HIV service delivery after the PEPFAR and USAID HIV funding withdrawal in Uganda and Zimbabwe: an interrupted time-series study

Abstract

BACKGROUND: In January 2025, the US Government froze foreign aid and halted the President's Emergency Plan for AIDS Relief (PEPFAR), the largest external funder of HIV services globally. Early modelling studies and rapid assessments warned of major harm to millions, but robust quantitative evidence from those who relied most on the lost funding has been absent. We aimed to estimate the effect of the US funding withdrawal on HIV prevention, pre-exposure prophylaxis (PrEP), testing, and treatment services provided by non-governmental organisations (NGOs) serving primarily key populations in Uganda and Zimbabwe. METHODS: In this interrupted time-series study, we used monthly and quarterly service-delivery data from NGOs in Uganda and Zimbabwe from January 2023 up to March 2026. All received stop-work orders and subsequent funding cuts. Core service indicators across prevention, PrEP, treatment, and testing were normalised into domain indices, in which 100 represents their mean 2024 amount. The main outcome was the change in these service indicators because of funding cuts. Specifying February 2025 as the interruption point, we estimated effects with an unweighted panel interrupted time-series (the organisation level) and a client-weighted interrupted time-series (the key-population level) on these indices. FINDINGS: Eight organisations agreed to participate; four were subsequently excluded for reasons of data quality, lack of funding impact, and location, with four subsequently included in this study. All four service domains showed large, sustained declines. Across both the unweighted and weighted specifications, prevention fell by 36·8-62·7 index points, PrEP by 43·0-71·6, treatment by 22·0-31·5, and testing by 58·7-63·8 index points in February 2025 (index points are equivalent to percentage change from mean 2024 amounts). 95% CIs excluded zero for all estimates except PrEP in the unweighted panel. Services remained substantially below the 2024 amount up to March 2026. The antiretroviral therapy humanitarian waiver attenuated treatment effects but did not prevent substantial decline. INTERPRETATION: The sudden withdrawal of US funding was followed by severe, sustained disruptions to HIV service delivery in Uganda and Zimbabwe across all major domains, with the largest declines in prevention, PrEP, and testing services for key populations. These results are the first quantitative findings on service-volume changes in NGOs whose US funding was terminated or sharply cut and illustrate the effect on the NGO-led, key-population layer of HIV services in sub-Saharan Africa. These services are crucial to people living with HIV to remain healthy and have a good quality of life. Urgent investment in service-continuity protocols and domestic financing is needed to prevent a rebound in HIV incidence. FUNDING: The Josiah Charles Trent Memorial Foundation Endowment Fund, the Sanford School of Public Policy, and Duke Global Publications Fund.

The authors' abstract, as published at the source. The Lancet Global Health, 2026 · DOI ↗