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115th Congress } { Report
HOUSE OF REPRESENTATIVES
2d Session } { 115-1014
======================================================================
PEPFAR EXTENSION ACT OF 2018
_______
November 9, 2018.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Royce of California, from the Committee on Foreign Affairs,
submitted the following
R E P O R T
together with
ADDITIONAL VIEWS
[To accompany H.R. 6651]
[Including cost estimate of the Congressional Budget Office]
The Committee on Foreign Affairs, to whom was referred the
bill (H.R. 6651) to extend certain authorities relating to
United Sates efforts to combat HIV/AIDS, tuberculosis, and
malaria globally, and for other purposes, having considered the
same, report favorably thereon with an amendment and recommend
that the bill as amended do pass.
CONTENTS
Page
The Amendment.................................................... 2
Summary and Purpose.............................................. 2
Background and Need for the Legislation.......................... 3
Hearings......................................................... 11
Committee Consideration.......................................... 12
Committee Oversight Findings..................................... 13
New Budget Authority, Tax Expenditures, and Federal Mandates..... 13
Congressional Budget Office Cost Estimate........................ 13
Directed Rule Making............................................. 14
Non-Duplication of Federal Programs.............................. 14
Performance Goals and Objectives................................. 14
Congressional Accountability Act................................. 15
New Advisory Committees.......................................... 15
Earmark Identification........................................... 15
Section-by-Section Analysis...................................... 15
Changes in Existing Law Made by the Bill, as Reported............ 15
Additional Views................................................. 37
The Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``PEPFAR Extension Act of 2018''.
SEC. 2. INSPECTORS GENERAL AND ANNUAL STUDY.
Section 101 of the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7611) is amended--
(1) in subsection (f)(1)--
(A) in subparagraph (A), by striking ``2018'' and
inserting ``2023''; and
(B) in subparagraph (C)(iv)--
(i) by striking ``four'' and inserting
``nine''; and
(ii) by striking ``2018'' and inserting
``2023''; and
(2) in subsection (g)--
(A) in paragraph (1), by striking ``2019'' and
inserting ``2024''; and
(B) in paragraph (2)--
(i) in the heading, by striking ``2018'' and
inserting ``2024''; and
(ii) by striking ``September 30, 2018'' and
inserting ``September 30, 2024''.
SEC. 3. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS,
AND MALARIA.
Section 202(d) of the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7622(d)) is amended--
(1) in paragraph (4)--
(A) in subparagraph (A)--
(i) in clause (i), by striking ``fiscal years
2009 through 2018'' and inserting ``fiscal
years 2004 through 2023'';
(ii) in clause (ii), by striking ``2018'' and
inserting ``2023''; and
(iii) by striking clause (vi); and
(B) in subparagraph (B)--
(i) by striking clause (ii);
(ii) by redesignating clauses (iii) and (iv)
as clauses (ii) and (iii), respectively;
(iii) in clause (ii) (as redesignated by
clause (ii) of this subparagraph)--
(I) in the first sentence, by adding
at the end before the period the
following: ``or section 104B or 104C of
such Act''; and
(II) in the second sentence, by
striking ``for HIV/AIDS assistance'';
and
(iv) in clause (iii) (as redesignated by
clause (ii) of this subparagraph), by striking
``2018'' and inserting ``2023''; and
(2) in paragraph (5), by striking ``2018'' and inserting
``2023''.
SEC. 4. ALLOCATION OF FUNDS.
Section 403 of the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7673) is amended--
(1) in subsection (b), by striking ``2018'' and inserting
``2023''; and
(2) in subsection (c), in the matter preceding paragraph (1),
by striking ``2018'' and inserting ``2023''.
Summary and Purpose
H.R. 6651, the PEPFAR Extension Act of 2018, extends
authorities, limitations, and reporting requirements relating
to the President's Emergency Plan for AIDS Relief (PEPFAR), as
initially authorized by Congress in 2003 and reauthorized in
2008 and 2013, respectively. The bill extends through Fiscal
Year 2023 a requirement for the Inspectors General of the U.S.
Department of State, the Department for Health and Human
Services (HHS), and the United States Agency for International
Development (USAID) to develop joint auditing plans that ensure
greater unity of efforts, reduce gaps in program oversight and
performance, and eliminate waste. It extends through Fiscal
Year 2023 annual reporting requirements relating to HIV/AIDS
treatment providers and costs. It also extends two funding
directives, including the requirement to allocate at least half
of the PEPFAR budget to HIV/AIDS treatment and care, and at
least 10 percent of the PEPFAR budget to children orphaned or
made vulnerable by HIV/AIDS.
The bill also addresses United States participation in the
Global Fund to Fight AIDS, Tuberculosis, and Malaria (the
Global Fund). Specifically, the bill extends the existing 33
percent cap on U.S. contributions to the Global Fund and
clarifies that the limitation applies to cumulative
contributions made between Fiscal Years 2004 and 2023. It
extends through Fiscal Year 2023 a requirement to withhold
contributions to the Global Fund in an amount equal to any
assistance provided to a State Sponsor of Terrorism and
clarifies that any funds withheld from the Global Fund for any
purpose may be made available for U.S. bilateral HIV/AIDS,
tuberculosis, or malaria programs. The bill additionally
extends through Fiscal Year 2023 a requirement to withhold 20
percent of planned annual U.S. contributions to the Global Fund
until statutory transparency requirements are met.
Background and Need for the Legislation
PEPFAR, the largest bilateral global health initiative
aimed at combatting a single disease in history, was first
announced by President George W. Bush during his January 28,
2003, State of the Union Address. The closely held--but
welcome--announcement took experts and advocates by surprise,
including those leading efforts within USAID and the Centers
for Disease Control and Prevention (CDC) to combat the HIV/AIDS
pandemic, as well as Members of Congress, many of whom had been
advocating for a more effective response for several years.
``Seldom has history offered a greater opportunity to do so
much for so many . . . to meet a severe and urgent crisis
abroad, tonight I propose an emergency plan for AIDS relief . .
. a work of mercy beyond all current international efforts to
help the people of Africa.''--President George W. Bush, January
28, 2003.
Congress promptly responded by enacting the ``U.S. Global
Leadership Against AIDS, Tuberculosis and Malaria Act of 2003''
(P.L. 108-25, known as ``the Leadership Act''), which was
signed by the President on May 27, 2003. The bill--supported by
a diverse, bipartisan coalition of Members, advocates,
academics, implementers, the faith community, non-governmental
organizations, and other leaders from around the globe--
authorized a 5-year, $15 billion initiative to be led by a U.S.
Global AIDS Coordinator within the Department of State. This
initiative would concentrate resources in 15 ``focus''
countries to provide life-saving treatment for 2 million
people, prevent 7 million new infections, and provide
palliative care for 10 million people suffering from AIDS. The
U.S. Global AIDS Coordinator was specifically charged with
developing and overseeing implementation of a 5-year integrated
strategy to meet these ambitious targets by aligning the
efforts of relevant Federal departments and agencies
(particularly USAID and the Departments of State, Defense, and
HHS/CDC/NIH), managing resources, coordinating with other
donors and partner countries, eliminating duplication and
waste, and managing U.S. participation in the Global Fund. Of
the funds made available for combatting HIV/AIDS globally, the
bill required that 55 percent be directed toward treatment, 20
percent toward prevention, 15 percent toward care, and 10
percent toward supporting children orphaned or made vulnerable
by HIV/AIDS.
In addition to combatting HIV/AIDS, the bill amended the
Foreign Assistance Act of 1961 (22 U.S.C. 2151 et seq.) to
establish combatting malaria and tuberculosis as major U.S.
foreign policy objectives and authorized ``such sums as may be
necessary'' to carry out related programs. Finally, the bill
authorized the United States to participate in the Global
Fund--a multilateral financing mechanism established in 2002 to
combat AIDS, tuberculosis, and malaria--subject to a 33 percent
cap on U.S. contributions and other restrictions.
At the time of enactment, fewer than 50,000 people living
with HIV/AIDS in sub-Saharan Africa had access to life-saving
antiretroviral treatment (ART). Health systems were collapsing
under the strain of new infections and, with no treatment
options available, patients were sent home to die. Teachers,
factory workers, health care providers, and soldiers were dying
faster than they could be replaced. Economies declined. In the
hardest hit countries, life expectancy plummeted to just 30
years. Newborns were infected by their mothers and, by 2003, an
estimated 13 million children had lost one or both parents. The
situation was so dire that, in January 2000, the National
Intelligence Estimate identified the AIDS pandemic as a threat
to U.S. national security, noting in particular that dramatic
declines in life expectancy would heighten the risk of
``revolutionary wars, ethnic wars, genocides and disruptive
regime transitions'' in the developing world. The HIV/AIDS
pandemic that was ravaging sub-Saharan Africa and parts of Asia
and the Caribbean had evolved from a global health challenge to
a national security threat.
PEPFAR changed the course of the HIV/AIDS pandemic. During
the ``emergency'' phase--Fiscal Years 2004 through 2008--
Congress provided over $18.8 billion for PEPFAR\1\, including
over $3 billion in contributions to the Global Fund, enabling
the program to rapidly scale-up testing, treatment, and care
services in the 15 focus countries. An estimated 3.7 million
health workers were trained, nearly 57 million people received
voluntary testing and counseling (VTC) services, 2.1 million
people received ART, and 10.1 million people, including 4
million orphans and vulnerable children (OVC), were supported
through care programs. In addition, prevention of mother-to-
child transmission (PMTCT) services were provided during nearly
16 million pregnancies, helping to avert at least 240,000
newborn infections.
---------------------------------------------------------------------------
\1\PEPFAR totals include funding for bilateral HIV/AIDS programs,
U.S. contributions to the Global Fund, and bilateral tuberculosis
programs. Bilateral funding for malaria has been segregated since
Fiscal Year 2006, after the launch of the President's Malaria
Initiative (PMI). The cumulative total of funding for bilateral malaria
programs under the PMI between Fiscal Years 2006 and 2017 is $5.65
billion.
---------------------------------------------------------------------------
Building upon the success of the Leadership Act, President
Bush signed the Tom Lantos and Henry J. Hyde United States
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008 (P.L. 110-293, known as ``the
Lantos-Hyde Act'') on July 30, 2008. The bill was intended to
set the stage for a transition from an emergency program to a
sustainable response that would build partner capacity and
better enable focus countries to achieve epidemic control. To
that end, it introduced the concept of country and regional
``compacts'' or ``framework agreements'' that would more
clearly define the commitments and responsibilities of the
United States, the Global Fund, other donors, and the partner
governments themselves in designing and implementing
coordinated national HIV/AIDS strategies. It also established a
requirement for the Inspectors General of the Department of
State, HHS, and USAID to jointly develop annual oversight plans
for the programs authorized under the Act.
More broadly, the Lantos-Hyde Act reauthorized the PEFPAR
program for an additional 5 years (Fiscal Years 2009 through
2013), emphasized the importance of combatting malaria and
tuberculosis, and increased HIV/AIDS prevention, care, and
treatment targets. It increased the level of authorized
appropriations from $15 billion to $48 billion, adjusted the
funding directives for HIV/AIDS treatment and care to not less
than 50 percent, and changed the OVC funding directive from a
10 percent minimum requirement to a more permissive Sense of
Congress. Finally, the bill reset the timeframe for calculating
the 33 percent cap on U.S. contributions to the Global Fund
from Fiscal Years 2004 through 2008 to Fiscal Years 2009
through 2013 and added a requirement to withhold 20 percent of
planned annual U.S. contributions until the Global Fund adopted
certain transparency requirements.
