Africa’s HIV Response and Emerging Health Security Redesign

Introduction

The impact of the U.S. government’s sudden retreat on foreign assistance in 2025 has been most pronounced in Africa. For decades, African countries received the majority of U.S. global health assistance. The United States’ most successful global health program—the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)—also concentrated operations on the continent. As the largest donor government in the global HIV response, the United States is credited with changing the trajectory of the disease, saving an estimated 26 million lives. The U.S. foreign assistance downsizing coincides with potentially game-changing HIV developments—most notably, the impending rollout of FDA-approved lenacapavir, a highly effective twice-yearly injectable for HIV pre-exposure prophylaxis (PrEP), and the first HIV antiretrovirals manufactured in one African country and procured for use in another.

These shifts are significantly altering health security efforts in Africa, of which HIV has been the dominant focus. However, a redesigned approach has been forming—one with new opportunities for leadership and commitments to domestic health investments, innovative financing mechanisms, biomedical research, medical product market development, public-private partnerships, and multilateralism. There also are upcoming pivotal events with implications for African countries, including November’s G20 meeting hosted by South Africa and the concurrent summit of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) co-hosted by South Africa.

The Trump administration’s September release of the America First Global Health Strategy has further implications for health efforts on the African continent. The strategy underscores the administration’s vision for a minimized U.S. role in global health, prioritizing investments directly aligned with U.S. interests and placing less emphasis on multilateralism. At the same time, it affirms that the United States “remains committed to being the world’s health leader” and aims to “move countries toward resilient and durable local health systems.” While the strategy highlights HIV and PEPFAR, presenting the latter’s successes and challenges, it is short on details about PEPFAR’s future. There have been calls within the U.S. government to further scale back PEPFAR. Further, the United States has indicated its intention to more deeply focus on regions outside of Africa. Experts have been weighing in on PEPFAR developments and the Trump administration’s new strategy, discussing the strategy’s opportunities, the disconnect between its goals and U.S. actions on health assistance, and the unknowns, as well as potential responses from African countries.

Against this backdrop, in what ways is the HIV/AIDS approach in Africa evolving, who are emerging as potential stakeholders, and what actions could the United States consider to preserve its leadership on HIV/AIDS and global health security?

Redesigning the HIV/AIDS Response in Africa

Since the first quarter of 2025, the global HIV/AIDS community has sounded loud and consistent alarms about the impacts of U.S. cuts. It has also pledged to reinvigorate the global response, including through the Kigali Declaration, signed by HIV/AIDS leaders in conjunction with July’s International AIDS Society Conference on HIV Science in Rwanda. The declaration called for HIV leadership and research to “shift closer to home” and urged that the response should “adapt outdated models, unlock new financing and partnerships, [and] embrace innovation and new technologies.”

Contributing to the calls to action are growing agreement and concern that no single entity will replace the United States, given the enormity of its financial commitment to global health—especially on HIV/AIDS. The United States is also not the only donor government pulling back. The United Kingdom, France, and Germany have indicated that they will reduce aid, and they have not announced large-scale efforts to fill the funding gap left by the United States. In response to financing challenges, the Global Fund has planned to reprioritize grants. There have been brighter spots, however, as some European countries have already stepped forward to renew Global Fund pledges. Further, some experts see European donors as uniquely positioned to reinforce the Global Fund and support African governments’ plans.

In Africa, numerous entities have been working to carve a path forward. In April, the Africa Centres for Disease Control and Prevention (CDC) released a concept paper outlining the continent’s strategy for health financing given the decline in development assistance. The paper calls for innovative financing and investment, as well as market expansion and local manufacturing of health products. In this vein, the institution recently signed an agreement with global health organization Unitaid to intensify local production of medical equipment and supplies on the continent, including those related to HIV. African leaders also gathered in Accra, Ghana, in August for the Africa Health Sovereignty Summit. President John Mahama of Ghana, the summit host, called for the formation of a Presidential High Level Task Force on Global Health Governance to work with countries and partners to redesign health systems in Africa and urged African finance ministers to view spending on health as economic investment. Olusegun Obasanjo, the former president of Nigeria, called for a health fund under the African Development Bank.

