In May 2001, President Bush made the founding pledge of $200 million to a new,yet-to-be-named global fund to fight AIDS at a White House Rose Garden ceremony attended byU.N. Secretary General Kofi Annan and Nigeria's President Olusegun Obasanjo. (7) U.S. officials played aprominent role in the subsequent negotiations on creating the Global Fund, and the new organizationbegan operations in January 2002, with its mission expanded to include tuberculosis and malaria. The Global Fund is an innovative organization in many ways. The Fund's board includesrepresentatives of both donor and recipient governments, NGOs, the private sector, and communitiesaffected by the three diseases. UNAIDS, the World Health Organization (WHO), and the WorldBank also participate. The Fund's Secretariat in Geneva is relatively small, with about 135employees. This is possible because the Global Fund is not an implementing agency, but rather a"financial instrument" designed to mobilize new resources for fighting disease and to manage anddisburse those resources. (8) The CCMs in the recipient countries bring together the interested parties or "stakeholders" to agreeon national priorities and to develop and submit coordinated applications to the Fund. CCMsinclude representatives of government, NGOs, the private sector, multilateral and bilateral aidagencies operating in the country, academic institutions, and people living with the diseases. Theapplications identify one or more Principal Recipients, such as the national health ministry or oneor more NGOs, which are legally responsible for grant implementation. Applications are reviewedby a Technical Review Panel of independent experts, and if a grant is made, the Fund contracts aLocal Fund Agent, typically a large accounting firm, to oversee its implementation. The GlobalFund's grant-making takes place in "Rounds," which are announced when the Fund estimates thatit has funds available to cover the first two years of a large number of new grants. The two-yearrequirement, known as the Comprehensive Funding Policy, is intended to assure that the projectsbeing funded, including treatment projects, are not interrupted for lack of money. President George W. Bush announced the launching of PEPFAR in his January 2003 Stateof the Union Address. The United States had been implementing bilateral international AIDSprojects through the U.S. Agency for International Development (USAID) since the mid-1980s. TheClinton Administration's 1999 LIFE (Leadership and Investment in Fighting an Epidemic) initiativebrought other agencies, particularly the Centers for Disease Control and Prevention of theDepartment of Health and Human Services, into the effort as well. PEPFAR, which was authorizedin May 2003 by P.L. 108-25 (see above), brought these efforts into a single program headed by aGlobal AIDS Coordinator carrying the rank of Ambassador and based at the Department of State. Randall Tobias, former Chairman, President, and CEO of Eli Lilly, the pharmaceutical corporation,was named to the post by President Bush in July 2003 and confirmed in October. The PEPFAR initiative promised substantial new resources for fighting AIDS, including $9billion over five years to be committed in 14 (later expanded to 15) of the most afflicted countriesof the world. (9) This newfunding is being channeled through the Global HIV/AIDS Initiative (GHAI) directed by the Officeof the Global AIDS Coordinator (OGAC). PEPFAR also promised $5 billion over five years forongoing bilateral AIDS programs in 105 other countries, (10) as well as $1 billion in contributions to the Global Fund. Officials said that overall, PEPFAR represented $10 billion in "new money," -- that is, $10 billionin additional funds beyond spending that would have occurred if existing programs had simply beencontinued at then-current spending levels. AIDS activists and others have been impatient with the pace at which PEPFAR and theGlobal Fund have been meeting the difficult challenge of scaling up their efforts to combat the globalAIDS pandemic. (11) However, both are already claiming considerable success. PEPFAR aims at supporting treatmentfor 2 million HIV-infected people by 2008, preventing 7 million new HIV infections, and"supporting care for 10 million people infected and affected by HIV/AIDS, including orphans andvulnerable children." (12) The Office of the Global AIDS Coordinator reports that at the end of March 2005, the PEPFARGlobal HIV/AIDS Initiative was supporting antiretroviral therapy for more than 235,000 AIDSpatients in the focus countries. (13) Through September 2004, 1.7 million were receiving care,including 630,000 Orphans and Vulnerable Children. (14) OGAC estimates that in FY2004 it reached 120 million people in the focus countries withprevention messages focusing on abstinence and being