99–010

Calendar No. 482

107TH CONGRESS REPORT

1st Session " ! SENATE 107–206

UNITED STATES LEADERSHIP AGAINST HIV/AIDS,

TUBERCULOSIS, AND MALARIA ACT OF 2002

JULY 3, 2002.—Ordered to be printed

Filed under the authority of the order of the Senate of June 26, 2002

Mr. BIDEN, from the Committee on Foreign Relations,

submitted the following

REPORT

[To accompany S. 2525]

The Committee on Foreign Relations, to which was referred the

bill (S. 2525) to amend the Foreign Assistance Act of 1961 to increase assistance for foreign countries seriously affected by HIV/

AIDS, tuberculosis, and malaria, and for other purposes, having

considered the same, reports favorably thereon and recommends

that the bill do pass.

CONTENTS

Page

I. Purpose ........................................................................................................... 1

II. Major Provisions ............................................................................................ 2

III. Funding Chart ............................................................................................... 3

IV. Background .................................................................................................... 3

V. Committee Action .......................................................................................... 5

VI. Committee Comments ................................................................................... 5

VII. Section-by-Section Analysis .......................................................................... 8

VIII. Cost Estimate ................................................................................................. 16

IX. Evaluation of Regulatory Impact .................................................................. 18

X. Changes in Existing Law .............................................................................. 19

I. PURPOSE

The purpose of the United States Leadership Against HIV/AIDS,

Tuberculosis, and Malaria Act of 2002 is to strengthen U.S. leadership and the effectiveness of the U.S. response to the global spread

of HIV/AIDS, tuberculosis (TB), and malaria by establishing a comprehensive, integrated 5-year global strategy to fight HIV/AIDS;

providing increased resources for multilateral efforts to fight HIV/

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AIDS; providing increased resources for U.S. bilateral efforts to

combat HIV/AIDS, TB, and malaria; encouraging the expansion of

private sector efforts and expanding public-private partnerships to

combat HIV/AIDS; and intensifying efforts to support the development of vaccines and treatment for HIV/AIDS, TB, and malaria.

II. MAJOR PROVISIONS

The bill has five titles. Title I strengthens policy planning and

coordination across the U.S. Government to combat the HIV/AIDS

pandemic. A key provision of this title mandates the establishment

of a comprehensive, integrated 5-year U.S. Government strategy to

promote the goals and objectives of the June 2001 U.N. General Assembly Declaration of Commitment on HIV/AIDS and to strengthen

the capacity of the United States to be an effective leader of the

international campaign against AIDS.

This title also requires the U.S. Agency for International Development (USAID) to develop a plan specifically designed to empower

women to prevent the spread of HIV/AIDS, including the provision

of currently available technologies. It also creates a new HIV/AIDS

Response Coordinator in the Department of State.

Title II authorizes funding for the Global Fund to Fight AIDS,

Tuberculosis and Malaria and relevant public-private partnerships

focused on vaccine research for these three diseases. The bill authorizes appropriations of $1 billion for the Global Fund in FY 03

and $1.2 billion in FY 04.

Title III authorizes expanded debt relief for poor countries to provide resources to combat HIV/AIDS, TB, or malaria. The Secretary

of the Treasury is authorized to conclude as soon as possible an

agreement with the World Bank and other appropriate multilateral

development institutions and donors to modify the Enhanced HIPC

(Heavily Indebted Poor Countries) Initiative to achieve debt reduction for health programs.

Title IV strengthens and expands U.S. bilateral efforts to respond to the health crises posed by AIDS, TB, and malaria. The

Foreign Assistance Act of 1961 is amended to provide USAID with

expanded and more detailed authorities with respect to the provision of assistance to combat each of these diseases. This title authorizes appropriations for USAID of $800 million in FY 03 and

$900 million in FY 04 for HIV/AIDS programs, $150 million in FY

03 and $200 million in FY 04 for TB programs, and $70 million in

FY 03 and $80 million in FY 04 for malaria programs.

Title IV also establishes a new Health Care Provider Service and

Training Program to enable American health care professionals to

provide basic health care services and on-the-ground training to African and other countries severely affected by HIV/AIDS, TB and

Malaria, expands the Department of Defense’s HIV/AIDS prevention assistance program to countries beyond sub-Saharan Africa

and to international peacekeepers, and requires the submission of

a comprehensive report on U.S. efforts to increase access to treatment for people living with HIV/AIDS.

In recognition of the needs of children and families, Title IV requires that the 5-year U.S. Government strategy mandated by the

bill meet or exceed the mother-to-child transmission (MTCT) prevention goals in the U.N. Declaration of Commitment on HIV/AIDS

and include testing and treatment programs for HIV-positive

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women and their family members and expanded programs for children orphaned by AIDS. The bill also creates a new assistance program for children and families to provide care and treatment to

parents and/or caregivers infected with HIV.

Title V sets forth a voluntary code of conduct for U.S. businesses

operating in countries affected by the HIV/AIDS pandemic. This

code includes best principles and practices for handling the challenges posed by HIV/AIDS in the workplace including discrimination and stigmatization, testing and confidentiality of HIV status,

work tenure and separation, the development of HIV/AIDS policies

and programs for the workplace and access to them, and availability of treatment.

III. FUNDING CHART

U.S. LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA ACT

OF 2002—Funding Levels

FY02 FY03 FY04

(appropriated) (under the bill) (under the bill)

Global Fund to Fight HIV/AIDS,

TB and Malaria ........................... 1$300 million $1.0 billion $1.2 billion

USAID–Bilateral ............................. 435 million 800 million 900 million

(Microbicide Research) 2 .............. (15 million) (20 million) (24 million)

(Pharmaceuticals) 2 ...................... 3 N/A (100 million) (120 million)

Vaccine Fund ................................... 53 million 60 million 70 million

International AIDS Vaccine Initiative ................................................ 10 million 12 million 15 million

Children’s Program ......................... 3 N/A 15 million 30 million

Health Care Professionals Program ............................................. 3 N/A 10 million 20 million

DOD HIV/AIDS Expanded Program ............................................. 14 million 50 million 55 million

TB–USAID Programs ..................... 75 million 150 million 200 million

Malaria Vaccine Fund (PATH) ...... 3 N/A 5 million 6 million

Malaria–USAID Program ............... 65 million 70 million 80 million

Total in billions ........................ $.952 $2.172 $2.576

1 Includes $100 million from FY01 Supplemental Appropriations bill.

2Sub-authorization under USAID Bilateral Funding.

3N/A—Spending has not been previously authorized.

IV. BACKGROUND

In the twenty years since AIDS was first recognized as an international health problem, the numbers of those infected with the

HIV virus and dying of AIDS has increased steadily and alarmingly. The epidemic, confined to sub-Saharan Africa for many

years, is now worldwide. According to the Joint United Nations

Programme on HIV/AIDS (UNAIDS) more than 60 million people

have been infected with HIV since the epidemic began. AIDS has

now become the fourth-highest cause of death globally, already

claiming the lives of 22 million people. More than three-quarters of

these deaths—more than 17 million—have been in sub-Saharan Africa, where AIDS is now the leading cause of death. Last year

alone, AIDS killed 2.3 million African people. Experts project that

the disease will eventually take the lives of one in four adults

throughout that region. Because of AIDS, Botswana, Zimbabwe,

and South Africa are already experiencing negative population

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growth, and life expectancy for children born in some parts of the

continent has dropped to as low as 35 years. Of the estimated 40

million people now living with HIV globally, 28.1 million are in

sub-Saharan Africa. This number includes 3.4 million people who

were infected last year alone.

The Caribbean is now the second most affected region, with 2.3%

of adults infected with HIV. Eastern Europe, especially the Russian

Federation, is experiencing the world’s fastest-growing epidemic,

mainly from injection drug use. In Asia and the Pacific region, 7.1

million people are infected with HIV or living with AIDS. Although

national prevalence rates in most countries throughout that region

are relatively low, localized epidemics have broken out in many

areas, and there is a serious threat of major outbreaks of the virus

in China, India, and a number of other countries. A newly released

U.N. study estimates that as many as 1.5 million Chinese contracted HIV last year and that China might have more HIV infections in the near future than any other country in the world.

The AIDS crisis takes a severe toll on children and young people.

Nearly one-third of the 40 million people currently living with HIV

are between the ages of 15 and 24; one-half of all new infections

occur in this age group. Mother-to-child transmission is responsible

for the vast majority of infections among children under the age of

15. Without preventive measures, 30–40% of infants born to HIVpositive mothers contract the virus. Even those who are not infected in this manner can confront tremendous difficulties—more

than 13 million children under age 15 have already lost their mothers or both parents to AIDS, and this number is expected to more

than double by the end of the decade. Children orphaned by AIDS

are susceptible to extreme poverty, malnutrition, psychological distress, and a long list of other hardships. Many of these orphans

turn to crime in order to survive.

