[Senate Report 110-325]
[From the U.S. Government Publishing Office]
Calendar No. 698
110th Congress Report
SENATE
2d Session 110-325
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THE TOM LANTOS AND HENRY J. HYDE GLOBAL LEADERSHIP AGAINST HIV/AIDS,
TUBERCULOSIS, AND MALARIA REAUTHORIZATION ACT OF 2008
_______
April 15, 2008.--Ordered to be printed
_______
Mr. Biden, from the Committee on Foreign Relations,
submitted the following
REPORT
together with
MINORITY VIEWS
[To accompany S. 2731]
The Committee on Foreign Relations, having had under
consideration the bill (S. 2731) to authorize appropriations
for fiscal years 2009 through 2013 to provide assistance to
foreign countries to combat HIV/AIDS, tuberculosis, and
malaria, and for other purposes, reports favorably thereon with
an amendment and recommends that the bill, as amended, do pass.
CONTENTS
Page
I. Summary..........................................................1
II. Background and Purpose of the Legislation........................2
III. Reauthorization Act of 2008......................................6
IV. Committee Action................................................21
V. Section-by-Section Analysis.....................................22
VI. Cost Estimate...................................................31
VII. Minority Views..................................................36
VIII.Changes in Existing Law.........................................40
I. Summary
S. 2731, the Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 [hereafter the Reauthorization
Act], authorizes $50 billion for United States bilateral and
multilateral programs to combat human immunodeficiency virus
(HIV) and the acquired immunodeficiency syndrome (AIDS)
[hereafter referred to as ``HIV/AIDS''], tuberculosis (TB) and
malaria for fiscal years 2009 through 2013. This Act seeks to
build on the remarkable successes achieved during the last 5
years by the President's Emergency Plan for AIDS Relief
(PEPFAR) and by the promising start of the President's Malaria
Initiative and to support a transition from an emergency
approach to more country-driven strategies that will better
allow public health professionals on the ground to combat the
local HIV/AIDS, TB, and malaria epidemics that they confront.
This Act sets out ambitious targets for HIV/AIDS
prevention, treatment, and care while removing funding
directives that have served as stove-pipes for those
interventions and limited the flexibility of professionals in
the field who plan and implement the programs. Of the three
goals, it prioritizes prevention as the most critical element
in slowing the pandemic and reversing its course. In pursuing
this goal, the Act requires a balanced approach to the
prevention of the sexual transmission of HIV--emphasizing the
importance of behavior change programs to promote abstinence,
fidelity, the reduction of concurrent sexual partners, and the
delay of sexual debut along with programs to promote the
correct and consistent use of condoms.
HIV/AIDS epidemics do not occur in isolation. Persons and
communities affected by HIVAIDS are also affected by other
economic and health challenges that can have a direct effect on
prevention, care, and treatment outcomes. Continuing the
guidelines established in the U.S. Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) [hereafter
the 2003 Leadership Act], this Act promotes the further
coordination of care and treatment programs with other life-
changing interventions such as nutritional support, and more
cohesive integration of these disease-specific programs within
the broader United States health and development agenda. S.
2731 increases the focus on women and girls, particularly in
terms of addressing the factors that make them more vulnerable
to the transmission of HIV. It emphasizes the need for improved
internal coordination and enhanced harmonization with other
international actors and partner countries and authorizes,
although it does not mandate, bilateral and regional framework
or ``compact'' agreements. It seeks to strengthen health
capacity in developing countries affected by these epidemics,
by promoting the training and retention of personnel and
improvements in infrastructure, management, finances, and
health systems. The legislation enhances oversight and
emphasizes the importance of operations research to evaluate
and maximize the impact of United States assistance. Finally,
the Reauthorization Act would repeal a provision in law that
differentiates HIV/AIDS from all other diseases and currently
makes HIV infection the only statutory grounds for barring
prospective international visitors from entry into the United
States.
II. Background and Purpose of the Legislation
In his State of the Union address on January 28, 2003,
President George W. Bush announced a dramatic proposal: To
spend $15 billion over 5 years to combat HIV/AIDS globally,
particularly in sub-Saharan Africa, the region hardest hit by
the pandemic, and he called for the creation of the President's
Emergency Plan for AIDS Relief (PEPFAR). Congress responded
promptly, authorizing the full amount requested by the
President and expanding the diseases covered through the 2003
Leadership Act which was signed into law May 27, 2003.
Congressional support for the program has been strong and
steady; Congress has appropriated over $19.7 billion since then
to combat these three diseases through bilateral and
multilateral programs.
The 2003 Leadership Act provided a roadmap for an ambitious
plan to achieve objectives in the prevention, care, and
especially the treatment of HIV/AIDS.\1\ To oversee these
programs, the 2003 Leadership Act established within the
Department of State--a Coordinator of United States Government
Activities to Combat HIV/AIDS Globally [hereafter the Global
AIDS Coordinator], to be appointed by the President with the
advice and consent of the Senate. The Office of the Global AIDS
Coordinator (OGAC) leads interagency implementation and
administration of U.S. global HIV/AIDS policy. The 2003
Leadership Act required a 5-year emergency plan (for fiscal
years 2004-2008) designed to coordinate all U.S.-funded
bilateral HIV/AIDS programs, including those established by the
President's Emergency Plan for AIDS Relief, and administered
through seven implementing agencies,\2\ to address the
emergency. The bill specifically mentioned 14 countries within
the Coordinator's oversight and authorized the President to
name additional countries to this list.\3\ The 2003 legislation
also included provisions to address TB and malaria and
authorized participation in the Global Fund to Fight AIDS,
Tuberculosis and Malaria [hereafter the Global Fund]--a
multilateral financing mechanism to manage and disburse
resources to fight the three diseases. The Global Fund now
provides grants in 138 countries. The United States remains the
leading contributor to the Global Fund, having pledged over
$3.7 billion to date.
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\1\The human immunodeficiency virus is the underlying cause of
AIDS. Most people who are infected with HIV are not yet in need of ARV
treatment; rather they need monitoring of their condition. AIDS is
diagnosed when an HIV-positive person's immune system deteriorates to a
specific point, most often evaluated on the basis of a person's CD4
count or when he/she acquires certain opportunistic infections or
malignancies associated with AIDS. [CD4 cells coordinate the immune
system's response to certain micro-organisms such as viruses and may be
seen as one barometer of a person's progression toward AIDS--if CD4
counts fall below a certain level, physicians recommend initiating ARV
treatment, which must then be continued for life.]
\2\The Department of State, the United States Agency for
International Development (USAID), the Department of Health and Human
Services, the Department of Defense, the Department of Commerce, the
Department of Labor, and the Peace Corps.
\3\The original 14 named countries were Botswana, Cote d'Ivoire,
Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda,
South Africa, Tanzania, Uganda, and Zambia. The President added Vietnam
to this list in 2004. Currently approximately 60 percent of PEPFAR
assistance is directed to these 15 countries.
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In 2003, roughly 50,000 people in all of Africa were
receiving antiretroviral (ARV) pharmaceutical treatment for
AIDS, though, according to current data, an estimated 21.6
million people in Africa were HIV positive at that time.\4\
Some people argued that large-scale, successful treatment in
such resource-poor settings was impossible. To counter these
arguments and to address this most urgent issue--trying to
reverse a sentence of certain death for millions and
simultaneously provide an incentive for getting tested for
HIV--the 2003 Leadership Act emphasized treatment among the
three goals, establishing first through a Sense of Congress
provision and subsequently through a budgetary directive that
55 percent of bilateral assistance should go to therapeutic
medical care, with at least 75 percent of that allocation to be
expended for the purchase and distribution of antiretroviral
pharmaceuticals. The legislation also recommended that 15
percent of funds go toward palliative or supportive care\5\ and
required in the later fiscal years that 10 percent of funding
go to provide for the needs of orphans and vulnerable children.
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\4\As the available HIV/AIDS data has improved, the Joint United
Nations Programme on HIV/AIDS (UNAIDS) has revised earlier estimates of
HIV prevalence. In 2003, when the Leadership Act was enacted, it was
estimated that approximately 42 million individuals were infected with
HIV; UNAIDS' more recent analysis estimates that 30.9 million people
were likely HIV positive in 2003, of whom 21.6 million were in sub-
Saharan Africa.
\5\OGAC guidance on palliative care states ``Comprehensive
palliative care is essential to the health and well-being of people
living with HIV/AIDS (PLWHA) and is an integral part of the President's
Emergency Plan for AIDS Relief (the Emergency Plan). Palliative care
has traditionally been associated with terminal or end-of-life care.
However, current thought and practice and Emergency Plan policy take
the broader view that palliative care encompasses care provided from
the time that HIV is diagnosed and throughout the continuum of HIV
infection.''
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As part of the 2003 Leadership Act, Congress also
established parameters to support prevention efforts. The 2003
legislation recommended a spending level of 20 percent for
prevention programs and, for fiscal years 2006 to 2008,
required that one-third of prevention funds go toward promoting
abstinence until marriage. This prevention approach was based
on examples of successful efforts in Uganda and elsewhere to
reduce the transmission of HIV/AIDS through an ``ABC
approach''--Abstain, Be faithful, and use Condoms.
The 2003 Leadership Act recognized the importance of a
multidimensional strategy and the bill included provisions
relating to the empowerment of women, including requiring
strategies to enhance their empowerment in interpersonal
situations and to increase their access to employment
opportunities, income, productive resources, and microfinance
programs and authorizing assistance in these areas. The Act
also recognized the importance of nutrition and called for the
Administrator of the United States Agency for International
Development (USAID) to integrate nutrition programs with HIV/
AIDS activities as appropriate.
Over the course of the last 5 years, the United States has
made tremendous strides in leading the global campaign against
HIV/AIDS, particularly establishing treatment programs. With
the support of PEPFAR and the Global Fund, over 1.99 million
people have received ARVs.\6\ Millions more have been the
beneficiaries of palliative care and prevention educational and
outreach efforts and commodities. U.S. programs have helped to
ensure that over 150,000 infants, most in sub-Saharan Africa,
who likely would have been infected with HIV in utero or during
birth were not. Over 33.7 million people have received
voluntary counseling and HIV testing. Faith-based and
community-based organizations have played pivotal roles in the
success of these programs, delivering services on the front
lines of the war against HIV/AIDS.
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\6\According to the most recent PEPFAR report to Congress, PEPFAR
and the Global Fund jointly support 909,000 people on treatment; PEPFAR
alone supports approximately 544,000 people, and the Global Fund alone
supports 539,000 people.
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While these achievements are impressive, the pandemic
continues to outpace them. The 2007 AIDS Epidemic Update of the
Joint United Nations Programme on HIV/AIDS (UNAIDS) brought the
welcome news that global prevalence estimates were lower than
earlier projections, but even these revised numbers indicated
that approximately 33.2 million people in the world are living
with HIV; that 2.1 million people died of AIDS-related causes
in 2007; and that 2.5 million people became newly infected in
2007, meaning that for every person who enrolled in a treatment
program, approximately six more reportedly became HIV
positive.\7\ Furthermore, most people who are infected with HIV
remain untested and undiagnosed.
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\7\Data on global and regional prevalence and incidence rates are
from the report of the United Nations Programme on HIV/AIDS (UNAIDS)
and the World Health Organization (WHO), ``AIDS epidemic update''
(December 2007). The December UNAIDS 2007 report significantly reduced
prevalence estimates from previous years and included a revised
estimate of approximately 32 million persons living with HIV, down from
the 2006 estimate of 38.6 million. These revised estimates stemmed most
directly from improved data in countries such as India, rather than
changes in the epidemic, but they also reflected notable reductions in
prevalence rates in several countries, including Kenya and Zimbabwe.
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Sub-Saharan Africa remains by far the most affected region
of the world: An estimated 22.5 million people there are living
with HIV, over two-thirds of the global population of persons
who are HIV-positive, and the region suffered more than three
quarters of all AIDS deaths in 2007. In six countries in
southern Africa (Botswana, Lesotho, South Africa, Swaziland,
Zambia, and Zimbabwe), estimated prevalence rates continue to
exceed 15 percent. Women and girls make up over 60 percent of
persons in sub-Saharan Africa who are HIV infected, and the
disparities along gender lines are even more striking among
younger age cohorts. Africa is most affected but not alone.
Rates of HIV incidence (the number of new infections in a
population in a given year) are rising in East Asia. The
Caribbean has the second highest regional prevalence rate at
1.0 percent (with Haiti and the Dominican Republic accounting
for three quarters of the 230,000 people living with HIV in the
Caribbean), while Eastern Europe and Central Asia are
experiencing prevalence rates of 0.9 percent with an estimated
1.6 million people living with HIV. Illicit injection drug use
continues to be a major driver of the epidemic; unsafe sex
among men who have sex with men and the commercial sex trade
are also significant means of transmission in many areas. These
basic demographic realities must continue to shape the U.S.
strategy on HIV/AIDS, as should the economic need of recipient
countries, as these programs enter a new phase of operations.
The U.S. global HIV/AIDS initiative, like the Marshall
Plan, represents American foreign policy at its best. It
demonstrates the efficacy of U.S. assistance and the generosity
of the American people. It has also demonstrated the ability to
adapt both to changing conditions on the ground and to more
accurate data as it has become available. This Reauthorization
Act seeks to enhance that flexibility and to reflect the
progress that has been made and the lessons learned. As this
program continues to grow and potentially expands to other poor
countries, it will face new challenges. As treatment rosters
grow, so does the responsibility to maintain them--a patient on
ARV treatment must, for now at least, continue taking the
medication for the rest of his or her life. This fact, and its
clear economic and moral implications, reinforces the need to
improve and expand prevention efforts. While treatment must
remain a key component of our strategy, without greater
emphasis on prevention, HIV/AIDS will never be successfully
controlled or contained. Countries currently receiving our
assistance are eager to assume greater leadership but lack much
of the capacity, healthcare workforce, and delivery systems to
do so. Improved harmonization of U.S. programs with one another
and with other international actors is necessary to maximize
impact; and a clearer roadmap is needed of how global HIV/AIDS
programs fit into the broader U.S. health and development
agenda.
S. 2731 recognizes the lethal impact of tuberculosis and
malaria and authorizes a substantial increase in resources to
address these deadly diseases. Together, TB and malaria claim
over 2.6 million lives a year, and they have a devastating
effect on economic development in many countries. The Act,
building on the initial inclusion of these diseases in the 2003
Leadership Act, seeks to strengthen these efforts and to
promote improved coordination across prevention and care
programs for HIV/AIDS, TB, and malaria and between these
programs and other U.S. assistance efforts.
III. Reauthorization Act of 2008
The reauthorization of the 2003 Leadership Act for FY 2009-
2013 is designed to respond to these challenges. It sets
ambitious targets for treatment, care, prevention, pediatric
treatment, care for orphans and vulnerable children, and the
prevention of mother-to-child transmission, and for helping
countries to train and retain healthcare workers. Among these
goals, the Act explicitly prioritizes prevention as critical to
saving lives in recognition of both the progress made in
initiating path-breaking treatment programs and the fact that
we must do more to break the cycle of new infections. It
underscores the value of the ABC approach to preventing the
sexual transmission of HIV and requires a balanced approach to
prevention. The Reauthorization Act recognizes that the drivers
of the epidemic vary from country to country and that our
public health professionals and their partners should be given
the means to respond to these variances as well. The
legislation emphasizes capacity-building, coordination, and
evaluation and oversight and calls for an increased focus on
the needs and vulnerabilities of women and girls. It addresses
the grave threats posed by malaria and tuberculosis, including
the increasing dangers of drug-resistant TB. Finally, it
supports a transition from a U.S.-led emergency approach to a
more sustainable, country-driven public health strategy toward
HIV/AIDS, including increased technical assistance to improve
the capabilities of partner governments to play such a role. To
accomplish these goals, the Reauthorization Act increases U.S.
funding for bilateral and multilateral HIV/AIDS, tuberculosis,
and malaria programs to $50 billion over the next 5 fiscal
years.
Estimates of Funding
The $50 billion, 5-year authorization will provide a total
of $41 billion for bilateral HIV/AIDS programs and the Global
Fund, $5 billion for malaria programs, and $4 billion for
tuberculosis programs. The committee chose not to assign annual
spending for the $50 billion in order to allow for these
programs to be increased over time as services are expanded and
to accommodate absorptive capacities. The Reauthorization Act
authorizes up to $2 billion for the Global Fund for fiscal year
2009 and such sums as are necessary for the following 4 fiscal
years.
The Global Stop TB Partnership, of which the United States
is a member, has estimated that total country needs to achieve
the goals of the Global Plan to Stop TB will require $24.9
billion over the 2009 to 2013 period. The plan calls for 57
percent of funds to go toward the expansion of Daily Observed
Treatment Short-course (DOTS) therapy, with the remainder
directed primarily toward TB/HIV programs; DOTS-Plus programs
that supplement the standard DOTS strategy in areas with
significant drug resistance; TB drugs; and vaccine research and
development.
The WHO's current best estimate of global need for malaria
programs as outlined in the Global Malaria Business Plan of the
Roll Back Malaria partnership is $4.1 billion per year (which
the WHO breaks down to $3.2 billion for implementation and $0.9
billion for research and development). The Reauthorization Act
authorizes up to $5 billion as the U.S. Government's
contribution to this global effort over 5 years.
HIV Prevention Policy
A growing body of evidence led the committee to reform the
approach to budgetary allocations or earmarks within U.S.
global HIV/AIDS programs. Simply put, current earmarks have
constrained the ability of the U.S. Government and its partners
to combat the local epidemics that they are facing in
individual countries. They also undercut efforts to promote
harmonization with other national and international efforts.
This conclusion was highlighted in the Institute of Medicine's
report, ``PEPFAR Implementation: Progress and Promise,'' which
was mandated under the 2003 Leadership Act and which stated
that the short-term targets manifested in the budget
allocations have ``adversely affected implementation of the
U.S. Global AIDS Initiative.''\8\ Other types of activities,
such as the prevention of mother to child transmission (PMTCT),
as well as more comprehensive approaches to the prevention of
the sexual transmission of HIV that combine abstince, fidelity,
and condom programming (A, B, and C), have sometimes directly
suffered as a result of budget allocations, according to
reports by the Government Accountability Office (GAO).\9\
Additionally, an independent comparative analysis of PEPFAR,
the Global Fund, and the World Bank concluded that, of the
three, ``PEPFAR funding is least conducive to allowing
recipients to implement comprehensive approaches that combine
elements of treatment, prevention, and care.''\10\
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\8\Institute of Medicine, ``PEPFAR Implementation: Progress and
Promise,'' Washington, D.C.: National Academies Press, 2007, p. 10.
\9\Government Accountability Office, ``Spending Requirement
Presents Challenges for Allocating Prevention Funding under the
President's Emergency Plan for AIDS Relief,'' GAO-06-395 (April 4,
2006).
\10\Nandini Oomman, et al. ``Following the Funding for HIV/AIDS: A
Comparative Analysis of the Funding Practices of PEPFAR, the Global
Fund and World Bank MAP in Mozambique, Uganda and Zambia,'' Center for
Global Development (October 10, 2007), p. xii.
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The committee believes that goals rather than numerical
percentages should guide programming. By setting a goal of
preventing 12 million new infections through a balanced
approach and strengthening evaluations of prevention programs,
the committee hopes to make a greater impact in stemming the
epidemic.
In order to increase flexibility and allow for the more
effective allocation of resources in response to local
conditions, S. 2731 removes the one-third ``abstinence until
marriage'' funding directive from the 2003 Leadership Act,
along with all other numerical earmarks within HIV/AIDS
funding, except for the 10-percent allocation for orphans and
vulnerable children. The Reauthorization Act explicitly
prioritizes prevention and continues support for a balanced
approach in which behavior change programs that are aimed at
promoting abstinence and fidelity, reducing numbers of
concurrent partners, and delaying sexual debut, which may
collectively be termed ``AB,'' are to be funded in a meaningful
and equitable way, in tandem with ``C'' prevention tools
promoting the correct and consistent use of condoms. Because
the committee believes that both the ``AB'' behavior change
elements and the ``C'' elements of the ABC approach are crucial
to stopping the spread of HIV/AIDS, language in the
Reauthorization Act explicitly requires the Global AIDS
Coordinator to report to Congress if the funding ratio for
these ``AB'' behavior change programs and for ``C'' (condom)
programs falls below one to one (AB:C). Additional means of
prevention including programs to empower women and others,
medical male circumcision, the safeguarding of blood supplies,
and the potential development of new mechanisms or approaches
are also addressed, separately from this one to one ratio.
S. 2731 strengthens an existing provision in the 2003
Leadership Act to ensure that no organization shall be required
to endorse, participate in, or make a referral to any program
to which that organization has a moral or religious objection,
nor shall they be required to endorse or participate in a
multisectoral or comprehensive approach to HIV/AIDS. Such
organizations cannot be discriminated against in grants or
other agreements as a result of electing not to endorse,
participate in, or refer patients to such programmatic
activities.
As noted, the Reauthorization Act requires a prevention
strategy for each country in which the United States maintains
an HIV/AIDS program; if, in that strategy, less than 50 percent
of the prevention programs aimed at the sexual transmission of
HIV are directed toward behavior change programs aimed at
reducing or delaying sexual activity or reducing numbers of
sexual partners as outlined above, then the Global AIDS
Coordinator must provide a justification to Congress. The
objective epidemiological evidence to be used for the
Coordinator's determination should be primarily partner country
Demographic and Health Surveys, the AIDS Information Service
(AIS), and other United States Government supported surveys and
data, including surveys requested by the Congress; other
independent, scientifically sound studies may also be taken
into account. The modification of the previous abstinence
spending requirement should not be interpreted to imply that
abstinence and be faithful programs are no longer considered by
the committee to be a priority for prevention funding.
Modifications in the directive and the required country
strategies are intended to promote locally guided approaches to
prevention that respond to changes in patterns of incidence
(new HIV infections) and to specific drivers of the epidemic.
Any program to change cultural norms should be led by the
partner countries, with the U.S. Government providing financial
and technical assistance when appropriate; one of the clear
lessons of Uganda's early success in reducing HIV prevalence
rates is that national and local leadership matters.
The prevention of the transmission of HIV from mother to
child represents an important component of the overall
prevention strategy. S. 2731 establishes a goal of helping
partner countries to achieve 80 percent access to counseling,
testing, and treatment to prevent mother-to-child transmission
and emphasizes the importance of maintaining a continuum of
care before and after birth and of promoting provider-initiated
or ``opt-out'' HIV testing.\11\ The committee also recognizes
new and promising developments regarding the use of ARVs to
reduce the transmission of HIV through breast milk and supports
expansion of these interventions as appropriate.
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\11\For PMTCT in developing countries, 80 percent is often defined
as ``universal access'' because 100 percent access is not realistically
achievable. ``Opt out'' testing refers to a protocol in which all
clients in a medical facility are asked if they would be willing to
take an HIV test, rather than waiting for clients to request testing.
All voluntary counseling and testing should follow WHO guidelines.
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HIV/AIDS Treatment and Care Policy
S. 2731 maintains treatment and care as core priorities of
U.S. HIV/AIDS programs and sets a target of supporting
treatment for 3 million people by 2013, an increase of 1
million people to be added to treatment rosters, and additional
access to treatment through contributions to the Global Fund.
The bill also sets a target of supporting care for 12 million
people, including 5 million orphans and vulnerable
children.\12\ In order to measure progress toward the treatment
objective, the Reauthorization Act requires a timetable with
yearly global treatment targets and subsequent reporting,
including country-level explanations if the timetable's goals
are not on track to be achieved. As with most of the other HIV/
AIDS budget directives, S. 2731 removes the allocation
requiring that 55 percent of funding go toward treatment, again
reflecting the committee's preference that goals to guide
planning and resources rather than numerical directives. The 55
percent earmark was seen as necessary 5 years ago when
treatment was almost nonexistent in resource-poor settings such
as Africa, and some claimed it was not even possible, but
current data demonstrate that this directive is no longer
needed or appropriate. The President's Emergency Plan for AIDS
Relief has proven the skeptics wrong: Today, due to the
combined efforts of PEPFAR and the Global Fund, nearly 2
million people are on treatment, mostly in Africa.
Additionally, with the availability of less expensive generic
drugs and better supply chain management in place, the cost of
ARV supply and distribution has decreased, while other public
and private partners have increased their role in supporting
treatment programs. The 55 percent earmark for treatment was
also set at a time when the infrastructure to deliver treatment
was almost completely absent in many areas and the costs were
considered by some to be prohibitively expensive. This 55
percent figure has never correlated with actual treatment costs
in pursuit of the targets of the 2003 Leadership Act, and the
goal of supporting 3 million people on treatment by 2013 does
not require such a budgetary directive.
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\12\In his 2003 State of the Union Address, President Bush
established targets of treating 2 million people, preventing 7 million
new infections and providing care for millions more. Currently, over
1.4 million people are enrolled in ARV treatment programs through U.S.
bilateral assistance programs. The direct impact of prevention programs
is more difficult to measure.
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Some have suggested that a target of 3 million people on
treatment is insufficient. While the committee would prefer
that all who need treatment receive it, the committee shares
the view of the Global AIDS Coordinator, Ambassador Mark Dybul,
that ``we cannot treat our way out of this epidemic.'' For
every person put on ARVs last year, six more became newly
infected with HIV; prevention efforts, capacity building, and
other programs are critical to establishing a more sustainable
approach. Treatment targets should be and are ambitious, but
the committee believes it is neither advisable nor financially
feasible for the United States to be the sole supplier of ARVs.
In a number of communities, U.S. bilateral programs now focus
on providing the more complex ``second line drugs'' (for
patients whose initial treatments have failed), while the
Global Fund, private foundations, or others provide many of the
``first line'' drugs). The committee encourages such shared
efforts. The U.S. commitment to support treatment for 3 million
people in this Act would constitute well over half of the
commitment made to date by the entire Group of Eight (G-8). The
world, not just the United States, needs to confront this
crisis, and members of the G-8 and others need to do more,
particularly because treatment, as noted previously, is a long-
term commitment--at this time, it must be life-long for every
person who begins taking ARVs.
Furthermore, the committee believes that in seeking to
provide treatment for at least 3 million people, the United
States, and its implementing partners, must also do more to
ensure that its programs achieve the desired outcome, namely
the long-term survival of people on treatment and their return
to productive lives. In some PEPFAR-supported programs, as many
as a quarter or more of those who begin treatment are
subsequently ``lost to followup'' and disappear from rosters.
Some of these patients will have died; others may have dropped
out or enrolled elsewhere. Poor adherence to ARV regimes is
extremely dangerous for the individual and has larger
ramifications as it may contribute to the spread of drug
resistant strains of HIV/AIDS, which are more difficult and
costly to treat. Through enhanced oversight and analysis, along
with strengthened coordination with nutrition programs and
other support, the Reauthorization Act seeks to save more lives
through improved as well as expanded treatment and care.
