69–010 

Calendar No. 698 

110TH CONGRESS REPORT " ! SENATE 2d Session 110–325 

THE TOM LANTOS AND HENRY J. HYDE GLOBAL LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA REAUTHORIZATION ACT OF 2008 

APRIL 15, 2008.—Ordered to be printed 

Mr. BIDEN, from the Committee on Foreign Relations, 

submitted the following 

R E P O R T 

together with 

MINORITY VIEWS 

[To accompany S. 2731] 

The Committee on Foreign Relations, having had under consideration the bill (S. 2731) to authorize appropriations for fiscal years 

2009 through 2013 to provide assistance to foreign countries to 

combat HIV/AIDS, tuberculosis, and malaria, and for other purposes, reports favorably thereon with an amendment and recommends that the bill, as amended, do pass. 

CONTENTS 

Page 

I. Summary ........................................................................................................ 1 

II. Background and Purpose of the Legislation ................................................ 2 

III. Reauthorization Act of 2008 ......................................................................... 6 

IV. Committee Action .......................................................................................... 21 

V. Section-by-Section Analysis .......................................................................... 22 

VI. Cost Estimate ................................................................................................. 31 

VII. Minority Views ............................................................................................... 36 

VIII. Changes in Existing Law .............................................................................. 40 

I. SUMMARY

S. 2731, the Tom Lantos and Henry J. Hyde United States 

Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria 

Reauthorization Act of 2008 [hereafter the Reauthorization Act], 

authorizes $50 billion for United States bilateral and multilateral 


wwoods2 on PRODPC68 with REPORTS
2 

programs to combat human immunodeficiency virus (HIV) and the 

acquired immunodeficiency syndrome (AIDS) [hereafter referred to 

as ‘‘HIV/AIDS’’], tuberculosis (TB) and malaria for fiscal years 2009 

through 2013. This Act seeks to build on the remarkable successes 

achieved during the last 5 years by the President’s Emergency Plan 

for AIDS Relief (PEPFAR) and by the promising start of the President’s Malaria Initiative and to support a transition from an emergency approach to more country-driven strategies that will better 

allow public health professionals on the ground to combat the local 

HIV/AIDS, TB, and malaria epidemics that they confront. 

This Act sets out ambitious targets for HIV/AIDS prevention, 

treatment, and care while removing funding directives that have 

served as stove-pipes for those interventions and limited the flexibility of professionals in the field who plan and implement the programs. Of the three goals, it prioritizes prevention as the most critical element in slowing the pandemic and reversing its course. In 

pursuing this goal, the Act requires a balanced approach to the 

prevention of the sexual transmission of HIV—emphasizing the importance of behavior change programs to promote abstinence, fidelity, the reduction of concurrent sexual partners, and the delay of 

sexual debut along with programs to promote the correct and consistent use of condoms. 

HIV/AIDS epidemics do not occur in isolation. Persons and communities affected by HIVAIDS are also affected by other economic 

and health challenges that can have a direct effect on prevention, 

care, and treatment outcomes. Continuing the guidelines established in the U.S. Leadership Against HIV/AIDS, Tuberculosis, and 

Malaria Act of 2003 (P.L. 108–25) [hereafter the 2003 Leadership 

Act], this Act promotes the further coordination of care and treatment programs with other life-changing interventions such as nutritional support, and more cohesive integration of these diseasespecific programs within the broader United States health and development agenda. S. 2731 increases the focus on women and girls, 

particularly in terms of addressing the factors that make them 

more vulnerable to the transmission of HIV. It emphasizes the 

need for improved internal coordination and enhanced harmonization with other international actors and partner countries and 

authorizes, although it does not mandate, bilateral and regional 

framework or ‘‘compact’’ agreements. It seeks to strengthen health 

capacity in developing countries affected by these epidemics, by 

promoting the training and retention of personnel and improvements in infrastructure, management, finances, and health systems. The legislation enhances oversight and emphasizes the importance of operations research to evaluate and maximize the impact of United States assistance. Finally, the Reauthorization Act 

would repeal a provision in law that differentiates HIV/AIDS from 

all other diseases and currently makes HIV infection the only statutory grounds for barring prospective international visitors from 

entry into the United States. 

II. BACKGROUND AND PURPOSE OF THE LEGISLATION

In his State of the Union address on January 28, 2003, President 

George W. Bush announced a dramatic proposal: To spend $15 billion over 5 years to combat HIV/AIDS globally, particularly in subSaharan Africa, the region hardest hit by the pandemic, and he 


wwoods2 on PRODPC68 with REPORTS
3 

1The human immunodeficiency virus is the underlying cause of AIDS. Most people who are 

infected with HIV are not yet in need of ARV treatment; rather they need monitoring of their 

condition. AIDS is diagnosed when an HIV-positive person’s immune system deteriorates to a 

specific point, most often evaluated on the basis of a person’s CD4 count or when he/she acquires 

certain opportunistic infections or malignancies associated with AIDS. [CD4 cells coordinate the 

immune system’s response to certain micro-organisms such as viruses and may be seen as one 

barometer of a person’s progression toward AIDS—if CD4 counts fall below a certain level, physicians recommend initiating ARV treatment, which must then be continued for life.] 2The Department of State, the United States Agency for International Development (USAID), 

the Department of Health and Human Services, the Department of Defense, the Department 

of Commerce, the Department of Labor, and the Peace Corps. 3The original 14 named countries were Botswana, Coˆte d’Ivoire, Ethiopia, Guyana, Haiti, 

Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. 

The President added Vietnam to this list in 2004. Currently approximately 60 percent of 

PEPFAR assistance is directed to these 15 countries. 4 As the available HIV/AIDS data has improved, the Joint United Nations Programme on HIV/ 

AIDS (UNAIDS) has revised earlier estimates of HIV prevalence. In 2003, when the Leadership 

Act was enacted, it was estimated that approximately 42 million individuals were infected with 

HIV; UNAIDS’ more recent analysis estimates that 30.9 million people were likely HIV positive 

in 2003, of whom 21.6 million were in sub-Saharan Africa. 

called for the creation of the President’s Emergency Plan for AIDS 

Relief (PEPFAR). Congress responded promptly, authorizing the 

full amount requested by the President and expanding the diseases 

covered through the 2003 Leadership Act which was signed into 

law May 27, 2003. Congressional support for the program has been 

strong and steady; Congress has appropriated over $19.7 billion 

since then to combat these three diseases through bilateral and 

multilateral programs. 

The 2003 Leadership Act provided a roadmap for an ambitious 

plan to achieve objectives in the prevention, care, and especially 

the treatment of HIV/AIDS.1 To oversee these programs, the 2003 

Leadership Act established within the Department of State—a Coordinator of United States Government Activities to Combat HIV/ 

AIDS Globally [hereafter the Global AIDS Coordinator], to be appointed by the President with the advice and consent of the Senate. 

The Office of the Global AIDS Coordinator (OGAC) leads interagency implementation and administration of U.S. global HIV/ 

AIDS policy. The 2003 Leadership Act required a 5-year emergency 

plan (for fiscal years 2004–2008) designed to coordinate all U.S.- 

funded bilateral HIV/AIDS programs, including those established 

by the President’s Emergency Plan for AIDS Relief, and administered through seven implementing agencies,2 to address the emergency. The bill specifically mentioned 14 countries within the Coordinator’s oversight and authorized the President to name additional countries to this list.3 The 2003 legislation also included provisions to address TB and malaria and authorized participation in 

the Global Fund to Fight AIDS, Tuberculosis and Malaria [hereafter the Global Fund]—a multilateral financing mechanism to 

manage and disburse resources to fight the three diseases. The 

Global Fund now provides grants in 138 countries. The United 

States remains the leading contributor to the Global Fund, having 

pledged over $3.7 billion to date. 

In 2003, roughly 50,000 people in all of Africa were receiving 

antiretroviral (ARV) pharmaceutical treatment for AIDS, though, 

according to current data, an estimated 21.6 million people in Africa were HIV positive at that time.4 Some people argued that largescale, successful treatment in such resource-poor settings was impossible. To counter these arguments and to address this most 

urgent issue—trying to reverse a sentence of certain death for millions and simultaneously provide an incentive for getting tested for 


wwoods2 on PRODPC68 with REPORTS
4 

5OGAC guidance on palliative care states ‘‘Comprehensive palliative care is essential to the 

health and well-being of people living with HIV/AIDS (PLWHA) and is an integral part of the 

President’s Emergency Plan for AIDS Relief (the Emergency Plan). Palliative care has traditionally been associated with terminal or end-of-life care. However, current thought and practice 

and Emergency Plan policy take the broader view that palliative care encompasses care provided from the time that HIV is diagnosed and throughout the continuum of HIV infection.’’ 6 According to the most recent PEPFAR report to Congress, PEPFAR and the Global Fund 

jointly support 909,000 people on treatment; PEPFAR alone supports approximately 544,000 

people, and the Global Fund alone supports 539,000 people. 

HIV—the 2003 Leadership Act emphasized treatment among the 

three goals, establishing first through a Sense of Congress provision and subsequently through a budgetary directive that 55 percent of bilateral assistance should go to therapeutic medical care, 

with at least 75 percent of that allocation to be expended for the 

purchase and distribution of antiretroviral pharmaceuticals. The 

legislation also recommended that 15 percent of funds go toward 

palliative or supportive care 5 and required in the later fiscal years 

that 10 percent of funding go to provide for the needs of orphans 

and vulnerable children. 

As part of the 2003 Leadership Act, Congress also established 

parameters to support prevention efforts. The 2003 legislation recommended a spending level of 20 percent for prevention programs 

and, for fiscal years 2006 to 2008, required that one-third of prevention funds go toward promoting abstinence until marriage. This 

prevention approach was based on examples of successful efforts in 

Uganda and elsewhere to reduce the transmission of HIV/AIDS 

through an ‘‘ABC approach’’—Abstain, Be faithful, and use 

Condoms. 

The 2003 Leadership Act recognized the importance of a multidimensional strategy and the bill included provisions relating to 

the empowerment of women, including requiring strategies to enhance their empowerment in interpersonal situations and to increase their access to employment opportunities, income, productive resources, and microfinance programs and authorizing assistance in these areas. The Act also recognized the importance of nutrition and called for the Administrator of the United States Agency for International Development (USAID) to integrate nutrition 

programs with HIV/AIDS activities as appropriate. 

Over the course of the last 5 years, the United States has made 

tremendous strides in leading the global campaign against HIV/ 

AIDS, particularly establishing treatment programs. With the support of PEPFAR and the Global Fund, over 1.99 million people 

have received ARVs.6 Millions more have been the beneficiaries of 

palliative care and prevention educational and outreach efforts and 

commodities. U.S. programs have helped to ensure that over 

150,000 infants, most in sub-Saharan Africa, who likely would have 

been infected with HIV in utero or during birth were not. Over 33.7 

million people have received voluntary counseling and HIV testing. 

Faith-based and community-based organizations have played pivotal roles in the success of these programs, delivering services on 

the front lines of the war against HIV/AIDS. 

While these achievements are impressive, the pandemic continues to outpace them. The 2007 AIDS Epidemic Update of the 

Joint United Nations Programme on HIV/AIDS (UNAIDS) brought 

the welcome news that global prevalence estimates were lower 

than earlier projections, but even these revised numbers indicated 

that approximately 33.2 million people in the world are living with 


wwoods2 on PRODPC68 with REPORTS
5 

7Data on global and regional prevalence and incidence rates are from the report of the United 

Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), ‘‘AIDS 

epidemic update’’ (December 2007). The December UNAIDS 2007 report significantly reduced 

prevalence estimates from previous years and included a revised estimate of approximately 32 

million persons living with HIV, down from the 2006 estimate of 38.6 million. These revised 

estimates stemmed most directly from improved data in countries such as India, rather than 

changes in the epidemic, but they also reflected notable reductions in prevalence rates in several 

countries, including Kenya and Zimbabwe. 

HIV; that 2.1 million people died of AIDS-related causes in 2007; 

and that 2.5 million people became newly infected in 2007, meaning that for every person who enrolled in a treatment program, approximately six more reportedly became HIV positive.7 Furthermore, most people who are infected with HIV remain untested and 

undiagnosed. 

Sub-Saharan Africa remains by far the most affected region of 

the world: An estimated 22.5 million people there are living with 

HIV, over two-thirds of the global population of persons who are 

HIV-positive, and the region suffered more than three quarters of 

all AIDS deaths in 2007. In six countries in southern Africa (Botswana, Lesotho, South Africa, Swaziland, Zambia, and Zimbabwe), 

estimated prevalence rates continue to exceed 15 percent. Women 

and girls make up over 60 percent of persons in sub-Saharan Africa 

who are HIV infected, and the disparities along gender lines are 

even more striking among younger age cohorts. Africa is most affected but not alone. Rates of HIV incidence (the number of new 

infections in a population in a given year) are rising in East Asia. 

The Caribbean has the second highest regional prevalence rate at 

1.0 percent (with Haiti and the Dominican Republic accounting for 

three quarters of the 230,000 people living with HIV in the Caribbean), while Eastern Europe and Central Asia are experiencing 

prevalence rates of 0.9 percent with an estimated 1.6 million people 

living with HIV. Illicit injection drug use continues to be a major 

driver of the epidemic; unsafe sex among men who have sex with 

men and the commercial sex trade are also significant means of 

transmission in many areas. These basic demographic realities 

must continue to shape the U.S. strategy on HIV/AIDS, as should 

the economic need of recipient countries, as these programs enter 

a new phase of operations. 

The U.S. global HIV/AIDS initiative, like the Marshall Plan, represents American foreign policy at its best. It demonstrates the efficacy of U.S. assistance and the generosity of the American people. 

It has also demonstrated the ability to adapt both to changing conditions on the ground and to more accurate data as it has become 

available. This Reauthorization Act seeks to enhance that flexibility and to reflect the progress that has been made and the lessons learned. As this program continues to grow and potentially 

expands to other poor countries, it will face new challenges. As 

treatment rosters grow, so does the responsibility to maintain 

them—a patient on ARV treatment must, for now at least, continue 

taking the medication for the rest of his or her life. This fact, and 

its clear economic and moral implications, reinforces the need to 

improve and expand prevention efforts. While treatment must remain a key component of our strategy, without greater emphasis 

on prevention, HIV/AIDS will never be successfully controlled or 

contained. Countries currently receiving our assistance are eager to 

assume greater leadership but lack much of the capacity, 


wwoods2 on PRODPC68 with REPORTS
6 

healthcare workforce, and delivery systems to do so. Improved harmonization of U.S. programs with one another and with other 

international actors is necessary to maximize impact; and a clearer 

roadmap is needed of how global HIV/AIDS programs fit into the 

broader U.S. health and development agenda. 

S. 2731 recognizes the lethal impact of tuberculosis and malaria 

and authorizes a substantial increase in resources to address these 

deadly diseases. Together, TB and malaria claim over 2.6 million 

lives a year, and they have a devastating effect on economic development in many countries. The Act, building on the initial inclusion of these diseases in the 2003 Leadership Act, seeks to 

strengthen these efforts and to promote improved coordination 

across prevention and care programs for HIV/AIDS, TB, and malaria and between these programs and other U.S. assistance efforts. 

III. REAUTHORIZATION ACT OF 2008 

The reauthorization of the 2003 Leadership Act for FY 2009– 2013 is designed to respond to these challenges. It sets ambitious 

targets for treatment, care, prevention, pediatric treatment, care 

for orphans and vulnerable children, and the prevention of motherto-child transmission, and for helping countries to train and retain 

healthcare workers. Among these goals, the Act explicitly 

prioritizes prevention as critical to saving lives in recognition of 

both the progress made in initiating path-breaking treatment programs and the fact that we must do more to break the cycle of new 

infections. It underscores the value of the ABC approach to preventing the sexual transmission of HIV and requires a balanced approach to prevention. The Reauthorization Act recognizes that the 

drivers of the epidemic vary from country to country and that our 

public health professionals and their partners should be given the 

means to respond to these variances as well. The legislation emphasizes capacity-building, coordination, and evaluation and oversight and calls for an increased focus on the needs and vulnerabilities of women and girls. It addresses the grave threats posed by 

malaria and tuberculosis, including the increasing dangers of drugresistant TB. Finally, it supports a transition from a U.S.-led emergency approach to a more sustainable, country-driven public health 

strategy toward HIV/AIDS, including increased technical assistance 

to improve the capabilities of partner governments to play such a 

role. To accomplish these goals, the Reauthorization Act increases 

U.S. funding for bilateral and multilateral HIV/AIDS, tuberculosis, 

and malaria programs to $50 billion over the next 5 fiscal years. 

Estimates of Funding 

The $50 billion, 5-year authorization will provide a total of $41 billion for bilateral HIV/AIDS programs and the Global Fund, $5 

billion for malaria programs, and $4 billion for tuberculosis programs. The committee chose not to assign annual spending for the 

$50 billion in order to allow for these programs to be increased over 

time as services are expanded and to accommodate absorptive capacities. The Reauthorization Act authorizes up to $2 billion for the 

Global Fund for fiscal year 2009 and such sums as are necessary 

for the following 4 fiscal years. 

The Global Stop TB Partnership, of which the United States is 

a member, has estimated that total country needs to achieve the 


wwoods2 on PRODPC68 with REPORTS
7 

8 Institute of Medicine, ‘‘PEPFAR Implementation: Progress and Promise,’’ Washington, D.C.: 

National Academies Press, 2007, p. 10. 9Government Accountability Office, ‘‘Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief,’’ GAO–06– 395 (April 4, 2006). 10 Nandini Oomman, et al. ‘‘Following the Funding for HIV/AIDS: A Comparative Analysis of 

the Funding Practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, 

Uganda and Zambia,’’ Center for Global Development (October 10, 2007), p. xii. 

goals of the Global Plan to Stop TB will require $24.9 billion over 

the 2009 to 2013 period. The plan calls for 57 percent of funds to 

go toward the expansion of Daily Observed Treatment Short-course 

(DOTS) therapy, with the remainder directed primarily toward TB/ 

HIV programs; DOTS-Plus programs that supplement the standard 

DOTS strategy in areas with significant drug resistance; TB drugs; 

and vaccine research and development. 

The WHO’s current best estimate of global need for malaria programs as outlined in the Global Malaria Business Plan of the Roll 

Back Malaria partnership is $4.1 billion per year (which the WHO 

breaks down to $3.2 billion for implementation and $0.9 billion for 

research and development). The Reauthorization Act authorizes up 

to $5 billion as the U.S. Government’s contribution to this global 

effort over 5 years. 

HIV Prevention Policy 

A growing body of evidence led the committee to reform the approach to budgetary allocations or earmarks within U.S. global 

HIV/AIDS programs. Simply put, current earmarks have constrained the ability of the U.S. Government and its partners to 

combat the local epidemics that they are facing in individual countries. They also undercut efforts to promote harmonization with 

other national and international efforts. This conclusion was highlighted in the Institute of Medicine’s report, ‘‘PEPFAR Implementation: Progress and Promise,’’ which was mandated under the 2003 

Leadership Act and which stated that the short-term targets manifested in the budget allocations have ‘‘adversely affected implementation of the U.S. Global AIDS Initiative.’’ 8 Other types of activities, such as the prevention of mother to child transmission 

(PMTCT), as well as more comprehensive approaches to the prevention of the sexual transmission of HIV that combine abstince, 

fidelity, and condom programming (A, B, and C), have sometimes 

directly suffered as a result of budget allocations, according to reports by the Government Accountability Office (GAO).9 Additionally, an independent comparative analysis of PEPFAR, the Global 

Fund, and the World Bank concluded that, of the three, ‘‘PEPFAR 

funding is least conducive to allowing recipients to implement comprehensive approaches that combine elements of treatment, prevention, and care.’’ 10

The committee believes that goals rather than numerical percentages should guide programming. By setting a goal of preventing 12 million new infections through a balanced approach and 

strengthening evaluations of prevention programs, the committee 

hopes to make a greater impact in stemming the epidemic. 

In order to increase flexibility and allow for the more effective allocation of resources in response to local conditions, S. 2731 removes the one-third ‘‘abstinence until marriage’’ funding directive 

from the 2003 Leadership Act, along with all other numerical earVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00007 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
8 

marks within HIV/AIDS funding, except for the 10-percent allocation for orphans and vulnerable children. The Reauthorization Act 

explicitly prioritizes prevention and continues support for a balanced approach in which behavior change programs that are aimed 

at promoting abstinence and fidelity, reducing numbers of concurrent partners, and delaying sexual debut, which may collectively be 

termed ‘‘AB,’’ are to be funded in a meaningful and equitable way, 

in tandem with ‘‘C’’ prevention tools promoting the correct and consistent use of condoms. Because the committee believes that both 

the ‘‘AB’’ behavior change elements and the ‘‘C’’ elements of the 

ABC approach are crucial to stopping the spread of HIV/AIDS, language in the Reauthorization Act explicitly requires the Global 

AIDS Coordinator to report to Congress if the funding ratio for 

these ‘‘AB’’ behavior change programs and for ‘‘C’’ (condom) programs falls below one to one (AB:C). Additional means of prevention including programs to empower women and others, medical 

male circumcision, the safeguarding of blood supplies, and the potential development of new mechanisms or approaches are also addressed, separately from this one to one ratio. 

S. 2731 strengthens an existing provision in the 2003 Leadership 

Act to ensure that no organization shall be required to endorse, 

participate in, or make a referral to any program to which that 

organization has a moral or religious objection, nor shall they be 

required to endorse or participate in a multisectoral or comprehensive approach to HIV/AIDS. Such organizations cannot be discriminated against in grants or other agreements as a result of 

electing not to endorse, participate in, or refer patients to such programmatic activities. 

As noted, the Reauthorization Act requires a prevention strategy 

for each country in which the United States maintains an HIV/ 

AIDS program; if, in that strategy, less than 50 percent of the prevention programs aimed at the sexual transmission of HIV are directed toward behavior change programs aimed at reducing or delaying sexual activity or reducing numbers of sexual partners as 

outlined above, then the Global AIDS Coordinator must provide a 

justification to Congress. The objective epidemiological evidence to 

be used for the Coordinator’s determination should be primarily 

partner country Demographic and Health Surveys, the AIDS Information Service (AIS), and other United States Government supported surveys and data, including surveys requested by the Congress; other independent, scientifically sound studies may also be 

taken into account. The modification of the previous abstinence 

spending requirement should not be interpreted to imply that abstinence and be faithful programs are no longer considered by the 

committee to be a priority for prevention funding. Modifications in 

the directive and the required country strategies are intended to 

promote locally guided approaches to prevention that respond to 

changes in patterns of incidence (new HIV infections) and to specific drivers of the epidemic. Any program to change cultural norms 

should be led by the partner countries, with the U.S. Government 

providing financial and technical assistance when appropriate; one 

of the clear lessons of Uganda’s early success in reducing HIV prevalence rates is that national and local leadership matters. 

The prevention of the transmission of HIV from mother to child 

represents an important component of the overall prevention stratVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00008 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
9 

11For PMTCT in developing countries, 80 percent is often defined as ‘‘universal access’’ because 100 percent access is not realistically achievable. ‘‘Opt out’’ testing refers to a protocol 

in which all clients in a medical facility are asked if they would be willing to take an HIV test, 

rather than waiting for clients to request testing. All voluntary counseling and testing should 

follow WHO guidelines. 12 In his 2003 State of the Union Address, President Bush established targets of treating 2 

million people, preventing 7 million new infections and providing care for millions more. Currently, over 1.4 million people are enrolled in ARV treatment programs through U.S. bilateral 

assistance programs. The direct impact of prevention programs is more difficult to measure. 

egy. S. 2731 establishes a goal of helping partner countries to 

achieve 80 percent access to counseling, testing, and treatment to 

prevent mother-to-child transmission and emphasizes the importance of maintaining a continuum of care before and after birth 

and of promoting provider-initiated or ‘‘opt-out’’ HIV testing.11 The 

committee also recognizes new and promising developments regarding the use of ARVs to reduce the transmission of HIV through 

breast milk and supports expansion of these interventions as appropriate. 

HIV/AIDS Treatment and Care Policy 

S. 2731 maintains treatment and care as core priorities of U.S. 

HIV/AIDS programs and sets a target of supporting treatment for 

3 million people by 2013, an increase of 1 million people to be 

added to treatment rosters, and additional access to treatment 

through contributions to the Global Fund. The bill also sets a target of supporting care for 12 million people, including 5 million orphans and vulnerable children.12 In order to measure progress toward the treatment objective, the Reauthorization Act requires a 

timetable with yearly global treatment targets and subsequent reporting, including country-level explanations if the timetable’s 

goals are not on track to be achieved. As with most of the other 

HIV/AIDS budget directives, S. 2731 removes the allocation requiring that 55 percent of funding go toward treatment, again reflecting the committee’s preference that goals to guide planning and resources rather than numerical directives. The 55 percent earmark 

was seen as necessary 5 years ago when treatment was almost 

nonexistent in resource-poor settings such as Africa, and some 

claimed it was not even possible, but current data demonstrate 

that this directive is no longer needed or appropriate. The President’s Emergency Plan for AIDS Relief has proven the skeptics 

wrong: Today, due to the combined efforts of PEPFAR and the 

Global Fund, nearly 2 million people are on treatment, mostly in 

Africa. Additionally, with the availability of less expensive generic 

drugs and better supply chain management in place, the cost of 

ARV supply and distribution has decreased, while other public and 

private partners have increased their role in supporting treatment 

programs. The 55 percent earmark for treatment was also set at 

a time when the infrastructure to deliver treatment was almost 

completely absent in many areas and the costs were considered by 

some to be prohibitively expensive. This 55 percent figure has 

never correlated with actual treatment costs in pursuit of the targets of the 2003 Leadership Act, and the goal of supporting 3 million people on treatment by 2013 does not require such a budgetary 

directive. 

Some have suggested that a target of 3 million people on treatment is insufficient. While the committee would prefer that all who 

need treatment receive it, the committee shares the view of the 


wwoods2 on PRODPC68 with REPORTS
10 

Global AIDS Coordinator, Ambassador Mark Dybul, that ‘‘we cannot treat our way out of this epidemic.’’ For every person put on 

ARVs last year, six more became newly infected with HIV; prevention efforts, capacity building, and other programs are critical to establishing a more sustainable approach. Treatment targets should 

be and are ambitious, but the committee believes it is neither advisable nor financially feasible for the United States to be the sole 

supplier of ARVs. In a number of communities, U.S. bilateral programs now focus on providing the more complex ‘‘second line 

drugs’’ (for patients whose initial treatments have failed), while the 

Global Fund, private foundations, or others provide many of the 

‘‘first line’’ drugs). The committee encourages such shared efforts. 

The U.S. commitment to support treatment for 3 million people in 

this Act would constitute well over half of the commitment made 

to date by the entire Group of Eight (G–8). The world, not just the 

United States, needs to confront this crisis, and members of the G– 8 and others need to do more, particularly because treatment, as 

noted previously, is a long-term commitment—at this time, it must 

be life-long for every person who begins taking ARVs. 

Furthermore, the committee believes that in seeking to provide 

treatment for at least 3 million people, the United States, and its 

implementing partners, must also do more to ensure that its programs achieve the desired outcome, namely the long-term survival 

of people on treatment and their return to productive lives. In some 

PEPFAR-supported programs, as many as a quarter or more of 

those who begin treatment are subsequently ‘‘lost to followup’’ and 

disappear from rosters. Some of these patients will have died; others may have dropped out or enrolled elsewhere. Poor adherence to 

ARV regimes is extremely dangerous for the individual and has 

larger ramifications as it may contribute to the spread of drug resistant strains of HIV/AIDS, which are more difficult and costly to 

treat. Through enhanced oversight and analysis, along with 

strengthened coordination with nutrition programs and other support, the Reauthorization Act seeks to save more lives through improved as well as expanded treatment and care. 

In terms of care, S. 2731 recognizes the impact of opportunistic 

infections such as tuberculosis, bacterial pneumonia, toxoplasmosis, 

viral and fungal diseases, and HIV/AIDS-associated malignancies 

such as Kaposi’s sarcoma on many persons with HIV/AIDS and includes a provision calling for free or readily affordable prophylaxis 

and treatment for these infections as part of care and treatment. 

Palliative assistance and pain management are also important 

components of HIV/AIDS care and treatment programs, as noted in 

the Reauthorization Act. Additionally, the committee strongly supports expanded access to voluntary counseling and testing, particularly the adoption of provider-initiated or ‘‘opt-out’’ testing, expanded mobile services, and the use of rapid testing to reduce waiting times for patients and facilitate the delivery of test results. 

Pediatric participation in care and treatment programs has been 

underrepresented to date, in part because many HIV infected children die without ever being tested, particularly in countries with 

low rates of access to Prevention of Mother to Child Transmission 

(PMTCT) programs. Drawing on S. 2472, the Global Pediatric HIV/ 

AIDS Prevention and Treatment Act, the Reauthorization Act establishes a target for participation in treatment and care programs 


wwoods2 on PRODPC68 with REPORTS
11 

13PEPFAR Implementation: Progress and Promise, p. 157. 

for children in proportion to their percentage within the HIV-infected population of a given country as a policy objective of U.S. 

global HIV/AIDS programs. 

