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 Unites States 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.

Overall National Response

A Cabinet memo on the current situation and recommendations for the government of Kenya (GOK) to mitigate the situation has been developed by Ministry of Health and domestic resource allocation is a key recommendation as well as fast-tracking the development of the ongoing HIV sustainability roadmap.

A special national HIV inter coordination committee (ICC) that includes CSOs, communities, private sector, UN Agencies and government stakeholders was convened by UNSDCC on Friday, January 31st to assess the impact and suggest solutions.

Commodity Security

UNAIDS’ Country Office (UCO) has been part of the commodity security meetings.

All requests to distribute PEPFAR-supported products in country through USAID are on hold until further guidance is provided to unfreeze the initial communication.

Products that were to be distributed in January 2025 under USAID/PEPFAR include ARVs (Nevirapine syrup, Dolutegravir 10 mg and 50 mg). For these products, health facilities had a stock balance between 2 to 4 months by 31st December 2025.

The country may start experiencing erratic supply of Nevirapine syrup and Dolutegravir (DTG) 50 mg towards the end of March and May 2025, respectively, if the stop work order is not lifted.

The current stocks at Kenya Medical Supplies Authority (KEMSA) for DTG 10 mg will sustain the country beyond June 2025.

Viral load and EID products are mainly procured through PEPFAR support. This will be adversely affected if the stop order is not lifted as soon as possible as the quantity under the Global Fund is minimal, targeting specific point of care testing sites.

Stop Gap Measures for Commodity Security

GOK will be required to allocate funds for the distribution of these products from Missions for Essential Drugs and Supplies (MEDS) to health facilities. The estimated cost by KEMSA is approximately USD 10 million.

Procurement and delivery of health products will be facilitated by the Global Fund and government counterpart financing. Additionally, discussion to front load commodities under Global Fund year two will be initiated.

If the stop order continues, GOK will be required to allocate funds to cover the deficit.

Discussions to allow Government to distribute HIV commodities under MEDS is to be initiated if the stop work order is not lifted. (To note, as of February 2, 2025, there has been a reprieve with the new circular on waiver for administration costs for procurement and supplies of essential drugs. The circular is however yet to be implemented as it is a new directive)

Human Resources for Health

All PEPFAR-supported medical personnel/health workers have been requested to stop work as per the stop work order effected in PEPFAR supported counties and facilities.

All PEPFAR-supported implementing partners (CSOs, FBOs, UN) and sub-grantees have been requested to stop work and consequently, staff have been requested to proceed on leave for the duration of the stop work order (90 days).

In some of the counties, the county government has recalled all health workers who are on leave to cushion the situation.

UCO programs supported by PEPFAR through COAG (Community led monitoring and Strategic Information) have been halted.

Consequently, the five UCO CLM partners (CSOs, KP led organizations) have stopped work and over 148 staff IP staff have been affected, and service delivery constrained.

Way Forward

UCO to consider supporting a national communities’ meeting to discuss the impact on service delivery and make recommendations to national and county governments.

As mentioned above, as of February 2, 2025, there was a reprieve with the new circular on waiver for administration costs for procurement and supplies of essential drugs, including continued support for human resources. Hopefully, measures will be implemented this coming week to avert potential risks.

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.

Consultative meetings between stakeholders are ongoing as per the Ministry of Health’s press release.

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, CSOs and development partners to identify solutions to address gaps in the HIV, TB, Malaria and health andcCommunity systems responses in Ethiopia.

South Africa’s fight to end AIDS in children has received a major boost with the launch of the first provincial Global Alliance chapter in the Eastern Cape province. The Global Alliance is driving a global agenda to end AIDS in children by 2030 together with UNAIDS, the Joint United Nations Programme responsible for the global HIV and AIDS response, with a commitment to ensure that all children who are already living with HIV are on lifesaving treatment to live long and healthy lives and to prevent new HIV infections in newborns.

South Africa has one of the highest number of people living with HIV in the world, with approximately 7,7 million people living with HIV and about 150,000 children below 15 years living with HIV. The Eastern Cape province accounted for 24,856 children (aged 0-14 years) living with HIV in 2023.  Of these, 1,360 children were newly infected with HIV during the same period. There were 255 children who died of AIDS-related illnesses during the same period.

