Thousands of jobs axed, research projects halted in their tracks, key populations abandoned: the funding crisis in the fight against HIV is mainly hitting community players. As the withdrawal of Northern donors coincides with an anti-rights offensive and a move to overhaul the architecture of global health, organisations in the field are calling for this restructuring to lead to an effective transfer of resources, technology and power.
The first months of 2025 marked a turning point in global health with the abrupt halting of the President’s Emergency Plan for AIDS Relief (PEPFAR), the world’s leading funder of the fight against HIV.[1]This emergency plan for AIDS relief abroad was launched in 2003 by the president at the time, George W. Bush. This move followed in the footsteps of several political decisions taken by northern countries to reduce the funds allocated to international solidarity and to apply conditions on their use. This article will examine the effects of these cuts based on experience and data from the Coalition PLUS network,[2]Coalition PLUS is an international union of community-based organisations engaged in the fight against HIV, founded in 2008 and involving around a hundred organisations operating in 51 countries: … Continue reading looking into the reconfiguration of civil society space, the modus operandi of community action and the conditions for a decolonial and lasting response to HIV.
International aid in crisis: are we heading for a planned phase-out of solidarity?
The systemic impact of sudden disengagement
The withdrawal of United States (US) aid was immediate and abrupt, but was above all marked by conflicting orders and a general lack of clarity. In this context, Coalition PLUS released a survey in February 2025 within its network of community-based organisations.[3] Coalition PLUS, [Enquête] Santé mondiale et VIH : les partenaires de Coalition PLUS ébranlés par le gel de l’aide américaine, 28 février 2025, … Continue reading Among the 49 organisations who responded, 55% had already felt an impact on their service provision (screening and treatment) and 55% an impact on the partial or overall funding of their human resources. To be specific, 1,728 employees had lost their jobs or part of the funding for their salaries.
“In October 2025, it was estimated that 120,000 deaths could already be linked to the freezing and withdrawal of PEPFAR funding alone.”
In October 2025, it was estimated that 120,000 deaths could already be linked to the freezing and withdrawal of PEPFAR funding alone.[4]PEPFAR, PEPFAR Program Impact Tracker, https://pepfar.impactcounter.com Related impacts must also be taken into account, for example in the field of research where at least five major international projects have had to be terminated.[5]AVAC, Trials & Projects Halted by USAID Funding Suspension, 6 March 2025, https://avac.org/resource/infographic/trials-halted These sudden stoppages represent a breach of trust in the long history of medical experiments conducted on marginalised populations, in particular black ones. They foster a certain mistrust of scientific institutions that could hinder people’s access to care in the long run.[6]Stephanie Nolen, “Abandoned in the middle of clinical trials, because of a Trump order”, Global Health, The New York Times, 6 February 2025.
The increasing nationalist retreat in global health
It would be wrong to think of the cuts and suspensions of US foreign aid as an isolated phenomenon. Across Africa, the total volume of official development assistance (ODA) fell from 81 billion dollars in 2021 to 25 billion dollars in 2025, chiefly after the US cuts.[7]Kerry Cullinan, “PEPFAR reauthorisation expires with no clarity about renewed US funding for HIV”, Health Policy Watch, 25 March 2025, … Continue reading Before 2025, the funding of word health programmes was already deemed “precarious”, with low-and-middle-income countries (LMIC) in debt since the Covid-19 pandemic.[8]Allison Krugman, “A ‘defining moment’ for global health funding”, Think Global Health, 13 February 2025, https://www.thinkglobalhealth.org/article/defining-moment-global-health-funding
In 2025, Finland, France, Germany, the United Kingdom and the US have begun or will continue to reduce their contributions to global health. These cuts were justified by the need to prioritise national issues, in response to domestic criticism of the perceived effectiveness of this funding or to reallocate budget resources to the defence sector.[9]Pete Baker, Katherine Klemperer, Sam Hughes et al., “26 countries are most vulnerable to US global health aid cuts. Can other funders bridge the gap?”, Center For Global Development, 25 February … Continue reading Where multilateral aid channels remain in place, countries increasingly place specific conditions on how they are used; in other words, they are earmarked. Although many analyses point out the limits of this model, about two thirds of funding channelled through multilateral bodies is intended for specific uses in the humanitarian field.[10]Silke Weinlich, Max-Otto Baumann, Erik Lundsgaarde et al., Earmarking in the Multilateral Development System: Many Shades of Grey, Deutsches Institut für Entwicklungspolitik, 2020, … Continue reading
A political juncture like this calls for a rethinking of health funding in the countries of the South, in particular in Africa, where the needs are greatest. However, as pointed out by Mehdi Karkouri, president of Coalition PLUS, “the overnight withdrawal of resources on which the survival of millions of people depends, without any alternative being offered, is neither a move towards making healthcare systems more resilient, nor a way of enhancing health sovereignty”.[11]Press release, « De l’urgence à l’indépendance : repenser le financement de la santé en Afrique », Coalition PLUS, 5 février 2025, … Continue reading
Breaking free from dependence on international funding: how to transition when faced with disengagement?