In terms of care, S. 2731 recognizes the impact of
opportunistic infections such as tuberculosis, bacterial
pneumonia, toxoplasmosis, viral and fungal diseases, and HIV/
AIDS-associated malignancies such as Kaposi's sarcoma on many
persons with HIV/AIDS and includes a provision calling for free
or readily affordable prophylaxis and treatment for these
infections as part of care and treatment. Palliative assistance
and pain management are also important components of HIV/AIDS
care and treatment programs, as noted in the Reauthorization
Act. Additionally, the committee strongly supports expanded
access to voluntary counseling and testing, particularly the
adoption of provider-initiated or ``opt-out'' testing, expanded
mobile services, and the use of rapid testing to reduce waiting
times for patients and facilitate the delivery of test results.
Pediatric participation in care and treatment programs has
been underrepresented to date, in part because many HIV
infected children die without ever being tested, particularly
in countries with low rates of access to Prevention of Mother
to Child Transmission (PMTCT) programs. Drawing on S. 2472, the
Global Pediatric HIV/AIDS Prevention and Treatment Act, the
Reauthorization Act establishes a target for participation in
treatment and care programs for children in proportion to their
percentage within the HIV-infected population of a given
country as a policy objective of U.S. global HIV/AIDS programs.
The Role of HIV/AIDS, Tuberculosis, and Malaria Programs Within the
United States Health and Development Agenda
A core objective of this Act is to encourage the President
to situate programs to combat HIV/AIDS, tuberculosis, and
malaria more clearly within the United States health and
development agenda, particularly because HIV/AIDS programs have
come to dominate U.S. assistance in many countries in sub-
Saharan Africa and elsewhere. To address this issue, S. 2731
requires strategic planning for HIV/AIDS programs within this
broader context as well as long-range planning for the
initiative. The Reauthorization Act also seeks to improve
coordination between HIV/AIDS programs and other development
activities; to address the needs and heightened vulnerabilities
of girls and women to HIV; and to build capacity in the health
sectors of partner countries and promote a shift toward more
sustainable approaches grounded in national strategies. The Act
also calls for closer coordination between HIV/AIDS, TB, and
malaria programs. In approaching the question of how these
health programs fit into the broader U.S. development agenda,
the committee explicitly builds upon the 2003 Leadership Act;
with the insights gained from 5 years of programs, it seeks to
strengthen these activities in order to maximize the positive
impact of taxpayer dollars and to achieve improved outcomes in
saving lives and helping people resume productive activities.
Nutrition and Food Support for Persons With HIV/AIDS and Their Families
The Reauthorization Act strengthens linkages between HIV/
AIDS and nutritional and food support. The 2003 Leadership Act
recognized the importance of nutritional support, but persons
living with AIDS, clinicians, and other implementers working to
treat and support them through PEPFAR programs have repeatedly
identified inadequate access to food or nutrition as a major
problem in combating the effects of HIV/AIDS. Adequate
nutrition is important clinically in terms of improved health
outcomes and better adherence to regimes, in part because lack
of food can make it very difficult to tolerate ARVs, and many
malnourished patients will simply stop taking their ARVs
because the side effects are too severe.\13\ Current efforts to
address this issue through ``wraparound'' programs with the
World Food Program and other agencies cannot completely bridge
this gap. In wraparound programs, another agency provides a
service such as nutritional support for persons with HIV/AIDS.
These wraparound programs often lack the resources to provide
sufficient services to the individuals receiving PEPFAR support
and are frequently based in rural areas, while PEPFAR programs
tend to be more urban. S. 2731 directs the Global AIDS
Coordinator to integrate nutrition programs more fully with
HIV/AIDS activities and to establish services where referrals
are inadequate. The Reauthorization Act identifies nutritional
and food support as a basic component of care and treatment for
those persons with HIV/AIDS who meet established criteria of
need.
---------------------------------------------------------------------------
\13\PEPFAR Implementation: Progress and Promise, p. 157.
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Providing food assistance only or preferentially to persons
who are HIV-infected also poses clear ethical and policy
difficulties, both within any given community and in terms of
the overall distribution of resources. This community concern
may be offset somewhat by the grim economic impact of long-term
illness: Families whose breadwinner has been stricken by AIDS
have often been forced to sell off what assets they possess.
Therefore, even in a community where food insecurity is
widespread, these families may have fewer resources on which to
draw. Nonetheless, this matter remains an issue of concern. In
communities where HIV/AIDS and food insecurity are both highly
prevalent, the Reauthorization Act supports community-based
assistance programs, with an emphasis on sustainable approaches
such as community gardens.
Women and Girls and HIV/AIDS
Women and girls are biologically more vulnerable to the
sexual transmission of HIV, and sociological and economic
factors add to this heightened peril. Young women in much of
sub-Saharan Africa, where HIV/AIDS rates are the highest in the
world, are three times as likely as their male counterparts to
be infected with HIV; globally, two-thirds of all new
infections among young people aged 15 to 24 are among
women.\14\ S. 2731 emphasizes the issue of gender as a risk
factor for HIV on a number of levels, with the goal of
strengthening U.S. efforts to help partner countries address
the underlying issues that heighten vulnerabilities for girls
and women and to improve the quality and enhance the impact of
gender-based programming. Gender elements are central to the
required 5-year strategy and report and subsequent evaluations,
and the committee emphasizes the importance of programs to
reach men, women, and youth to reduce gender-based
vulnerabilities to, and the disparate impacts of, HIV/AIDS.
Gender-based programs must also be a core element of any future
compacts or framework agreements. Consistent with the
underlying 2003 Leadership Act, programmatic components to
address gender issues within the Reauthorization Act include
support for property and inheritance rights for women and
children as well as assistance to promote broader legal
equality and legal protection; support for civic organizations
run by and for women; life skills training for adolescents;
recognition and prevention of gender-based violence and
strengthened legal and support responses to violence; and
improved coordination with antitrafficking efforts. The
committee recommends that additional staff training and
development of expertise on gender-related issues be included
in planning for HIV/AIDS programs and country operational
plans, along with expanded local input from women, including
women living with HIV/AIDS. Similarly, additional technical
assistance may be needed to help encourage the participation
and involvement of women in drafting, coordinating, and
implementing the national HIV/AIDS strategic plans of their
countries.
---------------------------------------------------------------------------
\14\Office of the Global AIDS Coordinator, ``The President's
Emergency Plan for AIDS Relief Report on Gender-Based Violence and HIV/
AIDS'' (November 2006), p. 4.
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The committee believes it is important to monitor and
evaluate progress on outcomes and impacts linked to goals and
targets and to ensure that data are disaggregated by risk
factors, including sex, age, marital status, and other factors
relevant to local epidemics. The Global AIDS Coordinator should
provide clear guidance to field missions to integrate gender
across all prevention, care, and treatment programs; adopt
specific targets for reaching women and girls within the
country's prevention, care, and treatment targets; and
undertake gender analysis in order to identify priority
interventions. Gender-specific indicators are critical to
measure program outreach and effectiveness. Operations research
and evaluations of gender-responsive interventions, as required
under the Reauthorization Act, will help identify and encourage
replication or adaptation of effective models, and provide both
positive and negative lessons learned for dissemination among
programs supported by U.S. assistance in different countries or
regions.
The Reauthorization Act authorizes structural HIV
prevention efforts intended to help alter social, political,
and economic factors in the environment so that people may be
empowered to engage in safer behaviors. These efforts help
countries to address factors within the environment, such as
gender inequities or migration patterns that can create
conditions conducive to the spread of HIV, and begin to remedy
them, for example by supporting microcredit opportunities for
women or providing off-hours activities or housing options for
migrant men or transport workers. Such prevention approaches
also offer important opportunities for increased linkage across
development lines, through the promotion of livelihoods and
small enterprise development, job training, basic health
services, and education. These activities are particularly
relevant in terms of the needs of women and girls and continue
programs that were authorized under the 2003 Leadership Act.
Gender-based violence plays a significant role in the
transmission of HIV in many areas, and efforts to assist
countries in the development and enforcement of laws and
policies to prevent and respond to gender-based violence and to
promote screening and appropriate counseling, testing, and
treatment in both HIV/AIDS and gender-based violence programs
are important components of prevention, care, and treatment
programs as authorized under this Reauthorization Act. Violence
against women and girls in humanitarian relief, conflict, and
post-conflict operations is an issue of particular concern.
Domestic violence is widespread in some regions, including
areas of high HIV prevalence, but this situation can change.
Strengthening laws and enforcement mechanisms; publicizing laws
and penalties and expanding awareness of victims' services
through national media campaigns; expanding youth education
efforts; and promoting communication across gender lines, along
with efforts to address alcohol abuse, can help to change
social norms contributing to tolerance of violence. Increased
access to economic opportunities is also an important component
in the prevention of and response to domestic and sexual
violence. Recognizing the importance of these programs in the
fight against HIV/AIDS, microcredit activities continue to be
authorized under this legislation. Finally, the committee notes
that currently many women and girls are unable to rely on the
ABC strategy to protect themselves because they lack the power
to abstain, cannot control or depend on their partners'
faithfulness, and cannot impose the use of condoms within their
relationships. That fact makes efforts to strengthen women's
rights an important component of HIV/AIDS and national
development strategies and underscores the need for support for
programs such as those outlined above as well as new advances
in prevention methods that women themselves can control.
Children and HIV/AIDS
According to UNAIDS, an estimated 2.5 million children are
living with HIV; nearly 9 out of 10 live in sub-Saharan Africa.
Over 300,000 children under the age of 15 died of AIDS-related
causes in 2007. Over 14 million children in the world have lost
one or both parents to AIDS. Millions of more children are
affected by or vulnerable to HIV/AIDS. S. 2731 seeks to address
these issues confronting children on multiple levels, from
increasing emphasis on PMTCT programs and expanding access to
pediatric HIV/AIDS testing, treatment, and care, to supporting
assistance for orphans and other children directly affected by
the disease and expanding our understanding of what it means to
be vulnerable to HIV/AIDS.
The prevention of mother to child transmission (PMTCT)
represents an area where scientific certainty--we know how to
prevent transmission during pregnancy and childbirth--meets the
limitations of maternal healthcare access and infrastructure in
much of sub-Saharan Africa and elsewhere. Around the world,
approximately a thousand infants a day are infected with HIV,
most in sub-Saharan Africa. S. 2731 underscores the importance
of expanding access to PMTCT services and achieving delivery
targets and of supporting a continuum of care to connect
prenatal and antenatal services with health services for mother
and child after delivery.
To date, children with HIV/AIDS have been underserved
within global HIV/AIDS assistance programs. Barriers to
enrollment for children in treatment programs include limited
access to reliable HIV testing for the youngest children; a
shortage of providers trained in delivering pediatric care;
weak linkages between services to prevent mother-to-child
transmission and HIV/AIDS care and treatment and child health
programs; and the need for additional, low-cost pediatric
formulations of HIV/AIDS medications--pediatric treatment is
far more complex and expensive than that for adults. The
Reauthorization Act identifies treatment of children in
proportion to their percentage within the HIV infected
population of a given country as a policy objective and seeks
to help countries surmount these treatment barriers. The
committee strongly supports expanded treatment and care for
children not only through ARVs but also through increased
access to additional medications such as cotrimoxazole
prophylactic, for example, which at a cost of three cents a day
has been shown to cut childhood HIV/AIDS mortality rates
dramatically.
The one numerical budgetary allocation for HIV/AIDS
retained in this legislation is the 10-percent earmark for
orphans and vulnerable children. This directive continues to
receive broad support from implementers and U.S. Government
officials alike. It is important to retain this allocation, and
to maintain it separately from pediatric treatment, in order to
ensure that orphans and vulnerable children remain a priority
within U.S. HIV/AIDS country programs and to signal their
importance to partner countries, many of whom have not
sufficiently emphasized programs for children. S. 2731 also
recognizes that, particularly in areas with high HIV prevalence
rates, definitions of what it means to be vulnerable to HIV/
AIDS or its socioeconomic effects should be expanded. For this
reason, the legislation amends the original budget directive on
orphans and vulnerable children from ``orphans and vulnerable
children affected by HIV/AIDS'' to ``orphans and other children
affected by, or vulnerable to'' HIV/AIDS. The committee
encourages the Global AIDS Coordinator to provide clear
guidance to the field on this subject.
Capacity Building and Sustainability
Lack of health personnel, inadequate infrastructure and
health systems, and poor management represent formidable
roadblocks to progress in the battle against HIV/AIDS and other
infectious diseases and medical conditions, particularly in
sub-Saharan Africa. The HIV/AIDS pandemic has aggravated the
existing shortage of health workers through loss of life and
illness among medical staff, unsafe working conditions for
medical personnel, and increased workloads for diminished
staff. The shortage of health personnel in turn undermines
efforts to prevent infection and provide care and treatment for
those with HIV/AIDS and to address other health challenges.
Migration of health workers--often termed the ``brain drain''--
adds to these losses; the committee supports codes of conduct
and other measures to promote ethical practices in the
international recruiting of healthcare workers, as well as
steps to reduce ``push factors'' such as unsafe working
conditions that also fuel this brain drain. According to the
2003 United Nations Development Programme, Human Development
Report, approximately 3 out of 4 countries in sub-Saharan
Africa have fewer than 20 physicians per 100,000 people, the
minimum ratio recommended by the World Health Organization, and
14 countries have 5 or fewer physicians per 100,000 people.\15\
Numbers of nurses and other health professionals are also
critically low across much of the continent. The concentration
of professionals in cities further limits the delivery of
health services in rural areas. Capacity building is critical
to making progress against HIV/AIDS, tuberculosis, and malaria
and to shifting from a donor-led emergency line of attack to a
more sustainable, country-driven public health approach.
---------------------------------------------------------------------------
\15\According to the United Nations Development Program, Tanzania,
Malawi, Niger, Burundi, Ethiopia, Mozambique, Sierra Leone, Togo,
Benin, Chad, Lesotho, Eritrea, Rwanda, and Burkina Faso all have 5 or
fewer physicians per 100,000 people. The only other nations in the
world with such a small number of physicians per capita are Bhutan and
Papua New Guinea.
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The PEPFAR program has made real progress in training
personnel, increasing laboratory capacity, and improving
infrastructure. The Reauthorization Act seeks to build on that
progress and elevate the objective of capacity-building within
U.S. programs. Additional health professionals,
paraprofessionals, and compensated community health workers are
all needed in this effort. The Reauthorization Act draws on S.
805, the African Health Capacity Investment Act of 2007 (which
the committee approved in September 2007), to address the need
for health workers, infrastructure, and management development.
In order to help achieve needed staffing levels, S. 2731
sets a target of training and retaining 140,000 professionals
and paraprofessionals with the objective of helping countries
to achieve World Health Organization recommended minimum
staffing levels for doctors, nurses, and midwives. Doctors,
nurses, and other health professionals must be trained, but
also effectively deployed, under safe working conditions and
with additional incentives to support retention. Skilled
paraprofessionals, such as laboratory technicians, are needed,
as are community health workers who often serve on the front
lines of health services. The bulk of community health workers
in many PEPFAR programs are volunteers; the committee
recognizes the value of their service, but has concerns about
the sustainability of a volunteer-based model and relying upon
the poorest participants in the health workforce as volunteers.
Older orphans, vulnerable children, and at risk youth are
in need of educational and employment opportunities, while
virtually all countries receiving significant U.S. assistance
programs are in need of an expanded healthcare workforce.
Public-private partnerships and other mechanisms should be
pursued to help address this nexus through training of these
individuals as entry level health workers and as
paraprofessionals and through expanded support for higher
education, with appropriate measures to promote in-country
service following graduation.
In addition to training more individuals (and retaining
them in-country), systemic reforms and improvements are needed
to combat HIV/AIDS and other diseases and health challenges.
Task-shifting--in which lower-level health workers are
authorized to assume some duties formerly reserved for
physicians or other highly trained professionals--will help
address imbalances in service delivery, but is only a partial
solution and raises potential concerns that nurses and other
healthcare workers might be diverted from primary healthcare
duties for HIV/AIDS care.\16\ More diversified training is also
needed, including instruction in the detection of opportunistic
infections, pediatrics, gender-based violence assessments, TB/
HIV coinfection, prevention education, and counseling and
testing, to help achieve a work force with sufficient skills.
The Reauthorization Act supports such training efforts as well
as health and financial management reforms and infrastructural
development to allocate resources more effectively. In
undertaking such efforts, the potential benefit for the health
system as a whole should help guide decisionmaking, and every
precaution should be taken to ensure that HIV/AIDS programs do
not diminish access to, or quality of, broader health services.
---------------------------------------------------------------------------
\16\The World Health Organization has issued guidelines on task-
shifting in WHO, ``Treat, Train, Retain: Task Shifting: Rational
Redistribution of Tasks among Health Workforce Teams'' (December 2007).
---------------------------------------------------------------------------
Partner countries themselves must also invest more heavily
in their health and education sectors, and S. 2731 urges them
to do so, as set forth in the Abuja Declaration.\17\ The
Reauthorization Act underscores the importance of the national
HIV/AIDS and health strategies of partner countries in U.S.
planning and allows for additional technical assistance to
strengthen such instruments where needed. The legislation
authorizes the Secretary of the Treasury to provide assistance
to country health and finance ministries to attract and manage
international assistance more effectively. The committee also
emphasizes the importance of supply chain management and
equipment maintenance to ensure the effective use of purchased
and donated goods. Sustainability of global HIV/AIDS programs
cannot be achieved in the next 5 years, but it should
ultimately be one of the longer term objectives of U.S.
programs.\18\
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\17\In the Abuja Declaration of 2001, heads of state of the
Organization of African Unity [the predecessor of the African Union]
pledged to place the fight against HIV/AIDS at the forefront in
national development plans and committed to set a target of allocating
15 percent of annual budgets to the improvement of the health sector.
\18\The term sustainability is widely used but more rarely defined.
Dr. Helene Gayle of CARE, in testifying before the House Foreign
Affairs Committee on September 25, 2007, stated that ``sustainability
relates to a set of activities continuing, even after their initiator
exits. Another type refers to the durability of a certain impact: For
example, a vaccine that provides immunity to a disease. A deeper form
of sustainability is reflected in the ability of societies to maintain
processes of economic, social and cultural transformation.''
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Promoting country ownership of HIV/AIDS programs and
methodologies represents one of the underlying goals of this
legislation. Compacts or framework agreements between the
United States and regional or national governments may be one
way to achieve this objective. As part of his announcement
regarding the reauthorization of PEPFAR on May 30, 2007,
President Bush expressed his desire to establish partnership
compacts with participating nations. S. 2731 includes language
providing for the development of compacts or framework
agreements. Compacts would constitute partnership agreements,
with mutual obligations commensurate with national resources
and capabilities. For countries with greater resources, U.S.
contributions might be limited largely to technical assistance.
Compacts could be reached either with one or more individual
countries or with regions, such as the Caribbean Community
(CARICOM). Key components of prospective compacts include
health capacity-building; country investments; elements to
strengthen the legal, economic, educational, and social status
of women, girls, and vulnerable children and youth; civic
participation; the promotion of policies, regulations, and law
conducive to enhancing HIV/AIDS prevention, treatment, and
care; evaluation, research, and information-sharing; and
improved coordination of efforts to combat HIV/AIDS, TB, and
malaria with national health and development strategies.
Benchmarks, targets, and intended methodology to achieve them
should be included within such framework agreements.
Oversight and Evaluation of HIV/AIDS Programs
The scope of the U.S. global HIV/AIDS initiative and the
speed with which it has been developed and implemented under
the leadership of the Global AIDS Coordinator are extremely
impressive; this scope and speed, however, also contribute to
challenges of sustainability and accountability. As indicated
in reports by the offices of the Inspectors General for the
Department of State and USAID, PEPFAR country teams have tended
to be understaffed for the workload, budget, and
responsibilities associated with the programs that they
manage.\19\ Oversight, monitoring, and evaluation will almost
inevitably suffer if staffing is inadequate. To facilitate
smoother coordination and improve oversight and management of
programs, S. 2731 recommends the appointment of full-time,
experienced country coordinators for all U.S. missions with
significant HIV/AIDS programs, supports adequate staffing of
all country teams, and acknowledges the important contributions
of Foreign Service Nationals to these efforts.
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\19\USAID Office of Inspector General reports on Zimbabwe (October
2007), Malawi (September 2007), and Tanzania (May 2006) reported
respectively that staff shortages adversely affected basic monitoring
activities of partners; data collection and management; and reduced
site visits, which ``could jeopardize the achievement of future outputs
and targets, and impact the quality of the program data reported by the
partners to the Mission, and the target information reported to the
U.S. Government by USAID/Tanzania.''
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The committee has included several provisions in the
legislation to maintain and strengthen oversight and program
review of U.S. global HIV/AIDS efforts.
First, the bill calls for a report, including a preliminary
design plan and budget, by the Institute of Medicine of the
National Academies that assesses the performance of U.S. global
HIV/AIDS programs and an evaluation of the impact of these
programs on prevention, treatment, and care. The Institute
conducted a similar study during the first 5 years of the
global HIV/AIDS effort under the Leadership Act. That study,
released in 2007, helped inform the committee's work on the
Reauthorization Act, particularly in regard to whether to
retain certain funding allocations, or earmarks. The Institute
of Medicine study under the Reauthorization Act is intended to
address progress toward prevention, treatment, and care targets
and evaluate the impact of treatment and care programs (e.g.,
mortality, adherence, and resistance rates) and of programs
directed toward women and orphans and vulnerable children, as
well as seeking to assess the impact of these efforts on health
systems and service delivery in countries with significant
programs.
Second, the bill requires a review by the Government
Accountability Office (GAO) no later than 3 years after
enactment of this Act that will examine monitoring and
evaluation practices, interagency coordination, procurement
practices, and harmonization of the U.S. effort with national
and international strategies. It will also assess the effect of
HIV/AIDS investments on U.S. global health programming, and
provide recommendations for improving global HIV/AIDS programs.
Third, the Reauthorization Act emphasizes operations
research, in order to evaluate policies and program
outcomes.\20\ To promote the dissemination of information, the
bill requires the Global AIDS Coordinator to publish a ``best
practices'' report annually to highlight those programs with
potential for replication or adaptation, particularly those
programs that may be replicated or adapted at a low cost in
other settings. In this manner, U.S. programs can make an
indirect but important contribution to HIV/AIDS efforts where
the United States is not directly involved. The committee
regards it as important for OGAC to communicate information on
adverse outcomes or unsuccessful approaches as well.
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\20\Regarding operations research, S. 2731 draws on S. 2584, the
PEPFAR Accountability and Transparency Act.
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Finally, the bill requires the Inspectors General (IGs) of
the three largest U.S. Government agencies involved in the
global HIV/AIDS efforts--the Department of State, the
Department of Health and Human Services, and the U.S. Agency
for International Development--to coordinate on an annual
oversight plan of bilateral programs. The provision also
requires the Global AIDS Coordinator to make available not more
than $10 million to fund the oversight by the Inspectors
General. The committee is aware that the Offices of Inspector
General at State and USAID have received only modest budgetary
increases in recent appropriations, and are often asked to do
more with less. This financing mechanism--just .0002 percent of
the $50 billion authorized in this bill--will strengthen the
ability of those Offices to conduct regular audits,
inspections, and performance reviews of bilateral HIV/AIDS
programs. Oversight and monitoring and evaluation should be
seen as components of effective prevention, treatment, and care
programs rather than as competitors with them for resources.
The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria
S. 2731 authorizes up to $2 billion for the Global Fund for
fiscal year 2009 and such sums as necessary for the subsequent
4 fiscal years; this structure parallels section 202(d)(1) of
the 2003 Act, which authorized $1 billion for fiscal year 2004
and such sums as necessary for the remaining fiscal years. The
Global Fund represents the primary multilateral component of
the Reauthorization Act. The legislation recognizes the
increasingly effective coordination between the Global Fund and
bilateral U.S. assistance programs. The committee commends this
development, recognizes that the bilateral and multilateral
efforts each possess comparative advantages in certain areas,
and notes that the Global Fund model may have the potential for
greater capacity-building and sustainability in the long term.
The committee also regards the Global Fund as having made
significant progress toward addressing concerns raised by the
Government Accountability Office about transparency and
accountability and anticipates further progress as the newly
appointed Inspector General for the Global Fund attains full
staffing levels and undertakes monitoring activities.
In order to promote greater transparency, accountability,
and public availability of information, the Reauthorization Act
includes a provision to withhold 20 percent of the U.S.
contribution beginning in FY 2010 if certain benchmarks are not
met. Benchmarks include: The evaluation of Local Fund Agents;
the disclosure of information, performance data, and funding
levels for principal and subrecipients; the activities of the
Inspector General; reporting on standard indicators and
distribution of resources; the establishment of a tariff policy
and pursuit of steps to prevent the imposition of taxes on
Global Fund services; the Global Fund's continuation as a
financing institution focused on the three diseases; and
progress in sustaining a multisectoral approach with resources
allocated to different sectors, including governments, civil
society, and faith-and community-based programs.
Table 1.--Global Fund Contributions
(in U.S. dollars)
----------------------------------------------------------------------------------------------------------------
2001-02 2003 2004 2005 2006 2007 2008 est.
----------------------------------------------------------------------------------------------------------------
Total Global Contributions......... 947M 937M 1.5B 1.5B 2.2B 2.5B 3.5B
U.S. Appropriations................ 300M 348M 547M 435M 545M 724M 841M
U.S. Share of Contributions........ 32 33 32 31 24 28 28
(as a percentage)................
----------------------------------------------------------------------------------------------------------------
M = million.
B = billion.
Tuberculosis
Tuberculosis claims an estimated 1.6 million lives a year,
and drug resistant strains of the disease are becoming
increasingly common and more dangerous. This airborne disease,
including its drug-resistant variants, is becoming a more
generalized epidemic in many countries of the world. While
there are an estimated 9 million new tuberculosis cases per
year, only one-third of those with the disease currently
receive treatment. The World Health Organization recently
reported that 5 percent of new cases of TB are multidrug
resistant (MDR-TB), and that at least 40,000 persons are
thought to have extensively drug resistant TB (XDR-TB); this
number could be considerably higher as many countries lack the
capacity to test for resistance.\21\ Drug resistance emerges
most commonly when TB patients fail to complete their course of
treatment; mutations in the bacterium may then develop, and
drug-
resistant strains can subsequently be transmitted to others.
Tuberculosis normally requires a 6-month course of treatment
with costs as low as $20 per patient; treatment for MDR-TB may
take 2 years and cost thousands of dollars. XDR-TB is even more
difficult to treat and often fatal. Persons with HIV/AIDS are
particularly vulnerable to TB, and coinfection rates within the
HIV infected population top 50 percent in some countries.
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\21\MDR-TB is defined as TB demonstrating resistance to the two
most commonly used drug treatments, rifamin and isoniazid; XDR-TB is
resistant to those two first-line drugs and at least two other major
drug treatments.