Over the second authorization period following the Lantos-
Hyde Act, Congress provided over $33.4 billion for PEPFAR,
including nearly $6.4 billion in contributions to the Global
Fund, enabling the program to significantly expand in size and
scope. In Fiscal Year 2013 alone, PEPFAR provided VTC services
for 57.7 million people, including 12.8 million pregnant women,
nearly 800,000 of whom tested positive and received immediate
access to ART in order to prevent mother-to-child transmission
of the virus. Over 17 million people, including 5 million OVC,
received palliative care and support, and 4.2 million men
underwent voluntary medical male circumcisions.
PEPFAR also continued to support a rigorous research agenda
that contributed to the discovery of exciting breakthroughs in
prevention and treatment. First-line antiretroviral therapies
were improved, generics were developed, and supply chains were
strengthened, all of which enabled PEPFAR to more than triple
the number of people receiving life-saving treatment (from 2.1
million people in 2009 to 6.7 million people in 2013). The
expansion of treatment contributed to an overall reduction in
HIV/AIDS morbidity and mortality rates and a subsequent decline
in the number of HIV/AIDS orphans. Still, there were over 2.3
million new infections in 2012--the year leading up to the
PEPFAR Stewardship and Oversight Act--and appropriations had
declined from a high of $6.87 billion in Fiscal Year 2010 to
$6.58 billion in Fiscal Year 2013. The continuing and dire
needs abroad and budget constraints in the U.S. would have to
be reconciled.
On December 2, 2013, President Obama signed the PEPFAR
Stewardship and Oversight Act of 2013 (P.L. 113-56, known as
``the Stewardship Act''). While the bill did not specifically
authorize appropriations, it sought to enhance the transparency
and accountability of PEPFAR and the Global Fund so continued
appropriations could be used more efficiently and effectively.
It required more rigorous analysis and public disclosure of
prevention, treatment, and care needs in partner countries, as
well as the costs supported by the United States, the Global
Fund, and partner governments. The bill further conditioned
U.S. contributions to the Global Fund upon enhanced
transparency and improved grants management and pressed the
Office of the Global AIDS Coordinator (OGAC) and the Global
Fund to more clearly disaggregate and attribute results. It
required comprehensive, annual studies on treatment costs and
highlighted the need to establish metrics to measure partner
country capacity to manage their own epidemics. It also
extended through Fiscal Year 2018 the requirement for the
Inspectors General for the Department of State, HHS, and USAID
to jointly develop coordinated audit plans. Finally, it
extended through Fiscal Year 2018 the funding directives for
treatment and OVC and adjusted the 33 percent cap on U.S.
contributions to the Global Fund to cover cumulative
contributions between Fiscal Years 2009 through 2018.
Over this period, following the enactment of the
Stewardship Act, Congress provided nearly $34.19 billion for
PEPFAR, including over $7 billion in contributions to the
Global Fund. Thus, the U.S. has enacted a total of $79.7
billion for PEPFAR since Fiscal Year 2004, including $14.7
billion for the Global Fund.
According to the latest available data, PEPFAR is
supporting over 14 million people on ART and has provided VTC
for over 85.5 million people, helped avert 2.2 million
infections among babies born to HIV-positive mothers, provided
over 15.2 million voluntary medical male circumcisions to help
men and boys remain HIV-negative, and provided palliative care
for 6.4 million OVC. Additionally, OGAC is pioneering new
analytical tools, including Population-Based HIV Impact
Assessments (PHIAs), which enable partners to gather data,
identify needs, fill gaps, and measure results down to the
site-level. By more strategically targeting resources and
holding partners accountable for results, PEPFAR is helping
reduce the number of new infections among the most vulnerable
groups--particularly young women and adolescent girls between
the ages of 15 and 24--by as much as 40 percent. These results
are remarkable, yet more remains to be done.
The PEPFAR Extension Act of 2018 has been informed by 15
years of implementation and seeks to ensure that PEPFAR
resources are used efficiently, effectively, and for the
purposes specified by law so partner countries can achieve
epidemic control. The bill supports efforts by OGAC and the
Global Fund to expand access to treatment and prevent new
infections; reasserts the 33 percent cap on U.S. contributions
to the Global Fund while taking into account previous errors in
calculating compliance; clarifies Congressional intent on how
funds withheld from the Global Fund may be used; and continues
support for OVC while directing implementers to adapt programs
to better reflect current needs.
Ensuring PEPFAR Resources are Used Efficiently,
Effectively, and for the Purposes Specified by Law. A
combination of budget realities, a change of leadership within
OGAC, and the enactment of the Stewardship Act brought renewed
emphasis to data and evidence-based programming within the
PEPFAR program. Today, the Coordinator is using Country
Operational Plans (COPs, influenced in part by the framework
agreements envisioned in the Lantos-Hyde Act), the PHIAs, and
other strategic planning tools to restore program discipline
and ensure resources are being concentrated in the areas of
greatest need. The committee notes that this shift has been met
by episodic resistance in several partner countries and among
implementers that take an expanded view of PEPFAR. The
committee further notes that both PEPFAR and the Global Fund
were established to combat three diseases: AIDS, tuberculosis,
and malaria. While goals such as strengthening health systems,
combatting non-communicable diseases, and establishing social
safety nets for children in adversity are worthy objectives--
and PEPFAR and the Global Fund clearly have had corollary, net-
positive effects on these and other global health and
development priorities--these objectives can and should be
addressed through different initiatives. PEPFAR's past and
future success is contingent on remaining focused upon the
three core diseases.
The committee supports the efforts of OGAC to align budgets
with priorities, strategically target resources, and enhance
coordination among Federal departments and agencies, the Global
Fund, other donors, partner countries, and implementers,
including through the annual COP process. The committee notes
that the COP process is labor intensive and appreciates the
efforts of participants to ensure that it serves as an
effective planning tool that enhances transparency and
accountability. The committee directs all participating Federal
departments and agencies to strictly adhere to the COPs and to
seek specific authority from OGAC if a deviation becomes
necessary. Similarly, the committee directs all participating
Federal departments and agencies to obtain explicit approval
from OGAC prior to initiating research projects to be funded
with PEPFAR resources. OGAC shall report patterns of
noncompliance to the Committees on Foreign Affairs and
Appropriations in the House and Foreign Relations and
Appropriations in the Senate.
The coordinated Inspectors General audit plans, studies on
treatment providers and costs, and annual reporting
requirements that are extended in this Act are critical to
effective oversight and enhance the ability of OGAC to stretch
resources farther, program for impact, and eliminate
duplication and waste. The committee notes that execution of
the coordinated audit plans has been inconsistent. The
committee directs the Inspectors General to improve
coordination and pursue a robust audits and investigations
agenda, including by scrutinizing supply chains\2\ and OGAC's
efforts to expand utilization of local partners to ensure
resources continue to be used as efficiently and effectively as
possible. The committee also recommends enhanced coordination
with the Inspector General for the Peace Corps to ensure
program integrity.
---------------------------------------------------------------------------
\2\See ``Committee on Foreign Affairs Oversight Investigation:
USAID Global Health Supply Chain Contract'', October 2018, available at
https://foreignaffairs.house.gov/wp-content/uploads/2018/10/Oversight-
Investigation-USAID-Global-Health-Supply-Chain-Contract.pdf.
---------------------------------------------------------------------------
Expanding Access to Treatment as a Form of Prevention. In
2011, a study by the HIV Prevention Trials Network (HPTN),
known as HPTN 052, began showing evidence that early initiation
of ART could reduce the chances of transmission from an HIV-
positive person to an HIV-negative partner by more than 96
percent.\3\ The Joint United Nations Program on HIV/AIDS
(UNAIDS) seized upon these findings and, in 2014, launched
ambitious ``90-90-90'' targets--whereby, by 2020, 90% of people
living with HIV will know their status; 90% of those who know
their status will be on treatment; and 90% of those accessing
treatment will be virally suppressed. To reach these targets,
the World Health Organization (WHO) recommended in 2015 that
all countries move to a ``test-start-retain'' model--whereby
all people diagnosed with HIV immediately start ART regardless
of their CD-4 count (i.e., the measure of white blood cells, or
T cells, in a patient's bloodstream) and strictly adhere to the
treatment regime in order to achieve viral suppression.
According to the WHO, universal adoption of ``test-start-
retain'' policies and related progress toward the 90-90-90
targets would help avert 28 million new infections by 2030.
---------------------------------------------------------------------------
\3\The results of the HPTN 052 study were finalized and published
in the New England Journal of Medicine on September 1, 2016.
---------------------------------------------------------------------------
On July 24, 2018, UNAIDS reported that considerable
progress has been made--by the end of 2017, an estimated 75
percent of people living with HIV knew their status, of which
79 percent were receiving treatment, of which 81 percent were
virally suppressed--but entire populations and regions in
eastern Europe, central Asia, central and western Africa, and
the Middle East and North Africa are still being left behind.
Key populations, adolescents, and men are not being reached by
traditional testing approaches, and adolescent girls in
particular remain extremely vulnerable to infection. Moreover,
gaps in political will, societal stigma and discrimination--
especially against key populations--and the imposition of user
fees on HIV services remain significant barriers to progress.
The committee is encouraged by progress in meeting the 90-
90-90 targets and encourages all partner countries to adopt
effective test-start-retain policies and approaches. At the
same time, the committee recognizes that flat budgets will make
it increasingly difficult for OGAC and partner countries to
expand access to treatment and prevent new infections.
The committee expects OGAC to continue to collect, refine,
and apply data so PEPFAR resources can be targeted to the areas
of greatest need. The committee encourages OGAC, the Global
Fund, and other partners to work with the private sector to
develop and deploy cost-effective innovations in testing and
treatment for hard-to-reach populations. The committee also
urges partner countries to lower barriers to testing and
treatment, including by eliminating user fees, strengthening
supply chains, fighting stigma and discrimination, and enacting
policies that allow for early adoption and transition to
improved testing and treatment regimens.
The Global Fund Cap. The Leadership Act of 2003 established
a 33 percent cap on U.S. contributions to the Global Fund for
each of the Fiscal Years 2004 through 2008, and the Lantos-Hyde
Act of 2008 extended that cap for each of the Fiscal Years 2009
through 2013. During negotiations over the Stewardship Act, the
Administration indicated that they were having difficulty
calculating the cap on a year-to-year basis because the Global
Fund operates on a 3-year ``replenishment cycle'' and the
fiscal years of other donors do not necessarily align with
those of the United States. To that end, OGAC requested that
they be allowed to apply the cap to cumulative contributions
over the authorization period rather than annual contributions.
Congress consented and extended the cap in the Stewardship Act
so that it would apply to cumulative contributions between
Fiscal Year 2009 through 2018.
