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[Senate Report 113-112]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 202
113th Congress                                                   Report
                                 SENATE
 1st Session                                                    113-112

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

 
                    PEPFAR STEWARDSHIP AND OVERSIGHT
                         ACT OF 2013 (S. 1545)

                                _______
                                

                October 2, 2013.--Ordered to be printed

                                _______
                                

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

                                 REPORT

                         [To accompany S. 1545]

    The Committee on Foreign Relations, having had under 
consideration the bill S. 1545, to extend authorities related 
to global HIV/AIDS and to promote oversight of the United 
States programs, reports favorably thereon with amendments and 
recommends that the bill, as amended, do pass.

                                CONTENTS

                                                                   Page

  I. Purpose..........................................................1
 II. Committee Action.................................................1
III. Discussion.......................................................2
 IV. Cost Estimate....................................................5
  V. Evaluation of Regulatory Impact..................................5
 VI. Changes in Existing Law..........................................5

                               I. Purpose

    The purpose of S. 1545 is to extend provisions of PEPFAR 
that would otherwise expire and to update oversight 
requirements.

                          II. Committee Action

    S. 1545 was introduced by Senators Menendez and Corker on 
September 24, 2013. On September 30, 2013, the committee 
considered S. 1545 and ordered it reported, with amendments, by 
voice vote.
    The committee took the following action with regard to 
amendments: A manager's package of amendments was offered to 
the introduced bill, including proposed amendments from 
Senators Cardin and Durbin (modified by Senators Corker and 
Rubio), and was agreed to by voice vote. The subject matter 
areas covered by the manager's package of amendments included 
non-controversial amendments which require the annual report 
from the Office of the Global AIDS Coordinator to include 
reporting on HIV co-infections and co-morbidities, including 
tuberculosis co-infections; reporting on health care workforce 
training and retention; and a clarification that reporting on 
engagement with nongovernmental organizations covers engagement 
with local partners

                            III. Discussion

    Chairman Menendez and Ranking Member Corker introduced the 
PEPFAR Stewardship and Oversight Act of 2013 to extend valuable 
provisions of PEPFAR that would otherwise expire, and to update 
and refine oversight requirements. These updated and refined 
oversight requirements ensure that PEPFAR programs continue to 
be implemented efficiently and effectively and address the 
evolving HIV/AIDS epidemic.
    PEPFAR has saved millions of lives around the world--
especially in Africa--over the last decade. As a result of the 
United States' strong commitment to stopping the HIV/AIDS 
epidemic through PEPFAR, almost 6 million people are receiving 
life-sustaining antiretroviral treatment, more than 11 million 
pregnant women received HIV testing and counseling last year, 
and--as a result of adequate treatment--this year, the one-
millionth baby was born HIV-free. Because of PEPFAR, 15 million 
people--more than 4.5 million orphans and vulnerable children--
have received the care and support they need.
    Most provisions from PEPFAR have permanent authority and 
are not in need of extension. S. 1545 therefore focuses on 
extending expiring provisions in current law and updating 
oversight requirements. S. 1545 demonstrates continued 
congressional support for PEPFAR, helps guide the transition 
toward greater country ownership, and enhances effective 
oversight of this life-saving program.

