The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)

Key Facts

  • Although the U.S. has been involved in efforts to address the global AIDS crisis since the mid-1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.
  • PEPFAR is the largest commitment by any nation to address a single disease in the world; to date, its funding has totaled more than $90 billion, including funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), to which the U.S. government is the largest donor. PEPFAR is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic.
  • First authorized in 2003, the program has been reauthorized three times: in 2008, 2013, and most recently in December 2018.
  • U.S. funding for PEPFAR was $6.78 billion in FY 2019, up from $2.19 billion in FY 2004; this includes contributions to the Global Fund.
  • While viewed as one of the most significant and successful global health initiatives ever undertaken, PEPFAR faces several issues and challenges, including how best to: accelerate progress toward epidemic control in the context of flat or potentially reduced budgets; support and strengthen country ownership and sustainability; address the needs of young women and adolescents, as well as key populations; and leverage partnerships with the public and private sectors.

Global Situation

HIV, the virus that causes AIDS (acquired immunodeficiency syndrome), has become one of the world’s most serious health and development challenges. Today, there are approximately 37.9 million people living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic (see the KFF fact sheet on the global HIV epidemic).1
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Box 1: Snapshot of Global Epidemic Today
  • Number of people living with HIV: 37.9 million
  • Number of people newly infected with HIV: 1.7 million
  • Number of AIDS-related deaths: 770,000
  • Number of people with HIV on treatment: 23.3 million
NOTES: Reflects 2018 data.

U.S. Government Efforts

Although the U.S. has been involved in efforts to address the global HIV/AIDS crisis since the mid-1980s,2 the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.3 PEPFAR, the U.S. government’s global effort to combat HIV and the largest global health program devoted to a single disease, is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic. It was announced in January 2003 during President George W. Bush’s State of the Union and authorized by Congress that same year through the Leadership Act (see Table 1).The Leadership Act governs PEPFAR’s HIV response, as well as U.S. participation in the Global Fund (an independent, international multilateral financing institution that provides grants to countries to address HIV, TB, and malaria) and bilateral assistance for TB and malaria programs.4 Congress has updated, extended, and made changes to the program through the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, and the PEPFAR Extension Act of 2018, which goes through FY 2023. See Table 1 (see KFF brief on PEPFAR reauthorization).

Table 1: PEPFAR Legislation
Full Title Authorization Level Public Law # Years
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003
“The Leadership Act”
$15 billion P.L. 108-25 FY04–FY08
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008
“The Lantos-Hyde Act”
$48 billion P.L. 110-293 FY09–FY13
PEPFAR Stewardship and Oversight Act of 2013
“The PEPFAR Stewardship Act”
Did not specify authorization for funding* P.L. 113-56 FY14–FY18
PEPFAR Extension Act of 2018
“The PEPFAR Extension Act”
Did not specify authorization for funding* P.L. 115-305 FY19–FY23
NOTES: * Congress effectively authorizes funding when it appropriates funding for a purpose. See the KFF brief on PEPFAR Reauthorization, https://www.kff.org/global-health-policy/issue-brief/pepfar-reauthorization-side-by-side-of-existing-legislation/.

Organization

PEPFAR’s original authorization established new structures and authorities, consolidating all U.S. bilateral and multilateral activities and funding for global HIV/AIDS. Several U.S. agencies, host country governments, and other organizations are involved in implementation.5

PEPFAR is overseen by the U.S. Global AIDS Coordinator, who is appointed by the President, confirmed by the Senate, and reports directly to the Secretary of State, as established through PEPFAR’s authorizing legislation.6 The Coordinator, presently Deborah Birx, holds the rank of Ambassador and leads the Office of the Global AIDS Coordinator (OGAC) at the Department of State. Currently the Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy.7 The Coordinator has primary responsibility for the oversight and coordination of all U.S. global HIV activities and funding across multiple U.S. implementing agencies and departments. In addition, the Coordinator serves as the U.S. Government’s board member to the Global Fund (the U.S. Government holds a permanent seat on the Global Fund’s Board).