The Eastern Cape provincial chapter of the Global Alliance was launched at the Masizakhe Children’s home in Mdantsane on 30 November 2024 by the spouse of the Deputy President of South Africa, who is also the patron of the Global Alliance, Mrs Humile Mashatile. She said that it was crucial for the country to accelerate the fight against AIDS to end the AIDS epidemic, including vertical transmission of HIV – for breastfeeding mothers who are living with HIV – and ensuring that people who are not receiving antiretroviral treatment are initiated on it. The patron further called on the government and stakeholders to support the Global Alliance’s work in the province, including ensuring that no child who needs treatment is left behind, including children in remote areas of the country where access to health facilities is often difficult.

“While the Global Alliance activities are focused on health facilities, their success requires the collective effort of all sectors. I call upon all managers across all government departments, civil society leaders and the community-led organizations to adopt these shared values. This should be carried out with an understanding that it is about children’s future,” said Mrs Mashatile. “As we officially launch the Eastern Cape Chapter of the Global Alliance, let us work together to end AIDS in children who will grow up to be healthy and smart leaders of the future.”

Mrs Mashatile also urged leaders to tackle inequalities, including transactional relationships and “ukuthwala”, the practice that involves forced marriage of young girls to older men, as some of the issues that are fuelling new HIV infections in children. Deputy President Paul Mashatile led the pledge against gender-based violence during the national World AIDS Day commemoration event in Mdantsane on 1 December.

The United Nations Children’s Fund (UNICEF) Representative in South Africa, Christine Muhigana, said that progress to end AIDS in children in South Africa needs to be fast-tracked.

“As we conclude the commemoration of 30 years of democracy, we acknowledge the remarkable strides of this country in addressing the AIDS pandemic with South Africa implementing the largest HIV programme in the world," said Christine Muhigana, UNICEF Representative in South Africa. 

Eastern Cape Premier, Oscar Mabuyane affirmed the provincial government’s support for the Global Alliance Chapter launch in the province. He said that the province was committed to ending AIDS by 2030 as a public health threat.

“The Global Alliance Eastern Cape chapter envisions a future where every child grows free from HIV with equal opportunities by scaling up evidence-based interventions and community engagement leveraging the multisectoral responses and commitment,” said Oscar Mabuyane, Eastern Cape Premier. “Eastern Cape seeks to halt new HIV transmissions by 2030.”

Globally, UNAIDS reported that the AIDS epidemic is at a crossroads. According to Eva Kiwango, UNAIDS Country Director for South Africa, it is “important to prioritize the right to health of children living with HIV by ensuring that they receive the lifesaving antiretroviral treatment to end AIDS as a public health threat.”

Efforts to end AIDS in children combine the work of both government, civil society,  community-led organizations and pharmaceutical firms that produce HIV treatment. According to Simo Masondo, Head of Government Affairs and Trade Development at multinational pharmaceutical company, CIPLA, the firm would continue to work with the government of South Africa to end AIDS through the production of antiretroviral treatment, including treatment for children. Masondo said that CIPLA was committed to equitable access of treatment for all.

What does the HIV response look like beyond the 2030 targets to end AIDS? For the past year, UNAIDS has been working with partners and over 30 countries to develop country-led roadmaps for the sustainability of HIV prevention, treatment and care services far into the future.

Part of the sustainability journey includes reaching the global goal of ending AIDS in the next five years. According to a recent World Bank report, despite an early COVID-19 spending peak, per capita government health spending has steadily declined in low- and lower middle-income countries. Urgent action is needed in many countries to ensure reaching the health Sustainable Development Goals remains possible by 2030.

UNAIDS’s new sustainability approach, developed jointly with the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) in early 2024, focuses on five core areas. These are political leadership and commitment; enabling laws and policies; sustainable and equitable financing; science-driven, effective and high-impact HIV services and solutions; and systems built to deliver. The specific methods look different in each country, but all have equity and communities at the center.

“A multi-sectoral approach remains critical to the HIV response particularly in this last mile as we accelerate prevention and close gaps that require us to address the complex inequalities that persist,” said Anne Githuku-Shongwe at UNAIDS.  

As part of this initiative, UNAIDS and partners are supporting countries to create and implement sustainability roadmaps. The roadmaps identify key changes countries can take to shift towards self-reliant, efficient and impactful HIV responses both in the short- and long-term.

Representatives from 22 countries in Sub-Saharan Africa and the Dominican Republic gathered recently in Johannesburg, South Africa to hone their roadmaps during a workshop hosted in October by The South African National AIDS Council in collaboration with UNAIDS, PEPFAR and the GF.

