9
Sources: Prepared by CRS from appropriations legislation figures and interviews with Administration staff.
Note: This chart does not include discretionary spending on global HIV/AIDS, TB, and malaria programs, such as
CDC’s international HIV research and its global TB and malaria initiatives. “—” indicates that funds were not
earmarked, but could be provided at the Administration’s discretion. “NYE” means that the bill has not yet been
a. Includes $150.0 million provided to the Global HIV/AIDS Initiative for global TB efforts.
b. House and Senate appropriations committees began reporting out global malaria funds separately from
those supporting global HIV/AIDS and TB initiatives after President Bush launched the President’s Malaria
Initiative (PMI) in June 2005. The Administration reports that PMI became operational in FY2006 though
Congress first appropriated funds to PMI in FY2007. That fiscal year, Congress provided $248.0 million for
international malaria programs, including $149.0 million to expand PMI.
c. In FY2004, Congress withheld $87.8 million of the U.S. contribution to the Global Fund, because legislative
provisions prohibit U.S. contributions from exceeding 33% of all donor contributions to the Fund. FY2005
Consolidated Appropriations restored the funds.
d. Foreign Military Financing funds are used to purchase equipment for DOD HIV/AIDS programs (Line 15).
e. In FY2004, the International Mother and Child HIV Prevention Initiative expired. In subsequent fiscal years,
Congress appropriated funds for PMTCT activities to the Global HIV/AIDS Initiative account, though CDC
continues related efforts.
f. The figures used in Line 11 reflect the amount the Office of AIDS Research (OAR) reports it spends on
international HIV/AIDS research. Congress does not specify how much the Office should spend on this

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

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

Avert, an international HIV/AIDS charity, used UNAIDS data to reach its estimate. See world AIDS statistics at
13 Ibid.
14 PMI aims to increase U.S. support for global malaria programs by more than $1.2 billion between FY2006 and
FY2010 in 15 countries. For more information on PMI, see
15 Statistics on access to AIDS treatment was compiled from UNAIDS, Towards Universal Access: Scaling up priority
HIV/AIDS interventions in the health sector, April 2007.

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

16 Most children living with HIV acquire 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.
17 UNAIDS 2006 Global AIDS Report, p. 132,
18 UNAIDS 2006 Global AIDS Report, p. 132.
19 Ibid., p. 133.
20 Data from countries in sub-Saharan Africa indicate that the proportion of HIV-infected pregnant women receiving
ARVs in 2005 varied from under 1% to 54% and that the average regional coverage rate was 11%. In East, South, and
Southeast Asia, the average regional coverage rate was 5%, with individual country rates ranging from 3% to 10%. On
average, in Latin America and the Caribbean, 24% of HIV-infected mothers had access to ARVs; the coverage rate
ranged from 13% to 46%. It is estimated that overall coverage amounted to 75% in Eastern Europe and Central Asia
with coverage rates ranging from 38% to 95%. ARV coverage for HIV-infected pregnant women in North Africa and
the Middle East averaged less than 1%.

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

“Early Marriage and HIV Risks in Sub-Saharan Africa.Studies in Family Planning, Vol. 35, No. 3, September
2004., Protecting
Young Women from HIV/AIDS: The Case Against Child and Adolescent Marriage. International Family Planning
Perspectives, Vol. 32, No. 2, June 2006.
22 The Implications of Early Marriage for HIV/AIDS Policy. Population Council, 2004.
23 Violence Against Girls and Women: Effects on Sexual and Reproductive Health Decision Making. UNFPA website,
accessed on May 14, 2007
24 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.

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

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

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

Circumcision and Circumspection.The Lancet Infectious Diseases, May 2007, Vol. 7, No. 5,
26 WHO,WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV
prevention. March 28, 2007.
27 “Male Circumcision in HIV Prevention.The Lancet, Vol. 369, No. 9573, May 12, 2007,
28 “Male Circumcision in HIV Prevention.The Lancet, Vol. 369, No. 9573, May 12, 2007,
29 UNAIDS, Male Circumcision: Context, Criteria, and Culture.

