[Congressional Record Volume 153, Number 126 (Thursday, August 2, 2007)]
[Senate]
[Pages S10807-S10809]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. LUGAR:
  S. 1966. A bill to reauthorize HIV/AIDS assistance; to the Committee 
on Foreign Relations.
  Mr. LUGAR. Mr. President, I rise to introduce legislation to 
reauthorize the U.S. Leadership Against HIV/AIDS, Tuberculosis and 
Malaria Act of 2003, known as the Leadership Act, the largest 
international health initiative in history dedicated to a single 
disease.
  Five years ago, there was little hope in Africa and the developing 
world of an effective response to HIV/AIDS. Tragically, many of the 
nations hardest hit by this disease are among those with the fewest 
resources to draw on for a response. There appeared to be little basis 
for hope.
  Today, the pandemic continues. Yet there has been a change, and the 
American people have led that change.
  The original Leadership Act authorized $15 billion in appropriations 
over 5 years. And in a significant departure from earlier approaches to 
development, it linked that funding to accountability for goals: 
support for treatment of 2 million people, prevention of 7 million new 
infections, care for 10 million people, including orphans and 
vulnerable children.
  As many Senators will recall, when this legislation was first enacted 
in 2003, it was done with a certain amount of haste and after a request 
from the President for quick action. The G-8 summit was fast 
approaching, but even more importantly, rapid Senate action meant that 
the program could be established quickly, so that money could start to 
flow quickly to the fight. Given this, the Senate acted swiftly, 
passing the bill almost without amendment.
  Now we are approaching the expiration of that 5-year authorization at 
the end of fiscal year 2008. Whatever our misgivings about the 
Leadership Act as we enacted it in 2003, at this point we need to judge 
it by the results it has enabled us to deliver. Those results are 
simply remarkable.
  At the time the Leadership Act was announced, only 50,000 people in 
all of sub-Saharan Africa were receiving antiretroviral treatment. Yet 
through March of this year, the act has supported treatment for over 
1.1 million men, women and children, over a million of them are in 
Africa, in those 15 countries where AIDS was on the verge of wiping out 
whole generations. In addition to these focus countries, we are working 
with one hundred other countries as well touching millions of other 
lives. Five years ago, HIV was a death sentence. Now there is hope.
  During the first 3\1/2\ years of the act, U.S. bilateral programs 
have supported services for pregnant women to avoid transmission of HIV 
to their babies during more than 6 million pregnancies. In over 533,000 
of those pregnancies, the women were found to be HIV-positive and 
received antiretroviral prophylaxis, preventing an estimated 101,000 
infant infections through March 2007.
  Before the advent of the Leadership Act, there was little concerted 
effort to meet the needs of those orphaned by AIDS, or of other 
children made vulnerable by it. We have now supported care for more 
than 2 million orphans and vulnerable children, as well as 2.5 million 
people living with HIV/AIDS, through September 2006.
  Effective prevention, treatment and care all depend to a large extent 
on people knowing their HIV status, so they can take the necessary 
steps to stay healthy. The U.S. has supported 18.7 million HIV 
counseling and testing sessions for men, women and children.
  Across the act's programs, the majority of services have been 
provided to women and girls, and a growing number of services are 
reaching children.
  Our financial investment in this fight has been critical to our 
success, and thanks in large part to the flexibility of the Leadership 
Act, we have been able to obligate over 94 percent of its available 
$12.3 billion appropriated through this fiscal year.
  In addition to support for the U.S. bilateral programs, the 
Leadership Act has also authorized support for the Global Fund to Fight 
AIDS, Tuberculosis, and Malaria. The Global Fund provides an important 
avenue for the rest of the world to substantially increase its 
commitment, as we have done. The U.S. is the largest supporter of the 
Global Fund, having provided some $2 billion so far. It is important 
for the American people to understand and for the rest of the world to 
remember, that the American people are responsible for approximately 
\1/3\ of all the funding received by the fund.
  As we survey the results achieved by this legislation, it is apparent 
that our efforts have been exceptionally successful. But to build on 
that success, we must reauthorize the legislation for another 5 years. 
As we consider how to accomplish that reauthorization task, it is 
important to note that the vast majority of the authorities needed for 
the next phase of our effort are already contained in the current 
Leadership Act.
  The necessity for new authorities is in the eye of the beholder. Many 
Senators may wish to enhance issues such as TB/HIV, gender, nutrition, 
human capacity, infrastructure and health systems, and education. But 
the current law already articulates and authorizes activities in these 
very same areas, as evidenced by the many activities in these areas 
that the act has undertaken under existing authorities.
  In this case, I believe we should follow the old adage, ``If it ain't 
broke, don't fix it.'' We have a good, if not perfect, law that is 
succeeding. In lieu of drafting an entirely new bill, today I introduce 
a reauthorization which preserves the bulk of the authorities that have 
enabled the program succeed and makes only minor modifications.
  The U.S. Global AIDS Coordinator has interpreted the existing 
authorities well and has listened to the Congress and many 
stakeholders. As the Institute of Medicine recently said, the Global 
Leadership Act is a ``learning organization.'' The Coordinator is the 
first to admit, as he has before Congressional committees, that we can 
do better in every area of implementation. But new authorities are not 
needed; these are issues of implementation. In short, rather than 
absorbing the time of Congress, the coordinator, as well as 
stakeholders in drafting an entirely new bill, we should empower them 
to continue the work they are doing to improve upon program 
implementation utilizing the experience of these past 3\1/2\ years.

