PEPFAR: Policy Issues from FY2004 through FY2008

Congressional research reportNov 26, 2007

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Prepared for Members and Committees of Congress

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The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 33.2 million people

are living with human immunodeficiency virus/acquired immunodeficiency syndrome

(HIV/AIDS). The U.N. organization believes that in 2007, some 2.5 million people will contract

HIV and it will kill about 2.1 million. Sub-Saharan Africa is the most affected region, with about

68% of the world’s HIV-positive population, 90% of all HIV-infected children, and more than 11

million children who have lost one or both parents to the virus. UNAIDS anticipates that in 2007,

about 420,000 children will contract HIV, due in large part to inadequate access to drugs that

prevent mother-to-child HIV transmission; about 8% of pregnant women in low- and middleincome countries have access to PMTCT services.

In January 2003, President George Bush proposed that the United States spend $15 billion over

five years to combat HIV/AIDS, tuberculosis (TB), and malaria through the President’s

Emergency Plan for AIDS Relief (PEPFAR). The President proposed concentrating most of the

resources ($9 billion) in 15 countries, where the Administration estimated 50% of all HIVpositive people lived. The proposal allotted $5 billion of the funds to research and other bilateral

HIV/AIDS, TB, and malaria programs, and $1 billion for contributions to the Global Fund to

Fight AIDS, Tuberculosis, and Malaria (Global Fund). The President estimated that from FY2004

to FY2008, PEPFAR funds would support the purchase of anti-retroviral treatments (ARV) for 2

million people; the prevention of 7 million HIV infections; and care for 10 million people

affected by HIV/AIDS, including children orphaned by AIDS.

In May 2003, Congress passed the U.S. Leadership Against HIV/AIDS, Tuberculosis, and

Malaria Act of 2003 (P.L. 108-25), which authorized funds for PEPFAR and created the Office of

the Global AIDS Coordinator (OGAC) to manage U.S. funds aimed at addressing the three

diseases in 15 Focus Countries. As of March 31, 2007, PEPFAR has supported the treatment of

1.1 million people; and as of September 30, 2006, supported PMTCT service provision during

more than 6 million pregnancies and facilitated care for nearly 4.5 million people, including more

than 2 million orphans and vulnerable children. From FY2004 to FY2007, Congress provided

nearly $13.5 billion for U.S. global HIV/AIDS, TB, and malaria programs. In FY2008, the

President requested $5.8 billion for global HIV/AIDS, TB, and malaria efforts; the House and

Senate proposed spending almost $6.2 billion and nearly $6.1 billion, respectively.

On May 30, 2007, President Bush requested that Congress authorize $30 billion to fund PEPFAR

an additional five years. The President asserts that from FY2009 to FY2013, the plan would

support treatment for 2.5 million people, prevent more than 12 million new infections, and care

for more than 12 million people, including 5 million orphans and vulnerable children. Supporters

of the Administration’s plan applauded the President and congratulated him for leading global

efforts to address HIV/AIDS. Critics asserted that PEPFAR could treat more than 2.5 million

HIV-infected people and that PEPFAR’s spending requirements should be eliminated. This report

focuses on some of the key issues that Congress might consider as it faces the issue of whether,

and at what level, to reauthorize PEPFAR.

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Background ..................................................................................................................................... 1

HIV/AIDS ................................................................................................................................. 1

Revised Epidemic Estimates............................................................................................... 1

2007 Estimates.................................................................................................................... 1

Tuberculosis .............................................................................................................................. 4

Malaria ...................................................................................................................................... 4

Global Spending on HIV/AIDS ................................................................................................ 5

Policy Options for Congress............................................................................................................ 6

Define Focus of PEPFAR.......................................................................................................... 7

Revisit Prevention Efforts ......................................................................................................... 7

Increase Prevention of Mother to Child HIV Transmission (PMTCT) Initiatives.............. 8

Provide Contraceptives to HIV-Positive Women................................................................ 8

Address Gender Inequities.................................................................................................. 9

Expand Access to Condoms................................................................................................ 9

Explore the Potential Impact of Circumcision.................................................................. 10

Reconsider Spending Restrictions and Requirements..............................................................11

Evaluate the Impact of the Prostitution Pledge..................................................................11

Evaluate the Impact of the Mexico City Policy .................................................................11

Evaluate the Impact of the Abstinence-Until-Marriage Stipulation.................................. 12

Expand Access to Generic Anti-Retroviral Medication .......................................................... 12

Improve Integration of Health Programs ................................................................................ 13

Improve Food Security ..................................................................................................... 14

Support Maternal and Child Health .................................................................................. 15

Address Other Diseases That Kill..................................................................................... 15

Strengthen Health Systems...................................................................................................... 16

Address Health Worker Shortages .................................................................................... 16

Consider the Impact of Disease-Specific Approach on Health Systems........................... 18

Support Global Efforts to Strengthen Health Systems...................................................... 19

Provide Support for Health Systems Research ................................................................. 19

Consider Role of International Financial Institutions ....................................................... 20

Address the Needs of Children Affected by HIV/AIDS ......................................................... 21

Reconsider Emphasis on Focus Countries .............................................................................. 23

Table 1. Adult (15-49 years) HIV Prevalence in Countries That Have Conducted

Population-Based HIV Surveys Since 2001................................................................................. 2

Table 2. Regional HIV/AIDS Statistics, 2001 and 2007 ................................................................. 3

Table 3. U.S. Global HIV/AIDS, TB, and Malaria Appropriations................................................. 5

Table 4. Number and Shortage of Doctors, Nurses, and Midwives .............................................. 17

Table 5. Distribution of Health Workers in Africa and the United States...................................... 17

Table 6. Spending on Health in Africa and the United States........................................................ 21

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Author Contact Information .......................................................................................................... 24

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The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 33.2 million people

are living with human immunodeficiency virus/ acquired immunodeficiency syndrome

(HIV/AIDS); some 16% fewer people than it initially estimated in 2006 (about 39.5 million).

UNAIDS asserts that the decline reflects improvements in data collection and analysis. Expanded

and improved HIV surveillance systems and household surveys reportedly provided a more

precise count of HIV prevalence than earlier studies.1 In most of the 30 countries where

household studies were conducted, prevalence rates in 2007 were lower than those reported in

2006 (Table 1).

UNAIDS also used the expanded studies to adjust prevalence estimates of countries that had not

conducted household surveys but had similar epidemics. After retrospectively applying the

improved methodology, UNAIDS estimated that in 2006, 32.7 million people were living with

HIV (adjusted from the original estimate of 39.5 million). The revised estimates for India (2.5

million, down from 5.7 million), combined with revisions in five sub-Saharan African countries

(Angola, Kenya, Mozambique, Nigeria, and Zimbabwe) accounted for 70% of the reduction.2

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UNAIDS notes that HIV/AIDS prevalence rates have largely stabilized since 2001 and

HIV/AIDS incidence rates are mostly declining (see Table 2).3 Although prevalence rates have

stabilized and incidence rates are mostly declining, the total number of people living with

HIV/AIDS continue to rise, though at a slower rate. UNAIDS predicts that 2.5 million people will

contract HIV in 2007, compared to the estimated 3.2 million who became HIV-positive in 2001.

UNAIDS does not expect the number of HIV/AIDS-related deaths to decrease, however; in 2007,

some 2.1 are expected to die from AIDS, while 1.7 million died in 2001.

For example, in India, the number of sentinel surveillance sites increased to more than 1,100 in 2006 (up from 155 in

1998) and now more extensively cover at-risk populations. Since 2001, 30 countries in sub-Saharan Africa, Asia, and

the Caribbean have conducted national population-based surveys. Results from such population-based surveys have

generally indicated lower national HIV prevalence than extrapolations from sentinel site surveillance. For more

information on this process, see UNAIDS, 2007 AIDS Epidemic Update. http://data.unaids.org/pub/EPISlides/2007/

2007_epiupdate_en.pdf.

For 2006 estimates, see UNAIDS, 2006 Report on the Global AIDS Epidemic, http://www.unaids.org/en/HIV_data/

2006GlobalReport/default.asp.

Prevalence is the total number of cases within a given time period; incidence is the number of new cases within a

given time period, such as a year.

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. Adult (15-49 years) HIV Prevalence in Countries That Have Conducted

Population-Based HIV Surveys Since 2001

Table 1

Countries

Benin

Botswana

Burkina

Faso

Burundi

Cameroon

Central

African Rep.

