1

Results Report 2020 Mobile health workers Rubén and Erick are on their way to visit remote communities in the Bolivian Amazon to help diagnose, treat, and prevent malaria. UNDP and the Global Fund are working closely with the 2governmentSection of Bolivia to ensure these communities get the health services they need. 3 © UNDP Bolivia /Miguel Samper

Contents

4 Letter from the Executive Director 8 Key Results and Lives Saved 13 HIV: State of the Fight 25 Tuberculosis: State of the Fight 37 Malaria: State of the Fight 47 Resilient and Sustainable Systems for Health: the Cornerstone of Global Health Security

55 Fighting HIV, TB and Malaria in the Shadow of COVID-19 65 Investing for Impact 73 Note on Methodology

ON THE COVER: Nombasa Krune-Dumile is a front-line health care worker in Cape Town, South Africa, where she has dedicated her life to supporting tuberculosis patients through treatment. Nombasa has fought and survived HIV, TB and COVID-19. Now she has made it her life’s mission to help others in South Africa to also overcome these diseases. After beating COVID-19 in June, she is back in the trenches, supporting people suffering from TB. Nombasa has an urgent appeal to governments and global health partners to help. “Health workers need training and more PPE to protect themselves and their families. That support is needed now,” she says.

Read Nombasa’s full story here: https://www.theglobalfund.org/en/blog/ 4 Letter from the Executive Director 5

Letter from the Executive Director

At the end of 2019 there was a palpable sense COVID-19, we cannot escape the reality that There is still a long way to go. There were than 60% of new HIV infections globally; sex to around 30% in 2018. But approximately the results for 2020 will look very different still 690,000 AIDS-related deaths worldwide workers, men who have sex with men and 1.5 million people still died from this of excitement and expectation across the Global from the achievements of 2019 portrayed in in 2019, far too many, and much higher people who inject drugs are 26-30 times preventable, treatable disease in 2018, a Fund partnership as we celebrated the success this report. To protect hard won-gains and than UNAIDS’ global target of fewer than at greater risk of acquiring HIV than the shocking number. Moreover, multidrug- to sustain momentum, we must act with 500,000 by 2020. Even more concerning is general population, and transgender people resistant TB poses an increasing challenge, of the Global Fund’s Sixth Replenishment urgency, massively increasing collaboration, the slow pace of progress in reducing new are 13 times more likely to be infected. and now accounts for one-third of the world’s resources and innovation. Otherwise, we will HIV infections. Globally, there were Accelerating progress in addressing the deaths from antimicrobial resistance. Of the conference in Lyon, France. go backwards. 1.7 million new infections in 2019, meaning gender and human rights barriers to three diseases, TB is where we are furthest the global target of reducing new HIV accessing health care is vital to reducing off track. We have not been making fast We cannot let this happen. We must safeguard infections to fewer than 500,000 by 2020 the number of infections and improving the enough progress on deaths or infections Responding to our challenge to Step Up emergence of COVID-19. However, this year’s what we have achieved. And we must leverage would have been missed by a big margin, effectiveness of treatment services. to achieve a significant shift in trajectory. A the Fight, the world had committed more report underscores why we must do more to the lessons we have learned in fighting HIV, TB even before the impact of COVID-19. strategic initiative by the Global Fund, the than US$14 billion – the largest sum ever safeguard the gains we have made against HIV, and malaria to defeat COVID-19. TB was also once a global pandemic, and Stop TB Partnership and WHO that focuses raised by the Global Fund, and the largest TB and malaria as we fight the new pandemic. Human rights barriers to accessing heath while it is no longer a significant public health on 13 countries with the highest TB burden international fundraising in global health The fight against HIV and AIDS – the most care services, stigma, discrimination and threat in much of the developed world, it has sharply accelerated progress in finding ever. This success meant we could increase The stakes are extraordinarily high. Our 2019 recent deadly pandemic before COVID-19 – gender inequality continue to impede remains the world’s leading infectious disease people with TB. In these countries, by the end country allocations by 23.4% for the next results show the Global Fund partnership has demonstrates how a united world, led by strong progress in the fight against the HIV, TB killer, preying on poor and marginalized of 2018, more than 800,000 additional people three-year grant cycle, a huge step towards continued to achieve great impact against HIV, communities, can work together to drive a and malaria. In the fight against HIV, these communities. We have continued to step up ill with TB were found and treated, compared getting the world back on track towards TB and malaria, saving 38 million lives since disease into retreat. Deaths caused by the three issues continue to make key populations progress against TB, building on the increased with the baseline of 2015. In 2019, we also saw ending the three epidemics by 2030. 2002, including 6 million in 2019 alone. But diseases have dropped by nearly half since and adolescent girls and young women political commitment emerging from the UN indications of improvement in treatment of the knock-on effects of COVID-19 could be the peak of the epidemics in countries where much more vulnerable to infection. For High-Level Meeting on the Fight Against TB those with multidrug-resistant TB. We began Then the COVID-19 pandemic hit, and catastrophic. Recent modelling studies show the Global Fund invests. The world has made instance, in sub-Saharan Africa, five in six in 2018. The percentage of people with TB 2020 committed to stepping up such efforts everything changed. that deaths from HIV, TB and malaria could as progress in expanding testing and treatment new infections among adolescents aged “missed” by health systems – people who go even further, as well as investing more in much as double in the next year as a result of towards UNAIDS’s 90-90-90 targets1. At the 15-19 years are among girls. Key populations undiagnosed, untreated and unreported – treating latent TB by broadening access to As usual, our annual Global Fund Results COVID-19, wiping out decades of progress. end of 2019, nine countries in which the Global and their sexual partners account for more dropped significantly from nearly 40% in 2017 better preventive therapy. Report focuses primarily on the progress and Fund invests — Botswana, Cambodia, Eswatini, challenges of the previous year, so most of While the Global Fund partnership is already Namibia, Rwanda, Thailand, Uganda, Zambia the facts and data included here predate the acting to mitigate the knock-on impact of and Zimbabwe – had achieved this target. 1 Global targets of 90% of HIV-positive people who know their status; 90% of HIV-positive people who know their status on treatment; 90% of people on ARVs with suppressed viral load by 2020 6 Letter from the Executive Director 7 The Global Fund / Vincent Becker

In the fight against malaria, another disease massive gains in malaria control in the Since the beginning of March 2020, the point. We can surrender the gains we have world, whether rich or poor. In the richest that was once a global pandemic, the earlier part of the decade, progress has Global Fund has been actively supporting “ made against HIV, TB and malaria, and parts of the world where these diseases number of deaths worldwide continues to slowed significantly. countries’ responses to COVID-19, making This is an inflection allow our progress towards the SDGs to be have been mostly eliminated as public health decline – from 585,000 in 2010 to 405,000 up to US$1 billion available to adapt sharply reversed. Or we can act with speed threats, some may think the fight against in 2018. Since 2016, six countries – Algeria, To end these epidemics and to confront new existing HIV, TB and malaria programs, set point. We can surrender and scale, investing far greater resources these diseases has been won. The harsh truth Argentina, Kyrgyzstan, Paraguay, Sri Lanka threats like COVID-19, we must continue to up COVID-19 testing, tracing and patient the gains we have made than have yet been committed, to counter is that in the fight against HIV, TB and malaria and Uzbekistan – have been certified by build more resilient and sustainable systems care, and reinforce key components of both the direct impact of COVID-19 and to the world did leave people behind and these WHO as malaria-free, and other countries for health. We must strengthen workforce health and community systems, such as against HIV, TB and mitigate the knock-on consequences for diseases continue to kill millions of people are getting closer to this hugely important capacities, support dynamic community laboratory networks and community-led HIV, TB and malaria. in poor and marginalized communities. milestone. However, the reductions in malaria responses, build more efficient and effective monitoring. We must act with urgency to malaria, and allow our The Global Fund’s mission is to correct that mortality rates and number of malaria cases supply chains and data systems, and minimize disruption to lifesaving programs progress towards the The battle against COVID-19 cannot be wrong by ending the epidemics for everyone, have slowed markedly. In 2018, an estimated secure adequate and sustainable financing. to prevent and treat HIV, TB and malaria seen in isolation. We must see this not just everywhere. We must not repeat this mistake 228 million cases of malaria occurred The Global Fund is already the largest through investment in modified service SDGs to be sharply as a fight against a specific virus, but as with COVID-19, leaving the fight only part worldwide compared with 251 million cases multilateral funder of grants for systems for delivery approaches. We must provide reversed. Or we can act a catalyst to finish the as yet unfinished won. And we must redouble our efforts to in 2010. Cases of malaria in pregnant women health, investing more than US$1 billion a front-line health workers across formal and fights against HIV, TB and malaria, and to finish the fight against HIV, TB and malaria so and children remain high. Children under year, and the increased resources from the informal health sectors with the training and with speed and scale, strengthen preparedness against future that no one is left behind. In the fight against 5 accounted for 67% of the total malaria Sixth Replenishment will enable significant equipment they need to protect themselves investing far greater pathogens. We must measure success not infectious diseases as formidable as these, deaths in 2018, while an estimated 11 million expansion of funding, particularly in the and their communities. And we must just in reducing the death toll from COVID-19 and we know there will be more, no one is pregnant women living in sub-Saharan highest burden, lowest income countries. ensure all countries have the tools to fight resources than have itself, but in reducing the total impact of the truly safe until everyone is safe. Africa were infected with the disease and COVID-19, so that in the fight against this pandemic, including the knock-on effects on as a result 872,000 children were born with We began 2020 committed to stepping new virus, as in the ongoing fights against yet been committed, to the three epidemics. And we must leverage By its nature, a results report such as this is a low birth-weight. Moreover, insecticide up the fight against HIV, TB and malaria, HIV, TB and malaria, we leave no one behind. counter both the direct all the lessons from the fight against HIV, TB backward-looking, setting out the progress resistance threatens to undermine the determined to save even more lives, and malaria, and the capabilities we have achieved in previous years. But given the effectiveness of two of our most powerful accelerate the end of the epidemics, and help This report is published as the world grapples impact of COVID-19 and developed, to maximize our effectiveness in crisis we face, this report should also be tools: insecticide-treated mosquito nets and turbocharge progress towards SDG 3: health with an extraordinary global health crisis that to mitigate the knock-on combating the new virus. seen as a call to action. In 2020 we could indoor residual spraying. Drug resistance to and well-being for all. However, COVID-19 has already destabilized the global economy lose all we have achieved in the previous the most commonly used malaria treatment, threatens to derail our plans and reverse the and threatens to derail the entire Sustainable consequences for HIV, HIV, TB and malaria were all once global decade. We cannot let that happen. We artemisinin, is also on the rise. After making gains we have all worked so hard to achieve. Development Agenda. This is an inflection TB and malaria. pandemics, threatening people across the must unite to fight. Children play while waiting for a consultation at the Centro de Saude Pescadores in Maputo City, Mozambique. 8 Key Results and Lives Saved 9

20.1 million* Key Results PEOPLE ON ANTIRETROVIRAL THERAPY FOR HIV

The Global Fund / Karin Schermbrucker Karin / Fund Global The PEOPLE LIVING WITH HIV WHO ART COVERAGE PEOPLE LIVING WITH HIV WITH and Lives Saved KNOW THEIR STATUS SUPPRESSED VIRAL LOAD 71% 82% 90% 23% 67% 81% 41% 59% 73%

In the fight to end HIV, TB and malaria as epidemics, we measure our progress against the targets set in the global plans for HIV, tuberculosis and malaria1 and in Sustainable Development Goal 3: Health 2015 2019 2010 2019 2015 2019 and well-being for all. 2020 2020 2020 global target global target global target

The following page highlights the key results in the countries where the Global Fund invests in 2019. 5.7 million* PEOPLE WITH TB TREATED

1Targets for each disease are included in the UNAIDS Fast-Track Update on Investments Needed in the AIDS TB TREATMENT COVERAGE TB TREATMENT SUCCESS RATE ART COVERAGE AMONG HIV+ TB PATIENTS Response, 2016; WHO Global Technical Strategy for (ALL FORMS) Malaria, 2015; WHO End TB Strategy, 2014; and The 48% 65% 90% 86% 85% 90% 45% 88% 100% Stop TB Partnership Global Plan to End TB 2016 to 2020, 2015.

2010 2018 2025 2012 2017 2025 2010 2018 2025 global target global target global target 160 million* MOSQUITO NETS DISTRIBUTED

MOSQUITO NETS POPULATION COVERAGE MOSQUITO NETS POPULATION USE SUSPECTED MALARIA CASES TESTED

34% 58% Universal 30% 51% Universal 67% 90% Universal coverage coverage coverage

2010 2018 2030 2010 2018 2030 2010 2018 2030 global target global target global target

*Programmatic results achieved during 2019 by countries and regions where the Global Fund invests. Progress graphs are based on latest published data from WHO (2019 release for TB and malaria) and UNAIDS (2020 release).

Malaria coverage calculated based on 38 African countries for which data is available from WHO / Malaria Atlas Project estimates. 10 Key Results and Lives Saved 11

Health programs supported by the Global Fund partnership had saved 38 million lives as of the end of 2019. Overall, the number of

The Global Fund / Mustafa Hussain deaths caused by AIDS, TB and malaria each year has been reduced by nearly 50% since the peak of the epidemics in countries where the Global Fund invests.

It is important to recognize that this achievement is the result of efforts by a wide array of actors comprising the Global Fund partnership, including significant investments and initiatives implemented independently 38 million of the Global Fund. Key partners contributing to the progress against the three diseases include implementing countries; civil society groups; people affected by the diseases; bilateral partners such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), lives saved the President’s Malaria Initiative (PMI), Agence Française de Développement, the UK’s Foreign, Commonwealth & Development Office, Germany and Japan; key multilateral and technical partners such as World Health Organization, UNAIDS, the RBM Partnership to End Malaria, the Stop TB Partnership, Unitaid and Gavi, the Vaccine Alliance; private sector partners such as (RED); and foundations such as the Bill & Melinda Gates Foundation. For more information, see Note on Methodology section.

Coverage of treatment and prevention interventions

IN COUNTRIES WHERE THE GLOBAL FUND INVESTS

HIV - % of people living with HIV on antiretroviral therapy TB - % of TB treatment coverage Malaria - % of population with access to a long-lasting insecticide-treated net

100%

The Global Fund was founded

75%

50%

25%

0% 2000 2005 2010 2015 2019

On 21 November 2019 10,000 adolescent girls from 58 schools Malaria coverage calculated based on 38 African countries for which data is available from WHO / Malaria Atlas Project estimates in countries where the Global Fund invests. HIV and TB estimates gathered in Karachi, Pakistan to showcase the potential of are based on all countries where the Global Fund invests. Latest published WHO / UNAIDS data is used. Interactive Research and Development (IRD) Pakistan’s “Kiran Sitara” program, which trains and empowers girls to help fight TB in their communities while promoting healthy lifestyles. Activists march ahead of the 2019 launch of South Africa’s new national strategy to tackle human rights barriers to HIV and TB services. 12 Section 13 The Global Fund / Vincent Becker

HIV: State of the Fight

The fight against HIV and AIDS – the most recent deadly pandemic before COVID-19 – demonstrates how a united world, led by strong communities, can work together to drive a disease into retreat. 14 HIV: State of the Fight 15 The Global Fund / Kevin Keen The Global Fund / JB Russel / Panos

Educators from Alliance Côte d’Ivoire provide HIV prevention information and testing for HIV at a transport hub for buses, taxis and trucks in Toumodi, Côte d’Ivoire. In Ulaanbaatar, Mongolia, Delgerzaya M. and Usukhbayar D. help connect sex workers with the Perfect Ladies, a nongovernmental organization that provides HIV prevention training, outreach, testing, stress management resources and counseling for sex workers.