The Role of HIV/AIDS, Tuberculosis, and Malaria Programs Within the United States Health and Development Agenda 

A core objective of this Act is to encourage the President to situate programs to combat HIV/AIDS, tuberculosis, and malaria 

more clearly within the United States health and development 

agenda, particularly because HIV/AIDS programs have come to 

dominate U.S. assistance in many countries in sub-Saharan Africa 

and elsewhere. To address this issue, S. 2731 requires strategic 

planning for HIV/AIDS programs within this broader context as 

well as long-range planning for the initiative. The Reauthorization 

Act also seeks to improve coordination between HIV/AIDS programs and other development activities; to address the needs and 

heightened vulnerabilities of girls and women to HIV; and to build 

capacity in the health sectors of partner countries and promote a 

shift toward more sustainable approaches grounded in national 

strategies. The Act also calls for closer coordination between HIV/ 

AIDS, TB, and malaria programs. In approaching the question of 

how these health programs fit into the broader U.S. development 

agenda, the committee explicitly builds upon the 2003 Leadership 

Act; with the insights gained from 5 years of programs, it seeks to 

strengthen these activities in order to maximize the positive impact 

of taxpayer dollars and to achieve improved outcomes in saving 

lives and helping people resume productive activities. 

Nutrition and Food Support for Persons With HIV/AIDS and Their 

Families 

The Reauthorization Act strengthens linkages between HIV/ 

AIDS and nutritional and food support. The 2003 Leadership Act 

recognized the importance of nutritional support, but persons living 

with AIDS, clinicians, and other implementers working to treat and 

support them through PEPFAR programs have repeatedly identified inadequate access to food or nutrition as a major problem in 

combating the effects of HIV/AIDS. Adequate nutrition is important clinically in terms of improved health outcomes and better adherence to regimes, in part because lack of food can make it very 

difficult to tolerate ARVs, and many malnourished patients will 

simply stop taking their ARVs because the side effects are too severe.13 Current efforts to address this issue through ‘‘wraparound’’

programs with the World Food Program and other agencies cannot 

completely bridge this gap. In wraparound programs, another agency provides a service such as nutritional support for persons with 

HIV/AIDS. These wraparound programs often lack the resources to 

provide sufficient services to the individuals receiving PEPFAR 

support and are frequently based in rural areas, while PEPFAR 

programs tend to be more urban. S. 2731 directs the Global AIDS 

Coordinator to integrate nutrition programs more fully with HIV/ 

AIDS activities and to establish services where referrals are inadequate. The Reauthorization Act identifies nutritional and food 


wwoods2 on PRODPC68 with REPORTS
12 

14Office of the Global AIDS Coordinator, ‘‘The President’s Emergency Plan for AIDS Relief 

Report on Gender-Based Violence and HIV/AIDS’’ (November 2006), p. 4. 

support as a basic component of care and treatment for those persons with HIV/AIDS who meet established criteria of need. 

Providing food assistance only or preferentially to persons who 

are HIV-infected also poses clear ethical and policy difficulties, 

both within any given community and in terms of the overall distribution of resources. This community concern may be offset somewhat by the grim economic impact of long-term illness: Families 

whose breadwinner has been stricken by AIDS have often been 

forced to sell off what assets they possess. Therefore, even in a 

community where food insecurity is widespread, these families may 

have fewer resources on which to draw. Nonetheless, this matter 

remains an issue of concern. In communities where HIV/AIDS and 

food insecurity are both highly prevalent, the Reauthorization Act 

supports community-based assistance programs, with an emphasis 

on sustainable approaches such as community gardens. 

Women and Girls and HIV/AIDS 

Women and girls are biologically more vulnerable to the sexual 

transmission of HIV, and sociological and economic factors add to 

this heightened peril. Young women in much of sub-Saharan Africa, where HIV/AIDS rates are the highest in the world, are three 

times as likely as their male counterparts to be infected with HIV; 

globally, two-thirds of all new infections among young people aged 

15 to 24 are among women.14 S. 2731 emphasizes the issue of gender as a risk factor for HIV on a number of levels, with the goal 

of strengthening U.S. efforts to help partner countries address the 

underlying issues that heighten vulnerabilities for girls and women 

and to improve the quality and enhance the impact of gender-based 

programming. Gender elements are central to the required 5-year 

strategy and report and subsequent evaluations, and the committee 

emphasizes the importance of programs to reach men, women, and 

youth to reduce gender-based vulnerabilities to, and the disparate 

impacts of, HIV/AIDS. Gender-based programs must also be a core 

element of any future compacts or framework agreements. Consistent with the underlying 2003 Leadership Act, programmatic 

components to address gender issues within the Reauthorization 

Act include support for property and inheritance rights for women 

and children as well as assistance to promote broader legal equality and legal protection; support for civic organizations run by and 

for women; life skills training for adolescents; recognition and prevention of gender-based violence and strengthened legal and support responses to violence; and improved coordination with 

antitrafficking efforts. The committee recommends that additional 

staff training and development of expertise on gender-related 

issues be included in planning for HIV/AIDS programs and country 

operational plans, along with expanded local input from women, including women living with HIV/AIDS. Similarly, additional technical assistance may be needed to help encourage the participation 

and involvement of women in drafting, coordinating, and implementing the national HIV/AIDS strategic plans of their countries. 

The committee believes it is important to monitor and evaluate 

progress on outcomes and impacts linked to goals and targets and 


wwoods2 on PRODPC68 with REPORTS
13 

to ensure that data are disaggregated by risk factors, including sex, 

age, marital status, and other factors relevant to local epidemics. 

The Global AIDS Coordinator should provide clear guidance to field 

missions to integrate gender across all prevention, care, and treatment programs; adopt specific targets for reaching women and girls 

within the country’s prevention, care, and treatment targets; and 

undertake gender analysis in order to identify priority interventions. Gender-specific indicators are critical to measure program 

outreach and effectiveness. Operations research and evaluations of 

gender-responsive interventions, as required under the Reauthorization Act, will help identify and encourage replication or adaptation of effective models, and provide both positive and negative lessons learned for dissemination among programs supported by U.S. 

assistance in different countries or regions. 

The Reauthorization Act authorizes structural HIV prevention efforts intended to help alter social, political, and economic factors in 

the environment so that people may be empowered to engage in 

safer behaviors. These efforts help countries to address factors 

within the environment, such as gender inequities or migration 

patterns that can create conditions conducive to the spread of HIV, 

and begin to remedy them, for example by supporting microcredit 

opportunities for women or providing off-hours activities or housing 

options for migrant men or transport workers. Such prevention approaches also offer important opportunities for increased linkage 

across development lines, through the promotion of livelihoods and 

small enterprise development, job training, basic health services, 

and education. These activities are particularly relevant in terms 

of the needs of women and girls and continue programs that were 

authorized under the 2003 Leadership Act. 

Gender-based violence plays a significant role in the transmission of HIV in many areas, and efforts to assist countries in the 

development and enforcement of laws and policies to prevent and 

respond to gender-based violence and to promote screening and appropriate counseling, testing, and treatment in both HIV/AIDS and 

gender-based violence programs are important components of prevention, care, and treatment programs as authorized under this 

Reauthorization Act. Violence against women and girls in humanitarian relief, conflict, and post-conflict operations is an issue of particular concern. Domestic violence is widespread in some regions, 

including areas of high HIV prevalence, but this situation can 

change. Strengthening laws and enforcement mechanisms; publicizing laws and penalties and expanding awareness of victims’

services through national media campaigns; expanding youth education efforts; and promoting communication across gender lines, 

along with efforts to address alcohol abuse, can help to change social norms contributing to tolerance of violence. Increased access to 

economic opportunities is also an important component in the prevention of and response to domestic and sexual violence. Recognizing the importance of these programs in the fight against HIV/ 

AIDS, microcredit activities continue to be authorized under this 

legislation. Finally, the committee notes that currently many 

women and girls are unable to rely on the ABC strategy to protect 

themselves because they lack the power to abstain, cannot control 

or depend on their partners’ faithfulness, and cannot impose the 

use of condoms within their relationships. That fact makes efforts 


wwoods2 on PRODPC68 with REPORTS
14 

to strengthen women’s rights an important component of HIV/AIDS 

and national development strategies and underscores the need for 

support for programs such as those outlined above as well as new 

advances in prevention methods that women themselves can control. 

Children and HIV/AIDS 

According to UNAIDS, an estimated 2.5 million children are living with HIV; nearly 9 out of 10 live in sub-Saharan Africa. Over 

300,000 children under the age of 15 died of AIDS-related causes 

in 2007. Over 14 million children in the world have lost one or both 

parents to AIDS. Millions of more children are affected by or vulnerable to HIV/AIDS. S. 2731 seeks to address these issues confronting children on multiple levels, from increasing emphasis on 

PMTCT programs and expanding access to pediatric HIV/AIDS 

testing, treatment, and care, to supporting assistance for orphans 

and other children directly affected by the disease and expanding 

our understanding of what it means to be vulnerable to HIV/AIDS. 

The prevention of mother to child transmission (PMTCT) represents an area where scientific certainty—we know how to prevent 

transmission during pregnancy and childbirth—meets the limitations of maternal healthcare access and infrastructure in much of 

sub-Saharan Africa and elsewhere. Around the world, approximately a thousand infants a day are infected with HIV, most in 

sub-Saharan Africa. S. 2731 underscores the importance of expanding access to PMTCT services and achieving delivery targets and 

of supporting a continuum of care to connect prenatal and 

antenatal services with health services for mother and child after 

delivery. 

To date, children with HIV/AIDS have been underserved within 

global HIV/AIDS assistance programs. Barriers to enrollment for 

children in treatment programs include limited access to reliable 

HIV testing for the youngest children; a shortage of providers 

trained in delivering pediatric care; weak linkages between services 

to prevent mother-to-child transmission and HIV/AIDS care and 

treatment and child health programs; and the need for additional, 

low-cost pediatric formulations of HIV/AIDS medications—pediatric 

treatment is far more complex and expensive than that for adults. 

The Reauthorization Act identifies treatment of children in proportion to their percentage within the HIV infected population of a 

given country as a policy objective and seeks to help countries surmount these treatment barriers. The committee strongly supports 

expanded treatment and care for children not only through ARVs 

but also through increased access to additional medications such as 

cotrimoxazole prophylactic, for example, which at a cost of three 

cents a day has been shown to cut childhood HIV/AIDS mortality 

rates dramatically. 

The one numerical budgetary allocation for HIV/AIDS retained in 

this legislation is the 10-percent earmark for orphans and vulnerable children. This directive continues to receive broad support 

from implementers and U.S. Government officials alike. It is important to retain this allocation, and to maintain it separately from 

pediatric treatment, in order to ensure that orphans and vulnerable children remain a priority within U.S. HIV/AIDS country programs and to signal their importance to partner countries, many of 


wwoods2 on PRODPC68 with REPORTS
15 

15 According to the United Nations Development Program, Tanzania, Malawi, Niger, Burundi, 

Ethiopia, Mozambique, Sierra Leone, Togo, Benin, Chad, Lesotho, Eritrea, Rwanda, and 

Burkina Faso all have 5 or fewer physicians per 100,000 people. The only other nations in the 

world with such a small number of physicians per capita are Bhutan and Papua New Guinea. 

whom have not sufficiently emphasized programs for children. S. 

2731 also recognizes that, particularly in areas with high HIV 

prevalence rates, definitions of what it means to be vulnerable to 

HIV/AIDS or its socioeconomic effects should be expanded. For this 

reason, the legislation amends the original budget directive on orphans and vulnerable children from ‘‘orphans and vulnerable children affected by HIV/AIDS’’ to ‘‘orphans and other children affected 

by, or vulnerable to’’ HIV/AIDS. The committee encourages the 

Global AIDS Coordinator to provide clear guidance to the field on 

this subject. 

Capacity Building and Sustainability 

Lack of health personnel, inadequate infrastructure and health 

systems, and poor management represent formidable roadblocks to 

progress in the battle against HIV/AIDS and other infectious diseases and medical conditions, particularly in sub-Saharan Africa. 

The HIV/AIDS pandemic has aggravated the existing shortage of 

health workers through loss of life and illness among medical staff, 

unsafe working conditions for medical personnel, and increased 

workloads for diminished staff. The shortage of health personnel in 

turn undermines efforts to prevent infection and provide care and 

treatment for those with HIV/AIDS and to address other health 

challenges. Migration of health workers—often termed the ‘‘brain 

drain’’—adds to these losses; the committee supports codes of conduct and other measures to promote ethical practices in the international recruiting of healthcare workers, as well as steps to reduce ‘‘push factors’’ such as unsafe working conditions that also 

fuel this brain drain. According to the 2003 United Nations Development Programme, Human Development Report, approximately 3 

out of 4 countries in sub-Saharan Africa have fewer than 20 physicians per 100,000 people, the minimum ratio recommended by the 

World Health Organization, and 14 countries have 5 or fewer physicians per 100,000 people.15 Numbers of nurses and other health 

professionals are also critically low across much of the continent. 

The concentration of professionals in cities further limits the delivery of health services in rural areas. Capacity building is critical 

to making progress against HIV/AIDS, tuberculosis, and malaria 

and to shifting from a donor-led emergency line of attack to a more 

sustainable, country-driven public health approach. 

The PEPFAR program has made real progress in training personnel, increasing laboratory capacity, and improving infrastructure. The Reauthorization Act seeks to build on that progress and 

elevate the objective of capacity-building within U.S. programs. Additional health professionals, paraprofessionals, and compensated 

community health workers are all needed in this effort. The Reauthorization Act draws on S. 805, the African Health Capacity Investment Act of 2007 (which the committee approved in September 

2007), to address the need for health workers, infrastructure, and 

management development. 

In order to help achieve needed staffing levels, S. 2731 sets a target of training and retaining 140,000 professionals and paraprofesVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00015 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
16 

16The World Health Organization has issued guidelines on task-shifting in WHO, ‘‘Treat, 

Train, Retain: Task Shifting: Rational Redistribution of Tasks among Health Workforce Teams’’ (December 2007). 17 In the Abuja Declaration of 2001, heads of state of the Organization of African Unity [the 

predecessor of the African Union] pledged to place the fight against HIV/AIDS at the forefront 

in national development plans and committed to set a target of allocating 15 percent of annual 

budgets to the improvement of the health sector. 

sionals with the objective of helping countries to achieve World 

Health Organization recommended minimum staffing levels for 

doctors, nurses, and midwives. Doctors, nurses, and other health 

professionals must be trained, but also effectively deployed, under 

safe working conditions and with additional incentives to support 

retention. Skilled paraprofessionals, such as laboratory technicians, 

are needed, as are community health workers who often serve on 

the front lines of health services. The bulk of community health 

workers in many PEPFAR programs are volunteers; the committee 

recognizes the value of their service, but has concerns about the 

sustainability of a volunteer-based model and relying upon the 

poorest participants in the health workforce as volunteers. 

Older orphans, vulnerable children, and at risk youth are in need 

of educational and employment opportunities, while virtually all 

countries receiving significant U.S. assistance programs are in need 

of an expanded healthcare workforce. Public-private partnerships 

and other mechanisms should be pursued to help address this 

nexus through training of these individuals as entry level health 

workers and as paraprofessionals and through expanded support 

for higher education, with appropriate measures to promote incountry service following graduation. 

In addition to training more individuals (and retaining them incountry), systemic reforms and improvements are needed to combat 

HIV/AIDS and other diseases and health challenges. Task-shifting—in which lower-level health workers are authorized to assume 

some duties formerly reserved for physicians or other highly 

trained professionals—will help address imbalances in service delivery, but is only a partial solution and raises potential concerns 

that nurses and other healthcare workers might be diverted from 

primary healthcare duties for HIV/AIDS care.16 More diversified 

training is also needed, including instruction in the detection of opportunistic infections, pediatrics, gender-based violence assessments, TB/HIV coinfection, prevention education, and counseling 

and testing, to help achieve a work force with sufficient skills. The 

Reauthorization Act supports such training efforts as well as 

health and financial management reforms and infrastructural development to allocate resources more effectively. In undertaking 

such efforts, the potential benefit for the health system as a whole 

should help guide decisionmaking, and every precaution should be 

taken to ensure that HIV/AIDS programs do not diminish access to, 

or quality of, broader health services. 

Partner countries themselves must also invest more heavily in 

their health and education sectors, and S. 2731 urges them to do 

so, as set forth in the Abuja Declaration.17 The Reauthorization Act 

underscores the importance of the national HIV/AIDS and health 

strategies of partner countries in U.S. planning and allows for additional technical assistance to strengthen such instruments where 

needed. The legislation authorizes the Secretary of the Treasury to 

provide assistance to country health and finance ministries to atVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00016 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
17 

18The term sustainability is widely used but more rarely defined. Dr. Helene Gayle of CARE, 

in testifying before the House Foreign Affairs Committee on September 25, 2007, stated that 

‘‘sustainability relates to a set of activities continuing, even after their initiator exits. Another 

type refers to the durability of a certain impact: For example, a vaccine that provides immunity 

to a disease. A deeper form of sustainability is reflected in the ability of societies to maintain 

processes of economic, social and cultural transformation.’’ 19 USAID Office of Inspector General reports on Zimbabwe (October 2007), Malawi (September 

2007), and Tanzania (May 2006) reported respectively that staff shortages adversely affected 

basic monitoring activities of partners; data collection and management; and reduced site visits, 

which ‘‘could jeopardize the achievement of future outputs and targets, and impact the quality 

of the program data reported by the partners to the Mission, and the target information reported to the U.S. Government by USAID/Tanzania.’’

tract and manage international assistance more effectively. The 

committee also emphasizes the importance of supply chain management and equipment maintenance to ensure the effective use of 

purchased and donated goods. Sustainability of global HIV/AIDS 

programs cannot be achieved in the next 5 years, but it should ultimately be one of the longer term objectives of U.S. programs.18

Promoting country ownership of HIV/AIDS programs and methodologies represents one of the underlying goals of this legislation. 

Compacts or framework agreements between the United States and 

regional or national governments may be one way to achieve this 

objective. As part of his announcement regarding the reauthorization of PEPFAR on May 30, 2007, President Bush expressed his desire to establish partnership compacts with participating nations. 

S. 2731 includes language providing for the development of compacts or framework agreements. Compacts would constitute partnership agreements, with mutual obligations commensurate with 

national resources and capabilities. For countries with greater resources, U.S. contributions might be limited largely to technical assistance. Compacts could be reached either with one or more individual countries or with regions, such as the Caribbean Community 

(CARICOM). Key components of prospective compacts include 

health capacity-building; country investments; elements to 

strengthen the legal, economic, educational, and social status of 

women, girls, and vulnerable children and youth; civic participation; the promotion of policies, regulations, and law conducive to 

enhancing HIV/AIDS prevention, treatment, and care; evaluation, 

research, and information-sharing; and improved coordination of efforts to combat HIV/AIDS, TB, and malaria with national health 

and development strategies. Benchmarks, targets, and intended 

methodology to achieve them should be included within such 

framework agreements. 

Oversight and Evaluation of HIV/AIDS Programs 

The scope of the U.S. global HIV/AIDS initiative and the speed 

with which it has been developed and implemented under the leadership of the Global AIDS Coordinator are extremely impressive; 

this scope and speed, however, also contribute to challenges of sustainability and accountability. As indicated in reports by the offices 

of the Inspectors General for the Department of State and USAID, 

PEPFAR country teams have tended to be understaffed for the 

workload, budget, and responsibilities associated with the programs that they manage.19 Oversight, monitoring, and evaluation 

will almost inevitably suffer if staffing is inadequate. To facilitate 

smoother coordination and improve oversight and management of 

programs, S. 2731 recommends the appointment of full-time, experienced country coordinators for all U.S. missions with significant 


wwoods2 on PRODPC68 with REPORTS
18 

20 Regarding operations research, S. 2731 draws on S. 2584, the PEPFAR Accountability and 

Transparency Act. 

HIV/AIDS programs, supports adequate staffing of all country 

teams, and acknowledges the important contributions of Foreign 

Service Nationals to these efforts. 

The committee has included several provisions in the legislation 

to maintain and strengthen oversight and program review of U.S. 

global HIV/AIDS efforts. 

First, the bill calls for a report, including a preliminary design 

plan and budget, by the Institute of Medicine of the National Academies that assesses the performance of U.S. global HIV/AIDS programs and an evaluation of the impact of these programs on prevention, treatment, and care. The Institute conducted a similar 

study during the first 5 years of the global HIV/AIDS effort under 

the Leadership Act. That study, released in 2007, helped inform 

the committee’s work on the Reauthorization Act, particularly in 

regard to whether to retain certain funding allocations, or earmarks. The Institute of Medicine study under the Reauthorization 

Act is intended to address progress toward prevention, treatment, 

and care targets and evaluate the impact of treatment and care 

programs (e.g., mortality, adherence, and resistance rates) and of 

programs directed toward women and orphans and vulnerable children, as well as seeking to assess the impact of these efforts on 

health systems and service delivery in countries with significant 

programs. 

Second, the bill requires a review by the Government Accountability Office (GAO) no later than 3 years after enactment of this 

Act that will examine monitoring and evaluation practices, interagency coordination, procurement practices, and harmonization of 

the U.S. effort with national and international strategies. It will 

also assess the effect of HIV/AIDS investments on U.S. global 

health programming, and provide recommendations for improving 

global HIV/AIDS programs. 

Third, the Reauthorization Act emphasizes operations research, 

in order to evaluate policies and program outcomes.20 To promote 

the dissemination of information, the bill requires the Global AIDS 

Coordinator to publish a ‘‘best practices’’ report annually to highlight those programs with potential for replication or adaptation, 

particularly those programs that may be replicated or adapted at 

a low cost in other settings. In this manner, U.S. programs can 

make an indirect but important contribution to HIV/AIDS efforts 

where the United States is not directly involved. The committee regards it as important for OGAC to communicate information on adverse outcomes or unsuccessful approaches as well. 

Finally, the bill requires the Inspectors General (IGs) of the 

three largest U.S. Government agencies involved in the global HIV/ 

AIDS efforts—the Department of State, the Department of Health 

and Human Services, and the U.S. Agency for International Development—to coordinate on an annual oversight plan of bilateral programs. The provision also requires the Global AIDS Coordinator to 

make available not more than $10 million to fund the oversight by 

the Inspectors General. The committee is aware that the Offices of 

Inspector General at State and USAID have received only modest 

budgetary increases in recent appropriations, and are often asked 


wwoods2 on PRODPC68 with REPORTS
19 

to do more with less. This financing mechanism—just .0002 percent of the $50 billion authorized in this bill—will strengthen the ability 

of those Offices to conduct regular audits, inspections, and performance reviews of bilateral HIV/AIDS programs. Oversight and monitoring and evaluation should be seen as components of effective 

prevention, treatment, and care programs rather than as competitors with them for resources. 

The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria 

S. 2731 authorizes up to $2 billion for the Global Fund for fiscal 

year 2009 and such sums as necessary for the subsequent 4 fiscal 

years; this structure parallels section 202(d)(1) of the 2003 Act, 

which authorized $1 billion for fiscal year 2004 and such sums as 

necessary for the remaining fiscal years. The Global Fund represents the primary multilateral component of the Reauthorization 

Act. The legislation recognizes the increasingly effective coordination between the Global Fund and bilateral U.S. assistance programs. The committee commends this development, recognizes that 

the bilateral and multilateral efforts each possess comparative advantages in certain areas, and notes that the Global Fund model 

may have the potential for greater capacity-building and sustainability in the long term. The committee also regards the Global 

Fund as having made significant progress toward addressing concerns raised by the Government Accountability Office about transparency and accountability and anticipates further progress as the 

newly appointed Inspector General for the Global Fund attains full 

staffing levels and undertakes monitoring activities. 

In order to promote greater transparency, accountability, and 

public availability of information, the Reauthorization Act includes 

a provision to withhold 20 percent of the U.S. contribution beginning in FY 2010 if certain benchmarks are not met. Benchmarks 

include: The evaluation of Local Fund Agents; the disclosure of information, performance data, and funding levels for principal and 

subrecipients; the activities of the Inspector General; reporting on 

standard indicators and distribution of resources; the establishment of a tariff policy and pursuit of steps to prevent the imposition of taxes on Global Fund services; the Global Fund’s continuation as a financing institution focused on the three diseases; and 

progress in sustaining a multisectoral approach with resources allocated to different sectors, including governments, civil society, and 

faith-and community-based programs. 

Table 1.—Global Fund Contributions 

(in U.S. dollars) 

2001–02 2003 2004 2005 2006 2007 2008 est. 

Total Global Contributions ............... 947M 937M 1.5B 1.5B 2.2B 2.5B 3.5B 

U.S. Appropriations .......................... 300M 348M 547M 435M 545M 724M 841M 

U.S. Share of Contributions .............

(as a percentage) ....................... 32 33 32 31 24 28 28 

M = million. 

B = billion. 

Tuberculosis 

Tuberculosis claims an estimated 1.6 million lives a year, and 

drug resistant strains of the disease are becoming increasingly 


wwoods2 on PRODPC68 with REPORTS
20 

21MDR–TB is defined as TB demonstrating resistance to the two most commonly used drug 

treatments, rifamin and isoniazid; XDR–TB is resistant to those two first-line drugs and at least 

two other major drug treatments. 

common and more dangerous. This airborne disease, including its 

drug-resistant variants, is becoming a more generalized epidemic 

in many countries of the world. While there are an estimated 9 million new tuberculosis cases per year, only one-third of those with 

the disease currently receive treatment. The World Health Organization recently reported that 5 percent of new cases of TB are 

multidrug resistant (MDR–TB), and that at least 40,000 persons 

are thought to have extensively drug resistant TB (XDR–TB); this 

number could be considerably higher as many countries lack the 

capacity to test for resistance.21 Drug resistance emerges most 

commonly when TB patients fail to complete their course of treatment; mutations in the bacterium may then develop, and drugresistant strains can subsequently be transmitted to others. Tuberculosis normally requires a 6-month course of treatment with costs 

as low as $20 per patient; treatment for MDR–TB may take 2 years 

and cost thousands of dollars. XDR–TB is even more difficult to 

treat and often fatal. Persons with HIV/AIDS are particularly vulnerable to TB, and coinfection rates within the HIV infected population top 50 percent in some countries. 

Drawing upon S. 968, the Stop Tuberculosis (TB) Now Act of 

2007, which was favorably reported by the committee in October 

2007, S. 2731 recognizes the global threat posed by tuberculosis, 

and particularly MDR– and XDR–TB, and authorizes $4 billion to 

combat the disease over 5 years. The World Health Organization’s ‘‘Stop TB’’ Strategy offers a roadmap for combating tuberculosis 

and reducing the threats of increasing drug resistance and for the 

resources necessary for this effort. Directly Observed Treatment 

Short-course (DOTS) treatment for TB is one of the most cost-effective health interventions available today. The committee emphasizes the importance of both ensuring maximum on the ground impact of resources to combat TB and of maintaining the quality of 

programs and services delivered, not least because of the extraordinary public health costs associated with poor adherence to standard treatment for TB. Patient services, training for health workers 

and the maintenance of safe working conditions, laboratory capacity, and drugs and diagnostics should be prioritized. The committee 

recognizes and supports funding for the global TB work of the Centers for Disease Control and Prevention. The committee also supports robust funding for the Global Tuberculosis Drug Facility and 

recommends significantly increased annual U.S. contributions, 

building on recent appropriations. 

Coinfection between HIV/AIDS and TB represents a significant 

public health problem in many countries, making increased coordination between HIV/AIDS and TB programs a continuing priority; 

TB remains the leading cause of death among persons with AIDS. 

Diagnosis can be difficult particularly because TB symptoms may 

manifest themselves differently in HIV positive persons, often as 

sputum smear-negative pulmonary and extra-pulmonary forms of 

TB that are more difficult to detect and that are associated with 

higher mortality rates. In order to help achieve the objectives set 

forth in the Stop TB Strategy and the Millennium Development 

Goals, expanded diagnostic and treatment capacity for all forms of 


wwoods2 on PRODPC68 with REPORTS
21 

TB is necessary, as is expanded laboratory capacity to detect drug 

resistance. 

Malaria 

Over 1 million people a year die of malaria, most of them children under the age of 5 or pregnant women. The President’s 

Malaria Initiative, launched in 2005, is already beginning to make 

an impact in the fight against this deadly and preventable disease. 

S. 2731 authorizes $5 billion for fiscal years 2009 to 2013 in order 

to build on this early progress by expanding the resources and 

reach of U.S antimalarial programs. In order to advance these efforts and improve the operations of antimalarial programs and coordination across U.S. agencies and with other multilateral, national, and private actors, the Reauthorization Act codifies a position within USAID of a Coordinator of United States Government 

Activities to Combat Malaria Globally [hereafter, the Malaria Coordinator]. 