African governments, including those of Nigeria, South Africa, and others, have taken action as they reel from U.S. cuts, pledging to increase domestic resources for HIV and health more broadly, as well as bolster biomedical research and pharmaceutical markets. Some of the countries proposing the boldest steps are also taking the biggest hits. Despite being the top recipient of U.S. global health assistance overall and a top recipient of HIV/AIDS assistance in FY 2023, for example, Nigeria announced significant investments in its health system and infrastructure, including for medical product development. South Africa has also been a top recipient of health and HIV assistance, despite already covering a large share of its HIV response with domestic resources. The country experienced a loss in funding for programs, in addition to reduced support for its robust biomedical research infrastructure, with far-reaching implications for the world.

However, these countries are also emerging players on the global stage—particularly South Africa, which is leveraging current leadership roles to highlight issues facing Africa, including the threat of resurgent HIV. South Africa currently holds the G20 presidency and hosted the G20 Health Working Group, which was focused on health workforce strengthening. The country also is cohosting the Global Fund replenishment this year to raise funds for the 2027–2029 period. Additionally, South Africa recently hosted a meeting at the Global Fund’s headquarters for African leaders focused on building momentum for replenishment and leaders’ increasing role in health systems, as well as highlighting the impact of the Global Fund in Africa. Beyond participation in the G20 and Global Fund, South African lawmakers also have indicated that they may enhance ties with fellow BRICS countries in the wake of U.S. decisions.

The Role of BRICS Countries in Contributing to Africa’s HIV/AIDS Response

The BRICS first emerged as a concept in 2001 and was formally established in 2009 to enhance cooperation among Global South countries and serve as a counterweight to Western geopolitical powers. The bloc originally included Brazil, Russia, India, and China, with South Africa added later. Over time, members and partners expanded, and the bloc now includes more African nations, such as Nigeria and Ethiopia (the latter being another top recipient of U.S. health assistance). Among the BRICS are countries that have transitioned from aid dependence, cultivated domestic pharmaceutical industries, and deepened their global health engagement, as well as countries directly affected by U.S. cuts. Their experiences raise important questions about how they can further contribute leadership, resources, and lessons individually and, potentially, collectively to the HIV/AIDS response and broader global health security efforts as they evolve in Africa. Contributions to HIV/AIDS efforts from BRICS countries include the following:

• Over several decades, Brazil transitioned from a heavy reliance on aid and built a nationally led HIV/AIDS response that increased domestic health spending, prioritized universal healthcare and the integration of HIV services—including antiretrovirals—into its primary care system, and manufactured HIV medications. In the early 2000s, Brazil declined bilateral PEPFAR funding given different approaches to HIV programming but did receive U.S. funding for research and other health efforts. Brazil has engaged in HIV/AIDS efforts in Africa, including providing expertise to Lusophone countries, prioritizing pandemic preparedness during its G20 presidency last year, and serving as a founding member of Unitaid.
• India also reduced its reliance on foreign aid over time and has developed robust internal medical product manufacturing capabilities. India’s pharmaceutical industry already provides antiretrovirals in Africa, and companies in the country were issued voluntary licensing agreements by Gilead, the maker of lenacapavir, to eventually manufacture the drug generically. Two Indian companies were recently cited in the news about partnerships increasing access to lenacapavir for as little as $40 per person annually.
• Health has been a feature of China’s Belt and Road global diplomacy effort, which has largely focused on debt-funded health infrastructure projects and expanding markets for China’s medical products. China sent its largest-ever delegation to the World Health Organization’s (WHO) World Health Assembly and announced a $500 million commitment to the WHO in May. While China has not been a major HIV/AIDS donor, the country has contributed to the Global Fund and recently signed agreements with the Joint United Nations Programme on HIV/AIDS, UNAIDS, regarding efforts in low- and middle-income countries. China has supported the Africa CDC from its inception, financing its headquarters and reference laboratory and enhancing cooperation with the regional body. China was the only donor government singled out in the new U.S. global health strategy, with the Trump administration viewing U.S. health efforts as an “important counterweight” to China, especially in Africa.
• New BRICS partners have elevated their roles in global health. For instance, Saudi Arabia has collaborated with countries on health infrastructure projects and increased its contributions to the Global Fund in recent years.

BRICS countries have collaborated in different permutations, but their cohesion and geopolitical role remain unclear. Additionally, their approaches to assistance and cooperation differ. While numerous countries have engaged in global health activities, the bloc does not have coordinated health financing or governance mechanisms. However, health cooperation was on this past July’s BRICS summit agenda, and members’ health ministers reached consensus on a declaration emphasizing cooperation related to pandemic preparedness, financing health workforce and systems, the impact of climate change on health, as well as on tuberculosis. Although HIV/AIDS was not a dominant feature, these priorities are closely tied to HIV/AIDS and health security efforts.

