The Precarious Future of HIV and AIDS Programs in Zimbabwe Following International Funding Freeze: Impact and Strategic Interventions

Abstract

Over the past few decades, significant progress has been made in the global fight against HIV and AIDS, largely driven by international funding mechanisms such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund. These initiatives have been instrumental in expanding access to antiretroviral therapy (ART), implementing prevention programs, and strengthening healthcare infrastructure, particularly in Sub-Saharan Africa (SSA), a region disproportionately affected by HIV. Zimbabwe, in particular, has achieved remarkable success in combating the epidemic, recently meeting the UNAIDS 95–95-95 fast-track targets, a testament to sustained international support and national commitment. However, the recent suspension of foreign aid, including funding for HIV programs, threatens to undermine these gains. For Zimbabwe, a prolonged freeze could lead to a resurgence of new infections, an increase in AIDS-related mortality, and further strain on Zimbabwe’s already fragile healthcare system. This commentary examines the potential consequences of the aid suspension on Zimbabwe’s HIV and AIDS response and explores strategies to mitigate its impact.

Introduction

The global fight against HIV and AIDS has achieved significant milestones over the past few decades. Yet, these advancements remain precarious, especially for vulnerable groups such as sex workers, people who inject drugs, men who have sex with men (MSM), transgender individuals, incarcerated populations, and those in other closed settings [19]. Additionally, women, young people, migrants, refugees, and internally displaced persons face heightened risks due to social and structural barriers [19, 38]. The Trump administration's decision to reduce funding for HIV programs threatens to reverse these gains, potentially creating a chaotic situation in the health sector, particularly among vulnerable populations who depend on such programs for treatment, prevention, and education [15, 48]. The fight against HIV and AIDS has been a global health priority for over four decades, with international funding playing a crucial role in reducing infections, expanding treatment, and strengthening health systems [4]. The United States (US), through initiatives like PEPFAR, has been a leading donor in global HIV and AIDS relief, Malaria, and Tuberculosis respectively supporting millions worldwide.

However, recent policy shifts under the Trump administration, including a 90-day pause on U.S. foreign aid, have raised alarm. In an executive order issued on January 20, 2025, Trump stated that the U.S. foreign aid system and its bureaucracy were not aligned with American interests and, in many cases, conflicted with American values [36]. As a result, the emergency suspension was deemed necessary for reassessment [36]. However, the suspension of funds led to job losses, halted medical services, and disrupted essential HIV treatment programs [21]. It is unclear, whether the US-funded projects can be reinstated. A recent study has underscored the severe impact of discontinued PEPFAR funding, estimating that between 2025 and 2030, around 1,809,890 new HIV infections and 720,230 HIV-related deaths could occur across 26 modeled low and middle-income countries (LMICs), Zimbabwe included [7]. Furthermore, in SSA, HIV funding freeze could result in over 100,000 additional HIV-related deaths within a year [35]. There are already reports from Zimbabwe that some patients have resorted to rationing their medication, taking half-doses, or skipping days to make their limited supply last longer. Therefore this disruption in HIV prevention and treatment services means that UNAIDS-prescribed prevention targets for 2030 are likely to be missed [11, 34].

The suspension of international aid has not only put lives at risk but has also jeopardized the stability of the country’s health infrastructure, raising fears that Zimbabwe could face a resurgence of HIV and AIDS reminiscent of the early 2000 when the epidemic was at its peak and the prevalence was estimated to be 33.7% [40]. Sweeping notices of termination have been sent to organizations working with HIV and AIDS across Africa including Zimbabwe, Malawi, Zambia, and Tanzania [20]. Furthermore, a recent update from USAID to Congress indicates that funding cuts have already begun to impact critical HIV programs. In Zimbabwe, for example, the USAID implementing partner, Zimbabwe Health Interventions (ZHI), had its $53,195,423.00 grant originally intended to reduce new infections among adolescent girls and young women and scheduled to run until September 2026 terminated abruptly [46]. Therefore, with NGOs and government programs heavily dependent on U.S. funding, the halt in financial support has already forced clinics to shut down, medical staff to go unpaid, and patients to miss their treatments [18]. Without proper intervention, an increase in new HIV infections among vulnerable such as adolescents and young people is inevitable [12, 39].

