Freeze in International Funding Could Significantly Reverse Progress in HIV Treatment

Progress in the global HIV response could be significantly reversed by 2030 with the introduction of funding reductions by the US, leaving many countries vulnerable, according to a study published in Lancet HIV.1 Countries located in sub-Saharan Africa are thought to be the most vulnerable to adverse consequences of budget cuts.

International funding has been at the forefront of tackling the HIV crisis around the world. Donors have made up 40% of all HIV funding in low- and middle-income countries (LMICs) since 2015, making them a vital resource for these countries. The US accounted for up to 72.6% of total international HIV funding as of 2023, with the remaining 4 countries—United Kingdom, France, Germany, and the Netherlands—also providing donations; all these countries have announced funding cuts, equaling a 4.4% cut in 2025 and a further 19.6% cut in 2026.2 This study aimed to assess how these cuts would affect LMICs over the next 5 years when it comes to addressing the HIV crisis.

The Optima HIV model, calibrated for 26 countries, was used in this analysis. The model was established between January 1, 2022, and December 31, 2024, for all 26 countries. Each model includes prevention and testing spending for HIV. The Global AIDS Monitoring database was used to collect additional data on finances for each country. Both domestic and international funding sources were calculated for total spending.

Discontinuing international HIV funding could have major implications in both infections and deaths around the world. | Image credit: Stillfx - stock.adobe.com

The model was split into 5 scenarios to calculate potential effects of cuts. The first scenario was a maintaining of the status quo, the second scenario calculated for proportional cuts, the third scenario allocated prevention budget to treatment, the fourth scenario discontinued support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) with mitigation, and the fifth scenario was discontinuation of PEPFAR without mitigation. The second and third scenarios were based on reductions of international aid announced in February of 2025. The number of new infections of HIV and deaths related to HIV were calculated in the model for each scenario.

The international funding provided between 2019 and 2023 ranged from 0% to 96% depending on the country. Total national HIV funding ranged from 0.2% to 66% in regard to use of PEPFAR, with the 12 countries who used the funding including Colombia, Mozambique, South Africa, Uganda, Zimbabwe, and Kenya.

For 6 of the 8 countries from sub-Saharan Africa that are supported by PEPFAR, the funding accounts for more than 40% of their total funding, with Malawi, Mozambique, Uganda, and Zimbabwe relying on PEPFAR for 60% of their total funding. Should the fourth and fifth scenarios come to fruition, this would equate to 45% of all HIV spending in 26 countries being subject to budget cuts.

Prevention spending ranged from 2% to 66% of overall HIV spending. Countries with smaller epidemics had higher rates of prevention spending. A mean of 78% of spending on prevention was subject to cuts in the third scenario, with the possibility of testing and prevention interventions entirely defunded if the cuts were taken primarily from those areas.

An estimated total of 1,809,890 new infections and 720,230 deaths related to HIV would occur from 2025 to 2030 in the 26 countries if the status quo of budgeting is maintained. This would increase in the second and third scenarios, with an estimated addition of 40,000 to 850,000 new HIV infections and 3000 to 30,000 million deaths added to the status quo estimate. An additional 2.30 to 5.13 million new HIV infections and 410,000 to 1.38 million deaths would occur compared with the status quo if PEPFAR support were also discontinued between 2025 and 2030.

An additional 4.43 to 10.75 million new infections and 770,000 to 2.93 million deaths would occur compared with the status quo across all LMICs if there are international aid reductions and PEPFAR support is discontinued. Sub-Saharan African countries would have the highest effects due to the broader interventions that take place. The fifth scenario could also lead to 586,900 new HIV infections in children compared with the status quo of 182,700 transmissions.

The number of infections in the 26 modeled countries could return to 2010 levels should the fifth scenario come to fruition, whereas the 2030 Joint United Nations Programme on HIV/AIDS targets could be reached in these countries by 2036 in the status quo scenario. The deaths related to HIV could also return to the levels of 2010 by 2031 if the fifth scenario comes to fruition.

"This research estimates that, in a worst-case scenario, new HIV infections in low- and middle-income countries could reach 3.4 million by 2030—matching the peak of the epidemic in 1995, when 3.3 million new infections were recorded. HIV knows no borders, and without decisive action, this will be a global crisis," said Debra ten Brink, MD, co-author of the study.

There were some limitations to this study. It is unknown whether PEPFAR will be reinstated, if reductions in funding will escalate, and what mitigation efforts will be introduced in these countries, which could affect the overall result. The Optima HIV budget and the Global AIDS Monitoring database could be mismatched. Further, more recent data could have been included in the Optima HIV model that was not included, any uncertainty in the parameters of the model were not presented, and only 26 countries were included. Also, the status quo scenario did not account for any efficiencies in cost or technical efficiencies because of the use of a fixed spending scenario.

The researchers concluded that the anticipated budget cuts to international aid for HIV could result in a reversal of progression countries around the world, specifically sub-Saharan African countries. Preventing a resurgence in the HIV epidemic should be the top priority of governments and donors to come up with strategies that can mitigate immediate budget cuts in these countries.

References

1. ten Brink D, Martin-Hughes R, Bowring AL, et al. Impact of an international HIV funding crisis on HIV infections and mortality in low-income and middle-income countries: a modelling study. Lancet HIV. Published online March 26, 2025. doi:10.1016/S2352-3018(25)00074-8
2. Chiappa C. Nearly 3M HIV deaths due to foreign aid cuts, study forecasts. Politico. March 27, 2025. Accessed April 1, 2025. https://www.politico.eu/article/nearly-3m-hiv-deaths-due-to-foreign-aid-cuts-study-forecasts