Reflections on reforming the architecture of global health cannot continue to serve as a roadmap for Northern countries’ immediate withdrawal of funding without a realistic approach to existing wealth disparities, power imbalances and the processes that sustain them. Though national contributions from states are a necessity for the sustainability of programmes, in line with the commitments of the Abuja declaration,[12]More than twenty years ago, African Union heads of state committed to spending 15% of their national budget on health: Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious … Continue reading expectations of them must remain realistic. Many LMICs have limited fiscal space. Some spend over five times more to service their national debt than on public health spending. In sub-Saharan Africa, nearly 80% of HIV prevention funding is dependent on foreign aid, and a quarter of donor funding of HIV programmes in 2023 was for civil society organisations and community networks.[13]UNAIDS, 2025 Global AIDS Update – AIDS, Crisis and the Power to Transform, 10 July 2025, https://www.unaids.org/en/resources/documents/2025/2025-global-aids-update Yet for Northern countries, aid remains a modest contribution. It is estimated, for example, that the North’s net appropriation of the South’s labour and resources is thirty times greater than official development assistance.[14]Jason Hickel, Christian Dorninger, Hanspeter Wieland et al., “Imperialist appropriation in the world economy: Drain from the global South through unequal exchange, 1990–2015”, Global … Continue reading
In 2025, the replenishment of the resources of the Global Fund to Fight AIDS, Tuberculosis and Malaria, now the main international donor for these three diseases, is undoubtedly the most significant event for future responses. Where bilateral aid is given and withdrawn at the mercy of policy shifts, the multilateral partnership model is a guarantee of continuity.
Repression of rights and marginalisation of community knowledge in the austerity turnaround
The community response to HIV: a democratic model of empowerment and innovation in healthcare under threat
“It is therefore necessary to point out a fact that has already been demonstrated many times in the fight against HIV: community-based action is vital.”
A context of scarce resources has very quickly led to a prioritisation of programmes, at the level of both states and the Global Fund.[15]The Global Fund, GC7 Reprioritization and revision of grant activities, 2025, https://resources.theglobalfund.org/en/gc7-reprioritization The first recommendations of the latter insisted on the need to maintain so-called “lifesaving” programmes, promptly causing serious concerns among activists.[16]Communities Delegation, Global Fund Grant Revision Process 2025: Protocol for Reporting Barriers and Abuses of Process, June 2025, https://communitiesdelegation.org/reportingbarriersabuseofprocess2025 The temptation to prioritise biomedical over community-based approaches was a reality soon seen in the field. It is therefore necessary to point out a fact that has already been demonstrated many times in the fight against HIV: community-based action is vital.[17]Chris J. Collins, Matthew N. Greenall, Chris Mallouris et al., “Time for full inclusion of community actions in the response to AIDS”, Journal of the International AIDS Society, vol. 19, no. 1, … Continue reading
The promotion of experiential knowledge, the focus on determining factors in health, the demands for social justice and the fight for access to treatment have redefined the parameters of public health since the outbreak of the epidemic.[18]Hélène Rossert, Rien pour nous, sans nous : 40 ans de mobilisation communautaire contre le sida, Coalition PLUS, mars 2022, … Continue reading Its institutionalisation may be threatened today, but this community-based expertise has not lost its activist roots and its ability to innovate in times of crisis.
The example of the Epidemic Control (EpiC) community-based research programme in the COVID‑19 pandemic and the central role of peers in crisis management
Community participation in HIV research has emerged as a key driver of knowledge and service provision, including in times of crisis. In the current context, the EpiC community-based research programme[19]Rosemary M. Delabre, Marion Di Ciaccio, Nicolas Lorente et al., “Impact of the COVID-19 health crisis on key populations at higher risk for, or living with, HIV or Hepatitis C virus and people … Continue reading (studies to measure the impact of the COVID-19 health crisis at the community level) would probably not have seen the light of day. This programme, developed through close collaboration between the Research Division of Coalition PLUS and community players[20]Lucas Riegel, Marion Di Ciaccio, Amal Ben Moussa et al., « La recherche communautaire en temps de pandémie : retour sur l’étude multi-pays EPIC », Santé Publique, vol. 33, n° 6, 2021, p. … Continue reading was launched in an emergency situation. While states were imposing lockdown measures and other restrictions at all levels, community-based players in the Coalition PLUS network were reporting alarming situations for the key populations they were working with and a total lack of public response. The EpiC community programme, developed jointly by community players and researchers, not only made it possible to document the community organisations’ innovative measures and adaptations to respond to the new needs of key populations or those living with HIV, but also to produce scientific data to make the impact of the pandemic on the most vulnerable people more visible, in order to improve responses to future epidemics. Generating this type of data is essential for the future of global health, and yet today its feasibility is under threat.
