Safer option: A patient with extensively drug-resistant tuberculosis at Jose Pearson Hospital in Port Elizabeth, Eastern Cape. Bedaquiline is the first new TB drug in more than 40 years and is safer and more tolerable than the injectable drugs it replaces. Picture: CHRIS FREY
Safer option: A patient with extensively drug-resistant tuberculosis at Jose Pearson Hospital in Port Elizabeth, Eastern Cape. Bedaquiline is the first new TB drug in more than 40 years and is safer and more tolerable than the injectable drugs it replaces. Picture: CHRIS FREY

Since 2002, funding from the Global Fund to Fight Aids, Tuberculosis and Malaria has put 17.5-million people in 95 countries on antiretroviral treatment and 5-million on TB treatment.

The fund has also financed treatment for 108-million cases of malaria and the distribution of 197-million mosquito nets.

These are the latest numbers from the fund, released last week in its 2018 results report. As one of the two main financers globally of programmes for HIV (the US President’s Emergency Plan for Aids Relief created in 2003 is the other), and the largest funder in the world of TB programmes, the Global Fund underwrites most developing countries’ national disease programmes for these three biggest killer infectious diseases — $38bn so far.

The report makes it clear that the world has made huge progress in combating infectious diseases: "Overall, the number of deaths caused by Aids, TB and malaria each year has been reduced by one-third since 2002 in countries where the Global Fund invests," it says.

But it also highlights the tension between these enormous strides made — 27-million lives saved, the fund estimates, from its investments across the three diseases — and the fact that there are still millions dying from them (2.5-million people in 2016).

The report telegraphs the next wave of challenges: the rate of the decline in new HIV infections is slowing in some parts of the world (Eastern Europe) and in some "key populations" (minorities, often unreached or discriminated against). New infection rates are rising — unthinkable when tools exist to prevent new infections.

TB, including terrifying drug-resistant forms, is a not so hidden global threat. About 4.1-million people are "missed" (undiagnosed) every year and in turn infect others.

SA is among six Group of 20 (G20) countries with the highest TB burdens in the world, "shattering the myth that TB has been relegated to low-income countries", the report says. TB will cost the global economy $1-trillion over the next 15 years.

The Global Fund was a game-changer in global health, in its performance-based funding model, its principles of "country ownership", transparency and accountability. Called into being by former UN secretary-general Kofi Annan in 2001, it was established to inject unprecedented amounts of money into the health systems of countries that urgently needed to launch their own national programmes, spurred by the global outcry against inequity in HIV treatment.

The Global Fund partnership is the vast network that makes the programmes work: an "ecosystem" of governments (both donor and implementer), civil society, private sector, technical partners, policy makers, scientists, activists and, crucially, community health workers. Rigorous monitoring, evaluation and auditing systems ensure that money is spent where and how it is intended.

There are serious consequences (tranches of funding stop) if things deviate from plans agreed between the Global Fund and the implementing entity.

It shows graphically SA’s top-line good news: HIV incidence — the rate of new infections — has dropped by 50% since 2000 (to 270,000 in 2017); HIV-related mortality has dropped by more than 25%, and malaria infections and deaths have dropped by almost 100%.

More than 15 years and nearly $40bn later, the fund’s impact is immense in "lives saved" and in the less quantifiable measures of empowerment and skill for countries and communities that had never before been enabled to fight their own battles.

In its latest funding cycle, 27% of the fund’s investments went into "health systems strengthening", including cross-cutting systems functions such as data, supply chains and service delivery integration.

This model has up-ended the "black hole" stereotype still held in the minds of sceptics, and the fund not only put performance — and results — based funding on the map in global health, but established it as so effective a concept and practice that it is now how many mainstream international organisations approach their work. SA, where the fund has invested $845m, has also made huge progress in dealing with HIV. At least 4.4-million people are on antiretroviral treatment and 85% of South Africans living with HIV know their status.

It is also doing much better than most developing countries in taking responsibility for funding, with around 80% of its HIV and TB programmes domestically financed.

While the fund’s report does not systematically look at all national programmes it supports, it gives high-level results for 21 "high-burden" countries, SA among them.

It shows graphically SA’s top-line good news: HIV incidence — the rate of new infections — has dropped by 50% since 2000 (to 270,000 in 2017); HIV-related mortality has dropped by more than 25%, and malaria infections and deaths have dropped by almost 100%.

SA’s progress is substantial and millions of lives have been saved — especially since free antiretroviral treatment became available in 2004 — in part thanks to the fund.

There is no room for complacency, however. TB incidence is up by 30%. Young people aged 15-24 still have alarmingly high rates of HIV infection — 7.9% on average. It is three times higher among girls than boys.

As the report says, progress in "normalising" HIV has led to the paradoxical effect of reducing the sense of urgency around prevention, especially among young people.

If new HIV infections, using new prevention tools, are not curbed in this age group with its projected imminent "demographic bulge", and especially among adolescent girls and young women, a fresh catastrophe lies ahead: the risk of "a return to the level of the epidemic in the 2000s", according to the fund.

But SA’s astonishing turnaround in its HIV work in the past decade, and the unprecedented, concerted global effort that has fuelled the Global Fund partnership’s successes, proves that what once seemed impossible can be made possible — again, or anew.

• Sulcas is a global health and food systems writer and acting editor of the Global Fund Observer.