On November 13, 2007, the President signed the FY2008 Department of Defense Appropriations ( P.L. 110-116 ) into law, which included not less than $8 million for Department of Defense global HIV/AIDS activities. On December 26, 2007, the President signed the FY2008 Consolidated Appropriations into law ( P.L. 110-161 ), which includes the State/Foreign Operations and Labor/HHS appropriations. The act includes $6.3 billion for global HIV/AIDS, tuberculosis (TB), and malaria initiatives, of which $5.8 billion is appropriated to international HIV/AIDS initiatives, including $840.3 million for U.S. contributions to the Global Fund to Fight HIV/AIDS, TB, and Malaria. Congress exceeded the President's FY2008 request for global HIV/AIDS, TB, and malaria programs by $570.1 million (most of which was provided to the Global Fund) and by $4.7 billion for PEPFAR's entire five-year term. It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million people each year. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), at the end of 2007, an estimated 33.2 million people were living with HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the course of that year. More than two million of those living with HIV/AIDS at the end of 2007 were children and some 330,000 of those who died of AIDS that year were under 15 years old. Nearly 90% of all children infected with HIV reside in sub-Saharan Africa, which is home to 2.2 million of the estimated 2.5 million children living with HIV worldwide. On each day of 2007, some 1,000 children worldwide became newly infected with HIV, due in large part to little access to drugs that prevent the transmission of HIV from mother to child. An estimated 9% of pregnant women in low-and middle-income countries were offered services to prevent HIV transmission to their newborns. The World Health Organization (WHO) estimates that at the end of 2004, more than 14 million people were infected with TB, of whom almost 9 million were newly infected. More than 80% of those living with TB in 2004 were in southeast Asia and sub-Saharan Africa, with the greatest per capita rate found in Africa. According to WHO, each year there are about 300 million acute malaria cases, which cause more than one million deaths annually; in 2004, the disease killed about 2 million people. Health experts believe that between 85% and 90% of malaria deaths occur in Africa, mostly among children, killing an African child every 30 seconds. Appropriations for combating the global spread of HIV/AIDS have grown considerably since President Bush entered office. U.S. contributions to the Global Fund and the launching of two initiatives—the Prevention of Mother and Child Transmission Initiative and the President's Emergency Plan for AIDS Relief (PEPFAR)—have contributed to this growth. In FY2002, the President requested that Congress provide $500 million to fund a new initiative he called the International Mother and Child HIV Prevention Initiative. The Initiative sought to prevent the transmission of HIV from mothers to infants and to improve health care delivery in Africa and the Caribbean. Congress provided that up to $100 million (excluding rescissions) be made available to USAID for the initiative in FY2003. In FY2004, Congress provided $150 million (excluding rescissions) to CDC for PMTCT programs. Conferees also expressed an expectation that $150 million would be made available for the initiative from the newly established Global HIV/AIDS Initiative (GHAI; H.Rept. 108-401 ). Since the initiative expired in FY2004, Congress has included funds for PMTCT programs in the GHAI account. On January 28, 2003, during his State of the Union Address, President Bush proposed that the United States spend $15 billion over the next five fiscal years to combat HIV/AIDS through PEPFAR. The President proposed channeling $10 billion to prevention, treatment, and care services in the 15 Focus Countries through GHAI, $4 billion to existing bilateral HIV/AIDS, TB, and malaria programs and research conducted in more than 100 non-Focus Countries, and $1 billion to the Global Fund. In May 2003, Congress authorized sufficient funds to support the initiative through P.L. 108-25 , the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (the Leadership Act). Between FY2004 and FY2008, PEPFAR programs aim to support care for 10 million HIV-affected people, including children orphaned by AIDS; support the prevention of 7 million new HIV infections; and help 2 million people receive ARVs. Congress appropriates the bulk of PEPFAR funds to the GHAI account. The account was established to streamline funds for global HIV/AIDS, TB, and malaria programs to the 15 Focus Countries. The Office of the Global AIDS Coordinator (OGAC) at the U.S. Department of State transfers funds from GHAI to implementing agencies and departments. The funds that Congress appropriates directly to U.S. agencies and departments are utilized in the non-Focus Countries. U.S. agencies and departments might also allocate additional resources to international