GFO Issue 466, Article Number: 6
ABSTRACT
This article analyses the Global Fund's 2025 Report: 70 million lives saved and significant progress made against HIV, TB and malaria. However, the 'last mile' remains, with challenges such as PrEP, DR-TB, pockets of malaria transmission, rights and data. The article shows that future impact depends less on new tools than on targeted funding for system functions such as supply chains, laboratories, data and community resources, and focused delivery where the marginal return is greatest. In short, the Eighth Replenishment is the litmus test to avoid backtracking and deliver on the 2030 promise.
Introduction - a partnership that saves massively, but a tougher equation.
The 2025 Results Report clearly and usefully informs decision-makers that supported programs in countries where the Global Fund invests have saved 70 million lives by the end of 2024. At the same time, the combined mortality rate for the three diseases has fallen by 63% since 2002 and the combined incidence rate by 42%. The report also reminds us that these gains are the result of collaboration between governments, communities, technical agencies and donors, and that they could be jeopardised if global funding continues to decline. The strategic implication is twofold: maintain pressure on delivery while safeguarding the financing and systems architecture that make these results possible.
Health results: undeniable progress, but gaps remain
HIV is showing the best cascade levels ever observed in investment countries. - 88% of people living with HIV know their status;
- 79% are receiving antiretroviral therapy;
- 74% have a suppressed viral load. ARV coverage among HIV-positive pregnant women reaches 85%. These high levels are supported by substantial intervention volumes in 2024, including 46.6 million HIV tests, 12.3 million people reached by prevention services (7.7 million of whom were from key populations), 648,000 HIV-positive pregnant women on ARVs, 1.4 million people on PrEP, and 25.6 million people on antiretroviral therapy. While there is momentum for both expansion and consolidation, the 2025 global targets (95-90-86) have not yet been fully realised.
In 2023, treatment coverage for all forms of tuberculosis reached 75%, with 44% of people with drug-resistant TB starting treatment and achieving an 88% success rate, and 91% of people co-infected with HIV and TB receiving ART. Since 2002, TB mortality and incidence have declined by 57% and 28%, respectively, in countries with increased investment. While these figures reflect improved detection and retention, drug-resistant TB remains a critical issue requiring more aggressive market and access approaches.
In terms of malaria, access to insecticide-treated mosquito nets (ITNs) climbed to 61% in 2023, with usage reaching 53%. The 2024 intervention scale remains substantial, with 162 million mosquito nets distributed, 360 million suspected cases tested, 173 million cases treated, and 50.9 million children covered by seasonal chemoprevention, as well as 17.8 million pregnant women protected by preventive treatment. While these figures support the decline in malaria mortality, which remains highly concentrated among children under 5 in sub-Saharan Africa, they are hampered by pockets of intensity and local resistance. This highlights the need for rapid innovations in tools.
Critical analysis: Taken together, these results confirm the existence of a ripple effect in systems under strain. However, the Achilles heel appears in the 'last mile': key populations for HIV, such as young women and adolescent girls; DR-TB; and malaria districts with persistent transmission. Progress remains vulnerable to supply chain disruptions, underinvestment in data and laboratories, and the closure of civic spaces. In other words, effective execution of plans is necessary but not sufficient; achieving targets requires structural, targeted and resilient investments.
Health and community systems are finally receiving adequate funding.
The report documents an unprecedented acceleration in investments in health and community systems: approximately US$6.1 billion between 2024 and 2026, representing a 49% increase compared to the previous cycle. This includes US$2.7 billion invested in 2024 alone. Meanwhile, the reallocation of around US$2.1 billion from C19RM after the emergency phase has enabled critical catch-up on core functions such as human resources, community systems, laboratories, surveillance and data, oxygen, waste and supply. The Global Fund emphasises that this is the largest systems effort in its history and that the most effective defence against infectious diseases is systems that can rapidly contain outbreaks.
This increase in funding comes at a time when international health funding is declining, which is weakening service delivery in high-burden countries and increasing the risk of a major health crisis. The report reiterates the urgent need for sustained and predictable domestic and external financing to avoid reversing two decades of progress and undermining pandemic preparedness. In practice, the 'Accelerated Implementation' initiative provides targeted support to priority countries through action plans and the early identification and resolution of issues.