Section-by-Section Summary

    Section 1 of S. 1545 provides the short title: the ``PEPFAR 
Stewardship and Oversight Act of 2013.''
    Section 2 extends for 5 years the requirement that the 
Inspectors General of the State Department, the U.S. Agency for 
International Development, and the Department of Health and 
Human Services develop annual joint oversight and audit plans.
    Section 3 extends for 5 years a reporting requirement that 
captures per-patient costs for PEPFAR-supported treatment and 
care and adds two new requirements for the study: (1) that the 
Office of the Global AIDS Coordinator (OGAC) must provide a 
plan for conducting a cost study in each partner country; and 
(2) that the study include a comprehensive expenditure analysis 
by partner country.
    Section 4 extends for 5 years the current 33 percent cap on 
U.S. contributions to the Global Fund. This cap is a ceiling on 
U.S. funding, with the specific amount being set each year 
through the appropriations process. It also extends for 5 years 
the requirement that funds be withheld from state sponsors of 
terrorism, currently prohibiting any funding to Cuba, Iran, 
Sudan, and Syria. Additionally, the legislation extends for 5 
years a requirement that 20 percent of the Global Fund 
contributions be withheld unless the Global Fund fulfills 
transparency requirements. New reporting requirements for the 
Global Fund contained in S. 1545 include providing new metrics 
that the Global Fund has started to collect, including 
performance and expenditure data on all of the Global Fund's 
principal and sub-recipients, in an open and machine readable 
format.
    The committee recognizes the Global Fund's work to 
implement more timely, detailed, and accurate reporting at both 
the principal recipient and sub-recipient level. The committee 
also recognizes that the collection of detailed data on the 
smallest sub-recipients might not represent an optimal 
allocation of staff resources to identify and manage risk 
across the entire portfolio. As such, the committee recommends 
a threshold for sub-recipient reporting only in countries 
receiving $10 million or more in the course of a Global Fund 
funding replenishment cycle. In countries receiving $10 million 
or greater during a funding replenishment cycle, the Global 
Fund should focus on sub-recipients receiving grants in the 
amount of $500,000 or greater, annually, or $1 million over a 
grant cycle, whichever is lower.
    Section 5 of the legislation requires the submission of a 
revised annual report regarding the PEPFAR program by striking 
the previous report required by 22 U.S.C. 2151b-2(f) and 
replacing it with new reporting requirements. Among other 
things, the revised report is required to include national and 
bilateral program targets. Subsection (f)(3)(B)(iii) requires 
the President to establish and subsequently measure progress 
toward reaching bilateral programmatic targets across 
prevention, treatment, and care. The measurement of progress 
must include data on the number of adults and children on HIV 
treatment, disaggregated by those directly supported by PEPFAR 
and those otherwise supported through PEPFAR.
    The committee recognizes that during the emergency phase of 
PEPFAR, the need for rapid scale-up of treatment and related 
services necessitated high levels of direct support. In this 
phase, calculating the number of individuals on HIV treatment 
that could be attributed specifically to PEPFAR interventions 
was straightforward. However, as PEPFAR continues the 
transition from an emergency program toward a program focused 
on sustainable outcomes, greater country ownership, and greater 
collaboration with multilateral and other funding sources, such 
attribution is more difficult. As a result, the committee has 
differentiated between individuals that are directly supported 
by PEPFAR and those that are otherwise supported through 
PEPFAR.
    The committee notes that while a definition of ``direct 
support'' currently exists, it is too broad for the level of 
detail the committee expects in the report. The legislation 
therefore requires the President, in subsection (f)(3)(O) of 
the revised report, to provide and disseminate a new, clear, 
operable definition of direct support that will resolve 
outstanding concerns about programmatic attribution and 
contribution. While the President is provided the necessary 
flexibility to define these terms, it is the committee's 
expectation that the definition of direct support will provide 
for the measurement of the number of adults and children for 
whom the U.S. government provides a majority of the cost of 
care and treatment. Care and treatment may include medicines, 
clinical and community-based health staff and training, 
laboratories, facilities, site-based quality control, clinic-
based information systems, and other essential site-based 
services.
    Subsection (f)(3)(G) of the revised report requires an 
assessment of progress towards achieving targets, including a 
report on supportive care. In subsection (f)(3)(G)(vii), the 
committee expects that such reporting will include a discussion 
of food and nutritional support provided to those affected by 
HIV/AIDS.
    Subsection (f)(3)(P) of the revised report requires a 
description, globally and by country, of specific efforts to 
address co-infections and co-morbidities of HIV/AIDS, including 
tuberculosis co-infections. The committee expects that this 
description will also include a discussion on AIDS-related 
cancers, including trends with respect to cervical cancer, and 
efforts to address such cancers.
    Subsection (f)(3)(K)(iii) of the revised report requires a 
description of measures taken to improve partner country 
capacity to achieve positive outcomes. The committee expects 
that this description will include a discussion of activities 
to ensure that the pace of the scale up of core interventions 
is sustained as appropriate, that service delivery within 
partner countries continues, and that coverage is expanded as 
partner countries pursue a sustainable response to the local 
epidemic. The committee further expects that the description of 
measures required by subsection (f)(3)(K)(iii) of the revised 
report will include a specific discussion of measures intended 
to increase participation and integration of civil society in 
HIV/AIDS planning and implementation.
    Subsection (f)(3)(H) of the revised report requires, among 
other things, a description of partner country and United 
States-funded HIV/AIDS prevention programs. The committee 
encourages the Office of the Global AIDS Coordinator to discuss 
all relevant methods, including, but not limited to, the role 
of door-to-door voluntary testing and provider initiated 
counseling and testing, in describing such prevention programs 
specifically with respect to the discussion of other 
programmatic activities to prevent the transmission of HIV.
    Since the beginning of PEPFAR, Congress has demonstrated a 
consistent commitment to addressing the unique needs of orphans 
and vulnerable children affected by the HIV/AIDS epidemic by 
requiring 10 percent of all program funds be specifically 
allocated to programs focused on orphans and vulnerable 
children. This requirement is continued in section 6 of this 
legislation. While recognizing the importance of continued 
support for orphans and vulnerable children in the context of 
the AIDS pandemic, the committee requests greater transparency 
in the use of these funds. The committee therefore expects the 
reporting requirement under subsection (f)(3)(K) to provide a 
description of the finances of PEPFAR-supported programs for 
orphans and vulnerable children, as well as a description of 
the goals, scope, and performance indicators used to measure 
the effectiveness of such programs.
    Subsection (f)(3)(F) of the revised report requires a 
description and explanation of changes in guidance or policies 
related to the implementation of programs supported under this 
section. It is the committee's expectation that the description 
required by subsection (f)(3)(F) of the revised report will 
include a discussion of any relevant World Health Organization 
guidance with respect to HIV/AIDS prevention, treatment, and 
care, as well as a description of how any policy changes or 
related matters may affect the program. This includes, but is 
not limited to, relevant past guidance, such as the June 2013 
World Health Organization-issued guidelines on the use of 
antiretroviral drugs for treating and preventing HIV infection.
    Section 6 extends for 5 years existing requirements that 
more than half of funding be used for treatment and care and 
that not less than 10 percent be used to support orphans and 
vulnerable children.

