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GFO Issue 293



David Garmaise

Article Type:

Article Number: 3

Key populations will suffer the most if the Global Fund’s replenishment target is not met

ABSTRACT Not meeting the Global Fund’s replenishment target of $13 billion will mean more infections and more lives unnecessarily lost, according to a report released by the Global Fund Advocates Network. Key populations will be the most severely affected.

Failing to meet the Global Fund’s replenishment target will mean more infections, more lives unnecessarily lost, more difficulties providing treatment if drug resistance gains a stronger foothold, and rapidly escalating economic costs. Those who will suffer the most from insufficient investments will be those who are most at risk: key and vulnerable populations.

This is the message contained in a report released by the Global Fund Advocates Network (GFAN), entitled Investing in the Global Fund: The Cost of Inaction.

The Global Fund has set a goal to raise at least $13 billion in its Fifth Replenishment, as its contribution towards the $97.5 billion in combined domestic and external funding it says is needed to fight HIV, TB, and malaria for 2017-2019. The $97.5 billion is based on the global plans of the Fund’s technical partners: UNAIDS, the STOP TB Partnership, and Roll Back Malaria.

In its Investment Case for the  the replenishment, the Global Fund estimated that $13 billion would:

  • save up to eight million lives through programs supported by the Fund;
  • avert up to 300 million new infections across the three diseases; and
  • lead to broad economic gains of up to $290 billion over the coming years and decades, based on partner estimates.

For HIV, the UNAIDS estimates are based on their Fast-Track Strategy, which seeks to end the epidemic by 2030 (defined as achieving a 90% reduction in new infections and deaths compared to 2010). This goal is dependent on key targets being reached by 2020. These targets include 90% of people living with HIV know their status; 90% of people tested will be on treatment; and 90% of those on treatment will be virally suppressed.

According to The Cost of Inaction report, UNAIDS believes that to achieve the goal of ending the epidemic by 2030, especially in high burden countries, the pace to achieve the 2020 targets must be accelerated. The report says that maintaining coverage at 2013 levels would allow the epidemic to “outrun the response, increase the long-term need for treatment and therefore dramatically increase future costs.” It adds that if we only reach the 2020 targets in 2030, the delay would result in three million more new infections and three million more AIDS-related deaths between 2020 and 2030.

With respect to TB, the report states that none of the goals outlined in the Stop TB Partnership’s Global Plan to End TB nor the World Health Organization’s End TB Strategy are at all feasible without increased investment in the Global Fund. The Fund “is by far the most influential and impactful external donor to TB, and the best chance the world has at putting an end to TB.”

Concerning malaria, the report says that while malaria financing has increased substantially since 2000, it continues to fall far short of the amounts required to achieve the 2030 malaria goals. According to the Roll Back Malaria Partnership, the report said, just over $100 billion is needed to reach these goals. To achieve the globally agreed first milestone of reducing malaria mortality and incidence rates by at least 40% by 2020, annual investments in the global malaria fight must increase to $6.4 billion by 2020. The Cost of Inaction report states that despite the current resource gap, “there are good prospects for increasing investment in malaria through a mixture of domestic and external financing” and that “a fully funded Global Fund has a critical role to play in realizing this potential.”

For all three diseases, the report concludes, one of the key costs of failing to fully fund the Global Fund would be unnecessary, increased infections. “We no longer can afford to maintain current funding levels: the status quo would be, quite literally, deadly.”

The report also examines three other costs of inaction: (1) the risk that drug resistance will roll back gains; (2) the negative impact of ignoring key and vulnerable populations; and (3) the negative economic consequences.

Drug resistance

According to The Cost of Inaction report, an underfunded HIV response will threaten the availability of adequate and consistent drug and diagnostic supplies and the quality and availability of linkage to care, social support, and crucial adherence support services. The report says that intermittent availability of drugs and services directly increases the risk of treatment failure, the development of drug resistance, and the transmission of drug-resistant HIV. “This, in turn, will increase the need for more expensive second- and third-line treatment regimens.”

The report says that the main cause of TB drug resistance is under-supported healthcare systems that can’t handle a six-month long treatment regimen that requires daily supervised visits from patients. “Unless this challenge is addressed now, decades of progress will be undone and the billions of dollars invested in fighting TB will be wasted.”

The report states that the emergence of artemisinin resistance threatens to roll back gains in the fight against malaria. A successful Global Fund replenishment will allow the Global Fund to continue to support efforts to control artemisinin resistance, it says. “Without such support, drug resistance could spread to other regions of the world and the most important treatment intervention for malaria could be lost.”

Key and vulnerable populations

GFAN believes that key and vulnerable population networks are key to reaching the people most in need and to ending the epidemics.

The majority of Global Fund grants in middle-income countries are allocated toward services for key populations. Underfunding the Global Fund, the report says, will have a disproportionate impact on these groups. “These are populations that are already severely underserved. The same stigma and discrimination that keeps key populations from seeking out and receiving treatment and prevention services keeps governments from providing adequate resources to serve these populations.”

Economic consequences

The report says that the economic costs of inaction will be huge if services remain at current levels. For example:

  • For HIV, we would lose the opportunity to save 21 million lives, and an additional 28 million people would be living with HIV by 2030. The number of people on treatment would be drastically reduced. The important prevention benefits that come from earlier use of ARV treatment would not be realized. Continuation of current coverage levels would mean that the world would have to pay an additional $24 billion every year for ARV therapy by 2030.
  • A five-year delay in new investments for TB would have potentially catastrophic results, including 8.4 million additional TB cases and 1.4 million additional deaths, as well as $5.3 billion in additional TB treatment costs and $181 billion in lost productivity.
  • If current malaria coverage levels are allowed to revert to 2007 levels, the economic costs would be staggering: $5.2 billion in direct costs to health systems and households; and $1.2 trillion in forgone economic output.


GFAN says that the Global Fund as a financing mechanism is widely considered to be among the great success stories of the progress made towards the Millennium Development Goals. “However, significant increased financing is needed to maintain current treatment regimens, to find new ways to address the changing nature of the diseases including drug-resistance, to develop vaccines to prevent future infections, and to scale up to reach those still without access to community and health systems.”

At $13 billion, the replenishment target is $2 billion lower than the one set in 2013 for the last replenishment. Although that target was not met, the Global Fund continued to produce results. Nevertheless, GFAN says that key and vulnerable populations, networks groups and civil society have questioned the lower replenishment target for 2017-2019 because they believe that “the gains made over the past few years seem particularly vulnerable to complacency.”

GFAN says that “the cost of inaction is real to hundreds of millions of people and their families, their livelihoods and their communities. We can work together to end the epidemics now or feel the greater burden of our inaction later.”

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