HIV/AIDS, TB, and malaria programs not funded through PEPFAR. In each fiscal year since PEPFAR was launched, appropriators have included a chart in the foreign operations appropriations conference reports that itemizes how global HIV/AIDS, TB, and malaria funds are authorized to be spent ( Table 1 ). Press accounts of U.S. global HIV/AIDS spending are usually derived from this chart, though it does not include all U.S. global HIV/AIDS, TB, and malaria support. In January 2002, the Global Fund was established in Geneva, Switzerland. The Fund provides grants to developing countries aimed at reducing the number of HIV, TB, and malaria infections, as well as the other illnesses and deaths that result from such infections. The Fund is an independent foundation led by a board of directors comprised of representatives from seven donor countries and seven developing countries. In an effort to include all major stakeholders, each of the following communities also has one representative on the board: developed country non-governmental organizations (NGOs), developing country NGOs, the business community, private foundations, and people living with HIV/AIDS, tuberculosis or malaria. The Fund projects that by 2007, the grants it has approved will have provided treatment for 1.8 million HIV-positive people, 5 million people infected with TB, and 145 million malaria patients; prevented the spread of HIV to 52 million people through voluntary HIV counseling and testing services; financed the purchase and distribution of 109 million insecticide-treated bed nets to prevent the spread of the malaria; and supported care for 1 million orphans. Although there appears to be strong support for the Global Fund, Congress has placed restrictions on U.S. contributions to the Fund for various reasons. In FY2006, due to concerns about the Fund's spending practices, Congress required that 20% of U.S. contributions to the Fund be withheld until the Secretary of State certified that the Fund had undertaken a number of steps to strengthen oversight and spending practices ( P.L. 109-102 ). The act allowed the Secretary to waive the requirement if she determined that a waiver was important to U.S. national interest. Similar language has been included in subsequent appropriations legislation. In FY2008, the President proposed that the United States contribute $300 million to the Global Fund through Labor/HHS Appropriations. Congress provided that amount through Labor/HHS Appropriations (excluding rescissions) and appropriated an additional $550 million through Foreign Operations Appropriations (excluding rescissions). After deducting rescissions, in FY2008, Congress provided a total of $840.3 million; since PEPFAR was launched in FY2004, appropriators provided about $3 billion, and nearly $3.8 billion since making the first appropriation in FY2001 ( Table 2 ). According to the Global Fund's website, the organization has approved proposals totaling $10 billion and disbursed about half of those funds. The funds have been used to support ARV treatment for an estimated 1.4 million people (about 75% of whom were in Africa), treatment for almost 3 million people infected with TB, and distribution of some 30 million insecticide-treated bed nets to prevent malaria transmission. In June 2005, President Bush launched the President's Malaria Initiative (PMI), a plan to increase support for U.S. international malaria programs by more than $1.2 billion between FY2006 and FY2010 in 15 countries. Since launching PMI, the Administration has requested that all support for bilateral malaria efforts be provided to the U.S. Agency for International Development (USAID) as the coordinating agency for the initiative. When the Administration shifted leadership for bilateral malaria programs to USAID in FY2005, it determined that OGAC would no longer include malaria spending in its annual reports to Congress and that budgetary requests for the disease would be made separately from HIV/AIDS and TB requests. For comparability, and because P.L. 108-25 considers efforts to combat malaria as a critical part of PEPFAR, Table 1 includes appropriations to malaria programs. In FY2006 and FY2007, appropriators provided $102 million and $248 million for bilateral malaria efforts, respectively. According to the PMI website, in FY2006, $30 million of the $99 million that USAID spent on malaria programs was allocated to PMI, and an estimated $135 million was spent on the initiative in FY2007. The Administration requested $387.5 million for malaria initiatives in FY2008, of which $300 million would be for PMI; Congress appropriated $347.2 million to USAID and $36.0 million to CDC for international malaria efforts. According to a December 2007 press release, through September 30, 2007, PEPFAR has supported the provision of anti-retroviral treatment for approximately 1.4 million people; prevention of mother-to-child HIV transmission services for women during more than 10 million pregnancies and an estimated 152,000 infant infections; care for nearly 6.7 million