November 2018 | Issue Brief PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation Kellie Moss and Jen Kates Overview The President’s Emergency Plan for AIDS Relief (PEPFAR) is the U.S. government’s global effort to combat HIV and the largest global health program devoted to a single disease (for more information, see the KFF fact sheet on PEPFAR). It was first proposed by President George W. Bush in 2003. Three major pieces of authorizing legislation govern PEPFAR’s HIV response, as well as U.S. participation in the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and bilateral assistance for tuberculosis (TB) and malaria programs: The Leadership Act, The Lantos-Hyde Act, and The PEPFAR Stewardship Act (see Table 1). These legislative vehicles have permanently authorized much of the program within U.S. law but have also created some time-bound provisions. PEPFAR’s current authorizing legislation goes through Fiscal Year (FY) 2018, which ended on September 30, 2018, and most of these time-bound provisions have expired. On August 3, 2018, the House introduced a bill (H.R. 6651) to reauthorize PEPFAR through FY 2023 and FY 2024, depending on the provision. The Senate introduced a similar bill (S. 3476) on September 18, 2018. The House passed H.R. 6651 on November 13, 2018, and the Senate passed it on November 28, 2018. The bill is now headed to the White House for the President’s consideration and signature. Table 1: PEPFAR Legislation Full Title Common Title Public Law # Years United States Leadership Against HIV/AIDS, “The Leadership Act” P.L. 108-25 FY 2004 - FY 2008 Tuberculosis, and Malaria Act of 2003 Tom Lantos and Henry J. Hyde United States Global “The Lantos-Hyde Act” P.L. 110-293 FY 2009 - FY 2013 Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 PEPFAR Stewardship and Oversight Act of 2013 “The PEPFAR P.L. 113-56 FY 2014 - FY 2018 Stewardship Act” This brief identifies the PEPFAR authorities that expired at the end of FY 2018 and notes how they are addressed by the proposed reauthorization bills (see Table 2). It also provides a detailed comparison of PEPFAR’s authorizing legislation over time (see Table 3). It will be updated as needed. Legislative Changes to PEPFAR Over Time After first setting the broad parameters for PEPFAR and creating its main structures in 2003, PEPFAR’s subsequent authorizing legislation has made several key changes to the program, as the HIV response has evolved and as PEPFAR has moved from an emergency response to one supporting longer-term sustainability and epidemic control. These include changes to funding authorization levels and spending directives, as well as requirements for reporting and oversight. Among the major changes over time are:  Funding authorization levels: The Leadership Act authorized $15 billion during PEPFAR’s first five-year period (FY 2004 – FY 2008), which marked a significant increase in funding for HIV by the U.S. government. The Lantos-Hyde Act authorized even more, with $48 billion over the next five-year period (FY 2009 – FY 2013). The Stewardship Act did not specify authorization of funding for the most recent five-year period (FY 2014 – FY 2018).  Spending directives: Congress has provided several spending directives to PEPFAR through its authorizing legislation, although these have generally been relaxed over time. For example, in the Leadership Act, Congress required that at least 33% of prevention funds be spent on abstinence-until- marriage programs during the FY 2004 – FY 2009 period. This was relaxed in the Lantos-Hyde Act, which removed the 33% directive and replaced it with a requirement of “balanced funding” for prevention, to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized epidemic.  Reporting, monitoring, and transparency: Each of the authorizing bills has included reporting requirements to provide Congress and others with data and information about the program and to support oversight and evaluation. For example, the Leadership Act and the Lantos-Hyde Act required the Institute of Medicine to conduct evaluations of PEPFAR; however, this was not included in the PEPFAR Stewardship Act. The Lantos-Hyde Act and the PEPFAR Stewardship Act require the Inspectors General of several U.S. agencies (the Department of State, the Department of Health and Human Services, and the U.S. Agency for International Development) to jointly develop coordinated annual plans for overseeing U.S. government global HIV, TB, and malaria programs. It is important to note that Congress has also made changes to PEPFAR through other legislative vehicles. For example, Congress has used appropriations legislation in certain years to change the amount of withholding required from the annual U.S. contribution to the Global Fund, pending