JOHANNESBURG – The Global Fund (GF) has only raised $4 billion of its $18 billion budget for the next three years – so much is riding on its Replenishment Summit in Johannesburg on Friday (21 November) as it seeks the balance to advance progress against HIV, tuberculosis (TB) and malaria.

The United States has been the largest donor to the Global Fund, contributing around one-third of its budget – but whether it will still contribute generously is an open question, given the Trump administration’s “America First” focus.

“We have been in almost constant dialogue with the US since the beginning of the year, and we have not received any stop-work order or any sort of notification that the funding will be stopped,” Francoise Vanni, the Fund’s external relations and communications director, told a media briefing in Johannesburg on Thursday.

“We are confident that they will pledge to the Replenishment tomorrow,” added Vanni, pointing out that the US and the GF are working closely to roll out the long-acting HIV prevention medicine, lenacapavir, in several African countries.

South Africa and the United Kingdom (UK) are co-hosting the Replenishment, but that did not prevent the UK from cutting its contribution by 15%.

The Fund provides 73% of all international financing for TB, 60% for malaria and 24% for HIV.

Médecins Sans Frontières (MSF) has described initial pledges as “deeply concerning”. “Germany and the United Kingdom – the only major traditional donors to pledge so far – have both decreased their commitments compared to the last cycle. Specifically, Germany has pledged €1 billion instead of €1.3 billion and the UK has pledged £850 million instead of £1 billion,” MSF noted on Thursday.

“No donor has increased their pledge when considering inflation. If other major donors follow Germany and the UK’s examples, the results would be catastrophic for people impacted by TB, HIV, and malaria worldwide,” MSF said.

“Failure to meet this [$14 billion] goal would risk catastrophic cuts to essential services, threaten the resurgence of HIV, TB, and malaria – the world’s top three deadliest infectious diseases – and put the financial burden of health care onto the world’s most vulnerable patients.”

Saving 70 million lives

The GF is the world’s largest funder of global health, and it has saved an estimated 70 million lives since its establishment 22 years ago, according to its Results Report 2025.

Around $103 billion has also been saved in reduced hospitalisations, freeing countries’ health systems to address other diseases and other health needs, Vanni noted.

While it works in over 100 countries, its effect has been felt primarily in Africa, where 73% of its budget has been spent.

In 15 priority countries in sub-Saharan Africa, life expectancy has increased from 49 years old in 2001 to 61 in 2021 – mostly thanks to people with HIV getting access to antiretroviral medicine. In Zambia, for example, life expectancy has increased by 19 years from 43 to 58 years.

Since the GF was launched in 2002, AIDS-related deaths have been reduced by almost three-quarters in the countries where the Global Fund operates, and new infections have been reduced by 62%. 

Without these interventions, AIDS deaths would have increased by 90% and new HIV infections by 75% over the same period.

In 2024 alone, Fund-supported TB programmes treated 7.4 million people with TB. 

Between 2002 and 2023, GF efforts have reduced TB deaths by 40%. Without these, TB deaths would have increased by 134% and TB cases by 40% over the same period. 

Malaria deaths were reduced by 29% between 2002 and 2023, “even though the population in these countries has increased by 46%”, the Results Report notes. “Without malaria control measures, deaths would have increased by 94% over the same period.”

Malaria ‘way off target’

Despite progress, HIV, TB and malaria remain the world’s deadliest infectious diseases. The $18 billion budget could save 23 million lives between 2027 and 2029, avert 400 million new infections and result in a 1:19 return on investment across the three diseases, according to Fund modelling.

“Malaria is way off track, with 600,000 people a year dying,” admits Kate Kolaczinski, the Fund’s senior specialist on the disease.

“Malaria is the leading cause of outpatient visits in sub-Saharan Africa,” she adds, with 263 million malaria cases in 2023.

Between 2002 and 2023, malaria cases in countries supported by the Global Fund increased by 8%

“Rising conflict, disruptions from extreme weather events and increasing resistance to antimalarial drugs and insecticides have complicated efforts to combat malaria in 2024,” according to the Results Report 2025.

“The goal of ending [malaria] by 2030 looks daunting. Reductions in global health funding could undermine progress against malaria. A widening funding gap, combined with existing crises and an expected population growth in areas at high-risk of malaria, could threaten the lives of millions.”

HIV resurgence?

“There’s a risk of HIV resurgence, especially now that we have funding challenges that we’re facing,” says the Fund’s HIV head, Izukanji Sikazwe, pointing out that 9.2 million people living with HIV still need access to treatment.

“We are off target for HIV prevention. In 2024, there were 1.3 million new infections. We need a fourfold reduction to meet the 2025 target of 370,000.”

Meanwhile, TB surged during the COVID-19 pandemic and but 2024 brought new progress against the disease.

“Robust funding commitments in 2025 are absolutely critical to maintaining our momentum against TB and preventing a resurgence that could undo decades of hard-won progress,” according to the Results Report 2025.

It describes an “exciting pipeline of innovative tools”, including new TB tests, better treatments and “at least five TB vaccines in phase III efficacy trials”. 

Private sector contributions

While the bulk of the Fund’s budget comes from country contributions, the private sector also contributes – with the Gates Foundation being the biggest and most consistent private donor, contributing $3.91 billion since 2002.

“The Global Fund will go down in history as one of humanity’s biggest achievements. It’s also one of the kindest things people have ever done for each other,” according to Gates Foundation chair Bill Gates.

The Global Fund’s track record proves it is an excellent investment for our global health dollars. Its work is critical to achieving the goal of ending AIDS, TB and malaria, and making our world a more equitable place for people everywhere.”

The Children’s Investment Fund Foundation (CIFF) has significantly increased its contribution recently, focusing on expanding access to lenacapavir by both supporting procurement and the development of generics.

John Fairhurst, who heads the Fund’s private sector mobilisation, says that the sector has contributed over $5.3 billion in the past 20 years – often playing a “catalytic role” in innovation.

Unlike countries, which give unrestricted funds, private donors are able to earmark their contributions.

Image Credits: Tommy Trenchard/ Global Fund, Global Fund.