In recent months we have witnessed a dramatic and rapid change to the funding landscape for HIV treatment and prevention across Africa. The withdrawal of USAID and PEPFAR funding has been publicised extensively and this, coupled with anticipated reductions in US contributions to the latest Global Fund renewal, raises serious questions about the sustainability of HIV programmes.
Against the backdrop of chaos caused by clinics closing overnight and without warning, and people with HIV (PWH) and at-risk individuals being cut-off from their essential medications, governments are having to find solutions rapidly to sustain and continue to advance in the fight against HIV. While the gradual reduction in international aid was already well underway before the USAID/PEPFAR cuts, the sudden and dramatic reduction in health aid since February 2025 has pushed HIV programmes in Africa off a cliffedge. Governments have had no time to complete the collection of necessary evidence, finalise transition strategies, and start disentangling decades of USAID resources from sector-wide health initiatives. Consequently, governments require urgent solutions to respond to this transition much sooner than anyone expected.
But what does the evidence tell us about the impact of these cuts? And how can the fields of epidemiological modelling and health economics help to inform governments’ responses?
On 26 June 2025, the Thanzi Programme in collaboration with the East, Central & Southern Africa Health Community and the WHO Africa Office, convened a webinar with international academics and regional experts and advocates to explore the latest scientific evidence on this topic. This included a deep-dive into the critical new research from the HIV Modelling Consortium which offers practical recommendations on how to reduce costs while simultaneously improving HIV-related health outcomes.
Key takeaways from academic leaders
Impacts of U.S. bilateral aid disruptions on HIV in Zambia
The EMOD-HIV agent based network transition model explored the impact of aid cuts to Zambia’s HIV programmes. Zambia is particularly vulnerable in this current climate; it has a high HIV prevalence and is uniquely reliant on aid: 84% of Zambia’s HIV programme was supported by PEPFAR in 2024.
The model shows how a prolonged and unabated disruption to Zambia’s HIV programmes would lead to a dramatic increase in HIV prevalence and reversal of years of gruelling work to tackle the HIV pandemic. Their results predict 3.3 million more HIV acquisitions and 1.6 million avoidable deaths from HIV by 2055. Unsurprisingly, women and children would be most severely impacted but overtime HIV prevalence across all demographics will have increased substantially.
Results show how keeping disruption to HIV programmes to the shortest period of time possible (e.g. 3 months) would still result in negative health impacts, however, this would be less disastrous than a longer or sustained disruption. The number of excess infections and deaths would be more limited if there was disruption for only 3 months, and there would be no change to HIV prevalence rates after 20 years. But how can countries like Zambia respond with this tight timeframe?
Sustaining progress through self-care: the power of local provision
The HIV Modelling Consortium’s latest research on cost-effective provision of HIV care and prevention in East, Central, Southern & West Africa (ECSWA) used the HIV Synthesis individual based model. The team simulated a range of 1,000 epidemics and testing, prevention and treatment programmes representing the range of situations in ESCWA. Then they simulated the effect of introducing an “enabled self care” intervention that involves local provision of free HIV self-tests (replacing clinic based testing) and antiretroviral drugs for prevention (in place of existing PrEP programmes) and treatment (as an additional source of drug for PWH) in local pharmacies and from community based health workers. They assumed loss of some programmes, such as viral load testing and male circumcision, regardless of whether this intervention was adopted.
The results of the Consortium’s modelling indicates that this community-focussed policy would generate positive health results. A move towards a strategy of self-care in the community, and away from the more traditional clinic-located treatment, results in a cost-saving and sustained decline in HIV incidence. This evidence is extremely promising for ministries of health which must sustain HIV treatment/prevention with considerably fewer resources. These positive health outcomes are reliant, however, upon a close and sustained collaboration between national/federal policy-makers, community stakeholders (pharmacies, community-based health worker organisations) and the communities themselves. It also relies upon a resilience and sustainable supply chain for tests and drugs to a large number of pharmacies and community-based health workers.
Modelling for sustainability: insights from the HIV Modelling Consortium
The HIV Modelling Consortium emphasised the vital importance of engaging with local communities to ensure that models meet the needs of the contexts in which they are deployed. Of particular relevance to the current climate, the team highlighted how important high quality data are to generating relevant evidence for policy-makers. During a period where resources for disease surveillance and maintenance of health information systems are also under threat from aid cuts, the team called attention to the importance of investing to maintain these systems.
Reflections from regional experts
Potential impact of reductions in development assistance on health systems and financing vulnerabilities in Africa
The WHO Regional Office for Africa highlighted sobering findings from recent research undertaken on the continental impacts of the USAID cuts, and illustrated the scale of the task facing African policy-makers.
While there is considerable variation across the continent, external aid contributes nearly a quarter of health spending overall. The USA has been the biggest donor for some time, providing roughly 35% of the total international aid contributions to Africa for health (approximately $5.11 billion). However, very little of this aid is managed through government channels (<10%). While the issue this mechanism generates has been recognised for some time, it further hampers countries’ responses to aid cuts. Without a clear picture of how and where these funds are spent, governments are in the dark on the full scale of the impact from the cuts.
The team’s research reveals that 27 countries face very high or high levels of vulnerability to the cuts owing to a combination of: very low health spending per capita; very high dependence on international aid; stagnated or contracted budgets; and being in debt distress or close to it. Recommendations centre upon protecting essential health services with a particular focus on vulnerable groups; trying to preserve and expand health budgets through other channels; and aligning their responses to their own vulnerabilities and fiscal spaces.
The African Union (AU) Commission on the other hand shared feedback from member states on their concerns about funding shortfalls for essential health services and interventions. Innovative responses are already being explored by governments including the integration of disease-specific services into broader health systems and cross-country collaboration. The AU Commission, however, asserts that despite the serious consequences of the international aid cuts, this situation provides a unique opportunity for governments to transform their health financing arrangements, and place themselves more firmly in the driving seat in the future.
Missed the live webinar? Catch up with the recording here.
Acknowledgement
Thanks to the webinar presenters and research teams behind the work described in this blog. Edward Kataika (ECSA Health Community); James Avoka Asamani (WHO Africa Office); Andrew Phillips (University College London); Edinah Mudimu (University of South Africa); Anna Bershteyn (NYU Grossman School of Medicine); Lloyd B Mulenga (University of Zambia); Moustapha Zakari (African Union Commission); Paul Revill (University of York).
By: Alexandra Rollinger 1; Juliet Nabyonga-Orem 2; Katherine Devlin 1, Edward Kataika 3
1 Centre for Health Economics, University of York (UK) ; 2 WHO Namibia Country Office ; 3 East Central & Southern Africa Health Community (Tanzania)