The AIDS pandemic strikes at the foundations of societies—

threatening family cohesion and productivity; undermining local

and national economies; and weakening a broad range of institutions by taking the lives of educators, health care providers, police,

military personnel, and civil servants. These forces cripple the potential for long-term economic development and jeopardize political

and social stability and national security in sub-Saharan Africa,

the most-severely affected region, and increasingly in all corners of

the world. These ramifications of the AIDS crisis pose serious security concerns for the international community because they increase the potential for instability and failing states.

The devastation wrought by the HIV/AIDS pandemic is compounded by the prevalence of two other infectious diseases—tuberculosis and malaria—particularly in developing countries where the

poorest and most vulnerable members of society, such as women,

children and those living with HIV/AIDS, become infected. In the

year 2001, HIV/AIDS, TB, and malaria claimed the lives of more

than 5.7 million people and caused debilitating illnesses in millions

more. Tuberculosis, a highly communicable disease, causes the

death of one out of every three people with AIDS. HIV infection is

the leading threat to TB control. Tuberculosis, in turn, accelerates

the onset of AIDS in those infected with HIV.

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There is an alarming resurgence of malaria, the most deadly of

all tropical parasitic diseases, because of increasing resistance of

the malaria parasite to existing drug therapies and standard insecticides. The World Health Organization (WHO) estimates that between 2 and 3 million people die from malaria annually. Ninety

percent of these deaths are in sub-Saharan Africa. Those infected

with HIV are particularly vulnerable to malaria.

The spread of the pandemic has led the international community

to accelerate its response. In April 2001 the U.N. Secretary General, Kofi Annan, issued a call for action on HIV/AIDS including

the creation of a global fund to fight AIDS and other infectious diseases. At the end of the U.N. Special Session on HIV/AIDS, held

in June 2001, the Secretary General announced the creation of the

fund and welcomed pledges from donor nations and the private sector. The U.N. General Assembly concluded the session with the

adoption of the Declaration of Commitment on HIV/AIDS. This

Declaration set forth an international strategy for responding to

the AIDS crisis including specific targets for reducing the rate of

infection and death from HIV/AIDS.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is a

public-private partnership with a board comprised of representatives of donor countries, developing countries, non-governmental organizations, the private sector, relevant U.N. agencies, and those

living with or affected by one of the three diseases. The Fund solicits proposals and funds those that are deemed by the Technical Review Committee to have a clear and demonstrable impact in the

fight against AIDS, TB, and malaria. At the end of May 2002, the

Fund had some $2 billion in pledges with $700 million available for

disbursement in 2002. The United States has pledged $300 million

to the Fund through FY 02. The Bush Administration has requested $200 million for the Fund in its FY 03 budget.

V. COMMITTEE ACTION

The committee held two days of hearings on the HIV/AIDS crisis

and the United States Government response on February 13 and

14, 2002. On June 13, by unanimous voice vote, the committee ordered reported favorably without amendment S. 2525, the ‘‘United

States Leadership Against HIV/AIDS, Tuberculosis, and Malaria

Act of 2002,’’ introduced by Senators Kerry and Frist with 12 cosponsors on May 15.

VI. COMMITTEE COMMENTS

The committee recognizes that the HIV/AIDS pandemic presents

a serious moral and humanitarian crisis as well as one of the largest public health crises to date. While the rates of infection and incidence of death seem overwhelming, there is reason to believe that

this crisis can be addressed effectively. Behavior can be changed

through prevention and education programs, especially if those programs make treatment available to those individuals who already

have AIDS. The transmission of the HIV virus from mother to child

can be drastically reduced through the use of the drug nevirapine.

More children can be prevented from becoming ‘‘AIDS orphans,’’

that is children who lose one or both parents to AIDS, if voluntary

counseling, testing, and where necessary treatment is provided to

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the parents or caregivers through expansion of MTCT programs,

commonly called ‘‘MTCT plus.’’ It is the intention of the committee

that funding levels for programs for mother-to-child transmission

and treatment of family members and for programs for orphans

shall continue to rise above current levels.

HIV/AIDS is a global health crisis which must be addressed

through the full range of medical responses including access to

drugs, care and treatment for those who are ill, prevention programs for those not yet infected, and research to find a vaccine.

Parallel responses must also be directed toward TB and malaria.

However, the AIDS crisis is a multi-dimensional crisis with ramifications at the family, community, national and international

level. Dimensions beyond the health sector must be recognized and

factored into the response of the United States and others in the

international community.

The challenges posed by the AIDS pandemic demand a sustained

response at international and bilateral levels. The Global Fund is

a central element of the international response, mobilizing resources and moving governments in affected nations to draw up essential national strategies to combat the epidemic. However, a successful response requires intensified efforts on the part of all those

in the campaign against AIDS: the United States and other donor

nations, national governments in those countries severely affected,

non-governmental organizations, local community organizations,

charitable foundations, pharmaceutical companies, and others in

the private sector. The committee recognizes the major challenge of

developing as rapidly as possible the human and physical infrastructure required to undertake successful programs against AIDS.

The committee believes that this problem must be addressed urgently by all parties.

The committee believes that active participation and leadership

of the United States are critical to the success of the international

community’s campaign against HIV/AIDS. The United States has

much to bring to the effort: resources, technical expertise and

training, scientific research and knowledge, and a host of interested and committed parties in the private sector. The bill approved by the committee, S. 2525, will strengthen the capacity of

the United States to undertake this leadership role and enhance

the effectiveness of the U.S. bilateral response.

In recognition of the critical need for resources, the bill authorizes substantial increases in appropriations for Fiscal Years 03 and

04 for U.S. contributions to the Global Fund and for bilateral programs administered by USAID for HIV/AIDS, TB, and malaria.

The bill authorizes a total of $2.17 billion in FY 03—approximately

$1 billion more than the FY 02 appropriated level—and a total of

$2.57 billion for FY 04.

The bill brings coherence and rationality to the U.S. response by

ensuring that the United States has a 5-year, comprehensive, and

integrated government-wide strategy for addressing the global

AIDS crisis and meeting the targets set by the international community in the Declaration of Commitment on HIV/AIDS. The strategy mandate reflects the committee’s view that the U.S. response

must address the fundamental elements of prevention and education; care and treatment including access to drug therapies; research for vaccines, new drug protocols, and technologies for

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women; training of health care workers and the strengthening of

health care infrastructure and delivery systems.

The committee believes that the formulation of an integrated

strategy will reduce the duplication of efforts by the panoply of

U.S. Government agencies now involved in the fight against global

AIDS, including the Department of State, USAID, the Department

of Health and Human Resources and agencies under its control,

and the Department of Defense. It will also provide for greater coordination among these agencies and ensure that each agency undertakes programs primarily in those areas where it has the greatest expertise and experience. The committee also believes that the

creation of a new post, an HIV/AIDS Response Coordinator in the

Department of State, will improve inter-agency coordination.

The bill expands and strengthens the legislative mandate for

USAID to undertake the broad range of programs necessary to

combat not only HIV/AIDS but also TB, and malaria. While the

committee understands that funding limitations often force the

agency to make difficult choices, the committee expects USAID to

ensure that there is a fair balance between prevention and education programs, on the one hand, and care and treatment programs including programs that provide antiretrovirals and other

necessary drug therapies, on the other.

The committee realizes that a successful campaign to combat

these three major infectious diseases will require not only increased resources but also sustained cooperation among the donor

nations and between the donors and international organizations

such as the Global Fund and UNAIDS and increased efforts on the

part of the governments of countries acutely impacted. The bill

seeks to enhance the capacity of these governments by authorizing

expanded debt relief under the Enhanced HIPC Initiative as long

as the resources are devoted to health and poverty reduction programs.

Ultimately the ‘‘cure’’ for AIDS and other infectious diseases lies

in the development of effective vaccines. The committee strongly

supports ongoing efforts, such as those by the International AIDS

Vaccine Initiative and the Malaria Vaccine Initiative, to develop

vaccines. While efforts to produce a vaccine continue, it is essential

that plans be made now to assure prompt access to vaccines once

they are developed. Populations in resource-limited countries have

typically waited a decade or longer to receive life-saving vaccines

after they are licensed for use in industrialized nations. Similar

delays have occurred with access to AIDS therapies. The committee

understands that steps must be taken in advance of licensure of

AIDS, malaria, and TB vaccines to ensure that these vaccines are

rapidly available around the world. The public sector has an important role to play in providing resources to purchase vaccines for use

in resource-limited countries. Tax credits and other incentives may

also be useful in promoting sale of priority vaccines for use in these

countries. In addition, the public sector can significantly contribute

to accelerated vaccine access by working with vaccine manufacturers to ensure a sufficient, affordable supply of vaccines for developing country markets and avoid shortages.