                           IV. Cost Estimate

    In accordance with Rule XXVI, paragraph 11(a) of the 
Standing Rules of the Senate, the committee notes that the cost 
estimate provided by the Congressional Budget Office was not 
available for inclusion in this report. The estimate will be 
printed in either a supplemental report or the Congressional 
Record when it is available.

                   V. Evaluation of Regulatory Impact

    In compliance with rule XXVI of the Standing Rules of the 
Senate, the committee finds that no significant regulatory 
impact will result from the enactment of S. 1545.

                      VI. Changes in Existing Law

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

     Section 101 of the United States Leadership Against HIV/AIDS, 
                 Tuberculosis, and Malaria Act of 2003

SEC. 101. DEVELOPMENT OF A COMPREHENSIVE, FIVE-YEAR, GLOBAL STRATEGY.

           *       *       *       *       *       *       *

    (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] coordinated annual plans for 
                oversight activity in each of the fiscal years 
                2009 through 2018, with regard to the programs 
                authorized under this Act and sections 104A, 
                104B, and 104C of the Foreign Assistance Act of 
                1961.
                  (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] 2010 through 2013 
                        plans._Each of [the last four plans] 
                        the plans for fiscal years 2010 through 
                        2013 developed under subparagraph (A) 
                        shall be completed not later than 30 
                        days before each of the fiscal years 
                        2010 through 2013, respectively.
                          (iii) 2014 plan.--The plan developed 
                        under subparagraph (A) for fiscal year 
                        2014 shall be completed not later than 
                        60 days after the date of the enactment 
                        of the PEPFAR Stewardship and Oversight 
                        Act of 2013.
                          [(iii)] (iv) 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 2015 through 2018, 
                        respectively.

