Q&A: US funding disruption pushes Africa's HIV programmes to brink

NAIROBI - People with HIV are rationing vital drugs as wage-starved health workers helplessly watch years of progress unravel in Kenya, Uganda and Tanzania because of disruptions to a flagship U.S. programme to fight the disease, new research has found.

Physicians for Human Rights (PHR) said in a new report that  funding disruptions to the President's Emergency Plan for AIDS Relief (PEPFAR), which has saved around 26 million lives over the last two decades, had closed clinics, disrupted drug supplies and increased stigma.

After freezing all U.S. foreign aid in January, President Donald Trump's administration issued a waiver that allowed PEPFAR to resume funding "life-saving" services and some HIV prevention efforts.

But experts say the disruption caused by the pause and broader foreign aid cuts, including the gutting of the U.S. Agency for International Development (USAID), has undermined efforts to treat and prevent HIV across the world.

U.S. lawmakers are due to discuss reauthorising some PEPFAR funding later this month, and PHR wants urgent renewal of resources.

Thomas McHale, PHR's public health director and co-author of the report, spoke to Context about what the research found about the impact of PEPFAR cuts across East Africa.

What are the main impacts of the PEPFAR funding disruptions in the countries you looked at?    

Services for HIV prevention and treatment in Uganda, Tanzania and Kenya are on the brink of catastrophe.

Healthcare workers and people living with HIV told PHR of widespread disruptions to HIV service delivery ecosystems, including clinics being shut down, community drug distribution points closed and health workers being unpaid.

The abrupt disruption ... harmed patients' health, and we received reports of people living with HIV having to ration or skip doses of life-saving antiretroviral medications.

How has the LGBTQ+ community been affected?

The funding disruptions have intensified stigma, discrimination and violence against vulnerable groups, particularly LGBTQI+ people.

In Tanzania and Uganda, where homosexuality is criminalised, LGBTQI+ people and health workers reported increased levels of stigma, denial of health and justice services and incidents of verbal and physical abuse.

Some linked this rise directly to the Trump administration's rhetoric, including its executive order recognising only two biological genders, which they felt legitimised discrimination.

Specialised HIV services are being folded into general health systems, leaving LGBTQI+ people fearful of involuntary disclosure of their HIV status and further exposure to discrimination.

A transgender woman in Tanzania told PHR that when she seeks care in hospitals, 'people speak badly to us,' adding that Trump's rhetoric has emboldened such hostility.

What are the consequences of medication rationing and interrupted HIV services for people living with HIV?

Uncertainty about future drug supplies has led to dose-skipping and rationing.

Because each drug clears from the body at a different rate, skipping doses allows the virus to replicate and drug-resistant strains to emerge.

Interruptions in care, whether caused by stockouts or barriers to access, are also shaping peoples' life decisions.

One person reported having an unwanted abortion, fearing they would not be able to access medication needed to prevent mother-to-child transmission.  

How have healthcare workers and the public health infrastructure been affected?

In Tanzania and Uganda, some services were nominally restarted through waivers, but programmes that supply medicines and link patients to care remained dormant.

Clinical health workers with years of experience described the emotional toll of being unable to provide life-saving care and watching patients' health decline.

What long-term risks could these funding cuts pose for the progress made in HIV/AIDS control in East Africa?

Decades of investment in community-led responses, human resources and clinical systems mean that deaths and new infections may not spike overnight, but without stable funding, a slow-moving wave of public health impacts will rise steadily.

Some services have been partially restored through stop-gap measures, yet these come too late to prevent all harms.

Without urgent stabilisation, the cuts risk reversing hard won gains in HIV prevention and treatment across East Africa.   

What policy actions or solutions do you recommend?

Right now there is a narrow, but urgent window to stabilise HIV services and prevent backsliding on decades of progress in care, treatment and prevention.

U.S. policymakers should immediately restore, preserve and fully fund global health programmes at levels commensurate with need, including in the budget for 2026, and move swiftly to reauthorise PEPFAR.

This must include reinstating support for HIV treatment, pre-exposure prophylaxis (PrEP) access, differentiated service delivery models, peer-led and community-led initiatives and embedded health workers providing testing, counselling and linkage to care for key populations.

This interview has been edited for brevity and clarity.

(Reporting by Nita Bhalla; Editing by Ayla Jean Yackley.)