certification of certain benchmarks by the Secretary of State. Still, by the time of the Stewardship Act, a decade after PEPFAR’s creation, most changes were relatively minor, focused on adding new or refining existing reporting requirements. Permanent and Expiring Authorities PEPFAR operates largely under permanent authorities of U.S. law that allow for ongoing funding and the continuation of the major structures of the program, such as the Office of the Global AIDS Coordinator at the Department of State as well as the position of Global AIDS Coordinator, U.S. participation in the Global Fund, and annual reporting on PEPFAR efforts. Absent a reauthorization, the PEPFAR program would continue, provided funds are appropriated. Still, seven of PEPFAR’s congressionally-mandated requirements expired at the end of FY 2018, while one (a requirement for an annual treatment study) will expire at the end of FY 2019. Of these, two relate to how HIV funding is allocated, four specify requirements related to the U.S. contribution to the Global Fund, and two address reporting or oversight. Both H.R. 6651 and S. 3476 would extend these expiring authorities, and after changes to the House bill PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 2 during committee markup, the bills are virtually identical. Both chambers of Congress have now passed H.R. 6651, and the bill moves to the President for consideration and signature. If, however, a reauthorization bill is not enacted, these provisions could be extended through appropriations legislation or via some other legislative vehicle. Table 2: PEPFAR Legislation - Expiring Provisions and Proposed Legislation Topic of Provision Description H.R. 6651 S. 3476 (8-3-18 (9-18-18 introduced; introduced) passed House 11-13-18 and Senate 11-28-18) HIV Bilateral Funding Requires that more than half of funds appropriated or Extended through Extended through Allocation: Treatment, otherwise made available for bilateral HIV be FY 2023 FY 2023 Care, Nutrition and Food expended for treatment, care, and nutrition and food Support support for people living with HIV (through FY 2018) HIV Bilateral Funding Requires that not less than 10% of funds appropriated Bill as introduced Extended through Allocation: Orphans and or otherwise made available for bilateral HIV be did not include an FY 2023 Vulnerable Children (OVC) expended for programs targeting orphans and other extension; added children affected by, of vulnerable to, HIV (through FY extension through 2018) FY 2023 during committee markup on 9-27- 18 Global Fund Contribution: Limits U.S. contributions to the Global Fund to not Extended through Extended through 1/3 Cap exceed 33% of all funds donated to the Global Fund FY 2023, FY 2023, during a specified period (“1/3 cap”) (through FY calculated from calculated from 2018) FY 2004 FY 2004 Global Fund Contribution: Authorizes that any of the U.S. contribution to the Extended through Extended through Use of Funds Withheld Global Fund withheld due to the 1/3 cap may be used FY 2023 FY 2023 Due to 1/3 Cap for bilateral HIV, TB, and malaria programs (through FY 2018) Global Fund Contribution: Requires withholding 20% of annual U.S. contribution Extended through Extended through Withholding Obligation of to the Global Fund pending certification of certain FY 2023 FY 2023 20% Pending Certification accountability and transparency benchmarks by the Secretary of State* (through FY 2018) Global Fund Contribution: Requires withholding a portion of the U.S. contribution Extended through Extended through Withholding Portion if to the Global Fund, the next fiscal year, equal to the FY 2023** FY 2023** Funds Expended to amount expended by the Global Fund to country Certain Governments governments determined by the Secretary of State to have “repeatedly provided support for acts of international terrorism” (through FY 2018) Annual Treatment Directs the Global AIDS Coordinator to annually Extended through Extended through Providers Study complete a study of treatment providers for HIV FY 2024 FY 2024 programs, including spending by the Global Fund and partner countries (through FY 2019) Oversight Plans of Directs various agencies’ inspectors general to jointly Extended through Extended through Inspectors General develop coordinated annual plans for overseeing HIV, FY 2023 FY 2023 malaria, and TB programs (through FY 2018) NOTES: * In certain years, Congress directed the withholding to be 10%, rather than 20%. **Would also amend the use of funds withheld due to this provision to them to be used for bilateral HIV, TB, and malaria programs (current legislation allows them to be used for bilateral HIV only). Also would also apply to any funds withheld due if certain expenses exceeding 10%. SOURCES: KFF