           *       *       *       *       *       *       *

    (g) Annual Study.--
          (1) In general.--Not later than September 30, 2009, 
        and annually thereafter [through September 30, 2013] 
        through September 30, 2019, the Global AIDS Coordinator 
        shall complete a study of treatment providers that--
                  (A) represents a range of countries and 
                service environments;
                  (B) estimates the per-patient cost of 
                antiretroviral HIV/AIDS treatment and the care 
                of people with HIV/AIDS not receiving 
                antiretroviral treatment, including a 
                comparison of the costs for equivalent services 
                provided by programs not receiving assistance 
                under this Act;
                  (C) estimates per-patient costs across the 
                program and in specific categories of service 
                providers, including--
                          (i) urban and rural providers;
                          (ii) country-specific providers; and
                          (iii) other subcategories, as 
                        appropriate.
          (2) 2013 through 2018 studies.--The studies required 
        to be submitted by September 30, 2014, and annually 
        thereafter through September 30, 2018, shall include, 
        in addition to the elements set forth under paragraph 
        (1), the following elements:
                  (A) A plan for conducting cost studies of 
                United States assistance under section 104A of 
                the Foreign Assistance Act of 1961 (22 U.S.C. 
                2151b-2) in partner countries, taking into 
                account the goal for more systematic collection 
                of data, as well as the demands of such 
                analysis on available human and fiscal 
                resources.
                  (B) A comprehensive and harmonized 
                expenditure analysis by partner country, 
                including--
                          (i) an analysis of Global Fund and 
                        national partner spending and 
                        comparable data across United States, 
                        Global Fund, and national partner 
                        spending; or
                          (ii) where providing such comparable 
                        data is not currently practicable, an 
                        explanation of why it is not currently 
                        practicable, and when it will be 
                        practicable.
          [(2)] (3)  Publication.--Not later than 90 days after 
        the completion of each study under paragraph (1), the 
        Global AIDS Coordinator shall make the results of such 
        study available on a publicly accessible Web site.
          (4) Partner country defined.--In this subsection, the 
        term ``partner country'' means a country with a minimum 
        United States Government investment of HIV/AIDS 
        assistance of at least $5,000,000 in the prior fiscal 
        year.

     Section 202 of the United States Leadership Against HIV/AIDS, 
                 Tuberculosis, and Malaria Act of 2003

SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS 
                    AND MALARIA.

           *       *       *       *       *       *       *

    (d) United States Financial Participation.--

           *       *       *       *       *       *       *

          (4) Limitation.--
                  (A)(i) At any time during fiscal years 2009 
                through [2013] 2018, 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 International Monetary Fund 
                shall not be considered in determining 
                compliance with this paragraph.
                  (ii) If, at any time during any of the fiscal 
                years 2009 through [2013] 2018, 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. [The President 
                may waive the application of this clause with 
                respect to assistance for Sudan that is 
                overseen by the Southern Country Coordinating 
                Mechanism, including Southern Sudan, Southern 
                Kordofan, Blue Nile State, and Abyei, if the 
                President determines that the national interest 
                or humanitarian reasons justify such a waiver. 
                The President shall publish each waiver of this 
                clause in the Federal Register and, not later 
                than 15 days before the waiver takes effect, 
                shall consult with the committee on Foreign 
                Relations of the Senate and the committee on 
                Foreign Affairs of the House of Representatives 
                regarding the proposed waiver.]
                  (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) 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 fiscal years 2009 
                through [2013] 2018 that are not contributed to 
                fulfill a commitment made for a fiscal year 
                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 Fund 
                and shall remain available under the same terms 
                and conditions as funds appropriated [pursuant 
                to the authorization of appropriations under 
                section 401] to carry out section 104A of the 
                Foreign Assistance Act of 1961 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 fiscal years 2009 through 
                [2013] 2018, 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).

           *       *       *       *       *       *       *

          (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] 2018 shall be withheld from 
        obligation to the Global Fund until the Secretary of 
        State certifies to the appropriate congressional 
        committees that the Global Fund--