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The committee believes that resource-limited countries should

have technical assistance available from developed country regulatory bodies, including the Food and Drug Administration, to assist with review of preclinical, clinical and manufacturing data.

This assistance will facilitate local decision making about hosting

clinical trials of particular products and expand each country’s ability to assure the safety and consistency of new products.

The committee regards assistance for vaccine research and development, and expanded access to vaccines once developed, as key

components of the strategy mandated by the bill.

VII. SECTION-BY-SECTION ANALYSIS

Section 1. Short Title: Table of Contents

This section entitles the Act as the ‘‘United States Leadership

Against HIV/AIDS, Tuberculosis, and Malaria Act of 2002.’’ The

Act is divided into five titles. The titles, with the sections each contains, are listed herein.

Sec. 2. Findings

This section presents findings regarding the magnitude and

scope of the global HIV/AIDS crisis, its impact at the family, community and national levels, and the type of response this crisis requires of the international community and the United States. Section 2 also contains findings on the impact of TB and malaria.

Sec. 3. Definitions

This section defines the key terms used throughout the Act.

Sec. 4. Purpose

This section states that the purpose of the Act is to strengthen

U.S. leadership and the effectiveness of the U.S. response to the

AIDS pandemic by establishing a comprehensive, integrated 5-year

global strategy, providing increased resources for multilateral and

bilateral efforts, encouraging the expansion of private sector efforts

and public-private sector partnerships, and intensify efforts to support the development of vaccines and treatment for HIV/AIDS, TB,

and malaria.

TITLE I—POLICY PLANNING AND COORDINATION

Sec. 101. Development of a Comprehensive, Five-Year, Global Strategy

This section mandates the President to establish a comprehensive, integrated 5-year strategy to combat global HIV/AIDS that

promotes the goals and objectives of the U.N. Declaration of Commitment on HIV/AIDS and strengthens the capacity of the United

States to be a leader in the international campaign against HIV/

AIDS. The strategy must address key issues including goals, strategies for vulnerable groups including treatment strategies, priorities

for relevant executive branch agencies and improving coordination

among them and at the international level, projected resource levels, expanding public private-sector partnerships, and maximizing

United States capabilities in the areas of technical assistance and

training and research including vaccine research. The President is

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required to submit a strategy report to Congress within 180 days

of enactment of the bill. Specific elements to be included in the report are listed in this section.

The committee views a 5-year strategy as essential to a successful U.S. Government response to the HIV/AIDS crisis and to effective American leadership on this issue. Many U.S. Government

agencies administer worthy international AIDS programs, but often

there is insufficient coordination and duplication of effort. A strategy that sets specific objectives and benchmarks for measuring success, addresses the full range of health issues including treatment

of those infected with the HIV virus and the needs of vulnerable

groups, treats AIDS as a multi-sectoral challenge, integrates the

programs of U.S. Government agencies into a rational approach,

and matches needs with resources will enable the United States to

undertake a credible and responsible leadership role in the fight

against AIDS.

Sec. 102. Comprehensive Plan to Empower Women to Prevent the

Spread of HIV/AIDS

This section requires USAID to develop a comprehensive plan to

empower women to protect themselves against the spread of HIV/

AIDS and lists specific elements to be included in the plan including increased access to currently available technologies for women

and microbicides when available. Section 102 mandates a report

within 270 days of enactment of the Act, and every year for the

next three years, on the programs and other activities undertaken

under the plan.

The committee recognizes that in many developing societies

women lack control over sexual encounters and that women are

biologically four times more vulnerable to HIV/AIDS infection than

men. These same women, who represent 55% of the HIV infections

in sub-Saharan Africa, are also the primary care givers to those infected with the disease.

The purpose of this section is to ensure that women of all ages

have access to education programs including health education and

economic empowerment programs in order to reduce their vulnerability to HIV and/or to mitigate its impact. USAID is directed to

devise a plan aimed at empowering women socially and economically to reduce their vulnerability to pressures which lead to unsafe

sexual practices. The plan is to include ways to target refugee populations as well.

As part of the plan, the Agency must increase women’s access to

micro-finance programs. In addition, the committee expects the

Agency to make use of a variety of existing programs which increase women’s access to regular paid employment, productive resources, and income.

The plan must also include an expansion of education programs

for men and boys which emphasize responsible sexual behavior,

such as refraining from coercive sexual practices, delaying sexual

debut, using safe sexual practices, and respecting the rights of

women and girls. Programs such as these are important and necessary components of any strategy to empower women to protect

themselves against HIV/AIDS.

Access to microbicides and other female initiated prevention

methods is an essential means of preventing infection and lowering

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the HIV/AIDS infection rate. The committee expects the Agency to

ensure that its programs for women provide access to currently

available technologies and others as they become available at an

affordable price for women in developing countries.

Sec. 103. HIV/AIDS Response Coordinator

Section 103 establishes the position of HIV/AIDS Response Coordinator, to be appointed by the President with the advice and consent of the Senate, in the Department of State. The Coordinator

shall report directly to the Secretary of State and have ambassadorial rank. The Coordinator shall have primary responsibility for

the oversight and coordination of all U.S. Government activities to

combat the HIV/AIDS pandemic and for pursuing coordination with

other countries and international organizations.

The committee believes that coordination of executive branch

agencies involved in the fight against HIV/AIDS is essential if the

U.S. Government response is to be effective. The Coordinator is to

ensure that U.S. Government programs are carried out in a coherent and structured manner and that there is communication between the agencies which contribute to efforts to fight the disease

overseas. While it is not the committee’s intent that the Coordinator manage or approve individual agency programs, the committee intends that the Coordinator make all final decisions regarding the resolution of disputes among various agencies as to

program coordination, policy and funding.

Sec.104. Report on Reversing the Exodus of Critical Talent

This section requires the President to submit a report to Congress within one year of the date of enactment analyzing the out

migration of critically important medical and public health personnel from sub-Saharan African countries that are acutely impacted by HIV/AIDS. Included in the report must be a description

of incentives and programs that the United States could provide to

encourage critical personnel to remain and work in their home

countries.

TITLE II—PUBLIC-PRIVATE PARTNERSHIPS

Sec. 201. Sense of Congress on Public-Private Partnerships

This section presents findings on the importance of public-private

partnerships in addressing international health crises and expresses the sense of Congress that these partnerships should be a

priority of the U.S. strategy to combat HIV/AIDS and other global

infectious diseases.

Sec. 202. Participation in the Global Fund to Fight AIDS, Tuberculosis, and Malaria

This section provides the authority for the United States to participate in the Global Fund to Fight Aids, Tuberculosis and Malaria

and authorizes appropriations of $1 billion for FY 03 and $1.2 billion for FY 04 for contributions to the Fund. It also mandates an

annual report on the activities of the Fund.

The committee applauds the establishment of the Global Fund,

which will serve as a focal point for the international community’s

campaign against the three major infectious global diseases—HIV/

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AIDS, TB, and malaria. The authorizations in this section reflect

the committee’s view that the provision of substantial resources to

the Fund is and must be a key component of U.S. leadership. Demands on the Fund will no doubt grow as national HIV/AIDS strategies are developed and grant applications increase. The committee

would support an increase in U.S. contributions to the Fund above

the authorization levels provided in this section to address these

demands.

While the committee expects the United States to demonstrate

strong support for the Fund and its work, the committee also believes that bilateral U.S. programs to combat AIDS, TB, and malaria should be strengthened and expanded. The committee does

not want to see contributions for the Global Fund made at the expense of these bilateral programs. To the contrary, funding for

these programs should increase because they are essential components of the U.S. response.

Sec. 203. Voluntary Contributions to International Vaccine Funds

This section authorizes appropriations for Fiscal Years 03 and 04

for the Vaccine Fund, the International AIDS Vaccine Initiative

(IAVI), and the Malaria Vaccine Initiative of the Program for Appropriate Technologies in Health (PATH). The Vaccine Fund is authorized at $60 million for FY 03 and $70 million for FY 04. IAVI

is authorized at $12 million for FY 03 and $15 million for FY 04.

The Malaria Vaccine Initiative is authorized at $5 million for FY

03 and $6 million for FY 04.