Zimbabwe has one of the highest HIV prevalence rates globally, with an estimated 1.3 million [1.2–1.4 million] individuals living with HIV as of 2023 [2]. Despite this, the country has made significant progress in controlling the epidemic, largely due to foreign aid. In particular, PEPFAR has played a crucial role in providing antiretroviral therapy (ART) to over one million Zimbabweans, enabling them to live healthier lives and reducing the risk of transmission [21–23]. Moreover, 97% of individuals receiving treatment have achieved viral suppression, significantly reducing the likelihood of transmitting the virus if they maintain adherence to their medication and maintain undetectable viral loads [37, 49].

While foreign aid has played a significant role in Zimbabwe’s HIV response [16], it is equally important to recognize the country’s domestic efforts too, which reflect strong governmental commitment and innovation in both prevention and treatment. For example, the introduction of the AIDS Levy, which generated over US$35 million annually by 2016, may have helped attract additional donor support [5]. In addition, Zimbabwe has been implemented key population-focused programs that incorporate new prevention technologies and enhance treatment strategies within the public sector, despite operating within a challenging legal environment [27].

Long-Term Consequences: A Return to Crisis?

Disruptions in HIV Treatment Access

The recent disruption in international HIV funding poses a critical threat to Zimbabwe’s progress in HIV prevention and treatment. For example, since 2003, the Global Fund has invested $1.8 billion into Zimbabwe’s HIV response and has approved an additional $437 million for the 2024–2026 period. Similarly, USAID allocated $15.3 million in FY2023/24 for antiretroviral (ARV) procurement and $7.2 million for laboratory services. However, the recent suspension of international funding has raised significant concerns about continued access to treatment, as it signals the withdrawal of critical international support that has been instrumental to Zimbabwe’s healthcare system. UNAIDS has called the termination of this partnership a “serious development,” warning that it is likely to undermine access to lifesaving services [30]. Linda-Gail Bekker, Chief Operating Officer of the Desmond Tutu HIV Foundation in South Africa, who collaborates with various organizations in Zimbabwe, warned that the withdrawal of funding could lead to loss of lives, placing the most vulnerable populations at heightened risk of reinfection and death [30].

The disruption of essential HIV prevention, testing, treatment services, contact tracing, and tracking poses a significant challenge to Zimbabwe’s efforts to achieve the UNAIDS goal of ending HIV by 2030. The recent suspension of international funding further threatens the country’s progress, making sustained improvements unlikely. This is particularly concerning as Zimbabwe was the first African nation to introduce Cabotegravir LA (CAB-LA) PrEP, a groundbreaking advancement in reducing new HIV infections [8, 17]. However, without alternative funding sources, these advancements will come to a halt once current supplies are depleted, placing additional strain on an already struggling healthcare system.

Health Worker Crisis and Impact on MTCT

Zimbabwe’s public health system, already struggling with economic instability and a shortage of medical supplies, is now on the brink of collapse. The loss of foreign aid could lead to increased maternal mortality rates, a rise in opportunistic infections, and further strain on already overwhelmed hospitals. The funding halt has also led to widespread job losses in the health sector. Many NGOs depend on U.S. aid to pay their staff and have been forced to lay off healthcare workers or stop operations entirely [3]. Nurses, doctors, and community health workers who provide HIV care are left without salaries, leading to an exodus of trained professionals from the sector. The loss of healthcare workers is particularly devastating in rural areas, where PEPFAR-funded clinics often serve as the primary healthcare providers. The closure of these clinics not only affects HIV patients but also disrupts maternal health services, tuberculosis treatment, and general medical care for vulnerable populations [3]. Notably, PEPFAR supports 16,708 healthcare workers in Zimbabwe, allocating $59.6 million for human resource support and $30.7 million for non-service delivery. The loss of this critical human infrastructure poses an urgent threat to the continuity of essential health services across the country.