Chad

Cote

d’Ivoire

Equatorial

Guinea

Ethiopia

Ghana

Guinea

Kenya

Lesotho

Malawi

Mali

Niger

Rwanda

Senegal

Sierra

Leone

South Africa

Swaziland

Uganda

Tanzania

Zambia

Zimbabwe

PopulationBased Survey

HIV Prevalence

Rate (%)

2001

Prevalence

(%) Reported

Year

Populationin 2002 AIDS

Based Survey

Epidemic

Conducted

Report

Sub-Saharan Africa

2003

Prevalence

(%) Reported

in 2004 AIDS

Epidemic

Report

2005

Prevalence (%)

Reported in

2006 AIDS

Epidemic

Report

1.2

2006

3.6

1.9

1.8

25.2

1.8

2004

2003

38.8

6.5

38.0

4.2

24.1

2.0

3.6

5.5

6.2

2002

2004

2006

8.3

11.8

12.9

6.0

7.0

13.5

3.3

5.4

10.7

3.3

4.7

2005

3.6

9.7

4.8

7.0

3.5

7.1

3.2

2004

3.4

Not Available

3.2

1.4

2.2

1.5

6.7

23.5

11.8

1.3

0.7

3.0

0.7

1.5

2005

2003

2005

2003

2004

2006

2005

6.4

3.0

Not Available

15.0

31.0

15.0

1.7

Not Available

8.9

0.5

7.0

4.4

3.1

2.8

6.7

29.3

14.2

1.9

1.2

5.1

0.8

Not Available

0.9 - 3.5

2.3

1.5

6.1

23.2

14.1

1.7

1.1

3.1

0.9

1.6

16.2

25.9

7.1

7.0

15.6

18.1

2005

2006-2007

2004-2005

2004

2001-2002

2005-2006

20.1

33.4

5.0

7.8

21.5

33.7

20.9

38.8

4.1

9.0

16.5

24.6

18.8

33.4

6.7

6.5

17.0

20.1

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2003

Prevalence

(%) Reported

in 2004 AIDS

Epidemic

Report

2005

Prevalence (%)

Reported in

2006 AIDS

Epidemic

Report

Based Survey

HIV Prevalence

Rate (%)

Year

PopulationBased Survey

Conducted

2001

Prevalence

(%) Reported

in 2002 AIDS

Epidemic

Report

Asia

Cambodia

India

0.6

0.28

2005

2005-2006

2.7

0.8

2.6

0.9

1.6

0.9

Dominican

Republic

Haiti

1.0

2002

2.5

1.7

1.1

2.2

2005-2006

6.1

5.6

3.8

Population-

Countries

Latin America and Caribbean

Source: UNAIDS, 2007 AIDS Epidemic Update

Table 2. Regional HIV/AIDS Statistics, 2001 and 2007

Adults and

Children Living with

HIV

(thousands)

2001

2007

Sub-Saharan Africa

South & Southeast

Asia

Latin America

North America

E. Europe &

Central Asia

Western & Central

Europe

East Asia

Middle East & N.

Africa

Caribbean

Oceania

Total

Source:

Adults and

Children Newly Infected

with HIV

(thousands)

2001

2007

Adult

Prevalence

(%)

2001 2007

Adult and

Child Deaths

Due to AIDS

(thousands)

2001 2007

20,900

22,500

2,200

1,700

5.8

5.0

1,400

1,600

3,500

1,300

1,100

4,000

1,600

1,300

450

130

340

100

0.3

0.4

0.6

0.3

0.5

0.6

170

270

630

1,600

230

150

0.4

0.9

620

420

760

800

0.2

<0.1

0.3

0.1

300

190

380

230

3.8

0.3

1.0

0.2

0.3

1.0

0.4

<0.5

1.2

29,000

33,200

3,200

2,500

0.8

1,700

2,100

UNAIDS, 2007 AIDS Epidemic Update.

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HIV/AIDS is contributing to rising TB prevalence in areas with high HIV/AIDS prevalence,

particularly in Africa.4 The weakened immune systems of HIV-positive people places them at

greater risk of contracting TB. Correspondingly, TB considerably shortens the survival of people

with HIV/AIDS. In 2005, about 80% of all HIV-positive people with TB were found in Africa.

That year, nearly 630,000 people were co-infected with HIV/AIDS and TB, some 500,000 of

whom were African. About 160,000 of the nearly 195,000 co-infected patients who died from TB

were African, representing 82% of those deaths.

Although most forms of TB are curable, the World Health Organization (WHO) estimates that in

2005 (the year for which the most current data are available), the disease killed 1.6 million

people, including 195,000 who were also infected with HIV/AIDS.5 Some 8.8 million people

contracted the disease in 2005, of which 84% of the cases occurred in 22 countries.6 All but three

of those high-burden countries were found in Africa or Asia. About half of all new TB cases were

in six countries: Bangladesh, China, India, Indonesia, Pakistan, and the Philippines.

While HIV/AIDS, TB, and malaria are preventable diseases, their impacts have been catastrophic,

particularly in sub-Saharan Africa. Researchers have found that people infected with one of the

three illnesses are more likely to contract either of the other two, and the symptoms are more

severe in people with two or more of the diseases. According to WHO, each year there are about

300 million acute malaria cases,7 which cause more than 1 million deaths annually. Health experts

believe that between 85% and 90% of malaria deaths occur in Africa, mostly among children,8

killing an African child every 30 seconds.9

Information in this paragraph was summarized from WHO, Frequently asked questions about TB and HIV/AIDS.

http://www.who.int/tb/HIV/AIDS/faq/en/index.htm. For more information on the impacts of TB and HIV/AIDS coinfection see CRS Report RL34246, Tuberculosis: International Efforts and Issues for Congress, by (name redacte

d).

WHO Report 2006, Global Tuberculosis Control: Surveillance, Planning, Financing, at http://www.who.int/tb/

publications/global_report/en/index.html. For more information on TB, see CRS Report RL34246, Tuberculosis:

International Efforts and Issues for Congress, by (name redacted).

The 22 high-burden countries were: Afghanistan, Bangladesh, Brazil, Burma, Cambodia, China, Democratic Republic

of Congo, Ethiopia, India, Indonesia, Kenya, Mozambique, Nigeria, Pakistan, Philippines, Russia, South Africa,

Tanzania, Thailand, Uganda, Vietnam, and Zimbabwe.

There are four types of malaria: Plasmodium (P.) vivax, P. malaria, P. ovale, and P. falciparum. P. falciparum, the

deadliest kind, is most common in sub-Saharan Africa and is a significant factor in the region’s high malarial mortality

rate. People contract malaria from infected mosquitos; and mosquitos can get malaria if they ingest blood from an

infected person. http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm.

WHO estimates that annually, 300 million malaria cases cause 1 million deaths with 90% of the deaths in sub-Saharan

Africa. The World Bank believes average annual cases exceed 500 million and about 85% of malarial deaths are in subSaharan Africa, 8% in southeast Asia, 5% in the Middle East, 1% in the Western Pacific, and 0.1% in the Americas.

WHO’s Roll Back Malaria website, http://malaria.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm.

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UNAIDS asserts that it would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in

2008 to effectively fight HIV/AIDS.10 In FY2006, Congress provided $3.4 billion for global

HIV/AIDS, tuberculosis (TB), and malaria programs (Table 3). Most recent statistics indicate that

in 2006, global spending reached nearly $9 billion, $6 billion less than UNAIDS advocated.11

Table 3. U.S. Global HIV/AIDS,TB, and Malaria Appropriations

($U.S. current, millions)

PROGRAM

1. USAID HIV/AIDS

(excluding Global

Fund)

2. USAID Tuberculosis

3. USAID Malariab

4. USAID Global Fund

Contribution

5. FY2004 Global Fund

Carryoverc

6. State Department

GHAI

7. GHAI Global Fund

Contribution

8. Foreign Military

Financingd

FY2004 FY2005 FY2006 FY2007

Actual Actual Actual

549.2

382.8

373.8

100.4

100.9

87.8

98.2

91.5

102.0

397.6

247.9

-87.8

Request

FY2008

House Senate

Enacted

346.3

382.0

350.0

NYE

248.0

89.9

387.5

313.5a

352.5

200.0

357.5

NYE

247.5

0.0

250.0

NYE

87.8

n/a

NYE

488.1

1,373.5

1775.1

2,869.0

4,150.0

NYE

0.0

198.0

377.5

0.0

300.0

340.0

NYE

1.5

1.9

—

0.0

NYE

2279.9 2,789.8

4,206.5

4,973.7 5,748.0

5,647.5

464.5

9. Subtotal, Foreign

Operations

Appropriations

1549.9

10. CDC Global AIDS

Programe

291.8

123.8

122.7

120.8

121.2

122.7

NYE

317.2

370.0

373.0

372.0

373.0

—

NYE

149.1

99.2

99.0

300.0

NYE

11. NIH International

Researchf

12. NIH Global Fund

contribution

UNAIDS, Towards Universal Access: Assessment by the Joint United Nations Program on HIV/AIDS on Scaling Up

HIV Prevention, Treatment, Care and Support, March 2006. http://data.unaids.org/pub/InformationNote/2006/

20060324_hlm_ga_a60737_en.pdf.

Financing the Response to AIDS in Low- and Middle- Income Countries: International Assistance from the G8,

European Commission and Other Donor Governments, Kaiser Family Foundation, 2006, http://www.kff.org/hivaids/

upload/7347_03.pdf.

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PROGRAM

13. DOL AIDS in the

Workplace Initiative

14. Subtotal,

Labor/HHS

Appropriations

15. DOD HIV/AIDS

prevention

education

16. Section 416(b) Food

Aid

FY2004 FY2005 FY2006 FY2007

Actual Actual Actual

Request

FY2008

House Senate

9.9

1.9

0.0

—

0.0

768.0

594.9

594.7

591.8

794.2

—

4.2

7.5

5.2

—

0.0

10.0

—

24.8

—

0.0

—

Enacted

NYE

8.0

NYE

17. TOTAL

2346.9 2907.1 3,414.5 4,798.3 5,767.9

—

Sources: Prepared by CRS from appropriations legislation figures and interviews with Administration staff.

