Comparison of House and Senate PEPFAR Legislation and Suggested Changes Developed by Health GAP, 3/24/08 Download this as a     PDF Click below to be taken directly to a section Treatment Targets | Opportunistic Infection Drugs | WHO Treatment Guidelines | Microbicides Development    Prostitution Pledge | Funding | Medicines Pricing | Equipment and SCMS | Training New Health Professionals HIV Travel/Immigration Ban | IMF | Abstinence and Prevention | Family Planning | Women and Girls Treatment Targets Current Law: Treat 2 million people by the end of 2008. Currently, the US Supports treatment for 1.4 million, inlcuding a large percentage of those whose treatment is primarily or entirely due to the Global Fund House Bill (HR 5501): Support treatment for 3 million individuals, with a goal of treating 450,000 orphans (pg. 51, lines 18-20). Calls for treatment of one-third of people in clinical need in the “poorest countries”, including funding for free medication to treat opportunistic infections (pg. 59, lines 5-11) Senate Bill (S 2773): Support treatment for three million people (pg 14, lines 16-19, page 59) “plus additional treatment through coordinated multilateral efforts,” meaning: 3 million plus people treated by the Global Fund, rather than current practice, which is to include large percentages of the people the GFATM supports on treatment. Suggested Changes: Retain Senate treatment targets. Retain House “soft target” language to treat one third of those in clinical need Opportunistic Infection Drugs Current Law: No language on funding for free opportunistic infection medication House Bill: Supports free OI drugs Senate Bill: Calls for funding for free or “easily affordable” opportunistic infections medication (pg. 67, lines 6-11) Suggested Changes: Retain House language WHO treatment guidelines for antiretroviral therapy (to help increase access to new, more powerful medicines in countries currently using substandard therapy) Current Law: Not in 2003 legislation House Bill: Not in House Bill Senate Bill: Not in Senate Bill Suggested Changes: Amendment needed which calls for ARV therapy “in concordance with WHO standards for antiretroviral use in resource-limited settings” Microbicides Development Current Law: Not in 2003 legislation House Bill: Supports access to microbicides, no funding of microbicide development (p. 46, lines 9-16) Senate Bill: Provides assistance to development and access to microbicides (p. 66, lines 12-21) Suggested Changes: Retain Senate language Prostitution Pledge Current Law: Although not part of PEPFAR legislation, groups receiving U.S. assistance must sign a certification stating they have a “policy opposing prostitution” to be eligible for funding. House Bill: No change from current law Senate Bill: No change from current law Suggested Changes: Amendment which would remove the U.S. policy that groups sign a pledge opposing prostitution. Funding Current Law: Authorizes $15 billion for FY 04-08, actual appropriations totaled over $19 billion for that time period House Bill: $10 billion for each year, FY 09-13 (pg. 115, line 10); Includes earmarks of $4 billion for TB (pg. 96, lines 3-4) and $5 billion for malaria  (pg. 96, lines 19-20). Senate Bill: $50 billion over FY 09-13 (pg. 106, lines 14-15); Includes earmarks of $4 billion for TB (pg. 94, lines 17-18) and $5 billion for malaria (pg. 95, line 11) Suggested Changes: $59 billion total (a $9 billion increase), including earmarks of $4 billion for tuberculosis and $5 billion for malaria Medicine Pricing Current Law: Not in 2003 legislation. House Bill: Promotes purchase of lowest-priced antiretroviral medication (p. 63, lines 11-18). Requires annual reporting on the prices paid for drugs, vendors used, and totals spent on generic vs. brand-name medicines (p. 69, lines 20-25, p. 70, lines 1-10) Senate Bill: Contains same language on mechanisms to promote purchase of low-cost medicines (p. 69 lines 8-16) Contains no language on reporting. Suggested Changes: Retain House language on both mechanisms and reporting Equipment and Supply Chain Management System (SCMS) Current Law: Nothing on SCMS, and little on medical equipment. House Bill: Requires SCMS to purchase equipment, including necessary and commonly missing like CD4 and X-Ray machines, reagents and basic medical supplies like gloves and syringes (p. 127, lines 3-13. Requires SCMS to work towards benchmarks to strengthen national and existing faith-based supply chain systems Senate Bill: Not in Senate bill Suggested Changes: Retain House language Training New Health Professionals Current Law: Not in 2003 Legislation House Bill: Policy of the United States to “train at least 140,000 new health care professionals and workers for HIV/AIDS prevention, treatment and care” (pg. 52, lines 1-4); 5-year health workforce plans are developed with partner countries. The U.S. provides funding to support implementation of the plans, and a soft target of 2.3 doctors, nurses and midwives per thousand country residents is included. Senate Bill: US 5-year strategy to “train and support retention of health care professionals and paraprofessionals, with the target of training and retaining at least 140,000 new health care professionals and paraprofessionals” (pg. 15 and 60) – but paraprofessionals are defined as anyone who is employed (even only paid a stipend) to “assist” with providing “basic” provide health services—in other words, not the doctors and nurses needed to meet health needs or even to successfully deploy community health workers. The hard “Policy” target on page 60 also is ambiguous about whether the U.S. is responsible for making new health workers, and adds community health workers into the mix of 140,000 (pg. 60, lines 20-24) Suggested Changes: Amendment to change “healthcare professionals and workers” (House) and “health care professionals and paraprofessionals” (Senate) to “Train and support retention for at least 140,000 new health professionals, plus additional paraprofessionals and community health workers as needed." HIV