	Introduction

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria are three of the world's leading causes of morbidity and mortality. In FY2012, of the $8.8 billion the United States spent on global health programs under the Global Health Initiative (GHI)—the Obama Administration's effort to coordinate and improve U.S. global health programming—approximately 84% was on bilateral and multilateral HIV/AIDS, TB, and malaria combined, with bilateral HIV/AIDS programs accounting for 58% of all funding. The United States is currently the single largest donor for global HIV/AIDS and has played a key role in generating a robust international response to TB and malaria. This report highlights some of the current challenges posed by HIV/AIDS, TB, and malaria, as well as several cross-cutting policy issues that the 112 th Congress may consider as it determines U.S. global health funding for these three diseases, including
health systems strengthening, country ownership, research and development, monitoring and evaluation, and engagement with multilateral organizations. U.S. Policy Background

U.S. efforts to address HIV/AIDS, TB, and malaria have grown significantly over the last few decades, as successive Administrations and Congresses have increasingly recognized the severity and impact of these diseases. Bush Administration

The George W. Bush Administration greatly elevated the fight against HIV/AIDS, TB, and malaria in the U.S. foreign policy agenda. In 2003, the Bush Administration announced the establishment of the President's Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion over the course of five years to combat HIV/AIDS, TB, and malaria. Trends in Funding for HIV/AIDS, TB, and Malaria: FY2001-FY2012

Over the past decade, Congress has demonstrated significant support for U.S. programs targeting global HIV/AIDS, TB, and malaria. FY2012 funding for HIV/AIDS, TB, and malaria programs together was slightly lower than in FY2011, and included a decrease in funding for global HIV/AIDS programs, slight increases in funding for global TB and malaria programs, and a larger increase in funding for the U.S. contribution to the Global Fund. Some health experts have expressed concern over the leveling of global health funding, particularly for HIV/AIDS, over the past few years. These experts argue that divestment in U.S. global HIV/AIDS and TB programs could imperil lives, reverse recent progress, undermine significant scientific findings, and lead to decreasing levels of support from other donors. Progress in global TB control is also challenged by HIV/TB co-infection and new forms of drug resistant TB. Despite these common factors, each disease presents unique challenges, which Congress may consider as it debates the U.S. response to each disease. For more information on the particular characteristics of and U.S. response to each of the diseases, see the following CRS reports by Alexandra Kendall: CRS Report R41645, U.S. Response to the Global Threat of HIV/AIDS: Basic Facts ; CRS Report R41643, U.S. Response to the Global Threat of Tuberculosis: Basic Facts ; and CRS Report R41644, U.S. Response to the Global Threat of Malaria: Basic Facts . Treatment has been a central component of PEPFAR programs. Despite this commitment, many health experts call for increased U.S. support of HIV/AIDS prevention efforts in general, and efforts targeting high-risk groups in particular. Key Cross-Cutting Issues

Along with the challenges specific to HIV/AIDS, TB, and malaria, a number of issues extend to all three diseases. Looking Forward

