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. 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. 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. 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. 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). 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. 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). 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. 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 ).