In late 2015, OGAC reported that they had misinterpreted
how compliance with the cap was to be calculated. Rather than
limiting U.S. contributions to the Global Fund to 33 percent of
the cumulative contributions received between Fiscal Years 2009
and 2018 as the Stewardship Act stipulated, OGAC had been
applying the cap to cumulative contributions received between
Fiscal Years 2004--rather than 2009--and 2018. Since total U.S.
contributions to the Global Fund prior to 2008 were below 33
percent, this calculation allowed OGAC to provide additional
U.S. funding to the Global Fund. By the time the new Global
AIDS Coordinator detected and reported the error in December
2015, the United States had provided more than $500 million in
excess contributions to the Global Fund. Without statutory
relief, the consequence of this miscalculation meant that OGAC
would have to pull back over $500 million from signed Global
Fund agreements, potentially resulting in patients losing
access to treatment.
To avoid having to cut off treatment to patients in need, a
bipartisan agreement to provide temporary cap relief was
reached in December 2015 with enactment of the Consolidated
Appropriations Act, 2016 (P.L. 114-113). This agreement, which
simply substituted ``2004'' for ``2009'' for the purposes of
calculating the Global Fund cap, was extended by the
Consolidated Appropriations Act, 2017 (P.L. 115-31) and the
Consolidated Appropriations Act, 2018 (P.L. 115-141).
To ensure compliance with existing law and prevent the need
to carry temporary relief through annual appropriations bills,
the PEPFAR Extension Act of 2018 eliminates any ambiguity about
how the cap is to be calculated during the next Global Fund
replenishment cycle, by permanently amending the Leadership Act
and applying the 33 percent cap to cumulative contributions
between Fiscal Years 2004 and 2023. The bill also extends the
requirement to withhold contributions to the Global Fund in an
amount equal to any assistance provided to a State Sponsor of
Terrorism and clarifies that any funds withheld from the Global
Fund for any purpose may be made available for U.S. bilateral
HIV/AIDS, tuberculosis, or malaria programs.
Together, PEPFAR and the Global Fund have helped save 27
million lives. The number of AIDS-related deaths has been cut
in half since 2005, while malaria deaths have decreased by 60
percent since 2000. In 2017 alone, over 79.1 million HIV tests
were administered and 17.5 million people were receiving life-
saving ART. Nearly 200 million insecticide-treated bed nets
were distributed, while 108 million people received treatment
for malaria. Unfortunately, progress in combatting tuberculosis
remains slow and hampered by significant gaps in case
detection. Tuberculosis, while curable, kills more people
worldwide than any other infectious disease and is the leading
killer of people living with HIV/AIDS. As such, failure to
accelerate progress against tuberculosis threatens to undermine
the substantial progress achieved through PEPFAR and the Global
Fund. Despite these challenges, an estimated 60 percent of
tuberculosis patients know their HIV status and 85 percent of
HIV-positive people co-infected with tuberculosis receive
treatment for both.
These results could not have been possible absent a laser
focus on these three diseases. The committee urges the Global
Fund to maintain this focus while exploring innovating testing,
treatment, and financing options. The committee also reminds
partners that U.S. participation in the Global Fund is
voluntary. The committee directs OGAC to continue to condition
U.S. contributions to the Global Fund upon performance and
compliance with transparency and accountability requirements.
Orphans and Vulnerable Children. In 2003, AIDS was a death
sentence that was threatening a generation of caregivers in
sub-Saharan Africa. According to UNAIDS and WHO, over 4 million
children under the age of 15 had been infected--90 percent of
whom had been infected by their mothers at birth or through
breastfeeding--and another 13 million children had lost one or
both parents to AIDS.\4\ In Zimbabwe alone, life expectancy had
dropped to 37 years and 1.32 million children had become ``AIDS
orphans.''\5\ Traditional communal care norms were broken and
an alarming number of children were abandoned, left to raise
other children, or forced to adopt negative coping mechanisms
to survive. It was against this backdrop that Congress
established the requirement under the Leadership Act to direct
not less than 10 percent of the PEPFAR budget toward OVC.
---------------------------------------------------------------------------
\4\The World Health Organization defines ``AIDS orphans'' as
children under the age of 15 who have lost their mother or both parents
to AIDS. See UNAIDS/WHO, ``2003 AIDS epidemic update: December 2003.''
https://www.who.int/ceh/risks/otherisks/en/index2.html.
\5\See UNICEF, ``Africa's Orphaned and Vulnerable Generations:
Children Affected by AIDS.''
---------------------------------------------------------------------------
Thanks to PEPFAR's success, the scale and demographics of
the OVC crisis have dramatically shifted. With treatment now
much more accessible, parents and caregivers are surviving. The
worst-case scenario predicted by UNAIDS in 2003--41 million
AIDS orphans by 2010--has not come to pass.\6\ Moreover, the
OVC of 2003 are now adults and require significantly different
types of support than they did when the funding directive was
established.
---------------------------------------------------------------------------
\6\UNAIDS/WHO, ``2003 AIDS epidemic update: December 2003.''
---------------------------------------------------------------------------
The committee believes it is important to maintain a focus
on mitigating the harmful impact HIV/AIDS has on children and
adolescents. However, the OVC programming supported by the 10
percent funding directive extended by this Act must continue to
evolve to meet the demands of a changing epidemic and its
impacts on children and adolescents today. Despite having
invested more than $2 billion in comprehensive OVC programs
since Fiscal Year 2004, only 52 percent of children ages 0-14
with HIV have access to ART and 180,000 children were newly
infected in 2017. Effective OVC programming must take into
account the aging population and, consequently, evolving needs
of OVC, the disproportionately high risk of HIV infection and
sexual violence for adolescent girls and young women, and the
number of HIV-positive orphans yet to be diagnosed and linked
to treatment. The committee directs OGAC to report on how
PEPFAR--in particular the 10 percent OVC funding directive--is
working to prevent new infections among OVC, with a particular
emphasis on girls between the ages of 9 and 17, and to expand
access to treatment for OVC.
Hearings
Over the past 5 years, the committee has continued its
active oversight of U.S. development, economic, and global
health assistance programs, including 12 hearings related to
the PEPFAR program:
July 12, 2018, hearing before the Subcommittee on
Africa, Global Health, Global Human Rights, and
International Organizations on ``Combating Tuberculosis
in Southern Africa'' (The Honorable Deborah L. Birx,
M.D., U.S. Global AIDS Coordinator and U.S. Special
Representative for Global Health Diplomacy, U.S.
Department of State; Ms. Irene Koek, Deputy Assistant
Administrator, Bureau for Global Health, USAID; Rebecca
Martin, Ph.D., Director, Center for Global Health, U.S.
Centers for Disease Control and Prevention);
May 17, 2018, hearing before the Subcommittee on
Africa, Global Health, Global Human Rights, and
International Organizations on ``Global Health Supply
Chain Management: Lessons Learned and Ways Forward''
(Ms. Irene Koek, Deputy Assistant Administrator; Bureau
for Global Health, USAID; the Honorable Deborah L.
Birx, M.D., U.S. Global AIDS Coordinator and U.S.
Special Representative for Global Health Diplomacy,
U.S. Department of State);
March 21, 2018, hearing before the full committee on
``The FY 2019 Foreign Assistance Budget'' (The
Honorable Mark Green, Administrator, USAID);
October 11, 2017, hearing before the Subcommittee on
Africa, Global Health, Global Human Rights, and
International Organizations on ``The State Department
and USAID FY 2018 Africa Budget'' (The Honorable Donald
Yamamoto, Acting Assistant Secretary, Bureau of African
Affairs, U.S. Department of State; Ms. Cheryl Anderson,
Acting Assistant Administrator, Bureau for Africa,
USAID);
June 14, 2017, hearing before the full committee on
``The FY 2018 Foreign Affairs Budget'' (The Honorable
Rex W. Tillerson, Secretary of State, U.S. Department
of State);
May 18, 2017, hearing before the full committee on
``U.S. Interests in Africa'' (General William E. Ward,
USA, Retired, President and Chief Operating Officer,
SENTEL Corporation and Former Commander, U.S. Africa
Command; Mr. Bryan Christy, Explorer and Investigative
Reporter, National Geographic Society; Mr. Anthony
Carroll, Adjunct Professor, School of Advanced
International Studies, Johns Hopkins University; the
Honorable Reuben E. Brigety II, Dean, Elliott School of
International Affairs, the George Washington University
and former U.S. Representative to the African Union,
U.S. Department of State);
March 28, 2017, hearing before the full committee on
``The Budget, Diplomacy, and Development'' (Stephen D.
Krasner, Ph.D., Senior Fellow, Hoover Institution; Ms.
Danielle Pletka, Senior Vice President, Foreign and
Defense Policy Studies, American Enterprise Institute;
the Honorable R. Nicholas Burns, Roy and Barbara
Goodman Family Professor of Diplomacy and International
Relations, Belfer Center for Science and International
Affairs, John F. Kennedy School of Government, Harvard
University and former Under Secretary for Political
Affairs, U.S. Department of State);
December 8, 2015, hearing and briefing before the
Subcommittee on Africa, Global Health, Global Human
Rights, and International Organizations on ``Drug-
Resistant Tuberculosis: The Next Global Health Crisis''
(Tom Frieden, M.D., Director, CDC; the Honorable Ariel
Pablos-Mendez, M.D., Assistant Administrator Bureau for
Global Health, USAID; the Honorable Eric P. Goosby,
M.D., Special Envoy on Tuberculosis, United Nations and
former Global AIDS Coordinator, U.S. Department of
State);
March 17, 2015, hearing before the full committee on
``The FY 2016 Budget Request: Assessing U.S. Foreign
Assistance Effectiveness'' (Hon. Alfonso E. Lenhardt,
Acting Administrator, USAID; Hon. Dana J. Hyde, CEO,
Millennium Challenge Corporation);
September 17, 2014, hearing before the Subcommittee
on Africa, Global Health, Global Human Rights, and
International Organizations on ``Global Efforts to
Fight Ebola'' (Anthony S. Fauci, M.D., Director,
National Institute of Allergy and Infectious Diseases,
HHS; Luciana Borio, M.D., Director, Office of
Counterterrorism and Emerging Threats, Office of the
Chief Scientist, U.S. Food and Drug Administration,
HHS; the Honorable Nancy Lindborg, Assistant
Administrator, Bureau for Democracy, Conflict and
Humanitarian Assistance, USAID; Beth P. Bell, M.D.,
Director, National Center for Emerging and Zoonotic
Infectious Diseases, CDC; Kent Brantly, M.D., Medical
Missionary, Samaritan's Purse; Chinua Akukwe, M.D.,
Chair, Africa Working Group, National Academy of Public
Administration; Mr. Ted Alemayhu, Founder & Executive
Chairman, U.S. Doctors for Africa; Dougbeh Chris Nyan,
M.D., Director of the Secretariat, Diaspora Liberian
Emergency Response Task Force on the Ebola Crisis); and
August 7, 2014, hearing before the Subcommittee on
Africa, Global Health, Global Human Rights, and
International Organizations on ``Combatting the Ebola
Threat'' (Tom Frieden, M.D., Director, CDC; Ariel
Pablos-Mendez, M.D., Assistant Administrator, Bureau
for Global Health, USAID; the Honorable Bisa Williams,
Deputy Assistant Secretary, Bureau of African Affairs,
U.S. Department of State; Mr. Ken Isaacs, Vice
President of Program and Government Relations,
Samaritan's Purse; Frank Glover, M.D., Missionary,
SIM);
April 9, 2014, hearing before the full committee on
``U.S. Foreign Assistance in FY 2015: What Are the
Priorities, How Effective?'' (The Honorable Rajiv Shah,
Administrator, USAID).
