Rio de Janeiro, Brazil — “What is the plan before we get back to a stage where we are burying people?”
When Belinda Tewela, a South African healthcare worker, took the microphone at the International AIDS Conference in Rio de Janeiro, she did not speak about billion-dollar funding gaps or international policy.
She spoke about waiting.
“The waiting time has increased. The shortages of staff in facilities are real,” said Tewela, who also lives with HIV. “There were people from organisations like Anova who filled a huge gap, and now they’re gone. That results in the quality of healthcare services that we’re getting declining.”
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For Tewela, the impact of shrinking United States support for HIV programmes is no longer an abstract policy debate. It is visible every time she visits a clinic, where longer queues, fewer healthcare workers and growing pressure on public health facilities have become the new reality.
“What is the plan before we get back to a stage where we are burying people?” she asked. “As a person living with HIV, it’s really scary.”
Her question hung over the rest of the session – a session convened, in part, to examine Africa’s HIV response in the wake of sweeping cuts to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the programme that has underpinned much of the continent’s HIV response for more than two decades.
For South Africa, the stakes are especially high. Home to the world’s largest HIV treatment programme, the country has made remarkable progress in expanding access to antiretroviral therapy and reducing AIDS-related deaths. While the government finances most HIV medicines, years of PEPFAR investment have supported thousands of healthcare workers, community organisations, HIV prevention programmes, research studies and specialised services for key populations. As that support contracts, health officials, researchers and community advocates warn that the effects are already being felt.
The global HIV response is entering one of its most uncertain chapters in more than two decades.
African countries are struggling to contain the fallout from sweeping cuts to United States funding that have disrupted treatment, prevention, research, and community health programmes alike. Clinics have closed. Prevention programmes have been scaled back. Research has stalled. Thousands of people are already losing access to services that, until recently, they took for granted.
Those concerns are reflected in new international data.
According to a report released by KFF and UNAIDS, donor government funding for HIV programmes in low- and middle-income countries fell by US$2.1 billion in 2025, a 25% decline from the previous year and the sharpest single-year drop since global HIV financing expanded more than two decades ago. Funding has now fallen back to levels last seen in 2008 after the Trump administration dramatically reduced spending on global health programmes and personnel. Although the United States remains the world’s largest HIV donor, the scale of the cuts has sent shockwaves through health systems across Africa.
Kenneth Ngure, IAS President-elect and a researcher at Jomo Kenyatta University of Agriculture and Technology in Kenya, described the past 18 months as one of the most disruptive periods the HIV response has faced, with funding cuts affecting treatment, prevention, HIV testing, research and the health workforce.
“These are not simply numbers,” Ngure said. “They represent interruptions to life-saving services, and that is not acceptable.”
He said new analysis shows that 77,000 fewer children living with HIV received supported treatment in fiscal year 2025 than the year before – a 14% drop in a single year. Compounding the funding decline, Ngure said, is a shift in how remaining U.S. support is structured: many African countries are now negotiating new bilateral memoranda of understanding with Washington as a condition of continued funding, agreements that raise difficult questions around data-sharing requirements, healthcare privacy, and national sovereignty. Several are already the subject of pending court cases.
He said while African governments would need to take greater ownership of their HIV programmes, that transition could not happen overnight.
“Sustainable progress will increasingly depend on countries investing in and prioritising their own HIV responses,” he said. “But we also have to acknowledge an important reality. Many of the countries with the highest burden are also carrying significant debt and are facing severe fiscal constraints.” Ngure said that African governments have an essential leadership role to play, and that sustainable progress will depend increasingly on countries investing in their own HIV responses.
“Greater domestic ownership cannot become an excuse for global disengagement,” he said.
Inside PEPFAR
Mark Reid, associate professor at the University of California, San Francisco, and former chief of science at PEPFAR, said the funding crisis threatened to undermine one of the conference’s most hopeful messages: the arrival of powerful new HIV prevention tools.
While calling new long-acting prevention medicines groundbreaking, Reid warned that scientific innovation alone will not end the epidemic if the health systems needed to deliver it keep weakening. “One of the main roadblocks to scaling up these prevention innovations will be the lack of testing and access to services for key populations,” he said.
Reid, who previously worked within the U.S. administration, said his reflection on this moment is one of “real sadness and disappointment.” He described PEPFAR over its first two decades as a programme that was “data-driven and equity-informed” – a description he was no longer confident still applied.
