PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding
Released: 2009-01-29T00:00:00

Introduction

On May 30, 2007, President Bush announced that he would request $30 billion for the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR), which is the coordinated U.S. government effort to combat HIV/AIDS globally. The President estimated PEPFAR would support treatments for 2.5 million people infected with the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the prevention of more than 12 million new HIV infections, and care for more than 12 million HIV-affected people, including 5 million orphans and vulnerable children. In 2003, Congress authorized $15 billion for U.S. efforts to combat global HIV/AIDS, tuberculosis, and malaria from FY2004 through FY2008 with the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 ( P.L. 108-25 ) (Leadership Act).

On July 24, 2008, Congress authorized $48 billion for U.S. global efforts to fight HIV/AIDS, tuberculosis, and malaria and for U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) from FY2009 through FY2013 through H.R. 5501 , the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-Hyde Act). The Lantos-Hyde Act ( P.L. 110-293 ) was signed into law on July 30, 2008.

This report describes U.S. efforts to combat international HIV/AIDS through PEPFAR including an overview of its implementation structure, key program elements, and results. It details actual and requested funding for U.S. bilateral and multilateral efforts to fight HIV/AIDS, tuberculosis, and malaria globally through FY2009. The report discusses key policy debates surrounding international HIV/AIDS, malaria, and tuberculosis programs and funding as the 110 th Congress considered legislation to reauthorize PEPFAR programs. It describes the differences, similarities, and possible policy implementation implications of key proposals included in H.R. 5501 at two points during its consideration by the 110 th Congress: when it was passed by the House on April 2, 2008, and later when it was passed by the Senate on July 16, 2008. Finally, this report details key changes to programs and funding for U.S. international efforts to fight HIV/AIDS, tuberculosis, and malaria programs as directed by the 110 th Congress in the Lantos-Hyde Act as enacted. This report does not describe U.S. efforts to combat tuberculosis and malaria.

PEPFAR Background

On January 28, 2003, President Bush proposed the President's Emergency Plan for AIDS Relief (PEPFAR) in his State of the Union address, requesting $15 billion over five years to combat HIV/AIDS. Congress authorized $15 billion for U.S. efforts to combat global HIV/AIDS, tuberculosis (TB), and malaria from FY2004 through FY2008 with the Leadership Act ( P.L. 108-25 ), which was enacted on May 27, 2003.

Implementation Structure

OGAC and PEPFAR Countries

The Leadership Act created the Office of the Global AIDS Coordinator (OGAC) in the Department of State and outlined its role. OGAC directly approves all U.S. activities and funding related to combating HIV/AIDS in the 15 PEPFAR Focus Countries. In addition to the Focus Countries, OGAC has primary responsibility for the oversight and coordination of all U.S. government resources and international activities to combat HIV/AIDS. This role extends to ensuring program and policy coordination among the relevant executive branch agencies and non-governmental organizations (NGOs), including auditing, monitoring, and evaluating all such programs including activities conducted in non-Focus Countries.

In 2003, the 15 PEPFAR Focus Countries accounted for over 50% of all HIV-infected people in the world. The 15 Focus Countries are Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. OGAC estimates that from FY2004 through FY2008, 58% of PEPFAR funds will have been spent on the 15 Focus Countries. OGAC transfers funds to PEPFAR-participating agencies that administer HIV/AIDS programs in Focus Countries.

Participating U.S. Agencies

PEPFAR-participating agencies and departments, which receive funding transfers from OGAC, include the U.S. Agency for International Development (USAID); the Department of State (State); the Department of Health and Human Services (HHS) through the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Health Resources and Services Administration (HRSA), the Food and Drug Administration (FDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA); the Department of Labor (DOL); the Department of Commerce; the Peace Corps; and the Department of Defense (DOD). These agencies may allocate their own agency funds for global HIV/AIDS, tuberculosis, and malaria programs.

International Organizations and International Initiatives

The Leadership Act authorized funds to support U.S. contributions to some multilateral organizations and international research initiatives including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund), the United Nations Joint Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI).

