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[Senate Report 110-193]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 415
110th Congress                                                   Report
                                 SENATE
 1st Session                                                    110-193

======================================================================

 
                 STOP TUBERCULOSIS (TB) NOW ACT OF 2007

                                _______
                                

                 October 9, 2007.--Ordered to be printed

Filed under the authority of the order of the Senate of October 4, 2007

                                _______
                                

   Mr. Biden, from the Committee on Foreign Relations, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 968]

    The Committee on Foreign Relations, having had under 
consideration S. 968, a bill to amend the Foreign Assistance 
Act of 1961 to provide increased assistance for the prevention, 
treatment, and control of tuberculosis, and for other purposes, 
reports favorably thereon and recommends that the bill do pass.

                                CONTENTS

                                                                   Page

  I. Purpose..........................................................1
 II. Committee Action.................................................1
III. Discussion.......................................................2
 IV. Cost Estimate....................................................3
  V. Evaluation of Regulatory Impact..................................4
 VI. Changes in Existing Law..........................................4

                               I. Purpose

    The purpose of S. 968 is to improve the detection of 
tuberculosis (TB), to reduce the global number of TB-related 
deaths, and to support multilateral efforts to improve the 
capacity of countries with high TB rates and other affected 
countries to implement the Stop TB Strategy and specific 
strategies related to addressing extensively drug resistant 
tuberculosis (XDR-TB).

                          II. Committee Action

    S. 968 was introduced by Senators Boxer, Smith, Durbin, and 
Brown on March 22, 2007. An additional 10 members cosponsored 
the legislation. On September 11, 2007, the committee ordered 
the bill, with an amendment in the nature of a substitute, 
reported favorably by voice vote.

                            III. Discussion

    Tuberculosis is one of the deadliest infectious diseases in 
the world, killing an estimated 1.6 million people per year. 
One third of the world's population is infected with the 
tuberculosis bacterium, and an estimated 8.8 million people 
develop active TB each year. Resistance to standard drug 
treatments for TB is increasing in number and severity: the 
emergence of extensively drug-resistant tuberculosis (XDR-TB) 
poses a significant global public health threat. Persons with 
HIV/AIDS are particularly vulnerable to TB and the convergence 
of these epidemics undermines gains in HIV/AIDS prevention, 
care, and treatment.
    S. 968 seeks to support the Global Plan to Stop TB, a ten-
year strategy launched last year at the World Economic Forum by 
an international coalition of 500 governments, non-governmental 
organizations, private sector organizations, and others to cut 
the number of TB deaths in half by 2015. The bill identifies 
the control of TB as a major United States foreign assistance 
objective and calls for U.S. development programs in high 
prevalence areas to prioritize the halving of the TB death and 
disease burden in part through improvements in the TB detection 
and cure rates in those countries.
    In order to advance this strategy, the bill authorizes 
support for a variety of activities, including: implementing 
the Directly Observed Therapy Short-course (DOTS) approach; 
treating persons who are co-infected with TB and HIV; treating 
persons with multi-drug resistant tuberculosis (MDR-TB); 
strengthening health systems; encouraging adherence to the 
International Standards for Tuberculosis Care; and expanding 
research to improve diagnostics, drugs, and vaccines to combat 
TB. The bill states that the President should ensure that $15 
million of the funds authorized in the legislation are used to 
make a contribution to the Global Tuberculosis Facility. The 
bill also authorizes the President to provide increased 
resources to the World Health Organization (WHO) and the Stop 
Tuberculosis Partnership to improve the capacity of countries 
with high rates of TB to combat the epidemic and address the 
issue of drug resistance.
    The bill amends section 104A(e)(2)(C)(iii) of the Foreign 
Assistance Act of 1961 (22 U.S.C. 2151b-2(e)(2)(C)(iii)) to 
require inclusion of annual reporting on the percentage of 
United States foreign assistance provided for diagnosis and 
treatment of individuals with tuberculosis in countries with 
the highest burden of tuberculosis, as determined by the World 
Health Organization.
    S. 968 authorizes the appropriation of up to $400 million 
for fiscal year 2008 and up to $550 million for fiscal year 
2009 to carry out the objectives of this Act. Of the amounts 
subsequently appropriated for this purpose, the bill states 
that up to $70 million may be available for fiscal year 2008 
and up to $100 million may be available for fiscal year 2009 
for the Centers for Disease Control and Prevention for the 
purpose of carrying out global tuberculosis activities. Funds 
appropriated pursuant to the authorization provided in this 
bill are to remain available until expended.