This legislation supports numerous primary interventions, including long-lasting insecticide-treated bednets; indoor residual 

spraying with insecticides; intermittent presumptive treatment of 

pregnant women in areas of high malaria transmission; community-based symptoms detection, management and care; artemisininbased combination therapies (ACTs); and other measures to 

promote treatment, care, and prevention. As with other health 

interventions, capacity-building is a critical element in the fight 

against malaria. The Reauthorization Act also supports research 

activities to develop and evaluate new diagnostics, treatment regimens, and prevention and control measures. Artemisinin-based 

drugs and insecticides are potentially subject to increasing resistance over time. The spread of counterfeit drugs may hasten the 

emergence of more widespread drug resistance, signs of which are 

already appearing in the Mekong Delta region. The World Health 

Organization also indicates that malaria-carrying mosquitoes have 

developed resistance to some of the 12 approved insecticides in the 

Amazon Basin, the Mekong Delta, and particular regions of Africa, 

thus reducing the efficacy of insecticide-treated bednets and indoor 

spraying programs. S. 2731 requires the monitoring of global malaria trends and the assessment of the environmental and health 

impact of malarial vector control efforts, including the use and production of insecticides for bednets and residential spraying. The 

committee also underscores the importance of adherence to World 

Health Organization and other relevant standards in the use and 

control of these products. 

IV. COMMITTEE ACTION

Last year, the committee held two hearings directly related to 

the subject matter of the bill. On October 24, 2007, the committee 

held a hearing on ‘‘The Next Phase of the Global Fight against 

HIV/AIDS,’’ at which Ambassador Mark Dybul, the Global AIDS 

Coordinator, testified. On December 13, 2007, it held a hearing 

with outside witnesses on ‘‘Perspectives on the Next Phase of the 

Global Fight against HIV/AIDS, Tuberculosis, and Malaria.’’

On March 7, 2008, Senators Biden, Lugar, Kennedy, and Sununu 

introduced S. 2731, a bill to authorize appropriations for fiscal 

years 2009 through 2013 to provide assistance to foreign countries 


wwoods2 on PRODPC68 with REPORTS
22 

to combat HIV/AIDS, tuberculosis, and malaria, and for other purposes. 

On March 13, 2008, the committee held a business meeting to 

consider S. 2731. The committee approved a series of amendments 

by voice vote. The amendments were as follows: 

• An amendment by Senator Biden making technical amendments to section 101(f) on Inspectors General. 

• An amendment by Senators Biden and Lugar to alter the conscience clause provision to conform to the House bill. 

• An amendment by Senator Biden to change ‘‘healthcare workers and professionals’’ to ‘‘healthcare paraprofessionals and 

professionals’’ in section 301 and adding definition of paraprofessionals. 

• An amendment by Senator DeMint regarding the Global Fund. 

• An amendment by Senators Biden and Lugar to eliminate the 

phrase ‘‘behavior change’’ in several places in the bill to conform to the House bill and clarify its meaning. 

• An amendment by Senators Biden and Dodd to make adjustments to the provisions on pediatric treatment. 

• An amendment by Senator Biden to define ‘‘structural prevention.’’

• An amendment by Senator Dodd to create a panel to review 

Prevention of Mother-to-Child Transmission. 

• An amendment by Senator Kerry to promote vaccine development. 

• An amendment by Senator Obama to promote microbicide development. 

• An amendment by Senator DeMint to ensure that CDC surveillance activities on malaria do not duplicate the work of the 

World Health Organization. 

• An amendment by Senators Nelson and Menendez to highlight 

the Caribbean region as a potential partner for regional approaches to HIV/AIDS. 

• An amendment by Senators Biden and Lugar to add a new section 401(b) on the scaleup of the spending over the course of 

the five fiscal years. 

• An amendment by Senator Cardin to promote preservice training for health capacity. 

• An amendment by Senators Biden and Lugar to make a technical change to insert section 307 and to renumber the rest of 

Title III accordingly. 

The committee then voted to order the bill, as amended, reported 

favorably by a vote of 18 to 3. Voting in favor of the bill were Senators Biden, Dodd, Kerry, Feingold, Boxer, Nelson, Obama, Menendez, Cardin, Casey, Webb, Lugar, Hagel, Coleman, Corker, 

Voinovich, Murkowski, and Isakson. Voting against the bill were 

Senators DeMint, Vitter, and Barrasso. 

V. SECTION-BY-SECTION ANALYSIS

Section 1. Short title 

The short title is the ‘‘Tom Lantos and Henry J. Hyde United 

States Global Leadership Against HIV/AIDS, Tuberculosis, and 

Malaria Reauthorization Act of 2008.’’


wwoods2 on PRODPC68 with REPORTS
23 

Sec. 2. Findings 

This section amends the findings in the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 (‘‘the 

2003 Leadership Act’’) by adding to that Act additional findings 

with updated data on human immunodeficiency virus (HIV) and 

the acquired immunodeficiency syndrome (AIDS) (hereafter referred to as ‘‘HIV/AIDS’’), tuberculosis (TB), and malaria around 

the world and the impact of U.S. assistance in combating these diseases since the 2003 Leadership Act was enacted. The findings also 

identify ongoing and growing challenges in meeting the needs for 

treatment, care, prevention, cure and research of and related to 

these diseases. 

Sec. 3. Definitions 

This section amends the 2003 Leadership Act by adding additional definitions of terms. 

Sec. 4. Purpose 

This section amends the purpose section of the 2003 Leadership 

Act and sets out the overall goals and objectives of this bill. It refers to the mandate for a new 5-year coordinated strategy to combat HIV/AIDS, tuberculosis, and malaria as part of the overall 

United States global health and development agenda; calls for increased resources for bilateral and multilateral efforts to combat 

these diseases; intensifies prevention, treatment, and care efforts 

and seeks to enhance program effectiveness including addressing 

the particular vulnerabilities of girls and women; encourages public-private partnerships; reinforces vaccine development and other 

research, including operations research; and helps partner countries to strengthen health systems and improve capacity. 

Sec. 5. Authority to consolidate and combine reports 

This section maintains a provision in current law allowing the 

executive branch to consolidate and combine reports, with a minor 

technical amendment. 

TITLE I—POLICY PLANNING AND COORDINATION 

Sec. 101. Development of a comprehensive, 5-year, global strategy 

This section amends section 101 of the 2003 Leadership Act by 

providing additional guidance to the President on the development 

of the second 5-year plan to combat HIV/AIDS globally and a subsequent report to Congress. 

It instructs the President to seek to situate United States efforts 

to combat HIV/AIDS, tuberculosis, and malaria within the broader 

health and development agenda; to provide a plan to be carried out 

over the next 5 years to prevent 12 million new HIV infections, 

support care for 12 million adults and children with HIV/AIDS (including 5 million orphans and other children affected by HIV/ 

AIDS), and to support treatment for 3 million persons with HIV/ 

AIDS through bilateral efforts as well as additional persons 

through multilateral programs. 

It also establishes targets to promote universal access (defined as 

80 percent) to services to prevent mother-to-child transmission, to 

treat children in proportion to their numbers within a country’s 


wwoods2 on PRODPC68 with REPORTS
24 

population of persons with HIV/AIDS, and to strengthen health 

workforces. The strategy prioritizes the importance of HIV prevention, including programs to promote abstinence, fidelity, and the 

use of condoms, as well as other prevention tools. To ensure that 

treatment is not neglected, it requires a timetable for achieving 

treatment targets. It instructs the President to strengthen health 

capacity in, and to enhance attention to the national HIV/AIDS 

strategies of partner countries, and to promote coordination in 

United States responses to HIV/AIDS, tuberculosis, and malaria. 

This section calls for a plan for regional priorities for resource 

distribution and a structure for potential new compacts or framework agreements. It underscores the importance of addressing the 

needs and vulnerabilities of women and girls. Finally, it calls for 

a long-range estimate of projected resource needs and progress toward sustainability. 

This section also instructs the Global AIDS Coordinator to commission a study by the Institute of Medicine (with prior design plan 

and budget) to assess progress and outcomes of United States 

global HIV/AIDS programs and provides for a Government Accountability Office report on monitoring and evaluation, coordination, and impact of HIV/AIDS funding and programs on United 

States global health programs as a whole. It requires annual publication of a ‘‘Best Practices’’ report based on operations research. To 

enhance oversight, it requires joint, coordinated plans by the Inspectors General (IGs) of the three largest U.S. Government agencies carrying out this program (State Department, HHS, and 

USAID) and authorizes the transfer of up to $10 million to the IGs 

to support financial audits, inspections, and performance reviews. 

Sec. 102. Interagency working group 

This section amends current law to strengthen and expand the 

duties of the Global AIDS Coordinator, including enhancing the 

role of the Coordinator in consulting and coordinating with foreign 

governments, nongovernmental organizations, and other U.S. Government agencies. It expands the duties of the AIDS Coordinator 

to include establishing and heading a working group consisting of 

representatives from the United States Agency for International 

Development (USAID) and the Department of Health and Human 

Services. 

Sec. 103. Sense of Congress 

This section provides a sense of Congress about the importance 

of country coordinators, foreign service nationals, and staffing levels for country teams. 

TITLE II—SUPPORT FOR MULTILATERAL FUNDS, 

PROGRAMS, AND PUBLIC-PRIVATE PARTNERSHIPS 

Sec. 201. Voluntary contributions to International vaccine funds 

This section reauthorizes the existing programs under section 

302 of the Foreign Assistance Act for fiscal years 2009–2013, specifically the vaccine fund, the International AIDS Vaccine Initiative, and the malaria vaccine development program. This section 

also provides a new authorization for a U.S. contribution to tuberculosis vaccine development programs. 


wwoods2 on PRODPC68 with REPORTS
25 

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

This section amends section 202 of the 2003 Leadership Act relating to U.S. contributions to the Global Fund. Subsection (a) updates findings in the Act and expresses the sense of Congress regarding transparency, accountability, and coordination. Subsection 

(b) increases the annual authorization for the U.S. contribution to 

the Global Fund from $1 billion to up to $2 billion for fiscal years 

2009, and such sums as necessary for fiscal years 2010–2013. 

The subsection includes new benchmarks designed to improve 

the accountability and transparency of the Global Fund’s activities, 

including a provision, beginning in fiscal year 2010, that would 

withhold 20 percent of appropriated funds until the Secretary of 

State certifies achievement of certain benchmarks. 

Sec. 203. Microbicide research 

Subsection (a) expresses the sense of Congress recognizing the 

need and urgency to expand the range of interventions for preventing the transmission of HIV, including nonvaccine prevention 

methods that can be controlled by women. 

Subsection (b) amends the Public Health Service Act (42 U.S.C. 

300cc-40 et seq.) by directing the Director of the National Institutes 

of Health Office of AIDS Research to develop and implement Federal strategic plans for microbicide research and to review and update such plans annually, prioritizing funding and activities relative to scientific urgency and potential market readiness of 

microbicide products as appropriate. The subsection also directs the 

Director to consult with representatives of other relevant Federal 

agencies, the microbicide research community, and health advocates. The subsection includes authorization of such sums as necessary. 

Subsection (c) amends the Public Health Service Act by directing 

the Director of the National Institute of Allergy and Infectious Diseases (NIAID) to conduct research and development of microbicides 

for use in developing countries to prevent HIV transmission. The 

Director shall ensure adequate staffing and structure to carry out 

such activities, such as through a dedicated microbicide research 

and development branch. 

Subsection (d) directs the Director of the Centers for Disease 

Control and Prevention (CDC) to fully implement the CDC’s 

microbicide agenda to support research and development of 

microbicides. It authorizes as such sums as may be necessary for 

each of fiscal years 2009 through 2013 to carry out these activities. 

Subsection (e) authorizes the Administrator of USAID, in coordination with the Coordinator of U.S. Government Activities to Combat HIV/AIDS Globally, to develop and implement a program to 

facilitate wide scale availability of microbicides that prevent the 

transmission of HIV if such microbicides are proven safe and effective. It authorizes such sums as may be necessary for fiscal years 

2009 through 2013 to carry out this section. 


wwoods2 on PRODPC68 with REPORTS
26 

Sec. 204. Combating HIV/AIDS, tuberculosis, and malaria by 

strengthening health policies and health systems of partner 

countries 

This section amends title II of the 2003 Leadership Act by adding 

a new section 204 relating to strengthening health policies and 

health systems of host countries. Subsection (a) provides a statement of policy regarding the need for strengthening of such health 

policies and systems. Subsection (b) authorizes the appropriation of 

funds authorized under section 401 of the Act to the Department 

of Treasury to provide technical assistance to host countries to improve the public finance management systems of such countries to 

enable them to receive HIV/AIDS assistance, collect revenue, and 

manage their own programs. 

Sec. 205. Facilitating effective operations of the Centers for Disease 

Control and Prevention 

This section amends the Public Health Service Act by authorizing the Secretary of Health and Human Services to participate 

with other countries in cooperative endeavors in research, 

healthcare services, and other activities authorized under the Reauthorization Act. The section also strikes a provision prohibiting 

the Secretary from providing financial assistance for the construction of any facility in any foreign country. It authorizes the provision of funds by advance or reimbursement to the Secretary of 

State, as may be necessary, to pay for the acquisition, lease, construction alteration, equipping, or managing of facilities outside the 

United States and authorizes grants or cooperative agreements relating to such activities, in consultation with the Secretary of State. 

Section 206. Facilitating vaccine development 

Subsection (a) authorizes the USAID Administrator to strengthen the capacity of developing countries’ governments to conduct 

proper protocols for the introduction of new vaccines, if such vaccines are proven safe and effective, to review protocols for clinical 

trials and impact studies and improve implementation, and to ensure adequate supply chain and delivery systems. 

Subsection (b) directs the Secretary of the Treasury to enter into 

negotiations with appropriate entities including the World Bank 

and GAVI Alliance to establish advanced market commitments to 

purchase vaccines to combat HIV/AIDS, tuberculosis, malaria, and 

other related infectious diseases. In such negotiations, the Secretary is directed to take into account factors regarding pricing, 

transparency, safety, dispute settlement, and needed flexibility. 

Not later than 1 year after enactment, the Secretary shall provide 

the appropriate congressional committees with a report on negotiations and the President shall produce a report by a study group of 

qualified professionals setting forth a strategy for vaccine development. 


wwoods2 on PRODPC68 with REPORTS
27 

TITLE III—BILATERAL EFFORTS 

Subtitle A—General Assistance and Programs 

Sec. 301. Assistance to combat HIV/AIDS 

This section amends section 104A of the Foreign Assistance Act 

of 1961 and section 301 of the 2003 Leadership Act, both of which 

relate to bilateral U.S. HIV/AIDS assistance. 

Subsection (a) modifies the findings of the 2003 Leadership Act 

and identifies that it is a policy objective of the United States for 

FY 2009–2013 to assist countries in: 

• Preventing 12 million new HIV infections; • Supporting treatment of at least 3 million people with HIV/ 

AIDS as well as additional support through multilateral 

efforts; • Supporting care for 12 million people including care and support for 5 million children affected by HIV/AIDS; • Providing access to counseling and services for prevention of 

mother-to-child transmission to 80 percent of the target population (80 percent is the level most often defined as ‘‘universal 

access’’); • Providing care and treatment services to children with HIV/ 

AIDS in proportion to their percentage within the population 

of persons who are infected within a given country; and 

• Training 140,000 new paraprofessionals and professionals. 

The subsection further amends section 104A by supporting a coordinated global strategy to confront HIV/AIDS in sub-Saharan Africa, the Caribbean, Central Asia, Eastern Europe, Latin America, 

and other countries and regions to help address generalized and 

concentrated HIV/AIDS epidemics, highlighting the importance of 

prevention. 

Section 301 also notes the activities for which U.S. HIV/AIDS assistance can be used for prevention, including an increased focus on 

counseling, delay of sexual debut, abstinence, fidelity, life skills, 

prevention of mother-to-child HIV transmission, and medical male 

circumcision. It also provides for a more coordinated approach to 

HIV/AIDS by supporting access to treatment for opportunistic infections and development programs that can improve the effectiveness of HIV/AIDS efforts, such as nutrition, education, and programs that improve the livelihood of individuals with HIV/AIDS as 

well as programs to address the needs and vulnerabilities of girls 

and women. It promotes the use of provider-initiated or ‘‘opt out’’

voluntary counseling and testing as well as rapid testing. 

The section underscores the importance of operations research as 

a component of HIV/AIDS activities, and amends the 2003 Leadership Act to create an enhanced focus on food and nutrition assistance as critical to an integrated approach to treatment of individuals with HIV/AIDS. Section 301 authorizes, though does not 

mandate, compacts or framework agreements in order to promote 

a more sustainable, country-driven approach. The section includes 

necessary components of such compacts. It also expands the annual 

report to address a number of the new approaches described in this 

Act and to emphasize outcomes of programs. 

Section 301 also amends section 301 of the 2003 Leadership Act 

to extend the authorization to fiscal years 2009 through 2013. 


wwoods2 on PRODPC68 with REPORTS
28 

Subsection (h) clarifies that not only are groups receiving funds 

under the Act not required to endorse or utilize any activities or 

programs to which they have a moral or religious objection, they 

are also not required to integrate with, or refer to programs to 

which they have a moral or religious objections. 

Sec. 302. Assistance to combat tuberculosis 

Subsections (a) and (b) amend section 104B of the Foreign Assistance Act of 1961 relating to assistance to combat tuberculosis, 

drawing from S. 968, the Stop Tuberculosis (TB) Now Act of 2007, 

which the committee approved on September 11, 2007. These 

amendments include a revised statement of policy; a requirement 

to provide assistance to combat tuberculosis and a list of activities 

to be carried out, including diagnostic testing and counseling, treatment, and implementation of protocols to address drug resistance. 

Subsection (c) authorizes the provision of increased resources to 

the World Health Organization. 

Subsection (d) offers definitions of additional terms. 

Subsection (e) amends section 302 of the 2003 Leadership Act to 

authorize up to a total of $4 billion for fiscal years 2009 to 2013 

from the overall amounts authorized by section 401 of the 2003 

Leadership Act (as amended by this Act) for assistance to combat 

tuberculosis. 

Sec. 303. Assistance to combat malaria 

Subsection (a) amends section 104C of the Foreign Assistance Act 

of 1961 to ensure that treatment is part of U.S. efforts to combat 

malaria. 

Subsection (b) amends section 303 of the 2003 Leadership Act to 

authorize up to a total of $5 billion for fiscal years 2009 to 2013 

from the overall amounts authorized by section 401 of the 2003 

Leadership Act (as amended by this Act) for assistance to combat 

malaria. 

Subsection (c) provides a statement of policy regarding malaria. 

Subsection (d) requires the President to provide a comprehensive 

5-year strategy to combat malaria. 

Sec. 304. Malaria Response Coordinator 

Section 304 amends section 304 of the 2003 Leadership Act by 

adding a requirement for a comprehensive strategy to combat malaria and to establish within USAID a malaria coordinator. It also 

authorizes contributions to the Roll Back Malaria Partnership and 

the World Health Organization; research by relevant U.S. agencies 

to address prevention, treatment, and care of malaria; and requires 

an annual report on the prevention, treatment, control and elimination of malaria. 

Sec. 305. Amendment to the Immigration and Nationality Act 

Section 305 amends section 212(a)(1)(A) of the Immigration and 

Nationality Act by removing the statutory prohibition on persons 

with HIV entering the country. Under section 212, should this provision be enacted, aliens remain inadmissible if they have a ‘‘communicable disease of public health significance’’ under regulations 

issued by the Secretary for Health and Human Services. 


wwoods2 on PRODPC68 with REPORTS
29 

Sec. 306. Clerical amendment 

This provides a technical amendment to a subtitle heading in the 

2003 Act. 

Sec. 307. Requirements 

This section amends section 312 of the 2003 Leadership Act to 

provide for additional policy and other requirements, including the 

establishment of targets for reaching 80 percent of the target population for prevention of mother-to-child transmission (PMTCT) of 

HIV and to ensure that the proportion of children receiving care 

and treatment for HIV/AIDS is proportionate to their numbers 

within the population. The section also calls for integrating care 

and treatment with PMTCT programs; expanding programs for 

orphans and for children who are affected by or vulnerable to HIV/ 

AIDS; increasing access of women in PMTCT programs to maternal 

and child health services; and establishing a timeline for expanding 

access to PMTCT regimes. 

Sec. 308. Annual reports on prevention of mother-to-child transmission of the HIV infection 

This section amends section 313 of the 2003 Leadership Act by 

extending the duration of the annual PMTCT report required by 

such subsection and requires that such report include additional information on the number of women who receive various types of assistance related to PMTCT. 

Section 309. Prevention of mother-to-child transmission expert panel 

This section amends section 312 of the 2003 Leadership Act by 

directing the Global AIDS Coordinator to establish a panel of experts on the prevention of mother-to-child transmission of HIV to 

review PMTCT activities and make recommendations to the Global 

AIDS Coordinator and the appropriate congressional committees. 

The panel shall terminate 60 days after said report is submitted. 

TITLE IV—FUNDING ALLOCATIONS 

Sec. 401. Authorization of appropriations 

Subsection (a) increases the authorization under section 401(a) of 

the 2003 Leadership Act to $50 billion for fiscal years 2009 to 2013. 

Unlike the House bill, which provides an authorization of $10 

billion per fiscal year, this allows for a gradual expansion of the 

program. 

Subsection (b) expresses the sense of the Congress that these 

funds should be gradually increased over the 5 fiscal years covered 

by the bill and in a manner consistent with program requirements, 

absorptive capacity, and priorities set forth in the Act. The committee does not expect the President to request or the Congress to 

fund these programs all in 1 year. For fiscal year 2008, Congress 

appropriated $6.327 billion for these programs, according to the 

Congressional Research Service. 

Sec. 402. Sense of Congress 

This section amends the ‘‘sense of Congress’’ language included 

in section 402(b) of the 2003 Leadership Act to eliminate specific 

spending directives in the legislation expressed as a sense of ConVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00029 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
30 

gress for percentage allocations for treatment and for the use of 

prevention funds for abstinence programs. 

Sec. 403. Allocation of funds 

This section amends section 403(a) of the 2003 Leadership Act to 

maintain focus on balanced prevention programming. This section 

includes a requirement that the Coordinator provide balanced 

funding for prevention activities for sexual transmission of HIV/ 

AIDS and ensure that abstinence, delay sexual debut, monogamy, 

fidelity and partner reduction programs are implemented and 

funded in a meaningful and equitable way in the strategy for each 

host country, based on objective epidemiological evidence as to the 

source of infection and in consultation with the government of each 

host country involved in HIV/AIDS prevention activities. 

The new subsection also provides that the Coordinator shall establish an HIV sexual transmission prevention strategy governing 

the expenditure of funds authorized by the Act used to prevent the 

sexual transmission of HIV in any host country with a generalized 

epidemic. In each such host country, if this strategy provides less 

than 50 percent of such funds for behavior change programs including abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities, the Coordinator shall, within 30 days of 

the issuance of this strategy, report to the appropriate congressional committees on the justification for this decision. The subsection excludes new prevention technologies or modalities such as 

medical male circumcision or microbicides as well as PMTCT activities, blood safety measures, and other prevention tools unrelated to the sexual transmission of HIV from calculations to determine compliance with the balanced funding reporting requirement. 

Finally, this section maintains the 10-percent earmark for 

orphans and vulnerable children, and modifies the focus of this effort to include children who are vulnerable to, as well as affected 

by, HIV/AIDS to allow greater flexibility in providing services to atrisk children, especially in communities with high prevalence rates. 

VI. 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. 

U.S. CONGRESS, CONGRESSIONAL BUDGET OFFICE, Washington, DC, April 11, 2008. 

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. 2731, the Tom Lantos and 

Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. 


wwoods2 on PRODPC68 with REPORTS
31 

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

to provide them. The CBO staff contact is Michelle S. Patterson. 

Sincerely, 

ROBERT A. SUNSHINE

(For Peter R. Orszag, Director). 

Enclosure. 

S. 2731—Tom Lantos and Henry J. Hyde U.S. Global Leadership 

Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization 

Act of 2008 

Summary: S. 2731 would reauthorize several assistance programs aimed at preventing and treating HIV/AIDS, tuberculosis, 

and malaria in other countries. For those programs, the bill would 

authorize the appropriation of $50 billion over the next 5 years. 

Other provisions of the bill would authorize funding for U.S. contributions to international vaccine funds and for research on the 

development of substances that can be applied topically to limit the 

transmission of HIV. CBO estimates that implementing S. 2731 

would cost $35 billion over the 2009–2013 period, assuming appropriation of the authorized amounts. (Additional amounts would be 

spent after 2013.) 

In addition, enacting S. 2731 would increase direct spending. The 

bill would allow immigrants with HIV/AIDS to enter the United 

States. CBO estimates that providing certain benefits to those 

immigrants and their children would increase direct spending by 

less than $500,000 in 2010 and by $83 million over the 2010–2018 

period. Enacting S. 2731 would have no effect on revenues. 

S. 2731 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). 

CBO estimates that state spending for Medicaid would increase by 

$53 million over the 2010–2018 period as a result of the bill’s immigration provisions, but such spending would not result from 

intergovernmental mandates. 

Estimated cost to the Federal Government: The estimated budgetary impact of S. 2731 is shown in Table 1. The costs of this legislation fall within budget functions 150 (international affairs), 550 

(health), and 600 (income security). 

TABLE 1.—ESTIMATED BUDGETARY IMPACT OF S. 2731 

By fiscal year, in millions of dollars—

2009 2010 2011 2012 2013 2009– 2013 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

HIV/AIDS, Tuberculosis, and Malaria Programs: 

Estimated Authorization Level ................................. 10,000 10,000 10,000 10,000 10,000 50,000 

Estimated Outlays ................................................... 1,392 6,392 8,262 9,082 9,482 34,610 

Contributions to Vaccine Funds: 

Estimated Authorization Level ................................. 108 108 108 158 158 640 

Estimated Outlays ................................................... 108 108 108 158 158 640 

Microbicide Research: 

Estimated Authorization Level ................................. 10 11 13 12 12 58 

Estimated Outlays ................................................... 4 9 11 12 12 48 

Total Changes: 

Estimated Authorization .......................................... 10,118 10,119 10,121 10,170 10,170 50,698 

Level Estimated Outlays .......................................... 1,504 6,509 8,381 9,252 9,652 35,298 


wwoods2 on PRODPC68 with REPORTS
32 

TABLE 1.—ESTIMATED BUDGETARY IMPACT OF S. 2731—Continued 

By fiscal year, in millions of dollars—

2009 2010 2011 2012 2013 2009–

2013 

CHANGES IN DIRECT SPENDING 1

Estimated Budget Authority ............................................. 0 * * 1 2 3 

Estimated Outlays ............................................................ 0 * * 1 2 3 

1 In addition to the direct spending effects shown here, enacting S. 2731 would have effects on direct spending after 2013 (see Table 2). 

The estimated increase in direct spending sums to $3 million over the 2010–2013 period and $83 million over the 2010–2018 period. 

Note: * = less than $500,000. 

Basis of estimate: For this estimate, CBO assumes that the bill 

will be enacted by September 30, 2008, that the authorized 

amounts will be appropriated, and that outlays will follow historical spending patterns for existing programs. 

Spending subject to appropriation 

S. 2731 would reauthorize several assistance programs and increase the funding levels for those programs. It also would require 

research into various vaccines and microbicides. In total, implementing the bill would have discretionary costs of $1.5 billion in 

2009 and $35 billion over the 2009–2013 period. 

HIV/AIDS, Tuberculosis, and Malaria Programs. Section 401 

would authorize the appropriation of $50 billion over the 2009–

2013 period. For this estimate, CBO assumes that $10 billion 

would be appropriated for each of the 5 years, though the allocation 

of the $50 billion authorization could vary from that assumption. 

The funds would be used to operate and expand the existing assistance programs that provide grants and contributions to organizations and global funds devoted to treating the effects of HIV/AIDS, 

tuberculosis, and malaria, and to preventing the transmission of 

those diseases. Those programs, which received a total of $6 billion 

for 2008, are run by the Department of State, the U.S. Agency for 

International Development (USAID), and the Department of 

Health and Human Services. 

Based on information from the Department of State, CBO estimates that the authorized 5-year total of $50 billion is sufficient to 

fund the expanded requirements. CBO estimates that implementing section 401 would cost about $35 billion over the 2009–

2013 period. Most of the additional amounts from the authorized 

funding would be spent by 2018. 

Contribution to Vaccine Funds. Section 201 would authorize the 

appropriation of such sums as may be necessary to make contributions for research and development of various vaccines. Based on 

information from USAID on the current amount of contributions to 

those funds (about $100 million in 2008) and, after 2011, the 

amount needed to fund the final stages of development for a tuberculosis vaccine, CBO estimates that implementing section 201 

would cost $640 million over the 2009–2013 period. 

