Impact of shifts on the global HIV response - Countries Resources

The U.S. decision in January to freeze all funding for U.S. foreign assistance, including for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), has had a critical impact on several countries in Latin America and the Caribbean, exacerbating existing challenges in the HIV response. More than 20 countries in the region rely on these funds to deliver HIV treatment, prevention, and care services, including community-led services focused on the most discriminated and marginalized communities.

Following the decision to freeze all U.S. funding for foreign assistance, the U.S. Government issued a waiver allowing some funding to support lifesaving services. However, confusion about which services may be supported and a lack of support for some services means the situation remains critical, posing a serious risk of setbacks in the AIDS response in the region. While some key treatment services and prevention of vertical transmission have been gradually coming back into operation, most countries have been facing disruptions in their HIV treatment programs.

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As of 17 February 2024, UNAIDS had received at least one status report from 52 countries (39 PEPFAR-funded and 13 countries that receive some US support). The 39 countries represent 71% of all PEPFAR-funded countries. 

Collectively, these status reports reveal a range of significant impacts resulting from the US Government’s decision to freeze and review all US foreign assistance (see the chart below). The situation continues to evolve rapidly as waivers are requested, issued and implemented.

UNAIDS is also working at the country level to understand exactly which HIV services are not operational, and which populations are not being reached. It is essential to maintain high-impact HIV testing, treatment and prevention programmes and community-led services.

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The Ministry of Health in Cameroon has developed a set of mitigation measures to ensure continuity of HIV services to people living with HIV and vulnerable populations that could be impacted by the suspension of United Stated Government funding. The mitigation measures describe immediate, medium and long-term actions that also represent an accelerated move towards sustainability.

The minister has issued a circular to all regional delegates and directors of hospitals to take appropriate measures within their authority to ensure continuation of HIV, TB and Malaria services with priority given to the most vulnerable, these include reallocation of health personnel and readjusting of workload to fill the gaps of the 2332 personnel that were under PEPFAR funding. The objective is to ensure that there would be no interruption of services to anyone. Talks are ongoing with the Global Fund country team and other partners to find possibilities of reallocation of resources.

Funding for the HIV Response in Botswana

Prior to the U.S pause of foreign assistance, the Government of Botswana funded two thirds of its HIV response (approximately US$ 90 - 95 M). The remaining costs were covered by the U.S. Government (US$ 55 M via the U.S. President’s Emergency Plan for AIDS Relief, PEPFAR, and US$ 12M via the Global Fund to Fight AIDS, Tuberculosis and Malaria).

Immediate Risks

The pause and stop order will:

1. Undermine Botswana’s ability to fully achieve UNAIDS’ 95-95-95 targets and the efforts to finding the missing 5-2-2 in Botswana. That means reaching an additional five percent of all people living with HIV with testing so they are aware of their HIV status; ensuring that an additional two percent of all people who are living with HIV and are aware on treatment and ensuring an additional two percent of all those aware of their status and on treatment have their viral load suppressed.
2. Take away safe spaces for key populations (KPs) and adolescent girls and young women (AGYW) and increase their vulnerability to HIV-related sigma and discrimination, gender-based violence, mental health problems and other related social ills.
3. Reduce access to early diagnosis and treatment for HIV which leads to health complications and higher default rates for treatment adherence which correlates to a lack of viral suppression.

Impact on Civil Societies and Communities

In Botswana, the impact of the pause on U.S. foreign assistance and related stop order has already affected delivery of HIV prevention and treatment services by civil society organisations (CSOs) and will have implications for the entire system across the national HIV response.

UNAIDS consulted with a significant number of CSOs to establish the impact of the pause and stop order on the provision of services. Additionally, a task force set up by NAHPA and the Ministry of Health and cochaired by UNAIDS met to establish a complete picture of disruptions not just for CSOs but also within MOH and NAHPA where a total of about 207 positions are funded by PEPFAR.

Most of the affected CSOs are those providing some services for key and vulnerable populations (AGYW, MSM, SW, PLWHIV). The government continues to provide services and encourages the affected CSOs to refer and link clients to government facilities. While CSOs have been funded to provide demand creation activities, only three of those consulted have clinics or drop-in centres that were considered safe by the aforementioned population groups. They offer HIV counselling and testing Services, ART dispensing, PrEP dispensing, adherence and psychosocial support, condom distribution and referral and linkages to other services. The stop order has led to the closure of these CSO clinics and drop-in centres and disrupted service delivery.