This report captures the latest information amount needed to effectively respond to HIV new adult HIV infections globally in 2019. We AIDS-related deaths Key results for 2019 in available on progress against HIV. The initial in 2020. While new infections have declined must do more to ramp up HIV prevention countries where the impact of COVID-19 on the fight against HIV since the peak of the epidemic, progress is efforts among those who carry the highest and HIV infections Global Fund invests: in 2020 is addressed on page 57. too slow. An estimated 1.7 million people were burden or are most vulnerable to the disease. infected with HIV in 2019 – the same number by age and sex The challenge as in 2018. The rise of antimicrobial resistance is also IN COUNTRIES WHERE THE • 133 million HIV tests taken; HIV-positive a factor we must grapple with in the fight GLOBAL FUND INVESTS people with knowledge of their status The world has made remarkable progress To end HIV as an epidemic, we must reach against HIV. Drugs for HIV treatment are increased from 71% in 2015 to 82% in 2019. 20.1m in the fight against HIV over the last people with the greatest HIV prevention needs at risk of becoming partly or fully inactive Global target: 90% by 2020. Female Male two decades. Efforts by communities, with prevention programs and break down the because of the emergence of drug-resistant PEOPLE ON ANTIRETROVIRAL governments and global health partners barriers that prevent people from accessing forms of the virus. To counter drug-resistance, • 20.1 million people on antiretroviral THERAPY FOR HIV IN 2019 have led to a decline in the number of new services. For example, while we have seen the Global Fund has aligned funding requests AIDS-RELATED DEATHS, 2019 therapy for HIV. Coverage increased

HIV infections and saved millions of lives. a 27% decrease in HIV infections among with the WHO Global Action Plan on HIV Aged 0-14 from 48% in 2015 to 67% in 2019. Treatment for people with HIV in particular young women and girls globally since 2010, Drug Resistance (2017-2021), which seeks to Global target: 81% by 2020. has registered great success. For instance, as gender-based violence and gender-related prevent HIV drug resistance from undermining 49% (45k) 51% (47k) of 2019, 14 countries – many of them in Africa inequalities continue to make young women efforts to achieve global targets on health • People living with HIV with suppressed viral Aged 15+ 718,000 – had achieved the UNAIDS 90-90-90 HIV and adolescent girls disproportionately and HIV, and to provide the most effective load increased from 41% in 2015 to 59% in treatment targets (90% of HIV-positive people vulnerable to HIV in the hardest-hit regions. treatment to all people living with HIV. 44% (223k) 56% (279k) 2019. Global target: 73% by 2020. HIV-POSITIVE MOTHERS RECIEVED MEDICINE TO PREVENT TRANSMITTING who know their status; 90% of HIV-positive In 2019, young women and adolescent girls in 0% 100% people who know their status on treatment; sub-Saharan Africa accounted for one in four • 718,000 HIV-positive mothers received HIV TO THEIR BABIES IN 2019 90% of people on ARVs with suppressed viral new infections, despite making up just 10% of medicine to keep them alive and prevent The Global Fund response NEW HIV INFECTIONS, 2019 load by 2020). the total population. transmitting HIV to their babies in 2019; The Global Fund provides 21% of all Aged 0-14 coverage increased from 44% in 2010 to But continued progress is not a given without Globally, infections among key populations international financing for HIV programs (9% 85% in 2019. Global target: 100% by 2020. 49% (71k) 51% (73k) sustained political and financial commitment. remain high. Sex workers, people who inject of all available resources) and has invested Total HIV funding for low- and middle- drugs, prisoners, transgender people, and US$21.2 billion in programs to prevent and Aged 15+ income countries continues to decline, with men who have sex with men – and their sexual treat HIV and AIDS and US$2.8 billion in TB/ 53% (601k) 47% (523k) an estimated shortfall of 30% in the overall partners – accounted for more than 60% of HIV programs as of June 2020. 0% 100% 16 HIV: State of the Fight 17

Treatment, care and support five prevention pillars – adolescent girls The HER Voice Fund is supported by ViiV of female sex workers stated that they were Key results for 2019 in and young women and their partners; key Healthcare Positive Action and implemented unable to access at least two HIV prevention countries where the Together with PEPFAR, the implementation populations; condoms; voluntary medical by the Global Network of Young People services in the three months preceding the of WHO’s “treat all” guidance and the male circumcision; and pre-exposure Living with HIV (Y+), with technical support survey. Among gay men and other men Global Fund invests: UNAIDS 90-90-90 strategy have led to a prophylaxis (PrEP) for populations at risk from Global Network of People Living with who have sex with men in 13 of 27 reporting significant increase in the number of – the Global Fund is increasing funding HIV (GNP+). countries, only one-third of this group was able • 9.9 million people reached with HIV people tested and started on antiretroviral and attention to HIV investments in these to access at least two HIV prevention services prevention services, including 5 million 9.9m therapy. Timely antiretroviral therapy saves five areas. For example, we are improving In these 13-hardes hit countries, the Global in a similar period. For men who inject drugs, members of key populations and 3.4 million lives, reduces onward transmission of HIV condom programming by strengthening Fund’s matching funds program used access to at least two HIV prevention services young people. PEOPLE REACHED and is highly cost-effective. While the demand creation and last mile supply efforts, US$55 million to mobilize an additional in the three months preceding the survey was WITH HIV PREVENTION IN 2019 90-90-90 strategy alone is not enough to along with ongoing investment in condom US$140 million for programs to reduce new recorded in 5 out of 9 reporting countries, • 1.3 million medical male circumcisions end the epidemic, achieving these targets and lubricant supplies. HIV infections, violence, and unintended while one-third of transgender women for HIV prevention. is crucial to cutting the death toll and pregnancies among 1 million adolescent girls achieved similar results in 8 of 9 reporting reducing new infections. The Global Fund’s HER initiative, launched and young women. countries1. The Global Fund continues to invest • Working together with PEPFAR and in 2018, works with the private sector in more to expand access to prevention services other organizations, the Global Fund has 1.3m 13 priority countries in sub-Saharan Africa Access to HIV prevention services for key for key populations and improve monitoring increased our investments in adolescent Prevention - Botswana, Cameroon, Eswatini, Kenya, populations varies greatly in countries evaluation systems to track progress. girls and young women fivefold in the MEDICAL MALE CIRCUMCISIONS Lesotho, Malawi, Mozambique, Namibia, where the Global Fund invests, and despite 2017-2019 period, to US$200 million. FOR HIV PREVENTION IN 2019 The Global Fund is committed to scaling up South Africa, Tanzania, Uganda, Zambia and significant progress more must be done Global Fund investments in HIV prevention the quality and quantity of HIV prevention Zimbabwe – to reduce HIV infection rates to protect these groups from HIV. In many are increasing. We will continue to track this programs and to increasing investments among adolescent girls and young women. countries that have conducted surveys since trend as we strive to see that HIV prevention in HIV prevention for key and vulnerable 2016 and reported the data to UNAIDS, access investments continue to be prioritized, populations. The Global Fund’s determination The HER Voice Fund, established with for key populations to HIV prevention services alongside our investments in high-impact to strengthen HIV prevention is reflected in support from the Global Fund, offers such as condoms and lubricants, counselling HIV testing and treatment programs. our participation in the Global HIV Prevention adolescent girls and young women small on condom use and safe sex, testing for Coalition and our commitment to the grants to ensure they are at the center of sexually transmitted infections and sterile 10-point plan to improve country delivery of designing, delivering and evaluating injection equipment remains low. In 12 out 1 Data on HIV prevention services for key populations is from the UNAIDS 2020 report “SEIZING THE MOMENT GLOBAL AIDS UPDATE : 2020 Tackling entrenched inequalities to end epidemics” prevention programs. Building on the plan’s programs and to reduce new HIV infections. of 20 countries, approximately two-thirds https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_en.pdf

New cases of HIV among 15 to 24-year-olds

PER 100,000 PEOPLE AT RISK, IN 13 PRIORITY COUNTRIES (RED)/ Jonx Pillemer Jonx (RED)/

Female Male

2001

2004

2007

2010

2013

2016

2019

2,000 1,500 1,000 500 0 0 500 1,000 1,500 2,000

HIV burden estimates from UNAIDS, 2020 release. 13 priority countries: Botswana, Cameroon, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, The IHATA Shelter hosts a sexual reproductive health workshop in Cape Town, South Africa. Zambia, Zimbabwe. These gatherings provide vital services to young women such as TB/HIV care and HIV testing. 18 HIV: State of the Fight 19

differentiated testing measures such as HIV investing in improving the quality of program “ self-testing means more people can know implementation across the prevention Trends in AIDS-related deaths their status so that those with HIV can start and treatment cascades with a focus on IN COUNTRIES WHERE THE GLOBAL FUND INVESTS In 2000, a one-year treatment, while those without the virus can differentiated service delivery and overall supply of antiretroviral access prevention services, thereby reducing program planning, continuous improvement infection rates. At least 77 countries around and assurance. With prevention and ARVs (actual) If there had been no prevention or ARVs % CHANGE, 2002-2019 therapy cost more than the world have adopted HIV self-testing US$10,000; now the policies, while many others are currently Progress 5 million developing them. The Global Fund supported figure is as low the purchase of 3.7 million self-testing kits In countries where the Global Fund invests, between 2018 and 2019. AIDS-related deaths since the Global Fund as US$66 per year. 4 was founded in 2002 have been reduced by +176% 61% and new infections have been reduced by Change in AIDS-related deaths if there had The Global Fund was founded been no prevention or ARVs Improved implementation 41% (see graphs on page 19). This achievement reflects steady progress toward the UNAIDS 3 HIV testing is an important strategy for We continue to achieve great financial 90-90-90 targets. The Global Fund’s prevention and to enable entry into treatment. savings in HIV health products through allocation model channels investments to the We support countries to expand differentiated increased coordination with other partners countries with the highest disease burden and 2 testing measures with the goal of increasing and more innovative, cost-effective the lowest economic capacity to respond, the number of people who know their HIV approaches. By leveraging economies of so the impact is maximized. While girls are status. HIV self-testing kits, developed with scale, working with partners such as USAID, still disproportionately affected compared to 1 the support of Unitaid, are a powerful and and negotiating directly with manufacturers, their male peers, HIV infection rates among innovative tool for increasing access to testing the Global Fund has had remarkable success adolescent girls and young women have for populations at higher risk of HIV infection in reducing prices for key medicines and dropped by 51% since 2010 in the 13 priority -61% 0 Actual change in AIDS-related deaths with by empowering them to choose where and health equipment. In 2000, a one-year countries (see graph below). prevention and ARVs 2000 2005 2010 2015 2019 when they want to take an HIV test. At the end supply of antiretroviral therapy cost more of 2019, globally 81% of people living with HIV than US$10,000; now the figure is as low knew their HIV status. Accelerating access to as US$66 per year. The Global Fund is also

New HIV infections among women age 15 to 24 Trends in new HIV infections

% CHANGE IN 13 PRIORITY COUNTRIES, 2010-2019 IN COUNTRIES WHERE THE GLOBAL FUND INVESTS

NEW HIV INFECTIONS, 2019 With prevention and ARVs (actual) If there had been no prevention or ARVs % CHANGE, 2002-2019

Eswatini South AfricaCameroon Lesotho Zimbabwe Kenya Botswana Namibia Uganda Malawi Tanzania, UnitedMozambique RepublicZambia 0% 55,000 8 million 30,000 The Global Fund was founded 10,000 1,500 -20% 6 +181% Change in new HIV infections if there had been no prevention or ARVs

-40% 4

-60% 2 -44% Actual change in new HIV infections -80% 0 with prevention and ARVs 2000 2005 2010 2015 2019

HIV burden estimates from UNAIDS, 2020 release. HIV burden estimates from UNAIDS, 2020 release. Estimation of “no prevention or ARVs” trends from Goals, AEM and AIM models. 20 HIV: State of the Fight 21

Investment and impact: HIV

AIDS-related HIV incidence People living People living People living Prevention of HIV AIDS-related HIV incidence People living People living People living Prevention of HIV deaths rate, per with HIV who with HIV with HIV with mother-to-child investment - deaths rate, per with HIV who with HIV with HIV with mother-to-child investment - 100,000 people know their receiving ARVs suppressed transmission Global Fund 100,000 people know their receiving ARVs suppressed transmission Global Fund status viral load coverage (2002-2020) status viral load coverage (2002-2020)

2010 2019 2015 2019 2010 2019 2015 2019 2010 2019 2010 2019 2015 2019 2010 2019 2015 2019 2010 2019 % change -42% -40% 1.0m 50 71% 82% 23% 67% 41% 59% 44% 85% Ethiopia -52% -58% 70% 82% 33% 74% 50% 66% 26% 74% $1.41bn (f) Countries where 30 the Global Fund $22.2bn 24k invests 595k 12k 37 16

Zambia -27% -37% 78% 90% 37% 85% 57% 77% 67% 86% $0.94bn (i, f) Countries with highest HIV burden and high level of Global Fund investments 24k 503 317 17k 2010 2019 2015 2019 2010 2019 2015 2019 2010 2019 -61% South Africa 183k -58% 85% 92% 23% 70% 45% 64% 71% >95% $0.97bn Lesotho -38% -48% 84% 93% 31% 65% 54% 61% 64% 84% $0.24bn (i) (d, i, f) 1.2k 948 7.8k 643 398 72k 4.8k

Nigeria -35% -31% 61% 73% 25% 65% 38% 52% 27% 43% $0.87bn Botswana -28% -44% 82% 92% 47% 82% 65% 79% 75% >95% $0.03bn (d, f) (i) 69k 854 6.9k 478 45k 74 52 5.0k

Mozambique -20% -35% 61% 77% 14% 60% 27% 45% 24% >95% $0.76bn Rwanda -43% -58% 80% 89% 42% 87% 64% 79% 61% >95% $0.97bn (d, i, f) (f) 63k 719 468 5.0k 104 44 51k 2.8k

Uganda -60% -59% 80% 89% 20% 84% 47% 75% 30% >95% $0.67bn Eswatini -49% -68% 89% 98% 34% 96% 62% 92% 66% >95% $0.21bn (d, i) (i) 1.5k 53k 4.6k 490 335 138 21k 2.3k