Microbicide Research. Section 203 would direct the Centers for 

Disease Control and Prevention (CDC) to conduct research with the 

goal of developing topical mircobicides that could be used to limit 

the transmission of HIV. For that purpose, it would authorize the 

appropriation of such sums as necessary. 


wwoods2 on PRODPC68 with REPORTS
33 

Based on information from the CDC, CBO estimates that such 

research would require $10 million in 2009 and $58 million over 

the 2009–2013 period. Assuming appropriation of those amounts, 

and that spending for those activities would follow historical spending patterns, CBO estimates that implementing section 203 would 

cost $48 million over the 2009–2013 period. 

AIDS Drug Assistance Programs. The Ryan White Care Act provides grants to states to run the AIDS Drug Assistance Program 

(ADAP). ADAP provides prescription drug benefits to certain lowincome individuals with HIV/AIDS. Implementing S. 2731 would 

increase the number of individuals eligible for ADAP benefits. CBO 

estimates that the number of people newly eligible for ADAP benefits would reach about 1,000 in 2011. 

The Ryan White Care Act authorizes the appropriation of specific 

amounts for ADAP through 2011. Absent a change in the specific 

authorization or appropriation for ADAP, no new Federal funding 

would be available to meet this increased demand. If additional 

funding were provided for the ADAP program, CBO estimates it 

would cost about $20 million in 2010 and 2011 to provide ADAP 

benefits to individuals affected by section 305. (This section would 

have direct spending costs, as explained below.) 

Direct spending 

Section 305 would amend the Immigration and Nationality Act 

by removing language that explicitly identified HIV infection—and 

consequently AIDS—as one of the communicable diseases of publichealth significance that render aliens ineligible for visas or admission to the United States. Based on information from the CDC, 

CBO expects that the agency would amend the regulations concerning communicable diseases to allow aliens with HIV or AIDS 

into the United States if section 305 were enacted. CBO expects 

that the amended regulations would take effect at the beginning of 

fiscal year 2010. 

Enacting section 305 would enable additional immigrants to receive visas to enter the United States, primarily in the visa program for immediate family members. (For some visa programs, the 

number of immigrants with HIV/AIDS would increase, but the total 

number of immigrants admitted would not change.) Based on information from the CDC, the World Health Organization, and the 

Department of Homeland Security, CBO estimates the annual 

number of additional immigrants with HIV/AIDS would total about 

900 in 2010 and grow to approximately 4,300 in fiscal year 2013. 

Thereafter, the number of additional immigrants would grow in 

line with overall immigration, totaling roughly 5,600 in 2018. Additionally, CBO estimates that about 800 citizen-children would be 

born to those immigrants between 2010 and 2018, a markedly 

lower birth rate than that for non-HIV/AIDS immigrants. 

CBO estimates that a small percentage of the immigrants who 

would enter the United States under section 305 would receive 

Federal disability, health, and nutrition benefits. In total, CBO estimates that providing benefits to those immigrants and their children would increase spending by less than $500,000 in 2010 and 

$83 million over the 2010–2018 period, as shown in Table 2. 

(Through 2017, the end of the Senate’s enforcement period for diVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00033 Fmt 6659 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
34 

rect spending under the current budget resolution, the bill would 

increase direct spending by $46 million.) 

TABLE 2.—COMPONENTS OF DIRECT SPENDING UNDER S. 2731 

By fiscal year, in millions of dollars—

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2009- 

2013 

2009- 

2018 

CHANGES IN DIRECT SPENDING 

Medicaid: 

Estimated Budget Authority ........... 0 * * 1 2 3 5 10 18 31 3 70 

Estimated Outlays .......................... 0 * * 1 2 3 5 10 18 31 3 70 

Food and Nutrition Programs: 

Estimated Budget Authority ........... 0 * * * * 1 1 1 3 3 * 9 

Estimated Outlays .......................... 0 * * * * 1 1 1 3 3 * 9 

Supplemental Security Income: 

Estimated Budget Authority ........... 0 * * * * * * * 1 3 * 4 

Estimated Outlays .......................... 0 * * * * * * * 1 3 * 4 

Total Changes: 

Estimated Budget Authority ........... 0 * * 1 2 4 6 11 22 37 3 83 

Estimated Outlays .......................... 0 * * 1 2 4 6 11 22 37 3 83 

Note: * = less than $500,000. 

Medicaid. Under the Medicaid eligibility rules for noncitizens, 

immigrants entering under section 305 who meet Medicaid’s income and categorical eligibility criteria would have to wait 5 years 

before they could receive full Medicaid benefits. However, those individuals would be eligible for emergency Medicaid services before 

the end of the 5-year waiting period. 

CBO estimates that enacting section 305 would increase direct 

spending for the Federal share of the Medicaid program by $3 million over the 2010–2013 period and $70 million over the 2010–2018 

period. The increase in estimated costs after 2014 reflects individuals becoming eligible for full Medicaid benefits after completing 

the 5-year waiting period. 

Food and Nutrition Programs. By 2018, CBO estimates that 

about 1,300 newly admitted immigrants would qualify for Food 

Stamps with an average benefit of about $130 a month. In addition, about 4,000 children of the additional immigrants would be 

eligible for child nutrition programs in 2018, with an average 

monthly cost of about $30 (in 2018 dollars). In total, CBO estimates 

that direct spending for the Food Stamp and Child Nutrition programs would increase by less than $500,000 in 2010 and $9 million 

over the 2010–2018 period. 

Supplemental Security Income (SSI). CBO estimates that direct 

spending for the Supplemental Security Income program would increase by less than $500,000 in 2010 and $4 million over the 2010–

2018 period. Under current law, immigrants generally have to wait 

until they became naturalized citizens before they can receive SSI. 

Based on data from the CDC, the Social Security Administration, 

and private researchers, CBO estimates that nearly 400 of the additional immigrants under section 305 would enter the rolls by 

2018. Over that period, CBO projects average monthly benefits 

would grow from $500 to $590. 

Social Security Disability Insurance. CBO estimates that, under 

section 305, off-budget direct spending for the Social Security 

Disability Insurance (DI) program would increase by less than 

$500,000 over the 10-year budget window. Based on the age and 


wwoods2 on PRODPC68 with REPORTS
35 

health profile of immigrants, CBO estimates that few people would 

qualify for DI over that period. 

Medicare. Noncitizens can become eligible for Medicare if they 

are over the age of 65 and are residents of the United States for 

five consecutive years, or after receiving DI for 2 years. CBO assumes that few of the new entrants under section 305 would meet 

either of these eligibility criteria. Therefore, CBO estimates that direct spending for Medicare would increase by less than $500,000 

over the 2010–2018 period. 

Estimated impact on state, local, and tribal governments: S. 2731 

contains no intergovernmental mandates as defined in UMRA, but 

changes to immigration law would result in an increased number 

of individuals eligible for Medicaid, SSI, and ADAP. State spending 

for those programs would increase, but that additional spending 

would not result from intergovernmental mandates. 

CBO estimates state spending for Medicaid would increase by $53 million over the 2010–2018 period, while state spending for 

supplemental SSI payments would increase only slightly. ADAP 

benefits are state-controlled, voluntary, and federally funded 

through grants. Any additional costs to state, local, or tribal governments might incur in that program, including matching funds, 

would result from complying with conditions of aid. 

Estimated impact on the private sector: S. 2731 contains no new 

private-sector mandates as defined in UMRA. 

Previous CBO estimate: On March 5, 2008, CBO transmitted a 

cost estimate for H.R. 5501, the Tom Lantos and Henry J. Hyde 

U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, as ordered reported by the 

House Committee on Foreign Affairs on February 28, 2008. While 

the two pieces of legislation have many provisions in common, S. 

2731 contains two provisions that are not included in H.R. 5501. 

Section 305 of S. 2731 would allow immigrants with HIV to enter 

the United States, which CBO estimates would increase direct 

spending. In addition, section 203 of S. 2731 would require the 

CDC to conduct additional research. Differences in the estimated 

costs of S. 2731 and H.R. 5501 reflect those differences in the legislation. 

Estimate prepared by: Federal Costs: Foreign Aid—Michelle S. 

Patterson; Centers for Disease Control and Prevention—Tim 

Gronniger; Supplemental Security Income—David Rafferty; Medicaid—Andrea Kastin Noda; Food and Nutrition Programs—Jonathan Morancy. 

Impact on State, Local, and Tribal Governments: Neil Hood; Impact on the Private Sector: MarDestinee C. Perez. 

Estimate approved by: Peter H. Fontaine, Assistant Director for 

Budget Analysis. 


wwoods2 on PRODPC68 with REPORTS
(36) 

VII. MINORITY VIEWS 

We strongly dissent from the committee’s report of S. 2731 to the 

full Senate. We are gravely concerned that the President’s Emergency Plan for AIDS Relief (PEPFAR) program is under serious 

threat of dramatic policy reversals that endanger the lives of millions around the world suffering from and at risk of contracting 

HIV/AIDS. First authorized in 2003, PEPFAR was a historic new 

approach to combating HIV/AIDS. The elements of the program 

were unprecedented: 

• Saving the lives of people with AIDS: For the first time, the 

U.S. would fund antiretroviral treatment for millions. • Evidence-based prevention: The U.S. would implement the African-grown ‘‘ABC’’ model of abstinence, ‘‘be faithful’’ and 

condoms that had led to such dramatic reductions in HIV incidence in Uganda. • Concentration of effort: Targeted funding for the poorest countries in sub-Saharan Africa and the Caribbean with the worst 

AIDS epidemics. 

As the bill to authorize this new initiative moved through the 

Congress, its sponsors and supporters fought hard to keep off the 

many worthy, but competing initiatives that would have diluted 

the impact of the PEPFAR program. Unfortunately, S. 2731 fails 

to protect the program from similar efforts; and we are gravely concerned that the noble impact and long-term legacy of the program 

are being threatened. Specifically, we believe that S. 2731 has the 

following serious flaws: 

Politics Trump Proven Prevention Policy 

We object to the bill’s elimination of the protected funding for abstinence-until-marriage programs required under current law and 

replaces it with watered-down, ill-defined language that would permit a prevention program to operate without measurable, significant support for abstinence and fidelity programs. Prior to the implementation of PEPFAR, the only country to ever demonstrate a 

nationwide reduction in HIV incidence was Uganda. The success 

was driven by the African-grown, grassroots, low-tech, low-cost 

‘‘ABC’’ model of HIV prevention, based on three commonsense messages, each targeted to a different population: (1) The promotion of 

abstinence until marriage or delay of sexual debut for youth and 

unmarried adults, (2) the promotion of fidelity within marriage and 

partner reduction for sexually active unmarried adults, and (3) the 

promotion of the consistent and correct use of condoms for especially high-risk subpopulations, such as prostitutes and their customers, substance abusers and their equipment-sharing and sexual 

partners, and HIV-serodiscordant married couples. The evidence is 

clear: ABC works to prevent sexual transmission of HIV/AIDS in 

a generalized epidemic such as you find in sub-Saharan Africa. 


wwoods2 on PRODPC68 with REPORTS
37 

Nothing else ever has. As a result of this sound approach, Uganda 

now has company: Several PEPFAR focus countries have started to 

see reductions, including Kenya, Coˆte D’Ivoire, and Ethiopia. 

No Conscience Protections for Organizations Providing HIV/AIDS 

Care 

The bill removes most references to faith-based organizations 

contained in current law, causing us to question whether the bill 

authors intend PEPFAR to retreat from its important recognition 

of the indispensable role of such organizations in reaching communities affected by HIV/AIDS in the developing world that might 

never be successfully reached using U.S.-based USAID contractors. 

Of even more concern, however, is the bill’s elimination of conscience protections for organizations providing the critical third element of the HIV treatment, prevention, and care combination. The 

bill protects organizations participating in HIV/AIDS treatment, 

prevention, and monitoring programs from being required to support or provide services to which they have a moral or religious objection. However, no such protection is provided for organizations 

providing HIV ‘‘care’’ programs, which include all programs for orphans and vulnerable children, hospice and palliative care services, 

support groups and psychosocial services and many other services. 

Support for Morally Dubious Activities 

The bill contains many references to activities ‘‘demonstrated to 

be effective in reducing the transmission of HIV infection among 

injection drug users without increasing illicit drug use.’’ Given the 

claim by some that programs to distribute clean needles to injection drug users are effective at reducing transmission and do not 

lead to more drug use, these provisions could be interpreted to support needle exchange programs, a practice not currently supported 

domestically or abroad using U.S. funds. Americans should not be 

forced to subsidize the distribution of paraphernalia for illicit drug 

use, when the best HIV prevention for injection drug use would be 

treatment of the underlying addiction. 

The Global Fund Takes Cues from the U.N. 

When the 108th Congress authorized the first contribution to the 

Global Fund to Fight HIV/AIDS, Tuberculosis, we were assured 

that the Fund would not be like the U.N. and that the Fund would 

guarantee full transparency and accountability. The current law 

contains some important provisions to protect the taxpayer investment in this multilateral disease-fighting organization. However, 

we have seen during the first few years of the Fund’s operation 

that these provisions have not been sufficient to ensure full accountability and transparency by the scandal-ridden Fund. What’s 

more, the Fund has failed to provide Congress with all documents 

requested, including reports of the so-called ‘‘independent’’ Inspector General. The Fund has lost money by relying on the U.N. Development Program (UNDP) in Burma, and failed to recoup funds 

from terminated grants there. Burma is not the only country where 

the Fund relies on UNDP, but actually uses the U.N. agency as a 

‘‘safer’’ alternative to directly funding rogue regimes such as 

Zimbabwe and Sudan. UNDP is under investigation by the U.S. 


wwoods2 on PRODPC68 with REPORTS
38 

Senate Permanent Subcommittee on Investigations for using donor 

money to finance North Korea illicit weapons sales; laundering untold millions from terrorist regimes through U.N. bank accounts; 

using donor money to help Zimbabwe officials purchase ‘‘blood diamonds’’; and a variety of other crimes. 

Further, the Fund has failed to adequately safeguard the quality 

of medicines procured using its funding. While we support the bill’s 

provision conditioning 20 percent of the U.S. contribution to the 

Fund to the achievement of certain accountability measures, the 

bill also contains a variety of important transparency measures in 

a nonbinding ‘‘Sense of Congress’’ provision. We believe that these 

provisions should be made binding, as well. 

Fiscal Irresponsibility 

Before PEPFAR was authorized, the U.S. spent less than $200 

million annually on global AIDS. Compared to past levels, 

PEPFAR’s initial authorization of $15 billion over 5 years was a 

dramatic increase. Indeed, the administration has ramped up to an 

annual spending level that grossly exceeds the statutory limit in 

current law. Even if Congress agreed to extend funding at these 

unauthorized levels, we would ‘‘only’’ need to pass a reauthorization bill to provide between $25–$30 billion over the next 5 years. 

S. 2731, however, authorizes $50 billion over 5 years in addition to 

numerous, ‘‘such sums’’ authorizations. 

What’s more, the current targeted, effective HIV/AIDS program 

is under assault in this bill by ‘‘mission creep’’ that threatens to dilute the impact of the program and violate all pretentions of fiscal 

restraint by prioritizing seemingly every activity except HIV treatment, prevention, and care. The bill’s HIV programs are crowded 

out by every possible development program imaginable, including 

schools, poverty alleviation, microcredit, legal aid, government advocacy, women’s ‘‘empowerment,’’ ‘‘stigma reduction,’’ nutrition, 

U.S.-based university agricultural research, biomedical vaccine development, and health workforce development. In addition to 

squeezing-out the higher priority HIV programs, the inclusion of all 

these additional development programs will only guarantee that 

the pressure to exceed the authorization caps in the bill will be irresistible in the out years as the development needs of the world 

can never be fully met. 

CONCLUSION

The PEPFAR program has been one of the few success stories of 

U.S. foreign assistance policy. The scientific policy has been sound, 

the fiscal priorities appropriate, and the results astounding. As a 

means of building diplomatic good will, PEPFAR has been an unquestioned success in strengthening bilateral relationships in the 

important emerging governments and economies in Africa. Simply 

put, the program isn’t ‘‘broken.’’ The best approach to reauthorization would be to simply extend current authorities at a fiscally responsible level. S. 2731 is a radical departure from current policy, 

and will serve to reverse the many gains the program has achieved 


wwoods2 on PRODPC68 with REPORTS
39 

to date. We dissent from the committee’s report of the bill to the 

Senate for full consideration. 

Sincerely, 

DAVID VITTER, 

U.S. Senator. 

JIM DEMINT, 

U.S. Senator. 


wwoods2 on PRODPC68 with REPORTS
(40) 

VIII. 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 United States Leadership Against HIV/AIDS, 

Tuberculosis, and Malaria Act of 2003 

* * * * * * * 

SEC. 2. FINDINGS. 

Congress makes the following findings: 

(1) * * * 

* * * * * * * 

(28) * * * 

(29) On May 27, 2003, the President signed this Act into law, 

launching the largest international public health program of its 

kind ever created. 

(30) Between 2003 and 2008, the United States, through the 

President’’s Emergency Plan for AIDS Relief (PEPFAR) and in 

conjunction with other bilateral programs and the multilateral 

Global Fund has helped to— (A) provide antiretroviral therapy for over 1,900,000 people; 

(B) ensure that over 150,000 infants, most of whom 

would have likely been infected with HIV during pregnancy 

or childbirth, were not infected; and 

(C) provide palliative care and HIV prevention assistance 

to millions of other people. 

(31) While United States leadership in the battles against 

HIV/AIDS, tuberculosis, and malaria has had an enormous 

impact, these diseases continue to take a terrible toll on the 

human race. 

(32) According to the 2007 AIDS Epidemic Update of the 

Joint United Nations Programme on HIV/AIDS (UNAIDS)—

(A) an estimated 2,100,000 people died of AIDS-related 

causes in 2007; and 

(B) an estimated 2,500,000 people were newly infected 

with HIV during that year. 

(33) According to the World Health Organization, malaria 

kills more than 1,000,000 people per year, 70 percent of whom 

are children under 5 years of age. 

(34) According to the World Health Organization, 1⁄3 of the 

world’’s population is infected with the tuberculosis bacterium, 

and tuberculosis is 1 of the greatest infectious causes of death 

of adults worldwide, killing 1,600,000 people per year. 


wwoods2 on PRODPC68 with REPORTS
41 

(35) Efforts to promote abstinence, fidelity, the correct and 

consistent use of condoms, the delay of sexual debut, and the reduction of concurrent sexual partners represent important elements of strategies to prevent the transmission of HIV/AIDS. 

(36) According to UNAIDS—

(A) women and girls make up nearly 60 percent of persons in sub-Saharan Africa who are HIV positive; 

(B) women and girls are more biologically, economically, 

and socially vulnerable to HIV infection; and 

(C) gender issues are critical components in the effort to 

prevent HIV/AIDS and to care for those affected by the disease. 

(37) Children who have lost a parent to HIV/AIDS, who are 

otherwise directly affected by the disease, or who live in areas 

of high HIV prevalence may be vulnerable to the disease or its 

socioeconomic effects. 

(38) Lack of health capacity, including insufficient personnel 

and inadequate infrastructure, in sub-Saharan Africa and 

other regions of the world is a critical barrier that limits the 

effectiveness of efforts to combat HIV/AIDS, tuberculosis, and 

malaria, and to achieve other global health goals. 

(39) On March 30, 2007, the Institute of Medicine of the National Academies released a report entitled ‘‘PEPFAR Implementation: Progress and Promise’’, which found that budget allocations setting percentage levels for spending on prevention, 

care, and treatment and for certain subsets of activities within 

the prevention category—

(A) have ‘‘adversely affected implementation of the U.S. 

Global AIDS Initiative’’; 

(B) have inhibited comprehensive, integrated, evidence 

based approaches; 

(C) ‘‘have been counterproductive’’; 

(D) ‘‘may have been helpful initially in ensuring a balance of attention to activities within the 4 categories of prevention, treatment, care, and orphans and vulnerable children’’; 

(E) ‘‘have also limited PEPFAR’’s ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries’’ national 

plans’’; and 

(F) should be removed by Congress and replaced with 

more appropriate mechanisms that—

(i) ‘‘ensure accountability for results from Country 

Teams to the U.S. Global AIDS Coordinator and to 

Congress’’; and 

(ii) ‘‘ensure that spending is directly linked to and 

commensurate with necessary efforts to achieve both 

country and overall performance targets for prevention, 

treatment, care, and orphans and vulnerable children’’. 

(40) The United States Government has endorsed the principles of harmonization in coordinating efforts to combat HIV/ 

AIDS commonly referred to as the ‘‘Three Ones’’, which includes—


wwoods2 on PRODPC68 with REPORTS
42 

(A) 1 agreed HIV/AIDS action framework that provides 

the basis for coordination of the work of all partners; 

(B) 1 national HIV/AIDS coordinating authority, with a 

broadbased multisectoral mandate; and 

(C) 1 agreed HIV/AIDS country-level monitoring and 

evaluating system. 

(41) In the Abuja Declaration on HIV/AIDS, Tuberculosis 

and Other Related Infectious Diseases, of April 26–27, 2001 (referred to in this Act as the ‘‘Abuja Declaration’’), the Heads of 

State and Government of the Organization of African Unity 

(OAU)—

(A) declared that they would ‘‘place the fight against 

HIV/AIDS at the forefront and as the highest priority issue 

in our respective national development plans’’; 

(B) committed ‘‘TO TAKE PERSONAL RESPONSIBILITY AND PROVIDE LEADERSHIP for the activities of 

the National AIDS Commissions/Councils’’; 

(C) resolved ‘‘to lead from the front the battle against 

HIV/AIDS, Tuberculosis and Other Related Infectious Diseases by personally ensuring that such bodies were properly 

convened in mobilizing our societies as a whole and providing focus for unified national policymaking and programme implementation, ensuring coordination of all sectors at all levels with a gender perspective and respect for 

human rights, particularly to ensure equal rights for people 

living with HIV/AIDS’’; and 

(D) pledged ‘‘to set a target of allocating at least 15% of 

our annual budget to the improvement of the health sector’’. 

* * * * * * * 

SEC. 3. DEFINITIONS. 

In this Act: 

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

(2) APPROPRIATE CONGRESSIONAL COMMITTEES.—The term 

‘‘appropriate congressional committees’’ means the Committee 

on Foreign Relations of the Senate and the øCommittee on 

International Relations¿ Committee on Foreign Affairs of the 

House of Representatives, the Committee on Appropriations of 

the Senate, and the Committee on Appropriations of the House 

of Representatives. 

(3) GLOBAL AIDS COORDINATOR.—The term ‘‘Global AIDS Coordinator’’ means the Coordinator of United States Government 

Activities to Combat HIV/AIDS Globally. 

ø(3)¿ (4) GLOBAL FUND.—The term ‘‘Global Fund’’ means the 

public-private partnership known as the Global Fund to Fight 

AIDS, Tuberculosis and Malaria established pursuant to Article 80 of the Swiss Civil Code. 

ø(4)¿ (5) HIV.—The term ‘‘HIV’’ means the human immunodeficiency virus, the pathogen that causes AIDS. 

ø(5)¿ (6) HIV/AIDS.—The term ‘‘HIV/AIDS’’ means, with respect to an individual, an individual who is infected with HIV 

or living with AIDS. 


wwoods2 on PRODPC68 with REPORTS
43 

(7) IMPACT EVALUATION RESEARCH.—The term ‘‘impact evaluation research’’ means the application of research methods and 

statistical analysis to measure the extent to which change in a 

population-based outcome can be attributed to program intervention instead of other environmental factors. 

(8) OPERATIONS RESEARCH.—The term ‘‘operations research’’

means the application of social science research methods and 

statistical analysis to judge, compare, and improve policies and 

program outcomes, from the earliest stages of defining and designing programs through their development and implementation, with the objective of the rapid dissemination of conclusions 

and concrete impact on programming. 

(9) PARAPROFESSIONAL.—The term ‘‘paraprofessional’’ means 

an individual who is trained and employed as a health agent 

for the provision of basic assistance in the identification, prevention, or treatment of illness or disability. 

(10) PARTNER GOVERNMENT.—The term ‘‘partner government’’

means a government with which the United States is working 

to provide assistance to combat HIV/AIDS, tuberculosis, or malaria on behalf of people living within the jurisdiction of such 

government. 

(11) PROGRAM MONITORING.—The term ‘‘program monitoring’’

means the collection, analysis, and use of routine program data 

to determine—

(A) how well a program is carried out; and 

(B) how much the program costs. 

(12) STRUCTURAL HIV PREVENTION.—The term ‘‘structural 

HIV prevention’’ means activities or programs designed to—

(A) address environmental factors that could create conditions conducive to the spread of HIV; and 

(B) determine the best ways to remedy such factors by enhancing life skills and promoting changes in laws, policies, 

and social norms. 

ø(6)¿ (13) RELEVANT EXECUTIVE BRANCH AGENCIES.—The 

term ‘‘relevant executive branch agencies’’ means the Department of State, the United States Agency for International Development, and any other department or agency of the United 

States that participates in international HIV/AIDS activities 

pursuant to the authorities of such department or agency or 

the Foreign Assistance Act of 1961. 

øSEC. 4. PURPOSE. 

øThe purpose of this Act is to strengthen United States leadership and the effectiveness of the United States response to certain 

global infectious diseases by—

ø(1) establishing a comprehensive, integrated five-year, global strategy to fight HIV/AIDS that encompasses a plan for 

phased expansion of critical programs and improved coordination among relevant executive branch agencies and between 

the United States and foreign governments and international 

organizations; 

ø(2) providing increased resources for multilateral efforts to 

fight HIV/AIDS; 


wwoods2 on PRODPC68 with REPORTS
44 

ø(3) providing increased resources for United States bilateral 

efforts, particularly for technical assistance and training, to 

combat HIV/AIDS, tuberculosis, and malaria; 

ø(4) encouraging the expansion of private sector efforts and 

expanding public-private sector partnerships to combat HIV/ 

AIDS; and 

ø(5) intensifying efforts to support the development of vaccines and treatment for HIV/AIDS, tuberculosis, and malaria.¿ 

SEC. 4. PURPOSE. 

The purpose of this Act is to strengthen and enhance United 

States leadership and the effectiveness of the United States response 

to the HIV/AIDS, tuberculosis, and malaria pandemics and other 

related and preventable infectious diseases as part of the overall 

United States health and development agenda by—

(1) establishing comprehensive, coordinated, and integrated 

5-year, global strategies to combat HIV/AIDS, tuberculosis, and 

malaria by—

(A) building on progress and successes to date; 

(B) improving harmonization of United States efforts 

with national strategies of partner governments and other 

public and private entities; and 

(C) emphasizing capacity building initiatives in order to 

promote a transition toward greater sustainability through 

the support of country-driven efforts; 

(2) providing increased resources for bilateral and multilateral efforts to fight HIV/AIDS, tuberculosis, and malaria as integrated components of United States development assistance; 

(3) intensifying efforts to—

(A) prevent HIV infection; 

(B) ensure the continued support for, and expanded access to, treatment and care programs; 

(C) enhance the effectiveness of prevention, treatment, 

and care programs; and 

(D) address the particular vulnerabilities of girls and 

women; 

(4) encouraging the expansion of private sector efforts and expanding public-private sector partnerships to combat HIV/ 

AIDS, tuberculosis, and malaria; 

(5) reinforcing efforts to—

(A) develop safe and effective vaccines, microbicides, and 

other prevention and treatment technologies; and 

(B) improve diagnostics capabilities for HIV/AIDS, tuberculosis, and malaria; and 

(6) helping partner countries to—

(A) strengthen health systems; 

(B) improve human health capacity; and 

(C) address infrastructural weaknesses. 

SEC. 5. AUTHORITY TO CONSOLIDATE AND COMBINE REPORTS. 

With respect to the reports required by this Act to be submitted 

by the President, to ensure an efficient use of resources, the President may, in his discretion and notwithstanding any other provision of this Act, consolidate or combine any of these reports, except 

for the report required by section 101 of this Act, so long as the 


wwoods2 on PRODPC68 with REPORTS
45 

required elements of each report are addressed and reported within 

a 90-day period from the original deadline date for submission of 

the report specified in this Act. The President may also enter into 

contracts with organizations with relevant expertise to develop, 

originate, or contribute to any of the reports required by this Act 

to be submitted by the President, with the exception of the 5-year 

strategy. 

TITLE I—POLICY PLANNING AND COORDINATION 

SEC. 101. DEVELOPMENT OF A COMPREHENSIVE, FIVE-YEAR, GLOBAL 

STRATEGY. 

