The Impact of US Government Stop-Work Order and Limited Waiver on HIV Program in LASUTH, Nigeria: A Retrospective Review

Abstract

Background:

Human Immunodeficiency Virus (HIV) management programme is largely donor-driven in Low- and Medium-Income Countries (LMIC), including Nigeria. The programme was temporarily disrupted following a stop work order (SWO) issued by the United States Government in January, 2025. The study retrospectively reviewed the impact of the SWO on HIV management at LASUTH, Nigeria.

Methods:

This is a retrospective study reviewing the impact of the SWO on the management of HIV programmes at LASUTH. The data of all the five thousand five hundred and thirty-eight (5538) HIV patients who registered before January, 2025 were reviewed to determine the impact of the SWO on the programme. HIV testing services (HTS), missed appointments, retention rate and viral load coverage were assessed. The data obtained were presented in a graphical format.

Results:

There was a 30% drop in the HTS, a rise in the missed appointment from six (6) to ninety-one (91), a drop in the retention rate from 97.8% to 96.6% and viral load coverage from 99.1% to 95.1%.

Conclusion:

The HIV testing services, missed appointment, retention rate, and viral load coverage were negatively impacted during the stop work order. Countries in LMIC should de-emphasize dependency on donor funding of HIV programmes.

Background:

Retention in HIV care is critical for achieving viral suppression, preventing transmission, and ensuring long-term health outcomes for people living with HIV (PLHIV). Consistent clinic attendance and uninterrupted access to antiretroviral therapy (ART) are central to this goal. However, policy shifts and funding disruptions can severely undermine treatment continuity [1]

In January 2025, the U.S. government issued stop-work orders (SWO) and froze funding for global HIV programs, including those supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) [1]. These measures led to clinic closures, stockouts, workforce layoffs, and discontinuation of community-based differentiated service delivery models [2,3]. Early reports from countries such as Uganda, Tanzania, Mozambique, Kenya and South Africa highlighted reductions in ART initiation, viral load monitoring, and retention in care, as well as increases in missed appointments and loss to follow-up [4-6].

The United States is the largest global health funder, and any shift in its priorities has ripple effects across the world—disrupting fund flow and threatening progress on critical health challenges [7]. Given the reliance of many low and middle-income countries on donor-supported programs, this disruption underscores the vulnerability of HIV care systems to political and financial shocks [7]. Even though a limited humanitarian waiver was introduced to sustain treatment for pregnant and lactating women, sero-discordant couples, and general PLHIV cohorts experienced severe interruptions in care [3,5,6].

The 2025 stop-work order disrupted HIV service delivery at multiple levels. Patients experienced ART interruptions, reduced access to differentiated service delivery, a decline in multi-month ARV dispensing and stigma-related barriers that led to reduced retention in care. Preliminary evidence suggests declines in retention rates and increases in missed appointments, but there is limited systematic evaluation of these outcomes.

The Stop Work Order

The SWO was announced on the 24^th January, 2025, prior to the stop work order, there were full ranges of prevention services: such as pre-exposure prophylaxis (PrEP) for all population, promotion and distribution of condoms, HIV care and treatment, cervical cancer screening and treatment, surveillance activities, prevention of mother to child transmission (PMTCT) activities, gender based violence activities, non-communicable disease integration (NCDs) services, full Scale community-based socio-economic activities for orphan and vulnerable children (OVC) and their households.

Allowable services under the Limited Waiver granted

By February 10^th 2025, a limited waiver was granted, and services allowed include: HIV testing services for all populations and HIV care and treatment services for all PLHIV, advanced HIV disease screening, laboratory support, supply chain management, life-threatening opportunistic infections management - including TB activities and HIV pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women.

Non-Allowable Services under the waiver

The following services were barred from the programme: HIV pre-exposure prophylaxis (PrEP) for the general population, cervical cancer screening, community services for OVC not directly impacting on clients' treatment, e.g. household socioeconomic empowerment, population-based surveillance activities, e.g. Recency, mortality, gender-based violence activities and non-communicable disease integration (NCDs) Services.

The disruption directly impacted retention rates, as patients were unable to continue regular convenient engagement with health facilities. Without robust analysis, health systems risk underestimating the long-term consequences of such disruptions. This retrospective study provided evidence on how the 2025 stop-work order affected patients’ retention and appointment adherence, offering insights into strengthening health system resilience.

