Canada’s reduced pledge to the Global Fund will threaten infectious disease control at home

Commentaries in this issue of CMAJ highlight Canada’s mixed performance on tackling 2 globally important infectious diseases: tuberculosis (TB) and HIV.^1,2 Another recent CMAJ article discussed the indirect impact of United States government cuts to the President’s Emergency Plan for AIDS Relief (PEPFAR) funding on health care systems globally.³ All 3 articles conclude with a call for Canada and other countries to step up to fund global research into and control of TB and HIV. And yet, on Nov. 21, 2025, several high-income countries reduced their pledges to the 2026–28 replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria compared with previous years; Canada’s pledge reduced by 16%, its first ever decrease.⁴ The Carney government’s choice not to stand up as a global leader in replenishing the Global Fund is short-sighted.

Tuberculosis and HIV are not just foreign problems. As the related articles emphasize, these diseases are important in the Canadian context too, and the reduced support for their control internationally will affect Canada’s capacity to meet its own stated targets.

Most new TB disease in Canada occurs among people born in high-risk countries,⁵ with 85% acquiring TB infection before immigration. In many cases, disease develops decades after people are well-established members of Canadian society. Targeted newcomer screening for TB infection is good and effective, but not all immigrants are screened. Merely expanding this screening is cost-prohibitive for several reasons, including the sheer prevalence of TB infection globally, the infection’s long latency, and the relatively low rate of conversion to TB disease. About 22% of foreign-born residents of Canada have TB infection, and the rate at which infection becomes active disease is only 5% to 10% over a person’s lifetime.⁶ This underscores the wisdom of acting to eliminate TB as a public health threat in Canada by ensuring control in countries from which newcomers emigrate.⁵

Although a much lower proportion of newcomers to Canada are living with HIV at entry (0.37% in 2023) than TB,⁷ the chronic disease requires lifelong treatment to reduce risk of transmission, which TB infection does not. Like TB disease, however, HIV carries a high ongoing burden of stigma, socioeconomic consequences, and limitations on societal participation.⁸

Unfortunately, HIV and TB control will not be the only casualties of the current global funding short-sightedness. In public and global health, managing problems in silos may seem appealing, but health threats do not fit into neat containers; they affect systems. As the COVID-19 pandemic revealed plainly, surges in rates of 1 infectious disease can ultimately affect health systems’ ability to manage others. A decrease in resources for disease management adds complexity to this problem. With reduced aid from the Global Fund, Country Coordinating Mechanisms will be forced to divert resources away from other disease prevention and elimination programs, with global ramifications for antimicrobial resistance and the control of many other communicable diseases. Recent cuts to PEPFAR and the virtual shutdown of the US Agency for International Development have already resulted in withdrawal of critical disease-prevention and life-saving services.⁹

A disproportionate number of Indigenous people in Canada also live with TB and HIV infection, with a likewise disproportionately high number progressing to TB disease and AIDS, respectively. Shifting funding from global to local solutions could therefore be argued to be wise. However, although the high rates of TB and HIV in local and global populations constitute separate epidemics,^10,11 these are linked by their close association with social determinants such as poverty, housing insecurity, racism, and associated difficulties with accessing health care.⁸ Global funding does not just prop up health systems in less well-resourced countries; it feeds into coordinated research and innovation in treatment, diagnostic technologies, vaccinations, and implementation science, from which affected communities in Canada also benefit.

Short-term political wins often leave long-term negative health impacts. Canada’s reduced pledge to the Global Fund reflects short-sighted political thinking that fails to appreciate the complexity of global health threats and long-term health consequences. If the anticipated shortfall in pledges to the Fund is not offset, Canada should anticipate reduced success in domestic TB and HIV control in forthcoming years, rather than the progress toward elimination that is hoped for. For now, Canada should plan to invest heavily in improving the social determinants that perpetuate TB and HIV epidemics at home and to implement the domestic disease-specific solutions outlined in the related commentaries.^1–3 Investment in the Global Fund is an investment in combating AIDS and TB and in strengthening public health systems that protect everyone.

See related articles at www.cmaj.ca/lookup/doi/10.1503/cmaj.250722 and www.cmaj.ca/lookup/doi/10.1503/cmaj.251245