ø(a) STRATEGY.—The President shall establish a comprehensive, 

integrated, five-year strategy to combat global HIV/AIDS that 

strengthens the capacity of the United States to be an effective 

leader of the international campaign against HIV/AIDS. Such 

strategy shall maintain sufficient flexibility and remain responsive 

to the ever-changing nature of the HIV/AIDS pandemic and shall—

ø(1) include specific objectives, multisectoral approaches, and 

specific strategies to treat individuals infected with HIV/AIDS 

and to prevent the further spread of HIV infections, with a 

particular focus on the needs of families with children (including the prevention of mother-to-child transmission), women, 

young people, and children (such as unaccompanied minor children and orphans); 

ø(2) as part of the strategy, implement a tiered approach to 

direct delivery of care and treatment through a system based 

on central facilities augmented by expanding circles of local delivery of care and treatment through local systems and capacity; 

ø(3) assign priorities for relevant executive branch agencies; 

ø(4) provide that the reduction of HIV/AIDS behavioral risks 

shall be a priority of all prevention efforts in terms of funding, 

educational messages, and activities by promoting abstinence 

from sexual activity and substance abuse, encouraging monogamy and faithfulness, promoting the effective use of condoms, 

and eradicating prostitution, the sex trade, rape, sexual assault and sexual exploitation of women and children; 

ø(5) improve coordination and reduce duplication among relevant executive branch agencies, foreign governments, and 

international organizations; 

ø(6) project general levels of resources needed to achieve the 

stated objectives; 

ø(7) expand public-private partnerships and the leveraging of 

resources; 

ø(8) maximize United States capabilities in the areas of technical assistance and training and research, including vaccine 

research; 

ø(9) establish priorities for the distribution of resources 

based on factors such as the size and demographics of the population with HIV/AIDS, tuberculosis, and malaria and the 

needs of that population and the existing infrastructure or 

funding levels that may exist to cure, treat, and prevent HIV/ 

AIDS, tuberculosis, and malaria; and 


wwoods2 on PRODPC68 with REPORTS
46 

ø(10) include initiatives describing how the President will 

maximize the leverage of private sector dollars in reduction 

and treatment of HIV/AIDS, tuberculosis, and malaria.¿ 

(a) STRATEGY.—The President shall establish a comprehensive, integrated, 5-year strategy to expand and improve efforts to combat 

global HIV/AIDS. This strategy shall— (1) further strengthen the capability of the United States to 

be an effective leader of the international campaign against this 

disease and strengthen the capacities of nations experiencing 

HIV/AIDS epidemics to combat this disease; 

(2) maintain sufficient flexibility and remain responsive to— (A) changes in the epidemic; 

(B) challenges facing partner countries in developing and 

implementing an effective national response; and 

(C) evidence-based improvements and innovations in the 

prevention, care, and treatment of HIV/AIDS; 

(3) situate United States efforts to combat HIV/AIDS, tuberculosis, and malaria within the broader United States global 

health and development agenda, establishing a roadmap to link 

investments in specific disease programs to the broader goals of 

strengthening health systems and infrastructure and to integrate and coordinate HIV/AIDS, tuberculosis, or malaria programs with other health or development programs, as appropriate; 

(4) provide a plan to— (A) prevent 12,000,000 new HIV infections worldwide; 

(B) support treatment of at least 3,000,000 individuals 

with HIV/AIDS and support additional treatment through 

coordinated multilateral efforts; 

(C) support care for 12,000,000 individuals with HIV/ 

AIDS, including 5,000,000 orphans and vulnerable children affected by HIV/AIDS, with an emphasis on promoting a comprehensive, coordinated system of services to 

be integrated throughout the continuum of care; 

(D) help partner countries in the effort to achieve goals 

of 80 percent access to counseling, testing, and treatment to 

prevent the transmission of HIV from mother to child, emphasizing a continuum of care model; 

(E) help partner countries to provide care and treatment 

services to children with HIV in proportion to their percentage within the HIV-infected population in each country; 

(F) promote preservice training for health professionals 

designed to strengthen the capacity of institutions to develop and implement policies for training health workers to 

combat HIV/AIDS, tuberculosis, and malaria; 

(G) equip teachers with skills needed for HIV/AIDS prevention, treatment, and care; 

(H) provide and share best practices for combating HIV/ 

AIDS with health professionals; and 

(I) help partner countries to train and support retention 

of healthcare professionals and paraprofessionals, with the 

target of training and retaining at least 140,000 new 

healthcare professionals and paraprofessionals and to 

strengthen capacities in developing countries, especially in 


wwoods2 on PRODPC68 with REPORTS
47 

sub-Saharan Africa, to deliver primary healthcare with the 

objective of helping countries achieve staffing levels of at 

least 2.3 doctors, nurses, and midwives per 1,000 population, as called for by the World Health Organization; 

(5) include multisectoral approaches and specific strategies to 

treat individuals infected with HIV/AIDS and to prevent the 

further transmission of HIV infections, with a particular focus 

on the needs of families with children (including the prevention 

of mother-to-child transmission), women, young people, orphans, and vulnerable children; 

(6) establish a timetable with annual global treatment targets; 

(7) expand the integration of timely and relevant research 

within the prevention, care, and treatment of HIV/AIDS; 

(8) include a plan for program monitoring, operations research, and impact evaluation and for the dissemination of a 

best practices report to highlight findings; 

(9) provide for consultation with local leaders and officials to 

develop prevention strategies and programs that are tailored to 

the unique needs of each country and community and targeted 

particularly toward those most at risk of acquiring HIV infection; 

(10) make the reduction of HIV/AIDS behavioral risks a priority of all prevention efforts by— (A) promoting abstinence from sexual activity and encouraging monogamy and faithfulness; 

(B) encouraging the correct and consistent use of male 

and female condoms and increasing the availability of, and 

access to, these commodities; 

(C) promoting the delay of sexual debut and the reduction of multiple concurrent sexual partners; 

(D) promoting education for discordant couples (where an 

individual is infected with HIV and the other individual is 

uninfected or whose status is unknown) about safer sex 

practices; 

(E) promoting voluntary counseling and testing, addiction therapy, and other prevention and treatment tools for 

illicit injection drug users and other substance abusers; 

(F) educating men and boys about the risks of procuring 

sex commercially and about the need to end violent behavior toward women and girls; 

(G) supporting comprehensive programs to promote alternative livelihoods, safety, and social reintegration strategies 

for commercial sex workers and their families; 

(H) promoting cooperation with law enforcement to prosecute offenders of trafficking, rape, and sexual assault 

crimes with the goal of eliminating such crimes; and 

(I) working to eliminate rape, gender-based violence, sexual assault, and the sexual exploitation of women and children; 

(11) include programs to reduce the transmission of HIV 

through structural prevention efforts, particularly addressing 

the heightened vulnerabilities of women and girls to HIV in 

many countries; and 


wwoods2 on PRODPC68 with REPORTS
48 

(12) support other important means of preventing or reducing 

the transmission of HIV, including— (A) medical male circumcision; 

(B) the maintenance of a safe blood supply; and 

(C) other mechanisms to reduce the transmission of HIV; 

(13) increase support for prevention of mother-to-child transmission; 

(14) build capacity within the public health sector of developing countries by improving health systems and public health 

infrastructure and developing indicators to measure changes in 

broader public health sector capabilities; 

(15) increase the coordination of HIV/AIDS programs with 

development programs; 

(16) provide a framework for expanding or developing existing or new country or regional programs, including— (A) drafting compacts or other agreements, as appropriate; 

(B) establishing criteria and objectives for such compacts 

and agreements; and 

(C) promoting sustainability; 

(17) provide a plan for national and regional priorities for resource distribution and a global investment plan by region; 

(18) provide a plan to address the immediate and ongoing 

needs of women and girls, which— (A) addresses the vulnerabilities that contribute to their 

elevated risk of infection; 

(B) includes specific goals and targets to address these 

factors; 

(C) provides clear guidance to field missions to integrate 

gender across prevention, care, and treatment programs; 

(D) sets forth gender-specific indicators to monitor 

progress on outcomes and impacts of gender programs; 

(E) supports efforts in countries in which women or orphans lack inheritance rights and other fundamental protections to promote the passage, implementation, and enforcement of such laws; 

(F) supports life skills training and other structural prevention activities, especially among women and girls, with 

the goal of reducing vulnerabilities to HIV/AIDS; 

(G) addresses and prevents gender-based violence; and 

(H) addresses the posttraumatic and psychosocial consequences and provides postexposure prophylaxis protecting 

against HIV infection to victims of gender-based violence 

and rape; 

(19) provide a plan to address the vulnerabilities and needs 

of orphans and children who are vulnerable to, or affected by, 

HIV/AIDS; 

(20) provide a framework to work with international actors 

and partner countries toward universal access to HIV/AIDS 

prevention, treatment, and care programs, recognizing that prevention is of particular importance in terms of sequencing; 

(21) enhance the coordination of United States bilateral efforts to combat global HIV/AIDS with other major public and 

private entities; 


wwoods2 on PRODPC68 with REPORTS
49 

(22) enhance the attention given to the national strategic 

HIV/AIDS plans of countries receiving United States assistance 

by—

(A) reviewing the planning and programmatic decisions 

associated with that assistance; and 

(B) helping to strengthen such national strategies, if necessary; 

(23) support activities described in the Global Plan to Stop 

TB, including—

(A) expanding and enhancing the coverage of the Directly 

Observed Treatment Short-course (DOTS) in order to treat 

individuals infected with tuberculosis and HIV, including 

multi-drug resistant or extensively drug resistant tuberculosis; and 

(B) improving coordination and integration of HIV/AIDS 

and tuberculosis programming; 

(24) ensure coordination between the Global AIDS Coordinator and the Malaria Coordinator and address issues of comorbidity between HIV/AIDS and malaria; and 

(25) include a longer term estimate of the projected resource 

needs, progress toward greater sustainability and country ownership of HIV/AIDS programs, and the anticipated role of the 

United States in the global effort to combat HIV/AIDS during 

the 10-year period beginning on October 1, 2013. 

ø(b) REPORT.—

ø(1) IN GENERAL.—Not later than 270 days after the date of 

enactment of this Act, the President shall submit to the appropriate congressional committees a report setting forth the 

strategy described in subsection (a). 

ø(2) REPORT CONTENTS.—The report required by paragraph 

(1) shall include a discussion of the elements described in paragraph (3) and may include a discussion of additional elements 

relevant to the strategy described in subsection (a). Such discussion may include an explanation as to why a particular element described in paragraph (3) is not relevant to such strategy. 

ø(3) REPORT ELEMENTS.—The elements referred to in paragraph (2) are the following: 

ø(A) The objectives, general and specific, of the strategy. 

ø(B) A description of the criteria for determining success 

of the strategy. 

ø(C) A description of the manner in which the strategy 

will address the fundamental elements of prevention and 

education, care, and treatment (including increasing access 

to pharmaceuticals and to vaccines), the promotion of abstinence, monogamy, avoidance of substance abuse, and 

use of condoms, research (including incentives for vaccine 

development and new protocols), training of healthcare 

workers, the development of healthcare infrastructure and 

delivery systems, and avoidance of substance abuse. 

ø(D) A description of the manner in which the strategy 

will promote the development and implementation of national and community-based multisectoral strategies and 


wwoods2 on PRODPC68 with REPORTS
50 

programs, including those designed to enhance leadership 

capacity particularly at the community level. 

ø(E) A description of the specific strategies developed to 

meet the unique needs of women, including the empowerment of women in interpersonal situations, young people 

and children, including those orphaned by HIV/AIDS and 

those who are victims of the sex trade, rape, sexual abuse, 

assault, and exploitation. 

ø(F) A description of the specific strategies developed to 

encourage men to be responsible in their sexual behavior, 

child rearing and to respect women including the reduction 

of sexual violence and coercion. 

ø(G) A description of the specific strategies developed to 

increase women’s access to employment opportunities, income, productive resources, and microfinance programs. 

ø(H) A description of the programs to be undertaken to 

maximize United States contributions in the areas of technical assistance, training (particularly of healthcare workers and community-based leaders in affected sectors), and 

research, including the promotion of research on vaccines 

and microbicides. 

ø(I) An identification of the relevant executive branch 

agencies that will be involved and the assignment of priorities to those agencies. 

ø(J) A description of the role of each relevant executive 

branch agency and the types of programs that the agency 

will be undertaking. 

ø(K) A description of the mechanisms that will be utilized to coordinate the efforts of the relevant executive 

branch agencies, to avoid duplication of efforts, to enhance 

on-site coordination efforts, and to ensure that each agency 

undertakes programs primarily in those areas where the 

agency has the greatest expertise, technical capabilities, 

and potential for success. 

ø(L) A description of the mechanisms that will be utilized to ensure greater coordination between the United 

States and foreign governments and international organizations including the Global Fund, UNAIDS, international 

financial institutions, and private sector organizations. 

ø(M) The level of resources that will be needed on an annual basis and the manner in which those resources would 

generally be allocated among the relevant executive 

branch agencies. 

ø(N) A description of the mechanisms to be established 

for monitoring and evaluating programs, promoting successful models, and for terminating unsuccessful programs. 

ø(O) A description of the manner in which private, nongovernmental entities will factor into the United States 

Government-led effort and a description of the type of 

partnerships that will be created to maximize the capabilities of these private sector entities and to leverage resources. 

ø(P) A description of the ways in which United States 

leadership will be used to enhance the overall interVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00050 Fmt 6604 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
51 

national response to the HIV/AIDS pandemic and particularly to heighten the engagement of the member states of 

the G–8 and to strengthen key financial and coordination 

mechanisms such as the Global Fund and UNAIDS. 

ø(Q) A description of the manner in which the United 

States strategy for combating HIV/AIDS relates to and 

supports other United States assistance strategies in developing countries. 

ø(R) A description of the programs to be carried out 

under the strategy that are specifically targeted at women 

and girls to educate them about the spread of HIV/AIDS. 

ø(S) A description of efforts being made to address the 

unique needs of families with children with respect to HIV/ 

AIDS, including efforts to preserve the family unit. 

ø(T) An analysis of the emigration of critically important 

medical and public health personnel, including physicians, 

nurses, and supervisors from sub-Saharan African countries that are acutely impacted by HIV/AIDS, including a 

description of the causes, effects, and the impact on the 

stability of health infrastructures, as well as a summary of 

incentives and programs that the United States could provide, in concert with other private and public sector partners and international organizations, to stabilize health institutions by encouraging critical personnel to remain in 

their home countries. 

ø(U) A description of the specific strategies developed to 

promote sustainability of HIV/AIDS pharmaceuticals (including antiretrovirals) and the effects of drug resistance 

on HIV/AIDS patients. 

ø(V) A description of the specific strategies to ensure 

that the extraordinary benefit of HIV/AIDS pharmaceuticals (especially antiretrovirals) are not diminished 

through the illegal counterfeiting of pharmaceuticals and 

black market sales of such pharmaceuticals. 

ø(W) An analysis of the prevalence of Human Papilloma 

Virus (HPV) in sub-Saharan Africa and the impact that 

condom usage has upon the spread of HPV in sub-Saharan 

Africa.¿ 

(b) REPORT.—

(1) IN GENERAL.—Not later than October 1, 2009, the President shall submit a report to the appropriate congressional 

committees that sets forth the strategy described in subsection 

(a). 

(2) CONTENTS.—The report required under paragraph (1) 

shall include a discussion of the following elements: 

(A) The purpose, scope, methodology, and general and 

specific objectives of the strategy. 

(B) The problems, risks, and threats to the successful 

pursuit of the strategy. 

(C) The desired goals, objectives, activities, and outcomerelated performance measures of the strategy. 

(D) A description of future costs and resources needed to 

carry out the strategy. 


wwoods2 on PRODPC68 with REPORTS
52 

(E) A delineation of United States Government roles, responsibility, and coordination mechanisms of the strategy. 

(F) A description of the strategy—

(i) to promote harmonization of United States assistance with that of other international, national, and 

private actors as elucidated in the ‘‘Three Ones’’; and 

(ii) to address existing challenges in harmonization 

and alignment. 

(G) A description of the manner in which the strategy 

will—

(i) further the development and implementation of 

the national multisectoral strategic HIV/AIDS frameworks of partner governments; and 

(ii) enhance the centrality, effectiveness, and sustainability of those national plans. 

(H) A description of how the strategy will seek to achieve 

the specific targets described in subsection (a) and other 

targets, as appropriate. 

(I) A description of, and rationale for, the timetable for 

annual global treatment targets. 

(J) A description of how operations research is addressed 

in the strategy and how such research can most effectively 

be integrated into care, treatment, and prevention activities 

in order to—

(i) improve program quality and efficiency; 

(ii) ascertain cost effectiveness; 

(iii) ensure transparency and accountability; 

(iv) assess population-based impact; 

(v) disseminate findings and best practices; and 

(vi) optimize delivery of services. 

(K) An analysis of United States-assisted strategies to 

prevent the transmission of HIV/AIDS, including methodologies to promote abstinence, monogamy, faithfulness, 

the correct and consistent use of male and female condoms, 

reductions in concurrent sexual partners, and delay of sexual debut, and of intended monitoring and evaluation approaches to measure the effectiveness of prevention programs and ensure that they are targeted to appropriate audiences. 

(L) Within the analysis required under subparagraph (J), 

an examination of additional planned means of preventing 

the transmission of HIV including medical male circumcision, maintenance of a safe blood supply, and other tools. 

(M) A description of the specific targets, goals, and strategies developed to address the needs and vulnerabilities of 

women and girls to HIV/AIDS, including—

(i) structural prevention activities; 

(ii) activities directed toward men and boys; 

(iii) activities to enhance educational, microfinance, 

and livelihood opportunities for women and girls; 

(iv) activities to promote and protect the legal empowerment of women, girls, and orphans and vulnerable children; 


wwoods2 on PRODPC68 with REPORTS
53 

(v) programs targeted toward gender-based violence 

and sexual coercion; 

(vi) strategies to meet the particular needs of adolescents; 

(vii) assistance for victims of rape, sexual abuse, assault, exploitation, and trafficking; and 

(viii) programs to prevent alcohol abuse. 

(N) A description of strategies— (i) to address the needs of orphans and vulnerable 

children, including an analysis of— (I) factors contributing to children’s vulnerability 

to HIV/AIDS; and 

(II) vulnerabilities caused by the impact of HIV/ 

AIDS on children and their families; and 

(ii) in areas of higher HIV/AIDS prevalence, to promote a community-based approach to vulnerability, 

maximizing community input into determining which 

children participate. 

(O) A description of capacity-building efforts undertaken 

by countries themselves, including adherents of the Abuja 

Declaration and an assessment of the impact of International Monetary Fund macroeconomic and fiscal policies 

on national and donor investments in health. 

(P) A description of the strategy to— (i) strengthen capacity building within the public 

health sector; 

(ii) improve healthcare in those countries; 

(iii) help countries to develop and implement national health workforce strategies; 

(iv) strive to achieve goals in training, retaining, and 

effectively deploying health staff; 

(v) promote ethical recruiting practices for healthcare 

workers; and 

(vi) increase the sustainability of health programs. 

(Q) A description of the criteria for selection, objectives, 

methodology, and structure of compacts or other framework 

agreements with countries or regional organizations, including—

(i) the role of civil society; 

(ii) the degree of transparency; 

(iii) benchmarks for success of such compacts or 

agreements; and 

(iv) the relationship between such compacts or agreements and the national HIV/AIDS and public health 

strategies and commitments of partner countries. 

(R) A strategy to better coordinate HIV/AIDS assistance 

with nutrition and food assistance programs. 

(S) A description of transnational or regional initiatives 

to combat regionalized epidemics in highly affected areas 

such as the Caribbean. 

(T) A description of planned resource distribution and 

global investment by region. 

(U) A description of coordination efforts in order to better 

implement the Stop TB Strategy and to address the probVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00053 Fmt 6604 Sfmt 6603 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
54 

lem of coinfection of HIV/AIDS and tuberculosis and of 

projected challenges or barriers to successful implementation. 

(V) A description of coordination efforts to address malaria and comorbidity with malaria and HIV/AIDS. 

ø(c) STUDY; DISTRIBUTION OF RESOURCES.— ø(1) STUDY.—Not later than 3 years after the date of the enactment of this Act, the Institute of Medicine shall publish 

findings comparing the success rates of the various programs 

and methods used under the strategy described in subsection 

(a) to reduce, prevent, and treat HIV/AIDS, tuberculosis, and 

malaria. 

ø(2) DISTRIBUTION OF RESOURCES.— In prioritizing the distribution of resources under the strategy described in subsection (a), the President shall consider the findings published 

by the Institute of Medicine under this subsection.¿ 

(c) STUDY OF PROGRESS TOWARD ACHIEVEMENT OF POLICY OBJEC- TIVES.—

(1) DESIGN AND BUDGET PLAN FOR DATA EVALUATION.—The 

Global AIDS Coordinator shall enter into a contract with the 

Institute of Medicine of the National Academies that provides 

that not later than 18 months after the date of the enactment 

of the Tom Lantos and Henry J. Hyde United States Global 

Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, the Institute, in consultation with the 

Global AIDS Coordinator and other relevant parties representing the public and private sector, shall provide the Global 

AIDS Coordinator with a design plan and budget for the evaluation and collection of baseline and subsequent data to address the elements set forth in paragraph (2)(B). The Global 

AIDS Coordinator shall submit the budget and design plan to 

the appropriate congressional committees. 

(2) STUDY.— (A) IN GENERAL.—Not later than 4 years after the date of 

the enactment of the Tom Lantos and Henry J. Hyde 

United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, the 

Institute of Medicine of the National Academies shall publish a study that includes—

(i) an assessment of the performance of United 

States-assisted global HIV/AIDS programs; and 

(ii) an evaluation of the impact on health of prevention, treatment, and care efforts that are supported by 

United States funding, including multilateral and bilateral programs involving joint operations. 

(B) CONTENT.—The study conducted under this paragraph shall include—

(i) an assessment of progress toward prevention, 

treatment, and care targets; 

(ii) an assessment of the effects on health systems, including on the financing and management of health 

systems and the quality of service delivery and staffing; 

(iii) an assessment of efforts to address gender-specific aspects of HIV/AIDS, including gender related 


wwoods2 on PRODPC68 with REPORTS
55 

constraints to accessing services and addressing underlying social and economic vulnerabilities of women and 

men; 

(iv) an evaluation of the impact of treatment and 

care programs on 5-year survival rates, drug adherence, and the emergence of drug resistance; 

(v) an evaluation of the impact of prevention programs on HIV incidence in relevant population groups; 

(vi) an evaluation of the impact on child health and 

welfare of interventions authorized under this Act on 

behalf of orphans and vulnerable children; 

(vii) an evaluation of the impact of programs and activities authorized in this Act on child mortality; and 

(viii) recommendations for improving the programs 

referred to in subparagraph (A)(i). 

(C) METHODOLOGIES.—Assessments and impact evaluations conducted under the study shall utilize sound statistical methods and techniques for the behavioral sciences, 

including random assignment methodologies as feasible. 

Qualitative data on process variables should be used for assessments and impact evaluations, wherever possible. 

(3) CONTRACT AUTHORITY.—The Institute of Medicine may 

enter into contracts or cooperative agreements or award grants 

to conduct the study under paragraph (2). 

(4) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as may be necessary to carry 

out the study under this subsection. 

(d) COMPTROLLER GENERAL REPORT.—

(1) REPORT REQUIRED.—Not later than 3 years after the date 

of the enactment of the Tom Lantos and Henry J. Hyde United 

States Global Leadership Against HIV/AIDS, Tuberculosis, 

and Malaria Reauthorization Act of 2008, the Comptroller General of the United States shall submit a report on the global 

HIV/AIDS programs of the United States to the appropriate 

congressional committees. 

(2) CONTENTS.—The report required under paragraph (1) 

shall include—

(A) a description and assessment of the monitoring and 

evaluation practices and policies in place for these programs; 

(B) an assessment of coordination within Federal agencies involved in these programs, examining both internal 

coordination within these programs and integration with 

the larger global health and development agenda of the 

United States; 

(C) an assessment of procurement policies and practices 

within these programs; 

(D) an assessment of harmonization with national government HIV/AIDS and public health strategies as well as 

other international efforts; 

(E) an assessment of the impact of global HIV/AIDS 

funding and programs on other United States global health 

programming; and 


wwoods2 on PRODPC68 with REPORTS
56 

(F) recommendations for improving the global HIV/AIDS 

programs of the United States. 

(e) BEST PRACTICES REPORT.—

(1) IN GENERAL.—Not later than 1 year after the date of the 

enactment of the Tom Lantos and Henry J. Hyde United States 

Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, and annually thereafter, the 

Global AIDS Coordinator shall publish a best practices report 

that highlights the programs receiving financial assistance from 

the United States that have the potential for replication or 

adaption, particularly at a low cost, across global AIDS programs, including those that focus on both generalized and localized epidemics. 

(2) DISSEMINATION OF FINDINGS.—

(A) PUBLICATION ON INTERNET WEBSITE.—The Global 

AIDS Coordinator shall disseminate the full findings of the 

annual best practices report on the Internet website of the 

Office of the Global AIDS Coordinator. 

(B) DISSEMINATION GUIDANCE.—The Global AIDS Coordinator shall develop guidance to ensure timely submission 

and dissemination of significant information regarding best 

practices with respect to global AIDS programs. 

(f) INSPECTORS GENERAL.—

(1) OVERSIGHT PLAN.—

(A) DEVELOPMENT.—The Inspectors General of the Department of State and Broadcasting Board of Governors, 

the Department of Health and Human Services, and the 

United States Agency for International Development shall 

jointly develop 5 coordinated annual plans for oversight activity in each of the fiscal years 2009 through 2013, with 

regard to the programs authorized under this Act and sections 104A, 104B, and 104C of the Foreign Assistance Act 

of 1961 (22 U.S.C. 2151b–2, 2151b–3, and 2151b–4). 

(B) CONTENTS.—The plans developed under subparagraph (A) shall include a schedule for financial audits, inspections, and performance reviews, as appropriate. 

(C) DEADLINE.—

(i) INITIAL PLAN.—The first plan developed under 

subparagraph (A) shall be completed not later than the 

later of—

(I) September 1, 2008; or 

(II) 60 days after the date of the enactment of the 

Tom Lantos and Henry J. Hyde United States 

Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. 

(ii) SUBSEQUENT PLANS.—Each of the last four plans 

developed under subparagraph (A) shall be completed 

not later than 30 days before each of the fiscal years 

2010 through 2013, respectively. 

(2) COORDINATION.—In order to avoid duplication and maximize efficiency, the Inspectors General described in paragraph 

(1) shall coordinate their activities with—

(A) the Government Accountability Office; and 


wwoods2 on PRODPC68 with REPORTS
57 

(B) the Inspectors General of the Department of Commerce, the Department of Defense, the Department of Labor, 

and the Peace Corps, as appropriate, pursuant to the 2004 

Memorandum of Agreement Coordinating Audit Coverage 

of Programs and Activities Implementing the President’s 

Emergency Plan for AIDS Relief, or any successor agreement. 

(3) FUNDING.—The Global AIDS Coordinator and the Coordinator of the United States Government Activities to Combat 

Malaria Globally shall make available necessary funds not exceeding $10,000,000 during the 5-year period beginning on October 1, 2008 to the Inspectors General described in paragraph 

(1) for the audits, inspections, and reviews described in that 

paragraph. 

SEC. 102. HIV/AIDS RESPONSE COORDINATOR. 

(a) ESTABLISHMENT OF POSITION.—* * * 

* * * * * * * 

(d) SENSE OF CONGRESS.—It is the sense of Congress that—

(1) full-time country level coordinators, preferably with management experience, should head each HIV/AIDS country team 

for United States missions overseeing significant HIV/AIDS 

programs; 

(2) foreign service nationals provide critically important services in the design and implementation of United States countrylevel HIV/AIDS programs and their skills and experience as 

public health professionals should be recognized within hiring 

and compensation practices; and 

(3) staffing levels for United States country-level HIV/AIDS 

teams should be adequately maintained to fulfill oversight and 

other obligations of the positions. 

* * * * * * * 

TITLE II—SUPPORT FOR MULTILATERAL FUNDS, 

PROGRAMS, AND PUBLIC-PRIVATE PARTNERSHIPS 

SEC. 201. SENSE OF CONGRESS ON PUBLIC-PRIVATE PARTNERSHIPS. 

* * * * * * * 

SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA. 

ø(a) FINDINGS.—The Congress finds as follows: 

ø(1) The establishment of the Global Fund in January 2002 

is consistent with the general principles for an international 

AIDS trust fund first outlined by the Congress in the Global 

AIDS and Tuberculosis Relief Act of 2000 (Public Law 106–

264). 

ø(2) Section 2, Article 5 of the bylaws of the Global Fund 

provides for the International Bank for Reconstruction and Development to serve as the initial collection trustee for the Global Fund. 

ø(3) The trustee agreement signed between the Global Fund 

and the International Bank for Reconstruction and Development narrows the range of duties to include receiving and inVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00057 Fmt 6604 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
58 

vesting funds from donors, disbursing the funds upon the instruction of the Global Fund, reporting on trust fund resources 

to donors and the Global Fund, and providing an annual external audit report to the Global Fund.¿ 

(a) FINDINGS; SENSE OF CONGRESS.—

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

(A) The establishment of the Global Fund in January 

2002 is consistent with the general principles for an international AIDS trust fund first outlined by Congress in the 

Global AIDS and Tuberculosis Relief Act of 2000 (Public 

Law 106–264). 