Restrictions on Spending and Programs

Though Focus Countries receive the bulk of PEPFAR funding, individual Focus Countries may not necessarily receive more funds than non-Focus Countries: for example, India, which is not a Focus Country, receives more funding than Guyana, a Focus Country. OGAC determines annual funding allocations for each Focus Country based on past funding allocations and provides an initial budget estimate to U.S. staff in each PEPFAR country to help them formulate a Country Operational Plan (COP). A COP provides data that informs OGAC's final funding decision. OGAC uses the COP to evaluate country-based information on the extent of the HIV/AIDS epidemic, absorptive capacity for funding, effectiveness of PEPFAR efforts to date, and country team projections of need.

In the Leadership Act, Congress outlined both funding distribution guidelines and "spending directives" for HIV/AIDS assistance. Congress recommended that 20% of HIV/AIDS funds should be spent on prevention. It required that from FY2006 through FY2008 at least 33% of these prevention funds must be spent on abstinence-until-marriage programs. In addition, Congress directed that from FY2006 through FY2008 not less than 55% of HIV/AIDS funds must be spent on treatment, and of these, it recommended that 75% should support the purchase and distribution of antiretroviral (ARV) drugs, while the remaining 25% should be spent on related care for treatment patients. Congress also recommended that 15% of HIV/AIDS funds should be spent on palliative care of HIV-affected people. Finally, it required that from FY2006 through FY2008 the remaining 10% of HIV/AIDS funds must be spent on orphans and vulnerable children (OVC). It required that at least 50% of these OVC funds must be provided through non-profit NGOs, including faith-based organizations (FBOs), that implement programs on the community level.

Results

When President Bush proposed PEPFAR in 2003, he projected that the five-year initiative to combat HIV/AIDS globally would prevent 7 million new HIV infections, would provide antiretroviral treatment for 2 million people, and would support care for 10 million HIV-affected people.

As of September 30, 2008, OGAC reports that it has accomplished the following:

Prevention : supported HIV counseling and testing for nearly 57 million people; supported prevention of mother-to-child [HIV] transmission (PMTCT) services during nearly 16 million pregnancies; and prevented an estimated 240,000 infant infections. Treatment : supported antiretroviral treatment for more than 2.1 million people, including 130,100 children. Care : supported care for more than 10.1 million HIV-affected people, including more than 4 million orphans and vulnerable children (OVC).

U.S. Funding for Global HIV/AIDS, TB, Malaria, and the Global Fund

The Leadership Act authorized $15 billion to address HIV/AIDS, tuberculosis, and malaria globally and to provide U.S. contributions to the Global Fund from FY2004 through FY2008. OGAC calculates PEPFAR funding as the total of enacted funding for U.S. efforts to combat HIV/AIDS globally, U.S. efforts to combat tuberculosis internationally, and U.S. contributions to the Global Fund. Prior to FY2006, OGAC-reported PEPFAR funding also included U.S. efforts to combat malaria. Then in June 2005 President Bush introduced the President's Malaria Initiative (PMI) to expand U.S. government efforts to combat malaria globally. As a result, OGAC excluded malaria funding from PEPFAR calculations beginning in FY2006. Since that time, U.S. government spending on malaria has been reported separately. Since the Leadership Act authorization included malaria programs, the funding data in this report includes malaria and PMI funding. This report details funding separately for HIV/AIDS, TB, malaria, and U.S. contributions for the Global Fund.

FY2004-2008 Funding

From FY2004 through FY2008, U.S. funding for programs to fight the three diseases bilaterally and multilaterally was nearly $19.8 billion. Over these five years, funding for U.S. programs to combat global HIV/AIDS was $15.3 billion, of which $10.6 billion was spent in the 15 PEPFAR Focus Countries through the Global HIV/AIDS Initiative (GHAI). For the same period, funding for U.S. programs to combat TB was $535 million, while funding for U.S. programs to combat malaria was $915 million ( Table 1 ).

From FY2004 through FY2008, the United States contributed $3.0 billion to the Global Fund ( Table 2 ). OGAC reports that this amounts to 16% of all PEPFAR funds during that period.

FY2009 Request

The Administration's FY2009 budget request included $6 billion for U.S. international HIV/AIDS and tuberculosis programs. Of this $6 billion, $500 million was requested for a U.S. contribution to the Global Fund. The President also separately requested $385 million for the President's Malaria Initiative (PMI) for U.S. global malaria eradication efforts.