analysis of: U.S. Congress, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), May 27, 2003; Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), July 30, 2008; PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56), Dec. 2, 2013; U.S. Code, Title 22: Foreign Relations and Intercourse, Chapter 83 (UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA) and Chapter 32 (FOREIGN ASSISTANCE), Sections 2151b - 2151b-4; appropriations legislation; Congressional Research Service, International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding, RL34569, July 14, 2008. Congressional Research Service, The President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Global HIV/AIDS, Tuberculosis, and Malaria Programs: A Description of Permanent and Expiring Authorities, R43232, September 27, 2013; Congressional Research Service, “PEPFAR Stewardship and Oversight Act: Expiring Authorities,” IF10797, May 18, 2018; U.S. Congress, PEPFAR Extension Act of 2018, H.R. 6651; U.S. Congress, PEPFAR Extension Act of 2018, S. 3476. PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 3 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT OVERVIEW Full Title United States Leadership Against Tom Lantos and Henry J. Hyde United PEPFAR Stewardship and Oversight HIV/AIDS, Tuberculosis, and Malaria States Global Leadership Against Act of 2013 Act of 2003 HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 Date Enacted May 27, 2003 July 30, 2008 December 2, 2013 Public Law # P.L. 108-25 P.L. 110-293 P.L. 113-56 Authorization of Authorizes U.S. global HIV, TB and malaria Maintains current law Maintains current law Programs efforts Authorizes U.S. participation in the Global Fund to Fight AIDS, TB, and Malaria Authorization of FY04 – FY08: FY09 – FY13: FY14 - FY18: Funding Authorizes $15 billion ($3 billion/year), of which: Authorizes $48 billion (in totala), of which: Does not specify authorization for funding for HIV,  Up to $1 billion for Global Fund in  Up to $2 billion for Global Fund in TB, or malaria (however, Congress effectively FY04; such sums as necessary in FY05 – FY09; such sums as necessary in FY10 – authorizes funding when it appropriates funding FY08 FY13 for a purpose)  Such sums as necessary for HIV  Such sums as necessary for HIV  Such sums as necessary for TB  $4 billion for TB (in total)  Such sums as necessary for malaria  $5 billion for malaria (in total) Program Establishes Office of the Global HIV/AIDS Maintains current law regarding Global HIV/AIDS Maintains current law Coordinator/ Coordinator and Global HIV/AIDS Coordinator at Coordinator Department of State Office Establishes Malaria Coordinator at USAID HIV Major Objective Providing assistance for the prevention, Providing assistance for the prevention and Maintains current law treatment, and control of HIV/AIDS is a “major treatment of HIV/AIDS and the care of those objective of the foreign assistance program of the affected by the disease is a “major objective of United States” the foreign assistance program of the United States” 5-Year Strategy, Requires: Requires: Maintains current law regarding annual report on Reports,  5-year HIV/AIDS strategy  Updated 5-year HIV/AIDS strategy Best Practices Targets/Goals  Annual report on U.S. global HIV efforts o Include a longer-term estimate of  Annual report on PMTCT for 5 years projected resource needs and anticipated Requires: role of the U.S. in global HIV efforts  Annual report on U.S. global HIV efforts Recommends (Sense of Congress) an urgent during the 10-year period beginning FY13  Treatment Providers Study annually through priority be the rapid increase in distribution of  Annual report on U.S. global HIV efforts FY19b antiretroviral treatment so that U.S. assistance  Annual report on PMTCT for 10 years (from provides treatment for: FY04) PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 4 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT  At least 500,000 individuals with HIV/AIDS by  Submission of one-time report by PMTCT Maintains current law regarding targets/goals end of FY04 expert panel specified in the Lantos-Hyde Act  At least 1 million individuals with HIV/AIDS by  Annual report on Best Practices end of FY05  Treatment Providers Study (with treatment Requires annual report to include :  At least 2 million individuals with HIV/AIDS by cost data) annually through FY13  PEPFAR targets in partner countriesb end of FY06  National targets established by partner Includes U.S. policy objective to, by FY13, assist countries or, when not available, a description Recommends (as U.S. policy): partner countries to: of progress towards developing them  Placing high priority on prevention of mother-  Prevent 12 million new HIV infections  Description of how partner country