Foreign aid has had a significant impact on mother-to-child transmission (MTCT) of HIV. For instance, a $60 million project launched over a decade ago aimed to reduce the MTCT rate from 14% to below 5% by 2015 [29]. By 2018, approximately 94% of HIV-positive pregnant women were receiving antiretroviral therapy (ART) to prevent MTCT, supported by over $400 million in annual funding. In contrast, only 24% had access to ART in 2008 due to financial constraints [24]. Without ART, pregnant women face an increased risk of AIDS-related complications such as pneumonia, tuberculosis, and meningitis. Additionally, HIV-infected pregnant women with weakened immune systems are more vulnerable to mortality from pregnancy-related conditions, including sepsis, hemorrhage, and other direct causes [1, 24, 25]. However, with the current funding cuts, these gains are at risk, potentially leading to an increase in infant HIV infections and associated mortalities. The broader healthcare infrastructure is also under strain. Zimbabwe has faced challenges such as healthcare worker strikes due to inadequate remuneration and poor working conditions, further exacerbated by a lack of personal protective equipment. The sudden withdrawal of U.S. support compounds these issues, jeopardizing the sustainability of essential health services and the well-being of vulnerable populations.

Disruptions in HIV Prevention

The closure of healthcare facilities due to the funding freeze has left thousands of Zimbabweans without access to essential medical services [13]. Zimbabwe’s lack of funding could cause a significant decrease in community-led HIV prevention efforts, and a reduction in treatment adherence, counseling, and social support and monitoring activities [42]. The sudden halt in foreign aid has disrupted the supply chain of vital preventive tools, such as condoms, which are essential in reducing HIV transmission [9]. Consequently, the shortfalls will increase the risks of new HIV infections, lack of HIV knowledge, and a deterioration in the quality of care for people living with HIV [42].This shortage not only limits individual protection but also weakens broader public health initiatives aimed at controlling the spread of HIV [43].

Furthermore, the reduction in funding has led to the downsizing or complete discontinuation of HIV education programs globally [45]. These programs play a vital role in raising awareness, promoting safe practices, and combating stigma. In Zimbabwe, many community-based organizations have scaled back outreach activities due to financial constraints, leaving vulnerable populations without critical resources [44]. While PEPFAR contributes approximately $3.1 million annually to condom procurement in Zimbabwe, the bulk of condom supplies comes from other partners. Notably, the Global Fund planned to procure 107,646,048 male condoms as part of its 2023–2025 Grant Cycle 7 funding request for Zimbabwe, underscoring its central role in prevention supply [33]. Despite this, overall prevention programming including condom distribution, HIV testing, and PrEP has been disrupted in several regions, threatening the progress made over past decades [13, 28, 31]. These setbacks place marginalized groups such as adolescents, sex workers, and rural populations at increased risk of new infections.

Solutions and the Path Forward

While the situation is dire, there are potential solutions that could help mitigate the crisis:

Emergency International Funding

The reduction in international funding has led to the downsizing or complete discontinuation of HIV education programs across the globe [45]. These programs are crucial for raising awareness, promoting safe practices, and combating HIV and AIDS-related stigma. Due to financial constraints, many community-based organizations have been forced to scale back their outreach activities, leaving vulnerable populations without access to critical information and resources [44]. This gap in education significantly increases the risk of new infections and threatens to reverse decades of progress in HIV prevention [31].

In Zimbabwe, essential HIV prevention programs including condom distribution, HIV testing services, and pre-exposure prophylaxis (PrEP) have been suspended in several regions due to funding shortfalls [42, 43]. These programs play a vital role in reducing new infections, particularly among youth, sex workers, and marginalized populations [28]. According to a recent UNAIDS update, engagements with international partners such as China, Egypt, and the Gates Foundation are ongoing in an effort to secure additional support for health programs in Zimbabwe [42]. While the Global Fund can reallocate some of its Seventh Replenishment Grant Cycle (GC7) resources to address urgent gaps left by USAID’s retreat, the Fund itself is facing serious challenges. Pledge conversions for the GC7 particularly from the United States remain below expectations, and the ongoing replenishment for the GC8 is unlikely to meet the global need. These developments suggest a ripple effect that could further destabilize global health initiatives stemming from the U.S.’s reduced commitment to international health funding.

Government Action

In response to the potential funding cuts from international donors, the Zimbabwean government must take immediate action to prioritize domestic funding for HIV and AIDS programs. This includes reallocating resources within the national budget to ensure the sustainability of HIV prevention, treatment, and care services. One potential avenue for increasing domestic funding is through the implementation of targeted taxes on industries or goods related to public health [6]. This could include taxes on alcohol, tobacco, or luxury items, with the revenue generated directed toward HIV and AIDS programs [6]. Strengthening domestic funding is essential to reduce dependence on external donors and to ensure that the government takes ownership of its national HIV response. This proactive approach can help mitigate the impact of external funding fluctuations and ensure continued support for those affected by HIV.

