[House Report 110-546]
[From the U.S. Government Publishing Office]
110th Congress Rept. 110-546
HOUSE OF REPRESENTATIVES
2d Session Part 1
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TOM LANTOS AND HENRY J. HYDE UNITED STATES GLOBAL LEADERSHIP AGAINST
HIV/AIDS, TUBERCULOSIS, AND MALARIA REAUTHORIZATION ACT OF 2008
_______
March 10, 2008.--Ordered to be printed
_______
Mr. Berman, from the Committee on Foreign Affairs, submitted the
following
R E P O R T
[To accompany H.R. 5501]
[Including cost estimate of the Congressional Budget Office]
The Committee on Foreign Affairs, to whom was referred the
bill (H.R. 5501) 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, having considered the same, reports favorably thereon
without amendment and recommends that the bill do pass.
TABLE OF CONTENTS
Page
Summary.......................................................... 1
Background and Purpose for the Legislation....................... 2
Hearings......................................................... 11
Committee Consideration.......................................... 11
Votes of the Committee........................................... 11
Committee Oversight Findings..................................... 11
New Budget Authority and Tax Expenditures........................ 11
Congressional Budget Office Cost Estimate........................ 12
Performance Goals and Objectives................................. 14
Constitutional Authority Statement............................... 14
New Advisory Committees.......................................... 14
Congressional Accountability Act................................. 14
Earmark Identification........................................... 14
Section-by-Section Analysis and Discussion....................... 14
Changes in Existing Law Made by the Bill, as Reported............ 20
Summary
H.R. 5501, the ``Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008,'' authorizes $50 billion for the
United States' bilateral and multilateral programs to combat
HIV/AIDS, tuberculosis (TB) and malaria for Fiscal Years 2009
through 2013. It seeks to continue the bipartisan commitment to
aggressively prevent, treat, and care for those living with
HIV/AIDS, and prevent and cure those with TB and malaria in the
least developed countries by launching a second five-year
strategy to achieve these goals.
In the first five years of the U.S. response to the global
HIV/AIDS pandemic, U.S. policy was driven by the urgency of an
emergency response. Under this Act, the United States will
develop and implement strategies to transition from the
emergency phase to long-term sustainability that can be
maintained by the host countries. The new authorization also
seeks to further integrate HIV/AIDS programs with TB and
malaria programs. It strengthens health care delivery systems
to boost host country capacities to reach and provide HIV/AIDS
services to populations that are difficult to reach. In
addition, the Reauthorization Act invests in rebuilding the
health care workforce through training and the redistribution
of tasks among health workers. Lastly, H.R. 5501 includes a
provision that employs the expertise of the Department of the
Treasury to work with the finance and health ministries of
focus countries to establish public finance management systems
for greater accountability.
Background and Purpose for the Legislation
In his State of the Union address in 2003, President George
W. Bush announced the ``President's Emergency Plan for AIDS
Relief'' (PEPFAR), requesting $15 billion to intervene in the
worst global health pandemic since the Plague.
In 2003, according to UNAIDS, 3 million people were newly
infected with HIV and 2 million died. Worldwide, an estimated
30.9 million people were living with HIV/AIDS. Sub-Saharan
Africa, the most severely affected region of the world,
accounted for over 2.1 million of these new infections and 1.6
million AIDS deaths. Every day in 2003, an estimated 8,200
people were newly infected with HIV worldwide.\1\ At the time,
antiretroviral drug treatment regimens in poor settings were
viewed by some policy makers as prohibitively expensive and
complicated. Primary focus was on the cheaper and more easily
administered drugs for the prevention of mother-to-child
transmission.
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\1\UNAIDS, 2007
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Soon after the President's announcement, Congress passed
and the President signed the ``U.S Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003,'' Public Law 108-25
(``the 2003 Act''), authorizing $15 billion in assistance to
combat these diseases for Fiscal Years 2004--2008.\2\ President
Bush signed the Act into law in May 2003.
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\2\The efforts were concentrated primarily in 14 ``focus
countries''--Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya,
Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda,
and Zambia. Vietnam was later added as a 15th focus country, and PEPFAR
also supports bilateral programs in dozens of other countries.
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The 2003 Act established, within the Department of State, a
Coordinator of United States Government Activities to Combat
HIV/AIDS Globally, appointed by the President with the advice
and consent of the Senate. The Office of the Global AIDS
Coordinator (OGAC) now leads interagency implementation of and
administers U.S. global HIV/AIDS policy. The Reauthorization
Act seeks to strengthen the Coordinator's role of coordinating
the Federal agencies engaged in implementing global HIV/AIDS
policy.
The 2003 Act required a five-year emergency plan (2004-
2008) designed to coordinate all U.S.-funded bilateral HIV/AIDS
programs, including those established by PEPFAR and
administered through the seven implementing agencies,\3\ to
address the emergency. With this new funding, combined with
other HIV/AIDS program funding, the U.S. bilateral programs to
combat HIV/AIDS, tuberculosis, and malaria were expanded to 114
countries. The U.S. now supports programs in 136 countries,
including programs funded by the United States and administered
through The Global Fund to Fight AIDS, Tuberculosis and Malaria
(the Global Fund), an international financing mechanism for
collective global funding of programs to combat these three
diseases. A major goal of the 2003 Act was to focus the
delivery of services through local community and faith-based
organizations in the host countries. On World AIDS Day in 2005,
the President announced the creation of ``The New Partners
Initiative'' (NPI) to provide technical assistance enabling
faith-based and community organizations with little prior
experience working with the U.S. Government to administer
sustainable HIV/AIDS programs.
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\3\Department of State, USAID, Department of Defense, Department of
Commerce, Department of Labor, Department of Health and Human Services
and the Peace Corps.
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The initial ``emergency phase'' was also designed to scale
up HIV/AIDS treatment, care, and prevention programs (including
prevention of mother-to-child transmission programs), and
extend them to hard-to-reach rural areas and vulnerable
populations, including women, girls, orphans and vulnerable
children. The three major infectious diseases--HIV/AIDS, TB,
and malaria--were covered by the 2003 Act because research
demonstrated that co-infection with HIV/AIDS and one or both of
the other diseases resulted in more severe symptoms and certain
and untimely death. For example, according to the World Health
Organization (WHO), 90% of people living with AIDS die within
months of contracting TB if they do not receive TB
treatment.\4\
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\4\``Frequently Asked Questions About TB and HIV/AIDS,'' World
Health Organization, 2008.
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For the past five years, the United States has been the
leading international provider of global HIV/AIDS support for
prevention, treatment, and care. Over this period, Congress
appropriated more funds than were initially authorized. In
Fiscal Years 2004 through 2008, the U.S. appropriated more than
$19 billion for programs to combat HIV/AIDS, tuberculosis and
malaria internationally, including more than $3 billion in
contributions to The Global Fund.
The U.S. emergency program intervened in this horrific
pandemic and performed well in the face of a massive
humanitarian disaster, broken infrastructure and a major
shortage of health care workers. As of September 30, 2007: the
U.S. had supported life-saving antiretroviral treatment for
1,445,500 men, women, and children; supported care for more
than 6.6 million, including care for more than 2.7 million
orphans and vulnerable children; and supported prevention of an
estimated 157,000 infant infections (cumulative for Fiscal
Years 2004 through 2007). In virtually every host country, in
order to treat and care for individuals, major investment in
infrastructure and workforce training has taken place, though
there is still much more to be done. Shortages of health care
workers, clinics, hospitals, laboratories, and storage
facilities in many areas of host countries have made it
incredibly difficult to reach vast numbers of individuals who
needed care and treatment.
By 2007, the news, while still grim, was beginning to
improve. The HIV/AIDS prevalence rates were leveling off and
annual deaths stabilized. According to UNAIDS, in 2007 there
were 33.2 million people worldwide living with HIV/AIDS, of
whom 2.5 million were children under the age of 15; 2.5 million
were newly infected, of whom 420,000 were children under the
age of 15; and there were 2.1 million deaths, of whom 330,000
were children under the age of 15. Due to the massive
intervention by the U.S. Government, the Global Fund, other
bilateral donors, and the governments and people of the
countries most affected by the disease, the growth of the
pandemic has slowed and the estimates are headed in the right
direction.
Host countries that have partnered with the U.S. to fight
HIV/AIDS have expressed their deep appreciation of the program.
As President Jakaya Kikwete of Tanzania said when talking to
President Bush in February 2008, ``Today there are thousands of
children who have managed to avoid joining the already long
list of orphans, and who continue to enjoy the love, guidance
and support of their parents who are alive because of the AIDS
care and treatment they get with the support of PEPFAR
initiative. Mr. President, thank you. Today, as a result of
PEPFAR, parents with AIDS are able to take care of their
children.''\5\
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\5\Joint Press Availability with President Kikwete and President
Bush in Tanzania, 2/17/08
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In September 2007, President Festus Mogae of Botswana said,
``. . . The modest successes we have recorded in my country . .
. and indeed in many African countries, could not have been
achieved without United States support under the President
Bush's Emergency Fund for AIDS Relief, PEPFAR. . . . The fund
has, in addition, provided impetus to other donors and major
contributors to contribute to international efforts to fight
the scourge of HIV/AIDS around the world. The quantum of
resources under PEPFAR, a significant amount from a single
source by any standard, has helped translate international
consensus into tangible opportunity and hope for millions
around the world. . . . PEPFAR has galvanized donor countries
and agencies alike to act in concert in the interest of
humanity.''\6\
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\6\``Botswana's Future: Reflections on HIV/AIDS, Democratization,
and U.S.-Botswana Relations,'' Center for Strategic & International
Studies, Washington, DC, 9/21/2007.
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While the program has been able to reach a large number of
people, the more difficult challenges lie ahead. The number of
those receiving prevention, treatment, and care services needs
to increase towards the goal of universal access, and host
country programs must be strengthened to sustain those on
treatment for life. Measures must be taken to create
sustainability of host country HIV/AIDS programs far into the
future. Research is needed to address further developments of
the virus and the disease. Lastly, health care delivery systems
strengthening and maintenance and workforce stability must be
achieved. Without these improvements, the threat of a rapid
expansion of HIV/AIDS in countries where the epidemic has
become generalized and into countries that have relatively low
prevalence rates remains grave.
REAUTHORIZATION ACT OF 2008
The reauthorization of the Act for FY 2009-2013 is designed
with four major priorities to move the U.S. global HIV/AIDS
response from the ``emergency phase'' towards long-term
``sustainability.'' The first priority is to continue to
designate and meet ambitious targets for prevention, treatment,
and care that will move poor countries toward universal access
(defined as providing treatment and other services to 80% of
the affected population). The second priority is to strengthen
and build the capacity of health care delivery systems,
including refurbishing hospital facilities, free-standing
clinics, and laboratories; providing supplies; and training and
extending the workforce to expand the reach of HIV/AIDS
programs to those yet to be serviced. The third priority is to
coordinate HIV/AIDS programs closely with programs for
tuberculosis, malaria, and, where appropriate, other diseases.
The fourth priority is to provide technical assistance to
improve the ability of host governments to plan, direct,
finance, and manage the programs that the U.S. Government and
other donors have helped to put in place. To that end, the
reauthorization increases U.S. funding for HIV/AIDS,
tuberculosis, and malaria to $50 billion over the next five
fiscal years.
Estimates of Funding
The $50 billion five-year authorization will provide a
total of $41 billion for HIV/AIDS programs, $5 billion for
malaria programs, and $4 billion for tuberculosis programs
through bilateral programs and Global Fund contributions
combined. According to projections based on the most recent
UNAIDS estimates of prevalence, developing country financial
needs to fight HIV/AIDS (not including tuberculosis and
malaria) will be $28 billion per annum in 2009 and will rise to
$45 billion in 2013. The 2009-2013 total projected low and
middle-income country need is $198 billion for HIV/AIDS
programs. Donors collectively should take on 70% of the total
finances required and the host countries should cover 30% of
these costs. Assuming the appropriate U.S. contribution to
address the global need is the same as the 33% ``cap'' on
contributions to the Global Fund, the U.S. share of developing
world HIV/AIDS financing would be $46 billion for five years.
Based on the work of the WHO Commission on Macroeconomics
and Health, developed countries need to provide at least one-
third of country-level needs identified in the WHO Global Plan
to Stop TB, and 50% of the extensively drug resistant
tuberculosis (XDR-TB) and multi-drug resistant tuberculosis
(MDR-TB) costs. Thirty-three percent of this donor share is
$3.85 billion for the Fiscal Years 2009 to 2013. Additional
resources are required for research and development of new
diagnostics, drugs, and vaccines.
The current best estimate of global need for malaria
programs by the World Malaria Report is $4.1 billion ($3.2
billion for implementation; $0.9 billion for research and
development) per year. The Reauthorization Act authorizes up
to$5 billion as the U.S. Government's contribution to this
global effort.
Prevention Policy
The Reauthorization Act continues support for the
``Abstinence, Be Faithful, Correct and Consistent Use of
Condoms'' (ABC) approach that has proven to be effective in
combating the spread of HIV/AIDS, with modifications. The Act
emphasizes prevention by increasing the importance of
abstinence, delay of sexual debut and faithfulness programming.
It requires that policy makers further prioritize these
approaches in their programming and reporting as part of the
integrated ABC prevention approach. The Committee remains
committed to each part of this approach, recognizing that the
greatest gains have been found when all three components of ABC
are used in an integrated approach. The Committee also values
the benefit of abstinence and be faithful-only programs,
particularly in countries where the epidemic is generalized.
The Committee is committed to the enforcement of the
``conscience clause'' to protect and ensure the participation
of organizations that have a religious or moral objection to
certain programs or activities.
Reflecting the Committee's continued commitment to the ABC
approach, H.R. 5501 removes the one-third ``abstinence until
marriage'' funding directive from the 2003 Act. Instead, it
includes a requirement that the Coordinator provide balanced
funding for prevention activities for sexual transmission of
HIV/AIDS and ensure that behavioral change programs, including
abstinence, delay of 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 objective epidemiological evidence to be used for the
Coordinator's determination should be primarily the Demographic
and Health Surveys, the AIDS Information Service (AIS), and
other United States Government supported surveys, including
surveys requested by the Congress and other independent,
scientifically-sound studies. 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.
In addition, H.R. 5501 provides that the Coordinator shall
establish an HIV sexual transmission prevention strategy
governing the expenditure of funds authorized by the Act and
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 behavioral change programs (defined to include abstinence,
delay of sexual debut, monogamy, fidelity, and partner
reduction), 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 country-by-country breakout for FY 2008, which
indicates current patterns of prevention efforts under the
Global HIV/AIDS program, was as follows:
PEPFAR Focus Countries Sexual Prevention Planned Funding--FY 2008
Field & Central Programs (in USD million)
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Sexual Prevention AB as a % of All Sexual
Country Funding AB Funding Prevention
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Botswana 12.4................... 8.4.................... 67.6%
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Cote D'Ivoire 11.9................... 7.8.................... 65.9%
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Ethiopia 36.3................... 16.9................... 46.5%
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Guyana 3.8.................... 2.3.................... 60.0%
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Haiti 8.4.................... 5.1.................... 60.8%
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Kenya 64.0................... 38.0................... 59.4%
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Mozambique 24.1................... 14.1................... 58.7%
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Namibia 16.6................... 11.0................... 66.1%
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Nigeria 27.5................... 18.2................... 66.1%
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Rwanda 12.1................... 8.0.................... 66.0%
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South Africa 60.2................... 37.5................... 62.2%
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Tanzania 29.6................... 18.2................... 61.5%
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Uganda 30.3................... 17.2................... 56.9%
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Vietnam 15.8................... 2.9.................... 18.3%
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Zambia 32.9................... 20.8................... 63.3%
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All Focus Countries 385.8.................. 226.4.................. 58.7%
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Faith-Based Organizations
The Reauthorization Act continues the support of
nongovernmental organizations, including faith-based
organizations, which have long played a critical role in the
provision of heath care services in the poorest countries in
the world. In many communities in developing nations, the only
medical services available within a reasonable distance from
people's homes are those provided by clinics and hospitals run
by churches and other nongovernmental organizations. Faith-
based organizations have played an important role in providing
prevention, treatment and care services for HIV/AIDS since
before the passage of the 2003 Act, and have taken the lead in
integrating nutrition with treatment and care services,
particularly to orphans and vulnerable children.