Tanzania, United -47% -38% 65% 83% 18% 75% 42% 69% 54% 92% $1.41bn Namibia -22% -46% 89% 95% 42% 85% 63% 78% 65% >95% $0.26bn Republic (i) (d, f) 52k 570 3.8k 310 235 146 27k 3.0k

Zimbabwe -61% -56% 80% 90% 30% 85% 54% 73% 30% 91% $1.22bn (d, i, f) 52k 639 281 20k For a detailed look at HIV results per country, visit the Global Fund Data Explorer at

Kenya -59% -55% 84% 90% 31% 74% 55% 68% 49% 94% $0.74bn data.theglobalfund.org (d) All data is based on mid-point estimates from UNAIDS 2020 release http://aidsinfo.unaids.org/, other than Global Fund disbursements which are available on the Global Fund Data Explorer. 51k The denominator for the three 90s is People Living with HIV. 208 21k 92 1. Countries listed on this page were selected based on three criteria: • being among the top-10 countries with the highest number of deaths in 2010 (d) • being among the top-10 countries with the highest incidence rate in 2010 (i) Congo, Democratic -61% -54% 24% 54% 8% 53% 18% 40% 6% 45% $0.62bn • being among top-10 countries that received the largest amount of funding from the Global Fund from 2002 to end-June 2020 to support HIV programs (f) Republic (d) Some countries appear in multiple lists; therefore, the total number of countries is less than 30. 37k 49 22 2. The aggregate numbers presented as “Countries where the Global Fund Invests” are limited to countries that received an allocation for the 2017-2019 cycle. These countries received 15k US$22.2 billion over 2002 to end-June 2020 to support HIV/AIDS and a portion of TB programs. Additionally, they received US$853 million for cross-cutting support across the three diseases. Countries that did not receive an allocation over the 2017-2019 cycle received US$1.3 billion since 2002 resulting in a total of US$23.5 billion. Malawi -59% -54% 78% 90% 28% 79% 52% 72% 27% >95% $1.20bn (d, i, f) 3. Having received more than US$ 1.2 billion in HIV/AIDS funding from the Global Fund, India ranks 4th in terms of share of Global Fund investment for HIV, however, the data for disease burden estimate and service coverage was not available from UNAIDS at the time of publication. 32k 425 194 4. In line with the Global Fund results reporting methodology, these charts reflect the achievements of national health programs, representing the outcomes and efforts and 13k investments of all partners domestic and international. For High Impact countries, Country Results Profiles provide further detail including investment from all funding sources: https://data.theglobalfund.org/home. See https://www.theglobalfund.org/en/methodology/ for a description of the Global Fund results methodology. 22 HIV: State of the Fight 23 Pact

Eswatini meets global 95-95-95 HIV target

Eswatini, a tiny country of just over a million countries with a high burden of HIV among Pact “ people in southern Africa, has one of the adolescent girls, the Global Fund invests in This success can highest HIV prevalence rates in the world: education, health and economic programs 27% of adults live with the disease. that focus on girls and young women to help be attributed to reduce their vulnerability to the disease. This But Eswatini, together with Switzerland, are includes through “Girl Champ”, a program by investments in the first countries to achieve the ‘95-95-95’ Project Last Mile in Eswatini that informs and HIV prevention global HIV target. This means that 95% of empowers adolescent girls to protect their people living with HIV in Eswatini know their health by setting up safe, girls-only spaces and treatment status, that 95% of people who know their for youth-centered dialogue on vital health interventions HIV-positive status are accessing treatment issues including HIV prevention. and that 95% of people on treatment have targeting the suppressed viral load. The ‘95-95-95’ hardest-to-reach deadline is 2030, meaning Eswatini reached the target an entire decade in advance. and most vulnerable This success can be attributed to investments populations. This in HIV prevention and treatment interventions includes girls and targeting the hardest-to-reach and most vulnerable populations. This includes girls and young women. young women – who across East and southern Africa continue to be disproportionately affected by HIV. In Eswatini, 63% of people living with HIV are women. 63% There is evidence that keeping adolescent girls in school reduces their vulnerability OF PEOPLE LIVING WITH HIV to HIV infection. Across Eswatini and other IN ESWATINI ARE WOMEN Adolescent girls and young women take part in a safe sex training facilitated by Pact Eswaziland, where they learn about relationships, safe sex, HIV prevention, gender and strategies for those living HIV. Aliou Diof takes his treatment at a TB health center in Yeumbeul, Senegal. 24 Section 25 The Global Fund / Ricci Shryock

Tuberculosis: State of the Fight

Once a global pandemic, TB remains the world’s leading infectious disease killer, preying on poor and marginalized communities. 26 Tuberculosis: State of the Fight 27 © UNDP / Aurelia Rusek The Global Fund / Vincent Becker

A Syrian family in Zaatari refugee camp in Jordan. The father completed treatment for TB. TB treatment is available free of charge to people living inside the camp. A patient undergoes a chest exam at the only hospital in the small South Pacific island country Tuvalu.

This report captures the latest information with drug-resistant TB, with 78% of them from 49% in 2014 to 33% in 2018. The largest “ available on progress against TB. The initial developing multidrug-resistant TB. Testing and treatment increases in the numbers of people being The gap between TB notifications and TB impact of COVID-19 on the fight against TB in Only one in three people with drug- diagnosed with TB were achieved in some 2020 is addressed on page 57. resistant TB accessed care – and only In the last two years, a coalition of global of the countries with the highest burden of incidence in 13 focus countries fell from 49% half of those completed treatment. The health partners including the Global Fund TB in Asia: Bangladesh, India, Indonesia and The challenge other half died or continued to spread has invested vigorously to find more of the the Philippines. African countries such as in 2014 to 33% in 2018. The largest increases in the disease. This drug-resistant form of millions of people falling ill with TB who are Mozambique and the Democratic Republic the numbers of people being diagnosed with TB remains the world’s biggest infectious TB poses a potentially catastrophic risk missed by health systems. Those efforts are of Congo also achieved large proportionate killer, with 1.5 million people dying of the to global health security. Already drug- bearing fruit. In 2018, 7 million people with increases in their TB case notifications. This TB were achieved in some of the countries disease in 2018 (including HIV-positive resistant TB accounts for one-third of TB were found globally – up from 6.4 million progress in finding missing people with TB with the highest burden of TB in Asia. people). The disease is still the leading killer deaths caused by all types of in 2017. The percentage of people missed by puts us on track to meet the goal set at the of people living with HIV, causing one in antimicrobial resistance. health systems dropped significantly from UN High-Level Meeting on the Fight Against three deaths. Progress in ending TB as an 46% in 2013 to around 30% in 2018. TB of finding and treating 40 million people epidemic remains slow. by 2022. The Global Fund response The Global Fund is working with the Stop TB “Missing” people with TB – people who Partnership and WHO to find 1.5 million more To fight antimicrobial resistance, we must go undetected, untreated or unreported – The Global Fund provides 73% of all “missing” people with TB every year (against invest strongly in the fight against drug- contribute to ongoing transmission of international financing for TB (9% of total a 2015 baseline) in the 13 countries that resistant TB. Our partnership has also the disease and the spread of drug- available resources) and has invested account for 75% of missing cases globally negotiated reduced prices for bedaquiline resistant TB. Of the 10 million people who US$7.2 billion in programs to prevent and (Bangladesh, Democratic Republic of Congo, – a relatively new drug to treat drug-resistant fell ill with TB in 2018, around 3 million treat TB as of June 2020. Key indicators India, Indonesia, Kenya, Mozambique, TB. The drug has fewer side effects and people were missed by health systems. for success in the fight against TB focus Myanmar, Nigeria, Pakistan, Philippines, is more effective than earlier treatments, One person with active, untreated TB can on: finding more missing people with TB; South Africa, Tanzania and Ukraine). The increasing the probability that people will spread the disease to as many as 15 other improving access to quality diagnosis, results recorded in these countries in the stay on the treatment and be cured. 169,571 people in a year. treatment and care; scaling up prevention; last year are tremendously encouraging. CHILDREN EXPOSED TO TB RECEIVED and identifying and treating drug-resistant The Global Tuberculosis Report 2019 shows PREVENTIVE THERAPY IN 2019 Drug-resistant TB is on the rise. In 2018, TB. We have accelerated progress on all that the gap between TB notifications and about half a million people became ill these fronts. TB incidence in these 13 focus countries fell 28 Tuberculosis: State of the Fight 29

Prevention Improved access to TB diagnosis and Treatment outcomes “ transition to newer regimens for multidrug- To win the fight against TB, preventing more resistant TB are also yielding results. IN WHO HIGH BURDEN COUNTRIES SUPPORTED BY THE GLOBAL FUND In countries where infections is fundamental. About 30% of Improved case notification through contact the Global Fund the Global Fund’s TB investments support tracing will require the effective use of interventions on TB care and prevention, a range of systems, including stronger Treatment successful Failed Died Lost to follow up Not evaluated invests, TB deaths particularly for children and other vulnerable community systems to ensure people ill since the Global groups such as people living with HIV. In line with TB are treated and monitored. DRUG-SENSITIVE TB CASES, 2017 with the global targets set at the 2018 UN All countries where the Global Fund invests Fund was founded Ethiopia High-Level Meeting on the Fight Against TB, Cambodia in 2002 have been 169,571 children in contact with TB patients Progress Bangladesh received preventive therapy in 2019 in Pakistan reduced by 25%. countries where the Global Fund invests. In countries where the Global Fund invests, Viet Nam Philippines TB deaths (excluding HIV positive) since the Congo, Democratic Republic In 2019, we entered into an agreement with Global Fund was founded in 2002 have been Mozambique Unitaid and Sanofi to achieve a significant reduced by 25%. TB control measures have Sierra Leone reduction in the price of rifapentine, a critically stopped the TB epidemic from expanding Tanzania, United Republic Zambia important drug used to prevent TB. The (see Trends in TB cases graph on page 30). Myanmar agreement will bolster efforts to treat latent Nigeria TB infection – currently estimated to affect Namibia 1.7 billion people worldwide – by broadening Indonesia access to better preventive therapy. The Thailand Korea, Democratic Peoples Republic volume-based agreement will discount the Kenya price of a three-month treatment course of Zimbabwe rifapentine by nearly 70%, from approximately India US$45 to US$15 in the public sectors of 100 Central African Republic Liberia low- and middle-income countries burdened South Africa by TB and TB/HIV coinfection. Lesotho Papua New Guinea Congo Angola 0% 20% 40% 60% 80% 100% TB cases by Key results in age and sex countries where the MDR-TB CASES, 2016 Global Fund invests: All countries where the Global Fund invests IN COUNTRIES WHERE THE Congo, Democratic Republic GLOBAL FUND INVESTS Korea, Democratic Peoples Republic • 5.7 million people treated for TB in 2019. TB Kazakhstan treatment coverage increased from 48% in Myanmar Somalia 2010 to 65% in 2018, and the TB treatment 5.7m Bangladesh TB CASES, AGED 0-14, 2018 success rate reached 85% in 2017. Global Nigeria 100% targets for coverage and treatment success PEOPLE TREATED FOR TB IN 2019 Papua New Guinea rates: 90% by 2025. Ethiopia 48% of TB cases were Viet Nam female (512k) Kenya • 125,000 people on treatment for multidrug- Belarus resistant TB in 2019; treatment coverage Tajikistan reached 38% in 2018 and MDR-TB treatment Pakistan 52% success rate increased from 51% in 2010 to Thailand of TB cases were male 125,000 Azerbaijan 0% (553k) 57% in 2016. Global targets: 90% MDR-TB Peru treatment coverage and success by 2030. PEOPLE ON TREATMENT FOR Philippines MDR-TB IN 2019 Uzbekistan • 6,107 people with extensively drug- Zimbabwe TB CASES, AGED 15+, 2018 South Africa resistant TB on treatment in 2019. Kyrgyzstan 100% Moldova 36% • 315,000 HIV-positive TB patients on Mozambique of TB cases were female Ukraine (2.8m) antiretroviral therapy during TB treatment Indonesia in 2019; coverage of ARVs in notified HIV- 6,107 India positive TB patients increased from 45% in Angola 64% 2010 to 88% in 2018. Global target: 100% PEOPLE WITH EXTENSIVELY DRUG- 0% 20% 40% 60% 80% 100% of TB cases were male among detected cases. RESISTANT TB ON TREATMENT IN 2019 Source: TB treatment outcomes for new and relapse TB cases, WHO Global TB Report 2019, WHO list of high burden countries. See footnote 3, p. 33 regarding data for India. 0% (4.8m) A lab worker at the laboratory of the Republican Scientific and Practical Center of Pulmonology and Tuberculosis (RSPCPT) in Minsk, Belarus, holds a test tube with a sample 30 Tuberculosis: State of the Fight used for TB diagnosis.Tuberculosis: The lab was State established of the with Fight Global Fund support in 2013. 31

Trends in TB deaths (excluding HIV-positive)*

IN COUNTRIES WHERE THE GLOBAL FUND INVESTS The Global Fund / Vincent Becker

With TB control (actual) If there had been no TB control % CHANGE, 2002-2018

4 million

The Global Fund was founded

3 +118% Change in deaths if there had been no TB control

2

1 -25% Actual change in deaths with TB control

0 2000 2005 2010 2015 2018

*While major control eorts for malaria and HIV began with the launch of the Millennium Development Goals in 2000, TB control eorts began much earlier. The counter-factual and actual results therefore diverged from each other much earlier, making this graph look considerably dierent than its HIV and malaria counterparts.