Key Reauthorization Proposals and Debates

On May 30, 2007, President Bush urged Congress to extend PEPFAR from FY2009 through FY2013 with a $30 billion authorization. The Administration estimated that $30 billion would support treatment for 2.5 million people, the prevention of more than 12 million new infections, and care for more than 12 million people, including 5 million orphans and vulnerable children.

The following section focuses on key proposed changes to U.S. programs that combat HIV/AIDS, tuberculosis, and malaria globally, as suggested by the April 2, 2008, version of the Lantos-Hyde Act ( H.R. 5501 ) that was passed by the House and the July 16, 2008, version of the Lantos-Hyde Act ( H.R. 5501 ) that was passed by the Senate. The Senate-passed version of H.R. 5501 was subsequently voted on and passed by the House on July 24, 2008, and enacted into law on July 30, 2008. This section highlights key proposed requirements and funding allocations included in either version of the bill and discusses the debate surrounding the proposals, including debates about possible policy implementation implications.

Funding Authorization Increase

H.R. 5501 as passed by the House proposed up to $50 billion for U.S. international efforts to combat HIV/AIDS, tuberculosis, and malaria during the reauthorization period of FY2009 through FY2013. It would have authorized $10 billion for each of the five years. The Senate version proposed $48 billion in total over the same period for these activities. Both versions also proposed authorizing higher funding levels for U.S. efforts to combat tuberculosis and malaria and for U.S. contributions to the Global Fund ( Table 3 ).

The Senate version of H.R. 5501 also proposed authorizing $2 billion for an emergency fund for Indian health and safety from FY2008 through FY2013. The Senate adopted S.Amdt. 5076 to S. 2731 , the basis for the substitute amendment to H.R. 5501 , and S.Amdt. 5084 , which amended S.Amdt. 5076 . These amendments added language that requires an emergency plan to address the law enforcement, water, and health care needs of Indian tribes and directs the expenditure of the funds for particular purposes.

Critics of the $50 billion and $48 billion authorization levels argued that it would be fiscally irresponsible to spend such levels in light of U.S. military operations in Iraq and Afghanistan, a near economic recession in the United States, and questions about the absorptive capacity of recipient countries. Some analysts suggested that increased disease-specific funding in the foreign operations appropriations would drain available funding from other aid priorities in developing countries, such as agriculture assistance and private sector growth. Others opposed increased funding because they did not want to expand current PEPFAR activities to support additional Focus Countries and to fund activities not directly related to HIV/AIDS. Critics of high spending levels were concerned about proposals to increase the number of Focus Countries and to extend PEPFAR funds to support health care infrastructure as well as to enhance nutrition and feeding programs. For example, Senators who placed a hold on H.R. 5501 and S. 2731 had stated that the bills would "transform a targeted and accountable $15 billion dollar AIDS program into an unaccountable, unspecified $50 billion development program."

Proponents of the authorization level argued that access to HIV/AIDS prevention, treatment, and care for all would require greater resources. As a result, debate among bill advocates focused on where the dollars should be spent and what priorities the increased funding should support. Some urged Congress to consider further definition of tuberculosis authorities and targets, improved coordination of tuberculosis activities with HIV/AIDS activities in areas of co-infection, and strengthened reporting requirements for tuberculosis. Backers of the increased authorization argued that the next stage in fighting AIDS, tuberculosis, and malaria must occur alongside the strengthening of health systems. They argued that these activities must be integrated with related development efforts in order to ensure the sustainability of efforts to fight the three diseases.

Some opponents used the Congressional Budget Office's (CBO) cost estimates to justify a lower authorization funding level. CBO estimated that implementing either H.R. 5501 or S. 2731 , which was the bill from which language for the Senate-passed version of H.R. 5501 was drawn, would cost $35 billion from FY2009 through FY2013 and that most of the additional amounts of authorized funding would be spent by FY2018. Some argued that the CBO cost estimates assumed that outlays will follow historical spending patterns for existing programs and did not reflect the proposed increases in authorization levels for tuberculosis and malaria spending and for the U.S. contribution to the Global Fund.

