[Congressional Record Volume 159, Number 182 (Friday, December 20, 2013)]
[Senate]
[Pages S9094-S9095]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                                 PEPFAR

  Mr. COBURN. Madam President, PEPFAR has been and remains one of the 
most successful foreign policy achievements of the United States in the 
21st century. This unprecedented humanitarian effort has touched 
millions, either through providing lifesaving HIV/AIDS treatment, 
keeping together families impacted by the disease, caring for orphans, 
or improving the lives of others affected and infected by this horrible 
disease as well as tuberculosis and malaria. In an era of war abroad 
and deep political divisions at home, this program is one that has 
bipartisan support here and has generated good will toward the United 
States abroad. Every American should be proud of the success of this 
initiative as it represents what is great about our Nation and has 
restored hope for so many.
  The Senate Foreign Relations Committee worked hard to get S. 1545, 
the PEPFAR Stewardship and Oversight Act, through this Chamber. I thank 
Chairman Menendez and Ranking Member Corker for their cooperation and 
attentiveness in the process. This bill, which became law on December 
2, is a positive step toward increasing program transparency and 
accountability in PEPFAR's annual report. It also renews and 
strengthens several components of the last reauthorization, including 
Global Fund governance provisions and the requirement that more than 50 
percent of PEPFAR's appropriations to be spent on treatment and 
essential medical care.
  This latter component, the treatment spending requirement, is one of 
the key accountability provisions my colleagues and I fought for in the 
past. In short, PEPFAR is required to spend at least 50 percent of its 
appropriations on essential medical treatment and care. Members on both 
sides of the aisle voted for authorizations with this treatment floor. 
Congress sought to prevent the program from straying from its core 
mission of treating and caring for patients. If PEPFAR were to lose 
sight of this goal, the result would not just be a waste of money, it 
would be lives lost on account of mission creep. We cannot let PEPFAR 
become another well-intentioned but unfruitful and nebulous 
international development program.
  This statutory treatment floor has changed somewhat over the last 
decade, but the purpose has remained the same throughout: to focus more 
than half of PEPFAR's total appropriations on essential treatment and 
medical care. Unfortunately, as I will discuss in a moment, the Office 
of the U.S. Global Coordinator, OGAC, at the Department of State has 
not been following this law. Rather, it has excluded a significant 
portion of its appropriations from the calculation and is now spending 
less than is statutorily required on treatment and care.
  The original PEPFAR authorization in 2003, P.L. 108-25, first 
included a treatment spending floor that said, ``Not less than 55 
percent of the amounts appropriated pursuant to the authorization of 
appropriations . . . shall be expended for therapeutic medical care of 
individuals infected with HIV, of which such amount at least 75 percent 
should be expended for the purchase and distribution of antiretroviral 
pharmaceuticals and at least 25 percent should be for related care.''
  Similarly, the full reauthorization of PEPFAR in 2008, P.L. 110-293, 
included a treatment requirement that said, ``More than half of the 
amounts appropriated for bilateral global HIV/AIDS assistance . . . 
shall be expended for . . . (1) antiretroviral treatment for HIV/AIDS; 
(2) clinical monitoring of HIV-seropositive people not in need of 
antiretroviral treatment; (3) care for associated opportunistic 
infections; (4) nutrition and food support for people living with HIV/
AIDS; and (5) other essential HIV/AIDS-related medical care for people 
living with HIV/AIDS.''
  This version expanded somewhat on the original category of 
``therapeutic medical care,'' but Congress maintained a minimum 
percentage of appropriations intended for direct care and treatment 
services.
  Lastly, the recent PEPFAR legislation, S.1545, now P.L. 113-56, 
reiterates and even clarifies the treatment requirement further. This 
new law says more than half of the funds appropriated for activities 
under section 104A of the Foreign Assistance Act--which contains all of 
PEPFAR's functions ranging from drug treatment to training health 
professionals and capacity building--need to be going to these five 
categories of essential medical treatment and care.
  None of these definitions from laws in 2003, 2008, or 2013 has 
allowed for an exclusion of certain components of PEPFAR's funding from 
the treatment calculation. No appropriations bill has implemented an 
exception to the calculation. The charge and requirement has always 
been to examine total PEPFAR appropriations in a given year and ensure 
at least half goes to services in these five categories.

[[Page S9095]]

