World AIDS Day: the Global Fund Turns 20 in the COVID-19 Era

“As we celebrate 20 years of impact of the Global Fund, I celebrate the 44 million lives saved including my life and the lives of my loved ones. It is commendable that in the past 20 years the Global Fund has reduced AIDS related mortality by 65%. What amazing progress.” Joyce is a 24 year-old activist from Kenya who lives openly with HIV. She is addressing a room packed with decision-makers during a side-event of the United Nations General Assembly in September.

Her remarks are bittersweet. 2021 marks the 20th anniversary of the Global Fund to Fight AIDS, Tuberculosis and Malaria and events marking the occasion have been in the work for months. There is much to celebrate, but it is easy to get lost in statistics, so Joyce explains to her audience how these billions change individual lives.

“I remember when I was newly diagnosed with HIV at 17. I was in a boarding school and in my final year of secondary education. I was in deep shock. I saw my future slowly fading away from me. From the stories I heard, the movies I had watched, the way the people around me reacted to my diagnosis, I was certain I had no more than a few months to live. My greatest fear however was that I was not going to be able to afford a daily pill for the rest of my life. But I was wrong. I was enrolled on treatment almost immediately. I have never lacked that lifesaving pill, not even for a single day in my life since then.“

Stories like hers was what everyone wanted to hear for the Global Fund’s anniversary. But 2021 would turn out to be the year we first grasped the full extent of the impact of COVID-19 on the fight against HIV. Put simply: COVID-19 devastated prevention and treatment programs. For the first time since the Global Fund’s founding, in 2020 the world lost ground. HIV Testing and prevention were hit the hardest. There were even worse setbacks in the fight against tuberculosis, for which both case detection and treatment dropped drastically last year. And of course, the economic impact of COVID-19 worsened inequities, and created increased health risks for the most vulnerable and marginalized. Joyce would have been less likely to get access to the services that have saved her life had she fallen sick in 2020 rather than 2014. It is not a reassuring thought.

The reality is that as a society, we have failed to address COVID-19. The response has been deeply inequitable, leaving everyone vulnerable. This pandemic is having a knock-on effects on other health issues. HIV and tuberculosis were especially impacted because they affect marginalized and hard to reach populations, who have precarious access to health services at the best of times. As Joyce reminded her audience, people living with HIV still face real hardship, even when they have access to treatment: “Living with HIV is not easy. I have faced many challenges on this journey. I am constantly stigmatized; I have had my share of mental health issues, I have had treatment fatigue, fear of opportunistic infections and many others.” That is why strong community-led systems are key to the fight against HIV and tuberculosis. In hard times, decentralized local organizations that are trusted by vulnerable groups can maintain access when the formal health system cannot.

Not all has been grim this year. Despite the odds, HIV programs have proven resilient. While prevention and testing dropped last year, treatment levels were maintained, in part thanks to the flexibility of community-led systems. Emergency funds raised by the Global Fund through the COVID-19 Response Mechanism (C19RM) have help soften the blow; more than $3 billion have already been awarded to countries to help them with their pandemic response. While all eyes are on the firefighting, in 2022 there will be a need to look ahead. The Global Fund will be going through its 7th Replenishment, raising funds for its 2023-25 implementation cycle. It will be our chance to claw ourselves back out of the hole in which COVID-19 has put us, and get back on track towards ending AIDS. Of course, doing so will require money, and the needs are high.

The Global Fund Advocates Network (GFAN), using data from UNAIDS, the World Health Organization and the Stop TB Partnership, estimates that the Global Fund will need $28.5 billion for the 7th Replenishment, out of which $9 billion would go to the fight against HIV. It is a high number. In the words of Khuat Thi Hai Oanh, who runs a large civil society organization in Vietnam, it is “not a politically correct number”. And yet, it is a realistic number – realistic because it accurately represents what is needed. In June 2021, governments committed during the United Nations General Assembly to End AIDS by 2030. Next year will be a first test of whether they are willing to do what it will take to keep their word.