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

USAID’s policy directive on the prostitution pledge can be found at
business_opportunities/cib/pdf/aapd05_04.pdf. Criticisms of PEPFAR spending requirements include AIDS Taskforce
of Greater Cleveland, Is PEPFAR Working? A Response to the Recent Annual Report Issued by the President’s
Emergency Plan for AIDS Relief, May 2006.
72BF3DD44B1E4B93A1077EC95C655E81/PEPFAR.pdf; Health Gap, U.S. Global AIDS Initiative, Round 2: From
Emergency to Sustainability. May 29, 2007.; Center for Health and
Gender Equity Policy Brief, Implications of U.S. Policy Restrictions for Programs Aimed at Commercial Sex Workers
and Victims of Trafficking Worldwide, November 2005.
ProstitutionOathImplications.pdf;The US Anti-Prostitution Pledge: First Amendment Challenges and Public Health
Priorities.” PLoS Medicine, Vol. 4, No. 7,
document&doi=10.1371/journal.pmed.0040207&ct=1; Advocates for Youth, Improving U.S. Global AIDS Policy for
Young People, 2007,; and Open Society Institute, “Anti-
Prostitution” Materials, June 2007
31 TheMexico 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 are undertaken with non-U.S. funds. For more
information on the policy, see CRS Report RL33250, International Population Assistance and Family Planning
Programs: Issues for Congress, by Luisa Blanchfield.

appropriations (H.R. 2764) that prevented the “Mexico City Policy” from being the sole reason
that U.S. funds could not be used to provide contraceptives. A conference is pending. Opposing
Members expect the President to veto any bill that repeals the “Mexico City Policy.”
Some health experts assert that congressional HIV prevention stipulations are not well-balanced,
place too much emphasis on abstinence until marriage, and limit countries’ ability to use
prevention funds in a manner that is most relevant to local conditions. P.L. 108-25, which
delineates how PEPFAR funds should be allocated, stipulates that between FY2006 and FY2008,

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

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

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

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

GAO, Spending Requirement Presents Challenges for Allocating Prevention Funding Under the Presidents
Emergency Plan for AIDS Relief, April 2006, at
33 Section 101 (c)(1) of P.L. 108-25 mandated that not later than three years after its enactment, the Institute of
Medicine (IOM) would “publish findings comparing the success rates of the various programs and methods used under
the [PEPFAR] strategy.” In March 2007, IOM released, PEPFAR Implementation: Progress and Promise. IOM
concluded thatPEPFAR has made a promising start, but the need for U.S. leadership in the effort to control the
HIV/AIDS pandemic continues.
34 DFID, Millennium Development Goals: Health Facts and Figures

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

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 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
36 Interviews with staff at the Office of the AIDS Coordinator, April 1, 2004.
37 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; and “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
38 GAO, Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications Provided Under U.S. Emergency Plan Is
Limited, January 2005.
40 OGAC, The Power of Partnerships: The Presidents Emergency Plan for AIDS Relief, 2007.
41 PEPFAR website, FDA Grants Tentative Approval for 50th and 51st Anti-Retroviral Drugs Under President’s AIDS
Relief Plan, August 13, 2007. For more information on FDAs role in
reviewing ARVs, see

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

FAO factsheet, HIV/AIDS, food security, and rural livelihoods
43 Statement made by Stuart Gillespie at the 2006 International AIDS Conference, Breaking the Vicious Cycle of
HIV/AIDS and Hunger.
44 FAO, The Impact of HIV/AIDS on Agriculture and Food Security, 2003,

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

Neonatal refers to the first four weeks of life.
46 United Nations, The Millennium Development Goals Report: 2007,
mdg2007.pdf. While the greatest shortage of health care workers in absolute terms are in southeast Asia (mostly in
Bangladesh, India, and Indonesia), sub-Saharan Africa suffers from the greatest proportional shortage of health care
workers in the world. WHO estimates that there are 57 countries with critical shortages of health care workers, 36 of
which are in Africa and none of which are in industrialized nations. Globally, WHO estimates that an additional 4.3
million health workers are needed, and that Africa would need to increase its number of health workers by about 140%
in order to meet the minimum threshold of 2.5 health care professionals per 1,000 people. WHO, 2006 World Health
47 United Nations, Africa and the Millennium Development Goals: 2007 Update,
48 Laurie Garrett, “The Challenge of Global Health,” Foreign Affairs, New York: January/February 2007, Vol. 86,
Issue 1,
49 See UNAIDS, 2006 AIDS Epidemic Update, and CDC, Interaction of HIV and Malaria,
50 WHO, 2006 Global Tuberculosis Control Report, People
living with HIV/AIDS are at greater risk of becoming infected with TB because of their weakened immunity. Each
disease speeds up the progress of the other, and TB considerably shortens the survival of people with HIV/AIDS.
HIV/AIDS is the most potent risk factor for converting latent TB into active TB, while TB bacteria accelerate the
progress of AIDS. Many people affected by HIV/AIDS in developing countries develop TB as the first manifestation of
AIDS. In HIV/AIDS-positive people, TB is harder to diagnose, progresses faster, is almost always fatal if undiagnosed
or left untreated, and kills up to half of all AIDS patients worldwide. People with HIV/AIDS are up to 50 times more
likely to develop TB in a given year than HIV/AIDS-negative people. About 90% of people living with AIDS die
within four to twelve months of contracting TB if not treated.
51 Information in this paragraph summarized from WHO, 2006 Global Tuberculosis Control Report,