Travel/Immigration Ban Current Law: Not in 2003 Legislation House Bill: Not in House bill Senate Bill: Amends Immigration and Nationality Act to remove ban on immigration or travel by HIV+ non-US citizens to the US (p. 104, lines 3-7). Suggested Changes: Retain Senate language. Healthcare Worker Retention Current Law: Not in 2003 Legislation House Bill: Section on health workforce planning includes authorization for compensation (p. 125, lines 9-14) Calls for provision of confidential, comprehensive health care for health workers participating in programs funded by PEPFAR (p. 124, lines 21-25, pg. 125, lines 1-14). Calls for proper training to ensure safe working conditions for health workers (p. 124, lines 13-20) Senate Bill: Compensation not included in Senate bill. Healthcare for health workers not included in Senate bill. Annual report calls for reporting on advancing safe working conditions (pg. 81, lines 10-12) Suggested Changes: Retain House version, with slight change: ““In order to fulfill the purposes of this Act, the Coordinator shall, as appropriate, finance pre-service training and provide compensation or other benefits for health workers in order to enhance recruitment and retention of such workers.” Retain House language on healthcare for health workers. Retain House language on working conditions. International Monetary Fund Current Law: Not in 2003 Legislation House Bill: Calls for the Secretary of the   Treasury to use the “voice, vote, and influence of the United States to oppose” IMF loans that do not exempt increased spending on health care from national wage bill ceilings. (p. 127 lines 11-21). Senate Bill: Does not include any operative language. Suggested Changes: Strengthen House language from “the Secretary of the Treasury shall instruct the United States Executive Director at the IMF to use the voice, vote, and influence of the United States to oppose…” to “the Secretary of the Treasury shall instruct the United States Executive Director at the IMF to use the voice, vote, and influence of the United States to oppose any loan, project, agreement, memorandum, instrument, plan, or other program of the International Monetary Fund that does not exempt increased government spending on health care and education from national budget caps or restraints, hiring or wage bill ceilings, or other limits..." Abstinence and Prevention Current Law: Thirty-three percent of all prevention funds set aside for “abstinence until marriage” programs Sense of Congress that 20% should be spent on prevention House Bill: No abstinence spending requirement, but a report to Congress by OGAC is required if spending for sexual transmission prevention in a country with a generalized epidemic falls below 50% of funds used for behavior change activities including abstinence and fidelity programs (p. 117, lines 3-16). Requires that 20% be spent on prevention (p. 116, line 7-14). Senate Bill: No abstinence requirement, but a report to Congress by OGAC is required if spending for sexual transmission prevention in a country with a generalized epidemic falls below 50% of funds used for behavior change activities including abstinence and fidelity programs (p. 108. Lines 3-13). Suggested Changes: Retain strike of the abstinence-only funding earmark in both the House and Senate versions Remove language triggering a report if less than 50% of prevention funding is spent on behavior change in countries with generalized epidemics that potentially limit funds to abstinence/fidelity programs. Clarify the “behavior change” is not limited to “A/B” activity only. Guidance on prevention should include information on female condoms, as a prevention method that can be initiated and controlled by women. Family Planning Current Law: Allows family planning groups to get money only for HIV/AIDS services Exempts such family planning groups from the so-called Mexico City policy, which prohibits U.S. funding of overseas groups that promote or provide abortion. House Bill: Includes integration and referral between family planning services and HIV/AIDS programs, thereby reducing fragmentation at the country level, authorizing family planning groups to receive PEPFAR funding and referrals for HIV testing and education. However, an important limitation is placed that can limit funding and referrals to only groups that are already receiving U.S. funding–therefore potentially limited to those that adhere to Mexico City policy. Senate Bill: No reference to Family Planning. Suggested Changes: Retain House language, but remove “supported by the United States Government” language from the bill. Women and Girls Current Law: 5-year strategy to focus on women and girls, includes empowerment, addressing coping with sexual violence, economic opportunities; Calls for annual report on program effectiveness in reducing HIV infection in women and girls. House Bill: Requires the President to formulate and submit to Congress within six months a separate prevention strategy that seeks to reduce the factors that lead to gender disparities in the rate of HIV infection, including: cross-generational sex, access to female condoms, addressing gender-based violence and rape, micro-enterprise/ economic empowerment, access to education, property/inheritance rights, and coordinating with existing services targeting women and youth (p. 109-14). Senate Bill: 5-year strategy, including reduction in behavioral risks, a plan to address the needs of women and girls Report on the five-year plan must be submitted annually to Congress, expands monitoring and evaluation and operations research to include collection and analysis of data on gender-responsive interventions, and develop gender indicators, authorizes new IOM evaluation four years later to assess performance, calls for compacts with countries about how they will address the needs of women and girls. Suggested Changes: Retain House language detailing programmatic areas where the needs of women and girls should be addressed; Retain Senate language on reporting, accountability and oversight.