[Senate Report 110-325]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 698
110th Congress                                                   Report
                                 SENATE
 2d Session                                                     110-325

======================================================================



 
 THE TOM LANTOS AND HENRY J. HYDE GLOBAL LEADERSHIP AGAINST HIV/AIDS, 
         TUBERCULOSIS, AND MALARIA REAUTHORIZATION ACT OF 2008

                                _______
                                

                 April 15, 2008.--Ordered to be printed

                                _______
                                

          Mr. Biden, from the Committee on Foreign Relations,
                        submitted the following

                                 REPORT

                             together with

                             MINORITY VIEWS

                         [To accompany S. 2731]

    The Committee on Foreign Relations, having had under 
consideration the bill (S. 2731) to authorize appropriations 
for fiscal years 2009 through 2013 to provide assistance to 
foreign countries to combat HIV/AIDS, tuberculosis, and 
malaria, and for other purposes, reports favorably thereon with 
an amendment and recommends that the bill, as amended, do pass.

                                CONTENTS

                                                                   Page

  I. Summary..........................................................1
 II. Background and Purpose of the Legislation........................2
III. Reauthorization Act of 2008......................................6
 IV. Committee Action................................................21
  V. Section-by-Section Analysis.....................................22
 VI. Cost Estimate...................................................31
VII. Minority Views..................................................36
VIII.Changes in Existing Law.........................................40


                               I. Summary

    S. 2731, the Tom Lantos and Henry J. Hyde United States 
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
Reauthorization Act of 2008 [hereafter the Reauthorization 
Act], authorizes $50 billion for United States bilateral and 
multilateral programs to combat human immunodeficiency virus 
(HIV) and the acquired immunodeficiency syndrome (AIDS) 
[hereafter referred to as ``HIV/AIDS''], tuberculosis (TB) and 
malaria for fiscal years 2009 through 2013. This Act seeks to 
build on the remarkable successes achieved during the last 5 
years by the President's Emergency Plan for AIDS Relief 
(PEPFAR) and by the promising start of the President's Malaria 
Initiative and to support a transition from an emergency 
approach to more country-driven strategies that will better 
allow public health professionals on the ground to combat the 
local HIV/AIDS, TB, and malaria epidemics that they confront.
    This Act sets out ambitious targets for HIV/AIDS 
prevention, treatment, and care while removing funding 
directives that have served as stove-pipes for those 
interventions and limited the flexibility of professionals in 
the field who plan and implement the programs. Of the three 
goals, it prioritizes prevention as the most critical element 
in slowing the pandemic and reversing its course. In pursuing 
this goal, the Act requires a balanced approach to the 
prevention of the sexual transmission of HIV--emphasizing the 
importance of behavior change programs to promote abstinence, 
fidelity, the reduction of concurrent sexual partners, and the 
delay of sexual debut along with programs to promote the 
correct and consistent use of condoms.
    HIV/AIDS epidemics do not occur in isolation. Persons and 
communities affected by HIVAIDS are also affected by other 
economic and health challenges that can have a direct effect on 
prevention, care, and treatment outcomes. Continuing the 
guidelines established in the U.S. Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003 (P.L. 108-25) [hereafter 
the 2003 Leadership Act], this Act promotes the further 
coordination of care and treatment programs with other life-
changing interventions such as nutritional support, and more 
cohesive integration of these disease-specific programs within 
the broader United States health and development agenda. S. 
2731 increases the focus on women and girls, particularly in 
terms of addressing the factors that make them more vulnerable 
to the transmission of HIV. It emphasizes the need for improved 
internal coordination and enhanced harmonization with other 
international actors and partner countries and authorizes, 
although it does not mandate, bilateral and regional framework 
or ``compact'' agreements. It seeks to strengthen health 
capacity in developing countries affected by these epidemics, 
by promoting the training and retention of personnel and 
improvements in infrastructure, management, finances, and 
health systems. The legislation enhances oversight and 
emphasizes the importance of operations research to evaluate 
and maximize the impact of United States assistance. Finally, 
the Reauthorization Act would repeal a provision in law that 
differentiates HIV/AIDS from all other diseases and currently 
makes HIV infection the only statutory grounds for barring 
prospective international visitors from entry into the United 
States.

             II. Background and Purpose of the Legislation

    In his State of the Union address on January 28, 2003, 
President George W. Bush announced a dramatic proposal: To 
spend $15 billion over 5 years to combat HIV/AIDS globally, 
particularly in sub-Saharan Africa, the region hardest hit by 
the pandemic, and he called for the creation of the President's 
Emergency Plan for AIDS Relief (PEPFAR). Congress responded 
promptly, authorizing the full amount requested by the 
President and expanding the diseases covered through the 2003 
Leadership Act which was signed into law May 27, 2003. 
Congressional support for the program has been strong and 
steady; Congress has appropriated over $19.7 billion since then 
to combat these three diseases through bilateral and 
multilateral programs.
    The 2003 Leadership Act provided a roadmap for an ambitious 
plan to achieve objectives in the prevention, care, and 
especially the treatment of HIV/AIDS.\1\ To oversee these 
programs, the 2003 Leadership Act established within the 
Department of State--a Coordinator of United States Government 
Activities to Combat HIV/AIDS Globally [hereafter the Global 
AIDS Coordinator], to be appointed by the President with the 
advice and consent of the Senate. The Office of the Global AIDS 
Coordinator (OGAC) leads interagency implementation and 
administration of U.S. global HIV/AIDS policy. The 2003 
Leadership Act required a 5-year emergency plan (for fiscal 
years 2004-2008) designed to coordinate all U.S.-funded 
bilateral HIV/AIDS programs, including those established by the 
President's Emergency Plan for AIDS Relief, and administered 
through seven implementing agencies,\2\ to address the 
emergency. The bill specifically mentioned 14 countries within 
the Coordinator's oversight and authorized the President to 
name additional countries to this list.\3\ The 2003 legislation 
also included provisions to address TB and malaria and 
authorized participation in the Global Fund to Fight AIDS, 
Tuberculosis and Malaria [hereafter the Global Fund]--a 
multilateral financing mechanism to manage and disburse 
resources to fight the three diseases. The Global Fund now 
provides grants in 138 countries. The United States remains the 
leading contributor to the Global Fund, having pledged over 
$3.7 billion to date.
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    \1\The human immunodeficiency virus is the underlying cause of 
AIDS. Most people who are infected with HIV are not yet in need of ARV 
treatment; rather they need monitoring of their condition. AIDS is 
diagnosed when an HIV-positive person's immune system deteriorates to a 
specific point, most often evaluated on the basis of a person's CD4 
count or when he/she acquires certain opportunistic infections or 
malignancies associated with AIDS. [CD4 cells coordinate the immune 
system's response to certain micro-organisms such as viruses and may be 
seen as one barometer of a person's progression toward AIDS--if CD4 
counts fall below a certain level, physicians recommend initiating ARV 
treatment, which must then be continued for life.]
    \2\The Department of State, the United States Agency for 
International Development (USAID), the Department of Health and Human 
Services, the Department of Defense, the Department of Commerce, the 
Department of Labor, and the Peace Corps.
    \3\The original 14 named countries were Botswana, Cote d'Ivoire, 
Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, 
South Africa, Tanzania, Uganda, and Zambia. The President added Vietnam 
to this list in 2004. Currently approximately 60 percent of PEPFAR 
assistance is directed to these 15 countries.
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    In 2003, roughly 50,000 people in all of Africa were 
receiving antiretroviral (ARV) pharmaceutical treatment for 
AIDS, though, according to current data, an estimated 21.6 
million people in Africa were HIV positive at that time.\4\ 
Some people argued that large-scale, successful treatment in 
such resource-poor settings was impossible. To counter these 
arguments and to address this most urgent issue--trying to 
reverse a sentence of certain death for millions and 
simultaneously provide an incentive for getting tested for 
HIV--the 2003 Leadership Act emphasized treatment among the 
three goals, establishing first through a Sense of Congress 
provision and subsequently through a budgetary directive that 
55 percent of bilateral assistance should go to therapeutic 
medical care, with at least 75 percent of that allocation to be 
expended for the purchase and distribution of antiretroviral 
pharmaceuticals. The legislation also recommended that 15 
percent of funds go toward palliative or supportive care\5\ and 
required in the later fiscal years that 10 percent of funding 
go to provide for the needs of orphans and vulnerable children.
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    \4\As the available HIV/AIDS data has improved, the Joint United 
Nations Programme on HIV/AIDS (UNAIDS) has revised earlier estimates of 
HIV prevalence. In 2003, when the Leadership Act was enacted, it was 
estimated that approximately 42 million individuals were infected with 
HIV; UNAIDS' more recent analysis estimates that 30.9 million people 
were likely HIV positive in 2003, of whom 21.6 million were in sub-
Saharan Africa.
    \5\OGAC guidance on palliative care states ``Comprehensive 
palliative care is essential to the health and well-being of people 
living with HIV/AIDS (PLWHA) and is an integral part of the President's 
Emergency Plan for AIDS Relief (the Emergency Plan). Palliative care 
has traditionally been associated with terminal or end-of-life care. 
However, current thought and practice and Emergency Plan policy take 
the broader view that palliative care encompasses care provided from 
the time that HIV is diagnosed and throughout the continuum of HIV 
infection.''
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    As part of the 2003 Leadership Act, Congress also 
established parameters to support prevention efforts. The 2003 
legislation recommended a spending level of 20 percent for 
prevention programs and, for fiscal years 2006 to 2008, 
required that one-third of prevention funds go toward promoting 
abstinence until marriage. This prevention approach was based 
on examples of successful efforts in Uganda and elsewhere to 
reduce the transmission of HIV/AIDS through an ``ABC 
approach''--Abstain, Be faithful, and use Condoms.
    The 2003 Leadership Act recognized the importance of a 
multidimensional strategy and the bill included provisions 
relating to the empowerment of women, including requiring 
strategies to enhance their empowerment in interpersonal 
situations and to increase their access to employment 
opportunities, income, productive resources, and microfinance 
programs and authorizing assistance in these areas. The Act 
also recognized the importance of nutrition and called for the 
Administrator of the United States Agency for International 
Development (USAID) to integrate nutrition programs with HIV/
AIDS activities as appropriate.
    Over the course of the last 5 years, the United States has 
made tremendous strides in leading the global campaign against 
HIV/AIDS, particularly establishing treatment programs. With 
the support of PEPFAR and the Global Fund, over 1.99 million 
people have received ARVs.\6\ Millions more have been the 
beneficiaries of palliative care and prevention educational and 
outreach efforts and commodities. U.S. programs have helped to 
ensure that over 150,000 infants, most in sub-Saharan Africa, 
who likely would have been infected with HIV in utero or during 
birth were not. Over 33.7 million people have received 
voluntary counseling and HIV testing. Faith-based and 
community-based organizations have played pivotal roles in the 
success of these programs, delivering services on the front 
lines of the war against HIV/AIDS.
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    \6\According to the most recent PEPFAR report to Congress, PEPFAR 
and the Global Fund jointly support 909,000 people on treatment; PEPFAR 
alone supports approximately 544,000 people, and the Global Fund alone 
supports 539,000 people.
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    While these achievements are impressive, the pandemic 
continues to outpace them. The 2007 AIDS Epidemic Update of the 
Joint United Nations Programme on HIV/AIDS (UNAIDS) brought the 
welcome news that global prevalence estimates were lower than 
earlier projections, but even these revised numbers indicated 
that approximately 33.2 million people in the world are living 
with HIV; that 2.1 million people died of AIDS-related causes 
in 2007; and that 2.5 million people became newly infected in 
2007, meaning that for every person who enrolled in a treatment 
program, approximately six more reportedly became HIV 
positive.\7\ Furthermore, most people who are infected with HIV 
remain untested and undiagnosed.
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    \7\Data on global and regional prevalence and incidence rates are 
from the report of the United Nations Programme on HIV/AIDS (UNAIDS) 
and the World Health Organization (WHO), ``AIDS epidemic update'' 
(December 2007). The December UNAIDS 2007 report significantly reduced 
prevalence estimates from previous years and included a revised 
estimate of approximately 32 million persons living with HIV, down from 
the 2006 estimate of 38.6 million. These revised estimates stemmed most 
directly from improved data in countries such as India, rather than 
changes in the epidemic, but they also reflected notable reductions in 
prevalence rates in several countries, including Kenya and Zimbabwe.
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    Sub-Saharan Africa remains by far the most affected region 
of the world: An estimated 22.5 million people there are living 
with HIV, over two-thirds of the global population of persons 
who are HIV-positive, and the region suffered more than three 
quarters of all AIDS deaths in 2007. In six countries in 
southern Africa (Botswana, Lesotho, South Africa, Swaziland, 
Zambia, and Zimbabwe), estimated prevalence rates continue to 
exceed 15 percent. Women and girls make up over 60 percent of 
persons in sub-Saharan Africa who are HIV infected, and the 
disparities along gender lines are even more striking among 
younger age cohorts. Africa is most affected but not alone. 
Rates of HIV incidence (the number of new infections in a 
population in a given year) are rising in East Asia. The 
Caribbean has the second highest regional prevalence rate at 
1.0 percent (with Haiti and the Dominican Republic accounting 
for three quarters of the 230,000 people living with HIV in the 
Caribbean), while Eastern Europe and Central Asia are 
experiencing prevalence rates of 0.9 percent with an estimated 
1.6 million people living with HIV. Illicit injection drug use 
continues to be a major driver of the epidemic; unsafe sex 
among men who have sex with men and the commercial sex trade 
are also significant means of transmission in many areas. These 
basic demographic realities must continue to shape the U.S. 
strategy on HIV/AIDS, as should the economic need of recipient 
countries, as these programs enter a new phase of operations.
    The U.S. global HIV/AIDS initiative, like the Marshall 
Plan, represents American foreign policy at its best. It 
demonstrates the efficacy of U.S. assistance and the generosity 
of the American people. It has also demonstrated the ability to 
adapt both to changing conditions on the ground and to more 
accurate data as it has become available. This Reauthorization 
Act seeks to enhance that flexibility and to reflect the 
progress that has been made and the lessons learned. As this 
program continues to grow and potentially expands to other poor 
countries, it will face new challenges. As treatment rosters 
grow, so does the responsibility to maintain them--a patient on 
ARV treatment must, for now at least, continue taking the 
medication for the rest of his or her life. This fact, and its 
clear economic and moral implications, reinforces the need to 
improve and expand prevention efforts. While treatment must 
remain a key component of our strategy, without greater 
emphasis on prevention, HIV/AIDS will never be successfully 
controlled or contained. Countries currently receiving our 
assistance are eager to assume greater leadership but lack much 
of the capacity, healthcare workforce, and delivery systems to 
do so. Improved harmonization of U.S. programs with one another 
and with other international actors is necessary to maximize 
impact; and a clearer roadmap is needed of how global HIV/AIDS 
programs fit into the broader U.S. health and development 
agenda.
    S. 2731 recognizes the lethal impact of tuberculosis and 
malaria and authorizes a substantial increase in resources to 
address these deadly diseases. Together, TB and malaria claim 
over 2.6 million lives a year, and they have a devastating 
effect on economic development in many countries. The Act, 
building on the initial inclusion of these diseases in the 2003 
Leadership Act, seeks to strengthen these efforts and to 
promote improved coordination across prevention and care 
programs for HIV/AIDS, TB, and malaria and between these 
programs and other U.S. assistance efforts.

                    III. Reauthorization Act of 2008

    The reauthorization of the 2003 Leadership Act for FY 2009-
2013 is designed to respond to these challenges. It sets 
ambitious targets for treatment, care, prevention, pediatric 
treatment, care for orphans and vulnerable children, and the 
prevention of mother-to-child transmission, and for helping 
countries to train and retain healthcare workers. Among these 
goals, the Act explicitly prioritizes prevention as critical to 
saving lives in recognition of both the progress made in 
initiating path-breaking treatment programs and the fact that 
we must do more to break the cycle of new infections. It 
underscores the value of the ABC approach to preventing the 
sexual transmission of HIV and requires a balanced approach to 
prevention. The Reauthorization Act recognizes that the drivers 
of the epidemic vary from country to country and that our 
public health professionals and their partners should be given 
the means to respond to these variances as well. The 
legislation emphasizes capacity-building, coordination, and 
evaluation and oversight and calls for an increased focus on 
the needs and vulnerabilities of women and girls. It addresses 
the grave threats posed by malaria and tuberculosis, including 
the increasing dangers of drug-resistant TB. Finally, it 
supports a transition from a U.S.-led emergency approach to a 
more sustainable, country-driven public health strategy toward 
HIV/AIDS, including increased technical assistance to improve 
the capabilities of partner governments to play such a role. To 
accomplish these goals, the Reauthorization Act increases U.S. 
funding for bilateral and multilateral HIV/AIDS, tuberculosis, 
and malaria programs to $50 billion over the next 5 fiscal 
years.

Estimates of Funding

    The $50 billion, 5-year authorization will provide a total 
of $41 billion for bilateral HIV/AIDS programs and the Global 
Fund, $5 billion for malaria programs, and $4 billion for 
tuberculosis programs. The committee chose not to assign annual 
spending for the $50 billion in order to allow for these 
programs to be increased over time as services are expanded and 
to accommodate absorptive capacities. The Reauthorization Act 
authorizes up to $2 billion for the Global Fund for fiscal year 
2009 and such sums as are necessary for the following 4 fiscal 
years.
    The Global Stop TB Partnership, of which the United States 
is a member, has estimated that total country needs to achieve 
the goals of the Global Plan to Stop TB will require $24.9 
billion over the 2009 to 2013 period. The plan calls for 57 
percent of funds to go toward the expansion of Daily Observed 
Treatment Short-course (DOTS) therapy, with the remainder 
directed primarily toward TB/HIV programs; DOTS-Plus programs 
that supplement the standard DOTS strategy in areas with 
significant drug resistance; TB drugs; and vaccine research and 
development.
    The WHO's current best estimate of global need for malaria 
programs as outlined in the Global Malaria Business Plan of the 
Roll Back Malaria partnership is $4.1 billion per year (which 
the WHO breaks down to $3.2 billion for implementation and $0.9 
billion for research and development). The Reauthorization Act 
authorizes up to $5 billion as the U.S. Government's 
contribution to this global effort over 5 years.

HIV Prevention Policy

    A growing body of evidence led the committee to reform the 
approach to budgetary allocations or earmarks within U.S. 
global HIV/AIDS programs. Simply put, current earmarks have 
constrained the ability of the U.S. Government and its partners 
to combat the local epidemics that they are facing in 
individual countries. They also undercut efforts to promote 
harmonization with other national and international efforts. 
This conclusion was highlighted in the Institute of Medicine's 
report, ``PEPFAR Implementation: Progress and Promise,'' which 
was mandated under the 2003 Leadership Act and which stated 
that the short-term targets manifested in the budget 
allocations have ``adversely affected implementation of the 
U.S. Global AIDS Initiative.''\8\ Other types of activities, 
such as the prevention of mother to child transmission (PMTCT), 
as well as more comprehensive approaches to the prevention of 
the sexual transmission of HIV that combine abstince, fidelity, 
and condom programming (A, B, and C), have sometimes directly 
suffered as a result of budget allocations, according to 
reports by the Government Accountability Office (GAO).\9\ 
Additionally, an independent comparative analysis of PEPFAR, 
the Global Fund, and the World Bank concluded that, of the 
three, ``PEPFAR funding is least conducive to allowing 
recipients to implement comprehensive approaches that combine 
elements of treatment, prevention, and care.''\10\
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    \8\Institute of Medicine, ``PEPFAR Implementation: Progress and 
Promise,'' Washington, D.C.: National Academies Press, 2007, p. 10.
    \9\Government Accountability Office, ``Spending Requirement 
Presents Challenges for Allocating Prevention Funding under the 
President's Emergency Plan for AIDS Relief,'' GAO-06-395 (April 4, 
2006).
    \10\Nandini Oomman, et al. ``Following the Funding for HIV/AIDS: A 
Comparative Analysis of the Funding Practices of PEPFAR, the Global 
Fund and World Bank MAP in Mozambique, Uganda and Zambia,'' Center for 
Global Development (October 10, 2007), p. xii.
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    The committee believes that goals rather than numerical 
percentages should guide programming. By setting a goal of 
preventing 12 million new infections through a balanced 
approach and strengthening evaluations of prevention programs, 
the committee hopes to make a greater impact in stemming the 
epidemic.
    In order to increase flexibility and allow for the more 
effective allocation of resources in response to local 
conditions, S. 2731 removes the one-third ``abstinence until 
marriage'' funding directive from the 2003 Leadership Act, 
along with all other numerical earmarks within HIV/AIDS 
funding, except for the 10-percent allocation for orphans and 
vulnerable children. The Reauthorization Act explicitly 
prioritizes prevention and continues support for a balanced 
approach in which behavior change programs that are aimed at 
promoting abstinence and fidelity, reducing numbers of 
concurrent partners, and delaying sexual debut, which may 
collectively be termed ``AB,'' are to be funded in a meaningful 
and equitable way, in tandem with ``C'' prevention tools 
promoting the correct and consistent use of condoms. Because 
the committee believes that both the ``AB'' behavior change 
elements and the ``C'' elements of the ABC approach are crucial 
to stopping the spread of HIV/AIDS, language in the 
Reauthorization Act explicitly requires the Global AIDS 
Coordinator to report to Congress if the funding ratio for 
these ``AB'' behavior change programs and for ``C'' (condom) 
programs falls below one to one (AB:C). Additional means of 
prevention including programs to empower women and others, 
medical male circumcision, the safeguarding of blood supplies, 
and the potential development of new mechanisms or approaches 
are also addressed, separately from this one to one ratio.
    S. 2731 strengthens an existing provision in the 2003 
Leadership Act to ensure that no organization shall be required 
to endorse, participate in, or make a referral to any program 
to which that organization has a moral or religious objection, 
nor shall they be required to endorse or participate in a 
multisectoral or comprehensive approach to HIV/AIDS. Such 
organizations cannot be discriminated against in grants or 
other agreements as a result of electing not to endorse, 
participate in, or refer patients to such programmatic 
activities.
    As noted, the Reauthorization Act requires a prevention 
strategy for each country in which the United States maintains 
an HIV/AIDS program; if, in that strategy, less than 50 percent 
of the prevention programs aimed at the sexual transmission of 
HIV are directed toward behavior change programs aimed at 
reducing or delaying sexual activity or reducing numbers of 
sexual partners as outlined above, then the Global AIDS 
Coordinator must provide a justification to Congress. The 
objective epidemiological evidence to be used for the 
Coordinator's determination should be primarily partner country 
Demographic and Health Surveys, the AIDS Information Service 
(AIS), and other United States Government supported surveys and 
data, including surveys requested by the Congress; other 
independent, scientifically sound studies may also be taken 
into account. The modification of the previous abstinence 
spending requirement should not be interpreted to imply that 
abstinence and be faithful programs are no longer considered by 
the committee to be a priority for prevention funding. 
Modifications in the directive and the required country 
strategies are intended to promote locally guided approaches to 
prevention that respond to changes in patterns of incidence 
(new HIV infections) and to specific drivers of the epidemic. 
Any program to change cultural norms should be led by the 
partner countries, with the U.S. Government providing financial 
and technical assistance when appropriate; one of the clear 
lessons of Uganda's early success in reducing HIV prevalence 
rates is that national and local leadership matters.
    The prevention of the transmission of HIV from mother to 
child represents an important component of the overall 
prevention strategy. S. 2731 establishes a goal of helping 
partner countries to achieve 80 percent access to counseling, 
testing, and treatment to prevent mother-to-child transmission 
and emphasizes the importance of maintaining a continuum of 
care before and after birth and of promoting provider-initiated 
or ``opt-out'' HIV testing.\11\ The committee also recognizes 
new and promising developments regarding the use of ARVs to 
reduce the transmission of HIV through breast milk and supports 
expansion of these interventions as appropriate.
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    \11\For PMTCT in developing countries, 80 percent is often defined 
as ``universal access'' because 100 percent access is not realistically 
achievable. ``Opt out'' testing refers to a protocol in which all 
clients in a medical facility are asked if they would be willing to 
take an HIV test, rather than waiting for clients to request testing. 
All voluntary counseling and testing should follow WHO guidelines.
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HIV/AIDS Treatment and Care Policy

    S. 2731 maintains treatment and care as core priorities of 
U.S. HIV/AIDS programs and sets a target of supporting 
treatment for 3 million people by 2013, an increase of 1 
million people to be added to treatment rosters, and additional 
access to treatment through contributions to the Global Fund. 
The bill also sets a target of supporting care for 12 million 
people, including 5 million orphans and vulnerable 
children.\12\ In order to measure progress toward the treatment 
objective, the Reauthorization Act requires a timetable with 
yearly global treatment targets and subsequent reporting, 
including country-level explanations if the timetable's goals 
are not on track to be achieved. As with most of the other HIV/
AIDS budget directives, S. 2731 removes the allocation 
requiring that 55 percent of funding go toward treatment, again 
reflecting the committee's preference that goals to guide 
planning and resources rather than numerical directives. The 55 
percent earmark was seen as necessary 5 years ago when 
treatment was almost nonexistent in resource-poor settings such 
as Africa, and some claimed it was not even possible, but 
current data demonstrate that this directive is no longer 
needed or appropriate. The President's Emergency Plan for AIDS 
Relief has proven the skeptics wrong: Today, due to the 
combined efforts of PEPFAR and the Global Fund, nearly 2 
million people are on treatment, mostly in Africa. 
Additionally, with the availability of less expensive generic 
drugs and better supply chain management in place, the cost of 
ARV supply and distribution has decreased, while other public 
and private partners have increased their role in supporting 
treatment programs. The 55 percent earmark for treatment was 
also set at a time when the infrastructure to deliver treatment 
was almost completely absent in many areas and the costs were 
considered by some to be prohibitively expensive. This 55 
percent figure has never correlated with actual treatment costs 
in pursuit of the targets of the 2003 Leadership Act, and the 
goal of supporting 3 million people on treatment by 2013 does 
not require such a budgetary directive.
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    \12\In his 2003 State of the Union Address, President Bush 
established targets of treating 2 million people, preventing 7 million 
new infections and providing care for millions more. Currently, over 
1.4 million people are enrolled in ARV treatment programs through U.S. 
bilateral assistance programs. The direct impact of prevention programs 
is more difficult to measure.
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    Some have suggested that a target of 3 million people on 
treatment is insufficient. While the committee would prefer 
that all who need treatment receive it, the committee shares 
the view of the Global AIDS Coordinator, Ambassador Mark Dybul, 
that ``we cannot treat our way out of this epidemic.'' For 
every person put on ARVs last year, six more became newly 
infected with HIV; prevention efforts, capacity building, and 
other programs are critical to establishing a more sustainable 
approach. Treatment targets should be and are ambitious, but 
the committee believes it is neither advisable nor financially 
feasible for the United States to be the sole supplier of ARVs. 
In a number of communities, U.S. bilateral programs now focus 
on providing the more complex ``second line drugs'' (for 
patients whose initial treatments have failed), while the 
Global Fund, private foundations, or others provide many of the 
``first line'' drugs). The committee encourages such shared 
efforts. The U.S. commitment to support treatment for 3 million 
people in this Act would constitute well over half of the 
commitment made to date by the entire Group of Eight (G-8). The 
world, not just the United States, needs to confront this 
crisis, and members of the G-8 and others need to do more, 
particularly because treatment, as noted previously, is a long-
term commitment--at this time, it must be life-long for every 
person who begins taking ARVs.
    Furthermore, the committee believes that in seeking to 
provide treatment for at least 3 million people, the United 
States, and its implementing partners, must also do more to 
ensure that its programs achieve the desired outcome, namely 
the long-term survival of people on treatment and their return 
to productive lives. In some PEPFAR-supported programs, as many 
as a quarter or more of those who begin treatment are 
subsequently ``lost to followup'' and disappear from rosters. 
Some of these patients will have died; others may have dropped 
out or enrolled elsewhere. Poor adherence to ARV regimes is 
extremely dangerous for the individual and has larger 
ramifications as it may contribute to the spread of drug 
resistant strains of HIV/AIDS, which are more difficult and 
costly to treat. Through enhanced oversight and analysis, along 
with strengthened coordination with nutrition programs and 
other support, the Reauthorization Act seeks to save more lives 
through improved as well as expanded treatment and care.
    In terms of care, S. 2731 recognizes the impact of 
opportunistic infections such as tuberculosis, bacterial 
pneumonia, toxoplasmosis, viral and fungal diseases, and HIV/
AIDS-associated malignancies such as Kaposi's sarcoma on many 
persons with HIV/AIDS and includes a provision calling for free 
or readily affordable prophylaxis and treatment for these 
infections as part of care and treatment. Palliative assistance 
and pain management are also important components of HIV/AIDS 
care and treatment programs, as noted in the Reauthorization 
Act. Additionally, the committee strongly supports expanded 
access to voluntary counseling and testing, particularly the 
adoption of provider-initiated or ``opt-out'' testing, expanded 
mobile services, and the use of rapid testing to reduce waiting 
times for patients and facilitate the delivery of test results.
    Pediatric participation in care and treatment programs has 
been underrepresented to date, in part because many HIV 
infected children die without ever being tested, particularly 
in countries with low rates of access to Prevention of Mother 
to Child Transmission (PMTCT) programs. Drawing on S. 2472, the 
Global Pediatric HIV/AIDS Prevention and Treatment Act, the 
Reauthorization Act establishes a target for participation in 
treatment and care programs for children in proportion to their 
percentage within the HIV-infected population of a given 
country as a policy objective of U.S. global HIV/AIDS programs.

The Role of HIV/AIDS, Tuberculosis, and Malaria Programs Within the 
        United States Health and Development Agenda

    A core objective of this Act is to encourage the President 
to situate programs to combat HIV/AIDS, tuberculosis, and 
malaria more clearly within the United States health and 
development agenda, particularly because HIV/AIDS programs have 
come to dominate U.S. assistance in many countries in sub-
Saharan Africa and elsewhere. To address this issue, S. 2731 
requires strategic planning for HIV/AIDS programs within this 
broader context as well as long-range planning for the 
initiative. The Reauthorization Act also seeks to improve 
coordination between HIV/AIDS programs and other development 
activities; to address the needs and heightened vulnerabilities 
of girls and women to HIV; and to build capacity in the health 
sectors of partner countries and promote a shift toward more 
sustainable approaches grounded in national strategies. The Act 
also calls for closer coordination between HIV/AIDS, TB, and 
malaria programs. In approaching the question of how these 
health programs fit into the broader U.S. development agenda, 
the committee explicitly builds upon the 2003 Leadership Act; 
with the insights gained from 5 years of programs, it seeks to 
strengthen these activities in order to maximize the positive 
impact of taxpayer dollars and to achieve improved outcomes in 
saving lives and helping people resume productive activities.