           *       *       *       *       *       *       *

                  (C) has adopted, and is implementing, a 
                policy to publish on a publicly available Web 
                site in an open, machine readable format--
                          (i) grant performance reviews;
                          (ii) all reports of the Inspector 
                        General of the Global Fund, in a manner 
                        that is consistent with the Policy for 
                        Disclosure of Reports of the Inspector 
                        General, approved at the 16th Meeting 
                        of the Board of the Global Fund;
                          (iii) decision points of the Board of 
                        the Global Fund;
                          (iv) reports from Board committees to 
                        the Board; and
                          [(v) a regular collection and 
                        analysis of performance data and 
                        funding of grants of the Global Fund, 
                        which shall cover all principal 
                        recipients and all subrecipients;]
                          (v) a regular collection, analysis, 
                        and reporting of performance data and 
                        funding of grants of the Global Fund, 
                        which covers all principal recipients 
                        and all subrecipients on the fiscal 
                        cycle of each grant, and includes the 
                        distribution of resources, by grant and 
                        principal recipient and subrecipient, 
                        for prevention, care, treatment, drugs, 
                        and commodities purchase, and other 
                        purposes as practicable;
                  (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) compiles regular, publicly 
                        published audits, in an open, machine 
                        readable format, of financial, 
                        programmatic, and reporting aspects of 
                        the Global Fund, its grantees, and 
                        LFAs;
                  (E) has established, and is reporting 
                publicly, in an open, machine readable format, 
                on, standard indicators for all program areas;
                  (F) has established a methodology to track 
                and is publicly 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;]
                          (ii) all principal recipients and 
                        subrecipients and the amount of funds 
                        disbursed to each principal recipient 
                        and subrecipient on the fiscal cycle of 
                        the grant;
                          (iii) expenditure data--
                                  (I) tracked by principal 
                                recipients and subrecipients by 
                                program area, where 
                                practicable, prevention, care, 
                                and treatment and reported in a 
                                format that allows comparison 
                                with other funding streams in 
                                each country; or
                                  (II) if such expenditure data 
                                is not available, outlay or 
                                disbursement data, and an 
                                explanation of progress made 
                                toward providing such 
                                expenditure data; and
                          (iv) high-quality grant performance 
                        evaluations measuring inputs, outputs, 
                        and outcomes, as appropriate, with the 
                        goal of achieving outcome reporting;
                  [(G) has established a policy on tariffs 
                imposed by national governments on all goods 
                and services financed by the Global Fund;]
                  (G) has published an annual report on a 
                publicly available Web site in an open, machine 
                readable format, that includes--
                          (i) a list of all countries imposing 
                        import duties and internal taxes on any 
                        goods or services financed by the 
                        Global Fund;
                          (ii) a description of the types of 
                        goods or services on which the import 
                        duties and internal taxes are levied;
                          (iii) the total cost of the import 
                        duties and internal taxes;
                          (iv) recovered import duties or 
                        internal taxes; and
                          (v) the status of country status-
                        agreements;