Committee Consideration
On September 22, 2018, the Foreign Affairs Committee marked
up H.R. 6651 pursuant to notice, in open session. The chairman
obtained unanimous consent to consider the bill en bloc with
Smith 113, an amendment offered by Rep. Smith. The items
considered en bloc were agreed to by voice vote. The committee
ordered H.R. 6651, as amended, favorably reported by unanimous
consent.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII of Rules of
the House of Representatives, the committee reports that
findings and recommendations of the committee, based on
oversight activities under clause 2(b)(1) of House Rule X, are
incorporated in the descriptive portions of this report,
particularly in the section on ``Background and Need for the
Legislation.''
New Budget Authority, Tax Expenditures, and Federal Mandates
In compliance with clause 3(c)(2) of House Rule XIII and
the Unfunded Mandates Reform Act (P.L. 104-4), the committee
adopts as its own the estimate of new budget authority,
entitlement authority, tax expenditure or revenues, and Federal
mandates 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
U.S. Congress,
Congressional Budget Office,
Washington, DC, October 11, 2018.
Hon. Edward R. Royce, 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. 6651, the PEPFAR
Extension Act of 2018.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell, who can be reached at 226-2840.
Sincerely,
Keith Hall,
Director.
Enclosure
cc:
Honorable Eliot L. Engel
Ranking Member
H.R. 6651--PEPFAR Extension Act of 2018.
As ordered reported by the House Committee on Foreign
Affairs on September 27, 2018.
H.R. 6651 would reauthorize, through 2023, certain expired
provisions of foreign assistance programs to combat HIV/AIDS,
malaria, and tuberculosis (commonly known as the U.S.
President's Emergency Plan for AIDS Relief or PEPFAR). CBO
estimates that implementing the bill would cost $15 million
over the 2019-2023 period, assuming appropriation of the
necessary amounts.
Section 2 would extend through 2023 a requirement for the
Inspectors General (IGs) of the Department of State and
Broadcasting Board of Governors, the Department of Health and
Human Services, and the U.S. Agency for International
Development to coordinate and conduct oversight of PEPFAR
programs. Under current law, that directive expired at the end
of fiscal year 2018. According to the Office of the U.S. Global
AIDS Coordinator (OGAC)--the office within the Department of
State that coordinates all PEPFAR activities--the IGs spent
roughly $15 million on such oversight over the past 5 years.
CBO expects that each of the three IGs would require
appropriations of roughly $1 million per year to continue such
oversight. Thus, implementing that provision would cost $15
million over the 2019-2023 period, CBO estimates.
Section 2 also would extend through 2024 an annual
requirement to provide a report on HIV/AIDS treatment
providers. OGAC plans to collect and analyze the necessary
information in the absence of this statutory requirement. CBO
estimates that the additional costs of preparing the report
would be less than $500,000 over the 2019-2023 period.
Enacting H.R. 6651 would not affect direct spending or
revenues; therefore, pay-as-you-go procedures do not apply.
CBO estimates that enacting H.R. 6651 would not increase
net direct spending or on-budget deficits in any of the four
consecutive 10-year periods beginning in 2029.
H.R. 6651 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act.
On October 2, 2018, CBO transmitted a cost estimate for S.
3476, the PEPFAR Extension Act of 2018, as ordered reported by
the Senate Committee on Foreign Relations on September 26,
2018. H.R. 6651 is similar to S. 3476, and their estimated
costs are the same.
The CBO staff contact for this estimate is Ann E. Futrell.
The estimate was reviewed by Leo Lex, Deputy Assistant Director
for Budget Analysis.
Directed Rule Making
Pursuant to clause 3(c) of House Rule XIII, as modified by
section 3(i) of H. Res. 5 during the 115th Congress, the
committee notes that H.R. 6651 contains no directed rule-making
provisions.
Non-Duplication of Federal Programs
Pursuant to clause 3(c)(5) of House Rule XIII, the
committee states that no provision of this bill establishes or
reauthorizes a program of the Federal Government known to be
duplicative of another Federal program, a program that was
included in any report from the Government Accountability
Office to Congress pursuant to section 21 of Public Law 111-
139, or a program related to a program identified in the most
recent Catalog of Federal Domestic Assistance.
Performance Goals and Objectives
The objective of this legislation is to extend and enhance
U.S. efforts to combat AIDS, tuberculosis, and malaria through
implementation of PEPFAR and participation in the Global Fund.
Section 2 requires the Inspectors General of the U.S.
Department of State, HHS, and USAID to develop joint auditing
plans and requires the U.S. Global AIDS Coordinator to conduct
annual studies of HIV/AIDS treatment providers and costs. These
audits and studies will enable Congress to conduct effective
oversight of performance and results.
Congressional Accountability Act
H.R. 6651 does not apply to terms and conditions of
employment or to access to public services or accommodations
within the legislative branch.
New Advisory Committees
H.R. 6651 does not establish or authorize any new advisory
committees.
Earmark Identification
H.R. 6651 contains no congressional earmarks, limited tax
benefits, or limited tariff benefits as described in clauses
9(e), 9(f), and 9(g) of House Rule XXI.
Section-by-Section Analysis
Section 1. Short Title. States that the Act may be cited as
the ``PEPFAR Extension Act of 2018.''
Section 2. Inspectors General and Annual Study. Amends
Section 101 of the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7611) to: (1)
extend through Fiscal Year 2023 the requirement for the
Inspectors General of the U.S. Department of State, HHS, and
USAID to develop joint auditing plans; and (2) to extend
through September 31, 2024 the requirement for the U.S. Global
AIDS Coordinator to conduct annual studies of treatment
providers and costs.
Section 3. Participation in the Global Fund to Fight AIDS,
Tuberculosis, and Malaria. Amends Section 202(d) of the United
States Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Act of 2003 (22 U.S.C. 7622(d)) to: (1) extend through Fiscal
Year 2023 the 33 percent cap on U.S. contributions to the
Global Fund and clarify that the limitation applies to
cumulative contributions between Fiscal Years 2004 and 2023;
(2) extend through Fiscal Year 2023 a requirement to withhold
contributions to the Global Fund in an amount equal to any
assistance provided to a State Sponsor of Terrorism; and (3)
clarify that any funds withheld from the Global Fund for any
purpose may be made available for U.S. bilateral HIV/AIDS,
tuberculosis, or malaria programs
Section 4. Allocation of Funds. Amends Section 403 of the
United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003 (22 U.S.C. 7673) to extend through Fiscal
Year 2023 the requirement to allocate at least 10 percent of
the PEPFAR budget to programs that support children orphaned or
made vulnerable by HIV/AIDS and at least half of the PEPFAR
budget to HIV/AIDS treatment and care.
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 italic, and existing law in which no
change is proposed is shown in roman):
UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA
ACT OF 2003
* * * * * * *
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, 5-year strategy to expand and improve efforts to
combat global HIV/AIDS. This strategy shall--
(1) further strengthen the capability of the United
States to be an effective leader of the international
campaign against this disease and strengthen the
capacities of nations experiencing HIV/AIDS epidemics
to combat this disease;
(2) maintain sufficient flexibility and remain
responsive to--
(A) changes in the epidemic;
(B) challenges facing partner countries in
developing and implementing an effective
national response; and
(C) evidence-based improvements and
innovations in the prevention, care, and
treatment of HIV/AIDS;
(3) situate United States efforts to combat HIV/AIDS,
tuberculosis, and malaria within the broader United
States global health and development agenda,
establishing a roadmap to link investments in specific
disease programs to the broader goals of strengthening
health systems and infrastructure and to integrate and
coordinate HIV/AIDS, tuberculosis, or malaria programs
with other health or development programs, as
appropriate;
(4) provide a plan to--
(A) prevent 12,000,000 new HIV infections
worldwide;
(B) support--
(i) the increase in the number of
individuals with HIV/AIDS receiving
antiretroviral treatment above the goal
established under section 402(a)(3) and
increased pursuant to paragraphs (1)
through (3) of section 403(d); and
(ii) additional treatment through
coordinated multilateral efforts;
(C) support care for 12,000,000 individuals
infected with or affected by HIV/AIDS,
including 5,000,000 orphans and vulnerable
children affected by HIV/AIDS, with an emphasis
on promoting a comprehensive, coordinated
system of services to be integrated throughout
the continuum of care;
(D) help partner countries in the effort to
achieve goals of 80 percent access to
counseling, testing, and treatment to prevent
the transmission of HIV from mother to child,
emphasizing a continuum of care model;
(E) help partner countries to provide care
and treatment services to children with HIV in
proportion to their percentage within the HIV-
infected population in each country;
(F) promote preservice training for health
professionals designed to strengthen the
capacity of institutions to develop and
implement policies for training health workers
to combat HIV/AIDS, tuberculosis, and malaria;
(G) equip teachers with skills needed for
HIV/AIDS prevention and support for persons
with, or affected by, HIV/AIDS;
(H) provide and share best practices for
combating HIV/AIDS with health professionals;
(I) promote pediatric HIV/AIDS training for
physicians, nurses, and other health care
workers, through public-private partnerships if
possible, including through the designation, if
appropriate, of centers of excellence for
training in pediatric HIV/AIDS prevention,
care, and treatment in partner countries; and
(J) help partner countries to train and
support retention of health care professionals
and paraprofessionals, with the target of
training and retaining at least 140,000 new
health care professionals and paraprofessionals
with an emphasis on training and in country
deployment of critically needed doctors and
nurses and to strengthen capacities in
developing countries, especially in sub-Saharan
Africa, to deliver primary health care with the
objective of helping countries achieve staffing
levels of at least 2.3 doctors, nurses, and
midwives per 1,000 population, as called for by
the World Health Organization;
(5) include multisectoral approaches and specific
strategies to treat individuals infected with HIV/AIDS
and to prevent the further transmission of HIV
infections, with a particular focus on the needs of
families with children (including the prevention of
mother-to-child transmission), women, young people,
orphans, and vulnerable children;
(6) establish a timetable with annual global
treatment targets with country-level benchmarks for
antiretroviral treatment;
(7) expand the integration of timely and relevant
research within the prevention, care, and treatment of
HIV/AIDS;
(8) include a plan for program monitoring, operations
research, and impact evaluation and for the
dissemination of a best practices report to highlight
findings;
(9) support the in-country or intra-regional
training, preferably through public-private
partnerships, of scientific investigators, managers,
and other staff who are capable of promoting the
systematic uptake of clinical research findings and
other evidence-based interventions into routine
practice, with the goal of improving the quality,
effectiveness, and local leadership of HIV/AIDS health
care;
(10) expand and accelerate research on and
development of HIV/AIDS prevention methods for women,
including enhancing inter-agency collaboration,
staffing, and organizational infrastructure dedicated
to microbicide research;
(11) provide for consultation with local leaders and
officials to develop prevention strategies and programs
that are tailored to the unique needs of each country
and community and targeted particularly toward those
most at risk of acquiring HIV infection;
(12) make the reduction of HIV/AIDS behavioral risks
a priority of all prevention efforts by--
(A) promoting abstinence from sexual activity
and encouraging monogamy and faithfulness;
(B) encouraging the correct and consistent
use of male and female condoms and increasing
the availability of, and access to, these
