Without US funding, Zimbabwe could see over 75,000 new HIV infections in a year

The US has recently ended all health funding to Zimbabwe after the two countries failed to reach consensus regarding the terms of a bilateral agreement. 

The consequences for HIV prevention will likely be dire, according to a new modelling study: 75,440 new infections within a year, over half from disruptions to antiretroviral treatment (ART) programmes, and a quarter from lack of access to prevention programmes, such as PrEP and voluntary medical male circumcision. 

“The effects may take months to show,” Professor Chris Beyrer, one of the study’s authors, said in a recent op-ed. “People with medication at home can keep taking it for now. But if clinics lose staff, lab tests stop, or refills become harder to get, people will begin falling out of care. By the time the numbers show it, the damage will already be done.”

Background

Zimbabwe is an exemplar of what the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been able to achieve. One of the original fifteen countries given support in 2003, Zimbabwe has seen HIV incidence fall by 80% since 2010, while life expectancy increased from 46 years in 2000 to 62 years in 2023. This is not all down to funding – health system strengthening driven by a strong local response has been central to Zimbabwe’s success. 

As part of the Trump administration’s America First Global Health Strategy, the US government entered into bilateral negotiations with countries to carve out the terms of new, fixed-term health agreements. The US reduced its financial support, while requiring substantial increases in African governments’ health spending. The agreements reportedly came with hefty consequences for recipient countries, such as sharing of sensitive health data without clear assurances of equitable access to any health products – such as vaccines, diagnostics or treatments – generated as a result. Earlier this year, Zimbabwe withdrew from these discussions after being reportedly offered $367 million over a five-year period in return to agreeing to all the US government’s terms. While many countries have reached bilateral agreements with the US, others, such as Zimbabwe, have pushed back against what they view as a challenge to sovereignty. 

The study

Dr Khai Hoan Tram, from the University of Washington, and colleagues modelled how many new HIV infections Zimbabwe would have within a year of all US funding ending, considering infections from the loss of HIV testing, prevention and treatment services. 

They based these calculations on PEPFAR performance data from 2024 to 2025 and prior research. Researchers considered factors such as the number of people on ART in Zimbabwe, those who are virally suppressed, years of life expectancy without treatment and various other inputs to generate these estimates. 

A dramatic resurgence of HIV infections

Based on the modelling estimates, there could be an estimated 75,440 new HIV infections in Zimbabwe within a year of full PEPFAR withdrawal, assuming no additional national or international funding. 

Due to the loss of PEPFAR HIV testing services, there could be 8939 new HIV infections within the next year. In 2024, PEPFAR supported 1.46 million tests in Zimbabwe, yielding 57,305 diagnoses. Based on an observed drop between 2024 and 2025, the researchers estimated a 45% reduction in detection of new HIV diagnoses over the next year without US funding. 

Following the loss of prevention services, the researchers estimated an additional 19,139 new HIV infections within a year. In 2024, PEPFAR delivered condoms, education and other prevention services to 94,828 clients from key populations (such as sex workers and men who have sex with men) and 242,438 clients from priority populations (such as adolescent girls and young women). PEPFAR also supported 114,769 male circumcisions and 72,473 PrEP users. The researchers assumed a 90% reduction in these prevention services, and effectiveness against HIV of 65% for circumcision, 85% for general prevention programmes and 93% for PrEP. 

The researchers emphasised that overall HIV annual incidence among adults in Zimbabwe has been somewhat resistant to change, as shown in surveys from 2015-2016 and 2020. This has been the case despite access to testing and treatment – indicating the central role prevention will continue to play in shaping Zimbabwe’s epidemic, especially over the longer term. At a time when lenacapavir is rolling out across the continent (it’s been approved for use in Zimbabwe), a dip in prevention now will likely have long-lasting consequences for future epidemic control. Importantly, it’s not just about access to prevention drugs, but also about the health systems and personnel required to provide them. 

The most striking estimate from the modelling came from reduced access to treatment. While PEPFAR and the Global Fund supported 1.21 million adults on ART in Zimbabwe in 2024, the researchers estimated that a full PEPFAR withdrawal would cause 11% of them to lose access to treatment. As an undetectable viral load prevents onward transmission, these interruptions would result in 46,313 new HIV infections within a year, a severe blow to epidemic control in the country. 

Vertical prevention services would also be direly impacted with PEPFAR withdrawal. PEPFAR supported treatment for 31,830 pregnant and lactating women in 2024. Assuming that 11% of clients would lose services, this would result in 1050 new infant infections. 

The researchers also modelled both low- and high-impact scenarios, or more and less optimistic outlooks: this ranged from 30,002 new HIV infections to a staggering 122,601 new infections within a year. 

Conclusion

“Zimbabwe’s experience illustrates both the achievements of PEPFAR and the risks of an incomplete transition planning,” the researchers conclude. “Although external support has enabled remarkable progress in HIV control, durable epidemic control will ultimately require a gradual increase in country ownership and domestic investment aligned with national fiscal realities... Without careful management of this transition period, short-term disruptions may translate into long-term setbacks for HIV epidemic control.”

References

Tram, KR et al. Projected Effect of US PEPFAR Withdrawal on Zimbabwe and Implications for the Global HIV Response. JAIDS Journal of Acquired Immune Deficiency Syndromes 101: 1065-1068, 2026. 

https://doi.org/10.1097/qai.0000000000003925

Image credit: Elizabeth Glaser Pediatric AIDS Foundation/DFID. Available on Flickr under a Creative Commons licence CC BY-NC-ND 2.0.