Trends in new TB cases (all forms)

IN COUNTRIES WHERE THE GLOBAL FUND INVESTS

With TB control (actual) If there had been no TB control % CHANGE, 2002-2018

12 million The Global Fund was founded +31% 10 Change in cases if there had been no TB control

8

6 -2% Actual change in cases with TB control 4

2

0 2000 2005 2010 2015 2018

TB burden estimates from WHO Global TB Report 2019. Estimation of “no TB control” trends for TB deaths from WHO and for new TB cases based on the assumption of constant trend in new TB cases since 2000. 32 Tuberculosis: State of the Fight 33

Investment and impact: Tuberculosis

TB deaths TB incidence TB treatment TB treatment MDR-TB HIV+ TB TB investment - TB deaths TB incidence TB treatment TB treatment MDR-TB HIV+ TB TB investment - (excluding HIV+) rate, per coverage success rate treatment patients on Global Fund (excluding HIV+) rate, per coverage success rate treatment patients on Global Fund 100,000 people success rate ART (2002-2020) 100,000 people success rate ART (2002-2020)

2010 2018 2010 2018 2012 2017 2010 2016 2010 2018 2010 2018 2010 2018 2012 2017 2010 2016 2010 2018 % change -11% -17% 1.3m 258 48% 65% 86% 85% 51% 57% 45% 88% Viet Nam -43% -21% 48% 57% 91% 92% 78% 68% 43% 93% $0.14bn Countries where 214 the Global Fund $7.1bn (m) 18k 231 182 invests 1.2m 11k

Mozambique +43% +1% 34% 57% 87% 90% 29% 50% 25% 96% $0.09bn (i, m) Countries with highest TB burden and high level of Global Fund investments 21k 545 551 15k

2010 2018 2010 2018 2012 2017 2010 2016 2010 2018 Ukraine -55% -27% 67% 75% 71% 76% 29% 49% 39% 79% $0.15bn (m) 8.2k -11% 110 80 India 494k -20% 44% 71% 88% 81% 48% 48% 57% 90% $0.85bn 3.7k (d, m, f) +21% No change 28% 43% 68% 78% No 59% 62% 85% $0.01bn 247 199 Central African 440k Republic data (i) 4.8k 540 540 4.0k Indonesia -17% -8% 36% 67% 86% 85% 72% 48% 29% 40% $0.36bn (d, m, f) 112k 342 316 Namibia -4% -41% 60% 61% 85% 86% 58% 71% 44% 97% $0.05bn 93k (i) 892 1.6k 524 1.6k Nigeria +44% No change 24% 24% 86% 86% 61% 77% 33% 87% $0.35bn (d, m, f) 125k Gabon +17% -6% 42% 51% 54% 25% No 57% 52% 46% $0.004bn 219 219 87k (i) data 1.6k 559 525 1.4k Bangladesh -41% No change 47% 75% 92% 94% 75% 78% 100% 94% $0.34bn (d, f) 79k Lesotho -17% -45% 52% 55% 71% 76% 68% 77% 27% 92% $0.03bn 221 221 47k (i) 1.1k 1.1k 611 Myanmar -58% -32% 52% 76% 89% 87% 70% 79% 98% 71% $0.21bn 1.0k (d, m, f) 50k 500 338 Djibouti -39% -58% 80% 80% 31% 85% No 69% 11% 63% $0.01bn 21k (i) data 0.4k 621 260 0.3k Pakistan -9% -4% 53% 64% 91% 93% 70% 64% 43% 66% $0.40bn (d, m, f) 47k 276 265 Eswatini -45% -72% 80% 80% 72% 86% 57% 72% 35% 98% $0.04bn 43k (i) 1.2k 0.3k 329 0.1k Congo, Democratic +15% -2% 54% 63% 88% 90% 36% 86% 9% 87% $0.18bn Republic (d, f) 43k 327 321 37k

Tanzania, United -36% -41% 32% 53% 90% 90% 75% 80% 35% 98% $0.12bn Republic 35k For a detailed look at TB results per country, visit the Global Fund Data Explorer at (d) 426 253 22k data.theglobalfund.org

Kenya -41% -45% 45% 63% 86% 83% 82% 68% 48% 97% $0.16bn All data is based on mid-point estimates from Global tuberculosis report 2019 https://www.who.int/tb/data/en/, other than Global Fund disbursements which are available on (d, i, f) the Global Fund Data Explorer. 33k 531 292 19k 1. Countries listed on this page were selected based on four criteria: • being among the top-10 countries with the highest number of deaths in 2010 (d) • being among the top-10 countries with the highest incidence rate in 2010 (i) Ethiopia -24% -44% 66% 69% 91% 96% 84% 72% 39% 91% $0.20bn • being among the top-10 countries with highest number of estimated MDR-TB cases in 2018 (m) (d, f) • being among top-10 countries received highest amount of funding from the Global Fund from 2002 to end-June 2020 to support TB programs (f) 32k 268 151 24k Some countries appear in multiple lists; therefore, the total number of countries is less than 40.

2. The aggregate numbers presented as “Countries where the Global Fund invests” are limited to countries that received an allocation for the 2017-2019 cycle. These countries received US$7.1 Philippines -17% +4% 33% 63% 88% 91% 42% 58% No 91% $0.33bn billion from 2002 through June 2020 to support TB and a portion of HIV programs. Additionally, they received US$870 million for cross-cutting support across three diseases. Countries that (i, m, f) data 31k 531 554 did not receive an allocation over 2017-2019 cycle received US$764 million since 2002, resulting in a total of US$7.8 billion 26k 3. Due to the improved method for monitoring treatment outcomes in India which is a significant country for portfolio level results, the 2016 and 2017 treatment success rate results cannot be compared with the historical results. The TB patients reported from the private sector to the national program were excluded from the 2016 and 2017 cohort for India since the monitoring South Africa -18% -45% 73% 76% 77% 77% 40% 54% 54% 87% $0.05bn system for assessing their outcome was not fully in place. (i, m) 948 26k 520 4. In line with the Global Fund results reporting methodology, the charts reflect the achievements of national health programmes, representing the outcomes, efforts and 21k investments of all partners, domestic and international. For High Impact countries, Country Results Profiles provide further detail including investment from all funding sources: https://data.theglobalfund.org/home. See https://www.theglobalfund.org/en/methodology/ for a description of the Global Fund results methodology. 34 Tuberculosis: State of the Fight 35

The Global Fund / Vincent Becker

Inside a high-tech mobile testing lab, a lab technician uses a GeneXpert machine to identify the presence of TB bacteria in sputum samples. These mobile vans travel from clinic to clinic throughout rural India, increasing local TB testing capacity.

Finding and treating India’s “missing” TB patients A mobile testing lab is parked outside a rural clinic east of Mumbai, India.

molecular technology that is more accurate “ and yields faster results than traditional An initiative supported by the Global Fund, TB diagnosis methods. In the town of Rajgurunagar, about 150 kilometers east of WHO and the Stop TB Partnership showed that Mumbai, these machines cut down TB test result wait times from eight days to only a six countries in Asia found an additional 555,000 few hours. cases of TB in 2018 compared to 2017 results. With continued investments in finding More than 60% of these patients – approximately “missing” TB patients, India is making steady 344,000 people – were in India. progress to meet its ambitious goal of eliminating TB by 2025.

A significant challenge in the fight against its “missing” patients. Early results from TB is identifying the estimated 3 million an initiative supported by the Global Fund, “missing” people with active TB – those who WHO and the Stop TB Partnership showed are undiagnosed, unreported and untreated that six countries in Asia found an additional – each year. Often these patients come from 555,000 cases of TB in 2018 compared to 2017 groups that are particularly vulnerable to the results. More than 60% of these patients – disease and who continue to face barriers approximately 344,000 people – were in India. accessing their right to health care such as migrants, miners, prisoners, children and Getting cutting-edge technology into hard- people affected by HIV. to-reach communities has been vital to this success. In India a fleet of vans equipped 344,000 India has the world’s largest TB epidemic, with TB testing machines are regularly “MISSING” TB PATIENTS but recently, the country has experienced deployed, providing rural and hard-to- IN INDIA FOUND IN 2018 significant progress in finding and treating reach communities access to sophisticated Patients wait in the entrance hall of a rural clinic east of Mumbai India. TB testing and treatment is provided at no cost to the patient. 36 Section 37

Malaria: State of the Fight

In the fight against malaria, another disease that was once a global pandemic, the number of deaths worldwide continues to decline – however, the reductions in malaria mortality rates and number of cases have slowed markedly.

A community health worker in Burkina Faso examines a child before administering an anti- malaria prophylactic as part of a nationwide seasonal malaria chemoprevention campaign to reduce the prevalence of malaria in children. Malaria is the deadliest disease in Burkina Faso.

The country continues to be one of the 10 countries most affected by malaria in the world. The Global Fund / JB Russel / Panos 38 Malaria: State of the Fight 39

This report captures the latest information Testing and treatment early 2020. Studies have shown that the new In the Sahel, where we see some of the “ available on progress against malaria. The nets are better than standard nets at repelling world’s highest rates of malaria among Global malaria initial impact of COVID-19 on the fight against Community health workers are on the and killing mosquitoes, including those children, the Global Fund supports 243m malaria in 2020 is addressed on page 57. frontlines in testing and treating people for resistant to pyrethroids. The fact that the nets community health workers to implement death rates have malaria. These health workers are at the are treated with two insecticides means they seasonal malaria chemoprevention SUSPECTED CASES TESTED FOR dropped by The challenge center of malaria prevention and treatment can still kill mosquitos that are resistant to campaigns to prevent malaria in children MALARIA IN 2019 in many countries. They are trained to one of the two main insecticides, thus better under 5. Investments to provide this 60% since 2000. While great progress continues to be offer basic education and primary care protecting people who use the nets. Global intervention in the Sahel over four Between 2010 and made against malaria, the world’s in the fight against infectious diseases, health partners are working to determine transmission seasons — 2015 to 2018 — are extraordinary achievements in the fight bringing access to malaria prevention and how much better these new nets are when estimated to have prevented over 22.5 million 2018, estimated against the disease in the past 20 years treatment to homes of underserved rural compared with standard nets to help inform malaria cases and 100,000 deaths. are at risk. Global malaria death rates have communities out of reach of health clinics. both global and national-level decision malaria deaths dropped by 60% since 2000. Between 2010 They support communities to use mosquito making on the best tools for each setting. globally declined and 2018, estimated malaria deaths globally nets to prevent malaria and in testing and Progress declined from 585,000 to 405,000, and treating the disease. The community health In 2019, Ghana, Kenya and Malawi launched from 585,000 malaria cases fell from 251 million to workers offer a trusted first point of care pilots of the world’s first malaria vaccine in Since 2010, the highest burden countries to 405,000, and 228 million. In 2016, WHO identified 21 for people with malaria. In WHO’s African partnership with the Global Fund, WHO, Gavi, have achieved significant declines in the countries with the potential to eliminate Region, which accounts for more than 90% the Vaccine Alliance, and Unitaid. The pilots overall number of deaths as well as driving malaria cases fell malaria by the year 2020. Since then six of malaria cases, there are about a million aim to vaccinate around 360,000 children down incidence rates (see graphs on page from 251 million countries – Algeria, Argentina, Kyrgyzstan, community health workers. per year in the three countries to assess the 40). In countries where the Global Fund Paraguay, Sri Lanka and Uzbekistan – have vaccine’s potential role in reducing childhood invests, malaria deaths have reduced by 46% to 228 million. been certified by WHO as malaria-free. Responding to the threat of increasing drug deaths and its safety in the context of routine since 2002. Through leveraging economies of Other countries are edging closer to resistance in the Greater Mekong region, use. If successful, these trials could give us scale, working with partners and negotiating this milestone. the Global Fund continues to invest strongly a potentially valuable new tool in the fight directly with manufacturers, the cost of an through the Regional Artemisinin-resistance against the disease. insecticide-treated mosquito net is now down However, we continue to face challenges Initiative (RAI). It is the Global Fund’s largest to less than US$2 and the cost of antimalarial that threaten our investments in malaria. regional grant and seeks to accelerate Malaria knows no borders, so we are also treatment dropped to US$0.58 in 2019 – Insecticide resistance has become a malaria elimination in the region through increasing cross-border partnerships. In savings that enabled us to purchase more significant threat, undermining the efficacy rigorous testing, treating and tracking of 2019, together with the U.S. President’s than 14 million extra nets and treat more than of two of our greatest tools: insecticide- malaria cases. The RAI program shows what Malaria Initiative (PMI) we supported the 24 million additional people for malaria. treated nets and indoor residual spraying can be done through a targeted, multi- governments of Senegal and Gambia to Malaria deaths of homes and other buildings. In Asia’s country approach: the number of cases has launch a joint campaign to distribute 11 million by age Mekong region, we are seeing growing fallen by 71% since 2012, and deaths have mosquito nets to fight malaria, synchronizing 124m resistance to today’s most effective plummeted by 91%. Continued progress mass net distribution on both sides of an IN COUNTRIES WHERE THE malaria drug, artemisinin. Progress in is critical to avoid drug resistance from international border for the first time. CASES OF MALARIA TREATED IN 2019 GLOBAL FUND INVESTS malaria control over the past decade has spreading, which could lead to a devastating stalled, with the number of malaria cases setback for the region itself and elsewhere increasing in several high burden countries. 100% The number of deaths from malaria is not Key results in countries where the Global Fund invests: 33% decreasing fast enough. To safeguard the Prevention of malaria deaths in 2018 gains we have made against the disease, were among children over 5 and adults and continue to make progress towards To prevent malaria, a multi-pronged • 160 million mosquito nets distributed (132k) ending malaria, we must continue to approach using multiple tools is key: mass to protect families from malaria in 2019 develop, test and bring to scale new tools distributions of insecticide-treated nets; Coverage of population with access to 160m 8m and solutions. surveillance systems to track and report a long-lasting insecticide-treated net MOSQUITO NETS DISTRIBUTED STRUCTURES COVERED BY INDOOR on outbreaks; indoor residual spraying to increased from 34% in 2010 to 58% in 2018. TO PROTECT FAMILIES FROM RESIDUAL SPRAYING IN 2019 kill mosquitos in homes and buildings; and MALARIA IN 2019 The Global Fund response seasonal malaria chemoprevention, which • Coverage of population using a net helps to prevent malaria in children under 5. increased from 30% in 2010 to 51% in 2018. The Global Fund provides 56% of all But as the malaria parasite evolves and drug Global target: Universal access to vector international financing for malaria resistance increases, we must develop more control for populations at risk. programs (37% of total available resources) innovative tools and approaches. and has invested more than US$13.2 billion • 11 million pregnant women received 11m in malaria control programs as of June The Global Fund and Unitaid are each preventive therapy in 2019. PREGNANT WOMEN RECIEVED 2020. We are taking urgent steps to investing US$33 million from 2018 to 2022 to PREVENTATIVE THERAPY FOR invest to safeguard progress against the introduce new insecticide-treated nets to fight • 8 million structures covered by indoor MALARIA IN 2019 67% disease as well as push to accelerate the malaria-carrying mosquitoes. The nets were residual spraying in 2019. of malaria deaths in 2018 were among children under 5 progress towards meeting the global goal first deployed in 2019 in Burkina Faso with 0% (271k) of ending malaria by 2030. further distributions in Mali and Rwanda in In Guinea-Bissau, five-year-old Ramatu has slept under a mosquito net since she was born and has never had malaria. Her mother received the net during a distribution campaign in 2017. Every three years, the 40 Malaria: State of the Fight Global Fund and UNDP finance and organize a national mosquito net distribution campaign in Guinea- 41 Bissau. Malaria is the leading cause of mortality and a significant cause of poverty across the country.