           Section 104A of the Foreign Assistance Act of 1961

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

           *       *       *       *       *       *       *

    [(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 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;
                  [(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;
                          [(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 health care 
                                delivery systems (including the 
                                training of health care 
                                workers, including doctors, 
                                nurses, midwives, pharmacists, 
                                laboratory technicians, and 
                                compensated community health 
                                workers, and the use of codes 
                                of conduct for ethical 
                                recruiting practices for health 
                                care workers);
                                  [(II) advancing safe working 
                                conditions for health care 
                                workers; and
                                  [(III) improving 
                                infrastructure to promote 
                                progress toward universal 
                                access to HIV/AIDS prevention, 
                                treatment, and care by 2013;
                          [(iii) 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;
                          [(iv) 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;
                          [(v) 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'';
                          [(vi) 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;
                          [(vii) 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);
                          [(viii) 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;
                          [(ix) 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 health 
                                care 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;
                          [(x) a description of--
                                  [(I) the specific strategies 
                                funded to ensure the reduction 
                                of HIV infection among 
                                injection drug users;
                                  [(II) the number of injection 
                                drug users, by country, reached 
                                by such strategies; and
                                  [(III) medication-assisted 
                                drug treatment for individuals 
                                with HIV or at risk of HIV;
                          [(xi) 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;
                          [(xii) building capacity to identify, 
                        investigate, and stop nosocomial 
                        transmission of infectious diseases, 
                        including HIV and tuberculosis; 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.]
    (f) Annual Report.--
          (1) In general.--Not later than February 15, 2014, 
        and annually thereafter, the President shall submit to 
        the Committee on Foreign Relations of the Senate and 
        the Committee on Foreign Affairs of the House of 
        Representatives a report in an open, machine readable 
        format, on the implementation of this section for the 
        prior fiscal year.
          (2) Report due in 2014.--The report due not later 
        than February 15, 2014, shall include the elements 
        required by law prior to the enactment of the PEPFAR 
        Stewardship and Oversight Act of 2013.
          (3) Report elements.--Each report submitted after 
        February 15, 2014, shall include the following:
                  (A) A description based on internationally 
                available data, and where practicable high-
                quality country-based data, of the total global 
                burden and need for HIV/AIDS prevention, 
                treatment, and care, including--
                          (i) estimates by partner country of 
                        the global burden and need; and
                          (ii) HIV incidence, prevalence, and 
                        AIDS deaths for the reporting period.
                  (B) Reporting on annual targets across 
                prevention, treatment, and care interventions 
                in partner countries, including--
                          (i) a description of how those 
                        targets are designed to--
                                  (I) ensure that the annual 
                                increase in new patients on 
                                antiretroviral treatment 
                                exceeds the number of annual 
                                new HIV infections;
                                  (II) reduce the number of new 
                                HIV infections below the number 
                                of deaths among persons 
                                infected with HIV; and
                                  (III) achieve an AIDS-free 
                                generation;
                          (ii) national targets across 
                        prevention, treatment, and care that 
                        are--
                                  (I) established by partner 
                                countries; or
                                  (II) where such national 
                                partner country-developed 
                                targets are unavailable, a 
                                description of progress towards 
                                developing national partner 
                                country targets; and
                          (iii) bilateral programmatic targets 
                        across prevention, treatment, and care, 
                        including--
                                  (I) the number of adults and 
                                children to be directly 
                                supported on HIV treatment 
                                under United States-funded 
                                programs;
                                  (II) the number of adults and 
                                children to be otherwise 
                                supported on HIV treatment 
                                under United States-funded 
                                programs; and
                                  (III) other programmatic 
                                targets for activities directly 
                                and otherwise supported by 
                                United States-funded programs.
                  (C) A description, by partner country, of 
                HIV/AIDS funding from all sources, including 
                funding levels from partner countries, other 
                donors, and the private sector, as practicable.
                  (D) A description of how United States-funded 
                programs, in conjunction with the Global Fund, 
                other donors, and partner countries, together 
                set targets, measure progress, and achieve 
                positive outcomes in partner countries.
                  (E) An annual assessment of outcome indicator 
                development, dissemination, and performance for 
                programs supported under this section, 
                including ongoing corrective actions to improve 
                reporting.
                  (F) A description and explanation of changes 
                in related guidance or policies related to 
                implementation of programs supported under this 
                section.
                  (G) An assessment and quantification of 
                progress over the reporting period toward 
                achieving the targets set forth in subparagraph 
                (B), including--
                          (i) the number, by partner country, 
                        of persons on HIV treatment, including 
                        specifically--
                                  (I) the number of adults and 
                                children on HIV treatment 
                                directly supported by United 
                                States-funded programs; and
                                  (II) the number of adults and 
                                children on HIV treatment 
                                otherwise supported by United 
                                States-funded programs;
                          (ii) HIV treatment coverage rates by 
                        partner country;
                          (iii) the net increase in persons on 
                        HIV treatment by partner country;
                          (iv) new infections of HIV by partner 
                        country;
                          (v) the number of HIV infections 
                        averted;
                          (vi) antiretroviral treatment program 
                        retention rates by partner country, 
                        including--
                                  (I) performance against 
                                annual targets for program 
                                retention; and
                                  (II) the retention rate of 
                                persons on HIV treatment 
                                directly supported by United 
                                States-funded programs; and
                          (vii) a description of supportive 
                        care.
                  (H) A description of partner country and 
                United States-funded HIV/AIDS prevention 
                programs and policies, including--
                          (i) an assessment by country of 
                        progress towards targets set forth in 
                        subparagraph (B), with a detailed 
                        description of the metrics used to 
                        assess--
                                  (I) programs to prevent 
                                mother to child transmission of 
                                HIV/AIDS, including coverage 
                                rates;
                                  (II) programs to provide or 
                                promote voluntary medical male 
                                circumcision, including 
                                coverage rates;
                                  (III) programs for behavior-
                                change; and
                                  (IV) other programmatic 
                                activities to prevent the 
                                transmission of HIV;
                          (ii) antiretroviral treatment as 
                        prevention; and
                          (iii) a description of any new 
                        preventative interventions or 
                        methodologies.
                  (I) A description of the goals, scope, and 
                measurement of program efforts aimed at women 
                and girls.
                  (J) A description of the goals, scope, and 
                measurement of program efforts aimed at 
                orphans, vulnerable children, and youth.
                  (K) A description of the indicators and 
                milestones used to assess effective, strategic, 
                and appropriately timed country ownership, 
                including--
                          (i) an explanation of the metrics 
                        used to determine whether the pace of 
                        any transition to such ownership is 
                        appropriate for that country, given 
                        that country's level of readiness for 
                        such transition;
                          (ii) an analysis of governmental and 
                        local nongovernmental capacity to 
                        sustain positive outcomes;
                          (iii) a description of measures taken 
                        to improve partner country capacity to 
                        sustain positive outcomes where needed; 
                        and
                          (iv) for countries undergoing a 
                        transition to greater country 
                        ownership, a description of strategies 
                        to assess and mitigate programmatic and 
                        financial risk and to ensure continued 
                        quality of care for essential services.
                  (L) A description, globally and by partner 
                country, of specific efforts to achieve and 
                incentivize greater programmatic and cost 
                effectiveness, including--
                          (i) progress toward establishing 
                        common economic metrics across 
                        prevention, care and treatment with 
                        partner counties and the Global Fund;
                          (ii) average costs, by country and by 
                        core intervention;
                          (iii) expenditure reporting in all 
                        program areas, supplemented with 
                        targeted analyses of the cost-
                        effectiveness of specific 
                        interventions; and
                          (iv) import duties and internal taxes 
                        imposed on program commodities and 
                        services, by country.
                  (M) A description of partnership framework 
                agreements with countries, and regions where 
                applicable, including--
                          (i) the objectives and structure of 
                        partnership framework agreements with 
                        countries, including--
                                  (I) how these agreements are 
                                aligned with national HIV/AIDS 
                                plans and public health 
                                strategies and commitments of 
                                such countries; and
                                  (II) how these agreements 
                                incorporate a role for civil 
                                society; and
                          (ii) a description of what has been 
                        learned in advancing partnership 
                        framework agreements with countries, 
                        and regions as applicable, in terms of 
                        improved coordination and 
                        collaboration, definition of clear 
                        roles and responsibilities of 
                        participants and signers, and 
                        implications for how to further 
                        strengthen these agreements with 
                        mutually accountable measures of 
                        progress.
                  (N) A description of efforts and activities 
                to engage new partners, including faith-based, 
                locally-based, and United States minority-
                serving institutions.
                  (O) A definition and description of the 
                differentiation between directly and otherwise 
                supported activities, including specific 
                efforts to clarify programmatic attribution and 
                contribution, as well as timelines for 
                dissemination and implementation.
                  (P) A description, globally and by country, 
                of specific efforts to address co-infections 
                and co-morbidities of HIV/AIDS, including--
                          (i) the number and percent of people 
                        in HIV care or treatment who started 
                        tuberculosis treatment; and
                          (ii) the number and percentage of 
                        eligible HIV positive patients starting 
                        isoniazid preventative therapy.
                  (Q) A description of efforts by partner 
                countries to train, employ, and retain health 
                care workers, including efforts to address 
                workforce shortages.
          (4) Partner country defined.--In this subsection, the 
        term ``partner country'' means a country with a minimum 
        United States Government investment of HIV/AIDS 
        assistance of at least $5,000,000 in the prior fiscal 
        year.