“While it is valuable that we come together to learn and share insights, it is crucial to recognize the level of responsibility each of us carries in our respective countries. We are not here simply to exchange ideas, but to take on a leadership role in driving meaningful change,” said Thembisile Xulu  of the South African National AIDS Council as she addressed the participants.

During the workshop, countries shared experiences and learned from each other about their individual sustainability journeys. In addition, countries agreed to establish a virtual peer learning network to facilitate future cross-border partnerships and share successes and challenges in moving towards sustainability. Some of the findings so far along the journey include the necessity of high-level political support, coordinated multi-sectoral efforts and diversified funding sources.

Furthermore, countries recommended that development partners craft consistent messages about their ongoing commitment levels to fund HIV and health services. The need for transparent, responsible and inclusive conversations was emphasized by all in Johannesburg when discussing the transition from donor financed to country financed responses.

“The fiscal space for HIV is tightening, and we need to be pragmatic as we work to sustain the response with a focus on simplification and efficiency,” said Sarah Dominis from the U.S. State Department Bureau of Global Health Security and Diplomacy, Office of Financial and Programmatic Stability. “The future HIV response will be led by country governments in partnership with community and private sector partners. PEPFAR is not going away but will focus on supporting countries to sustain the HIV response, aligning to the vision they have committed to in their roadmaps.”

As the roadmaps roll out publicly, governments are recognizing the role of communities in the long-term response. For example, Tanzania’s roadmap identifies that community-led organizations play a pivotal role in community mobilisation, facilitating social and behaviour change, addressing social/cultural norms, primary HIV prevention interventions, adherence to antiretroviral treatment and retention in care. As a result, the roadmap lists actions to bolster communities, such as scaling up the network of community health workers and reinforcing community-led monitoring programs.

“When we talk about HIV sustainability we need to go back to the basics. It's about planning around the lives of PLHIV. Communities are always at the centre of service delivery, demand creation and monitoring. There is the opportunity for us all to tap into the infrastructure and willingness of communities to provide treatment and prevention services - through strong sustainable partnerships,” said Sibongile Nkosi from The Global Network of People Living with HIV.

This past World AIDS Day, ten countries launched their sustainability roadmaps, and more will follow in early 2025. To follow the process, visit: https://sustainability.unaids.org/

Progress towards ending AIDS as a public health threat has been strongest in the countries and regions with sufficient investments in their HIV responses, especially in countries from eastern and southern Africa. However, a critical part of this success lies in understanding where resources are being allocated and ensuring that investments are directed towards the most impactful interventions.

“HIV financial data is essential for decision-making”, said Jaime Atienza, Director of Equitable Finance at UNAIDS. “This is especially important when we can see constraints, now and around the corner.”

To reflect on the current use and future potential of HIV financial data, UNAIDS and the Global Fund to Fight AIDS, TB and Malaria brought together representatives from 10 African countries to Cape Town, South Africa. During the event, countries shared how they are using HIV financial data to transform their national HIV responses.

In the case of Kenya, for example, the 2022 National AIDS Spending Assessment (NASA) revealed that approximately 84% of the funds for care and treatment programmes came from external sources. This heavy reliance on external funding prompted the development of a cabinet advisory note on local commodity manufacturing, aimed at addressing commodity security risks. In response, the Office of the Presidency issued a statement on Worlds AIDS day 2022 directing that the government would support the pharmaceutical sector to strengthen its local manufacturing capacity and review relevant regulations and tax policies to create an enabling environment.

In Mozambique another NASA study showed how the country spent 26% less on HIV treatment than the National Strategic Plan required, while still surpassing the antiretroviral (ART) coverage target. ART unit costs have fallen from US$ 208 in 2017 to US$ 137 in 2022—well below most countries in the region. Economies of scale and differentiated service delivery likely contributed to this outcome. “We are using this data to inform multi-sectoral plans and state budgets” said Francisco Mbofana, Executive Secretary of Mozambique's National AIDS Council.  

HIV financial data is also seen by countries as an effective tool for mobilizing resources. Ethiopia’s NASA and National Health Accounts (NHA) informed a Domestic Resource Mobilization Strategy. The Strategy aims to boost domestic investment from US$ 27.9 million in 2020 to US$ 68.5 million by 2025 through government revenues, AIDS fund(s), targeted mainstreaming, community care coalitions, and earmarked taxes. In addition, South Africa demonstrated to the Global Fund that of the US$ 6.3 billion the government committed to invest in HIV from 2022-2025, US$ 6.2 billion (98.99%) is likely to be realized. This, in turn, unlocks the US$ 92.7 million co-financing incentive from the Global Fund grant for 2025-2028.