This study aimed to retrospectively assess the impact of the 2025 U.S. stop-work order on retention rates and appointment adherence among PLHIV in Lagos State University Teaching Hospital, LASUTH, Ikeja, a HIV prevention and treatment donor-dependent health system.

Materials and Methods

Study Design:

A retrospective study.

Study Setting:

This study was conducted at the Haematology Department of the Lagos State University Teaching Hospital (LASUTH), Ikeja, a leading healthcare facility established in 1955. Located in the South West part of Nigeria, it acts as a key referral centre for hospitals within Lagos State and nearby states. LASUTH provides comprehensive HIV/AIDS care to 5,538 people living with HIV/AIDs as of January 2025 through support from the Centre for Integrated Health Program (CIHP) Nigeria, a PEPFAR-funded implementing partner providing free testing services, antiretrovirals and opportunistic infectious disease medications for prevention and treatment purposes.

The antiretroviral therapy (ART) clinic operates every weekday, offering a variety of tailored treatments, including counselling, screening, consultation, pharmaceutical services, laboratory investigations, and medical and surgical interventions. It serves a diverse patients’ population, ensuring accessible and inclusive care for individuals from various ethnic and socioeconomic backgrounds.

The ART clinic is coordinated by the department of haematology and blood transfusion, operated by two (2) physicians, five (5) pharmacists, seven (7) nurses, four (4) medical lab scientists, six (6) record staff, four (4) monitoring and evaluation personnel, eight (8) case managers and three (3) support staff. The daily patient turnout at the clinic is approximately 150.

Study Population:

PLHIV enrolled in ART programs in Lagos State University Teaching Hospital (LASUTH), Ikeja, before January 2025.

Data Sources:

• Facility-level ART registers

• Electronic medical records (EMRs)

• Appointment logs

• Pharmacy refill records

• Programmatic reports from implementing partners

Inclusion Criteria:

• Patients with at least one clinic visit before January 2025.

Exclusion Criteria:

• Patients transferred out before January 2025.

• Records with incomplete data.

Data Collection:

• Retention is measured as being alive and on ART 12 months after initiation or the proportion retained in care by quarterly cohorts.

• Missed appointments are defined as failure to attend a clinic ≥30 days after a scheduled visit.

• Variables: age, sex, ART regimen, baseline viral load.

Data Analysis:

• Descriptive statistics to compare baseline characteristics.

• Interrupted time series (ITS) analysis to assess temporal changes before and after January 2025.

Ethical Considerations

Ethics committee approval was obtained before the commencement of the study from the Health Research and Ethics Committee of Lagos State University Teaching Hospital, Ikeja. Patient identifiers were de-identified before analysis. Data was stored securely with access limited to research staff.

Results:

A total of five thousand five hundred and thirty-eight clients were on treatment as of January 2025. The median viral load was 19 copies/ml, the median ages for males and females were 53.5 and 53 years, respectively, and the overall median age was 53.5 years.

The reduction in HIV testing was noted during the SWO by a drop of 30%. Figure 1

Figure 1:

Reduction in HIV testing during the SWO

There was a rise in the missed appointments between January to February 2025 from six (6) to ninety-one (91). Figure 2

Figure 2:

Missed appointments curve

There was a drop in the retention rate from 97.8% to 96.6%, as shown in Figure 3

Key: QoQ---Quarter on quarter

FY—Financial year

Similarly, the viral load coverage dropped from 99.1% to 95.1% between quarters 3 and 4 of 2025

Key: QoQ---Quarter on quarter

FY—Financial year

Discussions

The U.S. government has historically played a central role in global HIV programs, particularly through PEPFAR, launched in 2003 under President George W. Bush. PEPFAR has been credited with saving millions of lives and currently supports antiretroviral therapy (ART) for more than 20 million people worldwide. In January 2025, abrupt policy shifts within the United States government led to significant disruptions in the global HIV response. A series of federal directives, grant cancellations, and stop-work orders affecting the Centers for Disease Control and Prevention (CDC) and associated foreign assistance programs destabilized both U.S. and global HIV program initiatives. These measures not only halted service delivery but also disrupted collaboration with key global partners, such as the World Health Organization (WHO) [2].