commodities;
(C) promoting the delay of sexual debut and
the reduction of multiple concurrent sexual
partners;
(D) promoting education for discordant
couples (where an individual is infected with
HIV and the other individual is uninfected or
whose status is unknown) about safer sex
practices;
(E) promoting voluntary counseling and
testing, addiction therapy, and other
prevention and treatment tools for illicit
injection drug users and other substance
abusers;
(F) educating men and boys about the risks of
procuring sex commercially and about the need
to end violent behavior toward women and girls;
(G) supporting partner country and community
efforts to identify and address social,
economic, or cultural factors, such as
migration, urbanization, conflict, gender-based
violence, lack of empowerment for women, and
transportation patterns, which directly
contribute to the transmission of HIV;
(H) supporting comprehensive programs to
promote alternative livelihoods, safety, and
social reintegration strategies for commercial
sex workers and their families;
(I) promoting cooperation with law
enforcement to prosecute offenders of
trafficking, rape, and sexual assault crimes
with the goal of eliminating such crimes; and
(J) working to eliminate rape, gender-based
violence, sexual assault, and the sexual
exploitation of women and children;
(13) include programs to reduce the transmission of
HIV, particularly addressing the heightened
vulnerabilities of women and girls to HIV in many
countries; and
(14) support other important means of preventing or
reducing the transmission of HIV, including--
(A) medical male circumcision;
(B) the maintenance of a safe blood supply;
(C) promoting universal precautions in formal
and informal health care settings;
(D) educating the public to recognize and to
avoid risks to contract HIV through blood
exposures during formal and informal health
care and cosmetic services;
(E) investigating suspected nosocomial
infections to identify and stop further
nosocomial transmission; and
(F) other mechanisms to reduce the
transmission of HIV;
(15) increase support for prevention of mother-to-
child transmission;
(16) build capacity within the public health sector
of developing countries by improving health systems and
public health infrastructure and developing indicators
to measure changes in broader public health sector
capabilities;
(17) increase the coordination of HIV/AIDS programs
with development programs;
(18) provide a framework for expanding or developing
existing or new country or regional programs,
including--
(A) drafting compacts or other agreements, as
appropriate;
(B) establishing criteria and objectives for
such compacts and agreements; and
(C) promoting sustainability;
(19) provide a plan for national and regional
priorities for resource distribution and a global
investment plan by region;
(20) provide a plan to address the immediate and
ongoing needs of women and girls, which--
(A) addresses the vulnerabilities that
contribute to their elevated risk of infection;
(B) includes specific goals and targets to
address these factors;
(C) provides clear guidance to field missions
to integrate gender across prevention, care,
and treatment programs;
(D) sets forth gender-specific indicators to
monitor progress on outcomes and impacts of
gender programs;
(E) supports efforts in countries in which
women or orphans lack inheritance rights and
other fundamental protections to promote the
passage, implementation, and enforcement of
such laws;
(F) supports life skills training, especially
among women and girls, with the goal of
reducing vulnerabilities to HIV/AIDS;
(G) addresses and prevents gender-based
violence; and
(H) addresses the posttraumatic and
psychosocial consequences and provides
postexposure prophylaxis protecting against HIV
infection to victims of gender-based violence
and rape;
(21) provide a plan to--
(A) determine the local factors that may put
men and boys at elevated risk of contracting or
transmitting HIV;
(B) address male norms and behaviors to
reduce these risks, including by reducing
alcohol abuse;
(C) promote responsible male behavior; and
(D) promote male participation and leadership
at the community level in efforts to promote
HIV prevention, reduce stigma, promote
participation in voluntary counseling and
testing, and provide care, treatment, and
support for persons with HIV/AIDS;
(22) provide a plan to address the vulnerabilities
and needs of orphans and children who are vulnerable
to, or affected by, HIV/AIDS;
(23) encourage partner countries to develop health
care curricula and promote access to training tailored
to individuals receiving services through, or exiting
from, existing programs geared to orphans and
vulnerable children;
(24) provide a framework to work with international
actors and partner countries toward universal access to
HIV/AIDS prevention, treatment, and care programs,
recognizing that prevention is of particular
importance;
(25) enhance the coordination of United States
bilateral efforts to combat global HIV/AIDS with other
major public and private entities;
(26) enhance the attention given to the national
strategic HIV/AIDS plans of countries receiving United
States assistance by--
(A) reviewing the planning and programmatic
decisions associated with that assistance; and
(B) helping to strengthen such national
strategies, if necessary;
(27) support activities described in the Global Plan
to Stop TB, including--
(A) expanding and enhancing the coverage of
the Directly Observed Treatment Short-course
(DOTS) in order to treat individuals infected
with tuberculosis and HIV, including multi-drug
resistant or extensively drug resistant
tuberculosis; and
(B) improving coordination and integration of
HIV/AIDS and tuberculosis programming;
(28) ensure coordination between the Global AIDS
Coordinator and the Malaria Coordinator and address
issues of comorbidity between HIV/AIDS and malaria; and
(29) include a longer term estimate of the projected
resource needs, progress toward greater sustainability
and country ownership of HIV/AIDS programs, and the
anticipated role of the United States in the global
effort to combat HIV/AIDS during the 10-year period
beginning on October 1, 2013.
(b) Report.--
(1) In general.--Not later than October 1, 2009, the
President shall submit a report to the appropriate
congressional committees that sets forth the strategy
described in subsection (a).
(2) Contents.--The report required under paragraph
(1) shall include a discussion of the following
elements:
(A) The purpose, scope, methodology, and
general and specific objectives of the
strategy.
(B) The problems, risks, and threats to the
successful pursuit of the strategy.
(C) The desired goals, objectives,
activities, and outcome-related performance
measures of the strategy.
(D) A description of future costs and
resources needed to carry out the strategy.
(E) A delineation of United States Government
roles, responsibility, and coordination
mechanisms of the strategy.
(F) A description of the strategy--
(i) to promote harmonization of
United States assistance with that of
other international, national, and
private actors as elucidated in the
``Three Ones''; and
(ii) to address existing challenges
in harmonization and alignment.
(G) A description of the manner in which the
strategy will--
(i) further the development and
implementation of the national
multisectoral strategic HIV/AIDS
frameworks of partner governments; and
(ii) enhance the centrality,
effectiveness, and sustainability of
those national plans.
(H) A description of how the strategy will
seek to achieve the specific targets described
in subsection (a) and other targets, as
appropriate.
(I) A description of, and rationale for, the
timetable for annual global treatment targets
with country-level estimates of numbers of
persons in need of antiretroviral treatment,
country-level benchmarks for United States
support for assistance for antiretroviral
treatment, and numbers of persons enrolled in
antiretroviral treatment programs receiving
United States support. If global benchmarks are
not achieved within the reporting period, the
report shall include a description of steps
being taken to ensure that global benchmarks
will be achieved and a detailed breakdown and
justification of spending priorities in
countries in which benchmarks are not being
met, including a description of other donor or
national support for antiretroviral treatment
in the country, if appropriate.
(J) A description of how operations research
is addressed in the strategy and how such
research can most effectively be integrated
into care, treatment, and prevention activities
in order to--
(i) improve program quality and
efficiency;
(ii) ascertain cost effectiveness;
(iii) ensure transparency and
accountability;
(iv) assess population-based impact;
(v) disseminate findings and best
practices; and
(vi) optimize delivery of services.
(K) An analysis of United States-assisted
strategies to prevent the transmission of HIV/
AIDS, including methodologies to promote
abstinence, monogamy, faithfulness, the correct
and consistent use of male and female condoms,
reductions in concurrent sexual partners, and
delay of sexual debut, and of intended
monitoring and evaluation approaches to measure
the effectiveness of prevention programs and
ensure that they are targeted to appropriate
audiences.
(L) Within the analysis required under
subparagraph (K), an examination of additional
planned means of preventing the transmission of
HIV including medical male circumcision,
maintenance of a safe blood supply, public
education about risks to acquire HIV infection
from blood exposures, promotion of universal
precautions, investigation of suspected
nosocomial infections and other tools.
(M) A description of efforts to assist
partner country and community to identify and
address social, economic, or cultural factors,
such as migration, urbanization, conflict,
gender-based violence, lack of empowerment for
women, and transportation patterns, which
directly contribute to the transmission of HIV.
(N) A description of the specific targets,
goals, and strategies developed to address the
needs and vulnerabilities of women and girls to
HIV/AIDS, including--
(i) activities directed toward men
and boys;
(ii) activities to enhance
educational, microfinance, and
livelihood opportunities for women and
girls;
(iii) activities to promote and
protect the legal empowerment of women,
girls, and orphans and vulnerable
children;
(iv) programs targeted toward gender-
based violence and sexual coercion;
(v) strategies to meet the particular
needs of adolescents;
(vi) assistance for victims of rape,
sexual abuse, assault, exploitation,
and trafficking; and
(vii) programs to prevent alcohol
abuse.
(O) A description of strategies to address
male norms and behaviors that contribute to the
transmission of HIV, to promote responsible
male behavior, and to promote male
participation and leadership in HIV/AIDS
prevention, care, treatment, and voluntary
counseling and testing.
(P) A description of strategies--
(i) to address the needs of orphans
and vulnerable children, including an
analysis of--
(I) factors contributing to
children's vulnerability to
HIV/AIDS; and
(II) vulnerabilities caused
by the impact of HIV/AIDS on
children and their families;
and
(ii) in areas of higher HIV/AIDS
prevalence, to promote a community-
based approach to vulnerability,
maximizing community input into
determining which children participate.
(Q) A description of capacity-building
efforts undertaken by countries themselves,
including adherents of the Abuja Declaration
and an assessment of the impact of
International Monetary Fund macroeconomic and
fiscal policies on national and donor
investments in health.
(R) A description of the strategy to--
(i) strengthen capacity building
within the public health sector;
(ii) improve health care in those
countries;
(iii) help countries to develop and
implement national health workforce
strategies;
(iv) strive to achieve goals in
training, retaining, and effectively
deploying health staff;
(v) promote the use of codes of
conduct for ethical recruiting
practices for health care workers; and
(vi) increase the sustainability of
health programs.
(S) A description of the criteria for
selection, objectives, methodology, and
structure of compacts or other framework
agreements with countries or regional
organizations, including--
(i) the role of civil society;
(ii) the degree of transparency;
(iii) benchmarks for success of such
compacts or agreements; and
(iv) the relationship between such
compacts or agreements and the national
HIV/AIDS and public health strategies
and commitments of partner countries.
(T) A strategy to better coordinate HIV/AIDS
assistance with nutrition and food assistance
programs.
(U) A description of transnational or
regional initiatives to combat regionalized
epidemics in highly affected areas such as the
Caribbean.