targets are to-child transmission (PMTCT) of HIV, the (requires this goal to be increased consistent designed to: care and treatment of family members and with epidemiological evidence and available o ensure that the annual increase in new caregivers, and the care of children orphaned resources for FY09 – FY13) patients on treatment exceeds the by AIDS  Provide treatment to more than 2 million number of annual new HIV infections people with HIV/AIDS o reduce the number of new HIV infections Requires HIV/AIDS strategy to: o To be increased by at least the below the number of deaths among  Provide for meeting or exceeding the goal to percentage increase in the amount persons infected with HIV reduce the rate of mother-to-child appropriated for bilateral global HIV/AIDS o achieve an AIDS-free generation transmission of HIV by 20 percent by 2005 assistance in any FY as compared to and by 50 percent by 2010 FY08, for FY09 – FY13 o To be increased above this calculated number in proportion to the decrease in per patient cost to the U.S. Government of providing treatment in countries receiving bilateral global HIV/AIDS assistance, as compared with FY08, for FY09 – FY13  Support additional treatment through coordinated multilateral efforts  Support care for 12 million, including 5 million orphans and vulnerable children  Provide at least 80% of pregnant women with PMTCT coverage (requires this goal to be increased consistent with epidemiological evidence and available resources for FY09 – FY13)  Provide care and treatment to children with HIV/AIDS in proportion to their share of the HIV-infected population in a given country  Train at least 140,000 new health workers Authorization of FY04 – FY08: FY09 – FY13: FY14 - FY18: Funding and Authorizes $15 billion ($3 billion/year), of which: Authorizes $48 billion (in total), of which: Does not specify authorization for funding for HIV Spending  Such sums as necessary for HIV  Such sums as necessary for HIV (however, Congress effectively authorizes Directives funding when it appropriates funding for a purpose) PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 5 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT Recommends (Sense of Congress on funding Removes Sense of Congress on funding Requires for FY09 – FY18: distribution): distribution that was in the Leadership Act  More than half of bilateral aid be spent on  15% of funds be spent on palliative care treatment, care, and nutrition and food  20% of funds be spent on prevention Requires for FY09 – FY13: support for people living with HIV o At least 33% of prevention funds be  More than half of bilateral aid be spent on  Not less than 10% of bilateral aid be spent on spent on abstinence-until-marriage treatment, care, and nutrition and food orphans and vulnerable children programs support for people living with HIV  55% be spent on treatment  Not less than 10% be spent on orphans and Maintains current law regarding balanced funding  10% be spent on orphans and vulnerable vulnerable children for prevention requirement and no funds used to children promote or advocate the legalization or practice Requires the Global AIDS Coordinator provide of prostitution Requires for FY06 – FY08: balanced funding for prevention activities for  Not less than 33% of prevention funds be sexual transmission of HIV/AIDS +and: spent on abstinence-until-marriage programs  Ensure “activities promoting abstinence,  Not less than 55% be spent on treatment delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and  Not less than 10% be spent on orphans and funded in a meaningful and equitable way in vulnerable children the strategy for each host country based on objective epidemiological evidence as to the States that no funds may be used to promote or source of infections and in consultation with advocate the legalization or practice of the government of each host county involved prostitution in HIV/AIDS prevention activities”  Establish an HIV sexual transmission prevention strategy to govern prevention funding in any host country with a generalized epidemic  Provide a report to Congress with a justification of the decision if this strategy provides less than half of prevention funds for abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in each such host country (funds used for new prevention technologies/modalities excluded from determining compliance) Maintains current law regarding no funds used to promote or advocate the legalization or practice of prostitution Organizations’ States that no funds may be made available to Maintains current law regarding “prostitution Maintains current law Eligibility for provide assistance “to any group or organization pledge” Funding that does not have a policy explicitly opposing prostitution