“We actually are still colonised. White people are the ones who know how long we will live and how far they can go in helping us… How can the government lead the fight when they can’t pay the health workers?” This statement was made in 2008 by a staff member in an organisation working with people with HIV/AIDS, during research in Zambia on the distribution of aid for HIV/AIDS.
Credit: Tommy Trenchard/Panos Pictures
At the time that statement was made, consistent access to antiretrovirals for HIV positive people in the heavily affected Southern African region was still being established. Those whose lives depended on these drugs were painfully aware of their lack of control over supply – flows that have remained highly dependent on donor funding.
In recent weeks I have recalled such fears of people living with HIV/AIDS. Since late January 2025, the global health community has been left reeling from decisions made in the United States to dismantle USAID, that have affected funding across scales and with sudden and at times immediate effect. Other countries such as the UK have also announced reductions in development aid spending, albeit with staggered timelines.
A matter of life and death
What does this mean in practical terms, for instance for HIV services, data systems and research? In 2003, President Bush established the President’s Plan for AIDS Relief (PEPFAR), at a time of global mobilisation to address the mortality from the epidemic. Although not without controversy, PEPFAR has been a major funder of antiretroviral therapy.
The US re-evaluation of aid and associated uncertainty for HIV/AIDS services has threatened the lives of people with this disease at the most basic level: reports suggest for instance how people with HIV are anxious about the return of shortages of antiretrovirals, reminiscent of a past era. For these individuals, the impacts are quite literally a matter of life and death. UNAIDS has also expressed concerns about prevention efforts.
However, the effects of the cuts are far more extensive. During a visit to Zambia in mid-February, I heard first hand of staff positions in the balance at a leading epidemiology institute, to salaries of HIV peer educators under threat. South Africa has been hard hit at the level of research. Universities have lost millions of rands of grant funding such as from the U.S. National Institutes of Health, implicating hundreds of jobs and training of the next generation of scientists. Important existing clinical trials face termination.
There are also big shocks right up to the top of the global health architecture – on day one of his office, Trump withdrew the U.S. from the World Health Organisation. Again, this affects operational responses to diseases such as mpox, research efforts, and surveillance for early detection of (re)emerging diseases with epidemic potential. Considering HIV/AIDS again, the Global Fund for HIV, Tuberculosis and Malaria requires replenishment and the commitment to do so is now in question.
The outlook for global health funding
What will the future be of global health funding across these scales? There is speculation about whether private foundations such as the Wellcome Trust might be in a position to salvage some research efforts, or if other nations might step in, such as from the Gulf or East Asia.
We might hope that humanitarian assistance for health emergencies will be prioritised. In truth though, the boundary between acute and longer-term crises is not as clear as it might seem – a public health emergency of international concern such as mpox is manifesting in the context of a longstanding humanitarian crisis and insecurity in Eastern DRC. It is a concern that funding in an area such as pandemic preparedness might now contract to outbreak response, rather than prevention or sustained efforts to strengthen health care infrastructures and progress universal health coverage.
At the sixth conference of the Africa International Health Agenda in Kigali in early March, health leaders from the continent debated the future of health investment, in the face of the contraction of financial support. They emphasised health system strengthening and also pointed to the opportunity for building greater self-reliance. This offers a different vision for the future but one that will take time and resources to realise. And in the immediate term, it is hard to see where resources will be mobilised from.
‘Extensive and deep’ long-term impacts
Already in countries like South Africa, state austerity is encouraging a policy discourse oriented to community ‘resilience’, at a time when the post-Covid economic downturn is hitting the poorest people hardest. These realities make it inevitable that the sweeping and sudden nature of cuts to global health are causing suffering in the short term, and the longer-term ramifications might well be extensive and deep.