  As I said previously, PEPFAR management has not been abiding by the 
letter of the law. The Office of the U.S. Global AIDS Coordinator at 
the Department of State has been excluding several spending categories 
from the treatment and care calculation. A smaller denominator makes it 
easier for the program to meet the treatment calculation. In reality, 
hundreds of millions of dollars more should be going to treatment and 
care if the law were followed. Millions more patients could be 
receiving lifesaving antiretroviral treatment.
  A Government Accountability Office report released in March 2013 
highlighted how OGAC has been excluding a significant portion of PEPFAR 
appropriations, categorized as ``Other'' activities, from this 
calculation. In fiscal year 2008, this ``Other'' category accounted for 
about 15 percent of PEPFAR country budgets, or $574 million. By fiscal 
year 2012, the category increased to 21 percent of PEPFAR country 
budgets, or $710 million. Over the same timeframe, total spending on 
treatment and care decreased from $1.8 billion to $1.4 billion.
  This ``Other'' category includes spending for health systems 
strengthening, strategic information, management and operations, and 
laboratory strengthening. OGAC told GAO it had excluded the ``Other'' 
category based on OGAC's interpretation of the intent of the treatment 
spending requirement. They have also not included any of OGAC's 
administrative costs.
  As one directly involved with PEPFAR throughout my time in the 
Senate, I can say firmly the treatment spending requirement was 
intended for all of PEPFAR's appropriations, not just a portion.
  PEPFAR's operational plan for fiscal year 2011 shows that PEPFAR 
received about $5.0 billion for all bilateral activities, including 
headquarters administrative costs. To be meeting the treatment spending 
requirement as written, PEPFAR should have planned to spend about $2.5 
billion on treatment and care. Instead, it spent $1.6 billion. That 
figure about $900 million short of what should be going to direct 
treatment and care services that fit the categories already in law.
  I understand the need for PEPFAR to invest in some capacity building 
and other ancillary development. A nation needs labs to check HIV test 
results, for example. Labs and clinics need health professionals, and a 
host government needs to be able to track the program results. However, 
we have seen time and again how development programs get off track, 
lose focus, and fail to meet their goals. They spend money on 
activities that are noble but ineffective. For example, in 2012, the 
U.S. Agency for International Development used millions of dollars to 
fund an economic development program in Morocco that included pottery 
classes, even though Moroccans have been making pottery for thousands 
of years. Not only so, but the classes were poorly designed. The 
instructor only used materials not available in Morocco, and the 
class's translator was not fluent in English. Ultimately, the 
development program failed.
  To prevent mission creep and failure, Congress put a treatment and 
care requirement in law to ensure more than half of go to direct 
treatment and care services, which have a clear and measurable impact 
on the lives of those living with this HIV/AIDS.
  I call on PEPFAR to follow the letter of the law when it comes to 
spending on treatment and care. All PEPFAR appropriations should be 
entered into the denominator of this equation. No funding will be lost 
from doing so. Rather, hundreds of millions of additional dollars will 
be going to essential treatment and care. Millions of new patients 
could start receiving new life.
  I will continue to monitor whether PEPFAR is following this 
definition in the future. Given that 26 million people worldwide need 
antiretroviral treatment, we cannot afford to let PEPFAR get off track.
  Mr. CORKER. Mr. President, first, I want to say I appreciate Senator 
Coburn's work on the PEPFAR Program. He has been a tireless advocate 
and has made this program better, more efficient, and more focused. 
PEPFAR has saved millions of lives since President Bush signed it into 
law in 2003. I was pleased to work with Chairman Menendez and our 
colleagues in the House on legislation, the PEPFAR Stewardship and 
Oversight Act, which continues its important work, and I truly 
appreciate the support Senator Coburn offered to this critical effort. 
PEPFAR is the single most successful program to date to address the 
HIV/AIDS epidemic in Africa and the largest commitment by any nation to 
combat a single disease internationally. In fact, due to PEPFAR, almost 
6 million people are receiving life-sustaining antiretroviral 
treatment, millions have avoided infection, and more than 11 million 
pregnant women received HIV testing and counseling last year. PEPFAR 
has also provided care and support to nearly 15 million people, 
including more than 4.5 million orphans and vulnerable children. This 
is significant progress, but there is still work to do. The PEPFAR 
Stewardship and Oversight Act renews Congress's commitment to this 
vital program and ensures this work will continue our progress towards 
an AIDS-free generation.
  As my colleague Senator Coburn has stated, a provision in the PEPFAR 
Stewardship and Oversight Act extends authority from the Tom Lantos and 
Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, 
and Malaria Reauthorization Act of 2008 that requires ``more than half 
of the amounts appropriated for bilateral global HIV/AIDS assistance'' 
be spent on programs that provide treatment and care to HIV/AIDS 
patients. We included an extension of this authority in the 2013 bill 
because it is important to ensure the program remains focused on 
treating and caring for patients. The plain language of the provision 
requires the ``more than half'' calculation to be made on all ``amounts 
appropriated or otherwise made available to carry out the provisions of 
section 104A of the Foreign Assistance Act of 1961.'' We expect this 
requirement to be followed going forward.
  I look forward to working with Senator Coburn and the Office of the 
Global AIDS Coordinator to ensure that the provision as intended by 
Congress is properly carried out.
  Mr. CORKER. Mr. President, the Globe Fund to Fight AIDS, Tuberculosis 
and Malaria has recently made significant improvements and reforms, 
including building new data collection and reporting mechanisms. S. 
1545, the PEPFAR Stewardship and Oversight Act, takes advantage of 
these reforms and provides for additional public reporting from the 
Global Fund on import duties and taxes on Global Fund services and 
commodities under section 4(b)(1)(F). This reporting is intended to 
identify discriminatory duties and taxes levied upon the Global Fund, 
and therefore should not be construed to require the reporting of de 
minimus administrative charges or nondiscriminatory fees. In addition, 
in order to allow the Global Fund time to develop the data collection 
systems required to implement this reporting, it is our intention that 
these requirements become fully effective as soon as is practicable, 
but no later than the end of the 2015 fiscal year. In the meantime, the 
Global Fund's efforts to meet the requirements of section 4(b)(1)(F) 
with additional reporting on these matters should be sufficient to meet 
the requirements in our legislation.
  Mr. MENENDEZ. Mr. President, I thank the ranking member for his 
comments and work on this legislation. The reforms being made by the 
Global Fund are important and we both share the view that the reporting 
requirements for the Global Fund on import duties and taxes ought to be 
understood to provide flexibility until the end of the 2015 fiscal 
year.

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