Trends in malaria deaths

IN COUNTRIES WHERE THE GLOBAL FUND INVESTS

With malaria control (actual) If there had been no malaria control % CHANGE, 2002-2018 © UNDP Guinea Bissau / Gwenn Dubourthoumieu 1.5 million The Global Fund was founded +65% Change in deaths if there had been no 1.0 malaria control

0.5 -46% Actual change in deaths with malaria control

0 2000 2005 2010 2015 2018

Trends in malaria cases

IN COUNTRIES WHERE THE GLOBAL FUND INVESTS

With malaria control (actual) If there had been no malaria control % CHANGE, 2002-2018

400 million

The Global Fund was founded +62% Change in cases if there had been no malaria control 300

200 -5% Actual change in cases with malaria control

100

0 2000 2005 2010 2015 2018

Malaria burden estimates and estimation of “no malaria control” from WHO Global Malaria Program, 2019 release. 42 Malaria: State of the Fight 43

Investment and impact: Malaria

Malaria Case incidence People with access People using People with Malaria investment - Malaria Case incidence People with access People using People with Malaria investment - deaths rate, per 1,000 to long-lasting long-lasting suspected malaria Global Fund deaths rate, per 1,000 to long-lasting long-lasting suspected malaria Global Fund people at risk insecticidal nets insecticidal nets receiving (2002-2020) people at risk insecticidal nets insecticidal nets receiving (2002-2020) diagnostic test diagnostic test

2010 2018 2010 2018 2010 2018 2010 2018 2010 2018 2010 2018 2010 2018 2010 2018 % change -31% -21% 583k 94 34% 58% 30% 51% 67% 90% Côte d'Ivoire -44% -30% 37% 80% 33% 70% No 92% $0.39bn 74 (d, i, f) data Countries where 469 $12.4bn 331 the Global Fund 16k invests 404k 9.3k

Ghana -26% -38% 23% 75% 20% 66% 45% 60% $0.43bn (f) Countries with highest malaria burden and high level of Global Fund investments 364 15k 224 11k 2010 2018 2015 2018 2010 2018 2010 2018 -38% Nigeria 153k -27% 25% 49% 22% 43% 1% 74% $1.17bn Ethiopia -67% -75% 41% 39% 36% 35% 46% 96% $0.68bn (d, i, f) (f) 399 292 14k 128 32 96k 4.8k

Congo, Democratic -30% -25% 31% 71% 28% 63% 35% 95% $1.01bn Sierra Leone -53% -30% 5% 73% 4% 64% 100% 98% $0.07bn (i) Republic 459 (d, i, f) 63k 428 320 320 14k 45k 6.6k

Burkina Faso -59% -28% 29% 48% 26% 43% 19% 89% $0.29bn Guinea -39% -32% 17% 59% 15% 52% No 87% $0.15bn (d, i) 551 (i) data 415 399 284 31k 13k 13k 8.2k

India -68% -70% No data No data 100% 100% $0.21bn Kenya +8% +4% 43% 74% 38% 65% 32% 44% $0.38bn (d) (f)

30k 12k 68 70 10k 18 5 11k

Niger -21% -16% 49% 58% 44% 51% 72% 94% $0.20bn Central African -50% -20% 22% 63% 19% 55% No 98% $0.09bn (d, i) Republic data 426 (i) 435 357 347 22k 7.4k 17k 3.7k

Uganda -35% -31% 41% 88% 37% 78% 24% 82% $0.57bn Sudan +85% +52% 35% 51% 31% 45% 69% 80% $0.41bn (d, i, f) (f) 417 289 20k 5.0k 31 47 13k 2.7k

Tanzania, United +12% -15% 52% 59% 46% 52% 25% 99% $0.68bn Republic For a detailed look at malaria results per country, visit the Global Fund Data Explorer at (d, f) data.theglobalfund.org 22k 145 124 19k Data is based on mid-point estimates from World Malaria Report 2019 https://www.who.int/publications/i/item/9789241565721, World Malaria Atlas Project data for bednet access and use in countries for which estimates are available, https://malariaatlas.org/; and Global Fund disbursements which are available on the Global Fund Data Explorer.

Mozambique -15% -23% 34% 60% 30% 53% 70% 100% $0.42bn 1. Countries listed on this page were selected based on three criteria: (d, i, f) • being among the top-10 countries with the highest number of deaths in 2010 (d) 398 305 • being among the top-10 countries with the highest incidence rate in 2010 (i) 17k • being among top-10 countries received highest amount of funding from the Global Fund from 2002 to end-June 2020 to support malaria programs (f) 14k Some countries appear in multiple lists; therefore, the total number of countries is less than 30.

Mali -30% +1% 57% 68% 50% 60% 42% 93% $0.15bn 2. The aggregate numbers presented as “Countries where the Global Fund invests” are limited to countries that received an allocation for the 2017-2019 cycle. These countries received US$12.4 (d) billion from 2002 through June 2020 to support malaria programs. Additionally, they received US$848 million for cross-cutting support across three diseases. Countries that did not receive 384 387 an allocation over 2017-2019 cycle received US$730 million since 2002, resulting in a total of US$13.2 billion. 17k 3. In line with the Global Fund results reporting methodology, the charts reflect the achievements of national health programmes, representing the outcomes, efforts and 12k investments of all partners, domestic and international. For High Impact countries, Country Results Profiles provide further detail including investment from all funding sources: https://data.theglobalfund.org/home. See https://www.theglobalfund.org/en/methodology/ for a description of the Global Fund results methodology. 44 Malaria: State of the Fight 45

A community mobilizer prepares malaria treatment at a patient’s home in the village of Xwe Lay, Kayin State, Myanmar. The Global Fund / Quinn Ryan Mattingly

Myanmar makes major progress fighting malaria Naw Htay Htay Myint, a community mobilizer, supervises and checks in on a community malaria volunteer in the the village of Xwe Lay, Kayin State, Myanmar.

Ten years ago, more than 3,800 people lasting insecticide-treated nets which were “ died from malaria in Myanmar every year. distributed across the country. A decade ago, Today, that number has dropped to approximately 170. Global Fund investments are also supporting Myanmar had the development of new technology to more than 1 Much of this progress has been made support Myanmar’s fight against malaria. This through the tireless efforts of some 17,000 includes developing a “Malaria Case-based million malaria malaria health volunteers across the Reporting App” enabling health volunteers to country. These community volunteers, map malaria cases, enhancing the efficiency cases every year; through the support of the Global Fund and effectiveness of elimination efforts. today the country and partners, receive training and the basic tools and resources they need to protect A decade ago, Myanmar had more than 1 has slashed this their communities from the disease. This million malaria cases every year; today the number to 108,000. includes providing rapid malaria testing country has slashed this number to 108,000. and treatment as well as referring the With continued investments in prevention, most serious cases to health facilities. The treatment and education programs, volunteers also provide vital community- including supporting the country’s based education through national anti- thousands of health volunteers, Myanmar malaria campaigns. These health workers continues to make great strides forward in play a key role in improving access to malaria its efforts to address artemisinin resistance diagnosis and treatment for hard-to-reach and eliminate the disease. populations. Last year the Global Fund and partners provided community health workers with approximately 6 million long- Saw Soe Aung, a 21-year-old village health volunteer and trained microscopist, examines blood samples to screen for malaria in a rural health center in Xwe Lay village, Kayin State, Myanmar. Aminat Laketu with her 6-week-old baby at Ita-Elewa Primary Health Center in Ikorodu, Nigeria, where she has benefited from services to prevent46 transmissionSection of HIV from mother to child. 47 The Global Fund / Andrew Esiebo

Resilient and Sustainable Systems for Health: the Cornerstone of Global Health Security

Resilient and sustainable systems for health are the essential foundation to fighting infectious diseases, whether ending HIV, TB and malaria as epidemics, fighting new pandemics like COVID-19, or preparing and responding to future health threats. 48 Resilient and Sustainable Systems for Health 49

The challenge of HIV, TB and malaria, we will free up health invests to remove those barriers, making Improving procurement to changes in epidemiology and to learn Alliance supported the countrywide rollout system capacity for other health priorities. health services more readily available and supply chains which interventions are having most impact. of District Health Information Software Resilient and sustainable systems for health The impact of Global Fund investments on and financially accessible, and supporting The Global Fund, in coordination with 2 (DHiS2), an open source platform for are essential to fighting infectious diseases, health and community systems has been countries in their progress toward universal Efficient procurement and supply chain other partners, is supporting the rollout managing health data. yet many low- and middle-income countries evident in countries’ COVID-19 responses: the health coverage. systems are critical to fighting HIV, TB and and maintenance of electronic, integrated still have weak health and community systems, infrastructure, equipment and capabilities malaria, and are a key component of resilient national health management information with capability gaps and infrastructure put in place to fight HIV, TB and malaria have The Global Fund has invested approximately and sustainable systems for health. The Global systems in over 30 countries. The percentage Domestic resource deficiencies across multiple components. played a critical role. US$123 million to remove human rights Fund is investing in improving and integrating of countries that have fully deployed and mobilization This includes shortfalls in health workforce barriers in the 2017-2019 allocation cycle supply chains and pharmaceutical management functional health management information skills and numbers, costly and incomplete through the “Breaking Down Barriers” in order to improve product availability, reduce systems nearly doubled between 2018 and Encouraging and stimulating domestic supply chains, inadequate disease surveillance “ initiative. The initiative has helped to product waste and lower supply chain costs, 2019, from 22% to 43%. We are on track to investments in health is an essential systems, overburdened laboratory networks, catalyze increased investments in human not least by significantly improving forecast reach our target of 70% by the end of 2022. component of the Global Fund’s strategy. poor integration of formal and informal health There are more than rights and helps policymakers identify the accuracy and increasing inventory turnover. The US$14 billion raised for the Sixth and community systems, and weak financial 2 million community root causes of human rights and gender Grant investments supported by Supply Chain We are also working with partners to collect Replenishment seeks to spur domestic management and oversight mechanisms. In barriers, determine what is needed to tackle Transformation Plans aim to improve availability critical subnational data, such as mapping investment of US$46 billion through many such countries, people cannot access health workers in the them, and establish the costs involved. For of key medicines and diagnostics at the facility and estimating the size of key populations co-financing requirements, and technical testing and treatment because they are unable countries where the example, South Africa’s new three-year level. In 2019, the percentage availability of all and their needs. In some countries, collecting assistance on health financing. The Global to pay, live too far from health services, or are plan to tackle gender inequality and human diagnostics and first-line drugs for HIV and TB such data entails using a network of Fund’s Sustainability, Transition and Co- denied access due to stigma or discrimination. Global Fund invests, rights-related barriers to HIV and TB health needed in health facilities exceeded targets, mobile phones at community-level clinics Financing Policy aims to support countries Such shortcomings undermine the pace of services, launched in 2019, was shaped by the and the target of availability of malaria drugs to collect diagnostic, treatment and drug as they move toward full domestic funding progress in the fight against existing diseases mainly serving rural extensive baseline assessment studies into was nearly met (see graph below). delivery information. In others, it involves of their systems for health, including their and impede an effective response to infectious and hard-to-reach human rights and gender barriers conducted sophisticated laboratory analysis data. For HIV, TB and malaria programs. In our 2017- disease outbreaks. as part of “Breaking Down Barriers”. South instance, the Global Fund invests in Uganda’s 2022 strategy, the Global Fund commits populations. Africa’s new plan helps vulnerable and key Strengthening data Supranational Reference Laboratory, which to work with all implementing countries to COVID-19 and other infectious disease populations to access lifesaving health care systems and data use supports 21 countries across Africa with increase domestic resource mobilization outbreaks such as Ebola and MERS (Middle services, while addressing the root causes of drug resistance surveillance and to conduct for health, with a particular emphasis on East respiratory syndrome) demonstrate that Investing in human rights and gender-related barriers. More frequent and timely data allows complicated tests of drug-resistant TB. In investing in programs that support key and countries around the world rely on each other human resources countries to quickly identify and respond DRC, the Global Fund and Gavi, the Vaccine vulnerable populations. In 2019, the India having strong systems for health for our The Global Fund supports the African global health security. Local outbreaks can Investing in the training and support of Coalition to Fight TB (ACT Africa) in its use rapidly translate into global health threats. health workers, especially community of a gender responsive agenda to address Weaknesses in the systems for health of health workers, in both formal and informal TB in sub-Saharan African countries with the individual countries can allow pathogens to settings, remains critical to delivering the highest number of “missing” people with TB. Average on-shelf availability gain momentum and spread across borders. Global Fund’s mandate. There are more than The coalition integrates gender approaches COUNTRIES IN SUPPLY CHAIN TRANSFORMATION INITIATIVE In today’s increasingly interconnected world, 2 million community health workers in the in interventions such as strengthening no one is safe until everyone is safe. We all countries where the Global Fund invests, community voices in national TB programs; have an interest in the strength and resilience mainly serving rural and hard-to-reach training communities in gender assessment Target Actual All targets are a 15% relative of every health and community system. populations. The ability to train and deploy tools; planning TB programs; and developing improvement to each baseline 92% 93% community health workers rapidly, the trust community-led strategies for finding HIV first-line drugs that communities place in them, and their “missing” people with TB. The Global Fund response presence in areas with few resources make 91% 94% HIV diagnostics community health workers a vital part of The Malaria Matchbox tool, introduced with

Investment in resilient and sustainable systems for health in many low- and middle- partners in 2017, is now being used more 84% 89% systems for health is a core component of income countries. widely to assess inequities in access to TB first-line drugs the Global Fund’s strategy for 2017-2022. We malaria services and address human rights 77% 86% are already the largest multilateral investor and gender risks and vulnerabilities. In TB diagnostics in grants for systems for health, investing Investing in gender equity Niger for example, the national response to more than US$1 billion a year to strengthen malaria has increasingly used a gender and 82% 83% and human rights Malaria first-line drugs and build diagnostic tools and laboratory human rights lens to strengthen its strategy, facilities; data and surveillance systems; Removing barriers to accessing health care, including use of the Malaria Matchbox tool. 86% 93% procurement and supply chains; community helping end violations of human rights Working with Malaria No More and local Malaria diagnostics systems; and training of health workers. and striving to improve gender equity are communities, the National Malaria Control 0% 20% 40% 60% 80% 100% critical elements of efforts to end the three Program has used the tool to collect data The fight against HIV, TB, and malaria both epidemics. In many countries, people cannot and identify gaps in Niamey and Maradi Results reported at the end of 2019. depends on and contributes to stronger access prevention, testing or treatment regions. From this effort, Niger created an systems for health. We will not succeed services, because they are unable to action plan to better reach those under- On-shelf availability is measured as the percentage of health facilities visited providing tracer medicines available on the day of the visit or as per Logistics Management Information Systems status; or percentage of health facilities visited providing diagnostic services with tracer items on the day of the visit. in defeating the three epidemics without pay, live too far from health facilities, or served populations and to strengthen Countries included in the initiative are: Bangladesh, Burkina Faso, Côte d’Ivoire, Democratic Republic of Congo, Ethiopia, Ghana, Haiti, India, Liberia, Malawi, Niger, Nigeria, South Africa, Pakistan, reinforcing key components of health and are denied access due to discrimination, the overall participation of communities Tanzania and Uganda. community systems. By reducing the burden stigma or gender norms. The Global Fund in malaria programs. The Supply Chain Transformation Initiative strengthens in-country supply chains through renewed strategic e•orts that enhance and promote advances in the supply of medicines and other key health products to improve universal access. 50 Resilient and Sustainable Systems for Health 51

