UNAIDS Country Director reports on the impact of funding cuts to the HIV response

The HIV response in Zambia, known as a model of success in sub-Saharan Africa, is now facing major challenges following the abrupt and significant cuts to US funding. It has led to widespread disruption: clinics have closed, prevention services have been scaled back, and thousands have lost access to lifesaving medication. Yet the Zambian government and partners are stepping in to protect the progress made. 

In this interview, UNAIDS Country Director for Zambia, Isaac Ahemesah, details the fallout from these funding decisions on health services, vulnerable communities, and the country’s ability to sustain progress against HIV-and outlines what is urgently needed to avert further health crisis. 

Q: How have the US funding cuts impacted the HIV response in Zambia? 

Zambia has long relied on international aid, including substantial support from PEPFAR. Three years ago, the US government’s commitment stood at approximately US$ 402 million, which was subsequently reduced to US$ 392 million, and most recently to US$ 367 million. Despite these reductions, the contribution remains significant, not only to the HIV response, but to Zambia’s overall health sector. To put it in perspective, of the US$ 600 million in total US support to Zambia for development last year, US$ 367 million, around 60%, was allocated to HIV. 

However, the abrupt funding cuts led to the termination of key programmes. More than 11 000 health workers supporting the HIV response, and approximately 23 000 health workers providing services for malaria, tuberculosis, and other health needs, were impacted. 

Several essential initiatives were stopped. These include the closure of 32 wellness centres that served over 20 000 key populations, including LGBTQ+ people, sex workers, and people who inject drugs, across seven of Zambia’s ten provinces. These centres offered critical services such as HIV testing, treatment, and support. 

All DREAMS programmes, which supported adolescent girls and young women in 22 districts, have also been shut down. This has cut off access to HIV prevention, life skills, and economic empowerment activities for thousands of vulnerable girls. 

HIV prevention services have also been disrupted. Sixteen standalone centres providing voluntary medical male circumcision - a proven HIV prevention method - have ceased operations. Nearly half of Zambia’s pre-exposure prophylaxis (PrEP) services, which help prevent HIV infection, were funded by the US and have now been discontinued. 

Community-led monitoring programmes, which ensured quality and accountability in HIV care, have also been terminated. Furthermore, the Smart Health electronic medical records system, along with platforms used for forecasting and quantifying medical supplies, is no longer operational, making it increasingly difficult to manage patient care and maintain drug inventories.

Q: What will happen if the DREAMS programme is not reinstated? 

Currently, Zambia records approximately 23 000 new HIV infections annually, with about 8700 occurring among young people aged 15 to 24. Notably, 60% of infections in this age group happen among girls.Without support for prevention and treatment interventions, new HIV infections could surge to 180 000 per year by 2030. Among young people, infections could rise to over 60 000 annually by 2030. 

Gender-Based Violence (GBV) remains a growing concern in Zambia, and each GBV case carries a heightened risk of HIV transmission. Addressing this requires a coordinated, multi-sectoral approach that extends beyond HIV alone to include family planning and reproductive health services. National partners are working to reinvigorate this multi-sectoral response so that all relevant sectors-education, gender, internal affairs, and others-actively share responsibility for the HIV response. 

Given the challenges, there is a pressing need to pursue local initiatives and mobilize alternative funding sources to support adolescent girls and young women, safeguarding their health and rights. 

Q: Are there concerns about supplies of HIV medicines? 

Yes, there is significant concern. At present, Zambia has sufficient antiretroviral (ARV) medication to last until the end of the year. However, the US has announced an additional US$50 million cut in funding for medicines and health commodities, effective from next year, due to concerns about drug theft. This will make it extremely difficult to ensure an uninterrupted supply of ARVs, particularly for the most vulnerable populations. There have already been reports of people living with HIV receiving reduced quantities of medication - less than the standard three- to six-month supply - due to ongoing uncertainty and challenges in stock management. 

Q: What is UNAIDS doing to support Zambia during this crisis? 

At the onset of the US funding freeze, UNAIDS immediately partnered with the Ministry of Health to convene national leadership and all key stakeholders. This was critical to coordinate a unified and effective response to the sudden disruption. We quickly led an impact assessment to understand how the freeze was affecting Zambia’s HIV response on the ground. This provided the data needed to guide urgent decisions. 