and sex trafficking” (often called the Regarding the conscience clause: “prostitution pledge”1)  Explicitly states that "an organization" includes faith-based organizations PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 6 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT States that an organization that is otherwise  Expands language by broadening the eligible to receive HIV assistance shall not be conditions that organizations cannot be required, as a condition of receiving the required to meet as a condition for funding, assistance, to endorse or utilize a multisectoral including a “multisectoral or comprehensive approach to combatting HIV/AIDS, or to endorse, approach” and “to endorse, utilize, make a utilize, or participate in a prevention method or referral to, become integrated with, or treatment program to which the organization has otherwise participate in any program or a religious or moral objection (often called the activity“ (italics indicate changes) “conscience clause”)  Adds that organizations are not be discriminated against in the solicitation or issuance of grants, contracts, or cooperative agreements under such provisions of law for refusing to meet any requirement described above Focus Countries/ Requires the HIV/AIDS Coordinator to directly Adds: Maintains current law Regions and approve all U.S. activities and funding related to  Vietnam as 15th focus country Partnership HIV/AIDS in certain countries (often referred to as  Central Asia, Eastern Europe, and Latin Requires annual report to describe what has “PEPFAR focus countries”): America as specific regions where assistance been learned in advancing partnership framework Frameworks  14 countries (Botswana, Cote d’Ivoire, should be provided agreements and implications for how to further Ethiopia, Guyana, Haiti, Kenya, Mozambique,  With regard to designating additional focus strengthen these agreements (previously called Namibia, Nigeria, Rwanda, South Africa, countries, requires the President give priority “compacts” and “framework agreements”) Tanzania, Uganda, Zambia) and to those countries in which there is a high  Other countries designated by the President prevalence of HIV or risk of significantly (Vietnam was later so designated) increasing incidence of HIV within the general  Also states that assistance should be population and inadequate financial means provided to countries in sub-Saharan Africa within the country and the Caribbean, and to other countries and areas Authorizes “compacts” and “framework agreements” with recipient countries in order to promote host government commitment to deeper integration of HIV/AIDS services into health systems, contribute to health systems overall, enhance sustainability Requires annual report to describe compacts or framework agreements reached or negotiated with countries Prevention Requires that funding be used to carry out: Maintains existing funding requirements under Maintains current law (amends some annual  Prevention activities that “are designed or the Leadership Act, and adds requirement reporting requirements) intended to impart knowledge with the funding also be used to carry out the following exclusive purpose of helping individuals avoid prevention activities: behaviors that place them at risk of HIV  Addressing multiple concurrent sexual infection, including integration of such partnering programs into health programs and the  Male circumcision inclusion in counseling programs of PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 7 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT information on methods of avoiding infection  Female and male condoms (change from of HIV, including delaying sexual debut, “condoms”) abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual Expresses Sense of Congress recognizing need violence and coercion, including child and urgency to expand range of female-controlled marriage, widow inheritance, and polygamy, HIV prevention methods and where appropriate, use of condoms”  With particular emphasis on high risk Requires microbicides research at the National populations, preventative intervention Institutes of Health and “strongly encourage[s]” education and technologies activities, the Centers for Disease Control and Prevention including support for: bulk purchases of test to fully implement its microbicide agenda kits, condoms, and, when proven effective, microbicides; for the introduction and distribution of these commodities; and education and training on the use of the technologies Women & Girls / Recommends significant funding, of FY04 – FY08 Adds greater, more explicit emphasis on women Maintains current law (amends some annual Gender funding directed to a pilot program for care and and girls, particularly