Health Fund, an innovative fundraising initiative established by Tata Trusts and the Pooled Procurement Mechanism results Financial management systems meeting defined standards Global Fund in 2016, launched the nationwide 2014 2019 NUMBER OF COUNTRIES “Quest for Innovations towards Eliminating Tuberculosis” in partnership with the Global Fund, Tata Trusts, and India’s national TB Procurement On-time and Urgent order Price reduction Target Actual program, among others. This effort is meant mechanism volumes in-full delivery responsiveness (2014-2019) to support India’s ambitious aim to eliminate TB in India by 2025. 39% 82% 153 days 81 days -49% Antiretroviral 4.6m Target Actual Target Actual Target Actual Target Target Target people receiving therapies ARV treatment 6 5 16 13 26 23 36 46 46 Building stronger every month in 2019 community responses 41% 79% 183 days 96 days -35% 120m and systems Antimalarials Artemisinin-based combination courses Communities play a critical role in leading procured in 2019 the response to infectious diseases – as trusted providers of health information and 75% 81% No data -35% care, as advocates and, with new threats 81m Mosquito nets Nets procured such as COVID-19, as providers of disease in 2019 surveillance and data. The Global Fund 2017 2018 2019 2020 2021 2022 invests in community-led monitoring to support people in communities to assess the effectiveness, quality, accessibility and equity Defined standards are measured as at least 80% of agreed actions for improvement of financial systems implemented. of health services they receive. Communities All information as of the end of 2019. Indicative figures to show magnitude of procurement, not representative of every product procured through the Pooled Procurement Mechanism. Countries targeted include High Impact and Core Countries where the use of Public Financial Management Systems or Donor Harmonized Systems are not feasible, therefore the Global Fund decide what to monitor and what to act on supports grant implementers to strengthen their financial management systems for e­ective and e€cient management of grants/programs. The Pooled Procurement Mechanism is used to aggregate order volumes on behalf of participating grant implementers to once data is collected. By incorporating negotiate prices and delivery conditions with manufacturers. It provides access to competitive market terms and prices no ‘Agreed actions’ relate to agreed actions to strengthen the people, processes and information systems of financial management systems. advocacy in its framework, community- matter the size or value of the order, eliminates procurement delays, supports timely grant expenditure and ensures quality-assured goods and medicines reach those most in need in a timely manner. Financial management systems meeting defined standards represents only one of multiple RSSH key performance indicators. led monitoring uses evidence gathered to hold service providers and decision makers accountable. In this endeavor, the Global Fund has supported countries including health outcomes. For example, interventions transmitted infections, post-violence Georgia, Kyrgyzstan, Moldova, Tajikistan to prevent mother-to-child transmission of care and antenatal care, training of health Health management information systems and Ukraine to implement the Rights – HIV, ensure early diagnosis of HIV in infants, personnel and family planning. Addressing PERCENTAGE OF HIGH IMPACT/CORE COUNTRIES THAT ACHIEVED HMIS DEPLOYMENT, COMPLETENESS, Evidence – Action (REAct) system, which screen pregnant women and children for unmet HIV and other sexual health needs of TIMELINESS AND INTEGRATION THRESHOLDS allows communities to record and respond TB, and protect pregnant women and key and vulnerable populations through an to human rights violations among HIV and infants from malaria. These interventions are integrated sexual and reproductive health TB key populations. In Zimbabwe, the Global designed and implemented as components rights approach, combined with addressing 2018 2019 Fund’s technical assistance has supported of an integrated strategy for strengthening discrimination and violence against these the development of an adolescent girls and overall antenatal and postnatal care. groups of people, is critical to ending 88% 98% young women community scorecard, which the epidemics. HMIS deployment is helping to increase access to gender-based The Global Fund seeks to improve quality violence services. of care by supporting countries to achieve The integrated infrastructure, staff and integrated health services, which are resources created to fight HIV, TB and malaria 78% 88% Completeness The Global Fund invested more than safe, timely, efficient, and equitable. We contribute to the overall quality of primary US$100 million in community systems support countries as they strive to achieve health care and strengthen the health strengthening in the 2017-2019 a supportive policy and programmatic system’s ability to respond to new threats like 47% 63% allocation cycle. environment, which promotes and COVID-19 and prepare for future pandemics. Timeliness entrenches integrated services with the For instance, as the COVID-19 pandemic aim of achieving quality health care. That accelerated in South Africa in 2020, the 45% 61% Promoting integrated, includes investing to strengthen governance country repurposed infrastructure built over Integration people-centered and accountability to help maintain strategic the years in the fight against HIV and TB to health services oversight over health goals and priorities. fight the new pandemic, implementing the 0% 20% 40% 60% 80% 100% The Global Fund invests strongly in sexual same “find, treat and prevent” strategies. The Global Fund supports HIV, TB and and reproductive health and rights services. High Impact/Core Countries are the approximately 50 countries with the highest burden of at least one disease or largest Global Fund investment. malaria programs that go beyond a narrow Often, these services are the first point of Sub-indicators are: focus on the specific diseases to deliver contact with the health system for key and HMIS deployment: countries with > 80% of facilities/reporting units expected to submit monthly/quarterly reports to the electronic HMIS integrated, people-centered health services vulnerable populations. These services Completeness: countries where > 80% of expected facility monthly reports were actually received Timeliness: countries where > 80% of submitted facility monthly reports were received on time to maximize efficiency and improve overall include screening and testing of sexually Integration: countries where HIV, TB & malaria aggregate data integrated/interoperable with national HMIS 52 Resilient and Sustainable Systems for Health 53 Amref Health Africa / Kennedy Musyoka

Community health workers leading the fights against HIV, TB and malaria in Kenya

across sub-Saharan Africa where the Global “ Fund invests. These health workers – most Doreen Oruoch is one of whom are volunteers and receive only a small stipend – have been on the frontlines of the nearly 1 million of the fights against HIV, TB and malaria for years, providing vital health services to community health communities that are often the most remote workers in countries and hardest to reach.

across sub-Saharan There are currently around 63,000 Amref Health Africa / Kennedy Musyoka Africa where the community health workers in Kenya alone. This includes 11,000 community health Global Fund invests. workers supported through Global Fund partner Amref Health Africa. Since 2016, Amref-supported health workers have conducted 1.4 million malaria tests and treated 800,000 cases of malaria. The work of community health workers has contributed Community health worker Doreen Oruoch significantly to the progress made in the has helped protect hundreds of people fight against malaria particularly in malaria from malaria in Homa Bay, her community endemic regions like Homa Bay. in Western Kenya. She advises families on how to use mosquito nets, she tests for the These same community health workers are disease and provides treatment for people now leading efforts to prevent, detect and when they are diagnosed. respond to COVID-19 – while at the same time continuing to protect progress made in Oruoch is one of the nearly 1 million the fights against HIV, TB and malaria. community health workers in countries Nurse Mbayang Fall Bousso puts on protective gear at CEPIAD, a methadone clinic for people who inject drugs in Dakar, Senegal. 54 Section 55 The Global Fund / Ricci Shryock

Fighting HIV, TB and Malaria in the Shadow of COVID-19

To protect the progress outlined in the previous chapters and save lives, we must see the fights against COVID-19, HIV, TB and malaria as one and the same fight. 56 Fighting HIV, TB and Malaria in the Shadow of COVID-19 57

AIDS-related deaths: impact of COVID-19

POTENTIAL INCREASE IN AIDS-RELATED DEATHS DUE TO HIV TREATMENT DISRUPTION IN THE CONTEXT OF THE COVID-19 PANDEMIC IN SUB-SAHARAN AFRICA

AIDS-related deaths (actual) Projected AIDS-related deaths based on trends prior to COVID-19 pandemic

The Global Fund / Andrew Esiebo Potential additional AIDS-related deaths due to COVID-19 pandemic

1.5 million

AIDS-related deaths would be set back close to 2008 levels, eliminating approximately 10 years of progress 1 +534,000 Additional AIDS-related deaths in 12 months over 2020-2021 compared to 2018 as a result of the COVID-19 pandemic

0.5

0 2000 2008 2018 2021 Community TB worker Sewande Jekenu’s job is to talk to people in the streets of Lagos, Nigeria, about the dangers of tuberculosis and to collect sputum samples for testing. She says that misconceptions about COVID-19 and TB have made her work very difficult: “Some people send us away. They say we are coming to isolate them because of COVID-19. They should know TB is Estimates of AIDS-related deaths over 2000-2018 from UNAIDS, 2019 release. Estimation of projected AIDS-related deaths over 2018-2021, based on continuation of trends prior to COVID-19. not about isolation - it is about getting the right treatment.” Estimation of potential AIDS-related deaths as a result of the COVID-19 pandemic from modelling work convened by WHO and UNAIDS, 2020.

If the world’s poorest and most vulnerable health measures. Approximately three- as COVID-19; and people unwilling to child HIV infections rising by as much as 83% Molecular diagnostic instruments used “ countries don’t receive urgent and adequate quarters of HIV, TB and malaria programs have seek health services due to fear of getting in Mozambique, 106% in Zimbabwe, 139% in to diagnose TB are being diverted to test Deaths from the three support to fight COVID-19, deaths and been moderately or significantly impacted. infected with COVID-19 Uganda and 162% in Malawi (UNAIDS). for COVID-19. This has contributed to the infections from all four diseases will skyrocket. reduced effectiveness of programs to epidemics may as much In the first few months of 2020, lockdowns, reach “missing” TB patients. As with HIV, This is already happening. Deaths from restrictions on gatherings of people and Impact of COVID-19 on HIV Impact of COVID-19 on TB some people with TB have encountered as double in the coming COVID-19 in the first seven months of 2020 transport stoppages have been the main difficulties in sustaining their treatment year as health and have already exceeded the total deaths from reasons program activities have been COVID-19 is disrupting people’s access to The impact of COVID-19 on the fight against given impediments to accessing medicines, HIV and malaria combined in the same period suspended or delayed. As lockdowns have lifesaving ARV therapy and to prevention TB could be equally devastating. Some TB economic privation and disruption to community systems in 2019. Recent modelling studies by WHO, been at least partially relaxed in many and testing programs. According to recent laboratory services are under acute pressure. support mechanisms. are overwhelmed, UNAIDS and the Stop TB Partnership indicate countries, and as the pandemic itself projections by UNAIDS and WHO, deaths As of June 2020, 20% were experiencing deaths from the three epidemics may as has gained momentum, the pattern has from HIV and AIDS in sub-Saharan Africa high or very high levels of disruption. In According to the Stop TB Partnership treatment and much as double in the coming year as health begun to change, with more disruptions could double in the next 12 months – some places, new TB case notifications have the COVID-19 pandemic could result in prevention programs and community systems are overwhelmed, occurring as a result of the impact on reversing more than a decade of progress. dropped by up to 75%, which could result in an additional 525,000 TB deaths in 2020 treatment and prevention programs are health workers and the health system as a Results from the Global Fund’s COVID-19 increased numbers of “missing” TB patients. compared to 2018 levels. Combined with are disrupted, and disrupted, and resources are diverted. whole, and unavoidable fears among the monitoring tool suggest there has been a This is particularly concerning as identifying the extensive disruption to testing and general public to go to facilities for services. 50% decrease in the volume of HIV testing and treating the estimated 3 million TB prevention activities seen in many countries, resources are diverted. Since the pandemic began, the Global Fund Increasing disruptions to HIV, TB and malaria in some places, which could lead to a rise in patients who are “missed” every year is vital more than a decade of progress in the fight has conducted biweekly surveys in 106 programs are being observed, and include: new infections as people unaware of their to ending the epidemic. against TB could be reversed. countries to monitor the impact of COVID-19 the reassignment of existing medical and status continue to transmit the disease to on Global Fund supported programs. While laboratory staff from programs fighting others. Movement restrictions have resulted COVID-19 is especially concerning for qualitative, this monitoring tool provides HIV, TB and malaria to the fight against in community-based service delivery being people with TB, as often their lungs are Impact of COVID-19 invaluable insights into where and how COVID-19; health workers, in particular scaled back or halted completely including already damaged, making them particularly on malaria COVID-19 is having the most impact on laboratory workers, falling ill with COVID-19; for key populations. COVID-19 could also vulnerable to the respiratory stress COVID-19 Global Fund-supported programs. The results COVID-related stigma and the reluctance have a devastating impact on HIV infections can cause. The similarities between the initial On malaria, COVID-19 threatens to reverse show widespread disruptions to HIV, TB and of health workers to attend to people among children. Estimates from UNAIDS symptoms of COVID-19 and TB contribute to 20 years of progress. According to WHO malaria work as a result of both the COVID-19 suspected of having TB or malaria – which show that interruptions to ARVs for pregnant confusion and stigma, hindering efforts to estimates, COVID-19 could result in an pandemic itself, and the associated public have many of the same initial symptoms women and new mothers could lead to new identify and treat TB patients. additional 382,000 malaria deaths in 2020 58 Fighting HIV, TB and Malaria in the Shadow of COVID-19 59

Tuberculosis deaths: impact of COVID-19 alone. This would take worldwide deaths from decisively to the emergence of COVID-19 by lockdowns. We are also tracking the malaria back to levels not seen since 2000. and we are playing a critical role in the potential impact of COVID-19 on pricing POTENTIAL INCREASE IN TB DEATHS DUE TO TB SERVICE DISRUPTION IN THE CONTEXT OF THE COVID-19 PANDEMIC GLOBALLY COVID-19 response in the poorest and most and availability of essential commodities, as In some countries mosquito net distribution vulnerable countries. Together with partners, manufacturers switch capacity to COVID-19 TB deaths including HIV+ (actual) campaigns have been delayed. Case we are strengthening systems for health so medicines and diagnostics. For example, the Projected TB deaths (including HIV+) based on trends prior to COVID-19 pandemic management has been affected in some they can test, track and treat for the virus Global Fund has already taken action with Estimated TB deaths (including HIV+) as a result of the COVID-19 pandemic places by constraints on the movement now and be prepared to roll-out vaccines partners to ensure continuity of supply for 2.5 million and availability of health workers, while once available; procuring and distributing malaria rapid diagnostic tests. TB deaths would be set back some countries face potential stock-outs of COVID-19 diagnostics now and therapies close to 2009 levels, eliminating approximately 10 years of progress essential anti-malaria medicines. COVID-19 once available; protecting front-line health Fighting COVID-19 requires intense 2 symptoms, in particular fever, has led to workers with personal protective equipment; coordination and collaboration. The + malaria being thought to be COVID-19 and and adapting lifesaving HIV, TB and malaria Global Fund is a founding partner of the 525,000 vice-versa. Too often people who feel sick programs so they can safely continue. ACT-Accelerator (ACT-A) to accelerate Additional TB deaths in 2020 compared to are not seeking treatment, frightened of development, production and equitable 1.5 2018 as a result of the COVID-19 pandemic contracting COVID-19 at a health facility. In early March 2020, the Global Fund access to COVID-19 testing, treatment and introduced new grant flexibilities to enable vaccines. We are a co-convener of both the countries to use savings and reprogramming ACT-A Diagnostics Partnership (with the 1 Impact of COVID-19 from existing grants to rapidly adapt HIV, TB Foundation for Innovative New Diagnostics on systems for health and malaria programs, purchase protective – FIND) and of the ACT-A Health Systems equipment, procure COVID-19 diagnostics Connector (with the World Bank), and we