This chart does not include discretionary spending on global HIV/AIDS, TB, and malaria programs, such as

CDC’s international HIV research and its global TB and malaria initiatives. “—” indicates that funds were not

earmarked, but could be provided at the Administration’s discretion. “NYE” means that the bill has not yet been

enacted.

a. Includes $150.0 million provided to the Global HIV/AIDS Initiative for global TB efforts.

b. House and Senate appropriations committees began reporting out global malaria funds separately from

those supporting global HIV/AIDS and TB initiatives after President Bush launched the President’s Malaria

Initiative (PMI) in June 2005. The Administration reports that PMI became operational in FY2006 though

Congress first appropriated funds to PMI in FY2007. That fiscal year, Congress provided $248.0 million for

international malaria programs, including $149.0 million to expand PMI.

c. In FY2004, Congress withheld $87.8 million of the U.S. contribution to the Global Fund, because legislative

provisions prohibit U.S. contributions from exceeding 33% of all donor contributions to the Fund. FY2005

Consolidated Appropriations restored the funds.

d. Foreign Military Financing funds are used to purchase equipment for DOD HIV/AIDS programs (Line 15).

e. In FY2004, the International Mother and Child HIV Prevention Initiative expired. In subsequent fiscal years,

Congress appropriated funds for PMTCT activities to the Global HIV/AIDS Initiative account, though CDC

continues related efforts.

f. The figures used in Line 11 reflect the amount the Office of AIDS Research (OAR) reports it spends on

international HIV/AIDS research. Congress does not specify how much the Office should spend on this

effort.

Note:

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In 2003, Congress authorized $3 billion for each fiscal year from 2004 through 2008 to support

the President’s Emergency Plan for AIDS Relief (PEFAR). The 5-year initiative was created to

aid the millions of people sickened and killed by HIV/AIDS, malaria, and tuberculosis (TB).

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Some estimate that since HIV/AIDS was first identified in 1981, 65 million people have

contracted the virus and it has killed more than 25 million.12

PEPFAR provided an unprecedented amount of assistance for global HIV/AIDS efforts. The

United States remains the largest single donor for global HIV/AIDS efforts in the world,

providing nearly 50% of all donor funds.13 As Congress prepares to consider whether, and at what

level, to reauthorize PEPFAR, there has been considerable debate about the effectiveness of

PEPFAR. Some health experts contend that the life-saving intention of PEPFAR is weakened by

the single-disease approach. Other critics contend that ideological factors lessen the effectiveness

of the plan. A number of HIV/AIDS advocates urge the United States to harmonize its antiHIV/AIDS efforts with other donors to boost the impact of PEPFAR. Some of the key policy

prescriptions are discussed below.

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As Congress considers reauthorizing PEPFAR, there may be some debate on how many diseases

the initiative should address. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria

Act of 2003 (P.L. 108-25), requires the President to submit annual reports to appropriation

committees that describe how U.S. funds support efforts to prevent HIV/AIDS, TB, and malaria

and provide care and treatment for those affected by the three diseases. However, since President

Bush launched the President’s Malaria Initiative (PMI) in June 2005, the Office of the Global

AIDS Coordinator (OGAC) determined that it would no longer include malaria spending in its

annual reports to Congress and that budgetary requests for the disease would be made separately

from HIV/AIDS and TB requests.14 The Administration requests support for PMI through the

U.S. Agency for International Development (USAID) as the coordinating agency. For

comparability, and because P.L. 108-25 considers efforts to combat malaria as a critical part of

PEPFAR, Table 3 includes appropriations to malaria programs. As Congress considers whether to

authorize funds to extend PEPFAR, Members might decide whether to define it as solely an

HIV/AIDS initiative or one that includes the three diseases.

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As Congress considers reauthorizing PEPFAR, there is likely to be considerable debate on how

much funding to allocate to prevention. Consensus is growing among health experts that greater

emphasis needs to be placed on HIV prevention in global HIV/AIDS programs. The international

community has supported a tremendous increase in the number of people receiving HIV/AIDS

treatment. In 2001, about 240,000 people had access to anti-retroviral treatment (ARVs); in 2006,

more than 2 million were treated.15 Nonetheless, WHO estimated that in 2006, an additional 5.1

Avert, an international HIV/AIDS charity, used UNAIDS data to reach its estimate. See world AIDS statistics at

http://www.avert.org/worldstats.htm.

Ibid.

PMI aims to increase U.S. support for global malaria programs by more than $1.2 billion between FY2006 and

FY2010 in 15 countries. For more information on PMI, see http://www.pmi.gov/.

Statistics on access to AIDS treatment was compiled from UNAIDS, Towards Universal Access: Scaling up priority

HIV/AIDS interventions in the health sector, April 2007.

(continued...)

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million people who needed treatment received none. In sub-Saharan Africa, more than 1.3 million

people received treatment, reaching some 28% of those in need; three years prior, 100,000 were

treated and coverage amounted to 2%. In spite of these advances, the rate at which individuals

become infected with HIV far outpaces the rate at which they are treated. In 2006, 4.3 million

people contracted HIV, 2.8 million of whom were African (65%), and 2.9 million people died of

AIDS, 2.1 million of whom were African (72%).

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Many health experts advocate greater spending on PMTCT initiatives.16 Advocates of greater

PMTCT spending argue that providing ARVs during pregnancy is a well-documented way to

avert millions of HIV infections in a cost-efficient and effective manner, including in lowresource settings. UNAIDS estimates that 1,800 children worldwide become infected with HIV

each day, the vast majority of whom are newborns.17 More than 85% of children infected with

HIV live in sub-Saharan Africa, although mother-to-child transmission (MTCT) rates are rapidly

rising in Eastern Europe and Central Asia.18 UNAIDS estimates that in 2005, just less than 8% of

pregnant women in low- and middle-income countries had access to services that could prevent

the transmission of HIV to their babies.19 Two-thirds of all women who lack access to PMTCT

interventions come from 10 countries, all but one of which are in Africa; India is the exception.20

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Some reproductive health experts want HIV/AIDS and family planning services to be better

integrated should PEPFAR be reauthorized. Supporters of this idea contend that women who

receive PMTCT services should be subsequently offered contraceptives to lessen the likelihood

that they might give birth to HIV-positive children. Additionally, women who fear being

(...continued)

http://www.who.int/hiv/mediacentre/univeral_access_progress_report_en.pdf.

Most children living with HIV acquire the disease through mother-to-child transmission (MTCT), which can occur

during pregnancy, labor and delivery, or breastfeeding. In the absence of any intervention, the risk of such transmission

is 15%-30% in non-breastfeeding populations. Breastfeeding by an infected mother can increase the risk to 45%. The

risk of MTCT can be reduced to under 2% by interventions that include the provision of ARV treatments. Elective

caesarean delivery and complete avoidance of breastfeeding can also reduce the risk of HIV transmission. In many

resource-constrained settings, elective caesarean delivery is seldom feasible, and mothers often lack access to enough

clean water or formula to refrain from breastfeeding. Research is ongoing to evaluate several new approaches to

preventing HIV transmission during breastfeeding.

UNAIDS 2006 Global AIDS Report, p. 132, http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp.

UNAIDS 2006 Global AIDS Report, p. 132.

Ibid., p. 133.

Data from countries in sub-Saharan Africa indicate that the proportion of HIV-infected pregnant women receiving

ARVs in 2005 varied from under 1% to 54% and that the average regional coverage rate was 11%. In East, South, and

Southeast Asia, the average regional coverage rate was 5%, with individual country rates ranging from 3% to 10%. On

average, in Latin America and the Caribbean, 24% of HIV-infected mothers had access to ARVs; the coverage rate

ranged from 13% to 46%. It is estimated that overall coverage amounted to 75% in Eastern Europe and Central Asia

with coverage rates ranging from 38% to 95%. ARV coverage for HIV-infected pregnant women in North Africa and

the Middle East averaged less than 1%.

ȱȱȱ

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stigmatized if they visit an HIV center could receive PMTCT services while receiving standard

prenatal care. Members who endorsed the Ensuring Access to Contraceptives Act (H.R. 2367)

demonstrated their support for expanding access to family planning and contraceptives. The bill

would authorize $150 million for such services in each of fiscal years 2008 and 2009. Some in

Congress also support the United Nations Population Fund Women’s Health and Dignity Act

(H.R. 2604), which would provide financial and other support to UNFPA’s activities that save

women’s lives, limit the incidence of abortion and maternal mortality associated with unsafe

abortion, promote universal access to safe and reliable family planning, and assist women,

children, and men in developing countries live better lives.

