Eswatini, a country once described as the epicentre of the HIV epidemic with nearly 1 in 3 adults living with HIV in 2015 [adult HIV prevalence in 2015 was 31%]. But Eswatini managed to turn around its HIV epidemic, reducing new HIV infections from a peak of 21 000 per year in 2000 to 4 000 in 2023, a remarkable result, achieved with the support of US funding. 

However, the sudden US funding cuts threaten to undo years of progress. We sat down with Nuha Ceesay, UNAIDS Country Director in Eswatini, to discuss the current situation, the impact on HIV services, and the way forward.

Q: How are US funding cuts impacting Eswatini’s HIV response? 

Eswatini’s HIV response has been a success story, by transforming a crisis that once saw extremely high HIV prevalence rates, into a model of resilience and opportunity. But the recent US funding cuts, representing about half of the country’s HIV response budget, have left the people living with and affected by HIV in despair, the government was not notified and left unprepared, and the people working to end AIDS are in total shock. There is real concern that new HIV infections and AIDS-related deaths will rise, reversing years of hard-won progress. The cuts threaten not just HIV treatment and prevention, but also the broader health system improvements, data collection, jobs and empowerment of people living with HIV. 

Q: What disruptions are being seen on the ground? 

The effects are immediate and widespread. HIV testing services, the gateway to treatment, are now limited. With fewer people being tested, many may unknowingly be infected with HIV, missing the chance for early treatment and increasing the risk of further transmission. This could push annual new infections, which are currently around 4 000, even higher, and add pressure to already strained treatment resources. Stockouts of antiretroviral, lab test kits, and condoms are expected within months, and health worker layoffs are affecting service delivery and quality data collection. Primary prevention services, such as medicine to prevent HIV (PrEP), education campaigns, and voluntary medical male circumcision for HIV prevention (which is around 60% effective in preventing HIV) have also been scaled back or suspended. 

We are also seeing a stop of the DREAMS programme which is a major setback for adolescent girls and young women, who are disproportionately affected by HIV in Eswatini. DREAMS provided prevention education, skills, and socio-economic support to young women. Its termination leaves them more vulnerable to infection and strips away resources that have been central to empowering this high-risk group. HIV prevalence among young women and girls aged between 15 and 24 years was 70% higher than among young men in Eswatini in 2023. 

Read more about the impact on UNAIDS website 

Q: How is UNAIDS responding to these challenges? 

UNAIDS is working closely with the government and partners to continue the work of developing and implementing the HIV Sustainability Roadmap. This will help Eswatini’s HIV response to gradually shift from being reliant on international aid to increasing its domestic funding which will lead to the government taking full ownership of its HIV response. The first phase of this roadmap has already been launched, focusing on building resilience and long-term solutions. 

UNAIDS has also worked closely with the Ministry of Health and partners to map the impact of the funding cuts, identify service gaps, and strategize on mitigating disruptions. Collaboration with the Ministry of Health, UN partners, and civil society remains central, but the transition to sustainability is a complex and gradual process. 

Q: What’s your message to the international community? 

The successes that we celebrate in the HIV response are built on mutual accountability and global solidarity. That’s what enabled countries like Eswatini to shift the narrative-from a crisis by leading a response that brought down new HIV infection to 4 000 compared to when new infections were as high as 21 000. 

It is therefore devastating to see all the hard-won gains being reversed at this stage. This is the moment we need to come together in solidarity and in partnership to accelerate our collective efforts. 

Ending the epidemic is like a marathon. We have run the race many miles, but the end is what matters. If we cannot reach that finish line, it means we have not completed, and we cannot afford that. 

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads the global effort to end AIDS as a public health threat by 2030 as part of the Sustainable Development Goals. 

Following the US stop work order in January, UNAIDS is working closely with governments and partners in affected countries to ensure that all people living with or affected by HIV continue to access life-saving services. 

For the latest updates, please visit unaids.org