related to PMTCT and reporting requirements) treatment of orphans and other children and families, and language about gender and gender- young people affected by HIV, be directed to related vulnerabilities to HIV activities ensuring the importance of inheritance rights of women, in light of the impact of the Requires: epidemic  Funding be used to carry out activities improving accountability through more Requires: detailed measures regarding reaching  HIV/AIDS strategy to address needs of women and girls, as well as gender- and age- women and girls and include programs to specific measures make available testing and treatment to HIV-  HIV/AIDS strategy to address vulnerabilities positive women and their family members of women and youth to HIV infection in  Annual report to include reporting on prevention strategy and seek to reduce indicators related to reaching women and factors that lead to gender disparities in HIV girls  Annual report to describe programs serving women and girls  Establishment of PMTCT expert panel and submission of one-time report by panel Nutrition & Food Requires, as appropriate: Strengthens support for nutrition and food Maintains current law (amends some annual Support  support for nutrition and food for people living assistance: reporting requirements); does not include specific with and affected by HIV, including children  Authorizes use of such sums as necessary of funding authorization (however, Congress affected by HIV assistance (of overall $48 billion effectively authorizes funding when it  integration of nutrition programs with HIV authorization) for purchase of food as a appropriates funding for a purpose) activities, generally component of treatment for FY09 – FY13  Requires nutritional assessments in all HIV Expresses “Sense of Congress” that U.S. food programs assistance should be accepted by countries with PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 8 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT large populations of people living with HIV to help feed such individuals Immigration and No mentionc Ends statutory prohibition against HIV-positive Maintains current law Travel Ban of visitors and immigrants by amending Immigration HIV Positive & Nationality Actd Individuals GLOBAL FUND Global Fund to FY04 – FY08: FY09 – FY13: FY14 - FY18: Fight AIDS, TB, Authorizes $15 billion ($3 billion/year), of which: Authorizes $48 billion (in total), of which: Does not specify authorization for funding for and Malaria  Up to $1 billion for Global Fund in  Up to $2 billion for Global Fund in Global Fund (however, Congress effectively FY04 FY09 authorizes funding when it appropriates funding  Such sums as necessary for Global Fund  Such sums as necessary for Global Fund in for a purpose) FY05 - FY08 FY10 – FY13 “1/3 cap”: Limits U.S. contributions to 1/3 for “1/3 cap”: Limits U.S. contributions to Global “1/3 cap”: Limits U.S. contributions to 1/3 for FY09 – FY18h Fund to 1/3 (cannot exceed 33%) of contributions FY09 – FY13  Requires amount not contributed due to cap from all sources for FY04 – FY08  Requires amount not contributed due to cap to be contributed as soon as practicable.  Requires any amount not contributed due to to be contributed as soon as practicable.  Authorizes, after July 31 of each FY for FY09 1/3 cap to be contributed as soon as  Authorizes, after July 31 of each FY for FY09 – FY18, any amount still withheld due to cap practicable, after other sources have made – FY13, any amount still withheld due to cap to be made available for bilateral HIV, TB, additional contributions to the Global Fund to be made available for bilateral HIV, TB, and malaria  However, after July 31 of each FY for FY04 – and malaria FY08, any amount still withheld due to the Requires, for FY09 – FY18, withholding portion if cap is authorized to be made available for Requires, for FY09 – FY13, withholding portion if funding expended by the Global Fund to bilateral HIV, TB, and malaria (amendment funding expended by the Global Fund to governments that have “repeatedly provided made in 2004 via other legislatione) governments that have “repeatedly provided support for acts of international terrorism” support for acts of international terrorism” Requires, for FY04 – FY08, that if the President Maintains authorization for amounts withheld for determines the Global Fund has provided Maintains authorization for amounts withheld for this and other reasonsf to be made available for assistance to a country the government of which this and other reasonsf to be made available for bilateral HIV the Secretary of State has determined has bilateral HIV “repeatedly provided support for acts of Requires withholding 20% of annual contribution international terrorism,” then the U.S. shall