PEPFAR Reauthorization: Side-by-Side of Legislation Over Time

Authorizes U.S. participation in the Global Fund to Fight AIDS, TB, and Malaria

• Up to $1 billion for Global Fund in FY04; such sums as necessary in FY05 – FY08
• Such sums as necessary for HIV
• Such sums as necessary for TB
• Such sums as necessary for malaria

• Up to $2 billion for Global Fund in FY09; such sums as necessary in FY10 – FY13
• Such sums as necessary for HIV
• $4 billion for TB (in total)
• $5 billion for malaria (in total)

• 5-year HIV/AIDS strategy
• Annual report on U.S. global HIV efforts
• Annual report on PMTCT for 5 years

Recommends (Sense of Congress) an urgent priority be the rapid increase in distribution of antiretroviral treatment so that U.S. assistance provides treatment for:

• At least 500,000 individuals with HIV/AIDS by end of FY04
• At least 1 million individuals with HIV/AIDS by end of FY05
• At least 2 million individuals with HIV/AIDS by end of FY06

Recommends (as U.S. policy):

• Placing high priority on prevention of mother-to-child transmission (PMTCT) of HIV, the care and treatment of family members and caregivers, and the care of children orphaned by AIDS

Requires HIV/AIDS strategy to:

• 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

• Updated 5-year HIV/AIDS strategy
  • Include a longer-term estimate of projected resource needs and anticipated role of the U.S. in global HIV efforts during the 10-year period beginning FY13
• Annual report on U.S. global HIV efforts
• Annual report on PMTCT for 10 years (from FY04)
• Submission of one-time report by PMTCT expert panel
• Annual report on Best Practices
• Treatment Providers Study (with treatment cost data) annually through FY13

Includes U.S. policy objective to, by FY13, assist partner countries to:

• Prevent 12 million new HIV infections (requires this goal to be increased consistent with epidemiological evidence and available resources for FY09 – FY13)
• Provide treatment to more than 2 million people with HIV/AIDS
  • To be increased by at least the percentage increase in the amount appropriated for bilateral global HIV/AIDS assistance in any FY as compared to FY08, for FY09 – FY13
  • To be increased above this calculated number in proportion to the decrease in per patient cost to the U.S. Government of providing treatment in countries receiving bilateral global HIV/AIDS assistance, as compared with FY08, for FY09 – FY13
• Support additional treatment through coordinated multilateral efforts
• Support care for 12 million, including 5 million orphans and vulnerable children
• Provide at least 80% of pregnant women with PMTCT coverage (requires this goal to be increased consistent with epidemiological evidence and available resources for FY09 – FY13)
• Provide care and treatment to children with HIV/AIDS in proportion to their share of the HIV-infected population in a given country
• Train at least 140,000 new health workers

Requires:

• Annual report on U.S. global HIV efforts
• Treatment Providers Study annually through FY19^b

Maintains current law regarding targets/goals specified in the Lantos-Hyde Act

Requires annual report to include:

• PEPFAR targets in partner countries^b
• National targets established by partner countries or, when not available, a description of progress towards developing them
• Description of how partner country targets are designed to:
  • ensure that the annual increase in new patients on treatment exceeds the number of annual new HIV infections
  • reduce the number of new HIV infections below the number of deaths among persons infected with HIV
  • achieve an AIDS-free generation

Requires:

• Treatment Providers Study annually through FY24^b

Maintains current law regarding targets/goals specified in the Lantos Hyde Act

Maintains current law regarding annual report requirements

• Such sums as necessary for HIV

Recommends (Sense of Congress on funding distribution):

• 15% of funds be spent on palliative care
• 20% of funds be spent on prevention
  • At least 33% of prevention funds be spent on abstinence-until-marriage programs
• 55% be spent on treatment
• 10% be spent on orphans and vulnerable children

Requires for FY06 – FY08:

• Not less than 33% of prevention funds be spent on abstinence-until-marriage programs
• Not less than 55% be spent on treatment
• Not less than 10% be spent on orphans and vulnerable children

States that no funds may be used to promote or advocate the legalization or practice of prostitution

• Such sums as necessary for HIV

Removes Sense of Congress on funding distribution that was in the Leadership Act

Requires for FY09 – FY13:

• More than half of bilateral aid be spent on treatment, care, and nutrition and food support for people living with HIV
• Not less than 10% be spent on orphans and vulnerable children

Requires the Global AIDS Coordinator provide balanced funding for prevention activities for sexual transmission of HIV/AIDS +and:

• Ensure “activities promoting 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”
• Establish an HIV sexual transmission prevention strategy to govern prevention funding in any host country with a generalized epidemic
• Provide a report to Congress with a justification of the decision if this strategy provides less than half of prevention funds for abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in each such host country (funds used for new prevention technologies/modalities excluded from determining compliance)