(V) A description of planned resource
distribution and global investment by region.
(W) A description of coordination efforts in
order to better implement the Stop TB Strategy
and to address the problem of coinfection of
HIV/AIDS and tuberculosis and of projected
challenges or barriers to successful
implementation.
(X) A description of coordination efforts to
address malaria and comorbidity with malaria
and HIV/AIDS.
(c) Study of Progress Toward Achievement of Policy
Objectives.--
(1) Design and budget plan for data evaluation.--The
Global AIDS Coordinator shall enter into a contract
with the Institute of Medicine of the National
Academies that provides that not later than 18 months
after the date of the enactment of the Tom Lantos and
Henry J. Hyde United States Global Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act
of 2008, the Institute, in consultation with the Global
AIDS Coordinator and other relevant parties
representing the public and private sector, shall
provide the Global AIDS Coordinator with a design plan
and budget for the evaluation and collection of
baseline and subsequent data to address the elements
set forth in paragraph (2)(B). The Global AIDS
Coordinator shall submit the budget and design plan to
the appropriate congressional committees.
(2) Study.--
(A) In general.--Not later than 4 years after
the date of the enactment of the Tom Lantos and
Henry J. Hyde United States Global Leadership
Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008, the Institute of
Medicine of the National Academies shall
publish a study that includes--
(i) an assessment of the performance
of United States-assisted global HIV/
AIDS programs; and
(ii) an evaluation of the impact on
health of prevention, treatment, and
care efforts that are supported by
United States funding, including
multilateral and bilateral programs
involving joint operations.
(B) Content.--The study conducted under this
paragraph shall include--
(i) an assessment of progress toward
prevention, treatment, and care
targets;
(ii) an assessment of the effects on
health systems, including on the
financing and management of health
systems and the quality of service
delivery and staffing;
(iii) an assessment of efforts to
address gender-specific aspects of HIV/
AIDS, including gender related
constraints to accessing services and
addressing underlying social and
economic vulnerabilities of women and
men;
(iv) an evaluation of the impact of
treatment and care programs on 5-year
survival rates, drug adherence, and the
emergence of drug resistance;
(v) an evaluation of the impact of
prevention programs on HIV incidence in
relevant population groups;
(vi) an evaluation of the impact on
child health and welfare of
interventions authorized under this Act
on behalf of orphans and vulnerable
children;
(vii) an evaluation of the impact of
programs and activities authorized in
this Act on child mortality; and
(viii) recommendations for improving
the programs referred to in
subparagraph (A)(i).
(C) Methodologies.--Assessments and impact
evaluations conducted under the study shall
utilize sound statistical methods and
techniques for the behavioral sciences,
including random assignment methodologies as
feasible. Qualitative data on process variables
should be used for assessments and impact
evaluations, wherever possible.
(3) Contract authority.--The Institute of Medicine
may enter into contracts or cooperative agreements or
award grants to conduct the study under paragraph (2).
(4) Authorization of appropriations.--There are
authorized to be appropriated such sums as may be
necessary to carry out the study under this subsection.
(d) Comptroller General Report.--
(1) Report required.--Not later than 3 years after
the date of the enactment of the Tom Lantos and Henry
J. Hyde United States Global Leadership Against HIV/
AIDS, Tuberculosis, and Malaria Reauthorization Act of
2008, the Comptroller General of the United States
shall submit a report on the global HIV/AIDS programs
of the United States to the appropriate congressional
committees.
(2) Contents.--The report required under paragraph
(1) shall include--
(A) a description and assessment of the
monitoring and evaluation practices and
policies in place for these programs;
(B) an assessment of coordination within
Federal agencies involved in these programs,
examining both internal coordination within
these programs and integration with the larger
global health and development agenda of the
United States;
(C) an assessment of procurement policies and
practices within these programs;
(D) an assessment of harmonization with
national government HIV/AIDS and public health
strategies as well as other international
efforts;
(E) an assessment of the impact of global
HIV/AIDS funding and programs on other United
States global health programming; and
(F) recommendations for improving the global
HIV/AIDS programs of the United States.
(e) Best Practices Report.--
(1) In general.--Not later than 1 year after the date
of the enactment of the Tom Lantos and Henry J. Hyde
United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008,
and annually thereafter, the Global AIDS Coordinator
shall publish a best practices report that highlights
the programs receiving financial assistance from the
United States that have the potential for replication
or adaption, particularly at a low cost, across global
AIDS programs, including those that focus on both
generalized and localized epidemics.
(2) Dissemination of findings.--
(A) Publication on internet website.--The
Global AIDS Coordinator shall disseminate the
full findings of the annual best practices
report on the Internet website of the Office of
the Global AIDS Coordinator.
(B) Dissemination guidance.--The Global AIDS
Coordinator shall develop guidance to ensure
timely submission and dissemination of
significant information regarding best
practices with respect to global AIDS programs.
(f) Inspectors General.--
(1) Oversight plan.--
(A) Development.--The Inspectors General of
the Department of State and Broadcasting Board
of Governors, the Department of Health and
Human Services, and the United States Agency
for International Development shall jointly
develop coordinated annual plans for oversight
activity in each of the fiscal years 2009
through [2018] 2023, with regard to the
programs authorized under this Act and sections
104A, 104B, and 104C of the Foreign Assistance
Act of 1961 (22 U.S.C. 2151b-2, 2151b-3, and
2151b-4).
(B) Contents.--The plans developed under
subparagraph (A) shall include a schedule for
financial audits, inspections, and performance
reviews, as appropriate.
(C) Deadline.--
(i) Initial plan.--The first plan
developed under subparagraph (A) shall
be completed not later than the later
of--
(I) September 1, 2008; or
(II) 60 days after the date
of the enactment of the Tom
Lantos and Henry J. Hyde United
States Global Leadership
Against HIV/AIDS, Tuberculosis,
and Malaria Reauthorization Act
of 2008.
(ii) 2010 through 2013 plans.--Each
of the plans for fiscal years 2010
through 2013 developed under
subparagraph (A) shall be completed not
later than 30 days before each of the
fiscal years 2010 through 2013,
respectively.
(iii) 2014 plan.--The plan developed
under subparagraph (A) for fiscal year
2014 shall be completed not later than
60 days after the date of the enactment
of the PEPFAR Stewardship and Oversight
Act of 2013.
(iv) Subsequent plans.--Each of the
last [four] nine plans developed under
subparagraph (A) shall be completed not
later than 30 days before each of the
fiscal years 2015 through [2018] 2023 ,
respectively.
(2) Coordination.--In order to avoid duplication and
maximize efficiency, the Inspectors General described
in paragraph (1) shall coordinate their activities
with--
(A) the Government Accountability Office; and
(B) the Inspectors General of the Department
of Commerce, the Department of Defense, the
Department of Labor, and the Peace Corps, as
appropriate, pursuant to the 2004 Memorandum of
Agreement Coordinating Audit Coverage of
Programs and Activities Implementing the
President's Emergency Plan for AIDS Relief, or
any successor agreement.
(3) Funding.--The Global AIDS Coordinator and the
Coordinator of the United States Government Activities
to Combat Malaria Globally shall make available
necessary funds not exceeding $15,000,000 during the 5-
year period beginning on October 1, 2008 to the
Inspectors General described in paragraph (1) for the
audits, inspections, and reviews described in that
paragraph.
(g) Annual Study.--
(1) In general.--Not later than September 30, 2009,
and annually thereafter through September 30, [2019]
2024 , the Global AIDS Coordinator shall complete a
study of treatment providers that--
(A) represents a range of countries and
service environments;
(B) estimates the per-patient cost of
antiretroviral HIV/AIDS treatment and the care
of people with HIV/AIDS not receiving
antiretroviral treatment, including a
comparison of the costs for equivalent services
provided by programs not receiving assistance
under this Act;
(C) estimates per-patient costs across the
program and in specific categories of service
providers, including--
(i) urban and rural providers;
(ii) country-specific providers; and
(iii) other subcategories, as
appropriate.
(2) 2013 through [2018] 2024 studies.--The studies
required to be submitted by September 30, 2014, and
annually thereafter through [September 30, 2018]
September 30, 2024, shall include, in addition to the
elements set forth under paragraph (1), the following
elements:
(A) A plan for conducting cost studies of
United States assistance under section 104A of
the Foreign Assistance Act of 1961 (22 U.S.C.
2151b-2) in partner countries, taking into
account the goal for more systematic collection
of data, as well as the demands of such
analysis on available human and fiscal
resources.
(B) A comprehensive and harmonized
expenditure analysis by partner country,
including--
(i) an analysis of Global Fund and
national partner spending and
comparable data across United States,
Global Fund, and national partner
spending; or
(ii) where providing such comparable
data is not currently practicable, an
explanation of why it is not currently
practicable, and when it will be
practicable.
(3) Publication.--Not later than 90 days after the
completion of each study under paragraph (1), the
Global AIDS Coordinator shall make the results of such
study available on a publicly accessible Web site.
(4) Partner country defined.--In this subsection, the
term ``partner country'' means a country with a minimum
United States Government investment of HIV/AIDS
assistance of at least $5,000,000 in the prior fiscal
year.
(h) Message.--The Global AIDS Coordinator shall develop a
message, to be prominently displayed by each program receiving
funds under this Act, that--
(1) demonstrates that the program is a commitment by
citizens of the United States to the global fight
against HIV/AIDS, tuberculosis, and malaria; and
(2) enhances awareness by program recipients that the
program is an effort on behalf of the citizens of the
United States.
* * * * * * *
TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE
PARTNERSHIPS
* * * * * * *
SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS
AND MALARIA.
(a) Findings; Sense of Congress.--
(1) Findings.--Congress makes the following findings:
(A) The establishment of the Global Fund in
January 2002 is consistent with the general
principles for an international AIDS trust fund
first outlined by Congress in the Global AIDS
and Tuberculosis Relief Act of 2000 (Public Law
106-264).
(B) The Global Fund is an innovative
financing mechanism which--
(i) has made progress in many areas
in combating HIV/AIDS, tuberculosis,
and malaria; and
(ii) represents the multilateral
component of this Act, extending United
States efforts to more than 130
countries around the world.
(C) The Global Fund and United States
bilateral assistance programs--
(i) are demonstrating increasingly
effective coordination, with each
possessing certain comparative
advantages in the fight against HIV/
AIDS, tuberculosis, and malaria; and
(ii) often work most effectively in
concert with each other.
(D) The United States Government--
(i) is the largest supporter of the
Global Fund in terms of resources and
technical support;
(ii) made the founding contribution
to the Global Fund; and
(iii) is fully committed to the
success of the Global Fund as a
multilateral public-private
partnership.