It is the intention of the committee that the funding for the Malaria Vaccine Initiative be additional to the funding that USAID

currently provides for existing malaria programs, including malaria

vaccine programs.

TITLE III—MULTILATERAL EFFORTS

Sec. 301. Improvement of the Enhanced HIPC Initiative

This section proposes deeper international debt cancellation to

provide poor countries with financial resources necessary to respond to public health crises, promote human development, and reduce poverty. The Secretary of the Treasury is authorized and encouraged to engage in negotiations with other donor countries, the

International Monetary Fund, the World Bank, and other international financial institutions to improve the operation of the Enhanced HIPC Initiative.

Specifically, the debt of HIPC countries would be reduced to a

more sustainable level as measured by two criteria: first, net

present value of qualified debt not to exceed 150% of the annual

value of exports, the standard in the current HIPC Initiative; and

second, annual payments on qualified debt not to exceed 10%, or

in the case of a country facing a public health crisis, 5% of internal

revenues, an additional measure of a country’s ability to repay external debt.

In financing the objectives of this section, the international financial institutions shall give priority to using their own resources.

An eligible poor country must ensure that the financial benefits

of debt reduction are applied to combating major health crises like

AIDS, poverty reduction, human development and to redress enviVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00011 Fmt 6659 Sfmt 6602 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
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ronmental degradation; to ensure that the financial benefits are in

addition to current public health and poverty reduction programs;

and to implement good government measures.

Sec 302. Reports on Implementation of Improvements to the Enhanced HIPC Initiative

This section requires the Secretary of the Treasury to report no

later than 180 days after the date of enactment on progress toward

an agreement to improve the operation of the Enhanced HIPC Initiative. In addition, one year after the submission of that report,

the Secretary of the Treasury is required to report on the progress

of countries to implement an improved HIPC program.

TITLE IV—BILATERAL EFFORTS

SUBTITLE A—GENERAL ASSISTANCE AND PROGRAMS

Sec. 401. Assistance to Combat HIV/AIDS

This section amends the Foreign Assistance Act of 1961 to

strengthen and expand the authorities of USAID to furnish assistance to prevent, treat and monitor HIV/AIDS and to carry our related programs in sub-Saharan Africa and other countries and

areas. Specific authorities include the provision of medications to

prevent MTCT, assistance to ensure safe blood supplies, research

on microbicides, bulk purchases of available prevention technologies for women, treatment of those infected with the HIV virus

including the provision of antiretrovirals, and the purchase and

distribution of HIV/AIDS pharmaceuticals.

Section 401 authorizes appropriations of $800 million for FY 03

and $900 million for FY 04 for HIV/AIDS programs and activities

administered by USAID. Reflecting the committee’s view that care

and treatment programs are fundamental elements of an effective

response to the AIDS crisis, the bill authorizes $100 million of the

funds authorized for FY 03 and $120 million of the funds authorized for FY 04 for the procurement and distribution of HIV/AIDS

pharmaceuticals.

Recognizing the urgent public health need to develop new HIV

prevention options and the emerging scientific opportunities in the

field, the committee is strongly supportive of USAID’s microbicides

research and development program, and urges USAID’s Office of

HIV/AIDS, in conjunction with other Agency offices and other appropriate executive branch agencies, to fully implement the Agency’s comprehensive strategy to support the development of

microbicides, and facilitate wide-scale introduction once these products are available. The bill authorizes $20 million for FY 03 and

$24 million for FY 04 for microbicide research, reflecting the committee’s expectation that USAID will fully fund this program.

Sec 402. Assistance to Combat Tuberculosis

This section amends the Foreign Assistance Act of 1961 to expand the authorities of USAID to provide assistance for the prevention, treatment, control and elimination of tuberculosis. Priority is

to be given to activities that increase directly observed treatment

shortcourse (DOTS) coverage, including funding for the Global Tuberculosis Drug Facility and the Stop Tuberculosis Partnership.

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This section authorizes $150 million for FY 03 and $200 million for

FY 04 for TB programs.

The committee intends that the increased resources authorized

by this section be used to measurably increase the number of patients cured of TB through proven, effective DOTS treatment (and

DOTS-plus treatment for multi-drug resistant TB). The committee

expects USAID to devote a large majority of the funds to the provision of anti-TB drugs, commodities, direct patient services and

health worker training to increase treatment coverage.

Efforts to provide much needed drugs and patient services have

been enhanced through the work of the Stop Tuberculosis Partnership, the Global Tuberculosis Drug Facility, and the Global Alliance for Tuberculosis Drug Development. The committee supports

the activities of these organizations and encourages the Agency to

expand support for each of them, including increased U.S. contributions to the Global Tuberculosis Drug Facility in order to provide

high quality, very low-cost TB drugs and help fill the $53 million

anticipated need for drugs through the Facility in 2003, and to the

Stop Tuberculosis Partnership.

Sec 403. Assistance to Combat Malaria

This section amends the Foreign Assistance Act of 1961 to add

a new section specifically authorizing assistance for the prevention,

treatment, control, and elimination of malaria. Section 403 also authorizes appropriations of $70 million for FY 03 and $80 million for

FY 04 for bilateral programs to combat malaria.

The committee believes that the resurgence of the malaria epidemic, particularly in sub-Saharan Africa and other developing

countries, requires an expanded assistance effort by the United

States. This effort should include not only assistance for malaria

vaccine research, which is authorized in section 203 of the bill, but

also support for entities engaging in anti-malarial drug research.

Currently, drugs are the only intervention that can treat malaria,

but drugs now available may not be effective in 5 to 10 years because the malaria parasite develops resistance to them. Given this

situation, the development and bringing to market of new, affordable drugs is critical to control of the malaria epidemic. The Medicines for Malaria Venture (MMV), a public-private partnership

founded by the World Health Organization, the World Bank, donor

nations and various U.S. charitable foundations, is at the forefront

of the effort to develop new malaria drugs. The committee urges

USAID to support MMV’s work, which holds the promise of closing

the treatment gap and reversing the spread of malaria.

Sec. 404. Pilot Program for the Placement of Health Care Professionals in Overseas Areas Severely Affected by HIV/AIDS, Tuberculosis, and Malaria

This section requires the President to establish a program to enable American health care professionals to serve in sub-Saharan

Africa and other areas severely affected by HIV/AIDS, tuberculosis,

and malaria. Participants in the program must provide basic

health care services, training to medical and other personnel in the

area in which they are serving, and health care educational training to local residents. The President may offer financial incentives

as necessary to encourage participation in the program. Section 404

14

authorizes appropriations of $10 million for the program for FY 03

and $20 million for FY 04.

Sec 405. Department of Defense HIV/AIDS Prevention Assistance

Program

The Department of Defense currently has a program to provide

prevention counseling and education for sub-Saharan African militaries. Section 405 mandates an expansion of that program to the

militaries of other countries severely affected by the AIDS crisis

and also to those serving in international peacekeeping operations.

Section 405 authorizes appropriations of $50 million for FY 03 and

$55 million for FY 04 for the expanded program.

Sec 406. Report on Treatment Activities by Relevant Executive

Branch Agencies

This section mandates a report to Congress within 15 months

after the date of enactment on the programs and activities of

USAID, the Centers for Disease Control and Prevention (CDC), and

other relevant executive branch agencies to bring treatment to individuals infected with the HIV virus or living with AIDS in foreign

countries. Section 406 specifies elements to be included in the report, including efforts to treat opportunistic infections and to provide antiretrovirals.

In the committee’s view, treatment is fundamental to a successful strategy to combat AIDS. Access to treatment strengthens the

impact of prevention, education and counseling programs and prolongs the lives of those living with HIV/AIDS.

SUBTITLE B—ASSISTANCE FOR CHILDREN AND FAMILIES

Sec . 411. Findings

This section presents findings on the impact of the HIV/AIDS crisis on children and efforts to reduce that impact.

Sec. 412. Policy and Requirements

Section 412 states that the United States Government should

place high priority on the prevention of mother-to-child transmission, the care and treatment of family members and care givers,

and the care of children orphaned by AIDS. This section also requires that the United States meet or exceed the specific targets

set by the Declaration of Commitment on HIV/AIDS to reduce the

rate of MTCT, include programs in the U.S. strategy to make testing and treatment available to HIV-positive women and their families, and expand programs for children orphaned by AIDS.