The second session of the 112 th Congress will likely exercise oversight of and debate the appropriate funding amounts for global HIV/AIDS, TB, and malaria programs and priority areas within these programs. U.S. Malaria Strategy Targets
GHI goals and projected targets for U.S. malaria programs are:
to achieve Africa-wide impact, by halving the burden of malaria (morbidity and mortality) in 70% of at-risk populations in sub-Saharan Africa (approximately 450 million people), thereby removing malaria as a major public health problem and promoting economic growth and development throughout the region; to limit the spread of anti-malaria multi-drug resistance in Southeast Asia and the Americas; to increase emphasis on strategic integration of malaria prevention and treatment activities with maternal and child health, HIV/AIDS, neglected tropical diseases, and tuberculosis programs, and on multilateral collaboration to achieve internationally accepted goals; to intensify present efforts to strengthen health systems and strengthen the capacity of host-country workforces to ensure sustainability; to assist host countries to revise and update their National Malaria Control Strategies and Plans to reflect the declining burden of malaria, and link programming of U.S. malaria control resources to those host country strategies; and to ensure a woman-centered approach for malaria prevention and treatment activities at both the community and health facility levels, since women are the primary caretakers of young children in most families and are in the best position to help promote health behaviors related to malaria.
The spread of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria across the world poses a major global health challenge. The international community has progressively recognized the humanitarian impact of these diseases, along with the threat they represent to economic development and international security. The United States has historically been a leader in the fight against HIV/AIDS, TB, and malaria; it is currently the largest single donor for global HIV/AIDS and has been central to the global response to TB and malaria. In its second session, the 112th Congress will likely consider HIV/AIDS, TB, and malaria programs during debate on and review of U.S.-supported global health programs, U.S. foreign assistance spending levels, and foreign relations authorization bills.
Over the past decade, Congress has demonstrated bipartisan support for addressing HIV/AIDS, TB, and malaria worldwide, authorizing approximately $54 billion for U.S. global efforts to combat the diseases from FY2001 through FY2012. During this time, Congress supported initiatives proposed by President George W. Bush, including the President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI), both of which have demonstrated robust U.S. engagement in global health. Through the Global Health Initiative (GHI), President Barack Obama has led efforts to coordinate U.S. global HIV/AIDS, TB, and malaria programs and create an efficient, long-term, and sustainable approach to combating these diseases.
Despite ongoing progress in fighting HIV/AIDS, TB, and malaria, these diseases remain leading global causes of morbidity and mortality. Many health experts urge Congress to capitalize on recent gains and bolster U.S. leadership and funding to combat these diseases. In contrast, some Members of Congress have proposed cuts to these programs as part of deficit reduction efforts.
This report reviews the U.S. response to HIV/AIDS, TB, and malaria and discusses several issues Congress may consider as it debates spending levels and priority areas for related programs. The report includes analysis of:
Funding Trends: Combined funding for the three diseases has increased significantly over the past decade, from approximately $911 million in FY2001 to $7.4 billion in FY2012. The bulk of the increase over time has been targeted toward HIV/AIDS, although in recent years funding for global HIV/AIDS has begun to level off. When compared to FY2011, funding in FY2012 included decreases for global HIV/AIDS, and slight increases for global TB and malaria programs. Some health experts applaud what they see as a shift toward less expensive efforts that maximize health impact. Other experts warn that divestment from HIV/AIDS could significantly endanger the lives of those reliant on U.S. assistance and could reverse fragile gains made against the epidemic and other diseases. Disease-Specific Issues: HIV/AIDS, TB, and malaria each present unique challenges. Rising numbers of people in need of life-long HIV/AIDS treatment combined with reduced global HIV/AIDS funding have heightened concerns over the sustainability of treatment programs and incited debate over the appropriate balance of funding between antiretroviral treatment (ART) and other HIV/AIDS interventions. Growing rates of HIV/TB co-infection and drug-resistant TB strains have increased calls for escalating TB control efforts. Finally, growing resistance to anti-malaria drugs and insecticides threatens malaria control efforts, leading to calls for more attention to reducing resistance and developing new anti-malaria commodities. Cross-Cutting Issues: Several cross-cutting issues are currently being debated, particularly in relation to increased efficiency and sustainability of HIV/AIDS, TB, and malaria programs under the GHI. These include Health Systems Strengthening, Country Ownership in Recipient Countries, Research and Development, Monitoring and Evaluation, and Engagement with Multilateral Organizations.
For details on particular characteristics of the HIV/AIDS, TB, and malaria epidemics and the U.S. response, see the following CRS reports, by [author name scrubbed].
CRS Report R41645, U.S. Response to the Global Threat of HIV/AIDS: Basic Facts CRS Report R41643, U.S. Response to the Global Threat of Tuberculosis: Basic Facts CRS Report R41644, U.S. Response to the Global Threat of Malaria: Basic Facts