(2) Sense of congress.--It is the sense of Congress
that--
(A) transparency and accountability are
crucial to the long-term success and viability
of the Global Fund;
(B) the Global Fund has made significant
progress toward addressing concerns raised by
the Government Accountability Office by--
(i) improving risk assessment and
risk management capabilities;
(ii) providing clearer guidance for
and oversight of Local Fund Agents; and
(iii) strengthening the Office of the
Inspector General for the Global Fund;
(C) the provision of sufficient resources and
authority to the Office of the Inspector
General for the Global Fund to ensure that
office has the staff and independence necessary
to carry out its mandate will be a measure of
the commitment of the Global Fund to
transparency and accountability;
(D) regular, publicly published financial,
programmatic, and reporting audits of the Fund,
its grantees, and Local Fund Agents are also
important benchmarks of transparency;
(E) the Global Fund should establish and
maintain a system to track--
(i) the amount of funds disbursed to
each subrecipient on the grant's fiscal
cycle; and
(ii) the distribution of resources,
by grant and principal recipient, for
prevention, care, treatment, drug and
commodity purchases, and other
purposes;
(F) relevant national authorities in
recipient countries should exempt from duties
and taxes all products financed by Global Fund
grants and procured by any principal recipient
or subrecipient for the purpose of carrying out
such grants;
(G) the Global Fund, UNAIDS, and the Global
AIDS Coordinator should work together to
standardize program indicators wherever
possible;
(H) for purposes of evaluating total amounts
of funds contributed to the Global Fund under
subsection (d)(4)(A)(i), the timetable for
evaluations of contributions from sources other
than the United States should take into account
the fiscal calendars of other major
contributors; and
(I) the Global Fund should not support
activities involving the ``Affordable Medicines
Facility-Malaria'' or similar entities pending
compelling evidence of success from pilot
programs as evaluated by the Coordinator of
United States Government Activities to Combat
Malaria Globally.
(b) Authority for United States Participation.--
(1) United states participation.--The United States
is hereby authorized to participate in the Global Fund.
(2) Privileges and immunities.--The Global Fund shall
be considered a public international organization for
purposes of section 1 of the International
Organizations Immunities Act (22 U.S.C. 288).
(3) Statement of policy.--The United States
Government regards the imposition by recipient
countries of taxes or tariffs on goods or services
provided by the Global Fund, which are supported
through public and private donations, including the
substantial contribution of the American people, as
inappropriate and inconsistent with standards of good
governance. The Global AIDS Coordinator or other
representatives of the United States Government shall
work with the Global Fund to dissuade governments from
imposing such duties, tariffs, or taxes.
(c) Reports to Congress.--Not later than 1 year after the
date of the enactment of this Act, and annually thereafter for
the duration of the Global Fund, the President shall submit to
the appropriate congressional committees a report on the Global
Fund, including contributions pledged to, contributions
(including donations from the private sector) received by, and
projects funded by the Global Fund, and the mechanisms
established for transparency and accountability in the grant-
making process.
(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 $2,000,000,000
for fiscal year 2009,, and such sums as may be
necessary for each of the fiscal years 2010 through
2013, for contributions to the Global Fund.
(2) Availability of funds.--Amounts appropriated
under paragraph (1) are authorized to remain available
until expended.
(3) Reprogramming of fiscal year 2001 funds.--Funds
made available for fiscal year 2001 under section 141
of the Global AIDS and Tuberculosis Relief Act of
2000--
(A) are authorized to remain available until
expended; and
(B) shall be transferred to, merged with, and
made available for the same purposes as, funds
made available for fiscal years 2004 through
2008 under paragraph (1).
(4) Limitation.--
(A)(i) At any time during [fiscal years 2009
through 2018] fiscal years 2004 through 2023 ,
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 2009 through [2018] 2023 , the President
determines that the Global Fund has provided
assistance to a country, the government of
which the Secretary of State has determined,
for purposes of section 6(j)(1) of the Export
Administration Act of 1979 (50 U.S.C. App.
2405(j)(1)), has repeatedly provided support
for acts of international terrorism, then the
United States shall withhold from its
contribution for the next fiscal year an amount
equal to the amount expended by the Fund to the
government of each such country.
(iii) If at any time the President determines
that the expenses of the Governing,
Administrative, and Advisory Bodies (including
the Partnership Forum, the Foundation Board,
the Secretariat, and the Technical Review
Board) of the Global Fund exceed 10 percent of
the total expenditures of the Fund for any 2-
year period, the United States shall withhold
from its contribution for the next fiscal year
an amount equal the to the average annual
amount expended by the Fund for such 2-year
period for the expenses of the Governing,
Administrative, and Advisory Bodies in excess
of 10 percent of the total expenditures of the
Fund.
(iv) The President may waive the application
of clause (iii) if the President determines
that extraordinary circumstances warrant such a
waiver. No waiver under this clause may be for
any period that exceeds 1 year.
(v) If, at any time during any of the fiscal
years 2004 through 2008, the President
determines that the salary of any individual
employed by the Global Fund exceeds the salary
of the Vice President of the United States (as
determined under section 104 of title 3, United
States Code) for that fiscal year, then the
United States shall withhold from its
contribution for the next fiscal year an amount
equal to the aggregate amount by which the
salary of each such individual exceeds the
salary of the Vice President of the United
States.
[(vi) For the purposes 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 2009
through 2018 that are not contributed to
fulfill a commitment made for a fiscal year
before fiscal year 2009.]
(B)(i) Any amount made available that is
withheld by reason of subparagraph (A)(i) shall
be contributed to the Global Fund as soon as
practicable, subject to subparagraph (A)(i),
after additional contributions to the Global
Fund are made from other sources.
[(ii) Any amount made available that is
withheld by reason of subparagraph (A)(iii)
shall be transferred to the Activities to
Combat HIV/AIDS Globally Fund and shall remain
available under the same terms and conditions
as funds appropriated to carry out section 104A
of the Foreign Assistance Act of 1961 for HIV/
AIDS assistance.]
[(iii)] (ii) Any amount made available that
is withheld by reason of clause (ii) or (iii)
of subparagraph (A) is authorized to be made
available to carry out section 104A of the
Foreign Assistance Act of 1961 (as added by
section 301 of this Act) or section 104B or
104C of such Act . Amounts made available under
the preceding sentence are in addition to
amounts appropriated pursuant to the
authorization of appropriations under section
401 of this Act [for HIV/AIDS assistance].
[(iv)] (iii) Notwithstanding clause (i),
after July 31 of each of the fiscal years 2009
through [2018] 2023 , any amount made available
that is withheld by reason of
subparagraph(A)(i) is authorized to be made
available to carry out sections 104A, 104B, and
104C of the Foreign Assistance Act of 1961 (as
added by title III of this Act).
(C)(i) The President may suspend the
application of subparagraph (A) with respect to
a fiscal year if the President determines that
an international health emergency threatens the
national security interests of the United
States.
(ii) The President shall notify the Committee
on Foreign Affairs of the House of
Representatives and the Committee on Foreign
Relations of the Senate not less than 5 days
before making a determination under clause (i)
with respect to the application of subparagraph
(A)(i) and shall include in the notification--
(I) a justification as to why
increased United States Government
contributions to the Global Fund is
preferable to increased United States
assistance to combat HIV/AIDS,
tuberculosis, and malaria on a
bilateral basis; and
(II) an explanation as to why other
government donors to the Global Fund
are unable to provide adequate
contributions to the Fund.
(5) Withholding funds.--Notwithstanding any other
provision of this Act, 20 percent of the amounts
appropriated pursuant to this Act for a contribution to
support the Global Fund for each of the fiscal years
2010 through [2018] 2023 shall be withheld from
obligation to the Global Fund until the Secretary of
State certifies to the appropriate congressional
committees that the Global Fund--
(A) has established an evaluation framework
for the performance of Local Fund Agents
(referred to in this paragraph as ``LFAs'');
(B) is undertaking a systematic assessment of
the performance of LFAs;
(C) has adopted, and is implementing, a
policy to publish on a publicly available Web
site in an open, machine readable format--
(i) grant performance reviews;
(ii) all reports of the Inspector
General of the Global Fund, in a manner
that is consistent with the Policy for
Disclosure of Reports of the Inspector
General, approved at the 16th Meeting
of the Board of the Global Fund;
(iii) decision points of the Board of
the Global Fund;
(iv) reports from Board committees to
the Board; and
(v) aregular collection, analysis,
and reporting of performance data and
funding ofgrants of the Global Fund,
which covers all principal recipients
and allsubrecipients on the fiscal
cycle of each grant, and includes the
distributionof resources, by grant and
principal recipient and subrecipient,
forprevention, care, treatment, drugs,
and commodities purchase, and
otherpurposes aspracticable;
(D) is maintaining an independent, well-
staffed Office of the Inspector General that--
(i) reports directly to the Board of
the Global Fund; and
(ii) compiles regular, publicly
published audits, in an open, machine
readable format, of financial,
programmatic, and reporting aspects of
the Global Fund, its grantees, and
LFAs;
(E) has established, and is reporting
publicly, in an open, machine readable format,
on, standard indicators for all program areas;
(F) has established a methodology to track
and is publicly reporting on--
(i) all subrecipients and the amount
of funds disbursed to each subrecipient
on the grant's fiscal cycle;
(ii) all principalrecipients and
subrecipients and the amount of funds
disbursed to eachprincipal recipient
and subrecipient on the fiscal cycle of
the grant;
(iii) expendituredata--
(I) tracked byprincipal
recipients and subrecipients by
program area, where
practicable, prevention, care,
and treatment and reported in a
format that allows comparison
with other fundingstreams in
each country; or
(II) if suchexpenditure data
is not available, outlay or
disbursement data, and
anexplanation of progress made
toward providing such
expenditure data; and
(iv) high-qualitygrant performance
evaluations measuring inputs, outputs,
and outcomes, asappropriate, with the
goal of achieving outcomereporting;
(G) has published anannual report on a
publicly available Web site in an open, machine
readableformat, that includes--
(i) alist of all countries imposing
import duties and internal taxes on any
goods orservices financed by the Global
Fund;
(ii) a description ofthe types of
goods or services on which the import
duties and internal taxesare levied;
(iii) the total costof the import
duties and internal taxes;
(iv) recovered importduties or
internal taxes; and
(v) the status ofcountrystatus-
agreements;
(H) through its Secretariat, has taken
meaningful steps to prevent national
authorities in recipient countries from
imposing taxes or tariffs on goods or services
provided by the Fund;
(I) is maintaining its status as a financing
institution focused on programs directly
related to HIV/AIDS, malaria, and tuberculosis;
(J) is maintaining and making progress on--
(i) sustaining its multisectoral
approach, through country coordinating
mechanisms; and
(ii) the implementation of grants, as
reflected in the proportion of
resources allocated to different
sectors, including governments, civil
society, and faith- and community-based
organizations; and
(K) has established procedures providing
access by the Office of Inspector General of
the Department of State and Broadcasting Board
of Governors, as cognizant Inspector General,
and the Inspector General of the Health and
Human Services and the Inspector General of the
United States Agency for International
Development, to Global Fund financial data, and
other information relevant to United States
contributions (as determined by the Inspector
General in consultation with the Global AIDS
Coordinator).
(6) Summaries of board decisions and united states
positions.--Following each meeting of the Board of the
Global Fund, the Coordinator of United States
Government Activities to Combat HIV/AIDS Globally shall
report on the public website of the Coordinator a
summary of Board decisions and how the United States
Government voted and its positions on such decisions.
(e) Interagency Technical Review Panel.--
(1) Establishment.--The Coordinator of United States
Government Activities to Combat HIV/AIDS Globally,
established in section 1(f)(1) of the State Department
Basic Authorities Act of 1956 (as added by section
102(a) of this Act), shall establish in the executive
branch an interagency technical review panel.