The committee believes that a strong emphasis on preventing

MTCT is one of the most important steps that can be taken to stem

the tide of the HIV/AIDS pandemic. At the United Nations Special

Session on HIV/AIDS, the United States made a commitment to reduce global infections of infants in accordance with the targets

agreed to in the Declaration of Commitment on HIV/AIDS, including a 20% reduction in the rate of infection of infants by 2005 and

a 50% reduction by 2010. USAID and CDC have skills and experience in preventing MTCT abroad; both are specifically authorized

to proceed with rapid scale-up of MTCT programs in resource poor

15

nations, with an emphasis on meeting the targets set by the United

Nations.

Funding is not the only obstacle to preventing MTCT. USAID,

working with other appropriate executive branch agencies, should

support operational research aimed at improving the success of

these programs by increasing the number of pregnant women who

participate and the number of women and infants who receive a

drug intervention to prevent HIV infection of the infant.

Rapid expansion of MTCT activities by USAID and other U.S.

Government agencies should include close cooperation with the

governments of resource poor nations, non-governmental organizations, and international entities such as UNICEF, WHO, UNAIDS

and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Nationwide scale up of MTCT prevention programs should focus on a

select number of nations prepared to undertake this step.

Efforts to prevent MTCT can serve as a basis to provide expanded care and treatment services to mothers and families living

with HIV/ AIDS. The committee supports the expansion of MTCT

to MTCT plus programs and urges USAID to expand the availability of care and treatment services for family members at MTCT

prevention sites that are well established and ready to take the

next step forward.

While it is particularly important to have programs to prevent

MTCT in sub-Saharan Africa, where in some nations more than

one-third of pregnant mothers are HIV-positive, the committee believes that USAID, working with CDC, should begin to initiate

MTCT prevention programs in other countries and regions where

the HIV infection rates are growing.

Sec. 413. Annual Reports on the Prevention of Mother-to-Child

Transmission of the HIV Infection

This section mandates a report, the first to be submitted within

270 days after the date of enactment and annually thereafter for

the next eight years, on the activities of relevant U.S. Government

agencies to assist in the prevention of mother-to-child transmission

of the HIV infection. Section 413 lists specific elements to be included in the report.

Sec. 414. Pilot Program of Assistance for Children and Families Affected by HIV/AIDS

This section directs the Administrator of USAID to establish a

new program of assistance for the care and treatment of orphans

and other children and young people affected by the global AIDS

crisis. The program must build upon and be integrated into programs currently administered by the Agency for children affected

by HIV/AIDS. It must also meet other requirements set forth by

the section. Section 414 authorizes appropriations of $15 million for

FY 03 and $30 million for FY 04 for the new program.

16

TITLE V—BUSINESS PRINCIPLES

Sec. 501. Principles for United States Firms Operating in Countries

Affected by the HIV/AIDS Pandemic

This section presents findings on the impact of the HIV/AIDS

pandemic in the workplace and expresses the sense of Congress

that U.S. firms operating in countries affected by the pandemic can

make significant contributions to the U.S. response to the pandemic through the voluntary adoption of certain principles and

practices.

Section 501 lays out ten principles and practices dealing with a

range of workplace issues including discrimination and stigmatization, compulsory HIV/AIDS testing, confidentiality, work tenure

and separation policies, the development of HIV/AIDS programs

and policies for the workplace, and access to treatment.

VIII. COST ESTIMATE

UNITED STATES CONGRESS,

CONGRESSIONAL BUDGET OFFICE,

Washington, DC, June 24, 2002.

Honorable JOSEPH R. BIDEN, JR., Chairman

Committee on Foreign Relations,

United States Senate,

Washington, DC.

DEAR MR. CHAIRMAN:

The Congressional Budget Office has prepared the enclosed cost

estimate for S. 2525, the United States Leadership Against HIV/

AIDS, Tuberculosis, and Malaria Act of 2002.

If you wish further details on this estimate, we will be pleased

to provide them. The CBO staff contact is Joseph C. Whitehill.

Sincerely,

BARRY B. ANDERSON

(for Dan L. Crippen).

Enclosure.

S. 2525—UNITED STATES LEADERSHIP AGAINST HIV/AIDS,

TUBERCULOSIS, AND MALARIA ACT OF 2002

Summary

S. 2525 would require the President to develop a comprehensive

strategy for the prevention, treatment, and monitoring of acquired

immune deficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) and would authorize appropriations in

2003 and 2004 to fund those efforts. Specifically, the bill would authorize appropriations for contributions to the Global Fund to Fight

AIDS, Tuberculosis, and Malaria and to various international vaccine funds. It would authorize funding for bilateral assistance programs to prevent, treat, and monitor HIV/AIDS, tuberculosis, and

malaria and for assistance to the families and children of persons

affected by those diseases. Assuming appropriation of the authorized amounts, CBO estimates implementing S. 2525 would cost

$256 million in 2003 and almost $4.5 billion over the 2003-2007 peVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00016 Fmt 6659 Sfmt 6602 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
17

riod. The bill would not affect direct spending or receipts; therefore,

pay-as-you-go procedures would not apply.

S. 2525 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA)

and would impose no costs on the budgets of state, local, or tribal

governments.

Estimated cost to the Federal Government

The estimated budgetary impact of S. 2525 is shown in Table 1.

The estimate assumes that the bill will be enacted by September

30, 2002, and the authorized amounts will be appropriated each

year. The costs of this legislation fall within budget functions 150

(international affairs) and 050 (defense).

TABLE 1.—BUDGETARY IMPACT OF S. 2525

[By fiscal year, in millions of dollars]

2002 2003 2004 2005 2006 2007

SPENDING SUBJECT TO APPROPRIATION

Spending Under Current Law for HIV/AIDS and other Infectious Diseases:

Budget Authority 1 ........................................................ 785 0 0 0 0 0

Estimated Outlays ........................................................ 646 461 170 79 37 17

Proposed Changes:

Authorization Level ....................................................... 0 2,172 2,576 0 0 0

Estimated Outlays ........................................................ 0 256 1,478 1,789 655 303

Spending Under S. 2525 for HIV/AIDS and other Infectious Diseases:

Authorization Level 1 .................................................... 735 2,172 2,576 0 0 0

Estimated Outlays ........................................................ 646 717 1,648 1,868 692 320

1 The 2002 level is the amount appropriated for that year.

Basis of Estimate

S. 2525 would identify three diseases—HIV/AIDS, tuberculosis,

and malaria—as being of particular concern to the United States

and would require the President to develop a comprehensive strategy to combat these diseases on a global basis. It would establish

the position of Coordinator of U.S. Government Activities to Combat HIV/AIDS with the responsibility to oversee and to coordinate

U.S. programs with those of other countries and international organizations. The bill would require numerous reports to the Congress,

and it would permit a portion of the authorized amounts to be used

for administrative expenses.

Table 2 shows the amounts specifically authorized by the bill.

CBO estimates that spending for bilateral assistance programs and

for contributions to the international vaccine funds will follow historical patterns for similar programs. The Global Fund to Fight

AIDS, Tuberculosis, and Malaria is just starting operations, having

approved its first grants in April 2002. CBO estimates that disbursements to the fund will proceed relatively slowly with disbursements tied to the fund’s payments to grant recipients to preclude the fund from building up idle cash balances.

18

TABLE 2.—SPECIFIC AUTHORIZATIONS IN S. 2525

[By fiscal year, in millions of dollars]

2003 2004

Contribution to the Gobal Fund to Fight Aids, Tuberculosis, and Malaria .................................... $1,000 $1,200

Contributions to International Vaccine Funds:

Global Alliance for Vaccines and Immunizations ....................................................................... 60 70

AIDS Vaccine Initiatives .............................................................................................................. 12 15

Malaria Vaccine Initiative ........................................................................................................... 5 6

Bilateral Assistance Programs:

Assistance to Combat HIV/AIDS .................................................................................................. 800 900

Assistance to Combat Tuberculosis ............................................................................................ 150 200

Assistance to Combat Malaria ................................................................................................... 70 80

Department of Defense HIV/AIDS Prevention Assistance ........................................................... 50 55

Pilot Program to Place Health Professionals Overseas .............................................................. 10 20

Pilot Programs to Assist Children and Families ........................................................................ 15 30

Total Authorization Level ........................................................................................................ $2,172 $2,576

Title III would urge the Secretary of the Treasury to negotiate

an agreement with other bilateral and multilateral creditors to provide debt relief to highly indebted poor countries (HIPC) on terms

more generous than the enhanced HIPC initiative agreed to in

1999. The cost of this more generous debt relief would be borne by

other creditors because current law only authorizes the United

States to cancel its bilateral debt to HIPC countries. The bill would

not authorize funds for any United States’ contribution to multilateral, creditors for the cost of debt reduction that the U.S. government would be asking them to bear. CBO has no basis for estimating whether or not such negotiations would be successfully concluded.