U.S. Global Malaria Coordinator

Both bills would have established a Coordinator of United States Government Activities to Combat Malaria Globally (U.S. Global Malaria Coordinator) at USAID. The U.S. Global Malaria Coordinator would oversee and coordinate all U.S. resources for international activities related to combating malaria. The bills also would have authorized the U.S. Global Malaria Coordinator to provide financial assistance to multilateral efforts such as the Roll Back Malaria Partnership (RBM). The proposed authorization of a U.S. Global Malaria Coordinator was related to the creation of the President's Malaria Initiative (PMI), which President Bush announced in June 2005 and has been operational since FY2006. PMI is located at USAID.

Some observers opposed a disease-specific approach. They argued that it ignored the interconnected nature of health care challenges, and in resource-poor countries, it would create competition for limited human capacity such as doctors, public health specialists, and U.S. program managers. Supporters believed PMI would focus attention on malaria, which is a major killer in sub-Saharan Africa and some parts of Asia.

Others contended that directed efforts on specific diseases should occur simultaneously with efforts to build health capacity and infrastructure. While they applauded the initial emphasis on HIV/AIDS, which helped to build health system capacity in resource-poor settings, observers contended that the next stage of disease response under PEPFAR should integrate efforts to combat HIV/AIDS with the provision of basic healthcare and the prevention of childhood illness.

Some urged Congress to consider questions related to the establishment of PMI, including how PMI should coordinate its activities with PEPFAR; the further definition of authorities over the three diseases in the Leadership Act; the possibility of competing priorities between PMI and PEPFAR, especially where they operate in the same Focus Countries; and the implications of different initiative timetables for strategic planning, funding authorizations, and implementation.

List of Focus Countries Expansion

On February 6, 2007, Representative Luis Fortuño introduced H.R. 848 , a bill to amend the State Department Basic Authorities Act of 1956 to authorize assistance to combat HIV/AIDS in certain countries in the Caribbean. The bill would add Antigua and Barbuda, the Bahamas, Barbados, Belize, Dominica, Grenada, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Saint Lucia, Suriname, Trinidad and Tobago, and the Dominican Republic to the list of Focus Countries. When introduced, H.R. 5501 proposed adding Vietnam as a Focus Country as well as those countries listed in H.R. 848 . Representative Betty McCollum proposed adding Malawi, Swaziland and Lesotho to the list of Focus Countries in H.R. 5501 through H.Amdt. 975 , which was adopted. While the House-passed version of H.R. 5501 would have added these additional Focus Countries, the Senate version proposed adding only Vietnam as a Focus Country. Vietnam has been a Focus Country in practice since 2004 at the direction of President Bush; this language would have updated the list of 14 Focus Countries that was included in the Leadership Act. The new language in the Senate-passed version also specified that in designating additional Focus Countries priority shall be given to those countries in which there is a high prevalence of HIV or risk of significantly increasing incidence of HIV within the general population and inadequate financial means within the country.

Some observers questioned why the above-named countries were selected, particularly since OGAC did not put forth these countries for consideration. Proponents of the addition of these new Focus Countries argued that the designation would direct more HIV/AIDS funding to these areas. Debate about the Focus Countries list also centered on how authorized funds in excess of the President's $30 billion PEPFAR reauthorization proposal would be distributed across PEPFAR countries. It was not clear whether the proposed, newly-designated Focus Countries would have received more support than they did previously or whether they would have been funded at higher levels than non-Focus Countries for HIV/AIDS activities. Some would have liked the final reauthorization bill to clarify this issue.

Opponents of the proposed list argued that incidence rates—the rates of new infections—have been growing in East Asia and Oceania, while incidence rates appeared to have stabilized in the Caribbean. They also argued that prevalence rates—the percentages of given populations that are infected with HIV/AIDS—have been growing in Eastern Europe and Central Asia, while prevalence rates in the Caribbean appeared to have stabilized and in some countries have even declined. As new infections worldwide continued to outpace the numbers of infected persons placed on treatment, others asserted that a more complex analysis of need should be used in naming Focus Countries. Still others argued that Focus Countries should no longer be used to apportion funding and that distribution of funds should be based on country needs and recipient countries' access to other funding sources for HIV/AIDS programs.