(B) The Global Fund is an innovative financing mechanism which—

(i) has made progress in many areas in combating 

HIV/AIDS, tuberculosis, and malaria; and 

(ii) represents the multilateral component of this Act, 

extending United States efforts to more than 130 countries around the world. 

(C) The Global Fund and United States bilateral assistance programs—

(i) are demonstrating increasingly effective coordination, with each possessing certain comparative advantages in the fight against HIV/AIDS, tuberculosis, and 

malaria; and 

(ii) often work most effectively in concert with each 

other. 

(D) The United States Government—

(i) is the largest supporter of the Global Fund in 

terms of resources and technical support; 

(ii) made the founding contribution to the Global 

Fund; and 

(iii) is fully committed to the success of the Global 

Fund as a multilateral public-private partnership. 

(2) SENSE OF CONGRESS.—It is the sense of Congress that—

(A) transparency and accountability are crucial to the 

long-term success and viability of the Global Fund; 

(B) the Global Fund has made significant progress toward addressing concerns raised by the Government Accountability Office by—

(i) improving risk assessment and risk management 

capabilities; 

(ii) providing clearer guidance for and oversight of 

Local Fund Agents; and 

(iii) strengthening the Office of the Inspector General 

for the Global Fund; 

(C) the provision of sufficient resources and authority to 

the Office of the Inspector General for the Global Fund to 

ensure that office has the staff and independence necessary 

to carry out its mandate will be a measure of the commitment of the Global Fund to transparency and accountability; 

(D) regular, publicly published financial, programmatic, 

and reporting audits of the Fund, its grantees, and Local 


wwoods2 on PRODPC68 with REPORTS
59 

Fund Agents are also important benchmarks of transparency; 

(E) the Global Fund should establish and maintain a 

system to track— (i) the amount of funds disbursed to each subrecipient on the grant’s fiscal cycle; and 

(ii) the distribution of resources, by grant and principal recipient, for prevention, care, treatment, drug 

and commodity purchases, and other purposes; 

(F) relevant national authorities in recipient countries 

should exempt from duties and taxes all products financed 

by Global Fund grants and procured by any principal recipient or subrecipient for the purpose of carrying out such 

grants; 

(G) the Global Fund, UNAIDS, and the Global AIDS Coordinator should work together to standardize program indicators wherever possible; and 

(H) for purposes of evaluating total amounts of funds 

contributed to the Global Fund under subsection 

(d)(4)(A)(i), the timetable for evaluations of contributions 

from sources other than the United States should take into 

account the fiscal calendars of other major contributors. 

* * * * * * * 

(d) UNITED STATES FINANCIAL PARTICIPATION.— (1) AUTHORIZATION OF APPROPRIATIONS.—In addition to any 

other funds authorized to be appropriated for bilateral or multilateral HIV/AIDS, tuberculosis, or malaria programs, of the 

amounts authorized to be appropriated under section 401, 

there are authorized to be appropriated to the President up to 

ø$1,000,000,000 for the period of fiscal year 2004 beginning on 

January 1, 2004,¿ $2,000,000,000 for fiscal year 2009, and such 

sums as may be necessary for øthe fiscal years 2005–2008¿ 

each of the fiscal years 2010 through 2013, for contributions to 

the Global Fund. 

(2) AVAILABILITY OF FUNDS.—Amounts appropriated under 

paragraph (1) are authorized to remain available until expended. 

(3) REPROGRAMMING OF FISCAL YEAR 2001 FUNDS.—Funds 

made available for fiscal year 2001 under section 141 of the 

Global AIDS and Tuberculosis Relief Act of 2000— (A) are authorized to remain available until expended; 

and 

(B) shall be transferred to, merged with, and made available for the same purposes as, funds made available for 

fiscal years 2004 through 2008 under paragraph (1). 

(4) LIMITATION.— (A)(i) At any time during øfiscal years 2004 through 

2008¿ fiscal years 2009 through 2013, no United States 

contribution to the Global Fund may cause the total 

amount of United States Government contributions to the 

Global Fund to exceed 33 percent of the total amount of 

funds contributed to the Global Fund from all sources. 

Contributions to the Global Fund from the International 

Bank for Reconstruction and Development and the InterVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00059 Fmt 6604 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
60 

national Monetary Fund shall not be considered in determining compliance with this paragraph. 

(ii) If, at any time øduring any of the fiscal years 2004 

through 2008¿ during any of the fiscal years 2009 through 

2013, the President determines that the Global Fund has 

provided assistance to a country, the government of which 

the Secretary of State has determined, for purposes of section 6(j)(1) of the Export Administration Act of 1979 (50 

U.S.C. App. 2405(j)(1)), has repeatedly provided support 

for acts of international terrorism, then the United States 

shall withhold from its contribution for the next fiscal year 

an amount equal to the amount expended by the Fund to 

the government of each such country. 

(iii) If at any time the President determines that the expenses of the Governing, Administrative, and Advisory 

Bodies (including the Partnership Forum, the Foundation 

Board, the Secretariat, and the Technical Review Board) of 

the Global Fund exceed 10 percent of the total expenditures of the Fund for any 2-year period, the United States 

shall withhold from its contribution for the next fiscal year 

an amount equal the to the average annual amount expended by the Fund for such 2-year period for the expenses of the Governing, Administrative, and Advisory 

Bodies in excess of 10 percent of the total expenditures of 

the Fund. 

(iv) The President may waive the application of clause 

(iii) if the President determines that extraordinary circumstances warrant such a waiver. No waiver under this 

clause may be for any period that exceeds 1 year. 

(v) If, at any time during any of the fiscal years 2004 

through 2008, the President determines that the salary of 

any individual employed by the Global Fund exceeds the 

salary of the Vice President of the United States (as determined under section 104 of title 3, United States Code) for 

that fiscal year, then the United States shall withhold 

from its contribution for the next fiscal year an amount 

equal to the aggregate amount by which the salary of each 

such individual exceeds the salary of the Vice President of 

the United States. 

(vi) øfor the purposes¿ For the purposes of clause (i), 

‘‘funds contributed to the Global Fund from all sources’’

means funds contributed to the Global Fund at any time 

during øfiscal years 2004 through 2008¿ fiscal years 2009 

through 2013 that are not contributed to fulfill a commitment made for a fiscal year øprior to fiscal year 2004¿ before fiscal year 2009. 

(B)(i) Any amount made available under this subsection 

that is withheld by reason of subparagraph (A)(i) shall be 

contributed to the Global Fund as soon as practicable, subject to subparagraph (A)(i), after additional contributions 

to the Global Fund are made from other sources. 

(ii) Any amount made available under this subsection 

that is withheld by reason of subparagraph (A)(iii) shall be 

transferred to the Activities to Combat HIV/AIDS Globally 


wwoods2 on PRODPC68 with REPORTS
61 

Fund and shall remain available under the same terms 

and conditions as funds appropriated pursuant to the authorization of appropriations under section 401 for HIV/ 

AIDS assistance. 

(iii) Any amount made available under this subsection 

that is withheld by reason of clause (ii) or (iii) of subparagraph (A) is authorized to be made available to carry out 

section 104A of the Foreign Assistance Act of 1961 (as 

added by section 301 of this Act). Amounts made available 

under the preceding sentence are in addition to amounts 

appropriated pursuant to the authorization of appropriations under section 401 of this Act for HIV/AIDS assistance. 

(iv) Notwithstanding clause (i), after July 31 of each of 

the øfiscal years 2004 through 2008¿ fiscal years 2009 

through 2013, any amount made available under this subsection that is withheld by reason of subparagraph(A)(i) is 

authorized to be made available to carry out sections 104A, 

104B, and 104C of the Foreign Assistance Act of 1961 (as 

added by title III of this Act). 

(C)(i) The President may suspend the application of subparagraph (A) with respect to a fiscal year if the President 

determines that an international health emergency threatens the national security interests of the United States. 

(ii) The President shall notify the øCommittee on International Relations¿ Committee on Foreign Affairs of the 

House of Representatives and the Committee on Foreign 

Relations of the Senate not less than 5 days before making 

a determination under clause (i) with respect to the application of subparagraph (A)(i) and shall include in the notification—

(I) a justification as to why increased United States 

Government contributions to the Global Fund is preferable to increased United States assistance to combat 

HIV/AIDS, tuberculosis, and malaria on a bilateral 

basis; and 

(II) an explanation as to why other government donors to the Global Fund are unable to provide adequate contributions to the Fund. 

(5) WITHHOLDING FUNDS.—Notwithstanding any other provision of this Act, 20 percent of the amounts appropriated pursuant to this Act for a contribution to support the Global Fund 

for each of the fiscal years 2010 through 2013 shall be withheld 

from obligation to the Global Fund until the Secretary of State 

certifies to the appropriate congressional committees that the 

Global Fund—

(A) has established an evaluation framework for the performance of Local Fund Agents (referred to in this paragraph as ‘‘LFAs’’); 

(B) is undertaking a systematic assessment of the performance of LFAs; 

(C) is making available for public review, according to 

the Fund Board’s policies and practices on disclosure of information, a regular collection and analysis of performance 


wwoods2 on PRODPC68 with REPORTS
62 

data of Fund grants, which shall cover principal recipients 

and subrecipients; 

(D) is maintaining an independent, well-staffed Office of 

the Inspector General that— (i) reports directly to the Board of the Global Fund; 

and 

(ii) is responsible for regular, publicly published audits of financial, programmatic, and reporting aspects 

of the Global Fund, its grantees, and LFAs; 

(E) has established, and is reporting publicly on, standard indicators for all program areas; 

(F) has established a methodology to track and is reporting on—

(i) all subrecipients and the amount of funds disbursed to each subrecipient on the grant’s fiscal cycle; 

and 

(ii) the distribution of resources, by grant and principal recipient, for prevention, care, treatment, drugs 

and commodities purchase, and other purposes; 

(G) has established a policy on tariffs imposed by national governments on all goods and services financed by 

the Global Fund; 

(H) through its Secretariat, has taken meaningful steps 

to prevent national authorities in recipient countries from 

imposing taxes or tariffs on goods or services provided by 

the Fund; 

(I) is maintaining its status as a financing institution focused on programs directly related to HIV/AIDS, malaria, 

and tuberculosis; and 

(J) is maintaining and making progress on— (i) sustaining its multisectoral approach, through 

country coordinating mechanisms; and 

(ii) the implementation of grants, as reflected in the 

proportion of resources allocated to different sectors, including governments, civil society, and faith- and community-based organizations. 

SEC. 204. COMBATING HIV/AIDS, TUBERCULOSIS, AND MALARIA BY 

STRENGTHENING HEALTH POLICIES AND HEALTH SYSTEMS OF PARTNER COUNTRIES. 

(a) STATEMENT OF POLICY.—It shall be the policy of the United 

States Government—

(1) to invest appropriate resources authorized under this 

Act—

(A) to carry out activities to strengthen HIV/AIDS, tuberculosis, and malaria health policies and health systems; 

and 

(B) to provide workforce training and capacity-building 

consistent with the goals and objectives of this Act; and 

(2) to support the development of a sound policy environment 

in partner countries to increase the ability of such countries— (A) to maximize utilization of healthcare resources from 

donor countries; 

(B) to increase national investments in health and education and maximize the effectiveness of such investments; 


wwoods2 on PRODPC68 with REPORTS
63 

(C) to improve national HIV/AIDS, tuberculosis, and 

malaria strategies; 

(D) to deliver evidence-based services in an effective and 

efficient manner; and 

(E) to reduce barriers that prevent recipients of services 

from achieving maximum benefit from such services. 

(b) ASSISTANCE TO IMPROVE PUBLIC FINANCE MANAGEMENT SYS- TEMS.—

(1) IN GENERAL.—Consistent with the authority under section 

129 of the Foreign Assistance Act of 1961 (22 U.S.C. 2152), the 

Secretary of the Treasury, acting through the head of the Office 

of Technical Assistance, is authorized to provide assistance for 

advisors and partner country finance, health, and other relevant ministries to improve the effectiveness of public finance 

management systems in partner countries to enable such countries to receive funding to carry out programs to combat HIV/ 

AIDS, tuberculosis, and malaria and to manage such programs. 

(2) AUTHORIZATION OF APPROPRIATIONS.—Of the amounts authorized to be appropriated under section 401 for HIV/AIDS 

assistance, there are authorized to be appropriated to the Secretary of the Treasury such sums as may be necessary for each 

of the fiscal years 2009 through 2013 to carry out this subsection. 

* * * * * * * 

TITLE III—BILATERAL EFFORTS 

* * * * * * * 

SEC. 301. ASSISTANCE TO COMBAT HIV/AIDS. 

(a) AMENDMENT OF THE FOREIGN ASSISTANCE ACT OF 1961.—* * 

* 

* * * * * * * 

(b) AUTHORIZATION OF APPROPRIATIONS.—

(1) IN GENERAL.—In addition to funds available under section 104(c) of the Foreign Assistance Act of 1961 (22 U.S.C. 

2151b(c)) for such purpose or under any other provision of that 

Act, there are authorized to be appropriated to the President, 

from amounts authorized to be appropriated under section 401, 

such sums as may be necessary for each of the øfiscal years 

2004 through 2008¿ fiscal years 2009 through 2013 to carry out 

section 104A of the Foreign Assistance Act of 1961, as added 

by subsection (a). 

(2) AVAILABILITY OF FUNDS.—Amounts appropriated pursuant to paragraph (1) are authorized to remain available until 

expended. 

(3) ALLOCATION OF FUNDS.—Of the amount authorized to be 

appropriated by paragraph (1) for the øfiscal years 2004 

through 2008¿ fiscal years 2009 through 2013, such sums as 

may be necessary are authorized to be appropriated to carry 

out section 104A(d)(4) of the Foreign Assistance Act of 1961 (as 

added by subsection (a)), relating to the procurement and distribution of HIV/AIDS pharmaceuticals. 


wwoods2 on PRODPC68 with REPORTS
64 

ø(c) RELATIONSHIP TO ASSISTANCE PROGRAMS TO ENHANCE NUTRITION.—In recognition of the fact that malnutrition may hasten 

the progression of HIV to AIDS and may exacerbate the decline 

among AIDS patients leading to a shorter life span, the Administrator of the United States Agency for International Development 

shall, as appropriate—

ø(1) integrate nutrition programs with HIV/AIDS activities, 

generally; 

ø(2) provide, as a component of an anti-retroviral therapy 

program, support for food and nutrition to individuals infected 

with and affected by HIV/AIDS; and 

ø(3) provide support for food and nutrition for children affected by HIV/AIDS and to communities and households caring 

for children affected by HIV/AIDS.¿ 

(c) FOOD AND NUTRITIONAL SUPPORT.—

(1) IN GENERAL.—As indicated in the report produced by the 

Institute of Medicine, entitled ‘‘PEPFAR Implementation: 

Progress and Promise’’, inadequate caloric intake has been 

clearly identified as a principal reason for failure of clinical response to antiretroviral therapy. In recognition of the impact of 

malnutrition as a clinical health issue for many persons living 

with HIV/AIDS that is often associated with health and economic impacts on these individuals and their families, the 

Global AIDS Coordinator and the Administrator of the United 

States Agency for International Development shall—

(A) follow World Health Organization guidelines for 

HIV/AIDS food and nutrition services; 

(B) integrate nutrition programs with HIV/AIDS activities through effective linkages among the health, agricultural, and livelihood sectors and establish additional services in circumstances in which referrals are inadequate or 

impossible; 

(C) provide, as a component of care and treatment programs for persons with HIV/AIDS, food and nutritional 

support to individuals infected with, and affected by, HIV/ 

AIDS who meet established criteria for nutritional support 

(including clinically malnourished children and adults, 

and pregnant and lactating women in programs in need of 

supplemental support), including—

(i) anthropometric and dietary assessment; 

(ii) counseling; and 

(iii) therapeutic and supplementary feeding; 

(D) provide food and nutritional support for children affected by HIV/AIDS and to communities and households 

caring for children affected by HIV/AIDS; and 

(E) in communities where HIV/AIDS and food insecurity 

are highly prevalent, support programs to address these 

often intersecting health problems through communitybased assistance programs, with an emphasis on sustainable approaches. 

(2) AUTHORIZATION OF APPROPRIATIONS.—Of the amounts authorized to be appropriated under section 401, there are authorized to be appropriated to the President such sums as may be 


wwoods2 on PRODPC68 with REPORTS
65 

necessary for each of the fiscal years 2009 through 2013 to 

carry out this subsection. 

SEC. 302. ASSISTANCE TO COMBAT TUBERCULOSIS. 

* * * * * * * 

(b) AUTHORIZATION OF APPROPRIATIONS.— (1) IN GENERAL.—In addition to funds available under section 104(c) of the Foreign Assistance Act of 1961 (22 U.S.C. 

2151b(c)) for such purpose or under any other provision of that 

Act, there are authorized to be appropriated to the President, 

from amounts authorized to be appropriated under section 401, 

øsuch sums as may be necessary for each of the fiscal years 

2004 through 2008¿ a total of $4,000,000,000 for the 5-year period beginning on October 1, 2008 to carry out section 104B of 

the Foreign Assistance Act of 1961, as added by subsection (a). 

(2) AVAILABILITY OF FUNDS.—Amounts appropriated pursuant to the authorization of appropriations under paragraph (1) 

are authorized to remain available until expended. 

(3) TRANSFER OF PRIOR YEAR FUNDS.—Unobligated balances 

of funds made available for fiscal year 2001, 2002, or 2003 

under section 104(c)(7) of the Foreign Assistance Act of 1961 

(22 U.S.C. 2151b(c)(7) (as in effect immediately before the date 

of enactment of this Act) shall be transferred to, merged with, 

and made available for the same purposes as funds made 

available for øfiscal years 2004 through 2008¿ fiscal years 2009 

through 2013 under paragraph (1). 

* * * * * * * 

SEC. 303. ASSISTANCE TO COMBAT MALARIA. 

* * * * * * * 

(b) AUTHORIZATION OF APPROPRIATIONS.— (1) IN GENERAL.—In addition to funds available under section 104(c) of the Foreign Assistance Act of 1961 (22 U.S.C. 

2151b(c)) for such purpose or under any other provision of that 

Act, there are authorized to be appropriated to the President, 

from amounts authorized to be appropriated under section 401, 

øsuch sums as may be necessary for fiscal years 2004 through 

2008¿ $5,000,000,000 during the 5-year period beginning on 

October 1, 2008 to carry out section 104C of the Foreign Assistance Act of 1961, as added by subsection (a), including for the 

development of anti-malarial pharmaceuticals by theMedicines 

for Malaria Venture. 

(2) AVAILABILITY OF FUNDS.—Amounts appropriated pursuant to paragraph (1) are authorized to remain available until 

expended. 

(3) TRANSFER OF PRIOR YEAR FUNDS.—Unobligated balances 

of funds made available for fiscal year 2001, 2002, or 2003 

under section 104(c) of the Foreign Assistance Act of 1961 (22 

U.S.C. 2151b(c) (as in effect immediately before the date of enactment of this Act) and made available for the control of malaria shall be transferred to, merged with, and made available 

for the same purposes as funds made available for øfiscal years 

2004 through 2008¿ fiscal years 2009 through 2013 under 

paragraph (1). 


wwoods2 on PRODPC68 with REPORTS
66 

(c) CONFORMING AMENDMENT.—Section 104(c) of the Foreign Assistance Act of 1961 (22 U.S.C. 2151b(c)), as amended by section 

301 of this Act, is further amended by adding after paragraph (3) 

the following: * * * 

(c) STATEMENT OF POLICY.—Providing assistance for the prevention, control, treatment, and the ultimate eradication of malaria 

is—

(1) a major objective of the foreign assistance program of the 

United States; and 

(2) 1 component of a comprehensive United States global 

health strategy to reduce disease burdens and strengthen communities around the world. 

(d) DEVELOPMENT OF A COMPREHENSIVE 5-YEAR STRATEGY.—The 

President shall establish a comprehensive, 5-year strategy to combat 

global malaria that—

(1) strengthens the capacity of the United States to be an effective leader of international efforts to reduce malaria burden; 

(2) maintains sufficient flexibility and remains responsive to 

the ever-changing nature of the global malaria challenge; 

(3) includes specific objectives and multisectoral approaches 

and strategies to reduce the prevalence, mortality, incidence, 

and spread of malaria; 

(4) describes how this strategy would contribute to the United 

States’ overall global health and development goals; 

(5) clearly explains how outlined activities will interact with 

other United States Government global health activities, including the 5-year global AIDS strategy required under this Act; 

(6) expands public-private partnerships and leverage of resources; 

(7) coordinates among relevant Federal agencies to maximize 

human and financial resources and to reduce duplication 

among these agencies, foreign governments, and international 

organizations; 

(8) coordinates with other international entities, including the 

Global Fund; 

(9) maximizes United States capabilities in the areas of technical assistance and training and research, including vaccine 

research; and 

(10) establishes priorities and selection criteria for the distribution of resources based on factors such as—

(A) the size and demographics of the population with malaria; 

(B) the needs of that population; 

(C) the country’s existing infrastructure; and 

(D) the ability to closely coordinate United States Government efforts with national malaria control plans of partner 

countries. 

SEC. 304. PILOT PROGRAM FOR THE PLACEMENT OF healthcare PROFESSIONALS IN OVERSEAS AREAS SEVERELY AFFECTED 

BY HIV/AIDS, TUBERCULOSIS, AND MALARIA. 

ø(a) IN GENERAL.—The President should establish a program to 

demonstrate the feasibility of facilitating the service of United 

States healthcare professionals in those areas of sub-Saharan AfriVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00066 Fmt 6604 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
67 

ca and other parts of the world severely affected by HIV/AIDS, tuberculosis, and malaria. 

ø(b) REQUIREMENTS.—Participants in the program shall—

ø(1) provide basic healthcare services for those infected and 

affected by HIV/AIDS, tuberculosis, and malaria in the area in 

which they are serving; 

ø(2) provide on-the-job training to medical and other personnel in the area in which they are serving to strengthen the 

basic healthcare system of the affected countries; 

ø(3) provide healthcare educational training for residents of 

the area in which they are serving; 

ø(4) serve for a period of up to 3 years; and 

ø(5) meet the eligibility requirements in subsection (d). 

ø(c) ELIGIBILITY REQUIREMENTS.—To be eligible to participate in 

the program, a candidate shall—

ø(1) be a national of the United States who is a trained 

healthcare professional and who meets the educational and licensure requirements necessary to be such a professional such 

as a physician, nurse, physician assistant, nurse practitioner, 

pharmacist, other type of healthcare professional, or other individual determined to be appropriate by the President; or 

ø(2) be a retired commissioned officer of the Public Health 

Service Corps. 

ø(d) RECRUITMENT.—The President shall ensure that information 

on the program is widely distributed, including the distribution of 

information to schools for health professionals, hospitals, clinics, 

and nongovernmental organizations working in the areas of international health and aid. 

ø(e) PLACEMENT OF PARTICIPANTS.—

ø(1) IN GENERAL.—To the maximum extent practicable, participants in the program shall serve in the poorest areas of the 

affected countries, where healthcare needs are likely to be the 

greatest. The decision on the placement of a participant should 

be made in consultation with relevant officials of the affected 

country at both the national and local level as well as with 

local community leaders and organizations. 

ø(2) COORDINATION.—Placement of participants in the program shall be coordinated with the United States Agency for 

International Development in countries in which that Agency 

is conducting HIV/AIDS, tuberculosis, or malaria programs. 

Overall coordination of placement of participants in the program shall be made by the Coordinator of United States Government Activities to Combat HIV/AIDS Globally (as described 

in section 1(f) of the State Department Basic Authorities Act 

of 1956 (as added by section 102(a) of this Act)). 

ø(f) INCENTIVES.—The President may offer such incentives as the 

President determines to be necessary to encourage individuals to 

participate in the program, such as partial payment of principal, 

interest, and related expenses on government and commercial 

loans for educational expenses relating to professional health training and, where possible, deferment of repayments on such loans, 

the provision of retirement benefits that would otherwise be jeopardized by participation in the program, and other incentives. 


wwoods2 on PRODPC68 with REPORTS
68 

ø(g) REPORT.—Not later than 18 months after the date of enactment of this Act, the President shall submit to the appropriate congressional committees a report on steps taken to establish the program, including—

ø(1) the process of recruitment, including the venues for recruitment, the number of candidates recruited, the incentives 

offered, if any, and the cost of those incentives; 

ø(2) the process, including the criteria used, for the selection 

of participants; 

ø(3) the number of participants placed, the countries in 

which they were placed, and why those countries were selected; and 

ø(4) the potential for expansion of the program. 

ø(h) AUTHORIZATION OF APPROPRIATIONS.—

ø(1) IN GENERAL.—In addition to amounts otherwise available for such purpose, there are authorized to be appropriated 

to the President, from amounts authorized to be appropriated 

under section 401, such sums as may be necessary for each of 

the fiscal years 2004 through 2008 to carry out the program. 

ø(2) AVAILABILITY OF FUNDS.—Amounts appropriated pursuant to the authorization of appropriations under paragraph (1) 

are authorized to remain available until expended.¿ 

SEC. 304. MALARIA RESPONSE COORDINATOR. 

(a) IN GENERAL.—There is established within the United States 

Agency for International Development a Coordinator of United 

States Government Activities to Combat Malaria Globally (referred 

to in this section as the ‘‘Malaria Coordinator’’), who shall be appointed by the President. 

(b) AUTHORITIES.—The Malaria Coordinator, acting through nongovernmental organizations (including faith-based and communitybased organizations), partner country finance, health, and other relevant ministries, and relevant executive branch agencies as may be 

necessary and appropriate to carry out this section, is authorized 

to—

(1) operate internationally to carry out prevention, care, treatment, support, capacity development, and other activities to reduce the prevalence, mortality, and incidence of malaria; 

(2) provide grants to, and enter into contracts and cooperative 

agreements with, nongovernmental organizations (including 

faith-based organizations) to carry out this section; and 

(3) transfer and allocate executive branch agency funds that 

have been appropriated for the purposes described in paragraphs (1) and (2). 

(c) DUTIES.—

(1) IN GENERAL.—The Malaria Coordinator has primary responsibility for the oversight and coordination of all resources 

and international activities of the United States Government relating to efforts to combat malaria. 

(2) SPECIFIC DUTIES.—The Malaria Coordinator shall—

(A) facilitate program and policy coordination of 

antimalaria efforts among relevant executive branch agencies and nongovernmental organizations by auditing, monitoring, and evaluating such programs; 


wwoods2 on PRODPC68 with REPORTS
69 

(B) ensure that each relevant executive branch agency undertakes antimalarial programs primarily in those areas in 

which the agency has the greatest expertise, technical capability, and potential for success; 

(C) coordinate relevant executive branch agency activities 

in the field of malaria prevention and treatment; 

(D) coordinate planning, implementation, and evaluation 

with the Global AIDS Coordinator in countries in which 

both programs have a significant presence; 

(E) coordinate with national governments, international 

agencies, civil society, and the private sector; and 

(F) establish due diligence criteria for all recipients of 

funds appropriated by the Federal Government for malaria 

assistance. 

(d) ASSISTANCE FOR THE WORLD HEALTH ORGANIZATION.—In carrying out this section, the President may provide financial assistance to the Roll Back Malaria Partnership of the World Health Organization to improve the capacity of countries with high rates of 

malaria and other affected countries to implement comprehensive 

malaria control programs. 

(e) COORDINATION OF ASSISTANCE EFFORTS.—In carrying out this 

section and in accordance with section 104C of the Foreign Assistance Act of 1961 (22 U.S.C. 2151b–4), the Malaria Coordinator 

shall coordinate the provision of assistance by working with— (1) relevant executive branch agencies, including— (A) the Department of State (including the Office of the 

Global AIDS Coordinator); 

(B) the Department of Health and Human Services; 

(C) the Department of Defense; and 

(D) the Office of the United States Trade Representative; 

(2) relevant multilateral institutions, including— (A) the World Health Organization; 

(B) the United Nations Children’s Fund; 

(C) the United Nations Development Programme; 

(D) the Global Fund; 

(E) the World Bank; and 

(F) the Roll Back Malaria Partnership; 

(3) program delivery and efforts to lift barriers that would 

impede effective and comprehensive malaria control programs; 

and 

(4) partner or recipient country governments and national entities including universities and civil society organizations (including faith- and community-based organizations). 

(f) RESEARCH.—To carry out this section and in accordance with 

section 104C of the Foreign Assistance Act of 1961 (22 U.S.C. 

1151d–4), the Secretary of Health and Human Services, through the 

Centers for Disease Control and Prevention and the National Institutes of Health, shall conduct appropriate programmatically relevant clinical and operational research to identify and evaluate new 

diagnostics, treatment regimens, and interventions to prevent and 

control malaria. 

(g) MONITORING.—To ensure that adequate malaria controls are 

established and implemented, the Centers for Disease Control and 

Prevention shall carry out appropriate surveillance and evaluation 


wwoods2 on PRODPC68 with REPORTS
70 

activities to monitor global malaria trends and assess environmental and health impacts of malarial control efforts. Such activities shall complement the work of the World Health Organization, 

rather than duplicate such work. 