Maintains current law regarding no funds used to promote or advocate the legalization or practice of prostitution

Requires for FY09 – FY18:

• More than half of bilateral aid be spent on treatment, care, and nutrition and food support for people living with HIV
• Not less than 10% of bilateral aid be spent on orphans and vulnerable children

Maintains current law regarding balanced funding for prevention requirement and no funds used to promote or advocate the legalization or practice of prostitution

Requires for FY09 – FY23:

• More than half of bilateral aid be spent on treatment, care, and nutrition and food support for people living with HIV
• Not less than 10% of bilateral aid be spent on orphans and vulnerable children

Maintains current law regarding balanced funding for prevention requirement and no funds used to promote or advocate the legalization or practice of prostitution

States that an organization that is otherwise eligible to receive HIV assistance 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 (often called the “conscience clause”)

Regarding the conscience clause:

• Explicitly states that “an organization” includes faith-based organizations
• Expands language by broadening the conditions that organizations cannot be required to meet as a condition for funding, including a “multisectoral or comprehensive approach “and “to endorse, utilize, make a referral to, become integrated with, or otherwise participate in any program or activity“ (italics indicate changes)
• Adds that organizations are not be discriminated against in the solicitation or issuance of grants, contracts, or cooperative agreements under such provisions of law for refusing to meet any requirement described above

• 14 countries (Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia) and
• Other countries designated by the President (Vietnam was later so designated)
• Also states that assistance should be provided to countries in sub-Saharan Africa and the Caribbean, and to other countries and areas

• Vietnam as 15th focus country
• Central Asia, Eastern Europe, and Latin America as specific regions where assistance should be provided
• With regard to designating additional focus countries, requires the President give priority to those countries in which there is a high prevalence of HIV or risk of significantly increasing incidence of HIV within the general population and inadequate financial means within the country

Authorizes “compacts” and “framework agreements” with recipient countries in order to promote host government commitment to deeper integration of HIV/AIDS services into health systems, contribute to health systems overall, enhance sustainability

Requires annual report to describe compacts or framework agreements reached or negotiated with countries

Requires annual report to describe what has been learned in advancing partnership framework agreements and implications for how to further strengthen these agreements (previously called “compacts” and “framework agreements”)

• Prevention activities that “are designed or intended to impart knowledge with the exclusive purpose of helping individuals avoid behaviors that place them at risk of HIV infection, including integration of such programs into health programs and the inclusion in counseling programs of information on methods of avoiding infection of HIV, including delaying sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms”
• With particular emphasis on high risk populations, preventative intervention education and technologies activities, including support for: bulk purchases of test kits, condoms, and, when proven effective, microbicides; for the introduction and distribution of these commodities; and education and training on the use of the technologies

• Addressing multiple concurrent sexual partnering
• Male circumcision
• Female and male condoms (change from “condoms”)

Expresses Sense of Congress recognizing need and urgency to expand range of female-controlled HIV prevention methods

Requires microbicides research at the National Institutes of Health and “strongly encourage[s]” the Centers for Disease Control and Prevention to fully implement its microbicide agenda

Requires:

• HIV/AIDS strategy to address needs of women and girls and include programs to make available testing and treatment to HIV-positive women and their family members
• Annual report to include reporting on indicators related to reaching women and girls

Requires:

• Funding be used to carry out activities improving accountability through more detailed measures regarding reaching women and girls, as well as gender- and age-specific measures
• HIV/AIDS strategy to address vulnerabilities of women and youth to HIV infection in prevention strategy and seek to reduce factors that lead to gender disparities in HIV
• Annual report to describe programs serving women and girls
• Establishment of PMTCT expert panel and submission of one-time report by panel

• support for nutrition and food for people living with and affected by HIV, including children affected by HIV
• integration of nutrition programs with HIV activities, generally

Expresses “Sense of Congress” that U.S. food assistance should be accepted by countries with large populations of people living with HIV to help feed such individuals

• Authorizes use of such sums as necessary of assistance (of overall $48 billion authorization) for purchase of food as a component of treatment for FY09 – FY13
• Requires nutritional assessments in all HIV programs

• Up to $1 billion for Global Fund in FY04
• Such sums as necessary for Global Fund FY05 – FY08

“1/3 cap”: Limits U.S. contributions to Global Fund to 1/3 (cannot exceed 33%) of contributions from all sources for FY04 – FY08

• Requires any amount not contributed due to 1/3 cap to be contributed as soon as practicable, after other sources have made additional contributions to the Global Fund
• However, after July 31 of each FY, for FY04 – FY08, any amount still withheld due to the cap is authorized to be made available for bilateral HIV, TB, and malaria (amendment made in 2004 via other legislation^e)

