Immediate Risks or Disruptions

1. Stockouts:
   • Pre-Exposure Prophylaxis (PrEP): The HIV Program Unit of the Ministry of Health has only a four-month supply of PrEP remaining. However, The Global Fund authorized them to use remaining funds to purchase PrEP.
   • The USAID PASMO project, which implemented PrEP through private clinics, has not returned; they have only been authorized to work on offering self-testing.
2. Service Capacity:
   • HIV Testing & Treatment: antiretroviral therapy provision continues, but facilities are operating at reduced capacity.
   • HIV Prevention Services: Reduced capacity is affecting key populations such as gay men, sex workers, people who use drugs, and transgender people.
   • At the moment, the greatest impact is on prevention, as only 11 of the 30 promoters who supported doctors in initiating PrEP for key population users in the VICITS clinics have been rehired. Therefore, their workload has been overloaded by assigning them three VICITS clinics per promoter.
   • Comprehensive HIV Care Clinics: Projects supporting 20 out of 24 clinics were reinstated, allowing the return of 90% staff, including doctors, laboratory staff, pharmacies, data entry clerks, and community liaisons. The care and treatment areas are recovering despite the impact of the three-week pause that led to more than 1,200 antiretroviral therapy dropouts.
   • Human rights, key and vulnerable populations: All programs on stigma and discrimination have stopped affecting key populations, adolescent girls and young women, and people living with HIV.
3. Civil Society Organizations (CLOs):
   • CLOs are experiencing significant challenges, including service reductions or suspensions, staff losses, and funding cuts, which limit their ability to advocate for key issues. Additionally, their capacity to collect and report data has decreased due to a lack of funding for monitoring activities. As a result, many CLOs face the risk of closure or severe reductions in services.

Politically Relevant Updates

1. Government and UN Coordination:
   • UNAIDS conducted an early assessment and has been continuously updating it, presenting the impact to the UN country team.
   • A country-level task team is in place, with representation from REDSAL (a network of people living with HIV) and Colectivo Alejandría (representing key populations).
2. Funding and Support:
   • The USAID Global Health Supply Chain Program Procurement and Supply Management (PSM) resumed operations, providing support for supply chain projections and management.
   • The Data for Implementation (DATA.FI), funded by USAID in collaboration with Palladium and the Department of Epidemiology at Johns Hopkins returned to assist with data analysis in the case registration system.

Immediate Risks and Disruptions

PEPFAR Programme Delays:

• PEPFAR PrEP delivery to 2,500 people among key populations, mainly men who have sex with men, was canceled. However, as of 14 March PrEP provision services for key populations (MSM mainly) have been re-established and the MoH has taken over distribution.
  • Human resources and transport for viral load samples at ARV clinics provided by PEPFAR were canceled, affecting several cities:
    • Panama City: 8,100 people
    • Colón: 1,300 people
    • Pacora: 300 people
    • Ngäbe-Buglé population: 1,400 people, where HIV prevalence is high.
  • HIV commodities: Stocks available with minimal disruption.
  • Prevention of vertical transmission (PVT) and pediatric HIV services: No services affected.
  • HIV prevention: Disruptions in access, reduced capacity for HIV prevention services, including HIV counseling and testing, primarily affecting sex workers, men who have sex with men, and transgender people.
  • Condom promotion and demand generation activities: Impact noted on public sector, social marketing programs, NGOs, and community distribution.
  • Data collection: Continues at some facilities and service points, along with some data quality control and collation.
  • Study suspension: The suspension of a study on recent HIV diagnoses and the halt in laboratory sample transportation have further limited essential diagnostic and monitoring services
  • All programs on stigma and discrimination have stopped, affecting key populations. Communities have collected data on human rights issues, including increased stigma and discrimination.
  • Disruptions noted in HIV prevention programs affecting particularly men who have sex with men, sex workers and transgender people

Service Disruptions:

Politically Relevant Updates

1. Government Actions:
   • The Panamanian government began expanding friendly services to key populations to absorb the demand for PrEP that US funding was covering.
   • Adjustments were made to ARV services to temporarily cover the human resources provided by US funding, however, this impacted the quality and timeliness of service provision.
2. Civil Society Impact:
   • Community-based organizations (CLOs) are struggling but have alternative funding sources; however, they have noted a reduced ability to participate in policy discussions.
3. UN Response:
   • A country-level task team has been established but does not include representatives from people living with HIV and key population networks.
   • UNAIDS is collecting information from PEPFAR partners but has not received clear responses due to canceled field worker contracts.