Compacts with Recipient Countries

Some observers expressed concern about the long-term commitment that PEPFAR may require, particularly in the Focus Countries. As an alternative to adding Focus Countries, some suggested using compacts between the U.S. government and PEPFAR-recipient governments to clearly outline the scope and terms of U.S. involvement in AIDS prevention, treatment and care and to elicit recipient government involvement, ownership, and investment. Supporters asserted that compacts may have been helpful in outlining expectations for broader development efforts and investments that have been shown to have a significant impact on health. Some compacts, for example, might have included an agreement that aid recipient countries would reform property laws and inheritance laws. Such reforms have been shown to reduce the vulnerability of widows and orphans to HIV infection by providing them with greater financial security. The Senate-passed version of H.R. 5501 supported this idea, stating that compacts and framework agreements were "one mechanism to promote the transition from an emergency to a public health and development approach to HIV/AIDS" and could be "tailored to local circumstances to promote host government commitment to deeper integration of HIV/AIDS services into health systems, contribute to the health systems overall, and enhance sustainability." The language required that cost-sharing assurances from PEPFAR-recipient governments and transition strategies be included in compacts. The House-passed version of H.R. 5501 did not include similar language.

Role of Spending Directives

H.R. 5501 as passed by the House maintained funding distribution guidelines and spending directives of 20% for HIV prevention activities, 15% for HIV/AIDS care activities, and 10% for orphans and vulnerable children (OVC) activities, but it did not include the spending directive for HIV/AIDS treatment. The Senate-passed version maintained the spending directive for OVC and modified the spending directives for treatment and care by requiring that over half of bilateral HIV/AIDS assistance be spent on treatment, care, and nutritional and food support for HIV/AIDS-infected people. It did not include the funding distribution guidelines and spending directives for HIV/AIDS prevention. Both versions required balanced funding for HIV prevention activities, stating that a report to Congress must be provided to justify any decision to spend less than 50% of prevention funds on behavioral change programs, including abstinence and be faithful activities, in any PEPFAR recipient country with a generalized epidemic.

There was considerable debate about the effectiveness of congressional spending directives. Some observed that the spending directives limited Focus Country teams' ability to tailor budgets to local HIV transmission patterns. Critics contended that the spending directives also complicated efforts to address the specific nature of the HIV/AIDS epidemic in each country. HIV/AIDS rates among the Focus Countries ranged from 1% to over 33%. The current and proposed Focus Countries had epidemics that varied in nature and prevalance: some epidemics were concentrated among drug users or prostitutes while others were spread throughout the population. Some argued that Congress might consider eliminating some or all prevention, treatment, and care spending directives to promote operational planning that was responsive to the nature of the epidemic in each country and reflected the cost of implementation in that area. The Government Accountability Office (GAO) found that the spending restrictions did not account for the costs of particular HIV/AIDS activities that may vary from country to country or for changes in costs over time.

Some encouraged Congress to maintain its spending directives, particularly those related to orphans and vulnerable children (OVC). Supporters cited a GAO report that stated that without the spending directive, programs for OVC might not have been protected. Others stressed the importance of the spending directive that requires at least 55% of HIV/AIDS funds be spent on HIV/AIDS treatment, to maintaining support for the purchase and distribution of antiretroviral drugs and related care for those receiving treatment. Senator Tom Coburn introduced S. 2749 , the Save Lives First Act of 2008, on March 12, 2008, which maintains protections for AIDS treatment funding. Senator Coburn also signed a letter that requested a hold on H.R. 5501 and S. 2731 , noting the removal of the treatment spending directive. Congressional Quarterly subsequently reported that, after negotiating for changes to S. 2731 —which was the basis for the Senate-passed version of H.R. 5501 , Senator Coburn was "satisfied with language that would require more than half the money go to treatment, including antiretroviral drugs." Senator Coburn subsequently withdrew his objection to a motion to proceed to S. 2731 .

Program Objectives

Program objectives are goals that establish the number of people that U.S. HIV/AIDS activities, such as prevention, treatment, and care, will reach within a specified period. In 2003, for example, the PEPFAR five-year global program objective for treatment was to provide antiretroviral treatment for 2 million people. Some suggested that one alternative to spending directives was to allow U.S. staff in PEPFAR Focus Countries to set annual program objectives for prevention, treatment, and care that, in turn, would be added up to become the five-year country prevention, treatment, and care objectives. These then would have been totaled across countries to calculate the U.S. global program objectives for these program areas. At the time of consideration of H.R. 5501 , OGAC determined five-year country prevention, treatment, and care goals for the 15 Focus Countries, and then U.S. staff in PEPFAR Focus Countries set annual program objectives with the goal of reaching five-year country goals but with consideration for the challenges of the country's HIV/AIDS epidemic. OGAC then calculated global program objectives by adding up the five-year country targets.

