The US Senate later today is expected to approve an extension of PEPFAR, the President?s Emergency Plan for AIDS Relief. But on the eve of the vote, legislators continued to wrangle over terms of the $50 billion package, which was expanded earlier this year by the House of Representatives to include funds for combating malaria, and tuberculosis in African countries and other world health trouble spots. Negotiators had hoped to win final Senate approval with White House support before President Bush had left for the G8 summit in Japan earlier this month. But a handful of senators, led by Oklahoma Republican Tom Coburn, a physician, voiced concerns that some unspecified funding could be diverted to unrelated development and relief programs. Communications director David Bryden of the Global AIDS Alliance says  that a small, but concentrated minority of senators has had the ability to impact the shape of the final legislation.

?Under the Senate rules, an individual senator has a huge amount of power. An individual senator can place a hold on a bill. They can filibuster a bill. So it does require a significant number of votes to overcome that,? he noted.

Last Friday, the Senate seemed to clear the highest legislative roadblocks mounted by Senators David Vitter of Louisiana and Jim DeMint of South Carolina, who pushed, respectively, to lower what was seen as irresponsible spending and to maintain a current ban against admitting HIV positive visitors and immigrants to the United States. The bipartisan sponsors of the 2008 PEPFAR bill, Senators Joe Biden of Delaware and Richard Lugar of Indiana, were able to engineer a 65-3 cloture vote to allow the AIDS legislation to come up for actual debate, where it is expected to pass with strong bipartisan support. Bryden says the compromises produced few major changes in the intended legislation.

?What Biden and Lugar did was to agree that at least half of the money in the PEPFAR budget, for the bilateral AIDS program, has to be spent on treatment and medical care. They also agreed to a few of his (Senator Coburn?s) other suggestions. One was regarding how many people by the end of this five-year period the US should expect to have on treatment,? said Bryden.

Another concern by Senate opponents over abstinence and fidelity provisions of the bill was ironed out by the sponsors spelling out more clearly the reporting requirements of those programs. Bryden says that the most important advances preserved in the legislation, which funds overseas programs of treatment, medication, and services to severely ailing patients, is its embrace of additional funding for other menacing diseases.

?Lost in this debate, unfortunately, is the fact that a very large proportion of the bill is actually not on HIV and AIDS. It?s really the AIDS, TB, and malaria bill, and health systems. So even when we look at the funding, the $50-billion is not really $50-billion on AIDS. It?s important in Africa, too, because I do feel people are justified in being concerned about, ?well, wait a minute. What about other diseases besides AIDS $13-billion is TB and malaria, and that TB and malaria money was not there before. We?ve started to see some malaria funding, so that?s good. But there are some real innovations here. AIDS is still the lion?s share of the funding, but we were really able to expand this bill to be much broader,? Bryden noted. 

The Bush administration introduced its first five-year PEPFAR legislation in 2003. It has benefited enormously from the good will generated in African countries which have received the bulk of medicines and services needed to fight the deadly illness. This year?s remaking of the bill to provide foreign assistance in campaigns against HIV/AIDS, malaria, and tuberculosis would provide funding from fiscal years 2009 through 2013. Under its terms, the US Congress would be responsible for determining and approving spending levels on a year by year basis. The 2008 bill would authorize a total of $37 billion for AIDS programs over five years, a 27 percent increase, including the portion of the US contribution to the Global Fund that goes to AIDS.