Why does this matter? Investments in systems free up capacity beyond the three diseases. The report estimates that the HIV/TB/malaria scale-up contributed to improving the UHC service coverage index (from 45% in 2000 to 68% in 2021) and avoided billions of hospital days and outpatient visits, resulting in cumulative savings of US$103 billion. In other words, financing 'fundamentals' (data, laboratories, supply chains and human resources) is one of the most effective ways to improve efficiency and impact, even outside the three diseases.
Prevention and innovations: changing the scale, not just the tools
Demand for PrEP has exploded, increasing from 200,000 users in 2017 to an estimated 3.9 million in 2024. However, this figure remains well below the global target of 21.2 million by 2025, and the demand is highly concentrated. Five countries (Kenya, Nigeria, South Africa, Uganda and Zambia) account for 64% of PrEP users. The Global Fund has therefore increased its PrEP investments more than fivefold (from US$25 million in 2021–2023 to US$130 million in 2024–2026), with support from matching funds and a US$33 million commitment from CIFF. In terms of technology, the partnership is funding all the options recommended by the WHO: oral medication, the dapivirine vaginal ring and long-acting injectables (cabotegravir and lenacapavir). The aim is to shape the market by initially purchasing 150,000 rings to accelerate access, and by establishing access agreements to speed up the introduction of injectables, including lenacapavir, which are expected to reach two million people in the first wave. The strategic angle here is clear: to maximise adherence and user preference in order to convert 'latent demand' into effective prevention, while ensuring that the decline in funding does not stifle innovation at a crucial time.
In the fight against malaria, the transition to dual-active ingredient (DAI) mosquito nets is another innovative approach. Data from the New Nets Project shows that approximately 13 million cases and 24,600 deaths were averted in 17 countries, with a 45% reduction in cases compared to conventional nets. This technical shift addresses the growing resistance to pyrethroids directly and requires the logistical and financial capacity to purchase these more effective products repeatedly. Similarly, the standardisation of indicators (for example, the transition to 'people protected by IRS') demonstrates useful progress in monitoring to manage equity of access and resource allocation.
The key point: In both PrEP and dual AI cases, the challenge lies not so much in having 'better' tools, but in successfully combining fine population and area targeting with a supply model adapted to community-led services, confidentiality and integration into primary care, as well as multi-year budgetary security to avoid supply disruptions and 'stop-and-go' implementation.
Money, governance and leverage: the politics of results
The report highlights the Global Fund's position within the ecosystem, noting that it provides 26% of international financing for HIV, 73% for TB, and 59% for malaria.
It also emphasises an accountability approach that prioritises comprehensive national results over trying to isolate the 'Global Fund's share' of impact — a more honest approach in highly partnership-based environments, but one that demands high-quality, triangulated data and transparency. In other words, published performance is as much a test of execution as it is of the maturity of health information systems.
In terms of allocation choices, the 2025 signal is clear: in the face of announced cuts in global aid and the convergence of crises (conflicts, over-indebtedness, climate issues and human rights violations), the partnership is directing its resources towards countries, districts and functions where 'every dollar' will achieve the greatest reduction in mortality and transmission, including through operational acceleration in priority countries and the targeting of basic functions such as supply chains, data collection, laboratories, oxygen supplies and community systems. This is an 'integrated preparedness' strategy, which aims to reduce the burden of the three diseases immediately while strengthening health security.
Country examples and concentration of issues. The report highlights the geographical concentration of PrEP users (64% in five countries in East and Southern Africa), which is useful for rapid scaling up but reveals a need for equitable expansion. In sub-Saharan Africa, 76% of malaria deaths in 2023 will affect children under five, so allocation must remain aggressive for seasonal chemoprevention, IPTp, dual artemisinin-based ITNs and IRS in the densest foci. Regarding TB, efforts must continue with DR-TB (coverage is still insufficient) and prevention (TPT). By 2024, this had reached millions of people at risk.
Looking ahead: why the eighth re-enactment is the litmus test
The report is not just a review; it is an immediate roadmap. It identifies 2025 as a pivotal year for the eighth replenishment and clearly states that the success of this mobilisation is essential for continued progress and to prevent a resurgence of the three diseases. This would result in "devastating" human, social and economic consequences if investment is not urgent and targeted. In short, replenishment is not just an administrative exercise, but an act of global prevention.