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

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

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

Child mortality refers to the death of children younger than five years,
mortchildmortality/en/index.html. “The Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86,
Issue 1, “Lack
of money can no longer be blamed for the poor world’s health problems, The Economist, July 5, 2007.
53 WHO, 2006 World Health Report: Working Together for Health, The Joint
Learning Initiative (JLI), a network of global health leaders, defines a shortage as less than 2.5 health care professionals
per 1,000 people; the minimum proportion it deemed necessary to provide 80% of a countrys population with basic
health care (e.g., deliveries by skilled birth attendants and immunizations).
55Brain drain deprives Africa of vital talent.” Reuters, April 24, 2006

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

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

the Gates Foundation. According to Mr. Schouten, the Ministry is now implementing a program,
supported by PEPFAR, to attract Malawi health workers back to the country. Their tasks,
however, will be to distribute antiretoriviral medication. There is reportedly no support for
programs to attract health workers to treat malaria, diarrhea, and other common killers, such as
dysentery and respiratory infections.
Table 4. Number and Shortage of Doctors, Nurses, and Midwives
Number of Countries In Countries with Shortages
With Total Estimated Increase
WHO Region Total Shortages Workforce Shortage Required
Africa 46 36 590,198 817,992 139%
Americas 35 5 93,603 37,886 40%
Southeast Asia 11 6 2,332,054 1,164,001 50%
Europe 52 0 not applicable not applicable not applicable
Eastern 21 7 312,613 306,031 98%
Western Pacific 27 3 27,260 32,560 119%
World 192 57 3,355,728 2,358,470 70%
Source: WHO, 2006 World Health Report.
Table 5. Distribution of Health Workers in Africa and the United States
Physicians Nurses Midwives
Number Number Number Year
Population per per per Data
Country (2005) Number 1,000 Number 1,000 Number 1,000 Collected
Angola 15,941,000 881 0.08 13,135 1.15 492 0.04 1997
Cameroon 16,322,000 3124 0.19 26,042 1.60 45 0.00 2004
Ethiopia 77,431,000 1936 0.03 14,893 0.21 1,274 0.02 2003
Ghana 22,113,000 3240 0.15 19,707 0.92 3,910 0.18 2004
Mozambique 19,792,000 514 0.03 3,954 0.21 2,236 0.12 2004
Nigeria 131,530,000 34,923 0.28 210,306 1.70 6,344 0.05 2003
South Africa 47,432,000 34,829 0.77 184,459 4.08 82,726 0.67 2003
Uganda 28,816,000 2,209 0.08 16,221 0.61 4,164 0.16 2004

The Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86, Issue 1

Physicians Nurses Midwives
Number Number Number Year
Population per per per Data
Country (2005) Number 1,000 Number 1,000 Number 1,000 Collected
Tanzania 38,329,000 822 0.02 13,292 0.37 not available 2002
Zimbabwe 13,010,000 2,086 0.16 9,357 0.72 not available 2004
Africa 738,086,000 150,561 0.22 663,572 0.96 125,142 0.25 variable
United 295,410,000 730,801 2.56 2,669,603 9.37 not available 2000
Source: WHO, 2006 World Health Report.
Ambassador Dybul asserted at the April 2007 House hearing that PEPFAR strengthens health
systems and expands the health workforce. This assertion counters the findings that the Institute
of Medicine published in its March 2007 report, PEPFAR Implementation: Progress and 57
Promise. Though IOM concluded that “PEPFAR has made a promising start,” it found PEPFAR
might further limit health care options for those not suffering from HIV/AIDS.
PEPFAR’s HIV/AIDS activities have sometimes negatively affected other aspects of public
health systems and exacerbated resource constraints, particularly those related to national
human resource settings. If Focus Countries national plans for expanding their health
workforce are not supported, PEPFAR might worsen national shortages by shifting a
disproportionate share of the workforce to HIV/AIDS activities, which might cause other
health areas to be neglected.... PEPFAR’s initial emergency approach to meeting personnel
needs has been to focus on HIV-specific training of existing clinicians and other health care
workers. Support for expansion of the professional clinical workforce has been limited, even
when such expansion is an explicit part of the countrys HIV/AIDS plan, and the effort is
endorsed and supported by other donors... PEPFAR Country Teams often expressed concern
that they were not allowed to fund activities unless those activities were specifically part of
the HIV/AIDS effort and so could not support, for example, the training of new clinical 58
officers, who in some countries are the mainstay of the treatment efforts.
IOM recommended that OGAC work more closely with governments to analyze the impact that
PEPFAR-supported programs might have on public health systems, particularly in areas related to
maternal and child health and immunizations. IOM suggested that the analysis consider whether
PEPFAR’s incentives and salaries draw workers out of public systems and shift a disproportionate
share of the workforce to HIV/AIDS efforts. The report also asserted that PEPFAR should
increase support to the education of new health professionals.

58 Ibid.

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

10 Downing Street, PM announces International Health Partnership, August 22, 2007,
60 Ibid.
61 DFID, The International Health Partnership Launched Today, September 5, 2007,
62 Bilateral donors include Britain, Canada, France, Germany, Italy, the Netherlands, Norway, and Portugal.
Foundations and international organizations include Africa Development Bank, Bill and Melinda Gates Foundation,
European Commission, The Global Fund to Fight AIDS, TB, and Malaria, the Global Alliance for Vaccines and
Immunization (GAVI) Alliance, UNAIDS, UNICEF, United Nations Population Fund (UNFPA), WHO, and the World
63 The seven countries are Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal, and Zambia.
64Health systems encompasses the personnel, institutions, commodities, information, and the financing of health care
65 Global Health Council, Promoting Investments in Research to Strengthen Health Systems: Why and How, May 2006

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

For debate on this issue, seeA Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for
Controlling and Mitigating the Epidemic in Developing Countries,” American Journal of Public Health, July 2005,
Vol. 95, No. 7,; “Toward Ethical Review of Health System Transformations,” American
Journal of Public Health, March 2006, Vol. 96, No. 3,; and Center
for Global Development, Does the IMF Constrain Health Spending in Poor Countries, June 2007,
67Nurse Exodus Leaves Kenya in Crisis,” The Guardian Unlimited, May 21, 2006.
68 World Bank, Health Development: The World Bank Strategy for Health, Nutrition, and Population Results. April
69The Global HIV//AIDS Pandemic, Structural Inequalities, and the Politics of International Health,” American
Journal of Public Health, March 2002, Vol. 92, No. 3,
70 Oxfam, Debt Relief and the HIV/AIDS Crisis in Africa: Does the Heavily Indebted Poor Countries (HIPC) Initiative
Go Far Enough?, June 2002,