Some supporters of program targets being determined entirely by U.S. staff in PEPFAR Focus Countries contended that country teams have the greatest awareness of each country's needs and should establish prevention, treatment, and care targets. However, some PEPFAR country team members expressed concern about difficulties country teams might face in reaching a consensus about such targets. Critics of program targets being determined this way asserted that Congress could specify global targets as a way of guiding policy implementation and priorities without hampering the ability of country-based teams to respond flexibly to in-country realities and to coordinate with national health plans. They pointed to language in both versions of H.R. 5501 as examples: both bills proposed establishing a target for prevention of mother to child [HIV] transmission (PMTCT) activities that at least 80% of pregnant women would be reached in affected countries by 2013. The Senate version also proposed setting a target that the proportion of children receiving care and treatment would be proportionate to their numbers within the population of HIV-infected individuals in each country by 2013, while the House-passed version of H.R. 5501 proposed setting a target requiring that by 2013 up to 15% of those receiving treatment and care must be children.

Balance Between Prevention, Treatment, and Care

Debate about spending directives and program targets was closely related to debate about how to prioritize or balance HIV/AIDS prevention, treatment, and care activities. Some experts maintained that prevention should remain a focus of global efforts, because there is no cure for AIDS at this time and preventing new infections is the only way to stop the epidemic in the long term. In 2001 the U.N. General Assembly adopted the Declaration of Commitment on HIV/AIDS, which stated that "prevention must be the mainstay of our response." Some organizations, such as the Bill and Melinda Gates Foundation and the Global AIDS Prevention Working Group, focused their efforts on strategies and prevention research in an effort to "prevent the HIV epidemic from becoming generalized in countries with emerging epidemics" and to prevent millions of new infections.

On the other hand, some contended that focusing on prevention and neglecting treatment and care would ignore the economic and social impacts of the disease on those already infected, on the children and families of infected persons, and on countries with high prevalence rates. Some asserted that treatment and care were investments in hope and stability, preventing children from being orphaned and people from suffering the ravages of the disease when treatment to prolong life and improve its quality is available. Some argued that treatment costs were dropping very rapidly for not only first-line treatment regimens but also second-line antiretroviral therapies, a trend that was expected to continue as treatment expanded to cover more infected people in low and middle income countries and as more international donors negotiated for lower prices. Others maintained that combating HIV/AIDS required a combination of prevention, treatment, and care rather than a choice between these strategies.

HIV/AIDS Activities and Family Planning

H.R. 5501 as passed by the House included language that addressed U.S. HIV/AIDS activities' links and referral to family planning and maternal health programs. Section 101(a)(4) of H.R. 5501 proposed amending Section 101 of P.L. 108-25 , the Leadership Act. It stated that a comprehensive five-year global strategy to combat HIV/AIDS, tuberculosis, and malaria shall:

include specific plans for linkage to, and referral systems for non-governmental organizations that implement multisectoral approaches, including faith-based and community-based organizations, for ... access to HIV/AIDS education and testing in family planning and maternal health programs supported by the United States Government.

The Senate-passed version of H.R. 5501 did not include family planning program language.

Opponents of the language in the House version of H.R. 5501 argued that the language was ambiguous and might have applied the Mexico City policy to programs that receive PEPFAR funding. The Mexico City policy denies U.S. funds to foreign non-governmental organizations (NGOs) that perform or promote abortion as a method of family planning—even if the activities are undertaken with non-U.S. funds. Others opposed the language because they did not believe that it sufficiently supported the integration of family planning services in U.S.-supported HIV prevention programs. Proponents of the family planning program language in the House version of H.R. 5501 maintained that it would limit PEPFAR funding for family planning groups based on their compliance with the Mexico City policy. Other groups reserved endorsement or opposition until such as time as Congress might further clarify the language. Some expressed concern, however, that the family planning language might contradict their beliefs and principles.

