A Metamorphosis to Meet Our Mark: Overcoming new challenges in the global response to AIDS to ensure continued progress

At the precise moment the world was poised to make significant, additional progress against the AIDS pandemic, dramatic declines in international funding for development and for HIV, including by the United States - the largest contributor to our efforts - stalled, then critically challenged that progress.

The HIV funding cuts in 2025 arrived on the back of an almost 6% decline in official development assistance for HIV since its peak in 2013. This has been an anomalous trend: the share of official development assistance going to public health held steady between 2010 and 2022, but the share going to HIV programmes almost halved, from 6% to 3.4%. 

Almost overnight in early 2025, HIV prevention and treatment services in many countries reliant on foreign aid for their HIV programmes were disrupted. The funding cuts destabilized supply chains, shuttered health facilities, left thousands of health clinics without staff, set back prevention programmes, disrupted HIV testing efforts and forced many community organizations to reduce or halt their HIV activities, upending critical community systems. Levels of fear and uncertainty we haven’t experienced in decades spread rapidly among people dependent on donor support to avoid contracting HIV – or to stay healthy if they are living with the virus. 

The Joint United Nations Programme on HIV/AIDS (UNAIDS), for which I work, is reporting the impact of global health funding cuts in real time (https://www.unaids.org/en/impact-US-funding-cuts). 

I’ve done this work for more than 25 years. Given we’d developed effective HIV prevention and treatment, I didn’t imagine we’d ever again see conditions we experienced decades ago, before we knew how to stop HIV infections and AIDS. But for some people, in some countries, it feels like the early 1990s. People are frightened, anxious and, understandably, angry they are being left vulnerable when the tools to save them exist. It’s heartbreaking to consider rising levels of HIV infection, additional babies born with HIV and an increased number of AIDS-related deaths when all can be prevented.  

Not only is progress in the global AIDS response sliding backwards but the promise of fresh prevention options remains unrealized to date. For example, a new, injectable, long-acting form of HIV prevention – lenacapavir (LEN) – was recently approved by the WHO for use as pre-exposure prophylaxis. If we had the funding to add LEN to the combination HIV prevention toolkit – provided it was priced affordably - we could dramatically lower the rate of new HIV infections and accelerate progress towards the UN’s penultimate goal of ending AIDS as a public health threat by 2030.

International assistance accounts for 80% of prevention programmes in low- and middle-income countries. UNAIDS modelling shows that if funds lost in recent cuts aren’t replaced or offset, there could be an additional 6 million HIV infections and an additional 4 million AIDS-related deaths by 2029. 

The upside to the right levels of investments now would be remarkable. The HIV response has already saved 26.9 million lives. If we revolutionize our approach, we could end AIDS, saving many more lives – and resources. UNAIDS estimates that if the world embraces new technologies, efficiencies and approaches, the annual cost of the HIV response could fall by around US$ 7 billion. Preliminary estimates from UNAIDS indicate that achieving the global targets will require annual resources in 2030 of US$ 21.9 billion in low- and middle-income countries, down from the previously estimated US$ 29.3 billion. These new estimates are lower than those published in 2021 due to major cost efficiencies that have been achieved across the HIV response. For example, there have been significant price reductions for antiretroviral medicines and for products used in opioid agonist maintenance therapy. In addition, the new estimates reflect more efficient and targeted service delivery and a strong emphasis on prioritized approaches based on HIV risk. 

There is now widespread recognition of overreliance on a handful of donors - and on the U.S. government, in particular. There is desire, on the part of many countries, to be independent of this reliance. But, crippled by a combination of debt distress, slow economic growth and underperforming tax systems, especially in sub-Saharan Africa, many countries have not historically been able to fund their own response to HIV and are not able to offset the funding cuts immediately. There is an urgent need for diversified and durable financing mechanisms for HIV and other public health priorities via both domestic efforts and solutions to international debt. 

Many countries have been rebalancing their HIV programmes towards more sustainable models by increasing domestic funding for HIV. Even though domestic resource mobilization for HIV has been under strain since the beginning of the COVID-19 pandemic, more than half of reporting countries have increased their domestic HIV spending in the past five years. In 2024, domestic HIV resources accounted for 52% of the resources available for HIV programmes in low- and middle-income countries. 

Some countries are stepping up further to help their people in the wake of the cuts. The leadership of Botswana, a country with which I have a deep, personal connection, has promised continuity of most HIV services to all in need. South Africa has pledged even higher levels of domestic investments. Twenty-five of 60 countries reporting to Global AIDS Monitoring on forecasted budget trends for 2026 stated that they expect to increase their domestic public HIV budgets (https://www.unaids.org/en/resources/documents/2025/2025-global-aids-update). 

The future of the HIV response is nationally owned and led, sustainable, inclusive and multisectoral. That is why UNAIDS is working with international partners, countries and communities to create a sustainable response to AIDS.  

This transformation cannot happen overnight. Global solidarity and renewed commitment from funding partners are needed as countries plan and lead sustainable transitions towards self-financing. Critical work needs to be done to ensure that human rights protections and community leadership remain at the heart of national HIV responses, ideally, funded by national governments. 

The consensus behind the old model of financing the HIV response may be coming to an end, but the international community is forging a new path. At the fourth International Conference on Financing for Development in Seville, Spain, nations embraced calls for debt relief, international tax cooperation and reform of international financial institutions—the first steps towards a new economic settlement that can give countries the fiscal space needed to invest in the global HIV response.  

In a moment when we have less, there is more than ever to do. This requires metamorphosis - to find new ways of delivering lifesaving HIV services to meet the mark of our global goals on HIV: goals all UN Member States, including those who have cut their funding for HIV, agreed to reach. 

UNAIDS is extremely grateful for the support of all its donors who also underwrite efforts to end AIDS around the world. Germany has long been a leader in this regard and its contributions have saved millions of people in the face of AIDS. 

There is a non-negotiable nature to pandemics. If you ignore them, they don’t recede on their own.  

The AIDS response may be in crisis, but we have the power to transform and still achieve control of this pandemic. Communities, governments, and the United Nations are rising to the challenge, together. 

We have invited Christine Stegling (Deputy Executive Director, UNAIDS) to share her reflections on current challenges and progress in the fight against HIV/AIDS. The views expressed are her own and do not necessarily reflect those of the Global Health Hub Germany.