In the 110th Congress, legislation has been introduced in the House and Senate that authorizes
additional funds to voluntary family planning activities, improves coordination of HIV/AIDS and
other health initiatives, and strengthens supply chain logistics. The Focus on Family Health
Worldwide Act (H.R. 1225) would provide funds to expand access to voluntary family planning
programs in developing countries. The U.S. Commitment to Child Survival Act (S. 1418) would
provide assistance to improve the health of newborns, children, and mothers in developing
countries. The African Health Capacity Investment Act (S. 805) would amend the Foreign
Assistance Act of 1961 to assist countries in sub-Saharan Africa achieve internationally
recognized goals in the treatment and prevention of HIV/AIDS and other major diseases, reduce
maternal and child mortality, improve human health care capacity, and improve the retention of
medical health professionals.
Table 6. Spending on Health in Africa and the United States
Government External
Expenditure Resources
Per Capita Total as % of for Health
Per Capita Government Expenditure Total as % of Total
Population Expenditure Expenditure on Health as Government Expenditure
Country (000) on Health on Health % of GDP Expenditure on Health
Angola 15,490 $26.0 $41.0 2.8% 5.3% 6.7%
Cameroon 16,038 $37.0 $19.0 4.2% 8.0% 3.2%
Ethiopia 75,600 $5.0 $12.0 5.9% 9.6% 26.0%
Ghana 21,664 $16.0 $31.0 4.5% 5.0% 15.8%
Mozambique 19,424 $12.0 $28.0 4.7% 10.9% 40.8%
Nigeria 128,709 $22.0 $13.0 5.0% 3.2% 5.3%
South Africa 47,208 $295.0 $258.0 8.4% 10.2% 0.5%
Uganda 27,821 $18.0 $23.0 7.3% 10.7% 28.5%
Tanzania 37,627 $12.0 $16.0 4.3% 12.7% 21.9%
Zimbabwe 12,936 $40.0 $47.0 7.9% 9.2% 6.8%
United 295,410 $5,711.0 $2,548.0 15.2% 18.5% 0.0%
Source: WHO, 2006 World Health Report.
Note: All figures reflect data collected in 2003, except population, which was collected in 2004.
UNAIDS estimates that there are 2.5 million children living with HIV around the world, up from
1.5 million in 2001. Nearly 90% of all HIV-positive children live in sub-Saharan Africa. The rate
at which children are contracting the virus is declining, however, with 460,000 having acquired
HIV in 2001 and 420,000 in 2007. AIDS is also killing fewer children. In 2001, 330,000 children
succumbed to the virus; in 2005, 360,000 died from AIDS. But in 2007, the number fell to an
estimated 330,000.
HIV/AIDS affects not only those children living with the virus, but also those who lose their
parents to the virus and who live in homes that have taken in orphans. Children who have been

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

For more information on children affected by HIV/AIDS, see CRS Report RL32252, AIDS Orphans and Vulnerable
Children (OVC): Problems, Responses, and Issues for Congress, by Tiaji Salaam-Blyther.
72 Interview with Global Action for Children, a PEPFAR implementing partner, on November 21, 2007.
73 P.L. 109-95; 22 U.S.C. 2152f note. The act amended the Foreign Assistance Act of 1961 (P.L. 87-195) at Section
135 (22 U.S.C. 2152f) to establish the new program and position.

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

Elizabeth Glaser Pediatric AIDS Foundation, “In the Battle Against HIV/AIDS, Equal Treatment for Children,”
October 19, 2007,
75 PEPFAR webiste,Pediatric Treatment and Care,” June 2007,
76 The 2007 AIDS Epidemic Update did not provide 2007 prevalence estimates for Haiti and the Dominican Republic.
The report did indicate, however, that prevalence appears to have declined in Haiti since 1996. Among pregnant
women attending antenatal clinics, HIV prevalence fell from 5.9% in 1996 to 3.1% in 2004, and appeared to have
stabilized in 2006. UNAIDS attributes the declining trend to decreasing infection levels in the capital, Port-au-Prince,
and other cities, where HIV prevalence among 15 44-year-old women fell from 5.5% to 3% between 2000 and 2005.
The report also indicated that prevalence rates appears to have stabilized in Dominican Republic.

Glossary of Abbreviations and Acronyms
ARV Anti-Retroviral medication
DFID Department for International Development
FAO United Nations Food and Agriculture Organization
FDA U.S. Food and Drug Administration
GAO Government Accountability Office
GHAI Global HIV/AIDS Initiative
HIPC Highly Indebted Poor Countries
HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
IHP International Health Partnership
IMF International Monetary Fund
IOM Institute of Medicine
JLI Joint Learning Institute
MTCT Mother-to-Child Transmission
NIH National Institutes of Health
NGO Non-Governmental Organization
OAR Office of AIDS Research
OGAC Office of Global AIDS Coordinator
PEPFAR President’s Emergency Plan For AIDS Relief
PMI President’s Malaria Initiative
PMTCT Prevention of Mother-to-Child Transmission
TB Tuberculosis
UNAIDS Joint United Nations Program on HIV/AIDS
USAID U.S. Agency for International Development
WFP World Food Program
WHO World Health Organization
Tiaji Salaam-Blyther
Specialist in Global Health, 7-7677