The Committee applauds the important work of these
organizations and encourages the U.S. Government's continued
partnership with them. We look forward to continued
participation of these organizations in all aspects of HIV/AIDS
programming, including, for example, providing services related
to abstinence, delay of sexual debut and faithfulness. We
expect the Global HIV/AIDS program to continue to provide
services through faith-based organizations.
To strengthen the relationship with such organizations, the
2008 Act strengthens the ``conscience clause,'' a provision
that has ensured that faith-based organizations are not
required to endorse or utilize any prevention or treatment
method to which they have a religious or moral objection. The
2008 Act strengthens this provision by specifically adding
language indicating that faith-based groups are not required to
integrate with or refer people to other programs or activities
to which the organizations have a religious or moral objection
and are not discriminated against in the solicitation or
issuance of grants, contracts or cooperative agreements for
refusing to do so.
Expanding Program Linkages, Coordination and Cooperation
The Reauthorization Act of 2008 establishes stronger
linkages between HIV/AIDS programs and programs in nutrition
and education that are vital to improving the success of
treatment by enhancing the overall health of the person with
HIV/AIDS. The 2008 Act also strengthens prevention activities
for women and girls that were missing in the original Act. The
Coordinator is charged with developing strategies that will
make women and girls less vulnerable to situations that
increase their chances of getting HIV/AIDS, including the
provision of antiretroviral post-exposure prophylaxis for
victims of gender-based violence and rape, the development of
microenterprise and job creation programs, and empowering women
and youth to avoid cross-generational sex.
The Reauthorization Act calls for ensuring access to HIV/
AIDS education and testing in family planning and maternal
health programs supported by the United States Government. The
2008 Annual Report to Congress on the implementation of the
Global HIV/AIDS program specifically discussed existing
``linkages between HIV/AIDS and voluntary family planning
programs.'' The 2008 Act is consistent with the
Administration's implementation of the Global HIV/AIDS effort.
Currently, the Coordinator is providing grants for HIV/AIDS
prevention services in family planning settings in order to
reach a wider population. The Committee commends the
Coordinator for doing so and the new authorization of
assistance in this area is intended to build on existing
efforts.
The Reauthorization Act increases and strengthens the
linkage between HIV/AIDS and tuberculosis programs. The dual
epidemics of HIV/AIDS and tuberculosis are particularly deadly
due to widespread stigma, low levels of awareness, and poorly
coordinated services. In sub-Saharan Africa, tuberculosis is
the most common cause of death and illness for individuals with
HIV. Additionally, XDR-TB is particularly dangerous and almost
universally fatal for those living with HIV. Responding to the
need for greater mobilization and coordination efforts for
tuberculosis and HIV/AIDS co-infection, this Act provides
stronger linkages for prevention, care, and treatment services
to reduce tuberculosis-related illness and death among people
living with HIV/AIDS. It provides for tuberculosis diagnostic
counseling, testing, and treatment (including for MDR-TB and
XDR-TB) to those with HIV/AIDS and HIV/AIDS voluntary
counseling, testing, and treatment to those with any form of
tuberculosis. The Act supports the linking of individuals with
both HIV/AIDS and any form of tuberculosis to HIV/AIDS
treatment and care services.
Globally, malaria has become one of the many opportunistic
infections afflicting people living with HIV/AIDS. There is a
particular burden on pregnant women, children and those
individuals who suffer high HIV viral loads, and those in end
stage HIV disease. Pregnant women who experience malaria also
risk higher rates of cognitive disability in their newborn
children. Malaria is a disease that kills swiftly. According to
the World Health Organization, in many cases, the first 48
hours of malaria parasite infection are the most critical.
Individuals whose systems have been compromised by HIV/AIDS
stand little chance of surviving malaria. This Act establishes
strong linkages between HIV/AIDS and malaria programs to
prevent the debilitating and deadly effects of malaria on
individuals served by this program.
The Act calls for the training of health care workers to
diagnose, treat, and provide care for individuals with HIV/AIDS
and tuberculosis. According to the United Nations Development
Programme, Human Development Report 2003, 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 13 countries have 5 or fewer
physicians per 100,000 people. Nurses play particularly
important roles in sub-Saharan African health care systems, but
approximately one-quarter of sub-Saharan African countries have
fewer than 50 nurses per 100,000 people or less than 1/2 the
staffing levels recommended by the World Health Organization.
Paraprofessionals and community health workers can be trained
more quickly than nurses or doctors and are critically needed
in sub-Saharan Africa to meet immediate health care needs.
While the scope of the problem of dire shortfalls of personnel
and inadequacies of infrastructure in the sub-Saharan African
health systems is immense, effective and targeted interventions
to improve working conditions, management, and productivity
will yield significant dividends in improved health care.
To empower host countries to sustain these programs, the
Reauthorization Act of 2008 invests in strengthening health
care delivery systems and building health workforce capacities
through recruitment and training. The Committee has encouraged
stronger linkages between the Global HIV/AIDS programs and
initiatives to increase the capacity of the health care
delivery systems. For example, instead of equipping
laboratories with equipment that can only be used to test and
manage HIV/AIDS testing, through this Act laboratories will be
designed and equipped to handle general medical and public
health care. Also, the Act authorizes the Department of the
Treasury to carry out a public finance management program to
work with host countries to create policy environments that
will support the modernization of the health sector.
Since 1999, the International Monetary Fund (IMF) has
provided concessional loans to national governments with the
goal of reducing poverty and supporting economic growth in
developing countries. As a condition of receiving these loans,
national governments are required to develop Poverty Reduction
Strategy Papers which frequently prevent national governments
from increasing health sector spending to address urgent and
emerging health epidemics such as HIV/AIDS, tuberculosis, or
malaria. In response, this Act directs the Coordinator to work
with the Secretary of the Treasury to reform existing IMF
macroeconomic and fiscal policies that result in limitations on
health sector spending by national governments receiving
assistance from the IMF. The Act further directs the Secretary
of the Treasury to instruct the United States Executive
Director at the IMF to oppose all IMF programs that do not
exempt increased health sector spending by national governments
from any loan conditions set by the IMF.
THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS, AND MALARIA\7\
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\7\A United Nations General Assembly Special Session on AIDS in
June 2001 concluded with a commitment to create a global fund. The
commitment was endorsed by the G8 that helped finance it at their
meeting in Genoa in July 2001. Following that commitment, a
Transitional Working Group was formed to develop a framework for how
the Global Fund would be structured and operate on an ongoing basis and
in January 2002, a permanent secretariat was established in Geneva.
Three months later the Global Fund Board approved the first round of
grants to 36 countries. The U.S. was a leader in the creation of the
Global Fund and continues to be its largest contributor.
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In addition to our bilateral programs, the Global Fund to
Fight AIDS, Tuberculosis, and Malaria (the Global Fund) is a
vehicle through which the U.S. Government extends its support
even more broadly. The Global Fund is a public-private
partnership dedicated to raising and disbursing large amounts
of funding to prevent and treat the pandemics of HIV/AIDS,
malaria and tuberculosis. As a financing organization with no
regional or country offices, the Global Fund is unable (and not
intended) to provide hands-on technical support to improve
grant performance; this becomes the responsibility of
international and bilateral partners.\8\
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\8\http://www.pepfar.gov/coop/c18962.htm
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The U.S. Government, as a founding member of the Global
Fund and its first and largest contributor, continues to play a
leadership role in ensuring the success of this essential
international effort. Though the Fund was not established until
2002, President Bush made the founding contribution to the
Global Fund of $200 million in May 2001. As of February 2008,
donors have pledged more than $18 billion to the Fund, of which
nearly $10 billion has been paid. The funds have been used to
support nearly 500 grants totaling $8.3 billion for projects in
136 countries, of which $5.2 billion has been disbursed. To
date, the U.S. has appropriated and pledged $3.5 billion for
contributions to the Global Fund.
The 2003 Act included a provision that limits the U.S.
contribution to the Global Fund to 33% of overall
contributions. This policy was adopted to ensure other public
and private donors made substantial contributions to the Global
Fund and has allowed the leaders of the Global Fund to use the
U.S. funds as matching for others. Many believe that without
this restriction, other donor countries would not have stepped
forward to make significant contributions. Increased
investments by the Organization for Economic Development and
Cooperation's Development Assistance Committee (OECD/DAC)
countries have kept pace with the U.S. increases.\9\
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\9\Kates, J. et al., ``Financing the response to AIDS in the low-
and middle income countries: International assistance from the G8,
European Commission and other donor governments''. 2006.
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In the Reauthorization Act, the authorized U.S.
contribution to the Global Fund doubles from $1 billion to $2
billion per year. This level anticipates the growing demand on
funding from the Global Fund and increased bilateral funding
from other donor countries. The ``1/3 cap'' on the U.S.
Government contribution limits the total amount contributed in
any given year. The Reauthorization Act retains the ``1/3 cap''
as a demonstration of the Committee's commitment to
multilateral funding for the enormous challenges that lie ahead
for HIV/AIDS, tuberculosis and malaria programs. The ``1/3
cap'' expresses our intention to call on other donor countries
to make substantial contributions. In addition, the Committee
expects increased transparency and accountability for the Fund,
particularly in light of the authorization for increased
funding, and has provided a set of benchmarks to help improve
the Global Fund's operations.
Hearings
The Committee held five hearings directly related to the
subject matter of the bill. On March 21, 2007, the Subcommittee
on Africa and Global Health held a hearing entitled ``The
Global Threat of Drug-Resistant TB: A Call to Action for World
TB Day.'' On April 24, 2007, the full committee held a hearing
entitled ``PEPFAR: An Assessment of Progress and Challenges.''
On April 25, 2007, the Subcommittee on Africa and Global Health
held a hearing entitled ``Malaria Awareness Day: Leveraging
Progress for Future Advances.'' On September 25, 2007, the full
committee held a hearing entitled ``PEPFAR Reauthorization:
From Emergency to Sustainability.'' On October 9, 2007, the
Subcommittee on Africa and Global Health held a hearing
entitled ``The President's Emergency Plan for AIDS Relief: Is
It Fulfilling the Nutrition and Food Security Needs of People
Living with HIV/AIDS?''
Committee Consideration
On February 27, 2008, the Full Committee held a markup on
H.R. 5501, the Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008, and it was favorably reported to
the House, by voice vote, a quorum being present.
Votes of the Committee
There were no recorded votes on H.R. 5501.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII of the Rules
of the House of Representatives, the Committee reports that the
findings and recommendations of the Committee, based on
oversight activities under clause 2(b)(1) of rule X of the
Rules of the House of Representatives, are incorporated in the
descriptive portions of this report.
New Budget Authority and Tax Expenditures
In compliance with Clause 3(c) (2) of House Rule XIII, the
Committee adopts as its own the estimate of new budget
authority, entitlement authority, or tax expenditures or
revenues contained in the cost estimate prepared by the
Director of the Congressional Budget Office, pursuant to
section 402 of the Congressional Budget Act of 1974.
Congressional Budget Office Cost Estimate
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, the Committee sets forth, with
respect to the bill, H.R.5501, the following estimate and
comparison prepared by the Director of the Congressional Budget
Office under section 402 of the Congressional Budget Act of
1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, Month 5, 2008.
Hon. Howard L. Berman, Acting Chairman,
Committee on Foreign Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed 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.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Michelle S.
Patterson, who can be reached at 226-2840.
Sincerely,
Peter R. Orszag.
Enclosure
cc:
Honorable Ileana Ros-Lehtinen
Ranking Member
H.R. 5501--Tom Lantos and Henry J. Hyde U.S. Global Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008.
SUMMARY
H.R. 5501 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 $10 billion a year over the
2009-2013 period. CBO estimates that implementing H.R. 5501
would cost $1.5 billion in 2009 and $35 billion over the 2009-
2013 period, assuming appropriation of the authorized amounts.
Enacting the bill would not affect direct spending or receipts.
H.R. 5501 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would not affect the budgets of state, local, or tribal
governments.
ESTIMATED COST TO THE FEDERAL GOVERNMENT
The estimated budgetary impact of H.R. 5501 is shown in the
following table. The costs of this legislation fall within
budget functions 150 (international affairs) and 550 (health).
For this estimate, CBO assumes that the bill will be enacted by
September 30, 2008, that the authorized amounts are
appropriated for each year, and that outlays will follow
historical spending patterns for the existing programs.
By Fiscal Year, in Millions of Dollars
----------------------------------------------------------------------------------------------------------------
2009 2010 2011 2012 2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
HIV/AIDS, Tuberculosis, and Malaria Programs 10,000 10,000 10,000 10,000 10,000
Authorization Level
Estimated Outlays 1,392 6,392 8,262 9,082 9,482
Contributions to Vaccine Funds 108 108 108 158 158
Estimated Authorization Level
Estimated Outlays 108 108 108 158 158
Total Changes 10,108 10,108 10,108 10,158 10,158
Estimated Authorization Level
Estimated Outlays 1,500 6,500 8,370 9,240 9,640
----------------------------------------------------------------------------------------------------------------
BASIS OF ESTIMATE
Section 401 of H.R. 5501 would authorize the appropriation
of $10 billion each year from 2009 through 2013. Those 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 $3
billion in appropriations for 2008, are run by the Department
of State, the United States Agency for International
Development (USAID), and the Department of Health and Human
Services.
Section 203 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 the amount needed to fund the
final stages of development for a tuberculosis vaccine, CBO
estimates that implementing section 203 would cost $640 million
over the 2009-2013 period.
Based on information from the Department of State, CBO
estimates that the amount authorized to be appropriated is
sufficient to fund the expanded requirements. Because it will
take some time to expand existing programs and develop new
procedures and activities, CBO estimates that implementing this
bill would cost $1.5 billion in 2009 and about $35 billion over
the 2009-2013 period. Most of the additional amounts from the
authorized funding would be spent by 2018.
INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT
H.R. 5501 contains no intergovernmental or private-sector
mandates as defined in UMRA and would not affect the budgets of
state, local, or tribal governments.
ESTIMATE PREPARED BY:
Federal Costs: Michelle S. Patterson (226-2840)
Impact on State, Local, and Tribal Governments: Neil Hood (225-
3220)
Impact on the Private Sector: MarDestinee C. Perez (226-2940)
ESTIMATE APPROVED BY:
Peter H. Fontaine
Assistant Director for Budget Analysis
Performance Goals and Objectives
Pursuant to clause (3)(c) of House rule XIII, upon
enactment of this legislation, assistance should be expanded to
reach more people around the world with HIV/AIDS prevention,
treatment and care programs and should provide integrated food
and nutrition programs. Special attention should be given to
women, youth and mother-to-child transmission, and more
expansive programming to reduce the tuberculosis and malaria
pandemics.
Constitutional Authority Statement
Pursuant to clause 3(d) (1) of rule XIII of the Rules of
the House of Representatives, the Committee finds the authority
for this legislation in article I, section 8 of the
Constitution.
New Advisory Committees
H.R. 5501 does not establish or authorize any new advisory
committees.
Congressional Accountability Act
H.R. 5501 does not apply to the Legislative Branch.
Earmark Identification
H.R. 5501 does not include any earmarks, and does not
include limited tax benefits, or limited tariff benefits as
defined in clause 9(d), 9(e), or 9(f) of rule XXI.
Section-by-Section Analysis and Discussion
Sec. 1. Short Title and Table of Contents.
The short title of this Act 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 (22 U.S.C. 7601) (``the 2003 Act'') by adding to the end
of that Act's findings, additional findings with updated data
on human immunodeficiency virus (HIV) and the acquired
immunodeficiency syndrome (AIDS), hereinafter collectively
referred to as HIV/AIDS, tuberculosis and malaria around the
world and the impact of U.S. assistance in combating these
diseases since the 2003 Act was passed. 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 in coming years.
Sec. 3. Definitions.
This section amends the 2003 Act by updating the title of
the Committee to the ``Committee on Foreign Affairs.''
Sec. 4. Purpose.