ȱ ȱ ȱ

Women’s rights advocates also assert that the lower status of women in many of the most affected

countries must be better addressed in order to prevent new HIV infections. In many countries,

legal and social structures leave women feeling as though they have little control over their own

bodies and do not have the option to reject their husbands’ sexual advances; even when they are

aware of their husbands’ extramarital relationships. Research has shown that in Africa, married

girls and women are more likely to contract HIV than their single counterparts.21 For example,

30% of married adolescents’ spouses were HIV-positive in Kenya, while 11.5% of the partners of

their unmarried counterparts were infected with HIV. Similarly, in Zambia, 31.6% of married

girls’ partners were found to carry HIV, while 16.8% of unmarried girls’ boyfriends were HIVpositive.22 Societal forces also weaken women’s options, rights advocates contend, because in

many countries, health workers require women to obtain their husbands’ permission before

providing them contraception.23

¡ȱȱȱȱ

Global health activists also insist that OGAC’s policy of limiting condom distribution to “high

risk groups”24 ignores gender inequities and limits the effectiveness of prevention programs. U.S.

condom distribution strategies do not include married women, unless their husbands test positive

for HIV. Supporters of U.S. condom distribution guidelines counter that the definition of “high

risk” individuals is broad enough to include the most vulnerable groups. Some HIV/AIDS

proponents advocate that Congress expand the definition of “high risk” individuals to include

married young people. Advocates hope that an expanded definition might enable young married

people to access condoms through U.S.-supported programs.

“Early Marriage and HIV Risks in Sub-Saharan Africa.” Studies in Family Planning, Vol. 35, No. 3, September

2004. http://www.blackwell-synergy.com/links/doi/10.1111/j.1728-4465.2004.00019.x/pdf?cookieSet=1, “Protecting

Young Women from HIV/AIDS: The Case Against Child and Adolescent Marriage.” International Family Planning

Perspectives, Vol. 32, No. 2, June 2006. http://www.jstor.org/journals/01622749.html.

The Implications of Early Marriage for HIV/AIDS Policy. Population Council, 2004. http://www.popcouncil.org/

pdfs/CM.pdf.

Violence Against Girls and Women: Effects on Sexual and Reproductive Health Decision Making. UNFPA website,

accessed on May 14, 2007 http://www.unfpa.org/intercenter/violence/effects2a.htm.

High risk groups are defined as sex workers and their clients; sexually active discordant couples (when one partner is

HIV-positive and the other is not infected) or couples with unknown HIV status; substance abusers; mobile male

populations; men who have sex with men; and people living with HIV/AIDS.

ȱȱȱ

şȱ

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¡ȱȱȱ ȱȱȱ

Health experts have begun to debate the role that circumcision could play in HIV prevention

efforts. Three randomized trials conducted in South Africa, Kenya, and Uganda demonstrated that

male circumcision reduced the risk of acquiring HIV by more than half. Some believe that if mass

circumcision was to be conducted in areas of high transmission, the procedure could avert about

5.7 million new HIV infections and 3 million deaths over 20 years among both men and

women.25 WHO and UNAIDS have endorsed the practice to be added to HIV prevention

initiatives.26 The organizations warn, however, that the practice should not be seen as a “magic

bullet,” as it does not prevent men from acquiring the virus, it only reduces the risk of infection.

As a result, health experts urge those who perform the surgeries to counsel the men and explain

that they must maintain other protective practices, such as abstaining from sex, reducing their

number of sexual partners, and using condoms.

Some observers argue that the studies should not yet be widely embraced, particularly since only

a few trials have been conducted. A number of scientists question the validity of the studies since

they were terminated early; a practice, critics contend, that skews the results.27 Dissenters argue

that there may be other explanations for the drop in transmission. Skeptics contend that

circumcision reduces the incidence of genital symptoms, allowing men to receive fewer unsafe

injections and other blood exposures during treatment. Also, in sub-Saharan Africa, circumcised

virgins and adolescents are reportedly more likely to be HIV-infected than their uncircumcised

counterparts. Researchers suspect that unhygienic circumcision procedures might be a large factor

in this phenomenon.28

Critics and advocates of the practice agree that additional studies need to be conducted and a

number of precautions must be taken should the practice be implemented on a larger scale.29

Additional research is needed to determine how the procedure might impact HIV transmission to

women, the most affected population in Africa. There is consensus that male circumcision must

be considered part of a comprehensive HIV prevention package, which includes treatment for

sexually transmitted infections; the promotion of safer sex practices; and the provision of male

and female condoms and promotion of their correct and consistent use. HIV/AIDS advocates

maintain that men and their sexual partners must also be counseled to prevent them from

developing a false sense of security and engaging in high-risk behaviors that could undermine the

partial protection provided by male circumcision. Health experts agree that African health

systems need to be strengthened in order to ensure safe and clean operations. Circumcision must

be done under hygienic conditions by trained personnel with access to sterile surgical instruments

“Circumcision and Circumspection.” The Lancet Infectious Diseases, May 2007, Vol. 7, No. 5,

http://www.thelancet.com/journals/laninf/article/PIIS1473309907700877.

WHO, “WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV

prevention.” March 28, 2007. http://www.who.int/hiv/mediacentre/news68/en/index.html.

“Male Circumcision in HIV Prevention.” The Lancet, Vol. 369, No. 9573, May 12, 2007, http://www.thelancet.com/

journals/lancet/article/PIIS0140673607607375.

“Male Circumcision in HIV Prevention.” The Lancet, Vol. 369, No. 9573, May 12, 2007, http://www.thelancet.com/

journals/lancet/article/PIIS0140673607607351.

UNAIDS, Male Circumcision: Context, Criteria, and Culture. http://www.unaids.org/en/mediacentre/pressmaterials/

featurestory/20070226_MC_pt1.asp.

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and anaesthesia. Many facilities on the continent, however, lack sufficient supplies, such as

gloves, clean needles, and antiseptics. Some health experts fear that greater investment in

circumcision might disrupt other health care programs. Global health advocates urge Congress to

ensure that male circumcision services are integrated with other services, particularly in areas

with severe shortages of skilled health workers, should it include support for the practice in

PEPFAR.

ȱȱȱȱȱ

ȱȱ ȱȱȱȱȱ

A number of global health experts contend that some current U.S. AIDS-related spending

restrictions and requirements are ideologically based, negatively impact the effectiveness of

PEPFAR programs, and complicate implementing partners’ efforts. The U.S. Leadership Against

HIV/AIDS, TB, and Malaria Act (P.L. 108-25) mandates that no funds made available to carry

out the act may be used to assist any group or organization that does not have a policy explicitly

opposing prostitution and sex trafficking. This policy has become widely known as “the

prostitution pledge.” Critics of the pledge contend that the restriction should be eliminated,

because it limits implementing partners’ HIV/AIDS prevention efforts.30 Opponents argue that

groups serving sex workers fear that by signing the pledge and openly opposing prostitution, they

may isolate the very group that they are attempting to help.

ȱȱ ȱȱȱ¡ȱ¢ȱ¢ȱ

The “Mexico City Policy”31 has also come under considerable scrutiny. The policy prohibits

reproductive health organizations from providing information about abortion. Critics contend

that, in some countries, this policy has had devastating effects, because reproductive health

services is the only form of health care that many women receive. The House and Senate included

language in their reports (H.Rept. 110-197 and S.Rept. 110-128) for FY2008 Foreign Operations

USAID’s policy directive on the prostitution pledge can be found at http://www.usaid.gov/business/

business_opportunities/cib/pdf/aapd05_04.pdf. Criticisms of PEPFAR spending requirements include AIDS Taskforce

of Greater Cleveland, Is PEPFAR Working? A Response to the Recent Annual Report Issued by the President’s

Emergency Plan for AIDS Relief, May 2006. http://www.aidstaskforce.org/ASSETS/

72BF3DD44B1E4B93A1077EC95C655E81/PEPFAR.pdf; Health Gap, U.S. Global AIDS Initiative, Round 2: From

Emergency to Sustainability. May 29, 2007. http://www.healthgap.org/PEPFAR-Renewal.doc; Center for Health and

Gender Equity Policy Brief, Implications of U.S. Policy Restrictions for Programs Aimed at Commercial Sex Workers

and Victims of Trafficking Worldwide, November 2005. http://www.genderhealth.org/pubs/

ProstitutionOathImplications.pdf; “The US Anti-Prostitution Pledge: First Amendment Challenges and Public Health

Priorities.” PLoS Medicine, Vol. 4, No. 7, http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371/journal.pmed.0040207&ct=1; Advocates for Youth, Improving U.S. Global AIDS Policy for

Young People, 2007, http://www.advocatesforyouth.org/publications/pepfar.pdf; and Open Society Institute, “AntiProstitution” Materials, June 2007 http://www.soros.org/initiatives/health/focus/sharp/articles_publications/

publications/pledge_20070612.

The “Mexico City” policy denies U.S. funds to foreign non-governmental organizations (NGOs) that perform or

promote abortion as a method of family planning, even if the activities are undertaken with non-U.S. funds. For more

information on the policy, see CRS Report RL33250, International Population Assistance and Family Planning

Programs: Issues for Congress, by (name redacted).

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appropriations (H.R. 2764) that prevented the “Mexico City Policy” from being the sole reason

that U.S. funds could not be used to provide contraceptives. A conference is pending. Opposing

Members expect the President to veto any bill that repeals the “Mexico City Policy.”