In addition to the Department of State, other implementing departments and agencies for HIV activities include: the U.S. Agency for International Development (USAID); the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH); the Departments of Labor, Commerce, and Defense (DoD); and the Peace Corps.8

Strategy

PEPFAR is currently guided by two main strategies: the overarching strategy laid out in PEPFAR 3.0 – Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation and a complementary, more targeted strategy for accelerating implementation of PEPFAR efforts in certain high-burden countries laid out in The PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020). PEPFAR 3.0 focuses on achieving epidemic control (defined by the program to be reached when the total number of new HIV infections falls below the total number of deaths from all causes among people with HIV) of the global HIV epidemic through a focus on transparency, accountability, and impact.9 It also sets five core priorities for the program:

  1. Focusing on adolescent girls and women, with an emphasis on creating gender equity;
  2. Improving the lives of children living with and affected by HIV/AIDS;
  3. Addressing the needs of key populations, with an emphasis on ensuring human rights and leaving no one behind;
  4. Using data for impact in order to accelerate progress; and
  5. Leveraging partnerships to enhance sustainability of PEPFAR and other global HIV efforts.10

PEPFAR’s 2017-2020 strategy outlines its plan to accelerate implementation in a subset of 13 PEPFAR countries that, according to PEPFAR data, show the greatest potential to achieve epidemic control by 2020: Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe.11 The strategy emphasizes accelerating testing and treatment strategies, expanding prevention, using quality data, engaging with faith-based organizations and the private sector, and strengthening policy and financial contributions by partner countries.12 It is also intended to align with the UNAIDS 90-90-90 targets.13

Key Activities and Results

PEPFAR activities focus on expanding access to HIV prevention, treatment, and care interventions. These include provision of antiretroviral treatment, pre-exposure prophylaxis, voluntary male circumcision, and condoms (see Table 2).14 In addition, PEPFAR has launched specific initiatives in key strategic areas. For example, in 2015, PEPFAR launched DREAMS, a public-private partnership that aims to reduce HIV infections in adolescent girls and young women.

The latest results reported by PEPFAR indicate that it has, as of September 2018:

  • supported testing services for nearly 95 million people;
  • prevented more than 2.4 million babies from being born with HIV, who would have otherwise been infected;
  • provided care for more than 6.8 million orphans and vulnerable children (OVC);
  • supported training for more than 270,000 new health care workers; and
  • supported antiretroviral treatment for more than 14.6 million people.15
Table 2: Key PEPFAR-Funded HIV Interventions
Prevention Treatment & Care Other Activities
  • Blood supply safety
  • Injection safety
  • Prevention of mother-to-children transmission (PMTCT) of HIV
  • Risk reduction for youth, including sexual violence prevention
  • Sexual prevention programs, including condoms, contraceptive counseling, and pre-exposure prophylaxis (PrEP)
  • Harm reduction efforts for injecting drug users (IDUs) and non-injecting drug use
  • Voluntary medical male circumcision (VMMC)
  • Antiretroviral (ARV) drugs for adults and children
  • Care and support for adults and children living with HIV
  • HIV testing services
  • TB screening and TB preventative therapy for people living with HIV

 

 

 

  • Support for orphans and vulnerable children (OVC)
  • Health systems strengthening (health workforce, strategic information systems, laboratory infrastructure)

 

 

 

 

 

 

The latest results from the DREAMS initiative show declines in new HIV diagnoses among adolescent girls and young women in 85% of the highest HIV burden districts in the 15 African countries implementing DREAMS.16

Countries Reached

PEPFAR bilateral programs span more than 50 countries (see Figure 1).17 More countries are reached through U.S. contributions to the Global Fund.

Figure 1: U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) Countries

Most PEPFAR bilateral funding is concentrated in 31 countries, which receive at least $5 million in funding annually.18 These 31 countries19 and the Asia, Caribbean, Central America, and Central Asia regional programs are required to develop “Country Operational Plans” (COPs) and “Regional Operational Plans” (ROPs), respectively, to document annual investments and anticipated results.20 OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.

Funding21

Total PEPFAR funding22 includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS.23 It represents the majority of U.S. global health funding (62% in FY 2019, or $6.8 billion24) and is the largest commitment by any nation to address a single disease in the world. To date, PEPFAR funding has totaled more than $90 billion.

PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for HIV. Bilateral HIV funding, which accounts for the majority of PEPFAR funding (averaging approximately 80% each year), rose rapidly from $1.1 billion in FY 2003 (the year before PEPFAR) to a peak of $5.57 billion in FY 2010. Between FY 2010 and FY 2013, it declined by more than $800 million. While it has risen since then, it is still $147 million below its peak level and has been mostly flat for the past several years. Funding for the Global Fund also increased rapidly, rising from $347 million in FY 2003 (the year before PEPFAR) to a peak level of $1.65 billion in FY 2014 before declining to $1.35 billion in FY 2015 where it has remained for the past several years.25

Of the approximately $6.78 billion appropriated for PEPFAR in FY 2019:

  • $5.43 billion (80%) is for bilateral HIV and $1.35 billion (20%) for the Global Fund.26
  • The majority of PEPFAR funding is channeled by Congress to the State Department ($5.72 billion, which includes $4.37 billion for bilateral HIV, most of which is then transferred to other agencies, and a $1.35 billion contribution to the Global Fund), followed by NIH ($590 million), USAID ($330.2 million), CDC ($128.4 million), and a small amount to DoD ($8 million).
  • As in the past two years, the current Administration has proposed significantly reduced PEPFAR funding in FY 2020 ($4.89 billion) (see KFF fact sheets on the U.S. Global Health Budget: HIV/PEPFAR and the U.S. Global Health Budget: The Global Fund). Congress has thus far rejected proposed spending cuts.