                            V. Cost Estimate

    In accordance with Rule XXVI, paragraph 11(a) of the 
Standing Rules of the Senate, the committee provides this 
estimate of the costs of this legislation prepared by the 
Congressional Budget Office.

                            United States Congress,
                               Congressional Budget Office,
                                Washington, DC, September 18, 2007.

Hon. Joseph R. Biden, Jr.,
Chairman, Committee on Foreign Relations,
U.S. Senate, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 968, the Stop 
Tuberculosis (TB) Now Act of 2007.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
          Sincerely,
                                           Peter R. Orszag.

                                ------                                

               Congressional Budget Office Cost Estimate

                                                September 18, 2007.
    S. 968 would authorize the appropriation of $400 million in 
2008 and $550 million in 2009 for programs working to control 
the global spread of tuberculosis. CBO estimates that 
implementing the bill would cost $93 million in 2008 and about 
$900 million over the 2008-2012 period, assuming that the 
authorized amounts are appropriated and that outlays will 
follow historical spending patterns for those programs. 
Enacting the bill would not affect direct spending or revenues.
    The estimated budgetary impact of S. 968 is shown in the 
following table. The costs of this legislation fall within 
budget functions 150 (international affairs) and 550 (health).

                                      ESTIMATED BUDGETARY IMPACT OF S. 968
                                     By Fiscal Year, in Millions of Dollars
----------------------------------------------------------------------------------------------------------------
                                                              2008       2009       2010       2011       2012
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION
International Assistance
  Authorization Level....................................        330        450          0          0          0
  Estimated Outlays......................................         66        239        264        113         52
Centers for Disease Control and Prevention
  Authorization Level....................................         70        100          0          0          0
  Estimated Outlays......................................         27         68         52         16          5
Total Changes
  Authorization Level....................................        400        550          0          0          0
  Estimated Outlays......................................         93        307        316        129         57
----------------------------------------------------------------------------------------------------------------

    S. 968 would authorize the appropriation of $400 million in 
2008 and $550 million in 2009 for foreign assistance to improve 
the detection of tuberculosis, to reduce the number of 
tuberculosis-related deaths in other countries, and to provide 
funds for those purposes to international organizations. Of 
those amounts, $70 million in 2008 and $100 million in 2009 
would be earmarked for global antituberculosis programs of the 
Centers for Disease Control and Prevention.S. 968 contains no 
intergovernmental or private-sector mandates as defined in the 
Unfunded Mandates Reform Act and would not affect the budgets 
of state, local, or tribal governments.
    On September 7, 2007, CBO transmitted a cost estimate for 
H.R. 1567, the Stop Tuberculosis (TB) Now Act of 2007, as 
ordered reported by the House Committee on Foreign Affairs on 
July 31, 2007. The two bills are similar, and their estimated 
costs are identical.
    The CBO staff contact for this estimate is Sunita D'Monte. 
This estimate was approved by Peter H. Fontaine, Assistant 
Director for Budget Analysis.

                   V. Evaluation of Regulatory Impact

    Pursuant to Rule XXVI, paragraph 11(b) of the Standing 
Rules of the Senate, the committee has determined that there is 
no regulatory impact as a result of this legislation.

                      VI. Changes in Existing Law

    In compliance with Rule XXVI, paragraph 12 of the Standing 
Rules of the Senate, changes in existing law made by the bill, 
as reported, are shown as follows (existing law proposed to be 
omitted is enclosed in black brackets, new matter is printed in 
italic, existing law in which no change is proposed is shown in 
roman).

                   The Foreign Assistance Act of 1961

           *       *       *       *       *       *       *
                                 PART I

Chapter 1--Policy; Development Assistance Authorizations

           *       *       *       *       *       *       *

SEC. 104A. ASSISTANCE TO COMBAT HIV/AIDS.

    (a) Finding.--Congress recognizes that the alarming spread 
of HIV/AIDS in countries in sub-Saharan Africa, the Caribbean, 
and other developing countries is a major global health, 
national security, development, and humanitarian crisis.