people, including more than 2.7 million orphans and vulnerable children; and counseling and testing services for over 30 million people. Lines 1 and 2 refer to USAID's bilateral HIV/AIDS and TB programs in the non-Focus Countries, which are funded through a number of accounts, including the Child Survival and Health Account (CSH), Economic Support Fund aid (ESF), Assistance for the former Soviet Union under the Freedom Support Act (FSA), Assistance for Eastern Europe and the Baltics (SEED), and food aid. Line 3 refers to funds provided to USAID from all accounts for its bilateral malaria programs, including the President's Malaria Initiative (see above). Line 4 refers to contributions to the Global Fund provided through USAID accounts. In FY2004, $87.8 million of the amount appropriated to the Global Fund was withheld per legislative provisions limiting U.S. Global Fund contributions to 33% of the amount contributed by all donors, as indicated in Line 5 . P.L. 108-447 , FY2005 Consolidated Appropriations, directed that these withheld funds be transferred to the Global Fund in FY2005, subject, like the remainder of the U.S. contribution, to the 33% proviso. Congress provides funds for PEPFAR's 15 Focus Countries to the State Department's Global HIV/AIDS Initiative (GHAI), as indicated in Line 6 . U.S. contributions to other global AIDS efforts, such as international microbicide research, the International AIDS Vaccine Initiative (IAVI), and the United Nations Joint Program on HIV/AIDS (UNAIDS), are also provided through GHAI. GHAI Funds transferred to the Global Fund are reflected in Line 7 . Line 8 refers to funds appropriated to the Foreign Military Financing (FMF) account for equipment purchases that support the DoD's global HIV/AIDS efforts. DoD's bilateral HIV/AIDS programs, referred to in Line 15 , offer HIV/AIDS prevention education, primarily to African armed forces. Line 10 refers to the Centers for Disease Control and Prevention's (CDC) Global AIDS Program (GAP). CDC spends additional funds on international HIV/AIDS, TB, and malaria activities that are not earmarked by Congress, though they are included in the table ( Lines 11 - Lines 13 ). Line 14 reflects grants provided by the National Institutes of Health (NIH) for international HIV/AIDS research, which focus primarily on the development of an AIDS vaccine. NIH also transfers funds to the Global Fund, as indicated on Line 15 . The Administration has not requested funds for the Department of Labor's Global AIDS in the Workplace Initiative since FY2002 ( Line 16 ). Congress funded the initiative, however, until FY2006. The Department received additional funds from GHAI in support of its HIV/AIDS programs. In FY2008, the Administration did not request funds to support DoD's bilateral HIV/AIDS prevention programs, as indicated in Line 18 . Congress provided $8.0 million, however, for the activities.

Summary: On January 28, 2003, during his State of the Union Address, President George Bush proposed that the United States spend $15 billion over five years to combat HIV/AIDS, tuberculosis (TB), and malaria through the President's Emergency Plan for AIDS Relief (PEPFAR). The President proposed that most of the spending on PEPFAR programs be concentrated in 15 countries. Of the $15 billion, the President suggested spending $9 billion on prevention, treatment, and care services in the 15 Focus Countries, where the Administration estimated 50% of all HIV-positive people lived. The President also proposed that $5 billion of the funds be spent on existing bilateral HIV/AIDS, TB, and malaria programs and research, and $1 billion of PEFPAR funds be reserved for U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Between FY2004 and FY2008, PEPFAR aims to have supported care for 10 million people affected by HIV/AIDS, including children orphaned by AIDS; prevented 7 million new HIV infections; and supported efforts to provide anti-retroviral medication (ARV) to 2 million HIV-infected people. From FY2004 through FY2008 Congress provided almost $20 billion to fighting the global spread of HIV/AIDS, TB, and malaria, some $5 billion more than the President proposed. The President's FY2008 budget request included about $5.8 billion for global HIV/AIDS, TB, and malaria efforts. The Administration proposed that the bulk of the funds, about $5.0 billion, be provided through Foreign Operations appropriations and that about $800 million be provided through Labor/HHS appropriations, of which $300 million would be reserved for a U.S. contribution to the Global Fund. Congress exceeded the President's request by some $560 million, providing $6.3 billion for global HIV/AIDS, TB, and malaria efforts, including some $840 million for a U.S. contribution to the Global Fund. This report reviews U.S. appropriations for treatment and prevention of the three diseases from FY2004 through FY2008. The report will not be updated; PEPFAR authorization expires in FY2008. Subsequent reports will analyze additional funding should the initiative be reauthorized.