Nutrition and Food Support for Persons With HIV/AIDS and Their Families

    The Reauthorization Act strengthens linkages between HIV/
AIDS and nutritional and food support. The 2003 Leadership Act 
recognized the importance of nutritional support, but persons 
living with AIDS, clinicians, and other implementers working to 
treat and support them through PEPFAR programs have repeatedly 
identified inadequate access to food or nutrition as a major 
problem in combating the effects of HIV/AIDS. Adequate 
nutrition is important clinically in terms of improved health 
outcomes and better adherence to regimes, in part because lack 
of food can make it very difficult to tolerate ARVs, and many 
malnourished patients will simply stop taking their ARVs 
because the side effects are too severe.\13\ Current efforts to 
address this issue through ``wraparound'' programs with the 
World Food Program and other agencies cannot completely bridge 
this gap. In wraparound programs, another agency provides a 
service such as nutritional support for persons with HIV/AIDS. 
These wraparound programs often lack the resources to provide 
sufficient services to the individuals receiving PEPFAR support 
and are frequently based in rural areas, while PEPFAR programs 
tend to be more urban. S. 2731 directs the Global AIDS 
Coordinator to integrate nutrition programs more fully with 
HIV/AIDS activities and to establish services where referrals 
are inadequate. The Reauthorization Act identifies nutritional 
and food support as a basic component of care and treatment for 
those persons with HIV/AIDS who meet established criteria of 
need.
---------------------------------------------------------------------------
    \13\PEPFAR Implementation: Progress and Promise, p. 157.
---------------------------------------------------------------------------
    Providing food assistance only or preferentially to persons 
who are HIV-infected also poses clear ethical and policy 
difficulties, both within any given community and in terms of 
the overall distribution of resources. This community concern 
may be offset somewhat by the grim economic impact of long-term 
illness: Families whose breadwinner has been stricken by AIDS 
have often been forced to sell off what assets they possess. 
Therefore, even in a community where food insecurity is 
widespread, these families may have fewer resources on which to 
draw. Nonetheless, this matter remains an issue of concern. In 
communities where HIV/AIDS and food insecurity are both highly 
prevalent, the Reauthorization Act supports community-based 
assistance programs, with an emphasis on sustainable approaches 
such as community gardens.

Women and Girls and HIV/AIDS

    Women and girls are biologically more vulnerable to the 
sexual transmission of HIV, and sociological and economic 
factors add to this heightened peril. Young women in much of 
sub-Saharan Africa, where HIV/AIDS rates are the highest in the 
world, are three times as likely as their male counterparts to 
be infected with HIV; globally, two-thirds of all new 
infections among young people aged 15 to 24 are among 
women.\14\ S. 2731 emphasizes the issue of gender as a risk 
factor for HIV on a number of levels, with the goal of 
strengthening U.S. efforts to help partner countries address 
the underlying issues that heighten vulnerabilities for girls 
and women and to improve the quality and enhance the impact of 
gender-based programming. Gender elements are central to the 
required 5-year strategy and report and subsequent evaluations, 
and the committee emphasizes the importance of programs to 
reach men, women, and youth to reduce gender-based 
vulnerabilities to, and the disparate impacts of, HIV/AIDS. 
Gender-based programs must also be a core element of any future 
compacts or framework agreements. Consistent with the 
underlying 2003 Leadership Act, programmatic components to 
address gender issues within the Reauthorization Act include 
support for property and inheritance rights for women and 
children as well as assistance to promote broader legal 
equality and legal protection; support for civic organizations 
run by and for women; life skills training for adolescents; 
recognition and prevention of gender-based violence and 
strengthened legal and support responses to violence; and 
improved coordination with antitrafficking efforts. The 
committee recommends that additional staff training and 
development of expertise on gender-related issues be included 
in planning for HIV/AIDS programs and country operational 
plans, along with expanded local input from women, including 
women living with HIV/AIDS. Similarly, additional technical 
assistance may be needed to help encourage the participation 
and involvement of women in drafting, coordinating, and 
implementing the national HIV/AIDS strategic plans of their 
countries.
---------------------------------------------------------------------------
    \14\Office of the Global AIDS Coordinator, ``The President's 
Emergency Plan for AIDS Relief Report on Gender-Based Violence and HIV/
AIDS'' (November 2006), p. 4.
---------------------------------------------------------------------------
    The committee believes it is important to monitor and 
evaluate progress on outcomes and impacts linked to goals and 
targets and to ensure that data are disaggregated by risk 
factors, including sex, age, marital status, and other factors 
relevant to local epidemics. The Global AIDS Coordinator should 
provide clear guidance to field missions to integrate gender 
across all prevention, care, and treatment programs; adopt 
specific targets for reaching women and girls within the 
country's prevention, care, and treatment targets; and 
undertake gender analysis in order to identify priority 
interventions. Gender-specific indicators are critical to 
measure program outreach and effectiveness. Operations research 
and evaluations of gender-responsive interventions, as required 
under the Reauthorization Act, will help identify and encourage 
replication or adaptation of effective models, and provide both 
positive and negative lessons learned for dissemination among 
programs supported by U.S. assistance in different countries or 
regions.
    The Reauthorization Act authorizes structural HIV 
prevention efforts intended to help alter social, political, 
and economic factors in the environment so that people may be 
empowered to engage in safer behaviors. These efforts help 
countries to address factors within the environment, such as 
gender inequities or migration patterns that can create 
conditions conducive to the spread of HIV, and begin to remedy 
them, for example by supporting microcredit opportunities for 
women or providing off-hours activities or housing options for 
migrant men or transport workers. Such prevention approaches 
also offer important opportunities for increased linkage across 
development lines, through the promotion of livelihoods and 
small enterprise development, job training, basic health 
services, and education. These activities are particularly 
relevant in terms of the needs of women and girls and continue 
programs that were authorized under the 2003 Leadership Act.
    Gender-based violence plays a significant role in the 
transmission of HIV in many areas, and efforts to assist 
countries in the development and enforcement of laws and 
policies to prevent and respond to gender-based violence and to 
promote screening and appropriate counseling, testing, and 
treatment in both HIV/AIDS and gender-based violence programs 
are important components of prevention, care, and treatment 
programs as authorized under this Reauthorization Act. Violence 
against women and girls in humanitarian relief, conflict, and 
post-conflict operations is an issue of particular concern. 
Domestic violence is widespread in some regions, including 
areas of high HIV prevalence, but this situation can change. 
Strengthening laws and enforcement mechanisms; publicizing laws 
and penalties and expanding awareness of victims' services 
through national media campaigns; expanding youth education 
efforts; and promoting communication across gender lines, along 
with efforts to address alcohol abuse, can help to change 
social norms contributing to tolerance of violence. Increased 
access to economic opportunities is also an important component 
in the prevention of and response to domestic and sexual 
violence. Recognizing the importance of these programs in the 
fight against HIV/AIDS, microcredit activities continue to be 
authorized under this legislation. Finally, the committee notes 
that currently many women and girls are unable to rely on the 
ABC strategy to protect themselves because they lack the power 
to abstain, cannot control or depend on their partners' 
faithfulness, and cannot impose the use of condoms within their 
relationships. That fact makes efforts to strengthen women's 
rights an important component of HIV/AIDS and national 
development strategies and underscores the need for support for 
programs such as those outlined above as well as new advances 
in prevention methods that women themselves can control.

Children and HIV/AIDS

    According to UNAIDS, an estimated 2.5 million children are 
living with HIV; nearly 9 out of 10 live in sub-Saharan Africa. 
Over 300,000 children under the age of 15 died of AIDS-related 
causes in 2007. Over 14 million children in the world have lost 
one or both parents to AIDS. Millions of more children are 
affected by or vulnerable to HIV/AIDS. S. 2731 seeks to address 
these issues confronting children on multiple levels, from 
increasing emphasis on PMTCT programs and expanding access to 
pediatric HIV/AIDS testing, treatment, and care, to supporting 
assistance for orphans and other children directly affected by 
the disease and expanding our understanding of what it means to 
be vulnerable to HIV/AIDS.
    The prevention of mother to child transmission (PMTCT) 
represents an area where scientific certainty--we know how to 
prevent transmission during pregnancy and childbirth--meets the 
limitations of maternal healthcare access and infrastructure in 
much of sub-Saharan Africa and elsewhere. Around the world, 
approximately a thousand infants a day are infected with HIV, 
most in sub-Saharan Africa. S. 2731 underscores the importance 
of expanding access to PMTCT services and achieving delivery 
targets and of supporting a continuum of care to connect 
prenatal and antenatal services with health services for mother 
and child after delivery.
    To date, children with HIV/AIDS have been underserved 
within global HIV/AIDS assistance programs. Barriers to 
enrollment for children in treatment programs include limited 
access to reliable HIV testing for the youngest children; a 
shortage of providers trained in delivering pediatric care; 
weak linkages between services to prevent mother-to-child 
transmission and HIV/AIDS care and treatment and child health 
programs; and the need for additional, low-cost pediatric 
formulations of HIV/AIDS medications--pediatric treatment is 
far more complex and expensive than that for adults. The 
Reauthorization Act identifies treatment of children in 
proportion to their percentage within the HIV infected 
population of a given country as a policy objective and seeks 
to help countries surmount these treatment barriers. The 
committee strongly supports expanded treatment and care for 
children not only through ARVs but also through increased 
access to additional medications such as cotrimoxazole 
prophylactic, for example, which at a cost of three cents a day 
has been shown to cut childhood HIV/AIDS mortality rates 
dramatically.
    The one numerical budgetary allocation for HIV/AIDS 
retained in this legislation is the 10-percent earmark for 
orphans and vulnerable children. This directive continues to 
receive broad support from implementers and U.S. Government 
officials alike. It is important to retain this allocation, and 
to maintain it separately from pediatric treatment, in order to 
ensure that orphans and vulnerable children remain a priority 
within U.S. HIV/AIDS country programs and to signal their 
importance to partner countries, many of whom have not 
sufficiently emphasized programs for children. S. 2731 also 
recognizes that, particularly in areas with high HIV prevalence 
rates, definitions of what it means to be vulnerable to HIV/
AIDS or its socioeconomic effects should be expanded. For this 
reason, the legislation amends the original budget directive on 
orphans and vulnerable children from ``orphans and vulnerable 
children affected by HIV/AIDS'' to ``orphans and other children 
affected by, or vulnerable to'' HIV/AIDS. The committee 
encourages the Global AIDS Coordinator to provide clear 
guidance to the field on this subject.

Capacity Building and Sustainability

    Lack of health personnel, inadequate infrastructure and 
health systems, and poor management represent formidable 
roadblocks to progress in the battle against HIV/AIDS and other 
infectious diseases and medical conditions, particularly in 
sub-Saharan Africa. The HIV/AIDS pandemic has aggravated the 
existing shortage of health workers through loss of life and 
illness among medical staff, unsafe working conditions for 
medical personnel, and increased workloads for diminished 
staff. The shortage of health personnel in turn undermines 
efforts to prevent infection and provide care and treatment for 
those with HIV/AIDS and to address other health challenges. 
Migration of health workers--often termed the ``brain drain''--
adds to these losses; the committee supports codes of conduct 
and other measures to promote ethical practices in the 
international recruiting of healthcare workers, as well as 
steps to reduce ``push factors'' such as unsafe working 
conditions that also fuel this brain drain. According to the 
2003 United Nations Development Programme, Human Development 
Report, approximately 3 out of 4 countries in sub-Saharan 
Africa have fewer than 20 physicians per 100,000 people, the 
minimum ratio recommended by the World Health Organization, and 
14 countries have 5 or fewer physicians per 100,000 people.\15\ 
Numbers of nurses and other health professionals are also 
critically low across much of the continent. The concentration 
of professionals in cities further limits the delivery of 
health services in rural areas. Capacity building is critical 
to making progress against HIV/AIDS, tuberculosis, and malaria 
and to shifting from a donor-led emergency line of attack to a 
more sustainable, country-driven public health approach.
---------------------------------------------------------------------------
    \15\According to the United Nations Development Program, Tanzania, 
Malawi, Niger, Burundi, Ethiopia, Mozambique, Sierra Leone, Togo, 
Benin, Chad, Lesotho, Eritrea, Rwanda, and Burkina Faso all have 5 or 
fewer physicians per 100,000 people. The only other nations in the 
world with such a small number of physicians per capita are Bhutan and 
Papua New Guinea.
---------------------------------------------------------------------------
    The PEPFAR program has made real progress in training 
personnel, increasing laboratory capacity, and improving 
infrastructure. The Reauthorization Act seeks to build on that 
progress and elevate the objective of capacity-building within 
U.S. programs. Additional health professionals, 
paraprofessionals, and compensated community health workers are 
all needed in this effort. The Reauthorization Act draws on S. 
805, the African Health Capacity Investment Act of 2007 (which 
the committee approved in September 2007), to address the need 
for health workers, infrastructure, and management development.
    In order to help achieve needed staffing levels, S. 2731 
sets a target of training and retaining 140,000 professionals 
and paraprofessionals with the objective of helping countries 
to achieve World Health Organization recommended minimum 
staffing levels for doctors, nurses, and midwives. Doctors, 
nurses, and other health professionals must be trained, but 
also effectively deployed, under safe working conditions and 
with additional incentives to support retention. Skilled 
paraprofessionals, such as laboratory technicians, are needed, 
as are community health workers who often serve on the front 
lines of health services. The bulk of community health workers 
in many PEPFAR programs are volunteers; the committee 
recognizes the value of their service, but has concerns about 
the sustainability of a volunteer-based model and relying upon 
the poorest participants in the health workforce as volunteers.
    Older orphans, vulnerable children, and at risk youth are 
in need of educational and employment opportunities, while 
virtually all countries receiving significant U.S. assistance 
programs are in need of an expanded healthcare workforce. 
Public-private partnerships and other mechanisms should be 
pursued to help address this nexus through training of these 
individuals as entry level health workers and as 
paraprofessionals and through expanded support for higher 
education, with appropriate measures to promote in-country 
service following graduation.
    In addition to training more individuals (and retaining 
them in-country), systemic reforms and improvements are needed 
to combat HIV/AIDS and other diseases and health challenges. 
Task-shifting--in which lower-level health workers are 
authorized to assume some duties formerly reserved for 
physicians or other highly trained professionals--will help 
address imbalances in service delivery, but is only a partial 
solution and raises potential concerns that nurses and other 
healthcare workers might be diverted from primary healthcare 
duties for HIV/AIDS care.\16\ More diversified training is also 
needed, including instruction in the detection of opportunistic 
infections, pediatrics, gender-based violence assessments, TB/
HIV coinfection, prevention education, and counseling and 
testing, to help achieve a work force with sufficient skills. 
The Reauthorization Act supports such training efforts as well 
as health and financial management reforms and infrastructural 
development to allocate resources more effectively. In 
undertaking such efforts, the potential benefit for the health 
system as a whole should help guide decisionmaking, and every 
precaution should be taken to ensure that HIV/AIDS programs do 
not diminish access to, or quality of, broader health services.
---------------------------------------------------------------------------
    \16\The World Health Organization has issued guidelines on task-
shifting in WHO, ``Treat, Train, Retain: Task Shifting: Rational 
Redistribution of Tasks among Health Workforce Teams'' (December 2007).
---------------------------------------------------------------------------
    Partner countries themselves must also invest more heavily 
in their health and education sectors, and S. 2731 urges them 
to do so, as set forth in the Abuja Declaration.\17\ The 
Reauthorization Act underscores the importance of the national 
HIV/AIDS and health strategies of partner countries in U.S. 
planning and allows for additional technical assistance to 
strengthen such instruments where needed. The legislation 
authorizes the Secretary of the Treasury to provide assistance 
to country health and finance ministries to attract and manage 
international assistance more effectively. The committee also 
emphasizes the importance of supply chain management and 
equipment maintenance to ensure the effective use of purchased 
and donated goods. Sustainability of global HIV/AIDS programs 
cannot be achieved in the next 5 years, but it should 
ultimately be one of the longer term objectives of U.S. 
programs.\18\
---------------------------------------------------------------------------
    \17\In the Abuja Declaration of 2001, heads of state of the 
Organization of African Unity [the predecessor of the African Union] 
pledged to place the fight against HIV/AIDS at the forefront in 
national development plans and committed to set a target of allocating 
15 percent of annual budgets to the improvement of the health sector.
    \18\The term sustainability is widely used but more rarely defined. 
Dr. Helene Gayle of CARE, in testifying before the House Foreign 
Affairs Committee on September 25, 2007, stated that ``sustainability 
relates to a set of activities continuing, even after their initiator 
exits. Another type refers to the durability of a certain impact: For 
example, a vaccine that provides immunity to a disease. A deeper form 
of sustainability is reflected in the ability of societies to maintain 
processes of economic, social and cultural transformation.''
---------------------------------------------------------------------------
    Promoting country ownership of HIV/AIDS programs and 
methodologies represents one of the underlying goals of this 
legislation. Compacts or framework agreements between the 
United States and regional or national governments may be one 
way to achieve this objective. As part of his announcement 
regarding the reauthorization of PEPFAR on May 30, 2007, 
President Bush expressed his desire to establish partnership 
compacts with participating nations. S. 2731 includes language 
providing for the development of compacts or framework 
agreements. Compacts would constitute partnership agreements, 
with mutual obligations commensurate with national resources 
and capabilities. For countries with greater resources, U.S. 
contributions might be limited largely to technical assistance. 
Compacts could be reached either with one or more individual 
countries or with regions, such as the Caribbean Community 
(CARICOM). Key components of prospective compacts include 
health capacity-building; country investments; elements to 
strengthen the legal, economic, educational, and social status 
of women, girls, and vulnerable children and youth; civic 
participation; the promotion of policies, regulations, and law 
conducive to enhancing HIV/AIDS prevention, treatment, and 
care; evaluation, research, and information-sharing; and 
improved coordination of efforts to combat HIV/AIDS, TB, and 
malaria with national health and development strategies. 
Benchmarks, targets, and intended methodology to achieve them 
should be included within such framework agreements.

Oversight and Evaluation of HIV/AIDS Programs

    The scope of the U.S. global HIV/AIDS initiative and the 
speed with which it has been developed and implemented under 
the leadership of the Global AIDS Coordinator are extremely 
impressive; this scope and speed, however, also contribute to 
challenges of sustainability and accountability. As indicated 
in reports by the offices of the Inspectors General for the 
Department of State and USAID, PEPFAR country teams have tended 
to be understaffed for the workload, budget, and 
responsibilities associated with the programs that they 
manage.\19\ Oversight, monitoring, and evaluation will almost 
inevitably suffer if staffing is inadequate. To facilitate 
smoother coordination and improve oversight and management of 
programs, S. 2731 recommends the appointment of full-time, 
experienced country coordinators for all U.S. missions with 
significant HIV/AIDS programs, supports adequate staffing of 
all country teams, and acknowledges the important contributions 
of Foreign Service Nationals to these efforts.
---------------------------------------------------------------------------
    \19\USAID Office of Inspector General reports on Zimbabwe (October 
2007), Malawi (September 2007), and Tanzania (May 2006) reported 
respectively that staff shortages adversely affected basic monitoring 
activities of partners; data collection and management; and reduced 
site visits, which ``could jeopardize the achievement of future outputs 
and targets, and impact the quality of the program data reported by the 
partners to the Mission, and the target information reported to the 
U.S. Government by USAID/Tanzania.''
---------------------------------------------------------------------------
    The committee has included several provisions in the 
legislation to maintain and strengthen oversight and program 
review of U.S. global HIV/AIDS efforts.
    First, the bill calls for a report, including a preliminary 
design plan and budget, by the Institute of Medicine of the 
National Academies that assesses the performance of U.S. global 
HIV/AIDS programs and an evaluation of the impact of these 
programs on prevention, treatment, and care. The Institute 
conducted a similar study during the first 5 years of the 
global HIV/AIDS effort under the Leadership Act. That study, 
released in 2007, helped inform the committee's work on the 
Reauthorization Act, particularly in regard to whether to 
retain certain funding allocations, or earmarks. The Institute 
of Medicine study under the Reauthorization Act is intended to 
address progress toward prevention, treatment, and care targets 
and evaluate the impact of treatment and care programs (e.g., 
mortality, adherence, and resistance rates) and of programs 
directed toward women and orphans and vulnerable children, as 
well as seeking to assess the impact of these efforts on health 
systems and service delivery in countries with significant 
programs.
    Second, the bill requires a review by the Government 
Accountability Office (GAO) no later than 3 years after 
enactment of this Act that will examine monitoring and 
evaluation practices, interagency coordination, procurement 
practices, and harmonization of the U.S. effort with national 
and international strategies. It will also assess the effect of 
HIV/AIDS investments on U.S. global health programming, and 
provide recommendations for improving global HIV/AIDS programs.
    Third, the Reauthorization Act emphasizes operations 
research, in order to evaluate policies and program 
outcomes.\20\ To promote the dissemination of information, the 
bill requires the Global AIDS Coordinator to publish a ``best 
practices'' report annually to highlight those programs with 
potential for replication or adaptation, particularly those 
programs that may be replicated or adapted at a low cost in 
other settings. In this manner, U.S. programs can make an 
indirect but important contribution to HIV/AIDS efforts where 
the United States is not directly involved. The committee 
regards it as important for OGAC to communicate information on 
adverse outcomes or unsuccessful approaches as well.
---------------------------------------------------------------------------
    \20\Regarding operations research, S. 2731 draws on S. 2584, the 
PEPFAR Accountability and Transparency Act.
---------------------------------------------------------------------------
    Finally, the bill requires the Inspectors General (IGs) of 
the three largest U.S. Government agencies involved in the 
global HIV/AIDS efforts--the Department of State, the 
Department of Health and Human Services, and the U.S. Agency 
for International Development--to coordinate on an annual 
oversight plan of bilateral programs. The provision also 
requires the Global AIDS Coordinator to make available not more 
than $10 million to fund the oversight by the Inspectors 
General. The committee is aware that the Offices of Inspector 
General at State and USAID have received only modest budgetary 
increases in recent appropriations, and are often asked to do 
more with less. This financing mechanism--just .0002 percent of 
the $50 billion authorized in this bill--will strengthen the 
ability of those Offices to conduct regular audits, 
inspections, and performance reviews of bilateral HIV/AIDS 
programs. Oversight and monitoring and evaluation should be 
seen as components of effective prevention, treatment, and care 
programs rather than as competitors with them for resources.

The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria

    S. 2731 authorizes up to $2 billion for the Global Fund for 
fiscal year 2009 and such sums as necessary for the subsequent 
4 fiscal years; this structure parallels section 202(d)(1) of 
the 2003 Act, which authorized $1 billion for fiscal year 2004 
and such sums as necessary for the remaining fiscal years. The 
Global Fund represents the primary multilateral component of 
the Reauthorization Act. The legislation recognizes the 
increasingly effective coordination between the Global Fund and 
bilateral U.S. assistance programs. The committee commends this 
development, recognizes that the bilateral and multilateral 
efforts each possess comparative advantages in certain areas, 
and notes that the Global Fund model may have the potential for 
greater capacity-building and sustainability in the long term. 
The committee also regards the Global Fund as having made 
significant progress toward addressing concerns raised by the 
Government Accountability Office about transparency and 
accountability and anticipates further progress as the newly 
appointed Inspector General for the Global Fund attains full 
staffing levels and undertakes monitoring activities.
    In order to promote greater transparency, accountability, 
and public availability of information, the Reauthorization Act 
includes a provision to withhold 20 percent of the U.S. 
contribution beginning in FY 2010 if certain benchmarks are not 
met. Benchmarks include: The evaluation of Local Fund Agents; 
the disclosure of information, performance data, and funding 
levels for principal and subrecipients; the activities of the 
Inspector General; reporting on standard indicators and 
distribution of resources; the establishment of a tariff policy 
and pursuit of steps to prevent the imposition of taxes on 
Global Fund services; the Global Fund's continuation as a 
financing institution focused on the three diseases; and 
progress in sustaining a multisectoral approach with resources 
allocated to different sectors, including governments, civil 
society, and faith-and community-based programs.

                                       Table 1.--Global Fund Contributions
                                                (in U.S. dollars)
----------------------------------------------------------------------------------------------------------------
                                      2001-02      2003       2004       2005       2006       2007    2008 est.
----------------------------------------------------------------------------------------------------------------
Total Global Contributions.........       947M       937M       1.5B       1.5B       2.2B       2.5B       3.5B
U.S. Appropriations................       300M       348M       547M       435M       545M       724M       841M
U.S. Share of Contributions........         32         33         32         31         24         28         28
  (as a percentage)................
----------------------------------------------------------------------------------------------------------------
M = million.
B = billion.

Tuberculosis

    Tuberculosis claims an estimated 1.6 million lives a year, 
and drug resistant strains of the disease are becoming 
increasingly common and more dangerous. This airborne disease, 
including its drug-resistant variants, is becoming a more 
generalized epidemic in many countries of the world. While 
there are an estimated 9 million new tuberculosis cases per 
year, only one-third of those with the disease currently 
receive treatment. The World Health Organization recently 
reported that 5 percent of new cases of TB are multidrug 
resistant (MDR-TB), and that at least 40,000 persons are 
thought to have extensively drug resistant TB (XDR-TB); this 
number could be considerably higher as many countries lack the 
capacity to test for resistance.\21\ Drug resistance emerges 
most commonly when TB patients fail to complete their course of 
treatment; mutations in the bacterium may then develop, and 
drug-
resistant strains can subsequently be transmitted to others. 
Tuberculosis normally requires a 6-month course of treatment 
with costs as low as $20 per patient; treatment for MDR-TB may 
take 2 years and cost thousands of dollars. XDR-TB is even more 
difficult to treat and often fatal. Persons with HIV/AIDS are 
particularly vulnerable to TB, and coinfection rates within the 
HIV infected population top 50 percent in some countries.
---------------------------------------------------------------------------
    \21\MDR-TB is defined as TB demonstrating resistance to the two 
most commonly used drug treatments, rifamin and isoniazid; XDR-TB is 
resistant to those two first-line drugs and at least two other major 
drug treatments.
---------------------------------------------------------------------------
    Drawing upon S. 968, the Stop Tuberculosis (TB) Now Act of 
2007, which was favorably reported by the committee in October 
2007, S. 2731 recognizes the global threat posed by 
tuberculosis, and particularly MDR- and XDR-TB, and authorizes 
$4 billion to combat the disease over 5 years. The World Health 
Organization's ``Stop TB'' Strategy offers a roadmap for 
combating tuberculosis and reducing the threats of increasing 
drug resistance and for the resources necessary for this 
effort. Directly Observed Treatment Short-course (DOTS) 
treatment for TB is one of the most cost-effective health 
interventions available today. The committee emphasizes the 
importance of both ensuring maximum on the ground impact of 
resources to combat TB and of maintaining the quality of 
programs and services delivered, not least because of the 
extraordinary public health costs associated with poor 
adherence to standard treatment for TB. Patient services, 
training for health workers and the maintenance of safe working 
conditions, laboratory capacity, and drugs and diagnostics 
should be prioritized. The committee recognizes and supports 
funding for the global TB work of the Centers for Disease 
Control and Prevention. The committee also supports robust 
funding for the Global Tuberculosis Drug Facility and 
recommends significantly increased annual U.S. contributions, 
building on recent appropriations.
    Coinfection between HIV/AIDS and TB represents a 
significant public health problem in many countries, making 
increased coordination between HIV/AIDS and TB programs a 
continuing priority; TB remains the leading cause of death 
among persons with AIDS. Diagnosis can be difficult 
particularly because TB symptoms may manifest themselves 
differently in HIV positive persons, often as sputum smear-
negative pulmonary and extra-pulmonary forms of TB that are 
more difficult to detect and that are associated with higher 
mortality rates. In order to help achieve the objectives set 
forth in the Stop TB Strategy and the Millennium Development 
Goals, expanded diagnostic and treatment capacity for all forms 
of TB is necessary, as is expanded laboratory capacity to 
detect drug resistance.

Malaria

    Over 1 million people a year die of malaria, most of them 
children under the age of 5 or pregnant women. The President's 
Malaria Initiative, launched in 2005, is already beginning to 
make an impact in the fight against this deadly and preventable 
disease. S. 2731 authorizes $5 billion for fiscal years 2009 to 
2013 in order to build on this early progress by expanding the 
resources and reach of U.S antimalarial programs. In order to 
advance these efforts and improve the operations of 
antimalarial programs and coordination across U.S. agencies and 
with other multilateral, national, and private actors, the 
Reauthorization Act codifies a position within USAID of a 
Coordinator of United States Government Activities to Combat 
Malaria Globally [hereafter, the Malaria Coordinator].
    This legislation supports numerous primary interventions, 
including long-lasting insecticide-treated bednets; indoor 
residual spraying with insecticides; intermittent presumptive 
treatment of pregnant women in areas of high malaria 
transmission; community-based symptoms detection, management 
and care; artemisinin-based combination therapies (ACTs); and 
other measures to promote treatment, care, and prevention. As 
with other health interventions, capacity-building is a 
critical element in the fight against malaria. The 
Reauthorization Act also supports research activities to 
develop and evaluate new diagnostics, treatment regimens, and 
prevention and control measures. Artemisinin-based drugs and 
insecticides are potentially subject to increasing resistance 
over time. The spread of counterfeit drugs may hasten the 
emergence of more widespread drug resistance, signs of which 
are already appearing in the Mekong Delta region. The World 
Health Organization also indicates that malaria-carrying 
mosquitoes have developed resistance to some of the 12 approved 
insecticides in the Amazon Basin, the Mekong Delta, and 
particular regions of Africa, thus reducing the efficacy of 
insecticide-treated bednets and indoor spraying programs. S. 
2731 requires the monitoring of global malaria trends and the 
assessment of the environmental and health impact of malarial 
vector control efforts, including the use and production of 
insecticides for bednets and residential spraying. The 
committee also underscores the importance of adherence to World 
Health Organization and other relevant standards in the use and 
control of these products.

                          IV. Committee Action

    Last year, the committee held two hearings directly related 
to the subject matter of the bill. On October 24, 2007, the 
committee held a hearing on ``The Next Phase of the Global 
Fight against HIV/AIDS,'' at which Ambassador Mark Dybul, the 
Global AIDS Coordinator, testified. On December 13, 2007, it 
held a hearing with outside witnesses on ``Perspectives on the 
Next Phase of the Global Fight against HIV/AIDS, Tuberculosis, 
and Malaria.''
    On March 7, 2008, Senators Biden, Lugar, Kennedy, and 
Sununu introduced S. 2731, a bill to authorize appropriations 
for fiscal years 2009 through 2013 to provide assistance to 
foreign countries to combat HIV/AIDS, tuberculosis, and 
malaria, and for other purposes.
    On March 13, 2008, the committee held a business meeting to 
consider S. 2731. The committee approved a series of amendments 
by voice vote. The amendments were as follows:

   An amendment by Senator Biden making technical 
        amendments to section 101(f) on Inspectors General.
   An amendment by Senators Biden and Lugar to alter 
        the conscience clause provision to conform to the House 
        bill.
   An amendment by Senator Biden to change ``healthcare 
        workers and professionals'' to ``healthcare 
        paraprofessionals and professionals'' in section 301 
        and adding definition of paraprofessionals.
   An amendment by Senator DeMint regarding the Global 
        Fund.
   An amendment by Senators Biden and Lugar to 
        eliminate the phrase ``behavior change'' in several 
        places in the bill to conform to the House bill and 
        clarify its meaning.
   An amendment by Senators Biden and Dodd to make 
        adjustments to the provisions on pediatric treatment.
   An amendment by Senator Biden to define ``structural 
        prevention.''
   An amendment by Senator Dodd to create a panel to 
        review Prevention of Mother-to-Child Transmission.
   An amendment by Senator Kerry to promote vaccine 
        development.
   An amendment by Senator Obama to promote microbicide 
        development.
   An amendment by Senator DeMint to ensure that CDC 
        surveillance activities on malaria do not duplicate the 
        work of the World Health Organization.
   An amendment by Senators Nelson and Menendez to 
        highlight the Caribbean region as a potential partner 
        for regional approaches to HIV/AIDS.
   An amendment by Senators Biden and Lugar to add a 
        new section 401(b) on the scaleup of the spending over 
        the course of the five fiscal years.
   An amendment by Senator Cardin to promote preservice 
        training for health capacity.
   An amendment by Senators Biden and Lugar to make a 
        technical change to insert section 307 and to renumber 
        the rest of Title III accordingly.