faithful. In addition, 96 million condomswere purchased and shipped to focus countries for programs directed toward people who engage inhigh risk behavior. (15) The Global Fund reports that the 316 grants it had approved in 127 countries through July 2005 hadput 220,000 patients on HIV therapy, provided HIV testing and counseling for 2.5 million people,and provided 397,000 orphans with social, medical, and educational support. (16) Some patients receivingtreatment for AIDS are participating in programs supported by both PEPFAR and the Global Fund. This overlap was estimated at 63,000 in 2004. (17) The Global Fund estimates that it needs $3.3 billion in 2006 and 2007 to cover all existinggrants through the end of 2007. In addition, it is seeking $3.7 billion, for a total of $7 billion, inorder to respond to anticipated applications in Rounds 6 through 8 during the two-year period. (18) At a pledging conferenceheld in London in September 2005, donors pledged a total of $3.7 billion. Unless additional pledgesare made, the Global Fund will have the resources to do little more than fund its existing grants. Itwill not be able to bring new resources to bear in fighting the AIDS pandemic. Resource constraintswere evident when the Global Fund's board met in Geneva at the end of September 2005 to discussRound 5 grants. The Board decided to approve 26 grants costing $382 million over the first twoyears. Another 37 grants costing $344 million were provisionally accepted pending additionalpledges in the first half of 2006. If sufficient pledges are not received by the end of June 2006, the37 grants will be denied final approval. (19) The Board did not schedule a sixth Round. The United States made initial contributions to the Global Fund totaling $275 million fromappropriations for FY2001 and FY2002 ( Table 1 ). For FY2003 through FY2005, theAdministration requested $200 million annually, but Congress provided more than requested in eachyear. A $200 million request is in keeping with the PEPFAR promise of $1 billion over five years,but for FY2006, the Administration raised its request to $300 billion. Some speculated that thisreflected recognition on the Administration's part that Congress favored larger contributions. Houseand Senate versions of FY2006 appropriations would again provide more for the Global Fund thanrequested. Table 1. Funding for U.S. Contributions to the GlobalFund ($ millions) Global Fund contributions have been funded principally through the Foreign Operations Appropriations legislation and the appropriations for the Departments of Labor, Health and HumanServices, and Education (Labor/HHS). The amounts reported in Table 1 for appropriations inFY2003 through FY2005 reflect rescissions included in these appropriations bills. In FY2004, asshown in line 3, $87.8 million of the amount appropriated for the Global Fund was not provided dueto legislative provisions limiting the U.S. contribution for FY2004 through FY2008 to 33% of theamount contributed by all donors. (20) The FY2005 Consolidated Appropriations legislation directedthat these withheld funds be provided to the Global Fund in FY2005, subject, like the remainder ofthe U.S. contribution, to the 33% proviso. The amount reported in the Senate-passed ForeignOperations bill for FY2006 ( H.R. 3057 ) includes $100 million transferred from theEconomic Support Fund under Sec. 6118, added as a floor amendment during debate. The one-third rule governing contributions is not an issue in 2005, when the U.S.contribution is estimated at about 29% of total contributions for the calendar year (see below, Table2) . At the September 2005 pledging conference in London, U.S. Global AIDS Coordinator RandallTobias said that the United States would pledge a total of "at least" $600 million ($300 million ineach year) in 2006 and 2007. (21) Tobias noted, however, that the final amount would bedetermined by Congress -- a remark that was interpreted as suggesting that he expected theultimate U.S. contribution to be larger. The $600 million offered by Tobias represents 16% ofamounts pledged for the two years, and was second to the French pledge of $631 million. America'sEuropean partners together pledged $1.6 billion, including the French pledge. (22) The $600 million for theGlobal Fund in FY2006 in the Senate-passed version of the Foreign Operations Appropriation --without considering any additional amount for FY2007 -- would double the Administration requestfor the year and put the U.S. contribution at approximately 28% of the total. Representatives of the Global Fund and PEPFAR consistently maintain that the two arepartners rather than competitors in the struggle against AIDS. Ambassador Tobias told the Londonpledging conference that the U.S. contribution to the Global Fund is a "strategic priority" of PEPFAR.