0.5 In many countries, both the health and and medical supplies, and strengthen the are leading the workstream on procurement community systems and the workers who immediate response to the pandemic. In and deployment in the ACT-A Therapeutics make them function risk being overwhelmed April, the Global Fund launched the Partnership. For example, for COVID-19 by COVID-19. Laboratory networks in some COVID-19 Response Mechanism with an initial diagnostics, ACT-A partners are working 0 countries have been under acute pressure as capacity of an additional US$500 million. As together to accelerate the development and 2000 2009 2018 2020 they struggle to scale up COVID-19 testing, of 21 August, grant flexibilities totaling deployment of new antigen rapid diagnostic Estimates of TB deaths (including HIV+) over 2000-2018 from WHO Global TB Report 2019. Estimation of projected TB deaths over 2018-2020 based on continuation of trends prior to COVID-19. Potential TB deaths (including HIV+) globally as a result of the COVID-19 pandemic estimated for the year 2020 from Stop TB Partnership (and partners) modeling study, 2020 which assumed a with a negative impact on viral load testing US$184 million had been approved for tests. Meanwhile, we are providing existing conservative lockdown period of 3 months and recovery period of 10 months. These additional estimated TB deaths are due to TB service disruptions and exclude TB deaths that may happen in people for HIV and testing for TB. Restrictions on 92 countries and 11 multicountry programs, tests, including high throughput molecular living with HIV because of disruptions of ARV and other HIV-related services. See http://www.stoptb.org/assets/documents/news/Modeling%20Report_1%20May%202020_FINAL.pdf to learn more. movement have also impacted diagnostics, while US$514.5 million had been approved diagnostic cartridges, to low- and middle- including the transportation of TB specimens. through the COVID-19 Response Mechanism income countries, using an allocation to 73 countries and 2 multicountry programs. framework to ensure that the poorest Malaria deaths: impact of COVID-19 Many health workers, particularly community countries do not lose out. health workers, lack training on infection and Rapidly redesigning HIV, TB and malaria POTENTIAL INCREASE IN MALARIA DEATHS DUE TO MALARIA SERVICE DISRUPTION IN THE CONTEXT OF prevention and have inadequate access to programs to the COVID-19 context has The investments that the Global Fund has THE COVID-19 PANDEMIC IN SUB-SAHARAN AFRICA personal protective equipment, resulting in required intense effort, innovation and close made in systems for health over the last increasing numbers of health workers falling collaboration with partners. Innovative HIV 20 years are underpinning the response Malaria deaths (actual) sick, having to isolate or dying. Health workers prevention, testing and treatment approaches to COVID-19 in many low- and middle- Projected malaria deaths based on trends prior to COVID-19 pandemic without personal protective equipment can introduced by countries and community income countries. Billions of dollars invested Potential additional malaria deaths due to COVID-19 pandemic also face hostility from communities fearful groups include digital prevention programs, in front-line health workers, laboratory 0.8 million of infection. As the pandemic gains pace in multi-month dispensing and courier delivery systems, supply chain improvements, and + many of the countries in which HIV, TB and of antiretrovirals as well as increased health information systems have put many Malaria deaths would be set back to 382,000 malaria are prevalent, there is a risk that deployment of HIV self-testing. Significant low- and middle-income countries in a much around 2000 levels, eliminating Additional malaria deaths in 2020 compared health systems could collapse, with potentially investments have been made to procure stronger position, but these need to be vastly approximately 20 years of progress to 2018 as a result of the COVID-19 pandemic 0.6 disastrous consequences. additional molecular diagnostics machines expanded now. across high burden countries to mitigate the COVID-19 has caused considerable disruption risk of existing machines being diverted to to procurement and supply chain systems test for COVID-19. Virtual observation of TB Funding gap across the world in 2020. We are closely treatment via smartphone applications have 0.4 monitoring the impact on our supply chain, been introduced, alongside digital support The Global Fund urgently needs US$5 billion to be able to anticipate and prevent potential systems for TB preventative therapies. To be over the next 12 months to continue to problems. As of 14 August 2020, 16% of orders consistent with social distancing, mosquito net fight COVID-19, protect health workers and looked likely to be delayed by 30 days or more. campaigns are done door to door rather than systems for health, and defend progress in 0.2 having people collect the nets from central the fights against HIV, TB and malaria. distribution points. The Global Fund’s response So far only a small fraction of this funding To mitigate the risk of stock-outs, we have has been received, and it is estimated that 0 As the world’s trusted, proven partnership worked with partners to improve forecasting our emergency response fund will run out 2000 2018 2020 fighting major infectious disease at scale and bring forward orders and established of money by the end of September 2020. Estimates of malaria deaths over 2000-2018 from WHO World Malaria Report, 2019 release. Estimation of projected malaria deaths over 2018-2020 based on continuation of trends prior to the around the world, the Global Fund reacted mechanisms to expedite shipments delayed Without these urgently needed funds to fight COVID-19. Estimation of potential deaths as a result of the COVID-19 pandemic from WHO modelling study, 2020, due to cancellation of planned mosquito net distribution campaigns and severe disruptions (75% reductions) in continuous net distributions and use of antimalarial treatments. 60 Fighting HIV, TB and Malaria in the Shadow of COVID-19 61

Health service delivery Distribution of COVID-19 Response Mechanism funds

REPORTED LEVELS OF DISRUPTION TO THE SERVICE DELIVERY OF GLOBAL FUND-SUPPORTED PROGRAMS AS OF 21 AUGUST 2020 (ALL FIGURES IN USD) AS A RESULT OF THE COVID-19 PANDEMIC

HIV

18% 59% 17% None/Low Moderate High $514.5m $168m 1% 5% Total approved through the of COVID-19 Response Mechanism funds Don’t know Very high COVID-19 Response Mechanism have been invested in procurement of personal protective equipment TUBERCULOSIS

54% 35% Reinforcing national Mitigating COVID-19 impact on 20% 58% 17% COVID-19 response HIV, TB and malaria programs None/Low Moderate High

3% 3% Don’t know Very high

MALARIA

28% 50% 16% None/Low Moderate High

5% 2% 11% Don’t know Very high Urgent improvements in health and community systems Survey results as of 1 August 2020. The biweekly survey is completed online by country-based Local Fund Agents (Global Fund service providers) who consolidate views of various in-country stakeholders, but the data are not verified. The tool helps identify potential risks and disruptions to programs, but is not intended to be a rigorous assessment of the country situation, nor should it be interpreted as such. A total of 106 countries completed the survey.

COVID-19, countries will be unable to: deliver around a common goal, the deadliest The Global Fund has The Global Fund has adopted a “ on their targets for lifesaving services for infectious diseases can be driven into retreat adopted a four-pronged four-pronged response to the Decades of hard-won ongoing HIV, TB and malaria programs; and millions of lives can be saved. response to the pandemic: purchase personal protective equipment COVID-19 pandemic gains made against to protect health workers; and procure The world faces a critical turning point. additional COVID-19 tests or treatments Decades of hard-won gains made against • Adapt HIV, TB and malaria programs to HIV, TB and malaria – that are critical to fighting the disease. HIV, TB and malaria – and trillions of dollars mitigate the impact of COVID-19 and and trillions of dollars Private sector support, particularly rapid invested to fight disease and progress on safeguard progress; deployment of supply chain and information the 2030 Sustainable Development Goals – invested to fight disease technology solutions, is critical to help low- could be lost. The world must act with speed • Protect front-line health workers through and progress on the income countries quickly strengthen their and scale, investing far greater resources the provision of personal protective PROTECT capacities to fight COVID-19. than have yet been committed, to counter equipment (PPE) and training to front-line FRONT-LINE 2030 Sustainable both the direct impact of COVID-19 and to health staff, including community health HEALTH WORKERS ADAPT In the fight against COVID-19, we must mitigate the knock-on consequences for workers; Development Goals – HIV, TB AND FIGHT leave no one behind – because it’s the right HIV, TB and malaria. MALARIA COVID-19 could be lost. thing to do, and because everyone’s safety • Reinforce systems for health so they PROGRAMS REINFORCE depends on it. It is estimated that at least don’t collapse by supporting urgent SYSTEMS FOR US$28.5 billion is required to mitigate the enhancements, including to supply chains, HEALTH impact of COVID-19 on countries affected laboratory networks and community-led by HIV, TB and malaria over the next 12 response systems; months, train and protect health workers, reinforce systems for health so they don’t • Fight COVID-19 by supporting control collapse and are prepared to roll out testing, and containment interventions, including treatments and vaccines (once available), 75% testing, tracing and the support of isolation, and respond to COVID-19 itself. communications and treatment (as HIV, TB AND MALARIA PROGRAMS therapeutics become available). The Global Fund’s extraordinary record of MODERATELY OR SIGNIFICANTLY impact is proof that when the world unites IMPACTED BY COVID-19 62 Fighting HIV, TB and Malaria in the Shadow of COVID-19 63

In Ukraine courier services are being A nurse working at the Persahabatan Hospital in Jakarta, used to deliver ARVs and other where Indonesia’s leading TB center is located. medicines directly to people’s homes during COVID-19 lockdowns.

Country responses

Health worker Bogar Fiogbe distributes mosquito nets door-to- to COVID-19 door by motorbike in Benin during the COVID-19 outbreak. CO “100% Life” The Global Fund / Jiro Ose Hugues Ahounou/Catholic Relief Services

Delivering HIV medication The Global Fund is Protecting progress in number of trips they must take to health Going door to door The Global Fund is by post in Ukraine supporting countries to Indonesia’s fight against TB facilities and conducting TB training and to deliver 8 million supporting programs to mitigate the impact of monitoring activities online. mosquito nets in Benin mitigate the impact of Across the world, COVID-19 lockdowns and COVID-19 on the fight Indonesia has one of the heaviest TB burdens COVID-19 on the fight restrictions on public transportation have against HIV, such as: in the world, and COVID-19 threatens to make The Global Fund is As the rainy season approached in West and against malaria, such as: made it more difficult to access treatment. things worse. The Global Fund has worked supporting countries to Central Africa, the Global Fund worked with Not everyone can afford a taxi to their health closely with partners and the government mitigate the impact of partners to implement new strategies to center, and this seemingly small hurdle can • In Côte D’Ivoire patients receive drug to test and treat millions of people across distribute mosquito nets to protect families • In Afghanistan, malaria testing facilities result in death. supplies for one to three months for TB Indonesia, including testing 564,000 people COVID-19 on the fight from malaria within the context of COVID-19. have been expanded beyond the capital and HIV to reduce the number of trips in 2018 alone. Investments from the Global against TB, such as: of Kabul and additional testing kits and In Ukraine, the Global Fund is supporting to health centers. Fund also support the purchase of GeneXpert For the first time, community health workers antiseptics have been purchased. an initiative by “100% LIFE”, a local HIV machines – molecular diagnostic instruments • In El Salvador, TB and COVID-19 testing in Benin went door to door to distribute community network that organizes courier • In Malaysia, masks, gloves and other that have revolutionized TB control by capacity is being supported among more than 8 million mosquito nets across the • In Cambodia, mosquito nets have been services to deliver ARVs and other medicines protective equipment have been procured providing swift turnaround of test results. the prison population. Surgical masks, country. About 5,500 community workers distributed through door-to-door directly to people’s homes. The country’s two for outreach workers providing HIV With support from the Global Fund, over N95 respirator masks, alcohol gel and were mobilized to complete this lifesaving campaigns. Health workers have received biggest post operators, Ukrposhta and Nova services to key populations such as sex 800 of these machines have been installed in thermometers have been procured to activity in just 20 days. Other countries personal protective equipment and training Poshta, offer the service. People living with workers, transgender people, and men health facilities across the country. mitigate the impact of COVID-19 on across Africa have adopted this approach to on how to use remote working technologies. HIV in remote areas where postal services who have sex with men. TB programs. ensure distribution of mosquito nets continue are not available have their medications Now the Global Fund is enabling countries despite the COVID-19 pandemic. • In Mali, net distribution campaigns are delivered by car. Approximately 123,000 • In Uganda, HIV-positive mothers and to use GeneXpert machines in the fight • In Moldova, 5,000 HIV and TB testing now a mix of a door-to-door distribution in people are on ARV therapy for HIV in pregnant women receive door-to-door against COVID-19, through the procurement kits have been purchased as well as urban areas and fixed distribution points Ukraine, which has the second-largest HIV health services and ARVs to prevent of special testing cartridges that can test personal protective equipment. in rural areas. Fixed points are open for epidemic in Eastern Europe. transmission of the virus to their babies. for the new virus. This is being done while multiple days to avoid large crowds, and sustaining TB testing capacity by purchasing • In Niger, nomadic communities are families receive more nets than usual to new testing machines and running double being screened for TB though mobile ensure universal coverage. shifts for laboratory workers. Global Fund teams and laboratories. In the capital city partners are also distributing larger amounts Niamey, a new mobile TB data collection of medication to TB patients to reduce the tool was piloted. At the Global Fund’s Sixth Replenishment Conference in Lyon, France, on 10 October 2019, French President Emmanuel Macron 64shakes Sectionhands with Amanda Dushime of Burundi, who 65 was diagnosed with HIV at the age of 11 and is now ambassador of the “Growing Together” network. The Global Fund / David O’Dwyer