ȱȱ ȱȱȱȬȬȱȱ

Some health experts assert that congressional HIV prevention stipulations are not well-balanced,

place too much emphasis on abstinence until marriage, and limit countries’ ability to use

prevention funds in a manner that is most relevant to local conditions. P.L. 108-25, which

delineates how PEPFAR funds should be allocated, stipulates that between FY2006 and FY2008,

20% of global HIV/AIDS funds are to be used for prevention efforts, of which at least 33%

should be expended for abstinence-until- marriage programs. In 2006, the Government

Accountability Office (GAO) found that PEPFAR’s spending requirements limited the flexibility

with which prevention funds could be spent.32 GAO estimated that in order to meet the 33%

proviso, between FY2004 and FY2006, OGAC increased spending on prevention by almost 55%

and mandated that country teams spend half of prevention funds on sexual transmission

prevention and two-thirds of those funds on abstinence/faithfulness (AB) activities. In its

congressionally mandated report, the Institute of Medicine (IOM) reached similar conclusions.33

Some health specialists argue that these policies consume limited resources and time, as they

place additional reporting requirements on implementing partners. Britain’s Department for

International Development (DFID) reports that from 2003 to 2004 and 2006 to 2007, the

Ugandan government was reporting on 684 different aid instruments and associated agreements.34

Critics suggest that if Congress reauthorizes PEPFAR, it should eliminate these spending

restrictions, coordinate reporting requirements and funding processes with other donors, and urge

the United States to sign on to the International Health Partnership. Some in Congress have

supported legislation that was introduced to remove the spending provisions. The HIV Prevention

Act (S. 1553) and the Protection Against Transmission of HIV for Women and Youth Act (H.R.

1713) would strike the 33% abstinence-until-marriage spending requirement from P.L. 108-25.

The FY2008 House Foreign Operations Appropriations would allow the Administration to

determine whether to apply the 33% abstinence-until-marriage provision to global HIV/AIDS

programs.

¡ȱȱȱ ȱȬȱȱ

Access to generic HIV/AIDS treatments is another possible issue to arise in reauthorization

debates. Shortly after PEPFAR was launched, the Bush Administration expressed skepticism

GAO, Spending Requirement Presents Challenges for Allocating Prevention Funding Under the President’s

Emergency Plan for AIDS Relief, April 2006, at http://www.gao.gov/new.items/d06395.pdf.

Section 101 (c)(1) of P.L. 108-25 mandated that not later than three years after its enactment, the Institute of

Medicine (IOM) would “publish findings comparing the success rates of the various programs and methods used under

the [PEPFAR] strategy.” In March 2007, IOM released, PEPFAR Implementation: Progress and Promise. IOM

concluded that “PEPFAR has made a promising start, but the need for U.S. leadership in the effort to control the

HIV/AIDS pandemic continues.”

DFID, Millennium Development Goals: Health Facts and Figures http://www.dfid.gov.uk/mdg/health-factsfigures.asp#The_donor_coordination_challenge.

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about broad-based use of generic ARV medication. The Administration asserted that WHO’s

prequalification process was inadequate, and that generic drugs purchased with PEPFAR funds

had to be first inspected by the U.S. Food and Drug Administration (FDA).35 The Administration

argued that since WHO is not a regulatory body, its adherence to stringent FDA standards could

not be ensured.36 This policy sparked a debate with critics contending that the process was

unnecessary and delayed the distribution of ARVs.37 In January 2005, GAO reported that the

policy limited the selection of ARV products available, did not fully support the treatment

strategies of the focus countries, and was not optimally coordinated with other multinational

initiatives. GAO indicated that “better coordination with the Focus Countries and with other

treatment initiatives could facilitate more rapid implementation of the Emergency Plan.

Moreover, given the intended scale of the plan, lower prices for ARVs could result in savings of

hundreds of millions of dollars, which could be used to treat additional patients or to support

other aspects of the program.”38

In March 2007, IOM found that in many of the Focus Countries, a number of those implementing

HIV/AIDS programs complained that the U.S. treatment policy complicated national treatment

efforts.39 The Institute recommended that OGAC work to support WHO prequalification as the

accepted global standard for assuring the quality of generic medications and work with other

donors to support strengthening the process. According to OGAC’s third annual report to

Congress, OGAC has strengthened its coordination with WHO, by sharing information on the

WHO-approved generics. OGAC estimates that in FY2006, 27% of all ARVs purchased under

PEPFAR were generic.40 Since FDA began reviewing generic drug applications, more than 50

generic versions of patented ARVs have been approved or tentatively approved for use in

PEPFAR treatment plans.41

ȱ ȱȱ ȱȱ

In considering whether to extend PEPFAR, HIV/AIDS experts encourage Congress to stipulate

stronger integration of PEPFAR-supported programs with other health programs that save lives.

The WHO prequalifying process includes an assessment of product files (lasting approximately two to four months);

site inspections; and the procurement of data on all active pharmaceutical ingredients, specifications, product formulas,

and manufacturing methods. After the products and manufacturing sites meet the required standards, the medicine is

added to the list of prequalified products. For more information, see http://www.who.int/3by5/publications/briefs/amds/

en/.

Interviews with staff at the Office of the AIDS Coordinator, April 1, 2004.

David Brown and Ellen Nakashima, “U.S. Rule on AIDS Drugs Criticized,” Washington Post, July 14, 2004; Steve

Sternberg, “Bush’s AIDS Plan Could be Tough to Implement,” USA Today, July 14, 2004; and “The end of the

beginning? AIDS,” The Economist, July 17, 2004. For more on the debate about the FDA review process, see the

Kaisernetwork website at http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=27788.

GAO, Global HIV/AIDS Epidemic: Selection of Antiretroviral Medications Provided Under U.S. Emergency Plan Is

Limited, January 2005. http://www.gao.gov/new.items/d05133.pdf.

http://www.iom.edu/CMS/3783/24770/41804.aspx.

OGAC, The Power of Partnerships: The President’s Emergency Plan for AIDS Relief, 2007. http://www.pepfar.gov/

documents/organization/81019.pdf.

PEPFAR website, FDA Grants Tentative Approval for 50th and 51st Anti-Retroviral Drugs Under President’s AIDS

Relief Plan, August 13, 2007. http://www.pepfar.gov/press/91018.htm. For more information on FDA’s role in

reviewing ARVs, see http://www.fda.gov/oia/pepfar.htm.

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Many health experts contend that PEPFAR’s disease-specific approach threatens to supplant

support by the United States and recipient countries for other health areas, including nutrition,

maternal and child heath, and other infectious diseases.

ȱȱ¢ȱ

Malnutrition and lack of food may heighten exposure to HIV, raise the likelihood of engaging in

risky behavior (e.g., transactional sex), increase susceptibility to infection, and complicate efforts

to provide anti-retroviral (ARV) medication. Furthermore, those sickened by HIV/AIDS are often

too ill to till the land, lessening agricultural productivity. The United Nations’ Food and

Agriculture Organization (FAO) estimates that food consumption drops by 40% in homes affected

by HIV/AIDS, due in large part to diminished capacity to farm.42

In communities struggling with food security, decreased food production can complicate efforts to

maintain treatment regiments. If patients do not consume adequate amounts of nutritious food,

they can suffer significant side effects while taking ARVs and the drugs can be less effective. At

the 2006 International AIDS Conference, one AIDS advocate cited a study that showed that

patients who were malnourished when they started ARV therapy were six times more likely to die

than well-nourished patients, and were more likely to suffer side-effects, which often caused them

to stop taking the treatments.43 These issues are particularly acute in rural communities, where

AIDS incidence is rapidly increasing and access to care is usually more limited than in urban

areas. In the 25 most AIDS-affected countries in Africa, more than 2/3 of the population live in

rural areas and rely on agriculture for their livelihoods.44

In April 2007, the House Foreign Affairs Committee held a hearing on the progress of PEPFAR.

At the hearing, Global AIDS Coordinator Mark Dybul testified that PEPFAR funds provided

“limited food assistance for specific, highly vulnerable populations,” and cited support for a pilot

program that enables a local food manufacturer to distribute nutrient-dense food to orphans and

vulnerable children, clinically malnourished HIV-positive people, and HIV-positive pregnant and

lactating women enrolled in PMTCT programs. He also indicated that in FY2006, OGAC had

contributed $2.45 million contribution to the World Food Program (WFP) and would contribute

an additional $4.27 million in FY2007. Ambassador Dybul conceded that PEPFAR’s engagement

in food insecurity is limited. He contended, however, that efforts are intentionally limited,

because OGAC prefers to remain focused on HIV/AIDS. At the hearing, Ambassador Dybul

testified that PEPFAR supports other “wrap around” programs that support HIV-affected

populations, such as clean water programs, education initiatives, and gender projects.

FAO factsheet, HIV/AIDS, food security, and rural livelihoods http://www.fao.org/worldfoodsummit/english/fsheets/

aids.pdf.

Statement made by Stuart Gillespie at the 2006 International AIDS Conference, “Breaking the Vicious Cycle of

HIV/AIDS and Hunger.” http://www.ifpri.org/PRESSREL/2006/20060813.asp.

FAO, The Impact of HIV/AIDS on Agriculture and Food Security, 2003, http://www.fao.org/docrep/005/Y8331E/

Y8331E00.htm.

