The Trump Administration’s Foreign Aid Review: Status of U.S. Support for the Global Fund to Fight AIDS, Tuberculosis and Malaria

 Background on the U.S. and the Global Fund

• The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an independent public-private, multilateral financing entity created in 2002. It raises and pools resources from multiple donors to address HIV, TB, and malaria and in turn, invests more than $5 billion per year in more than 100 low- and middle-income countries.
• The Global Fund reports that it has helped to save 65 million lives and reduce the combined death rate of its three focus diseases by 61% since 2002. With its support, in 2023, 25 million people were on antiretroviral therapy, 7.1 million were treated for TB, and 227 million mosquito nets had been distributed.
• The U.S. government was instrumental in the creation of the Global Fund and is its largest donor, accounting for 33% of its funding. It also plays a significant role in governance and oversight of the Global Fund.
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold and meet disease burden criteria are eligible for Global Fund assistance. Countries are required to co-finance by investing in health systems and HIV, TB, and malaria national responses. To date, 11 countries have graduated from Global Fund support.
• The Global Fund is considered the “multilateral component” of PEPFAR, as well as U.S. bilateral efforts focused on malaria and TB, complementing and extending the reach of U.S. programs to many more countries. It also works differently thanS. bilateral health programs; unlike the U.S., it has no in-country presence and does not implement programs, instead providing financial assistance based on technical evaluations of country-led proposals. It also plays an important market shaping role through pooled procurement, driving down prices of health products, accelerating innovation and adoption of new products, and promoting quality standards, among other strategies.
• U.S. participation in the Global Fund is authorized in the legislation that created PEPFAR, as a permanent part of U.S. law. Other parts of the authorization are time-bound, including several related to the Global Fund such as a requirement that U.S. contributions to the Global Fund cannot exceed 33% of all contributions, used to limit U.S. funding and leverage support from other donors. Because PEPFAR’s current authorization expired on March 25, 2025, this requirement is not in place.
• The Global Fund replenishes funding every three years, through “pledging conferences.” Its last replenishment, hosted by the U.S. in 2022, generated $15.7 billion in pledges for the 2023-2025 period, including a pledge of $6 billion from the U.S. The next replenishment, for the 2026-2028 period, is scheduled for later this year, for which the Global Fund is seeking $18 billion, which it estimates would save an additional 23 million lives by 2029, and reduce mortality by 64% compared to 2023.

Current Status of U.S. Support for the Global Fund

• Funding: In FY 2024, U.S. funding for the Global Fund was $1.65 billion. The FY 2025 Continuing Resolution that passed in March included level funding for the Global Fund of $1.65 billion.
• U.S. Representation at the Global Fund Board: The U.S. also plays a role in the Global Fund’s governance and oversight, holding one of twenty Board seats and currently sitting on two Board committees.
• PEPFAR Reauthorization: While PEPFAR and U.S. participation in the Global Fund are permanently authorized in U.S. law, eight time-bound provisions expired on March 25, 2025, four of which pertain to the Global Fund. In addition to the 33% limit on U.S. contributions, the other provisions also served to direct or place limits on U.S. Global Fund contributions.
• Foreign aid review/freeze: While the actions taken by the administration to implement the executive order calling for a 90-day foreign aid review (which has been extended for 30 days) have thus far not been applied to the Global Fund, or other multilateral institutions, the Global Fund relies on PEPFAR and other U.S. implementers, as well as U.S. government staff and expertise, to assist countries in delivering services. As such, the disruption of that work has affected some Global Fund efforts as well. For example, a partnership announced last year between the Global Fund and PEPFAR to provide long-acting injectable PrEP to more than two million people (once approved by the FDA and recommended by the WHO), is now in jeopardy, as the administration has prohibited the provision of PrEP (except in limited cases). The Global Fund also recently announced that, due to significant service disruptions and funding uncertainty, it may seek to reprioritize investments to preserve the continuity of essential health services and ensure access to lifesaving interventions.
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with the Global Fund, and how or if Congress will respond to any such recommendations.
• PEPFAR reauthorization and lapsed legislative requirements: It is unknown if Congress will seek to reauthorize PEPFAR, which could afford it an opportunity to extend the time-bound provisions that apply to the Global Fund. It could also use another legislative vehicle to do so. Even without these requirements in place, the administration could still choose to follow them.
• Funding/Budget Request: The administration’s initial FY 2026 budget request includes significant reductions in funding for global health, as well as rescissions to prior year funding amounts. A more detailed budget request is expected to be released shortly.
• Replenishment. The Global Fund’s upcoming pledging conference later this year will be an important moment for the organization in determining its budget for the next five years.