[[Page S10808]]

  Let me highlight the basic changes I am suggesting to the existing 
legislation. First, it would increase to $30 billion the authorization 
for the next five fiscal years 2009-2013, a doubling of the initial 
commitment. I recognize that Senators may wish to revisit that funding 
level, and I trust that there will be opportunities for them to do so, 
in committee and on the floor.
  Second, as the Institute of Medicine and others have argued, I 
believe we need to keep the bill as free of funding directives as 
possible in order to ensure maximum flexibility for implementation. I 
am proposing that only two funding directives be included, one modified 
from its current form, the other maintained as is.
  The first modification would seek to address the abstinence directive 
in current law. The current Leadership Act requires that 33 percent of 
all prevention funding be spent on abstinence-until-marriage programs. 
The problem with this directive is that some countries need to focus 
their efforts not on abstinence per se but on, for example, mother-to-
child transmission, an activity which is considered to be nonsexual 
transmission of HIV/AIDS. The original directive thus forced theses 
countries to either spend money in areas where they did not necessarily 
need to spend it or to divert funds from areas where they truly needed 
to.
  The administration had interpreted and implemented this provision so 
as to include both abstinence and faithfulness programs, the `AB' of 
`ABC,' which stands for Abstinence, Be faithful, and the correct and 
consistent use of condoms. The directive has been helpful in ensuring 
an evidence-based, comprehensive approach to prevention. The ABC 
paradigm for prevention was developed in Africa by Africans, in order 
to address the wide range of risks faced by people within their 
nations, particularly in the context of generalized epidemics where HIV 
is widespread throughout the population. Recent evidence from a growing 
number of African countries shows a correlation between the adoption of 
all three of the ABC behaviors, and a clear association with declining 
HIV prevalence.
  Before the creation of the U.S. Global Aids Coordinator, the U.S. 
Government had relatively little experience implementing behavior 
change programs for global HIV/AIDS that included the whole array of 
ABC behavior change. This was the rationale for the directive, and I 
believe it has served a useful purpose. However, I agree with many 
others that we can improve upon it as we look to the future.
  The language I propose would provide that 50 percent of funding for 
prevention of sexual transmission of HIV, a sub-set all prevention 
funding, be dedicated to abstinence and faithfulness. This will enable 
greater flexibility to countries whose situation mirrors the one just 
described.
  At the same time, the language would ensure the continuation of 
funding for abstinence and faithfulness programs as part of 
comprehensive, evidence-based ABC activities. I think this compromise 
approach is the right one that can win support from across the 
political spectrum and provide increased flexibility while ensuring 
continued support for comprehensive, evidence-based prevention.
  There are a number of other directives in the current law that need 
no longer be maintained and the new bill does not contain them. The one 
other directive that I believe must be maintained is that 10 percent of 
funding be devoted to programs for orphans and vulnerable children, or 
``OVCs''. As I have noted, there were few programs focused on the needs 
of these children before the Leadership Act of 2005 and we remain in 
the early stages of the essential effort to serve them. This is one of 
the aspects of our effort that is most strongly supported by the 
American people, the maintenance of this directive will help to ensure 
that this effort remains focused on those who need our support the 
most. The directive will also help ensure the success of the Assistance 
for Orphans and Other Vulnerable Children in Developing Countries Act 
of 2005, a bill I drafted, one cosponsored by eleven of my Senate 
colleagues, and which the Congress passed in October 2005.
  Finally, let me describe some new language proposed for the inclusion 
regarding the Global Fund, an organization that enjoys wide support 
here in Congress. The Global Fund is a critically important partner of 
the U.S. in our fight against HIV/AIDS. Our contributions are not only 
financial, we are also active on its board, and our U.S. personnel 
overseas provide the technical assistance needed for the Global Fund's 
grants to work.
