Published on 13 November 2025
This article is an extension of our special issue “Aid in danger: after the shock of 2025, the consequences and the response” published in November 2025. According to the two authors, Côte d’Ivoire’s HIV success story masks a dangerous vulnerability. When PEPFAR funding vanished, community workers kept showing up unpaid while the government watched NGOs collapse. A chronicle of how foreign dependency condemns health systems to perpetual precarity.
When we began researching the HIV/AIDS response in Côte d’Ivoire in 2024, it appeared to be a story of progress. Approximately 400,000 people in the country were living with HIV,[1]UNAIDS, Côte d’Ivoire — Executive Summary, May 2024, 2024, https://sustainability.unaids.org/wp-content/uploads/2024/06/Cote-dIvoire-Executive-Summary-May-2024.pdf a national prevalence of 1.8% among adults overall, 4.8% for sex workers, 7.7% for men who have sex with men, and 3.4% for people who use drugs.[2]ONUSIDA, Situation de la prévention du VIH – Côte d’Ivoire, 2024, https://hivpreventioncoalition.unaids.org/sites/default/files/attachments/cote_divoire_poster_2024_0.pdf The country had made significant advances toward the Joint United Nations Programme on HIV and AIDS (UNAIDS) 95-95-95 targets:[3]The UNAIDS (ONUSIDA in French) 95-95-95 targets aim to ensure that by 2030, 95% of all people living with HIV know their HIV status, 95% of all people diagnosed with HIV receive sustained … Continue reading 82% of people living with HIV knew their status, 88% of those were on treatment, and 88% had achieved viral suppression.[4]Programme National de Lutte Contre le SIDA (PNLS), VIH pédiatrique – tableau de bord, 19 août 2024, https://www.pnlsci.com/donnees/vih-pediatrique On paper, Côte d’Ivoire was edging toward epidemic control.
But the political context shifted abruptly in 2025. In January, the U.S. administration announced a 90-day suspension of nearly all foreign aid, including HIV funding, creating immediate uncertainty among NGOs and health workers. By March, just as we arrived in Abidjan to begin field interviews, U.S. Secretary of State Marco Rubio announced the permanent termination of 83% of USAID-funded HIV programs, including the majority of those in Côte d’Ivoire.[5]Christina Lu, “USAID purge ends with 83 percent of programs canceled”, Foreign Policy, 10 March 2025, https://foreignpolicy.com/2025/03/10/trump-rubio-usaid-cuts-foreign-aid We had intended to conduct a study of a fragile yet functional system. Instead, our work became an observation of the system’s fragilities, which were laid bare when international funding was suspended.
On the front lines: community workers and NGOs
Before we left France, questions were raised about the need to investigate access to treatment in Côte d’Ivoire. The country is often cited as a model for HIV response in West Africa: antiretroviral medication is free, the system appears well-structured, and national coordination is centralised under the Programme National de Lutte contre le Sida (PNLS, National AIDS Control Programme). The PNLS is responsible for developing strategies, training personnel, coordinating surveillance, and setting guidelines. Drug supply is handled through the Nouvelle Pharmacie de Santé Publique (NPSP, New Public Health Pharmacy), which manages the national supply chain.
However, once the interviews began, we realised that the role played by NGOs and community workers was crucial to success. In many clinics, physicians see dozens of patients a day, sometimes for only two minutes, which is enough time to sign a prescription or renew treatment. The real work of care – explaining the importance of adherence, reminding patients to take pills with food, discussing disclosure, and offering psychosocial support – fell to community health workers employed outside the national health system. They accompanied patients over months and years, following up if someone missed a visit, visiting homes, and maintaining trust. Without them, adherence rates would plummet. For people with HIV, misunderstanding or neglecting treatment is not a minor risk: it is the difference between life and death.
Their work also extended beyond the individual patients. Many NGOs deliberately involved partners and children so families could understand the implications of treatment and help patients manage it. This transformed adherence into a collective responsibility and softened the isolation produced by stigma. By embedding treatment in family life, NGOs made survival less daunting.