Immediate Risks and Disruptions 

• Service Closures: US-supported facilities and international NGO-run services have shut down. Some antiretroviral therapy service facilities have closed, and there is no clear referral system in place.
• Supply Chain: antiretroviral supplies, HIV test kits, viral load tests, other lab tests, and male and female condoms are available with minimal disruption to distribution. However, condom stock levels are unavailable or not tracked.
• Service Disruptions: PrEP and HIV testing services have been disrupted. Prevention of vertical transmission and pediatric HIV services remain unaffected. 

Civil Society Impact and Response 

• CLOs: Community-led organizations (CLOs) face a reduction or suspension of services and have limited ability to advocate for key issues. Despite struggles, some CLOs have alternative funding sources. 

UN Response 

• Mitigation Actions: The UN country team has been engaged in actions to mitigate the impact of the USG shift. UNAIDS coordinated PEPFAR implementing partners to assess the impact. 

Stock Levels and Immediate Risks

• Stock Levels: A recent national stock-level assessment indicates that there are at least two months of stock at facilities and five months at central warehouses. This is consistent with normal operations, and no immediate risk of stockouts is anticipated. New shipments are expected in April.
• Service Disruptions: Some communities-based service delivery points are facing serious service interruptions, and there are currently no plans for referrals to other facilities. . Community HIV testing for the general population and key populations (KPs) has been significantly impacted due to disruptions in the community health workforce. Specialized wraparound services at over 80 One-Stop Shops have been disrupted in one way or another due to funding freezes. Disruptions in services for orphans and vulnerable children (OVC) may impact children living with HIV. 

Relevant Updates

• Government Actions: The Nigerian government has taken proactive steps to address potential AIDS funding gaps, particularly in response to the suspension of US-funded programs. The Federal Executive Council (FEC) has approved N4.8 billion for procuring 150,000 HIV treatment packs under the 2024/2025 HIV Program Alignment. The government is also strengthening national systems, securing local financing, and engaging the private sector, including plans to establish an AIDS Trust Fund.
• Healthcare Workforce: The Government is collecting information about the health care workers that have been impacted by the funding freeze, with the intention to determine the critical number and skillset of workers in each state to be recommended for absorption into the public health workforce. One of the states, Rivers State, recently recruited 1,000 healthcare workers, absorbing some who were affected by the funding freeze. The Network of people living with HIV is leading efforts to map the impact on the community health workforce, with a Ministerial Task Team reviewing findings and proposing state-level interventions.
• Community and Civil Society Response: Community-led and peer-led services is mostly supported through the Global Fund and has continued, those PEPFAR-funded components have been interrupted due to "stop-work" orders issued to PEPFAR Implementing Partners. Many partners have yet to communicate updates to community workers, despite directives in the February 4th Memo from the US Government. Some implementing partners, such as Heartland Alliance, which supported over 20 One-Stop Shops for Key Populations, have received official contract termination notices from USAID, with no clear transition plan for their services.
• Resilience and Adaptation: Despite these challenges, the community and civil society organizations have shown resilience. For example, about two-thirds of community workers who received "stop-work" orders in January/Early February have been recalled following the February 4th Waiver Memo from GHSD. Additionally, national acceleration efforts to prevent vertical transmission of HIV continue to scale up across all states under Global Fund funding, relying on public health institutions and Global Fund-supported community health workers.

Summary of Key Assessment Findings

The task team has been meeting at the governmental level, with UNAIDS supporting the Federal Ministry of Health and the National AIDS Council DG, who co-chairs the task team. 

Summary of key assessment findings:

1. Community Workforce: Over 95% of community workers received "stop-work" orders, but about two-thirds have been recalled.
2. ARV Access: Immediate access to antiretrovirals remains stable but testing and case-finding activities have stalled significantly. Investments by the Government of Nigeria and the Global Fund in the National PMTCT Acceleration Plan has however supported continued scale-up of PMTCT testing and treatment. 
3. ARV Stock Pipeline: The pipeline for 1st-line ARVs remains strong, with over six months of stock available. New shipments are expected to continue, but distribution challenges may arise.

