A year after the United States froze funding to the United States Agency for International Development (USAID) and withdrew from the World Health Organization and other UN agencies, African health systems are confronting acute financing gaps. HIV prevention, testing, and treatment programs face reduced funding, staff shortages, and strained supply chains. This piece examines the scale of these impacts and the policy choices African governments must make to protect essential health services.

USAID’s role in HIV/AIDS prevention in Africa and the impact of its disbandment
USAID’s funding freeze has disrupted HIV programs across Sub-Saharan Africa. The Lancet reports that USAID health support contributed to a 15% reduction in overall mortality and a 65% drop in HIV-related deaths, demonstrating the life-saving impact of sustained funding. According to a UNAIDS survey in one Sub-Saharan African country, 62% of people had difficulty accessing PrEP (pre-exposure prophylaxis) , 46% of people living with HIV experienced treatment interruptions, and 23% received fewer antiretroviral drugs than before the funding ended. 

The freeze has caused disruptions to critical programs, forced health worker retrenchments, and created bottlenecks in prevention services and community health systems, resulting in interruptions to HIV prevention, treatment, and caregiving. UNAIDS estimates that, without restored funding, there could be approximately 600 additional HIV-related deaths per day and 6.6 million new infections between 2025 and 2029. These figures show that the funding freeze is not just a financial gap; it is actively reversing progress in HIV prevention and care, putting millions at immediate risk.

HIV/AIDS remains a major public health challenge in Africa, which accounts for 75% of global infections. With no definitive cure, people living with HIV require lifelong access to treatment, monitoring, and psychosocial support, while epidemic control depends heavily on consistent preventive behaviors such as safe sex practices, partner fidelity, abstinence, regular testing, or consistent adherence to treatment. Beyond clinical care, HIV management outcomes are strongly shaped by human behavior, risk perception, and social norms. Therefore, in addition to medical interventions, effective control necessitates sustained public trust, behavioral compliance, and government support.

The United States’ withdrawal from WHO worsens the financial crisis, threatening access to treatment, prevention, testing, and research and slowing progress toward the 95‑95‑95 targets, putting decades of HIV/AIDS control at risk by 2030.

How can we adapt health systems to be more resilient after recent funding cuts in international development?

To maintain the momentum gained in HIV prevention and management in Africa, countries need to quickly adjust their HIV strategies. This calls for an increase in local funding and strengthening of health systems through partnerships between governments and development agencies in prevention, ongoing treatment, and streamlining supply chains to ensure steady delivery of required HIV/AIDS treatment and supplies. Closely related to this, it is important that institutions and governments share knowledge regarding successful strategies and areas that need further adjustment without overreliance on external funds. 

Moradzadeh and colleagues, in their article in the International Journal of Health Policy and Management, advise WHO member states to closely examine existing funding mechanisms to ensure that the organization’s budget does not become overly dependent on a single member, which could lead to disruptions if that member nation withdraws from the organization.

Most health systems and infrastructure established by USAID programs still exist even though funding is now a missing component in the health system’s puzzle. Thus, it is important that countries leverage these systems and infrastructure to scale up HIV/AIDS mitigation programs instead of implementing alternative programs that work in isolation. Below we suggest some strategies for adapting systems and HIV programs to be more resilient.

Determining post-donor baseline through comprehensive national research is now a top  priority

Governments, especially in the Global South, should urgently commission large-scale, nationally representative research to surface the true post-donor state of HIV response systems. Previous investments were often routed through bilateral programs, NGOs, faith-based organizations, and community platforms, meaning that substantial service capacity and infrastructure may not be fully reflected in government records. 

This research should generate a clear picture of the current HIV prevalence and incidence, service coverage, workforce capacity, laboratory and supply chain readiness, medication availability, and the financial gaps created by donor withdrawal. 

Also, since there is increasing worry that people see HIV as less of a threat (assuming it is easy to manage), it is essential to conduct studies on how communities view risk, stigma, treatment adherence, prevention actions, trust in services, and social norms that affect HIV outcomes.

Reorienting governments’ investment toward prevention and behavioral impact

Because prevention reduces future treatment costs, preserves health system capacity, and delivers high long-term returns, governments facing fiscal constraints should prioritize prevention as the most cost-effective and sustainable HIV strategy. 

The governments should invest in developing thorough, contextual awareness and campaigns, working with relevant stakeholders such as academics and behavioral change practitioners, to create messaging through iterative, evidence-based processes. Due to the competing financial priorities of most governments, campaigns should focus on the most at-risk groups, such as sex workers, men who have sex with men (MSM), and young people. The campaign messaging should be appealing and promote ways that stop or limit risks of HIV transmission, including proper condom use, regular testing, faithfulness, and treatment adherence, especially among HIV-positive people.

Improve timely detection and rapid response capability and capacity

Achieving HIV/AIDS control hinges significantly on early detection, prompt treatment initiation, and treatment adherence. The right space to expand this investment is the primary health care center (PHC), being the focal point of care for the majority of people, particularly in developing countries. 

