As countries dependent on United States aid for their HIV response report looming shortages of antiretroviral medicine, the Joint UN Programme on HIV/AIDS (UNAIDS) is also fighting for survival.

Meanwhile, more shocks may be ahead for the HIV sector as the US Health and Human Services plans to curtail research collaboration between US scientists and foreign researchers, a common occurrence in the HIV sector.

UNAIDS is cutting full-time staff by more than half – from 608 to 280 – and almost halving country offices, from 75 to 36, according to a communique sent to staff, as reported by Devex.

This follows the Trump administration’s decision to end US Agency for International Development (USAID) funds to UNAIDS, which affects around 40% of its budget.

Further cuts may be necessary if a proposal from an internal UN task force is heeded, which would see UNAIDS merging with the World Health Organization, as previously reported by Health Policy Watch.

But Farhan Aziz Haq, deputy spokesperson for the UN Secretary General’s Office, said that the UN restructuring proposals are “the preliminary result of an exercise to generate ideas and thoughts from senior officials”. The UN80 task force will report its final recommendations to the UN General Assembly in 2026.

Medicines, supply chains disrupted

While UNAIDS faces an internal crisis, so too do the countries and communities worst affected by HIV that it serves.

By the end of 2023, 30.7 million people were accessing antiretroviral (ARV) treatment and 61% lived in just 10 countries – South Africa, Mozambique, India, Nigeria, Tanzania, Kenya, Zambia, Uganda, Zimbabwe and Malawi.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) was one of the biggest purchasers of ARVs and the breakthrough injectable ARV, cabotegravir, that prevents HIV infection that was being rolled out as pre-exposure prophylaxis (PrEP).

PEPFAR spent almost $500 million a year on ARVs and PrEP, and any reduction in its orders is likely to push global prices up, yet another obstacle in the fight against HIV.

“Sustained predictability in HIV commodity demand forecasts is essential to guarantee a stable supply, maintain prices, and ensure the availability of affordable generic medicines for national HIV responses,” according to a UNAIDS report issued on 30 April.

PEPFAR also funded ARV supply chains and logistics in many countries, and almost half (46%) of the 56 countries most affected by HIV have reported supply chain disruptions in the past month or so, according to UNAIDS.

By the end of April, seven countries out of the 56 most HIV-affected reported that they had six or less months of stock in at least one antiretroviral line. These are Burundi, Côte d’Ivoire, Ghana, Haiti, Uganda, Ukraine and Zimbabwe.

The Democratic Republic of Congo (DRC), one of the biggest PEPFAR beneficiaries, expects both ARV and condom stockouts in the next three to six months.

It’s antenatal testing of pregnant women, delivery care for women living with HIV, early infant diagnosis and paediatric treatment services are all affected, UNAIDS reported last week.

However, 22 countries said that they were not reliant on PEPFAR funding for ARV procurements but that the loss of funds had disrupted their medicine supply chains.

Focus on ‘key populations’ is lost

The HIV sector’s focus on the “key populations” most vulnerable to HIV is likely to be lost – possibly forever – due to a lack of funds. 

Key populations comprise groups that face heavy stigma – sex workers, gay men and other men who have sex with men, transgender people, people who inject drugs and prisoners. 

HIV is stubbornly high in these groups, who are generally difficult to reach and often face legal barriers to access treatment. 

However, the scientific consensus in the sector is that HIV can only be stopped if it is addressed in these groups – and until Donald Trump became US president, PEPFAR was prepared to fund this approach.

In South Africa, for example, only 17% of the country’s HIV response was covered by PEPFAR, but the vast majority of those funds went to providing services for key populations.

But all PEPFAR-supported services for key populations have been stopped, as these groups are pariahs for Trump Republicans.

So too has a plan to integrate mental health and HIV services, according to Dr Gloria Maimela from the Foundation for Professional Research.

However, South Africa also prioritises young women who are amongst the most vulnerable to HIV, and outreach to them has also been curtailed.

The situation is similar in Ethiopia, where centres for key populations and young people have closed as staff have not been paid.

Centres offering services to key populations and young people in Bahir Dar to Mikadra, Humera, and Dansha have stopped.

“For two months, no new clients have been enrolled in PrEP, the prevention prophylaxis taken orally that protects from HIV infection. HIV testing has dropped by 43%. More than 800 people have faced treatment interruption. And 215 survivors of gender-based violence have lost access to the support services they once relied on,” according to a UNAIDS report issued last week.

Numerous countries report longer-term closures of certain ARV dispensing points, particularly at community level and those serving key populations, according to UNAIDS

Global PrEP rollout affected

PEPFAR funding covered more than 90% of PrEP initiations globally in 2024, and numerous countries report that they have been unable to sustain high-risk patients on PrEP, including in Guatemala, El Salvador, Haiti, Ukraine, Viet Nam and Zambia.

Last year, PEPFAR purchased 95% of ViiV’s cabotegravir stock for PrEP, but it has not delivered much of this to low and middle-income countries as promised, including to South Africa which was promised 230,000 doses.

“Restrictions in eligibility to access US government-funded HIV prevention commodities effectively leaves out numerous populations at high risk of acquisition,” UNAIDS notes.

HIV-linked commodities such as condoms and opiod replacement medication have also been disrupted thanks to the dominant role of PEPFAR in their  procurement, distribution and delivery.

Close to a quarter (23%) of countries reported six or less months of condom or PrEP stocks.

A recent survey by International Network of People who Use Drugs (INPUD) reports a large-scale suspension of outreach and harm reduction programmes, including needle and syringe distribution, HIV and hepatitis C testing, overdose prevention and legal support services.

Centres distributing opioid agonist maintenance therapy (OAMT) closed for a month in Uganda and Tanzania, for example.

OAMT is often prescribed as oral medication to alleviate the symptoms of withdrawal and reduce injecting drug use. In 2022, the risk of acquiring HIV was 14 times higher for people who inject drugs than the overall adult population.

“Fearing a stock out of methadone–the OAMT medicine–we have witnessed people returning to heroin use and hitting the black market,” Banza Omary Banza, director of Community Peers for Health and Environment Organisation in Tanzania, told UNAIDS.

Millions of lives at risk

While the Global Fund is helping to address some gaps, it is unable to fill the gap left by PEPFAR. 

UNAIDS modelling predicts that the permanent discontinuation of PEPFAR-supported HIV programmes would lead to an additional 6.6 million new HIV Infections (about 2300 per day) and an additional 4.2 million AIDS-related deaths (over 600 per day) by 2029.

Image Credits: The Global Fund/ Saiba Sehmi, Global Fund, UNAIDS.