One of our first steps was to work with the government and partners, we helped define a minimum package of essential HIV services that could realistically be maintained with the reduced resources available. We costed this package at about US$ 147 million and presented it to the Cabinet and Presidency for consideration in the national budget. 

At the same time, we supported the development of the HIV Sustainability Roadmap, which explores alternative domestic financing options. This includes innovative approaches such as leveraging health insurance schemes and introducing total market strategies-for example, making PrEP and vaginal rings available through pharmacies. 

 We also worked closely with the Ministry of Health to revise policies to better fit the current context. For example, we supported allowing longer antiretroviral therapy refills—for up to six months–—to reduce the burden on both patients and the health system. We also helped adjust HIV testing protocols to manage limited supplies more effectively and piloted new service delivery models outside traditional health facilities to expand access. 

 At the operational level, we partnered with WHO, UNICEF, UNFPA, and others to monitor weekly stock levels of HIV commodities, ensuring timely responses to shortages. We support civil society organizations, especially those representing key populations, in transitioning clients from closed wellness centers to public health facilities, helping maintain continuity of care. 

To address broader systemic challenges, UNAIDS contributed to the restructuring plan for the Zambia Medicines and Medical Supplies Agency to improve accountability and strengthen the supply chain. 

Our Resource Allocation Forecasting Tool was used to estimate the real cost of sustaining Zambia’s HIV response, which we estimated at around US$ 150 million annually. This tool helps the government and partners plan budgets more effectively. 

UNAIDS acts as the central hub for information-sharing and advocacy around the impact of US funding cuts. We regularly present needs assessments to the UN Country Team and support ongoing fundraising discussions to urgently mobilize resources to sustain services. 

Finally, we have supported training for health workers to promote respectful, non-discriminatory care for key populations now accessing mainstream health services. This is vital to ensure no one is left behind despite the challenges. 

Q: What is the solution to ensure sustainable financing for Zambia’s HIV response, and avoid such a crisis in the future? 

The key to sustainable financing lies in increasing domestic funding and reducing reliance on external donors. While the recent US funding cuts were abrupt and challenging, this situation was not entirely unexpected. For years, Zambia and other countries have been encouraged to take greater ownership of their HIV responses. The real surprise was the speed and scale of the funding reductions. 

To protect its HIV response, Zambia must now mobilize domestic resources. This includes engaging local philanthropic organizations, expanding the role of national health insurance schemes, and ensuring that HIV services are fully integrated within these systems. Innovative models like risk pooling and market-based access to prevention tools, such as making PrEP and vaginal rings available through pharmacies, will also be key to expanding reach and ensuring continuity. 

On the global level, the HIV response must increasingly pivot toward long-acting treatment and prevention options, such as injectable PrEP and antiretroviral treatment. These innovations can help simplify adherence and improve outcomes. 

Zambia is also exploring total market approaches, where the private sector helps supply prevention and treatment services. In addition, local production of ARVs could help reduce costs and improve supply chain stability. 

Critically, the country has already shown that essential HIV services can be maintained on smaller budgets, provided resources are used efficiently. But for long-term sustainability, the government must take the lead. This means prioritizing HIV in the national budget and exploring innovative domestic revenue sources, such as earmarked taxes on alcohol, tobacco, or health products. 

While international partners will remain important, the responsibility for a predictable, sustainable HIV response now rests squarely with Zambia itself—to protect the lives and health of its 1.4 million citizens living with HIV, and to ensure that no one is left behind. 

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

Today, I believe the global HIV response stands at a crossroads. The decisions we make now will either help the world achieve Sustainable Development Goal 3.3—the target of ending AIDS as a public health threat by 2030—or risk a devastating reversal. 

If we ease up, we could see a return to the 1990s, when new HIV infections spiraled out of control, HIV-related deaths surged, and the global economy suffered greatly.

All we ask for is a final push— a sustained commitment to support countries in fulfilling their promises to end AIDS as a public health threat. I urge the US government and all other donors to reconsider the recent funding cuts. We need to keep our foot firmly on the accelerator until we reach the finish line. 

Otherwise, my greatest fear is that we will return to the dark days of the epidemic, with significant increases in new infections and deaths. 

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 funding cuts 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