Crisis Response Plan: The newly inaugurated AIDS, TB and Malaria TWG, has been tasked to leading the convening of critical stakeholders to set-up crisis response plans at national and sub-national level, with clear communications channels for reporting service delivery disruptions. The committee has conducted a preliminary gaps analysis which informed the approval of a supplementary budget of about $200 million. 

Immediate Risks and Disruptions

A full resumption of HIV services is required for the effective delivery of HIV prevention services. HIV services are dependent, and different parts of the U.S. Government fund different components —for example, the Centers for Disease Control and Prevention funds HIV treatment - which received a partial waiver to continue - and USAID funds the supply chain. Partners funded by USAID received stop work orders, halting the flow of essential HIV treatment commodities and impacting the delivery of HIV treatment and prevention services. Partial waivers block the delivery of services.

The country has 37,000 vials of cabotegravir long acting injectables expiring in May 2026. A further 30,000 vials purchased under the Global Fund to Fight AIDS, Tuberculosis and Malaria will arrive in Malawi in June 2025 to support the scale-up of injectable PrEP.  To absorb the gap in the program created by U.S. funding cuts to the partner supporting this activity, the government has instructed the remaining implementer to continue with the scaling up of injectable PrEP focusing on people continuing PrEP and only recruit new pregnant and lactating women. However, the absence of implementing partners and the limit to recruit only continuing clients and pregnant and lactating women may not generate sufficient the client load risking the long acting injectables expiring. A resumption of the program to recruit on the full spectrum of eligible people into the program is required.

1. Human Resources:
   • Contract Terminations: More than 4,500 staff including 247 nurses, 1,642 Health Diagnostic Assistants, 1,871 treatment supporters, data clerks and others supported by U.S. funding have had their contracts terminated.  The exact numbers of staff impacted are difficult to quantify because of the stop-and -resume flow of human resources based on the stop-resume-stop implementation of the waivers.
   • Reduced Capacity: Although the government of Malawi has rationalized the continuation of services and deployed staff to fill the gaps created by the stop order and waiver, HIV services are yet to recover fully. Facilities providing prevention of vertical transmission of HIV, early infant diagnosis (EID), pediatric and adult HIV treatment services are operating at reduced capacity.  Community-led monitoring and other activities led by civil society have reduced. Only community-led activities supported by the GFATM are continuing, helping fill the gap in the availability of HIV services
   • Outreach Services: Outreach services, especially those targeting key populations, adolescent girls and young women, refugees and displaced people, have been affected, impacting prevention and treatment services and may lead to increased antiretroviral therapy default rates and new HIV infection.
2. Service Provision:
   • Facility Closures: Some facilities providing Antiretroviral Therapy (ART), especially the 18 drop-in centers serving more than 7,000 key populations living with HIV have reduced their operations and referred the people to to other facilities. Crowds of patients waiting for services typical of non-HIV services are now common in the HIV treatment section.
   • Testing Services: DNA-PCR testing for HIV Exposed Infants (HEI) will continue only at sites with point-of-care testing capacity. Other infants will be tested at 12 and 24 months using Rapid Diagnostic Tests (RDT).
   • Targeted viral load sample testing will take place in sites with point-of-care capacity. new HIV infections, with poor EID service, new HIV infections among children are likely to increase.
   • Supply chain and sample Transportation: The sample transportation system has been suspended. Although the government redeployed ambulances to transport samples, hundreds of thousands of samples remain stuck and unusable, A million HIV test kits risk expiring, without a revitalized HIV testing drive using local staff. Although implementing partners leading work on voluntary medical male circumcision (VMMC) received partial waivers to continue VMMC. Without a full resumption of the program, the VMMC faces an imminent stop in a month because the supplies are limited.
3. Commodity Stock Levels:
   • ARV Supplies: Stocks of antiretroviral (ARV) supplies, HIV, viral load (VL) and other lab test kits, and condoms are available with minimum disruption. However, dispensing of ARV emergency supplies has been suspended to avoid panic refills and depleting stocks.
   • Condom Stock Levels: Sufficient for the next 12 months, but non-facility condom programming has stopped.
4. Impact on Specific Populations:
   • Adolescent Girls and Young Women (AGYW): Reduced capacity for HIV prevention services, including PrEP, testing, and outreach programs. Malawi has 2,341,000 AGYW of which 2.4% are living with HIV. 25% of new HIV infections are among AGYW. Programs for orphans and vulnerable children have completely stopped and are not included the prioritization of HIV services.  
   • Key Populations (KPs): HIV prevention services for KPs have also been impacted. This includes continuation of provision of oral PrEP where human resources are available, and continuation of only old clients on injectable PrEP. Discontinuation of hepatitis B testing except in antenatal care and inpatient care. The Government with implementing partners support 18 Drop-in Centers spread across in Blantyre, Mangochi, Muzuzu and Lilongwe are devising a plan to keep the dropping centres. The centres cater to key populations with a total cohort of 7,600 people living with HIV accessing HIV treatment and 7,000 continuing PrEP. 

