The US cuts challenge African funders and governments to provide new models of PrEP access

A high-level panel discussion convened at the 13th International AIDS Society Conference on HIV Science (IAS 2025) in Kigali, Rwanda drew together representatives from global funding foundations, national health ministries, and advocacy and research organisations to debate the future of HIV PrEP in Africa in the wake of the drastic cuts to US funding.

While all panellists acknowledged the scale of the challenge facing the continuation of PrEP and HIV prevention programmes, the session adopted a constructive and at times even optimistic note on how the ‘PrEP crisis’ could be an opportunity to recast provision so it fits the needs of people at risk of HIV better and more economically.

The session dealt with the issue of how the momentum towards long-acting PrEP drugs could be maintained – which will be covered in another article – but dealt with much broader issues of PrEP provision, in particular how to deliver it in a way truly aligned with public health programmes rather than with medical ones.

Co-chair Mitchell Warren, Executive Director of AVAC, said that a previous campaign aim of AVAC had been to “make PrEP famous”. But “perhaps PrEP has never reached its true potential because it’s been too complicated, being built on a treatment model.” He summed up the session by saying that the aim should now be to “make PrEP simple.”

The implications of the PrEP cuts

Warren acknowledged that if none of the PrEP funding that PEPFAR had been providing was replaced, models showed that global HIV incidence in adults could quadruple, from one case in 200 people a year to one case in 50 by 2030.

Yet he also pointed out the irony that the US cuts had come at a time of an “innovation pile-up”. By mid-2027, generic two-monthly cabotegravir and six-monthly lenacapavir injections will likely be available, along with four-monthly patented cabotegravir and yearly patented lenacapavir. Soon after, in early 2028, monthly oral PrEP in the shape of Merck’s MK-8527 could arrive. “We have squandered opportunities in HIV prevention and treatment before,” he said. “Let’s not waste these ones.”

Due to a huge expansion in PrEP provision by PEPFAR between 2020 and 2022, the US programme ended up providing 90% of the world’s PrEP; by 2024, 8.6 million people had ever initiated PrEP, and 2.75 million started it that year. PEPFAR has not disappeared but is now concentrating on treatment and restricting PrEP to pregnant and breastfeeding women. How can other funders and governments make up the gap?

How do we plan for PrEP after PEPFAR? The government official

Professor Lloyd Mulenga is Director of Infectious Diseases at the Zambia Ministry of Health. He said: “Despite good treatment programmes that should also act as prevention, we still have 23 to 33,000 new infections a year, so we have to argue for prevention as a specific line in the state budget. I do not think it is entirely the fault of politicians that access to, for instance, cabotegravir has been a problem.”

Donor funding, he said, tends to be treated separately from the budgeting done by the finance ministries of his and many other countries – so much so that until a few years ago there was no budget line devoted to HIV prevention in the state budget, and that resulted in lack of prioritisation, and especially lack of prioritising the technical will to ensure there was access to PrEP. He had ensured there was a line in this year’s Zambian health budget costing the introduction of lenacapavir PrEP, even though it likely would not arrive for at least another year.

As he considered which PrEP options to prioritise, it’s been important to consider whether they can be provided by the ‘lower cadres’ such as peer navigators, educators, community advisors. These were the people crucial to delivering PrEP, for instance, to young people, who were not going to approach medical facilities for HIV prevention.

And cost can’t be ignored. “If you have something costing $20 and another which can do the same job costing $5,” it’s hard for governments to justify using the former. “We need to look at what is cheaper, what is reasonable to give our people.”

The health researcher

Professor Saiqa Mullick is implementation director of the Wits Reproductive Health and HIV Institute in South Africa, a country that already pays for its own oral PrEP. Referring to the new options of cabotegravir and lenacapavir PrEP, she agreed that: “We need to balance choice with pragmatism; right now we are sitting with a couple of products that are unaffordable to most governments.”

She suggested several ways of economising PrEP delivery.

“In future we will need more routine monitoring instead of expensive research studies, which implies smarter programmatic monitoring systems,” she said. This will help us understand people’s preferences, and how that affects uptake, in real world settings. “Understanding, for example, whether a product that requires attending three- or six-monthly appointments is easier or more difficult to adhere to for people with busy lives who may migrate for work.” She agreed with Professor Mulenga that there needed to be innovation in service delivery: “PrEP has to be delivered locally in an equitable way”.

The health policy advocate

Imelda Mahaka is director of the health consultancy Pangaea Zimbabwe, which campaigns for better and more equitable health coverage in that country and has influence with its health ministry.