He was careful to distinguish between the principle behind the current changes and how they’ve been carried out. The idea that PEPFAR needed to transition toward country ownership, he said, is something many public health advocates – himself included, as a former member of the PEPFAR team – have pushed for over many years. His objection is to execution. “The speed, the transactional nature of the process, the lack of deliberation, and the lack of transparency… calls for great concern,” he said.
“The speed, the transactional nature of the process, the lack of deliberation, and the lack of transparency… calls for great concern,” he said.
The consequences, he argued, are already visible. He pointed to a Zimbabwe-focused analysis suggesting that PEPFAR’s withdrawal could open the door to as many as 77,000 new infections in the coming year, a separate figure from Ngure’s pediatric treatment statistic, though the two numbers happen to coincide. Reid also cited steep disruption to condom distribution and broader population-level prevention programming in Zimbabwe as an early warning sign of what withdrawal looks like in practice.
Despite mounting evidence of disrupted HIV services across Africa, Reid said he hoped the crisis could ultimately become a turning point, as many affected communities right now are both angry and disappointed. “But I hope that this may well lead to an HIV response that is Africa-led and more resilient in nature,” he said.
Communities caught in the middle
If the funding cuts look dramatic on paper, Florence Riako Anam said they feel even more devastating on the ground.
The chair of the Global Network of People Living with HIV (GNP+) said communities across Africa had spent years preparing for a gradual transition away from donor dependence. Governments, civil society organisations and people living with HIV had worked together on sustainability plans designed to shift HIV services into stronger, nationally led health systems over five years.
Then, almost overnight, those plans unravelled.
Anam, who has lived with HIV since being diagnosed nearly two decades ago, said community health programming has always centered on one goal: keeping people alive. That work, she said, is what drew her into patient-led advocacy in the first place. Late January 2025 upended a basic assumption that underpinned it. For the first time, she said, people living with HIV confronted the reality that even antiretroviral treatment – long treated as an unshakable guarantee – was not secure.
The sudden suspension of U.S.-funded programmes left communities in shock as clinics closed, services were interrupted and uncertainty spread across countries that had relied heavily on donor support. “I got into this work to stay alive and to get the community that I represent… to stay alive,” she said. “It was a little bit of a shocker for us to wake up… and find a stable and safe home gone.”
Anam said governments, communities and international partners had already developed plans to gradually transition HIV programmes to greater domestic ownership.
Communities, key populations, and civil society groups had already been working with governments on formal transition and sustainability plans, plans released as recently as December 1, 2024, envisioning a gradual, five-year shift toward integrating HIV services into primary health care. Instead, the funding disruption compressed years of planning into a matter of days. What actually happened, she said, compressed that five-year runway into a matter of days: donor-funded facilities shut down, countries lost patient data, and misinformation spread quickly, leaving communities distraught.
She credited African governments with responding faster than they’re often given credit for, shifting into emergency budget postures to try to keep services running. Governments responded quickly to prevent a complete collapse of HIV services, including reallocating emergency funding to keep treatment programmes operating. But she said that the response was imperfect, and that stigma around HIV kept many people away from the alternative services that were stood up in place of the ones that closed, warning that the consequences continue to ripple through communities.
Drawing on the latest HIV Market Memo produced by the Clinton Health Access Initiative and UNITAID, Anam said treatment initiations across Africa had fallen by 42%, HIV testing by 12%, new HIV diagnoses by 28% and viral load testing by 21% since the funding disruptions began. Children, she said, remain among the hardest hit, with 26,000 fewer children receiving HIV treatment than before.
“This is people not getting services,” she said. “This is us stepping away from what we have worked so hard to ensure that everyone gets tested, gets on treatment and gets prevention.”
Her warning echoed the concerns raised by South African advocate Belinda Tewela. While the statistics illustrate the scale of the disruption, Anam said communities experience the crisis through missed appointments, interrupted services and growing uncertainty about whether care will still be available tomorrow.
The irony, she added, is that science has never offered more hope. Long-acting HIV prevention medicines and other innovations are beginning to transform what is possible, but access to those breakthroughs is becoming increasingly uncertain.
“We have a lot of tools available now,” she said. “But our fear… is that we will go back to that point where availability is not access.”
Governments forced to make difficult choices
For governments, protecting treatment has meant making painful compromises elsewhere.
Dr Lloyd Mulenga, Director of Infectious Diseases at Zambia’s Ministry of Health, said replacing hundreds of millions of dollars in lost donor support was simply beyond the reach of most African budgets. Instead, countries have focused on protecting antiretroviral treatment while scaling back prevention programmes, community outreach and other services that are essential to stopping new infections.
