Replenishment of the Global Fund: global solidarity needed

On Sept 16–17, 2016, in Montréal, Canada hosts the Fifth Replenishment Conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund is a partnership of governments, civil society, the private sector, and people affected by the diseases that works to accelerate the end of these epidemics. It raises and invests funds to support programmes run by local experts in countries and communities most in need. The Global Fund works to maximise eff orts against these diseases, mobilise increased resources, build sustainable and resilient health systems, and promote and protect human rights and gender equality.

95% of the Global Fund’s funding comes from donor governments with the remaining 5% coming from the private sector, private foundations, and innovative financing initiatives in 3-year replenishment cycles. Since it launched in 2002, the Global Fund estimates it has saved 20 million lives. The goal of the Fifth Replenishment is to help the Global Fund save an additional 8 million lives and avert 300 million new infections by 2020 by mobilising US$13 billion in 2017–19. In a context of sluggish global economic growth and competing demands on development assistance, this is no small challenge—but it is one that must be met. Meeting this goal is the Global Fund’s immediate challenge and translating those funds into lives saved is its mid-term opportunity. In the longer term, the challenge and opportunity is to accelerate progress and reach vulnerable groups that are disproportionately affected by HIV/AIDS, tuberculosis, and malaria—which requires innovation.

Since a key focus of the Canadian Government’s international development policy is to reach the poorest and most vulnerable and empower women and girls, we can expect to see this emphasis at the Replenishment Conference. Moreover, the Canadian Government has signalled that the conference will address “the fear, discrimination, gender inequality, violence, stigma and poverty that fuel these diseases”. The last Global Fund replenishment in 2013 raised $12 billion. Major contributions came from the USA, the UK, France, Germany, Japan, Canada, and the Bill & Melinda Gates Foundation. Smaller, but still substantial, contributions came from emerging economies, the Middle East, the private sector, and religious groups. The Fifth Replenishment is off to a good start at the time of writing. The USA has pledged up to $4·3 billion matching $1 for every two donated by others, up from $4·1 billion in the last replenishment. France has pledged €1·08 billion, matching its last pledge. Japan has pledged $800 million, a 46% increase when denominated in yen. Canada has pledged CAN$785 million, a 20% increase from its previous pledge. Italy has pledged €130 million and Kenya has pledged $5 million. Although the Global Fund does not directly support scientific research, it does help to create demand for technological innovations that could improve health and development outcomes. None of these three diseases has a highly effective vaccine; drugs for malaria, tuberculosis, and HIV encounter antimicrobial resistance; point of care diagnosis, especially for tuberculosis, could be improved; better vector control strategies for malaria are needed; and more precise health and outcomes data, including disaggregation by gender, income, and geography, are needed. Technological innovation is necessary but not sufficient.

Seemingly simple innovations in clinical practice or patient self-management could be used by Global Fund applicants for outsized impact. Canada is making contributions in this arena. One of the most important Canadian contributions is Treatment as Prevention for HIV/AIDS. Other examples, which are funded by Grand Challenges Canada, include HIVSmart!, an HIV self-testing mobile phone app to empower patients,6 and the use of standardised patients to show suboptimal quality of tuberculosis care by private Indian health-care providers. Integrating social and technological innovation can also help reach vulnerable groups through mobile health platforms, empowerment, or by addressing stigma. Every week, 7000 girls aged 15–24 years are infected with HIV worldwide.4 The Global Fund has a Gender Equality Strategy Action Plan and several partners have launched the DREAMS Innovation Challenge, which will shortly be announcing innovations to reduce HIV infections in women and girls.

Lesbian, gay, bisexual, and transgender (LGBT) rights are an overarching theme the Global Fund must continue to address. A new way to do so would be to launch a Grand Challenge to stimulate and scale innovation in the area, especially social innovations, to protect LGBT rights, tackle stigma, and improve access to care. The rights of LGBT people are highly insecure in many of the countries that the Global Fund supports, as the recent police raid on Pride Uganda showed, creating stigma that inhibits testing and treatment. Canada has a Prime Minister who has proudly marched in more Pride parades than any other head of state and the Canadian Government has hoisted the LGBT flag on Parliament Hill. Hopefully, Canada will raise its strong support for LGBT rights at the Replenishment Conference.

Finally, in an age of universal Sustainable Development Goals, every country should innovate to reach vulnerable domestic populations. For example, in Canada, HIV disproportionately affects Indigenous populations and tuberculosis rates in some Indigenous groups rival those of low-income countries. We live in an era of rising nationalism. The Global Fund, and its cousins GAVI, the Vaccine Alliance, and the Global Finance Facility in support of Every Woman Every Child, represent pillars of global solidarity. The Global Fund replenishment must succeed.