She said that the process of licensing drugs for PrEP was still too slow, singling out the European Medicines Agency for its approach to licensing. “We need fast-track approvals. Why would you need to stop the clock, go back to the manufacturers and wait for a response to restart the whole process?”

In the main, however, she agreed with the previous speakers that the delivery of PrEP is still overly medicalised: “It’s odd that people think it’s OK to flood health facilities with people who are well,” she said.

She also recommended local facilities staffed with “peer navigators and community PrEP champions instead of nurses,” and said there is too much caution and too many layers of staff people had to go through to get PrEP: “You have to see a health educator and then a nurse who walks you through different products.”

Like other speakers, she welcomed the announcement at the conference by the World Health Organization of its new PrEP guidance; not only because it now recommended injectable lenacapavir, but that it recommended simplified oral rapid tests for people using PrEP, and also that PrEP services should be “bundled” into services that PrEP users may want. For instance, a young woman who needs PrEP may also need contraception and STI services, and perhaps pregnancy services. But who will pay for these services?

“I think the money is there within our countries,” she said, “We have a national AIDS fund – but what other resources can we use such as blended public/private partnerships?”

“In the last two weeks,” she added, “Zimbabwe has been looking at a minimum core package of services for HIV, TB and other conditions. Now is not the time to fight for a product. Now is the time to look at the evidence for what works and prioritise.”

The funders

Hui Yang, Head of Supply Operations for the Global Fund agreed, saying it was a challenge “to translate ‘political will’ into actual policies” and that a community-centred approach was essential. PrEP programmes tended to be standalone, not well connected to pre-existing testing and treatment programmes.

The weaknesses of the current programmes were demonstrated by the fact that when some drug supplies were restored, the local infrastructure was not restored too: “We don’t want the product to sit in warehouses waiting to be distributed and implemented.”

There had to be more innovative healthcare structure, including public/private sector partnerships and widespread paid and voluntary community involvement, she said. The feasibility of public/private partnerships was supported by an audience member who noted that “betting shops, churches and alcohol shops all grow rich in Africa” and recommended setting up some healthcare services as social enterprises.

If countries and funders use the present crisis to innovate, she said, “I think we should see the first delivery of lenacapavir PrEP into at least one country within the first quarter of 2026.”

Dr Yogan Pillay, Director of HIV & TB Delivery for the Gates Foundation said that Global Fund and Gates support had to be regarded as ‘catalytic’ rather than foundational. He mentioned MK-8527, the monthly oral PrEP pill that might be available by 2028 and said we needed to be devising access programmes for that now, and planning how to integrate it into injectable and daily oral PrEP.

“Bundling PrEP programmes into, for example, family planning services is entirely feasible,” he said, “but you’d need to be looking at wholesale health innovation, and that’s a model we’d be interested in funding.” He thought AI could be used to model specific solutions.

More comments

Charles Brown, an AVAC Fellow and PrEP advocate from Uganda, asked the panel the ‘elephant in the room’ question of how to get PrEP to criminalised and stigmatised populations, including gay and bisexual men and trans women in his own country, with its notorious anti-gay legislation.

Lloyd Mulenga acknowledged it was difficult if countries budgeted for services to a general population without acknowledging the special needs of key populations, and that “accessing the usual service points might be very difficult.” But he added that local authorities may be able to provide venues that community service organisations could use to create safe spaces, such as offering support for LGBT+ people within youth services. In this way, funding for key populations can continue to be provided under more general budget lines.

“But,” he added, “we do need to make sure that safe spaces are more available.”

Closing the session, Mitchell Warren commented: “We’ve spent the first 40 years in HIV on treatment. But prevention is not just what you do after you get everyone treated. In the next 40 years can we be as ambitious for prevention?”

After the AVAC session, aidsmap spoke to Remko van Leeuven, strategic advisor for Aidsfonds, a funding organisation based in the Netherlands.

“I think the session was highly constructive,” he said. “It's encouraging to see key stakeholders stepping forward with concrete commitments, even as we continue to grapple with several unresolved questions.

“Lloyd Mulenga's candid remarks from the Zambian Ministry of Health were particularly valuable I thought. His openness about what approaches work – and don't work – from a political standpoint provided crucial insights that I think will benefit everyone's implementation strategies.

“It's genuinely encouraging to see multiple African governments now incorporating both HIV cure research and lenacapavir roll-out as a central pillar of their national AIDS strategies, signalling a significant shift in how the continent is approaching long-term HIV response planning.”