A Wake‐Up Call: Can Africa Sustain HIV/AIDS Programs Without Foreign Aid?

ABSTRACT

Background and Aims

Africa's HIV/AIDS response has historically depended on substantial foreign aid from initiatives such as PEPFAR, the Global Fund, and USAID. These programs have dramatically expanded access to antiretroviral therapy (ART), reducing mortality and transmission rates. However, with increasing uncertainty in global funding, the continent faces a pressing question: Can Africa sustain HIV/AIDS programs independently? This study investigates the implications of foreign aid withdrawal and explores sustainable strategies for the future of HIV/AIDS care on the continent.

Methods

This study involved a critical review and synthesis of peer‐reviewed literature, global health databases (WHO, UNAIDS), and policy documents focusing on foreign aid's role in African HIV/AIDS programs. We conducted a comparative case analysis, using Botswana as a model for successful domestic financing, and evaluated potential fiscal strategies and integration into Universal Health Coverage (UHC).

Results

Evidence shows that sudden foreign aid reductions have disrupted ART access, increased viral load and transmission rates, and reversed decades of health gains. Donor‐dependent nations reported fragmented care systems and decreased resilience. Conversely, Botswana's model—marked by diversified revenue sources, strong governance, and UHC integration—demonstrated resilience to funding fluctuations. Innovative fiscal measures such as sin taxes, private‐sector partnerships, and integrated national financing frameworks emerged as viable tools for sustainability. However, challenges persist, including political instability, weak governance, and economic fragility.

Conclusion

Foreign aid remains a critical lifeline, but Africa must urgently shift toward self‐reliant HIV/AIDS programs. Strengthening domestic financing, enhancing governance, leveraging public–private partnerships, and embedding HIV care into UHC are key pillars for sustainability. African governments must act decisively to future‐proof health systems against donor volatility and ensure uninterrupted access to life‐saving treatment for millions.

Abbreviations

INFF

integrated national financing framework

SDG

sustainable development goals

UHC

universal health coverage

Foreign aid has been instrumental in the fight against human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in Africa and other low‐ and middle‐income countries, primarily through initiatives like the United States Agency for International Development (USAID), President's Emergency Plan for AIDS Relief (PEPFAR), USA, and the Global Fund [1, 2]. These initiatives have considerably reduced HIV‐related mortality through the provision and administration of live‐saving antiretroviral therapy (ART) in more than 30 million individuals resident to over 50 countries worldwide [1, 2, 3]. However, the increasing uncertainty surrounding global funding raises a pressing question: Are African nations prepared to sustain these programs independently?

A temporary or permanent suspension of foreign aid would have devastating consequences, immediately placing millions at harm's risk (See Figure 1). The syndemic burden of HIV/AIDS, compounded by crises like COVID‐19, has further strained healthcare systems, disrupting ART supply chains and increasing transmission risks [4]. Without sustained funding, access to ART would be disrupted, precipitating perturbance to therapeutic interventions, increasing viral load counts, and higher rates of disease transmission. Moreover, decades of advancements in HIV care and prevention risk being undone, potentially regressing global efforts to mitigate HIV/AIDS to crisis levels reminiscent of the 1980s and 1990s. Beyond HIV, the deterioration of donor‐dependent health infrastructure could severely disrupt maternal health services, as well as tuberculosis and malaria programs, placing significant strain on entire healthcare systems [5].

Figure 1.

The consequences of funding cuts on HIV treatment in Africa [1, 2].

Moreover, it is illustrated as “a return to the HIV/AIDS crisis” with a sound amplification of viral load and transmission by the authors in Figure 1. However, the consideration must be whether such a crisis owes itself to a temporary or a permanent suspension of foreign assistance. While it could be very possible that foreign assistance yields something to this crisis, it is necessary to explore other factors, namely, local government, healthcare infrastructure, economy, etc., that could worsen the crisis.

Evidence suggests very direct links between the suspension and reduction of foreign aid, especially in health programs, and increased hindrances to HIV/AIDS programs. Marten et al. documented how the sudden scaling down or cessation of international funding for HIV programs in countries like Kenya or Uganda directly affected antiretroviral therapy (ART) availability and continuity, thus increasing incidence rates and transmission rates with raised viral load. The study, on the other hand, pointed out the vulnerability of those healthcare systems reliant on foreign aid, especially in places such as sub‐Saharan Africa, where local resources may not be enough to cover whole healthcare needs [6].

Additionally, evidence from the World Health Organization shows that reductions in funding from international sources for HIV/AIDS have actually been linked to increases in deaths due to HIV and to further spread of the virus in some areas of the world. Nations which do not have continuous external funding assistance are found to have lagged in the reductions made in new infections of HIV and access to antiretroviral therapy (ART) as compared with the overall progress made by them in reducing morbidity and mortality in the health systems of these countries in the last two decades, as said by WHO [7].

By supporting this argument, Brahmbhatt undertook a study which proposed that foreign aid—especially from international donors like the US President's Emergency Plan for AIDS Relief (PEPFAR) or the Global Fund—should be important in support of an adequate response to HIV/AIDS, especially in low‐income countries. The research was reduced in aid and allegedly brought about an almost instant reversal of gains made in reducing HIV transmission and viral load [8].