This section amends the purpose of the 2003 Act by adding
the creation of five-year plans for tuberculosis and malaria;
calling for increased resources for bilateral efforts for
prevention, treatment and care; expanding this assistance to
cover nutrition assistance, heath system and workforce
development, monitoring and evaluations and operations
research; and including efforts to develop research for
tuberculosis and other prevention technologies.
TITLE I--POLICY PLANNING AND COORDINATION
Sec. 101. Development of a Comprehensive, Five-Year, Global Strategy.
This section amends section 101 of the 2003 Act by
providing additional guidance to the President on the
development of the second five-year plan to combat HIV/AIDS
globally. It instructs the President to expand the strategic
approach to behavioral risks related to transmission of HIV/
AIDS. It instructs the President to provide for linkages and
referral systems to nutrition and food support for individuals
with HIV/AIDS, child health services and development programs,
and other social service programs related to HIV/AIDS. It also
calls on the President to provide access to HIV/AIDS education
and testing in family planning and maternal health programs
supported by the United States Government, and to maximize host
country capacity for HIV/AIDS training and research in the
five-year strategy.
Sec. 102. HIV/AIDS Response Coordinator.
This section amends section 1(f)(2) of the State Department
Basic Authorities Act of 1956 (22 U.S.C. 2651a(f)(2)) to
strengthen and expand the duties of the HIV/AIDS Response
Coordinator, including enhancing the role of the Coordinator in
consulting and coordinating with foreign governments,
nongovernmental organizations and other U.S. Government
agencies.
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
Sec. 201. Sense of Congress on Public-Private Partnerships.
This section amends section 201 of the 2003 Act by updating
the purpose of public-private partnerships to address easily
preventable and treatable infectious diseases.
Sec. 202. Participation in the Global Fund to Fight AIDS, Tuberculosis
and Malaria.
This section amends section 202 of the 2003 Act relating to
U.S. contributions to the Global Fund. Subsection (a) updates
findings in that Act. Subsection (b) increases the annual
authorization for the U.S. contribution to the Global Fund from
$1 billion to $2 billion for Fiscal Years 2009 and 2010 of the
amounts authorized to be appropriated under section 401 of the
2003 Act. It also moves the deadline after which funds
appropriated for such contribution can be transferred to the
U.S. bilateral programs from July 1 to December 31 of the year
after the funds are appropriated (if they are available for
more than one fiscal year) and provides new benchmarks designed
to improve the accountability and transparency of the Global
Fund's activities.
Sec. 203. Voluntary Contributions to International Vaccine Funds.
This section amends section 302 of the Foreign Assistance
Act of 1961 to reauthorize the existing programs for the
vaccine fund authorized under section 302(k) of that Act, the
International AIDS Vaccine authorized by section 302(l) of such
Act and the malaria vaccine development program authorized by
section 302(m) of such Act. Section 203 also adds a new section
302(n) relating to authorizing a U.S. contribution to research
and development of a tuberculosis vaccine.
Sec. 204. Program to Facilitate Availability of Microbicides to Prevent
Transmission of HIV and Other Diseases.
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 non-vaccine
prevention methods that can be controlled by women.
Subsection (b) 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 after such microbicides are
proven safe and effective.
Subsection (c) authorizes of the amounts authorized by
section 401 of the 2003 Act, such sums as may be necessary for
Fiscal Years 2009 through 2013 to carry out this section.
Sec. 205. Plan to Combat HIV/AIDS, Tuberculosis, and Malaria by
Strengthening Health Policies and Health Systems of Host
Countries.
This section amends Title II of the 2003 Act by adding a
new section 204 relating to strengthening health policies and
health systems of host countries. Subsection (a) provides
findings on the need for strengthening of such health policies
and systems. Subsection (b) provides for a statement of policy
directed to this need. Subsection (c) requires the Coordinator
to develop and implement a plan to combat HIV/AIDS by
strengthening such policies and systems as part of the United
States Agency for International Development's ``Health Systems
2020 Project.'' Subsection (d) authorizes the appropriation of
funds authorized under section 401 of the Act to the Department
of the 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.
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 Act, both of which
relate to bilateral U.S. HIV/AIDS assistance.
Subsection (a) amends section 104A by updating and
sharpening the focus on certain assistance activities. In
particular, the amendments to section 104A create new targets
for U.S. HIV/AIDS assistance by 2013 of preventing 12 million
infections, treating 3 million persons with HIV/AIDS and caring
for 12 million individuals (including 5 million HIV/AIDS
orphans and vulnerable children), and training health workers
and professionals for HIV/AIDS prevention, treatment and care;
widening U.S. efforts to regions such as Central and Eastern
Europe and South and Southeast Asia; and creating a new focus
on support for host countries.
Subsection (a) also expands 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 the use of safe and effective
microbicides when they become available. It also expands
activities for treatment, including assistance to support
treatment for one-third of all individuals in clinical need of
treatment in the poorest countries worldwide, assistance to
reduce barriers to treatment, and assistance for psycho-social
treatment for youth to ensure adherence to treatment. It also
provides for a more integrated approach to HIV/AIDS by
supporting referral of individuals with HIV/AIDS to relevant
services and enhanced support of related programs that can
improve the effectiveness of HIV/AIDS programs, such as
nutrition, education, and programs that improve the livelihood
of individuals with HIV/AIDS. Subsection (a) also expands the
annual report required by section 104A(e) to address a number
of the new approaches described in this Act.
Subsection (b) amends section 301 of the 2003 Act to expand
the authorization to Fiscal Years 2009 through 2013.
Subsection (c) amends section 301(c) of the 2003 Act to
create an enhanced focus on food and nutrition assistance as
critical to an integrated approach to treatment of individuals
with HIV/AIDS.
Subsection (d) 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
objection.
Subsection (e) repeals a sense of Congress that is
superfluous in light of the amendment made by subsection (c).
Subsection (f) requires the Coordinator to provide a report
identifying a target for the number of additional health
professionals and workers needed in host countries to provide
HIV/AIDS prevention, treatment and care.
Sec. 302. Assistance to Combat Tuberculosis.
Subsection (a) makes amendments to section 104B of the
Foreign Assistance Act of 1961 relating to assistance to combat
tuberculosis, drawing from the House-passed version of H.R.
1567, the Stop Tuberculosis (TB) Now Act of 2007. These
amendments include additional findings and an amended 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
integration of HIV/AIDS and tuberculosis training. The
amendments also include providing for a new U.S. strategy to
combat tuberculosis and an authorization to provide increased
resources to the World Health Organization.
Subsection (b) amends section 302 of the 2003 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 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 the
U.S. effort to combat malaria.
Subsection (b) amends section 303 of the 2003 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 Act (as amended by this Act) for assistance to combat
malaria.
Subsection (c) further amends section 303 of the 2003 Act
by adding a requirement for a comprehensive strategy to combat
malaria and to establish within USAID a malaria coordinator. It
also provides for contributions to the Roll Back Malaria
Partnership and the World Health Organization; for research by
relevant U.S. agencies to address prevention, treatment and
care of malaria; and for an annual report on the prevention,
treatment, control and elimination of malaria.
Sec. 304. Health Care Partnerships to Combat HIV/AIDS.
This section supports the development of partnerships
between institutions based in the United States and foreign
institutions, including national and local health agencies,
medical facilities, health education and training institutions,
and faith- and community-based organizations involved in
prevention, treatment and care of individuals with HIV/AIDS.
Subtitle B--Assistance for Women, Children, and Families
Sec. 311. Policy and Requirements.
This section amends section 312 of the 2003 Act to provide
for additional policy and other requirements. Subsection (a)
provides for collaboration among all relevant actors that
combat HIV/AIDS. Subsection (b) revises section 312(b) of the
2003 Act to provide for requirements regarding the five-year
strategy required by section 101 of the 2003 Act, including
establishing targets for reaching 80 percent of pregnant women
for prevention of mother-to-child transmission (PMTCT) of HIV;
for requiring that up to 15 percent of those receiving
treatment and up to 15 percent of those receiving care from
U.S. HIV/AIDS assistance are children; for integrating care and
treatment with PMTCT programs; and for expanding programs to
care for children orphaned by HIV/AIDS.
Sec. 312. Annual Reports on Prevention of Mother-to-Child Transmission
of the HIV Infection.
This section amends section 313 of the 2003 Act by
extending the duration of the annual PMTCT report required by
such section and requires that such report include additional
information on the number of women who receive various types of
assistance related to PMTCT.
Sec. 313. Strategy to Prevent HIV Infections Among Women and Youth.
This section provides for a comprehensive, integrated and
culturally appropriate global HIV/AIDS prevention strategy that
addresses the vulnerabilities of women and youth. Subsection
(a) provides a statement of policy regarding this matter.
Subsection (b) requires the strategy and describes its
elements. Subsection (c) provides, in formulating and
implementing the strategy required by subsection (b),
coordination with relevant actors involved in combating HIV/
AIDS. Subsection (d) provides for guidance to field missions
based on the strategy described in subsection (b). Subsection
(e) requires a report on the implementation of the strategy.
Sec. 314. Clerical Amendment.
This section makes a clerical amendment to the 2003 Act.
TITLE IV--AUTHORIZATION OF APPROPRIATIONS
Sec. 401. Authorization of Appropriations.
This section increases the authorization under section
401(a) of the 2003 Act to $10 billion for each of the Fiscal
Years 2009 to 2013.
Sec. 402. Sense of Congress.
This section amends the sense of Congress language included
in section 402(b) of the 2003 Act to eliminate specific
spending directives in the legislation, including the 55%
directive, expressed as a sense of Congress, for treatment, and
the directive, again expressed as a sense of Congress, that
one-third of prevention funds be used for abstinence programs.
Sec. 403. Allocation of Funds.
This section amends section 403(a) of the 2003 Act to
maintain focus on balanced prevention programming. In
particular, the new subsection (a) provides that 20 percent of
all funds authorized for HIV/AIDS programs by the Act shall be
used to support HIV prevention programs. In addition, the
revised section 403(a) includes a requirement that the
Coordinator provide balanced funding for prevention activities
for sexual transmission of HIV/AIDS and 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 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 a 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 behavioral change programs (defined
to include abstinence, delay of sexual debut, monogamy,
fidelity, and partner reduction), the Coordinator shall, within
30 days of the issuance of this strategy, report to the
appropriate congressional committees on the justification for
this decision. Finally, this section extends the focus of the
Act relating to orphans and vulnerable children.
Sec. 404. Prohibition on Taxation by Foreign Governments.
Subsection (a) provides that none of the funds appropriated
pursuant to the authorization of the 2003 Act, as amended by
this Act, may be made available to provide assistance for a
foreign country under a new bilateral agreement governing the
terms and conditions under which such assistance is to be
provided unless such agreement includes a provision stating
that assistance provided by the United States shall be exempt
from taxation, or reimbursed, by the foreign government, and
the Secretary of State shall expeditiously seek to negotiate
amendments to existing bilateral agreements, as necessary, to
conform with this requirement.
Subsection (b) provides for a de minimus exception to this
section.
Subsection (c) authorizes that any funds withheld pursuant
to subsection (a) shall be reprogrammed for HIV/AIDS assistance
to another country.
Subsection (d) provides that subsection (a) shall not apply
if the Secretary of State determines that a country does not
assess such taxes, has a mechanism for reimbursement of such
taxes, or that U.S. foreign policy interests outweigh the
purposes of subsection (a).
Subsection (e) provides for the issuance of regulations
regarding this section.
Subsection (f) provides definitions.
TITLE V--SUSTAINABILITY AND STRENGTHENING OF HEALTH CARE SYSTEMS
Sec. 501. Sustainability and Strengthening of Health Care Systems.
This section amends the 2003 Act by adding a new title
relating to sustainability and strengthening of health care
systems in countries as part of overall efforts to combat HIV/
AIDS. The new title also directs U.S. representatives to
relevant international financial institutions to support the
exemption of health expenditures from any proposed national
budget caps or other limits.
Sec. 502. Clerical Amendment.
This section makes a clerical amendment to the 2003 Act to
reflect the new title.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, 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 italics, existing law in which no change
is proposed is shown in roman):
UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA
ACT OF 2003
AN ACT To provide assistance to foreign countries to combat HIV/AIDS,
tuberculosis, and malaria, and for other purposes.
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) * * *
(b) Table of Contents.--The table of contents for this Act
is as follows:
Sec. 1. Short title; table of contents.
* * * * * * *
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
Sec. 201. Sense of Congress on public-private partnerships.
* * * * * * *
Sec. 204. Plan to combat HIV/AIDS by strengthening health policies and
health systems of host countries.
TITLE III--BILATERAL EFFORTS
Subtitle A--General Assistance and Programs
Sec. 301. Assistance to combat HIV/AIDS.
* * * * * * *
[Sec. 304. Pilot program for the placement of health care professionals
in overseas areas severely affected by HIV/AIDS, tuberculosis,
and malaria.]
Sec. 304. Health care partnerships to combat HIV/AIDS.
* * * * * * *
[Subtitle B--Assistance for Children and Families]
Subtitle B--Assistance for Women, Children, and Families
Sec. 311. Findings.
* * * * * * *
Sec. 316. Strategy to prevent HIV infections among women and youth.
* * * * * * *
TITLE VI--SUSTAINABILITY AND STRENGTHENING OF HEALTH CARE SYSTEMS
Sec. 601. Findings.
Sec. 602. National health workforce strategies and other policies.
Sec. 603. Exemption of investments in health from limits sought by
international financial institutions.
Sec. 604. Public-sector procurement, drug registration, and supply chain
management systems.
Sec. 605. Authorization of appropriations.
* * * * * * *
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) * * *
* * * * * * *
(29) The HIV/AIDS pandemic continues to pose a
major threat to the health of the global community,
from the most severely-affected regions of sub-Saharan
Africa and the Caribbean, to the emerging epidemics of
Eastern Europe, Central Asia, South and Southeast Asia,
and Latin America.
(30) According to UNAIDS' 2007 global estimates,
there are 33.2 million individuals with HIV/AIDS
worldwide, including 2.5 million people newly-infected
with HIV. Of those infected with HIV, 2.5 million are
children under 15 who also account for 460,000 of the
newly-infected individuals.
(31) Sub-Saharan Africa continues to be the region
most affected by the HIV/AIDS pandemic. More than 68
percent of adults and nearly 90 percent of children
with HIV/AIDS live in sub-Saharan Africa, and more than
76 percent of AIDS deaths in 2007 occurred in sub-
Saharan Africa.
(32) Although sub-Saharan Africa carries the
heaviest disease burden of HIV/AIDS, the HIV/AIDS
pandemic continues to affect virtually every world
region. While prevalence rates are relatively low in
Eastern Europe, Central Asia, South and Southeast Asia,
and Latin America, without effective prevention
strategies, HIV prevalence rates could rise quickly in
these regions.
(33) By world region, according to UNAIDS' 2007
global estimates--
(A) in sub-Saharan Africa, there were 22.5
million adults and children infected with HIV,
up from 20.9 million in 2001, with 1.7 million
new HIV infections, a 5 percent prevalence
rate, and 1.6 million deaths;
(B) in South and Southeast Asia, there were
4 million adults and children infected with
HIV, up from 3.5 million in 2001, with 340,000
new HIV infections, a 0.3 percent prevalence
rate, and 270,000 deaths;
(C) in East Asia, there were 800,000 adults
and children infected with HIV, up from 420,000
in 2001, with 92,000 new HIV infections, a 0.1
percent prevalence rate, and 32,000 deaths;
(D) in Eastern and Central Europe, there
were 1.6 million adults and children infected
with HIV, up from 630,000 in 2001, with 150,000
new HIV infections, a 0.9 percent prevalence
rate, and 55,000 deaths; and
(E) in the Caribbean, there were 230,000
adults and children infected with HIV, up from
190,000 in 2001, with 17,000 new HIV
infections, a 1 percent prevalence rate, and
11,000 deaths.
(34) Tuberculosis is the number one killer of
individuals with HIV/AIDS and is responsible for up to
one-half of HIV/AIDS deaths in Africa.
(35) The wide extent of drug resistant
tuberculosis, including both multi-drug resistant
tuberculosis (MDR-TB) and extensively drug resistant
tuberculosis (XDR-TB), driven by the HIV/AIDS pandemic
in sub-Saharan Africa, has hampered both HIV/AIDS and
tuberculosis treatment services. The World Health
Organization (WHO) has declared the prevalence of
tuberculosis to be at emergency levels in sub-Saharan
Africa.