     Section 403 of the United States Leadership Against HIV/AIDS, 
                 Tuberculosis, and Malaria Act of 2003

SEC. 403. ALLOCATION OF FUNDS.

           *       *       *       *       *       *       *

    (b) Orphans and Vulnerable Children.--For fiscal years 2009 
through [2013] 2018, not less than 10 percent of the [amounts 
appropriated pursuant to the authorization of appropriations 
under section 401] amounts appropriated or otherwise made 
available to carry out the provisions of section 104A of the 
Foreign Assistance Act of 1961 (22 U.S.C. 2151b-2) for HIV/AIDS 
assistance for each such fiscal year shall be expended for 
assistance for orphans and 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.
    (c) Funding Allocation.--For each of the fiscal years 2009 
through [2013] 2018, more than half of the [amounts 
appropriated for bilateral global HIV/AIDS assistance pursuant 
to section 401] amounts appropriated or otherwise made 
available to carry out the provisions of section 104A of the 
Foreign Assistance Act of 1961 (22 U.S.C. 2151b-2) shall be 
expended for--
          (1) antiretroviral treatment for HIV/AIDS;
          (2) clinical monitoring of HIV-seropositive people 
        not in need of antiretroviral treatment;
          (3) care for associated opportunistic infections;
          (4) nutrition and food support for people living with 
        HIV/AIDS; and
          (5) other essential HIV/AIDS-related medical care for 
        people living with HIV/AIDS.

                                  
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