(h) ANNUAL REPORT.—

(1) SUBMISSION.—Not later than 1 year after the date of the 

enactment of the Tom Lantos and Henry J. Hyde United States 

Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, and annually thereafter, the 

President shall submit a report to the appropriate congressional 

committees that describes United States assistance for the prevention, treatment, control, and elimination of malaria. 

(2) CONTENTS.—The report required under paragraph (1) 

shall describe—

(A) the countries and activities to which malaria resources have been allocated; 

(B) the number of people reached through malaria assistance programs, including data on children and pregnant 

women; 

(C) research efforts to develop new tools to combat malaria, including drugs and vaccines; 

(D) the collaboration and coordination of United States 

antimalarial efforts with the World Health Organization, 

the Global Fund, the World Bank, other donor governments, major private efforts, and relevant executive agencies; 

(E) the coordination of United States antimalarial efforts 

with the national malarial strategies of other donor or 

partner governments and major private initiatives; 

(F) the estimated impact of United States assistance on 

childhood mortality and morbidity from malaria; 

(G) the coordination of antimalarial efforts with broader 

health and development programs; and 

(H) the constraints on implementation of programs posed 

by health workforce shortages or capacities; and 

(I) the number of personnel trained as health workers 

and the training levels achieved. 

øSubtitle B—Assistance for Children and Families¿ 

Subtitle B—Assistance for Women, Children, and Families 

* * * * * * * 

SEC. 312. POLICY AND REQUIREMENTS. 

(a) POLICY.—The United States Government’s response to the 

global HIV/AIDS pandemic should place high priority on the prevention of mother-to-child transmission, the care and treatment of 

family members and caregivers, and the care of children orphaned 

by AIDS. To the maximum extent possible, the United States Government should seek to leverage its funds by seeking matching contributions from the private sector, other national governments, and 

international organizations. 

(b) REQUIREMENTS.—The 5-year United States Government strategy required by section 101 of this Act shall—


wwoods2 on PRODPC68 with REPORTS
71 

ø(1) provide for meeting or exceeding the goal to reduce the 

rate of mother-to-child transmission of HIV by 20 percent by 

2005 and by 50 percent by 2010; 

ø(2) include programs to make available testing and treatment to HIV-positive women and their family members, including drug treatment and therapies to prevent mother-to-child 

transmission; and 

ø(3) expand programs designed to care for children orphaned 

by AIDS.¿ 

(1) establish a target for the prevention and treatment of 

mother-to-child transmission of HIV that, by 2013, will reach 

at least 80 percent of pregnant women in those countries most 

affected by HIV/AIDS in which the United States has HIV/ 

AIDS programs; 

(2) establish a target that, by 2013, the proportion of children 

receiving care and treatment under this Act is proportionate to 

their numbers within the population of HIV infected individuals in each country; 

(3) integrate care and treatment with prevention of mother-tochild transmission of HIV programs to improve outcomes for 

HIV-affected women and families as soon as is feasible and 

support strategies that promote successful follow-up and continuity of care of mother and child; 

(4) expand programs designed to care for children orphaned 

by, affected by, or vulnerable to HIV/AIDS; 

(5) ensure that women in prevention of mother-to-child transmission of HIV programs are provided with, or referred to, appropriate maternal and child services; and 

(6) develop a timeline for expanding access to more effective 

regimes to prevent mother-to-child transmission of HIV, consistent with the national policies of countries in which programs are administered under this Act and the goal of achieving universal use of such regimes as soon as possible. 

(c) PREVENTION OF MOTHER-TO-CHILD TRANSMISSION EXPERT

PANEL.—

(1) ESTABLISHMENT.—The Global AIDS Coordinator shall establish a panel of experts to be known as the Prevention of 

Mother-to-Child Transmission Panel (referred to in this subsection as the ‘‘Panel’’) to—

(A) provide an objective review of activities to prevent 

mother-to-child transmission of HIV; and 

(B) provide recommendations to the Global AIDS Coordinator and to the appropriate committees of Congress for 

scale-up of mother-to-child transmission prevention services 

under this Act in order to achieve the target established in 

subsection (b)(1). 

(2) MEMBERSHIP.—The Panel shall be convened and chaired 

by the Global AIDS Coordinator, who shall serve as a nonvoting member. The Panel shall consist of not more than 15 

members (excluding the Global AIDS Coordinator), to be appointed by the Global AIDS Coordinator not later than 1 year 

after the date of the enactment of this Act, including—


wwoods2 on PRODPC68 with REPORTS
72 

(A) 2 members from the Department of Health and 

Human Services with expertise relating to the prevention of 

mother-to-child transmission activities; 

(B) 2 members from the United States Agency for International Development with expertise relating to the prevention of mother-to-child transmission activities; 

(C) 2 representatives from among health ministers of national governments of foreign countries in which programs 

under this Act are administered; 

(D) 3 members representing organizations implementing 

prevention of mother-to-child transmission activities under 

this Act; 

(E) 2 healthcare researchers with expertise relating to 

global HIV/AIDS activities; and 

(F) representatives from among patient advocate groups, 

healthcare professionals, persons living with HIV/AIDS, 

and non-governmental organizations with expertise relating 

to the prevention of mother-to-child transmission activities, 

giving priority to individuals in foreign countries in which 

programs under this Act are administered. 

(3) DUTIES OF PANEL.—The Panel shall—

(A) assess the effectiveness of current activities in reaching the target described in subsection (b)(1); 

(B) review scientific evidence related to the provision of 

mother-to-child transmission prevention services, including 

programmatic data and data from clinical trials; 

(C) review and assess ways in which the Office of the 

United States Global AIDS Coordinator collaborates with 

international and multilateral entities on efforts to prevent 

mother-to-child transmission of HIV in affected countries; 

(D) identify barriers and challenges to increasing access 

to mother-to-child transmission prevention services and 

evaluate potential mechanisms to alleviate those barriers 

and challenges; 

(E) identify the extent to which stigma has hindered 

pregnant women from obtaining HIV counseling and testing or returning for results, and provide recommendations 

to address such stigma and its effects; 

(F) identify opportunities to improve linkages between 

mother-to-child transmission prevention services and care 

and treatment programs; and 

(G) recommend specific activities to facilitate reaching 

the target described in subsection (b)(1). 

(4) REPORT.—

(A) IN GENERAL.—Not later than 1 year after the date on 

which the Panel is first convened, the Panel shall submit 

a report containing a detailed statement of the recommendations, findings, and conclusions of the Panel to 

the appropriate congressional committees. 

(B) AVAILABILITY.—The report submitted under subparagraph (A) shall be made available to the public. 

(C) CONSIDERATION BY COORDINATOR.—The Coordinator 

shall—


wwoods2 on PRODPC68 with REPORTS
73 

(i) consider any recommendations contained in the 

report submitted under subparagraph (A); and 

(ii) include in the annual report required under section 104A(f) of the Foreign Assistance Act of 1961 a description of the activities conducted in response to the 

recommendations made by the Panel and an explanation of any recommendations not implemented at the 

time of the report. 

(5) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated to the Panel such sums as may be necessary for each of the fiscal years 2009 through 2011 to carry 

out this section. 

(6) TERMINATION.—The Panel shall terminate on the date 

that is 60 days after the date on which the Panel submits the 

report to the appropriate congressional committees under paragraph (4). 

SEC. 313. ANNUAL REPORTS ON PREVENTION OF MOTHER-TO-CHILD 

TRANSMISSION OF THE HIV INFECTION. 

(a) IN GENERAL.—Not later than 1 year after the date of the enactment of this Act, and annually thereafter for a period of ø5 

years¿ 10 years, the President shall submit to appropriate congressional committees a report on the activities of relevant executive 

branch agencies during the reporting period to assist in the prevention of mother-to-child transmission of the HIV infection. 

(b) REPORT ELEMENTS.—Each report shall include— (1) a statement of whether or not all relevant executive 

branch agencies have met the goal described in section 

312(b)(1); and 

(2) a description of efforts made by the relevant executive 

branch agencies to expand those activities, including— (A) information on the number of sites supported for the 

prevention of mother-to-child transmission of the HIV infection; 

(B) the specific activities supported; 

(C) the number of women tested and counseled; and 

(D) the number of women receiving preventative drug 

therapies. 

(c) REPORTING PERIOD DEFINED.—In this section, the term ‘‘reporting period’’ means, in the case of the initial report, the period 

since the date of enactment of this Act and, in the case of any subsequent report, the period since the date of submission of the most 

recent report. 

* * * * * * * 

TITLE IV—AUTHORIZATION OF APPROPRIATIONS 

SEC. 401. AUTHORIZATION OF APPROPRIATIONS. 

(a) IN GENERAL.—There are authorized to be appropriated to the 

President to carry out this Act and the amendments made by this 

Act ø$3,000,000,000 for each of the fiscal years 2004 through 2008¿ 

$50,000,000,000 for the 5-year period beginning on October 1, 2008. 

(b) AVAILABILITY.—Amounts appropriated pursuant to the authorization of appropriations in subsection (a) are authorized to remain available until expended. 


wwoods2 on PRODPC68 with REPORTS
74 

(c) AVAILABILITY OF AUTHORIZATIONS.—Authorizations of appropriations under subsection (a) shall remain available until the appropriations are made. 

SEC. 402. SENSE OF CONGRESS. 

(a) INCREASE IN HIV/AIDS ANTIRETROVIRAL TREATMENT.—It is a 

sense of the Congress that an urgent priority of United States assistance programs to fight HIV/AIDS should be the rapid increase 

in distribution of antiretroviral treatment so that—

(1) by the end of fiscal year 2004, at least 500,000 individuals with HIV/AIDS are receiving antiretroviral treatment 

through United States assistance programs; 

(2) by the end of fiscal year 2005, at least 1,000,000 such individuals are receiving such treatment; and 

(3) by the end of fiscal year 2006, at least 2,000,000 such individuals are receiving such treatment. 

(b) EFFECTIVE DISTRIBUTION OF HIV/AIDS FUNDS.—It is the 

sense of Congress that, of the amounts appropriated pursuant to 

the authorization of appropriations under section 401 for HIV/AIDS 

assistance, øan effective distribution of such amounts would be—

ø(1) 55 percent of such amounts for treatment of individuals 

with HIV/AIDS; 

ø(2) 15 percent of such amounts for palliative care of individuals with HIV/AIDS; 

ø(3) 20 percent of such amounts for HIV/AIDS prevention 

consistent with section 104A(d) of the Foreign Assistance Act 

of 1961 (as added by section 301 of this Act), of which such 

amount at least 33 percent should be expended for abstinenceuntil-marriage programs; and 

ø(4) 10 percent of such amounts¿ 10 percent should be used 

for orphans and vulnerable children. 

SEC. 403. ALLOCATION OF FUNDS. 

ø(a) THERAPEUTIC MEDICAL CARE.—For fiscal years 2006 through 

2008, not less than 55 percent of the amounts appropriated pursuant to the authorization of appropriations under section 401 for 

HIV/AIDS assistance for each such fiscal year shall be expended for 

therapeutic medical care of individuals infected with HIV, of which 

such amount at least 75 percent should be expended for the purchase and distribution of antiretroviral pharmaceuticals and at 

least 25 percent should be expended for related care. For fiscal 

years 2006 through 2008, not less than 33 percent of the amounts 

appropriated pursuant to the authorization of appropriations under 

section 401 for HIV/AIDS prevention consistent with section 

104A(d) of the Foreign Assistance Act of 1961 (as added by section 

301 of this Act) for each such fiscal year shall be expended for abstinence-until-marriage programs.¿ 

(a) BALANCED FUNDING REQUIREMENT.—

(1) IN GENERAL.—The Global AIDS Coordinator shall—

(A) provide balanced funding for prevention activities for 

sexual transmission of HIV/AIDS; and 

(B) ensure that behavioral change programs, including 

abstinence, delay of sexual debut, monogamy, fidelity, and 

partner reduction, are implemented and funded in a meaningful and equitable way in the strategy for each host counVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00074 Fmt 6604 Sfmt 6603 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
75 

try based on objective epidemiological evidence as to the 

source of infections and in consultation with the government of each host county involved in HIV/AIDS prevention 

activities. 

(2) PREVENTION STRATEGY.— (A) ESTABLISHMENT.—In carrying out paragraph (1), the 

Global AIDS Coordinator shall establish a HIV sexual 

transmission prevention strategy governing the expenditure 

of funds authorized under this Act to prevent the sexual 

transmission of HIV in any host country with a generalized 

epidemic. 

(B) REPORT.—In each host country described in subparagraph (A), if the strategy established under subparagraph 

(A) provides less than 50 percent of the funds described in 

subparagraph (A) for behavioral change programs, including abstinence, delay of sexual debut, monogamy, fidelity, 

and partner reduction, the Global AIDS Coordinator shall, 

not later than 30 days after the issuance of this strategy, 

report to the appropriate congressional committees on the 

justification for this decision. 

(3) EXCLUSION.—Programs and activities that implement or 

purchase new prevention technologies or modalities, such as 

medical male circumcision, pre-exposure pharmaceutical prophylaxis to prevent transmission of HIV, or microbicides and 

programs and activities that provide counseling and testing for 

HIV or prevent mother-to-child prevention of HIV, shall not be 

included in determining compliance with paragraph (2). 

(4) REPORT.—Not later than 1 year after the date of the enactment of the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria 

Reauthorization Act of 2008, and annually thereafter as part of 

the annual report required under section 104A(e) of the Foreign 

Assistance Act of 1961 (22 U.S.C. 2151b-2(e)), the President 

shall—

(A) submit a report on the implementation of paragraph 

(2) for the most recently concluded fiscal year to the appropriate congressional committees; and 

(B) make the report described in subparagraph (A) available to the public. 

(b) ORPHANS AND VULNERABLE CHILDREN.—For øfiscal years 

2006 through 2008¿ fiscal years 2009 through 2013, not less than 

10 percent of the amounts appropriated pursuant to the authorization of appropriations under section 401 for HIV/AIDS assistance 

for each such fiscal year shall be expended for assistance for orphans and øvulnerable children affected by¿ other children affected 

by, or vulnerable to, HIV/AIDS, of which such amount at least 50 

percent shall be provided through non-profit, nongovernmental organizations, including faith-based organizations, that implement 

programs on the community level. 

* * * * * * * 

The Foreign Assistance Act of 1961 

* * * * * * * 


wwoods2 on PRODPC68 with REPORTS
76 

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, Central Asia, Eastern Europe, Latin America, and other developing 

countries is a major global health, national security, development, 

and humanitarian crisis. 

ø(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, the Caribbean, 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 protect women and prevent mother-to-child transmission of the HIV infection.¿ 

(b) POLICY.—

(1) OBJECTIVES.—It is a major objective of the foreign assistance program of the United States to provide assistance for the 

prevention and treatment of HIV/AIDS and the care of those 

affected by the disease. It is the policy objective of the United 

States, by 2013, to—

(A) assist partner countries to—

(i) prevent 12,000,000 new HIV infections worldwide; 

(ii) support treatment of at least 3,000,000 individuals with HIV/AIDS; 

(iii) support additional treatment through coordinated multilateral efforts; 

(iv) support care for 12,000,000 individuals with 

HIV/AIDS, including 5,000,000 orphans and vulnerable children affected by HIV/AIDS, with an emphasis 

on promoting a comprehensive, coordinated system of 

services to be integrated throughout the continuum of 

care; 

(v) provide at least 80 percent of the target population with access to counseling, testing, and treatment 

to prevent the transmission of HIV from mother-tochild; 

(vi) provide care and treatment services to children 

with HIV in proportion to their percentage within the 

HIV-infected population of a given partner country; 

and 

(vii) train and support retention of healthcare professionals, paraprofessionals, and community health 

workers in HIV/AIDS prevention, treatment, and care, 

with the target of providing such training to at least 

140,000 new healthcare professionals and paraprofessionals; 


wwoods2 on PRODPC68 with REPORTS
77 

(B) strengthen the capacity to deliver primary healthcare 

in developing countries, especially in sub-Saharan Africa; 

and 

(C) help countries achieve staffing levels of at least 2.3 

doctors, nurses, and midwives per 1,000 population, as 

called for by the World Health Organization. 

(2) COORDINATED GLOBAL STRATEGY.—The United States and 

other countries with the sufficient capacity should provide assistance to countries in sub-Saharan Africa, the Caribbean, 

Central Asia, Eastern Europe, and Latin America, and other 

countries and regions confronting HIV/AIDS epidemics in a coordinated global strategy to help address generalized and concentrated epidemics through HIV/AIDS prevention, treatment, 

care, monitoring and evaluation, and related activities. 

(3) PRIORITIES.—The United States Government’s response to 

the global HIV/AIDS pandemic and the Government’s efforts to 

help countries assume leadership of sustainable campaigns to 

combat their local epidemics should place high priority on—

(A) the prevention of the transmission of HIV; and 

(B) moving toward universal access to HIV/AIDS prevention counseling and services. 

(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, for HIV/AIDS, including to prevent, treat, and monitor HIV/AIDS, and carry out 

related activities, in countries in sub-Saharan Africa, the Caribbean, øand other countries and areas.¿ Central Asia, Eastern 

Europe, Latin America, and other countries and areas, particularly with respect to refugee populations or those in postconflict 

settings in such countries and areas with significant or increasing HIV incidence rates. 

(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 

(including faith-based and community-based organizations) in 

countries in sub-Saharan Africa, the Caribbean, øand other 

countries and areas affected by the HIV/AIDS pandemic¿ Central Asia, Eastern Europe, Latin America, and other countries 

and areas affected by the HIV/AIDS pandemic, particularly 

with respect to refugee populations or those in post-conflict settings in such countries and areas with significant or increasing 

HIV incidence rates. 

(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 øforeign countries¿ 


wwoods2 on PRODPC68 with REPORTS
78 

partner countries, other international actors, appropriate governmental and nongovernmental organizations, and relevant 

executive branch agencies within the framework of the principles of the Three Ones. 

(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) programs and efforts that are designed or intended 

to impart knowledge with the exclusive purpose of helping 

individuals avoid behaviors that place them at risk of HIV 

infection, including integration of such programs into 

health programs and the inclusion in counseling programs 

of information on methods of avoiding infection of HIV, including delaying sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering and multiple concurrent sexual partnering, reducing sexual violence 

and coercion, including child marriage, widow inheritance, 

and polygamy, and where appropriate, use of øcondoms¿ 

male and female condoms; 

(B) assistance to establish and implement culturally appropriate HIV/AIDS education and prevention øprograms 

that¿ programs that are designed with local input and 

focus on helping individuals avoid infection of HIV/AIDS, 

implemented through nongovernmental organizations, including faith-based and community-based organizations, 

particularly øthose organizations¿ those locally based organizations that utilize both professionals and volunteers 

with appropriate skills, experience, and community presence; 

(C) assistance for the purpose of encouraging men to be 

responsible in their sexual behavior, child rearing, and to 

respect women; 

(D) assistance for the purpose of providing voluntary 

testing and counseling (including the incorporation of confidentiality protections with respect to such testing and 

counseling) and promoting the use of provider-initiated or 

‘‘opt-out’’ voluntary testing in accordance with World 

Health Organization guidelines; 

(E) 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; 

(F) assistance to—

(i) achieve the goal of reaching 80 percent of pregnant women for prevention and treatment of mother-tochild transmission of HIV in countries in which the 

United States is implementing HIV/AIDS programs by 

2013; and 

(ii) promote infant feeding options and treatment 

protocols that meet the most recent criteria established 

by the World Health Organization; 


wwoods2 on PRODPC68 with REPORTS
79 

(G) medical male circumcision programs as part of national strategies to combat the transmission of HIV/AIDS; 

ø(F)¿ (H) assistance to ensure a safe blood supply and 

sterile medical equipment; 

ø(G)¿ (I) assistance to help avoid substance abuse and 

intravenous drug use that can lead to HIV infection; øand¿ 

ø(I)¿ (J) assistance for the purpose of increasing women’s access to employment opportunities, income, productive resources, and microfinance programs, where appropriateø.¿, including education and services demonstrated to 

be effective in reducing the transmission of HIV infection 

without increasing illicit drug use; and 

(K) assistance for counseling, testing, treatment, care, 

and support programs, including— (i) counseling and other services for the prevention of 

reinfection of individuals with HIV/AIDS; 

(ii) counseling to prevent sexual transmission of HIV, 

including— (I) life skills development for practicing abstinence and faithfulness; 

(II) reducing the number of sexual partners; 

(III) delaying sexual debut; and 

(IV) ensuring correct and consistent use of 

condoms; 

(iii) assistance to engage underlying vulnerabilities 

to HIV/AIDS, especially those of women and girls, 

through structural prevention programs; 

(iv) assistance for appropriate HIV/AIDS education 

programs and training targeted to prevent the transmission of HIV among men who have sex with men; 

(v) assistance to provide male and female condoms; 

(vi) diagnosis and treatment of other sexually transmitted infections; 

(vii) strategies to address the stigma and discrimination that impede HIV/AIDS prevention efforts; and 

(viii) assistance to facilitate widespread access to 

microbicides for HIV prevention, if safe and effective 

products become available, including financial and 

technical support for culturally appropriate introductory programs, procurement, distribution, logistics 

management, program delivery, acceptability studies, 

provider training, demand generation, and 

postintroduction monitoring. 

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

HIV/AIDS, including—

(A) assistance to establish and implement programs to 

strengthen and broaden indigenous healthcare 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 healthcare providers; 

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


wwoods2 on PRODPC68 with REPORTS
80 

AIDS, their families, and the primary caregivers of such 

patients, including programs that utilize faith-based and 

community-based organizations; øand¿ 

(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, pain management, nutritional support, and 

other treatment modalitiesø.¿; 

(D) as part of care and treatment of HIV/AIDS, assistance (including prophylaxis and treatment) for common 

HIV/AIDS-related opportunistic infections for free or at a 

rate at which it is easily affordable to the individuals and 

populations being served; and 

(E) as part of care and treatment of HIV/AIDS, assistance or referral to available and adequately resourced service providers for nutritional support, including counseling 

and where necessary the provision of commodities, for persons meeting malnourishment criteria and their families; 

(3) PREVENTATIVE INTERVENTION EDUCATION AND TECHNOLOGIES.—(A) With particular emphasis on specific populations that represent a particularly high risk of contracting or 

spreading HIV/AIDS, including those exploited through the sex 

trade, victims of rape and sexual assault, individuals already 

infected with HIV/AIDS, and in cases of occupational exposure 

of healthcare workers, assistance with efforts to reduce the 

risk of HIV/AIDS infection including post-exposure pharmaceutical prophylaxis, and necessary pharmaceuticals and commodities, including test kits, condoms, and, when proven effective, microbicides. 

(B) Bulk purchases of available test kits, condoms, and, 

when proven effective, microbicides that are intended to reduce 

the risk of HIV/AIDS transmission and for appropriate program support for the introduction and distribution of these 

commodities, as well as education and training on the use of 

the technologies. 

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

activities carried out pursuant to paragraphs (1) through (3), 

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; 

(B) appropriate evaluation and surveillance activities; 

(C) monitoring to ensure that appropriate measures are 

being taken to maintain the sustainability of HIV/AIDS 

pharmaceuticals (especially antiretrovirals) and ensure 

that drug resistance is not compromising the benefits of 

such pharmaceuticals; øand¿ 

(D) monitoring to ensure appropriate law enforcement 

officials are working to ensure that HIV/AIDS pharmaceuticals are not diminished through illegal counterfeiting 

or black market sales of such pharmaceuticalsø.¿; 


wwoods2 on PRODPC68 with REPORTS
81 

(E) carrying out and expanding program monitoring, impact evaluation research and analysis, and operations research and disseminating data and findings through mechanisms to be developed by the Coordinator of United States 

Government Activities to Combat HIV/AIDS Globally, in 

coordination with the Director of the Centers for Disease 

Control, in order to—

(i) improve accountability, increase transparency, 

and ensure the delivery of evidence-based services 

through the collection, evaluation, and analysis of data 

regarding gender-responsive interventions, disaggregated by age and sex; 

(ii) identify and replicate effective models; and 

(iii) develop gender indicators to measure outcomes 

and the impacts of interventions; and 

(F) establishing appropriate systems to—

(i) gather epidemiological and social science data on 

HIV; and 

(ii) evaluate the effectiveness of prevention efforts 

among men who have sex with men, with due consideration to stigma and risks associated with disclosure. 

(5) 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 appropriate medicines are quality-controlled and sustainably 

supplied. 

(C) MECHANISM TO ENSURE COST-EFFECTIVE DRUG PURCHASING.—Subject to subparagraph (B), mechanisms to ensure that safe and effective pharmaceuticals, including 

antiretrovirals and medicines to treat opportunistic infections, are purchased at the lowest possible price at which 

such pharmaceuticals may be obtained in sufficient quantity on the world market. 

ø(C)¿ (D) 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. 

(6) øRELATED ACTIVITIES.—¿ RELATED AND COORDINATED 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; 


wwoods2 on PRODPC68 with REPORTS
82 

(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; 

øand¿ 

(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 worldø.¿; 

(D) coordinated or referred activities to—

(i) enhance the clinical impact of HIV/AIDS care 

and treatment; and 

(ii) ameliorate the adverse social and economic costs 

often affecting AIDS-impacted families and communities through the direct provision, as necessary, or 

through the referral, if possible, of support services, including—

(I) nutritional and food support; 

(II) nutritional counseling; 

(III) income-generating activities and livelihood 

initiatives; 

(IV) maternal and child healthcare; 

(V) primary healthcare; 

(VI) the diagnosis and treatment of other infectious or sexually transmitted diseases; 

(VII) substance abuse and treatment services; 

and 

(VIII) legal services; 

(E) coordinated or referred activities to link programs addressing HIV/AIDS with programs addressing genderbased violence in areas of significant HIV prevalence to assist countries in the development and enforcement of women’s health, children’s health, and HIV/AIDS laws and 

policies that—

(i) prevent and respond to violence against women 

and girls; 

(ii) promote the integration of screening and assessment for gender-based violence into HIV/AIDS programming; 

(iii) promote appropriate HIV/AIDS counseling, testing, and treatment into gender-based violence programs; and 

(iv) assist governments to develop partnerships with 

civil society organizations to create networks for psychosocial, legal, economic, or other support services; 

(F) coordinated or referred activities to—

(i) address the frequent coinfection of HIV and tuberculosis, in accordance with World Health Organization 

guidelines; 

(ii) promote provider-initiated or ‘‘opt-out’’ HIV/ 

AIDS counseling and testing and appropriate referral 

for treatment and care to individuals with tuberculosis 


wwoods2 on PRODPC68 with REPORTS
83 

or its symptoms, particularly in areas with significant 

HIV prevalence; and 

(iii) strengthen programs to ensure that individuals 

testing positive for HIV receive tuberculosis screening 

and appropriate screening and to improve laboratory 

capacities, infection control, and adherence; and 

(G) activities to— (i) improve the effectiveness of national responses to 

HIV/AIDS; and 

(ii) strengthen overall health systems in high-prevalence countries, including support for workforce training, retention, and effective deployment, capacity building, laboratory development, equipment maintenance 

and repair, and public health and related public financial management systems and operations. 

(7) COMPREHENSIVE HIV/AIDS PUBLIC-PRIVATE PARTNERSHIPS.—The establishment and operation of public-private 

partnership entities within countries in sub-Saharan Africa, 

the Caribbean, and other countries affected by the HIV/AIDS 

pandemic that are dedicated to supporting the national strategy of such countries regarding the prevention, treatment, and 

monitoring of HIV/AIDS. Each such public-private partnership 

should) 

(A) support the development, implementation, and management of comprehensive HIV/AIDS plans in support of 

the national HIV/AIDS strategy; 

(B) operate at all times in a manner that emphasizes efficiency, accountability, and results-driven programs; 

(C) engage both local and foreign development partners 

and donors, including businesses, government agencies, 

academic institutions, nongovernmental organizations, 

foundations, multilateral development agencies, and faithbased organizations, to assist the country in coordinating 

and implementing HIV/AIDS prevention, treatment, and 

monitoring programs in accordance with its national HIV/ 

AIDS strategy; 

(D) provide technical assistance, consultant services, financial planning, monitoring and evaluation, and research 

in support of the national HIV/AIDS strategy; and 

(E) establish local human resource capacities for the national HIV/AIDS strategy through the transfer of medical, 

managerial, leadership, and technical skills. 

(8) COMPACTS AND FRAMEWORK AGREEMENTS.—The development of compacts or framework agreements, tailored to local 

circumstances, with national governments or regional partnerships in countries with significant HIV/AIDS burdens to promote host government commitment to deeper integration of 

HIV/AIDS services into health systems, contribute to health 

systems overall, and enhance sustainability. 