Regarding malaria, the report explicitly links funding instability and threats (conflict, climate and resistance) to the risk of backsliding, and identifies the eighth replenishment as the means to maintain momentum and prevent an increase in mortality and incidence.
Introduction - a partnership that saves massively, but a tougher equation.
The 2025 Results Report clearly and usefully informs decision-makers that supported programs in countries where the Global Fund invests have saved 70 million lives by the end of 2024. At the same time, the combined mortality rate for the three diseases has fallen by 63% since 2002 and the combined incidence rate by 42%. The report also reminds us that these gains are the result of collaboration between governments, communities, technical agencies and donors, and that they could be jeopardised if global funding continues to decline. The strategic implication is twofold: maintain pressure on delivery while safeguarding the financing and systems architecture that make these results possible.
Health results: undeniable progress, but gaps remain
HIV is showing the best cascade levels ever observed in investment countries. - 88% of people living with HIV know their status;
- 79% are receiving antiretroviral therapy;
- 74% have a suppressed viral load. ARV coverage among HIV-positive pregnant women reaches 85%. These high levels are supported by substantial intervention volumes in 2024, including 46.6 million HIV tests, 12.3 million people reached by prevention services (7.7 million of whom were from key populations), 648,000 HIV-positive pregnant women on ARVs, 1.4 million people on PrEP, and 25.6 million people on antiretroviral therapy. While there is momentum for both expansion and consolidation, the 2025 global targets (95-90-86) have not yet been fully realised.
In 2023, treatment coverage for all forms of tuberculosis reached 75%, with 44% of people with drug-resistant TB starting treatment and achieving an 88% success rate, and 91% of people co-infected with HIV and TB receiving ART. Since 2002, TB mortality and incidence have declined by 57% and 28%, respectively, in countries with increased investment. While these figures reflect improved detection and retention, drug-resistant TB remains a critical issue requiring more aggressive market and access approaches.
In terms of malaria, access to insecticide-treated mosquito nets (ITNs) climbed to 61% in 2023, with usage reaching 53%. The 2024 intervention scale remains substantial, with 162 million mosquito nets distributed, 360 million suspected cases tested, 173 million cases treated, and 50.9 million children covered by seasonal chemoprevention, as well as 17.8 million pregnant women protected by preventive treatment. While these figures support the decline in malaria mortality, which remains highly concentrated among children under 5 in sub-Saharan Africa, they are hampered by pockets of intensity and local resistance. This highlights the need for rapid innovations in tools.
Critical analysis: Taken together, these results confirm the existence of a ripple effect in systems under strain. However, the Achilles heel appears in the 'last mile': key populations for HIV, such as young women and adolescent girls; DR-TB; and malaria districts with persistent transmission. Progress remains vulnerable to supply chain disruptions, underinvestment in data and laboratories, and the closure of civic spaces. In other words, effective execution of plans is necessary but not sufficient; achieving targets requires structural, targeted and resilient investments.
Health and community systems are finally receiving adequate funding.
The report documents an unprecedented acceleration in investments in health and community systems: approximately US$6.1 billion between 2024 and 2026, representing a 49% increase compared to the previous cycle. This includes US$2.7 billion invested in 2024 alone. Meanwhile, the reallocation of around US$2.1 billion from C19RM after the emergency phase has enabled critical catch-up on core functions such as human resources, community systems, laboratories, surveillance and data, oxygen, waste and supply. The Global Fund emphasises that this is the largest systems effort in its history and that the most effective defence against infectious diseases is systems that can rapidly contain outbreaks.
This increase in funding comes at a time when international health funding is declining, which is weakening service delivery in high-burden countries and increasing the risk of a major health crisis. The report reiterates the urgent need for sustained and predictable domestic and external financing to avoid reversing two decades of progress and undermining pandemic preparedness. In practice, the 'Accelerated Implementation' initiative provides targeted support to priority countries through action plans and the early identification and resolution of issues.
Why does this matter? Investments in systems free up capacity beyond the three diseases. The report estimates that the HIV/TB/malaria scale-up contributed to improving the UHC service coverage index (from 45% in 2000 to 68% in 2021) and avoided billions of hospital days and outpatient visits, resulting in cumulative savings of US$103 billion. In other words, financing 'fundamentals' (data, laboratories, supply chains and human resources) is one of the most effective ways to improve efficiency and impact, even outside the three diseases.