(36) Forty percent of the world's population,
mostly poor, live in malarial zones, and malaria, which
is highly preventable, kills more than 1 million
individuals worldwide each year. Ninety percent of
malaria's victims are in sub-Saharan Africa and 70
percent of malaria's victims are children under the age
of 5. Additionally, hunger and malnutrition kill
another 6 million individuals worldwide each year.
(37) Assistance to combat HIV/AIDS must address the
nutritional factors associated with the disease in
order to be effective and sustainable. The World Food
Program estimates that 6.4 million individuals affected
by HIV will need nutritional support by 2008.
(38) Women and girls continue to be vulnerable to
HIV, in large part, due to gender-based cultural norms
that leave many women and girls powerless to negotiate
social relationships.
(39) Women make up 50 percent of individuals
infected with HIV worldwide. In sub-Saharan Africa,
where the HIV/AIDS epidemic is most severe, women make
up 57 percent of individuals infected with HIV, and 75
percent of young people infected with HIV in sub-
Saharan Africa are young women ages 15 to 24.
(40) Women and girls are biologically, socially,
and economically more vulnerable to HIV infection.
Gender disparities in the rate of HIV infection are the
result of a number of factors, including the following:
(A) Cross-generational sex with older men
who are more likely to be infected with HIV,
and a lack of choice regarding when and whom to
marry, leading to early marriages and high
rates of child marriages with older men. About
one-half of all adolescent females in sub-
Saharan Africa and two-thirds of adolescent
females in Asia are married by age 18.
(B) Studies show that married women and
married and unmarried girls often are unable or
find it difficult to negotiate the frequency
and timing of sexual intercourse, ensure their
partner's faithfulness, or insist on condom
use. Under these circumstances, women often run
the risk of being infected by husbands or male
partners in societies where men in
relationships have more than one partner.
Behavior change is particularly important in
societies in which this is a common practice.
(C) Because young married women and girls
are more likely to have unprotected sex and
have more frequent sex than their unmarried
peers, and women and girls who are faithful to
their spouses can be placed at risk of HIV/AIDS
through a husband's infidelity or prior
infection, marriage is not always a guarantee
against HIV infection, although it is a
protective factor overall.
(D) Social and economic inequalities based
largely on gender limit access for women and
girls to education and employment opportunities
and prevent them from asserting their
inheritance and property rights. For many
women, a lack of independent economic means
combines with socio-cultural practices to
sustain and exacerbate their fear of
abandonment, eviction, or ostracism from their
homes and communities and can leave many more
women trapped within relationships where they
are vulnerable to HIV infection.
(E) A lack of educational opportunities for
women and girls is linked to younger sexual
debut, earlier childhood marriage, earlier
childbearing, decreased child survival,
worsening nutrition, and increased risk of HIV
infection.
(F) High rates of gender-based violence,
rape, and sexual coercion within and outside
marriage contribute to high rates of HIV
infection. According to the World Health
Organization, between one-sixth and three-
quarters of women in various countries and
settings have experienced some form of physical
or sexual violence since the age of 15 within
or outside of marriage. Women who are unable to
protect themselves from such violence are often
unable to protect themselves from being
infected with HIV through forced sexual
contact.
(G) Fear of domestic violence and the
continuing stigma and discrimination associated
with HIV/AIDS prevent many women from accessing
information about HIV/AIDS, getting tested,
disclosing their HIV status, accessing services
to prevent mother-to-child transmission of HIV,
or receiving treatment and counseling even when
they already know they have been infected with
HIV.
(H) According to UNAIDS, the vulnerability
of individuals involved in commercial sex acts
to HIV infection is heightened by
stigmatization and marginalization, limited
economic options, limited access to health,
social, and legal services, limited access to
information and prevention means, gender-
related differences and inequalities, sexual
exploitation and trafficking, harmful or non-
protective laws and policies, and exposure to
risks associated with commercial sex acts, such
as violence, substance abuse, and increased
mobility.
(I) Lack of access to basic HIV prevention
information and education and lack of
coordination with existing primary health care
to reduce stigma and maximize coverage.
(J) Lack of access to currently available
female-controlled HIV prevention methods, such
as the female condom, and lack of training on
proper use of either male or female condoms.
(K) High rates of other sexually
transmitted infections and complications during
pregnancies and childbirth.
(L) An absence of functioning legal
frameworks to protect women and girls and,
where such frameworks exist, the lack of
accountable and effective enforcement of such
frameworks.
(41) In addition to vulnerabilities to HIV
infection, women in sub-Saharan Africa face a 1-in-13
chance of dying in childbirth compared to a 1-in-16
chance in least-developed countries worldwide, a 1-in-
60 chance in developing countries, and a 1-in-4,100
chance in developed countries.
(42) Due to these high maternal mortality rates and
high HIV prevalence rates in certain countries, special
attention is needed in these countries to help HIV-
positive women safely deliver healthy babies and save
women's lives.
(43) Unprotected sex within or outside of marriage
is the single greatest factor in the transmission of
HIV worldwide and is responsible for 80 percent of new
HIV infections in sub-Saharan Africa.
(44) Multiple randomized controlled trials have
established that male circumcision reduces a man's risk
of contracting HIV by 60 percent or more. Twelve
acceptability studies have found that in regions of
sub-Saharan Africa where circumcision is not
traditionally practiced, a majority of men want the
procedure. Broader availability of male circumcision
services could prevent millions of HIV infections not
only in men but also in their female partners.
(45)(A) Youth also face particular challenges in
receiving services for HIV/AIDS.
(B) Nearly one-half of all orphans who have lost
one parent and two-thirds of those who have lost both
parents are ages 12 to 17. These orphans are in
particular need of services to protect themselves
against sexually-transmitted infections, including HIV.
(C) Research indicates that many youth benefit from
full disclosure of medically accurate, age-appropriate
information about abstinence, partner reduction, and
condoms. Providing comprehensive information about HIV,
including delay of sexual debut and the ABC model:
``Abstain, Be faithful, use Condoms'', and linking such
information to health care can help improve awareness
of safe sex practices and address the fact that only 1
in 3 young men and 1 in 5 young women ages 15 to 24 can
correctly identify ways to prevent HIV infection.
(D) Surveys indicate that no country has succeeded
in fully educating more than one-half of its youth
about the prevention and transmission of HIV.
(46) According to the United Nations High
Commissioner for Refugees (UNHCR), HIV/AIDS prevalence
rates among refugees are generally lower than the HIV/
AIDS prevalence rates for their host communities,
though perceptions run counter to this fact. However,
peacekeeping operations that no longer deploy HIV/AIDS-
positive troops still face vulnerabilities to sexual
transmission of HIV with HIV-positive individuals in
refugee camps. Host countries generally do not provide
HIV/AIDS prevention, treatment, and care services for
refugees.
(47) Continuing progress to reach the millions of
impoverished individuals who need voluntary testing,
counseling, treatment, and care for HIV/AIDS requires
increased efforts to strengthen health care delivery
systems and infrastructure, rebuild and expand the
health care workforce, and strengthen allied and
support services in countries receiving United States
global HIV/AIDS assistance.
(48) While HIV/AIDS poses the greatest health
threat of modern times, it also poses the greatest
development challenge for developing countries with
fragile economies and weak public financial management
systems that are ill equipped to shoulder the burden of
this disease. International donors will have to play a
critical role in providing resources for HIV/AIDS
programs far into the future.
(49) The emerging partnerships between countries
most affected by HIV/AIDS and the United States must
include stronger coordination between HIV/AIDS programs
and other United States foreign assistance programs,
and stronger collaboration with other donors in the
areas of economic development and growth strategies.
(50) The future control of HIV/AIDS demands
coordination between international organizations such
as the Global Fund to Fight AIDS, Tuberculosis and
Malaria, UNAIDS, the World Health Organization (WHO),
the World Bank and the International Monetary Fund
(IMF), the international donor community, national
governments, and private sector organizations,
including community and faith-based organizations.
(51) The future control of HIV/AIDS further
requires effective and transparent public finance
management systems in developing countries to advance
the ability of such countries to manage public revenues
and donor funds aimed at combating HIV/AIDS and other
diseases.
(52) The HIV/AIDS pandemic contributes to the
shortage of health care personnel through loss of life
and illness, unsafe working conditions, increased
workloads for diminished staff, and resulting stress
and burnout, while the shortage of health care
personnel undermines efforts to prevent and provide
care and treatment for individuals with HIV/AIDS.
(53) The shortage of health care personnel,
including doctors, nurses, pharmacists, counselors,
laboratory staff, paraprofessionals, trained lay
workers, and researchers is one of the leading
obstacles to combating HIV/AIDS in sub-Saharan Africa.
(54) Since 2003, important progress has been made
in combating HIV/AIDS, yet there is more to be done.
The number of new HIV infections is still increasing at
an alarming rate. According to the United States
National Institute of Allergy and Infectious Diseases,
globally, for every 1 individual put on antiretroviral
therapy, 6 individuals are newly infected with HIV.
(55) The United States Government continues to be
the world's leader in the fight against HIV/AIDS and
the unsurpassed partner with developing countries in
their efforts to control this disease.
(56) By September 2007, the United States, through
the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7601
et seq.), had provided services to prevent mother-to-
child-transmission of HIV to women during 10 million
pregnancies; provided antiretroviral prophylaxis for
women during over 827,300 pregnancies; prevented an
estimated 157,240 HIV infections in infants; cared for
over 6.6 million individuals, including over 2.7
million orphans and vulnerable children; supported
lifesaving antiretroviral therapies for approximately
1.4 million men, women, and children in sub-Saharan
Africa, Asia, and the Carribean; and provided
counseling and testing to over 33.7 million men, women,
and children in developing countries.
(57) These numbers were achieved because of the
commitment of substantial resources and support of the
United States Government to our partners on the front
lines--the dedicated and committed women and men,
communities, and nations who are taking control of the
HIV/AIDS epidemics in their own countries.
SEC. 3. DEFINITIONS.
In this Act:
(1) * * *
(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.
* * * * * * *
[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 global leadership and the effectiveness of the United
States response to the HIV/AIDS, tuberculosis, and malaria
pandemics and other related and preventable infectious diseases
in developing countries by--
(1) establishing a comprehensive, integrated five-
year, global strategy to fight HIV/AIDS, tuberculosis,
and malaria that encompasses a plan for continued
expansion and coordination 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 United States
bilateral efforts to combat HIV/AIDS, tuberculosis, and
malaria, particularly for prevention, treatment, and
care (including nutritional support), technical
assistance and training, the strengthening of health
care systems, health care workforce development,
monitoring and evaluations systems, and operations
research;
(3) providing increased resources for multilateral
efforts 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, microbicides, and other prevention
technologies and improved diagnostics treatment for
HIV/AIDS, tuberculosis, and malaria.
* * * * * * *
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] to
develop efforts further 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) * * *
* * * * * * *
[(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;]
(4) provide that the reduction of HIV/AIDS
behavioral risks shall be a priority of all prevention
efforts in terms of funding, scientifically-accurate
educational services, and activities by--
(A) designing prevention strategies and
programs based on sound epidemiological
evidence, tailored to the unique needs of each
country and community, and reaching those
populations found to be most at risk for
acquiring HIV infection;
(B) promoting abstinence from sexual
activity and substance abuse;
(C) encouraging delay of sexual debut,
monogamy, fidelity, and partner reduction;
(D) promoting the effective use of male and
female condoms;
(E) promoting the use of measures to reduce
the risk of HIV transmission for discordant
couples (where one individual has HIV/AIDS and
the other individual does not have HIV/AIDS or
whose status is unknown);
(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) promoting the rapid expansion of safe
and voluntary male circumcision services;
(H) promoting life skills training and
development for children and youth;
(I) supporting advocacy for child and youth
community-based protective social services;
(J) eradicating trafficking in persons and
creating alternatives to prostitution;
(K) promoting cooperation with law
enforcement to prosecute offenders of
trafficking, rape, and sexual assault crimes
with the goal of eliminating such crimes;
(L) promoting services demonstrated to be
effective in reducing the transmission of HIV
infection among injection drug users without
increasing illicit drug use;
(M) promoting policies and programs to end
the sexual exploitation of and violence against
women and children; and
(N) promoting prevention and treatment
services for men who have sex with men;
(5) include specific plans for linkage to, and
referral systems for nongovernmental organizations that
implement multisectoral approaches, including faith-
based and community-based organizations, for--
(A) nutrition and food support for
individuals with HIV/AIDS and affected
communities;
(B) child health services and development
programs;
(C) HIV/AIDS prevention and treatment
services for injection drug users;
(D) access to HIV/AIDS education and
testing in family planning and maternal health
programs supported by the United States
Government; and
(E) medical, social, and legal services for
victims of violence;
[(5)] (6) improve coordination and reduce
duplication among relevant executive branch agencies,
foreign governments, and international organizations;
[(6)] (7) project general levels of resources
needed to achieve the stated objectives;
[(7)] (8) expand public-private partnerships and
the leveraging of resources;
[(8)] (9) maximize United States capabilities in
the areas of technical assistance and training and
research, including vaccine research;
(10) maximize host country capacities in training
and research, particularly operations research;
[(9)] (11) 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)] (12) include initiatives describing how the
President will maximize the leverage of private sector
dollars in reduction and treatment of HIV/AIDS,
tuberculosis, and malaria.
(b) Report.--
(1) In general.--Not later than 270 days after the
date of enactment of [this Act] the Tom Lantos and
Henry J. Hyde Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008,
the President shall submit to the appropriate
congressional committees a report setting forth the
strategy described in subsection (a).
* * * * * * *
(3) Report elements.--The elements referred to in
paragraph (2) are the following:
(A) * * *
* * * * * * *
[(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 health care workers,
the development of health care infrastructure
and delivery systems, and avoidance of
substance abuse.]
(C) A description of the manner in which
the strategy will address the following:
(i) The fundamental elements of
prevention and education, care and
treatment, including increasing access
to pharmaceuticals, vaccines, and
microbicides, as they become available,
screening, prophylaxis, and treatment
of major opportunistic infections,
including tuberculosis, and increasing
access to nutrition and food for
individuals on antiretroviral
therapies.
(ii) The promotion of delay of
sexual debut, abstinence, monogamy,
fidelity, and partner reduction.
(iii) The promotion of correct and
consistent use of male and female
condoms and other strategies and skills
development to reduce the risk of HIV
transmission.
(iv) Increasing voluntary access to
safe male circumcision services.
(v) Life-skills training.
(vi) The provision of information
and services to encourage young people
to delay sexual debut and ensure access
to HIV/AIDS prevention information and
services.
(vii) Prevention of sexual violence
leading to transmission of HIV and
assistance for victims of violence who
are at risk of HIV transmission.
(viii) HIV/AIDS prevention, care,
and treatment services for injection
drug users.
(ix) Research, including incentives
for HIV vaccine development and new
protocols.
(x) Advocacy for community-based
child and youth protective services.
(xi) Training of health care
workers.
(xii) The development of health
care infrastructure and delivery
systems.
(xiii) Prevention efforts for
substance abusers.
(xiv) Prevention, treatment, care,
and outreach efforts for men who have
sex with men.
(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,
including through faith-based and other
nongovernmental organizations.
(E) A description of the specific
strategies developed to meet the unique needs
of women, including access to HIV/AIDS
education and testing in family planning and
maternal and child health programs supported by
the United States Government and 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 (including
by accessing voluntary clinical circumcision
services), 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 and
men's access to employment opportunities,
income, productive resources, and microfinance
programs.
* * * * * * *
(M) A description of efforts to be
undertaken to strengthen the public finance
management systems of selected host countries
to ensure transparent, efficient, and effective
management of national and donor financial
investments in health.
[(M)] (N) 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)] (O) A description of the mechanisms
to be established for monitoring and
[evaluating programs,] evaluating programs to
ensure medical accuracy, operations research,
promoting successful models, and for
terminating unsuccessful programs.