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ȱȱȱȱ ȱ

According to the United Nations, maternal and neonatal45 mortality rates could be significantly

reduced if more women, particularly in Africa, had sufficient access to skilled health personnel

who are trained to detect problems early and can effectively provide or refer women to

emergency obstetric care. The United Nations has found that regions with the lowest proportions

of skilled health attendants at birth also have the highest number of maternal deaths.46 In subSaharan Africa, 1 of every 16 women who becomes pregnant will die from complications arising

during her pregnancy or childbirth. For comparison, the rate in industrialized countries is one in

3,800.47 Experts have also found that child survival rates are higher in areas with ample numbers

of health workers to administer immunizations, clean water, controlled mosquito populations, and

sufficient access to nutritious food.48

ȱȱȱȱ ȱ

Those who support integrating PEPFAR into other health programs contend that disease-specific

programs like PEPFAR fail to address adequately the intersection of diseases.49 Research has

demonstrated that since HIV weakens the immune systems of those infected, they are more

susceptible to a range of illness, including malaria. HIV-positive people are more likely to be

hospitalized and sickened by malaria than those not carrying the virus. According to WHO, Africa

is the only region in the world where incidence of new TB infections continues to rise, due in

large part to HIV/AIDS co-infection.50 In 2004, more than 740,000 people who contracted TB

were co-infected with HIV/AIDS.51 Some 600,000 of those co-infected with TB and HIV/AIDS

Neonatal refers to the first four weeks of life.

United Nations, The Millennium Development Goals Report: 2007, http://www.un.org/millenniumgoals/pdf/

mdg2007.pdf. While the greatest shortage of health care workers in absolute terms are in southeast Asia (mostly in

Bangladesh, India, and Indonesia), sub-Saharan Africa suffers from the greatest proportional shortage of health care

workers in the world. WHO estimates that there are 57 countries with critical shortages of health care workers, 36 of

which are in Africa and none of which are in industrialized nations. Globally, WHO estimates that an additional 4.3

million health workers are needed, and that Africa would need to increase its number of health workers by about 140%

in order to meet the minimum threshold of 2.5 health care professionals per 1,000 people. WHO, 2006 World Health

Report, http://www.who.int/whr/2006/en/.

United Nations, Africa and the Millennium Development Goals: 2007 Update, http://www.un.org/millenniumgoals/

docs/MDGafrica07.pdf.

Laurie Garrett, “The Challenge of Global Health,” Foreign Affairs, New York: January/February 2007, Vol. 86,

Issue 1, http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html.

See UNAIDS, 2006 AIDS Epidemic Update, and CDC, Interaction of HIV and Malaria, http://www.cdc.gov/malaria/

pdf/Malaria_HIV_Rick_website.pdf.

WHO, 2006 Global Tuberculosis Control Report, http://www.who.int/tb/publications/global_report/2006/en/. People

living with HIV/AIDS are at greater risk of becoming infected with TB because of their weakened immunity. Each

disease speeds up the progress of the other, and TB considerably shortens the survival of people with HIV/AIDS.

HIV/AIDS is the most potent risk factor for converting latent TB into active TB, while TB bacteria accelerate the

progress of AIDS. Many people affected by HIV/AIDS in developing countries develop TB as the first manifestation of

AIDS. In HIV/AIDS-positive people, TB is harder to diagnose, progresses faster, is almost always fatal if undiagnosed

or left untreated, and kills up to half of all AIDS patients worldwide. People with HIV/AIDS are up to 50 times more

likely to develop TB in a given year than HIV/AIDS-negative people. About 90% of people living with AIDS die

within four to twelve months of contracting TB if not treated.

Information in this paragraph summarized from WHO, 2006 Global Tuberculosis Control Report,

http://www.who.int/tb/publications/global_report/2006/en/.

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were found in sub-Saharan Africa, representing more than 80% of all co-infected cases. About

205,000 of the more than 248,000 co-infected patients who died from TB were African,

representing 83% of those deaths. Most poorly equipped health systems in Africa are unable to

contain TB, as they have limited case detection capacity; meager financing; too few health

workers in numbers and who are sufficiently trained; inconsistent drug supplies; and little means

to monitor and evaluate TB control programs.

ȱ ȱ¢ȱ

PEPFAR critics urge Congress to consider not only the degree to which resources are skewed

towards HIV/AIDS initiatives, but also what impact such unbalanced spending has on health

systems overall. Many global health experts maintain that the generous salaries and other

incentives (such as housing stipends) offered by donor-supported HIV/AIDS programs draw

health workers from public health facilities and threaten other life-saving interventions offered at

those clinics, such as maternal and child survival health initiatives.52

ȱ ȱȱȱ

According to WHO, the global shortage of health care workers is the single most important health

issue facing countries today.53 While the greatest shortages of health care workers in absolute

terms are in southeast Asia (mostly in Bangladesh, India, and Indonesia), sub-Saharan Africa

suffers from the greatest proportional shortage of health care workers in the world (Table 4).

WHO estimates that there are 57 countries with critical shortages of health care workers; 36 are in

Africa and none are in industrialized nations. Globally, WHO estimates that an additional 4.3

million health workers are needed, and that Africa would need to increase its number of health

workers by about 140% in order to meet the minimum threshold. None of the countries in Table 5

have enough doctors to meet the most basic health care needs; though when nurses and midwives

are included, some do meet the minimum standard. The amount and quality of health worker

numbers are positively associated with immunization coverage, outreach of primary care, as well

as infant, child, and maternal survival.

After the release of the World Bank’s report, International Migration, Remittances, and the Brain

Drain, a number of articles in the press featured the issue, and highlighted some of the data

provided in the work.54 It is estimated that 20,000 skilled professionals leave Africa each year.55

Erik Schouten, the HIV Coordinator for the Malawi Ministry of Health announced that over the

Child mortality refers to the death of children younger than five years, http://www.who.int/healthinfo/statistics/

mortchildmortality/en/index.html. “The Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86,

Issue 1, http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html. “Lack

of money can no longer be blamed for the poor world’s health problems,” The Economist, July 5, 2007.

http://www.economist.com/world/international/displaystory.cfm?story_id=9441391.

WHO, 2006 World Health Report: Working Together for Health, http://www.who.int/whr/2006/en/. The Joint

Learning Initiative (JLI), a network of global health leaders, defines a shortage as less than 2.5 health care professionals

per 1,000 people; the minimum proportion it deemed necessary to provide 80% of a country’s population with basic

health care (e.g., deliveries by skilled birth attendants and immunizations).

http://www.worldbank.org.

“Brain drain deprives Africa of vital talent.” Reuters, April 24, 2006 http://www.alertnet.org.

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last five years, the government had lost 53% of its health administrators, 64% of its nurses, and

85% of its physicians—mostly to foreign NGOs, largely funded by Britain, the United States, and

the Gates Foundation.56 According to Mr. Schouten, the Ministry is now implementing a program,

supported by PEPFAR, to attract Malawi health workers back to the country. Their tasks,

however, will be to distribute antiretoriviral medication. There is reportedly no support for

programs to attract health workers to treat malaria, diarrhea, and other common killers, such as

dysentery and respiratory infections.

. Number and Shortage of Doctors, Nurses, and Midwives

Table 4

WHO Region

Africa

Americas

Southeast Asia

Europe

Eastern

Mediterranean

Western Pacific

World

Source:

Number of Countries

With

Total Shortages

In Countries with Shortages

Total

Estimated

Increase

Workforce

Shortage

Required

590,198

93,603

2,332,054

not applicable

312,613

817,992

37,886

1,164,001

not applicable

306,031

192

27,260

3,355,728

32,560

2,358,470

139%

40%

50%

not applicable

98%

119%

70%

WHO, 2006 World Health Report.

Table 5. Distribution of Health Workers in Africa and the United States

Physicians

Country

Population

(2005)

Number

Angola

Cameroon

Ethiopia

Ghana

Mozambique

Nigeria

South Africa

Uganda

15,941,000

16,322,000

77,431,000

22,113,000

19,792,000

131,530,000

47,432,000

28,816,000

881

3124

1936

3240

514

34,923

34,829

2,209

Nurses

Midwives

Year

Number

Data

per

1,000 Number 1,000 Number 1,000 Collected

0.08

0.19

0.03

0.15

0.03

0.28

0.77

0.08

13,135

26,042

14,893

19,707

3,954

210,306

184,459

16,221

1.15

1.60

0.21

0.92

0.21

1.70

4.08

0.61

492

1,274

3,910

2,236

6,344

82,726

4,164

0.04

0.00

0.02

0.18

0.12

0.05

0.67

0.16

1997

2004

2003

2004

2003

2004

“The Challenge of Global Health,” Foreign Affairs, January/February 2007, Vol. 86, Issue 1

http://www.foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health.html.

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Physicians

Population

Country

Tanzania

Zimbabwe

(2005)

38,329,000

13,010,000

Nurses

Midwives

Year

Number

Data

per

Number 1,000 Number 1,000 Number 1,000 Collected

822

2,086

0.02

0.16

13,292

9,357

0.37

0.72

Africa

Total

738,086,000

150,561

0.22

663,572

0.96

United

295,410,000

730,801

2.56

2,669,603

9.37

125,142

not available

0.25

not available

2002

2004

variable

2000

States

Source: WHO, 2006 World Health Report.