Politically Relevant Updates

1. Government Actions:
   • Task Team: A country-level task team has been convened to discuss the impact on service delivery and identify mitigation measures. This includes representatives from people living with HIV and key population networks.
   • Mitigation actions by government and country partners include expanded community health worker or peer-led health services and integration of HIV services into other health services.
   • Transitional Plan: The government is developing a plan for HIV commodities warehousing and distribution to transition from the current service provider to the Central Medical Stores Trust.
2. Civil Society Impact:
   • Community-Led Organizations (CLOs): CLOs are at risk of closure or severe reduction in services due to funding cuts. This affects their ability to deliver services, advocate for key issues, and participate in policy discussions.

 Current Challenges and Disruptions

1. Decline in HIV Case Identification and Contact Tracing:
   • Limited availability of HIV testing (including self-testing, workplace testing, and community-based approaches).
   • As a result, of being unaware of their HIV status, pregnant women living with HIV may have compromised access to vital services to prevent vertical transmission of HIV.
   • Due to limited access to testing, there has been a significant decline in HIV case identification, contact tracing efforts, and peer-based linkage, particularly among high-risk populations such as men and youth.
2. Healthcare Worker Job Cuts:
   • HIV Programme Officers have had - and others may have – there jobs cut. For those who have retained jobs, there is a proposal to align their salaries with government pay scales.
   • This has affected the capacity of facilities/service points that provided antiretroviral therapy, leading to reduced availability of HIV testing and other services.
   • Data collection at all facilities/service points continues, but data quality control and data collation are affected.
3. Disruption in Distribution of Supplies:
   • Distribution of antiretroviral supplies, HIV, viral load, and other lab test kits, and condoms is disrupted.
   • Stockouts are foreseen in 3-6 months, although the country has sufficient condom stocks for the next 12 months.
4. Impact on HIV Prevention Services:
   • Primary HIV prevention services have been disrupted, including reduced availability of PrEP services, suspension or reduction of HIV prevention education and awareness campaigns, limited or suspended implementation of voluntary medical male circumcision services, and delays or disruptions in community-based HIV prevention outreach programmes.
   • HIV prevention programmes for adolescent girls and young women (AGYW) have been impacted, affecting between 120,000 -150,000 AGYW. These include a reduced capacity of service delivery points for HIV prevention, delays in linkages to HIV prevention services, discontinuation of AGYW-specific outreach programmes, reduced availability of HIV prevention education and awareness campaigns, and a reduction in the availability of counselling and social support services for AGYW. The DREAMS programmes targeting AGYWs are no longer operating, which is creating disruptions in PrEP access for AGYW and increasing their risk of HIV infection, while also negatively impacting their behaviour change in the long term.
5. Human rights, key and vulnerable populations Eswatini received U.S. funding for work on stigma, discrimination and enabling legal environments. Some programmes have stopped; other work is ongoing with reduced capacity. This funding has not been redirected to other programmes. 