  However, the fund is subject to pressures from many donors and in 
many directions. It has become clear that it would benefit from greater 
transparency and accountability. In keeping with my concerns with 
transparency and accountability of international organizations that 
receive U.S. funding, including the World Bank and International 
Monetary Fund, my proposed language would establish similar benchmarks 
for U.S. funding for the Global Fund. I don't believe any of these 
proposed benchmarks will be controversial, but if Senators have 
concerns about any of them, I look forward to working with them to 
address them.
  It is also worth noting that the bill would maintain the limitation 
in the existing Leadership Act that U.S. contributions to the fund may 
never exceed 33 percent of its funding from all sources. This 
limitation has proven to be a valuable tool for increasing 
contributions to the fund from other funding sources, such as other 
governments, and I believe there is wide agreement that this provision 
should be maintained as we move forward.
  In closing, let me turn to the issue of legislative timing. It is 
critical to the contents of my approach to reauthorization. It is 
critically important to reauthorize this bill during 2007, as opposed 
to awaiting its expiration September 2008.
  The US Global Aids Coordinator depends on his implementing partners, 
including host governments and nongovernmental organizations, including 
faith- and community-based organizations, to scale up programs rapidly 
to reach as many people as possible. They have been a critical part of 
programs success to date.
  But HIV and AIDS are different from many diseases: once HIV-positive 
persons are provided treatment or orphans enrolled in care programs, 
their treatment and care become ongoing commitments for program 
partners. Thus, for partners to continue to scale up programs in 2008, 
they need assurances of a continued U.S. commitment beyond 2008. These 
partners recognize that at this point, they have only a Presidential 
proposal, not actual reauthorization.
  In fact, some of my staff on the Foreign Relations Committee have 
recently returned from countries receiving our assistance and verified 
this concern. Various ministries of health are refusing to expand the 
number of patients currently receiving antiretroviral medication for 
fear that they will not receive enough money in the years to come to 
purchase next year's doses for these new patients.
  Without reauthorization in 2007, partners have indicated that they 
will be unable to scale up programs in 2008, and as my staff have 
confirmed, there is already evidence that some have begun to slow 
enrollment in programs. Without continued rapid scale-up this year and 
next, we may not achieve the ambitious goals for the first phase of 
PEFPAR, treatment for 2 million, prevention of 7 million new 
infections, care for 10 million, including orphans and vulnerable 
children. However, time will be needed to develop sustainable programs 
with commitments from our partner countries as we move into the next 5-
year commitment from the American people.
  Thus it is essential that we act before we go out of session this 
year. I recognize that we face a crowded calendar. But we can do it if 
we will take the most direct path to passage, a clean bill.
  This body can be proud of its contribution to the remarkable 
turnaround on the issue of global HIV/AIDS, from concern to action. We 
have represented well the compassion and generosity of the American 
people and the demand for accountability by the American taxpayer. I 
call on my colleagues to join me in sponsoring this bill to reauthorize 
the Leadership Act in 2007, and to extend the authorities that have 
enabled the American people to make such a difference in the lives of 
others.
  I have no pride of authorship. But we need to start the 
reauthorization process now. I welcome the involvement

[[Page S10809]]

and inputs of my colleagues. We should let the mark-up and amendment 
process work. Secondly, I would welcome the assistance of other 
Committees and their memberships. Thirdly, I look for strong support 
and guidance from the NGO and faith-based communities. These 
organizations will be key to the reauthorization effort. We will 
require the constructive engagement of the administration in this 
reauthorization effort.
  If we pull together and display the spirit of compromise necessary 
for good legislation, we can complete the job in 2007.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1966

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``HIV/AIDS Assistance 
     Reauthorization Act of 2007''.

