The funding scramble: countries desperately seek HIV finance solutions

How will countries fund and sustain their national HIV responses moving forward? This was a central question at the recent 13th International AIDS Society Conference on HIV Science (IAS 2025) in Kigali, Rwanda. Sweeping funding cuts from the US have wreaked havoc on many countries’ national HIV responses – especially for those who were largely dependent on donor funding.

While this funding – and its associated systems, processes and people power – has been built up over decades, its removal has been swift and brutal. And while there has been a move towards more sustainable national HIV responses, the current situation is forcing a rapid fast forward. As Tione Chilambe from the National AIDS Commission in Malawi expressed it, they knew that funding would slowly dwindle, but not take a “nosedive” as it did.

Richard Ochanda, a senior regional implementation advocacy manager for AVAC, indicated that of seven countries reviewed – Ethiopia, Kenya, Malawi, Nigeria, Tanzania, Zambia and Zimbabwe – none had fully implemented the Abuja Declaration, despite all being signatories. This states that at least 15% of a country’s overall budget should be dedicated to healthcare expenditure.

According to UNAIDS, 25 out of the 60 countries reporting to Global AIDS Monitoring have found ways to increase domestic funding for their 2026 HIV budgets. Most are PEPFAR-supported countries, including Côte d’Ivoire which recently committed an additional $60-65 million for HIV in 2025, increasing to $80-85 million from 2026 onwards. “This is the future of the HIV response – nationally owned and led, sustainable, inclusive and multisectoral,” Winnie Byanyima, executive director of UNAIDS, stated in their recent update.

But domestic funding increases alone will not fill the funding gaps. It’s still unclear which services are going to be most affected going forward, and how this will impact the overall HIV response. It seems likely that community-based organisations and prevention services will be hardest hit. While there’s been much talk about integrating HIV services into broader health services, this isn’t something communities can easily accept – especially when it feels like a rushed ‘solution’ to a much larger problem.

The Gates Foundation has pledged $200 billion in funding by the time it wraps up operations in 2045 – mainly for countries in Africa. The foundation is a significant donor to mechanisms such as the Global Fund. But their focus remains on investment in research and development, innovation in service delivery and new technologies such as long-acting HIV treatments. “What we can’t do is fill the gap left by the US government, because that gap is so big,” Yogan Pillay, director of HIV and TB delivery, stated.

Filling the substantial gaps left by funding cuts

“International assistance accounts for 80% of prevention programmes in low- and middle-income countries,” Winnie Byanyima, Executive Director of UNAIDS stated in its 2025 update. “UNAIDS modelling shows that if the funding permanently disappears, there could be an additional 6 million HIV infections and an additional 4 million AIDS-related deaths by 2029.”

During the conference, delegates were relieved to hear that PEPFAR would be spared from a recission package that would have clawed back $400 million in funds that had previously been approved. But this doesn’t mean that lost prevention services will return – the US government has limited HIV prevention activities to pregnant and breastfeeding women. As many speakers at the conference expressed, there won’t be a return to the way things were before.

Carolyn Amole, vice president of HIV, hepatitis and TB at the Clinton Health Access Initiative, provided data showing how communities are already suffering from the pause in PEPFAR funding and the dismantling of USAID. The drop in people starting PrEP in the first quarter of this year has been dramatic: across a subset of countries, there have been 140,000 missed new initiations. Even the supply of condoms and lubricant has been interrupted.

PEPFAR often supported services that may have otherwise been challenging to provide, such as PrEP for gay and bisexual men or sex workers. Most African countries continue to criminalise sex work and drug possession for personal use. Many criminalise same-sex sexual activity in private, with some countries imposing the death penalty. Even in countries where there aren’t specific legal barriers in place, conservative and stigmatising environments for key populations can make access to sexual health services immensely challenging.

The funding cuts have created a dire situation for other vulnerable populations, such as children with HIV. Across just five countries, at least 9000 were missing from care, Amole shared. The number of early infant diagnoses had decreased and new treatment initiations among children have dropped by 13% in one of the countries. Declines of up to 64% in CD4 testing may mean that cases of advanced HIV disease will be missed, which may progress to life-threating opportunistic infections.

Charting a course towards sustainability

“What gives me hope is that it’s not too late to course correct,” Amole said. She suggested three ways of moving towards sustainable national solutions.

To begin with, gap mitigation and reprioritisation is essential. This requires working with ministries of health to identify high-risk areas for HIV spread and to prioritise resources accordingly. Establishing a co-ordinated market mechanism will ensure that there are sustainable, co-ordinated supply chains and ways to support the acceleration of innovations. Finally, focused transition planning is needed. Even if PEPFAR funding cuts aren’t as drastic as feared, it is essential to plan gradual transitions away from “unreliable external aid”, moving towards greater integration, efficiency and sustainability.