(2) Duties.--The interagency technical review panel
shall serve as a ``shadow'' panel to the Global Fund
by--
(A) periodically reviewing all proposals
received by the Global Fund; and
(B) providing guidance to the United States
persons who are representatives on the panels,
committees, and boards of the Global Fund, on
the technical efficacy, suitability, and
appropriateness of the proposals, and ensuring
that such persons are fully informed of
technical inadequacies or other aspects of the
proposals that are inconsistent with the
purposes of this or any other Act relating to
the provision of foreign assistance in the area
of AIDS.
(3) Membership.--The interagency technical review
panel shall consist of qualified medical and
development experts who are officers or employees of
the Department of Health and Human Services, the
Department of State, and the United States Agency for
International Development.
(4) Chair.--The Coordinator referred to in paragraph
(1) shall chair the interagency technical review panel.
(f) Monitoring by Comptroller General.--
(1) Monitoring.--The Comptroller General shall
monitor and evaluate projects funded by the Global
Fund.
(2) Report.--The Comptroller General shall on a
biennial basis shall prepare and submit to the
appropriate congressional committees a report that
contains the results of the monitoring and evaluation
described in paragraph (1) for the preceding 2-year
period.
(g) Provision of Information to Congress.--The Coordinator of
United States Government Activities to Combat HIV/AIDS Globally
shall make available to the Congress the following documents
within 30 days of a request by the Congress for such documents:
(1) All financial and accounting statements for the
Global Fund and the Activities to Combat HIV/AIDS
Globally Fund, including administrative and grantee
statements.
(2) Reports provided to the Global Fund and the
Activities to Combat HIV/AIDS Globally Fund by
organizations contracted to audit recipients of funds.
(3) Project proposals submitted by applicants for
funding from the Global Fund and the Activities to
Combat HIV/AIDS Globally Fund, but which were not
funded.
(4) Progress reports submitted to the Global Fund and
the Activities to Combat HIV/AIDS Globally Fund by
grantees.
(h) Sense of the Congress Regarding Encouragement of Private
Contributions to the Global Fund.--It is the sense of the
Congress that the President should--
(1) conduct an outreach campaign that is designed
to--
(A) inform the public of the existence of--
(i) the Global Fund; and
(ii) any entity that will accept
private contributions intended for use
by the Global Fund; and
(B) encourage private contributions to the
Global Fund; and
(2) encourage private contributions intended for use
by the Global Fund by--
(A) establishing and operating an Internet
website, and publishing information about the
website; and
(B) making public service announcements on
radio and television.
* * * * * * *
TITLE IV--AUTHORIZATION OF APPROPRIATIONS
* * * * * * *
SEC. 403. ALLOCATION OF FUNDS.
(a) Balanced Funding Requirement.--
(1) In general.--The Global AIDS Coordinator shall--
(A) provide balanced funding for prevention
activities for sexual transmission of HIV/AIDS;
and
(B) ensure that 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.
(2) Prevention strategy.--
(A) Establishment.--In carrying out paragraph
(1), the Global AIDS Coordinator shall
establish an HIV sexual transmission prevention
strategy governing the expenditure of funds
authorized under this Act to prevent the sexual
transmission of HIV in any host country with a
generalized epidemic.
(B) Report.--In each host country described
in subparagraph (A), if the strategy
established under subparagraph (A) provides
less than 50 percent of the funds described in
subparagraph (A) for activities promoting
abstinence, delay of sexual debut, monogamy,
fidelity, and partner reduction, the Global
AIDS Coordinator shall, not later than 30 days
after the issuance of this strategy, report to
the appropriate congressional committees on the
justification for this decision.
(3) Exclusion.--Programs and activities that
implement or purchase new prevention technologies or
modalities, such as medical male circumcision, public
education about risks to acquire HIV infection from
blood exposures, promoting universal precautions,
investigating suspected nosocomial infections, pre-
exposure pharmaceutical prophylaxis to prevent
transmission of HIV, or microbicides and programs and
activities that provide counseling and testing for HIV
or prevent mother-to-child prevention of HIV, shall not
be included in determining compliance with paragraph
(2).
(4) Report.--Not later than 1 year after the date of
the enactment of the Tom Lantos and Henry J. Hyde
United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008,
and annually thereafter as part of the annual report
required under section 104A(e) of the Foreign
Assistance Act of 1961 (22 U.S.C. 2151b-2(e)), the
President shall--
(A) submit a report on the implementation of
paragraph (2) for the most recently concluded
fiscal year to the appropriate congressional
committees; and
(B) make the report described in subparagraph
(A) available to the public.
(b) Orphans and Vulnerable Children.--For fiscal years 2009
through [2018] 2023 , not less than 10 percent of the amounts
appropriated or otherwise made available to carry out the
provisions of section 104A of the Foreign Assistance Act of
1961 (22 U.S.C. 2151b-2) for HIV/AIDS assistance for each such
fiscal year shall be expended for assistance for orphans and
other children affected by, or vulnerable to, HIV/AIDS, of
which such amount at least 50 percent shall be provided through
non-profit, nongovernmental organizations, including faith-
based organizations, that implement programs on the community
level.
(c) Funding Allocation.--For each of the fiscal years 2009
through [2018] 2023 , more than half of the amounts
appropriated or otherwise made available to carry out the
provisions of section 104A of the Foreign Assistance Act of
1961 (22 U.S.C. 2151b-2) shall be expended for--
(1) antiretroviral treatment for HIV/AIDS;
(2) clinical monitoring of HIV-seropositive people
not in need of antiretroviral treatment;
(3) care for associated opportunistic infections;
(4) nutrition and food support for people living with
HIV/AIDS; and
(5) other essential HIV/AIDS-related medical care for
people living with HIV/AIDS.
(d) Treatment, Prevention, and Care Goals.--For each of the
fiscal years 2009 through 2013--
(1) the treatment goal under section 402(a)(3) shall
be increased above 2,000,000 by at least the percentage
increase in the amount appropriated for bilateral
global HIV/AIDS assistance for such fiscal year
compared with fiscal year 2008;
(2) any increase in the treatment goal under section
402(a)(3) above the percentage increase in the amount
appropriated for bilateral global HIV/AIDS assistance
for such fiscal year compared with fiscal year 2008
shall be based on long-term requirements,
epidemiological evidence, the share of treatment needs
being met by partner governments and other sources of
treatment funding, and other appropriate factors;
(3) the treatment goal under section 402(a)(3) shall
be increased above the number calculated under
paragraph (1) by the same percentage that the average
United States Government cost per patient of providing
treatment in countries receiving bilateral HIV/AIDS
assistance has decreased compared with fiscal year
2008; and
(4) the prevention and care goals established in
clauses (i) and (iv) of section 104A(b)(1)(A) of the
Foreign Assistance Act of 1961 (22 U.S.C. 2151b-
2(b)(1)(A)) shall be increased consistent with
epidemiological evidence and available resources.
* * * * * * *
ADDITIONAL VIEWS
I concur with the views expressed in the full Committee
report accompanying H.R. 6651, the PEPFAR Extension Act of 2018
and recommend that the bill as amended do pass.
The President's Emergency Plan for AIDS Relief (PEPFAR) has
brought about tremendous progress across the Bush and Obama
Administrations in the global fight to end HIV/AIDS, as
detailed in the full Committee report. However, the Trump
Administration has threatened this progress by asking Congress
to enact deep funding cuts and impeding health care access
through the reinstatement and expansion of the Mexico City
Policy, or Global Gag Rule.
Draconian Cuts to PEPFAR and the Global Fund Jeopardize 15 Years of
Progress
The Administration proposed an 11 percent cut to PEPFAR
funding and a 17 percent cut to the Global Fund for Fiscal Year
(FY) 2018, relative to FY 2017 levels. While Congress rejected
this proposal and maintained level funding for both PEPFAR and
the Global Fund, the Trump Administration subsequently
requested an even deeper 20 percent cut to PEPFAR and 31
percent cut to the Global Fund for FY 2019.
If enacted, the Trump Administration's budget would
jeopardize America's tremendous success in the fight against
HIV/AIDS, likely leading to hundreds of thousands of additional
HIV/AIDS patients and thousands of deaths. According to a
report issued by the ONE Campaign:
Conservative estimates project that implementing the
FY 2018 budget proposal would have led to the first
global increase in new HIV infections since 1995, with
nearly 200,000 additional HIV infections in the first
year. If these cuts were maintained, nearly 600,000
additional people could be infected by 2020, dragging
the world back to levels of new infections last seen in
2011. Slowing U.S. efforts to fight HIV/AIDS for three
years could set the global response back nine years and
squander much of the $64 billion that the U.S. has
invested over that time.\1\
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\1\``Red Ribbon or White Flag? The Future of the U.S. Global AIDS
Response.'' The ONE Campaign. November 29, 2017. https://
s3.amazonaws.com/one.org/pdfs/ONE_WAD_Report_2017.pdf.
I urge the Administration to return to the bipartisan
consensus and accelerate the progress that PEPFAR and the
Global Fund have allowed by prioritizing the fight against HIV/
AIDS in the FY 2020 budget request.
The Expanded Global Gag Rule Hampers the Fight to End
HIV/AIDS
On January 23, 2017, President Donald Trump reinstated the
Global Gag Rule. Previous iterations of this policy barred
foreign nongovernmental organizations (NGOs) from receiving
U.S. bilateral family planning funds if they used private, non-
U.S. funds to perform legal abortions, offer counseling
regarding abortion services, or advocate for access to safe,
legal abortion. This policy is unwise, but the Trump
Administration has made it even worse, expanding it to all
foreign NGOs that receive U.S. global health assistance,
including PEPFAR implementers.
The effects of the Global Gag Rule are antithetical to the
goals of the PEPFAR program. For example, a Mozambican
Association for Family Development clinic in Mozambique's Xai-
Xai district tested nearly 6,000 patients for HIV over a three-
month period between July and September of 2017.\2\ During the
next three-month period, the Global Gag Rule forced the clinic
to forego U.S. funding, and just 671 patients were tested for
HIV--a drop of more than 88 percent.\3\
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\2\``Prescribing Chaos in Global Health: The Global Gag Rule from
1984-2018.'' Center for Health and Gender Equity. June 2018. http://
www.genderhealth.org/files/uploads/change/
publications/Prescribing_Chaos_in_Global_Health_full_report.pdf.
\3\See 2.
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I urge the Administration to immediately rescind the Global
Gag Rule and ensure that those served by U.S. global health
assistance can continue to receive comprehensive care from the
providers they trust. If the Global Gag Rule remains in effect,
health care providers will continue to dramatically scale back
essential services, like HIV tests, or close their doors
altogether.\4\ This will endanger 15 years of progress in the
global effort to end HIV/AIDS, much of which has been achieved
with U.S. support.
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\4\Anna, Cara. ``Trump's global gag rule goes far beyond abortion,
groups say.'' AP. January 23, 2018. https://www.apnews.com/
868c8211b4f948d8b7f7ce58ab08a78b/Trump's-global-gag-rule-goes-far-
beyond-abortion,-groups-say.
Eliot L. Engel.
[all]