[(O)] (P) 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)] (Q) A description of the ways in
which United States leadership will be used to
enhance the overall international response to
the HIV/AIDS pandemic, strengthen national
health care delivery systems, and increase
national health workforce capacities, 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)] (R) 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, including strategies relating to
agricultural development, trade and economic
growth, and education.
[(R)] (S) 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)] (T) A description of efforts being
made to address the unique needs of families
with children with respect to HIV/AIDS,
including efforts of intergenerational
caregivers and efforts to preserve the family
unit.
[(T)] (U) 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.
(V) A plan to strengthen and implement
health care workforce strategies to enable
countries to increase the supply and retention
of all cadres of trained professional and
paraprofessional health care workers by numbers
that move toward global health program needs
and toward targets established by the World
Health Organization, while enabling health
systems to expand coverage consistent with
national and international targets and goals.
[(U)] (W) 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)] (X) 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.]
(Y) A description of the specific
strategies, developed in coordination with
existing health programs, to prevent mother-to-
child transmission of HIV, including the extent
to which HIV-positive women and men in
treatment, care, and support programs and HIV-
negative women and men are counseled about
methods of preventing HIV transmission and the
extent to which HIV prevention methods are
provided on-site or by referral in treatment,
care, and support programs.
(Z) A description of the specific
strategies developed to maximize the capacity
of health care providers, including faith-based
and other nongovernmental organizations, and
family planning providers supported by the
United States Government to ensure access to
necessary and comprehensive information about
reducing sexual transmission of HIV among
women, men, and young people, including
strategies to ensure HIV/AIDS prevention
training for such providers.
(AA) A strategy to work with international
and host country partners toward universal
access to HIV/AIDS prevention, treatment, and
care programs.
* * * * * * *
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
SEC. 201. SENSE OF CONGRESS ON PUBLIC-PRIVATE PARTNERSHIPS.
(a) Findings.--Congress makes the following findings:
(1) * * *
(2) Public-private sector partnerships multiply
local and international capacities to strengthen the
delivery of health services in developing countries and
to accelerate research for vaccines and other
pharmaceutical products that are essential to combat
[infectious diseases] easily preventable and treatable
infectious diseases decimating the populations of these
countries.
* * * * * * *
(4) Sustaining existing public-private partnerships
and building new ones are critical to the success of
the international community's efforts to combat HIV/
AIDS and other [infectious diseases] easily preventable
and treatable infectious diseases around the globe.
* * * * * * *
SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS
AND MALARIA.
(a) Findings.--The Congress finds as follows:
(1) The Global Fund to Fight AIDS, Tuberculosis and
Malaria is the multilateral component of this Act,
extending United States efforts to a total of 136
countries around the world.
(2) Created in 2002, the Global Fund has played a
leading role in the fight against HIV/AIDS,
tuberculosis, and malaria around the world and has
grown into an organization that currently provides
nearly a quarter of all international financing to
combat HIV/AIDS and two-thirds of all international
financing to combat tuberculosis and malaria.
(3) By 2010, it is estimated that the demand for
funding by the Global Fund will grow in size to between
$6 and $8 billion annually, requiring significant
contributions from donors around the world, including
at least $2 billion annually from the United States.
(4) The Global Fund is an innovative financing
mechanism to combat HIV/AIDS, tuberculosis, and
malaria, and has made progress in many areas.
(5) The United States Government is the largest
supporter of the Global Fund, both in terms of
resources and technical support.
(6) The United States made the initial contribution
to the Global Fund and is fully committed to its
success.
[(1)] (7) 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)] (8) 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)] (9) 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.
* * * * * * *
(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 each of the fiscal years
2009 and 2010, and such sums as may be necessary for
[the fiscal years 2005-2008] each of the fiscal years
2011 through 2013, for contributions to the Global
Fund.
* * * * * * *
(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] 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.
* * * * * * *
(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] fiscal year 2009.
(B)(i) * * *
* * * * * * *
(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), unless such
amount is made available for more than one
fiscal year, in which case such amount is
authorized to be made available for such
purposes after December 31 of the fiscal year
following the fiscal year in which such funds
first became available..
(C)(i) * * *
(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) * * *
* * * * * * *
SEC. 204. PLAN TO COMBAT HIV/AIDS, TUBERCULOSIS, AND MALARIA BY
STRENGTHENING HEALTH POLICIES AND HEALTH SYSTEMS OF
HOST COUNTRIES.
(a) Findings.--Congress makes the following findings:
(1) One of the most significant barriers to
achieving universal access to HIV/AIDS treatment and
prevention in developing countries is the lack of
health infrastructure, particularly in sub-Saharan
Africa.
(2) In addition to HIV/AIDS programs, other
treatable and preventable infectious diseases could be
treated concurrently and easily if health care delivery
systems in developing countries were significantly
improved.
(3) More public investment in basic primary health
care should be a priority in public spending in
developing countries.
(b) Statement of Policy.--It shall be the policy of the
United States Government--
(1) to invest appropriate resources authorized
under this Act and the amendments made by this Act to
carry out activities to strengthen HIV/AIDS health
policies and health systems and provide workforce
training and capacity-building consistent with the
goals and objectives of this Act and the amendments
made by this Act; and
(2) to support the development of a sound policy
environment in host countries to increase the ability
of such countries to maximize utilization of health
care resources from donor countries, deliver services
to the people of such host countries in an effective
and efficient manner, and reduce barriers that prevent
recipients of services from achieving maximum benefit
from such services.
(c) Plan Required.--The Coordinator of United States
Government Activities to Combat HIV/AIDS Globally, in
collaboration with the Administrator of the United States
Agency for International Development, shall develop and
implement a plan to combat HIV/AIDS by strengthening health
policies and health systems of host countries as part of the
United States Agency for International Development's ``Health
Systems 2020'' project.
(d) Assistance to Improve Public Finance Management
Systems.--
(1) In general.--The Secretary of the Treasury,
acting through the head of the Office of Technical
Assistance, is authorized to provide assistance for
advisors and host country finance, health, and other
relevant ministries to improve the effectiveness of
public finance management systems in host 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
Subtitle A--General Assistance and Programs
SEC. 301. ASSISTANCE TO COMBAT HIV/AIDS.
(a) * * *
(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).
* * * * * * *
(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.
[(d) Eligibility for Assistance.--An organization that is
otherwise eligible to receive assistance under section 104A of
the Foreign Assistance Act of 1961 (as added by subsection (a))
or under any other provision of this Act (or any amendment made
by this Act) to prevent, treat, or monitor HIV/AIDS shall not
be required, as a condition of receiving the assistance, to
endorse or utilize a multisectoral approach to combatting HIV/
AIDS, or to endorse, utilize, or participate in a prevention
method or treatment program to which the organization has a
religious or moral objection.]
(c) Food Security and Nutrition Support.--
(1) Findings.--Congress finds the following:
(A) The United States provides more than 60
percent of all food assistance worldwide.
(B) According to the United Nations World
Food Program and other United Nations agencies,
food insecurity of individuals with HIV/AIDS is
a major problem in countries with large
populations of such individuals, particularly
in sub-Saharan African countries.
(C) Individuals infected with HIV have
higher nutritional requirements than
individuals who are not infected with HIV,
particularly with respect to the need for
protein. Also, there is evidence to suggest
that the full benefit of therapy to treat HIV/
AIDS may not be achieved in individuals who are
malnourished, particularly in pregnant and
lactating women.
(2) Sense of congress.--It is the sense of Congress
that--
(A) malnutrition, especially for
individuals with HIV/AIDS, is a clinical health
issue with wider nutrition, health, and social
implications for such individuals, their
families, and their communities that must be
addressed by United States HIV/AIDS prevention,
treatment, and care programs;
(B) food security and nutrition directly
impact an individual's vulnerability to HIV
infection, the progression of HIV to AIDS, an
individual's ability to begin an antiretroviral
medication treatment regimen, the efficacy of
an antiretroviral medication treatment regimen
once an individual begins such a regimen, and
the ability of communities to effectively cope
with the HIV/AIDS epidemic and its impacts;
(C) international guidelines established by
the World Health Organization (WHO) should
serve as the reference standard for HIV/AIDS
food and nutrition activities supported by this
Act and the amendments made by this Act;
(D) the Coordinator of United States
Government Activities to Combat HIV/AIDS
Globally and the Administrator of the United
States Agency for International Development
should make it a priority to work together and
with other United States Government agencies,
donors, and multilateral institutions to
increase the integration of food and nutrition
support and livelihood activities into HIV/AIDS
prevention, treatment, and care activities
funded by the United States and other
governments and organizations;
(E) for purposes of determining which
individuals infected with HIV should be
provided with nutrition and food support--
(i) children with moderate or
severe malnutrition, according to WHO
standards, shall be given priority for
such nutrition and food support; and
(ii) adults with a body mass index
(BMI) of 18.5 or less, or at the
prevailing WHO-approved measurement for
BMI, should be considered
``malnourished'' and should be given
priority for such nutrition and food
support;
(F) programs funded by the United States
should include therapeutic and supplementary
feeding, food, and nutrition support and should
include strong links to development programs
that provide support for livelihoods; and
(G) the inability of individuals with HIV/
AIDS to access food for themselves or their
families should not be allowed to impair or
erode the therapeutic status of such
individuals with respect to HIV/AIDS or related
co-morbidities.
(3) Statement of policy.--It is the policy of the
United States to--
(A) address the food and nutrition needs of
individuals with HIV/AIDS and affected
individuals, including orphans and vulnerable
children;
(B) fully integrate food and nutrition
support into HIV/AIDS prevention, treatment,
and care programs carried out under this Act
and the amendments made by this Act;
(C) ensure, to the extent practicable,
that--
(i) HIV/AIDS prevention, treatment,
and care providers and health care
workers are adequately trained so that
such providers and workers can provide
accurate and informed information
regarding food and nutrition support to
individuals enrolled in treatment and
care programs and individuals affected
by HIV/AIDS; and
(ii) individuals with HIV/AIDS who,
with their households, are identified
as food insecure are provided with
adequate food and nutrition support;
and
(D) effectively link food and nutrition
support provided under this Act and the
amendments made by this Act to individuals with
HIV/AIDS, their households, and their
communities, to other food security and
livelihood programs funded by the United States
and other donors and multilateral agencies.
(4) Integration of food security and nutrition
activities into hiv/aids prevention, treatment, and
care activities.--
(A) Requirements relating to global aids
coordinator.--Consistent with the statement of
policy described in paragraph (3), the
Coordinator of United States Government
Activities to Combat HIV/AIDS Globally shall--
(i) ensure, to the extent
practicable, that--
(I) an assessment, using
validated criteria, of the food
security and nutritional status
of each individual enrolled in
antiretroviral medication
treatment programs supported
with funds authorized under
this Act or any amendment made
by this Act is carried out; and
(II) appropriate
nutritional counseling is
provided to each individual
described in subclause (I);
(ii) coordinate with the
Administrator of the United States
Agency for International Development,
the Secretary of Agriculture, and the
heads of other relevant executive
branch agencies to--
(I) ensure, to the extent
practicable, that, in
communities in which a
significant proportion of
individuals with HIV/AIDS are
in need of food and nutrition
support, a status and needs
assessment for such support
employing validated criteria is
conducted and a plan to provide
such support is developed and
implemented;
(II) improve and enhance
coordination between food
security and livelihood
programs for individuals
infected with HIV in host
countries and food security and
livelihood programs that may
already exist in such
countries;
(III) establish effective
linkages between the health and
agricultural development and
livelihoods sectors in order to
enhance food security; and
(IV) ensure, by providing
increased resources if
necessary, effective
coordination between activities
authorized under this Act and
the amendments made by this Act
and activities carried out
under other provisions of the
Foreign Assistance Act of 1961
when establishing new HIV/AIDS
treatment sites;
(iii) develop effective, validated
indicators that measure outcomes of
nutrition and food security
interventions carried out under this
section and use such indicators to
monitor and evaluate the effectiveness
of such interventions; and
(iv) evaluate the role of and, to
the extent appropriate, support and
expand partnerships and linkages
between United States postsecondary
educational institutions with
postsecondary educational institutions
in host countries in order to provide
training and build indigenous human and
institutional capacity and expertise to
respond to HIV/AIDS, and to improve
capacity to address nutrition, food
security, and livelihood needs of HIV/
AIDS-affected and impoverished
communities.
(B) Requirements relating to usaid
administrator.--Consistent with the statement
of policy described in paragraph (3), the
Administrator of the United States Agency for
International Development, in coordination with
the Coordinator of United States Government
Activities to Combat HIV/AIDS Globally and the
Secretary of Agriculture, shall provide, to the
extent practicable, as an essential component
of antiretroviral medication treatment programs
supported with funds authorized under this Act
and the amendments made by this Act, food and
nutrition support to each individual with HIV/
AIDS who is determined to need such support by
the assessing health professional, based on a
body mass index (BMI) of 18.5 or less, or at
the prevailing WHO-approved measurement for
BMI, and the individual's household, for a
period of not less than 180 days, either
directly or through referral to an assistance
program or organization with demonstrable
ability to provide such support.
(C) Report.--Not later than October 31,
2010, and annually thereafter, the Coordinator
of United States Government Activities to
Combat HIV/AIDS Globally, in consultation with
the Administrator of the United States Agency
for International Development, shall submit to
the appropriate congressional committees a
report on the implementation of this subsection
for the prior fiscal year. The report shall
include a description of--
(i) the effectiveness of
interventions carried out to improve
the nutritional status of individuals
with HIV/AIDS;
(ii) the amount of funds provided
for food and nutrition support for
individuals with HIV/AIDS and affected
individuals in the prior fiscal year
and the projected amount of funds to be
provided for such purpose for next
fiscal year; and
(iii) a strategy for improving the
linkage between assistance provided
with funds authorized under this
subsection and food security and
livelihood programs under other
provisions of law as well as activities
funded by other donors and multilateral
organizations.
(D) 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 President
such sums as may be necessary for each of the
fiscal years 2009 through 2013 to carry out
this subsection.
(d) Eligibility for Assistance.--An organization, including
a faith-based organization, that is otherwise eligible to
receive assistance under section 104A of the Foreign Assistance
Act of 1961 (as added by subsection (a)) or under any other
provision of this Act (or any amendment made by this Act or the
Tom Lantos and Henry J. Hyde Global Leadership Against HIV/
AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008) to
prevent, treat, or monitor HIV/AIDS--
(1) shall not be required, as a condition of
receiving the assistance, to endorse or utilize a
multisectoral approach to combating HIV/AIDS, or to
endorse, utilize, make a referral to, become integrated
with or otherwise participate in any program or
activity to which the organization has a religious or
moral objection; and
(2) shall not be discriminated against in the
solicitation or issuance of grants, contracts, or
cooperative agreements under such provisions of law for
refusing to do so.
* * * * * * *
[(g) Sense of Congress Relating to Food Assistance for
Individuals Living With HIV/AIDS.--
[(1) Findings.--Congress finds the following:
[(A) The United States provides more than
60 percent of all food assistance worldwide.
[(B) According to the United Nations World
Food Program and other United Nations agencies,
food insecurity of individuals infected or
living with HIV/AIDS is a major problem in
countries with large populations of such
individuals, particularly in African countries.
[(C) Although the United States is willing
to provide food assistance to these countries
in need, a few of the countries object to part
or all of the assistance because of fears of
benign genetic modifications to the foods.
[(D) Healthy and nutritious foods for
individuals infected or living with HIV/AIDS
are an important complement to HIV/AIDS
medicines for such individuals.
[(E) Individuals infected with HIV have
higher nutritional requirements than
individuals who are not infected with HIV,
particularly with respect to the need for
protein. Also, there is evidence to suggest
that the full benefit of therapy to treat HIV/
AIDS may not be achieved in individuals who are
malnourished, particularly in pregnant and
lactating women.
[(2) Sense of congress.--It is therefore the sense
of Congress that United States food assistance should
be accepted by countries with large populations of
individuals infected or living with HIV/AIDS,
particularly African countries, in order to help feed
such individuals.]
SEC. 302. ASSISTANCE TO COMBAT TUBERCULOSIS.
(a) * * *
(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] $4,000,000,000 for fiscal years 2009 through 2013
to carry out section 104B of the Foreign Assistance Act
of 1961, as added by subsection (a).
