The significant health progress made over the past decade in Central, Eastern, Southern and West Africa—where many countries were on track to ending their AIDS epidemics—is now at risk of being reversed due to inadequate financing. One of the major causes of the funding shortfall is rising debts.

In 2020, as the Covid-19 pandemic halted economies and overwhelmed emergency rooms, many African countries borrowed from creditors to provide emergency services to their citizens. But four years later, the terms of those loans are forcing governments to make debt payments at the expense of health and other social services. Nearly two thirds of people living with HIV reside in countries that have not received significant debt relief post-Covid.

In West and Central Africa, debt to GDP ratios increased by 9 percent between 2018 and 2023. Countries such as Burkina Faso, Burundi, the Republic of the Congo, Côte d’Ivoire, Ghana, Liberia, Senegal and Sierra Leone have seen significant rises in their debt burden, now reaching at least 15% of GDP. 

In East and Southern Africa, the situation is even more dire: in Angola, Kenya, Malawi, Rwanda, Uganda and Zambia, governments spend over 50 percent of their tax revenues on debt servicing. Many of these debts are from external private creditors seeking unreasonable profits – for example, one creditor in Zambia would make a 110 percent profit if the country paid back its debts. (As context, even highly profitable companies like Apple do not have profits that surpass 48 percent.) 

Despite Zambia successfully reaching a debt restructuring deal with official creditors, effectively getting some debt relief last year, it’s still slated to pay two-thirds of its budget towards debts over the next two years largely due to not yet reaching a deal with private-creditors. On the ground, crises are already proliferating; hospitals lack essential medicines and equipment. Labor unions and health activists have rallied across Lusaka demanding debt cancellation. 

“Countries are facing life and death decisions,” said Charles Birungi, who leads UNAIDS’ work on macroeconomic and fiscal policy. “Do I pay for hospitals, medicines and education – or do I pay my debt? What if paying my debt means that my hospitals go without drugs?”

Two recent UNAIDS reports focusing on Eastern and Southern Africa and on Western and Central Africa outline that the future of funding for the HIV response in many African countries, as well as broader health and social welfare, rests on innovative measures to ensure governments can invest their own tax revenue for citizens. 

“Progress is being made in the fight against HIV in both regions,” said one of the report authors and development finance specialist Gail Hurley. “Of course there were setbacks, including those related to Covid-19, but external funding and strong political commitment has provided a solid foundation to build on. Countries now need partial or even whole scale debt relief in order to achieve global health goals.”

Debt relief is especially critical for countries that want to move away from relying on international donors to finance their HIV responses. In East and Southern Africa, for instance, most HIV financing comes from two donors: the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to fight AIDS, Tuberculosis and Malaria (which is also heavily supported by the US government). But without debt relief, countries cannot invest tax revenue in health systems.

Based on extensive consultation with economists and policy experts, UNAIDS has called for lenders and international institutions to re-negotiate debt payments to comprise at least less than 15 percent of respective countries’ annual budgets. Such a policy for the heavily indebted countries of Angola, Burundi, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, South Sudan, United Republic of Tanzania, Uganda, Zambia and Zimbabwe would free up $41 billion a year for health, education and social welfare. The strategy has a precedent: the Heavily Indebted Poor Countries (HIPC) Initiative, launched in 1996 by the IMF and World Bank, aimed to ensure that states did not struggle under an unmanageable debt burden. It took a similar approach and relieved 37 countries of more than $100 billion in debt.

UNAIDS also recommends that governments increase tax revenue through measures like raising the income tax of the ultra-wealthy, wealth taxes, reducing tax exemptions and clamping down on tax-dodging. Amnesty International estimates that Zambia, for example, loses over USD 4.5 billion annually through tax evasion and tax avoidance. 

Another option not included in the reports but recommended by UNAIDS’s partner WHO is a ‘health tax’ on products that lead to or exacerbate health issues, including sugary beverages, tobacco and alcohol. In 2023, WHO called on all countries to increase taxes on alcohol and sugary drinks (and has previously suggested taxes on tobacco). These monies could then be re-invested in health systems. 

But UNAIDS cautions that even raising tax revenue will not be enough to address funding gaps unless it goes hand in hand with debt reduction. Without swift changes to enable African governments to invest in health, Birungi fears what the future could hold. “What happens if we wake up tomorrow and the donors are gone?” he asked. “Will we go back to the 80s and 90s when people were dying in massive numbers?”

In 2025, for the first time, the G20 is chaired by an African nation: South Africa. President Cyril Ramaphosa has set debt as one of the priorities for action of the G20 Ministers of Finance. Former South African Finance Minister Trevor Manuel has been appointed to chair the newly established G20 Africa Expert Panel, an international commission of experts to advance proposals. UNAIDS will join efforts with other UN agencies and experts such as Nobel Prize laureate Joseph Stiglitz, co-chair of UNAIDS sponsored “Global Council on Inequality, AIDS and Pandemics”, to advocate for fair financing and debt resolution mechanisms to be advanced in the G20 this year.