           *       *       *       *       *       *       *

    (e) Annual Report.--
          (1) In general.--Not later than January 31 of each 
        year, the President shall submit to the Committee on 
        Foreign Relations of the Senate and the Committee on 
        International Relations of the House of Representatives 
        a report on the implementation of this section for the 
        prior fiscal year.
          (2) Report elements.--Each report shall include--
                  (A) * * *

           *       *       *       *       *       *       *

                  (C) a detailed assessment of the impact of 
                programs established pursuant to such sections, 
                including
                          (i)(I) the effectiveness of such 
                        programs in reducing the spread of the 
                        HIV infection, particularly in women 
                        and girls, in reducing mother-to-child 
                        transmission of the HIV infection, and 
                        in reducing mortality rates from HIV/
                        AIDS; and
                          (II) the number of patients currently 
                        receiving treatment for AIDS in each 
                        country that receives assistance under 
                        this Act.
                          (ii) the progress made toward 
                        improving health care delivery systems 
                        (including the training of adequate 
                        numbers of staff) and infrastructure to 
                        ensure increased access to care and 
                        treatment;
                          (iii) with respect to tuberculosis, 
                        the increase in the number of people 
                        treated and the increase in number of 
                        tuberculosis patients cured through 
                        each program, project, or activity 
                        receiving United States foreign 
                        assistance for tuberculosis control 
                        purposes including the percentage of 
                        such United States foreign assistance 
                        provided for diagnosis and treatment of 
                        individuals with tuberculois in 
                        countries with the highest burden of 
                        tuberculosis, as determined by the 
                        World Health Organization (WHO); and

           *       *       *       *       *       *       *

SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.

    (a) Findings.--Congress makes the following findings:

           *       *       *       *       *       *       *

    [(b) Policy.--It is a major objective of the foreign 
assistance program of the United States to control 
tuberculosis, including the detection of at least 70 percent of 
the cases of infectious tuberculosis, and the cure of at least 
85 percent of the cases detected, not later than December 31, 
2005, in those countries classified by the World Health 
Organization as among the highest tuberculosis burden, and not 
later than December 31, 2010, in all countries in which the 
United States Agency for International Development has 
established development programs.]
    (b) Policy--It is a major objective of the foreign 
assistance program of the United States to control 
tuberculosis. In all countries in which the Government of the 
United States has established development programs, 
particularly in countries with the highest burden of 
tuberculosis and other countries with high rates of 
tuberculosis, the United States Government should prioritize 
the achievement of the following goals by not later than 
December 31, 2015:
          (1) Reduce by half the tuberculosis death and disease 
        burden from the 1990 baseline.
          (2) Sustain or exceed the detection of at least 70 
        percent of sputum smear-positive cases of tuberculosis 
        and the cure of at least 85 percent of those cases 
        detected.
    (c) [Authorization.] Assistance Required.--To carry out 
this section and consistent with section 104(c), the President 
[is authorized to] shall furnish assistance, on such terms and 
conditions as the President may determine, for the prevention, 
treatment, control, and elimination of tuberculosis.
    (d) Coordination.--In carrying out this section, the 
President shall coordinate with the World Health Organization, 
the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and 
other organizations with respect to the development and 
implementation of a comprehensive tuberculosis control program.
    [(e) Priority to DOTS Coverage.--In furnishing assistance 
under subsection (c), the President shall give priority to 
activities that increase Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant 
tuberculosis where needed using DOTS-Plus, including funding 
for the Global Tuberculosis Drug Facility, the Stop 
Tuberculosis Partnership, and the Global Alliance for TB Drug 
Development. In order to meet the requirement of the preceding 
sentence, the President should ensure that not less than 75 
percent of the amount made available to carry out this section 
for a fiscal year should be expended for antituberculosis 
drugs, supplies, direct patient services, and training in 
diagnosis and treatment for Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant 
tuberculosis using DOTS-Plus, including substantially increased 
funding for the Global Tuberculosis Drug Facility.]
    (e) Priority To Stop TB Strategy.--(1) Priority.--In 
furnishing assistance under subsection (c), the President shall 
give priority to--
          (A) activities described in the Stop TB Strategy, 
        including expansion and enhancement of DOTS coverage, 
        treatment fro individuals infected with both 
        tuberculosis and HIV and treatment for individuals with 
        multi-drug resistant tuberculosis (MDR-TB), 
        strengthening of health systems, use of the 
        International Standards for Tuberculosis Care by all 
        providers, empowering individuals with tuberculosis, 
        and enabling and promoting research to develop new 
        diagnostics, drugs, and vaccines, and program-based 
        operational research relating to tuberculosis; and
          (B) funding for the Global Tuberculosis Drug 
        Facility, the Stop Tuberculosis Partnership, and the 
        Global Alliance for TB Drug Development.
    (2) Availability of amounts.--In order to meet the 
requirements of paragraph (1), the President--
          (A) shall ensure that not less than 75 percent of the 
        amount made available to carry out this section for a 
        fiscal year should be expended for anti-tuberculosis 
        drugs, supplies, direct patient services, and training 
        in diagnosis and treatment to implement the Stop TB 
        Strategy; and
          (B) should ensure that not less than $15,000,000 of 
        the amount made available to carry out this section for 
        a fiscal year is used to make a contribution to the 
        Global Tuberculosis Drug Facility.
    (f) Assistance for WHO and the Stop Tuberculosis 
Partnership.--In carrying out this section, the President, 
acting through the Administrator of the United States Agency 
for International Development, is authorized to provide 
increased resources to the World Health Organization (WHO) and 
the Stop Tuberculosis Partnership to improve the capacity of 
countries with high rates of tuberculosis and other affected 
countries to implement the Stop TB Strategy and specific 
strategies related to addressing extensively drug resistant 
tuberculosis (XDR-TB).
    [(f)] (g) Definitions.--In this section:
          (1) DOTS.--The term ``DOTS'' or ``Directly Observed 
        Treatment Short-course'' means the World Health 
        Organization-recommended strategy for treating 
        tuberculosis, including low cost and effective 
        diagnosis, treatment, and monitoring of tuberculosis, 
        as well as a reliable drug supply, and a management 
        strategy for public health systems, with health system 
        strengthening, promotion of the use of the 
        International Standards for Tuberculosis Care by all 
        care providers, bacteriology under an external quality 
        assessment framework, short-course chemotherapy, and 
        sound reporting and recording systems.
          (2) DOTS-plus.--The term ``DOTS-Plus'' means a 
        comprehensive tuberculosis management strategy that is 
        built upon and works as a supplement to the standard 
        DOTS strategy, and which takes into account specific 
        issues (such as use of second line anti-tuberculosis 
        drugs) that need to be addressed in areas where there 
        is high prevalence of multi-drug resistant 
        tuberculosis.
          (3) Global alliance for tuberculosis drug 
        development.--The term ``Global Alliance for 
        Tuberculosis Drug Development'' means the public-
        private partnership that brings together leaders in 
        health, science, philanthropy, and private industry to 
        devise new approaches to tuberculosis and to ensure 
        that new medications are available and affordable in 
        high tuberculosis burden countries and other affected 
        countries.
          (4) Global tuberculosis drug facility.--The term 
        ``Global Tuberculosis Drug Facility (GDF)'' means the 
        new initiative of the Stop Tuberculosis Partnership to 
        increase access to high-quality tuberculosis drugs to 
        facilitate DOTS expansion.
          (5) Stop tuberculosis partnership.--The term ``Stop 
        Tuberculosis Partnership'' means the partnership of the 
        World Health Organization, donors including the United 
        States, high tuberculosis burden countries, 
        multilateral agencies, and nongovernmental and 
        technical agencies committed to short- and long-term 
        measures required to control and eventually eliminate 
        tuberculosis as a public health problem in the world.
          (6) Stop TB Strategy.--The term ``Stop TB Strategy'' 
        means the six-point strategy to reduce tuberculosis 
        developed by the World Health Organization. The 
        strategy is described in the Global Plan to Stop TB 
        2007-2016: Actions for Life, a comprehensive plan 
        developed by the Stop Tuberculosis Partnership that 
        sets out the actions necessary to achieve the 
        millennium development goal of cutting tuberculosis 
        deaths and disease burden in half by 2016.

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