“Redesigning country-led and efficient systems – while centring the voices of people living with HIV – is at the core of a sustainable response to ongoing HIV programme disruptions,” Amole concluded.

Chilambe described what’s being done in Malawi to ensure that they maintain their 95-95-95 cascade, with 95% of those with HIV diagnosed, 95% on treatment and 95% virally suppressed. After the stop-work order was issued by the US government, their ministry of health assessed the situation to see where services were most needed: more than half of the health facilities across the country were donor supported, with human resources and data systems for HIV testing and antiretroviral therapy (ART) provision mainly affected.

The Malawian government immediately increased funding for their national HIV response: funding for treatment increased by $600,000, while the budget for sample transportation increased by $1.4 million. Additionally, healthcare workers were recruited to provide HIV services, with a capacity-building budget of $290,000. While these amounts may not seem like much, Chilambe said they make a sizeable difference to maintaining HIV services in the country.

An analysis of testing, prevention and treatment stocks showed the country was in a good position, with around 11 months of availability – some in current supply, some in the pipeline. Malawi is doing better than many other countries in this regard – almost a quarter of 56 countries surveyed in April reported having less than six months stock of condoms and PrEP, according to UNAIDS.

Crucially, Malawi’s efforts have been multisectoral, with both the private and faith sectors stepping in to help. While ART is free at the point of delivery, even in private settings, there’s now a focus on getting  private health insurance to pay for medications for both treatment and prevention. Public-Private Partnerships will need to play a larger role going forward. The faith sector has helped with expanding HIV service delivery at a community level. 

Ochanda presented data from a review on domestic resource mobilisation strategies and policies in the seven countries mentioned above. Their review revealed a heavy dependence on donor funding – it accounted for over 70% of the overall HIV response. While HIV prevalence varies in these countries, with Nigeria at 2.1% and Zimbabwe at 11.5%, and many of them have met the 95-95-95 targets, they are all similarly reliant on donor funding.

Ochanda outlined six main strategies employed. The first focuses on generating money domestically, such as prioritising health in national budgets. Other fiscal changes could include earmarked taxes or levies devoted to healthcare funding, such as Zimbabwe’s National AIDS Trust Fund. Showing successes in national responses between 2015 and 2024, Dr Progress Agboola, from Sage and Enamel Foundation in Nigeria, presented data showing that Zimbabwe includes a 3% levy on income and business tax sources to fund their national HIV response. In 2023, this source generated approximately $30 million.

The second strategy involves thinking about how health is financed, and considering ways to expand insurance. Here, a crucial component is reducing out-of-pocket expenses for HIV services and considering different forms of health insurance, such as community-based and social mechanisms, as well as increased private involvement. Risk-pooling schemes spread financial risk over a larger group of people, helping affected communities pay for health expenses.

The third strategy utilises partnerships and collaborations, such as those mentioned in Malawi. Here, corporates can take greater ownership of HIV responses, especially when many of their employees are impacted by HIV – for example, mining communities in Tanzania and South Africa.

Ochanda also spoke about innovative financing mechanisms, such as concessionary loans with favourable interest terms from international financial institutions. This could also include debt conversion, which exchanges debt for domestic investment in health projects: a creditor nation agrees to forego debt repayments if that money is redirected towards health initiatives, such as with the Global Fund’s Debt2Health initiative. Agboola stated that Botswana generated $20 million using this approach, while Côte d’Ivoire has freed up $27 million. Lastly, Ochanda mentioned programmatic and efficiency-related changes, such as integration of HIV services.

Countries like Indonesia show that increasing domestic funding for HIV can be achieved – with an intentional plan. However, it’s taken time: domestic funding increased from $26.7 million to $109 million between 2010 and 2022. During this time, the number of new HIV infections decreased by 40%. While there were some yearly fluctuations, the Indonesian government was committed to increasing domestic HIV funding over time, resulting in a slow move away from donor funding towards a smaller epidemic and a more sustainable domestic response.

“Political will can either make or break response gains,” Musa Manganye, the director of HIV treatment in South Africa, stated. Speaking for the largest ART treatment programme in the world, and on behalf of a government who have just recently increased their HIV budget, he noted that: “[We] must shift from rhetoric into a more measurable commitment. It’s not a speech at a high-level meeting. It’s not research products – they don’t necessarily result in policy shifts. It’s the budget line that has been approved: a long-term commitment.”