Figure 2: U.S. Funding for the President’s Emergency Plan for AIDS Relief (PEPFAR), FY 2004 – FY 2020 Request

Spending Directives27

PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:

  1. The Leadership Act, PEPFAR’s original authorization, included the following spending directives: 55% of funds were to be spent on treatment; 15% on palliative care; 20% on prevention, of which at least 33% be spent on abstinence-until-marriage programs; and 10% on OVC. While these were included as “sense of Congress” recommendations, the treatment, OVC, and abstinence-until-marriage earmarks were made requirements as of FY 2006.
  2. The Lantos-Hyde Act relaxed some of these directives for the FY 2009 – FY 2013 period: while still requiring that 10% of funds be spent on programs targeting OVC, it changed the treatment earmark from 55% to requiring that at least half of bilateral HIV assistance be spent on treatment and care. It removed the 33% abstinence-until-marriage directive and replaced it with a requirement of “balanced funding” for prevention to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized (high prevalence) epidemic.
  3. The PEPFAR Stewardship Act and The PEPFAR Extension Act have maintained the language in the Lantos-Hyde Act.

PEPFAR & The Global Fund

The U.S. is the single largest donor to the Global Fund. Congressional appropriations to the Global Fund totaled nearly $18 billion from FY 2001 through FY 2019.28 The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV.29 To date, over 150 countries have received Global Fund grants; 53% of Global Fund support has been committed to HIV and HIV/TB programs,30 29% to malaria, 16% to TB, and 2% to other health issues.31 The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions;32 this requirement is in effect through FY 2023 (see fact sheet).33

Key Issues for the U.S.

The U.S. government is the largest donor to international HIV efforts in the world, including the largest donor to the Global Fund,34 and PEPFAR is viewed as one of the most significant and successful global health initiatives ever undertaken. Looking ahead, there are several issues and challenges facing PEPFAR, starting with questions about the extent to which the current Administration will continue to support PEPFAR’s ongoing efforts, particularly in light of its budget proposal to significantly reduce bilateral HIV funding and U.S. contributions to the Global Fund. Other issues and challenges include:  

  • maintaining a focus on sustainable country-led efforts that emphasizes greater country financing of HIV responses over time;
  • continuing to expand access to HIV services;
  • meeting the needs of key populations;
  • targeting PEPFAR funding based on data-driven analyses of how the epidemic is unfolding, in order to inform the right balance among HIV prevention, treatment, and care;
  • supporting research and development efforts to advance new drugs and interventions;
  • ensuring synergies with other U.S. global health and development programs; and
  • closely coordinating efforts with other donors, including the Global Fund, which will have its next replenishment in 2019.
Endnotes
  1. UNAIDS. Global AIDS Update 2019: Communities at the Centre; July 2019.

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  2. The U.S. first provided funding to address the global HIV epidemic in 1986. Then, in 1999, President Bill Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to address HIV in 14 African countries and in India. Later, in 2002, President George W. Bush announced the International Mother and Child HIV Prevention Initiative focused on 12 African and two Caribbean countries.

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  3. PEPFAR. 2009 Annual Report to Congress; Jan. 2009. KFF. The U.S. Government Engagement in Global Health: A Primer; Feb. 2019.

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  4. U.S. Congress. P.L. 108-25; May 27, 2003.

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  5. KFF. The U.S. Government Engagement in Global Health: A Primer; Feb. 2019. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009.

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  6. U.S. Congress. Public Law No: 108-25; May 27, 2003.

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  7. PEPFAR. “About OGAC,” webpage, https://www.pepfar.gov/about/ogac/.

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  8. KFF. The U.S. Government Engagement in Global Health: A Primer; Feb. 2019. PEPFAR. “About Us,” webpage, https://www.pepfar.gov/about/270968.htm.

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  9. PEPFAR. “Strategy,” webpage, https://www.pepfar.gov/about/strategy/index.htm.

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  10. PEPFAR. “Strategy,” webpage, https://www.pepfar.gov/about/strategy/index.htm. PEPFAR. “Our Priorities,” webpage, https://www.pepfar.gov/priorities/index.htm.