Health Systems and the Single Disease Approach

Section 501 of the House version of H.R. 5501 proposed the development of five-year health workforce strategies by countries that receive assistance under the reauthorization. It directed the Global AIDS Coordinator and the Secretary of the Treasury to work to reform International Monetary Fund (IMF) policies that result in limitations on national and donor investments in health. It also directed the Global AIDS Coordinator to work with relevant stakeholders to develop effective public sector procurement and supply chain management systems for supplies and drugs in countries receiving assistance under the reauthorization. The Senate-passed version of H.R. 5501 included similar language through the use of compacts and actions required of the Administrator of USAID.

H.R. 5501 as passed by the House also would have required OGAC and USAID to create and implement a plan to combat HIV/AIDS by strengthening health policies and health systems of PEPFAR countries as part of USAID's Health Systems 20/20 project. The plan, in part, would have aimed to encourage post-secondary institutions in host countries, especially in Africa, to develop human and institutional capacity to support the health care system in those countries. This included collaboration with U.S. post-secondary educational institutions including historically black colleges and universities. The Senate-passed version included similar language.

The Senate version of H.R. 5501 also proposed requiring the U.S. strategy to combat global AIDS to "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." This language required greater strategic planning across U.S. global health and development programs to coordinate efforts across program areas.

Some health experts were concerned about the single disease approach to global health and how it focused limited resources in high burden countries on one disease while, they contended, the overall health infrastructure and workforces in resource-poor countries minimally improved. Some also were concerned about the possible long term implications of the increased funding levels if the funds were spent on treatment and care of individuals who are infected with AIDS. One study pointed out that treatment of infected individuals is a lifelong commitment and that treatment itself prolongs that length of time; it estimated that if scale-up of treatment continued at the historical rate since FY2004 and drug prices and treatment costs remained the same, maintenance of treatment funding levels would necessitate either a 20% increase in total U.S. overseas development assistance by FY2016 or a reallocation of 20% of the current overseas development assistance budget of $23 billion to AIDS treatment funding alone. It argued this might raise questions about how funding for other global health programs and development efforts might be adversely affected.

Supporters of language that addressed issues of coordination of U.S. global health and development programs with disease-specific initiatives like PEPFAR and PMI argued that the more comprehensive development of health infrastructure and training of health workforces in these areas would increase the effectiveness of PEPFAR and other single-disease programs and decrease the need for disease-specific efforts in the future by building local capacity to address disease and basic health. Critics argued that such investment was outside the scope of PEPFAR and would distract from the program's focus on HIV/AIDS.

HIV/AIDS Activities and Nutrition Programs

Both versions of H.R. 5501 encouraged the integration of HIV/AIDS activities with nutrition programs through linkages and referrals to ensure that treated individuals receive the needed daily caloric intake to support effective treatment. Where such linkages and referrals were not possible, the Senate-passed version of H.R. 5501 proposed establishing additional services to provide nutritional support directly, and it also encouraged support for programs that address the intersections between food insecurity and health problems like HIV/AIDS. The House version of H.R. 5501 included similar language that authorized the direct provision of food and nutritional support to HIV/AIDS-infected individuals receiving antiretroviral treatment through PEPFAR where referrals were not possible. Both bills encouraged providing food and nutritional support for children affected by HIV/AIDS.

Language in both versions of H.R. 5501 addressing health system infrastructure and nutrition did not differ greatly from language included in the Leadership Act. The new language in both versions went into greater detail about the nature of the infrastructure and nutrition challenges in certain regions. Both encouraged greater integration of U.S. HIV/AIDS efforts with broader pre-existing and parallel efforts by U.S. agencies and others, such as non-governmental organizations (NGOs), and promoted linking affected individuals through referrals with such services. Programs that might have been coordinated with or linked to include those that strengthen health care infrastructure, nutrition programs, safe drinking programs, income security programs, and programs that offer technical assistance in health care capacity building and public finance management.

Immigration and Nationality Act Amendment

H.R. 5501 as passed by the Senate proposed eliminating the language in the Immigration and Nationality Act (INA) that statutorily bars foreign nationals with HIV/AIDS from entering the United States. The House-passed version of H.R. 5501 did not include similar language.