These findings underline the critical role foreign aid plays in sustaining treatments for HIV/AIDS and controlling the epidemic. However, factors such as national health policies, economic instability, and infrastructural issues also exacerbate the overall health crisis. Therefore, while the suspension of foreign aid may indeed be a crucial factor, it cannot be viewed as the only factor that has contributed to the rise in HIV/AIDS cases. Rather, a multifaceted approach is required.

To ensure the long‐term sustainability of African HIV/AIDS programs, governments must prioritize domestic health financing by increasing budget allocations for essential services, infrastructure, and medication procurement. Innovative financing options can constitute a sustainable means of attaining revenue necessary for health programs without rendering financial requirements to existing systems. These include fiscal measures targeting alcohol, tobacco, sugar‐sweetened beverages, processed foods, plastic bags, fossil fuels, gambling, online gaming, luxury and non‐essential goods, and mobile transactions. While these products are by no means basic necessities, their wide consumption across the globe and health hazards caused make them appropriate to be taxed to raise funds for public health.

However, it is vital to keep in mind the various levels in which the governments could exercise control over these industries, particularly when they are run by private entities or foreign investors. In such cases, putting these fiscal policies into operation and enforcing them may constitute a problem. In addition, if political turbulence, economic stagnation, or other disruptions get in the way, then the expected revenue flows could be severely disrupted, thereby shedding light on the chilling of cash flow and, hence, funding for health‐oriented programs, including those for HIV/AIDS.

Hence, while innovative financing may provide a promising means toward a sustainable model for health financing, it should be considered merely in contention within a resource‐maximizing strategy that covers improvements in domestic health financing, governance, and other revenue‐generating means to ensure that HIV/AIDS programs on the continent remain somehow resilient and sustainable (See Table 1).

Table 1.

Comparison of Botswana's HIV financing approach and donor‐dependent models [3, 5].

Factor	Ideal sustainable model	Botswana's approach	Donor‐dependent countries
Government role	Strong domestic health financing with minimal reliance on external aid	Integrate Sustainable Development Goals (SDG) financing into Vision 2036 for domestic health financing	High reliance on donor funding (e.g., PEPFAR, Global Fund)
Resource mobilization	Multiple revenue sources, including taxation, social health insurance, and private‐sector contributions	Use of Integrated National Financing Framework (INFF), tax reforms, and private sector investment	Limited mobilization and established framework for domestic funding reception and utilization
Financial sustainability	A self‐sustaining HIV budget, with a healthy balance plan between donor and domestic funding	Focus on closing SDG financing gaps reduce inefficiencies that might be caused by funding cuts	Issues with donor funding threaten sustainability of HIV programs causing service disruptions
Health system integration	Integration of HIV care and services into National Universal Health Coverage (UHC)	Integrate HIV care into the national health plans allowing for fiscal decentralization	HIV programs operate separate from established national health frameworks
Innovative financing strategies	Use of unique country specific financing methods and sustainable taxation models	Implement new financing models like green and health bonds, as well as targeted taxes	Reliance on traditional donor funding methods with limited room for exploration

Enhancing governance within health systems is paramount for financial efficiency, transparency, and accountability. Implementing robust oversight mechanisms is crucial for governments to ensure the effective allocation of funds, thereby reducing the risk of corruption. Evidence shows that domiciles with bolstered clinical governance structuring experience better health outcomes and improved financial sustainability of their healthcare programs [9]. Public‐private partnerships (PPPs) may enhance the sustainability of said HIV/AIDS programs through mobilizing additional resources and expertise. Effective collaborations have been shown to improve service delivery and drive innovation. Furthermore, integrating HIV/AIDS services into Universal Health Coverage (UHC) frameworks may enhance accessibility and affordability, ensuring continued treatment availability regardless of donor funding levels. Furthermore, fostering community engagement in program design and implementation enhances adherence to treatment, broadens reach, and potentiates long‐term health outcomes, as evidenced in Rwanda [10].

In addition, strengthening health information systems to ensure real‐time data collection and analysis can support evidence‐based decision‐making, enhancing the adaptability and efficiency of HIV/AIDS programs. Expanding investments in workforce training and retention, particularly in underserved regions, is essential to build resilient healthcare systems capable of sustaining progress.

To conclude, African leaders must urgently reassess their reliance on foreign aid and enforce proactive steps toward self‐sustaining HIV/AIDS programs. Regardless of changes in external funding, it is imperative to invest in long‐term solutions today to protect advancing progress and guarantee ongoing access to life‐saving healthcare.

Author Contributions

Olivier Uwishema: conceptualization, writing – original draft, methodology, writing – review and editing, formal analysis, project administration, data curation, supervision, resources, visualization, validation. Jud Ahmad Chakik: data curation, formal analysis, methodology, writing – original draft. Boluwatife Samuel Fatokun: data curation, formal analysis, visualization, methodology, writing – original draft. Subham Roy: data curation, formal analysis, writing – review and editing, writing – original draft.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Olivier Uwishema, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Uwishema O., Chakik J. A., Fatokun B. S., and Roy S., “A Wake‐Up Call: Can Africa Sustain HIV/AIDS Programs Without Foreign Aid?,” Health Science Reports 8 (2025): 1‐4. 10.1002/hsr2.71248.

Data Availability Statement

Data sharing not applicable to this article as no data sets were generated or analyzed during the current study.