     SEC. 2. AUTHORIZATION OF APPROPRIATIONS.

       Section 401(a) of the United States Leadership Against HIV/
     AIDS, Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 
     7671(a)) (in this Act referred to as the ``Act'') is amended 
     by inserting after ``2008'' the following: ``, 
     $30,000,000,000 for fiscal years 2009 through 2013, and such 
     sums as may be necessary for each fiscal year thereafter''.

     SEC. 3. MODIFICATIONS TO ALLOCATION OF FUNDS.

       (a) Promotion of Abstinence, Fidelity, and Other 
     Preventative Measures.--Section 403(a) of the Act (22 U.S.C. 
     7673(a)) is amended to read as follows:
       ``(a) Promotion of Abstinence, Fidelity, and Other 
     Preventative Measures.--Not less than 50 percent of the 
     amounts appropriated pursuant to the authorization of 
     appropriations under section 401 and available for programs 
     and activities that include a priority emphasis on public 
     health measures to prevent the sexual transmission of HIV 
     shall be dedicated to abstinence and fidelity as components 
     of a comprehensive approach including abstinence, fidelity, 
     and the correct and consistent use of condoms, consistent 
     with other provisions of law and the epidemiology of HIV 
     infection in a given country. Programs and activities that 
     implement or purchase new prevention technologies or 
     modalities such as medical male circumcision, pre-exposure 
     prophylaxis, or microbicides shall not be included in 
     determining compliance with this subsection.''.
       (b) Extension of Orphans and Vulnerable Children Funding 
     Requirement.--Section 403(b) of the Act (22 U.S.C. 7673(b)) 
     is amended by striking ``2008'' and inserting ``2013''.

     SEC. 4. FINDINGS AND PURPOSE.

       (a) Findings.--Congress makes the following findings:
       (1) On May 30, 2007, President George W. Bush announced his 
     intent to double the commitment of the United States to fight 
     global HIV/AIDS with a new $30,000,000,000, 5-year proposal 
     to reauthorize the United States Leadership Against HIV/AIDS, 
     Tuberculosis, and Malaria Act of 2003.
       (2) With the enactment of the President's fiscal year 2008 
     budget, the United States Government will have committed 
     $18,000,000,000 to the President's Emergency Plan for AIDS 
     Relief (PEPFAR), which exceeds the original 5-year, 
     $15,000,000,000 commitment.
       (3) After 3 years of PEPFAR implementation, the American 
     people have supported treatment of 1,100,000 people in the 15 
     focus countries, including more than 1,000,000 people in 
     Africa.
       (4) PEPFAR is on track to meet its 5-year goals to support 
     treatment for 2,000,000 people, prevention of 7,000,000 new 
     infections, and care for 10,000,000 people, including orphans 
     and vulnerable children.
       (5) The success of PEPFAR is rooted in support for country-
     owned strategies and programs with commitment of resources 
     and dedication to results, achieved through the power of 
     partnerships with governments, with nongovernmental, faith-
     based, and community-based organizations, and with the 
     private sector.
       (6) United States efforts to address global HIV/AIDS will 
     be multiplied by engaging in partnerships with countries 
     dedicating to fighting their HIV epidemics and with 
     multilateral partners, such as the Global Fund, which can 
     help leverage international resources and build upon the 
     efforts of the United States to combat global HIV/AIDS. In 
     his announcement of his intent to double the commitment of 
     the United States to fight global HIV/AIDS, President Bush 
     reiterated his call for developed and developing countries, 
     in particular middle-income countries where projections 
     suggest many new infections will occur, to increase their 
     contributions to fighting AIDS. HIV/AIDS is a global crisis 
     that requires a global response. The United States currently 
     provides as many resources for global HIV/AIDS as all other 
     developed country governments combined. But only together can 
     we turn the tide against the global epidemic.
       (b) Purpose.--It is the purpose of this Act to expand 
     PEPFAR, including the expansion of life-saving treatment, 
     comprehensive prevention programs, and care for those in 
     need, including orphans and vulnerable children, in the next 
     5-year period as a signal of the commitment of the United 
     States to support, strengthen, and expand United States and 
     global efforts to address these health crises in partnership 
     with others.