    The committee then voted to order the bill, as amended, 
reported favorably by a vote of 18 to 3. Voting in favor of the 
bill were Senators Biden, Dodd, Kerry, Feingold, Boxer, Nelson, 
Obama, Menendez, Cardin, Casey, Webb, Lugar, Hagel, Coleman, 
Corker, Voinovich, Murkowski, and Isakson. Voting against the 
bill were Senators DeMint, Vitter, and Barrasso.

                     V. Section-by-Section Analysis


Section 1. Short title

    The short title is the ``Tom Lantos and Henry J. Hyde 
United States Global Leadership Against HIV/AIDS, Tuberculosis, 
and Malaria Reauthorization Act of 2008.''

Sec. 2. Findings

    This section amends the findings in the United States 
Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 
2003 (``the 2003 Leadership Act'') by adding to that Act 
additional findings with updated data on human immunodeficiency 
virus (HIV) and the acquired immunodeficiency syndrome (AIDS) 
(hereafter referred to as ``HIV/AIDS''), tuberculosis (TB), and 
malaria around the world and the impact of U.S. assistance in 
combating these diseases since the 2003 Leadership Act was 
enacted. The findings also identify ongoing and growing 
challenges in meeting the needs for treatment, care, 
prevention, cure and research of and related to these diseases.

Sec. 3. Definitions

    This section amends the 2003 Leadership Act by adding 
additional definitions of terms.

Sec. 4. Purpose

    This section amends the purpose section of the 2003 
Leadership Act and sets out the overall goals and objectives of 
this bill. It refers to the mandate for a new 5-year 
coordinated strategy to combat HIV/AIDS, tuberculosis, and 
malaria as part of the overall United States global health and 
development agenda; calls for increased resources for bilateral 
and multilateral efforts to combat these diseases; intensifies 
prevention, treatment, and care efforts and seeks to enhance 
program effectiveness including addressing the particular 
vulnerabilities of girls and women; encourages public-private 
partnerships; reinforces vaccine development and other 
research, including operations research; and helps partner 
countries to strengthen health systems and improve capacity.

Sec. 5. Authority to consolidate and combine reports

    This section maintains a provision in current law allowing 
the executive branch to consolidate and combine reports, with a 
minor technical amendment.

               TITLE I--POLICY PLANNING AND COORDINATION


Sec. 101. Development of a comprehensive, 5-year, global strategy

    This section amends section 101 of the 2003 Leadership Act 
by providing additional guidance to the President on the 
development of the second 5-year plan to combat HIV/AIDS 
globally and a subsequent report to Congress.
    It instructs the President to seek to situate United States 
efforts to combat HIV/AIDS, tuberculosis, and malaria within 
the broader health and development agenda; to provide a plan to 
be carried out over the next 5 years to prevent 12 million new 
HIV infections, support care for 12 million adults and children 
with HIV/AIDS (including 5 million orphans and other children 
affected by HIV/AIDS), and to support treatment for 3 million 
persons with HIV/AIDS through bilateral efforts as well as 
additional persons through multilateral programs.
    It also establishes targets to promote universal access 
(defined as 80 percent) to services to prevent mother-to-child 
transmission, to treat children in proportion to their numbers 
within a country's population of persons with HIV/AIDS, and to 
strengthen health workforces. The strategy prioritizes the 
importance of HIV prevention, including programs to promote 
abstinence, fidelity, and the use of condoms, as well as other 
prevention tools. To ensure that treatment is not neglected, it 
requires a timetable for achieving treatment targets. It 
instructs the President to strengthen health capacity in, and 
to enhance attention to the national HIV/AIDS strategies of 
partner countries, and to promote coordination in United States 
responses to HIV/AIDS, tuberculosis, and malaria.
    This section calls for a plan for regional priorities for 
resource distribution and a structure for potential new 
compacts or framework agreements. It underscores the importance 
of addressing the needs and vulnerabilities of women and girls. 
Finally, it calls for a long-range estimate of projected 
resource needs and progress toward sustainability.
    This section also instructs the Global AIDS Coordinator to 
commission a study by the Institute of Medicine (with prior 
design plan and budget) to assess progress and outcomes of 
United States global HIV/AIDS programs and provides for a 
Government Accountability Office report on monitoring and 
evaluation, coordination, and impact of HIV/AIDS funding and 
programs on United States global health programs as a whole. It 
requires annual publication of a ``Best Practices'' report 
based on operations research. To enhance oversight, it requires 
joint, coordinated plans by the Inspectors General (IGs) of the 
three largest U.S. Government agencies carrying out this 
program (State Department, HHS, and USAID) and authorizes the 
transfer of up to $10 million to the IGs to support financial 
audits, inspections, and performance reviews.

Sec. 102. Interagency working group

    This section amends current law to strengthen and expand 
the duties of the Global AIDS Coordinator, including enhancing 
the role of the Coordinator in consulting and coordinating with 
foreign governments, nongovernmental organizations, and other 
U.S. Government agencies. It expands the duties of the AIDS 
Coordinator to include establishing and heading a working group 
consisting of representatives from the United States Agency for 
International Development (USAID) and the Department of Health 
and Human Services.

Sec. 103. Sense of Congress

    This section provides a sense of Congress about the 
importance of country coordinators, foreign service nationals, 
and staffing levels for country teams.

TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE 
                              PARTNERSHIPS


Sec. 201. Voluntary contributions to International vaccine funds

    This section reauthorizes the existing programs under 
section 302 of the Foreign Assistance Act for fiscal years 
2009-2013, specifically the vaccine fund, the International 
AIDS Vaccine Initiative, and the malaria vaccine development 
program. This section also provides a new authorization for a 
U.S. contribution to tuberculosis vaccine development programs.

Sec. 202. Participation in the Global Fund to Fight AIDS, Tuberculosis 
        and Malaria

    This section amends section 202 of the 2003 Leadership Act 
relating to U.S. contributions to the Global Fund. Subsection 
(a) updates findings in the Act and expresses the sense of 
Congress regarding transparency, accountability, and 
coordination. Subsection (b) increases the annual authorization 
for the U.S. contribution to the Global Fund from $1 billion to 
up to $2 billion for fiscal years 2009, and such sums as 
necessary for fiscal years 2010-2013.
    The subsection includes new benchmarks designed to improve 
the accountability and transparency of the Global Fund's 
activities, including a provision, beginning in fiscal year 
2010, that would withhold 20 percent of appropriated funds 
until the Secretary of State certifies achievement of certain 
benchmarks.

Sec. 203. Microbicide research

    Subsection (a) expresses the sense of Congress recognizing 
the need and urgency to expand the range of interventions for 
preventing the transmission of HIV, including nonvaccine 
prevention methods that can be controlled by women.
    Subsection (b) amends the Public Health Service Act (42 
U.S.C. 300cc-40 et seq.) by directing the Director of the 
National Institutes of Health Office of AIDS Research to 
develop and implement Federal strategic plans for microbicide 
research and to review and update such plans annually, 
prioritizing funding and activities relative to scientific 
urgency and potential market readiness of microbicide products 
as appropriate. The subsection also directs the Director to 
consult with representatives of other relevant Federal 
agencies, the microbicide research community, and health 
advocates. The subsection includes authorization of such sums 
as necessary.
    Subsection (c) amends the Public Health Service Act by 
directing the Director of the National Institute of Allergy and 
Infectious Diseases (NIAID) to conduct research and development 
of microbicides for use in developing countries to prevent HIV 
transmission. The Director shall ensure adequate staffing and 
structure to carry out such activities, such as through a 
dedicated microbicide research and development branch.
    Subsection (d) directs the Director of the Centers for 
Disease Control and Prevention (CDC) to fully implement the 
CDC's microbicide agenda to support research and development of 
microbicides. It authorizes as such sums as may be necessary 
for each of fiscal years 2009 through 2013 to carry out these 
activities.
    Subsection (e) authorizes the Administrator of USAID, in 
coordination with the Coordinator of U.S. Government Activities 
to Combat HIV/AIDS Globally, to develop and implement a program 
to facilitate wide scale availability of microbicides that 
prevent the transmission of HIV if such microbicides are proven 
safe and effective. It authorizes such sums as may be necessary 
for fiscal years 2009 through 2013 to carry out this section.

Sec. 204. Combating HIV/AIDS, tuberculosis, and malaria by 
        strengthening health policies and health systems of partner 
        countries

    This section amends title II of the 2003 Leadership Act by 
adding a new section 204 relating to strengthening health 
policies and health systems of host countries. Subsection (a) 
provides a statement of policy regarding the need for 
strengthening of such health policies and systems. Subsection 
(b) authorizes the appropriation of funds authorized under 
section 401 of the Act to the Department of Treasury to provide 
technical assistance to host countries to improve the public 
finance management systems of such countries to enable them to 
receive HIV/AIDS assistance, collect revenue, and manage their 
own programs.

Sec. 205. Facilitating effective operations of the Centers for Disease 
        Control and Prevention

    This section amends the Public Health Service Act by 
authorizing the Secretary of Health and Human Services to 
participate with other countries in cooperative endeavors in 
research, healthcare services, and other activities authorized 
under the Reauthorization Act. The section also strikes a 
provision prohibiting the Secretary from providing financial 
assistance for the construction of any facility in any foreign 
country. It authorizes the provision of funds by advance or 
reimbursement to the Secretary of State, as may be necessary, 
to pay for the acquisition, lease, construction alteration, 
equipping, or managing of facilities outside the United States 
and authorizes grants or cooperative agreements relating to 
such activities, in consultation with the Secretary of State.

Section 206. Facilitating vaccine development

    Subsection (a) authorizes the USAID Administrator to 
strengthen the capacity of developing countries' governments to 
conduct proper protocols for the introduction of new vaccines, 
if such vaccines are proven safe and effective, to review 
protocols for clinical trials and impact studies and improve 
implementation, and to ensure adequate supply chain and 
delivery systems.
    Subsection (b) directs the Secretary of the Treasury to 
enter into negotiations with appropriate entities including the 
World Bank and GAVI Alliance to establish advanced market 
commitments to purchase vaccines to combat HIV/AIDS, 
tuberculosis, malaria, and other related infectious diseases. 
In such negotiations, the Secretary is directed to take into 
account factors regarding pricing, transparency, safety, 
dispute settlement, and needed flexibility. Not later than 1 
year after enactment, the Secretary shall provide the 
appropriate congressional committees with a report on 
negotiations and the President shall produce a report by a 
study group of qualified professionals setting forth a strategy 
for vaccine development.

                      TITLE III--BILATERAL EFFORTS


              Subtitle A--General Assistance and Programs


Sec. 301. Assistance to combat HIV/AIDS

    This section amends section 104A of the Foreign Assistance 
Act of 1961 and section 301 of the 2003 Leadership Act, both of 
which relate to bilateral U.S. HIV/AIDS assistance.
    Subsection (a) modifies the findings of the 2003 Leadership 
Act and identifies that it is a policy objective of the United 
States for FY 2009-2013 to assist countries in:

   Preventing 12 million new HIV infections;
   Supporting treatment of at least 3 million people 
        with HIV/AIDS as well as additional support through 
        multilateral efforts;
   Supporting care for 12 million people including care 
        and support for 5 million children affected by HIV/
        AIDS;
   Providing access to counseling and services for 
        prevention of mother-to-child transmission to 80 
        percent of the target population (80 percent is the 
        level most often defined as ``universal access'');
   Providing care and treatment services to children 
        with HIV/AIDS in proportion to their percentage within 
        the population of persons who are infected within a 
        given country; and
   Training 140,000 new paraprofessionals and 
        professionals.

    The subsection further amends section 104A by supporting a 
coordinated global strategy to confront HIV/AIDS in sub-Saharan 
Africa, the Caribbean, Central Asia, Eastern Europe, Latin 
America, and other countries and regions to help address 
generalized and concentrated HIV/AIDS epidemics, highlighting 
the importance of prevention.
    Section 301 also notes the activities for which U.S. HIV/
AIDS assistance can be used for prevention, including an 
increased focus on counseling, delay of sexual debut, 
abstinence, fidelity, life skills, prevention of mother-to-
child HIV transmission, and medical male circumcision. It also 
provides for a more coordinated approach to HIV/AIDS by 
supporting access to treatment for opportunistic infections and 
development programs that can improve the effectiveness of HIV/
AIDS efforts, such as nutrition, education, and programs that 
improve the livelihood of individuals with HIV/AIDS as well as 
programs to address the needs and vulnerabilities of girls and 
women. It promotes the use of provider-initiated or ``opt out'' 
voluntary counseling and testing as well as rapid testing.
    The section underscores the importance of operations 
research as a component of HIV/AIDS activities, and amends the 
2003 Leadership Act to create an enhanced focus on food and 
nutrition assistance as critical to an integrated approach to 
treatment of individuals with HIV/AIDS. Section 301 authorizes, 
though does not mandate, compacts or framework agreements in 
order to promote a more sustainable, country-driven approach. 
The section includes necessary components of such compacts. It 
also expands the annual report to address a number of the new 
approaches described in this Act and to emphasize outcomes of 
programs.
    Section 301 also amends section 301 of the 2003 Leadership 
Act to extend the authorization to fiscal years 2009 through 
2013.
    Subsection (h) clarifies that not only are groups receiving 
funds under the Act not required to endorse or utilize any 
activities or programs to which they have a moral or religious 
objection, they are also not required to integrate with, or 
refer to programs to which they have a moral or religious 
objections.

Sec. 302. Assistance to combat tuberculosis

    Subsections (a) and (b) amend section 104B of the Foreign 
Assistance Act of 1961 relating to assistance to combat 
tuberculosis, drawing from S. 968, the Stop Tuberculosis (TB) 
Now Act of 2007, which the committee approved on September 11, 
2007. These amendments include a revised statement of policy; a 
requirement to provide assistance to combat tuberculosis and a 
list of activities to be carried out, including diagnostic 
testing and counseling, treatment, and implementation of 
protocols to address drug resistance.
    Subsection (c) authorizes the provision of increased 
resources to the World Health Organization.
    Subsection (d) offers definitions of additional terms.
    Subsection (e) amends section 302 of the 2003 Leadership 
Act to authorize up to a total of $4 billion for fiscal years 
2009 to 2013 from the overall amounts authorized by section 401 
of the 2003 Leadership Act (as amended by this Act) for 
assistance to combat tuberculosis.

Sec. 303. Assistance to combat malaria

    Subsection (a) amends section 104C of the Foreign 
Assistance Act of 1961 to ensure that treatment is part of U.S. 
efforts to combat malaria.
    Subsection (b) amends section 303 of the 2003 Leadership 
Act to authorize up to a total of $5 billion for fiscal years 
2009 to 2013 from the overall amounts authorized by section 401 
of the 2003 Leadership Act (as amended by this Act) for 
assistance to combat malaria.
    Subsection (c) provides a statement of policy regarding 
malaria.
    Subsection (d) requires the President to provide a 
comprehensive 5-year strategy to combat malaria.

Sec. 304. Malaria Response Coordinator

    Section 304 amends section 304 of the 2003 Leadership Act 
by adding a requirement for a comprehensive strategy to combat 
malaria and to establish within USAID a malaria coordinator. It 
also authorizes contributions to the Roll Back Malaria 
Partnership and the World Health Organization; research by 
relevant U.S. agencies to address prevention, treatment, and 
care of malaria; and requires an annual report on the 
prevention, treatment, control and elimination of malaria.

Sec. 305. Amendment to the Immigration and Nationality Act

    Section 305 amends section 212(a)(1)(A) of the Immigration 
and Nationality Act by removing the statutory prohibition on 
persons with HIV entering the country. Under section 212, 
should this provision be enacted, aliens remain inadmissible if 
they have a ``communicable disease of public health 
significance'' under regulations issued by the Secretary for 
Health and Human Services.

Sec. 306. Clerical amendment

    This provides a technical amendment to a subtitle heading 
in the 2003 Act.

Sec. 307. Requirements

    This section amends section 312 of the 2003 Leadership Act 
to provide for additional policy and other requirements, 
including the establishment of targets for reaching 80 percent 
of the target population for prevention of mother-to-child 
transmission (PMTCT) of HIV and to ensure that the proportion 
of children receiving care and treatment for HIV/AIDS is 
proportionate to their numbers within the population. The 
section also calls for integrating care and treatment with 
PMTCT programs; expanding programs for orphans and for children 
who are affected by or vulnerable to HIV/AIDS; increasing 
access of women in PMTCT programs to maternal and child health 
services; and establishing a timeline for expanding access to 
PMTCT regimes.

Sec. 308. Annual reports on prevention of mother-to-child transmission 
        of the HIV infection

    This section amends section 313 of the 2003 Leadership Act 
by extending the duration of the annual PMTCT report required 
by such subsection and requires that such report include 
additional information on the number of women who receive 
various types of assistance related to PMTCT.

Section 309. Prevention of mother-to-child transmission expert panel

    This section amends section 312 of the 2003 Leadership Act 
by directing the Global AIDS Coordinator to establish a panel 
of experts on the prevention of mother-to-child transmission of 
HIV to review PMTCT activities and make recommendations to the 
Global AIDS Coordinator and the appropriate congressional 
committees. The panel shall terminate 60 days after said report 
is submitted.

                     TITLE IV--FUNDING ALLOCATIONS


Sec. 401. Authorization of appropriations

    Subsection (a) increases the authorization under section 
401(a) of the 2003 Leadership Act to $50 billion for fiscal 
years 2009 to 2013. Unlike the House bill, which provides an 
authorization of $10 billion per fiscal year, this allows for a 
gradual expansion of the program.
    Subsection (b) expresses the sense of the Congress that 
these funds should be gradually increased over the 5 fiscal 
years covered by the bill and in a manner consistent with 
program requirements, absorptive capacity, and priorities set 
forth in the Act. The committee does not expect the President 
to request or the Congress to fund these programs all in 1 
year. For fiscal year 2008, Congress appropriated $6.327 
billion for these programs, according to the Congressional 
Research Service.

Sec. 402. Sense of Congress

    This section amends the ``sense of Congress'' language 
included in section 402(b) of the 2003 Leadership Act to 
eliminate specific spending directives in the legislation 
expressed as a sense of Congress for percentage allocations for 
treatment and for the use of prevention funds for abstinence 
programs.

Sec. 403. Allocation of funds

    This section amends section 403(a) of the 2003 Leadership 
Act to maintain focus on balanced prevention programming. This 
section includes a requirement that the Coordinator provide 
balanced funding for prevention activities for sexual 
transmission of HIV/AIDS and ensure that abstinence, delay 
sexual debut, monogamy, fidelity and partner reduction programs 
are implemented and funded in a meaningful and equitable way in 
the strategy for each host country, based on objective 
epidemiological evidence as to the source of infection and in 
consultation with the government of each host country involved 
in HIV/AIDS prevention activities.
    The new subsection also provides that the Coordinator shall 
establish an HIV sexual transmission prevention strategy 
governing the expenditure of funds authorized by the Act used 
to prevent the sexual transmission of HIV in any host country 
with a generalized epidemic. In each such host country, if this 
strategy provides less than 50 percent of such funds for 
behavior change programs including abstinence, delay of sexual 
debut, monogamy, fidelity, and partner reduction activities, 
the Coordinator shall, within 30 days of the issuance of this 
strategy, report to the appropriate congressional committees on 
the justification for this decision. The subsection excludes 
new prevention technologies or modalities such as medical male 
circumcision or microbicides as well as PMTCT activities, blood 
safety measures, and other prevention tools unrelated to the 
sexual transmission of HIV from calculations to determine 
compliance with the balanced funding reporting requirement.
    Finally, this section maintains the 10-percent earmark for 
orphans and vulnerable children, and modifies the focus of this 
effort to include children who are vulnerable to, as well as 
affected by, HIV/AIDS to allow greater flexibility in providing 
services to at-risk children, especially in communities with 
high prevalence rates.

                           VI. Cost Estimate

    In accordance with rule XXVI, paragraph 11(a) of the 
Standing Rules of the Senate, the committee provides this 
estimate of the costs of this legislation prepared by the 
Congressional Budget Office.

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, April 11, 2008.
Hon. Joseph R. Biden, Jr.,
Chairman, Committee on Foreign Relations,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 2731, the Tom Lantos 
and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Reauthorization Act of 2008.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Michelle S. 
Patterson.
            Sincerely,
                                         Robert A. Sunshine
                                   (For Peter R. Orszag, Director).
     Enclosure.

S. 2731--Tom Lantos and Henry J. Hyde U.S. Global Leadership Against 
        HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008

    Summary: S. 2731 would reauthorize several assistance 
programs aimed at preventing and treating HIV/AIDS, 
tuberculosis, and malaria in other countries. For those 
programs, the bill would authorize the appropriation of $50 
billion over the next 5 years. Other provisions of the bill 
would authorize funding for U.S. contributions to international 
vaccine funds and for research on the development of substances 
that can be applied topically to limit the transmission of HIV. 
CBO estimates that implementing S. 2731 would cost $35 billion 
over the 2009-2013 period, assuming appropriation of the 
authorized amounts. (Additional amounts would be spent after 
2013.)
    In addition, enacting S. 2731 would increase direct 
spending. The bill would allow immigrants with HIV/AIDS to 
enter the United States. CBO estimates that providing certain 
benefits to those immigrants and their children would increase 
direct spending by less than $500,000 in 2010 and by $83 
million over the 2010-2018 period. Enacting S. 2731 would have 
no effect on revenues.
    S. 2731 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA). 
CBO estimates that state spending for Medicaid would increase 
by $53 million over the 2010-2018 period as a result of the 
bill's immigration provisions, but such spending would not 
result from intergovernmental mandates.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 2731 is shown in Table 1. The costs of 
this legislation fall within budget functions 150 
(international affairs), 550 (health), and 600 (income 
security).

                                 TABLE 1.--ESTIMATED BUDGETARY IMPACT OF S. 2731
----------------------------------------------------------------------------------------------------------------
                                                               By fiscal year, in millions of dollars--
                                                    ------------------------------------------------------------
                                                       2009      2010      2011      2012      2013    2009-2013
----------------------------------------------------------------------------------------------------------------

                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

HIV/AIDS, Tuberculosis, and Malaria Programs:
    Estimated Authorization Level..................    10,000    10,000    10,000    10,000    10,000     50,000
    Estimated Outlays..............................     1,392     6,392     8,262     9,082     9,482     34,610
Contributions to Vaccine Funds:
    Estimated Authorization Level..................       108       108       108       158       158        640
    Estimated Outlays..............................       108       108       108       158       158        640
Microbicide Research:
    Estimated Authorization Level..................        10        11        13        12        12         58
    Estimated Outlays..............................         4         9        11        12        12         48
Total Changes:
    Estimated Authorization........................    10,118    10,119    10,121    10,170    10,170     50,698
    Level Estimated Outlays........................     1,504     6,509     8,381     9,252     9,652     35,298

                                          CHANGES IN DIRECT SPENDING\1\

Estimated Budget Authority.........................         0         *         *         1         2          3
Estimated Outlays..................................         0         *         *         1         2          3
----------------------------------------------------------------------------------------------------------------
\1\In addition to the direct spending effects shown here, enacting S. 2731 would have effects on direct spending
  after 2013 (see Table 2). The estimated increase in direct spending sums to $3 million over the 2010-2013
  period and $83 million over the 2010-2018 period.

Note: * = less than $500,000.

    Basis of estimate: For this estimate, CBO assumes that the 
bill will be enacted by September 30, 2008, that the authorized 
amounts will be appropriated, and that outlays will follow 
historical spending patterns for existing programs.

Spending subject to appropriation

    S. 2731 would reauthorize several assistance programs and 
increase the funding levels for those programs. It also would 
require research into various vaccines and microbicides. In 
total, implementing the bill would have discretionary costs of 
$1.5 billion in 2009 and $35 billion over the 2009-2013 period.
    HIV/AIDS, Tuberculosis, and Malaria Programs. Section 401 
would authorize the appropriation of $50 billion over the 2009-
2013 period. For this estimate, CBO assumes that $10 billion 
would be appropriated for each of the 5 years, though the 
allocation of the $50 billion authorization could vary from 
that assumption. The funds would be used to operate and expand 
the existing assistance programs that provide grants and 
contributions to organizations and global funds devoted to 
treating the effects of HIV/AIDS, tuberculosis, and malaria, 
and to preventing the transmission of those diseases. Those 
programs, which received a total of $6 billion for 2008, are 
run by the Department of State, the U.S. Agency for 
International Development (USAID), and the Department of Health 
and Human Services.
    Based on information from the Department of State, CBO 
estimates that the authorized 5-year total of $50 billion is 
sufficient to fund the expanded requirements. CBO estimates 
that implementing section 401 would cost about $35 billion over 
the 2009-2013 period. Most of the additional amounts from the 
authorized funding would be spent by 2018.
    Contribution to Vaccine Funds. Section 201 would authorize 
the appropriation of such sums as may be necessary to make 
contributions for research and development of various vaccines. 
Based on information from USAID on the current amount of 
contributions to those funds (about $100 million in 2008) and, 
after 2011, the amount needed to fund the final stages of 
development for a tuberculosis vaccine, CBO estimates that 
implementing section 201 would cost $640 million over the 2009-
2013 period.
    Microbicide Research. Section 203 would direct the Centers 
for Disease Control and Prevention (CDC) to conduct research 
with the goal of developing topical mircobicides that could be 
used to limit the transmission of HIV. For that purpose, it 
would authorize the appropriation of such sums as necessary.
    Based on information from the CDC, CBO estimates that such 
research would require $10 million in 2009 and $58 million over 
the 2009-2013 period. Assuming appropriation of those amounts, 
and that spending for those activities would follow historical 
spending patterns, CBO estimates that implementing section 203 
would cost $48 million over the 2009-2013 period.
    AIDS Drug Assistance Programs. The Ryan White Care Act 
provides grants to states to run the AIDS Drug Assistance 
Program (ADAP). ADAP provides prescription drug benefits to 
certain low-income individuals with HIV/AIDS. Implementing S. 
2731 would increase the number of individuals eligible for ADAP 
benefits. CBO estimates that the number of people newly 
eligible for ADAP benefits would reach about 1,000 in 2011.
    The Ryan White Care Act authorizes the appropriation of 
specific amounts for ADAP through 2011. Absent a change in the 
specific authorization or appropriation for ADAP, no new 
Federal funding would be available to meet this increased 
demand. If additional funding were provided for the ADAP 
program, CBO estimates it would cost about $20 million in 2010 
and 2011 to provide ADAP benefits to individuals affected by 
section 305. (This section would have direct spending costs, as 
explained below.)

Direct spending

    Section 305 would amend the Immigration and Nationality Act 
by removing language that explicitly identified HIV infection--
and consequently AIDS--as one of the communicable diseases of 
public-health significance that render aliens ineligible for 
visas or admission to the United States. Based on information 
from the CDC, CBO expects that the agency would amend the 
regulations concerning communicable diseases to allow aliens 
with HIV or AIDS into the United States if section 305 were 
enacted. CBO expects that the amended regulations would take 
effect at the beginning of fiscal year 2010.
    Enacting section 305 would enable additional immigrants to 
receive visas to enter the United States, primarily in the visa 
program for immediate family members. (For some visa programs, 
the number of immigrants with HIV/AIDS would increase, but the 
total number of immigrants admitted would not change.) Based on 
information from the CDC, the World Health Organization, and 
the Department of Homeland Security, CBO estimates the annual 
number of additional immigrants with HIV/AIDS would total about 
900 in 2010 and grow to approximately 4,300 in fiscal year 
2013. Thereafter, the number of additional immigrants would 
grow in line with overall immigration, totaling roughly 5,600 
in 2018. Additionally, CBO estimates that about 800 citizen-
children would be born to those immigrants between 2010 and 
2018, a markedly lower birth rate than that for non-HIV/AIDS 
immigrants.
    CBO estimates that a small percentage of the immigrants who 
would enter the United States under section 305 would receive 
Federal disability, health, and nutrition benefits. In total, 
CBO estimates that providing benefits to those immigrants and 
their children would increase spending by less than $500,000 in 
2010 and $83 million over the 2010-2018 period, as shown in 
Table 2. (Through 2017, the end of the Senate's enforcement 
period for direct spending under the current budget resolution, 
the bill would increase direct spending by $46 million.)

                              TABLE 2.--COMPONENTS OF DIRECT SPENDING UNDER S. 2731
----------------------------------------------------------------------------------------------------------------
                                                        By fiscal year, in millions of dollars--
                                       -------------------------------------------------------------------------
                                                                                                    2009-  2009-
                                        2009  2010  2011  2012  2013  2014  2015  2016  2017  2018   2013   2018
----------------------------------------------------------------------------------------------------------------
                                           CHANGES IN DIRECT SPENDING

Medicaid:
  Estimated Budget Authority..........     0     *     *     1     2     3     5    10    18    31     3     70
  Estimated Outlays...................     0     *     *     1     2     3     5    10    18    31     3     70
Food and Nutrition Programs:
  Estimated Budget Authority..........     0     *     *     *     *     1     1     1     3     3     *      9
  Estimated Outlays...................     0     *     *     *     *     1     1     1     3     3     *      9
Supplemental Security Income:
  Estimated Budget Authority..........     0     *     *     *     *     *     *     *     1     3     *      4
  Estimated Outlays...................     0     *     *     *     *     *     *     *     1     3     *      4
Total Changes:
  Estimated Budget Authority..........     0     *     *     1     2     4     6    11    22    37     3     83
  Estimated Outlays...................     0     *     *     1     2     4     6    11    22    37     3     83
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.

    Medicaid. Under the Medicaid eligibility rules for 
noncitizens, immigrants entering under section 305 who meet 
Medicaid's income and categorical eligibility criteria would 
have to wait 5 years before they could receive full Medicaid 
benefits. However, those individuals would be eligible for 
emergency Medicaid services before the end of the 5-year 
waiting period.
    CBO estimates that enacting section 305 would increase 
direct spending for the Federal share of the Medicaid program 
by $3 million over the 2010-2013 period and $70 million over 
the 2010-2018 period. The increase in estimated costs after 
2014 reflects individuals becoming eligible for full Medicaid 
benefits after completing the 5-year waiting period.
    Food and Nutrition Programs. By 2018, CBO estimates that 
about 1,300 newly admitted immigrants would qualify for Food 
Stamps with an average benefit of about $130 a month. In 
addition, about 4,000 children of the additional immigrants 
would be eligible for child nutrition programs in 2018, with an 
average monthly cost of about $30 (in 2018 dollars). In total, 
CBO estimates that direct spending for the Food Stamp and Child 
Nutrition programs would increase by less than $500,000 in 2010 
and $9 million over the 2010-2018 period.
    Supplemental Security Income (SSI). CBO estimates that 
direct spending for the Supplemental Security Income program 
would increase by less than $500,000 in 2010 and $4 million 
over the 2010-2018 period. Under current law, immigrants 
generally have to wait until they became naturalized citizens 
before they can receive SSI. Based on data from the CDC, the 
Social Security Administration, and private researchers, CBO 
estimates that nearly 400 of the additional immigrants under 
section 305 would enter the rolls by 2018. Over that period, 
CBO projects average monthly benefits would grow from $500 to 
$590.
    Social Security Disability Insurance. CBO estimates that, 
under section 305, off-budget direct spending for the Social 
Security Disability Insurance (DI) program would increase by 
less than $500,000 over the 10-year budget window. Based on the 
age and health profile of immigrants, CBO estimates that few 
people would qualify for DI over that period.
    Medicare. Noncitizens can become eligible for Medicare if 
they are over the age of 65 and are residents of the United 
States for five consecutive years, or after receiving DI for 2 
years. CBO assumes that few of the new entrants under section 
305 would meet either of these eligibility criteria. Therefore, 
CBO estimates that direct spending for Medicare would increase 
by less than $500,000 over the 2010-2018 period.
    Estimated impact on state, local, and tribal governments: 
S. 2731 contains no intergovernmental mandates as defined in 
UMRA, but changes to immigration law would result in an 
increased number of individuals eligible for Medicaid, SSI, and 
ADAP. State spending for those programs would increase, but 
that additional spending would not result from 
intergovernmental mandates.
    CBO estimates state spending for Medicaid would increase by 
$53 million over the 2010-2018 period, while state spending for 
supplemental SSI payments would increase only slightly. ADAP 
benefits are state-controlled, voluntary, and federally funded 
through grants. Any additional costs to state, local, or tribal 
governments might incur in that program, including matching 
funds, would result from complying with conditions of aid.
    Estimated impact on the private sector: S. 2731 contains no 
new private-sector mandates as defined in UMRA.
    Previous CBO estimate: On March 5, 2008, CBO transmitted a 
cost estimate for H.R. 5501, the Tom Lantos and Henry J. Hyde 
U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and 
Malaria Reauthorization Act of 2008, as ordered reported by the 
House Committee on Foreign Affairs on February 28, 2008. While 
the two pieces of legislation have many provisions in common, 
S. 2731 contains two provisions that are not included in H.R. 
5501. Section 305 of S. 2731 would allow immigrants with HIV to 
enter the United States, which CBO estimates would increase 
direct spending. In addition, section 203 of S. 2731 would 
require the CDC to conduct additional research. Differences in 
the estimated costs of S. 2731 and H.R. 5501 reflect those 
differences in the legislation.
    Estimate prepared by: Federal Costs: Foreign Aid--Michelle 
S. Patterson; Centers for Disease Control and Prevention--Tim 
Gronniger; Supplemental Security Income--David Rafferty; 
Medicaid--Andrea Kastin Noda; Food and Nutrition Programs--
Jonathan Morancy.
    Impact on State, Local, and Tribal Governments: Neil Hood; 
Impact on the Private Sector: MarDestinee C. Perez.
    Estimate approved by: Peter H. Fontaine, Assistant Director 
for Budget Analysis.

