Impact of an international HIV funding crisis on HIV infections and mortality in low-and middle-income countries: a modelling study
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Background
International funding for HIV has been critical in reducing new HIV transmissions and deaths. Five countries providing over 90% of international HIV funding announced reductions in international aid of 10%–70% between 2025–2026, with the US government ceasing aid on 20-January-2025. We investigated the potential impact of these funding reductions on HIV incidence and mortality through mathematical modelling.
Methods
We used 26 country-validated Optima HIV models (Albania, Armenia, Azerbaijan, Belarus, Bhutan, Cambodia, Colombia, Costa Rica, Côte d’Ivoire, Dominican Republic, Eswatini, Georgia, Kazakhstan, Kenya, Kyrgyzstan, Malawi, Malaysia, Moldova, Mongolia, Mozambique, South Africa, Sri Lanka, Tajikistan, Uganda, Uzbekistan, Zimbabwe). HIV incidence and mortality were projected across 2025–2030 for a status-quo scenario (most recent HIV spending continued) and scenarios capturing the impact of anticipated international aid reductions for HIV prevention and testing; plus additional impact on treatment and facility-based testing resulting from immediate discontinuation of President’s Emergency Fund for AIDS Relief (PEPFAR) support. Country-specific impacts were estimated using sources of country-reported HIV funding. We extrapolated scenario outcomes to all low-and middle-income countries based on the modelled proportion of globally reported international aid by source (49% overall, 54% PEPFAR). Upper and lower bounds reflected different mitigation and absorption assumptions.
Findings
Across all low-and middle-income countries, anticipated 24% (weighted average) international aid reductions plus discontinued PEPFAR support could cause an additional 4·43–10·75 million new HIV infections and 0·77–2·93 million HIV-related deaths between 2025–2030 compared with the status-quo. If PEPFAR support could be reinstated or equivalently recovered, this reduced to 0·07–1·73 million additional new HIV infections and 0·005–0·06 million HIV-related deaths. Impacts were greatest in countries with a higher percentage of international funding and those with increasing incidence among key populations.
Interpretation
Unmitigated funding reductions could significantly reverse progress in the HIV response by 2030, disproportionately affecting sub-Saharan African countries and key and vulnerable populations. Sustainable financing mechanisms are critical to ensure people have continued access to HIV prevention, testing, and treatment programs, thereby reducing new infections and deaths.
Funding
None.