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  11. PEPFAR. Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); Sept. 2017. In 2016, PEPFAR reported that evidence had shown that, in large part due to PEPFAR support, five African countries were approaching control of their HIV epidemics; these five countries were Eswatini (formerly known as Swaziland), Lesotho, Malawi, Zambia, and Zimbabwe. These and other countries that showed the potential to achieve epidemic control by 2020 were then included in the 2017-2020 strategy for accelerating PEPFAR efforts toward control. PEPFAR. Fact Sheet: PEPFAR Latest Global Results, 2016. PEPFAR. “Five African Countries Approach Control of Their HIV Epidemics as U.S. Government Launches Bold Strategy to Accelerate Progress,” press release; Sept. 2017.

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  12. PEPFAR. PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); Sept. 2017.

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  13. The 90-90-90 targets were set in 2014 and aim to achieve, by 2020, “90% of people living with HIV knowing their HIV status; 90% of people who know their HIV-positive status on treatment; and 90% of people on treatment with suppressed viral loads.” UNAIDS. Fast-Track: ending the AIDS epidemic by 2030; 2014. See also United Nations. Transforming our world: the 2030 Agenda for Sustainable Development; 2015, which discusses the Sustainable Development Goals (SDGs) adopted in 2015 and include a target aiming to end the AIDS epidemic by 2030 under SDG Goal 3 (“ensure healthy lives and promote well-being for all at all ages”).

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  14. Table 2 categorization is based on PEPFAR’s COP Guidance budget codes. PEFPAR. PEFPAR 2018 Country Operational Plan Guidance for Standard Process Countries.

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  15. PEPFAR. Fact Sheet: PEPFAR Latest Global Results; November 2018.

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  16. The 15 African countries implementing DREAMS are Botswana, Cote d’Ivoire, Eswatini, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. PEPFAR. Fact Sheet: PEPFAR Latest Global Results; November 2018. PEPFAR, Dreaming of an AIDS-Free Future, Nov. 2018.

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  17. KFF analysis of data from congressional budget justification documents; PEPFAR FY 2018 Country Operational Plans webpage, https://www.pepfar.gov/countries/cop/fy2018/index.htm; PEPFAR 2018 Country Operational Plan Guidance for Standard Process Countries; 2018 PEPFAR Progress Report on the PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020); and CDC’s “Where We Work” webpage, https://www.cdc.gov/globalhivtb/where-we-work/index.html. PEPFAR. Press release, “Secretary Pompeo Announces Latest Lifesaving PEPFAR Results,” November 27, 2018.

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  18. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication. These countries are Angola, Botswana, Burma, Burundi, Cambodia, Cameroon, Côte d’Ivoire, the Democratic Republic of the Congo, the Dominican Republic, Eswatini (formerly known as Swaziland), Ethiopia, Ghana, Haiti, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Papua New Guinea, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.

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  19. Of these 31 countries, 14 were “focus countries” targeted in PEPFAR’s first phase: Botswana, Cote d’Ivoire, Ethiopia, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. Guyana, the 15th initial PEPFAR focus country, is now supported through a PEPFAR regional program. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication; PEPFAR. 2009 Annual Report to Congress; Jan. 2009; and PEPFAR. Where We Work, webpage, https://www.pepfar.gov/countries/index.htm.

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  20. PEPFAR. PEPFAR Country/Regional Operational Plan (COP/ROP) 2018 Guidance for Standard Process Countries; Jan. 2018.

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  21. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  22. While overall PEPFAR funding technically includes bilateral funding for HIV, TB, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, this analysis focuses on funding for bilateral HIV and the Global Fund.

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  23. UNAIDS is the Joint United Nations Programme on HIV/AIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS.

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  24. Includes bilateral funding for HIV as well as U.S. contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

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  25. U.S. Congress. Public Law No: 112-25; Aug. 2, 2011. White House Office of Management and Budget (OMB). OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013; March 1, 2013. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  26. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  27. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 115-305; Dec. 11, 2018.

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  28. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; Office of Management and Budget, personal communication.

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  29. Congress states that the Global Fund is the multilateral component of PEPFAR in the following: U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013.

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  30. Of the 53% committed to HIV and HIV/TB programs, 48% was for HIV activities and 5% was for HIV/TB activities.

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  31. The Global Fund. Data Explorer; accessed July 2019: https://data.theglobalfund.org/home.

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  32. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. KFF. PEPFAR Reauthorization, brief.

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  33. See the KFF. The U.S. & The Global Fund to Fight AIDS, TB and Malaria, fact sheet; and KFF. PEPFAR Reauthorization, brief.

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  34. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. Totals include funding for HIV and the Global Fund. KFF/UNAIDS. Donor Government Funding for HIV in Low- and Middle-Income Countries in 2018; July 2019.

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