“When you don’t invest in community services, the first thing that will suffer is new HIV infections,” Mulenga said. “You start seeing pockets of new HIV infections because you are not following communities, you are not testing people, and you are not linking those who test positive to care.”
Like many governments, Zambia developed what Mulenga described as a minimum package of HIV services, preserving treatment while reducing community HIV testing, specialised service centres and other programmes that could no longer be fully funded. Prevention programmes were often the first casualty, he said, as governments moved to preserve treatment services and commodities above all else. “Many governments would like to preserve treatment and commodities first, but these other aspects, which are very key to sustaining the response, do suffer,” Mulenga said.
Zambia has largely sustained its treatment commodities pipeline, with U.S. support holding relatively steady last year even as prevention-commodity funding was scaled back; the government stepped in with domestic funds to help cover the gap. But replacing the more than $340 million Zambia had been receiving annually from the U.S. government is not something the domestic budget can readily absorb.
As a result, Zambia developed a minimum package of HIV services, making difficult decisions about which programmes could continue and which had to be scaled back. “We’ve had to look at which services we can drop,” he said. For example, to separate funding for circumcision and surgical services from the core package, scaling back community testing outreach in favor of facility-based testing, and cutting so-called “green light centres” despite their impact, because the cost of sustaining them is more than government budgets can carry. Community services, he acknowledged, are the clearest casualty of these trade-offs.
“The transition needs to be done in a phased manner, and it should be on the terms of governments,” he said.
For South Africa, the challenge is not simply replacing lost donor funding but reimagining how the country’s HIV response is financed and sustained.
Deputy Health Minister Joe Phaahla acknowledged that the withdrawal of international funding had disrupted programmes across the continent, but insisted African governments had never expected donor support to last forever.
“There is no doubt that the progress which has been made… has been achieved through solidarity and multilateralism,” Phaahla said.
He said governments, including South Africa’s, had already begun planning for a gradual transition towards greater domestic financing well before the recent funding cuts. The problem, he argued, was not the principle of country ownership but the pace at which it had been forced upon countries.
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“The commitment to increase domestic funding was already there,” he said. “But it has been disrupted by the speed of the disruption.”
For South Africa, that transition comes at a particularly difficult time.
The country is home to the world’s largest HIV treatment programme and has long relied on partnerships with PEPFAR to support healthcare workers, community organisations, HIV prevention programmes, research and services for vulnerable populations. At the same time, government is grappling with sluggish economic growth, competing health priorities and growing pressure on the national budget.
Phaahla said those pressures have been compounded by rising debt, inflation and broader global economic instability, leaving governments to fill widening funding gaps while responding to increasing demands on public services.
Even so, he argued that the answer is not to retreat from the HIV response but to strengthen it through greater political leadership, domestic investment and closer alignment between international partners and national health systems.
“This is about saving lives,” he said. “No one is safe until all of us are safe. That slogan should not be forgotten.”
He called on wealthier countries, philanthropic organisations and the private sector to continue supporting Africa’s HIV response, while urging remaining donor funding to strengthen national health systems rather than creating parallel programmes.
For South Africa, he said, the consequences of the funding cuts extend beyond clinical services. HIV and tuberculosis research programmes have been disrupted, forcing government to divert scarce resources to sustain work that was already underway.
Looking ahead, Phaahla said Africa must also reduce its dependence on imported medicines by expanding local manufacturing and securing licences to produce more health commodities on the continent.
“We should not just focus on procurement,” he said. “We should also push for licensing so that we can be able to be self-sufficient.”
That question – is there a plan?
“We are all working around the clock to make sure that we can close the gaps,” said Phaahla.
He said the abrupt nature of the funding cuts had made it impossible for government to fully replace the hundreds of millions of dollars previously provided through PEPFAR. Although National Treasury released contingency funding after the cuts, he said it could not match the scale of the funding that had been lost. “The magnitude is just too high,” he said.
He said government has been forced to reprioritise spending, integrate specialised HIV services into the public health system and redeploy health workers where possible. But replacing programmes that had relied on donor funding remains a major challenge, particularly after more than 15,000 workers were reportedly laid off following the initial funding cuts, with thousands more jobs expected to disappear as additional U.S.-funded programmes come to an end.
Phaahla said global economic pressures, including rising food and fuel prices, had further constrained the government’s ability to increase health spending despite its commitment to strengthening the HIV response. “It’s not a lack of will,” he said. “We have to do those adjustments with the practical needs of the resources at our disposal.”
He said the transition had not been seamless and that gaps remained.
“We do acknowledge that there are shortcomings,” he said, “but I can assure you that it’s not as a result of inequities.”