                          VII. MINORITY VIEWS

    We strongly dissent from the committee's report of S. 2731 
to the full Senate. We are gravely concerned that the 
President's Emergency Plan for AIDS Relief (PEPFAR) program is 
under serious threat of dramatic policy reversals that endanger 
the lives of millions around the world suffering from and at 
risk of contracting HIV/AIDS. First authorized in 2003, PEPFAR 
was a historic new approach to combating HIV/AIDS. The elements 
of the program were unprecedented:

   Saving the lives of people with AIDS: For the first 
        time, the U.S. would fund antiretroviral treatment for 
        millions.
   Evidence-based prevention: The U.S. would implement 
        the African-grown ``ABC'' model of abstinence, ``be 
        faithful'' and condoms that had led to such dramatic 
        reductions in HIV incidence in Uganda.
   Concentration of effort: Targeted funding for the 
        poorest countries in sub-Saharan Africa and the 
        Caribbean with the worst AIDS epidemics.

    As the bill to authorize this new initiative moved through 
the Congress, its sponsors and supporters fought hard to keep 
off the many worthy, but competing initiatives that would have 
diluted the impact of the PEPFAR program. Unfortunately, S. 
2731 fails to protect the program from similar efforts; and we 
are gravely concerned that the noble impact and long-term 
legacy of the program are being threatened. Specifically, we 
believe that S. 2731 has the following serious flaws:
Politics Trump Proven Prevention Policy
    We object to the bill's elimination of the protected 
funding for abstinence-until-marriage programs required under 
current law and replaces it with watered-down, ill-defined 
language that would permit a prevention program to operate 
without measurable, significant support for abstinence and 
fidelity programs. Prior to the implementation of PEPFAR, the 
only country to ever demonstrate a nationwide reduction in HIV 
incidence was Uganda. The success was driven by the African-
grown, grassroots, low-tech, low-cost ``ABC'' model of HIV 
prevention, based on three commonsense messages, each targeted 
to a different population: (1) The promotion of abstinence 
until marriage or delay of sexual debut for youth and unmarried 
adults, (2) the promotion of fidelity within marriage and 
partner reduction for sexually active unmarried adults, and (3) 
the promotion of the consistent and correct use of condoms for 
especially high-risk subpopulations, such as prostitutes and 
their customers, substance abusers and their equipment-sharing 
and sexual partners, and HIV-serodiscordant married couples. 
The evidence is clear: ABC works to prevent sexual transmission 
of HIV/AIDS in a generalized epidemic such as you find in sub-
Saharan Africa. Nothing else ever has. As a result of this 
sound approach, Uganda now has company: Several PEPFAR focus 
countries have started to see reductions, including Kenya, Cote 
D'Ivoire, and Ethiopia.
No Conscience Protections for Organizations Providing HIV/AIDS Care
    The bill removes most references to faith-based 
organizations contained in current law, causing us to question 
whether the bill authors intend PEPFAR to retreat from its 
important recognition of the indispensable role of such 
organizations in reaching communities affected by HIV/AIDS in 
the developing world that might never be successfully reached 
using U.S.-based USAID contractors. Of even more concern, 
however, is the bill's elimination of conscience protections 
for organizations providing the critical third element of the 
HIV treatment, prevention, and care combination. The bill 
protects organizations participating in HIV/AIDS treatment, 
prevention, and monitoring programs from being required to 
support or provide services to which they have a moral or 
religious objection. However, no such protection is provided 
for organizations providing HIV ``care'' programs, which 
include all programs for orphans and vulnerable children, 
hospice and palliative care services, support groups and 
psychosocial services and many other services.
Support for Morally Dubious Activities
    The bill contains many references to activities 
``demonstrated to be effective in reducing the transmission of 
HIV infection among injection drug users without increasing 
illicit drug use.'' Given the claim by some that programs to 
distribute clean needles to injection drug users are effective 
at reducing transmission and do not lead to more drug use, 
these provisions could be interpreted to support needle 
exchange programs, a practice not currently supported 
domestically or abroad using U.S. funds. Americans should not 
be forced to subsidize the distribution of paraphernalia for 
illicit drug use, when the best HIV prevention for injection 
drug use would be treatment of the underlying addiction.
The Global Fund Takes Cues from the U.N.
    When the 108th Congress authorized the first contribution 
to the Global Fund to Fight HIV/AIDS, Tuberculosis, we were 
assured that the Fund would not be like the U.N. and that the 
Fund would guarantee full transparency and accountability. The 
current law contains some important provisions to protect the 
taxpayer investment in this multilateral disease-fighting 
organization. However, we have seen during the first few years 
of the Fund's operation that these provisions have not been 
sufficient to ensure full accountability and transparency by 
the scandal-ridden Fund. What's more, the Fund has failed to 
provide Congress with all documents requested, including 
reports of the so-called ``independent'' Inspector General. The 
Fund has lost money by relying on the U.N. Development Program 
(UNDP) in Burma, and failed to recoup funds from terminated 
grants there. Burma is not the only country where the Fund 
relies on UNDP, but actually uses the U.N. agency as a 
``safer'' alternative to directly funding rogue regimes such as 
Zimbabwe and Sudan. UNDP is under investigation by the U.S. 
Senate Permanent Subcommittee on Investigations for using donor 
money to finance North Korea illicit weapons sales; laundering 
untold millions from terrorist regimes through U.N. bank 
accounts; using donor money to help Zimbabwe officials purchase 
``blood diamonds''; and a variety of other crimes.
    Further, the Fund has failed to adequately safeguard the 
quality of medicines procured using its funding. While we 
support the bill's provision conditioning 20 percent of the 
U.S. contribution to the Fund to the achievement of certain 
accountability measures, the bill also contains a variety of 
important transparency measures in a nonbinding ``Sense of 
Congress'' provision. We believe that these provisions should 
be made binding, as well.
Fiscal Irresponsibility
    Before PEPFAR was authorized, the U.S. spent less than $200 
million annually on global AIDS. Compared to past levels, 
PEPFAR's initial authorization of $15 billion over 5 years was 
a dramatic increase. Indeed, the administration has ramped up 
to an annual spending level that grossly exceeds the statutory 
limit in current law. Even if Congress agreed to extend funding 
at these unauthorized levels, we would ``only'' need to pass a 
reauthorization bill to provide between $25-$30 billion over 
the next 5 years. S. 2731, however, authorizes $50 billion over 
5 years in addition to numerous, ``such sums'' authorizations.
    What's more, the current targeted, effective HIV/AIDS 
program is under assault in this bill by ``mission creep'' that 
threatens to dilute the impact of the program and violate all 
pretentions of fiscal restraint by prioritizing seemingly every 
activity except HIV treatment, prevention, and care. The bill's 
HIV programs are crowded out by every possible development 
program imaginable, including schools, poverty alleviation, 
microcredit, legal aid, government advocacy, women's 
``empowerment,'' ``stigma reduction,'' nutrition, U.S.-based 
university agricultural research, biomedical vaccine 
development, and health workforce development. In addition to 
squeezing-out the higher priority HIV programs, the inclusion 
of all these additional development programs will only 
guarantee that the pressure to exceed the authorization caps in 
the bill will be irresistible in the out years as the 
development needs of the world can never be fully met.

                               CONCLUSION

    The PEPFAR program has been one of the few success stories 
of U.S. foreign assistance policy. The scientific policy has 
been sound, the fiscal priorities appropriate, and the results 
astounding. As a means of building diplomatic good will, PEPFAR 
has been an unquestioned success in strengthening bilateral 
relationships in the important emerging governments and 
economies in Africa. Simply put, the program isn't ``broken.'' 
The best approach to reauthorization would be to simply extend 
current authorities at a fiscally responsible level. S. 2731 is 
a radical departure from current policy, and will serve to 
reverse the many gains the program has achieved to date. We 
dissent from the committee's report of the bill to the Senate 
for full consideration.
            Sincerely,

                                   David Vitter,
                                           U.S. Senator.
                                   Jim DeMint,
                                           U.S. Senator.

                     VIII. Changes in Existing Law

    In compliance with Rule XXVI, paragraph 12 of the Standing 
Rules of the Senate, changes in existing law made by the bill, 
as reported, are shown as follows (existing law proposed to be 
omitted is enclosed in black brackets, new matter is printed in 
italic, existing law in which no change is proposed is shown in 
roman).

   The United States Leadership Against HIV/AIDS, Tuberculosis, and 
Malaria Act of 2003

           *       *       *       *       *       *       *


SEC. 2. FINDINGS.

    Congress makes the following findings:
          (1) * * *

           *       *       *       *       *       *       *

          (28) * * *
          (29) On May 27, 2003, the President signed this Act 
        into law, launching the largest international public 
        health program of its kind ever created.
          (30) Between 2003 and 2008, the United States, 
        through the President''s Emergency Plan for AIDS Relief 
        (PEPFAR) and in conjunction with other bilateral 
        programs and the multilateral Global Fund has helped 
        to--
                  (A) provide antiretroviral therapy for over 
                1,900,000 people;
                  (B) ensure that over 150,000 infants, most of 
                whom would have likely been infected with HIV 
                during pregnancy or childbirth, were not 
                infected; and
                  (C) provide palliative care and HIV 
                prevention assistance to millions of other 
                people.
          (31) While United States leadership in the battles 
        against HIV/AIDS, tuberculosis, and malaria has had an 
        enormous impact, these diseases continue to take a 
        terrible toll on the human race.
          (32) According to the 2007 AIDS Epidemic Update of 
        the Joint United Nations Programme on HIV/AIDS 
        (UNAIDS)--
                  (A) an estimated 2,100,000 people died of 
                AIDS-related causes in 2007; and
                  (B) an estimated 2,500,000 people were newly 
                infected with HIV during that year.
          (33) According to the World Health Organization, 
        malaria kills more than 1,000,000 people per year, 70 
        percent of whom are children under 5 years of age.
          (34) According to the World Health Organization, \1/
        3\ of the world''s population is infected with the 
        tuberculosis bacterium, and tuberculosis is 1 of the 
        greatest infectious causes of death of adults 
        worldwide, killing 1,600,000 people per year.
          (35) Efforts to promote abstinence, fidelity, the 
        correct and consistent use of condoms, the delay of 
        sexual debut, and the reduction of concurrent sexual 
        partners represent important elements of strategies to 
        prevent the transmission of HIV/AIDS.
          (36) According to UNAIDS--
                  (A) women and girls make up nearly 60 percent 
                of persons in sub-Saharan Africa who are HIV 
                positive;
                  (B) women and girls are more biologically, 
                economically, and socially vulnerable to HIV 
                infection; and
                  (C) gender issues are critical components in 
                the effort to prevent HIV/AIDS and to care for 
                those affected by the disease.
          (37) Children who have lost a parent to HIV/AIDS, who 
        are otherwise directly affected by the disease, or who 
        live in areas of high HIV prevalence may be vulnerable 
        to the disease or its socioeconomic effects.
          (38) Lack of health capacity, including insufficient 
        personnel and inadequate infrastructure, in sub-Saharan 
        Africa and other regions of the world is a critical 
        barrier that limits the effectiveness of efforts to 
        combat HIV/AIDS, tuberculosis, and malaria, and to 
        achieve other global health goals.
          (39) On March 30, 2007, the Institute of Medicine of 
        the National Academies released a report entitled 
        ``PEPFAR Implementation: Progress and Promise'', which 
        found that budget allocations setting percentage levels 
        for spending on prevention, care, and treatment and for 
        certain subsets of activities within the prevention 
        category--
                  (A) have ``adversely affected implementation 
                of the U.S. Global AIDS Initiative'';
                  (B) have inhibited comprehensive, integrated, 
                evidence based approaches;
                  (C) ``have been counterproductive'';
                  (D) ``may have been helpful initially in 
                ensuring a balance of attention to activities 
                within the 4 categories of prevention, 
                treatment, care, and orphans and vulnerable 
                children'';
                  (E) ``have also limited PEPFAR''s ability to 
                tailor its activities in each country to the 
                local epidemic and to coordinate with the level 
                of activities in the countries'' national 
                plans''; and
                  (F) should be removed by Congress and 
                replaced with more appropriate mechanisms 
                that--
                          (i) ``ensure accountability for 
                        results from Country Teams to the U.S. 
                        Global AIDS Coordinator and to 
                        Congress''; and
                          (ii) ``ensure that spending is 
                        directly linked to and commensurate 
                        with necessary efforts to achieve both 
                        country and overall performance targets 
                        for prevention, treatment, care, and 
                        orphans and vulnerable children''.
          (40) The United States Government has endorsed the 
        principles of harmonization in coordinating efforts to 
        combat HIV/AIDS commonly referred to as the ``Three 
        Ones'', which includes--
                  (A) 1 agreed HIV/AIDS action framework that 
                provides the basis for coordination of the work 
                of all partners;
                  (B) 1 national HIV/AIDS coordinating 
                authority, with a broadbased multisectoral 
                mandate; and
                  (C) 1 agreed HIV/AIDS country-level 
                monitoring and evaluating system.
          (41) In the Abuja Declaration on HIV/AIDS, 
        Tuberculosis and Other Related Infectious Diseases, of 
        April 26-27, 2001 (referred to in this Act as the 
        ``Abuja Declaration''), the Heads of State and 
        Government of the Organization of African Unity (OAU)--
                  (A) declared that they would ``place the 
                fight against HIV/AIDS at the forefront and as 
                the highest priority issue in our respective 
                national development plans'';
                  (B) committed ``TO TAKE PERSONAL 
                RESPONSIBILITY AND PROVIDE LEADERSHIP for the 
                activities of the National AIDS Commissions/
                Councils'';
                  (C) resolved ``to lead from the front the 
                battle against HIV/AIDS, Tuberculosis and Other 
                Related Infectious Diseases by personally 
                ensuring that such bodies were properly 
                convened in mobilizing our societies as a whole 
                and providing focus for unified national 
                policymaking and programme implementation, 
                ensuring coordination of all sectors at all 
                levels with a gender perspective and respect 
                for human rights, particularly to ensure equal 
                rights for people living with HIV/AIDS''; and
                  (D) pledged ``to set a target of allocating 
                at least 15% of our annual budget to the 
                improvement of the health sector''.

           *       *       *       *       *       *       *


SEC. 3. DEFINITIONS.

    In this Act:
          (1) AIDS.--The term ``AIDS'' means the acquired 
        immune deficiency syndrome.
          (2) Appropriate congressional committees.--The term 
        ``appropriate congressional committees'' means the 
        Committee on Foreign Relations of the Senate and the 
        [Committee on International Relations] Committee on 
        Foreign Affairs of the House of Representatives, the 
        Committee on Appropriations of the Senate, and the 
        Committee on Appropriations of the House of 
        Representatives.
          (3) Global aids coordinator.--The term ``Global AIDS 
        Coordinator'' means the Coordinator of United States 
        Government Activities to Combat HIV/AIDS Globally.
          [(3)] (4) Global fund.--The term ``Global Fund'' 
        means the public-private partnership known as the 
        Global Fund to Fight AIDS, Tuberculosis and Malaria 
        established pursuant to Article 80 of the Swiss Civil 
        Code.
          [(4)] (5) HIV.--The term ``HIV'' means the human 
        immunodeficiency virus, the pathogen that causes AIDS.
          [(5)] (6) HIV/AIDS.--The term ``HIV/AIDS'' means, 
        with respect to an individual, an individual who is 
        infected with HIV or living with AIDS.
          (7) Impact evaluation research.--The term ``impact 
        evaluation research'' means the application of research 
        methods and statistical analysis to measure the extent 
        to which change in a population-based outcome can be 
        attributed to program intervention instead of other 
        environmental factors.
          (8) Operations research.--The term ``operations 
        research'' means the application of social science 
        research methods and statistical analysis to judge, 
        compare, and improve policies and program outcomes, 
        from the earliest stages of defining and designing 
        programs through their development and implementation, 
        with the objective of the rapid dissemination of 
        conclusions and concrete impact on programming.
          (9) Paraprofessional.--The term ``paraprofessional'' 
        means an individual who is trained and employed as a 
        health agent for the provision of basic assistance in 
        the identification, prevention, or treatment of illness 
        or disability.
          (10) Partner government.--The term ``partner 
        government'' means a government with which the United 
        States is working to provide assistance to combat HIV/
        AIDS, tuberculosis, or malaria on behalf of people 
        living within the jurisdiction of such government.
          (11) Program monitoring.--The term ``program 
        monitoring'' means the collection, analysis, and use of 
        routine program data to determine--
                  (A) how well a program is carried out; and
                  (B) how much the program costs.
          (12) Structural hiv prevention.--The term 
        ``structural HIV prevention'' means activities or 
        programs designed to--
                  (A) address environmental factors that could 
                create conditions conducive to the spread of 
                HIV; and
                  (B) determine the best ways to remedy such 
                factors by enhancing life skills and promoting 
                changes in laws, policies, and social norms.
          [(6)] (13) Relevant executive branch agencies.--The 
        term ``relevant executive branch agencies'' means the 
        Department of State, the United States Agency for 
        International Development, and any other department or 
        agency of the United States that participates in 
        international HIV/AIDS activities pursuant to the 
        authorities of such department or agency or the Foreign 
        Assistance Act of 1961.

[SEC. 4. PURPOSE.

    [The purpose of this Act is to strengthen United States 
leadership and the effectiveness of the United States response 
to certain global infectious diseases by--
          [(1) establishing a comprehensive, integrated five-
        year, global strategy to fight HIV/AIDS that 
        encompasses a plan for phased expansion of critical 
        programs and improved coordination among relevant 
        executive branch agencies and between the United States 
        and foreign governments and international 
        organizations;
          [(2) providing increased resources for multilateral 
        efforts to fight HIV/AIDS;
          [(3) providing increased resources for United States 
        bilateral efforts, particularly for technical 
        assistance and training, to combat HIV/AIDS, 
        tuberculosis, and malaria;
          [(4) encouraging the expansion of private sector 
        efforts and expanding public-private sector 
        partnerships to combat HIV/AIDS; and
          [(5) intensifying efforts to support the development 
        of vaccines and treatment for HIV/AIDS, tuberculosis, 
        and malaria.]

SEC. 4. PURPOSE.

  The purpose of this Act is to strengthen and enhance United 
States leadership and the effectiveness of the United States 
response to the HIV/AIDS, tuberculosis, and malaria pandemics 
and other related and preventable infectious diseases as part 
of the overall United States health and development agenda by--
          (1) establishing comprehensive, coordinated, and 
        integrated 5-year, global strategies to combat HIV/
        AIDS, tuberculosis, and malaria by--
                  (A) building on progress and successes to 
                date;
                  (B) improving harmonization of United States 
                efforts with national strategies of partner 
                governments and other public and private 
                entities; and
                  (C) emphasizing capacity building initiatives 
                in order to promote a transition toward greater 
                sustainability through the support of country-
                driven efforts;
          (2) providing increased resources for bilateral and 
        multilateral efforts to fight HIV/AIDS, tuberculosis, 
        and malaria as integrated components of United States 
        development assistance;
          (3) intensifying efforts to--
                  (A) prevent HIV infection;
                  (B) ensure the continued support for, and 
                expanded access to, treatment and care 
                programs;
                  (C) enhance the effectiveness of prevention, 
                treatment, and care programs; and
                  (D) address the particular vulnerabilities of 
                girls and women;
          (4) encouraging the expansion of private sector 
        efforts and expanding public-private sector 
        partnerships to combat HIV/AIDS, tuberculosis, and 
        malaria;
          (5) reinforcing efforts to--
                  (A) develop safe and effective vaccines, 
                microbicides, and other prevention and 
                treatment technologies; and
                  (B) improve diagnostics capabilities for HIV/
                AIDS, tuberculosis, and malaria; and
          (6) helping partner countries to--
                  (A) strengthen health systems;
                  (B) improve human health capacity; and
                  (C) address infrastructural weaknesses.

SEC. 5. AUTHORITY TO CONSOLIDATE AND COMBINE REPORTS.

    With respect to the reports required by this Act to be 
submitted by the President, to ensure an efficient use of 
resources, the President may, in his discretion and 
notwithstanding any other provision of this Act, consolidate or 
combine any of these reports, except for the report required by 
section 101 of this Act, so long as the required elements of 
each report are addressed and reported within a 90-day period 
from the original deadline date for submission of the report 
specified in this Act. The President may also enter into 
contracts with organizations with relevant expertise to 
develop, originate, or contribute to any of the reports 
required by this Act to be submitted by the President, with the 
exception of the 5-year strategy.

               TITLE I--POLICY PLANNING AND COORDINATION


SEC. 101. DEVELOPMENT OF A COMPREHENSIVE, FIVE-YEAR, GLOBAL STRATEGY.