​While the Zimbabwean government should explore avenues to increase domestic resources for HIV and AIDS programs, such as implementing targeted taxes and fostering private sector partnerships, it is crucial to acknowledge the country's limited capacity to fully offset the funding shortfall resulting from the withdrawal of international donors like USAID. The National AIDS Trust Fund, established through a 3% levy on income and corporate profits, has been instrumental in mobilizing domestic resources, generating approximately US$30 million in 2023 [41]. However, this amount represents only a fraction of the funding required to sustain comprehensive HIV and AIDS interventions nationwide. Given these financial constraints, it is imperative for remaining international donors, including the Global Fund, the European Union, and bilateral partners, to significantly increase their support for countries like Zimbabwe that lack the fiscal capacity to bridge the funding gap. Such enhanced prioritization is essential to prevent the erosion of the substantial progress made in combating HIV and AIDS and to ensure the continued provision of life-saving services to the population.

Diplomatic Pressure on the U.S.

In light of the potential U.S. funding freeze, international organizations, activists, and governments should exert diplomatic pressure to urge the U.S. to reverse the freeze and reinstate financial support for global HIV programs. By continuously raising awareness of the vital role U.S. funding plays in tackling global health challenges, these stakeholders can underscore the humanitarian consequences of such budget cuts. A small group of external funders, including the United Kingdom, United States, European Union institutions, and the Bill & Melinda Gates Foundation, disproportionately control global health financing [10, 32, 47]. Highlighting the freeze’s impact on vulnerable populations, such as individuals living with HIV in Zimbabwe, can strengthen advocacy efforts to persuade U.S. policymakers to reconsider their stance. Coordinated efforts to emphasize the long-term public health and socio-economic repercussions of reduced HIV funding will be essential in urging the U.S. to address this critical issue.

Strengthening Local Health Systems

To ensure the sustainability and resilience of its healthcare system, Zimbabwe must invest in long-term strategies aimed at reducing its reliance on foreign aid, particularly in the context of HIV and AIDS programs. One of the most critical areas for investment is healthcare infrastructure, which includes improving facilities, equipping hospitals with modern medical technology, and enhancing the availability of essential medications. Strengthening the physical infrastructure of health systems will enable Zimbabwe to better respond to healthcare challenges, including HIV prevention and treatment, and to ensure that health services are accessible to all communities, including remote and rural areas [26]. This investment in infrastructure will also help improve the overall quality of care, which is essential for the long-term success of HIV programs.

Beyond improving physical infrastructure, Zimbabwe must also focus on strengthening the training and capacity of its healthcare workforce. Expanding training opportunities for doctors, nurses, and community health workers will help build a skilled cadre of professionals capable of delivering high-quality care and services to the population [14]. Local health workers, in particular, are crucial for community outreach, health education, and prevention initiatives which are key components in the fight against HIV. Enhancing both the health system's infrastructure and its human resources will not only reduce dependence on international aid but also position Zimbabwe to sustainably meet its healthcare needs, even amid shifts in external funding.

Conclusion

The suspension of funding has placed Zimbabwe’s HIV and AIDS programs in a precarious position, jeopardizing access to essential treatment and prevention services for millions. Despite numerous appeals, it remains uncertain whether financial support will be reinstated, raising concerns about a potential resurgence of the epidemic. This crisis highlights the fragility of reliance on external funding and underscores the need for sustainable, long-term investment in global health. While international advocacy for stable funding remains crucial, Zimbabwe must also prioritize domestic resource mobilization through taxes and other revenue streams to reduce dependence on foreign aid. Additionally, while the aid freeze is unconscionable, it could provide an opportunity for program evaluation and reform. By presenting effective reforms and demonstrating a commitment to improving program efficiency and outcomes, Zimbabwe may increase its chances of securing the return of vital international support.

Author Contributions

Writing and editing of this commentary was solely done by Christopher Jimu.

Funding

Not applicable.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Ethics Approval

Not applicable.

Consent for Publication

Not applicable.

Competing interests

The authors declare no competing interests.