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Drawing upon S. 968, the Stop Tuberculosis (TB) Now Act of
2007, which was favorably reported by the committee in October
2007, S. 2731 recognizes the global threat posed by
tuberculosis, and particularly MDR- and XDR-TB, and authorizes
$4 billion to combat the disease over 5 years. The World Health
Organization's ``Stop TB'' Strategy offers a roadmap for
combating tuberculosis and reducing the threats of increasing
drug resistance and for the resources necessary for this
effort. Directly Observed Treatment Short-course (DOTS)
treatment for TB is one of the most cost-effective health
interventions available today. The committee emphasizes the
importance of both ensuring maximum on the ground impact of
resources to combat TB and of maintaining the quality of
programs and services delivered, not least because of the
extraordinary public health costs associated with poor
adherence to standard treatment for TB. Patient services,
training for health workers and the maintenance of safe working
conditions, laboratory capacity, and drugs and diagnostics
should be prioritized. The committee recognizes and supports
funding for the global TB work of the Centers for Disease
Control and Prevention. The committee also supports robust
funding for the Global Tuberculosis Drug Facility and
recommends significantly increased annual U.S. contributions,
building on recent appropriations.
Coinfection between HIV/AIDS and TB represents a
significant public health problem in many countries, making
increased coordination between HIV/AIDS and TB programs a
continuing priority; TB remains the leading cause of death
among persons with AIDS. Diagnosis can be difficult
particularly because TB symptoms may manifest themselves
differently in HIV positive persons, often as sputum smear-
negative pulmonary and extra-pulmonary forms of TB that are
more difficult to detect and that are associated with higher
mortality rates. In order to help achieve the objectives set
forth in the Stop TB Strategy and the Millennium Development
Goals, expanded diagnostic and treatment capacity for all forms
of TB is necessary, as is expanded laboratory capacity to
detect drug resistance.
Malaria
Over 1 million people a year die of malaria, most of them
children under the age of 5 or pregnant women. The President's
Malaria Initiative, launched in 2005, is already beginning to
make an impact in the fight against this deadly and preventable
disease. S. 2731 authorizes $5 billion for fiscal years 2009 to
2013 in order to build on this early progress by expanding the
resources and reach of U.S antimalarial programs. In order to
advance these efforts and improve the operations of
antimalarial programs and coordination across U.S. agencies and
with other multilateral, national, and private actors, the
Reauthorization Act codifies a position within USAID of a
Coordinator of United States Government Activities to Combat
Malaria Globally [hereafter, the Malaria Coordinator].
This legislation supports numerous primary interventions,
including long-lasting insecticide-treated bednets; indoor
residual spraying with insecticides; intermittent presumptive
treatment of pregnant women in areas of high malaria
transmission; community-based symptoms detection, management
and care; artemisinin-based combination therapies (ACTs); and
other measures to promote treatment, care, and prevention. As
with other health interventions, capacity-building is a
critical element in the fight against malaria. The
Reauthorization Act also supports research activities to
develop and evaluate new diagnostics, treatment regimens, and
prevention and control measures. Artemisinin-based drugs and
insecticides are potentially subject to increasing resistance
over time. The spread of counterfeit drugs may hasten the
emergence of more widespread drug resistance, signs of which
are already appearing in the Mekong Delta region. The World
Health Organization also indicates that malaria-carrying
mosquitoes have developed resistance to some of the 12 approved
insecticides in the Amazon Basin, the Mekong Delta, and
particular regions of Africa, thus reducing the efficacy of
insecticide-treated bednets and indoor spraying programs. S.
2731 requires the monitoring of global malaria trends and the
assessment of the environmental and health impact of malarial
vector control efforts, including the use and production of
insecticides for bednets and residential spraying. The
committee also underscores the importance of adherence to World
Health Organization and other relevant standards in the use and
control of these products.
IV. Committee Action
Last year, the committee held two hearings directly related
to the subject matter of the bill. On October 24, 2007, the
committee held a hearing on ``The Next Phase of the Global
Fight against HIV/AIDS,'' at which Ambassador Mark Dybul, the
Global AIDS Coordinator, testified. On December 13, 2007, it
held a hearing with outside witnesses on ``Perspectives on the
Next Phase of the Global Fight against HIV/AIDS, Tuberculosis,
and Malaria.''
On March 7, 2008, Senators Biden, Lugar, Kennedy, and
Sununu introduced S. 2731, a bill to authorize appropriations
for fiscal years 2009 through 2013 to provide assistance to
foreign countries to combat HIV/AIDS, tuberculosis, and
malaria, and for other purposes.
On March 13, 2008, the committee held a business meeting to
consider S. 2731. The committee approved a series of amendments
by voice vote. The amendments were as follows:
An amendment by Senator Biden making technical
amendments to section 101(f) on Inspectors General.
An amendment by Senators Biden and Lugar to alter
the conscience clause provision to conform to the House
bill.
An amendment by Senator Biden to change ``healthcare
workers and professionals'' to ``healthcare
paraprofessionals and professionals'' in section 301
and adding definition of paraprofessionals.
An amendment by Senator DeMint regarding the Global
Fund.
An amendment by Senators Biden and Lugar to
eliminate the phrase ``behavior change'' in several
places in the bill to conform to the House bill and
clarify its meaning.
An amendment by Senators Biden and Dodd to make
adjustments to the provisions on pediatric treatment.
An amendment by Senator Biden to define ``structural
prevention.''
An amendment by Senator Dodd to create a panel to
review Prevention of Mother-to-Child Transmission.
An amendment by Senator Kerry to promote vaccine
development.
An amendment by Senator Obama to promote microbicide
development.
An amendment by Senator DeMint to ensure that CDC
surveillance activities on malaria do not duplicate the
work of the World Health Organization.
An amendment by Senators Nelson and Menendez to
highlight the Caribbean region as a potential partner
for regional approaches to HIV/AIDS.
An amendment by Senators Biden and Lugar to add a
new section 401(b) on the scaleup of the spending over
the course of the five fiscal years.
An amendment by Senator Cardin to promote preservice
training for health capacity.
An amendment by Senators Biden and Lugar to make a
technical change to insert section 307 and to renumber
the rest of Title III accordingly.
The committee then voted to order the bill, as amended,
reported favorably by a vote of 18 to 3. Voting in favor of the
bill were Senators Biden, Dodd, Kerry, Feingold, Boxer, Nelson,
Obama, Menendez, Cardin, Casey, Webb, Lugar, Hagel, Coleman,
Corker, Voinovich, Murkowski, and Isakson. Voting against the
bill were Senators DeMint, Vitter, and Barrasso.
V. Section-by-Section Analysis
Section 1. Short title
The short title is the ``Tom Lantos and Henry J. Hyde
United States Global Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Reauthorization Act of 2008.''
Sec. 2. Findings
This section amends the findings in the United States
Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of
2003 (``the 2003 Leadership Act'') by adding to that Act
additional findings with updated data on human immunodeficiency
virus (HIV) and the acquired immunodeficiency syndrome (AIDS)
(hereafter referred to as ``HIV/AIDS''), tuberculosis (TB), and
malaria around the world and the impact of U.S. assistance in
combating these diseases since the 2003 Leadership Act was
enacted. The findings also identify ongoing and growing
challenges in meeting the needs for treatment, care,
prevention, cure and research of and related to these diseases.
Sec. 3. Definitions
This section amends the 2003 Leadership Act by adding
additional definitions of terms.
Sec. 4. Purpose
This section amends the purpose section of the 2003
Leadership Act and sets out the overall goals and objectives of
this bill. It refers to the mandate for a new 5-year
coordinated strategy to combat HIV/AIDS, tuberculosis, and
malaria as part of the overall United States global health and
development agenda; calls for increased resources for bilateral
and multilateral efforts to combat these diseases; intensifies
prevention, treatment, and care efforts and seeks to enhance
program effectiveness including addressing the particular
vulnerabilities of girls and women; encourages public-private
partnerships; reinforces vaccine development and other
research, including operations research; and helps partner
countries to strengthen health systems and improve capacity.
Sec. 5. Authority to consolidate and combine reports
This section maintains a provision in current law allowing
the executive branch to consolidate and combine reports, with a
minor technical amendment.
TITLE I--POLICY PLANNING AND COORDINATION
Sec. 101. Development of a comprehensive, 5-year, global strategy
This section amends section 101 of the 2003 Leadership Act
by providing additional guidance to the President on the
development of the second 5-year plan to combat HIV/AIDS
globally and a subsequent report to Congress.
It instructs the President to seek to situate United States
efforts to combat HIV/AIDS, tuberculosis, and malaria within
the broader health and development agenda; to provide a plan to
be carried out over the next 5 years to prevent 12 million new
HIV infections, support care for 12 million adults and children
with HIV/AIDS (including 5 million orphans and other children
affected by HIV/AIDS), and to support treatment for 3 million
persons with HIV/AIDS through bilateral efforts as well as
additional persons through multilateral programs.
It also establishes targets to promote universal access
(defined as 80 percent) to services to prevent mother-to-child
transmission, to treat children in proportion to their numbers
within a country's population of persons with HIV/AIDS, and to
strengthen health workforces. The strategy prioritizes the
importance of HIV prevention, including programs to promote
abstinence, fidelity, and the use of condoms, as well as other
prevention tools. To ensure that treatment is not neglected, it
requires a timetable for achieving treatment targets. It
instructs the President to strengthen health capacity in, and
to enhance attention to the national HIV/AIDS strategies of
partner countries, and to promote coordination in United States
responses to HIV/AIDS, tuberculosis, and malaria.
This section calls for a plan for regional priorities for
resource distribution and a structure for potential new
compacts or framework agreements. It underscores the importance
of addressing the needs and vulnerabilities of women and girls.
Finally, it calls for a long-range estimate of projected
resource needs and progress toward sustainability.
This section also instructs the Global AIDS Coordinator to
commission a study by the Institute of Medicine (with prior
design plan and budget) to assess progress and outcomes of
United States global HIV/AIDS programs and provides for a
Government Accountability Office report on monitoring and
evaluation, coordination, and impact of HIV/AIDS funding and
programs on United States global health programs as a whole. It
requires annual publication of a ``Best Practices'' report
based on operations research. To enhance oversight, it requires
joint, coordinated plans by the Inspectors General (IGs) of the
three largest U.S. Government agencies carrying out this
program (State Department, HHS, and USAID) and authorizes the
transfer of up to $10 million to the IGs to support financial
audits, inspections, and performance reviews.
Sec. 102. Interagency working group
This section amends current law to strengthen and expand
the duties of the Global AIDS Coordinator, including enhancing
the role of the Coordinator in consulting and coordinating with
foreign governments, nongovernmental organizations, and other
U.S. Government agencies. It expands the duties of the AIDS
Coordinator to include establishing and heading a working group
consisting of representatives from the United States Agency for
International Development (USAID) and the Department of Health
and Human Services.
Sec. 103. Sense of Congress
This section provides a sense of Congress about the
importance of country coordinators, foreign service nationals,
and staffing levels for country teams.
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
Sec. 201. Voluntary contributions to International vaccine funds
This section reauthorizes the existing programs under
section 302 of the Foreign Assistance Act for fiscal years
2009-2013, specifically the vaccine fund, the International
AIDS Vaccine Initiative, and the malaria vaccine development
program. This section also provides a new authorization for a
U.S. contribution to tuberculosis vaccine development programs.
Sec. 202. Participation in the Global Fund to Fight AIDS, Tuberculosis
and Malaria
This section amends section 202 of the 2003 Leadership Act
relating to U.S. contributions to the Global Fund. Subsection
(a) updates findings in the Act and expresses the sense of
Congress regarding transparency, accountability, and
coordination. Subsection (b) increases the annual authorization
for the U.S. contribution to the Global Fund from $1 billion to
up to $2 billion for fiscal years 2009, and such sums as
necessary for fiscal years 2010-2013.
The subsection includes new benchmarks designed to improve
the accountability and transparency of the Global Fund's
activities, including a provision, beginning in fiscal year
2010, that would withhold 20 percent of appropriated funds
until the Secretary of State certifies achievement of certain
benchmarks.
Sec. 203. Microbicide research
Subsection (a) expresses the sense of Congress recognizing
the need and urgency to expand the range of interventions for
preventing the transmission of HIV, including nonvaccine
prevention methods that can be controlled by women.
Subsection (b) amends the Public Health Service Act (42
U.S.C. 300cc-40 et seq.) by directing the Director of the
National Institutes of Health Office of AIDS Research to
develop and implement Federal strategic plans for microbicide
research and to review and update such plans annually,
prioritizing funding and activities relative to scientific
urgency and potential market readiness of microbicide products
as appropriate. The subsection also directs the Director to
consult with representatives of other relevant Federal
agencies, the microbicide research community, and health
advocates. The subsection includes authorization of such sums
as necessary.
Subsection (c) amends the Public Health Service Act by
directing the Director of the National Institute of Allergy and
Infectious Diseases (NIAID) to conduct research and development
of microbicides for use in developing countries to prevent HIV
transmission. The Director shall ensure adequate staffing and
structure to carry out such activities, such as through a
dedicated microbicide research and development branch.
Subsection (d) directs the Director of the Centers for
Disease Control and Prevention (CDC) to fully implement the
CDC's microbicide agenda to support research and development of
microbicides. It authorizes as such sums as may be necessary
for each of fiscal years 2009 through 2013 to carry out these
activities.
Subsection (e) authorizes the Administrator of USAID, in
coordination with the Coordinator of U.S. Government Activities
to Combat HIV/AIDS Globally, to develop and implement a program
to facilitate wide scale availability of microbicides that
prevent the transmission of HIV if such microbicides are proven
safe and effective. It authorizes such sums as may be necessary
for fiscal years 2009 through 2013 to carry out this section.
Sec. 204. Combating HIV/AIDS, tuberculosis, and malaria by
strengthening health policies and health systems of partner
countries
This section amends title II of the 2003 Leadership Act by
adding a new section 204 relating to strengthening health
policies and health systems of host countries. Subsection (a)
provides a statement of policy regarding the need for
strengthening of such health policies and systems. Subsection
(b) authorizes the appropriation of funds authorized under
section 401 of the Act to the Department of Treasury to provide
technical assistance to host countries to improve the public
finance management systems of such countries to enable them to
receive HIV/AIDS assistance, collect revenue, and manage their
own programs.
Sec. 205. Facilitating effective operations of the Centers for Disease
Control and Prevention
This section amends the Public Health Service Act by
authorizing the Secretary of Health and Human Services to
participate with other countries in cooperative endeavors in
research, healthcare services, and other activities authorized
under the Reauthorization Act. The section also strikes a
provision prohibiting the Secretary from providing financial
assistance for the construction of any facility in any foreign
country. It authorizes the provision of funds by advance or
reimbursement to the Secretary of State, as may be necessary,
to pay for the acquisition, lease, construction alteration,
equipping, or managing of facilities outside the United States
and authorizes grants or cooperative agreements relating to
such activities, in consultation with the Secretary of State.
Section 206. Facilitating vaccine development
Subsection (a) authorizes the USAID Administrator to
strengthen the capacity of developing countries' governments to
conduct proper protocols for the introduction of new vaccines,
if such vaccines are proven safe and effective, to review
protocols for clinical trials and impact studies and improve
implementation, and to ensure adequate supply chain and
delivery systems.
Subsection (b) directs the Secretary of the Treasury to
enter into negotiations with appropriate entities including the
World Bank and GAVI Alliance to establish advanced market
commitments to purchase vaccines to combat HIV/AIDS,
tuberculosis, malaria, and other related infectious diseases.
In such negotiations, the Secretary is directed to take into
account factors regarding pricing, transparency, safety,
dispute settlement, and needed flexibility. Not later than 1
year after enactment, the Secretary shall provide the
appropriate congressional committees with a report on
negotiations and the President shall produce a report by a
study group of qualified professionals setting forth a strategy
for vaccine development.
TITLE III--BILATERAL EFFORTS
Subtitle A--General Assistance and Programs
Sec. 301. Assistance to combat HIV/AIDS
This section amends section 104A of the Foreign Assistance
Act of 1961 and section 301 of the 2003 Leadership Act, both of
which relate to bilateral U.S. HIV/AIDS assistance.
Subsection (a) modifies the findings of the 2003 Leadership
Act and identifies that it is a policy objective of the United
States for FY 2009-2013 to assist countries in:
Preventing 12 million new HIV infections;
Supporting treatment of at least 3 million people
with HIV/AIDS as well as additional support through
multilateral efforts;
Supporting care for 12 million people including care
and support for 5 million children affected by HIV/
AIDS;
Providing access to counseling and services for
prevention of mother-to-child transmission to 80
percent of the target population (80 percent is the
level most often defined as ``universal access'');
Providing care and treatment services to children
with HIV/AIDS in proportion to their percentage within
the population of persons who are infected within a
given country; and
Training 140,000 new paraprofessionals and
professionals.
The subsection further amends section 104A by supporting a
coordinated global strategy to confront HIV/AIDS in sub-Saharan
Africa, the Caribbean, Central Asia, Eastern Europe, Latin
America, and other countries and regions to help address
generalized and concentrated HIV/AIDS epidemics, highlighting
the importance of prevention.
Section 301 also notes the activities for which U.S. HIV/
AIDS assistance can be used for prevention, including an
increased focus on counseling, delay of sexual debut,
abstinence, fidelity, life skills, prevention of mother-to-
child HIV transmission, and medical male circumcision. It also
provides for a more coordinated approach to HIV/AIDS by
supporting access to treatment for opportunistic infections and
development programs that can improve the effectiveness of HIV/
AIDS efforts, such as nutrition, education, and programs that
improve the livelihood of individuals with HIV/AIDS as well as
programs to address the needs and vulnerabilities of girls and
women. It promotes the use of provider-initiated or ``opt out''
voluntary counseling and testing as well as rapid testing.
The section underscores the importance of operations
research as a component of HIV/AIDS activities, and amends the
2003 Leadership Act to create an enhanced focus on food and
nutrition assistance as critical to an integrated approach to
treatment of individuals with HIV/AIDS. Section 301 authorizes,
though does not mandate, compacts or framework agreements in
order to promote a more sustainable, country-driven approach.
The section includes necessary components of such compacts. It
also expands the annual report to address a number of the new
approaches described in this Act and to emphasize outcomes of
programs.
Section 301 also amends section 301 of the 2003 Leadership
Act to extend the authorization to fiscal years 2009 through
2013.
Subsection (h) clarifies that not only are groups receiving
funds under the Act not required to endorse or utilize any
activities or programs to which they have a moral or religious
objection, they are also not required to integrate with, or
refer to programs to which they have a moral or religious
objections.
Sec. 302. Assistance to combat tuberculosis
Subsections (a) and (b) amend section 104B of the Foreign
Assistance Act of 1961 relating to assistance to combat
tuberculosis, drawing from S. 968, the Stop Tuberculosis (TB)
Now Act of 2007, which the committee approved on September 11,
2007. These amendments include a revised statement of policy; a
requirement to provide assistance to combat tuberculosis and a
list of activities to be carried out, including diagnostic
testing and counseling, treatment, and implementation of
protocols to address drug resistance.
Subsection (c) authorizes the provision of increased
resources to the World Health Organization.
Subsection (d) offers definitions of additional terms.
Subsection (e) amends section 302 of the 2003 Leadership
Act to authorize up to a total of $4 billion for fiscal years
2009 to 2013 from the overall amounts authorized by section 401
of the 2003 Leadership Act (as amended by this Act) for
assistance to combat tuberculosis.
Sec. 303. Assistance to combat malaria
Subsection (a) amends section 104C of the Foreign
Assistance Act of 1961 to ensure that treatment is part of U.S.
efforts to combat malaria.
Subsection (b) amends section 303 of the 2003 Leadership
Act to authorize up to a total of $5 billion for fiscal years
2009 to 2013 from the overall amounts authorized by section 401
of the 2003 Leadership Act (as amended by this Act) for
assistance to combat malaria.
Subsection (c) provides a statement of policy regarding
malaria.
Subsection (d) requires the President to provide a
comprehensive 5-year strategy to combat malaria.
Sec. 304. Malaria Response Coordinator
Section 304 amends section 304 of the 2003 Leadership Act
by adding a requirement for a comprehensive strategy to combat
malaria and to establish within USAID a malaria coordinator. It
also authorizes contributions to the Roll Back Malaria
Partnership and the World Health Organization; research by
relevant U.S. agencies to address prevention, treatment, and
care of malaria; and requires an annual report on the
prevention, treatment, control and elimination of malaria.
Sec. 305. Amendment to the Immigration and Nationality Act
Section 305 amends section 212(a)(1)(A) of the Immigration
and Nationality Act by removing the statutory prohibition on
persons with HIV entering the country. Under section 212,
should this provision be enacted, aliens remain inadmissible if
they have a ``communicable disease of public health
significance'' under regulations issued by the Secretary for
Health and Human Services.
Sec. 306. Clerical amendment
This provides a technical amendment to a subtitle heading
in the 2003 Act.
Sec. 307. Requirements
This section amends section 312 of the 2003 Leadership Act
to provide for additional policy and other requirements,
including the establishment of targets for reaching 80 percent
of the target population for prevention of mother-to-child
transmission (PMTCT) of HIV and to ensure that the proportion
of children receiving care and treatment for HIV/AIDS is
proportionate to their numbers within the population. The
section also calls for integrating care and treatment with
PMTCT programs; expanding programs for orphans and for children
who are affected by or vulnerable to HIV/AIDS; increasing
access of women in PMTCT programs to maternal and child health
services; and establishing a timeline for expanding access to
PMTCT regimes.
Sec. 308. Annual reports on prevention of mother-to-child transmission
of the HIV infection
This section amends section 313 of the 2003 Leadership Act
by extending the duration of the annual PMTCT report required
by such subsection and requires that such report include
additional information on the number of women who receive
various types of assistance related to PMTCT.
Section 309. Prevention of mother-to-child transmission expert panel
This section amends section 312 of the 2003 Leadership Act
by directing the Global AIDS Coordinator to establish a panel
of experts on the prevention of mother-to-child transmission of
HIV to review PMTCT activities and make recommendations to the
Global AIDS Coordinator and the appropriate congressional
committees. The panel shall terminate 60 days after said report
is submitted.
TITLE IV--FUNDING ALLOCATIONS
Sec. 401. Authorization of appropriations
Subsection (a) increases the authorization under section
401(a) of the 2003 Leadership Act to $50 billion for fiscal
years 2009 to 2013. Unlike the House bill, which provides an
authorization of $10 billion per fiscal year, this allows for a
gradual expansion of the program.
Subsection (b) expresses the sense of the Congress that
these funds should be gradually increased over the 5 fiscal
years covered by the bill and in a manner consistent with
program requirements, absorptive capacity, and priorities set
forth in the Act. The committee does not expect the President
to request or the Congress to fund these programs all in 1
year. For fiscal year 2008, Congress appropriated $6.327
billion for these programs, according to the Congressional
Research Service.
Sec. 402. Sense of Congress
This section amends the ``sense of Congress'' language
included in section 402(b) of the 2003 Leadership Act to
eliminate specific spending directives in the legislation
expressed as a sense of Congress for percentage allocations for
treatment and for the use of prevention funds for abstinence
programs.
Sec. 403. Allocation of funds
This section amends section 403(a) of the 2003 Leadership
Act to maintain focus on balanced prevention programming. This
section includes a requirement that the Coordinator provide
balanced funding for prevention activities for sexual
transmission of HIV/AIDS and ensure that abstinence, delay
sexual debut, monogamy, fidelity and partner reduction programs
are implemented and funded in a meaningful and equitable way in
the strategy for each host country, based on objective
epidemiological evidence as to the source of infection and in
consultation with the government of each host country involved
in HIV/AIDS prevention activities.
The new subsection also provides that the Coordinator shall
establish an HIV sexual transmission prevention strategy
governing the expenditure of funds authorized by the Act used
to prevent the sexual transmission of HIV in any host country
with a generalized epidemic. In each such host country, if this
strategy provides less than 50 percent of such funds for
behavior change programs including abstinence, delay of sexual
debut, monogamy, fidelity, and partner reduction activities,
the Coordinator shall, within 30 days of the issuance of this
strategy, report to the appropriate congressional committees on
the justification for this decision. The subsection excludes
new prevention technologies or modalities such as medical male
circumcision or microbicides as well as PMTCT activities, blood
safety measures, and other prevention tools unrelated to the
sexual transmission of HIV from calculations to determine
compliance with the balanced funding reporting requirement.
Finally, this section maintains the 10-percent earmark for
orphans and vulnerable children, and modifies the focus of this
effort to include children who are vulnerable to, as well as
affected by, HIV/AIDS to allow greater flexibility in providing
services to at-risk children, especially in communities with
high prevalence rates.
VI. Cost Estimate
In accordance with rule XXVI, paragraph 11(a) of the
Standing Rules of the Senate, the committee provides this
estimate of the costs of this legislation prepared by the
Congressional Budget Office.
U.S. Congress,
Congressional Budget Office,
Washington, DC, April 11, 2008.
Hon. Joseph R. Biden, Jr.,
Chairman, Committee on Foreign Relations,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 2731, the Tom Lantos
and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Michelle S.
Patterson.
Sincerely,
Robert A. Sunshine
(For Peter R. Orszag, Director).
Enclosure.
S. 2731--Tom Lantos and Henry J. Hyde U.S. Global Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008
Summary: S. 2731 would reauthorize several assistance
programs aimed at preventing and treating HIV/AIDS,
tuberculosis, and malaria in other countries. For those
programs, the bill would authorize the appropriation of $50
billion over the next 5 years. Other provisions of the bill
would authorize funding for U.S. contributions to international
vaccine funds and for research on the development of substances
that can be applied topically to limit the transmission of HIV.
CBO estimates that implementing S. 2731 would cost $35 billion
over the 2009-2013 period, assuming appropriation of the
authorized amounts. (Additional amounts would be spent after
2013.)
In addition, enacting S. 2731 would increase direct
spending. The bill would allow immigrants with HIV/AIDS to
enter the United States. CBO estimates that providing certain
benefits to those immigrants and their children would increase
direct spending by less than $500,000 in 2010 and by $83
million over the 2010-2018 period. Enacting S. 2731 would have
no effect on revenues.
S. 2731 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
CBO estimates that state spending for Medicaid would increase
by $53 million over the 2010-2018 period as a result of the
bill's immigration provisions, but such spending would not
result from intergovernmental mandates.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 2731 is shown in Table 1. The costs of
this legislation fall within budget functions 150
(international affairs), 550 (health), and 600 (income
security).
TABLE 1.--ESTIMATED BUDGETARY IMPACT OF S. 2731
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
------------------------------------------------------------
2009 2010 2011 2012 2013 2009-2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
HIV/AIDS, Tuberculosis, and Malaria Programs:
Estimated Authorization Level.................. 10,000 10,000 10,000 10,000 10,000 50,000
Estimated Outlays.............................. 1,392 6,392 8,262 9,082 9,482 34,610
Contributions to Vaccine Funds:
Estimated Authorization Level.................. 108 108 108 158 158 640
Estimated Outlays.............................. 108 108 108 158 158 640
Microbicide Research:
Estimated Authorization Level.................. 10 11 13 12 12 58
Estimated Outlays.............................. 4 9 11 12 12 48
Total Changes:
Estimated Authorization........................ 10,118 10,119 10,121 10,170 10,170 50,698
Level Estimated Outlays........................ 1,504 6,509 8,381 9,252 9,652 35,298
CHANGES IN DIRECT SPENDING\1\
Estimated Budget Authority......................... 0 * * 1 2 3
Estimated Outlays.................................. 0 * * 1 2 3
----------------------------------------------------------------------------------------------------------------
\1\In addition to the direct spending effects shown here, enacting S. 2731 would have effects on direct spending
after 2013 (see Table 2). The estimated increase in direct spending sums to $3 million over the 2010-2013
period and $83 million over the 2010-2018 period.