There is a need to integrate targeted, regular testing into outpatient and reproductive health services, along with strengthened contact tracing systems, at the PHC level. Other high-traffic and high-risk locations that should be considered include tertiary institutions and even religious places. Early diagnosis enables timely treatment initiation, reduces onward transmission, and lowers long-term health system burden.

Integrate HIV services into universal health coverage frameworks

There is a global push for, and visible progress in, expanding universal health coverage (UHC) across developing nations. This presents an opportunity to move HIV programs from a donor-supported, standalone, adjacent health service delivery into the national and subnational health benefit packages. This integration will reduce inefficiencies, enable better allocation of resources to adjusted priority areas, and reduce fragmentation and support sustainable long-term planning. 

The most practical approach is to integrate HIV service into the primary health care system and harmonize the supply chains across the board. Global modeling evidence consistently shows that treatment continuity prevents the largest spike in HIV-related deaths and new infections. Indeed, any long-term disruption to antiretroviral medications might increase the risk of viral rebound and drug resistance.

Increase financial resources and availability from domestic sources 

HIV programming is an expensive undertaking. Thus, with the waning of global funding, it is crucial that African countries explore innovative local revenue sources to plug the deficit as much as possible. Governments can, where such mechanisms do not already exist, introduce sin taxes on harmful products such as tobacco, alcohol, and sugar-sweetened beverages, and where they do exist, allocate a significant share of the revenue to HIV/AIDS programming. 

Additional options include expanding social health insurance, pursuing debt-for-health swaps, mobilizing private-sector co-financing, strengthening public–private partnerships, issuing diaspora bonds, engaging local philanthropies, and leveraging blended finance models. As global HIV financing gaps widen, these mechanisms are becoming essential to closing emerging shortfalls and stabilizing national HIV responses.

Protecting the HIV workforce through absorption and contracting models

A key factor for the progress recorded so far is the enormous workforce that has been built over the years as a result of long-term donor support. Clinicians, laboratory scientists, community health workers, and data officers have been essential to maintaining treatment adherence, prevention outreach, and service continuity, especially in the hard-to-reach and underserved communities. 
Now, the dwindling resources pose a risk of dismantling the network of health workers, which could directly undermine program performance and patient outcomes. To mitigate this risk, countries should prioritize finding ways to retain essential health workers who have become redundant due to funding cuts, either through direct absorption into the civil service structure or through other contracting arrangements.

Set up or strengthen national/regional procurement and local capacity for manufacturing

Antiretroviral medications remain the central ingredient to HIV epidemic response and control. Therefore, any disruption to its availability due to decreased funding is dangerous. Thus, the need for strengthening local research and development (R&D) capacity to manufacture the essential medications has become crucial. However, such a venture is not a short-term response and will require consistent, long-term investments. As such, in the interim, countries can come together and explore shared and pooled resources for essential integrated HIV programs, including laboratory, procurement, and supply chain platforms.

For instance, in Africa, regional entities like the African Union (AU) can anchor some of these shared resources. Fortunately, lenacapavir, the newly introduced long-acting antiretroviral medication that only requires two injections in a year, offers a strategic option for countries in reducing their logistical burden and costs compared to the daily antiretroviral medications. Lenacapavir has also been shown to reduce adherence burdens and improve care retention.

Conclusion

Safeguarding the gains made so far in HIV/AIDS mitigation calls for a multifaceted approach—one that in the long term reduces overreliance on foreign funds and ties public health to the national security and prosperity of respective African nations. For several decades, most African countries have relied on foreign aid and multilateral funders to plug deficits in their health budgets, but the unpredictability in international development points to the need for different posturing in government priorities. In the near term, there is a need for governments in developing nations to prioritize internal budgetary allocations and to anchor HIV/AIDS programs to universal health coverage and PHC services. This will help ensure that both those at risk of infection and those who have already started treatment receive the necessary support. In the long run, the cuts in funding show that governments and international development partners need to be better prepared to find new sources of funding and protect the money they already have in case of the next uncertainty. While there is no universally applicable solution to the current funding quagmire, it is crucial to adopt a proactive approach by prioritizing existing domestic resources and fostering cross-collaboration among African countries.

References

1. Mugari, C., Lukwa, A. T., Okova, D., Chiwire, P., & Hiligsmann, M. (2025). Cost-effectiveness of HIV prevention interventions in sub-Saharan Africa (2019-2025): a systematic review. Expert review of pharmacoeconomics & outcomes research, 25(9), 1295–1307. https://doi.org/10.1080/14737167.2025.2570695
2. Hontelez, J. A. C., Goymann, H., Berhane, Y., Bhattacharjee, P., Borf, J., Chabata, S. T., et al. (2025). The impact of the PEPFAR funding freeze on HIV deaths and infections: A mathematical modelling study of seven countries in sub-Saharan Africa. The Lancet EClinicalMedicine, 83, 103233. https://doi.org/10.1016/j.eclinm.2025.103233
3. World Health Organization: WHO. (2025, November 3). WHO issues guidance to address drastic global health financing cuts. https://www.who.int/news/item/03-11-2025-who-issues-guidance-to-address-drastic-global-health-financing-cuts?utm_source=chatgpt.com
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