Financial data has also stressed the major underinvestment in HIV prevention. “The de-prioritization of HIV prevention is among the top sustainability threats,” said Thembisile Xulu, Chief Executive Officer of the South African National AIDS Council. While prevention will require a third (32.8%) of total HIV resources by 2025, NASA data shows current HIV prevention spending is at 9.4% in Kenya, 9% in Namibia, 11% in South Africa, and 13% in Uganda.

Nonetheless, several strategies to boost HIV prevention investments are being developed following evidence provided by HIV financial data. Kenya used its NASA data to develop guidelines for harnessing resources from construction projects to support HIV prevention. Zimbabwe’s resource tracking influenced a new policy to implement social contracting with a least one civil society organization per province, to channel domestic resources to community-led HIV responses. Zimbabwe has committed to invest 21% of domestic funds in HIV prevention, with a focus on key populations.

In the current environment of dwindling resources for HIV—2023 recorded the lowest amount of resources available for HIV in low-and-middle income countries in a decade—strengthening HIV resource tracking is key to ensure effective and sustainable HIV responses. “We need to plan for sustainability,” said Nertila Tavanxhi, Senior Manager for Health Financing Country Support at the Global Fund. “To do this, we really need to understand who is funding what, where and whom. This will show us the gaps, and where we must focus.”

“We are in a time of transformations towards sustainability,” said Mr Azcona. The National HIV Response Sustainability Roadmaps are an essential part of the work that the Global Fund, UNAIDS, PEFPAR and country partners are undergoing in 2024 and 2025. “This makes it even more important to have the right data to make the best possible choices on what these transformations must be.” 

Marouane Abouzid, a 25-year-old from Casablanca, grew up in an environment where social challenges and gender stereotypes were pervasive. However, his perspective changed the day he joined "The Ball is Your Protection" program, an initiative by Tibu Africa in partnership with UNAIDS, which uses sports to raise awareness about HIV, gender equality, and gender-based violence. 

Before joining the program, Marouane had limited knowledge about HIV and gender equality. “The training on HIV awareness led by UNAIDS and Tibu Africa was a transformative experience,” he says. “It equipped me with essential skills like effective communication and active listening.” Thanks to the program, Marouane discovered how sports can be a powerful tool to engage young people on often-overlooked topics, such as HIV prevention and breaking gender stereotypes. 

Now, trained to be a change ambassador in his community, Marouane leads sports activities and participates in educational sessions, becoming a role model for his peers. “I talk openly about what I’ve learned. I encourage my friends to get tested for HIV and respect the rights of others,” he shares. 

For Marouane, this program was more than just training. “Today, I feel ready to take action and share what I’ve learned with my community,” he says. 

During the closing ceremony of the "The Ball is Your Protection” project, Marouane facilitated workshops and sports activities with other young participants. “I saw how sports could become a tool for awareness and social mobilization,” he explains. These activities created a safe space for young people to discuss issues related to HIV and gender equality, free from societal judgment. 

In Morocco, approximately 23,000 people live with HIV, nearly 50% of whom are women. Although the prevalence rate is relatively low, vulnerable groups such as sex workers, men who have sex with men, and people who inject drugs are particularly at risk. “Before, I thought HIV didn’t have a real impact on those around me. Now, I understand that we all have a role to play,” Marouane adds. 

Marouane is not alone on this journey. Assia Ezzahraoui, 25, a participant in Tibu Africa’s Sports Vocational School program, reflects: “HIV awareness was a profoundly enriching experience. It gave me new insights into symptoms, prevention methods, and available treatments.” For Assia, taking part in the educational event deepened her understanding of HIV and reinforced the importance of protecting her health and that of those around her. 

“I want to thank everyone who contributed to this initiative. Their commitment to young athletes in Morocco is truly inspiring,” says Assia, emphasizing the value of such events in educating youth about HIV. 

Thanks to initiatives like "The Ball is Your Protection," young people like Marouane and Assia are playing an active role in addressing gender inequalities and HIV-related stigma. These young leaders are helping to build a healthier and more equitable future, proving that change can start with something as simple as a ball.