The global fight against HIV calls for a reinforced Global Fund

The wailing is what I remember most. 

Several times every hour, anguished cries would echo over the open-air corridors of the central hospital in Lilongwe, Malawi, leading us to pause our clinical rounds as we mourned the loss of yet another young life to HIV. Providing clinical care without access to HIV medicines in 1999 was heart-wrenching and left me and my Malawian colleagues deeply moved. Since then, I have experienced many highs and lows in medical care and public health, but never have I witnessed a set of inequities so troubling or in need of change.  

Although it seemed like an eternity, the world acted in a big way three years later. In the midst of my medical residency at Harvard in 2002, I was invited to attend a meeting about a fund being set up to support access to treatment and prevention for HIV, tuberculosis (TB) and malaria in hard-hit countries. Shortly thereafter, I returned to Malawi to support a locally-led effort through the Malawi vice president’s office to craft an application to the newly formulated Global Fund to Fight AIDS, TB and Malaria (Global Fund).  

Malawian leaders understood the enormous power of listening to those on the front lines, and convened district health officers from the far corners of the country to incorporate their ideas into the application. The writing team worked tirelessly to craft a plan that could be rapidly implemented and built from the existing health system. And with the leadership of the government, civil society, faith leaders and many others, Malawi’s proposal was one of the first to be approved by the Global Fund.  

This funding started saving lives on day one by procuring lifesaving antiretroviral therapy, establishing programs for longitudinal care, and supporting prevention programs to break through the stigma and fear to increase testing. Now, 20 years later, that funding is up for its most consequential renewal ever — an $18 billion goal to get “back on track” from COVID-related setbacks and to meet rapidly approaching 2030 targets. 

President Biden’s leadership in hosting the upcoming Seventh Replenishment Conference in New York tomorrow — along with his $2 billion 2023 budget request — should be hailed for setting a standard that donor nations, foundations and the private sector should urgently match.  

The Global Fund’s initial grants, combined with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), rescued a generation of people. For example, Malawi’s sustained progress has enabled 93 percent of people living with HIV to know their HIV status, and 91 percent of those eligible to receive HIV treatment, leading to rapid declines in the death rate. And although much remains to be done, treatment for mothers has enabled 100,000 babies to be born HIV-free, and new HIV infections in Malawi have reduced by over 80 percent since their peak. 

Today, the fund has provided this kind of remarkable support to 155 countries, disbursed over $50 billion, and is estimated to have saved a staggering 44 million lives. And, as it did in Malawi, it has encouraged governments and civil society to take not just a leadership role but the leadership role in defining the national HIV response. And when problems occur, the Global Fund takes transparent actions to hold governments and other actors accountable, while ensuring that health gains are maintained.  

It also invests hand in hand with other donors. During my time serving as PEPFAR’s chief medical officer and as deputy global AIDS coordinator during the Obama-Biden administration, we worked in close partnership with the Global Fund to strategically align our funding. Meeting with governments and civil society of more than 30 countries during that time convinced me that the dual multilateral and bilateral approaches were a yin and yang of public health, allowing nimbleness, responsiveness and country leadership.  

Today’s historic moment rivals that of the days leading up to the founding of the Global Fund. We’ve been through a massive new pandemic that cost millions of lives. Yet this time, the fund played a foundational role in supporting their partner countries to detect, prevent and respond to COVID, and to reduce backsliding against HIV, TB and malaria. Similarly, PEPFAR, the U.S. President’s Malaria Initiative (PMI) and others performed admirably by protecting gains and serving as a vehicle for delivering global health security. Their success and momentum must be built upon, not squandered. 

It’s inconceivable today to imagine a world without the Global Fund. It has provided hope and delivered on the promise of partnerships between nations and solidarity of mankind. Yet we cannot achieve our 2030 goals or a strengthened posture of pandemic preparedness unless we match our ambition to the current threats we face. If we’ve learned one thing since those tragic days before the Global Fund was established, it’s that we must never go back.  

Charles B. Holmes, MD, MPH is director of Georgetown University’s Center for Innovation in Global Health, professor of medicine at Georgetown Medical School, and a distinguished scholar at the O’Neill Institute for National and Global Health Law. He previously served as chief medical officer and deputy coordinator for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) during the Obama-Biden administration.