LAGOS, Nigeria – At an HIV treatment clinic in Lagos, patients are seated in worn pews, waiting for their turn to receive their six-month supply of antiretroviral therapy (ART).

Without subsidies, the cost of these drugs could reach $4,500 a month, but with the support of foreign donors such as the US President’s Emergency Plan for AIDS Relief (PEPFAR), these patients are charged less than $2.

But the continuation of this programme is no longer assured since the Trump administration decided this week to permanently cut over 90% of US Agency for International Development (USAID) grants.

Formal notifications of contract terminations were issued from Wednesday night. HIV organisations across the continent that are funded by PEPFAR via USAID have already been informed that their grants have been terminated. 

Earlier in January, President Trump issued an Executive Order freezing USAID funding, but waivers was later granted, allowing life-saving humanitarian programmes, including HIV projects, to continue temporarily. However, in many cases this did not happen in practice as the USAID staff to ensure payment of bills had been fired.

However, some PEPFAR projects funded through the US Centers for Disease Control and Prevention (CDC) are covered by temporary waivers but they too are in jeopardy when these expire at the end of April. The reauthorisation of PEPFAR comes before the US Congress on 25 March.

“For now, we’re giving out what we have in stock. But when the drugs run out, you may have to start paying,” says the clinic’s matron, addressing the patients.

The Nigerian government is yet to comment on whether the country has been affected by the cuts. But following the Executive Orders, the country intensified focus on domestic efforts in its HIV response, which is part of a long-term strategy to reduce the impact of the USAID freeze and subsequent changes in foreign donor aid policies.

USAID support for Nigeria’s HIV response

Nigeria has the highest number of people living with HIV/AIDS in West and Central Africa, and the fourth-highest globally. 

USAID has contributed approximately $2.8 billion to the health care of Nigerians between 2022 and 2024, and this has been spent mainly on combating HIV/AIDS, malaria, tuberculosis, and polio.

In 2023, the country was on of the top 10 recipients of USAID funding, receiving over $600 million in health assistance. This aid has been directed towards efforts to prevent malaria, end HIV, deliver vaccines, and contain outbreaks.

PEPFAR is the country’s largest HIV donor, supporting 90% of Nigeria’s treatment burden. Its greatest contribution to Nigeria’s HIV response is in service delivery, where it has enhanced both prevention and care for those living with HIV. 

Through PEPFAR’s support, more than 1.6 million Nigerians out of an estimated two million living with HIV, now have access to antiretroviral (ARV) treatment.

Service disruption

With the pause on foreign aid, Nigeria’s HIV response, like in many other PEPFAR-supported countries, has experienced immediate service disruptions.

At the clinic, only one staff member from its PEPFAR-implementing partner showed up for work.

“There have been salary delays for health workers, and not all ad hoc staff have been called back. Covering the gaps left by these absences has been overwhelming,” says Dr Jibril Adamu, executive director of Yobe State Agency for Control of AIDS (YOSACA), one of Nigeria’s organisations coordinating HIV response at the level of the state government.

While the limited PEPFAR waiver provided some reprieve in the fight against HIV, the inaccessibility of USAID’s payment system has caused delays in resuming distribution of foreign assistance.

As a result, many of the “life-saving humanitarian assistance programmes” cleared to resume work are unable to do so.

“PEPFAR’s continued success is hugely dependent on the survival of USAID,” says Adamu.

“The focus is now only on providing existing services, so new cases will face delays,” he explains.

This has led to reduced testing and interrupted outreach programmes, which are key to Nigeria’s progress toward HIV elimination by 2030.

The waiver also excludes high-risk groups, such as sex workers and men who have sex with men (MSM), from receiving HIV prevention medication. 

“These groups already face limited access to ART due to discrimination,” says Adamu. Nigeria’s legal system criminalises same-sex relations and considers sex work illegal.

“If no immediate action is taken, Nigeria risks a public health crisis that would have both regional and global implications,” he warns.

Increased domestic funding

“In 2024, there was significant advocacy for increased local funding and community ownership of HIV control programmes, in anticipation of when foreign partners will withdraw, as is happening now,” says Adamu. 

Within the same year, Nigeria’s national agency for HIV control held its first-ever conference on HIV prevention. Among its objectives were strategies to boost local funding efforts.

During the first meeting of the federal executive council after the USAID freeze, Nigeria’s president formed a multi-stakeholder committee to oversee its transition away from reliance on donor funding for its HIV interventions. This is coupled with a $3.2 million allocation for 150,000 treatment packs to be distributed over the next four months.

“While we greatly appreciate the US government’s contributions over the past 20 years and look forward to continued collaboration, the Nigerian government, under the president, is committed to transforming the sector by strengthening national systems, securing local financing, and exploring other funding sources to ensure that patients do not lose access to their treatment,” says Dr Muhammad Ali Pate, Nigeria’s Coordinating Minister of Health and Social Welfare, during the council meeting.

With several HIV programmes across Africa receiving letters notifying them of their contract terminations with the US government, it is only a matter of time before Nigeria knows its fate.

Meanwhile, in a recent statement issued on Thursday, Nigeria’s National Agency for the Control of AIDS (NACA) maintains that HIV treatment in government-run health facilities is still ongoing and remains free of charge

Shifting dependence

Over 81% of Nigeria’s HIV spending comes from foreign donors. “We rely heavily on them,” says Adamu. “But this is not sustainable, as it leaves the country vulnerable in the long term.”

“There are viable alternatives, and it is unfortunate that we are considering them only at this stage,” says Dr Abdul Muminu Isah, principal investigator for the Person-Centred HIV Research Team (PeCHIVRet). He recommends forming partnerships with other successful countries in the Global South, incorporating HIV treatment into the national health insurance scheme, and engaging the private sector to improve service delivery.

Nigeria has announced plans to begin domestic production of HIV commodities, including test kits and antiretroviral drugs, by the end of 2025.

“Previously, we didn’t have an answer to whether Nigeria could achieve self-sufficiency, but based on recent actions, I am optimistic,” says Adamu.

Adamu adds that Nigeria has enough antiretroviral drug supplies to last until the end of the 90-day freeze, though it must find a way to prevent transmission.

He urged the international community to “balance accountability with flexibility, protecting decades of investment in HIV control and restoring the HIV response to its previous capacity, with an eye toward the 2030 target.”

Image Credits: Health Ministry of Nigeria.