Government Response

Botswana’s government health facilities continue to operate and provide services. The Ministry of Health issued a press release on 29 January assuring Batswana living with HIV that the pause of U.S. assistance will not affect the availability of ARVs as they are directly procured by the Government of Botswana. This was followed by another press release on 6 February further assuring continuity of services.

Mitigation Measures

Through the Joint Oversight Committee, a task team will be established to monitor developments and ensure that HIV services are not disrupted, clients are referred and linked to care at government facilities and that CSO’s providing services will receive domestic funding.

The pause of U.S. foreign assistance on Ethiopia will affect many areas of development, however its impact on Ethiopia’s national HIV response is particularly severe.

Ethiopia is on track to reach the global 95-95-95 targets: with 90% of people in Ethiopia living with HIV being aware of their HIV status; 94% of those diagnosed with HIV receiving antiretroviral (ARV) therapy; and 96% of people on ARV therapy achieving viral suppression.  ARV treatment is currently provided to 503,000 people via 1,400 health facilities across the country.   However, with ongoing challenges to the country health system and socio-economic development, Ethiopia remains reliant on external donors for its HIV response. 

SERVICE DISRUPTION: Pause of U.S. assistance to community programs and drop in centres serving women, young girls and priority populations at higher risk of HIV infection means tens of thousands of individuals will no longer be able to access critical services such as HIV testing, antiretroviral treatment, pre-exposure prophylaxis (PrEP) for HIV prevention, and screenings for tuberculosis, sexually transmitted infections and support to address gender-based violence.  The closure of many drop-in centres and the termination of outreach workers’ and peer educators’ contracts will effectively shut off support to vulnerable groups.

Table: Breakdown of Service Disruption in three regions in Ethiopia: Addis Ababa; Oromia and Gambella

SUPPLY CHAIN DISRUPTIONS: The funding freeze has caused critical delays in the supply of essential HIV services, including testing kits and other resources. Notably, PEPFAR is responsible for 100% of the procurement of viral load and Early Infant Diagnosis (EID) reagents. The interruption in funding is limiting the availability of these crucial supplies, undermining the program’s ability to conduct timely viral load and EID testing, which are essential for effective patient monitoring and treatment.

REDUCED CAPACITY FOR HEALTHCARE SUPPORT: The pause threatens to stall efforts to build local healthcare capacity. It impacts the training and support of health workers, slowing progress in Ethiopia’s fight against HIV. This reduction in capacity limits the ability of healthcare professionals to respond effectively to the growing HIV epidemic. The disruption of ICAP’s capacity building, M&E, and clinical mentoring threatens care for advanced HIV patients, putting Ethiopia’s progress at risk. The freeze is also likely to scale back key prevention programs, including outreach, education, and services for key populations, worsening the epidemic

HEALTH INFORMATION SYSTEM DISRUPTION: Ethiopia's Health Information System is severely affected by the stop work order. The termination of 10,000 data clerks, who are essential for entering ART data into the health information management system, is compromising data management, particularly in tracking lost-to-follow-up cases. This disrupts key national activities, such as HIV estimations and studies of key populations. Furthermore, the cessation of the HIV surveys and surveillances, and HIV Estimation Technical Working Group (TWG) which includes CDC, USAID, and PEPFAR undermines the accuracy of HIV data and threatens the continuity of critical HIV data management systems.

HUMAN RESOURCES IMPACT:  Ministry of Health shared that 5,000 public health workers’ contracts funded by U.S. assistance from all regions in Ethiopia have been terminated.  These health workers are supporting Ethiopia’s HIV response – improving regional capacity to accelerate progress towards Ending AIDS.   While the government of Ethiopia will take over the gap, the sudden loss of programmatic experience and the transition period will be rough.

ACTIONS TO ADDRESS THE SITUATION: On 4 February 2025, The Ministry of Health of Ethiopia issued a circular to all regional health bureau to assure regional health offices that the government will step in to manage the work that was performed by the US-funded personnel in order to ensure programme continuity. 

UNAIDS Ethiopia together with WHO will be convening a situation assessment briefing on 11 February 2025 with government, civil society organizations and development partners to identify solutions to address gaps in the HIV, TB, Malaria and health and community systems responses in Ethiopia.