Note: * = less than $500,000.
Basis of estimate: For this estimate, CBO assumes that the
bill will be enacted by September 30, 2008, that the authorized
amounts will be appropriated, and that outlays will follow
historical spending patterns for existing programs.
Spending subject to appropriation
S. 2731 would reauthorize several assistance programs and
increase the funding levels for those programs. It also would
require research into various vaccines and microbicides. In
total, implementing the bill would have discretionary costs of
$1.5 billion in 2009 and $35 billion over the 2009-2013 period.
HIV/AIDS, Tuberculosis, and Malaria Programs. Section 401
would authorize the appropriation of $50 billion over the 2009-
2013 period. For this estimate, CBO assumes that $10 billion
would be appropriated for each of the 5 years, though the
allocation of the $50 billion authorization could vary from
that assumption. The funds would be used to operate and expand
the existing assistance programs that provide grants and
contributions to organizations and global funds devoted to
treating the effects of HIV/AIDS, tuberculosis, and malaria,
and to preventing the transmission of those diseases. Those
programs, which received a total of $6 billion for 2008, are
run by the Department of State, the U.S. Agency for
International Development (USAID), and the Department of Health
and Human Services.
Based on information from the Department of State, CBO
estimates that the authorized 5-year total of $50 billion is
sufficient to fund the expanded requirements. CBO estimates
that implementing section 401 would cost about $35 billion over
the 2009-2013 period. Most of the additional amounts from the
authorized funding would be spent by 2018.
Contribution to Vaccine Funds. Section 201 would authorize
the appropriation of such sums as may be necessary to make
contributions for research and development of various vaccines.
Based on information from USAID on the current amount of
contributions to those funds (about $100 million in 2008) and,
after 2011, the amount needed to fund the final stages of
development for a tuberculosis vaccine, CBO estimates that
implementing section 201 would cost $640 million over the 2009-
2013 period.
Microbicide Research. Section 203 would direct the Centers
for Disease Control and Prevention (CDC) to conduct research
with the goal of developing topical mircobicides that could be
used to limit the transmission of HIV. For that purpose, it
would authorize the appropriation of such sums as necessary.
Based on information from the CDC, CBO estimates that such
research would require $10 million in 2009 and $58 million over
the 2009-2013 period. Assuming appropriation of those amounts,
and that spending for those activities would follow historical
spending patterns, CBO estimates that implementing section 203
would cost $48 million over the 2009-2013 period.
AIDS Drug Assistance Programs. The Ryan White Care Act
provides grants to states to run the AIDS Drug Assistance
Program (ADAP). ADAP provides prescription drug benefits to
certain low-income individuals with HIV/AIDS. Implementing S.
2731 would increase the number of individuals eligible for ADAP
benefits. CBO estimates that the number of people newly
eligible for ADAP benefits would reach about 1,000 in 2011.
The Ryan White Care Act authorizes the appropriation of
specific amounts for ADAP through 2011. Absent a change in the
specific authorization or appropriation for ADAP, no new
Federal funding would be available to meet this increased
demand. If additional funding were provided for the ADAP
program, CBO estimates it would cost about $20 million in 2010
and 2011 to provide ADAP benefits to individuals affected by
section 305. (This section would have direct spending costs, as
explained below.)
Direct spending
Section 305 would amend the Immigration and Nationality Act
by removing language that explicitly identified HIV infection--
and consequently AIDS--as one of the communicable diseases of
public-health significance that render aliens ineligible for
visas or admission to the United States. Based on information
from the CDC, CBO expects that the agency would amend the
regulations concerning communicable diseases to allow aliens
with HIV or AIDS into the United States if section 305 were
enacted. CBO expects that the amended regulations would take
effect at the beginning of fiscal year 2010.
Enacting section 305 would enable additional immigrants to
receive visas to enter the United States, primarily in the visa
program for immediate family members. (For some visa programs,
the number of immigrants with HIV/AIDS would increase, but the
total number of immigrants admitted would not change.) Based on
information from the CDC, the World Health Organization, and
the Department of Homeland Security, CBO estimates the annual
number of additional immigrants with HIV/AIDS would total about
900 in 2010 and grow to approximately 4,300 in fiscal year
2013. Thereafter, the number of additional immigrants would
grow in line with overall immigration, totaling roughly 5,600
in 2018. Additionally, CBO estimates that about 800 citizen-
children would be born to those immigrants between 2010 and
2018, a markedly lower birth rate than that for non-HIV/AIDS
immigrants.
CBO estimates that a small percentage of the immigrants who
would enter the United States under section 305 would receive
Federal disability, health, and nutrition benefits. In total,
CBO estimates that providing benefits to those immigrants and
their children would increase spending by less than $500,000 in
2010 and $83 million over the 2010-2018 period, as shown in
Table 2. (Through 2017, the end of the Senate's enforcement
period for direct spending under the current budget resolution,
the bill would increase direct spending by $46 million.)
TABLE 2.--COMPONENTS OF DIRECT SPENDING UNDER S. 2731
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-------------------------------------------------------------------------
2009- 2009-
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2013 2018
----------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Medicaid:
Estimated Budget Authority.......... 0 * * 1 2 3 5 10 18 31 3 70
Estimated Outlays................... 0 * * 1 2 3 5 10 18 31 3 70
Food and Nutrition Programs:
Estimated Budget Authority.......... 0 * * * * 1 1 1 3 3 * 9
Estimated Outlays................... 0 * * * * 1 1 1 3 3 * 9
Supplemental Security Income:
Estimated Budget Authority.......... 0 * * * * * * * 1 3 * 4
Estimated Outlays................... 0 * * * * * * * 1 3 * 4
Total Changes:
Estimated Budget Authority.......... 0 * * 1 2 4 6 11 22 37 3 83
Estimated Outlays................... 0 * * 1 2 4 6 11 22 37 3 83
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.
Medicaid. Under the Medicaid eligibility rules for
noncitizens, immigrants entering under section 305 who meet
Medicaid's income and categorical eligibility criteria would
have to wait 5 years before they could receive full Medicaid
benefits. However, those individuals would be eligible for
emergency Medicaid services before the end of the 5-year
waiting period.
CBO estimates that enacting section 305 would increase
direct spending for the Federal share of the Medicaid program
by $3 million over the 2010-2013 period and $70 million over
the 2010-2018 period. The increase in estimated costs after
2014 reflects individuals becoming eligible for full Medicaid
benefits after completing the 5-year waiting period.
Food and Nutrition Programs. By 2018, CBO estimates that
about 1,300 newly admitted immigrants would qualify for Food
Stamps with an average benefit of about $130 a month. In
addition, about 4,000 children of the additional immigrants
would be eligible for child nutrition programs in 2018, with an
average monthly cost of about $30 (in 2018 dollars). In total,
CBO estimates that direct spending for the Food Stamp and Child
Nutrition programs would increase by less than $500,000 in 2010
and $9 million over the 2010-2018 period.
Supplemental Security Income (SSI). CBO estimates that
direct spending for the Supplemental Security Income program
would increase by less than $500,000 in 2010 and $4 million
over the 2010-2018 period. Under current law, immigrants
generally have to wait until they became naturalized citizens
before they can receive SSI. Based on data from the CDC, the
Social Security Administration, and private researchers, CBO
estimates that nearly 400 of the additional immigrants under
section 305 would enter the rolls by 2018. Over that period,
CBO projects average monthly benefits would grow from $500 to
$590.
Social Security Disability Insurance. CBO estimates that,
under section 305, off-budget direct spending for the Social
Security Disability Insurance (DI) program would increase by
less than $500,000 over the 10-year budget window. Based on the
age and health profile of immigrants, CBO estimates that few
people would qualify for DI over that period.
Medicare. Noncitizens can become eligible for Medicare if
they are over the age of 65 and are residents of the United
States for five consecutive years, or after receiving DI for 2
years. CBO assumes that few of the new entrants under section
305 would meet either of these eligibility criteria. Therefore,
CBO estimates that direct spending for Medicare would increase
by less than $500,000 over the 2010-2018 period.
Estimated impact on state, local, and tribal governments:
S. 2731 contains no intergovernmental mandates as defined in
UMRA, but changes to immigration law would result in an
increased number of individuals eligible for Medicaid, SSI, and
ADAP. State spending for those programs would increase, but
that additional spending would not result from
intergovernmental mandates.
CBO estimates state spending for Medicaid would increase by
$53 million over the 2010-2018 period, while state spending for
supplemental SSI payments would increase only slightly. ADAP
benefits are state-controlled, voluntary, and federally funded
through grants. Any additional costs to state, local, or tribal
governments might incur in that program, including matching
funds, would result from complying with conditions of aid.
Estimated impact on the private sector: S. 2731 contains no
new private-sector mandates as defined in UMRA.
Previous CBO estimate: On March 5, 2008, CBO transmitted a
cost estimate for H.R. 5501, the Tom Lantos and Henry J. Hyde
U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Reauthorization Act of 2008, as ordered reported by the
House Committee on Foreign Affairs on February 28, 2008. While
the two pieces of legislation have many provisions in common,
S. 2731 contains two provisions that are not included in H.R.
5501. Section 305 of S. 2731 would allow immigrants with HIV to
enter the United States, which CBO estimates would increase
direct spending. In addition, section 203 of S. 2731 would
require the CDC to conduct additional research. Differences in
the estimated costs of S. 2731 and H.R. 5501 reflect those
differences in the legislation.
Estimate prepared by: Federal Costs: Foreign Aid--Michelle
S. Patterson; Centers for Disease Control and Prevention--Tim
Gronniger; Supplemental Security Income--David Rafferty;
Medicaid--Andrea Kastin Noda; Food and Nutrition Programs--
Jonathan Morancy.
Impact on State, Local, and Tribal Governments: Neil Hood;
Impact on the Private Sector: MarDestinee C. Perez.
Estimate approved by: Peter H. Fontaine, Assistant Director
for Budget Analysis.
VII. MINORITY VIEWS
We strongly dissent from the committee's report of S. 2731
to the full Senate. We are gravely concerned that the
President's Emergency Plan for AIDS Relief (PEPFAR) program is
under serious threat of dramatic policy reversals that endanger
the lives of millions around the world suffering from and at
risk of contracting HIV/AIDS. First authorized in 2003, PEPFAR
was a historic new approach to combating HIV/AIDS. The elements
of the program were unprecedented:
Saving the lives of people with AIDS: For the first
time, the U.S. would fund antiretroviral treatment for
millions.
Evidence-based prevention: The U.S. would implement
the African-grown ``ABC'' model of abstinence, ``be
faithful'' and condoms that had led to such dramatic
reductions in HIV incidence in Uganda.
Concentration of effort: Targeted funding for the
poorest countries in sub-Saharan Africa and the
Caribbean with the worst AIDS epidemics.
As the bill to authorize this new initiative moved through
the Congress, its sponsors and supporters fought hard to keep
off the many worthy, but competing initiatives that would have
diluted the impact of the PEPFAR program. Unfortunately, S.
2731 fails to protect the program from similar efforts; and we
are gravely concerned that the noble impact and long-term
legacy of the program are being threatened. Specifically, we
believe that S. 2731 has the following serious flaws:
Politics Trump Proven Prevention Policy
We object to the bill's elimination of the protected
funding for abstinence-until-marriage programs required under
current law and replaces it with watered-down, ill-defined
language that would permit a prevention program to operate
without measurable, significant support for abstinence and
fidelity programs. Prior to the implementation of PEPFAR, the
only country to ever demonstrate a nationwide reduction in HIV
incidence was Uganda. The success was driven by the African-
grown, grassroots, low-tech, low-cost ``ABC'' model of HIV
prevention, based on three commonsense messages, each targeted
to a different population: (1) The promotion of abstinence
until marriage or delay of sexual debut for youth and unmarried
adults, (2) the promotion of fidelity within marriage and
partner reduction for sexually active unmarried adults, and (3)
the promotion of the consistent and correct use of condoms for
especially high-risk subpopulations, such as prostitutes and
their customers, substance abusers and their equipment-sharing
and sexual partners, and HIV-serodiscordant married couples.
The evidence is clear: ABC works to prevent sexual transmission
of HIV/AIDS in a generalized epidemic such as you find in sub-
Saharan Africa. Nothing else ever has. As a result of this
sound approach, Uganda now has company: Several PEPFAR focus
countries have started to see reductions, including Kenya, Cote
D'Ivoire, and Ethiopia.
No Conscience Protections for Organizations Providing HIV/AIDS Care
The bill removes most references to faith-based
organizations contained in current law, causing us to question
whether the bill authors intend PEPFAR to retreat from its
important recognition of the indispensable role of such
organizations in reaching communities affected by HIV/AIDS in
the developing world that might never be successfully reached
using U.S.-based USAID contractors. Of even more concern,
however, is the bill's elimination of conscience protections
for organizations providing the critical third element of the
HIV treatment, prevention, and care combination. The bill
protects organizations participating in HIV/AIDS treatment,
prevention, and monitoring programs from being required to
support or provide services to which they have a moral or
religious objection. However, no such protection is provided
for organizations providing HIV ``care'' programs, which
include all programs for orphans and vulnerable children,
hospice and palliative care services, support groups and
psychosocial services and many other services.
Support for Morally Dubious Activities
The bill contains many references to activities
``demonstrated to be effective in reducing the transmission of
HIV infection among injection drug users without increasing
illicit drug use.'' Given the claim by some that programs to
distribute clean needles to injection drug users are effective
at reducing transmission and do not lead to more drug use,
these provisions could be interpreted to support needle
exchange programs, a practice not currently supported
domestically or abroad using U.S. funds. Americans should not
be forced to subsidize the distribution of paraphernalia for
illicit drug use, when the best HIV prevention for injection
drug use would be treatment of the underlying addiction.
The Global Fund Takes Cues from the U.N.
When the 108th Congress authorized the first contribution
to the Global Fund to Fight HIV/AIDS, Tuberculosis, we were
assured that the Fund would not be like the U.N. and that the
Fund would guarantee full transparency and accountability. The
current law contains some important provisions to protect the
taxpayer investment in this multilateral disease-fighting
organization. However, we have seen during the first few years
of the Fund's operation that these provisions have not been
sufficient to ensure full accountability and transparency by
the scandal-ridden Fund. What's more, the Fund has failed to
provide Congress with all documents requested, including
reports of the so-called ``independent'' Inspector General. The
Fund has lost money by relying on the U.N. Development Program
(UNDP) in Burma, and failed to recoup funds from terminated
grants there. Burma is not the only country where the Fund
relies on UNDP, but actually uses the U.N. agency as a
``safer'' alternative to directly funding rogue regimes such as
Zimbabwe and Sudan. UNDP is under investigation by the U.S.
Senate Permanent Subcommittee on Investigations for using donor
money to finance North Korea illicit weapons sales; laundering
untold millions from terrorist regimes through U.N. bank
accounts; using donor money to help Zimbabwe officials purchase
``blood diamonds''; and a variety of other crimes.
Further, the Fund has failed to adequately safeguard the
quality of medicines procured using its funding. While we
support the bill's provision conditioning 20 percent of the
U.S. contribution to the Fund to the achievement of certain
accountability measures, the bill also contains a variety of
important transparency measures in a nonbinding ``Sense of
Congress'' provision. We believe that these provisions should
be made binding, as well.
Fiscal Irresponsibility
Before PEPFAR was authorized, the U.S. spent less than $200
million annually on global AIDS. Compared to past levels,
PEPFAR's initial authorization of $15 billion over 5 years was
a dramatic increase. Indeed, the administration has ramped up
to an annual spending level that grossly exceeds the statutory
limit in current law. Even if Congress agreed to extend funding
at these unauthorized levels, we would ``only'' need to pass a
reauthorization bill to provide between $25-$30 billion over
the next 5 years. S. 2731, however, authorizes $50 billion over
5 years in addition to numerous, ``such sums'' authorizations.
What's more, the current targeted, effective HIV/AIDS
program is under assault in this bill by ``mission creep'' that
threatens to dilute the impact of the program and violate all
pretentions of fiscal restraint by prioritizing seemingly every
activity except HIV treatment, prevention, and care. The bill's
HIV programs are crowded out by every possible development
program imaginable, including schools, poverty alleviation,
microcredit, legal aid, government advocacy, women's
``empowerment,'' ``stigma reduction,'' nutrition, U.S.-based
university agricultural research, biomedical vaccine
development, and health workforce development. In addition to
squeezing-out the higher priority HIV programs, the inclusion
of all these additional development programs will only
guarantee that the pressure to exceed the authorization caps in
the bill will be irresistible in the out years as the
development needs of the world can never be fully met.
CONCLUSION
The PEPFAR program has been one of the few success stories
of U.S. foreign assistance policy. The scientific policy has
been sound, the fiscal priorities appropriate, and the results
astounding. As a means of building diplomatic good will, PEPFAR
has been an unquestioned success in strengthening bilateral
relationships in the important emerging governments and
economies in Africa. Simply put, the program isn't ``broken.''
The best approach to reauthorization would be to simply extend
current authorities at a fiscally responsible level. S. 2731 is
a radical departure from current policy, and will serve to
reverse the many gains the program has achieved to date. We
dissent from the committee's report of the bill to the Senate
for full consideration.
Sincerely,
David Vitter,
U.S. Senator.
Jim DeMint,
U.S. Senator.
VIII. 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).
The United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003
* * * * * * *
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) * * *
* * * * * * *
(28) * * *
(29) On May 27, 2003, the President signed this Act
into law, launching the largest international public
health program of its kind ever created.
(30) Between 2003 and 2008, the United States,
through the President''s Emergency Plan for AIDS Relief
(PEPFAR) and in conjunction with other bilateral
programs and the multilateral Global Fund has helped
to--
(A) provide antiretroviral therapy for over
1,900,000 people;
(B) ensure that over 150,000 infants, most of
whom would have likely been infected with HIV
during pregnancy or childbirth, were not
infected; and
(C) provide palliative care and HIV
prevention assistance to millions of other
people.
(31) While United States leadership in the battles
against HIV/AIDS, tuberculosis, and malaria has had an
enormous impact, these diseases continue to take a
terrible toll on the human race.
(32) According to the 2007 AIDS Epidemic Update of
the Joint United Nations Programme on HIV/AIDS
(UNAIDS)--
(A) an estimated 2,100,000 people died of
AIDS-related causes in 2007; and
(B) an estimated 2,500,000 people were newly
infected with HIV during that year.
(33) According to the World Health Organization,
malaria kills more than 1,000,000 people per year, 70
percent of whom are children under 5 years of age.
(34) According to the World Health Organization, \1/
3\ of the world''s population is infected with the
tuberculosis bacterium, and tuberculosis is 1 of the
greatest infectious causes of death of adults
worldwide, killing 1,600,000 people per year.
(35) Efforts to promote abstinence, fidelity, the
correct and consistent use of condoms, the delay of
sexual debut, and the reduction of concurrent sexual
partners represent important elements of strategies to
prevent the transmission of HIV/AIDS.
(36) According to UNAIDS--
(A) women and girls make up nearly 60 percent
of persons in sub-Saharan Africa who are HIV
positive;
(B) women and girls are more biologically,
economically, and socially vulnerable to HIV
infection; and
(C) gender issues are critical components in
the effort to prevent HIV/AIDS and to care for
those affected by the disease.
(37) Children who have lost a parent to HIV/AIDS, who
are otherwise directly affected by the disease, or who
live in areas of high HIV prevalence may be vulnerable
to the disease or its socioeconomic effects.
(38) Lack of health capacity, including insufficient
personnel and inadequate infrastructure, in sub-Saharan
Africa and other regions of the world is a critical
barrier that limits the effectiveness of efforts to
combat HIV/AIDS, tuberculosis, and malaria, and to
achieve other global health goals.
(39) On March 30, 2007, the Institute of Medicine of
the National Academies released a report entitled
``PEPFAR Implementation: Progress and Promise'', which
found that budget allocations setting percentage levels
for spending on prevention, care, and treatment and for
certain subsets of activities within the prevention
category--
(A) have ``adversely affected implementation
of the U.S. Global AIDS Initiative'';
(B) have inhibited comprehensive, integrated,
evidence based approaches;
(C) ``have been counterproductive'';
(D) ``may have been helpful initially in
ensuring a balance of attention to activities
within the 4 categories of prevention,
treatment, care, and orphans and vulnerable
children'';
(E) ``have also limited PEPFAR''s ability to
tailor its activities in each country to the
local epidemic and to coordinate with the level
of activities in the countries'' national
plans''; and
(F) should be removed by Congress and
replaced with more appropriate mechanisms
that--
(i) ``ensure accountability for
results from Country Teams to the U.S.
Global AIDS Coordinator and to
Congress''; and
(ii) ``ensure that spending is
directly linked to and commensurate
with necessary efforts to achieve both
country and overall performance targets
for prevention, treatment, care, and
orphans and vulnerable children''.
(40) The United States Government has endorsed the
principles of harmonization in coordinating efforts to
combat HIV/AIDS commonly referred to as the ``Three
Ones'', which includes--
(A) 1 agreed HIV/AIDS action framework that
provides the basis for coordination of the work
of all partners;
(B) 1 national HIV/AIDS coordinating
authority, with a broadbased multisectoral
mandate; and
(C) 1 agreed HIV/AIDS country-level
monitoring and evaluating system.
(41) In the Abuja Declaration on HIV/AIDS,
Tuberculosis and Other Related Infectious Diseases, of
April 26-27, 2001 (referred to in this Act as the
``Abuja Declaration''), the Heads of State and
Government of the Organization of African Unity (OAU)--
(A) declared that they would ``place the
fight against HIV/AIDS at the forefront and as
the highest priority issue in our respective
national development plans'';
(B) committed ``TO TAKE PERSONAL
RESPONSIBILITY AND PROVIDE LEADERSHIP for the
activities of the National AIDS Commissions/
Councils'';
(C) resolved ``to lead from the front the
battle against HIV/AIDS, Tuberculosis and Other
Related Infectious Diseases by personally
ensuring that such bodies were properly
convened in mobilizing our societies as a whole
and providing focus for unified national
policymaking and programme implementation,
ensuring coordination of all sectors at all
levels with a gender perspective and respect
for human rights, particularly to ensure equal
rights for people living with HIV/AIDS''; and
(D) pledged ``to set a target of allocating
at least 15% of our annual budget to the
improvement of the health sector''.
* * * * * * *
SEC. 3. DEFINITIONS.
In this Act:
(1) AIDS.--The term ``AIDS'' means the acquired
immune deficiency syndrome.
(2) Appropriate congressional committees.--The term
``appropriate congressional committees'' means the
Committee on Foreign Relations of the Senate and the
[Committee on International Relations] Committee on
Foreign Affairs of the House of Representatives, the
Committee on Appropriations of the Senate, and the
Committee on Appropriations of the House of
Representatives.
(3) Global aids coordinator.--The term ``Global AIDS
Coordinator'' means the Coordinator of United States
Government Activities to Combat HIV/AIDS Globally.
[(3)] (4) Global fund.--The term ``Global Fund''
means the public-private partnership known as the
Global Fund to Fight AIDS, Tuberculosis and Malaria
established pursuant to Article 80 of the Swiss Civil
Code.
[(4)] (5) HIV.--The term ``HIV'' means the human
immunodeficiency virus, the pathogen that causes AIDS.
[(5)] (6) HIV/AIDS.--The term ``HIV/AIDS'' means,
with respect to an individual, an individual who is
infected with HIV or living with AIDS.
(7) Impact evaluation research.--The term ``impact
evaluation research'' means the application of research
methods and statistical analysis to measure the extent
to which change in a population-based outcome can be
attributed to program intervention instead of other
environmental factors.
(8) Operations research.--The term ``operations
research'' means the application of social science
research methods and statistical analysis to judge,
compare, and improve policies and program outcomes,
from the earliest stages of defining and designing
programs through their development and implementation,
with the objective of the rapid dissemination of
conclusions and concrete impact on programming.
(9) Paraprofessional.--The term ``paraprofessional''
means an individual who is trained and employed as a
health agent for the provision of basic assistance in
the identification, prevention, or treatment of illness
or disability.
(10) Partner government.--The term ``partner
government'' means a government with which the United
States is working to provide assistance to combat HIV/
AIDS, tuberculosis, or malaria on behalf of people
living within the jurisdiction of such government.
(11) Program monitoring.--The term ``program
monitoring'' means the collection, analysis, and use of
routine program data to determine--
(A) how well a program is carried out; and
(B) how much the program costs.
(12) Structural hiv prevention.--The term
``structural HIV prevention'' means activities or
programs designed to--
(A) address environmental factors that could
create conditions conducive to the spread of
HIV; and
(B) determine the best ways to remedy such
factors by enhancing life skills and promoting
changes in laws, policies, and social norms.
[(6)] (13) Relevant executive branch agencies.--The
term ``relevant executive branch agencies'' means the
Department of State, the United States Agency for
International Development, and any other department or
agency of the United States that participates in
international HIV/AIDS activities pursuant to the
authorities of such department or agency or the Foreign
Assistance Act of 1961.
[SEC. 4. PURPOSE.
[The purpose of this Act is to strengthen United States
leadership and the effectiveness of the United States response
to certain global infectious diseases by--
[(1) establishing a comprehensive, integrated five-
year, global strategy to fight HIV/AIDS that
encompasses a plan for phased expansion of critical
programs and improved coordination among relevant
executive branch agencies and between the United States
and foreign governments and international
organizations;
[(2) providing increased resources for multilateral
efforts to fight HIV/AIDS;
[(3) providing increased resources for United States
bilateral efforts, particularly for technical
assistance and training, to combat HIV/AIDS,
tuberculosis, and malaria;
[(4) encouraging the expansion of private sector
efforts and expanding public-private sector
partnerships to combat HIV/AIDS; and
[(5) intensifying efforts to support the development
of vaccines and treatment for HIV/AIDS, tuberculosis,
and malaria.]
SEC. 4. PURPOSE.
The purpose of this Act is to strengthen and enhance United
States leadership and the effectiveness of the United States
response to the HIV/AIDS, tuberculosis, and malaria pandemics
and other related and preventable infectious diseases as part
of the overall United States health and development agenda by--
(1) establishing comprehensive, coordinated, and
integrated 5-year, global strategies to combat HIV/
AIDS, tuberculosis, and malaria by--
(A) building on progress and successes to
date;
(B) improving harmonization of United States
efforts with national strategies of partner
governments and other public and private
entities; and
(C) emphasizing capacity building initiatives
in order to promote a transition toward greater
sustainability through the support of country-
driven efforts;
(2) providing increased resources for bilateral and
multilateral efforts to fight HIV/AIDS, tuberculosis,
and malaria as integrated components of United States
development assistance;
(3) intensifying efforts to--
(A) prevent HIV infection;
(B) ensure the continued support for, and
expanded access to, treatment and care
programs;
(C) enhance the effectiveness of prevention,
treatment, and care programs; and
(D) address the particular vulnerabilities of
girls and women;
(4) encouraging the expansion of private sector
efforts and expanding public-private sector
partnerships to combat HIV/AIDS, tuberculosis, and
malaria;
(5) reinforcing efforts to--
(A) develop safe and effective vaccines,
microbicides, and other prevention and
treatment technologies; and
(B) improve diagnostics capabilities for HIV/
AIDS, tuberculosis, and malaria; and
(6) helping partner countries to--
(A) strengthen health systems;
(B) improve human health capacity; and
(C) address infrastructural weaknesses.