* * * * * * *
(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.
(a) * * *
(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 for fiscal years 2009 through 2013 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 the
Medicines for Malaria Venture.
* * * * * * *
(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).
* * * * * * *
(d) Development of a Comprehensive Five-Year Strategy.--The
President shall establish a comprehensive, five-year strategy
to combat global malaria that strengthens the capacity of the
United States to be an effective leader of international
efforts to reduce the global malaria disease burden. Such
strategy shall maintain sufficient flexibility and remain
responsive to the ever-changing nature of the global malaria
challenge and shall--
(1) include specific objectives, multisectoral
approaches and strategies to treat and provide care to
individuals infected with malaria, to prevent the
further spread of malaria;
(2) describe how this strategy would contribute to
the United States' overall global health and
development goals;
(3) clearly explain how proposed activities to
combat malaria will be coordinated with other United
States global health activities, including the five-
year global HIV/AIDS and tuberculosis strategies
developed pursuant to section 101 of this Act;
(4) expand public-private partnerships and
leveraging of resources to combat malaria, including
private sector resources;
(5) coordinate among relevant executive branch
agencies providing assistance to combat malaria in
order to maximize human and financial resources and
reduce unnecessary duplication among such agencies and
other donors;
(6) maximize United States capabilities in the
areas of technical assistance, training, and research,
including vaccine research, to combat malaria; and
(7) establish priorities and selection criteria for
the distribution of resources to combat malaria based
on factors such as the size and demographics of the
population with malaria, the needs of that population,
the host countries' existing infrastructure, and the
host countries' ability to complement United States
efforts with strategies outlined in national malaria
control plans.
(e) Malaria Response Coordinator.--
(1) In general.--There should be established within
the United States Agency for International Development
a Coordinator of United States Government Activities to
Combat Malaria Globally, who should be appointed by the
President.
(2) Authorities.--The Coordinator, acting through
such nongovernmental organizations and relevant
executive branch agencies as may be necessary and
appropriate to effect the purposes of section 104C of
the Foreign Assistance Act of 1961 (22 U.S.C. 2151b-4),
is authorized--
(A) to operate internationally to carry out
prevention, treatment, care, support, capacity
development of health systems, and other
activities for combating malaria;
(B) to transfer and allocate funds to
relevant executive branch agencies;
(C) to provide grants to, and enter into
contracts with, nongovernmental organizations
to carry out the purposes of such section 104C;
(D) to enter into contracts and transfer
and allocate funds to international
organizations to carry out the purposes of such
section 104C; and
(E) to coordinate with a public-private
partnership to discover and develop effective
new antimalarial drugs, including drugs for
multi-drug resistant malaria and malaria in
pregnant women.
(3) Duties.--
(A) In general.--The Coordinator shall have
primary responsibility for the oversight and
coordination of all resources and global United
States government activities to combat malaria.
(B) Specific duties.--The Coordinator
shall--
(i) facilitate program and policy
coordination among relevant executive
branch agencies and nongovernmental
organizations, including auditing,
monitoring and evaluation of such
programs;
(ii) ensure that each relevant
executive branch agency has sufficient
resources to execute programs in areas
in which the agency has the greatest
expertise, technical capability, and
potential for success;
(iii) coordinate with the Office of
the Coordinator of United States
Government Activities to Combat HIV/
AIDS Globally and equivalent managers
of other relevant executive branch
agencies that are implementing global
health programs to develop and
implement program plans, country-level
interactions, and recipient
administrative requirements in
countries in which more than one
program operates;
(iv) coordinate relevant executive
branch agency activities in the field,
including coordination of planning,
implementation, and evaluation of
malaria programs with HIV/AIDS programs
in countries in which both programs are
being carried out;
(v) pursue coordinate program
implementation with host governments,
other donors, and the private sector;
and
(vi) establish due diligence
criteria for all recipients of funds
appropriated pursuant to the
authorizations of appropriations under
section 401 for malaria assistance.
(f) Assistance to Who.--In carrying out this section, the
President is authorized to make a United States contribution to
the Roll Back Malaria Partnership and the World Health
Organization (WHO) to improve the capacity of countries with
high rates of malaria and other affected countries to implement
comprehensive malaria control programs.
(g) Annual Report.--
(1) In general.--Not later than 270 days after the
date of the enactment of the Tom Lantos and Henry J.
Hyde Global Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Reauthorization Act of 2008, and annually
thereafter, the President shall transmit to the
appropriate congressional committees a report on United
States assistance for the prevention, treatment,
control, and elimination of malaria.
(2) Matters to be included.--The report required
under paragraph (1) shall include a description of--
(A) the countries and activities to which
malaria assistance has been allocated;
(B) the number of people reached through
malaria assistance programs;
(C) the percentage and number of children
and mothers reached through malaria assistance
programs;
(D) research efforts to develop new tools
to combat malaria, including drugs and
vaccines;
(E) collaboration with the World Health
Organization (WHO), the Global Fund to Fight
AIDS, Tuberculosis and Malaria, other donor
governments, and relevant executive branch
agencies to combat malaria;
(F) quantified impact of United States
assistance on childhood morbidity and
mortality;
(G) the number of children who received
immunizations through malaria assistance
programs; and
(H) the number of women receiving ante-
natal care through malaria assistance programs.
[SEC. 304. PILOT PROGRAM FOR THE PLACEMENT OF HEALTH CARE 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 health care 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 health care 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 health care system of the
affected countries;
[(3) provide health care 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 health care 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 health care 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
health care 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. HEALTH CARE PARTNERSHIPS TO COMBAT HIV/AIDS.
(a) Sense of Congress.--It is the sense of Congress that
the use of health care partnerships that link United States and
host country health care institutions create opportunities for
sharing of knowledge and expertise among individuals with
significant experience in health-related fields and build local
capacity to combat HIV/AIDS and increase scientific
understanding of the progression of HIV/AIDS and the HIV/AIDS
epidemic.
(b) Authority to Facilitate Health Care Partnerships to
Combat HIV/AIDS.--The President, acting through the Coordinator
of United States Government Activities to Combat HIV/AIDS
Globally, shall facilitate the development of health care
partnerships described in subsection (a) by-
(1) supporting short- and long-term institutional
partnerships, including partnerships that build
capacity in ministries of health, central- and
district-level health agencies, medical facilities,
health education and training institutions, academic
centers, and faith- and community-based organizations
involved in prevention, treatment, and care of HIV/
AIDS;
(2) supporting the development of consultation
services using appropriate technologies, including
online courses, DVDs, telecommunications services, and
other technologies to eliminate the barriers that
prevent host country professionals from accessing high
quality health care services information, particularly
providers located in rural areas;
(3) supporting the placements of highly qualified
individuals to strengthen human and organizational
capacity through the use of health care professionals
to facilitate skills transfer, building local capacity,
and to expand rapidly the pool of providers, managers,
and other health care staff delivering HIV/AID services
in host countries; and
(4) meeting individual country needs and, where
possible, insisting on the implementation of a national
strategic plan, by providing training and mentoring to
strengthen human and organizational capacity among
local health care service organizations.
(c) 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
President such sums as may be necessary for each of the fiscal
years 2009 through 2013 to carry out this section.
* * * * * * *
Subtitle B--Assistance for Children and Families
* * * * * * *
SEC. 312. POLICY AND REQUIREMENTS.
(a) Policy.--[The United States Government's]
(1) In general.--The United States 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.
(2) Collaboration.--The United States should work
in collaboration with governments, donors, the private
sector, nongovernmental organizations, and other key
stakeholders to carry out the policy described in
paragraph (1).
[(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.]
(b) Requirements.--The 5-year United States strategy
required by section 101 of this Act shall--
(1) establish a target for 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;
(2) establish a target requiring that by 2013 up to
15 percent of individuals receiving care and up to 15
percent of individuals receiving treatment under this
Act and the amendments made by this Act are children;
(3) integrate care and treatment with prevention of
mother-to-child transmission of HIV programs in order
to improve outcomes for HIV-affected women and families
as soon as is feasible, consistent with the national
government policies of countries in which programs
under this Act are administered, and including support
for strategies to ensure successful follow-up and
continuity of care;
(4) expand programs designed to care for children
orphaned by HIV/AIDS;
(5) develop a timeline for expanding access to more
effective regimes to prevent mother-to-child
transmission of HIV, consistent with the national
government policies of countries in which programs
under this Act are administered and the goal of
achieving universal use of such regimens as soon as
possible;
(6) ensure that women receiving voluntary
contraceptive counseling, services, or commodities in
programs supported by the United States Government have
access to the full range of HIV/AIDS services; and
(7) ensure that women in prevention of mother-to-
child transmission of HIV programs are provided with
appropriate maternal and child services, either
directly or by referral.
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.
* * * * * * *
SEC. 316. STRATEGY TO PREVENT HIV INFECTIONS AMONG WOMEN AND YOUTH.
(a) Statement of Policy.--In order to meet the United
States Government's goal of preventing 12,000,000 new HIV
infections worldwide, it shall be the policy of the United
States to pursue a global HIV/AIDS prevention strategy that
emphasizes the immediate and ongoing needs of women and youth
and addresses the factors that lead to gender disparities in
the rate of HIV infection.
(b) Strategy.--
(1) In general.--The President shall formulate a
comprehensive, integrated, and culturally-appropriate
global HIV/AIDS prevention strategy that, to the extent
epidemiologically appropriate, addresses the
vulnerabilities of women and youth to HIV infection and
seeks to reduce the factors that lead to gender
disparities in the rate of HIV infection.
(2) Elements.--The strategy required under
paragraph (1) shall include specific goals and targets
under the 5-year strategy outlined in section 101 and
shall include comprehensive HIV/AIDS prevention
education at the individual and national level
including the ABC (``Abstain, Be faithful, use
Condoms'') model as a means to reduce HIV infections
and shall include the following:
(A) Specific goals under the five-year
strategy outlined in section 101.
(B) Empowering women and youth to avoid
cross-generational sex and to decide when and
whom to marry in order to reduce the incidence
of early or child marriage.
(C) Dramatically increasing access to
currently available female-controlled
prevention methods and including investments in
training to increase the effective and
consistent use of both male and female condoms.
(D) Accelerating the de-stigmatization of
HIV/AIDS among women and youth as a major risk
factor for the transmission of HIV.
(E) Addressing and preventing post-
traumatic and psycho-social consequences and
providing post-exposure prophylaxis to victims
of gender-based violence and rape against women
and youth through appropriate medical, social,
educational, and legal assistance and through
prosecutions and legal penalties to address
such violence.
(F) Promoting changes in male attitudes and
behavior that respect the human rights of women
and youth and that support and foster gender
equality.
(G) Supporting the development of
microenterprise initiatives, job training
programs, and other such efforts to assist
women in developing and retaining independent
economic means.
(H) Supporting universal basic education
and expanded educational opportunities for
women and youth.
(I) Protecting the property and inheritance
rights of women.
(J) Coordinating inclusion of HIV/AIDS
prevention information and education services
and programs for individuals with HIV/AIDS with
existing health care services targeted to women
and youth, such as ensuring access to HIV/AIDS
education and testing in family planning
programs supported by the United States
Government and programs to reduce mother-to-
child transmission of HIV, and expanding the
reach of such HIV/AIDS health services.
(K) Promoting gender equality by supporting
the development of nongovernmental
organizations, including faith-based and
community-based organizations, that support the
needs of women and utilizing such organizations
that are already empowering women and youth at
the community level.
(L) Encouraging the creation and effective
enforcement of legal frameworks that guarantee
women equal rights and equal protection under
the law.
(M) Encouraging the participation and
involvement of women in drafting, coordinating,
and implementing the national HIV/AIDS
strategic plans of their countries.
(N) Responding to other economic and social
factors that increase the vulnerability of
women and youth to HIV infection.
(3) Transmission to congress and public
availability.--Not later than 180 days after the date
of the enactment of the Tom Lantos and Henry J. Hyde
Global Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Reauthorization Act of 2008, the President
shall transmit to the appropriate congressional
committees and make available to the public the
strategy required under paragraph (1).
(c) Coordination.--In formulating and implementing the
strategy required under subsection (b), the President shall
ensure that the United States coordinates its overall HIV/AIDS
policy and programs with the national governments of the
countries for which the United States provides assistance to
combat HIV/AIDS and, to the extent practicable, with
international organizations, other donor countries, and
indigenous organizations, including faith-based and community-
based organizations specifically for the purposes of ensuring
gender equality and promoting respect of the human rights of
women that impact their susceptibility to HIV/AIDS, improving
women's health, and expanding education for women and youth,
and organizations, including faith-based and other nonprofit
organizations, providing services to and advocating on behalf
of individuals with HIV/AIDS and individuals affected by HIV/
AIDS.
(d) Guidance.--
(1) In general.--The President shall provide clear
guidance to field missions of the United States
Government in countries for which the United States
provides assistance to combat HIV/AIDS, based on the
strategy required under subsection (b).
(2) Transmission to congress and public
availability.--The President shall transmit to the
appropriate congressional committees and make available
to the public a description of the guidance required
under paragraph (1).
(e) Report.--
(1) In general.--Not later than 1 year after the
date of the enactment of the Tom Lantos and Henry J.
Hyde 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 transmit to
the appropriate congressional committees and make
available to the public a report on the implementation
of this section for the prior fiscal year.
(2) Matters to be included.--The report required
under paragraph (1) shall include the following:
(A) A description of the prevention
programs designed to address the
vulnerabilities of women and youth to HIV/AIDS.
(B) A list of nongovernmental organizations
in each country that receive assistance from
the United States to carry out HIV prevention
activities, including the amount and the source
of funding received.
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] $10,000,000,000 for each of the
[fiscal years 2004 through 2008] fiscal years 2009 through
2013.
* * * * * * *
SEC. 402. SENSE OF CONGRESS.
(a) * * *
(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)] (1) 15 percent of such amounts for palliative
care of individuals with HIV/AIDS;
[(3)] (2) 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)] (3) 10 percent of such amounts 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) HIV/AIDS Prevention Activities.--
(1) In general.--For each of the fiscal years 2009
through 2013, not less than 20 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 HIV/AIDS prevention activities consistent with
section 104A(d) of the Foreign Assistance Act of 1961.
(2) Balanced funding requirement.--(A) The
Coordinator of United States Government Activities to
Combat HIV/AIDS Globally shall provide balanced funding
for prevention activities for sexual transmission of
HIV/AIDS and shall 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.
(B) In fulfilling the requirement under
subparagraph (A), the Coordinator shall establish a 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 behavioral change programs, including
abstinence, delay of sexual debut, monogamy, fidelity,
and partner reduction, the Coordinator shall, within 30
days of the issuance of this strategy, report to the
appropriate congressional committees on the
justification for this decision.
(C) Programs and activities that implement or
purchase new prevention technologies or modalities such
as medical male circumcision, pre-exposure prophylaxis,
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 this paragraph.
(3) Report.--Not later than 1 year after the date
of the enactment of the Tom Lantos and Henry J. Hyde
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 transmit to
the appropriate congressional committees and make
available to the public a report on the implementation
of paragraph (2) for the prior fiscal year.
(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 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.
* * * * * * *
TITLE VI--SUSTAINABILITY AND STRENGTHENING OF HEALTH CARE SYSTEMS
SEC. 601. FINDINGS.
Congress makes the following findings:
(1) The shortage of health personnel, including
doctors, nurses, pharmacists, counselors, laboratory
staff, and paraprofessionals, is one of the leading
obstacles to fighting HIV/AIDS in sub-Saharan Africa.
(2) The HIV/AIDS pandemic aggravates the 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, while the shortage of health
personnel undermines efforts to prevent and provide
care and treatment for individuals with HIV/AIDS.
(3) Failure to address the shortage of health care
professionals and paraprofessionals, and the factors
forcing such individuals to leave sub-Saharan Africa,
will undermine the objectives of United States
development policy and will subvert opportunities to
achieve internationally-recognized goals for the
prevention, treatment, and care of HIV/AIDS and other
diseases, the reduction of child and maternal
mortality, and for economic growth and development in
sub-Saharan Africa.
SEC. 602. NATIONAL HEALTH WORKFORCE STRATEGIES AND OTHER POLICIES.