Immediate Risks

1. Lack of US Funding:
   • US funding cuts could lead to dire setbacks in health initiatives, particularly in HIV and TB prevention, treatment, and care.
2. Stockouts and Reduced Service Capacity:
   • The disruption of the peer-led programme will result in limited access to HIV prevention services for key populations.
   • Reduced capacity of service delivery points and discontinuation of outreach programmes could increase the risk of HIV infection among vulnerable populations.

Politically Relevant Updates

Government convening/mitigation measures

Mitigation actions by government and country partners include integration of HIV services into other health services and mobilizing domestic resources to fill the financial gap. 

There is a country-level task team in place to discuss the impact on service delivery and identify mitigation measures. People living with HIV are part of the task team, while key populations are represented by the Ministry of Health's HIV programme focal point. 

Civil society impact, resilience and response 

Community-led organizations (CLOs) reported to be at risk of closure or severe reduction in services. The country reports suspension of services, loss of staff or funding cuts among CLOs involved in service delivery; reduced participation in policy discussions, limited ability to advocate for key issues and shift in focus due to funding constraints among CLOs involved in policy design, advocacy and work on societal enablers; and reduced ability to collect and report data, loss of funding for monitoring activities, and increased difficulty in accessing government or donor support among CLOs involved in community-led monitoring and data generation. 

Countries are continuing to adapt to the recent cuts to US funding for the global HIV response. The impacts of HIV service disruptions are being more clearly understood as more granular information becomes available.

For example, in Eswatini, there have been reports of declines in HIV case identification, contact tracing efforts and peer-based linkage, particularly among high-risk populations such as men and young people. In addition, in spite of a waiver intended to continue these services, the US funding cuts have affected services for pregnant women living with HIV, increasing the risk of vertical transmission during childbirth and breastfeeding. In Zimbabwe, where the government has limited fiscal capacity to fill gaps created by US funding cuts, the initial results of impact assessments warn that even a temporary halt in US funding will result in tens of thousands of additional HIV infections and thousands of additional deaths between 2025 and 2030.

Many countries have prioritized the continuation of HIV treatment and services to prevent vertical (mother-to-child) transmission. In some cases, national AIDS programmes have requested and/or obtained additional domestic resources to fill some of the most critical gaps. In Nigeria, for example, the federal government approved a new budget for procuring HIV medicines. Also, a national campaign to accelerate the prevention of vertical transmission is continuing to rollout across all states with Global Fund and national resources. 

Ethiopia’s parliament has introduced a new payroll tax as part of measures to fill the financial gap left by the US funding cuts. The new bill has been forwarded to a parliamentary committee for deliberation on the percentages to be contributed.  The funds collected will go to a new Ethiopian Disaster Risk Response Fund to pay for projects previously funded by USAID, which provided $1.8 billion in development and humanitarian assistance to the country during the 2023 financial year. In addition to food aid and services for 1 million refugees hosted by Ethiopia, the funds were spent on HIV medications, vaccines, literacy programmes and job-creation programmes.

In Kenya, the Ministry of Health has collaborated with partners, including UNAIDS, to develop a rapid assessment tool to measure the impacts of cuts to US funding. A high priority has been placed on accessing and distributing commodities from a PEPFAR-funded supply agency to sustain the availability of these commodities across the country. Despite these efforts, several services have been affected by the abrupt changes to the funding landscape. Condom stocks are alarmingly low. Stockouts of this critical HIV prevention commodity could lead to an increase in new HIV infections. County governments have been urged to allocate additional funding to local HIV services, and the parliament has been called upon to increase the health sector budget.

In Malawi, the government is working with partners, including UNAIDS, to ensure continuation of HIV services. However, pre-exposure prophylaxis (PrEP) and early infant diagnosis are among the priority services operating at reduced capacity due to US funding cuts. Outreach services for hard-to-reach communities are also disrupted, creating fears of an increase in treatment interruptions among people living with HIV.

Civil society and community organizations continue to play important monitoring and advocacy roles, despite the major funding challenges they face. For example, in Ukraine, a shipment of antiretroviral medicines arrived from Poland last week, securing the continuity of HIV treatment for about 90,000 people living with HIV. Civil society organizations are working to mobilize alternative sources of funding from both domestic and international partners. They have also stepped up their efforts to monitor stocks of HIV medicines, service disruptions and human rights violations affecting key populations.

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