Pay-as-you-go considerations

None.

Intergovernmental and private-sector impact

S. 2525 contains no intergovernmental or private-sector mandates as defined in UMRA and would impose no costs on the budgets of state, local, or tribal governments.

Estimate prepared by

Federal Costs: Joseph C. Whitehill. Impact on state, local, and

tribal governments: Greg Waring. Impact on the private sector:

Paige Piper/Bach.

Estimate approved by

Peter H. Fontaine, Deputy Assistant Director for Budget Analysis.

IX. EVALUATION OF REGULATORY IMPACT

In accordance with rule XXVI, paragraph 11(b) of the Standing

Rules of the Senate, the committee has concluded that there is no

regulatory impact from this legislation.

19

X. 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):

Foreign Assistance Act of 1961

PART I

CHAPTER 1—POLICY; DEVELOPMENT ASSISTANCE AUTHORIZATIONS

* * * * * * *

SEC. 104.—POPULATION AND HEALTH.

* * * * * * *

(c) ASSISTANCE FOR HEALTH AND DISEASE PREVENTION.—(1) In

order to contribute to improvements in the health of the greatest

number of poor people in developing countries, the President is authorized to furnish assistance, on such terms and conditions as he

may determine, for health programs. Assistance under this subsection shall be used primarily for basic integrated health services,

safe water and sanitation, disease prevention and control, and related health planning and research. The assistance shall emphasize

self-sustaining community-based health programs by means such

as training of health auxiliary and other appropriate personnel,

support for the establishment and evaluation of projects that can

be replicated on a broader scale, measures to improve management

of health programs, and other services and suppliers to support

health and disease prevention programs.

(2) (A) In carrying out the purposes of this subsection, the President shall promote, encourage, and undertake activities designed to

deal directly with the special health needs of children and mothers.

Such activities should utilize simple, available technologies which

can significantly reduce childhood mortality, such as improved and

expanded immunization programs, oral rehydration to combat

diarrhoeal diseases, and education programs aimed at improving

nutrition and sanitation and at promoting child spacing. In carrying out this paragraph, guidance shall be sought from knowledgeable health professionals from outside the agency primarily responsible for administering this part. In addition to government-togovernment programs, activities pursuant to this paragraph should

include support for appropriate activities of the types described in

this paragraph which are carried out by international organizations

(which may include international organizations receiving funds

under chapter 3 of this part) and by private and voluntary organizations, and should include encouragement to other donors to support such types of activities.

(B) In addition to amounts otherwise available for such purpose,

there are authorized to be appropriated to the President

$25,000,000 for fiscal year 1986 and $75,000,000 for fiscal year

1987 for use in carrying out this paragraph. Amounts appropriated

under this subparagraph are authorized to remain available until

expended.

20

(C) Appropriations pursuant to subparagraph (B) may be referred

to as the ‘‘Child Survival Fund.’’ (3) The Congress recognizes that the promotion of primary health

care is a major objective of the foreign assistance program. The

Congress further recognizes that simple, relatively low-cost means

already exist to reduce incidence of communicable diseases among

children, mothers, and infants. The promotion of vaccines for immunization, and salts for oral rehydration, therefore, is an essential feature of the health assistance program. To this end, the Congress expects the agency primarily responsible for administering

this part to set as a goal the protection of not less than 80 percent

of all children, in those countries in which such agency has established development programs, from immunizable diseases by January 1, 1991. Of the aggregate amounts made available for fiscal

year 1987 to carry out paragraph (2) of this subsection (relating to

the Child Survival Fund) and to carry out subsection (c) (relating

to development assistance for health), $50,000,000 shall be used to

carry out this paragraph.

ø(4) (A) Congress recognizes the growing international dilemma

of children with the human immunodeficiency virus (HIV) and the

merits of intervention programs aimed at this problem. Congress

further recognizes that mother-to-child transmission prevention

strategies can serve as a major force for change in developing regions, and it is, therefore, a major objective of the foreign assistance program to control the acquired immune deficiency syndrome

(AIDS) epidemic.

ø(B) The agency primarily responsible for administering this part

shall—

ø(i) coordinate with UNAIDS, UNICEF, WHO, national and

local governments, and other organizations to develop and implement effective strategies to prevent vertical transmission of

HIV; and

ø(ii) coordinate with those organizations to increase intervention programs and introduce voluntary counseling and testing,

antiretroviral drugs, replacement feeding, and other strategies.

ø(5) (A) Congress expects the agency primarily responsible for

administering this part to make the human immunodeficiency

virus (HIV) and the acquired immune deficiency syndrome (AIDS)

a priority in the foreign assistance program and to undertake a

comprehensive, coordinated effort to combat HIV and AIDS.

ø(B) Assistance described in subparagraph (A) shall include help

providing—

ø(i) primary prevention and education;

ø(ii) voluntary testing and counseling;

ø(iii) medications to prevent the transmission of HIV from

mother to child; and

ø(iv) care for those living with HIV or AIDS.

ø(6) (A) In addition to amounts otherwise available for such purpose, there is authorized to be appropriated to the President

$300,000,000 for each of the fiscal years 2001 and 2002 to carry out

paragraphs (4) and (5).

ø(B) Of the funds authorized to be appropriated under subparagraph (A), not less than 65 percent is authorized to be available

through United States and foreign nongovernmental organizations,

including private and voluntary organizations, for-profit organizaVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00020 Fmt 6659 Sfmt 6602 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
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tions, religious affiliated organizations, educational institutions,

and research facilities.

ø(C)(i) Of the funds authorized to be appropriated by subparagraph (A), not less than 20 percent is authorized to be available for

programs as part of a multidonor strategy to address the support

and education of orphans in sub-Saharan Africa, including AIDS

orphans.

ø(ii) Assistance made available under this subsection, and assistance made available under chapter 4 of part II to carry out the

purposes of this subsection, may be made available notwithstanding any other provision of law that restricts assistance to foreign countries.

ø(D) Of the funds authorized to be appropriated under subparagraph (A), not less than 8.3 percent is authorized to be available

to carry out the prevention strategies for vertical transmission referred to in paragraph (4)(A).

ø(E) Of the funds authorized to be appropriated by subparagraph

(A), not more than 7 percent may be used for the administrative

expenses of the agency primarily responsible for carrying out this

part of this Act in support of activities described in paragraphs (4)

and (5).

ø(F) Funds appropriated under this paragraph are authorized to

remain available until expended.

ø(7) (A) Congress recognizes the growing international problem of

tuberculosis and the impact its continued existence has on those

nations that had previously largely controlled the disease. Congress

further recognizes that the means exist to control and treat tuberculosis, and that it is therefore a major objective of the foreign assistance program to control the disease. To this end, Congress expects the agency primarily responsible for administering this

part)—

ø(i) to coordinate with the World Health Organization, the

Centers for Disease Control, the National Institutes of Health,

and other organizations toward the development and implementation of a comprehensive tuberculosis control program;

and

ø(ii) to set as a goal 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, in those countries in which the

agency has established development programs, by December

31, 2010.

ø(B) There is authorized to be appropriated to the President, $60,000,000 for each of the fiscal years 2001 and 2002 to be used

to carry out this paragraph. Funds appropriated under this subparagraph are authorized to remain available until expended.¿

(4) RELATIONSHIP TO OTHER LAWS.—Assistance made available under this subsection and sections 104A, 104B, and 104C,

and assistance made available under chapter 4 of part II to

carry out the purposes of this subsection and such other sections

of this Act, may be made available in accordance with this subsection and such other provisions of this Act notwithstanding

any other provision of law.

(d) INTEGRATION OF ASSISTANCE PROGRAMS.—

* * * * * * *

22

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

(a) FINDING.—Congress recognizes that the alarming spread of

HIV/AIDS in countries in sub-Saharan Africa and other developing

countries is a major global health, national security, and humanitarian crisis.

(b) POLICY.—It is a major objective of the foreign assistance program of the United States to provide assistance for the prevention,

treatment, and control of HIV/AIDS. The United States and other

developed countries should provide assistance to countries in subSaharan Africa and other countries and areas to control this crisis

through HIV/AIDS prevention, treatment, monitoring, and related

activities, particularly activities focused on women and youth, including strategies to prevent mother-to-child transmission of the

HIV infection.

(c) AUTHORIZATION.—

(1) IN GENERAL.—Consistent with section 104(c), the President is authorized to furnish assistance, on such terms and conditions as the President may determine, to prevent, treat, and

monitor HIV/AIDS, and carry out related activities, in countries in sub-Saharan Africa and other countries and areas.