(a) National Health Workforce Strategies.--
(1) Statement of policy.--It shall be the policy of
the United States Government to support countries
receiving United States assistance to combat HIV/AIDS,
tuberculosis, and malaria, and other health programs in
developing, strengthening, and implementing 5-year
health workforce strategies.
(2) Technical and financial assistance.--The
Administrator of the United States Agency for
International Development, in coordination with the
Coordinator of United States Government Activities to
Combat HIV/AIDS Globally, is authorized to provide
technical and financial assistance to countries
described in paragraph (1) to enable such countries, in
conjunction with other funding sources, to develop,
strengthen, and implement health workforce strategies.
(3) Activities supported.--Assistance provided
under paragraph (2) shall, to the maximum extent
practicable, be used to carry out the following:
(A) Activities to promote an inclusive
process that includes nongovernmental
organizations and individuals with HIV/AIDS in
developing health workforce strategies.
(B) Activities to achieve and sustain a
health workforce sufficient in numbers, skill,
and capacity to meet United States and host-
country international health commitments,
including the Millennium Development Goals and
universal access to HIV/AIDS prevention,
treatment, and care. In particular, such health
workforce strategies should include plans for
progress toward achieving the minimum ratio of
health professionals required to achieve these
goals by 2015, estimated by the World Health
Organization to require at least 2.3 doctors,
nurses, and midwives per 1,000 population, and
additional health workers such as pharmacists
and lab technicians.
(C) Activities to ensure that health
workforce strategies are aimed at creating
appropriate distribution of health workers and
prioritizing activities required to ensure
rural, marginalized, and other underserved
populations are able to access skilled and
equipped health workers.
(D) Activities to expand the capacity of
public and private medical, nursing,
pharmaceutical, and other health training
institutions.
(b) Positive Broader Health Impact.--It shall be the policy
of the United States to ensure to expand the capacity of the
health workforce engaged in HIV/AIDS programming in ways that
contribute to, and do not detract from, the capacity of
countries to meet other health needs, particularly child
survival and maternal health.
(c) Safety for Health Workers.--It is the sense of Congress
that the United States should ensure that all health workers
participating in programs that receive assistance under this
Act and the amendments made by this Act have the proper
training to create safe and sanitary working conditions in
accordance with universal precautions and other forms of
infection prevention and control.
(d) Health Care for Health Workers.--The Coordinator of
United States Government Activities to Combat HIV/AIDS Globally
shall ensure that comprehensive and confidential health
services shall be provided to all health workers participating
in programs that receive assistance under this Act and the
amendments made by this Act, including--
(1) testing and counseling for all such employees;
(2) providing HIV/AIDS treatment to HIV-positive
employees; and
(3) taking measures to reduce HIV-related stigma in
the workplace.
(e) Training and Compensation Finance.--Where the
Coordinator determines such financial support is essential to
fulfill the purposes of this Act, the Coordinator shall finance
training and provide compensation or other benefits for health
workers in order to enhance recruitment and retention of such
workers.
SEC. 603. EXEMPTION OF INVESTMENTS IN HEALTH FROM LIMITS SOUGHT BY
INTERNATIONAL FINANCIAL INSTITUTIONS.
(a) Coordination Within the United States Government.--The
Coordinator of United States Government Activities to Combat
HIV/AIDS Globally shall work with the Secretary of the Treasury
to reform International Monetary Fund macroeconomic and fiscal
policies that result in limitations on national and donor
investments in health.
(b) Position of the United States at the Imf.--The
Secretary of the Treasury shall instruct the United States
Executive Director at the International Monetary Fund to use
the voice, vote, and influence of the United States to oppose
any loan, project, agreement, memorandum, instrument, plan, or
other program of the International Monetary Fund that does not
exempt increased government spending on health care from
national budget caps or restraints, hiring or wage bill
ceilings, or other limits sought by any international financial
institution.
SEC. 604. PUBLIC-SECTOR PROCUREMENT, DRUG REGISTRATION, AND SUPPLY
CHAIN MANAGEMENT SYSTEMS.
(a) In General.--The Coordinator of United States
Government Activities to Combat AIDS Globally shall work with
the Partnership for Supply Chain Management Systems, host
countries, and nongovernmental organizations to develop
effective, reliable host country-owned and operated public-
sector procurement and supply chain management systems,
including regional distribution, with ongoing technical
assistance and sustained support to ensure the function of such
systems, as well as the function of existing non-public sector
supply chains, including those operated by faith-based and
other humanitarian organizations that procure and distribute
medical supplies.
(b) Availability of Equipment and Supplies.--The public-
sector procurement and supply chain management systems
developed pursuant to subsection (a) should ensure that
adequate laboratory equipment and supplies commonly needed to
fight HIV/AIDS, including diagnostic tests for CD4 and viral
load counts, x-ray machines, mobile and facility-based rapid
HIV test kits and other necessary assays, reagents and basic
supplies such as sterile syringes and gloves, are available and
distributed in a manner that is accessible to urban and rural
populations.
(c) Drug Registration.--The Coordinator shall work with
host country partners and development partners to support
efficient and effective drug approval and registration systems
that allow expeditious access to safe and effective drugs,
including antiretroviral drugs.
(d) Report.--The Coordinator shall submit to the
appropriate congressional committees an annual report on the
implementation of this section, including progress toward
specific benchmarks established by the Partnership for Supply
Chain Management Systems, and the projection of when host
countries can fully sustain their own procurement and supply
chain management and distribution systems at a scale necessary
for national primary health needs.
SEC. 605. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Of the amounts authorized to be
appropriated under section 401 for HIV/AIDS assistance, 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 title.
(b) Availability.--Amounts appropriated pursuant to the
authorization of appropriations under subsection (a) are
authorized to remain available until expended.
----------
STATE DEPARTMENT BASIC AUTHORITIES ACT OF 1956
* * * * * * *
TITLE I--BASIC AUTHORITIES GENERALLY
Section 1. (a) * * *
* * * * * * *
(f) HIV/AIDS Response Coordinator.--
(1) * * *
(2) Authorities and duties; definitions.--
(A) Authorities.--The Coordinator, acting
through such nongovernmental organizations
(including faith-based and community-based
organizations), host 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) * * *
* * * * * * *
(iii) to provide grants to, and
enter into contracts with,
nongovernmental organizations
(including faith-based and community-
based organizations) and host country
finance, health, and other relevant
ministries to carry out the purposes of
section.
(B) Duties.--
(i) * * *
(ii) Specific duties.--The duties
of the Coordinator shall specifically
include the following:
(I) * * *
* * * * * * *
[(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 that is comprised of,
but not limited to,
representatives from the United
States Agency for International
Development, the Department of
Health and Human Services
(including the Centers for
Disease Control and Prevention,
the National Institutes of
Health, and the Health
Resources and Services
Administration), the Department
of Labor, the Department of
Agriculture, the Millennium
Challenge Corporation, the
Department of Defense, and the
Office of the Coordinator of
United States Government
Activities to Combat Malaria
Globally, for the purposes of
coordination of activities
relating to HIV/AIDS. The
interagency working group
shall--
(aa) meet regularly
to review progress in
host countries toward
HIV/AIDS prevention,
treatment, and care
objectives;
(bb) participate in
the process of
identifying countries
in need of increased
assistance based on the
epidemiology of HIV/
AIDS in those
countries; and
(cc) review
policies that may be
obstacles to reaching
objectives set forth
for HIV/AIDS
prevention, treatment,
and care.
(V) Coordinating overall
United States HIV/AIDS policy
and programs with efforts led
by host countries and with the
assistance provided by other
relevant bilateral and
multilateral aid agencies and
other donor institutions to
achieve complementarity with
other programs aimed at
improving child and maternal
health, and food security,
promoting education, and
strengthening health care
systems.
* * * * * * *
(VII) Holding annual
consultations with host country
nongovernmental organizations
providing services to improve
health, and advocating on
behalf of the individuals with
HIV/AIDS and those at
particular risk of contracting
HIV/AIDS.
(VIII) Ensuring, through
interagency and international
coordination, that United
States HIV/AIDS programs are
coordinated with and
complementary to the delivery
of related global health, food
security, and education
services, including--
(aa) maternal and
child health care;
(bb) services for
other neglected and
easily preventable and
treatable infectious
diseases, such as
tuberculosis;
(cc) treatment and
care services for
injection drug users;
and
(dd) programs and
services to improve
legal, social, and
economic status of
women and girls.
[(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, Zambia, Vietnam,
Antigua and Barbuda, the
Bahamas, Barbados, Belize,
Dominica, Grenada, Jamaica,
Montserrat, Saint Kitts and
Nevis, Saint Vincent and the
Grenadines, Saint Lucia,
Suriname, Trinidad and Tobago,
the Dominican Republic 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. In
designating countries under
this subclause, the President
shall give priority to those
countries in which there is a
high prevalence of HIV/AIDS and
countries with large
populations that have a
concentrated HIV/AIDS epidemic.
(X) Working, in partnership with
host 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 drug use.
(XI) Working, in partnership with
host 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
create alternatives to prostitution.
[(VIII)] (XII) Establishing
due diligence criteria for all
recipients of [funds section]
funds appropriated pursuant to
the authorization of
appropriations under section
401 of the United States
Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act
of 2003 for HIV/AIDS assistance
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
pharmaceutical procurement
partners' purchasing decisions.
(XIV) Working in
partnership with host countries
in which the HIV/AIDS epidemic
is prevalent among men who have
sex with men, 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 among men
who have sex with men.
* * * * * * *
----------
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,
South and Southeast Asia, Central and Eastern Europe, and other
developing countries is a major global health, national
security, development, and humanitarian crisis.
(b) Policy.--[It is a major]
(1) General policy.--It is a major objective of the
foreign assistance program of the United States to
provide assistance for the prevention, treatment, and
[control] care 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 and to fulfill United States commitments to
move toward the goal of universal access to prevention,
treatment, and care of HIV/AIDS. The United States and
other developed countries should provide assistance for
the prevention, treatment, and care of HIV/AIDS to
countries in sub-Saharan Africa, the Caribbean, South
and Southeast Asia and Central and Eastern Europe,
addressing both generalized epidemics and epidemics
concentrated among populations at high risk of
infection.
(2) Specific policy.--It is therefore the policy of
the United States, by 2013, to--
(A) prevent 12,000,000 new HIV infections
worldwide;
(B) support treatment of at least 3,000,000
individuals with HIV/AIDS with the goal of
treating 450,000 children;
(C) provide care for 12,000,000 individuals
affected by HIV/AIDS, including 5,000,000
orphans and vulnerable children in communities
affected by HIV/AIDS, including orphans with
HIV/AIDS; and
(D) train at least 140,000 new health care
professionals and workers for HIV/AIDS
prevention, treatment and care.
(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,
South and Southeast Asia, Central and Eastern Europe,
and other countries and areas, and particularly with
respect to refugee populations in such countries and
areas.
(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, South and Southeast Asia,
Central and Eastern Europe, and other countries and
areas affected by the HIV/AIDS pandemic, and
particularly with respect to refugee populations in
such countries and areas.
(3) Role of public health care delivery systems.--
It is the sense of Congress that--
(A) the President should provide an
appropriate level of assistance under paragraph
(1) to help strengthen public health care
delivery systems financed by host countries;
and
(B) the President, acting through the
Coordinator of United States Government
Activities to Combat HIV/AIDS Globally, should
support the development of a policy framework
in such host countries for the long-term
sustainability of HIV/AIDS prevention,
treatment, and care programs, and for
strengthening health care delivery systems and
increasing health workforces through
recruitment, training, and policies that allows
the devolution of clinical responsibilities to
increase the work force able to deliver
prevention, treatment, and care services, as
necessary, with clearly identified objectives
and reporting strategies for such services.
[(3)] (4) 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] host countries and donor countries,
appropriate governmental and nongovernmental
organizations, and relevant executive branch agencies.
(5) Sense of congress.--
(A) In general.--It is the sense of
Congress that the Coordinator of United States
Government Activities to Combat HIV/AIDS
Globally and the heads of relevant executive
branch agencies (as such term is defined in
section 3 of the United States Leadership
Against HIV/AIDS, Tuberculosis, and Malaria Act
of 2003) should operate in a manner consistent
with the ``Three Ones'' goals of UNAIDS.
(B) ``Three ones'' goals of UNAIDS
defined.--In this paragraph, the term ```Three
Ones' goals of UNAIDS'' means--
(i) the goal of one agreed HIV/AIDS
action framework that provides the
basis for coordinating the work of all
partners in host countries;
(ii) the goal of one national HIV/
AIDS coordinating authority, with a
broad-based multisectoral mandate; and
(iii) the goal of one agreed
country-level data-collection,
monitoring, and evaluation system.
(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 efforts by faith-based and
other nongovernmental organizations and
integration of such programs into health
programs, including access to such programs and
efforts in family planning programs supported
by the United States Government, 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, reducing sexual violence and
coercion, including child marriage, widow
inheritance, and polygamy, and where
appropriate, use of male and female condoms;
(B) assistance to establish and implement
culturally relevant and appropriate HIV/AIDS
education and prevention programs that focus on
helping individuals avoid infection of HIV/
AIDS, implemented through nongovernmental
organizations, including faith-based and
community-based organizations, particularly
those organizations and programs that utilize
both professionals and volunteers with
appropriate skills, experience, level of
scientific and fact-based knowledge, and
community presence;
* * * * * * *
(D) assistance for the purpose of providing
voluntary testing and counseling (including the
incorporation of confidentiality protections
and nonjudgmental approaches with respect to
such testing and counseling);
[(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;]
(E) assistance to achieve the target 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, as described in section 312(b)(1) of
the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003, and to
promote infant feeding options that meet the
criteria described in the World Health
Organization's Global Strategy for Infant and
Young Child Feeding;
* * * * * * *
(G) assistance to help avoid substance
abuse and intravenous drug use that can lead to
HIV infection, including education and services
demonstrated to be effective in reducing the
transmission of HIV infection without
increasing illicit drug use; [and]
(H) assistance for the purpose of
increasing women's access to employment
opportunities, income, productive resources,
and microfinance programs, where
appropriate[.]; and
(I)(i) assistance for counseling, testing,
treatment, care, and support programs for
prevention of re-infection of individuals with
HIV/AIDS;
(ii) counseling to prevent sexual
transmission of HIV, including skill
development for practicing abstinence, reducing
the number of sexual partners, and providing
information on correct and consistent use of
male and female condoms;
(iii) assistance to provide male and female
condoms;
(iv) diagnosis and treatment of other
sexually-transmitted infections;
(v) strategies to address the stigma and
discrimination that impede HIV/AIDS prevention
efforts; and
(vi) assistance to facilitate widespread
access to microbicides for HIV prevention, as
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 post-introduction monitoring; and
(J) assistance for HIV/AIDS education
targeted to reach and prevent the spread of HIV
among men who have sex with men.
(2) Treatment.--The treatment and care of
individuals with HIV/AIDS, including--
(A) * * *
(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, nutritional
support, and other treatment modalities[.];
(D) assistance specifically to address
barriers that might limit the start of and
adherence to treatment services, especially in
rural areas, through such measures as mobile
and decentralized distribution of treatment
services, and where feasible and necessary,
direct linkages with nutrition and income
security programs, referrals to services for
victims of violence, support groups for
individuals with HIV/AIDS, and efforts to
combat stigma and discrimination against all
such individuals;
(E) assistance to support comprehensive
HIV/AIDS treatment (including free prophylaxis
and treatment for common HIV/AIDS-related
opportunistic infections) for at least one-
third of individuals with HIV/AIDS in the
poorest countries worldwide who are in clinical
need of antiretroviral treatment; and
(F) assistance to improve access to
psychosocial support systems and other
necessary services for youth who are infected
with HIV to ensure the start of and adherence
to treatment services.