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Ambassador Dybul asserted at the April 2007 House hearing that PEPFAR strengthens health

systems and expands the health workforce. This assertion counters the findings that the Institute

of Medicine published in its March 2007 report, PEPFAR Implementation: Progress and

Promise.57 Though IOM concluded that “PEPFAR has made a promising start,” it found PEPFAR

might further limit health care options for those not suffering from HIV/AIDS.

PEPFAR’s HIV/AIDS activities have sometimes negatively affected other aspects of public

health systems and exacerbated resource constraints, particularly those related to national

human resource settings. If Focus Countries’ national plans for expanding their health

workforce are not supported, PEPFAR might worsen national shortages by shifting a

disproportionate share of the workforce to HIV/AIDS activities, which might cause other

health areas to be neglected.... PEPFAR’s initial emergency approach to meeting personnel

needs has been to focus on HIV-specific training of existing clinicians and other health care

workers. Support for expansion of the professional clinical workforce has been limited, even

when such expansion is an explicit part of the country’s HIV/AIDS plan, and the effort is

endorsed and supported by other donors... PEPFAR Country Teams often expressed concern

that they were not allowed to fund activities unless those activities were specifically part of

the HIV/AIDS effort and so could not support, for example, the training of new clinical

officers, who in some countries are the mainstay of the treatment efforts.58

IOM recommended that OGAC work more closely with governments to analyze the impact that

PEPFAR-supported programs might have on public health systems, particularly in areas related to

maternal and child health and immunizations. IOM suggested that the analysis consider whether

PEPFAR’s incentives and salaries draw workers out of public systems and shift a disproportionate

share of the workforce to HIV/AIDS efforts. The report also asserted that PEPFAR should

increase support to the education of new health professionals.

http://www.iom.edu/CMS/3783/24770/41804.aspx.

Ibid.

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There is a growing consensus that health systems, including those that address HIV/AIDS, must

be strengthened in order for health interventions to be effective. On August 22, 2007, British

Prime Minister (name redacted) and German Chancellor Angela Merkel announced their intention

to launch an International Health Partnership (IHP) aimed at accelerating progress towards

reducing child and maternal mortality, combating infectious diseases, including HIV/AIDS, TB,

and malaria, and strengthening health systems.59 The leaders acknowledged in their statement that

the fragmented method of applying global health aid has reduced the effectiveness of aid, in large

part because donors compete for limited trained staff and implement the projects without

considering the countries’ priorities and structures.60 According to DFID, there are more than 40

bilateral donors and 90 global health initiatives each maintaining their own reporting

requirements and most focusing on specific health issues, such as HIV/AIDS.61 DFID asserts that

few global health efforts focus on activities that would strengthen struggling health systems, such

as training doctors and nurses, building clinics, or supporting basic health services. Parties62 of

the IHP commit to improving donor coordination, focusing on health systems rather than specific

diseases or health issues, and supporting the health plans of recipient countries. The leaders did

not indicate how much would be allocated towards this initiative or how it would be

implemented, though seven countries were identified as “first wave” partner countries.63

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Some health experts would like Congress to boost support for health systems research if it were to

extend PEPFAR.64 The Global Health Council estimates that less than 1% of research dollars are

spent on health systems research, though it could identify where health systems failures exist,

make health interventions more effective and affordable, and improve the accessibility of health

care.65 In HIV/AIDS programs, health systems research could help administrators develop

effective forecasting and distribution systems for drugs and other commodities and make stockouts and shortages of contraceptives, ARVs, and other commodities less frequent. Advocates

assert that health systems research could improve retention of health personnel, because they

would have sufficient tools to perform their jobs. Data from health systems research would reveal

10 Downing Street, PM announces International Health Partnership, August 22, 2007,

http://www.number-10.gov.uk/output/Page12903.asp.

Ibid.

DFID, The International Health Partnership Launched Today, September 5, 2007,

http://www.dfid.gov.uk/news/files/ihp/default.asp.

Bilateral donors include Britain, Canada, France, Germany, Italy, the Netherlands, Norway, and Portugal.

Foundations and international organizations include Africa Development Bank, Bill and Melinda Gates Foundation,

European Commission, The Global Fund to Fight AIDS, TB, and Malaria, the Global Alliance for Vaccines and

Immunization (GAVI) Alliance, UNAIDS, UNICEF, United Nations Population Fund (UNFPA), WHO, and the World

Bank.

The seven countries are Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal, and Zambia.

“Health systems” encompasses the personnel, institutions, commodities, information, and the financing of health care

delivery.

Global Health Council, Promoting Investments in Research to Strengthen Health Systems: Why and How, May 2006

http://www.globalhealth.org/images/pdf/publications/research_investments.pdf.

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which sort of care, prevention, and treatment programs are needed for the target population, and

which would make the programs more effective and efficient, proponents contend.

ȱȱȱ ȱȱ ȱ

Some have argued that structural adjustment programs mandated by international financial

institutions have led to a decline in public sector employment and limited investment in health

worker education.66 In many of the countries with health worker shortages, there are thousands of

unemployed health workers. While Kenya has a shortage of some 10,000 nurses in the public

sector, for example, thousands of unemployed nurses are leaving for Britain to find jobs, as the

Kenyan government is under a recruitment freeze due to World Bank and International Monetary

Fund (IMF) stipulations.67 Health sector reform, critics argue, has led to a decline in the quality of

education and training opportunities for medical students, a perpetual shortage of health supplies

and equipment (e.g., sanitation gloves and hyperdermic needles), insufficient medicine and

vaccine stocks, and “brain drain” of African health workers. According to WHO, on average each

year, the 57 countries with severe shortages of health workers spend an average of about $33 per

person on health (Table 6). The entire continent of Africa spends about 1% of the world’s

expenditure on health, the WHO contends. Comparatively, each year the United States spends

approximately $5,711 per capita on health.

Some analysts have expressed concern about the extent to which countries rely on the World

Bank to fund their health programs. The Bank estimates that it has lent $15 billion in health,

nutrition, and population funds from 1997 to 2006; an average of about $1.5 billion per year.68

Observers worry that the loans add to significant debt loads that many countries already face and

to which they commit considerable portions of their annual gross national products.69 In some

countries, governments are reportedly paying more on debt service than public health programs.

Oxfam estimates that of the 26 countries participating in the Highly Indebted Poor Countries

(HIPC) Initiative, half are still spending 15% or more of government revenues on debt

payments.70 Some health advocates urge Congress to use its vote to encourage the IMF to

maintain its debt relief commitments and accelerate its plans.

For debate on this issue, see “A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons Learned for

Controlling and Mitigating the Epidemic in Developing Countries,” American Journal of Public Health, July 2005,

Vol. 95, No. 7,

http://www.ajph.org/cgi/reprint/95/7/1162.pdf; “Toward Ethical Review of Health System Transformations,” American

Journal of Public Health, March 2006, Vol. 96, No. 3, http://www.ajph.org/cgi/content/abstract/96/3/447; and Center

for Global Development, Does the IMF Constrain Health Spending in Poor Countries, June 2007,

http://www.cgdev.org/content/publications/detail/14103/.

“Nurse Exodus Leaves Kenya in Crisis,” The Guardian Unlimited, May 21, 2006. http://www.guardian.co.uk/kenya/

story/0,,1779821,00.html.

World Bank, Health Development: The World Bank Strategy for Health, Nutrition, and Population Results. April

2007. http://www.worldbank.org.

“The Global HIV//AIDS Pandemic, Structural Inequalities, and the Politics of International Health,” American

Journal of Public Health, March 2002, Vol. 92, No. 3, http://www.ajph.org/cgi/reprint/92/3/343.pdf.

Oxfam, Debt Relief and the HIV/AIDS Crisis in Africa: Does the Heavily Indebted Poor Countries (HIPC) Initiative

Go Far Enough?, June 2002, http://www.oxfam.org/en/files/pp0206_no25_debt_relief_and_the_HIV_crisis.pdf.

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In the 110th Congress, legislation has been introduced in the House and Senate that authorizes

additional funds to voluntary family planning activities, improves coordination of HIV/AIDS and

other health initiatives, and strengthens supply chain logistics. The Focus on Family Health

Worldwide Act (H.R. 1225) would provide funds to expand access to voluntary family planning

programs in developing countries. The U.S. Commitment to Child Survival Act (S. 1418) would

provide assistance to improve the health of newborns, children, and mothers in developing

countries. The African Health Capacity Investment Act (S. 805) would amend the Foreign

Assistance Act of 1961 to assist countries in sub-Saharan Africa achieve internationally

recognized goals in the treatment and prevention of HIV/AIDS and other major diseases, reduce

maternal and child mortality, improve human health care capacity, and improve the retention of

medical health professionals.