Government and CSO Operations

• Government institutions continue to function, but two community support centers run by civil society organization partners have closed.
• Human resources affected include 32 community health workers, 15 doctors, 15 technical staff and management, and 16 CSO staff. Neither government nor partners are covering their salaries. According to the most conservative estimations, about 1700 key populations have been lost from the social support program, over 2000 clients were not tested for HIV, and about 100 new cases were not detected. Due to the closure, dozens of clients didn’t receive specialized medical services provided in those community centers. 

Service Provision

• ART Services: All facilities/service points are operating at full capacity with minimal disruption in ARV supplies, HIV test kits, viral load test kits, other lab test kits, and condoms. Condom stocks are sufficient for the next 12 months.
• Prevention of vertical transmission and Pediatric Services: All facilities are functioning at full capacity.
• HIV Prevention: There are disruptions in the distribution of condoms and other prevention commodities, suspension or reduction of HIV prevention education and awareness campaigns, and delays or disruptions in community-based HIV prevention outreach programs.
• Data Collection: Continues at all facilities, including data quality control and collation.

Immediate Risks or Disruptions

Human Rights and Key Populations

• PrEP Services: Disruption in access for sex workers, men who have sex with men (MSM) and gay men, people who use drugs – due to the disruptions in outreach work.
• HIV Prevention Services: Reduced capacity for sex workers, MSM and gay men, people who use drugs – due to the disruptions in outreach work by CSOs.
• HIV Testing Services: No discontinuation for key populations, but reduced availability of counseling and testing - due to the disruptions in outreach work by CSOs.
• ART Services: Disruption in access for sex workers, MSM and gay men, people who use drugs - due to the disruptions in outreach work by CSOs.
• Stigma and Discrimination: All PEPFAR-funded work has stopped, affecting key populations, adolescent girls and young women, and people living with HIV.
• Adolescent girls and young women (AGYW) HIV Prevention due to the disruptions in outreach work by CSOs.
• Outreach Programs: Discontinuation of AGYW-specific outreach programs.
• Education and Awareness: Reduced availability.
• Mental Health Support: Inability to provide support in HIV prevention programs.
• Counseling and Social Support: Reduction in availability.

Civil Society Impact

• Community-led organizations (CLOs): Reduction/suspension of services, loss of staff, or funding cuts.
• Community-Led Monitoring: Lack of funds to conduct CLM.
• Policy Discussions: Reduced participation due to funding constraints.
• Advocacy: Limited ability to advocate for key issues.
• Policy Design and Societal Enablers: Reduced ability to collect and report data, loss of funding for monitoring activities, increased difficulty in accessing government or donor support.

UN Response

• Consultations: UNAIDS conducted informal consultations with government and civil society partners. The situation is being monitored; regular updates are collected from partners. While testing, ART, and prevention services are available, outreach work is suspended, making most of the hard-to-reach groups inaccessible.

Current Funding and Impact

There has been no direct US Government funding for HIV-related programs in Uzbekistan. However, other crucial initiatives such as civic space development, human rights, education, and advocacy efforts relied on US funding. With the closure of these programs, organizations working on HIV-related legal reforms, anti-discrimination efforts, and rights-based healthcare access will face increased challenges in advocating for policy change

Alternative Funding Sources

UN agencies in Uzbekistan have started mobilizing alternative funding sources to ensure the continuation of key initiatives previously supported by the US Government funds. Negotiations are ongoing with embassies, the European Union (EU), and the Government of Uzbekistan to secure financial support.

Immediate Risks and Disruptions

The cessation of US funding has led to the stoppage of programs focused on stigma and discrimination, affecting key populations and people living with HIV. Communities have collected data on human rights issues, including stigma and discrimination. Additionally, the funding cuts have impacted the ability of civil society organizations to  advocate for HIV-related issues. 

Civil society impact, resilience and response 

The National Association of NGOs in Uzbekistan (NaNNO UZ) has stepped forward to support organizations that have been affected by the funding cuts. Through NaNNO UZ, the Government of Uzbekistan is exploring ways to compensate for the financial gaps created by these funding shifts. One of the key measures being considered is increasing allocations to the national grant-making mechanism and expand government contracting. 

Politically Relevant Updates

The Government of Uzbekistan is actively working to mobilize additional financial resources to support ongoing development projects and mitigate the impact of recent funding cuts. Efforts are focused on securing new funding streams to sustain progress in various sectors, including economic development, social welfare, human rights, and civic engagement. 

