	Introduction

It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million people each year. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), at the end of 2007, an estimated 33.2 million people were living with HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the course of that year. More than 2 million of those living with HIV/AIDS at the end of 2007 were children, and some 290,000 of those who died of AIDS that year were under 15 years old. On each day of 2007, some 1,000 children worldwide became newly infected with HIV, due in large part to little access to drugs that prevent the transmission of HIV from mother to child. An estimated 9% of pregnant women in low- and middle-income countries were offered services to prevent HIV transmission to their newborns. While HIV/AIDS, TB, and malaria are preventable diseases, their impacts have been catastrophic, particularly in sub-Saharan Africa. From FY2004 through FY2008, Congress provided almost $20 billion to fight the global spread of HIV/AIDS, TB, and malaria, of which $18.3 billion was appropriated for global HIV/AIDS programs and the Global Fund ( Table 2 ). Congress exceeded the President's request by some $570 million, providing $6.3 billion for global HIV/AIDS, TB, and malaria efforts, including $5.8 billion for global HIV/AIDS programs and a U.S. contribution to the Global Fund. Meanwhile, U.S. agencies and departments implement additional international HIV/AIDS, TB, and malaria programs not funded through PEPFAR. In 2003, about 1,000 volunteers worked on HIV/AIDS programs, and in 2004, about 3,100 volunteers engaged in HIV/AIDS activities. Still other HIV/AIDS analysts suggest that health infrastructure challenges and health worker shortages in many countries will have to be resolved if the United States is to combat effectively the global spread of HIV/AIDS. The section below analyzes some of the key issues that Congress might consider as it debates PEPFAR reauthorization. Some question whether U.S. contributions to the Fund are provided at the expense of U.S. bilateral HIV/AIDS programs. OGAC estimates that in FY2006, it allocated 9% of all spending on ARVs to children. The bill authorizes funds to improve health care capacity on the continent. Supporters of this idea argue that vaccine identification should be an intractable part of U.S. international HIV/AIDS assistance.
It is estimated that HIV/AIDS, TB, and malaria together kill more than 6 million people each year. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), at the end of 2007, an estimated 33.2 million people were living with HIV/AIDS, of whom 2.5 million were newly infected, and 2.1 million died in the course of that year. More than 2 million of those living with HIV/AIDS at the end of 2007 were children, and some 290,000 of those who died of AIDS that year were under 15 years old. On each day of 2007, some 1,000 children worldwide became newly infected with HIV, due in large part to little access to drugs that prevent the transmission of HIV from mother to child. An estimated 9% of pregnant women in low- and middle-income countries were offered services to prevent HIV transmission to their newborns.
UNAIDS asserts that an effective fight against the global spread of HIV/AIDS would cost $15 billion in 2006, $18 billion in 2007, and $22 billion in 2008. In FY2006, Congress provided about $3.1 billion for international HIV/AIDS programs and U.S. contributions to the Global Fund to Fight HIV/AIDS, TB, and Malaria, $4.3 billion in FY2007, and $5.7 billion in FY2008. Most recent statistics indicate that in 2005, some $8.3 billion was spent on HIV/AIDS globally, though UNAIDS estimated that $11.6 billion was needed. About $4.3 billion of those funds were provided by donor governments. The Kaiser Family Foundation asserts that in 2005, the United States provided the largest percentage of HIV/AIDS assistance in the world, comprising some 49% of all donor spending.
Although the United States is the leading provider of international HIV/AIDS assistance, some argue that it needs to give more, particularly to the Global Fund. Critics of increased AIDS spending, however, question whether the most affected region—sub-Saharan Africa—can absorb increased revenue flows. Some also contend that additional HIV/AIDS allocations will yield limited results, as poor health care systems and health worker shortages complicate efforts to scale up HIV/AIDS spending. While this report describes how HIV/AIDS, TB, and malaria are interlinked and exacerbate efforts to control each disease, it primarily addresses funding issues related to U.S. global HIV/AIDS initiatives. It provides background information on the key U.S. agencies that implement global HIV/AIDS programs, analyzes U.S. spending on HIV/AIDS by U.S. agency and department, and presents some issues Congress might consider, particularly as debate on PEPFAR reauthorization ensues. This report will not be updated; PEPFAR authorization expires in FY2008. Subsequent reports will analyze additional funding should the initiative be reauthorized.