Requires, for FY04 – FY08, that if the President determines the Global Fund has provided assistance to a country the government of which the Secretary of State has determined has “repeatedly provided support for acts of international terrorism,” then the U.S. shall withhold from the U.S. contribution for the next fiscal year an amount equaling the amount of funding expended by the Global Fund to the government of each such country

Authorizes amounts withheld for this and other reasons^f to be made available for bilateral HIV

• Up to $2 billion for Global Fund in FY09
• Such sums as necessary for Global Fund in FY10 – FY13

“1/3 cap”: Limits U.S. contributions to 1/3 for FY09 – FY13

• Requires amount not contributed due to cap to be contributed as soon as practicable
• Authorizes, after July 31 of each FY, for FY09 – FY13, any amount still withheld due to cap to be made available for bilateral HIV, TB, and malaria

Requires, for FY09 – FY13, withholding portion of U.S. contribution to the Global Fund equal to any amount expended by the Global Fund to country governments that have “repeatedly provided support for acts of international terrorism”

Maintains authorization for amounts withheld for this and other reasons^f to be made available for bilateral HIV

Requires withholding 20% of annual contribution from obligation for each year during FY10 – FY13 pending certification of certain accountability and transparency benchmarks by the Secretary of State^g

Finds the Global Fund represents the multilateral component of U.S. global HIV, TB, and malaria efforts and that the Global Fund and U.S. bilateral efforts in these areas “are demonstrating increasingly effective coordination, with each possessing certain comparative advantages” and “often work most effectively in concert with each other”; says the U.S. Government is “fully committed to the success of the Global Fund as a multilateral public-private partnership”

• Requires amount not contributed due to cap to be contributed as soon as practicable
• Authorizes, after July 31 of each FY, for FY09 – FY18, any amount still withheld due to cap to be made available for bilateral HIV, TB, and malaria

Requires, for FY09 – FY18, withholding portion of U.S. contribution to the Global Fund equal to any amount expended by the Global Fund to country governments that have “repeatedly provided support for acts of international terrorism”

Maintains authorization for amounts withheld for this and other reasons^f to be made available for bilateral HIV

Requires withholding 20% of annual contribution from obligation for each year during FY10 – FY18 pending certification of certain accountability and transparency benchmarks by the Secretary of State^g

Maintains current law regarding Global Fund and U.S. bilateral efforts

• Requires amount not contributed due to cap to be contributed as soon as practicable
• Authorizes, after July 31 of each FY, for FY09 – FY23, any amount still withheld due to cap to be made available for bilateral HIV, TB, and malaria

Requires, for FY09 – FY23, withholding portion of U.S. contribution to the Global Fund equal to any amount expended by the Global Fund to country governments that have “repeatedly provided support for acts of international terrorism”

Authorizes amounts withheld for this and other reasons ^f to be made available for bilateral HIV, TB, and malaria

Requires withholding 20% of annual contribution from obligation for each year during FY10 – FY23 pending certification of certain accountability and transparency benchmarks by the Secretary of State^g

Maintains current law regarding Global Fund and U.S. bilateral efforts

FY04 – FY08:
Authorizes $15 billion ($3 billion/year), of which:

• Such sums as necessary for TB

Requires funding priority be given to activities that increase Directly Observed Treatment Short-course (DOTS) coverage and MDR-TB treatment

Recommends that at least 75 percent of the amount made available for TB each year be spent on drugs, supplies, direct patient services, DOTS training, and treatment of multi-drug resistant tuberculosis using DOTS-Plus, including substantially increased funding for the Global Tuberculosis Drug Facility

FY09 – FY13:
Authorizes $48 billion (in total), of which:

• $4 billion for TB (in total)

Requires funding priority be given to direct services described in the Stop TB Strategy, including DOTS coverage, treatment for individuals co-infected with TB/HIV, and MDR-TB treatment; as well as to funding for the Global TB Drug Facility, the Stop TB Partnership, and the Global Alliance for TB Drug Development

Significantly strengthens and elevates focus on TB:

• Requires a 5-year TB strategy
• Requires annual report on U.S. TB efforts

Adds specific TB goals/ targets:

• Recommends achieving goals of 1) reducing by half the TB death and disease burden from the 1990 baseline and 2) sustaining or exceeding the detection of at least 70 percent of sputum smear-positive cases of TB and the successful treatment of at least 85 percent of the cases detected in countries with established USAID TB programs
• Requires TB strategy to include plan to support 1) the successful treatment of 4.5 million new sputum smear TB patients under DOTS programs by 2013, primarily through direct support for needed services, commodities, health workers, and training and additional treatment through coordinated multilateral efforts; and 2) the diagnosis and treatment of 90,000 new MDR-TB cases by 2013, and additional treatment through coordinated multilateral efforts