Requires withholding 20% of annual contribution from obligation for each year during FY10 – FY18 withhold from the U.S. contribution for the next pending certification of certain accountability and from obligation for each year during FY10 – FY13 fiscal year an amount equaling the amount of pending certification of certain accountability and transparency benchmarks by the Secretary of funding expended by the Global Fund to the transparency benchmarks by the Secretary of Stateg government of each such country Stateg Maintains current law regarding Global Fund and Authorizes amounts withheld for this and other U.S. bilateral efforts Finds the Global Fund represents the multilateral reasonsf to be made available for bilateral HIV component of U.S. global HIV, TB, and malaria efforts and that the Global Fund and U.S. bilateral efforts in these areas “are demonstrating increasingly effective coordination, with each PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 9 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT possessing certain comparative advantages” and “often work most effectively in concert with each other”; says the U.S. Government is “fully committed to the success of the Global Fund as a multilateral public-private partnership” TB Tuberculosis Control of tuberculosis (TB) is a “major objective Maintains current law regarding major objective Maintains current law Programs of the foreign assistance program of the United States” FY09 – FY13: FY14 – FY18: Authorizes $48 billion (in total), of which: Does not specify authorization for funding for TB FY04 – FY08:  $4 billion for TB (in total) (however, Congress effectively authorizes Authorizes $15 billion ($3 billion/year), of which: funding when it appropriates funding for a  Such sums as necessary for TB Requires funding priority be given to direct purpose) services described in the Stop TB Strategy, Requires funding priority be given to activities that including DOTS coverage, treatment for increase Directly Observed Treatment Short- individuals co-infected with TB/HIV, and MDR-TB course (DOTS) coverage and MDR-TB treatment treatment; as well as to funding for the Global TB Drug Facility, the Stop TB Partnership, and the Recommends that at least 75 percent of the Global Alliance for TB Drug Development amount made available for TB each year be spent on drugs, supplies, direct patient services, Significantly strengthens and elevates focus on DOTS training, and treatment of multi-drug TB: resistant tuberculosis using DOTS-Plus, including  Requires a 5-year TB strategy substantially increased funding for the Global  Requires annual report on U.S. TB efforts Tuberculosis Drug Facility Adds specific TB goals/targets:  Recommends achieving goals of 1) reducing by half the TB death and disease burden from the 1990 baseline and 2) sustaining or exceeding the detection of at least 70 percent of sputum smear-positive cases of TB and the successful treatment of at least 85 percent of the cases detected in countries with established USAID TB programs  Requires TB strategy to include plan to support 1) the successful treatment of 4.5 million new sputum smear TB patients under DOTS programs by 2013, primarily through direct support for needed services, commodities, health workers, and training and additional treatment through coordinated multilateral efforts; and 2) the diagnosis and treatment of 90,000 new MDR-TB cases by PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 10 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT 2013, and additional treatment through coordinated multilateral efforts MALARIA Malaria Providing assistance for the prevention, control, Adds providing assistance for treatment to major Maintains current law Programs and cure of malaria is a “major objective of the objective foreign assistance program of the United States” FY14 – FY18: Strengthens, embraces President’s Malaria Does not specify authorization for funding for FY04 – FY08: Initiative: malaria (however, Congress effectively Authorizes $15 billion ($3 billion/year), of which:  Requires a 5-year malaria strategy authorizes funding when it appropriates funding  Such sums as necessary for malaria  Requires annual report on U.S. malaria for a purpose) efforts  Establishes Malaria Coordinator at USAID, with primary responsibility for the oversight and coordination of all resources and international activities of the U.S. Government relating to efforts to combat malaria FY09 – FY13: Authorizes $48 billion (in total), of which:  $5 billion for malaria (in total) EVALUATION AND OVERSIGHT Evaluation and Requires IOM study comparing the success Requires IOM studies for: data evaluation plan; Does not require IOM (now the National Academy Oversight rates of the various programs