SEC. 5. AUTHORITY TO CONSOLIDATE AND COMBINE REPORTS.
With respect to the reports required by this Act to be
submitted by the President, to ensure an efficient use of
resources, the President may, in his discretion and
notwithstanding any other provision of this Act, consolidate or
combine any of these reports, except for the report required by
section 101 of this Act, so long as the required elements of
each report are addressed and reported within a 90-day period
from the original deadline date for submission of the report
specified in this Act. The President may also enter into
contracts with organizations with relevant expertise to
develop, originate, or contribute to any of the reports
required by this Act to be submitted by the President, with the
exception of the 5-year strategy.
TITLE I--POLICY PLANNING AND COORDINATION
SEC. 101. DEVELOPMENT OF A COMPREHENSIVE, FIVE-YEAR, GLOBAL STRATEGY.
[(a) Strategy.--The President shall establish a
comprehensive, integrated, five-year strategy to combat global
HIV/AIDS that strengthens the capacity of the United States to
be an effective leader of the international campaign against
HIV/AIDS. Such strategy shall maintain sufficient flexibility
and remain responsive to the ever-changing nature of the HIV/
AIDS pandemic and shall--
[(1) include specific objectives, multisectoral
approaches, and specific strategies to treat
individuals infected with HIV/AIDS and to prevent the
further spread of HIV infections, with a particular
focus on the needs of families with children (including
the prevention of mother-to-child transmission), women,
young people, and children (such as unaccompanied minor
children and orphans);
[(2) as part of the strategy, implement a tiered
approach to direct delivery of care and treatment
through a system based on central facilities augmented
by expanding circles of local delivery of care and
treatment through local systems and capacity;
[(3) assign priorities for relevant executive branch
agencies;
[(4) provide that the reduction of HIV/AIDS
behavioral risks shall be a priority of all prevention
efforts in terms of funding, educational messages, and
activities by promoting abstinence from sexual activity
and substance abuse, encouraging monogamy and
faithfulness, promoting the effective use of condoms,
and eradicating prostitution, the sex trade, rape,
sexual assault and sexual exploitation of women and
children;
[(5) improve coordination and reduce duplication
among relevant executive branch agencies, foreign
governments, and international organizations;
[(6) project general levels of resources needed to
achieve the stated objectives;
[(7) expand public-private partnerships and the
leveraging of resources;
[(8) maximize United States capabilities in the areas
of technical assistance and training and research,
including vaccine research;
[(9) establish priorities for the distribution of
resources based on factors such as the size and
demographics of the population with HIV/AIDS,
tuberculosis, and malaria and the needs of that
population and the existing infrastructure or funding
levels that may exist to cure, treat, and prevent HIV/
AIDS, tuberculosis, and malaria; and
[(10) include initiatives describing how the
President will maximize the leverage of private sector
dollars in reduction and treatment of HIV/AIDS,
tuberculosis, and malaria.]
(a) Strategy.--The President shall establish a comprehensive,
integrated, 5-year strategy to expand and improve efforts to
combat global HIV/AIDS. This strategy shall--
(1) further strengthen the capability of the United
States to be an effective leader of the international
campaign against this disease and strengthen the
capacities of nations experiencing HIV/AIDS epidemics
to combat this disease;
(2) maintain sufficient flexibility and remain
responsive to--
(A) changes in the epidemic;
(B) challenges facing partner countries in
developing and implementing an effective
national response; and
(C) evidence-based improvements and
innovations in the prevention, care, and
treatment of HIV/AIDS;
(3) 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;
(4) provide a plan to--
(A) prevent 12,000,000 new HIV infections
worldwide;
(B) support treatment of at least 3,000,000
individuals with HIV/AIDS and support
additional treatment through coordinated
multilateral efforts;
(C) support care for 12,000,000 individuals
with HIV/AIDS, including 5,000,000 orphans and
vulnerable children affected by HIV/AIDS, with
an emphasis on promoting a comprehensive,
coordinated system of services to be integrated
throughout the continuum of care;
(D) help partner countries in the effort to
achieve goals of 80 percent access to
counseling, testing, and treatment to prevent
the transmission of HIV from mother to child,
emphasizing a continuum of care model;
(E) help partner countries to provide care
and treatment services to children with HIV in
proportion to their percentage within the HIV-
infected population in each country;
(F) promote preservice training for health
professionals designed to strengthen the
capacity of institutions to develop and
implement policies for training health workers
to combat HIV/AIDS, tuberculosis, and malaria;
(G) equip teachers with skills needed for
HIV/AIDS prevention, treatment, and care;
(H) provide and share best practices for
combating HIV/AIDS with health professionals;
and
(I) help partner countries to train and
support retention of healthcare professionals
and paraprofessionals, with the target of
training and retaining at least 140,000 new
healthcare professionals and paraprofessionals
and to strengthen capacities in developing
countries, especially in sub-Saharan Africa, to
deliver primary healthcare with the objective
of helping countries achieve staffing levels of
at least 2.3 doctors, nurses, and midwives per
1,000 population, as called for by the World
Health Organization;
(5) include multisectoral approaches and specific
strategies to treat individuals infected with HIV/AIDS
and to prevent the further transmission of HIV
infections, with a particular focus on the needs of
families with children (including the prevention of
mother-to-child transmission), women, young people,
orphans, and vulnerable children;
(6) establish a timetable with annual global
treatment targets;
(7) expand the integration of timely and relevant
research within the prevention, care, and treatment of
HIV/AIDS;
(8) include a plan for program monitoring, operations
research, and impact evaluation and for the
dissemination of a best practices report to highlight
findings;
(9) provide for consultation with local leaders and
officials to develop prevention strategies and programs
that are tailored to the unique needs of each country
and community and targeted particularly toward those
most at risk of acquiring HIV infection;
(10) make the reduction of HIV/AIDS behavioral risks
a priority of all prevention efforts by--
(A) promoting abstinence from sexual activity
and encouraging monogamy and faithfulness;
(B) encouraging the correct and consistent
use of male and female condoms and increasing
the availability of, and access to, these
commodities;
(C) promoting the delay of sexual debut and
the reduction of multiple concurrent sexual
partners;
(D) promoting education for discordant
couples (where an individual is infected with
HIV and the other individual is uninfected or
whose status is unknown) about safer sex
practices;
(E) promoting voluntary counseling and
testing, addiction therapy, and other
prevention and treatment tools for illicit
injection drug users and other substance
abusers;
(F) educating men and boys about the risks of
procuring sex commercially and about the need
to end violent behavior toward women and girls;
(G) supporting comprehensive programs to
promote alternative livelihoods, safety, and
social reintegration strategies for commercial
sex workers and their families;
(H) promoting cooperation with law
enforcement to prosecute offenders of
trafficking, rape, and sexual assault crimes
with the goal of eliminating such crimes; and
(I) working to eliminate rape, gender-based
violence, sexual assault, and the sexual
exploitation of women and children;
(11) include programs to reduce the transmission of
HIV through structural prevention efforts, particularly
addressing the heightened vulnerabilities of women and
girls to HIV in many countries; and
(12) support other important means of preventing or
reducing the transmission of HIV, including--
(A) medical male circumcision;
(B) the maintenance of a safe blood supply;
and
(C) other mechanisms to reduce the
transmission of HIV;
(13) increase support for prevention of mother-to-
child transmission;
(14) build capacity within the public health sector
of developing countries by improving health systems and
public health infrastructure and developing indicators
to measure changes in broader public health sector
capabilities;
(15) increase the coordination of HIV/AIDS programs
with development programs;
(16) provide a framework for expanding or developing
existing or new country or regional programs,
including--
(A) drafting compacts or other agreements, as
appropriate;
(B) establishing criteria and objectives for
such compacts and agreements; and
(C) promoting sustainability;
(17) provide a plan for national and regional
priorities for resource distribution and a global
investment plan by region;
(18) provide a plan to address the immediate and
ongoing needs of women and girls, which--
(A) addresses the vulnerabilities that
contribute to their elevated risk of infection;
(B) includes specific goals and targets to
address these factors;
(C) provides clear guidance to field missions
to integrate gender across prevention, care,
and treatment programs;
(D) sets forth gender-specific indicators to
monitor progress on outcomes and impacts of
gender programs;
(E) supports efforts in countries in which
women or orphans lack inheritance rights and
other fundamental protections to promote the
passage, implementation, and enforcement of
such laws;
(F) supports life skills training and other
structural prevention activities, especially
among women and girls, with the goal of
reducing vulnerabilities to HIV/AIDS;
(G) addresses and prevents gender-based
violence; and
(H) addresses the posttraumatic and
psychosocial consequences and provides
postexposure prophylaxis protecting against HIV
infection to victims of gender-based violence
and rape;
(19) provide a plan to address the vulnerabilities
and needs of orphans and children who are vulnerable
to, or affected by, HIV/AIDS;
(20) provide a framework to work with international
actors and partner countries toward universal access to
HIV/AIDS prevention, treatment, and care programs,
recognizing that prevention is of particular importance
in terms of sequencing;
(21) enhance the coordination of United States
bilateral efforts to combat global HIV/AIDS with other
major public and private entities;
(22) enhance the attention given to the national
strategic HIV/AIDS plans of countries receiving United
States assistance by--
(A) reviewing the planning and programmatic
decisions associated with that assistance; and
(B) helping to strengthen such national
strategies, if necessary;
(23) support activities described in the Global Plan
to Stop TB, including--
(A) expanding and enhancing the coverage of
the Directly Observed Treatment Short-course
(DOTS) in order to treat individuals infected
with tuberculosis and HIV, including multi-drug
resistant or extensively drug resistant
tuberculosis; and
(B) improving coordination and integration of
HIV/AIDS and tuberculosis programming;
(24) ensure coordination between the Global AIDS
Coordinator and the Malaria Coordinator and address
issues of comorbidity between HIV/AIDS and malaria; and
(25) include a longer term estimate of the projected
resource needs, progress toward greater sustainability
and country ownership of HIV/AIDS programs, and the
anticipated role of the United States in the global
effort to combat HIV/AIDS during the 10-year period
beginning on October 1, 2013.
[(b) Report.--
[(1) In general.--Not later than 270 days after the
date of enactment of this Act, the President shall
submit to the appropriate congressional committees a
report setting forth the strategy described in
subsection (a).
[(2) Report contents.--The report required by
paragraph (1) shall include a discussion of the
elements described in paragraph (3) and may include a
discussion of additional elements relevant to the
strategy described in subsection (a). Such discussion
may include an explanation as to why a particular
element described in paragraph (3) is not relevant to
such strategy.
[(3) Report elements.--The elements referred to in
paragraph (2) are the following:
[(A) The objectives, general and specific, of
the strategy.
[(B) A description of the criteria for
determining success of the strategy.
[(C) A description of the manner in which the
strategy will address the fundamental elements
of prevention and education, care, and
treatment (including increasing access to
pharmaceuticals and to vaccines), the promotion
of abstinence, monogamy, avoidance of substance
abuse, and use of condoms, research (including
incentives for vaccine development and new
protocols), training of healthcare workers, the
development of healthcare infrastructure and
delivery systems, and avoidance of substance
abuse.
[(D) A description of the manner in which the
strategy will promote the development and
implementation of national and community-based
multisectoral strategies and programs,
including those designed to enhance leadership
capacity particularly at the community level.
[(E) A description of the specific strategies
developed to meet the unique needs of women,
including the empowerment of women in
interpersonal situations, young people and
children, including those orphaned by HIV/AIDS
and those who are victims of the sex trade,
rape, sexual abuse, assault, and exploitation.
[(F) A description of the specific strategies
developed to encourage men to be responsible in
their sexual behavior, child rearing and to
respect women including the reduction of sexual
violence and coercion.
[(G) A description of the specific strategies
developed to increase women's access to
employment opportunities, income, productive
resources, and microfinance programs.
[(H) A description of the programs to be
undertaken to maximize United States
contributions in the areas of technical
assistance, training (particularly of
healthcare workers and community-based leaders
in affected sectors), and research, including
the promotion of research on vaccines and
microbicides.
[(I) An identification of the relevant
executive branch agencies that will be involved
and the assignment of priorities to those
agencies.
[(J) A description of the role of each
relevant executive branch agency and the types
of programs that the agency will be
undertaking.
[(K) A description of the mechanisms that
will be utilized to coordinate the efforts of
the relevant executive branch agencies, to
avoid duplication of efforts, to enhance on-
site coordination efforts, and to ensure that
each agency undertakes programs primarily in
those areas where the agency has the greatest
expertise, technical capabilities, and
potential for success.
[(L) A description of the mechanisms that
will be utilized to ensure greater coordination
between the United States and foreign
governments and international organizations
including the Global Fund, UNAIDS,
international financial institutions, and
private sector organizations.
[(M) The level of resources that will be
needed on an annual basis and the manner in
which those resources would generally be
allocated among the relevant executive branch
agencies.
[(N) A description of the mechanisms to be
established for monitoring and evaluating
programs, promoting successful models, and for
terminating unsuccessful programs.
[(O) A description of the manner in which
private, nongovernmental entities will factor
into the United States Government-led effort
and a description of the type of partnerships
that will be created to maximize the
capabilities of these private sector entities
and to leverage resources.
[(P) A description of the ways in which
United States leadership will be used to
enhance the overall international response to
the HIV/AIDS pandemic and particularly to
heighten the engagement of the member states of
the G-8 and to strengthen key financial and
coordination mechanisms such as the Global Fund
and UNAIDS.
[(Q) A description of the manner in which the
United States strategy for combating HIV/AIDS
relates to and supports other United States
assistance strategies in developing countries.
[(R) A description of the programs to be
carried out under the strategy that are
specifically targeted at women and girls to
educate them about the spread of HIV/AIDS.
[(S) A description of efforts being made to
address the unique needs of families with
children with respect to HIV/AIDS, including
efforts to preserve the family unit.
[(T) An analysis of the emigration of
critically important medical and public health
personnel, including physicians, nurses, and
supervisors from sub-Saharan African countries
that are acutely impacted by HIV/AIDS,
including a description of the causes, effects,
and the impact on the stability of health
infrastructures, as well as a summary of
incentives and programs that the United States
could provide, in concert with other private
and public sector partners and international
organizations, to stabilize health institutions
by encouraging critical personnel to remain in
their home countries.
[(U) A description of the specific strategies
developed to promote sustainability of HIV/AIDS
pharmaceuticals (including antiretrovirals) and
the effects of drug resistance on HIV/AIDS
patients.
[(V) A description of the specific strategies
to ensure that the extraordinary benefit of
HIV/AIDS pharmaceuticals (especially
antiretrovirals) are not diminished through the
illegal counterfeiting of pharmaceuticals and
black market sales of such pharmaceuticals.
[(W) An analysis of the prevalence of Human
Papilloma Virus (HPV) in sub-Saharan Africa and
the impact that condom usage has upon the
spread of HPV in sub-Saharan Africa.]
(b) Report.--
(1) In general.--Not later than October 1, 2009, the
President shall submit a report to the appropriate
congressional committees that sets forth the strategy
described in subsection (a).
(2) Contents.--The report required under paragraph
(1) shall include a discussion of the following
elements:
(A) The purpose, scope, methodology, and
general and specific objectives of the
strategy.
(B) The problems, risks, and threats to the
successful pursuit of the strategy.
(C) The desired goals, objectives,
activities, and outcome-related performance
measures of the strategy.
(D) A description of future costs and
resources needed to carry out the strategy.
(E) A delineation of United States Government
roles, responsibility, and coordination
mechanisms of the strategy.
(F) A description of the strategy--
(i) to promote harmonization of
United States assistance with that of
other international, national, and
private actors as elucidated in the
``Three Ones''; and
(ii) to address existing challenges
in harmonization and alignment.
(G) A description of the manner in which the
strategy will--
(i) further the development and
implementation of the national
multisectoral strategic HIV/AIDS
frameworks of partner governments; and
(ii) enhance the centrality,
effectiveness, and sustainability of
those national plans.
(H) A description of how the strategy will
seek to achieve the specific targets described
in subsection (a) and other targets, as
appropriate.
(I) A description of, and rationale for, the
timetable for annual global treatment targets.
(J) A description of how operations research
is addressed in the strategy and how such
research can most effectively be integrated
into care, treatment, and prevention activities
in order to--
(i) improve program quality and
efficiency;
(ii) ascertain cost effectiveness;
(iii) ensure transparency and
accountability;
(iv) assess population-based impact;
(v) disseminate findings and best
practices; and
(vi) optimize delivery of services.
(K) An analysis of United States-assisted
strategies to prevent the transmission of HIV/
AIDS, including methodologies to promote
abstinence, monogamy, faithfulness, the correct
and consistent use of male and female condoms,
reductions in concurrent sexual partners, and
delay of sexual debut, and of intended
monitoring and evaluation approaches to measure
the effectiveness of prevention programs and
ensure that they are targeted to appropriate
audiences.
(L) Within the analysis required under
subparagraph (J), an examination of additional
planned means of preventing the transmission of
HIV including medical male circumcision,
maintenance of a safe blood supply, and other
tools.
(M) A description of the specific targets,
goals, and strategies developed to address the
needs and vulnerabilities of women and girls to
HIV/AIDS, including--
(i) structural prevention activities;
(ii) activities directed toward men
and boys;
(iii) activities to enhance
educational, microfinance, and
livelihood opportunities for women and
girls;
(iv) activities to promote and
protect the legal empowerment of women,
girls, and orphans and vulnerable
children;
(v) programs targeted toward gender-
based violence and sexual coercion;
(vi) strategies to meet the
particular needs of adolescents;
(vii) assistance for victims of rape,
sexual abuse, assault, exploitation,
and trafficking; and
(viii) programs to prevent alcohol
abuse.
(N) A description of strategies--
(i) to address the needs of orphans
and vulnerable children, including an
analysis of--
(I) factors contributing to
children's vulnerability to
HIV/AIDS; and
(II) vulnerabilities caused
by the impact of HIV/AIDS on
children and their families;
and
(ii) in areas of higher HIV/AIDS
prevalence, to promote a community-
based approach to vulnerability,
maximizing community input into
determining which children participate.
(O) A description of capacity-building
efforts undertaken by countries themselves,
including adherents of the Abuja Declaration
and an assessment of the impact of
International Monetary Fund macroeconomic and
fiscal policies on national and donor
investments in health.
(P) A description of the strategy to--
(i) strengthen capacity building
within the public health sector;
(ii) improve healthcare in those
countries;
(iii) help countries to develop and
implement national health workforce
strategies;
(iv) strive to achieve goals in
training, retaining, and effectively
deploying health staff;
(v) promote ethical recruiting
practices for healthcare workers; and
(vi) increase the sustainability of
health programs.
(Q) A description of the criteria for
selection, objectives, methodology, and
structure of compacts or other framework
agreements with countries or regional
organizations, including--
(i) the role of civil society;
(ii) the degree of transparency;
(iii) benchmarks for success of such
compacts or agreements; and
(iv) the relationship between such
compacts or agreements and the national
HIV/AIDS and public health strategies
and commitments of partner countries.
(R) A strategy to better coordinate HIV/AIDS
assistance with nutrition and food assistance
programs.
(S) A description of transnational or
regional initiatives to combat regionalized
epidemics in highly affected areas such as the
Caribbean.
(T) A description of planned resource
distribution and global investment by region.
(U) A description of coordination efforts in
order to better implement the Stop TB Strategy
and to address the problem of coinfection of
HIV/AIDS and tuberculosis and of projected
challenges or barriers to successful
implementation.
(V) A description of coordination efforts to
address malaria and comorbidity with malaria
and HIV/AIDS.
[(c) Study; Distribution of Resources.--
[(1) Study.--Not later than 3 years after the date of
the enactment of this Act, the Institute of Medicine
shall publish findings comparing the success rates of
the various programs and methods used under the
strategy described in subsection (a) to reduce,
prevent, and treat HIV/AIDS, tuberculosis, and malaria.
[(2) Distribution of resources.-- In prioritizing the
distribution of resources under the strategy described
in subsection (a), the President shall consider the
findings published by the Institute of Medicine under
this subsection.]
(c) Study of Progress Toward Achievement of Policy
Objectives.--
(1) Design and budget plan for data evaluation.--The
Global AIDS Coordinator shall enter into a contract
with the Institute of Medicine of the National
Academies that provides that not later than 18 months
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, the Institute, in consultation with the Global
AIDS Coordinator and other relevant parties
representing the public and private sector, shall
provide the Global AIDS Coordinator with a design plan
and budget for the evaluation and collection of
baseline and subsequent data to address the elements
set forth in paragraph (2)(B). The Global AIDS
Coordinator shall submit the budget and design plan to
the appropriate congressional committees.
(2) Study.--
(A) In general.--Not later than 4 years 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, the Institute of
Medicine of the National Academies shall
publish a study that includes--
(i) an assessment of the performance
of United States-assisted global HIV/
AIDS programs; and
(ii) an evaluation of the impact on
health of prevention, treatment, and
care efforts that are supported by
United States funding, including
multilateral and bilateral programs
involving joint operations.
(B) Content.--The study conducted under this
paragraph shall include--
(i) an assessment of progress toward
prevention, treatment, and care
targets;
(ii) an assessment of the effects on
health systems, including on the
financing and management of health
systems and the quality of service
delivery and staffing;
(iii) an assessment of efforts to
address gender-specific aspects of HIV/
AIDS, including gender related
constraints to accessing services and
addressing underlying social and
economic vulnerabilities of women and
men;
(iv) an evaluation of the impact of
treatment and care programs on 5-year
survival rates, drug adherence, and the
emergence of drug resistance;
(v) an evaluation of the impact of
prevention programs on HIV incidence in
relevant population groups;
(vi) an evaluation of the impact on
child health and welfare of
interventions authorized under this Act
on behalf of orphans and vulnerable
children;
(vii) an evaluation of the impact of
programs and activities authorized in
this Act on child mortality; and
(viii) recommendations for improving
the programs referred to in
subparagraph (A)(i).
(C) Methodologies.--Assessments and impact
evaluations conducted under the study shall
utilize sound statistical methods and
techniques for the behavioral sciences,
including random assignment methodologies as
feasible. Qualitative data on process variables
should be used for assessments and impact
evaluations, wherever possible.
(3) Contract authority.--The Institute of Medicine
may enter into contracts or cooperative agreements or
award grants to conduct the study under paragraph (2).
(4) Authorization of appropriations.--There are
authorized to be appropriated such sums as may be
necessary to carry out the study under this subsection.
(d) Comptroller General Report.--
(1) Report required.--Not later than 3 years 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, the Comptroller General of the United States
shall submit a report on the global HIV/AIDS programs
of the United States to the appropriate congressional
committees.
(2) Contents.--The report required under paragraph
(1) shall include--
(A) a description and assessment of the
monitoring and evaluation practices and
policies in place for these programs;
(B) an assessment of coordination within
Federal agencies involved in these programs,
examining both internal coordination within
these programs and integration with the larger
global health and development agenda of the
United States;
(C) an assessment of procurement policies and
practices within these programs;
(D) an assessment of harmonization with
national government HIV/AIDS and public health
strategies as well as other international
efforts;
(E) an assessment of the impact of global
HIV/AIDS funding and programs on other United
States global health programming; and
(F) recommendations for improving the global
HIV/AIDS programs of the United States.
(e) Best Practices Report.--
(1) In general.--Not later than 1 year 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,
and annually thereafter, the Global AIDS Coordinator
shall publish a best practices report that highlights
the programs receiving financial assistance from the
United States that have the potential for replication
or adaption, particularly at a low cost, across global
AIDS programs, including those that focus on both
generalized and localized epidemics.
(2) Dissemination of findings.--
(A) Publication on internet website.--The
Global AIDS Coordinator shall disseminate the
full findings of the annual best practices
report on the Internet website of the Office of
the Global AIDS Coordinator.
(B) Dissemination guidance.--The Global AIDS
Coordinator shall develop guidance to ensure
timely submission and dissemination of
significant information regarding best
practices with respect to global AIDS programs.
(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, with regard to the programs
authorized under this Act and sections 104A,
104B, and 104C of the Foreign Assistance Act of
1961 (22 U.S.C. 2151b-2, 2151b-3, and 2151b-4).
(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 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 2010 through 2013,
respectively.
(2) Coordination.--In order to avoid duplication and
maximize efficiency, the Inspectors General described
in paragraph (1) shall coordinate their activities
with--
(A) the Government Accountability Office; and
(B) the Inspectors General of the Department
of Commerce, the Department of Defense, the
Department of Labor, and the Peace Corps, as
appropriate, pursuant to the 2004 Memorandum of
Agreement Coordinating Audit Coverage of
Programs and Activities Implementing the
President's Emergency Plan for AIDS Relief, or
any successor agreement.
(3) Funding.--The Global AIDS Coordinator and the
Coordinator of the United States Government Activities
to Combat Malaria Globally shall make available
necessary funds not exceeding $10,000,000 during the 5-
year period beginning on October 1, 2008 to the
Inspectors General described in paragraph (1) for the
audits, inspections, and reviews described in that
paragraph.
SEC. 102. HIV/AIDS RESPONSE COORDINATOR.
(a) Establishment of Position.--* * *
* * * * * * *
(d) Sense of Congress.--It is the sense of Congress that--
(1) full-time country level coordinators, preferably
with management experience, should head each HIV/AIDS
country team for United States missions overseeing
significant HIV/AIDS programs;
(2) foreign service nationals provide critically
important services in the design and implementation of
United States country-level HIV/AIDS programs and their
skills and experience as public health professionals
should be recognized within hiring and compensation
practices; and
(3) staffing levels for United States country-level
HIV/AIDS teams should be adequately maintained to
fulfill oversight and other obligations of the
positions.
* * * * * * *
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
SEC. 201. SENSE OF CONGRESS ON PUBLIC-PRIVATE PARTNERSHIPS.
* * * * * * *
SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS
AND MALARIA.
[(a) Findings.--The Congress finds as follows:
[(1) The establishment of the Global Fund in January
2002 is consistent with the general principles for an
international AIDS trust fund first outlined by the
Congress in the Global AIDS and Tuberculosis Relief Act
of 2000 (Public Law 106-264).
[(2) Section 2, Article 5 of the bylaws of the Global
Fund provides for the International Bank for
Reconstruction and Development to serve as the initial
collection trustee for the Global Fund.
[(3) The trustee agreement signed between the Global
Fund and the International Bank for Reconstruction and
Development narrows the range of duties to include
receiving and investing funds from donors, disbursing
the funds upon the instruction of the Global Fund,
reporting on trust fund resources to donors and the
Global Fund, and providing an annual external audit
report to the Global Fund.]