(2) ROLE OF NGOS.—It is the sense of Congress that the President should provide an appropriate level of assistance under

paragraph (1) through nongovernmental organizations in countries in sub-Saharan Africa and other countries and areas affected by the HIV/AIDS pandemic.

(3) COORDINATION OF ASSISTANCE EFFORTS.—The President

shall coordinate the provision of assistance under paragraph (1)

with the provision of related assistance by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations

Children’s Fund (UNICEF), the World Health Organization

(WHO), the United Nations Development Programme (UNDP),

the Global Fund to Fight AIDS, Tuberculosis and Malaria and

other appropriate international organizations (such as the

International Bank for Reconstruction and Development), relevant regional multilateral development institutions, national,

state, and local governments of foreign countries, appropriate

governmental and nongovernmental organizations, and relevant

Executive branch agencies.

(d) ACTIVITIES SUPPORTED.—Assistance provided under subsection (c) shall, to the maximum extent practicable, be used to

carry out the following activities:

(1) PREVENTION.—Prevention of HIV/AIDS through activities

including— (A) education, voluntary testing, and counseling (including the incorporation of confidentiality protections with respect to such testing and counseling), including integration

of such programs into health programs and the inclusion

in counseling programs of information on methods of preventing transmission of the HIV infection, including delaying sexual debut, abstinence, reduction of casual sexual

partnering, and, where appropriate, the use of condoms;

(B) assistance for the purpose of preventing mother-tochild transmission of the HIV infection, including medications to prevent such transmission and access to infant formula and other alternatives for infant feeding;

23

(C) assistance to ensure a safe blood supply, to provide—

(i) post-exposure prophylaxis to victims of rape and

sexual assault and in cases of occupational exposure of

health care workers; and

(ii) necessary commodities, including test kits, pharmaceuticals, and condoms;

(D) assistance through nongovernmental organizations,

including faith-based organizations, particularly those organizations that utilize both professionals and volunteers

with appropriate skills and experience, to establish and implement culturally appropriate HIV/AIDS education and

prevention programs;

(E) research on microbicides which prevent the spread of

HIV/AIDS; and

(F) bulk purchases of available prevention technologies

for women and for appropriate program support for the introduction and distribution of these technologies, as well as

education and training on the use of the technologies.

(2) TREATMENT.—The treatment and care of individuals with

HIV/AIDS, including—

(A) assistance to establish and implement programs to

strengthen and broaden indigenous health care delivery

systems and the capacity of such systems to deliver HIV/

AIDS pharmaceuticals and otherwise provide for the treatment of individuals with HIV/AIDS, including clinical

training for indigenous organizations and health care providers;

(B) assistance to strengthen and expand hospice and palliative care programs to assist patients debilitated by HIV/

AIDS, their families, and the primary caregivers of such

patients, including programs that utilize faith-based and

community-based organizations; and

(C) assistance for the purpose of the care and treatment

of individuals with HIV/AIDS through the provision of

pharmaceuticals, including antiretrovirals and other pharmaceuticals and therapies for the treatment of opportunistic infections, nutritional support, and other treatment

modalities.

(3) MONITORING.—The monitoring of programs, projects, and

activities carried out pursuant to paragraphs (1) and (2),

including—

(A) monitoring to ensure that adequate controls are established and implemented to provide HIV/AIDS pharmaceuticals and other appropriate medicines to poor individuals with HIV/AIDS; and

(B) appropriate evaluation and surveillance activities.

(4) PHARMACEUTICALS.—

(A) PROCUREMENT.—The procurement of HIV/AIDS

pharmaceuticals, antiviral therapies, and other appropriate

medicines, including medicines to treat opportunistic infections.

(B) MECHANISMS FOR QUALITY CONTROL AND SUSTAINABLE SUPPLY.—Mechanisms to ensure that such HIV/AIDS

pharmaceuticals, antiretroviral therapies, and other approVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00023 Fmt 6659 Sfmt 6603 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
24

priate medicines are quality-controlled and sustainably

supplied.

(C) DISTRIBUTION.—The distribution of such HIV/AIDS

pharmaceuticals, antiviral therapies, and other appropriate

medicines (including medicines to treat opportunistic infections) to qualified national, regional, or local organizations

for the treatment of individuals with HIV/AIDS in accordance with appropriate HIV/AIDS testing and monitoring

requirements and treatment protocols and for the prevention of mother-to-child transmission of the HIV infection.

(5) RELATED ACTIVITIES.—The conduct of related activities,

including— (A) the care and support of children who are orphaned

by the HIV/AIDS pandemic, including services designed to

care for orphaned children in a family environment which

rely on extended family members;

(B) improved infrastructure and institutional capacity to

develop and manage education, prevention, and treatment

programs, including training and the resources to collect

and maintain accurate HIV surveillance data to target programs and measure the effectiveness of interventions;

(C) vaccine research and development partnership programs with specific plans of action to develop a safe, effective, accessible, preventive HIV vaccine for use throughout

the world; and

(D) the development and expansion of financially sustainable microfinance institutions and other income generation

programs that strengthen the economic and social viability

of communities afflicted by the HIV/AIDS pandemic, including support for the savings and productive capacity of

affected poor households caring for orphans.

(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) a description of efforts made to implement the policies

set forth in this section;

(B) a description of the programs established pursuant to

this section; and

(C) a detailed assessment of the impact of programs established pursuant to this section, including— (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 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.

(f) FUNDING LIMITATION.—Of the funds made available to carry

out this section in any fiscal year, not more than 7 percent may be

25

used for the administrative expenses of the United States Agency for

International Development in support of activities described in this

section. Such amount shall be in addition to other amounts otherwise available for such purposes.

(g) DEFINITIONS.—In this section:

(1) AIDS.—The term ‘‘AIDS’’ means acquired immune deficiency syndrome.

(2) HIV.—The term ‘‘HIV’’ means the human immunodeficiency virus, the pathogen that causes AIDS.

(3) HIV/AIDS.—The term ‘‘HIV/AIDS’’ means, with respect

to an individual, an individual who is infected with HIV or living with AIDS.

SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.

(a) FINDINGS.—Congress makes the following findings:

(1) Congress recognizes the growing international problem of

tuberculosis and the impact its continued existence has on those

countries that had previously largely controlled the disease.

(2) Congress further recognizes that the means exist to control

and treat tuberculosis through expanded use of the DOTS (Directly Observed Treatment Short-course) treatment strategy and

adequate investment in newly created mechanisms to increase

access to treatment, including the Global Tuberculosis Drug Facility established in 2001 pursuant to the Amsterdam Declaration to Stop TB.

(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.

(c) AUTHORIZATION.—To carry out this section and consistent with

section 104(c), the President is authorized to 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, the Department of

Health and Human Services (including the Centers for Disease Control and Prevention and the National Institutes of Health), and

other organizations with respect to the development and implementation of a comprehensive tuberculosis control program.

(e) ANNUAL REPORT.—Not later than January 31 of each year, the

President shall submit a report to the Committee on Foreign Relations of the Senate and the Committee on International Relations of

the House of Representatives specifying the increases in the number

of people treated and the increases in number of tuberculosis patients cured through each program, project, or activity receiving

United States foreign assistance for tuberculosis control purposes.

(f) PRIORITY TO DOTS COVERAGE.—In furnishing assistance

under subsection (c), the President shall give priority to activities

that increase directly observed treatment shortcourse (DOTS) covVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00025 Fmt 6659 Sfmt 6603 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
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erage, including funding for the Global Tuberculosis Drug Facility

and the Stop Tuberculosis Partnership.

(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.

(2) GLOBAL TUBERCULOSIS DRUG FACILITY.—The term ‘‘Global

Tuberculosis Drug Facility (GDF)’’ means the new initiative of

the Stop Tuberculosis Partnership to increase access to highquality tuberculosis drugs to facilitate DOTS expansion.

(3) 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.

SEC. 104C. ASSISTANCE TO COMBAT MALARIA.

(a) FINDING.—Congress finds that malaria kills more people annually than any other communicable disease except tuberculosis,

that more than 90 percent of all malaria cases are in sub-Saharan

Africa, and that children and women are particularly at risk. Congress recognizes that there are cost-effective tools to decrease the

spread of malaria and that malaria is a curable disease if promptly

diagnosed and adequately treated.

(b) POLICY.—It is a major objective of the foreign assistance program of the United States to provide assistance for the prevention,

control, and cure of malaria.

(c) AUTHORIZATION.—To carry out this section and consistent with

section 104(c), the President is authorized to furnish assistance, on

such terms and conditions as the President may determine, for the

prevention, treatment, control, and elimination of malaria.