     SEC. 5. UNITED STATES FINANCIAL PARTICIPATION IN THE GLOBAL 
                   FUND.

       (a) Authority to Increase Proportional Support.--Section 
     202(d) of the Act (22 U.S.C. 7622(d)) is amended by adding at 
     the end the following new paragraph:
       ``(5) Authority to increase proportional support.--
       ``(A) Findings.--Congress makes the following findings:
       ``(i) The Global Fund to Fight AIDS, Tuberculosis and 
     Malaria is an innovative financing mechanism to combat the 
     three diseases, and it has made progress in many areas.
       ``(ii) The United States Government is the largest 
     supporter of the Fund, both in terms of resources and 
     technical support.
       ``(iii) The United States made the founding contribution to 
     the Funds, remains committed to the original vision for the 
     Fund, and is fully committed to its success.
       ``(B) Authority.--The President may increase proportional 
     support for the Fund, within the amount authorized to be 
     appropriated by this Act, if benchmarks for performance, 
     accountability, and transparency are satisfactorily met, and 
     if the Fund remains committed to its founding principles. The 
     United States Global AIDS Coordinator should consider the 
     benchmarks set forth in subparagraphs (C) and (D) in 
     assessing whether to make the annual contribution of the 
     United States Government to the Fund.
       ``(C) Benchmarks related to transparency and 
     accountability.--Increased proportional support for the Fund 
     should be based upon achievement of the following benchmarks 
     related to transparency and accountability:
       ``(i) As recommended by the Government Accountability 
     Office, the Fund Secretariat has established standardized 
     expectations for the performance of Local Fund Agents (LFAs), 
     is undertaking a systematic assessment of the performance of 
     LFAs, and is making available for public review, according to 
     the Fund Board's policies and practices on disclosure of 
     information, a regular collection and analysis of performance 
     data of Fund grants, which shall cover both Principal 
     Recipients and sub-recipients.
       ``(ii) A well-staffed, independent Office of the Inspector 
     General reports directly to the Board and is responsible for 
     regular, publicly published audits of both financial and 
     programmatic and reporting aspects of the Fund, its grantees, 
     and LFAs.
       ``(iii) The Fund Secretariat has established and is 
     reporting publicly on standard indicators for all program 
     areas.
       ``(iv) The Fund Secretariat has established a database that 
     tracks all sub-recipients and the amounts of funds disbursed 
     to each, as well as the distribution of resources, by grant 
     and Principal Recipient, for prevention, care, treatment, the 
     purchases of drugs and commodities, and other purposes.
       ``(v) The Fund Board has established a penalty to offset 
     tariffs imposed by national governments on all goods and 
     services provided by the Fund.
       ``(vi) The Fund Board has successfully terminated its 
     Administrative Services Agreement with the World Health 
     Organization and completed the Fund Secretariat's transition 
     to a fully independent status under the Headquarters 
     Agreement the Fund has established with the Government of 
     Switzerland.
       ``(D) Benchmarks related to principles of fund.--Increased 
     proportional support for the Fund should be based upon 
     achievement of the following benchmarks related to the 
     founding principles of the Fund:
       ``(i) The Fund must maintain its status as a financing 
     institution.
       ``(ii) The Fund must remain focused on programs directly 
     related to HIV/AIDS, malaria, and tuberculosis.
       ``(iii) The Fund Board must maintain its Comprehensive 
     Funding Policy, which requires confirmed pledges to cover the 
     full amount of new grants before the Board approves them.
       ``(iv) The Fund must maintain and make progress on 
     sustaining its multi-sectoral approach, through Country 
     Coordinating Mechanisms (CCMs) and in the implementation of 
     grants, as reflected in percent and resources allocated to 
     different sectors, including governments, civil society, and 
     faith- and community-based organizations.''.
       (b) Extension of Authorization.--Section 202(d) of such Act 
     is further amended by striking ``2008'' each place it appears 
     and inserting ``2013''.
                                 ______