Supporters of the amendment argued that maintaining the restrictions on entry into the United States of AIDS-infected people was "discriminatory and unnecessary." They also argued that major international conferences on health and AIDS should not be held in countries that have laws restricting the entry of people living with AIDS. Opponents to the amendment contended that the amendment would add too many costs by increasing U.S. spending on health programs for HIV/AIDS-infected people. Others disputed this would be a significant amount.

Additional Oversight Activities

The Senate version of H.R. 5501 proposed requiring additional reporting, including a report by the Comptroller General that would discuss the coordination of U.S. global AIDS efforts and the impact of global HIV/AIDS funding and programs on other U.S. global health programming. It also required the dissemination of an annual report by OGAC on best practices that might be replicated or adapted by other AIDS programs. In addition, it provided for the Inspectors General of the Department of State, the Broadcasting Board of Governors (BBG), HHS, and USAID to jointly develop five coordinated annual plans for oversight activity in each of the fiscal years 2009 through 2013. The House version of H.R. 5501 did not include similar language.

Taxation of Assistance Funds by Foreign Governments Prohibited

H.R. 5501 as passed by the House prohibited funds appropriated under the legislation from being made available to a foreign country unless the agreement provided that such assistance funds were exempt from taxation or otherwise reimbursed by the foreign government. The Senate-passed version of S. 2731 did not include similar language.

Prevention of Mother to Child HIV Transmission (PMTCT) Panel

H.R. 5501 as passed by the Senate directed the Global AIDS Coordinator to establish an advisory panel of experts on prevention of mother to child HIV transmission (PMTCT) that would be known as the PMTCT Panel. The panel would review PMTCT efforts and make recommendations to OGAC and Congress on how to scale-up PMTCT services to ensure that, by 2013, such programs would provide access to counseling, testing, and treatment for at least 80% of pregnant women in those countries most affected by HIV/AIDS in which the United States has HIV/AIDS programs. The House version of H.R. 5501 did not include similar language.

Conscience Clause Expansion

Both versions of H.R. 5501 expanded "conscience clause" language included in the Leadership Act. The conscience clause in the Leadership Act stated that organizations that receive funding to prevent, treat, or monitor HIV/AIDS shall not be required, as a condition of receiving the assistance, to endorse or utilize a multisectoral approach to combating HIV/AIDS, or to endorse, utilize, or participate in a prevention method or treatment program to which the organization has a religious or moral objection. The new language in each version of H.R. 5501 referred to any HIV/AIDS program or activity to which an organization may have a religious or moral objection, whereas language in the Leadership Act referred only to any HIV/AIDS prevention method or treatment program to which the organization has a religious or moral objection. It further stated that organizations who opt-out of the above activities for religious or moral reasons shall not be discriminated against in the solicitation or issuance of grants, contracts, or cooperative agreements.

Key Reauthorization Changes to Programs and Funding

On July 24, 2008, the House passed the Senate version of H.R. 5501 , the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (Lantos-Hyde Act). The Lantos-Hyde Act ( P.L. 110-293 ) was enacted on July 30, 2008. The Lantos-Hyde Act authorizes $48 billion from FY2009 through FY2013 for U.S. efforts to fight HIV/AIDS, TB, and malaria globally ( Table 4 ) . It also authorizes $2 billion for an emergency fund for Indian health and safety from FY2008 through FY2013, requiring an emergency plan to address the law enforcement, water, and health care needs of Indian tribes and directing the expenditure of the funds for particular purposes.

Some experts observe that if Congress fully appropriated the authorized amount for TB and malaria ($9 billion total) and maintained the FY2004-FY2008 funding level for the Global Fund ($3 billion), then the remaining authorization for HIV/AIDS activities would be $36 billion from FY2009 through FY2013. Others note that the Lantos-Hyde Act included a number of provisions permitting "such sums as necessary" to be expended on several programs, including for U.S. contributions to the Global Fund. They say these provisions would allow for greater funding than the stated authorization level if Congress chose to fully appropriate the authorized amounts.

The Lantos-Hyde Act also directs a number of key changes to U.S. global HIV/AIDS, tuberculosis, and malaria programs ( Table 5 ) . The first column of the table corresponds to the key reauthorization proposals and debates discussed in the previous section of this report, which discussed possible policy implementation implications. The second column of the table describes changes directed by the 110 th Congress through the Lantos-Hyde Act.