* * * * * * *
(4) Monitoring.--[The monitoring]
(A) In general.--The monitoring of
programs, projects, and activities carried out
pursuant to paragraphs (1) through (3) and
paragraph (8), including--
[(A)] (i) 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)] (ii) appropriate evaluation and
surveillance activities;
[(C)] (iii) 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)] (iv) 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[.];
and
(v) carrying out and expanding
program monitoring, impact evaluation
research, and operations research
(including research and evaluations of
gender-responsive interventions,
disaggregated by age and sex, in order
to identify and replicate effective
models, develop gender indicators to
measure both outcomes and impacts of
interventions, especially interventions
designed to reduce gender inequalities,
and collect lessons learned for
dissemination among different
countries) in order to--
(I) improve the coverage,
efficiency, effectiveness,
quality and accessibility of
services provided under this
section;
(II) establish the cost-
effectiveness of program
models;
(III) assess the
population-level impact of
programs, projects, and
activities implemented;
(IV) ensure the
transparency and accountability
of services provided under this
section;
(V) disseminate and promote
the utilization of evaluation
findings, lessons, and best
practices in the implementation
of programs, projects, and
activities supported under this
section; and
(VI) encourage and evaluate
innovative service models and
strategies to optimize
functionality of programs,
projects, and activities.
(B) Definitions.--For purposes of
subparagraph (A)(v)--
(i) the term ``impact evaluation
research'' means the application of
research methods and statistical
analysis to measure the extent to which
a change in a population-based outcome
can be attributed to a program,
project, or activity as opposed to
other factors in the environment;
(ii) the term ``program
monitoring'' means the collection,
analysis, and use of routine data with
respect to a program, project, or
activity to determine how well the
program, project, or activity is
carried out and at what cost; and
(iii) the term ``operations
research'' means the application of
social science research methods and
statistical analysis to judge, compare,
and improve policy outcomes and
outcomes of a program, project, or
activity, from the earliest stages of
defining and designing the program,
project, or activity through the
development and implementation of the
program, project, or activity.
(5) Pharmaceuticals.--
(A) * * *
* * * * * * *
(C) Mechanisms to ensure cost-effective
drug purchasing.--Mechanisms to ensure that
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.
* * * * * * *
(8) Referral systems and coordination with other
assistance programs.--
(A) Referral systems.--Assistance to ensure
that a continuum of care is available to
individuals participating in HIV/AIDS
prevention, treatment, and care programs
through the development of referral systems for
such individuals to community-based programs
that, where practicable, are co-located with
such HIV/AIDS programs, and that provide
support activities for such individuals,
including HIV/AIDS treatment adherence, HIV/
AIDS support groups, food and nutrition
support, maternal health services, substance
abuse prevention and treatment services,
income-generation programs, legal services, and
other program support.
(B) Coordination with other assistance
programs.--
(i)(I) Assistance to integrate HIV/AIDS
testing with testing for other easily
detectable and treatable infectious diseases,
such as malaria, tuberculosis, and respiratory
infections, and to provide treatment if
possible or referral to appropriate treatment
programs.
(II) Assistance to provide, whenever
possible, as a component of HIV/AIDS
prevention, treatment, and care services, and
co-treatment of curable diseases, such as other
sexually transmitted diseases.
(III) Assistance and other activities to
ensure, through interagency and international
coordination, that United States global HIV/
AIDS programs are integrated and complementary
to delivering related health services.
(ii) Assistance to support schools and
related programs for children and youth that
increase the effectiveness of programs
described in this subsection by providing the
infrastructure, teachers, and other support to
such programs.
(iii) Assistance and other activities to
provide access to HIV/AIDS prevention,
treatment, and care programs in family planning
and maternal and child health programs
supported by the United States Government.
(iv) Assistance to United States and host
country nonprofit development organizations
that directly support livelihood initiatives in
HIV/AIDS-affected countries that provide
opportunities for direct lending to
microentrepreneurs by United States citizens or
opportunities for United States citizens to
purchase livestock and plants for families to
provide nutrition and generate income for
individual households and communities.
(v) Assistance to coordinate and provide
linkages between HIV/AIDS prevention,
treatment, and care programs with efforts to
improve the economic and legal status of women
and girls.
(vi) Technical assistance coordinated
across implementing agencies, offered on a
regular basis, and made available upon request,
for faith-based and community-based
organizations, especially indigenous
organizations and new partners who do not have
extensive experience managing United States
foreign assistance programs, including for
training and logistical support to establish
financial mechanisms to track program receipts
and expenditures and data management systems to
ensure data quality and strengthen reporting.
(vii) In accordance with the World Health
Organization's Interim Policy on TB/HIV
Activities (2004), assistance to individuals
with or symptomatic of tuberculosis, and
assistance to implement the following:
(I) Provide opt-out HIV/AIDS
counseling and testing and appropriate
referral for treatment and care to
individuals with or symptomatic of
tuberculosis, and work with host
countries to ensure that such
individuals in host countries are
provided such services.
(II) Ensure, in coordination with
host countries, that individuals with
HIV/AIDS receive tuberculosis screening
and other appropriate treatment.
(III) Provide increased funding for
HIV/AIDS and tuberculosis activities,
by increasing total resources for such
activities, including lab strengthening
and infection control.
(IV) Improve the management and
dissemination of knowledge gained from
HIV/AIDS and tuberculosis activities to
increase the replication of best
practices.
(e) 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) * * *
(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] 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 health care delivery systems
(including the training of adequate
numbers of staff) and infrastructure to
ensure increased access to care and
treatment;]
(i)(I) the effectiveness of such
programs in reducing the transmission
of HIV, particularly in women and
girls, in reducing mother-to-child
transmission of HIV, including through
drug treatment and therapies, either
directly or by referral, and in
reducing mortality rates from HIV/AIDS,
including through drug treatment, and
addiction therapies;
(II) a description of strategies,
goals, programs, and interventions to
address the specific needs and
vulnerabilities of young women and
young men; the progress toward
expanding access among young women and
young men to evidence-based,
comprehensive HIV/AIDS health care
services and HIV prevention and
sexuality and abstinence education
programs at the individual, community,
and national levels; and clear targets
for integrating adolescents who are
orphans, including adolescents who are
infected with HIV, into programs for
orphans and vulnerable children; and
(III) the amount of United States
funding provided under the authorities
of this Act to procure drugs for HIV/
AIDS programs in countries described in
section 1(f)(2)(B)(IX) of the State
Department Basic Authorities Act of
1956 (22 U.S.C. 2651a(f)(2)(B)(VIII)),
including a detailed description of
anti-retroviral drugs procured,
including--
(aa) the total amount
expended for each generic and
name brand drug;
(bb) the price paid per
unit of each drug; and
(cc) the vendor from which
each drug was purchased; and
(ii) the progress made toward
improving health care delivery systems
(including the training of adequate
numbers of health care professionals)
and infrastructure to ensure increased
access to care and treatment, including
a description of progress toward--
(I)(aa) the training and
retention of adequate numbers
of health care professionals in
order to meet a nationally-
determined ratio of doctors,
nurses, and midwives to
patients, based on the target
of the 2.3 per-thousand ratio
established by the World Health
Organization (WHO);
(bb) increases in the
number of other health care
professions, such as
pharmacists and lab
technicians, as necessary; and
(cc) the improvement of
infrastructure needed to ensure
universal access to HIV/AIDS
prevention, treatment, and care
by 2015;
(II) national health care
workforce strategy benchmarks,
as required by section
202(d)(5)(B) of the United
States Leadership Against HIV/
AIDS, Tuberculosis, and Malaria
Act of 2003, United States
contributions to developing and
implementing the benchmarks,
and main challenges to
implementing the benchmarks;
(III) ensuring, to the
extent practicable, that health
care workers providing services
under this Act have safe
working conditions and are
receiving health care services,
including services relating to
HIV/AIDS;
(IV) activities to
strengthen health care systems
in order to overcome obstacles
and barriers to the provision
of HIV/AIDS, tuberculosis, and
malaria services;
(V) improving integration
and coordination of HIV/AIDS
programs with related health
care services and supporting
the capacity of health care
programs to refer individuals
to community-based services;
and
(VI) strengthening
procurement and supply chain
management systems of host
countries;
(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, including 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 (WHO); 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[.];
(D) a description of efforts to integrate
HIV/AIDS and tuberculosis prevention,
treatment, and care programs, including--
(i) the number and percentage of
HIV-infected individuals receiving HIV/
AIDS treatment or care services who are
also receiving screening and subsequent
treatment for tuberculosis;
(ii) the number and percentage of
individuals with tuberculosis who are
receiving HIV/AIDS counseling and
testing, and appropriate referral to
HIV/AIDS services;
(iii) the number and location of
laboratories with the capacity to
perform tuberculosis culture tests and
tuberculosis drug susceptibility tests;
(iv) the number and location of
laboratories with the capacity to
perform appropriate tests for multi-
drug resistant tuberculosis (MDR-TB)
and extensively drug resistant
tuberculosis (XDR-TB); and
(v) the number of HIV-infected
individuals suspected of having
tuberculosis who are provided
tuberculosis culture diagnosis or
tuberculosis drug susceptibility
testing;
(E) a description of coordination efforts
with relevant executive branch agencies (as
such term is defined in section 3 of the United
States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003) and at
the global level in the effort to link HIV/AIDS
services with non-HIV/AIDS services;
(F) a description of programs serving women
and girls, including--
(i) a description of HIV/AIDS
prevention programs that address the
vulnerabilities of girls and women to
HIV/AIDS; and
(ii) information on the number of
individuals served by programs aimed at
reducing the vulnerabilities of women
and girls to HIV/AIDS;
(G) a description of the specific
strategies funded to ensure the reduction of
HIV infection among injection drug users, and
the number of injection drug users, by country,
reached by such strategies, including
medication-assisted drug treatment for
individuals with HIV or at risk of HIV, and HIV
prevention programs demonstrated to be
effective in reducing HIV transmission without
increasing drug use; and
(H) a detailed description of monitoring,
impact evaluation research, and operations
research of programs, projects, and activities
carried out pursuant to subsection
(d)(4)(A)(v).
(3) Public availability.--The Coordinator of United
States Government Activities to Combat HIV/AIDS
Globally shall make publicly available on the Internet
website of the Office of the Coordinator the
information contained in paragraph (2)(H) of each
report and, in addition, the individual evaluations and
other reports that were the basis of such information,
including lessons learned and collected in such
evaluations and reports.
* * * * * * *
SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.
(a) Findings.--Congress makes the following findings:
[(1) Congress recognizes the growing international
problem of tuberculosis and the impact its continued
existence has on those countries that had previously
largely controlled the disease.
[(2) Congress further recognizes that the means
exist to control and treat tuberculosis through
expanded use of the DOTS (Directly Observed Treatment
Short-course) treatment strategy, including DOTS-Plus
to address multi-drug resistant tuberculosis, and
adequate investment in newly created mechanisms to
increase access to treatment, including the Global
Tuberculosis Drug Facility established in 2001 pursuant
to the Amsterdam Declaration to Stop TB and the Global
Alliance for TB Drug Development.]
(1) Tuberculosis is one of the greatest infectious
causes of death of adults worldwide, killing 1.6
million individuals per year--one person every 20
seconds.
(2) Tuberculosis is the leading infectious cause of
death among individuals who are infected with HIV due
to their weakened immune systems, and it is estimated
that one-third of such individuals have tuberculosis.
Tuberculosis is also a leading killer of women of
reproductive age.
(3) Driven by the HIV/AIDS pandemic, incidence
rates of tuberculosis in sub-Saharan Africa have more
than doubled on average since 1990. The problem is so
pervasive that in August 2005, African health ministers
and the World Health Organization (WHO) declared
tuberculosis to be an emergency in sub-Saharan Africa.
(4)(A) The wide extent of drug resistance,
including both multi-drug resistant tuberculosis (MDR-
TB) and extensively drug resistant tuberculosis (XDR-
TB), represents both a critical challenge to the global
control of tuberculosis and a serious worldwide public
health threat.
(B) XDR-TB, which is a form of MDR-TB with
additional resistance to multiple second-line anti-
tuberculosis drugs, is associated with worst treatment
outcomes of any form of tuberculosis.
(C) XDR-TB is converging with the HIV/AIDS
epidemic, undermining gains in HIV/AIDS prevention and
treatment programs and requires urgent interventions.
(D) Drug resistance surveillance reports have
confirmed the serious scale and spread of tuberculosis,
with XDR-TB strains confirmed on six continents.
(E) Demonstrating the lethality of XDR-TB, an
initial outbreak in Tugela Ferry, South Africa, in 2006
killed 52 of 53 patients with hundreds more cases
reported since that time.
(F) Of the world's regions, sub-Saharan Africa,
faces the greatest gap in capacity to prevent, treat,
and care for individuals with XDR-TB.
[(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 one-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 such cases
detected.
* * * * * * *
(d) Activities Supported.--Assistance provided under
subsection (c) shall, to the maximum extent practicable, be
used to carry out the following activities:
(1) Provide diagnostic counseling and testing to
individuals with HIV/AIDS for tuberculosis (including a
culture diagnosis to rule out multi-drug resistant
tuberculosis (MDR-TB) and extensively drug resistant
tuberculosis (XDR-TB) and provide HIV/AIDS voluntary
counseling and testing to individuals with any form of
tuberculosis.
(2) Provide tuberculosis treatment to individuals
receiving treatment and care for HIV/AIDS who have
active tuberculosis and provide prophylactic treatment
to individuals with HIV/AIDS who also have a latent
tuberculosis infection.
(3) Link individuals with both HIV/AIDS and
tuberculosis to HIV/AIDS treatment and care services,
including antiretroviral therapy and cotrimoxazole
therapy.
(4) Ensure that health care workers trained to
diagnose, treat, and provide care for HIV/AIDS are also
trained to diagnose, treat, and provide care for
individuals with both HIV/AIDS and tuberculosis.
(5) Ensure that individuals with active pulmonary
tuberculosis are provided a culture diagnosis,
including drug susceptibility testing to rule out
multi-drug resistant tuberculosis (MDR-TB) and
extensively drug resistant tuberculosis (XDR-TB) in
areas with high prevalence of tuberculosis drug
resistance.
[(d)] (e) Coordination.--In carrying out this section, the
President shall coordinate with the World Health Organization,
the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and
other organizations with respect to the development and
implementation of a comprehensive tuberculosis control program.
[(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]
(f) Priority To Stop TB Strategy.--
(1) Priority.--In furnishing assistance under
subsection (c), the President shall give priority to--
(A) activities described in the Stop TB
Strategy, including expansion and enhancement
of Directly Observed Treatment Short-course
(DOTS) coverage, 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 care
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
(B) 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]
(2) Availability of amounts.--In order to meet the
requirements of paragraph (1), the President--
(A) shall 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,] to implement the Stop TB
Strategy; and [including substantially
increased funding for the Global Tuberculosis
Drug Facility.]
(B) should ensure that not less than
$15,000,000 of the amount made available to
carry out this section for a fiscal year is
used to make a contribution to the Global
Tuberculosis Drug Facility.
(g) Assistance for WHO 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 (WHO) 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 extensively drug resistant
tuberculosis (XDR-TB).
[(f)] (h) 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 low cost and effective
diagnosis and evaluation of treatment regimes,
vaccines, and monitoring of tuberculosis, as well as a
reliable drug supply, and a management strategy for
public health systems, with health system
strengthening, promotion of the use of the
International Standards for Tuberculosis Care by all
care providers, bacteriology under an external quality
assessment framework, short-course chemotherapy, and
sound reporting and recording systems.
* * * * * * *
(6) Stop tb strategy.--The term ``Stop TB
Strategy'' means the six-point strategy to reduce
tuberculosis developed by the World Health
Organization. The strategy is described in the Global
Plan to Stop TB 2007-2016: Actions for Life, a
comprehensive plan developed by the Stop Tuberculosis
Partnership that sets out the actions necessary to
achieve the millennium development goal of cutting
tuberculosis deaths and disease burden in half by 2016.
* * * * * * *
SEC. 104C. ASSISTANCE TO COMBAT MALARIA.
(a) * * *
(b) Policy.--It is a major objective of the foreign
assistance program of the United States to provide assistance
for the prevention, [control, and cure] treatment, and care of
malaria.
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TITLE XII--FAMINE PREVENTION AND FREEDOM FROM HUNGER
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Chapter 3--International Organizations and Programs
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Sec. 302. Authorization.--(a) * * *
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(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).
(n) 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 to be available for United States
contributions to research and development of a tuberculosis
vaccine.
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