    [(a) Strategy.--The President shall establish a 
comprehensive, integrated, five-year strategy to combat global 
HIV/AIDS that strengthens the capacity of the United States to 
be an effective leader of the international campaign against 
HIV/AIDS. Such strategy shall maintain sufficient flexibility 
and remain responsive to the ever-changing nature of the HIV/
AIDS pandemic and shall--
          [(1) include specific objectives, multisectoral 
        approaches, and specific strategies to treat 
        individuals infected with HIV/AIDS and to prevent the 
        further spread of HIV infections, with a particular 
        focus on the needs of families with children (including 
        the prevention of mother-to-child transmission), women, 
        young people, and children (such as unaccompanied minor 
        children and orphans);
          [(2) as part of the strategy, implement a tiered 
        approach to direct delivery of care and treatment 
        through a system based on central facilities augmented 
        by expanding circles of local delivery of care and 
        treatment through local systems and capacity;
          [(3) assign priorities for relevant executive branch 
        agencies;
          [(4) provide that the reduction of HIV/AIDS 
        behavioral risks shall be a priority of all prevention 
        efforts in terms of funding, educational messages, and 
        activities by promoting abstinence from sexual activity 
        and substance abuse, encouraging monogamy and 
        faithfulness, promoting the effective use of condoms, 
        and eradicating prostitution, the sex trade, rape, 
        sexual assault and sexual exploitation of women and 
        children;
          [(5) improve coordination and reduce duplication 
        among relevant executive branch agencies, foreign 
        governments, and international organizations;
          [(6) project general levels of resources needed to 
        achieve the stated objectives;
          [(7) expand public-private partnerships and the 
        leveraging of resources;
          [(8) maximize United States capabilities in the areas 
        of technical assistance and training and research, 
        including vaccine research;
          [(9) establish priorities for the distribution of 
        resources based on factors such as the size and 
        demographics of the population with HIV/AIDS, 
        tuberculosis, and malaria and the needs of that 
        population and the existing infrastructure or funding 
        levels that may exist to cure, treat, and prevent HIV/
        AIDS, tuberculosis, and malaria; and
          [(10) include initiatives describing how the 
        President will maximize the leverage of private sector 
        dollars in reduction and treatment of HIV/AIDS, 
        tuberculosis, and malaria.]
  (a) Strategy.--The President shall establish a comprehensive, 
integrated, 5-year strategy to expand and improve efforts to 
combat global HIV/AIDS. This strategy shall--
          (1) further strengthen the capability of the United 
        States to be an effective leader of the international 
        campaign against this disease and strengthen the 
        capacities of nations experiencing HIV/AIDS epidemics 
        to combat this disease;
          (2) maintain sufficient flexibility and remain 
        responsive to--
                  (A) changes in the epidemic;
                  (B) challenges facing partner countries in 
                developing and implementing an effective 
                national response; and
                  (C) evidence-based improvements and 
                innovations in the prevention, care, and 
                treatment of HIV/AIDS;
          (3) situate United States efforts to combat HIV/AIDS, 
        tuberculosis, and malaria within the broader United 
        States global health and development agenda, 
        establishing a roadmap to link investments in specific 
        disease programs to the broader goals of strengthening 
        health systems and infrastructure and to integrate and 
        coordinate HIV/AIDS, tuberculosis, or malaria programs 
        with other health or development programs, as 
        appropriate;
          (4) provide a plan to--
                  (A) prevent 12,000,000 new HIV infections 
                worldwide;
                  (B) support treatment of at least 3,000,000 
                individuals with HIV/AIDS and support 
                additional treatment through coordinated 
                multilateral efforts;
                  (C) support care for 12,000,000 individuals 
                with HIV/AIDS, including 5,000,000 orphans and 
                vulnerable children affected by HIV/AIDS, with 
                an emphasis on promoting a comprehensive, 
                coordinated system of services to be integrated 
                throughout the continuum of care;
                  (D) help partner countries in the effort to 
                achieve goals of 80 percent access to 
                counseling, testing, and treatment to prevent 
                the transmission of HIV from mother to child, 
                emphasizing a continuum of care model;
                  (E) help partner countries to provide care 
                and treatment services to children with HIV in 
                proportion to their percentage within the HIV-
                infected population in each country;
                  (F) promote preservice training for health 
                professionals designed to strengthen the 
                capacity of institutions to develop and 
                implement policies for training health workers 
                to combat HIV/AIDS, tuberculosis, and malaria;
                  (G) equip teachers with skills needed for 
                HIV/AIDS prevention, treatment, and care;
                  (H) provide and share best practices for 
                combating HIV/AIDS with health professionals; 
                and
                  (I) help partner countries to train and 
                support retention of healthcare professionals 
                and paraprofessionals, with the target of 
                training and retaining at least 140,000 new 
                healthcare professionals and paraprofessionals 
                and to strengthen capacities in developing 
                countries, especially in sub-Saharan Africa, to 
                deliver primary healthcare with the objective 
                of helping countries achieve staffing levels of 
                at least 2.3 doctors, nurses, and midwives per 
                1,000 population, as called for by the World 
                Health Organization;
          (5) include multisectoral approaches and specific 
        strategies to treat individuals infected with HIV/AIDS 
        and to prevent the further transmission of HIV 
        infections, with a particular focus on the needs of 
        families with children (including the prevention of 
        mother-to-child transmission), women, young people, 
        orphans, and vulnerable children;
          (6) establish a timetable with annual global 
        treatment targets;
          (7) expand the integration of timely and relevant 
        research within the prevention, care, and treatment of 
        HIV/AIDS;
          (8) include a plan for program monitoring, operations 
        research, and impact evaluation and for the 
        dissemination of a best practices report to highlight 
        findings;
          (9) provide for consultation with local leaders and 
        officials to develop prevention strategies and programs 
        that are tailored to the unique needs of each country 
        and community and targeted particularly toward those 
        most at risk of acquiring HIV infection;
          (10) make the reduction of HIV/AIDS behavioral risks 
        a priority of all prevention efforts by--
                  (A) promoting abstinence from sexual activity 
                and encouraging monogamy and faithfulness;
                  (B) encouraging the correct and consistent 
                use of male and female condoms and increasing 
                the availability of, and access to, these 
                commodities;
                  (C) promoting the delay of sexual debut and 
                the reduction of multiple concurrent sexual 
                partners;
                  (D) promoting education for discordant 
                couples (where an individual is infected with 
                HIV and the other individual is uninfected or 
                whose status is unknown) about safer sex 
                practices;
                  (E) promoting voluntary counseling and 
                testing, addiction therapy, and other 
                prevention and treatment tools for illicit 
                injection drug users and other substance 
                abusers;
                  (F) educating men and boys about the risks of 
                procuring sex commercially and about the need 
                to end violent behavior toward women and girls;
                  (G) supporting comprehensive programs to 
                promote alternative livelihoods, safety, and 
                social reintegration strategies for commercial 
                sex workers and their families;
                  (H) promoting cooperation with law 
                enforcement to prosecute offenders of 
                trafficking, rape, and sexual assault crimes 
                with the goal of eliminating such crimes; and
                  (I) working to eliminate rape, gender-based 
                violence, sexual assault, and the sexual 
                exploitation of women and children;
          (11) include programs to reduce the transmission of 
        HIV through structural prevention efforts, particularly 
        addressing the heightened vulnerabilities of women and 
        girls to HIV in many countries; and
          (12) support other important means of preventing or 
        reducing the transmission of HIV, including--
                  (A) medical male circumcision;
                  (B) the maintenance of a safe blood supply; 
                and
                  (C) other mechanisms to reduce the 
                transmission of HIV;
          (13) increase support for prevention of mother-to-
        child transmission;
          (14) build capacity within the public health sector 
        of developing countries by improving health systems and 
        public health infrastructure and developing indicators 
        to measure changes in broader public health sector 
        capabilities;
          (15) increase the coordination of HIV/AIDS programs 
        with development programs;
          (16) provide a framework for expanding or developing 
        existing or new country or regional programs, 
        including--
                  (A) drafting compacts or other agreements, as 
                appropriate;
                  (B) establishing criteria and objectives for 
                such compacts and agreements; and
                  (C) promoting sustainability;
          (17) provide a plan for national and regional 
        priorities for resource distribution and a global 
        investment plan by region;
          (18) provide a plan to address the immediate and 
        ongoing needs of women and girls, which--
                  (A) addresses the vulnerabilities that 
                contribute to their elevated risk of infection;
                  (B) includes specific goals and targets to 
                address these factors;
                  (C) provides clear guidance to field missions 
                to integrate gender across prevention, care, 
                and treatment programs;
                  (D) sets forth gender-specific indicators to 
                monitor progress on outcomes and impacts of 
                gender programs;
                  (E) supports efforts in countries in which 
                women or orphans lack inheritance rights and 
                other fundamental protections to promote the 
                passage, implementation, and enforcement of 
                such laws;
                  (F) supports life skills training and other 
                structural prevention activities, especially 
                among women and girls, with the goal of 
                reducing vulnerabilities to HIV/AIDS;
                  (G) addresses and prevents gender-based 
                violence; and
                  (H) addresses the posttraumatic and 
                psychosocial consequences and provides 
                postexposure prophylaxis protecting against HIV 
                infection to victims of gender-based violence 
                and rape;
          (19) provide a plan to address the vulnerabilities 
        and needs of orphans and children who are vulnerable 
        to, or affected by, HIV/AIDS;
          (20) provide a framework to work with international 
        actors and partner countries toward universal access to 
        HIV/AIDS prevention, treatment, and care programs, 
        recognizing that prevention is of particular importance 
        in terms of sequencing;
          (21) enhance the coordination of United States 
        bilateral efforts to combat global HIV/AIDS with other 
        major public and private entities;
          (22) enhance the attention given to the national 
        strategic HIV/AIDS plans of countries receiving United 
        States assistance by--
                  (A) reviewing the planning and programmatic 
                decisions associated with that assistance; and
                  (B) helping to strengthen such national 
                strategies, if necessary;
          (23) support activities described in the Global Plan 
        to Stop TB, including--
                  (A) expanding and enhancing the coverage of 
                the Directly Observed Treatment Short-course 
                (DOTS) in order to treat individuals infected 
                with tuberculosis and HIV, including multi-drug 
                resistant or extensively drug resistant 
                tuberculosis; and
                  (B) improving coordination and integration of 
                HIV/AIDS and tuberculosis programming;
          (24) ensure coordination between the Global AIDS 
        Coordinator and the Malaria Coordinator and address 
        issues of comorbidity between HIV/AIDS and malaria; and
          (25) include a longer term estimate of the projected 
        resource needs, progress toward greater sustainability 
        and country ownership of HIV/AIDS programs, and the 
        anticipated role of the United States in the global 
        effort to combat HIV/AIDS during the 10-year period 
        beginning on October 1, 2013.
    [(b) Report.--
          [(1) In general.--Not later than 270 days after the 
        date of enactment of this Act, the President shall 
        submit to the appropriate congressional committees a 
        report setting forth the strategy described in 
        subsection (a).
          [(2) Report contents.--The report required by 
        paragraph (1) shall include a discussion of the 
        elements described in paragraph (3) and may include a 
        discussion of additional elements relevant to the 
        strategy described in subsection (a). Such discussion 
        may include an explanation as to why a particular 
        element described in paragraph (3) is not relevant to 
        such strategy.
          [(3) Report elements.--The elements referred to in 
        paragraph (2) are the following:
                  [(A) The objectives, general and specific, of 
                the strategy.
                  [(B) A description of the criteria for 
                determining success of the strategy.
                  [(C) A description of the manner in which the 
                strategy will address the fundamental elements 
                of prevention and education, care, and 
                treatment (including increasing access to 
                pharmaceuticals and to vaccines), the promotion 
                of abstinence, monogamy, avoidance of substance 
                abuse, and use of condoms, research (including 
                incentives for vaccine development and new 
                protocols), training of healthcare workers, the 
                development of healthcare infrastructure and 
                delivery systems, and avoidance of substance 
                abuse.
                  [(D) A description of the manner in which the 
                strategy will promote the development and 
                implementation of national and community-based 
                multisectoral strategies and programs, 
                including those designed to enhance leadership 
                capacity particularly at the community level.
                  [(E) A description of the specific strategies 
                developed to meet the unique needs of women, 
                including the empowerment of women in 
                interpersonal situations, young people and 
                children, including those orphaned by HIV/AIDS 
                and those who are victims of the sex trade, 
                rape, sexual abuse, assault, and exploitation.
                  [(F) A description of the specific strategies 
                developed to encourage men to be responsible in 
                their sexual behavior, child rearing and to 
                respect women including the reduction of sexual 
                violence and coercion.
                  [(G) A description of the specific strategies 
                developed to increase women's access to 
                employment opportunities, income, productive 
                resources, and microfinance programs.
                  [(H) A description of the programs to be 
                undertaken to maximize United States 
                contributions in the areas of technical 
                assistance, training (particularly of 
                healthcare workers and community-based leaders 
                in affected sectors), and research, including 
                the promotion of research on vaccines and 
                microbicides.
                  [(I) An identification of the relevant 
                executive branch agencies that will be involved 
                and the assignment of priorities to those 
                agencies.
                  [(J) A description of the role of each 
                relevant executive branch agency and the types 
                of programs that the agency will be 
                undertaking.
                  [(K) A description of the mechanisms that 
                will be utilized to coordinate the efforts of 
                the relevant executive branch agencies, to 
                avoid duplication of efforts, to enhance on-
                site coordination efforts, and to ensure that 
                each agency undertakes programs primarily in 
                those areas where the agency has the greatest 
                expertise, technical capabilities, and 
                potential for success.
                  [(L) A description of the mechanisms that 
                will be utilized to ensure greater coordination 
                between the United States and foreign 
                governments and international organizations 
                including the Global Fund, UNAIDS, 
                international financial institutions, and 
                private sector organizations.
                  [(M) The level of resources that will be 
                needed on an annual basis and the manner in 
                which those resources would generally be 
                allocated among the relevant executive branch 
                agencies.
                  [(N) A description of the mechanisms to be 
                established for monitoring and evaluating 
                programs, promoting successful models, and for 
                terminating unsuccessful programs.
                  [(O) A description of the manner in which 
                private, nongovernmental entities will factor 
                into the United States Government-led effort 
                and a description of the type of partnerships 
                that will be created to maximize the 
                capabilities of these private sector entities 
                and to leverage resources.
                  [(P) A description of the ways in which 
                United States leadership will be used to 
                enhance the overall international response to 
                the HIV/AIDS pandemic and particularly to 
                heighten the engagement of the member states of 
                the G-8 and to strengthen key financial and 
                coordination mechanisms such as the Global Fund 
                and UNAIDS.
                  [(Q) A description of the manner in which the 
                United States strategy for combating HIV/AIDS 
                relates to and supports other United States 
                assistance strategies in developing countries.
                  [(R) A description of the programs to be 
                carried out under the strategy that are 
                specifically targeted at women and girls to 
                educate them about the spread of HIV/AIDS.
                  [(S) A description of efforts being made to 
                address the unique needs of families with 
                children with respect to HIV/AIDS, including 
                efforts to preserve the family unit.
                  [(T) An analysis of the emigration of 
                critically important medical and public health 
                personnel, including physicians, nurses, and 
                supervisors from sub-Saharan African countries 
                that are acutely impacted by HIV/AIDS, 
                including a description of the causes, effects, 
                and the impact on the stability of health 
                infrastructures, as well as a summary of 
                incentives and programs that the United States 
                could provide, in concert with other private 
                and public sector partners and international 
                organizations, to stabilize health institutions 
                by encouraging critical personnel to remain in 
                their home countries.
                  [(U) A description of the specific strategies 
                developed to promote sustainability of HIV/AIDS 
                pharmaceuticals (including antiretrovirals) and 
                the effects of drug resistance on HIV/AIDS 
                patients.
                  [(V) A description of the specific strategies 
                to ensure that the extraordinary benefit of 
                HIV/AIDS pharmaceuticals (especially 
                antiretrovirals) are not diminished through the 
                illegal counterfeiting of pharmaceuticals and 
                black market sales of such pharmaceuticals.
                  [(W) An analysis of the prevalence of Human 
                Papilloma Virus (HPV) in sub-Saharan Africa and 
                the impact that condom usage has upon the 
                spread of HPV in sub-Saharan Africa.]
  (b) Report.--
          (1) In general.--Not later than October 1, 2009, the 
        President shall submit a report to the appropriate 
        congressional committees that sets forth the strategy 
        described in subsection (a).
          (2) Contents.--The report required under paragraph 
        (1) shall include a discussion of the following 
        elements:
                  (A) The purpose, scope, methodology, and 
                general and specific objectives of the 
                strategy.
                  (B) The problems, risks, and threats to the 
                successful pursuit of the strategy.
                  (C) The desired goals, objectives, 
                activities, and outcome-related performance 
                measures of the strategy.
                  (D) A description of future costs and 
                resources needed to carry out the strategy.
                  (E) A delineation of United States Government 
                roles, responsibility, and coordination 
                mechanisms of the strategy.
                  (F) A description of the strategy--
                          (i) to promote harmonization of 
                        United States assistance with that of 
                        other international, national, and 
                        private actors as elucidated in the 
                        ``Three Ones''; and
                          (ii) to address existing challenges 
                        in harmonization and alignment.
                  (G) A description of the manner in which the 
                strategy will--
                          (i) further the development and 
                        implementation of the national 
                        multisectoral strategic HIV/AIDS 
                        frameworks of partner governments; and
                          (ii) enhance the centrality, 
                        effectiveness, and sustainability of 
                        those national plans.
                  (H) A description of how the strategy will 
                seek to achieve the specific targets described 
                in subsection (a) and other targets, as 
                appropriate.
                  (I) A description of, and rationale for, the 
                timetable for annual global treatment targets.
                  (J) A description of how operations research 
                is addressed in the strategy and how such 
                research can most effectively be integrated 
                into care, treatment, and prevention activities 
                in order to--
                          (i) improve program quality and 
                        efficiency;
                          (ii) ascertain cost effectiveness;
                          (iii) ensure transparency and 
                        accountability;
                          (iv) assess population-based impact;
                          (v) disseminate findings and best 
                        practices; and
                          (vi) optimize delivery of services.
                  (K) An analysis of United States-assisted 
                strategies to prevent the transmission of HIV/
                AIDS, including methodologies to promote 
                abstinence, monogamy, faithfulness, the correct 
                and consistent use of male and female condoms, 
                reductions in concurrent sexual partners, and 
                delay of sexual debut, and of intended 
                monitoring and evaluation approaches to measure 
                the effectiveness of prevention programs and 
                ensure that they are targeted to appropriate 
                audiences.
                  (L) Within the analysis required under 
                subparagraph (J), an examination of additional 
                planned means of preventing the transmission of 
                HIV including medical male circumcision, 
                maintenance of a safe blood supply, and other 
                tools.
                  (M) A description of the specific targets, 
                goals, and strategies developed to address the 
                needs and vulnerabilities of women and girls to 
                HIV/AIDS, including--
                          (i) structural prevention activities;
                          (ii) activities directed toward men 
                        and boys;
                          (iii) activities to enhance 
                        educational, microfinance, and 
                        livelihood opportunities for women and 
                        girls;
                          (iv) activities to promote and 
                        protect the legal empowerment of women, 
                        girls, and orphans and vulnerable 
                        children;
                          (v) programs targeted toward gender-
                        based violence and sexual coercion;
                          (vi) strategies to meet the 
                        particular needs of adolescents;
                          (vii) assistance for victims of rape, 
                        sexual abuse, assault, exploitation, 
                        and trafficking; and
                          (viii) programs to prevent alcohol 
                        abuse.
                  (N) A description of strategies--
                          (i) to address the needs of orphans 
                        and vulnerable children, including an 
                        analysis of--
                                  (I) factors contributing to 
                                children's vulnerability to 
                                HIV/AIDS; and
                                  (II) vulnerabilities caused 
                                by the impact of HIV/AIDS on 
                                children and their families; 
                                and
                          (ii) in areas of higher HIV/AIDS 
                        prevalence, to promote a community-
                        based approach to vulnerability, 
                        maximizing community input into 
                        determining which children participate.
                  (O) A description of capacity-building 
                efforts undertaken by countries themselves, 
                including adherents of the Abuja Declaration 
                and an assessment of the impact of 
                International Monetary Fund macroeconomic and 
                fiscal policies on national and donor 
                investments in health.
                  (P) A description of the strategy to--
                          (i) strengthen capacity building 
                        within the public health sector;
                          (ii) improve healthcare in those 
                        countries;
                          (iii) help countries to develop and 
                        implement national health workforce 
                        strategies;
                          (iv) strive to achieve goals in 
                        training, retaining, and effectively 
                        deploying health staff;
                          (v) promote ethical recruiting 
                        practices for healthcare workers; and
                          (vi) increase the sustainability of 
                        health programs.
                  (Q) A description of the criteria for 
                selection, objectives, methodology, and 
                structure of compacts or other framework 
                agreements with countries or regional 
                organizations, including--
                          (i) the role of civil society;
                          (ii) the degree of transparency;
                          (iii) benchmarks for success of such 
                        compacts or agreements; and
                          (iv) the relationship between such 
                        compacts or agreements and the national 
                        HIV/AIDS and public health strategies 
                        and commitments of partner countries.
                  (R) A strategy to better coordinate HIV/AIDS 
                assistance with nutrition and food assistance 
                programs.
                  (S) A description of transnational or 
                regional initiatives to combat regionalized 
                epidemics in highly affected areas such as the 
                Caribbean.
                  (T) A description of planned resource 
                distribution and global investment by region.
                  (U) A description of coordination efforts in 
                order to better implement the Stop TB Strategy 
                and to address the problem of coinfection of 
                HIV/AIDS and tuberculosis and of projected 
                challenges or barriers to successful 
                implementation.
                  (V) A description of coordination efforts to 
                address malaria and comorbidity with malaria 
                and HIV/AIDS.
    [(c) Study; Distribution of Resources.--
          [(1) Study.--Not later than 3 years after the date of 
        the enactment of this Act, the Institute of Medicine 
        shall publish findings comparing the success rates of 
        the various programs and methods used under the 
        strategy described in subsection (a) to reduce, 
        prevent, and treat HIV/AIDS, tuberculosis, and malaria.
          [(2) Distribution of resources.-- In prioritizing the 
        distribution of resources under the strategy described 
        in subsection (a), the President shall consider the 
        findings published by the Institute of Medicine under 
        this subsection.]
  (c) Study of Progress Toward Achievement of Policy 
Objectives.--
          (1) Design and budget plan for data evaluation.--The 
        Global AIDS Coordinator shall enter into a contract 
        with the Institute of Medicine of the National 
        Academies that provides that not later than 18 months 
        after the date of the enactment of the Tom Lantos and 
        Henry J. Hyde United States Global Leadership Against 
        HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act 
        of 2008, the Institute, in consultation with the Global 
        AIDS Coordinator and other relevant parties 
        representing the public and private sector, shall 
        provide the Global AIDS Coordinator with a design plan 
        and budget for the evaluation and collection of 
        baseline and subsequent data to address the elements 
        set forth in paragraph (2)(B). The Global AIDS 
        Coordinator shall submit the budget and design plan to 
        the appropriate congressional committees.
          (2) Study.--
                  (A) In general.--Not later than 4 years after 
                the date of the enactment of the Tom Lantos and 
                Henry J. Hyde United States Global Leadership 
                Against HIV/AIDS, Tuberculosis, and Malaria 
                Reauthorization Act of 2008, the Institute of 
                Medicine of the National Academies shall 
                publish a study that includes--
                          (i) an assessment of the performance 
                        of United States-assisted global HIV/
                        AIDS programs; and
                          (ii) an evaluation of the impact on 
                        health of prevention, treatment, and 
                        care efforts that are supported by 
                        United States funding, including 
                        multilateral and bilateral programs 
                        involving joint operations.
                  (B) Content.--The study conducted under this 
                paragraph shall include--
                          (i) an assessment of progress toward 
                        prevention, treatment, and care 
                        targets;
                          (ii) an assessment of the effects on 
                        health systems, including on the 
                        financing and management of health 
                        systems and the quality of service 
                        delivery and staffing;
                          (iii) an assessment of efforts to 
                        address gender-specific aspects of HIV/
                        AIDS, including gender related 
                        constraints to accessing services and 
                        addressing underlying social and 
                        economic vulnerabilities of women and 
                        men;
                          (iv) an evaluation of the impact of 
                        treatment and care programs on 5-year 
                        survival rates, drug adherence, and the 
                        emergence of drug resistance;
                          (v) an evaluation of the impact of 
                        prevention programs on HIV incidence in 
                        relevant population groups;
                          (vi) an evaluation of the impact on 
                        child health and welfare of 
                        interventions authorized under this Act 
                        on behalf of orphans and vulnerable 
                        children;
                          (vii) an evaluation of the impact of 
                        programs and activities authorized in 
                        this Act on child mortality; and
                          (viii) recommendations for improving 
                        the programs referred to in 
                        subparagraph (A)(i).
                  (C) Methodologies.--Assessments and impact 
                evaluations conducted under the study shall 
                utilize sound statistical methods and 
                techniques for the behavioral sciences, 
                including random assignment methodologies as 
                feasible. Qualitative data on process variables 
                should be used for assessments and impact 
                evaluations, wherever possible.
          (3) Contract authority.--The Institute of Medicine 
        may enter into contracts or cooperative agreements or 
        award grants to conduct the study under paragraph (2).
          (4) Authorization of appropriations.--There are 
        authorized to be appropriated such sums as may be 
        necessary to carry out the study under this subsection.
  (d) Comptroller General Report.--
          (1) Report required.--Not later than 3 years after 
        the date of the enactment of the Tom Lantos and Henry 
        J. Hyde United States Global Leadership Against HIV/
        AIDS, Tuberculosis, and Malaria Reauthorization Act of 
        2008, the Comptroller General of the United States 
        shall submit a report on the global HIV/AIDS programs 
        of the United States to the appropriate congressional 
        committees.
          (2) Contents.--The report required under paragraph 
        (1) shall include--
                  (A) a description and assessment of the 
                monitoring and evaluation practices and 
                policies in place for these programs;
                  (B) an assessment of coordination within 
                Federal agencies involved in these programs, 
                examining both internal coordination within 
                these programs and integration with the larger 
                global health and development agenda of the 
                United States;
                  (C) an assessment of procurement policies and 
                practices within these programs;
                  (D) an assessment of harmonization with 
                national government HIV/AIDS and public health 
                strategies as well as other international 
                efforts;
                  (E) an assessment of the impact of global 
                HIV/AIDS funding and programs on other United 
                States global health programming; and
                  (F) recommendations for improving the global 
                HIV/AIDS programs of the United States.
  (e) Best Practices Report.--
          (1) In general.--Not later than 1 year after the date 
        of the enactment of the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008, 
        and annually thereafter, the Global AIDS Coordinator 
        shall publish a best practices report that highlights 
        the programs receiving financial assistance from the 
        United States that have the potential for replication 
        or adaption, particularly at a low cost, across global 
        AIDS programs, including those that focus on both 
        generalized and localized epidemics.
          (2) Dissemination of findings.--
                  (A) Publication on internet website.--The 
                Global AIDS Coordinator shall disseminate the 
                full findings of the annual best practices 
                report on the Internet website of the Office of 
                the Global AIDS Coordinator.
                  (B) Dissemination guidance.--The Global AIDS 
                Coordinator shall develop guidance to ensure 
                timely submission and dissemination of 
                significant information regarding best 
                practices with respect to global AIDS programs.
  (f) Inspectors General.--
          (1) Oversight plan.--
                  (A) Development.--The Inspectors General of 
                the Department of State and Broadcasting Board 
                of Governors, the Department of Health and 
                Human Services, and the United States Agency 
                for International Development shall jointly 
                develop 5 coordinated annual plans for 
                oversight activity in each of the fiscal years 
                2009 through 2013, with regard to the programs 
                authorized under this Act and sections 104A, 
                104B, and 104C of the Foreign Assistance Act of 
                1961 (22 U.S.C. 2151b-2, 2151b-3, and 2151b-4).
                  (B) Contents.--The plans developed under 
                subparagraph (A) shall include a schedule for 
                financial audits, inspections, and performance 
                reviews, as appropriate.
                  (C) Deadline.--
                          (i) Initial plan.--The first plan 
                        developed under subparagraph (A) shall 
                        be completed not later than the later 
                        of--
                                  (I) September 1, 2008; or
                                  (II) 60 days after the date 
                                of the enactment of the Tom 
                                Lantos and Henry J. Hyde United 
                                States Global Leadership 
                                Against HIV/AIDS, Tuberculosis, 
                                and Malaria Reauthorization Act 
                                of 2008.
                          (ii) Subsequent plans.--Each of the 
                        last four plans developed under 
                        subparagraph (A) shall be completed not 
                        later than 30 days before each of the 
                        fiscal years 2010 through 2013, 
                        respectively.
          (2) Coordination.--In order to avoid duplication and 
        maximize efficiency, the Inspectors General described 
        in paragraph (1) shall coordinate their activities 
        with--
                  (A) the Government Accountability Office; and
                  (B) the Inspectors General of the Department 
                of Commerce, the Department of Defense, the 
                Department of Labor, and the Peace Corps, as 
                appropriate, pursuant to the 2004 Memorandum of 
                Agreement Coordinating Audit Coverage of 
                Programs and Activities Implementing the 
                President's Emergency Plan for AIDS Relief, or 
                any successor agreement.
          (3) Funding.--The Global AIDS Coordinator and the 
        Coordinator of the United States Government Activities 
        to Combat Malaria Globally shall make available 
        necessary funds not exceeding $10,000,000 during the 5-
        year period beginning on October 1, 2008 to the 
        Inspectors General described in paragraph (1) for the 
        audits, inspections, and reviews described in that 
        paragraph.

SEC. 102. HIV/AIDS RESPONSE COORDINATOR.

    (a) Establishment of Position.--* * *

           *       *       *       *       *       *       *

  (d) Sense of Congress.--It is the sense of Congress that--
          (1) full-time country level coordinators, preferably 
        with management experience, should head each HIV/AIDS 
        country team for United States missions overseeing 
        significant HIV/AIDS programs;
          (2) foreign service nationals provide critically 
        important services in the design and implementation of 
        United States country-level HIV/AIDS programs and their 
        skills and experience as public health professionals 
        should be recognized within hiring and compensation 
        practices; and
          (3) staffing levels for United States country-level 
        HIV/AIDS teams should be adequately maintained to 
        fulfill oversight and other obligations of the 
        positions.

           *       *       *       *       *       *       *


TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE 
                              PARTNERSHIPS


SEC. 201. SENSE OF CONGRESS ON PUBLIC-PRIVATE PARTNERSHIPS.

           *       *       *       *       *       *       *


SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS 
                    AND MALARIA.

    [(a) Findings.--The Congress finds as follows:
          [(1) The establishment of the Global Fund in January 
        2002 is consistent with the general principles for an 
        international AIDS trust fund first outlined by the 
        Congress in the Global AIDS and Tuberculosis Relief Act 
        of 2000 (Public Law 106-264).
          [(2) Section 2, Article 5 of the bylaws of the Global 
        Fund provides for the International Bank for 
        Reconstruction and Development to serve as the initial 
        collection trustee for the Global Fund.
          [(3) The trustee agreement signed between the Global 
        Fund and the International Bank for Reconstruction and 
        Development narrows the range of duties to include 
        receiving and investing funds from donors, disbursing 
        the funds upon the instruction of the Global Fund, 
        reporting on trust fund resources to donors and the 
        Global Fund, and providing an annual external audit 
        report to the Global Fund.]
  (a) Findings; Sense of Congress.--
          (1) Findings.--Congress makes the following findings:
                  (A) The establishment of the Global Fund in 
                January 2002 is consistent with the general 
                principles for an international AIDS trust fund 
                first outlined by Congress in the Global AIDS 
                and Tuberculosis Relief Act of 2000 (Public Law 
                106-264).
                  (B) The Global Fund is an innovative 
                financing mechanism which--
                          (i) has made progress in many areas 
                        in combating HIV/AIDS, tuberculosis, 
                        and malaria; and
                          (ii) represents the multilateral 
                        component of this Act, extending United 
                        States efforts to more than 130 
                        countries around the world.
                  (C) The Global Fund and United States 
                bilateral assistance programs--
                          (i) are demonstrating increasingly 
                        effective coordination, with each 
                        possessing certain comparative 
                        advantages in the fight against HIV/
                        AIDS, tuberculosis, and malaria; and
                          (ii) often work most effectively in 
                        concert with each other.
                  (D) The United States Government--
                          (i) is the largest supporter of the 
                        Global Fund in terms of resources and 
                        technical support;
                          (ii) made the founding contribution 
                        to the Global Fund; and
                          (iii) is fully committed to the 
                        success of the Global Fund as a 
                        multilateral public-private 
                        partnership.
          (2) Sense of congress.--It is the sense of Congress 
        that--
                  (A) transparency and accountability are 
                crucial to the long-term success and viability 
                of the Global Fund;
                  (B) the Global Fund has made significant 
                progress toward addressing concerns raised by 
                the Government Accountability Office by--
                          (i) improving risk assessment and 
                        risk management capabilities;
                          (ii) providing clearer guidance for 
                        and oversight of Local Fund Agents; and
                          (iii) strengthening the Office of the 
                        Inspector General for the Global Fund;
                  (C) the provision of sufficient resources and 
                authority to the Office of the Inspector 
                General for the Global Fund to ensure that 
                office has the staff and independence necessary 
                to carry out its mandate will be a measure of 
                the commitment of the Global Fund to 
                transparency and accountability;
                  (D) regular, publicly published financial, 
                programmatic, and reporting audits of the Fund, 
                its grantees, and Local Fund Agents are also 
                important benchmarks of transparency;
                  (E) the Global Fund should establish and 
                maintain a system to track--
                          (i) the amount of funds disbursed to 
                        each subrecipient on the grant's fiscal 
                        cycle; and
                          (ii) the distribution of resources, 
                        by grant and principal recipient, for 
                        prevention, care, treatment, drug and 
                        commodity purchases, and other 
                        purposes;
                  (F) relevant national authorities in 
                recipient countries should exempt from duties 
                and taxes all products financed by Global Fund 
                grants and procured by any principal recipient 
                or subrecipient for the purpose of carrying out 
                such grants;
                  (G) the Global Fund, UNAIDS, and the Global 
                AIDS Coordinator should work together to 
                standardize program indicators wherever 
                possible; and
                  (H) for purposes of evaluating total amounts 
                of funds contributed to the Global Fund under 
                subsection (d)(4)(A)(i), the timetable for 
                evaluations of contributions from sources other 
                than the United States should take into account 
                the fiscal calendars of other major 
                contributors.

           *       *       *       *       *       *       *

    (d) United States Financial Participation.--
          (1) Authorization of appropriations.--In addition to 
        any other funds authorized to be appropriated for 
        bilateral or multilateral HIV/AIDS, tuberculosis, or 
        malaria programs, of the amounts authorized to be 
        appropriated under section 401, there are authorized to 
        be appropriated to the President up to [$1,000,000,000 
        for the period of fiscal year 2004 beginning on January 
        1, 2004,] $2,000,000,000 for fiscal year 2009, and such 
        sums as may be necessary for [the fiscal years 2005-
        2008] each of the fiscal years 2010 through 2013, for 
        contributions to the Global Fund.
          (2) Availability of funds.--Amounts appropriated 
        under paragraph (1) are authorized to remain available 
        until expended.
          (3) Reprogramming of fiscal year 2001 funds.--Funds 
        made available for fiscal year 2001 under section 141 
        of the Global AIDS and Tuberculosis Relief Act of 
        2000--
                  (A) are authorized to remain available until 
                expended; and
                  (B) shall be transferred to, merged with, and 
                made available for the same purposes as, funds 
                made available for fiscal years 2004 through 
                2008 under paragraph (1).
          (4) Limitation.--
                  (A)(i) At any time during [fiscal years 2004 
                through 2008] fiscal years 2009 through 2013, 
                no United States contribution to the Global 
                Fund may cause the total amount of United 
                States Government contributions to the Global 
                Fund to exceed 33 percent of the total amount 
                of funds contributed to the Global Fund from 
                all sources. Contributions to the Global Fund 
                from the International Bank for Reconstruction 
                and Development and the International Monetary 
                Fund shall not be considered in determining 
                compliance with this paragraph.
                  (ii) If, at any time [during any of the 
                fiscal years 2004 through 2008] during any of 
                the fiscal years 2009 through 2013, the 
                President determines that the Global Fund has 
                provided assistance to a country, the 
                government of which the Secretary of State has 
                determined, for purposes of section 6(j)(1) of 
                the Export Administration Act of 1979 (50 
                U.S.C. App. 2405(j)(1)), has repeatedly 
                provided support for acts of international 
                terrorism, then the United States shall 
                withhold from its contribution for the next 
                fiscal year an amount equal to the amount 
                expended by the Fund to the government of each 
                such country.
                  (iii) If at any time the President determines 
                that the expenses of the Governing, 
                Administrative, and Advisory Bodies (including 
                the Partnership Forum, the Foundation Board, 
                the Secretariat, and the Technical Review 
                Board) of the Global Fund exceed 10 percent of 
                the total expenditures of the Fund for any 2-
                year period, the United States shall withhold 
                from its contribution for the next fiscal year 
                an amount equal the to the average annual 
                amount expended by the Fund for such 2-year 
                period for the expenses of the Governing, 
                Administrative, and Advisory Bodies in excess 
                of 10 percent of the total expenditures of the 
                Fund.
                  (iv) The President may waive the application 
                of clause (iii) if the President determines 
                that extraordinary circumstances warrant such a 
                waiver. No waiver under this clause may be for 
                any period that exceeds 1 year.
                  (v) If, at any time during any of the fiscal 
                years 2004 through 2008, the President 
                determines that the salary of any individual 
                employed by the Global Fund exceeds the salary 
                of the Vice President of the United States (as 
                determined under section 104 of title 3, United 
                States Code) for that fiscal year, then the 
                United States shall withhold from its 
                contribution for the next fiscal year an amount 
                equal to the aggregate amount by which the 
                salary of each such individual exceeds the 
                salary of the Vice President of the United 
                States.
                  (vi) [for the purposes] For the purposes of 
                clause (i), ``funds contributed to the Global 
                Fund from all sources'' means funds contributed 
                to the Global Fund at any time during [fiscal 
                years 2004 through 2008] fiscal years 2009 
                through 2013 that are not contributed to 
                fulfill a commitment made for a fiscal year 
                [prior to fiscal year 2004] before fiscal year 
                2009.
                  (B)(i) Any amount made available under this 
                subsection that is withheld by reason of 
                subparagraph (A)(i) shall be contributed to the 
                Global Fund as soon as practicable, subject to 
                subparagraph (A)(i), after additional 
                contributions to the Global Fund are made from 
                other sources.
                  (ii) Any amount made available under this 
                subsection that is withheld by reason of 
                subparagraph (A)(iii) shall be transferred to 
                the Activities to Combat HIV/AIDS Globally Fund 
                and shall remain available under the same terms 
                and conditions as funds appropriated pursuant 
                to the authorization of appropriations under 
                section 401 for HIV/AIDS assistance.
                  (iii) Any amount made available under this 
                subsection that is withheld by reason of clause 
                (ii) or (iii) of subparagraph (A) is authorized 
                to be made available to carry out section 104A 
                of the Foreign Assistance Act of 1961 (as added 
                by section 301 of this Act). Amounts made 
                available under the preceding sentence are in 
                addition to amounts appropriated pursuant to 
                the authorization of appropriations under 
                section 401 of this Act for HIV/AIDS 
                assistance.
                  (iv) Notwithstanding clause (i), after July 
                31 of each of the [fiscal years 2004 through 
                2008] fiscal years 2009 through 2013, any 
                amount made available under this subsection 
                that is withheld by reason of 
                subparagraph(A)(i) is authorized to be made 
                available to carry out sections 104A, 104B, and 
                104C of the Foreign Assistance Act of 1961 (as 
                added by title III of this Act).
                  (C)(i) The President may suspend the 
                application of subparagraph (A) with respect to 
                a fiscal year if the President determines that 
                an international health emergency threatens the 
                national security interests of the United 
                States.
                  (ii) The President shall notify the 
                [Committee on International Relations] 
                Committee on Foreign Affairs of the House of 
                Representatives and the Committee on Foreign 
                Relations of the Senate not less than 5 days 
                before making a determination under clause (i) 
                with respect to the application of subparagraph 
                (A)(i) and shall include in the notification--
                          (I) a justification as to why 
                        increased United States Government 
                        contributions to the Global Fund is 
                        preferable to increased United States 
                        assistance to combat HIV/AIDS, 
                        tuberculosis, and malaria on a 
                        bilateral basis; and
                          (II) an explanation as to why other 
                        government donors to the Global Fund 
                        are unable to provide adequate 
                        contributions to the Fund.
          (5) Withholding funds.--Notwithstanding any other 
        provision of this Act, 20 percent of the amounts 
        appropriated pursuant to this Act for a contribution to 
        support the Global Fund for each of the fiscal years 
        2010 through 2013 shall be withheld from obligation to 
        the Global Fund until the Secretary of State certifies 
        to the appropriate congressional committees that the 
        Global Fund--
                  (A) has established an evaluation framework 
                for the performance of Local Fund Agents 
                (referred to in this paragraph as ``LFAs'');
                  (B) is undertaking a systematic assessment of 
                the performance of LFAs;
                  (C) 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 
                principal recipients and subrecipients;
                  (D) is maintaining an independent, well-
                staffed Office of the Inspector General that--
                          (i) reports directly to the Board of 
                        the Global Fund; and
                          (ii) is responsible for regular, 
                        publicly published audits of financial, 
                        programmatic, and reporting aspects of 
                        the Global Fund, its grantees, and 
                        LFAs;
                  (E) has established, and is reporting 
                publicly on, standard indicators for all 
                program areas;
                  (F) has established a methodology to track 
                and is reporting on--
                          (i) all subrecipients and the amount 
                        of funds disbursed to each subrecipient 
                        on the grant's fiscal cycle; and
                          (ii) the distribution of resources, 
                        by grant and principal recipient, for 
                        prevention, care, treatment, drugs and 
                        commodities purchase, and other 
                        purposes;
                  (G) has established a policy on tariffs 
                imposed by national governments on all goods 
                and services financed by the Global Fund;
                  (H) through its Secretariat, has taken 
                meaningful steps to prevent national 
                authorities in recipient countries from 
                imposing taxes or tariffs on goods or services 
                provided by the Fund;
                  (I) is maintaining its status as a financing 
                institution focused on programs directly 
                related to HIV/AIDS, malaria, and tuberculosis; 
                and
                  (J) is maintaining and making progress on--
                          (i) sustaining its multisectoral 
                        approach, through country coordinating 
                        mechanisms; and
                          (ii) the implementation of grants, as 
                        reflected in the proportion of 
                        resources allocated to different 
                        sectors, including governments, civil 
                        society, and faith- and community-based 
                        organizations.