There could be opportunities to enhance roles individually or in concert to produce synergies, especially in areas aligning with African health agendas. These could include supporting HIV/AIDS programming, the integration of services into primary care systems, health infrastructure, local manufacturing and pharmaceutical industries to market affordable antiretrovirals, research capabilities, and evolving models of health financing. African BRICS countries, such as South Africa and Nigeria, can act as leaders on HIV/AIDS and serve as bridges between BRICS and African entities, helping to closely tie investments with local needs.

Options for U.S. Support Under the New Global Health Strategy

The new America First Global Health Strategy states that the United States is committed to continuing a leadership role in global health. How this vision will be realized amid the overhaul of global health assistance remains unclear. U.S. support of the emerging redesigned HIV/AIDS response in Africa and the stakeholders driving it—existing, evolving, and new—could preserve the gains the United States worked hard to help achieve over the last two decades while underpinning its health goals in Africa. Steps the United States could take include the following:

• Stabilize HIV/AIDS efforts as PEPFAR transitions: PEPFAR funding has been significantly reduced, and there are many questions about next steps. PEPFAR has historically had bipartisan support in Congress, and Congress recently intervened to protect the program, staving off $400 million in proposed cuts during rescission attempts. However, its approach to PEPFAR has become less clear, especially as legislation has been introduced to further whittle the program and as the Supreme Court upheld Trump’s order to withhold appropriated foreign aid funding. All indications point to a continued ebbing of PEPFAR, necessitating champions in the U.S. government and safeguards for the continuity of services as recipient countries transition their HIV responses, including as “bridge” programs and bilateral agreements are established.
• Fulfill the lenacapavir commitment: After months of uncertainty, the United States recently announced its intention to reach two million people by 2028 with the HIV prevention tool. This initiative focuses on preventing mother-to-child transmission of HIV and falls short of meeting current needs, but is a promising step and could be expanded over time.
• Uphold Global Fund support:S. contributions to the Global Fund remain essential to sustaining progress on HIV/AIDS and gains in countries, as well as the effective rollout of lenacapavir. While the U.S. approach deemphasizes multilateralism and recently introduced legislation proposes to significantly reduce the U.S. contribution to the Global Fund, the Trump administration’s strategy highlights the fund’s role in market creation and as a purchaser of U.S. medical products. A reduced U.S. contribution in the current Global Fund replenishment round risks weakening U.S. influence in the organization and could undermine the Global Fund’s ability to catalyze other donors—a key feature of the U.S. contribution. While it is unclear whether the fund will be successful in securing the $18 billion requested in its investment case for the next three-year period, robust support from the United States in this funding round would reinforce the fund’s stability, strengthen its potential to leverage the U.S. contribution to raise funds from current and emerging donors, and signal a commitment to continued partnership on global infectious disease challenges, even as bilateral programs shrink.
• Engage with Africa’s health leadership and partners: As African countries, regional bodies, and partners advance HIV/AIDS and health security efforts, innovative financing, market-shaping initiatives, local manufacturing, regulatory frameworks, and biomedical research capabilities, the United States can remain a constructive partner. Regulatory expertise, technology sharing, and strategic coinvesting where appropriate, for example, could complement stakeholder efforts and support U.S. goals. It will be important to monitor the development of the bilateral agreements proposed in the new strategy. Further, questions have arisen about the scope and potential impact of the global health compacts proposed in R. 5300, the Department of State Policy Provisions Act. This legislation includes a prohibition on establishing compacts with regional entities, such as the Africa CDC, which is laying health security groundwork that could accelerate the achievement of U.S. goals.
   

Conclusion

The seismic shifts in U.S. foreign assistance approaches since January have had the most profound impact in African countries, which had, through support from PEPFAR, strengthened regional HIV responses and health systems over more than two decades. However, a redesigned approach has been forming in the region—one that presents new opportunities for leadership and commitments to domestic health investments, innovative financing mechanisms, biomedical research, medical product market development, and public-private partnerships. By continuing to engage on HIV/AIDS and serving as a constructive partner to leadership in Africa and to other key stakeholders, including as new regional financing and governance approaches take shape, the United States can help preserve the progress on infectious diseases that would not have been possible without U.S. investment, work toward ending HIV as a public health threat, reinforce health systems, and support global health security goals in Africa.

Alicia L. Carbaugh is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.