FY14 – FY18:
Does not specify authorization for funding for TB (however, Congress effectively authorizes funding when it appropriates funding for a purpose)

FY19 – FY23:
Does not specify authorization for funding for TB (however, Congress effectively authorizes funding when it appropriates funding for a purpose)

FY04 – FY08:
Authorizes $15 billion ($3 billion/year), of which:

• Such sums as necessary for malaria

Strengthens, embraces President’s Malaria Initiative:

• Requires a 5-year malaria strategy
• Requires annual report on U.S. malaria efforts
• Establishes Malaria Coordinator at USAID, with primary responsibility for the oversight and coordination of all resources and international activities of the U.S. Government relating to efforts to combat malaria

FY09 – FY13:
Authorizes $48 billion (in total), of which:

• $5 billion for malaria (in total)

FY14 – FY18:
Does not specify authorization for funding for malaria (however, Congress effectively authorizes funding when it appropriates funding for a purpose)

FY19 – FY23:
Does not specify authorization for funding for malaria (however, Congress effectively authorizes funding when it appropriates funding for a purpose)

Requires U.S. Comptroller General to monitor and evaluate projects funded by the Global Fund and, every two years, prepare a report on its results

• IOM to include assessment of efforts to address gender-specific aspects of HIV/AIDS, including gender-related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men, in its evaluation

Maintains current law regarding U.S. Comptroller General and the Global Fund

Requires the Inspectors General of the Department of State and Broadcasting Board of Governors, the Department of Health and Human Services (HHS), and USAID to jointly develop five coordinated annual plans for overseeing U.S. Government global HIV, TB, and malaria programs from FY09 – FY13

Requires U.S. Comptroller General to submit a one-time report on U.S. global HIV/AIDS programs no later than 3 years after enactment of Lantos-Hyde Act

Maintains current law regarding U.S. Comptroller General and the Global Fund

Requires Inspectors General of the Department of State and Broadcasting Board of Governors, the Department of Health and Human Services (HHS), and USAID jointly develop annual oversight plans through FY18

Maintains current law regarding U.S. Comptroller General and the Global Fund

Requires Inspectors General of the Department of State and Broadcasting Board of Governors, the Department of Health and Human Services (HHS), and USAID jointly develop annual oversight plans through FY23

a: Also authorizes an additional $2 billion over five years for Emergency Fund for Indian Health and Safety and requires establishment of an emergency plan for Indian safety and health.

b: Defines (or maintains definition of) partner country as a country that receives a minimum of $5 million in HIV/AIDS assistance from the U.S. Government in the previous fiscal year, for the purposes of the annual report and the Treatment Provider Study.

c: Governed by Immigration & Nationality Act, which prohibits HIV-positive individuals from visiting or immigrating to the United States (except if a waiver is granted). HIV is only health condition specifically named as inadmissible in the law; for all others, the Secretary of Health and Human Services is given the authority to decide what conditions pose public health threats.

d: Returns decision about whether HIV should be considered a threat to public health to the Secretary of Health & Human Services, as is the case for all other health conditions.

e: This amendment to the Leadership Act was made in the Consolidated Appropriations Act of 2004 (P.L. 108-199).

f: Specifically, amounts withheld from the U.S. contribution 1) equaling the amount of funding, if any, expended by the Global Fund in the prior year to any governments that have “repeatedly provided support for acts of international terrorism” and 2) equaling the average annual amount of funding, if any, spent on certain administrative expenses in excess of 10% of the total expenditures of the Global Fund for any 2-year period.

g: In certain years, Congress directed 10% withholding, rather than 20%.

h: For U.S. contributions from FY 2015 through FY 2018, Congress directed that the basis for calculating the limitation of the overall U.S. contribution to not exceed 33% of total Global Fund contributions would be U.S. contributions relative to all contributions to the Global Fund from FY 2004 rather than FY 2009, as was directed in the 2013 PEPFAR Stewardship Act.

SOURCES: KFF analysis of: U.S. Congress, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), May 27, 2003; U.S. Congress, Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), July 30, 2008; U.S. Congress, PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56), Dec. 2, 2013; U.S. Congress, PEPFAR Extension Act of 2018 (P.L. 115-305), Dec. 11, 2018; U.S. Code, Title 22: Foreign Relations and Intercourse, Chapter 83 (UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA) and Chapter 32 (FOREIGN ASSISTANCE), Sections 2151b – 2151b-4; appropriations legislation; Congressional Research Service, International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding, RL34569, July 14, 2008. Congressional Research Service, The President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Global HIV/AIDS, Tuberculosis, and Malaria Programs: A Description of Permanent and Expiring Authorities, R43232, September 27, 2013; Congressional Research Service, “PEPFAR Stewardship and Oversight Act: Expiring Authorities,” IF10797, May 18, 2018.