SEC. 204. COMBATING HIV/AIDS, TUBERCULOSIS, AND MALARIA BY 
                    STRENGTHENING HEALTH POLICIES AND HEALTH SYSTEMS OF 
                    PARTNER COUNTRIES.

  (a) Statement of Policy.--It shall be the policy of the 
United States Government--
          (1) to invest appropriate resources authorized under 
        this Act--
                  (A) to carry out activities to strengthen 
                HIV/AIDS, tuberculosis, and malaria health 
                policies and health systems; and
                  (B) to provide workforce training and 
                capacity-building consistent with the goals and 
                objectives of this Act; and
          (2) to support the development of a sound policy 
        environment in partner countries to increase the 
        ability of such countries--
                  (A) to maximize utilization of healthcare 
                resources from donor countries;
                  (B) to increase national investments in 
                health and education and maximize the 
                effectiveness of such investments;
                  (C) to improve national HIV/AIDS, 
                tuberculosis, and malaria strategies;
                  (D) to deliver evidence-based services in an 
                effective and efficient manner; and
                  (E) to reduce barriers that prevent 
                recipients of services from achieving maximum 
                benefit from such services.
  (b) Assistance To Improve Public Finance Management 
Systems.--
          (1) In general.--Consistent with the authority under 
        section 129 of the Foreign Assistance Act of 1961 (22 
        U.S.C. 2152), the Secretary of the Treasury, acting 
        through the head of the Office of Technical Assistance, 
        is authorized to provide assistance for advisors and 
        partner country finance, health, and other relevant 
        ministries to improve the effectiveness of public 
        finance management systems in partner countries to 
        enable such countries to receive funding to carry out 
        programs to combat HIV/AIDS, tuberculosis, and malaria 
        and to manage such programs.
          (2) Authorization of appropriations.--Of the amounts 
        authorized to be appropriated under section 401 for 
        HIV/AIDS assistance, there are authorized to be 
        appropriated to the Secretary of the Treasury such sums 
        as may be necessary for each of the fiscal years 2009 
        through 2013 to carry out this subsection.

           *       *       *       *       *       *       *


TITLE III--BILATERAL EFFORTS

           *       *       *       *       *       *       *



SEC. 301. ASSISTANCE TO COMBAT HIV/AIDS.

    (a) Amendment of the Foreign Assistance Act of 1961.--* * *

           *       *       *       *       *       *       *

    (b) Authorization of Appropriations.--
          (1) In general.--In addition to funds available under 
        section 104(c) of the Foreign Assistance Act of 1961 
        (22 U.S.C. 2151b(c)) for such purpose or under any 
        other provision of that Act, there are authorized to be 
        appropriated to the President, from amounts authorized 
        to be appropriated under section 401, such sums as may 
        be necessary for each of the [fiscal years 2004 through 
        2008] fiscal years 2009 through 2013 to carry out 
        section 104A of the Foreign Assistance Act of 1961, as 
        added by subsection (a).
          (2) Availability of funds.--Amounts appropriated 
        pursuant to paragraph (1) are authorized to remain 
        available until expended.
          (3) Allocation of funds.--Of the amount authorized to 
        be appropriated by paragraph (1) for the [fiscal years 
        2004 through 2008] fiscal years 2009 through 2013, such 
        sums as may be necessary are authorized to be 
        appropriated to carry out section 104A(d)(4) of the 
        Foreign Assistance Act of 1961 (as added by subsection 
        (a)), relating to the procurement and distribution of 
        HIV/AIDS pharmaceuticals.
    [(c) Relationship to Assistance Programs to Enhance 
Nutrition.--In recognition of the fact that malnutrition may 
hasten the progression of HIV to AIDS and may exacerbate the 
decline among AIDS patients leading to a shorter life span, the 
Administrator of the United States Agency for International 
Development shall, as appropriate--
          [(1) integrate nutrition programs with HIV/AIDS 
        activities, generally;
          [(2) provide, as a component of an anti-retroviral 
        therapy program, support for food and nutrition to 
        individuals infected with and affected by HIV/AIDS; and
          [(3) provide support for food and nutrition for 
        children affected by HIV/AIDS and to communities and 
        households caring for children affected by HIV/AIDS.]
  (c) Food and Nutritional Support.--
          (1) In general.--As indicated in the report produced 
        by the Institute of Medicine, entitled ``PEPFAR 
        Implementation: Progress and Promise'', inadequate 
        caloric intake has been clearly identified as a 
        principal reason for failure of clinical response to 
        antiretroviral therapy. In recognition of the impact of 
        malnutrition as a clinical health issue for many 
        persons living with HIV/AIDS that is often associated 
        with health and economic impacts on these individuals 
        and their families, the Global AIDS Coordinator and the 
        Administrator of the United States Agency for 
        International Development shall--
                  (A) follow World Health Organization 
                guidelines for HIV/AIDS food and nutrition 
                services;
                  (B) integrate nutrition programs with HIV/
                AIDS activities through effective linkages 
                among the health, agricultural, and livelihood 
                sectors and establish additional services in 
                circumstances in which referrals are inadequate 
                or impossible;
                  (C) provide, as a component of care and 
                treatment programs for persons with HIV/AIDS, 
                food and nutritional support to individuals 
                infected with, and affected by, HIV/AIDS who 
                meet established criteria for nutritional 
                support (including clinically malnourished 
                children and adults, and pregnant and lactating 
                women in programs in need of supplemental 
                support), including--
                          (i) anthropometric and dietary 
                        assessment;
                          (ii) counseling; and
                          (iii) therapeutic and supplementary 
                        feeding;
                  (D) provide food and nutritional support for 
                children affected by HIV/AIDS and to 
                communities and households caring for children 
                affected by HIV/AIDS; and
                  (E) in communities where HIV/AIDS and food 
                insecurity are highly prevalent, support 
                programs to address these often intersecting 
                health problems through community-based 
                assistance programs, with an emphasis on 
                sustainable approaches.
          (2) Authorization of appropriations.--Of the amounts 
        authorized to be appropriated under section 401, there 
        are authorized to be appropriated to the President such 
        sums as may be necessary for each of the fiscal years 
        2009 through 2013 to carry out this subsection.

SEC. 302. ASSISTANCE TO COMBAT TUBERCULOSIS.

           *       *       *       *       *       *       *


    (b) Authorization of Appropriations.--
          (1) In general.--In addition to funds available under 
        section 104(c) of the Foreign Assistance Act of 1961 
        (22 U.S.C. 2151b(c)) for such purpose or under any 
        other provision of that Act, there are authorized to be 
        appropriated to the President, from amounts authorized 
        to be appropriated under section 401, [such sums as may 
        be necessary for each of the fiscal years 2004 through 
        2008] a total of $4,000,000,000 for the 5-year period 
        beginning on October 1, 2008 to carry out section 104B 
        of the Foreign Assistance Act of 1961, as added by 
        subsection (a).
          (2) Availability of funds.--Amounts appropriated 
        pursuant to the authorization of appropriations under 
        paragraph (1) are authorized to remain available until 
        expended.
          (3) Transfer of prior year funds.--Unobligated 
        balances of funds made available for fiscal year 2001, 
        2002, or 2003 under section 104(c)(7) of the Foreign 
        Assistance Act of 1961 (22 U.S.C. 2151b(c)(7) (as in 
        effect immediately before the date of enactment of this 
        Act) shall be transferred to, merged with, and made 
        available for the same purposes as funds made available 
        for [fiscal years 2004 through 2008] fiscal years 2009 
        through 2013 under paragraph (1).

           *       *       *       *       *       *       *


SEC. 303. ASSISTANCE TO COMBAT MALARIA.

           *       *       *       *       *       *       *


    (b) Authorization of Appropriations.--
          (1) In general.--In addition to funds available under 
        section 104(c) of the Foreign Assistance Act of 1961 
        (22 U.S.C. 2151b(c)) for such purpose or under any 
        other provision of that Act, there are authorized to be 
        appropriated to the President, from amounts authorized 
        to be appropriated under section 401, [such sums as may 
        be necessary for fiscal years 2004 through 2008] 
        $5,000,000,000 during the 5-year period beginning on 
        October 1, 2008 to carry out section 104C of the 
        Foreign Assistance Act of 1961, as added by subsection 
        (a), including for the development of anti-malarial 
        pharmaceuticals by theMedicines for Malaria Venture.
          (2) Availability of funds.--Amounts appropriated 
        pursuant to paragraph (1) are authorized to remain 
        available until expended.
          (3) Transfer of prior year funds.--Unobligated 
        balances of funds made available for fiscal year 2001, 
        2002, or 2003 under section 104(c) of the Foreign 
        Assistance Act of 1961 (22 U.S.C. 2151b(c) (as in 
        effect immediately before the date of enactment of this 
        Act) and made available for the control of malaria 
        shall be transferred to, merged with, and made 
        available for the same purposes as funds made available 
        for [fiscal years 2004 through 2008] fiscal years 2009 
        through 2013 under paragraph (1).
    (c) Conforming Amendment.--Section 104(c) of the Foreign 
Assistance Act of 1961 (22 U.S.C. 2151b(c)), as amended by 
section 301 of this Act, is further amended by adding after 
paragraph (3) the following: * * *
  (c) Statement of Policy.--Providing assistance for the 
prevention, control, treatment, and the ultimate eradication of 
malaria is--
          (1) a major objective of the foreign assistance 
        program of the United States; and
          (2) 1 component of a comprehensive United States 
        global health strategy to reduce disease burdens and 
        strengthen communities around the world.
  (d) Development of a Comprehensive 5-Year Strategy.--The 
President shall establish a comprehensive, 5-year strategy to 
combat global malaria that--
          (1) strengthens the capacity of the United States to 
        be an effective leader of international efforts to 
        reduce malaria burden;
          (2) maintains sufficient flexibility and remains 
        responsive to the ever-changing nature of the global 
        malaria challenge;
          (3) includes specific objectives and multisectoral 
        approaches and strategies to reduce the prevalence, 
        mortality, incidence, and spread of malaria;
          (4) describes how this strategy would contribute to 
        the United States' overall global health and 
        development goals;
          (5) clearly explains how outlined activities will 
        interact with other United States Government global 
        health activities, including the 5-year global AIDS 
        strategy required under this Act;
          (6) expands public-private partnerships and leverage 
        of resources;
          (7) coordinates among relevant Federal agencies to 
        maximize human and financial resources and to reduce 
        duplication among these agencies, foreign governments, 
        and international organizations;
          (8) coordinates with other international entities, 
        including the Global Fund;
          (9) maximizes United States capabilities in the areas 
        of technical assistance and training and research, 
        including vaccine research; and
          (10) establishes priorities and selection criteria 
        for the distribution of resources based on factors such 
        as--
                  (A) the size and demographics of the 
                population with malaria;
                  (B) the needs of that population;
                  (C) the country's existing infrastructure; 
                and
                  (D) the ability to closely coordinate United 
                States Government efforts with national malaria 
                control plans of partner countries.

SEC. 304. PILOT PROGRAM FOR THE PLACEMENT OF HEALTHCARE PROFESSIONALS 
                    IN OVERSEAS AREAS SEVERELY AFFECTED BY HIV/AIDS, 
                    TUBERCULOSIS, AND MALARIA.

    [(a) In General.--The President should establish a program 
to demonstrate the feasibility of facilitating the service of 
United States healthcare professionals in those areas of sub-
Saharan Africa and other parts of the world severely affected 
by HIV/AIDS, tuberculosis, and malaria.
    [(b) Requirements.--Participants in the program shall--
          [(1) provide basic healthcare services for those 
        infected and affected by HIV/AIDS, tuberculosis, and 
        malaria in the area in which they are serving;
          [(2) provide on-the-job training to medical and other 
        personnel in the area in which they are serving to 
        strengthen the basic healthcare system of the affected 
        countries;
          [(3) provide healthcare educational training for 
        residents of the area in which they are serving;
          [(4) serve for a period of up to 3 years; and
          [(5) meet the eligibility requirements in subsection 
        (d).
    [(c) Eligibility Requirements.--To be eligible to 
participate in the program, a candidate shall--
          [(1) be a national of the United States who is a 
        trained healthcare professional and who meets the 
        educational and licensure requirements necessary to be 
        such a professional such as a physician, nurse, 
        physician assistant, nurse practitioner, pharmacist, 
        other type of healthcare professional, or other 
        individual determined to be appropriate by the 
        President; or
          [(2) be a retired commissioned officer of the Public 
        Health Service Corps.
    [(d) Recruitment.--The President shall ensure that 
information on the program is widely distributed, including the 
distribution of information to schools for health 
professionals, hospitals, clinics, and nongovernmental 
organizations working in the areas of international health and 
aid.
    [(e) Placement of Participants.--
          [(1) In general.--To the maximum extent practicable, 
        participants in the program shall serve in the poorest 
        areas of the affected countries, where healthcare needs 
        are likely to be the greatest. The decision on the 
        placement of a participant should be made in 
        consultation with relevant officials of the affected 
        country at both the national and local level as well as 
        with local community leaders and organizations.
          [(2) Coordination.--Placement of participants in the 
        program shall be coordinated with the United States 
        Agency for International Development in countries in 
        which that Agency is conducting HIV/AIDS, tuberculosis, 
        or malaria programs. Overall coordination of placement 
        of participants in the program shall be made by the 
        Coordinator of United States Government Activities to 
        Combat HIV/AIDS Globally (as described in section 1(f) 
        of the State Department Basic Authorities Act of 1956 
        (as added by section 102(a) of this Act)).
    [(f) Incentives.--The President may offer such incentives 
as the President determines to be necessary to encourage 
individuals to participate in the program, such as partial 
payment of principal, interest, and related expenses on 
government and commercial loans for educational expenses 
relating to professional health training and, where possible, 
deferment of repayments on such loans, the provision of 
retirement benefits that would otherwise be jeopardized by 
participation in the program, and other incentives.
    [(g) Report.--Not later than 18 months after the date of 
enactment of this Act, the President shall submit to the 
appropriate congressional committees a report on steps taken to 
establish the program, including--
          [(1) the process of recruitment, including the venues 
        for recruitment, the number of candidates recruited, 
        the incentives offered, if any, and the cost of those 
        incentives;
          [(2) the process, including the criteria used, for 
        the selection of participants;
          [(3) the number of participants placed, the countries 
        in which they were placed, and why those countries were 
        selected; and
          [(4) the potential for expansion of the program.
    [(h) Authorization of Appropriations.--
          [(1) In general.--In addition to amounts otherwise 
        available for such purpose, there are authorized to be 
        appropriated to the President, from amounts authorized 
        to be appropriated under section 401, such sums as may 
        be necessary for each of the fiscal years 2004 through 
        2008 to carry out the program.
          [(2) Availability of funds.--Amounts appropriated 
        pursuant to the authorization of appropriations under 
        paragraph (1) are authorized to remain available until 
        expended.]

SEC. 304. MALARIA RESPONSE COORDINATOR.

  (a) In General.--There is established within the United 
States Agency for International Development a Coordinator of 
United States Government Activities to Combat Malaria Globally 
(referred to in this section as the ``Malaria Coordinator''), 
who shall be appointed by the President.
  (b) Authorities.--The Malaria Coordinator, acting through 
nongovernmental organizations (including faith-based and 
community-based organizations), partner country finance, 
health, and other relevant ministries, and relevant executive 
branch agencies as may be necessary and appropriate to carry 
out this section, is authorized to--
          (1) operate internationally to carry out prevention, 
        care, treatment, support, capacity development, and 
        other activities to reduce the prevalence, mortality, 
        and incidence of malaria;
          (2) provide grants to, and enter into contracts and 
        cooperative agreements with, nongovernmental 
        organizations (including faith-based organizations) to 
        carry out this section; and
          (3) transfer and allocate executive branch agency 
        funds that have been appropriated for the purposes 
        described in paragraphs (1) and (2).
  (c) Duties.--
          (1) In general.--The Malaria Coordinator has primary 
        responsibility for the oversight and coordination of 
        all resources and international activities of the 
        United States Government relating to efforts to combat 
        malaria.
          (2) Specific duties.--The Malaria Coordinator shall--
                  (A) facilitate program and policy 
                coordination of antimalaria efforts among 
                relevant executive branch agencies and 
                nongovernmental organizations by auditing, 
                monitoring, and evaluating such programs;
                  (B) ensure that each relevant executive 
                branch agency undertakes antimalarial programs 
                primarily in those areas in which the agency 
                has the greatest expertise, technical 
                capability, and potential for success;
                  (C) coordinate relevant executive branch 
                agency activities in the field of malaria 
                prevention and treatment;
                  (D) coordinate planning, implementation, and 
                evaluation with the Global AIDS Coordinator in 
                countries in which both programs have a 
                significant presence;
                  (E) coordinate with national governments, 
                international agencies, civil society, and the 
                private sector; and
                  (F) establish due diligence criteria for all 
                recipients of funds appropriated by the Federal 
                Government for malaria assistance.
  (d) Assistance for the World Health Organization.--In 
carrying out this section, the President may provide financial 
assistance to the Roll Back Malaria Partnership of the World 
Health Organization to improve the capacity of countries with 
high rates of malaria and other affected countries to implement 
comprehensive malaria control programs.
  (e) Coordination of Assistance Efforts.--In carrying out this 
section and in accordance with section 104C of the Foreign 
Assistance Act of 1961 (22 U.S.C. 2151b-4), the Malaria 
Coordinator shall coordinate the provision of assistance by 
working with--
          (1) relevant executive branch agencies, including--
                  (A) the Department of State (including the 
                Office of the Global AIDS Coordinator);
                  (B) the Department of Health and Human 
                Services;
                  (C) the Department of Defense; and
                  (D) the Office of the United States Trade 
                Representative;
          (2) relevant multilateral institutions, including--
                  (A) the World Health Organization;
                  (B) the United Nations Children's Fund;
                  (C) the United Nations Development Programme;
                  (D) the Global Fund;
                  (E) the World Bank; and
                  (F) the Roll Back Malaria Partnership;
          (3) program delivery and efforts to lift barriers 
        that would impede effective and comprehensive malaria 
        control programs; and
          (4) partner or recipient country governments and 
        national entities including universities and civil 
        society organizations (including faith- and community-
        based organizations).
  (f) Research.--To carry out this section and in accordance 
with section 104C of the Foreign Assistance Act of 1961 (22 
U.S.C. 1151d-4), the Secretary of Health and Human Services, 
through the Centers for Disease Control and Prevention and the 
National Institutes of Health, shall conduct appropriate 
programmatically relevant clinical and operational research to 
identify and evaluate new diagnostics, treatment regimens, and 
interventions to prevent and control malaria.
  (g) Monitoring.--To ensure that adequate malaria controls are 
established and implemented, the Centers for Disease Control 
and Prevention shall carry out appropriate surveillance and 
evaluation activities to monitor global malaria trends and 
assess environmental and health impacts of malarial control 
efforts. Such activities shall complement the work of the World 
Health Organization, rather than duplicate such work.
  (h) Annual Report.--
          (1) Submission.--Not later than 1 year after the date 
        of the enactment of the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008, 
        and annually thereafter, the President shall submit a 
        report to the appropriate congressional committees that 
        describes United States assistance for the prevention, 
        treatment, control, and elimination of malaria.
          (2) Contents.--The report required under paragraph 
        (1) shall describe--
                  (A) the countries and activities to which 
                malaria resources have been allocated;
                  (B) the number of people reached through 
                malaria assistance programs, including data on 
                children and pregnant women;
                  (C) research efforts to develop new tools to 
                combat malaria, including drugs and vaccines;
                  (D) the collaboration and coordination of 
                United States antimalarial efforts with the 
                World Health Organization, the Global Fund, the 
                World Bank, other donor governments, major 
                private efforts, and relevant executive 
                agencies;
                  (E) the coordination of United States 
                antimalarial efforts with the national malarial 
                strategies of other donor or partner 
                governments and major private initiatives;
                  (F) the estimated impact of United States 
                assistance on childhood mortality and morbidity 
                from malaria;
                  (G) the coordination of antimalarial efforts 
                with broader health and development programs; 
                and
                  (H) the constraints on implementation of 
                programs posed by health workforce shortages or 
                capacities; and
                  (I) the number of personnel trained as health 
                workers and the training levels achieved.

           [Subtitle B--Assistance for Children and Families]


Subtitle B--Assistance for Women, Children, and Families

           *       *       *       *       *       *       *


SEC. 312. POLICY AND REQUIREMENTS.

    (a) Policy.--The United States Government's response to the 
global HIV/AIDS pandemic should place high priority on the 
prevention of mother-to-child transmission, the care and 
treatment of family members and caregivers, and the care of 
children orphaned by AIDS. To the maximum extent possible, the 
United States Government should seek to leverage its funds by 
seeking matching contributions from the private sector, other 
national governments, and international organizations.
    (b) Requirements.--The 5-year United States Government 
strategy required by section 101 of this Act shall--
          [(1) provide for meeting or exceeding the goal to 
        reduce the rate of mother-to-child transmission of HIV 
        by 20 percent by 2005 and by 50 percent by 2010;
          [(2) include programs to make available testing and 
        treatment to HIV-positive women and their family 
        members, including drug treatment and therapies to 
        prevent mother-to-child transmission; and
          [(3) expand programs designed to care for children 
        orphaned by AIDS.]
          (1) establish a target for the prevention and 
        treatment of mother-to-child transmission of HIV that, 
        by 2013, will reach at least 80 percent of pregnant 
        women in those countries most affected by HIV/AIDS in 
        which the United States has HIV/AIDS programs;
          (2) establish a target that, by 2013, the proportion 
        of children receiving care and treatment under this Act 
        is proportionate to their numbers within the population 
        of HIV infected individuals in each country;
          (3) integrate care and treatment with prevention of 
        mother-to-child transmission of HIV programs to improve 
        outcomes for HIV-affected women and families as soon as 
        is feasible and support strategies that promote 
        successful follow-up and continuity of care of mother 
        and child;
          (4) expand programs designed to care for children 
        orphaned by, affected by, or vulnerable to HIV/AIDS;
          (5) ensure that women in prevention of mother-to-
        child transmission of HIV programs are provided with, 
        or referred to, appropriate maternal and child 
        services; and
          (6) develop a timeline for expanding access to more 
        effective regimes to prevent mother-to-child 
        transmission of HIV, consistent with the national 
        policies of countries in which programs are 
        administered under this Act and the goal of achieving 
        universal use of such regimes as soon as possible.
  (c) Prevention of Mother-to-Child Transmission Expert 
Panel.--
          (1) Establishment.--The Global AIDS Coordinator shall 
        establish a panel of experts to be known as the 
        Prevention of Mother-to-Child Transmission Panel 
        (referred to in this subsection as the ``Panel'') to--
                  (A) provide an objective review of activities 
                to prevent mother-to-child transmission of HIV; 
                and
                  (B) provide recommendations to the Global 
                AIDS Coordinator and to the appropriate 
                committees of Congress for scale-up of mother-
                to-child transmission prevention services under 
                this Act in order to achieve the target 
                established in subsection (b)(1).
          (2) Membership.--The Panel shall be convened and 
        chaired by the Global AIDS Coordinator, who shall serve 
        as a nonvoting member. The Panel shall consist of not 
        more than 15 members (excluding the Global AIDS 
        Coordinator), to be appointed by the Global AIDS 
        Coordinator not later than 1 year after the date of the 
        enactment of this Act, including--
                  (A) 2 members from the Department of Health 
                and Human Services with expertise relating to 
                the prevention of mother-to-child transmission 
                activities;
                  (B) 2 members from the United States Agency 
                for International Development with expertise 
                relating to the prevention of mother-to-child 
                transmission activities;
                  (C) 2 representatives from among health 
                ministers of national governments of foreign 
                countries in which programs under this Act are 
                administered;
                  (D) 3 members representing organizations 
                implementing prevention of mother-to-child 
                transmission activities under this Act;
                  (E) 2 healthcare researchers with expertise 
                relating to global HIV/AIDS activities; and
                  (F) representatives from among patient 
                advocate groups, healthcare professionals, 
                persons living with HIV/AIDS, and non-
                governmental organizations with expertise 
                relating to the prevention of mother-to-child 
                transmission activities, giving priority to 
                individuals in foreign countries in which 
                programs under this Act are administered.
          (3) Duties of panel.--The Panel shall--
                  (A) assess the effectiveness of current 
                activities in reaching the target described in 
                subsection (b)(1);
                  (B) review scientific evidence related to the 
                provision of mother-to-child transmission 
                prevention services, including programmatic 
                data and data from clinical trials;
                  (C) review and assess ways in which the 
                Office of the United States Global AIDS 
                Coordinator collaborates with international and 
                multilateral entities on efforts to prevent 
                mother-to-child transmission of HIV in affected 
                countries;
                  (D) identify barriers and challenges to 
                increasing access to mother-to-child 
                transmission prevention services and evaluate 
                potential mechanisms to alleviate those 
                barriers and challenges;
                  (E) identify the extent to which stigma has 
                hindered pregnant women from obtaining HIV 
                counseling and testing or returning for 
                results, and provide recommendations to address 
                such stigma and its effects;
                  (F) identify opportunities to improve 
                linkages between mother-to-child transmission 
                prevention services and care and treatment 
                programs; and
                  (G) recommend specific activities to 
                facilitate reaching the target described in 
                subsection (b)(1).
          (4) Report.--
                  (A) In general.--Not later than 1 year after 
                the date on which the Panel is first convened, 
                the Panel shall submit a report containing a 
                detailed statement of the recommendations, 
                findings, and conclusions of the Panel to the 
                appropriate congressional committees.
                  (B) Availability.--The report submitted under 
                subparagraph (A) shall be made available to the 
                public.
                  (C) Consideration by coordinator.--The 
                Coordinator shall--
                          (i) consider any recommendations 
                        contained in the report submitted under 
                        subparagraph (A); and
                          (ii) include in the annual report 
                        required under section 104A(f) of the 
                        Foreign Assistance Act of 1961 a 
                        description of the activities conducted 
                        in response to the recommendations made 
                        by the Panel and an explanation of any 
                        recommendations not implemented at the 
                        time of the report.
          (5) Authorization of appropriations.--There are 
        authorized to be appropriated to the Panel such sums as 
        may be necessary for each of the fiscal years 2009 
        through 2011 to carry out this section.
          (6) Termination.--The Panel shall terminate on the 
        date that is 60 days after the date on which the Panel 
        submits the report to the appropriate congressional 
        committees under paragraph (4).

SEC. 313. ANNUAL REPORTS ON PREVENTION OF MOTHER-TO-CHILD TRANSMISSION 
                    OF THE HIV INFECTION.

    (a) In General.--Not later than 1 year after the date of 
the enactment of this Act, and annually thereafter for a period 
of [5 years] 10 years, the President shall submit to 
appropriate congressional committees a report on the activities 
of relevant executive branch agencies during the reporting 
period to assist in the prevention of mother-to-child 
transmission of the HIV infection.
    (b) Report Elements.--Each report shall include--
          (1) a statement of whether or not all relevant 
        executive branch agencies have met the goal described 
        in section 312(b)(1); and
          (2) a description of efforts made by the relevant 
        executive branch agencies to expand those activities, 
        including--
                  (A) information on the number of sites 
                supported for the prevention of mother-to-child 
                transmission of the HIV infection;
                  (B) the specific activities supported;
                  (C) the number of women tested and counseled; 
                and
                  (D) the number of women receiving 
                preventative drug therapies.
    (c) Reporting Period Defined.--In this section, the term 
``reporting period'' means, in the case of the initial report, 
the period since the date of enactment of this Act and, in the 
case of any subsequent report, the period since the date of 
submission of the most recent report.

           *       *       *       *       *       *       *


               TITLE IV--AUTHORIZATION OF APPROPRIATIONS


SEC. 401. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--There are authorized to be appropriated to 
the President to carry out this Act and the amendments made by 
this Act [$3,000,000,000 for each of the fiscal years 2004 
through 2008] $50,000,000,000 for the 5-year period beginning 
on October 1, 2008.
    (b) Availability.--Amounts appropriated pursuant to the 
authorization of appropriations in subsection (a) are 
authorized to remain available until expended.
    (c) Availability of Authorizations.--Authorizations of 
appropriations under subsection (a) shall remain available 
until the appropriations are made.

SEC. 402. SENSE OF CONGRESS.

    (a) Increase in HIV/AIDS Antiretroviral Treatment.--It is a 
sense of the Congress that an urgent priority of United States 
assistance programs to fight HIV/AIDS should be the rapid 
increase in distribution of antiretroviral treatment so that--
          (1) by the end of fiscal year 2004, at least 500,000 
        individuals with HIV/AIDS are receiving antiretroviral 
        treatment through United States assistance programs;
          (2) by the end of fiscal year 2005, at least 
        1,000,000 such individuals are receiving such 
        treatment; and
          (3) by the end of fiscal year 2006, at least 
        2,000,000 such individuals are receiving such 
        treatment.
    (b) Effective Distribution of HIV/AIDS Funds.--It is the 
sense of Congress that, of the amounts appropriated pursuant to 
the authorization of appropriations under section 401 for HIV/
AIDS assistance, [an effective distribution of such amounts 
would be--
          [(1) 55 percent of such amounts for treatment of 
        individuals with HIV/AIDS;
          [(2) 15 percent of such amounts for palliative care 
        of individuals with HIV/AIDS;
          [(3) 20 percent of such amounts for HIV/AIDS 
        prevention consistent with section 104A(d) of the 
        Foreign Assistance Act of 1961 (as added by section 301 
        of this Act), of which such amount at least 33 percent 
        should be expended for abstinence-until-marriage 
        programs; and
          [(4) 10 percent of such amounts] 10 percent should be 
        used for orphans and vulnerable children.