(a) Findings; Sense of Congress.--
(1) Findings.--Congress makes the following findings:
(A) The establishment of the Global Fund in
January 2002 is consistent with the general
principles for an international AIDS trust fund
first outlined by Congress in the Global AIDS
and Tuberculosis Relief Act of 2000 (Public Law
106-264).
(B) The Global Fund is an innovative
financing mechanism which--
(i) has made progress in many areas
in combating HIV/AIDS, tuberculosis,
and malaria; and
(ii) represents the multilateral
component of this Act, extending United
States efforts to more than 130
countries around the world.
(C) The Global Fund and United States
bilateral assistance programs--
(i) are demonstrating increasingly
effective coordination, with each
possessing certain comparative
advantages in the fight against HIV/
AIDS, tuberculosis, and malaria; and
(ii) often work most effectively in
concert with each other.
(D) The United States Government--
(i) is the largest supporter of the
Global Fund in terms of resources and
technical support;
(ii) made the founding contribution
to the Global Fund; and
(iii) is fully committed to the
success of the Global Fund as a
multilateral public-private
partnership.
(2) Sense of congress.--It is the sense of Congress
that--
(A) transparency and accountability are
crucial to the long-term success and viability
of the Global Fund;
(B) the Global Fund has made significant
progress toward addressing concerns raised by
the Government Accountability Office by--
(i) improving risk assessment and
risk management capabilities;
(ii) providing clearer guidance for
and oversight of Local Fund Agents; and
(iii) strengthening the Office of the
Inspector General for the Global Fund;
(C) the provision of sufficient resources and
authority to the Office of the Inspector
General for the Global Fund to ensure that
office has the staff and independence necessary
to carry out its mandate will be a measure of
the commitment of the Global Fund to
transparency and accountability;
(D) regular, publicly published financial,
programmatic, and reporting audits of the Fund,
its grantees, and Local Fund Agents are also
important benchmarks of transparency;
(E) the Global Fund should establish and
maintain a system to track--
(i) 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, drug and
commodity purchases, and other
purposes;
(F) relevant national authorities in
recipient countries should exempt from duties
and taxes all products financed by Global Fund
grants and procured by any principal recipient
or subrecipient for the purpose of carrying out
such grants;
(G) the Global Fund, UNAIDS, and the Global
AIDS Coordinator should work together to
standardize program indicators wherever
possible; and
(H) for purposes of evaluating total amounts
of funds contributed to the Global Fund under
subsection (d)(4)(A)(i), the timetable for
evaluations of contributions from sources other
than the United States should take into account
the fiscal calendars of other major
contributors.
* * * * * * *
(d) United States Financial Participation.--
(1) Authorization of appropriations.--In addition to
any other funds authorized to be appropriated for
bilateral or multilateral HIV/AIDS, tuberculosis, or
malaria programs, of the amounts authorized to be
appropriated under section 401, there are authorized to
be appropriated to the President up to [$1,000,000,000
for the period of fiscal year 2004 beginning on January
1, 2004,] $2,000,000,000 for fiscal year 2009, and such
sums as may be necessary for [the fiscal years 2005-
2008] each of the fiscal years 2010 through 2013, for
contributions to the Global Fund.
(2) Availability of funds.--Amounts appropriated
under paragraph (1) are authorized to remain available
until expended.
(3) Reprogramming of fiscal year 2001 funds.--Funds
made available for fiscal year 2001 under section 141
of the Global AIDS and Tuberculosis Relief Act of
2000--
(A) are authorized to remain available until
expended; and
(B) shall be transferred to, merged with, and
made available for the same purposes as, funds
made available for fiscal years 2004 through
2008 under paragraph (1).
(4) Limitation.--
(A)(i) At any time during [fiscal years 2004
through 2008] fiscal years 2009 through 2013,
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 2004 through 2008] during any of
the fiscal years 2009 through 2013, 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.
(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] 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 2004 through 2008] fiscal years 2009
through 2013 that are not contributed to
fulfill a commitment made for a fiscal year
[prior to fiscal year 2004] 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 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 2004 through
2008] fiscal years 2009 through 2013, 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).
(C)(i) The President may suspend the
application of subparagraph (A) with respect to
a fiscal year if the President determines that
an international health emergency threatens the
national security interests of the United
States.
(ii) The President shall notify the
[Committee on International Relations]
Committee on Foreign Affairs of the House of
Representatives and the Committee on Foreign
Relations of the Senate not less than 5 days
before making a determination under clause (i)
with respect to the application of subparagraph
(A)(i) and shall include in the notification--
(I) a justification as to why
increased United States Government
contributions to the Global Fund is
preferable to increased United States
assistance to combat HIV/AIDS,
tuberculosis, and malaria on a
bilateral basis; and
(II) an explanation as to why other
government donors to the Global Fund
are unable to provide adequate
contributions to the Fund.
(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 shall be withheld from obligation to
the Global Fund until the Secretary of State certifies
to the appropriate congressional committees that the
Global Fund--
(A) has established an evaluation framework
for the performance of Local Fund Agents
(referred to in this paragraph as ``LFAs'');
(B) is undertaking a systematic assessment of
the performance of LFAs;
(C) is making available for public review,
according to the Fund Board's policies and
practices on disclosure of information, a
regular collection and analysis of performance
data of Fund grants, which shall cover
principal recipients and subrecipients;
(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) is responsible for regular,
publicly published audits of financial,
programmatic, and reporting aspects of
the Global Fund, its grantees, and
LFAs;
(E) has established, and is reporting
publicly on, standard indicators for all
program areas;
(F) has established a methodology to track
and is 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;
(G) has established a policy on tariffs
imposed by national governments on all goods
and services financed by the Global Fund;
(H) through its Secretariat, has taken
meaningful steps to prevent national
authorities in recipient countries from
imposing taxes or tariffs on goods or services
provided by the Fund;
(I) is maintaining its status as a financing
institution focused on programs directly
related to HIV/AIDS, malaria, and tuberculosis;
and
(J) is maintaining and making progress on--
(i) sustaining its multisectoral
approach, through country coordinating
mechanisms; and
(ii) the implementation of grants, as
reflected in the proportion of
resources allocated to different
sectors, including governments, civil
society, and faith- and community-based
organizations.
SEC. 204. COMBATING HIV/AIDS, TUBERCULOSIS, AND MALARIA BY
STRENGTHENING HEALTH POLICIES AND HEALTH SYSTEMS OF
PARTNER COUNTRIES.
(a) Statement of Policy.--It shall be the policy of the
United States Government--
(1) to invest appropriate resources authorized under
this Act--
(A) to carry out activities to strengthen
HIV/AIDS, tuberculosis, and malaria health
policies and health systems; and
(B) to provide workforce training and
capacity-building consistent with the goals and
objectives of this Act; and
(2) to support the development of a sound policy
environment in partner countries to increase the
ability of such countries--
(A) to maximize utilization of healthcare
resources from donor countries;
(B) to increase national investments in
health and education and maximize the
effectiveness of such investments;
(C) to improve national HIV/AIDS,
tuberculosis, and malaria strategies;
(D) to deliver evidence-based services in an
effective and efficient manner; and
(E) to reduce barriers that prevent
recipients of services from achieving maximum
benefit from such services.
(b) Assistance To Improve Public Finance Management
Systems.--
(1) In general.--Consistent with the authority under
section 129 of the Foreign Assistance Act of 1961 (22
U.S.C. 2152), the Secretary of the Treasury, acting
through the head of the Office of Technical Assistance,
is authorized to provide assistance for advisors and
partner country finance, health, and other relevant
ministries to improve the effectiveness of public
finance management systems in partner countries to
enable such countries to receive funding to carry out
programs to combat HIV/AIDS, tuberculosis, and malaria
and to manage such programs.
(2) Authorization of appropriations.--Of the amounts
authorized to be appropriated under section 401 for
HIV/AIDS assistance, there are authorized to be
appropriated to the Secretary of the Treasury such sums
as may be necessary for each of the fiscal years 2009
through 2013 to carry out this subsection.
* * * * * * *
TITLE III--BILATERAL EFFORTS
* * * * * * *
SEC. 301. ASSISTANCE TO COMBAT HIV/AIDS.
(a) Amendment of the Foreign Assistance Act of 1961.--* * *
* * * * * * *
(b) Authorization of Appropriations.--
(1) In general.--In addition to funds available under
section 104(c) of the Foreign Assistance Act of 1961
(22 U.S.C. 2151b(c)) for such purpose or under any
other provision of that Act, there are authorized to be
appropriated to the President, from amounts authorized
to be appropriated under section 401, such sums as may
be necessary for each of the [fiscal years 2004 through
2008] fiscal years 2009 through 2013 to carry out
section 104A of the Foreign Assistance Act of 1961, as
added by subsection (a).
(2) Availability of funds.--Amounts appropriated
pursuant to paragraph (1) are authorized to remain
available until expended.
(3) Allocation of funds.--Of the amount authorized to
be appropriated by paragraph (1) for the [fiscal years
2004 through 2008] fiscal years 2009 through 2013, such
sums as may be necessary are authorized to be
appropriated to carry out section 104A(d)(4) of the
Foreign Assistance Act of 1961 (as added by subsection
(a)), relating to the procurement and distribution of
HIV/AIDS pharmaceuticals.
[(c) Relationship to Assistance Programs to Enhance
Nutrition.--In recognition of the fact that malnutrition may
hasten the progression of HIV to AIDS and may exacerbate the
decline among AIDS patients leading to a shorter life span, the
Administrator of the United States Agency for International
Development shall, as appropriate--
[(1) integrate nutrition programs with HIV/AIDS
activities, generally;
[(2) provide, as a component of an anti-retroviral
therapy program, support for food and nutrition to
individuals infected with and affected by HIV/AIDS; and
[(3) provide support for food and nutrition for
children affected by HIV/AIDS and to communities and
households caring for children affected by HIV/AIDS.]
(c) Food and Nutritional Support.--
(1) In general.--As indicated in the report produced
by the Institute of Medicine, entitled ``PEPFAR
Implementation: Progress and Promise'', inadequate
caloric intake has been clearly identified as a
principal reason for failure of clinical response to
antiretroviral therapy. In recognition of the impact of
malnutrition as a clinical health issue for many
persons living with HIV/AIDS that is often associated
with health and economic impacts on these individuals
and their families, the Global AIDS Coordinator and the
Administrator of the United States Agency for
International Development shall--
(A) follow World Health Organization
guidelines for HIV/AIDS food and nutrition
services;
(B) integrate nutrition programs with HIV/
AIDS activities through effective linkages
among the health, agricultural, and livelihood
sectors and establish additional services in
circumstances in which referrals are inadequate
or impossible;
(C) provide, as a component of care and
treatment programs for persons with HIV/AIDS,
food and nutritional support to individuals
infected with, and affected by, HIV/AIDS who
meet established criteria for nutritional
support (including clinically malnourished
children and adults, and pregnant and lactating
women in programs in need of supplemental
support), including--
(i) anthropometric and dietary
assessment;
(ii) counseling; and
(iii) therapeutic and supplementary
feeding;
(D) provide food and nutritional support for
children affected by HIV/AIDS and to
communities and households caring for children
affected by HIV/AIDS; and
(E) in communities where HIV/AIDS and food
insecurity are highly prevalent, support
programs to address these often intersecting
health problems through community-based
assistance programs, with an emphasis on
sustainable approaches.
(2) Authorization of appropriations.--Of the amounts
authorized to be appropriated under section 401, there
are authorized to be appropriated to the President such
sums as may be necessary for each of the fiscal years
2009 through 2013 to carry out this subsection.
SEC. 302. ASSISTANCE TO COMBAT TUBERCULOSIS.
* * * * * * *
(b) Authorization of Appropriations.--
(1) In general.--In addition to funds available under
section 104(c) of the Foreign Assistance Act of 1961
(22 U.S.C. 2151b(c)) for such purpose or under any
other provision of that Act, there are authorized to be
appropriated to the President, from amounts authorized
to be appropriated under section 401, [such sums as may
be necessary for each of the fiscal years 2004 through
2008] a total of $4,000,000,000 for the 5-year period
beginning on October 1, 2008 to carry out section 104B
of the Foreign Assistance Act of 1961, as added by
subsection (a).
(2) Availability of funds.--Amounts appropriated
pursuant to the authorization of appropriations under
paragraph (1) are authorized to remain available until
expended.
(3) Transfer of prior year funds.--Unobligated
balances of funds made available for fiscal year 2001,
2002, or 2003 under section 104(c)(7) of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b(c)(7) (as in
effect immediately before the date of enactment of this
Act) shall be transferred to, merged with, and made
available for the same purposes as funds made available
for [fiscal years 2004 through 2008] fiscal years 2009
through 2013 under paragraph (1).
* * * * * * *
SEC. 303. ASSISTANCE TO COMBAT MALARIA.
* * * * * * *
(b) Authorization of Appropriations.--
(1) In general.--In addition to funds available under
section 104(c) of the Foreign Assistance Act of 1961
(22 U.S.C. 2151b(c)) for such purpose or under any
other provision of that Act, there are authorized to be
appropriated to the President, from amounts authorized
to be appropriated under section 401, [such sums as may
be necessary for fiscal years 2004 through 2008]
$5,000,000,000 during the 5-year period beginning on
October 1, 2008 to carry out section 104C of the
Foreign Assistance Act of 1961, as added by subsection
(a), including for the development of anti-malarial
pharmaceuticals by theMedicines for Malaria Venture.
(2) Availability of funds.--Amounts appropriated
pursuant to paragraph (1) are authorized to remain
available until expended.
(3) Transfer of prior year funds.--Unobligated
balances of funds made available for fiscal year 2001,
2002, or 2003 under section 104(c) of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b(c) (as in
effect immediately before the date of enactment of this
Act) and made available for the control of malaria
shall be transferred to, merged with, and made
available for the same purposes as funds made available
for [fiscal years 2004 through 2008] fiscal years 2009
through 2013 under paragraph (1).
(c) Conforming Amendment.--Section 104(c) of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b(c)), as amended by
section 301 of this Act, is further amended by adding after
paragraph (3) the following: * * *
(c) Statement of Policy.--Providing assistance for the
prevention, control, treatment, and the ultimate eradication of
malaria is--
(1) a major objective of the foreign assistance
program of the United States; and
(2) 1 component of a comprehensive United States
global health strategy to reduce disease burdens and
strengthen communities around the world.
(d) Development of a Comprehensive 5-Year Strategy.--The
President shall establish a comprehensive, 5-year strategy to
combat global malaria that--
(1) strengthens the capacity of the United States to
be an effective leader of international efforts to
reduce malaria burden;
(2) maintains sufficient flexibility and remains
responsive to the ever-changing nature of the global
malaria challenge;
(3) includes specific objectives and multisectoral
approaches and strategies to reduce the prevalence,
mortality, incidence, and spread of malaria;
(4) describes how this strategy would contribute to
the United States' overall global health and
development goals;
(5) clearly explains how outlined activities will
interact with other United States Government global
health activities, including the 5-year global AIDS
strategy required under this Act;
(6) expands public-private partnerships and leverage
of resources;
(7) coordinates among relevant Federal agencies to
maximize human and financial resources and to reduce
duplication among these agencies, foreign governments,
and international organizations;
(8) coordinates with other international entities,
including the Global Fund;
(9) maximizes United States capabilities in the areas
of technical assistance and training and research,
including vaccine research; and
(10) establishes priorities and selection criteria
for the distribution of resources based on factors such
as--
(A) the size and demographics of the
population with malaria;
(B) the needs of that population;
(C) the country's existing infrastructure;
and
(D) the ability to closely coordinate United
States Government efforts with national malaria
control plans of partner countries.
SEC. 304. PILOT PROGRAM FOR THE PLACEMENT OF HEALTHCARE PROFESSIONALS
IN OVERSEAS AREAS SEVERELY AFFECTED BY HIV/AIDS,
TUBERCULOSIS, AND MALARIA.
[(a) In General.--The President should establish a program
to demonstrate the feasibility of facilitating the service of
United States healthcare professionals in those areas of sub-
Saharan Africa and other parts of the world severely affected
by HIV/AIDS, tuberculosis, and malaria.
[(b) Requirements.--Participants in the program shall--
[(1) provide basic healthcare services for those
infected and affected by HIV/AIDS, tuberculosis, and
malaria in the area in which they are serving;
[(2) provide on-the-job training to medical and other
personnel in the area in which they are serving to
strengthen the basic healthcare system of the affected
countries;
[(3) provide healthcare educational training for
residents of the area in which they are serving;
[(4) serve for a period of up to 3 years; and
[(5) meet the eligibility requirements in subsection
(d).
[(c) Eligibility Requirements.--To be eligible to
participate in the program, a candidate shall--
[(1) be a national of the United States who is a
trained healthcare professional and who meets the
educational and licensure requirements necessary to be
such a professional such as a physician, nurse,
physician assistant, nurse practitioner, pharmacist,
other type of healthcare professional, or other
individual determined to be appropriate by the
President; or
[(2) be a retired commissioned officer of the Public
Health Service Corps.
[(d) Recruitment.--The President shall ensure that
information on the program is widely distributed, including the
distribution of information to schools for health
professionals, hospitals, clinics, and nongovernmental
organizations working in the areas of international health and
aid.
[(e) Placement of Participants.--
[(1) In general.--To the maximum extent practicable,
participants in the program shall serve in the poorest
areas of the affected countries, where healthcare needs
are likely to be the greatest. The decision on the
placement of a participant should be made in
consultation with relevant officials of the affected
country at both the national and local level as well as
with local community leaders and organizations.
[(2) Coordination.--Placement of participants in the
program shall be coordinated with the United States
Agency for International Development in countries in
which that Agency is conducting HIV/AIDS, tuberculosis,
or malaria programs. Overall coordination of placement
of participants in the program shall be made by the
Coordinator of United States Government Activities to
Combat HIV/AIDS Globally (as described in section 1(f)
of the State Department Basic Authorities Act of 1956
(as added by section 102(a) of this Act)).
[(f) Incentives.--The President may offer such incentives
as the President determines to be necessary to encourage
individuals to participate in the program, such as partial
payment of principal, interest, and related expenses on
government and commercial loans for educational expenses
relating to professional health training and, where possible,
deferment of repayments on such loans, the provision of
retirement benefits that would otherwise be jeopardized by
participation in the program, and other incentives.
[(g) Report.--Not later than 18 months after the date of
enactment of this Act, the President shall submit to the
appropriate congressional committees a report on steps taken to
establish the program, including--
[(1) the process of recruitment, including the venues
for recruitment, the number of candidates recruited,
the incentives offered, if any, and the cost of those
incentives;
[(2) the process, including the criteria used, for
the selection of participants;
[(3) the number of participants placed, the countries
in which they were placed, and why those countries were
selected; and
[(4) the potential for expansion of the program.
[(h) Authorization of Appropriations.--
[(1) In general.--In addition to amounts otherwise
available for such purpose, there are authorized to be
appropriated to the President, from amounts authorized
to be appropriated under section 401, such sums as may
be necessary for each of the fiscal years 2004 through
2008 to carry out the program.
[(2) Availability of funds.--Amounts appropriated
pursuant to the authorization of appropriations under
paragraph (1) are authorized to remain available until
expended.]
SEC. 304. MALARIA RESPONSE COORDINATOR.
(a) In General.--There is established within the United
States Agency for International Development a Coordinator of
United States Government Activities to Combat Malaria Globally
(referred to in this section as the ``Malaria Coordinator''),
who shall be appointed by the President.
(b) Authorities.--The Malaria Coordinator, acting through
nongovernmental organizations (including faith-based and
community-based organizations), partner country finance,
health, and other relevant ministries, and relevant executive
branch agencies as may be necessary and appropriate to carry
out this section, is authorized to--
(1) operate internationally to carry out prevention,
care, treatment, support, capacity development, and
other activities to reduce the prevalence, mortality,
and incidence of malaria;
(2) provide grants to, and enter into contracts and
cooperative agreements with, nongovernmental
organizations (including faith-based organizations) to
carry out this section; and
(3) transfer and allocate executive branch agency
funds that have been appropriated for the purposes
described in paragraphs (1) and (2).
(c) Duties.--
(1) In general.--The Malaria Coordinator has primary
responsibility for the oversight and coordination of
all resources and international activities of the
United States Government relating to efforts to combat
malaria.
(2) Specific duties.--The Malaria Coordinator shall--
(A) facilitate program and policy
coordination of antimalaria efforts among
relevant executive branch agencies and
nongovernmental organizations by auditing,
monitoring, and evaluating such programs;
(B) ensure that each relevant executive
branch agency undertakes antimalarial programs
primarily in those areas in which the agency
has the greatest expertise, technical
capability, and potential for success;
(C) coordinate relevant executive branch
agency activities in the field of malaria
prevention and treatment;
(D) coordinate planning, implementation, and
evaluation with the Global AIDS Coordinator in
countries in which both programs have a
significant presence;
(E) coordinate with national governments,
international agencies, civil society, and the
private sector; and
(F) establish due diligence criteria for all
recipients of funds appropriated by the Federal
Government for malaria assistance.
(d) Assistance for the World Health Organization.--In
carrying out this section, the President may provide financial
assistance to the Roll Back Malaria Partnership of the World
Health Organization to improve the capacity of countries with
high rates of malaria and other affected countries to implement
comprehensive malaria control programs.
(e) Coordination of Assistance Efforts.--In carrying out this
section and in accordance with section 104C of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b-4), the Malaria
Coordinator shall coordinate the provision of assistance by
working with--
(1) relevant executive branch agencies, including--
(A) the Department of State (including the
Office of the Global AIDS Coordinator);
(B) the Department of Health and Human
Services;
(C) the Department of Defense; and
(D) the Office of the United States Trade
Representative;
(2) relevant multilateral institutions, including--
(A) the World Health Organization;
(B) the United Nations Children's Fund;
(C) the United Nations Development Programme;
(D) the Global Fund;
(E) the World Bank; and
(F) the Roll Back Malaria Partnership;
(3) program delivery and efforts to lift barriers
that would impede effective and comprehensive malaria
control programs; and
(4) partner or recipient country governments and
national entities including universities and civil
society organizations (including faith- and community-
based organizations).
(f) Research.--To carry out this section and in accordance
with section 104C of the Foreign Assistance Act of 1961 (22
U.S.C. 1151d-4), the Secretary of Health and Human Services,
through the Centers for Disease Control and Prevention and the
National Institutes of Health, shall conduct appropriate
programmatically relevant clinical and operational research to
identify and evaluate new diagnostics, treatment regimens, and
interventions to prevent and control malaria.
(g) Monitoring.--To ensure that adequate malaria controls are
established and implemented, the Centers for Disease Control
and Prevention shall carry out appropriate surveillance and
evaluation activities to monitor global malaria trends and
assess environmental and health impacts of malarial control
efforts. Such activities shall complement the work of the World
Health Organization, rather than duplicate such work.
(h) Annual Report.--
(1) Submission.--Not later than 1 year 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,
and annually thereafter, the President shall submit a
report to the appropriate congressional committees that
describes United States assistance for the prevention,
treatment, control, and elimination of malaria.
(2) Contents.--The report required under paragraph
(1) shall describe--
(A) the countries and activities to which
malaria resources have been allocated;
(B) the number of people reached through
malaria assistance programs, including data on
children and pregnant women;
(C) research efforts to develop new tools to
combat malaria, including drugs and vaccines;
(D) the collaboration and coordination of
United States antimalarial efforts with the
World Health Organization, the Global Fund, the
World Bank, other donor governments, major
private efforts, and relevant executive
agencies;
(E) the coordination of United States
antimalarial efforts with the national malarial
strategies of other donor or partner
governments and major private initiatives;
(F) the estimated impact of United States
assistance on childhood mortality and morbidity
from malaria;
(G) the coordination of antimalarial efforts
with broader health and development programs;
and
(H) the constraints on implementation of
programs posed by health workforce shortages or
capacities; and
(I) the number of personnel trained as health
workers and the training levels achieved.
[Subtitle B--Assistance for Children and Families]
Subtitle B--Assistance for Women, Children, and Families
* * * * * * *
SEC. 312. POLICY AND REQUIREMENTS.
(a) Policy.--The United States Government's response to the
global HIV/AIDS pandemic should place high priority on the
prevention of mother-to-child transmission, the care and
treatment of family members and caregivers, and the care of
children orphaned by AIDS. To the maximum extent possible, the
United States Government should seek to leverage its funds by
seeking matching contributions from the private sector, other
national governments, and international organizations.
(b) Requirements.--The 5-year United States Government
strategy required by section 101 of this Act shall--
[(1) provide for meeting or exceeding the goal to
reduce the rate of mother-to-child transmission of HIV
by 20 percent by 2005 and by 50 percent by 2010;
[(2) include programs to make available testing and
treatment to HIV-positive women and their family
members, including drug treatment and therapies to
prevent mother-to-child transmission; and
[(3) expand programs designed to care for children
orphaned by AIDS.]
(1) establish a target for the prevention and
treatment of mother-to-child transmission of HIV that,
by 2013, will reach at least 80 percent of pregnant
women in those countries most affected by HIV/AIDS in
which the United States has HIV/AIDS programs;
(2) establish a target that, by 2013, the proportion
of children receiving care and treatment under this Act
is proportionate to their numbers within the population
of HIV infected individuals in each country;
(3) integrate care and treatment with prevention of
mother-to-child transmission of HIV programs to improve
outcomes for HIV-affected women and families as soon as
is feasible and support strategies that promote
successful follow-up and continuity of care of mother
and child;
(4) expand programs designed to care for children
orphaned by, affected by, or vulnerable to HIV/AIDS;
(5) ensure that women in prevention of mother-to-
child transmission of HIV programs are provided with,
or referred to, appropriate maternal and child
services; and
(6) develop a timeline for expanding access to more
effective regimes to prevent mother-to-child
transmission of HIV, consistent with the national
policies of countries in which programs are
administered under this Act and the goal of achieving
universal use of such regimes as soon as possible.
(c) Prevention of Mother-to-Child Transmission Expert
Panel.--
(1) Establishment.--The Global AIDS Coordinator shall
establish a panel of experts to be known as the
Prevention of Mother-to-Child Transmission Panel
(referred to in this subsection as the ``Panel'') to--
(A) provide an objective review of activities
to prevent mother-to-child transmission of HIV;
and
(B) provide recommendations to the Global
AIDS Coordinator and to the appropriate
committees of Congress for scale-up of mother-
to-child transmission prevention services under
this Act in order to achieve the target
established in subsection (b)(1).
(2) Membership.--The Panel shall be convened and
chaired by the Global AIDS Coordinator, who shall serve
as a nonvoting member. The Panel shall consist of not
more than 15 members (excluding the Global AIDS
Coordinator), to be appointed by the Global AIDS
Coordinator not later than 1 year after the date of the
enactment of this Act, including--
(A) 2 members from the Department of Health
and Human Services with expertise relating to
the prevention of mother-to-child transmission
activities;
(B) 2 members from the United States Agency
for International Development with expertise
relating to the prevention of mother-to-child
transmission activities;
(C) 2 representatives from among health
ministers of national governments of foreign
countries in which programs under this Act are
administered;
(D) 3 members representing organizations
implementing prevention of mother-to-child
transmission activities under this Act;
(E) 2 healthcare researchers with expertise
relating to global HIV/AIDS activities; and
(F) representatives from among patient
advocate groups, healthcare professionals,
persons living with HIV/AIDS, and non-
governmental organizations with expertise
relating to the prevention of mother-to-child
transmission activities, giving priority to
individuals in foreign countries in which
programs under this Act are administered.