(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, the Department of

Health and Human Services (the Centers for Disease Control and

Prevention and the National Institutes of Health), and other organizations with respect to the development and implementation of a

comprehensive malaria control program.

(e) ANNUAL REPORT.—Not later than January 31 of each year, the

President shall submit a report to the Committee on Foreign Relations of the Senate and the Committee on International Relations of

the House of Representatives specifying the increases in the number

of people treated and the increases in number of malaria patients

cured through each program, project, or activity receiving United

States foreign assistance for malaria control purposes.

* * * * * * *

SEC. 302. AUTHORIZATION.—

* * * * * * *

(k) In addition to amounts otherwise available under this section,

there is authorized to be appropriated to the President

ø$50,000,000 for each of the fiscal years 2001 and 2002¿

$60,000,000 for the fiscal year 2003 and $70,000,000 for the fiscal

27

year 2004 to be available only for United States contributions to

the øGlobal Alliance for Vaccines and Immunizations¿ Vaccine

Fund.

(l) In addition to amounts otherwise available under this section,

there is authorized to be appropriated to the President

ø$10,000,000 for each of the fiscal years 2001 and 2002¿

$12,000,000 for the fiscal year 2003 and $15,000,000 for the fiscal

year 2004 to be available only for United States contributions to

the International AIDS Vaccine Initiative.

(m) In addition to amounts otherwise available under this section,

there are authorized to be appropriated to the President $5,000,000

for the fiscal year 2003 and $6,000,000 for the fiscal year 2004 to

be available only for United States contributions to the Malaria

Vaccine Initiative of the Program for Appropriate Technologies in

Health (PATH).

State Department Basic Authorities Act of 1956

TITLE 1—BASIC AUTHORITIES GENERALLY

ORGANIZATION OF THE DEPARTMENT OF STATE

SECTION 1. (a) SECRETARY OF STATE.—

* * * * * * *

(f) HIV/AIDS RESPONSE COORDINATOR.—

(1) IN GENERAL.—There shall be within the Department of

State a Coordinator of United States Government Activities to

Combat HIV/AIDS Globally, who shall be appointed by the

President, by and with the advice and consent of the Senate.

The Coordinator shall report directly to the Secretary of State

and shall have the rank and status of ambassador.

(2) DUTIES.—(A) The Coordinator shall have primary responsibility for the oversight and coordination of all activities of the

United States Government to combat the international HIV/

AIDS pandemic, including all programs, projects, and activities

of the United States Government under this Act or any amendment made by this Act.

(B) The duties of the Coordinator shall specifically include

the following:

(i) Ensuring program and policy coordination among the

relevant Executive branch agencies.

(ii) Ensuring that each relevant Executive branch agency

undertakes programs primarily in those areas where the

agency has the greatest expertise, technical capabilities,

and potential for success.

(iii) Avoiding duplication of effort.

(iv) Enhancing onsite coordination.

(v) Pursuing coordination with other countries and international organizations.

(vi) Resolving policy, program, and funding disputes

among the relevant Executive branch agencies.

International Financial Institutions Act

* * * * * * *

28

TITLE XVI—HUMAN WELFARE

* * * * * * *

SEC. 1624. REFORM OF THE ENHANCED STRUCTUAL ADJUSTMENT FACILITY

* * * * * * *

SEC. 1625. IMPROVEMENT OF THE ENHANCED HIPC INITIATIVE.

(a) AUTHORITY.—In order to ensure that the Enhanced HIPC Initiative achieves the objective of substantially increasing resources

available for human development and poverty reduction in heavily

indebted poor countries, the Secretary of the Treasury is authorized

and requested to conclude as soon as possible an agreement within

the Paris Club of Official Creditors, as well as the International

Bank for Reconstruction and Development (World Bank), the International Monetary Fund, and other appropriate multilateral development institutions to accomplish the modifications in the Enhanced HIPC Initiative described in subsection (b).

(b) AGREEMENT.—The agreement referred to in subsection (a) is

an agreement that provides the following:

(1) LEVEL OF EXPORTS AND REVENUES.— (A) IN GENERAL.—The amount of debt stock reduction approved for a country eligible for debt relief under the Enhanced HIPC Initiative shall be sufficient to reduce, for at

least each of the first 3 years after the Decision Point— (i) the net present value of the outstanding public

and publicly guaranteed debt of the country to not

more than 150 percent of the annual value of exports

of the country for the year preceding the Decision Point;

and

(ii) the annual payments due on such public and

publicly guaranteed debt to not more than 10 percent

or, in the case of a country suffering a public health

crisis (as defined in subsection (c)), not more than 5

percent, of the amount of the annual current revenues

received by the country from internal sources.

(B) LIMITATION.—In financing the objectives of the Enhanced HIPC Initiative, an international financial institution shall give priority to using its own resources.

(2) RELATION TO POVERTY AND THE ENVIRONMENT.—The debt

cancellation under the Enhanced HIPC Initiative shall not be

conditioned on any agreement by an impoverished country to

implement or comply with policies that deepen poverty or degrade the environment, including any policy that—

(A) implements or extends user fees on primary education

or primary health care, including prevention and treatment

efforts for HIV/AIDS, tuberculosis, malaria, and infant,

child, and maternal well-being;

(B) provides for increased cost recovery from poor people

to finance basic public services such as education, health

care, clean water, or sanitation;

(C) reduces the country’s minimum wage to a level of less

than $2 per day or undermines workers’ ability to exercise

effectively their internationally recognized worker rights, as

defined under section 526(e) of the Foreign Operations, ExVerDate 11-MAY-2000 19:56 Jul 03, 2002 Jkt 099010 PO 00000 Frm 00028 Fmt 6659 Sfmt 6603 E:\PICKUP\107206.XY3 pfrm11 PsN: 107206
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port Financing and Related Programs Appropriations Act,

1995 (22 U.S.C. 262p–4p); or

(D) promotes unsustainable extraction of resources or results in reduced budget support for environmental programs.

(3) FOREIGN GOVERNMENT POLICIES.—A country shall not be

eligible for cancellation of debt under the Enhanced HIPC Initiative if the government of the country—

(A) has repeatedly provided support for acts of international terrorism, as determined by the Secretary of State

under section 6(j)(1) of the Export Administration Act of

1979 (50 U.S.C. App. 2405(j)(1)) or section 620A(a) of the

Foreign Assistance Act of 1961 (22 U.S.C. 2371(a)); and

(B) engages in a consistent pattern of gross violations of

internationally recognized human rights (including its

military or other security forces).

(4) PROGRAMS TO COMBAT HIV/AIDS, TUBERCULOSIS, AND MALARIA.—A country that is otherwise eligible to receive cancellation of debt under the Enhanced HIPC Initiative may receive

such cancellation only if the country has agreed—

(A) in the case of a country suffering a public health crisis (as defined in subsection (c)), to ensure that, where practicable, 10 to 20 percent of the financial benefits of debt

cancellation are applied to programs to combat HIV/AIDS,

tuberculosis, and malaria in that country;

(B) to ensure that the financial benefits of debt cancellation are applied to programs to combat poverty (in particular through concrete measures to improve basic services

in education, nutrition, and health), and to redress environmental degradation;

(C) to ensure that the financial benefits of debt cancellation are in addition to the government’s total spending on

programs to combat HIV/AIDS and poverty reduction for

the previous year or the average total of such expenditures

for the previous 3 years, whichever is greater;

(D) to implement transparent and participatory policymaking and budget procedures, good governance, and effective anticorruption measures; and

(E) to broaden public participation and popular understanding of the principles and goals of poverty reduction.

(c) DEFINITIONS.—In this section:

(1) COUNTRY SUFFERING A PUBLIC HEALTH CRISIS.—The term

‘‘country suffering a public health crisis’’ means—

(A) a country in which HIV/AIDS, tuberculosis, or malaria is causing significant family, community, or societal

disruption; and

(B) a country that has rapidly rising rates of incidence

of at least one of such diseases that is likely to lead to conditions described in subparagraph (A).

(2) DECISION POINT.—The term ‘‘Decision Point’’ means the

date on which the executive boards of the World Bank and the

International Monetary Fund review the debt sustainability

analysis for a country and determine that the country is eligible

for debt relief under the Enhanced HIPC Initiative.

30

(3) ENHANCED HIPC INITIATIVE.—The term ‘‘Enhanced HIPC

Initiative’’ means the multilateral debt initiative for heavily indebted poor countries presented in the Report of G–7 Finance

Ministers on the Cologne Debt Initiative to the Cologne Economic Summit, Cologne, June 18–20, 1999.

Æ