SEC. 403. ALLOCATION OF FUNDS.

    [(a) Therapeutic Medical Care.--For fiscal years 2006 
through 2008, not less than 55 percent of the amounts 
appropriated pursuant to the authorization of appropriations 
under section 401 for HIV/AIDS assistance for each such fiscal 
year 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 expended for related care. For fiscal years 2006 through 
2008, not less than 33 percent of the amounts appropriated 
pursuant to the authorization of appropriations under section 
401 for HIV/AIDS prevention consistent with section 104A(d) of 
the Foreign Assistance Act of 1961 (as added by section 301 of 
this Act) for each such fiscal year shall be expended for 
abstinence-until-marriage programs.]
  (a) Balanced Funding Requirement.--
          (1) In general.--The Global AIDS Coordinator shall--
                  (A) provide balanced funding for prevention 
                activities for sexual transmission of HIV/AIDS; 
                and
                  (B) ensure that behavioral change programs, 
                including abstinence, delay of sexual debut, 
                monogamy, fidelity, and partner reduction, are 
                implemented and funded in a meaningful and 
                equitable way in the strategy for each host 
                country based on objective epidemiological 
                evidence as to the source of infections and in 
                consultation with the government of each host 
                county involved in HIV/AIDS prevention 
                activities.
          (2) Prevention strategy.--
                  (A) Establishment.--In carrying out paragraph 
                (1), the Global AIDS Coordinator shall 
                establish a HIV sexual transmission prevention 
                strategy governing the expenditure of funds 
                authorized under this Act to prevent the sexual 
                transmission of HIV in any host country with a 
                generalized epidemic.
                  (B) Report.--In each host country described 
                in subparagraph (A), if the strategy 
                established under subparagraph (A) provides 
                less than 50 percent of the funds described in 
                subparagraph (A) for behavioral change 
                programs, including abstinence, delay of sexual 
                debut, monogamy, fidelity, and partner 
                reduction, the Global AIDS Coordinator shall, 
                not later than 30 days after the issuance of 
                this strategy, report to the appropriate 
                congressional committees on the justification 
                for this decision.
          (3) Exclusion.--Programs and activities that 
        implement or purchase new prevention technologies or 
        modalities, such as medical male circumcision, pre-
        exposure pharmaceutical prophylaxis to prevent 
        transmission of HIV, or microbicides and programs and 
        activities that provide counseling and testing for HIV 
        or prevent mother-to-child prevention of HIV, shall not 
        be included in determining compliance with paragraph 
        (2).
          (4) Report.--Not later than 1 year after the date of 
        the enactment of the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008, 
        and annually thereafter as part of the annual report 
        required under section 104A(e) of the Foreign 
        Assistance Act of 1961 (22 U.S.C. 2151b-2(e)), the 
        President shall--
                  (A) submit a report on the implementation of 
                paragraph (2) for the most recently concluded 
                fiscal year to the appropriate congressional 
                committees; and
                  (B) make the report described in subparagraph 
                (A) available to the public.
    (b) Orphans and Vulnerable Children.--For [fiscal years 
2006 through 2008] fiscal years 2009 through 2013, not less 
than 10 percent of the amounts appropriated pursuant to the 
authorization of appropriations under section 401 for HIV/AIDS 
assistance for each such fiscal year shall be expended for 
assistance for orphans and [vulnerable children affected by] 
other children affected by, or vulnerable to, HIV/AIDS, of 
which such amount at least 50 percent shall be provided through 
non-profit, nongovernmental organizations, including faith-
based organizations, that implement programs on the community 
level.

           *       *       *       *       *       *       *


The Foreign Assistance Act of 1961

           *       *       *       *       *       *       *



                                 PART I


Chapter 1--Policy; Development Assistance Authorizations

           *       *       *       *       *       *       *



SEC. 104A. ASSISTANCE TO COMBAT HIV/AIDS.

    (a) Finding.--Congress recognizes that the alarming spread 
of HIV/AIDS in countries in sub-Saharan Africa, the Caribbean, 
Central Asia, Eastern Europe, Latin America, and other 
developing countries is a major global health, national 
security, development, and humanitarian crisis.
    [(b) Policy.--It is a major objective of the foreign 
assistance program of the United States to provide assistance 
for the prevention, treatment, and control of HIV/AIDS. The 
United States and other developed countries should provide 
assistance to countries in sub-Saharan Africa, the Caribbean, 
and other countries and areas to control this crisis through 
HIV/AIDS prevention, treatment, monitoring, and related 
activities, particularly activities focused on women and youth, 
including strategies to protect women and prevent mother-to-
child transmission of the HIV infection.]
  (b) Policy.--
          (1) Objectives.--It is a major objective of the 
        foreign assistance program of the United States to 
        provide assistance for the prevention and treatment of 
        HIV/AIDS and the care of those affected by the disease. 
        It is the policy objective of the United States, by 
        2013, to--
                  (A) assist partner countries to--
                          (i) prevent 12,000,000 new HIV 
                        infections worldwide;
                          (ii) support treatment of at least 
                        3,000,000 individuals with HIV/AIDS;
                          (iii) support additional treatment 
                        through coordinated multilateral 
                        efforts;
                          (iv) support care for 12,000,000 
                        individuals with HIV/AIDS, including 
                        5,000,000 orphans and vulnerable 
                        children affected by HIV/AIDS, with an 
                        emphasis on promoting a comprehensive, 
                        coordinated system of services to be 
                        integrated throughout the continuum of 
                        care;
                          (v) provide at least 80 percent of 
                        the target population with access to 
                        counseling, testing, and treatment to 
                        prevent the transmission of HIV from 
                        mother-to-child;
                          (vi) provide care and treatment 
                        services to children with HIV in 
                        proportion to their percentage within 
                        the HIV-infected population of a given 
                        partner country; and
                          (vii) train and support retention of 
                        healthcare professionals, 
                        paraprofessionals, and community health 
                        workers in HIV/AIDS prevention, 
                        treatment, and care, with the target of 
                        providing such training to at least 
                        140,000 new healthcare professionals 
                        and paraprofessionals;
                  (B) strengthen the capacity to deliver 
                primary healthcare in developing countries, 
                especially in sub-Saharan Africa; and
                  (C) help countries achieve staffing levels of 
                at least 2.3 doctors, nurses, and midwives per 
                1,000 population, as called for by the World 
                Health Organization.
          (2) Coordinated global strategy.--The United States 
        and other countries with the sufficient capacity should 
        provide assistance to countries in sub-Saharan Africa, 
        the Caribbean, Central Asia, Eastern Europe, and Latin 
        America, and other countries and regions confronting 
        HIV/AIDS epidemics in a coordinated global strategy to 
        help address generalized and concentrated epidemics 
        through HIV/AIDS prevention, treatment, care, 
        monitoring and evaluation, and related activities.
          (3) Priorities.--The United States Government's 
        response to the global HIV/AIDS pandemic and the 
        Government's efforts to help countries assume 
        leadership of sustainable campaigns to combat their 
        local epidemics should place high priority on--
                  (A) the prevention of the transmission of 
                HIV; and
                  (B) moving toward universal access to HIV/
                AIDS prevention counseling and services.
    (c) Authorization.--
          (1) In general.--Consistent with section 104(c), the 
        President is authorized to furnish assistance, on such 
        terms and conditions as the President may determine, 
        for HIV/AIDS, including to prevent, treat, and monitor 
        HIV/AIDS, and carry out related activities, in 
        countries in sub-Saharan Africa, the Caribbean, [and 
        other countries and areas.] Central Asia, Eastern 
        Europe, Latin America, and other countries and areas, 
        particularly with respect to refugee populations or 
        those in postconflict settings in such countries and 
        areas with significant or increasing HIV incidence 
        rates.
          (2) Role of ngos.--It is the sense of Congress that 
        the President should provide an appropriate level of 
        assistance under paragraph (1) through nongovernmental 
        organizations (including faith-based and community-
        based organizations) in countries in sub-Saharan 
        Africa, the Caribbean, [and other countries and areas 
        affected by the HIV/AIDS pandemic] Central Asia, 
        Eastern Europe, Latin America, and other countries and 
        areas affected by the HIV/AIDS pandemic, particularly 
        with respect to refugee populations or those in post-
        conflict settings in such countries and areas with 
        significant or increasing HIV incidence rates.
          (3) Coordination of assistance efforts.--The 
        President shall coordinate the provision of assistance 
        under paragraph (1) with the provision of related 
        assistance by the Joint United Nations Programme on 
        HIV/AIDS (UNAIDS), the United Nations Children's Fund 
        (UNICEF), the World Health Organization (WHO), the 
        United Nations Development Programme (UNDP), the Global 
        Fund to Fight AIDS, Tuberculosis and Malaria and other 
        appropriate international organizations (such as the 
        International Bank for Reconstruction and Development), 
        relevant regional multilateral development 
        institutions, national, state, and local governments of 
        [foreign countries] partner countries, other 
        international actors, appropriate governmental and 
        nongovernmental organizations, and relevant executive 
        branch agencies within the framework of the principles 
        of the Three Ones.
    (d) Activities Supported.--Assistance provided under 
subsection (c) shall, to the maximum extent practicable, be 
used to carry out the following activities:
          (1) Prevention.--Prevention of HIV/AIDS through 
        activities including--
                  (A) programs and efforts that are designed or 
                intended to impart knowledge with the exclusive 
                purpose of helping individuals avoid behaviors 
                that place them at risk of HIV infection, 
                including integration of such programs into 
                health programs and the inclusion in counseling 
                programs of information on methods of avoiding 
                infection of HIV, including delaying sexual 
                debut, abstinence, fidelity and monogamy, 
                reduction of casual sexual partnering and 
                multiple concurrent sexual partnering, reducing 
                sexual violence and coercion, including child 
                marriage, widow inheritance, and polygamy, and 
                where appropriate, use of [condoms] male and 
                female condoms;
                  (B) assistance to establish and implement 
                culturally appropriate HIV/AIDS education and 
                prevention [programs that] programs that are 
                designed with local input and focus on helping 
                individuals avoid infection of HIV/AIDS, 
                implemented through nongovernmental 
                organizations, including faith-based and 
                community-based organizations, particularly 
                [those organizations] those locally based 
                organizations that utilize both professionals 
                and volunteers with appropriate skills, 
                experience, and community presence;
                  (C) assistance for the purpose of encouraging 
                men to be responsible in their sexual behavior, 
                child rearing, and to respect women;
                  (D) assistance for the purpose of providing 
                voluntary testing and counseling (including the 
                incorporation of confidentiality protections 
                with respect to such testing and counseling) 
                and promoting the use of provider-initiated or 
                ``opt-out'' voluntary testing in accordance 
                with World Health Organization guidelines;
                  (E) assistance for the purpose of preventing 
                mother-to-child transmission of the HIV 
                infection, including medications to prevent 
                such transmission and access to infant formula 
                and other alternatives for infant feeding;
                  (F) assistance to--
                          (i) achieve the goal of reaching 80 
                        percent of pregnant women for 
                        prevention and treatment of mother-to-
                        child transmission of HIV in countries 
                        in which the United States is 
                        implementing HIV/AIDS programs by 2013; 
                        and
                          (ii) promote infant feeding options 
                        and treatment protocols that meet the 
                        most recent criteria established by the 
                        World Health Organization;
                  (G) medical male circumcision programs as 
                part of national strategies to combat the 
                transmission of HIV/AIDS;
                  [(F)] (H) assistance to ensure a safe blood 
                supply and sterile medical equipment;
                  [(G)] (I) assistance to help avoid substance 
                abuse and intravenous drug use that can lead to 
                HIV infection; [and]
                  [(I)] (J) assistance for the purpose of 
                increasing women's access to employment 
                opportunities, income, productive resources, 
                and microfinance programs, where 
                appropriate[.], including education and 
                services demonstrated to be effective in 
                reducing the transmission of HIV infection 
                without increasing illicit drug use; and
                  (K) assistance for counseling, testing, 
                treatment, care, and support programs, 
                including--
                          (i) counseling and other services for 
                        the prevention of reinfection of 
                        individuals with HIV/AIDS;
                          (ii) counseling to prevent sexual 
                        transmission of HIV, including--
                                  (I) life skills development 
                                for practicing abstinence and 
                                faithfulness;
                                  (II) reducing the number of 
                                sexual partners;
                                  (III) delaying sexual debut; 
                                and
                                  (IV) ensuring correct and 
                                consistent use of condoms;
                          (iii) assistance to engage underlying 
                        vulnerabilities to HIV/AIDS, especially 
                        those of women and girls, through 
                        structural prevention programs;
                          (iv) assistance for appropriate HIV/
                        AIDS education programs and training 
                        targeted to prevent the transmission of 
                        HIV among men who have sex with men;
                          (v) assistance to provide male and 
                        female condoms;
                          (vi) diagnosis and treatment of other 
                        sexually transmitted infections;
                          (vii) strategies to address the 
                        stigma and discrimination that impede 
                        HIV/AIDS prevention efforts; and
                          (viii) assistance to facilitate 
                        widespread access to microbicides for 
                        HIV prevention, if safe and effective 
                        products become available, including 
                        financial and technical support for 
                        culturally appropriate introductory 
                        programs, procurement, distribution, 
                        logistics management, program delivery, 
                        acceptability studies, provider 
                        training, demand generation, and 
                        postintroduction monitoring.
          (2) Treatment.--The treatment and care of individuals 
        with HIV/AIDS, including--
                  (A) assistance to establish and implement 
                programs to strengthen and broaden indigenous 
                healthcare delivery systems and the capacity of 
                such systems to deliver HIV/AIDS 
                pharmaceuticals and otherwise provide for the 
                treatment of individuals with HIV/AIDS, 
                including clinical training for indigenous 
                organizations and healthcare providers;
                  (B) assistance to strengthen and expand 
                hospice and palliative care programs to assist 
                patients debilitated by HIV/AIDS, their 
                families, and the primary caregivers of such 
                patients, including programs that utilize 
                faith-based and community-based organizations; 
                [and]
                  (C) assistance for the purpose of the care 
                and treatment of individuals with HIV/AIDS 
                through the provision of pharmaceuticals, 
                including antiretrovirals and other 
                pharmaceuticals and therapies for the treatment 
                of opportunistic infections, pain management, 
                nutritional support, and other treatment 
                modalities[.];
                  (D) as part of care and treatment of HIV/
                AIDS, assistance (including prophylaxis and 
                treatment) for common HIV/AIDS-related 
                opportunistic infections for free or at a rate 
                at which it is easily affordable to the 
                individuals and populations being served; and
                  (E) as part of care and treatment of HIV/
                AIDS, assistance or referral to available and 
                adequately resourced service providers for 
                nutritional support, including counseling and 
                where necessary the provision of commodities, 
                for persons meeting malnourishment criteria and 
                their families;
          (3) Preventative intervention education and 
        technologies.--(A) With particular emphasis on specific 
        populations that represent a particularly high risk of 
        contracting or spreading HIV/AIDS, including those 
        exploited through the sex trade, victims of rape and 
        sexual assault, individuals already infected with HIV/
        AIDS, and in cases of occupational exposure of 
        healthcare workers, assistance with efforts to reduce 
        the risk of HIV/AIDS infection including post-exposure 
        pharmaceutical prophylaxis, and necessary 
        pharmaceuticals and commodities, including test kits, 
        condoms, and, when proven effective, microbicides.
          (B) Bulk purchases of available test kits, condoms, 
        and, when proven effective, microbicides that are 
        intended to reduce the risk of HIV/AIDS transmission 
        and for appropriate program support for the 
        introduction and distribution of these commodities, as 
        well as education and training on the use of the 
        technologies.
          (4) Monitoring.--The monitoring of programs, 
        projects, and activities carried out pursuant to 
        paragraphs (1) through (3), including--
                  (A) monitoring to ensure that adequate 
                controls are established and implemented to 
                provide HIV/AIDS pharmaceuticals and other 
                appropriate medicines to poor individuals with 
                HIV/AIDS;
                  (B) appropriate evaluation and surveillance 
                activities;
                  (C) monitoring to ensure that appropriate 
                measures are being taken to maintain the 
                sustainability of HIV/AIDS pharmaceuticals 
                (especially antiretrovirals) and ensure that 
                drug resistance is not compromising the 
                benefits of such pharmaceuticals; [and]
                  (D) monitoring to ensure appropriate law 
                enforcement officials are working to ensure 
                that HIV/AIDS pharmaceuticals are not 
                diminished through illegal counterfeiting or 
                black market sales of such pharmaceuticals[.];
                  (E) carrying out and expanding program 
                monitoring, impact evaluation research and 
                analysis, and operations research and 
                disseminating data and findings through 
                mechanisms to be developed by the Coordinator 
                of United States Government Activities to 
                Combat HIV/AIDS Globally, in coordination with 
                the Director of the Centers for Disease 
                Control, in order to--
                          (i) improve accountability, increase 
                        transparency, and ensure the delivery 
                        of evidence-based services through the 
                        collection, evaluation, and analysis of 
                        data regarding gender-responsive 
                        interventions, disaggre- gated by age 
                        and sex;
                          (ii) identify and replicate effective 
                        models; and
                          (iii) develop gender indicators to 
                        measure outcomes and the impacts of 
                        interventions; and
                  (F) establishing appropriate systems to--
                          (i) gather epidemiological and social 
                        science data on HIV; and
                          (ii) evaluate the effectiveness of 
                        prevention efforts among men who have 
                        sex with men, with due consideration to 
                        stigma and risks associated with 
                        disclosure.
          (5) Pharmaceuticals.--
                  (A) Procurement.--The procurement of HIV/AIDS 
                pharmaceuticals, antiviral therapies, and other 
                appropriate medicines, including medicines to 
                treat opportunistic infections.
                  (B) Mechanisms for quality control and 
                sustainable supply.--Mechanisms to ensure that 
                such HIV/AIDS pharmaceuticals, antiretroviral 
                therapies, and other appropriate medicines are 
                quality-controlled and sustainably supplied.
                  (C) Mechanism to ensure cost-effective drug 
                purchasing.--Subject to subparagraph (B), 
                mechanisms to ensure that safe and effective 
                pharmaceuticals, including antiretrovirals and 
                medicines to treat opportunistic infections, 
                are purchased at the lowest possible price at 
                which such pharmaceuticals may be obtained in 
                sufficient quantity on the world market.
                  [(C)] (D) Distribution.--The distribution of 
                such HIV/AIDS pharmaceuticals, antiviral 
                therapies, and other appropriate medicines 
                (including medicines to treat opportunistic 
                infections) to qualified national, regional, or 
                local organizations for the treatment of 
                individuals with HIV/AIDS in accordance with 
                appropriate HIV/AIDS testing and monitoring 
                requirements and treatment protocols and for 
                the prevention of mother-to-child transmission 
                of the HIV infection.
          (6) [Related activities.--] Related and coordinated 
        activities._The conduct of related activities, 
        including--
                  (A) the care and support of children who are 
                orphaned by the HIV/AIDS pandemic, including 
                services designed to care for orphaned children 
                in a family environment which rely on extended 
                family members;
                  (B) improved infrastructure and institutional 
                capacity to develop and manage education, 
                prevention, and treatment programs, including 
                training and the resources to collect and 
                maintain accurate HIV surveillance data to 
                target programs and measure the effectiveness 
                of interventions; [and]
                  (C) vaccine research and development 
                partnership programs with specific plans of 
                action to develop a safe, effective, 
                accessible, preventive HIV vaccine for use 
                throughout the world[.];
                  (D) coordinated or referred activities to--
                          (i) enhance the clinical impact of 
                        HIV/AIDS care and treatment; and
                          (ii) ameliorate the adverse social 
                        and economic costs often affecting 
                        AIDS-impacted families and communities 
                        through the direct provision, as 
                        necessary, or through the referral, if 
                        possible, of support services, 
                        including--
                                  (I) nutritional and food 
                                support;
                                  (II) nutritional counseling;
                                  (III) income-generating 
                                activities and livelihood 
                                initiatives;
                                  (IV) maternal and child 
                                healthcare;
                                  (V) primary healthcare;
                                  (VI) the diagnosis and 
                                treatment of other infectious 
                                or sexually transmitted 
                                diseases;
                                  (VII) substance abuse and 
                                treatment services; and
                                  (VIII) legal services;
                  (E) coordinated or referred activities to 
                link programs addressing HIV/AIDS with programs 
                addressing gender-based violence in areas of 
                significant HIV prevalence to assist countries 
                in the development and enforcement of women's 
                health, children's health, and HIV/AIDS laws 
                and policies that--
                          (i) prevent and respond to violence 
                        against women and girls;
                          (ii) promote the integration of 
                        screening and assessment for gender-
                        based violence into HIV/AIDS 
                        programming;
                          (iii) promote appropriate HIV/AIDS 
                        counseling, testing, and treatment into 
                        gender-based violence programs; and
                          (iv) assist governments to develop 
                        partnerships with civil society 
                        organizations to create networks for 
                        psychosocial, legal, economic, or other 
                        support services;
                  (F) coordinated or referred activities to--
                          (i) address the frequent coinfection 
                        of HIV and tuberculosis, in accordance 
                        with World Health Organization 
                        guidelines;
                          (ii) promote provider-initiated or 
                        ``opt-out'' HIV/AIDS counseling and 
                        testing and appropriate referral for 
                        treatment and care to individuals with 
                        tuberculosis or its symptoms, 
                        particularly in areas with significant 
                        HIV prevalence; and
                          (iii) strengthen programs to ensure 
                        that individuals testing positive for 
                        HIV receive tuberculosis screening and 
                        appropriate screening and to improve 
                        laboratory capacities, infection 
                        control, and adherence; and
                  (G) activities to--
                          (i) improve the effectiveness of 
                        national responses to HIV/AIDS; and
                          (ii) strengthen overall health 
                        systems in high-prevalence countries, 
                        including support for workforce 
                        training, retention, and effective 
                        deployment, capacity building, 
                        laboratory development, equipment 
                        maintenance and repair, and public 
                        health and related public financial 
                        management systems and operations.
          (7) Comprehensive hiv/aids public-private 
        partnerships.--The establishment and operation of 
        public-private partnership entities within countries in 
        sub-Saharan Africa, the Caribbean, and other countries 
        affected by the HIV/AIDS pandemic that are dedicated to 
        supporting the national strategy of such countries 
        regarding the prevention, treatment, and monitoring of 
        HIV/AIDS. Each such public-private partnership should)
                  (A) support the development, implementation, 
                and management of comprehensive HIV/AIDS plans 
                in support of the national HIV/AIDS strategy;
                  (B) operate at all times in a manner that 
                emphasizes efficiency, accountability, and 
                results-driven programs;
                  (C) engage both local and foreign development 
                partners and donors, including businesses, 
                government agencies, academic institutions, 
                nongovernmental organizations, foundations, 
                multilateral development agencies, and faith-
                based organizations, to assist the country in 
                coordinating and implementing HIV/AIDS 
                prevention, treatment, and monitoring programs 
                in accordance with its national HIV/AIDS 
                strategy;
                  (D) provide technical assistance, consultant 
                services, financial planning, monitoring and 
                evaluation, and research in support of the 
                national HIV/AIDS strategy; and
                  (E) establish local human resource capacities 
                for the national HIV/AIDS strategy through the 
                transfer of medical, managerial, leadership, 
                and technical skills.
          (8) Compacts and framework agreements.--The 
        development of compacts or framework agreements, 
        tailored to local circumstances, with national 
        governments or regional partnerships in countries with 
        significant HIV/AIDS burdens to promote host government 
        commitment to deeper integration of HIV/AIDS services 
        into health systems, contribute to health systems 
        overall, and enhance sustainability.
  (e) Compacts and Framework Agreements.--
          (1) Findings.--Congress makes the following findings:
                  (A) The congressionally mandated Institute of 
                Medicine report entitled ``PEPFAR 
                Implementation: Progress and Promise' states: 
                ``The next strategy [of the U.S. Global AIDS 
                Initiative] should squarely address the needs 
                and challenges involved in supporting 
                sustainable country HIV/AIDS programs, thereby 
                transitioning from a focus on emergency 
                relief.''
                  (B) One mechanism to promote the transition 
                from an emergency to a public health and 
                development approach to HIV/AIDS is through 
                compacts or framework agreements between the 
                United States Government and each participating 
                nation.
                  (C) Key components of a transition toward a 
                more sustainable approach toward fighting HIV/
                AIDS, tuberculosis, and malaria and thus 
                priorities for such compacts include--
                          (i) building capacity to expand the 
                        size of the trained healthcare 
                        workforce in partner countries and 
                        improve its retention, safety, 
                        deployment, and utilization of skills 
                        and to improve public health 
                        infrastructure and systems;
                          (ii) partner governments increasing 
                        their national investments in health 
                        and education systems, as called for in 
                        the Abuja Declaration;
                          (iii) increasing the focus of United 
                        States government efforts to address 
                        the factors that put women and girls at 
                        greater risk of HIV/AIDS and to 
                        strengthen the legal, economic, 
                        educational, and social status of 
                        women, girls, orphans, and vulnerable 
                        children and encouraging partner 
                        governments to do the same;
                          (iv) building on the New Partners 
                        Initiative and other efforts currently 
                        underway to strengthen the capacities 
                        of community- and faith-based 
                        organizations and civil society in 
                        partner countries to contribute to 
                        country efforts to prevent or manage 
                        the effects of HIV/AIDS, tuberculosis, 
                        and malaria epidemics and to improve 
                        healthcare delivery;
                          (v) improving the coordination of 
                        efforts to combat HIV/AIDS, 
                        tuberculosis, and malaria with broader 
                        national health and development 
                        strategies;
                          (vi) promoting HIV/AIDS-related laws, 
                        regulations, and policies that support 
                        voluntary diagnostic counseling and 
                        rapid testing, pediatric diagnosis, 
                        rapid, tariff-free regulatory 
                        procedures for drugs and commodities, 
                        and full inclusion of people living 
                        with HIV/AIDS in a multisectoral 
                        national response.
                          (vii) sharing and implementing 
                        findings based on program evaluations 
                        and operations research; and
                          (viii) reducing the disease burden of 
                        HIV/AIDS, tuberculosis, and malaria 
                        through improved prevention efforts.
                  (D) Such compacts should also take into 
                account the overall national health and 
                development and national HIV/AIDS and public 
                health strategies of each country and should 
                contain provisions including--
                          (i) the specific objectives that the 
                        country and the United States expect to 
                        achieve during the term of a compact;
                          (ii) the respective responsibilities 
                        of the country and the United States in 
                        the achievement of such objectives;
                          (iii) regular benchmarks to measure, 
                        where appropriate, progress toward 
                        achieving such objectives;
                          (iv) an identification of the 
                        intended beneficiaries, disaggregated 
                        by gender and age, and including 
                        information on orphans and vulnerable 
                        children, to the maximum extent 
                        practicable;
                          (v) the methods by which the compact 
                        is intended to address the factors that 
                        put women and girls at greater risk of 
                        HIV/AIDS and to strengthen the legal, 
                        economic, educational, and social 
                        status of women, girls, orphans, and 
                        vulnerable children;
                          (vi) the methods by which the compact 
                        will strengthen the healthcare 
                        capacity, including the training, 
                        retention, deployment, and utilization 
                        of healthcare workers, improve supply 
                        chain management, and improve the 
                        health systems and infrastructure of 
                        the partner country, including the 
                        ability of compact participants to 
                        maintain and operate equipment 
                        transferred or purchased as part of the 
                        compact;
                          (vii) proposed mechanisms to provide 
                        oversight;
                          (viii) the role of civil society in 
                        the development of a compact and the 
                        achievement of its objectives;
                          (ix) a description of the current and 
                        potential participation of other donors 
                        in the achievement of such objectives, 
                        as appropriate; and
                          (x) a plan to ensure appropriate 
                        fiscal accountability for the use of 
                        assistance.
          (2) Local input.--In entering into a compact 
        authorized under subsection (d)(8), the Coordinator of 
        United States Government Activities to Combat HIV/AIDS 
        Globally shall seek to ensure that the government of a 
        country--
                  (A) takes into account the local perspectives 
                of the rural and urban poor, including women, 
                in each country; and
                  (B) consults with private and voluntary 
                organizations, including faith-based 
                organizations, the business community, and 
                other donors in the country.
          (3) Congressional and public notification after 
        entering into a compact.--Not later than 10 days after 
        entering into a compact authorized under subsection 
        (d)(8), the Global AIDS Coordinator shall--
                  (A) submit a report containing a detailed 
                summary of the compact and a copy of the text 
                of the compact to--
                          (i) the Committee on Foreign 
                        Relations of the Senate;
                          (ii) the Committee on Appropriations 
                        of the Senate;
                          (iii) the Committee on Foreign 
                        Affairs of the House of 
                        Representatives; and
                          (iv) the Committee on Appropriations 
                        of the House of Representatives; and
                  (B) publish such information in the Federal 
                Register and on the Internet website of the 
                Office of the Global AIDS Coordinator.
    [(e)] (f) Annual Report.--
          (1) In general.--Not later than January 31 of each 
        year, the President shall submit to the Committee on 
        Foreign Relations of the Senate and the [Committee on 
        International Relations] Committee on Foreign Affairs 
        of the House of Representatives a report on the 
        implementation of this section for the prior fiscal 
        year.
          (2) Report elements.--Each report shall include--
                  (A) a description of efforts made by each 
                relevant executive branch agency to implement 
                the policies set forth in this section, section 
                104B, and section 104C;
                  (B) a description of the programs established 
                pursuant to such sections; [and]
                  [(C) a detailed assessment of the impact of 
                programs established pursuant to such sections, 
                including
                          [(i)(I) the effectiveness of such 
                        programs in reducing the spread of the 
                        HIV infection, particularly in women 
                        and girls, in reducing mother-to-child 
                        transmission of the HIV infection, and 
                        in reducing mortality rates from HIV/
                        AIDS; and
                          [(II) the number of patients 
                        currently receiving treatment for AIDS 
                        in each country that receives 
                        assistance under this Act.
                          [(ii) the progress made toward 
                        improving healthcare delivery systems 
                        (including the training of adequate 
                        numbers of staff) and infrastructure to 
                        ensure increased access to care and 
                        treatment;
                          [(iii) with respect to tuberculosis, 
                        the increase in the number of people 
                        treated and the increase in number of 
                        tuberculosis patients cured through 
                        each program, project, or activity 
                        receiving United States foreign 
                        assistance for tuberculosis control 
                        purposes; and
                          [(iv) with respect to malaria, the 
                        increase in the number of people 
                        treated and the increase in number of 
                        malaria patients cured through each 
                        program, project, or activity receiving 
                        United States foreign assistance for 
                        malaria control purposes.]
                  (C) a detailed breakdown of funding 
                allocations, by program and by country, for 
                prevention activities; and
                  (D) a detailed assessment of the impact of 
                programs established pursuant to such sections, 
                including--
                          (i)(I) the effectiveness of such 
                        programs in reducing--
                                  (aa) the transmission of HIV, 
                                particularly in women and 
                                girls;
                                  (bb) mother-to-child 
                                transmission of HIV, including 
                                through drug treatment and 
                                therapies, either directly or 
                                by referral; and
                                  (cc) mortality rates from 
                                HIV/AIDS;
                          (II) the number of patients receiving 
                        treatment for AIDS in each country that 
                        receives assistance under this Act;
                          (III) an assessment of progress 
                        towards the achievement of annual goals 
                        set forth in the timetable required 
                        under the 5-year strategy established 
                        under section 101 of the United States 
                        Leadership Against HIV/AIDS, 
                        Tuberculosis, and Malaria Act of 2003 
                        and, if annual goals are not being met, 
                        the reasons for such failure; and
                          (IV) retention and attrition data for 
                        programs receiving United States 
                        assistance, including mortality and 
                        loss to follow-up rates, organized 
                        overall and by country;
                          (ii) the progress made toward--
                                  (I) improving healthcare 
                                delivery systems (including the 
                                training of healthcare workers, 
                                including doctors, nurses, 
                                midwives, pharmacists, 
                                laboratory technicians, and 
                                compensated community health 
                                workers);
                                  (II) advancing safe working 
                                conditions for healthcare 
                                workers; and
                                  (III) improving 
                                infrastructure to promote 
                                progress toward universal 
                                access to HIV/AIDS prevention, 
                                treatment, and care by 2013;
                          (iii) with respect to tuberculosis--
                                  (I) the increase in the 
                                number of people treated and 
                                the number of tuberculosis 
                                patients cured through each 
                                program, project, or activity 
                                receiving United States foreign 
                                assistance for tuberculosis 
                                control purposes through, or in 
                                coordination with, HIV/AIDS 
                                programs;
                                  (II) a description of drug 
                                resistance rates among persons 
                                treated;
                                  (III) the percentage of such 
                                United States foreign 
                                assistance provided for 
                                diagnosis and treatment of 
                                individuals with tuberculosis 
                                in countries with the highest 
                                burden of tuberculosis, as 
                                determined by the World Health 
                                Organization; and
                                  (IV) a detailed description 
                                of efforts to integrate HIV/
                                AIDS and tuberculosis 
                                prevention, treatment, and care 
                                programs; and
                          (iv) a description of coordination 
                        efforts with relevant executive branch 
                        agencies to link HIV/AIDS clinical and 
                        social services with non-HIV/AIDS 
                        services as part of the United States 
                        health and development agenda;
                          (v) a detailed description of 
                        integrated HIV/AIDS and food and 
                        nutrition programs and services, 
                        including--
                                  (I) the amount spent on food 
                                and nutrition support;
                                  (II) the types of activities 
                                supported; and
                                  (III) an assessment of the 
                                effectiveness of interventions 
                                carried out to improve the 
                                health status of persons with 
                                HIV/AIDS receiving food or 
                                nutritional support;
                          (vi) a description of efforts to 
                        improve harmonization, in terms of 
                        relevant executive branch agencies, 
                        coordination with other public and 
                        private entities, and coordination with 
                        partner countries' national strategic 
                        plans as called for in the ``Three 
                        Ones'';
                          (vii) a description of--
                                  (I) the efforts of partner 
                                countries that were signatories 
                                to the Abuja Declaration on 
                                HIV/AIDS, Tuberculosis and 
                                Other Related Infectious 
                                Diseases to adhere to the goals 
                                of such Declaration in terms of 
                                investments in public health, 
                                including HIV/AIDS; and
                                  (II) a description of the 
                                HIV/AIDS investments of partner 
                                countries that were not 
                                signatories to such 
                                Declaration;
                          (viii) a detailed description of any 
                        compacts or framework agreements 
                        reached or negotiated between the 
                        United States and any partner 
                        countries, including a description of 
                        the elements of compacts described in 
                        subsection (e);
                          (ix) a description of programs 
                        serving women and girls, including--
                                  (I) HIV/AIDS prevention 
                                programs that address the 
                                vulnerabilities of girls and 
                                women to HIV/AIDS;
                                  (II) information on the 
                                number of individuals served by 
                                programs aimed at reducing the 
                                vulnerabilities of women and 
                                girls to HIV/AIDS and data on 
                                the types, objectives, and 
                                duration of programs to address 
                                these issues;
                                  (III) information on programs 
                                to address the particular needs 
                                of adolescent girls and young 
                                women; and
                                  (IV) programs to prevent 
                                gender-based violence or to 
                                assist victims of gender based 
                                violence as part, of or in 
                                coordination with, HIV/AIDS 
                                programs;
                          (x) a description of strategies, 
                        goals, programs, and interventions to--
                                  (I) address the needs and 
                                vulnerabilities of youth 
                                populations;
                                  (II) expand access among 
                                young men and women to 
                                evidence-based HIV/AIDS 
                                healthcare services and HIV 
                                prevention programs, including 
                                abstinence education programs; 
                                and
                                  (III) expand community-based 
                                services to meet the needs of 
                                orphans and of children and 
                                adolescents affected by or 
                                vulnerable to HIV/AIDS without 
                                increasing stigmatization;
                          (xi) a description of--
                                  (I) the specific strategies 
                                funded to ensure the reduction 
                                of HIV infection among 
                                injection drug users;
                                  (II) the number of injection 
                                drug users, by country, reached 
                                by such strategies;
                                  (III) medication-assisted 
                                drug treatment for individuals 
                                with HIV or at risk of HIV; and
                                  (IV) HIV prevention programs 
                                demonstrated to be effective in 
                                reducing HIV transmission 
                                without increasing drug use;
                          (xii) a detailed description of 
                        program monitoring, operations 
                        research, and impact evaluation 
                        research, including--
                                  (I) the amount of funding 
                                provided for each research 
                                type;
                                  (II) an analysis of cost-
                                effectiveness models; and
                                  (III) conclusions regarding 
                                the efficiency, effectiveness, 
                                and quality of services as 
                                derived from previous or 
                                ongoing research and monitoring 
                                efforts; and
                          (xiii) a description of staffing 
                        levels of United States government HIV/
                        AIDS teams in countries with 
                        significant HIV/AIDS programs, 
                        including whether or not a full-time 
                        coordinator was on staff for the year.
    [(f)] (g) Funding Limitation.--Of the funds made available 
to carry out this section in any fiscal year, not more than 7 
percent may be used for the administrative expenses of the 
United States Agency for International Development in support 
of activities described in section 104(c), this section, 
section 104B, and section 104C. Such amount shall be in 
addition to other amounts otherwise available for such 
purposes.
    [(g)] (h) Definitions.--In this section:
          (1) AIDS.--The term ``AIDS'' means acquired immune 
        deficiency syndrome.
          (2) HIV.--The term ``HIV'' means the human 
        immunodeficiency virus, the pathogen that causes AIDS.
          (3) HIV/AIDS.--The term ``HIV/AIDS'' means, with 
        respect to an individual, an individual who is infected 
        with HIV or living with AIDS.
          (4) Relevant executive branch agencies.--The term 
        ``relevant executive branch agencies'' means the 
        Department of State, the United States Agency for 
        International Development, the Department of Health and 
        Human Services (including its agencies and offices), 
        and any other department or agency of the United States 
        that participates in international HIV/AIDS activities 
        pursuant to the authorities of such department or 
        agency or this Act.