Table 6. Spending on Health in Africa and the United States

General

Government External

Expenditure Resources

as % of

for Health

Total

Government Expenditure

Total

as % of Total

Expenditure on Health as Government Expenditure

on Health

% of GDP Expenditure on Health

Per Capita

Country

Angola

Cameroon

Ethiopia

Ghana

Mozambique

Nigeria

South Africa

Uganda

Tanzania

Zimbabwe

United

States

Population

Expenditure

(000)

on Health

15,490

16,038

75,600

21,664

19,424

128,709

47,208

27,821

37,627

12,936

295,410

$26.0

$37.0

$5.0

$16.0

$12.0

$22.0

$295.0

$18.0

$12.0

$40.0

$5,711.0

$41.0

$19.0

$12.0

$31.0

$28.0

$13.0

$258.0

$23.0

$16.0

$47.0

$2,548.0

2.8%

4.2%

5.9%

4.5%

4.7%

5.0%

8.4%

7.3%

4.3%

7.9%

15.2%

5.3%

8.0%

9.6%

5.0%

10.9%

3.2%

10.2%

10.7%

12.7%

9.2%

18.5%

6.7%

3.2%

26.0%

15.8%

40.8%

5.3%

0.5%

28.5%

21.9%

6.8%

0.0%

WHO, 2006 World Health Report.

Note: All figures reflect data collected in 2003, except population, which was collected in 2004.

Source:

ȱȱȱȱȱȱ¢ȱ

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UNAIDS estimates that there are 2.5 million children living with HIV around the world, up from

1.5 million in 2001. Nearly 90% of all HIV-positive children live in sub-Saharan Africa. The rate

at which children are contracting the virus is declining, however, with 460,000 having acquired

HIV in 2001 and 420,000 in 2007. AIDS is also killing fewer children. In 2001, 330,000 children

succumbed to the virus; in 2005, 360,000 died from AIDS. But in 2007, the number fell to an

estimated 330,000.

HIV/AIDS affects not only those children living with the virus, but also those who lose their

parents to the virus and who live in homes that have taken in orphans. Children who have been

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orphaned by AIDS may be forced to leave school, begin working to supplement lost income,

suffer from depression and anger, or engage in survival sex, an activity that heightens their risk of

contracting HIV. Children who live in homes that take in orphans may see a decline in the

quantity and quality of food, education, love, nurturing, and may be stigmatized. Impoverished

children living in households with one or more ill parent are also affected, as health care

increasingly absorbs household funds, which frequently leads to the depletion of savings and

other resources reserved for education, food, and other basic needs. A number of HIV/AIDS

advocates call for increased spending on programs, such as skills building, microcredit lending,

daycare subsidization, and education, for caretakers of children orphaned by HIV/AIDS. 71

The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 authorizes 10%

of HIV/AIDS funds to be used to support children affected by the virus. Some of PEPFAR’s

implementing partners have reportedly suggested that in areas with high HIV/AIDS prevalence,

all children should be considered affected by or made vulnerable by HIV/AIDS; and that in high

prevalence areas, programs should allow communities to define vulnerability related to their

contexts and to identify which children participate in programs.72

In the 109th Congress, Congress enacted the Assistance for Orphans and Other Vulnerable

Children in Developing Countries Act of 2005 (P.L. 109-95), which established a monitoring and

evaluation system to measure the effectiveness of related assistance activities; required the

Secretary of State to appoint a Special Advisor for Assistance to Orphans and Vulnerable

Children within USAID; and required an annual report on project implementation. Congress did

not appropriate funds for these activities.73 A number of HIV/AIDS advocates encourage

Congress to appropriate funds to make permanent and bolster the power and influence of the

Special Advisor. Those who would like for Congress to fund such a permanent position suggest

that the advisor would report directly to the Secretary of State and have independent authority to

approve and coordinate all U.S. spending on activities related to orphans and vulnerable children.

Supporters of this idea also maintain that the Special Advisor would need appropriations for an

office that would be similar in structure to the one at USAID for the President’s Malaria

Initiative. Proponents contend that the office’s staff would: 1) devise a comprehensive U.S.

strategy to address the needs of children affected by HIV/AIDS; 2) ensure efficient use of U.S.

funds by coordinating all related U.S. programs, including those funded by OGAC, USAID, and

other U.S. Departments, international organizations like UNICEF, and public private

partnerships; and 3) monitor, evaluate, and submit reports to Congress that detail U.S. spending

on related programs. Critics of this idea counter that this position would duplicate and add to the

overhead costs of implementing U.S. global HIV/AIDS activities.

According to UNAIDS, more than 2.5 million children and infants are living with HIV/AIDS

worldwide, representing more than 7% of all cases; and some 420,000 children under 15 years are

expected to contract the virus in 2007, almost 17% of all new HIV infections. OGAC asserts that

For more information on children affected by HIV/AIDS, see CRS Report RL32252, AIDS Orphans and Vulnerable

Children (OVC): Problems, Responses, and Issues for Congress, by (name redacted).

Interview with Global Action for Children, a PEPFAR implementing partner, on November 21, 2007.

P.L. 109-95; 22 U.S.C. 2152f note. The act amended the Foreign Assistance Act of 1961 (P.L. 87-195) at Section

135 (22 U.S.C. 2152f) to establish the new program and position.

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children have disproportionately low access to HIV treatment and care relative to adult

populations in most developing countries. Without treatment and care, approximately 50% of all

HIV-positive children will die before age two and 75% will die before age five.74 Some advocates

for children urge Members to increase spending on pediatric HIV/AIDS ARVs so that funding

meets the needs of children without access to treatment. OGAC estimates that in FY2006, it

allocated 9% of all spending on ARVs to children.75

ȱȱȱȱȱ

HIV/AIDS analysts advocate that other countries where the virus is rapidly spreading be included

in GHAI. In Eastern Europe and Central Asia, HIV has become more entrenched. According to

UNAIDS, the number of people living with HIV in those regions has increased by more than

150% since 2001. An estimated 1.6 million people are living with HIV/AIDS in the region, up

from 630,000 in 2001. Nearly 90% of newly reported HIV diagnoses in this region in 2006 were

from two countries: the Russian Federation (66%) and Ukraine (21%).

A number of health experts are also concerned about the HIV/AIDS epidemic in the Caribbean.

Estimates indicate that prevalence rates have largely stabilized in the region, though they remain

high in Haiti and the Dominican Republic.76 Nearly 75% of all people living with HIV/AIDS in

the Caribbean reside in the two countries. Some 230,000 people are HIV-positive in the

Caribbean, of whom 11,000 UNAIDS expect to die from the virus. In February 2007,

Representative Luis Fortuño introduced H.R. 848, to Amend the State Department Basic

Authorities Act of 1956 to Authorize Assistance to Combat HIV/AIDS in Certain Countries of the

Caribbean Region.

Some caution that before Members consider expanding the number of Focus Countries, Congress

might first need to determine the extent of its commitment to supporting global HIV/AIDS

efforts. A number of HIV/AIDS advocates point out that HIV/AIDS is a chronic disease that

requires long-term care. In order for countries to assume ownership of HIV/AIDS initiatives and

expand them, this view holds, they must first know how much support to expect from the United

States and for how long that support might last.

Elizabeth Glaser Pediatric AIDS Foundation, “In the Battle Against HIV/AIDS, Equal Treatment for Children,”

October 19, 2007, http://www.pedaids.org/News/Publications/Fact%20Sheet/PEPFAR%20Fact%20Sheets.aspx.

PEPFAR webiste, “Pediatric Treatment and Care,” June 2007, http://www.pepfar.gov/pepfar/press/86524.htm.

The 2007 AIDS Epidemic Update did not provide 2007 prevalence estimates for Haiti and the Dominican Republic.

The report did indicate, however, that prevalence appears to have declined in Haiti since 1996. Among pregnant

women attending antenatal clinics, HIV prevalence fell from 5.9% in 1996 to 3.1% in 2004, and appeared to have

stabilized in 2006. UNAIDS attributes the declining trend to decreasing infection levels in the capital, Port-au-Prince,

and other cities, where HIV prevalence among 15 – 44-year-old women fell from 5.5% to 3% between 2000 and 2005.

The report also indicated that prevalence rates appears to have stabilized in Dominican Republic.

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ARV

DFID

FAO

FDA

GAO

GHAI

HIPC

HIV/AIDS

IHP

IMF

IOM

JLI

MTCT

NIH

NGO

OAR

OGAC

PEPFAR

PMI

PMTCT

UNAIDS

USAID

WFP

WHO

Glossary of Abbreviations and Acronyms

Anti-Retroviral medication

Department for International Development

United Nations Food and Agriculture Organization

U.S. Food and Drug Administration

Government Accountability Office

Global HIV/AIDS Initiative

Highly Indebted Poor Countries

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

International Health Partnership

International Monetary Fund

Institute of Medicine

Joint Learning Institute

Mother-to-Child Transmission

National Institutes of Health

Non-Governmental Organization

Office of AIDS Research

Office of Global AIDS Coordinator

President’s Emergency Plan For AIDS Relief

President’s Malaria Initiative

Prevention of Mother-to-Child Transmission

Tuberculosis

Joint United Nations Program on HIV/AIDS

U.S. Agency for International Development

World Food Program

World Health Organization

ȱȱ ȱ

(name redacted)

Specialist in Global Health

[redacted]@crs.loc.gov, 7-....

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