Investing for Impact

Since its creation in 2002 the Global Fund has disbursed more than US$45.4 billion in the fight against HIV, TB and malaria and for programs to strengthen systems for health across more than 155 countries, including regional grants, as of June 2020, making it one of the largest funders of global health. 66 Investing for Impact 67

journey towards delivering universal health Private donors pledged more than Replenishment cycle, which corresponds to coverage and the SDG 3 goal of health and US$1.1 billion for the first time ever, an the full conversion of expected contributions. wellbeing for all. extraordinary achievement led by the As of the same date, conversion of pledges Bill & Melinda Gates Foundation’s pledge of to the Sixth Replenishment, which has just US$760 million and (RED)’s pledge of US$150 begun, is also on track. US Global Fund resources million, alongside longstanding supporters $45.4 billion such as Dato Sri Dr. Tahir, Comic Relief and DISBURSED BY THE GLOBAL FUND AS OF JUNE 2020 The Global Fund raises funds in three-year Takeda. Six new private donors also returned Co-financing periods known as “replenishment cycles.” or joined, including Children’s Investment Fund The Sixth Replenishment cycle, which runs Foundation and the Rockefeller Foundation. As countries increase their investments in from 2020 to 2022, was launched at the Eleven partners committed other resources health, including the fights against HIV, TB Replenishment Conference in Lyon, France, to expand innovation and impact focused on and malaria, domestic resource commitments In 2019, the Global Fund disbursed An evolving in October 2019, hosted by French President key areas such as TB case finding, fighting have risen rapidly, in part catalyzed by Global “ US$3.5 billion across 150 countries, resourcing model Emmanuel Macron. In an extraordinary HIV among adolescent girls and young Fund co-financing requirements. Typically, including regional grants. To maximize show of global solidarity, donors pledged women, maternal and child health, reducing 15-30% of the Global Fund country allocation In 2019, the Global the impact of donor resources, the Global The financial model of the Global Fund US$14.02 billion for the next three years malaria among children, and strengthening is provided as a co-financing incentive which is Fund disbursed Fund uses a formula that directs funding partnership continues to evolve, reflecting against the target of US$14 billion – the largest of supply chain and data management. These accessible when the country invests additional to the countries with the highest burden of the strengths of our diverse stakeholders amount ever raised for a multilateral health included partners such as Google, Microsoft, domestic resources. This mechanism has US$3.5 billion across disease and lowest economic capacity. In and the changing needs and capacities organization, and the largest amount ever Mastercard, Thomson Reuters Foundation, proved remarkably successful in incentivizing 150 countries, including line with this methodology, approximately of implementing countries. While public raised by the Global Fund. This represents a Société Générale, YMCA, Zenysis Technologies increased domestic investment in health, with 74% of disbursements in the current donors continue to be the primary source 15% increase over the amount raised for the and Project Last Mile. co-financing commitments in the current regional grants. funding cycle went to countries in sub- of funding for the Global Fund with 92% of Fifth Replenishment. Many donors significantly cycle up 46% compared with 2015-2017. Saharan Africa, where HIV and malaria are total pledges in the Sixth Replenishment, increased their pledges, responding to the call The largest contributors to the Global For the implementation period of the most prevalent. The Global Fund strives private sector partners are playing a to “Step Up the Fight” and recognizing the Fund (on a cumulative basis) are the 2014-2016 allocation, actual co-financing to maximize impact through innovation, more significant role, complementing the urgency to take decisive action to get back on United States of America, France, the investment exceeded the overall target collaboration, and continuous improvement contributions of other development partners track towards ending the epidemics. Further United Kingdom, Germany, Japan and the (reaching 127% of target). in program quality. In 2019, the Global Fund through funding and innovative solutions. expanding our donor base, the Global Fund European Commission. Following their public continued to diversify our donor base, grow Yet the biggest change is the increasing also welcomed 21 new and returning public pledge announcements, donors then make Given the severe economic impact of COVID-19 domestic resource mobilization, expand role of domestic resource mobilization, donors. A record number of 24 implementing payments over the replenishment cycle, in most of the countries affected by HIV, TB and partnerships, and increase efficiencies and as national governments take on more of countries from Africa made pledges to the based on an agreed payment schedule. As malaria, we anticipate that some countries will effectiveness through greater collaboration the challenge of funding the fight against Global Fund, more than doubling the number of June 2020, donors had contributed a total find it challenging to meet Global Fund and economies of scale. the three epidemics as part of their overall in the previous replenishment. of US$11.4 billion under the previous Fifth co-financing requirements.

Global Fund investments by region International grants provided by the Global Fund in 2019

DISBURSEMENTS IN 2018-2020 AS OF JUNE 2019 3% Eastern Europe and Central Asia

4% North Africa and the Middle East 16% Asia and the Pacific 21% 73% 56% OF ALL INTERNATIONAL FINANCING FOR OF ALL INTERNATIONAL FINANCING FOR OF ALL INTERNATIONAL FINANCING FOR 3% HIV TB MALARIA Latin America and the Caribbean

9% of total available resources for HIV 9% of total available resources for TB 37% of total available resources for malaria

74% The Global Fund measures overall funding in US dollars but pledges and contributions are made in multiple currencies. The total amount pledged for the 6th Replenishment period from 2020-2022 is Sub-Saharan Africa US$14.02 billion as of December 2019, using the fixed 6th Replenishment exchange rate. Working closely with partners including the Global Fund, Project Last Mile helps improve availability of essential medicines68 at healthInvesting facilities for across Impact Liberia. 69 Project Last Mile Financial pledges for the Sixth Replenishment

AS OF DECEMBER 2019 (ALL FIGURES IN USD)

AMERICAS Norway Sweden $223.8m $290.2m

Canada Denmark Germany $699.4m 4 5 EUROPE 12 7 11 $51.7m $1.1bn 16 1 14 6 2 Netherlands United States 13 $172.1m $4.68bn European Commission Belgium $606.6m $16.5m

15 United Kingdom $1.72bn Ireland Luxembourg $55.1m 4 5 3 $10.3m 7 11 12 Central African Republic Congo, Democratic France Ukraine 16 $1m Republic $1.43bn $100k $6m 9 Spain Niger Chad $110.3m Greece $1m $1m Uganda $100k $2m Portugal $1.1m Mali AFRICA Monaco Italy $600k Kenya $400k 10 $177.6m $6m Switzerland Malta $64.5m $300k Rwanda Senegal $2.5m $1m 15 Côte d’Ivoire Burundi $1.5m $1m Burkina Faso Zambia $5.5m $1m 3 United Arab Emirates Togo Zimbabwe $55.1m $1m $1m Qatar China Korea (Republic) Benin Madagascar $50m $18m $25m $1m 9 $1m Azerbaijan Nigeria Eswatini $20m 8 $12m $6m Armenia

$15m4 5 Cameroon Congo South Africa 12 7 11 Japan $5m $5.5m 1 $10m 16 14 6 2 Kuwait $840m 13 $6m 10 Equatorial Guinea Namibia 9 $2.2m $1.5m Saudi Arabia $30m 15 ASIA AND OCEANIA

India 3 $22m Australia 9 $163.8m Thailand 8 $4.5m

New Zealand $1.6m

PLEDGES FROM PRIVATE SECTOR, NON-GOVERNMENT AND OTHERS

1. $760m Bill & Melinda Gates Foundation 10. $5.3m Takeda Pharmaceutical 2. $150m (RED) 11. $5.1m Co-Impact $14.02 billion 3. $30m Tahir Foundation 12. $5m Cordaid 4. $25m Children’s Investment Fund Foundation 13. $3m Catholic Relief Services TOTAL PLEDGES FOR SIXTH REPLENISHMENT 5. $17m Comic Relief 14. $2.9m Plan International and Plan Canada 6. $15m Rockefeller Foundation 15. $1m Le Nu Thuy Dong 7. $10m Human Crescent 16. $500k YMCA and Y’s Men International 8. $7.2m Rotary Australia World Community 17. $150.6m Other Public and Private Sector Service and Rotarians Against Malaria 18. $100m Commitments to be personally 9. $5.5m Goodbye Malaria secured by Bill Gates and Bono with the active support of France 70 Investing for Impact 71

US$175 million SAVED THROUGH THE GLOBAL FUND’S POOLED PROCUREMENT MECHANISM

Innovative partnerships Bank and the Global Fund have signed a Increased collaboration We must unite to fight co-financing framework agreement that and efficiencies The private sector can play a transformational outlines a new approach for joint financing The 2019 results show considerable role when it comes to ending the world’s of investment-type operations between the More than ever, collaboration and efficiencies progress in saving lives and fighting HIV, deadliest infectious diseases through two organizations, as well as results-based are needed to fight HIV, TB and malaria, TB and malaria. However, the COVID-19 investment in areas such as new technologies, financing. Collaboration with the World Bank build resilient and sustainable systems for pandemic threatens to reverse the health innovations and greater efficiency. also includes the ground-breaking innovative health, and unite to fight the new COVID-19 extraordinary gains made in the fight financing initiative to accelerate tuberculosis pandemic. During 2019 the Global Fund and against the three epidemics. Some examples in 2019 include (RED), a elimination in India and make progress 11 multilateral agencies launched Stronger groundbreaking initiative that works with the towards the Global End TB Strategy targets Collaboration, Better Health: Global Action Fighting COVID-19 and the impact of world’s biggest brands to fight HIV in Africa, through the financing of a partial buy-down Plan for Healthy Lives and Well-being the new pandemic on the countries most © UNDP Guinea Bissau / Gwenn Dubourthoumieu increasing its pledge to the Global Fund by of the principal of an IBRD and Government for All. The joint plan outlines how the 12 affected by HIV, TB and malaria requires swift 50% and bringing 16 new partners on board of India US$400 million loan. The Global agencies will collaborate to be more efficient action, extraordinary levels of leadership and including Johnson & Johnson and Primark. Fund has worked closely with the Lives and and provide more streamlined support to collaboration, and significant resources. (RED) has pledged more than US$750 million Livelihood Fund, a concessional financing countries to deliver universal health coverage to the Global Fund since inception. Co-Impact, facility established by the Islamic Development and achieve the health-related SDG targets We must recognize that this is not just a fight a global philanthropic collaborative, is making Bank and the Bill & Melinda Gates Foundation, over the next 10 years. against a single virus, but a fight to protect a US$20 million investment in partnership to support increased financing for health and save lives from multiple infectious with the Global Fund and Last Mile Health to systems strengthening in two countries. After The Global Fund was ranked in the top diseases. We must support efforts to combat strengthen support to Liberia’s community the finalization of the El Salvador debt swap category in the 2020 AID Transparency COVID-19 while sustaining the unfinished health worker program, increasing domestic for health (D2H) agreement with Germany Index for its transparency and accountability, fights against HIV, TB and malaria. We must investment and expanding access to health in 2018, cumulative D2H support to programs underlining our commitment to tracking unite to fight. care. A new partnership with PharmAccess fighting HIV, TB and malaria reached health investments and providing quality Foundation, a Dutch NGO, will support US$142.2 million as of June 2020. data. countries in sub-Saharan Africa to accelerate progress toward universal health coverage On-time and in-full deliveries of health by harnessing digital technology. Goodbye Allocation commodities remained high at 85% in 2019, Malaria, which is backed by the international resulting in decreasing reports of stock-outs. restaurant group Nando’s, supported Following the record-breaking Sixth the elimination of cross-border malaria Replenishment Conference, Global Fund transmission in Eswatini, Mozambique and allocations for the next three-year cycle Consolidated financial South Africa. Project Last Mile continued its are larger than ever before, comprising statements and work supporting supply chain efficiency and US$12.71 billion for country allocations and external audit effectiveness, as well as behavior change US$890 million for catalytic investments programs across 10 countries. for the period beginning 1 January 2020 In 2019 the Global Fund once again received – 23.4% more than for the previous three- a clean audit opinion from KPMG SA. The In 2019, the Global Fund strengthened its year period. The Global Fund’s 2020-2022 Global Fund has elected to maintain our collaboration with a number of development allocation methodology is geared toward financial statements in compliance with the finance institutions, exploring models of increasing the overall impact of programs to International Financial Reporting Standards blended finance to increase health funding prevent, treat and care for people affected and our financial year follows a standard for implementing countries. This includes a by HIV, TB and malaria, and to building calendar year. Since 2012, the Global Fund public-private alliance with the Inter-American resilient and sustainable systems for health. has kept operating costs steady at less than Development Bank and other partners that The allocations provide significantly more US$300 million per year. Full financial data is has committed US$102.5 million to finance resources for the highest burden and lowest available in our Annual Financial Report. the work of a Regional Initiative to Eliminate income countries, while maintaining current Idelzita Mendoça Ferreira, Warehouse Manager of the National Generic Drug Central Purchase (CECOME), is Malaria in Central America, Colombia, the funding levels or moderating the pace of checking a shipment of malaria drugs and mosquito Dominican Republic and Mexico. The World reductions in other contexts. nets for the region of Cacheu in northern Guinea-Bissau. Malaria is the leading cause of mortality and significant cause of poverty in the country. Free condoms are available for visitors to a clinic that provides health services for people most at risk of HIV in Kampala, Uganda. 72 Section 73 The Global Fund / Jiro Ose

Note on Methodology 74 Note on Methodology 75 The Global Fund / Quinn Ryan Mattingly

A woman checks her weight on a scale as part of being screened for malaria in Bosaum Village, Battambang Province, Cambodia.

The Global Fund Results Report 2020 the global figures presented in the WHO and from the number of deaths that would have presents selected programmatic results UNAIDS reports, which include all data from occurred in a scenario where key disease (e.g., people on antiretroviral therapy, people all countries worldwide. interventions did not take place. For example, with TB treated, mosquito nets distributed) consider a country in which there is a TB achieved by supported programs in 2019. The Global Fund reports full national results program that provides treatment to people for the countries where we invest, rather than with TB and in one year, 1,000 people To measure impact, the Global Fund reporting solely on the specific projects or diagnosed with TB were treated and 100 also uses the official disease burden and interventions we fund. This reflects a core people died of TB. If in that same country, impact estimates developed and published principle of the Global Fund: that we support studies showed that the probability of dying by our technical partners, including WHO national health programs and strategies with TB was 70%, it would be reasonable to and UNAIDS. to achieve national goals. By reporting full assume that 700 people would have died had national results, we can show the impact of there not be the availability of treatment for We do not create our own disease burden the programs we support together with all TB. Therefore, the estimate of the impact of and impact estimates. The disease burden partners and demonstrate where countries the treatment intervention in this case would and impact numbers are based on the latest are on the trajectory toward achieving 2030 be 600 lives saved. The same principle is available data from UNAIDS and WHO; in targets to end the epidemics. used in all countries and for all diseases, using this report, data for HIV are up to 2019, but the best available estimates of intervention data for TB and malaria are up to 2018, as the The “lives saved” figure in the Global Fund’s effectiveness and epidemiology. 2019 data from WHO was not yet available results is calculated in conjunction with at the time of publication. The Global Fund’s technical partners using the most advanced For a fuller explanation of the Global results (nets distributed, people on ARVs, as modeling methods currently available, Fund’s reporting methodology, visit well as coverage and outcomes for portfolio) yielding estimates, not scientifically exact theglobalfund.org/en/methodology. are calculated using the data for HIV, TB and figures. The number of lives saved in a given malaria in countries where we invest in a given country in a particular year is estimated by year. This means our results are different from subtracting the actual number of deaths

The Global Fund Results Report 2020 presents selected programmatic results (e.g., people on antiretroviral therapy, people with TB treated, mosquito nets distributed) achieved by supported Kamate Muhindo is head nurse at the Majengo Marie Health Center in the Democratic Republic programs in 2018. The full, aggregated 2019 and 2018 annual results are available at https://theglobalfund.org/en/archive/annual-reports and country specific results are available at of Congo. He is passionate about saving lives in his community, even if his salary is not enough https://data.theglobalfund.org with the most up-to-date data, which might differ from the previously published annual reports due to retroactive updates and corrections. to feed his six children. “The biggest problem is that many patients are not able to pay for treatment or consultation,” he says. He also says that COVID-19 has made the situation worse, “We hope that with partners and advocates we will have the necessary equipment to protect

ourselves during our work because at the moment there is not enough for everyone.” The Global Fund / Pamela Tulizo / Panos Community health worker Nombasa and her husband from Cape Town, South Africa have borne the full brunt of HIV, TB and COVID-19. “Health workers need training and more PPE (personal protective equipment)76 to protectSection themselves and their families,” she says. “That support is needed now.” The Global Fund / Karin Schermbrucker Karin / Fund Global The