Current Situation

Prevention of HIV and other sexually transmitted infections among key populations in Latin America and the Caribbean is heavily reliant on US funding. Recent decisions by the United States Government indicate that efforts to support prevention among key populations will not receive funding resources. This has led to significant disruptions in and challenges for HIV services in the region.

Immediate risks and disruptions

1. Humanitarian assistance: Transnational projects aimed at migrant populations have been suspended. Despite a waiver announced on February 1 allowing continued provision of some HIV services, resumption of humanitarian services has been hindered due to the absence of PEPFAR and USAID staff.
2. Service delivery: The suspension of US funding has affected the delivery of various HIV services, including those provided by civil society organizations, government entities, and United Nations agencies. NGOs are particularly vulnerable to the US funding cuts.
3. Impact on key populations: The US funding cuts have led to stress, depression, anxiety, and uncertainty among people living with HIV and key populations. There is a significant concern about the risk of being left without antiretroviral treatment, access to PrEP, and other essential services.
4. Funds allocated for non-contingency humanitarian assistance were primarily focused on the humanitarian crises in Haiti and Venezuela, Colombia's post-conflict challenges, and the Northern Triangle crisis (Guatemala, Honduras, El Salvador). Although these funds were not intended for a direct response to HIV, their absence deepens the structural vulnerability of migrant and other vulnerable populations—including people affected by conflict in Colombia—and puts them at risk of exploitation, human trafficking and survival sex, all of which increase vulnerability to HIV. 

Politically relevant updates

1. Emergence of extreme positions: In many countries in the region, outbursts of homophobia, transphobia and discrimination against people living with HIV have intensified. Many parliamentarians in the region have taken advantage of the situation to gain political leverage by attacking key populations.
2. Media Representation: Actions targeting societal enablers are being shown in the media as examples of waste of money and corruption.

Civil society impact and resilience:

• Survey Findings: A survey conducted by the civil society organization "Corresponsales Clave" (Key Correspondents) with 49 organizations from various countries in the region revealed that US funding cuts have led to significant disruption of services for key populations and emotional distress among people living with HIV and key populations.
• Community Response: Despite the challenges, civil society organizations and community leaders are working to ensure the sustainability of the HIV response by optimizing health services.
• UN Response: The offices of the UN Resident Coordinators are intensifying the search for non-traditional donors and making bilateral approaches with embassies to identify funding opportunities. UNAIDS and PAHO are working together to deliver technical assistance to optimize health services in three areas: integration of HIV services in primary health care, optimization of service delivery models, and facilitation of community response to HIV.
• UNAIDS is carrying out joint analyses with the Global Fund to align the resources of national grants destined to the strengthening and resilience of health e-services with the principles mentioned above. 

Additional Insights

• Regional Progress: The Caribbean has made substantial progress against HIV since 2010, with a 22% decrease in new HIV infections and a 57% decrease in AIDS-related deaths. Latin America is the most autonomous region of the Global South in terms of national funding for HIV treatment, but there are still major gaps in prevention and social enablers. Therefore, continued funding is a necessary strategy for a smooth transition towards full sustainability of the HIV response in the region.
• Funding Challenges: The critical impact of the US funding cuts has exacerbated existing challenges in the HIV response across Latin America and the Caribbean.

Current Coverage and Services

• Pre-exposure Prophylaxis (PrEP): According to the National AIDS authority, as of January 31, 2025, there are 210 health facilities nationwide providing PrEP services, with 44,780 people using the service. Of these, 92 facilities with 31,639 clients (70.7%) are funded by PEPFAR in 11 provinces. Antiretrovirals for PrEP committed by PEPFAR in COP 2024-2025 have been delivered by one third. Current stock can cover for PEPFAR-supported PrEP clients until end of May 2025. Relevant medical facilities supported by US CDC have resumed full package service, while those supported by USAID only provide PrEP medicines from available PEPFAR stock but do not cover associated costs, which fall on patients paying out-of-pocket. The development and implementation of the AIDS Information Management System, including PrEP management system, is on hold.
• Antiretroviral Treatment (ART): ART is mainly financed by social health insurance funds and partially by the Global Fund. Technical assistance to the supply chain and treatment information system, mostly through USAID, has been affected.
• HIV Testing and Treatment: Community outreach and lay testing have been heavily affected. All treatment facilities and service points are operating at full capacity. Prevention of vertical transmission and pediatric services are also functioning without disruption.
• Supplies: ARV supplies, HIV tests, viral load tests, and condoms are available with minimal disruption. According to the Viet Nam Administration of Disease Prevention, PEPFAR committed to support about 40,000 PrEP clients in 2025. The Global Fund is supporting 23,000 PrEP clients in 2025 and 25,000 in 2026. 