The immediate impacts of the stop work order are the reduced stock level of the rapid testing kits (RTKs) and the delayed transportation of viral load samples to the polymerase chain reaction (PCR) laboratories by the courier company responsible. Temporary disengagement of the short-term hire, project staff, and clinical mentors, which impacted negatively impacted services such as testing, refills, and documentation across all thematic areas. There was a barrier in communication which led to suboptimal counselling and follow-up for the newly diagnosed, newly initiated and virally unsuppressed clients. There was panic due to delayed last-mile distribution (LMD) supply, which led to limited stock of ARV and consequent reduction in the supplied ARV. Lastly, there was a halt to supportive supervision and community activities.

This report showed a 30% drop in HIV testing during the stop work order; this could be accounted for by the temporary displacement of short-term hire, project staff and clinical mentor. Workforce disruptions were a critical factor during the SWO; thousands of lay counsellors and ad hoc clinic staff supported by U.S. funding were laid off, leaving patients without adherence counselling or appointment reminders [9].

Community health workers, many of whom lost their jobs during the funding freeze, reported being inundated with calls for help as patients scrambled for alternatives [3]. Given the scale of U.S. investments in the HIV response—particularly through the President’s Emergency Plan for AIDS Relief (PEPFAR)— the resulting funding freeze created widespread concern about continuity of care, equity in prevention, and the long-term trajectory of the epidemic [2, 8].

There was a rise in the missed appointments during the disruption and a steep rise following the resumption of the limited waiver granted. Emerging studies from Mozambique and South Africa show that between February and May 2025, ART initiation dropped by approximately 14% compared to the previous year, while viral load testing declined significantly [4].

Missed appointments rose, and over 15,000 fewer people initiated ART during the first quarter of 2025 [4]. Evidence also points to behavioral adaptations among PLHIV, including medication rationing and dose-skipping due to anticipated shortages [3]. These behaviours, while pragmatic in the short term, increase risks of viral rebound and drug resistance, undermining long-term HIV control [3,4]. Furthermore, the erosion of trust in healthcare systems has been documented as patients questioned donor reliability and the sustainability of treatment programmes [6]. This disengagement further exacerbated missed appointments and loss to follow-up.

The retention rate also dropped from 97.8% to 96.6% because of a sudden drop in multi-month dispensing (MMD)-6 to MMD-1. While some were given medication lasting for only two weeks to conserve the medication stock for a wider reach because there was no communication regarding continuous medication supply. Furthermore, viral load coverage dropped from 99.1% to 95.1% between quarter 3 and 4 of 2025 due to the temporary disengagements of staff, which led to the disruption in the viral load sample transportation.

These indices are similar to values obtained in Mozambique [4], Mozambique ranks third globally in terms of the prevalence of PLHIV, with health facilities catering to roughly 2 million out of the 2.4 million individuals affected by the virus. It was reported [4] that there was a 25% decline in antiretroviral therapy (ART) initiation among adults, decreasing from over 22,000 to slightly above 17,000 in February 2025 compared with February 2024 [4]. Furthermore, among those undergoing treatment, there was a significant 38% decrease in the number of viral load tests administered [4]. Additionally, the result indicated a 37% reduction in the receipt of test outcomes and a consequential 33% decrease in the number of results indicating viral suppression [4].

In the pediatric population, there was a marked 44% reduction in viral load tests conducted, a 71% decline in the receipt of test results, and a 43% reduction in results reflecting viral suppression, thereby highlighting a disproportionate adverse effect on the child population.

The study forecasts that, should the interruption in funding continue unabated, Mozambique may experience an approximate increase of 83,000 new HIV infections (representing a 15% escalation) and 14,000 additional fatalities attributable to HIV (indicating a 10% rise) by the year 2030.

The broader implications of these findings highlight the fragility of donor-dependent HIV programmes. UNAIDS modelling suggests that long-term reductions in donor funding could lead to millions of additional infections and HIV-related deaths by 2030 if sustainable solutions are not found [1, 4, 10]. By directly reducing retention in care, the 2025 stop-work orders risk reversing decades of progress achieved through PEPFAR and similar programmes [10].

In conclusion, the HIV testing services, missed appointment, retention rate, and viral load coverage were negatively impacted during the stop work order. Due to the sudden cessation of HIV support by the US Government, it's obvious that donor fatigue is developing in the HIV program. Various countries benefiting from donor funding, including Nigeria, must begin to own the program and rely less on donor funding for the sake of sustainability and preventing the reversal of all the gains achieved during the period of PEPFAR support.

Acknowledgement:

The authors are grateful to the Centre for Integrated Health Programme (CIHP) for creating the platform for this review

Conflict of Interest:

None declared.

Funding:

Self-funded