A scaffolded system: the role of international donors
The work of NGOs and community health workers that sustains much of the HIV response is itself made possible by foreign donors. Since 2003, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has been one of the main backers of the HIV/AIDS response in Côte d’Ivoire. It quickly became the country’s top bilateral donor, funding a large share of HIV-related programs. In 2024, PEPFAR provided about 60% of the national HIV response, amounting to roughly $115 million.[6]Jean-François Laforgerie, « L’actu vue par Remaides : “Usaid, Pepfar : les gels des financements américains font déjà des dégâts”», AIDES, 10 mars … Continue reading The Global Fund came next, contributing around 15-20%, followed by the Ivorian government, which covered approximately 13-14%.[7] Programme National de Lutte contre le SIDA (PNLS), Plan stratégique national de lutte contre le VIH, le SIDA et les infections sexuellement transmissibles 2021–2025, 2020. That government share includes both domestic funding and international resources managed by the state through mechanisms like the National HIV/AIDS Response Fund (FNLS). Other agencies, such as the World Health Organisation, UNAIDS, and UNICEF, also provide support, though usually for specific projects like maternal health or child-focused care.
This structure has allowed the country to offer free HIV care since 2008, including antiretroviral medication, laboratory testing, and community services. Around 80% of the entire HIV response, however, relies on external funding. A significant share of PEPFAR and Global Fund resources passes through the PNLS, supporting drug supply and distribution via the NPSP, as well as training, monitoring, and advocacy. But another major channel flows directly to NGOs ‑ those same organisations employing the community workers who make the system function.
A fragile safety net: the cuts and their consequences
Since the suspension of USAID/PEPFAR funding, several community health workers have continued to work voluntarily, despite the lack of remuneration. In many centres, community teams have independently organised rotating shifts to maintain at least a minimal continuity of patient follow-up. In one centre in Abidjan, a community worker reported being responsible for tracking more than 1,300 patients on her own, and said she had no choice but to keep working at least two days a week, as “they couldn’t just let the patients die.”
The cuts disproportionately affect populations that already face stigma and exclusion. For years, donor insistence has ensured that sex workers, LGBTQ communities, and people who use drugs are included in national HIV strategies. Dedicated programmes reach them with testing, condoms, counselling, and treatment support. These services have often been controversial within domestic politics, but the external financing of NGOs has sustained them.
In this context, many actors fear a step backwards: the loss of contact with beneficiaries, an increase in undiagnosed infections, and lapses in treatment adherence. These concerns are heightened by the fact that certain sectors, particularly those linked to sex work or gender minorities, are not prioritised by some conservative U.S. donors, as was already observed under the Bush administration.
Government response and a fragile model revealed
The Ivorian government launched a contingency plan, initiated by presidential instruction, to prevent disruptions in HIV care. Official statements claim that services for people living with HIV/AIDS remain fully ensured and that a national funding mechanism has been activated to mitigate the effects of suspended external support.[8]« Santé : le ministre Pierre Dimba rassure sur la disponibilité des antirétroviraux et la prise en charge pleinement garantie du VIH/SIDA », Gouvernement de la République de Côte … Continue reading
Yet this official reassurance contrasts sharply with the scepticism expressed by many local actors. Numerous observers questioned the state’s long-term capacity to sustain the HIV response without international assistance. According to Anicet Zran, a historian of health and specialist in infectious diseases interviewed during fieldwork, historical patterns reveal that NGOs and community-based organisations – though central to the national response – have long received minimal support from domestic resources. As he explained:
“The resources that the state allocates to NGOs are negligible. […] The NGOs themselves do not feel supported by the state; they do not feel recognised as an essential link. In official speeches, yes, associations are said to be very important. But when it comes to providing resources, the state always says there is no money and that they should turn to international donors.”
Government representatives that we spoke to confirmed to us that mitigation measures would benefit only public institutions, explicitly excluding NGOs. Their phase-out was described as both inevitable and non-disruptive, despite the essential role these organisations play in maintaining access to care, particularly for remote communities and key populations.
What the cuts reveal about global aid
The 2025 cuts exposed the fragility of a system heavily reliant on external donors. The Ivorian government remained in charge of overall strategy, but it had little capacity to cushion the loss of external funds. Services collapsed not because of internal political choice or epidemiological irrelevance, but because a donor government had unilaterally redefined its priorities. Sovereignty without resources proved to be sovereignty in name only.
The 2025 cuts mark an important turning point. But its significance is best understood if we consider what the cuts reveal about the nature of aid: sovereignty cannot rest on external scaffolding; marginalised populations are doubly vulnerable if they rely on donor benevolence; humanitarian discourse cannot obscure the geopolitical logic of funding decisions. The future of HIV care in Côte d’Ivoire – and of global health more broadly – will depend on whether these lessons are taken seriously. Without new commitments to genuine sovereignty and sustainable financing, the politics of abandonment will continue to shape lives long after the headlines fade.
Picture credit: ©CICR Thierry Gassmann