Immediate Risks and Disruptions

• Funding Freeze: The freeze on PEPFAR funding has significantly impacted the expansion of PrEP coverage. This has led to disruptions in access to PrEP and reduced capacity for HIV prevention services, particularly affecting men who have sex with men, and transgender people.
• Stigma and Discrimination Programs: Almost all PEPFAR supported initiatives addressing stigma and discrimination have been halted and those allowed to continue with support through US CDC are requested to not refer to transgender persons and other key populations, which could exacerbate challenges faced by key populations.
• Civil Society Organizations (CSOs): There has been a reduction or suspension of services provided by CSOs, limiting their ability to participate in essential HIV services, policy discussions, data collection and reporting, and access to government or donor support.

Politically Relevant Updates

• Government Response: The Vietnamese government, through the Viet Nam Administration of Disease Prevention, has formed an informal task team to receive feedback from organizations of people living with HIV and key populations.  
• Precise numbers of the affected CBO community workers are not available. The government is not assuming the costs for the community workers affected by the PEPFAR freeze.
• International Support: The US funding cut has led to the suspension and/or termination of USAID-funded projects, including critical healthcare programs for tuberculosis and HIV prevention and strengthening of systems for health/HIV. Despite these challenges, the Vietnamese government remains committed to prioritizing resources and implementing effective measures for HIV prevention and control.

UNAIDS is releasing weekly updates to track the impact of US cuts to foreign assistance on HIV testing, treatment and prevention. These reports are based on status reports generated by UNAIDS’ Country Offices.

As of 13 March, at least one status report had been received from UNAIDS’ County Offices in 67 countries, including 84% of all PEPFAR-funded countries and an additional 20 countries that receive US support for their AIDS responses.

Low- and middle-income countries across several regions are building on short-term emergency measures to address cuts in US foreign assistance taking action to sustain their national AIDS responses in the medium and long term.

UNAIDS’ Country Offices are supporting these efforts by working with heads of government, Ministries of Health and national AIDS authorities to assess the full impact of the cuts so countries can ensure continuation of critical HIV services in the medium and long term. 

Many countries have conducted UNAIDS-supported rapid surveys to assess the impact of the cuts on recipients of HIV services. The results from one survey in a high-burden country in East Africa found that 62% of respondents reported difficulty accessing pre-exposure prophylaxis (PrEP), 46% of people living with HIV experienced disruptions in HIV treatment, and 23% of people living with HIV received smaller amounts of antiretroviral medicines (e.g. a three-month supply instead of the usual six-month supply) from local dispensaries. The survey also found that viral load testing, community outreach, condom distribution and TB diagnostic efforts were also significantly impacted.

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Immediate Risks and Disruptions 

1. Distribution Disruptions: 

• According to the policy brief to Parliament prepared by the Uganda AIDS Commission with support from UNAIDS, stocks of ARV supplies, HIV, viral load and other lab test kits are available. However, distribution from district hubs to lower health facilities is disrupted due to reliance on US-funded implementing partners. Facilities have adequate stocks for three months, but the impact will be felt from the second quarter of 2025 if not mitigated. 
• Condom stockouts are anticipated within the next 3-6 months due to challenges with last mile distribution. 

2. Service Capacity: 

• All ART-providing facilities are operating at reduced capacity.   Some community-led, peer-led, NGO-run, and private facilities have stopped services. 
• Reduced adherence to prevention of vertical transmission and early infant diagnosis services due to decreased numbers of expert clients and mentor mothers. 
• HIV prevention services for key populations at drop-in centres, including PrEP access, HIV testing, and antiretroviral treatment adherence counselling  for sex workers, men who have sex with men, transgender persons, people who use drugs, and prisoners, have been disrupted. 

3. Human Resources: 

• It is unclear whether US-funded health workers will be integrated into the government payroll. 
• Data clerks at facilities covered by USAID are not yet back at work, impacting data collection and quality control. 

Politically Relevant Updates 

1. Government Actions: 

• The Ugandan President directed the release of UGX 6 billion for the rollout of electronic medical records (EMR) in government health facilities to improve service delivery. 
• The Ministry of Health issued guidance on improving service delivery, including integrating HIV, TB, and other chronic disease services, training health workers in integrated service delivery, prioritizing recruitment of critical staff, utilization of primary health care funds for disease prevention outreach activities and strengthening accountability for medicines and laboratory supplies. 

2. Mitigation Measures: 

• The government is reallocating domestic resources to priority HIV programs and integrating HIV services into other health services. 
• Civil society partners have conducted rapid assessments to understand the impact of the US Government funding cuts on service delivery. 

3. Human Rights and Key Populations: 

• US funding for stigma, discrimination, and enabling legal environments has stopped, and no alternative funding has been found. 
• Communities are not collecting data on human rights issues, including increased stigma and discrimination. 
• Key populations groups have conducted a rapid assessment on the impact of the US funding cuts. There is also ongoing work to conduct an assessment with people living with HIV and key populations-related services at drop-in centres.