(3) Duties of panel.--The Panel shall--
(A) assess the effectiveness of current
activities in reaching the target described in
subsection (b)(1);
(B) review scientific evidence related to the
provision of mother-to-child transmission
prevention services, including programmatic
data and data from clinical trials;
(C) review and assess ways in which the
Office of the United States Global AIDS
Coordinator collaborates with international and
multilateral entities on efforts to prevent
mother-to-child transmission of HIV in affected
countries;
(D) identify barriers and challenges to
increasing access to mother-to-child
transmission prevention services and evaluate
potential mechanisms to alleviate those
barriers and challenges;
(E) identify the extent to which stigma has
hindered pregnant women from obtaining HIV
counseling and testing or returning for
results, and provide recommendations to address
such stigma and its effects;
(F) identify opportunities to improve
linkages between mother-to-child transmission
prevention services and care and treatment
programs; and
(G) recommend specific activities to
facilitate reaching the target described in
subsection (b)(1).
(4) Report.--
(A) In general.--Not later than 1 year after
the date on which the Panel is first convened,
the Panel shall submit a report containing a
detailed statement of the recommendations,
findings, and conclusions of the Panel to the
appropriate congressional committees.
(B) Availability.--The report submitted under
subparagraph (A) shall be made available to the
public.
(C) Consideration by coordinator.--The
Coordinator shall--
(i) consider any recommendations
contained in the report submitted under
subparagraph (A); and
(ii) include in the annual report
required under section 104A(f) of the
Foreign Assistance Act of 1961 a
description of the activities conducted
in response to the recommendations made
by the Panel and an explanation of any
recommendations not implemented at the
time of the report.
(5) Authorization of appropriations.--There are
authorized to be appropriated to the Panel such sums as
may be necessary for each of the fiscal years 2009
through 2011 to carry out this section.
(6) Termination.--The Panel shall terminate on the
date that is 60 days after the date on which the Panel
submits the report to the appropriate congressional
committees under paragraph (4).
SEC. 313. ANNUAL REPORTS ON PREVENTION OF MOTHER-TO-CHILD TRANSMISSION
OF THE HIV INFECTION.
(a) In General.--Not later than 1 year after the date of
the enactment of this Act, and annually thereafter for a period
of [5 years] 10 years, the President shall submit to
appropriate congressional committees a report on the activities
of relevant executive branch agencies during the reporting
period to assist in the prevention of mother-to-child
transmission of the HIV infection.
(b) Report Elements.--Each report shall include--
(1) a statement of whether or not all relevant
executive branch agencies have met the goal described
in section 312(b)(1); and
(2) a description of efforts made by the relevant
executive branch agencies to expand those activities,
including--
(A) information on the number of sites
supported for the prevention of mother-to-child
transmission of the HIV infection;
(B) the specific activities supported;
(C) the number of women tested and counseled;
and
(D) the number of women receiving
preventative drug therapies.
(c) Reporting Period Defined.--In this section, the term
``reporting period'' means, in the case of the initial report,
the period since the date of enactment of this Act and, in the
case of any subsequent report, the period since the date of
submission of the most recent report.
* * * * * * *
TITLE IV--AUTHORIZATION OF APPROPRIATIONS
SEC. 401. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--There are authorized to be appropriated to
the President to carry out this Act and the amendments made by
this Act [$3,000,000,000 for each of the fiscal years 2004
through 2008] $50,000,000,000 for the 5-year period beginning
on October 1, 2008.
(b) Availability.--Amounts appropriated pursuant to the
authorization of appropriations in subsection (a) are
authorized to remain available until expended.
(c) Availability of Authorizations.--Authorizations of
appropriations under subsection (a) shall remain available
until the appropriations are made.
SEC. 402. SENSE OF CONGRESS.
(a) Increase in HIV/AIDS Antiretroviral Treatment.--It is a
sense of the Congress that an urgent priority of United States
assistance programs to fight HIV/AIDS should be the rapid
increase in distribution of antiretroviral treatment so that--
(1) by the end of fiscal year 2004, at least 500,000
individuals with HIV/AIDS are receiving antiretroviral
treatment through United States assistance programs;
(2) by the end of fiscal year 2005, at least
1,000,000 such individuals are receiving such
treatment; and
(3) by the end of fiscal year 2006, at least
2,000,000 such individuals are receiving such
treatment.
(b) Effective Distribution of HIV/AIDS Funds.--It is the
sense of Congress that, of the amounts appropriated pursuant to
the authorization of appropriations under section 401 for HIV/
AIDS assistance, [an effective distribution of such amounts
would be--
[(1) 55 percent of such amounts for treatment of
individuals with HIV/AIDS;
[(2) 15 percent of such amounts for palliative care
of individuals with HIV/AIDS;
[(3) 20 percent of such amounts for HIV/AIDS
prevention consistent with section 104A(d) of the
Foreign Assistance Act of 1961 (as added by section 301
of this Act), of which such amount at least 33 percent
should be expended for abstinence-until-marriage
programs; and
[(4) 10 percent of such amounts] 10 percent should be
used for orphans and vulnerable children.
SEC. 403. ALLOCATION OF FUNDS.
[(a) Therapeutic Medical Care.--For fiscal years 2006
through 2008, not less than 55 percent of the amounts
appropriated pursuant to the authorization of appropriations
under section 401 for HIV/AIDS assistance for each such fiscal
year shall be expended for therapeutic medical care of
individuals infected with HIV, of which such amount at least 75
percent should be expended for the purchase and distribution of
antiretroviral pharmaceuticals and at least 25 percent should
be expended for related care. For fiscal years 2006 through
2008, not less than 33 percent of the amounts appropriated
pursuant to the authorization of appropriations under section
401 for HIV/AIDS prevention consistent with section 104A(d) of
the Foreign Assistance Act of 1961 (as added by section 301 of
this Act) for each such fiscal year shall be expended for
abstinence-until-marriage programs.]
(a) Balanced Funding Requirement.--
(1) In general.--The Global AIDS Coordinator shall--
(A) provide balanced funding for prevention
activities for sexual transmission of HIV/AIDS;
and
(B) ensure that behavioral change programs,
including abstinence, delay of sexual debut,
monogamy, fidelity, and partner reduction, are
implemented and funded in a meaningful and
equitable way in the strategy for each host
country based on objective epidemiological
evidence as to the source of infections and in
consultation with the government of each host
county involved in HIV/AIDS prevention
activities.
(2) Prevention strategy.--
(A) Establishment.--In carrying out paragraph
(1), the Global AIDS Coordinator shall
establish a HIV sexual transmission prevention
strategy governing the expenditure of funds
authorized under this Act to prevent the sexual
transmission of HIV in any host country with a
generalized epidemic.
(B) Report.--In each host country described
in subparagraph (A), if the strategy
established under subparagraph (A) provides
less than 50 percent of the funds described in
subparagraph (A) for behavioral change
programs, including abstinence, delay of sexual
debut, monogamy, fidelity, and partner
reduction, the Global AIDS Coordinator shall,
not later than 30 days after the issuance of
this strategy, report to the appropriate
congressional committees on the justification
for this decision.
(3) Exclusion.--Programs and activities that
implement or purchase new prevention technologies or
modalities, such as medical male circumcision, pre-
exposure pharmaceutical prophylaxis to prevent
transmission of HIV, or microbicides and programs and
activities that provide counseling and testing for HIV
or prevent mother-to-child prevention of HIV, shall not
be included in determining compliance with paragraph
(2).
(4) Report.--Not later than 1 year 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,
and annually thereafter as part of the annual report
required under section 104A(e) of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b-2(e)), the
President shall--
(A) submit a report on the implementation of
paragraph (2) for the most recently concluded
fiscal year to the appropriate congressional
committees; and
(B) make the report described in subparagraph
(A) available to the public.
(b) Orphans and Vulnerable Children.--For [fiscal years
2006 through 2008] fiscal years 2009 through 2013, not less
than 10 percent of the amounts appropriated pursuant to the
authorization of appropriations under section 401 for HIV/AIDS
assistance for each such fiscal year shall be expended for
assistance for orphans and [vulnerable children affected by]
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.
* * * * * * *
The Foreign Assistance Act of 1961
* * * * * * *
PART I
Chapter 1--Policy; Development Assistance Authorizations
* * * * * * *
SEC. 104A. ASSISTANCE TO COMBAT HIV/AIDS.
(a) Finding.--Congress recognizes that the alarming spread
of HIV/AIDS in countries in sub-Saharan Africa, the Caribbean,
Central Asia, Eastern Europe, Latin America, and other
developing countries is a major global health, national
security, development, and humanitarian crisis.
[(b) Policy.--It is a major objective of the foreign
assistance program of the United States to provide assistance
for the prevention, treatment, and control of HIV/AIDS. The
United States and other developed countries should provide
assistance to countries in sub-Saharan Africa, the Caribbean,
and other countries and areas to control this crisis through
HIV/AIDS prevention, treatment, monitoring, and related
activities, particularly activities focused on women and youth,
including strategies to protect women and prevent mother-to-
child transmission of the HIV infection.]
(b) Policy.--
(1) Objectives.--It is a major objective of the
foreign assistance program of the United States to
provide assistance for the prevention and treatment of
HIV/AIDS and the care of those affected by the disease.
It is the policy objective of the United States, by
2013, to--
(A) assist partner countries to--
(i) prevent 12,000,000 new HIV
infections worldwide;
(ii) support treatment of at least
3,000,000 individuals with HIV/AIDS;
(iii) support additional treatment
through coordinated multilateral
efforts;
(iv) support care for 12,000,000
individuals with HIV/AIDS, including
5,000,000 orphans and vulnerable
children affected by HIV/AIDS, with an
emphasis on promoting a comprehensive,
coordinated system of services to be
integrated throughout the continuum of
care;
(v) provide at least 80 percent of
the target population with access to
counseling, testing, and treatment to
prevent the transmission of HIV from
mother-to-child;
(vi) provide care and treatment
services to children with HIV in
proportion to their percentage within
the HIV-infected population of a given
partner country; and
(vii) train and support retention of
healthcare professionals,
paraprofessionals, and community health
workers in HIV/AIDS prevention,
treatment, and care, with the target of
providing such training to at least
140,000 new healthcare professionals
and paraprofessionals;
(B) strengthen the capacity to deliver
primary healthcare in developing countries,
especially in sub-Saharan Africa; and
(C) help countries achieve staffing levels of
at least 2.3 doctors, nurses, and midwives per
1,000 population, as called for by the World
Health Organization.
(2) Coordinated global strategy.--The United States
and other countries with the sufficient capacity should
provide assistance to countries in sub-Saharan Africa,
the Caribbean, Central Asia, Eastern Europe, and Latin
America, and other countries and regions confronting
HIV/AIDS epidemics in a coordinated global strategy to
help address generalized and concentrated epidemics
through HIV/AIDS prevention, treatment, care,
monitoring and evaluation, and related activities.
(3) Priorities.--The United States Government's
response to the global HIV/AIDS pandemic and the
Government's efforts to help countries assume
leadership of sustainable campaigns to combat their
local epidemics should place high priority on--
(A) the prevention of the transmission of
HIV; and
(B) moving toward universal access to HIV/
AIDS prevention counseling and services.
(c) Authorization.--
(1) In general.--Consistent with section 104(c), the
President is authorized to furnish assistance, on such
terms and conditions as the President may determine,
for HIV/AIDS, including to prevent, treat, and monitor
HIV/AIDS, and carry out related activities, in
countries in sub-Saharan Africa, the Caribbean, [and
other countries and areas.] Central Asia, Eastern
Europe, Latin America, and other countries and areas,
particularly with respect to refugee populations or
those in postconflict settings in such countries and
areas with significant or increasing HIV incidence
rates.
(2) Role of ngos.--It is the sense of Congress that
the President should provide an appropriate level of
assistance under paragraph (1) through nongovernmental
organizations (including faith-based and community-
based organizations) in countries in sub-Saharan
Africa, the Caribbean, [and other countries and areas
affected by the HIV/AIDS pandemic] Central Asia,
Eastern Europe, Latin America, and other countries and
areas affected by the HIV/AIDS pandemic, particularly
with respect to refugee populations or those in post-
conflict settings in such countries and areas with
significant or increasing HIV incidence rates.
(3) Coordination of assistance efforts.--The
President shall coordinate the provision of assistance
under paragraph (1) with the provision of related
assistance by the Joint United Nations Programme on
HIV/AIDS (UNAIDS), the United Nations Children's Fund
(UNICEF), the World Health Organization (WHO), the
United Nations Development Programme (UNDP), the Global
Fund to Fight AIDS, Tuberculosis and Malaria and other
appropriate international organizations (such as the
International Bank for Reconstruction and Development),
relevant regional multilateral development
institutions, national, state, and local governments of
[foreign countries] partner countries, other
international actors, appropriate governmental and
nongovernmental organizations, and relevant executive
branch agencies within the framework of the principles
of the Three Ones.
(d) Activities Supported.--Assistance provided under
subsection (c) shall, to the maximum extent practicable, be
used to carry out the following activities:
(1) Prevention.--Prevention of HIV/AIDS through
activities including--
(A) programs and efforts that are designed or
intended to impart knowledge with the exclusive
purpose of helping individuals avoid behaviors
that place them at risk of HIV infection,
including integration of such programs into
health programs and the inclusion in counseling
programs of information on methods of avoiding
infection of HIV, including delaying sexual
debut, abstinence, fidelity and monogamy,
reduction of casual sexual partnering and
multiple concurrent sexual partnering, reducing
sexual violence and coercion, including child
marriage, widow inheritance, and polygamy, and
where appropriate, use of [condoms] male and
female condoms;
(B) assistance to establish and implement
culturally appropriate HIV/AIDS education and
prevention [programs that] programs that are
designed with local input and focus on helping
individuals avoid infection of HIV/AIDS,
implemented through nongovernmental
organizations, including faith-based and
community-based organizations, particularly
[those organizations] those locally based
organizations that utilize both professionals
and volunteers with appropriate skills,
experience, and community presence;
(C) assistance for the purpose of encouraging
men to be responsible in their sexual behavior,
child rearing, and to respect women;
(D) assistance for the purpose of providing
voluntary testing and counseling (including the
incorporation of confidentiality protections
with respect to such testing and counseling)
and promoting the use of provider-initiated or
``opt-out'' voluntary testing in accordance
with World Health Organization guidelines;
(E) assistance for the purpose of preventing
mother-to-child transmission of the HIV
infection, including medications to prevent
such transmission and access to infant formula
and other alternatives for infant feeding;
(F) assistance to--
(i) achieve the goal of reaching 80
percent of pregnant women for
prevention and treatment of mother-to-
child transmission of HIV in countries
in which the United States is
implementing HIV/AIDS programs by 2013;
and
(ii) promote infant feeding options
and treatment protocols that meet the
most recent criteria established by the
World Health Organization;
(G) medical male circumcision programs as
part of national strategies to combat the
transmission of HIV/AIDS;
[(F)] (H) assistance to ensure a safe blood
supply and sterile medical equipment;
[(G)] (I) assistance to help avoid substance
abuse and intravenous drug use that can lead to
HIV infection; [and]
[(I)] (J) assistance for the purpose of
increasing women's access to employment
opportunities, income, productive resources,
and microfinance programs, where
appropriate[.], including education and
services demonstrated to be effective in
reducing the transmission of HIV infection
without increasing illicit drug use; and
(K) assistance for counseling, testing,
treatment, care, and support programs,
including--
(i) counseling and other services for
the prevention of reinfection of
individuals with HIV/AIDS;
(ii) counseling to prevent sexual
transmission of HIV, including--
(I) life skills development
for practicing abstinence and
faithfulness;
(II) reducing the number of
sexual partners;
(III) delaying sexual debut;
and
(IV) ensuring correct and
consistent use of condoms;
(iii) assistance to engage underlying
vulnerabilities to HIV/AIDS, especially
those of women and girls, through
structural prevention programs;
(iv) assistance for appropriate HIV/
AIDS education programs and training
targeted to prevent the transmission of
HIV among men who have sex with men;
(v) assistance to provide male and
female condoms;
(vi) diagnosis and treatment of other
sexually transmitted infections;
(vii) strategies to address the
stigma and discrimination that impede
HIV/AIDS prevention efforts; and
(viii) assistance to facilitate
widespread access to microbicides for
HIV prevention, if safe and effective
products become available, including
financial and technical support for
culturally appropriate introductory
programs, procurement, distribution,
logistics management, program delivery,
acceptability studies, provider
training, demand generation, and
postintroduction monitoring.
(2) Treatment.--The treatment and care of individuals
with HIV/AIDS, including--
(A) assistance to establish and implement
programs to strengthen and broaden indigenous
healthcare delivery systems and the capacity of
such systems to deliver HIV/AIDS
pharmaceuticals and otherwise provide for the
treatment of individuals with HIV/AIDS,
including clinical training for indigenous
organizations and healthcare providers;
(B) assistance to strengthen and expand
hospice and palliative care programs to assist
patients debilitated by HIV/AIDS, their
families, and the primary caregivers of such
patients, including programs that utilize
faith-based and community-based organizations;
[and]
(C) assistance for the purpose of the care
and treatment of individuals with HIV/AIDS
through the provision of pharmaceuticals,
including antiretrovirals and other
pharmaceuticals and therapies for the treatment
of opportunistic infections, pain management,
nutritional support, and other treatment
modalities[.];
(D) as part of care and treatment of HIV/
AIDS, assistance (including prophylaxis and
treatment) for common HIV/AIDS-related
opportunistic infections for free or at a rate
at which it is easily affordable to the
individuals and populations being served; and
(E) as part of care and treatment of HIV/
AIDS, assistance or referral to available and
adequately resourced service providers for
nutritional support, including counseling and
where necessary the provision of commodities,
for persons meeting malnourishment criteria and
their families;
(3) Preventative intervention education and
technologies.--(A) With particular emphasis on specific
populations that represent a particularly high risk of
contracting or spreading HIV/AIDS, including those
exploited through the sex trade, victims of rape and
sexual assault, individuals already infected with HIV/
AIDS, and in cases of occupational exposure of
healthcare workers, assistance with efforts to reduce
the risk of HIV/AIDS infection including post-exposure
pharmaceutical prophylaxis, and necessary
pharmaceuticals and commodities, including test kits,
condoms, and, when proven effective, microbicides.
(B) Bulk purchases of available test kits, condoms,
and, when proven effective, microbicides that are
intended to reduce the risk of HIV/AIDS transmission
and for appropriate program support for the
introduction and distribution of these commodities, as
well as education and training on the use of the
technologies.
(4) Monitoring.--The monitoring of programs,
projects, and activities carried out pursuant to
paragraphs (1) through (3), including--
(A) monitoring to ensure that adequate
controls are established and implemented to
provide HIV/AIDS pharmaceuticals and other
appropriate medicines to poor individuals with
HIV/AIDS;
(B) appropriate evaluation and surveillance
activities;
(C) monitoring to ensure that appropriate
measures are being taken to maintain the
sustainability of HIV/AIDS pharmaceuticals
(especially antiretrovirals) and ensure that
drug resistance is not compromising the
benefits of such pharmaceuticals; [and]
(D) monitoring to ensure appropriate law
enforcement officials are working to ensure
that HIV/AIDS pharmaceuticals are not
diminished through illegal counterfeiting or
black market sales of such pharmaceuticals[.];
(E) carrying out and expanding program
monitoring, impact evaluation research and
analysis, and operations research and
disseminating data and findings through
mechanisms to be developed by the Coordinator
of United States Government Activities to
Combat HIV/AIDS Globally, in coordination with
the Director of the Centers for Disease
Control, in order to--
(i) improve accountability, increase
transparency, and ensure the delivery
of evidence-based services through the
collection, evaluation, and analysis of
data regarding gender-responsive
interventions, disaggre- gated by age
and sex;
(ii) identify and replicate effective
models; and
(iii) develop gender indicators to
measure outcomes and the impacts of
interventions; and
(F) establishing appropriate systems to--
(i) gather epidemiological and social
science data on HIV; and
(ii) evaluate the effectiveness of
prevention efforts among men who have
sex with men, with due consideration to
stigma and risks associated with
disclosure.
(5) Pharmaceuticals.--
(A) Procurement.--The procurement of HIV/AIDS
pharmaceuticals, antiviral therapies, and other
appropriate medicines, including medicines to
treat opportunistic infections.
(B) Mechanisms for quality control and
sustainable supply.--Mechanisms to ensure that
such HIV/AIDS pharmaceuticals, antiretroviral
therapies, and other appropriate medicines are
quality-controlled and sustainably supplied.
(C) Mechanism to ensure cost-effective drug
purchasing.--Subject to subparagraph (B),
mechanisms to ensure that safe and effective
pharmaceuticals, including antiretrovirals and
medicines to treat opportunistic infections,
are purchased at the lowest possible price at
which such pharmaceuticals may be obtained in
sufficient quantity on the world market.
[(C)] (D) Distribution.--The distribution of
such HIV/AIDS pharmaceuticals, antiviral
therapies, and other appropriate medicines
(including medicines to treat opportunistic
infections) to qualified national, regional, or
local organizations for the treatment of
individuals with HIV/AIDS in accordance with
appropriate HIV/AIDS testing and monitoring
requirements and treatment protocols and for
the prevention of mother-to-child transmission
of the HIV infection.
(6) [Related activities.--] Related and coordinated
activities._The conduct of related activities,
including--
(A) the care and support of children who are
orphaned by the HIV/AIDS pandemic, including
services designed to care for orphaned children
in a family environment which rely on extended
family members;
(B) improved infrastructure and institutional
capacity to develop and manage education,
prevention, and treatment programs, including
training and the resources to collect and
maintain accurate HIV surveillance data to
target programs and measure the effectiveness
of interventions; [and]
(C) vaccine research and development
partnership programs with specific plans of
action to develop a safe, effective,
accessible, preventive HIV vaccine for use
throughout the world[.];
(D) coordinated or referred activities to--
(i) enhance the clinical impact of
HIV/AIDS care and treatment; and
(ii) ameliorate the adverse social
and economic costs often affecting
AIDS-impacted families and communities
through the direct provision, as
necessary, or through the referral, if
possible, of support services,
including--
(I) nutritional and food
support;
(II) nutritional counseling;
(III) income-generating
activities and livelihood
initiatives;
(IV) maternal and child
healthcare;
(V) primary healthcare;
(VI) the diagnosis and
treatment of other infectious
or sexually transmitted
diseases;
(VII) substance abuse and
treatment services; and
(VIII) legal services;
(E) coordinated or referred activities to
link programs addressing HIV/AIDS with programs
addressing gender-based violence in areas of
significant HIV prevalence to assist countries
in the development and enforcement of women's
health, children's health, and HIV/AIDS laws
and policies that--
(i) prevent and respond to violence
against women and girls;
(ii) promote the integration of
screening and assessment for gender-
based violence into HIV/AIDS
programming;
(iii) promote appropriate HIV/AIDS
counseling, testing, and treatment into
gender-based violence programs; and
(iv) assist governments to develop
partnerships with civil society
organizations to create networks for
psychosocial, legal, economic, or other
support services;
(F) coordinated or referred activities to--
(i) address the frequent coinfection
of HIV and tuberculosis, in accordance
with World Health Organization
guidelines;
(ii) promote provider-initiated or
``opt-out'' HIV/AIDS counseling and
testing and appropriate referral for
treatment and care to individuals with
tuberculosis or its symptoms,
particularly in areas with significant
HIV prevalence; and
(iii) strengthen programs to ensure
that individuals testing positive for
HIV receive tuberculosis screening and
appropriate screening and to improve
laboratory capacities, infection
control, and adherence; and
(G) activities to--
(i) improve the effectiveness of
national responses to HIV/AIDS; and
(ii) strengthen overall health
systems in high-prevalence countries,
including support for workforce
training, retention, and effective
deployment, capacity building,
laboratory development, equipment
maintenance and repair, and public
health and related public financial
management systems and operations.
(7) Comprehensive hiv/aids public-private
partnerships.--The establishment and operation of
public-private partnership entities within countries in
sub-Saharan Africa, the Caribbean, and other countries
affected by the HIV/AIDS pandemic that are dedicated to
supporting the national strategy of such countries
regarding the prevention, treatment, and monitoring of
HIV/AIDS. Each such public-private partnership should)
(A) support the development, implementation,
and management of comprehensive HIV/AIDS plans
in support of the national HIV/AIDS strategy;
(B) operate at all times in a manner that
emphasizes efficiency, accountability, and
results-driven programs;
(C) engage both local and foreign development
partners and donors, including businesses,
government agencies, academic institutions,
nongovernmental organizations, foundations,
multilateral development agencies, and faith-
based organizations, to assist the country in
coordinating and implementing HIV/AIDS
prevention, treatment, and monitoring programs
in accordance with its national HIV/AIDS
strategy;
(D) provide technical assistance, consultant
services, financial planning, monitoring and
evaluation, and research in support of the
national HIV/AIDS strategy; and
(E) establish local human resource capacities
for the national HIV/AIDS strategy through the
transfer of medical, managerial, leadership,
and technical skills.
(8) Compacts and framework agreements.--The
development of compacts or framework agreements,
tailored to local circumstances, with national
governments or regional partnerships in countries with
significant HIV/AIDS burdens to promote host government
commitment to deeper integration of HIV/AIDS services
into health systems, contribute to health systems
overall, and enhance sustainability.
(e) Compacts and Framework Agreements.--
(1) Findings.--Congress makes the following findings:
(A) The congressionally mandated Institute of
Medicine report entitled ``PEPFAR
Implementation: Progress and Promise' states:
``The next strategy [of the U.S. Global AIDS
Initiative] should squarely address the needs
and challenges involved in supporting
sustainable country HIV/AIDS programs, thereby
transitioning from a focus on emergency
relief.''
(B) One mechanism to promote the transition
from an emergency to a public health and
development approach to HIV/AIDS is through
compacts or framework agreements between the
United States Government and each participating
nation.
(C) Key components of a transition toward a
more sustainable approach toward fighting HIV/
AIDS, tuberculosis, and malaria and thus
priorities for such compacts include--
(i) building capacity to expand the
size of the trained healthcare
workforce in partner countries and
improve its retention, safety,
deployment, and utilization of skills
and to improve public health
infrastructure and systems;
(ii) partner governments increasing
their national investments in health
and education systems, as called for in
the Abuja Declaration;
(iii) increasing the focus of United
States government efforts to address
the factors that put women and girls at
greater risk of HIV/AIDS and to
strengthen the legal, economic,
educational, and social status of
women, girls, orphans, and vulnerable
children and encouraging partner
governments to do the same;
(iv) building on the New Partners
Initiative and other efforts currently
underway to strengthen the capacities
of community- and faith-based
organizations and civil society in
partner countries to contribute to
country efforts to prevent or manage
the effects of HIV/AIDS, tuberculosis,
and malaria epidemics and to improve
healthcare delivery;
(v) improving the coordination of
efforts to combat HIV/AIDS,
tuberculosis, and malaria with broader
national health and development
strategies;
(vi) promoting HIV/AIDS-related laws,
regulations, and policies that support
voluntary diagnostic counseling and
rapid testing, pediatric diagnosis,
rapid, tariff-free regulatory
procedures for drugs and commodities,
and full inclusion of people living
with HIV/AIDS in a multisectoral
national response.