Prevention and innovations: changing the scale, not just the tools
Demand for PrEP has exploded, increasing from 200,000 users in 2017 to an estimated 3.9 million in 2024. However, this figure remains well below the global target of 21.2 million by 2025, and the demand is highly concentrated. Five countries (Kenya, Nigeria, South Africa, Uganda and Zambia) account for 64% of PrEP users. The Global Fund has therefore increased its PrEP investments more than fivefold (from US$25 million in 2021–2023 to US$130 million in 2024–2026), with support from matching funds and a US$33 million commitment from CIFF. In terms of technology, the partnership is funding all the options recommended by the WHO: oral medication, the dapivirine vaginal ring and long-acting injectables (cabotegravir and lenacapavir). The aim is to shape the market by initially purchasing 150,000 rings to accelerate access, and by establishing access agreements to speed up the introduction of injectables, including lenacapavir, which are expected to reach two million people in the first wave. The strategic angle here is clear: to maximise adherence and user preference in order to convert 'latent demand' into effective prevention, while ensuring that the decline in funding does not stifle innovation at a crucial time.
In the fight against malaria, the transition to dual-active ingredient (DAI) mosquito nets is another innovative approach. Data from the New Nets Project shows that approximately 13 million cases and 24,600 deaths were averted in 17 countries, with a 45% reduction in cases compared to conventional nets. This technical shift addresses the growing resistance to pyrethroids directly and requires the logistical and financial capacity to purchase these more effective products repeatedly. Similarly, the standardisation of indicators (for example, the transition to 'people protected by IRS') demonstrates useful progress in monitoring to manage equity of access and resource allocation.
The key point: In both PrEP and dual AI cases, the challenge lies not so much in having 'better' tools, but in successfully combining fine population and area targeting with a supply model adapted to community-led services, confidentiality and integration into primary care, as well as multi-year budgetary security to avoid supply disruptions and 'stop-and-go' implementation.
Money, governance and leverage: the politics of results
The report highlights the Global Fund's position within the ecosystem, noting that it provides 26% of international financing for HIV, 73% for TB, and 59% for malaria.
It also emphasises an accountability approach that prioritises comprehensive national results over trying to isolate the 'Global Fund's share' of impact — a more honest approach in highly partnership-based environments, but one that demands high-quality, triangulated data and transparency. In other words, published performance is as much a test of execution as it is of the maturity of health information systems.
In terms of allocation choices, the 2025 signal is clear: in the face of announced cuts in global aid and the convergence of crises (conflicts, over-indebtedness, climate issues and human rights violations), the partnership is directing its resources towards countries, districts and functions where 'every dollar' will achieve the greatest reduction in mortality and transmission, including through operational acceleration in priority countries and the targeting of basic functions such as supply chains, data collection, laboratories, oxygen supplies and community systems. This is an 'integrated preparedness' strategy, which aims to reduce the burden of the three diseases immediately while strengthening health security.
Country examples and concentration of issues. The report highlights the geographical concentration of PrEP users (64% in five countries in East and Southern Africa), which is useful for rapid scaling up but reveals a need for equitable expansion. In sub-Saharan Africa, 76% of malaria deaths in 2023 will affect children under five, so allocation must remain aggressive for seasonal chemoprevention, IPTp, dual artemisinin-based ITNs and IRS in the densest foci. Regarding TB, efforts must continue with DR-TB (coverage is still insufficient) and prevention (TPT). By 2024, this had reached millions of people at risk.
Looking ahead: why the eighth re-enactment is the litmus test
The report is not just a review; it is an immediate roadmap. It identifies 2025 as a pivotal year for the eighth replenishment and clearly states that the success of this mobilisation is essential for continued progress and to prevent a resurgence of the three diseases. This would result in "devastating" human, social and economic consequences if investment is not urgent and targeted. In short, replenishment is not just an administrative exercise, but an act of global prevention.
Regarding malaria, the report explicitly links funding instability and threats (conflict, climate and resistance) to the risk of backsliding, and identifies the eighth replenishment as the means to maintain momentum and prevent an increase in mortality and incidence.