           *       *       *       *       *       *       *


SEC. 104B. ASSISTANCE TO COMBAT TUBERCULOSIS.

    (a) Findings.--Congress makes the following findings:

           *       *       *       *       *       *       *

    [(b) Policy.--It is a major objective of the foreign 
assistance program of the United States to control 
tuberculosis, including the detection of at least 70 percent of 
the cases of infectious tuberculosis, and the cure of at least 
85 percent of the cases detected, not later than December 31, 
2005, in those countries classified by the World Health 
Organization as among the highest tuberculosis burden, and not 
later than December 31, 2010, in all countries in which the 
United States Agency for International Development has 
established development programs.]
  (b) Policy.--It is a major objective of the foreign 
assistance program of the United States to control 
tuberculosis. In all countries in which the Government of the 
United States has established development programs, 
particularly in countries with the highest burden of 
tuberculosis and other countries with high rates of 
tuberculosis, the United States Government should prioritize 
the achievement of the following goals by not later than 
December 31, 2015:
          (1) Reduce by half the tuberculosis death and disease 
        burden from the 1990 baseline.
          (2) Sustain or exceed the detection of at least 70 
        percent of sputum smear-positive cases of tuberculosis 
        and the cure of at least 85 percent of those cases 
        detected.

           *       *       *       *       *       *       *

    [(e) Priority to DOTS Coverage.--In furnishing assistance 
under subsection (c), the President shall give priority to 
activities that increase Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant 
tuberculosis where needed using DOTS-Plus, including funding 
for the Global Tuberculosis Drug Facility, the Stop 
Tuberculosis Partnership, and the Global Alliance for TB Drug 
Development. In order to meet the requirement of the preceding 
sentence, the President should ensure that not less than 75 
percent of the amount made available to carry out this section 
for a fiscal year should be expended for antituberculosis 
drugs, supplies, direct patient services, and training in 
diagnosis and treatment for Directly Observed Treatment Short-
course (DOTS) coverage and treatment of multi-drug resistant 
tuberculosis using DOTS-Plus, including substantially increased 
funding for the Global Tuberculosis Drug Facility.]
  (e) Priority To Stop TB Strategy.--In furnishing assistance 
under subsection (c), the President shall give priority to--
          (1) activities described in the Stop TB Strategy, 
        including expansion and enhancement of Directly 
        Observed Treatment Short-course (DOTS) coverage, rapid 
        testing, treatment for individuals infected with both 
        tuberculosis and HIV, and treatment for individuals 
        with multi-drug resistant tuberculosis (MDR-TB), 
        strengthening of health systems, use of the 
        International Standards for Tuberculosis Care by all 
        providers, empowering individuals with tuberculosis, 
        and enabling and promoting research to develop new 
        diagnostics, drugs, and vaccines, and program-based 
        operational research relating to tuberculosis; and
          (2) funding for the Global Tuberculosis Drug 
        Facility, the Stop Tuberculosis Partnership, and the 
        Global Alliance for TB Drug Development.
  (f) Assistance for the World Health Organization and the Stop 
Tuberculosis Partnership.--In carrying out this section, the 
President, acting through the Administrator of the United 
States Agency for International Development, is authorized to 
provide increased resources to the World Health Organization 
and the Stop Tuberculosis Partnership to improve the capacity 
of countries with high rates of tuberculosis and other affected 
countries to implement the Stop TB Strategy and specific 
strategies related to addressing multiple drug resistant 
tuberculosis (MDR-TB) and extensively drug resistant 
tuberculosis (XDR-TB).
    [(f)] (g) Definitions.--In this section:
          (1) DOTS.--The term ``DOTS'' or ``Directly Observed 
        Treatment Short-course'' means the World Health 
        Organization-recommended strategy for treating 
        tuberculosis[.] including
                  (A) low-cost and effective diagnosis, 
                treatment, and monitoring of tuberculosis;
                  (B) a reliable drug supply;
                  (C) a management strategy for public health 
                systems;
                  (D) health system strengthening;
                  (E) promotion of the use of the International 
                Standards for Tuberculosis Care by all care 
                providers;
                  (F) bacteriology under an external quality 
                assessment framework;
                  (G) short-course chemotherapy; and
                  (H) sound reporting and recording systems.
          (2) DOTS-plus.--The term ``DOTS-Plus'' means a 
        comprehensive tuberculosis management strategy that is 
        built upon and works as a supplement to the standard 
        DOTS strategy, and which takes into account specific 
        issues (such as use of second line anti-tuberculosis 
        drugs) that need to be addressed in areas where there 
        is high prevalence of multi-drug resistant 
        tuberculosis.
          (3) Global alliance for tuberculosis drug 
        development.--The term ``Global Alliance for 
        Tuberculosis Drug Development'' means the public-
        private partnership that brings together leaders in 
        health, science, philanthropy, and private industry to 
        devise new approaches to tuberculosis and to ensure 
        that new medications are available and affordable in 
        high tuberculosis burden countries and other affected 
        countries.
          (4) Global tuberculosis drug facility.--The term 
        ``Global Tuberculosis Drug Facility (GDF)'' means the 
        new initiative of the Stop Tuberculosis Partnership to 
        increase access to high-quality tuberculosis drugs to 
        facilitate DOTS expansion.
          (5) Stop tb strategy.--The term ``Stop TB Strategy'' 
        means the 6-point strategy to reduce tuberculosis 
        developed by the World Health Organization, which is 
        described in the Global Plan to Stop TB 2006-2015: 
        Actions for Life, a comprehensive plan developed by the 
        Stop TB Partnership that sets out the actions necessary 
        to achieve the millennium development goal of cutting 
        tuberculosis deaths and disease burden in half by 2015.
          [(5)] (6) Stop tuberculosis partnership.--The term 
        ``Stop Tuberculosis Partnership'' means the partnership 
        of the World Health Organization, donors including the 
        United States, high tuberculosis burden countries, 
        multilateral agencies, and nongovernmental and 
        technical agencies committed to short- and long-term 
        measures required to control and eventually eliminate 
        tuberculosis as a public health problem in the world.

           *       *       *       *       *       *       *


SEC. 104C. ASSISTANCE TO COMBAT MALARIA.

           *       *       *       *       *       *       *


    (b) Policy.--It is a major objective of the foreign 
assistance program of the United States to provide assistance 
for the prevention, control, treatment, and cure of malaria.

           *       *       *       *       *       *       *


Chapter 3--International Organizations and Programs

           *       *       *       *       *       *       *


    Sec. 302. Authorization.--(a) * * *

           *       *       *       *       *       *       *

    (c) None of the funds available to carry out this chapter 
shall be contributed to any international organization or to 
any foreign government or agency thereof to pay the costs of 
developing or operating any volunteer program of such 
organization, government, or agency relating to the selection, 
training, and programing of volunteer manpower.
  (d) Tuberculosis Vaccine Development Programs.--In addition 
to amounts otherwise available under this section, there are 
authorized to be appropriated to the President such sums as may 
be necessary for each of the fiscal years 2009 through 2013, 
which shall be used for United States contributions to 
tuberculosis vaccine development programs, which may include 
the Aeras Global TB Vaccine Foundation.

           *       *       *       *       *       *       *

    (k) In addition to amounts otherwise available under this 
section, there is authorized to be appropriated to the 
President such sums as may be necessary for each of the [fiscal 
years 2004 through 2008] fiscal years 2009 through 2013 to be 
available only for United States contributions to the Vaccine 
Fund.
    (l) In addition to amounts otherwise available under this 
section, there is authorized to be appropriated to the 
President such sums as may be necessary for each of the [fiscal 
years 2004 through 2008] fiscal years 2009 through 2013 to be 
available only for United States contributions to the 
International AIDS Vaccine Initiative.
    (m) In addition to amounts otherwise available under this 
section, there are authorized to be appropriated to the 
President such sums as may be necessary for each of the [fiscal 
years 2004 through 2008] fiscal years 2009 through 2013 to be 
available for United States contributions to malaria vaccine 
development programs, including the Malaria Vaccine Initiative 
of the Program for Appropriate Technologies in Health (PATH).

           *       *       *       *       *       *       *


The Public Health Service Act

           *       *       *       *       *       *       *



CHAPTER 6A--PUBLIC HEALTH SERVICE

           *       *       *       *       *       *       *



SUBCHAPTER II.--GENERAL POWERS AND DUTIES

           *       *       *       *       *       *       *



                  Part A. Research and Investigations


SEC. 307. INTERNATIONAL COOPERATION.

    [(a) Cooperative Endeavors; Statement of Purpose.--For the 
purpose of advancing the status of the health sciences in the 
United States (and thereby the health of the American people), 
the Secretary may participate with other countries in 
cooperative endeavors in biomedical research, healthcare 
technology, and the health services research and statistical 
activities authorized by section 306 of this title and by 
subchapter VII of this chapter.]
  (a) The Secretary may participate with other countries in 
cooperative endeavors in--
          (1) biomedical research, healthcare technology, and 
        the health services research and statistical analysis 
        authorized under section 306 and title IX; and
          (2) biomedical research, healthcare services, 
        healthcare research, or other related activities in 
        furtherance of the activities, objectives or goals 
        authorized under the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008.
    (b) Authority of Secretary; Building Construction 
Prohibition.--In connection with the cooperative endeavors 
authorized by subsection (a) of this section, the Secretary 
may--
          (1) make such use of resources offered by 
        participating foreign countries as he may find 
        necessary and appropriate;
          (2) establish and maintain fellowships in the United 
        States and in participating foreign countries;
          (3) make grants to public institutions or agencies 
        and to nonprofit private institutions or agencies in 
        the United States and in participating foreign 
        countries for the purpose of establishing and 
        maintaining the fellowships authorized by paragraph 
        (2);
          (4) make grants or loans of equipment and materials, 
        for use by public or nonprofit private institutions or 
        agencies, or by individuals, in participating foreign 
        countries;
          (5) participate and otherwise cooperate in any 
        international meetings, conferences, or other 
        activities concerned with biomedical research, health 
        services research, health statistics, or healthcare 
        technology;
          (6) facilitate the interchange between the United 
        States and participating foreign countries, and among 
        participating foreign countries, of research scientists 
        and experts who are engaged in experiments or programs 
        of biomedical research, health services research, 
        health statistical activities, or healthcare technology 
        activities, and in carrying out such purpose may pay 
        per diem compensation, subsistence, and travel for such 
        scientists and experts when away from their places of 
        residence at rates not to exceed those provided in 
        section 5703(b) of Title 5 for persons in the 
        Government service employed intermittently;
          (7) procure, in accordance with section 3109 of Title 
        5, the temporary or intermittent services of experts or 
        consultants; [and]
          (8) enter into contracts with individuals for the 
        provision of services (as defined in section 104 of 
        part 37 of title 48, Code of Federal Regulations (48 
        CFR 37.104)) in participating foreign countries, which 
        individuals may not be deemed employees of the United 
        States [for any purpose] for the purpose of any law 
        administered by the Office of Personnel Management;
          (9) provide such funds by advance or reimbursement to 
        the Secretary of State, as may be necessary, to pay the 
        costs of acquisition, lease, construction, alteration, 
        equipping, furnishing or management of facilities 
        outside of the United States; and
          (10) in consultation with the Secretary of State, 
        through grant or cooperative agreement, make funds 
        available to public or nonprofit private institutions 
        or agencies in foreign countries in which the Secretary 
        is participating in activities described under 
        subsection (a) to acquire, lease, construct, alter, or 
        renovate facilities in those countries.
[The Secretary may not, in the exercise of his authority under 
this section, provide financial assistance for the construction 
of any facility in any foreign country.]
    (c) Benefits for Overseas Assignees.--The Secretary may 
provide to personnel appointed or assigned by the Secretary to 
serve abroad, allowances and benefits similar to those provided 
under chapter 9 of title I of the Foreign Service Act of [1990] 
1980 (22 U.S.C. 4081 et seq.) or section 903 of the Foreign 
Service Act of 1980 (22 U.S.C. 4083) . Leaves of absence for 
personnel under this subsection shall be on the same basis as 
that provided under subchapter I of chapter 63 of Title 5 to 
individuals serving in the Foreign Service.

           *       *       *       *       *       *       *


Part B. Federal-State Cooperation

           *       *       *       *       *       *       *



SEC. 317S. GENERAL GRANT OF AUTHORITY FOR COOPERATION.

           *       *       *       *       *       *       *


SEC. 317T. MICROBICIDE RESEARCH.

  (a) In General.--The Director of the Centers for Disease 
Control and Prevention shall fully implement the Centers' 
microbicide agenda to support research and development of 
microbicides for use in developing countries to prevent the 
transmission of the human immunodeficiency virus.
  (b) Authorization of Appropriations.--There are authorized to 
be appropriated such sums as may be necessary for each of 
fiscal years 2009 through 2013 to carry out this section.

SUBCHAPTER III--NATIONAL RESEARCH INSTITUTES

           *       *       *       *       *       *       *



  Part C--Specific Provisions Respecting National Research Institutes


    SUBPART 6--NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES

SEC. 477. PURPOSE OF INSTITUTE

    The general purpose of the National Institute of Allergy 
and Infectious Diseases is the conduct and support of research, 
training, health information dissemination, and other programs 
with respect to allergic and immunologic diseases and disorders 
and infectious diseases, including tropical diseases.

           *       *       *       *       *       *       *


SEC. 447C. MICROBICIDE RESEARCH AND DEVELOPMENT.

  The Director of the Institute, acting through the head of the 
Division of AIDS, shall carry out research on, and development 
of, a microbicide for use in developing countries to prevent 
the transmission of the human immunodeficiency virus. The 
Director shall ensure that there are a sufficient number of 
employees and structure dedicated to carrying out such 
activities.

  SUBCHAPTER XXI--RESEARCH WITH RESPECT TO ACQUIRED IMMUNE DEFICIENCY 
                                SYNDROME


                    Part D--Office of AIDS Research


           SUBPART I--INTERAGENCY COORDINATION OF ACTIVITIES

SEC. 2351. ESTABLISHMENT OF OFFICE.

           *       *       *       *       *       *       *


SEC. 2351A. MICROBICIDE RESEARCH.

  (a) Federal Strategic Plan.--
          (1) In general.--The Director of the Office shall--
                  (A) expedite the implementation of the 
                Federal strategic plans for the conduct and 
                support of research on, and development of, a 
                microbicide for use in developing countries to 
                prevent the transmission of the human 
                immunodeficiency virus; and
                  (B) annually review and, as appropriate, 
                revise such plan to prioritize funding and 
                activities relative to their scientific urgency 
                and potential market readiness.
          (2) Coordination.--In implementing, reviewing, and 
        prioritizing elements of the plan described in 
        paragraph (1), the Director of the Office shall consult 
        with--
                  (A) representatives of other Federal agencies 
                involved in microbicide research, including the 
                Coordinator of United States Government 
                Activities to Combat HIV/AIDS Globally, the 
                Director of the Centers for Disease Control and 
                Prevention, and the Administrator of the United 
                States Agency for International Development;
                  (B) the microbicide research and development 
                community; and
                  (C) health advocates.
  (b) Authorization of Appropriations.--There are authorized to 
be appropriated such sums as may be necessary for each of the 
fiscal years 2009 through 2013 to carry out this section.

           *       *       *       *       *       *       *


The State Department Basic Authorities Act of 1956

           *       *       *       *       *       *       *



                  TITLE I--BASIC AUTHORITIES GENERALLY


                ORGANIZATION OF THE DEPARTMENT OF STATE

    Section 1.(a) Secretary of State.--* * *

           *       *       *       *       *       *       *

    (f) HIV/AIDS Response Coordinator.--
          (1) In general.--There shall be established within 
        the Department of State in the immediate office of the 
        Secretary of State a Coordinator of United States 
        Government Activities to Combat HIV/AIDS Globally, who 
        shall be appointed by the President, by and with the 
        advice and consent of the Senate. The Coordinator shall 
        report directly to the Secretary.
          (2) Authorities and duties; definitions.--
                  (A) Authorities.--The Coordinator, acting 
                through such nongovernmental organizations 
                (including faith-based and community-based 
                organizations), partner country finance, 
                health, and other relevant ministries, and 
                relevant executive branch agencies as may be 
                necessary and appropriate to effect the 
                purposes of this section, is authorized--
                          (i) to operate internationally to 
                        carry out prevention, care, treatment, 
                        support, capacity development, and 
                        other activities for combatting HIV/
                        AIDS;
                          (ii) to transfer and allocate funds 
                        to relevant executive branch agencies; 
                        and
                          (iii) to provide grants to, and enter 
                        into contracts with, nongovernmental 
                        organizations (including faith-based 
                        and community-based organizations), 
                        partner country finance, health, and 
                        other relevant ministries, to carry out 
                        the purposes of section.
                  (B) Duties.--
                          (i) In general.--The Coordinator 
                        shall have primary responsibility for 
                        the oversight and coordination of all 
                        resources and international activities 
                        of the United States Government to 
                        combat the HIV/AIDS pandemic, including 
                        all programs, projects, and activities 
                        of the United States Government 
                        relating to the HIV/AIDS pandemic under 
                        the United States Leadership Against 
                        HIV/AIDS, Tuberculosis, and Malaria Act 
                        of 2003 or any amendment made by that 
                        Act.
                          (ii) Specific duties.--The duties of 
                        the Coordinator shall specifically 
                        include the following:
                                  (I) Ensuring program and 
                                policy coordination among the 
                                relevant executive branch 
                                agencies and nongovernmental 
                                organizations, including 
                                auditing, monitoring, and 
                                evaluation of all such 
                                programs.
                                  (II) Ensuring that each 
                                relevant executive branch 
                                agency undertakes programs 
                                primarily in those areas where 
                                the agency has the greatest 
                                expertise, technical 
                                capabilities, and potential for 
                                success.
                                  (III) Avoiding duplication of 
                                effort.
                                  [(IV) Ensuring coordination 
                                of relevant executive branch 
                                agency activities in the field.
                                  [(V) Pursuing coordination 
                                with other countries and 
                                international organizations.]
                                  (IV) Establishing an 
                                interagency working group on 
                                HIV/AIDS headed by the Global 
                                AIDS Coordinator and comprised 
                                of representatives from the 
                                United States Agency for 
                                International Development and 
                                the Department of Health and 
                                Human Services, for the 
                                purposes of coordination of 
                                activities relating to HIV/
                                AIDS, including--
                                          (aa) meeting 
                                        regularly to review 
                                        progress in partner 
                                        countries toward HIV/
                                        AIDS prevention, 
                                        treatment, and care 
                                        objectives;
                                          (bb) participating in 
                                        the process of 
                                        identifying countries 
                                        to consider for 
                                        increased assistance 
                                        based on the 
                                        epidemiology of HIV/
                                        AIDS in those 
                                        countries, including 
                                        clear evidence of a 
                                        public health threat, 
                                        as well as government 
                                        commitment to address 
                                        the HIV/AIDS problem, 
                                        relative need, and 
                                        coordination and joint 
                                        planning with other 
                                        significant actors;
                                          (cc) assisting the 
                                        Coordinator in the 
                                        evaluation, execution, 
                                        and oversight of 
                                        country operational 
                                        plans;
                                          (dd) reviewing 
                                        policies that may be 
                                        obstacles to reaching 
                                        targets set forth for 
                                        HIV/AIDS prevention, 
                                        treatment, and care; 
                                        and
                                          (ee) consulting with 
                                        representatives from 
                                        additional relevant 
                                        agencies, including the 
                                        National Institutes of 
                                        Health, the Health 
                                        Resources and Services 
                                        Administration, the 
                                        Department of Labor, 
                                        the Department of 
                                        Agriculture, the 
                                        Millennium Challenge 
                                        Corporation, the Peace 
                                        Corps, and the 
                                        Department of Defense.
                                  (V) Coordinating overall 
                                United States HIV/AIDS policy 
                                and programs, including 
                                ensuring the coordination of 
                                relevant executive branch 
                                agency activities in the field, 
                                with efforts led by partner 
                                countries, and with the 
                                assistance provided by other 
                                relevant bilateral and 
                                multilateral aid agencies and 
                                other donor institutions to 
                                promote harmonization with 
                                other programs aimed at 
                                preventing and treating HIV/
                                AIDS and other health 
                                challenges, improving primary 
                                health, addressing food 
                                security, promoting education 
                                and development, and 
                                strengthening healthcare 
                                systems.
                                  (VI) Resolving policy, 
                                program, and funding disputes 
                                among the relevant executive 
                                branch agencies.
                                  (VII) Holding annual 
                                consultations with 
                                nongovernmental organizations 
                                in partner countries that 
                                provide services to improve 
                                health, and advocating on 
                                behalf of the individuals with 
                                HIV/AIDS and those at 
                                particular risk of contracting 
                                HIV/AIDS, including 
                                organizations with members who 
                                are living with HIV/AIDS.
                                  (VIII) Ensuring, through 
                                interagency and international 
                                coordination, that HIV/AIDS 
                                programs of the United States 
                                are coordinated with, and 
                                complementary to, the delivery 
                                of related global health, food 
                                security, development, and 
                                education.
                                  [(VII)] (IX) Directly 
                                approving all activities of the 
                                United States (including 
                                funding) relating to combatting 
                                HIV/AIDS in each of Botswana, 
                                Cote d'Ivoire, Ethiopia, 
                                Guyana, Haiti, Kenya, 
                                Mozambique, Namibia, Nigeria, 
                                Rwanda, South Africa, Tanzania, 
                                Uganda, Vietnam, Zambia, and 
                                other countries designated by 
                                the President, which other 
                                designated countries may 
                                include those countries in 
                                which the United States is 
                                implementing HIV/AIDS programs 
                                as of the date of the enactment 
                                of the United States Leadership 
                                Against HIV/AIDS, Tuberculosis, 
                                and Malaria Act of 2003 and 
                                other countries in which the 
                                United States is implementing 
                                HIV/AIDS programs as part of 
                                its foreign assistance program. 
                                In designating additional 
                                countries under this 
                                subparagraph, the President 
                                shall give priority to those 
                                countries in which there is a 
                                high prevalence or 
                                significantly rising incidence 
                                of HIV/AIDS, countries with 
                                large populations and 
                                inadequate health 
                                infrastructure, countries in 
                                which a concentrated HIV/AIDS 
                                epidemic could become 
                                generalized to the entire 
                                population of the country, and 
                                in countries whose governments 
                                demonstrate a commitment to 
                                combating HIV/AIDS.
                                  (X) Working with partner 
                                countries in which the HIV/AIDS 
                                epidemic is prevalent among 
                                injection drug users to 
                                establish, as a national 
                                priority, national HIV/AIDS 
                                prevention programs, including 
                                education and services 
                                demonstrated to be effective in 
                                reducing the transmission of 
                                HIV infection among injection 
                                drug users without increasing 
                                illicit drug use.
                                  (XI) Working with partner 
                                countries in which the HIV/AIDS 
                                epidemic is prevalent among 
                                individuals involved in 
                                commercial sex acts to 
                                establish, as a national 
                                priority, national prevention 
                                programs, including education, 
                                voluntary testing, and 
                                counseling, and referral 
                                systems that link HIV/AIDS 
                                programs with programs to 
                                eradicate trafficking in 
                                persons and support 
                                alternatives to prostitution.
                                  [(VIII)] (XII) Establishing 
                                due diligence criteria for all 
                                recipients of [funds section] 
                                funds appropriated for HIV/ 
                                AIDS assistance pursuant to the 
                                authorization of appropriations 
                                under section 401 of the United 
                                States Leadership Against HIV/
                                AIDS, Tuberculosis, and Malaria 
                                Act of 2003 (22 U.S.C. 7671) 
                                and all activities subject to 
                                the coordination and 
                                appropriate monitoring, 
                                evaluation, and audits carried 
                                out by the Coordinator 
                                necessary to assess the 
                                measurable outcomes of such 
                                activities.
                                  (XIII) Publicizing updated 
                                drug pricing data to inform the 
                                purchasing decisions of 
                                pharmaceutical procurement 
                                partners.

           *       *       *       *       *       *       *


The Immigration and Nationality Act

           *       *       *       *       *       *       *



The Immigration and Nationality Act, as Amended

           *       *       *       *       *       *       *



                          INADMISSIBLE ALIENS

    Sec. 212. (a) Except as otherwise provided in this Act, 
aliens who are inadmissible under the following paragraphs are 
ineligible to receive visas and ineligible to be admitted to 
the United States:
          (1) Health-related grounds.
                  (A) In general. Any alien--
                          (i) who is determined (in accordance 
                        with regulations prescribed by the 
                        Secretary of Health and Human Services) 
                        to have a communicable disease of 
                        public health significance, [which 
                        shall include infection with the 
                        etiologic agent for acquired immune 
                        deficiency syndrome,];

           *       *       *       *       *       *       *


                                  
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