(vii) sharing and implementing
findings based on program evaluations
and operations research; and
(viii) reducing the disease burden of
HIV/AIDS, tuberculosis, and malaria
through improved prevention efforts.
(D) Such compacts should also take into
account the overall national health and
development and national HIV/AIDS and public
health strategies of each country and should
contain provisions including--
(i) the specific objectives that the
country and the United States expect to
achieve during the term of a compact;
(ii) the respective responsibilities
of the country and the United States in
the achievement of such objectives;
(iii) regular benchmarks to measure,
where appropriate, progress toward
achieving such objectives;
(iv) an identification of the
intended beneficiaries, disaggregated
by gender and age, and including
information on orphans and vulnerable
children, to the maximum extent
practicable;
(v) the methods by which the compact
is intended to address the factors that
put women and girls at greater risk of
HIV/AIDS and to strengthen the legal,
economic, educational, and social
status of women, girls, orphans, and
vulnerable children;
(vi) the methods by which the compact
will strengthen the healthcare
capacity, including the training,
retention, deployment, and utilization
of healthcare workers, improve supply
chain management, and improve the
health systems and infrastructure of
the partner country, including the
ability of compact participants to
maintain and operate equipment
transferred or purchased as part of the
compact;
(vii) proposed mechanisms to provide
oversight;
(viii) the role of civil society in
the development of a compact and the
achievement of its objectives;
(ix) a description of the current and
potential participation of other donors
in the achievement of such objectives,
as appropriate; and
(x) a plan to ensure appropriate
fiscal accountability for the use of
assistance.
(2) Local input.--In entering into a compact
authorized under subsection (d)(8), the Coordinator of
United States Government Activities to Combat HIV/AIDS
Globally shall seek to ensure that the government of a
country--
(A) takes into account the local perspectives
of the rural and urban poor, including women,
in each country; and
(B) consults with private and voluntary
organizations, including faith-based
organizations, the business community, and
other donors in the country.
(3) Congressional and public notification after
entering into a compact.--Not later than 10 days after
entering into a compact authorized under subsection
(d)(8), the Global AIDS Coordinator shall--
(A) submit a report containing a detailed
summary of the compact and a copy of the text
of the compact to--
(i) the Committee on Foreign
Relations of the Senate;
(ii) the Committee on Appropriations
of the Senate;
(iii) the Committee on Foreign
Affairs of the House of
Representatives; and
(iv) the Committee on Appropriations
of the House of Representatives; and
(B) publish such information in the Federal
Register and on the Internet website of the
Office of the Global AIDS Coordinator.
[(e)] (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
International Relations] 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; [and]
[(C) a detailed assessment of the impact of
programs established pursuant to such sections,
including
[(i)(I) the effectiveness of such
programs in reducing the spread of the
HIV infection, particularly in women
and girls, in reducing mother-to-child
transmission of the HIV infection, and
in reducing mortality rates from HIV/
AIDS; and
[(II) the number of patients
currently receiving treatment for AIDS
in each country that receives
assistance under this Act.
[(ii) the progress made toward
improving healthcare delivery systems
(including the training of adequate
numbers of staff) and infrastructure to
ensure increased access to care and
treatment;
[(iii) with respect to tuberculosis,
the increase in the number of people
treated and the increase in number of
tuberculosis patients cured through
each program, project, or activity
receiving United States foreign
assistance for tuberculosis control
purposes; and
[(iv) with respect to malaria, the
increase in the number of people
treated and the increase in number of
malaria patients cured through each
program, project, or activity receiving
United States foreign assistance for
malaria control purposes.]
(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 healthcare
delivery systems (including the
training of healthcare workers,
including doctors, nurses,
midwives, pharmacists,
laboratory technicians, and
compensated community health
workers);
(II) advancing safe working
conditions for healthcare
workers; and
(III) improving
infrastructure to promote
progress toward universal
access to HIV/AIDS prevention,
treatment, and care by 2013;
(iii) with respect to tuberculosis--
(I) the increase in the
number of people treated and
the number of tuberculosis
patients cured through each
program, project, or activity
receiving United States foreign
assistance for tuberculosis
control purposes through, or in
coordination with, HIV/AIDS
programs;
(II) a description of drug
resistance rates among persons
treated;
(III) the percentage of such
United States foreign
assistance provided for
diagnosis and treatment of
individuals with tuberculosis
in countries with the highest
burden of tuberculosis, as
determined by the World Health
Organization; and
(IV) a detailed description
of efforts to integrate HIV/
AIDS and tuberculosis
prevention, treatment, and care
programs; and
(iv) 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;
(v) 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;
(vi) 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'';
(vii) 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;
(viii) 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);
(ix) 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;
(x) 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
healthcare 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;
(xi) 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;
(III) medication-assisted
drug treatment for individuals
with HIV or at risk of HIV; and
(IV) HIV prevention programs
demonstrated to be effective in
reducing HIV transmission
without increasing drug use;
(xii) 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; 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)] (g) Funding Limitation.--Of the funds made available
to carry out this section in any fiscal year, not more than 7
percent may be used for the administrative expenses of the
United States Agency for International Development in support
of activities described in section 104(c), this section,
section 104B, and section 104C. Such amount shall be in
addition to other amounts otherwise available for such
purposes.
[(g)] (h) Definitions.--In this section:
(1) AIDS.--The term ``AIDS'' means acquired immune
deficiency syndrome.
(2) HIV.--The term ``HIV'' means the human
immunodeficiency virus, the pathogen that causes AIDS.
(3) HIV/AIDS.--The term ``HIV/AIDS'' means, with
respect to an individual, an individual who is infected
with HIV or living with AIDS.
(4) Relevant executive branch agencies.--The term
``relevant executive branch agencies'' means the
Department of State, the United States Agency for
International Development, the Department of Health and
Human Services (including its agencies and offices),
and any other department or agency of the United States
that participates in international HIV/AIDS activities
pursuant to the authorities of such department or
agency or this Act.
* * * * * * *
SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.
(a) Findings.--Congress makes the following findings:
* * * * * * *
[(b) Policy.--It is a major objective of the foreign
assistance program of the United States to control
tuberculosis, including the detection of at least 70 percent of
the cases of infectious tuberculosis, and the cure of at least
85 percent of the cases detected, not later than December 31,
2005, in those countries classified by the World Health
Organization as among the highest tuberculosis burden, and not
later than December 31, 2010, in all countries in which the
United States Agency for International Development has
established development programs.]
(b) Policy.--It is a major objective of the foreign
assistance program of the United States to control
tuberculosis. In all countries in which the Government of the
United States has established development programs,
particularly in countries with the highest burden of
tuberculosis and other countries with high rates of
tuberculosis, the United States Government should prioritize
the achievement of the following goals by not later than
December 31, 2015:
(1) Reduce by half the tuberculosis death and disease
burden from the 1990 baseline.
(2) Sustain or exceed the detection of at least 70
percent of sputum smear-positive cases of tuberculosis
and the cure of at least 85 percent of those cases
detected.
* * * * * * *
[(e) Priority to DOTS Coverage.--In furnishing assistance
under subsection (c), the President shall give priority to
activities that increase Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant
tuberculosis where needed using DOTS-Plus, including funding
for the Global Tuberculosis Drug Facility, the Stop
Tuberculosis Partnership, and the Global Alliance for TB Drug
Development. In order to meet the requirement of the preceding
sentence, the President should ensure that not less than 75
percent of the amount made available to carry out this section
for a fiscal year should be expended for antituberculosis
drugs, supplies, direct patient services, and training in
diagnosis and treatment for Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant
tuberculosis using DOTS-Plus, including substantially increased
funding for the Global Tuberculosis Drug Facility.]
(e) Priority To Stop TB Strategy.--In furnishing assistance
under subsection (c), the President shall give priority to--
(1) activities described in the Stop TB Strategy,
including expansion and enhancement of Directly
Observed Treatment Short-course (DOTS) coverage, rapid
testing, treatment for individuals infected with both
tuberculosis and HIV, and treatment for individuals
with multi-drug resistant tuberculosis (MDR-TB),
strengthening of health systems, use of the
International Standards for Tuberculosis Care by all
providers, empowering individuals with tuberculosis,
and enabling and promoting research to develop new
diagnostics, drugs, and vaccines, and program-based
operational research relating to tuberculosis; and
(2) funding for the Global Tuberculosis Drug
Facility, the Stop Tuberculosis Partnership, and the
Global Alliance for TB Drug Development.
(f) Assistance for the World Health Organization and the Stop
Tuberculosis Partnership.--In carrying out this section, the
President, acting through the Administrator of the United
States Agency for International Development, is authorized to
provide increased resources to the World Health Organization
and the Stop Tuberculosis Partnership to improve the capacity
of countries with high rates of tuberculosis and other affected
countries to implement the Stop TB Strategy and specific
strategies related to addressing multiple drug resistant
tuberculosis (MDR-TB) and extensively drug resistant
tuberculosis (XDR-TB).
[(f)] (g) Definitions.--In this section:
(1) DOTS.--The term ``DOTS'' or ``Directly Observed
Treatment Short-course'' means the World Health
Organization-recommended strategy for treating
tuberculosis[.] including
(A) low-cost and effective diagnosis,
treatment, and monitoring of tuberculosis;
(B) a reliable drug supply;
(C) a management strategy for public health
systems;
(D) health system strengthening;
(E) promotion of the use of the International
Standards for Tuberculosis Care by all care
providers;
(F) bacteriology under an external quality
assessment framework;
(G) short-course chemotherapy; and
(H) sound reporting and recording systems.
(2) DOTS-plus.--The term ``DOTS-Plus'' means a
comprehensive tuberculosis management strategy that is
built upon and works as a supplement to the standard
DOTS strategy, and which takes into account specific
issues (such as use of second line anti-tuberculosis
drugs) that need to be addressed in areas where there
is high prevalence of multi-drug resistant
tuberculosis.
(3) Global alliance for tuberculosis drug
development.--The term ``Global Alliance for
Tuberculosis Drug Development'' means the public-
private partnership that brings together leaders in
health, science, philanthropy, and private industry to
devise new approaches to tuberculosis and to ensure
that new medications are available and affordable in
high tuberculosis burden countries and other affected
countries.
(4) Global tuberculosis drug facility.--The term
``Global Tuberculosis Drug Facility (GDF)'' means the
new initiative of the Stop Tuberculosis Partnership to
increase access to high-quality tuberculosis drugs to
facilitate DOTS expansion.
(5) Stop tb strategy.--The term ``Stop TB Strategy''
means the 6-point strategy to reduce tuberculosis
developed by the World Health Organization, which is
described in the Global Plan to Stop TB 2006-2015:
Actions for Life, a comprehensive plan developed by the
Stop TB Partnership that sets out the actions necessary
to achieve the millennium development goal of cutting
tuberculosis deaths and disease burden in half by 2015.
[(5)] (6) Stop tuberculosis partnership.--The term
``Stop Tuberculosis Partnership'' means the partnership
of the World Health Organization, donors including the
United States, high tuberculosis burden countries,
multilateral agencies, and nongovernmental and
technical agencies committed to short- and long-term
measures required to control and eventually eliminate
tuberculosis as a public health problem in the world.
* * * * * * *
SEC. 104C. ASSISTANCE TO COMBAT MALARIA.
* * * * * * *
(b) Policy.--It is a major objective of the foreign
assistance program of the United States to provide assistance
for the prevention, control, treatment, and cure of malaria.
* * * * * * *
Chapter 3--International Organizations and Programs
* * * * * * *
Sec. 302. Authorization.--(a) * * *
* * * * * * *
(c) None of the funds available to carry out this chapter
shall be contributed to any international organization or to
any foreign government or agency thereof to pay the costs of
developing or operating any volunteer program of such
organization, government, or agency relating to the selection,
training, and programing of volunteer manpower.
(d) Tuberculosis Vaccine Development Programs.--In addition
to amounts otherwise available under this section, there are
authorized to be appropriated to the President such sums as may
be necessary for each of the fiscal years 2009 through 2013,
which shall be used for United States contributions to
tuberculosis vaccine development programs, which may include
the Aeras Global TB Vaccine Foundation.
* * * * * * *
(k) In addition to amounts otherwise available under this
section, there is authorized to be appropriated to the
President such sums as may be necessary for each of the [fiscal
years 2004 through 2008] fiscal years 2009 through 2013 to be
available only for United States contributions to the Vaccine
Fund.
(l) In addition to amounts otherwise available under this
section, there is authorized to be appropriated to the
President such sums as may be necessary for each of the [fiscal
years 2004 through 2008] fiscal years 2009 through 2013 to be
available only for United States contributions to the
International AIDS Vaccine Initiative.
(m) In addition to amounts otherwise available under this
section, there are authorized to be appropriated to the
President such sums as may be necessary for each of the [fiscal
years 2004 through 2008] fiscal years 2009 through 2013 to be
available for United States contributions to malaria vaccine
development programs, including the Malaria Vaccine Initiative
of the Program for Appropriate Technologies in Health (PATH).
* * * * * * *
The Public Health Service Act
* * * * * * *
CHAPTER 6A--PUBLIC HEALTH SERVICE
* * * * * * *
SUBCHAPTER II.--GENERAL POWERS AND DUTIES
* * * * * * *
Part A. Research and Investigations
SEC. 307. INTERNATIONAL COOPERATION.
[(a) Cooperative Endeavors; Statement of Purpose.--For the
purpose of advancing the status of the health sciences in the
United States (and thereby the health of the American people),
the Secretary may participate with other countries in
cooperative endeavors in biomedical research, healthcare
technology, and the health services research and statistical
activities authorized by section 306 of this title and by
subchapter VII of this chapter.]
(a) The Secretary may participate with other countries in
cooperative endeavors in--
(1) biomedical research, healthcare technology, and
the health services research and statistical analysis
authorized under section 306 and title IX; and
(2) biomedical research, healthcare services,
healthcare research, or other related activities in
furtherance of the activities, objectives or goals
authorized under the Tom Lantos and Henry J. Hyde
United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008.
(b) Authority of Secretary; Building Construction
Prohibition.--In connection with the cooperative endeavors
authorized by subsection (a) of this section, the Secretary
may--
(1) make such use of resources offered by
participating foreign countries as he may find
necessary and appropriate;
(2) establish and maintain fellowships in the United
States and in participating foreign countries;
(3) make grants to public institutions or agencies
and to nonprofit private institutions or agencies in
the United States and in participating foreign
countries for the purpose of establishing and
maintaining the fellowships authorized by paragraph
(2);
(4) make grants or loans of equipment and materials,
for use by public or nonprofit private institutions or
agencies, or by individuals, in participating foreign
countries;
(5) participate and otherwise cooperate in any
international meetings, conferences, or other
activities concerned with biomedical research, health
services research, health statistics, or healthcare
technology;
(6) facilitate the interchange between the United
States and participating foreign countries, and among
participating foreign countries, of research scientists
and experts who are engaged in experiments or programs
of biomedical research, health services research,
health statistical activities, or healthcare technology
activities, and in carrying out such purpose may pay
per diem compensation, subsistence, and travel for such
scientists and experts when away from their places of
residence at rates not to exceed those provided in
section 5703(b) of Title 5 for persons in the
Government service employed intermittently;
(7) procure, in accordance with section 3109 of Title
5, the temporary or intermittent services of experts or
consultants; [and]
(8) enter into contracts with individuals for the
provision of services (as defined in section 104 of
part 37 of title 48, Code of Federal Regulations (48
CFR 37.104)) in participating foreign countries, which
individuals may not be deemed employees of the United
States [for any purpose] for the purpose of any law
administered by the Office of Personnel Management;
(9) provide such funds by advance or reimbursement to
the Secretary of State, as may be necessary, to pay the
costs of acquisition, lease, construction, alteration,
equipping, furnishing or management of facilities
outside of the United States; and
(10) in consultation with the Secretary of State,
through grant or cooperative agreement, make funds
available to public or nonprofit private institutions
or agencies in foreign countries in which the Secretary
is participating in activities described under
subsection (a) to acquire, lease, construct, alter, or
renovate facilities in those countries.
[The Secretary may not, in the exercise of his authority under
this section, provide financial assistance for the construction
of any facility in any foreign country.]
(c) Benefits for Overseas Assignees.--The Secretary may
provide to personnel appointed or assigned by the Secretary to
serve abroad, allowances and benefits similar to those provided
under chapter 9 of title I of the Foreign Service Act of [1990]
1980 (22 U.S.C. 4081 et seq.) or section 903 of the Foreign
Service Act of 1980 (22 U.S.C. 4083) . Leaves of absence for
personnel under this subsection shall be on the same basis as
that provided under subchapter I of chapter 63 of Title 5 to
individuals serving in the Foreign Service.
* * * * * * *
Part B. Federal-State Cooperation
* * * * * * *
SEC. 317S. GENERAL GRANT OF AUTHORITY FOR COOPERATION.
* * * * * * *
SEC. 317T. MICROBICIDE RESEARCH.
(a) In General.--The Director of the Centers for Disease
Control and Prevention shall fully implement the Centers'
microbicide agenda to support research and development of
microbicides for use in developing countries to prevent the
transmission of the human immunodeficiency virus.
(b) Authorization of Appropriations.--There are authorized to
be appropriated such sums as may be necessary for each of
fiscal years 2009 through 2013 to carry out this section.
SUBCHAPTER III--NATIONAL RESEARCH INSTITUTES
* * * * * * *
Part C--Specific Provisions Respecting National Research Institutes
SUBPART 6--NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES
SEC. 477. PURPOSE OF INSTITUTE
The general purpose of the National Institute of Allergy
and Infectious Diseases is the conduct and support of research,
training, health information dissemination, and other programs
with respect to allergic and immunologic diseases and disorders
and infectious diseases, including tropical diseases.
* * * * * * *
SEC. 447C. MICROBICIDE RESEARCH AND DEVELOPMENT.
The Director of the Institute, acting through the head of the
Division of AIDS, shall carry out research on, and development
of, a microbicide for use in developing countries to prevent
the transmission of the human immunodeficiency virus. The
Director shall ensure that there are a sufficient number of
employees and structure dedicated to carrying out such
activities.
SUBCHAPTER XXI--RESEARCH WITH RESPECT TO ACQUIRED IMMUNE DEFICIENCY
SYNDROME
Part D--Office of AIDS Research
SUBPART I--INTERAGENCY COORDINATION OF ACTIVITIES
SEC. 2351. ESTABLISHMENT OF OFFICE.
* * * * * * *
SEC. 2351A. MICROBICIDE RESEARCH.
(a) Federal Strategic Plan.--
(1) In general.--The Director of the Office shall--
(A) expedite the implementation of the
Federal strategic plans for the conduct and
support of research on, and development of, a
microbicide for use in developing countries to
prevent the transmission of the human
immunodeficiency virus; and
(B) annually review and, as appropriate,
revise such plan to prioritize funding and
activities relative to their scientific urgency
and potential market readiness.
(2) Coordination.--In implementing, reviewing, and
prioritizing elements of the plan described in
paragraph (1), the Director of the Office shall consult
with--
(A) representatives of other Federal agencies
involved in microbicide research, including the
Coordinator of United States Government
Activities to Combat HIV/AIDS Globally, the
Director of the Centers for Disease Control and
Prevention, and the Administrator of the United
States Agency for International Development;
(B) the microbicide research and development
community; and
(C) health advocates.
(b) Authorization of Appropriations.--There are authorized to
be appropriated such sums as may be necessary for each of the
fiscal years 2009 through 2013 to carry out this section.
* * * * * * *
The State Department Basic Authorities Act of 1956
* * * * * * *
TITLE I--BASIC AUTHORITIES GENERALLY
ORGANIZATION OF THE DEPARTMENT OF STATE
Section 1.(a) Secretary of State.--* * *
* * * * * * *
(f) HIV/AIDS Response Coordinator.--
(1) In general.--There shall be established within
the Department of State in the immediate office of the
Secretary of State a Coordinator of United States
Government Activities to Combat HIV/AIDS Globally, who
shall be appointed by the President, by and with the
advice and consent of the Senate. The Coordinator shall
report directly to the Secretary.
(2) Authorities and duties; definitions.--
(A) Authorities.--The Coordinator, acting
through such nongovernmental organizations
(including faith-based and community-based
organizations), partner country finance,
health, and other relevant ministries, and
relevant executive branch agencies as may be
necessary and appropriate to effect the
purposes of this section, is authorized--
(i) to operate internationally to
carry out prevention, care, treatment,
support, capacity development, and
other activities for combatting HIV/
AIDS;
(ii) to transfer and allocate funds
to relevant executive branch agencies;
and
(iii) to provide grants to, and enter
into contracts with, nongovernmental
organizations (including faith-based
and community-based organizations),
partner country finance, health, and
other relevant ministries, to carry out
the purposes of section.
(B) Duties.--
(i) In general.--The Coordinator
shall have primary responsibility for
the oversight and coordination of all
resources and international activities
of the United States Government to
combat the HIV/AIDS pandemic, including
all programs, projects, and activities
of the United States Government
relating to the HIV/AIDS pandemic under
the United States Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Act
of 2003 or any amendment made by that
Act.
(ii) Specific duties.--The duties of
the Coordinator shall specifically
include the following:
(I) Ensuring program and
policy coordination among the
relevant executive branch
agencies and nongovernmental
organizations, including
auditing, monitoring, and
evaluation of all such
programs.
(II) Ensuring that each
relevant executive branch
agency undertakes programs
primarily in those areas where
the agency has the greatest
expertise, technical
capabilities, and potential for
success.
(III) Avoiding duplication of
effort.
[(IV) Ensuring coordination
of relevant executive branch
agency activities in the field.
[(V) Pursuing coordination
with other countries and
international organizations.]
(IV) Establishing an
interagency working group on
HIV/AIDS headed by the Global
AIDS Coordinator and comprised
of representatives from the
United States Agency for
International Development and
the Department of Health and
Human Services, for the
purposes of coordination of
activities relating to HIV/
AIDS, including--
(aa) meeting
regularly to review
progress in partner
countries toward HIV/
AIDS prevention,
treatment, and care
objectives;
(bb) participating in
the process of
identifying countries
to consider for
increased assistance
based on the
epidemiology of HIV/
AIDS in those
countries, including
clear evidence of a
public health threat,
as well as government
commitment to address
the HIV/AIDS problem,
relative need, and
coordination and joint
planning with other
significant actors;
(cc) assisting the
Coordinator in the
evaluation, execution,
and oversight of
country operational
plans;
(dd) reviewing
policies that may be
obstacles to reaching
targets set forth for
HIV/AIDS prevention,
treatment, and care;
and
(ee) consulting with
representatives from
additional relevant
agencies, including the
National Institutes of
Health, the Health
Resources and Services
Administration, the
Department of Labor,
the Department of
Agriculture, the
Millennium Challenge
Corporation, the Peace
Corps, and the
Department of Defense.
(V) Coordinating overall
United States HIV/AIDS policy
and programs, including
ensuring the coordination of
relevant executive branch
agency activities in the field,
with efforts led by partner
countries, and with the
assistance provided by other
relevant bilateral and
multilateral aid agencies and
other donor institutions to
promote harmonization with
other programs aimed at
preventing and treating HIV/
AIDS and other health
challenges, improving primary
health, addressing food
security, promoting education
and development, and
strengthening healthcare
systems.
(VI) Resolving policy,
program, and funding disputes
among the relevant executive
branch agencies.
(VII) Holding annual
consultations with
nongovernmental organizations
in partner countries that
provide services to improve
health, and advocating on
behalf of the individuals with
HIV/AIDS and those at
particular risk of contracting
HIV/AIDS, including
organizations with members who
are living with HIV/AIDS.
(VIII) Ensuring, through
interagency and international
coordination, that HIV/AIDS
programs of the United States
are coordinated with, and
complementary to, the delivery
of related global health, food
security, development, and
education.
[(VII)] (IX) Directly
approving all activities of the
United States (including
funding) relating to combatting
HIV/AIDS in each of Botswana,
Cote d'Ivoire, Ethiopia,
Guyana, Haiti, Kenya,
Mozambique, Namibia, Nigeria,
Rwanda, South Africa, Tanzania,
Uganda, Vietnam, Zambia, and
other countries designated by
the President, which other
designated countries may
include those countries in
which the United States is
implementing HIV/AIDS programs
as of the date of the enactment
of the United States Leadership
Against HIV/AIDS, Tuberculosis,
and Malaria Act of 2003 and
other countries in which the
United States is implementing
HIV/AIDS programs as part of
its foreign assistance program.
In designating additional
countries under this
subparagraph, the President
shall give priority to those
countries in which there is a
high prevalence or
significantly rising incidence
of HIV/AIDS, countries with
large populations and
inadequate health
infrastructure, countries in
which a concentrated HIV/AIDS
epidemic could become
generalized to the entire
population of the country, and
in countries whose governments
demonstrate a commitment to
combating HIV/AIDS.
(X) Working with partner
countries in which the HIV/AIDS
epidemic is prevalent among
injection drug users to
establish, as a national
priority, national HIV/AIDS
prevention programs, including
education and services
demonstrated to be effective in
reducing the transmission of
HIV infection among injection
drug users without increasing
illicit drug use.
(XI) Working with partner
countries in which the HIV/AIDS
epidemic is prevalent among
individuals involved in
commercial sex acts to
establish, as a national
priority, national prevention
programs, including education,
voluntary testing, and
counseling, and referral
systems that link HIV/AIDS
programs with programs to
eradicate trafficking in
persons and support
alternatives to prostitution.
[(VIII)] (XII) Establishing
due diligence criteria for all
recipients of [funds section]
funds appropriated for HIV/
AIDS assistance pursuant to the
authorization of appropriations
under section 401 of the United
States Leadership Against HIV/
AIDS, Tuberculosis, and Malaria
Act of 2003 (22 U.S.C. 7671)
and all activities subject to
the coordination and
appropriate monitoring,
evaluation, and audits carried
out by the Coordinator
necessary to assess the
measurable outcomes of such
activities.
(XIII) Publicizing updated
drug pricing data to inform the
purchasing decisions of
pharmaceutical procurement
partners.
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The Immigration and Nationality Act
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The Immigration and Nationality Act, as Amended
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INADMISSIBLE ALIENS
Sec. 212. (a) Except as otherwise provided in this Act,
aliens who are inadmissible under the following paragraphs are
ineligible to receive visas and ineligible to be admitted to
the United States:
(1) Health-related grounds.
(A) In general. Any alien--
(i) who is determined (in accordance
with regulations prescribed by the
Secretary of Health and Human Services)
to have a communicable disease of
public health significance, [which
shall include infection with the
etiologic agent for acquired immune
deficiency syndrome,];
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