(e) COMPACTS AND FRAMEWORK AGREEMENTS.— (1) FINDINGS.—Congress makes the following findings: 

(A) The congressionally mandated Institute of Medicine 

report entitled ‘‘PEPFAR Implementation: Progress and 

Promise’ states: ‘‘The next strategy [of the U.S. Global AIDS 


wwoods2 on PRODPC68 with REPORTS
84 

Initiative] should squarely address the needs and challenges involved in supporting sustainable country HIV/ 

AIDS programs, thereby transitioning from a focus on 

emergency relief.’’

(B) One mechanism to promote the transition from an 

emergency to a public health and development approach to 

HIV/AIDS is through compacts or framework agreements 

between the United States Government and each participating nation. 

(C) Key components of a transition toward a more sustainable approach toward fighting HIV/AIDS, tuberculosis, and malaria and thus priorities for such compacts 

include—

(i) building capacity to expand the size of the trained 

healthcare workforce in partner countries and improve 

its retention, safety, deployment, and utilization of 

skills and to improve public health infrastructure and 

systems; 

(ii) partner governments increasing their national investments in health and education systems, as called 

for in the Abuja Declaration; 

(iii) increasing the focus of United States government 

efforts to address the factors that put women and girls 

at greater risk of HIV/AIDS and to strengthen the 

legal, economic, educational, and social status of 

women, girls, orphans, and vulnerable children and 

encouraging partner governments to do the same; 

(iv) building on the New Partners Initiative and 

other efforts currently underway to strengthen the capacities of community- and faith-based organizations 

and civil society in partner countries to contribute to 

country efforts to prevent or manage the effects of HIV/ 

AIDS, tuberculosis, and malaria epidemics and to improve healthcare delivery; 

(v) improving the coordination of efforts to combat 

HIV/AIDS, tuberculosis, and malaria with broader 

national health and development strategies; 

(vi) promoting HIV/AIDS-related laws, regulations, 

and policies that support voluntary diagnostic counseling and rapid testing, pediatric diagnosis, rapid, 

tariff-free regulatory procedures for drugs and commodities, and full inclusion of people living with HIV/ 

AIDS in a multisectoral national response. 

(vii) sharing and implementing findings based on 

program evaluations and operations research; and 

(viii) reducing the disease burden of HIV/AIDS, tuberculosis, and malaria through improved prevention 

efforts. 

(D) Such compacts should also take into account the 

overall national health and development and national 

HIV/AIDS and public health strategies of each country 

and should contain provisions including—


wwoods2 on PRODPC68 with REPORTS
85 

(i) the specific objectives that the country and the 

United States expect to achieve during the term of a 

compact; 

(ii) the respective responsibilities of the country and 

the United States in the achievement of such objectives; 

(iii) regular benchmarks to measure, where appropriate, progress toward achieving such objectives; 

(iv) an identification of the intended beneficiaries, 

disaggregated by gender and age, and including information on orphans and vulnerable children, to the 

maximum extent practicable; 

(v) the methods by which the compact is intended to 

address the factors that put women and girls at greater 

risk of HIV/AIDS and to strengthen the legal, economic, educational, and social status of women, girls, 

orphans, and vulnerable children; 

(vi) the methods by which the compact will strengthen the healthcare capacity, including the training, retention, deployment, and utilization of healthcare 

workers, improve supply chain management, and improve the health systems and infrastructure of the partner country, including the ability of compact participants to maintain and operate equipment transferred 

or purchased as part of the compact; 

(vii) proposed mechanisms to provide oversight; 

(viii) the role of civil society in the development of a 

compact and the achievement of its objectives; 

(ix) a description of the current and potential participation of other donors in the achievement of such objectives, as appropriate; and 

(x) a plan to ensure appropriate fiscal accountability 

for the use of assistance. 

(2) LOCAL INPUT.—In entering into a compact authorized 

under subsection (d)(8), the Coordinator of United States Government Activities to Combat HIV/AIDS Globally shall seek to 

ensure that the government of a country—

(A) takes into account the local perspectives of the rural 

and urban poor, including women, in each country; and 

(B) consults with private and voluntary organizations, 

including faith-based organizations, the business community, and other donors in the country. 

(3) CONGRESSIONAL AND PUBLIC NOTIFICATION AFTER ENTERING INTO A COMPACT.—Not later than 10 days after entering 

into a compact authorized under subsection (d)(8), the Global 

AIDS Coordinator shall—

(A) submit a report containing a detailed summary of the 

compact and a copy of the text of the compact to—

(i) the Committee on Foreign Relations of the Senate; 

(ii) the Committee on Appropriations of the Senate; 

(iii) the Committee on Foreign Affairs of the House 

of Representatives; and 

(iv) the Committee on Appropriations of the House of 

Representatives; and 


wwoods2 on PRODPC68 with REPORTS
86 

(B) publish such information in the Federal Register and 

on the Internet website of the Office of the Global AIDS Coordinator. 

ø(e)¿ (f) 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 øCommittee on International Relations¿ 

Committee on Foreign Affairs 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 by each relevant executive branch agency to implement the policies set forth in 

this section, section 104B, and section 104C; 

(B) a description of the programs established pursuant 

to such sections; øand¿ 

ø(C) a detailed assessment of the impact of programs established pursuant to such sections, including 

ø(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 

ø(II) the number of patients currently receiving 

treatment for AIDS in each country that receives assistance under this Act. 

ø(ii) the progress made toward improving healthcare 

delivery systems (including the training of adequate 

numbers of staff) and infrastructure to ensure increased access to care and treatment; 

ø(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; and 

ø(iv) with respect to malaria, the increase in the 

number of people treated and the increase in number 

of malaria patients cured through each program, 

project, or activity receiving United States foreign assistance for malaria control purposes.¿ 

(C) a detailed breakdown of funding allocations, by program and by country, for prevention activities; and 

(D) a detailed assessment of the impact of programs established pursuant to such sections, including—

(i)(I) the effectiveness of such programs in reducing—

(aa) the transmission of HIV, particularly in 

women and girls; 

(bb) mother-to-child transmission of HIV, including through drug treatment and therapies, either directly or by referral; and 

(cc) mortality rates from HIV/AIDS; 

(II) the number of patients receiving treatment for 

AIDS in each country that receives assistance under 

this Act; 


wwoods2 on PRODPC68 with REPORTS
87 

(III) an assessment of progress towards the achievement of annual goals set forth in the timetable required 

under the 5-year strategy established under section 101 

of the United States Leadership Against HIV/AIDS, 

Tuberculosis, and Malaria Act of 2003 and, if annual 

goals are not being met, the reasons for such failure; 

and 

(IV) retention and attrition data for programs receiving United States assistance, including mortality and 

loss to follow-up rates, organized overall and by country; 

(ii) the progress made toward— (I) improving healthcare delivery systems (including the training of healthcare workers, including doctors, nurses, midwives, pharmacists, laboratory technicians, and compensated community 

health workers); 

(II) advancing safe working conditions for 

healthcare workers; and 

(III) improving infrastructure to promote 

progress toward universal access to HIV/AIDS 

prevention, treatment, and care by 2013; 

(iii) with respect to tuberculosis— (I) the increase in the number of people treated 

and the number of tuberculosis patients cured 

through each program, project, or activity receiving 

United States foreign assistance for tuberculosis 

control purposes through, or in coordination with, 

HIV/AIDS programs; 

(II) a description of drug resistance rates among 

persons treated; 

(III) the percentage of such 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; and 

(IV) a detailed description of efforts to integrate 

HIV/AIDS and tuberculosis prevention, treatment, 

and care programs; and 

(iv) a description of coordination efforts with relevant 

executive branch agencies to link HIV/AIDS clinical 

and social services with non-HIV/AIDS services as 

part of the United States health and development agenda; 

(v) a detailed description of integrated HIV/AIDS 

and food and nutrition programs and services, including—

(I) the amount spent on food and nutrition support; 

(II) the types of activities supported; and 

(III) an assessment of the effectiveness of interventions carried out to improve the health status of 

persons with HIV/AIDS receiving food or nutritional support; 


wwoods2 on PRODPC68 with REPORTS
88 

(vi) a description of efforts to improve harmonization, 

in terms of relevant executive branch agencies, coordination with other public and private entities, and coordination with partner countries’ national strategic 

plans as called for in the ‘‘Three Ones’’; 

(vii) a description of—

(I) the efforts of partner countries that were signatories to the Abuja Declaration on HIV/AIDS, 

Tuberculosis and Other Related Infectious Diseases to adhere to the goals of such Declaration in 

terms of investments in public health, including 

HIV/AIDS; and 

(II) a description of the HIV/AIDS investments 

of partner countries that were not signatories to 

such Declaration; 

(viii) a detailed description of any compacts or 

framework agreements reached or negotiated between 

the United States and any partner countries, including 

a description of the elements of compacts described in 

subsection (e); 

(ix) a description of programs serving women and 

girls, including—

(I) HIV/AIDS prevention programs that address 

the vulnerabilities of girls and women to HIV/ 

AIDS; 

(II) information on the number of individuals 

served by programs aimed at reducing the 

vulnerabilities of women and girls to HIV/AIDS 

and data on the types, objectives, and duration of 

programs to address these issues; 

(III) information on programs to address the 

particular needs of adolescent girls and young 

women; and 

(IV) programs to prevent gender-based violence 

or to assist victims of gender based violence as 

part, of or in coordination with, HIV/AIDS programs; 

(x) a description of strategies, goals, programs, and 

interventions to—

(I) address the needs and vulnerabilities of youth 

populations; 

(II) expand access among young men and women 

to evidence-based HIV/AIDS healthcare services 

and HIV prevention programs, including abstinence education programs; and 

(III) expand community-based services to meet 

the needs of orphans and of children and adolescents affected by or vulnerable to HIV/AIDS without increasing stigmatization; 

(xi) a description of—

(I) the specific strategies funded to ensure the reduction of HIV infection among injection drug 

users; 


wwoods2 on PRODPC68 with REPORTS
89 

(II) the number of injection drug users, by country, reached by such strategies; 

(III) medication-assisted drug treatment for individuals with HIV or at risk of HIV; and 

(IV) HIV prevention programs demonstrated to 

be effective in reducing HIV transmission without 

increasing drug use; 

(xii) a detailed description of program monitoring, 

operations research, and impact evaluation research, 

including— (I) the amount of funding provided for each research type; 

(II) an analysis of cost-effectiveness models; and 

(III) conclusions regarding the efficiency, effectiveness, and quality of services as derived from 

previous or ongoing research and monitoring efforts; and 

(xiii) a description of staffing levels of United States 

government HIV/AIDS teams in countries with significant HIV/AIDS programs, including whether or not a 

full-time coordinator was on staff for the year. 

ø(f)¿ (g) FUNDING LIMITATION.—Of the funds made available to 

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

may be used for the administrative expenses of the United States 

Agency for International Development in support of activities described in section 104(c), this section, section 104B, and section 

104C. Such amount shall be in addition to other amounts otherwise 

available for such purposes. 

ø(g)¿ (h) 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. 

(4) RELEVANT EXECUTIVE BRANCH AGENCIES.—The term ‘‘relevant executive branch agencies’’ means the Department of 

State, the United States Agency for International Development, the Department of Health and Human Services (including its agencies and offices), and any other department or 

agency of the United States that participates in international 

HIV/AIDS activities pursuant to the authorities of such department or agency or this Act. 

* * * * * * * 

SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS. 

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

* * * * * * * 

ø(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 


wwoods2 on PRODPC68 with REPORTS
90 

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. 

* * * * * * * 

ø(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.—In furnishing assistance 

under subsection (c), the President shall give priority to— (1) activities described in the Stop TB Strategy, including expansion and enhancement of Directly Observed Treatment 

Short-course (DOTS) coverage, rapid testing, treatment for individuals infected with both tuberculosis and HIV, and treatment 

for individuals with multi-drug resistant tuberculosis (MDRTB), 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 

(2) funding for the Global Tuberculosis Drug Facility, the 

Stop Tuberculosis Partnership, and the Global Alliance for TB 

Drug Development. 

(f) ASSISTANCE FOR THE WORLD HEALTH ORGANIZATION 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 and the Stop 

Tuberculosis Partnership to improve the capacity of countries with 


wwoods2 on PRODPC68 with REPORTS
91 

high rates of tuberculosis and other affected countries to implement 

the Stop TB Strategy and specific strategies related to addressing 

multiple drug resistant tuberculosis (MDR-TB) and extensively drug 

resistant tuberculosis (XDR-TB). 

ø(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 tuberculosisø.¿ including 

(A) low–cost and effective diagnosis, treatment, and monitoring of tuberculosis; 

(B) a reliable drug supply; 

(C) a management strategy for public health systems; 

(D) health system strengthening; 

(E) promotion of the use of the International Standards 

for Tuberculosis Care by all care providers; 

(F) bacteriology under an external quality assessment 

framework; 

(G) short-course chemotherapy; and 

(H) 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 highquality tuberculosis drugs to facilitate DOTS expansion. 

(5) STOP TB STRATEGY.—The term ‘‘Stop TB Strategy’’ means 

the 6-point strategy to reduce tuberculosis developed by the 

World Health Organization, which is described in the Global 

Plan to Stop TB 2006–2015: Actions for Life, a comprehensive 

plan developed by the Stop TB Partnership that sets out the actions necessary to achieve the millennium development goal of 

cutting tuberculosis deaths and disease burden in half by 2015. 

ø(5)¿ (6) 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. 

* * * * * * * 


wwoods2 on PRODPC68 with REPORTS
92 

SEC. 104C. ASSISTANCE TO COMBAT MALARIA. 

* * * * * * * 

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

control, treatment, and cure of malaria. 

* * * * * * * 

Chapter 3—International Organizations and Programs 

* * * * * * * 

Sec. 302. Authorization.—(a) * * * 

* * * * * * * 

(c) None of the funds available to carry out this chapter shall be 

contributed to any international organization or to any foreign government or agency thereof to pay the costs of developing or operating any volunteer program of such organization, government, or 

agency relating to the selection, training, and programing of volunteer manpower. 

(d) TUBERCULOSIS VACCINE DEVELOPMENT PROGRAMS.—In addition to amounts otherwise available under this section, there are authorized to be appropriated to the President such sums as may be 

necessary for each of the fiscal years 2009 through 2013, which 

shall be used for United States contributions to tuberculosis vaccine 

development programs, which may include the Aeras Global TB 

Vaccine Foundation. 

* * * * * * * 

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

there is authorized to be appropriated to the President such sums 

as may be necessary for each of the øfiscal years 2004 through 

2008¿ fiscal years 2009 through 2013 to be available only for 

United States contributions to the Vaccine Fund. 

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

there is authorized to be appropriated to the President such sums 

as may be necessary for each of the øfiscal years 2004 through 

2008¿ fiscal years 2009 through 2013 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 such 

sums as may be necessary for each of the øfiscal years 2004 

through 2008¿ fiscal years 2009 through 2013 to be available for 

United States contributions to malaria vaccine development programs, including the Malaria Vaccine Initiative of the Program for 

Appropriate Technologies in Health (PATH). 

* * * * * * * 

The Public Health Service Act 

* * * * * * * 

CHAPTER 6A—PUBLIC HEALTH SERVICE 

* * * * * * * 


wwoods2 on PRODPC68 with REPORTS
93 

SUBCHAPTER II.—GENERAL POWERS AND DUTIES 

* * * * * * * 

PART A. RESEARCH AND INVESTIGATIONS

SEC. 307. INTERNATIONAL COOPERATION. 

ø(a) COOPERATIVE ENDEAVORS; STATEMENT OF PURPOSE.—For the 

purpose of advancing the status of the health sciences in the 

United States (and thereby the health of the American people), the 

Secretary may participate with other countries in cooperative endeavors in biomedical research, healthcare technology, and the 

health services research and statistical activities authorized by section 306 of this title and by subchapter VII of this chapter.¿ 

(a) The Secretary may participate with other countries in cooperative endeavors in—

(1) biomedical research, healthcare technology, and the health 

services research and statistical analysis authorized under section 306 and title IX; and 

(2) biomedical research, healthcare services, healthcare research, or other related activities in furtherance of the activities, 

objectives or goals authorized under the Tom Lantos and Henry 

J. Hyde United States Global Leadership Against HIV/AIDS, 

Tuberculosis, and Malaria Reauthorization Act of 2008. 

(b) AUTHORITY OF SECRETARY; BUILDING CONSTRUCTION PROHIBITION.—In connection with the cooperative endeavors authorized by 

subsection (a) of this section, the Secretary may—

(1) make such use of resources offered by participating foreign countries as he may find necessary and appropriate; 

(2) establish and maintain fellowships in the United States 

and in participating foreign countries; 

(3) make grants to public institutions or agencies and to nonprofit private institutions or agencies in the United States and 

in participating foreign countries for the purpose of establishing and maintaining the fellowships authorized by paragraph (2); 

(4) make grants or loans of equipment and materials, for use 

by public or nonprofit private institutions or agencies, or by individuals, in participating foreign countries; 

(5) participate and otherwise cooperate in any international 

meetings, conferences, or other activities concerned with biomedical research, health services research, health statistics, or 

healthcare technology; 

(6) facilitate the interchange between the United States and 

participating foreign countries, and among participating foreign countries, of research scientists and experts who are engaged in experiments or programs of biomedical research, 

health services research, health statistical activities, or 

healthcare technology activities, and in carrying out such purpose may pay per diem compensation, subsistence, and travel 

for such scientists and experts when away from their places of 

residence at rates not to exceed those provided in section 

5703(b) of Title 5 for persons in the Government service employed intermittently; 


wwoods2 on PRODPC68 with REPORTS
94 

(7) procure, in accordance with section 3109 of Title 5, the 

temporary or intermittent services of experts or consultants; 

øand¿ 

(8) enter into contracts with individuals for the provision of 

services (as defined in section 104 of part 37 of title 48, Code 

of Federal Regulations (48 CFR 37.104)) in participating foreign countries, which individuals may not be deemed employees of the United States øfor any purpose¿ for the purpose of 

any law administered by the Office of Personnel Management; 

(9) provide such funds by advance or reimbursement to the 

Secretary of State, as may be necessary, to pay the costs of acquisition, lease, construction, alteration, equipping, furnishing 

or management of facilities outside of the United States; and 

(10) in consultation with the Secretary of State, through 

grant or cooperative agreement, make funds available to public 

or nonprofit private institutions or agencies in foreign countries 

in which the Secretary is participating in activities described 

under subsection (a) to acquire, lease, construct, alter, or renovate facilities in those countries. 

øThe Secretary may not, in the exercise of his authority under this 

section, provide financial assistance for the construction of any facility in any foreign country.¿ 

(c) BENEFITS FOR OVERSEAS ASSIGNEES.—The Secretary may provide to personnel appointed or assigned by the Secretary to serve 

abroad, allowances and benefits similar to those provided under 

chapter 9 of title I of the Foreign Service Act of ø1990¿ 1980 (22 

U.S.C. 4081 et seq.) or section 903 of the Foreign Service Act of 

1980 (22 U.S.C. 4083) . Leaves of absence for personnel under this 

subsection shall be on the same basis as that provided under subchapter I of chapter 63 of Title 5 to individuals serving in the Foreign Service. 

* * * * * * * 

PART B. FEDERAL-STATE COOPERATION

* * * * * * * 

SEC. 317S. GENERAL GRANT OF AUTHORITY FOR COOPERATION. 

* * * * * * * 

SEC. 317T. MICROBICIDE RESEARCH. 

(a) IN GENERAL.—The Director of the Centers for Disease Control 

and Prevention shall fully implement the Centers’ microbicide agenda to support research and development of microbicides for use in 

developing countries to prevent the transmission of the human immunodeficiency virus. 

(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to 

be appropriated such sums as may be necessary for each of fiscal 

years 2009 through 2013 to carry out this section. 

SUBCHAPTER III—NATIONAL RESEARCH INSTITUTES 

* * * * * * * 


wwoods2 on PRODPC68 with REPORTS
95 

PART C—SPECIFIC PROVISIONS RESPECTING NATIONAL RESEARCH

INSTITUTES

SUBPART 6—NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS

DISEASES

SEC. 477. PURPOSE OF INSTITUTE 

The general purpose of the National Institute of Allergy and Infectious Diseases is the conduct and support of research, training, 

health information dissemination, and other programs with respect 

to allergic and immunologic diseases and disorders and infectious 

diseases, including tropical diseases. 

* * * * * * * 

SEC. 447C. MICROBICIDE RESEARCH AND DEVELOPMENT. 

The Director of the Institute, acting through the head of the Division of AIDS, shall carry out research on, and development of, a 

microbicide for use in developing countries to prevent the transmission of the human immunodeficiency virus. The Director shall 

ensure that there are a sufficient number of employees and structure 

dedicated to carrying out such activities. 

SUBCHAPTER XXI—RESEARCH WITH RESPECT TO 

ACQUIRED IMMUNE DEFICIENCY SYNDROME 

PART D—OFFICE OF AIDS RESEARCH

SUBPART I—INTERAGENCY COORDINATION OF ACTIVITIES

SEC. 2351. ESTABLISHMENT OF OFFICE. 

* * * * * * * 

SEC. 2351A. MICROBICIDE RESEARCH. 

(a) FEDERAL STRATEGIC PLAN.—

(1) IN GENERAL.—The Director of the Office shall—

(A) expedite the implementation of the Federal strategic 

plans for the conduct and support of research on, and development of, a microbicide for use in developing countries 

to prevent the transmission of the human immunodeficiency 

virus; and 

(B) annually review and, as appropriate, revise such plan 

to prioritize funding and activities relative to their scientific urgency and potential market readiness. 

(2) COORDINATION.—In implementing, reviewing, and 

prioritizing elements of the plan described in paragraph (1), the 

Director of the Office shall consult with—

(A) representatives of other Federal agencies involved in 

microbicide research, including the Coordinator of United 

States Government Activities to Combat HIV/AIDS Globally, the Director of the Centers for Disease Control and 

Prevention, and the Administrator of the United States 

Agency for International Development; 

(B) the microbicide research and development community; and 

(C) health advocates. 


wwoods2 on PRODPC68 with REPORTS
96 

(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to 

be appropriated such sums as may be necessary for each of the fiscal years 2009 through 2013 to carry out this section. 

* * * * * * * 

The State Department Basic Authorities Act of 1956 

* * * * * * * 

TITLE I—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 established within the Department of State in the immediate office of the Secretary 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. 

(2) AUTHORITIES AND DUTIES; DEFINITIONS.— (A) AUTHORITIES.—The Coordinator, acting through such 

nongovernmental organizations (including faith-based and 

community-based organizations), partner country finance, 

health, and other relevant ministries, and relevant executive branch agencies as may be necessary and appropriate 

to effect the purposes of this section, is authorized— (i) to operate internationally to carry out prevention, 

care, treatment, support, capacity development, and 

other activities for combatting HIV/AIDS; 

(ii) to transfer and allocate funds to relevant executive branch agencies; and 

(iii) to provide grants to, and enter into contracts 

with, nongovernmental organizations (including faithbased and community-based organizations), partner 

country finance, health, and other relevant ministries, 

to carry out the purposes of section. 

(B) DUTIES.—

(i) IN GENERAL.—The Coordinator shall have primary responsibility for the oversight and coordination 

of all resources and international activities of the 

United States Government to combat the HIV/AIDS 

pandemic, including all programs, projects, and activities of the United States Government relating to the 

HIV/AIDS pandemic under the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act 

of 2003 or any amendment made by that Act. 

(ii) SPECIFIC DUTIES.—The duties of the Coordinator 

shall specifically include the following: 

(I) Ensuring program and policy coordination 

among the relevant executive branch agencies and 

nongovernmental organizations, including auditVerDate Aug 31 2005 02:09 Apr 16, 2008 Jkt 069010 PO 00000 Frm 00096 Fmt 6604 Sfmt 6602 E:\HR\OC\SR325.XXX SR325

wwoods2 on PRODPC68 with REPORTS
97 

ing, monitoring, and evaluation of all such programs. 

(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. 

ø(IV) Ensuring coordination of relevant executive branch agency activities in the field. 

ø(V) Pursuing coordination with other countries 

and international organizations.¿ 

(IV) Establishing an interagency working group 

on HIV/AIDS headed by the Global AIDS Coordinator and comprised of representatives from the 

United States Agency for International Development and the Department of Health and Human 

Services, for the purposes of coordination of activities relating to HIV/AIDS, including— (aa) meeting regularly to review progress in 

partner countries toward HIV/AIDS prevention, treatment, and care objectives; 

(bb) participating in the process of identifying countries to consider for increased assistance based on the epidemiology of HIV/AIDS 

in those countries, including clear evidence of 

a public health threat, as well as government 

commitment to address the HIV/AIDS problem, relative need, and coordination and joint 

planning with other significant actors; 

(cc) assisting the Coordinator in the evaluation, execution, and oversight of country operational plans; 

(dd) reviewing policies that may be obstacles 

to reaching targets set forth for HIV/AIDS 

prevention, treatment, and care; and 

(ee) consulting with representatives from additional relevant agencies, including the National Institutes of Health, the Health Resources and Services Administration, the Department of Labor, the Department of Agriculture, the Millennium Challenge Corporation, the Peace Corps, and the Department of 

Defense. 

(V) Coordinating overall United States HIV/ 

AIDS policy and programs, including ensuring the 

coordination of relevant executive branch agency 

activities in the field, with efforts led by partner 

countries, and with the assistance provided by 

other relevant bilateral and multilateral aid agencies and other donor institutions to promote harmonization with other programs aimed at preventing and treating HIV/AIDS and other health 

challenges, improving primary health, addressing 


wwoods2 on PRODPC68 with REPORTS
98 

food security, promoting education and development, and strengthening healthcare systems. 

(VI) Resolving policy, program, and funding disputes among the relevant executive branch agencies. 

(VII) Holding annual consultations with nongovernmental organizations in partner countries 

that provide services to improve health, and advocating on behalf of the individuals with HIV/ 

AIDS and those at particular risk of contracting 

HIV/AIDS, including organizations with members 

who are living with HIV/AIDS. 

(VIII) Ensuring, through interagency and international coordination, that HIV/AIDS programs 

of the United States are coordinated with, and 

complementary to, the delivery of related global 

health, food security, development, and education. 

ø(VII)¿ (IX) Directly approving all activities of 

the United States (including funding) relating to 

combatting HIV/AIDS in each of Botswana, Cote 

d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, 

Tanzania, Uganda, Vietnam, Zambia, and other 

countries designated by the President, which 

other designated countries may include those 

countries in which the United States is implementing HIV/AIDS programs as of the date of the 

enactment of the United States Leadership 

Against HIV/AIDS, Tuberculosis, and Malaria Act 

of 2003 and other countries in which the United 

States is implementing HIV/AIDS programs as 

part of its foreign assistance program. In designating additional countries under this subparagraph, the President shall give priority to those 

countries in which there is a high prevalence or 

significantly rising incidence of HIV/AIDS, countries with large populations and inadequate health 

infrastructure, countries in which a concentrated 

HIV/AIDS epidemic could become generalized to 

the entire population of the country, and in countries whose governments demonstrate a commitment to combating HIV/AIDS. 

(X) Working with partner countries in which the 

HIV/AIDS epidemic is prevalent among injection 

drug users to establish, as a national priority, national HIV/AIDS prevention programs, including 

education and services demonstrated to be effective 

in reducing the transmission of HIV infection 

among injection drug users without increasing illicit drug use. 

(XI) Working with partner countries in which 

the HIV/AIDS epidemic is prevalent among individuals involved in commercial sex acts to establish, as a national priority, national prevention 


wwoods2 on PRODPC68 with REPORTS
99 

programs, including education, voluntary testing, 

and counseling, and referral systems that link 

HIV/AIDS programs with programs to eradicate 

trafficking in persons and support alternatives to 

prostitution. 

ø(VIII)¿ (XII) Establishing due diligence criteria 

for all recipients of øfunds section¿ funds appropriated for HIV/ AIDS assistance pursuant to the 

authorization of appropriations under section 401 

of the United States Leadership Against HIV/ 

AIDS, Tuberculosis, and Malaria Act of 2003 (22 

U.S.C. 7671) and all activities subject to the coordination and appropriate monitoring, evaluation, and audits carried out by the Coordinator 

necessary to assess the measurable outcomes of 

such activities. 

(XIII) Publicizing updated drug pricing data to 

inform the purchasing decisions of pharmaceutical 

procurement partners. 

* * * * * * * 

The Immigration and Nationality Act 

* * * * * * * 

The Immigration and Nationality Act, as Amended 

* * * * * * * 

INADMISSIBLE ALIENS

SEC. 212. (a) Except as otherwise provided in this Act, aliens who 

are inadmissible under the following paragraphs are ineligible to 

receive visas and ineligible to be admitted to the United States: 

(1) HEALTH-RELATED GROUNDS. 

(A) IN GENERAL. Any alien—

(i) who is determined (in accordance with regulations prescribed by the Secretary of Health and 

Human Services) to have a communicable disease of 

public health significance, øwhich shall include infection with the etiologic agent for acquired immune deficiency syndrome,¿; 

* * * * * * * 

Æ 


wwoods2 on PRODPC68 with REPORTS