and methods used performance assessment; impact evaluation of Medicine, or NAM) study under the first 5-year strategy for combatting HIV,  IOM to include assessment of efforts to as well as TB and malaria address gender-specific aspects of Maintains current law reqarding U.S. Comptroller HIV/AIDS, including gender-related General and the Global Fund Requires U.S. Comptroller General to monitor constraints to accessing services and and evaluate projects funded by the Global Fund addressing underlying social and economic Requires Inspectors General of the Department and, every two years, prepare a report on its vulnerabilities of women and men, in its of State and Broadcasting Board of Governors, results evaluation the Department of Health and Human Services (HHS), and USAID jointly develop annual Maintains current law regarding U.S. Comptroller oversight plans through FY18 General and the Global Fund Requires the Inspectors General of the Department of State and Broadcasting Board of Governors, the Department of Health and Human Services (HHS), and USAID to jointly develop five coordinated annual plans for overseeing U.S. Government global HIV, TB, and malaria programs from FY09 – FY13 PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 11 Table 3: PEPFAR Legislation - Side-by-Side of Key Topics Common Title THE LEADERSHIP ACT THE LANTOS-HYDE ACT THE PEPFAR STEWARDSHIP ACT Requires U.S. Comptroller General to submit a one-time report on U.S. global HIV/AIDS programs no later than 3 years after enactment of Lantos-Hyde Act NOTES: Provisions expiring at the end of FY 2018 are in red. Existing law remains in force unless it was limited to a specific period (expiring at a particular point, such as funding that was authorized through the end of a certain fiscal year) or amended. a: Also authorizes an additional $2 billion over five years for Emergency Fund for Indian Health and Safety and requires establishment of an emergency plan for Indian safety and health. b: Defines partner country as a country that receives a minimum of $5 million in HIV/AIDS assistance from the U.S. Government in the previous fiscal year, for the purposes of the annual report and the Treatment Provider Study. c: Governed by Immigration & Nationality Act, which prohibits HIV-positive individuals from visiting or immigrating to the United States (except if a waiver is granted). HIV is only health condition specifically named as inadmissible in the law; for all others, the Secretary of Health and Human Services is given the authority to decide what conditions pose public health threats. d: Returns decision about whether HIV should be considered a threat to public health to the Secretary of Health & Human Services, as is the case for all other health conditions. e: This amendment to the Leadership Act was made in the Consolidated Appropriations Act of 2004 (P.L. 108-199). f: Specifically, amounts withheld from the U.S. contribution 1) equaling the amount of funding, if any, expended by the Global Fund in the prior year to any governments that have “repeatedly provided support for acts of international terrorism” and 2) equaling the average annual amount of funding, if any, spent on certain administrative expenses in excess of 10% of the total expenditures of the Global Fund for any 2-year period. g: In certain years, Congress directed 10% withholding, rather than 20%. h: For U.S. contributions from FY 2015 through FY 2018, Congress directed that the basis for calculating the limitation of the overall U.S. contribution to not exceed 33% of total Global Fund contributions would be U.S. contributions relative to all contributions to the Global Fund from FY 2004 rather than FY 2009, as was directed in the 2013 PEPFAR Stewardship Act. SOURCES: KFF analysis of: U.S. Congress, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), May 27, 2003; Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293), July 30, 2008; PEPFAR Stewardship and Oversight Act of 2013 (P.L. 113-56), Dec. 2, 2013; U.S. Code, Title 22: Foreign Relations and Intercourse, Chapter 83 (UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA) and Chapter 32 (FOREIGN ASSISTANCE), Sections 2151b - 2151b-4; appropriations legislation; Congressional Research Service, International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding, RL34569, July 14, 2008. Congressional Research Service, The President’s Emergency Plan for AIDS Relief (PEPFAR), U.S. Global HIV/AIDS, Tuberculosis, and Malaria Programs: A Description of Permanent and Expiring Authorities, R43232, September 27, 2013; Congressional Research Service, “PEPFAR Stewardship and Oversight Act: Expiring Authorities,” IF10797, May 18, 2018. PEPFAR Reauthorization: Side-by-Side of Existing and Proposed Legislation 12