The President’s Emergency Plan for AIDS Relief (PEPFAR): Funding Issues After a Decade of Implementation, FY2004-FY2013

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TiajiSalaam-Blyther
Specialist in Global Health

ThePresident’s Emergency Plan for AIDS Relief (PEPFAR) is the largest bilateralhealth initiative in the world. The 2003 pledge of President George W.Bush to spend $15 billion over five years on fighting HIV/AIDS,tuberculosis (TB), and malaria was considered groundbreaking. Theinitiative challenged the international community to reject claims thatlarge-scale HIV/AIDS treatment plans could not be carried out inlow-resource settings. In December 2002, one month before PEPFAR wasannounced, only 50,000 people of the estimated 4 million requiringantiretroviral (ARV) medicines in sub-Saharan Africa were receivingtreatment. By the end of FY2004, 155,000 people were receiving treatmentthrough PEPFAR.

As of March 2012, PEPFAR has supported

• the provision of anti-retroviral therapy (ART) for more than 4.5 millionpeople (up from 155,000 in 2005);
• testing and counseling for more than 40 million people, including 9.8 million pregnantwomen;
• prevention of mother-to-child HIV transmission (PMTCT) services for more than 660,000HIV-positive pregnant women, curbing some 200,000 HIV infections amonginfants; and
• care and support for more than 13 million people, including more than 4million orphans and vulnerable children (OVC).

Congress first authorized funds in support of PEPFAR in 2003 through P.L.108-25, the U.S. Leadership Against HIV/AIDS, Tuberculosis, and MalariaAct (Leadership Act). The $15 billion authorization was to be spent onglobal HIV/AIDS, TB, and malaria programs from FY2004 through FY2008.Strong bipartisan support for PEPFAR in particular and global health in general ledto annual appropriations amounts that exceeded authorized levels. During thefirst phase of PEPFAR (FY2004-FY2008), the Bush Administration spent $18.1billion on global HIV/AIDS programs.

As the expiration date of the Leadership Act approached, congressional supportfor PEPFAR remained enthusiastic. Members debated a range of issues (seeCRS Report RL34569, PEPFAR Reauthorization: Key Policy Debates andChanges to U.S. International HIV/AIDS, Tuberculosis, and Malaria Programsand Funding), but ultimately authorized an extension of PEPFAR. The TomLantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis,and Malaria Reauthorization Act of 2008 (P.L. 110-293, Lantos-Hyde Act) authorized$48 billion to be appropriated from FY2009 through FY2013 for combating thethree diseases. From FY2009 through FY2012, the Obama Administrationobligated nearly $26 billion on global HIV/AIDS programs.

As the September 30, 2013, expiration date for the authorization of the Lantos-HydeAct approaches, it is unclear whether Congress will again authorizemultiyear funding for PEPFAR. Bipartisan support for PEPFAR remainsstrong; nonetheless, congressional debate about key elements of theprogram has raised some concerns. For example, some Members question the extentto which family planning programs are integrated into global HIV/AIDSactivities. At the same time, growing unease about the federal budgetdeficit minimizes the likelihood that past trends of ever-increasingappropriations for global HIV/AIDS programs will be sustained.


Date of Report: October 10, 2012
Number of Pages: 17
Order Number: R42776
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