What will happen if Trump cuts the US’s Global Fund contributions?

Science can save lives; politics can take them. 

South Africa — and the world — learnt the hard way that science and politics don’t mix, when HIV denialism unnecessarily cost more than 300,000 lives in the country. Now history is repeating itself — except this time political decisions with “deadly consequences” come from a global superpower. 

An analysis published in the Journal of the International Aids Society in February shows that the 90-day halt in funding from the President’s Emergency Plan for Aids Relief (Pepfar), because of President Donald Trump ordering a freeze on US foreign aid would lead to 100,000 extra Aids-related deaths in the next year. 

It’s not where the world wants to be. In fact, the goal is to end Aids as a public health threat by 2030. But we’re way off track. In 2023 there were nearly 1.3-million new HIV infections in the world, 3.5 times more than the target of 370,000 by the end of this year — and the US funding freeze could make it worse.

Trump’s take on public health science during the Covid-19 pandemic has been called “sabotage” — with little seeming to have changed in his second term. 

But the US being a big player in the world’s health funding can’t be denied. In 2024 alone, it gave $12.4bn (R225bn) to global health efforts, with about 70% of that going towards programmes to fight HIV, tuberculosis (TB) and malaria. About a fifth of this chunk — $1.65bn (R29.9bn) — was its contribution to the Global Fund to Fight Aids, Tuberculosis (TB) and Malaria. 

While the fund is an independent organisation that handles a pot of money to which both governments and private donors from all over the world add — and so could be seen as somewhat cushioned from the Trump administration’s blow to foreign health aid — the snag is that of the money the US Congress approves for Pepfar, about a quarter goes towards its Global Fund contribution. 

“Pepfar will change as a result of the [US] foreign aid review,” Jirair Ratevosian, a former head of staff at Pepfar and now an associate research scientist at Yale University, told Bhekisisa in a podcast in February. 

Both chambers of the US Congress — the House of Representatives and the Senate — passed a continuing resolution earlier this month, which includes funding Pepfar and The Global Fund.

A continuing resolution is when the Congress gives permission for money to be used to pay for government operations when an annual appropriation bill has not yet been approved. 

“At least at this point,” Mitchell Warren, the executive director of the New York-based advocacy organisation, Avac, explains, “it appears that some aspects of Pepfar and the funding for Global Fund, will continue. But the president is certainly exercising discretion about what to fund, whether it’s legal or not. And Congress has seemingly abdicated its powers to be part of the process. So things could still change.”

It’s hard to predict how Pepfar will come out at the other end, Ratevosian says, especially with Congress’s reauthorisation decision due on March 25. “But one thing is for sure: Pepfar is not going to look the same.” 

So what does this mean for what the Global Fund can expect to have in the kitty in the future, how it distributes its money, and the investment in global health it’s hoping for over the next three years? 

We break down the numbers.

Who gives what to the Global Fund?

A third of the Global Fund’s money comes from the US, capped at this level by law. (The country’s contribution was what kickstarted the fund in 2001). Since then, the US has put $26.3bn (R477.5bn) into the kitty.

Four other countries — France, the UK, Germany and Japan — together have given a similar share as the US, though their individual contributions are only about 20—30% of that of the US.

The political leaders of Canada, the EU, Sweden and Italy, along with private donors such as big international corporations and philanthropic foundations, have put just over 20% into the fund in the past 20-odd years. The total from such private contributions is in the same ballpark as what Japan and Canada has each given up to now.

If, in the worst case, Pepfar is cancelled altogether and there’s no way to force the US government to make good on its Pepfar promises, the fund could lose out on $4.1bn (R74.4bn) of the $6bn (R109bn) the US said it would add to the pot between 2023 and 2025, as they’ve so far given only $1.8bn (R32.7bn) — 30% — of the pledged contribution for this period. 

Money for HIV, TB and malaria

The fund raises money in three-year cycles called “replenishments” (it’s currently in its seventh replenishment round and preparing for the eighth replenishment). Payouts to recipients generally start a year after the beginning of the collection period, which means that money donated up to the end of 2025 can be used to fund programmes until the end of 2026. 

In 2023 the world had close to $20bn (R363bn) to spend on HIV. It was about five times more than what was available for malaria, and 3.5 times what could go to TB.

Our calculations show that countries’ governments generally paid for large chunks of their HIV and TB programmes themselves — about 60% of the costs for HIV and 80% of that for TB were covered in-house. For malaria, it’s different: only a third comes from domestic health budgets.

The gaps — 41% in the case of HIV, 20% for TB and 67% for malaria — were covered by donors’ money. The Global Fund’s portion of that means that for HIV it gave just more than a 10th of what the total the world needed for HIV, close to a sixth of the amount for TB and more than a third for malaria. 

South Africa got just over $1.4bn (about R25.4bn) from the Global Fund since 2017, with, on average, 90% going to HIV programmes, and 10% being spent on TB. 

What’s $18bn worth over the next three years?

In February, the Global Fund published its investment case for its eighth replenishment cycle, for which fundraising will run from 2026 to 2028. (An investment case is an analysis that shows how much benefit can come from spending a certain amount of money.)

The fund’s figures show that getting the total deaths from HIV, TB and malaria down to under 1-million by 2029, would need a commitment of $18bn (R326.8bn) from donors over the next three years. Getting to that point would mean deaths from these three diseases would have halved in just six years, compared with the 18 years it took before to achieve the same result. 

Up to 2023, deaths due to Aids dropped the most of all three diseases and were the biggest reason for the overall decline. 

However, if the US stops its contribution, continuing on this path and so hitting the goal of no more than 920,000 combined deaths could be in jeopardy. In fact, the fund’s 2024 results report shows that without their donors’ money, deaths from each of these diseases would likely have close to doubled in the last 20 years. 

The investment case further also shows that every $1 (R18.15) donated in this cycle would yield $19 (R344.78) worth of health benefits over the next three years. That’s because putting money towards curing illness now or preventing people from getting sick in the first place means not only that they stay healthy and economically productive, but also that less money will likely have to be spent on health services in future. 

It’s for this reason that the Global Fund says they will stand by their commitment to help pay for 2-million people to get at least one shot of the twice-a-year anti-HIV jab lenacapavir — with or without the US’s help. (Study results showed that the medicine was 100% effective in preventing young cisgender women from contracting HIV.) 

Said Peter Sands, the fund’s executive director, in an interview with Bhekisisa earlier this month: “We cannot afford to miss such a game-changing opportunity.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.