Reduction of civic space in the reactionary backlash
The major funding crisis in global health and in the fight against HIV, part of today’s reactionary movement, exposes communities to abuses and transmissions. The anti-gender and anti-rights backlash is a political configuration in which budget cuts and moral crusades converge and marginalise the same groups.
Africa has been affected by the rise in anti-gender and anti-rights movements. The latter are not natural expressions of regressive customs in African societies, but the result of lobbying financed primarily by Northern countries. Following the defeat of Donald Trump in 2020, several conservative and religious US organisations saw their funding skyrocket and they have thereby been able to engage in aggressive lobbying, notably in Uganda[21]Kerry Cullinan, “As election draws close, Trump groups push hard against abortion, LGBTQ rights in Africa”, Health Policy Watch, 30 October 2024, … Continue reading where a law passed in 2023 has criminalised homosexuality.[22]Neil Datta, “Anti-gender in Africa: Role of Western organizations”, Hirschfeld-Eddy Foundation, 11 December 2024, https://blog.lsvd.de/anti-gender-in-africa-role-of-western-organizations Since the beginning of the year, organisations in civil society that continue to receive US aid are also forced to sign commitment letters to limit their actions and expressions on LGBTI and gender issues, in accordance with the global gag rule or “Mexico City Policy”.[23]Katie Keith, “Trump reinstates Mexico City policy, prioritizes Hyde Amendment enforcement”, Health Affairs, 26 January 2025, https://www.healthaffairs.org/do/10.1377/forefront.20250126.458363/full At the same time, Russian soft power supports similar narratives, claiming to defend “traditional African values”.[24]Neil Datta, “Anti-Gender in Africa: Role of…”, op. cit. ; Le Monde avec AFP, « Au Burkina Faso, l’homosexualité devient illégale et passible de prison », 2 septembre 2025. This influence is all the more powerful that, paradoxically, in certain regions, such as the Sahel, it is combined with decolonial rhetoric.[25]Maxime Audinet, « Stratégies d’influence de la Russie en Afrique », Crash, 3 avril 2025, https://msf-crash.org/fr/rencontres-debats/strategies-dinfluence-de-la-russie-en-afrique Players from key populations are particularly vulnerable to this, since the services intended for them are heavily dependent on foreign funding.[26]UNAIDS, 2025 Global AIDS Update – AIDS, Crisis…, op. cit. In response to this movement, some organisations such as Alliance Globale des Communautés pour la Santé et les Droits (AGCS PLUS) aim to give a decolonial response to combat LGBTI-phobia in Africa.[27]All Out, Appel à la décolonisation du plaidoyer et la dépénalisation, pétition, 21 juillet 2025, http://action.allout.org/fr/m/13ad836
This political exploitation can also be seen in the international research and public health ecosystems. The Trump administration has imposed censorship on terms related to gender and sexual minorities in public productions, marginalising researchers and programmes that made use of them and leading to self-censorship from all stakeholders in the ecosystem.[28]Joseph J. Amon, “Trump’s banned words and disastrous health policies”, Health and Human Rights Journal, Fight for rights Viewpoint series, vol. 27, no. 1, 3 February 2025, pp. 83–86, … Continue reading This also leads to concealment of practical implications of decisions, in particular budgetary ones.
Political restructuring of global health: finding a community-based, multilateral and decolonial response
Communities at the centre of global health: what drivers can be used to reach the most marginalised populations?
Full integration of communities in the bodies making the decisions that concern them is still the prerequisite for an effective response. This implies, for the health sovereignty of Southern nations, recognition of the role of peer educators and community human resources as fully fledged stakeholders in healthcare systems. In 2024, PEPFAR funded more than 113,000 community workers worldwide[29]UNAIDS, 2025 Global AIDS Update – AIDS, Crisis…, op. cit. and its axing exacerbates the shortage of healthcare personnel in many African countries. Projects such as REPAIR (REconnaissance de la PAIR education – Recognition of peer education), currently implemented in Senegal and Burundi, invest, for the long term, in community human resources to fight HIV, strengthen healthcare systems and pandemic preparedness. South-South cooperation also helps enhance knowledge derived from community practices. Projects such as EpiC (Study to Document the Impact of this Crisis at Community Level in the Fight against HIV and HCV [hepatitis C virus]) illustrate the ability of local players to produce valuable input for advocacy, to document the conditions in which they work and to develop responses tailored to realities on the ground.
Rebuilding the architecture of global health
The current state of world affairs has once again put the spotlight on criticism of a global health architecture based on structural dependence on volatile funding, often subject to the political interests of donor countries and its high degree of verticality. This fracture weakens access to healthcare but has also contributed to a restructuring of the healthcare sector, within which two trends are emerging. On the one hand, there is a retreat into nationalism and austerity, promoting a reduction of aid to its strictly opportunistic or security-related dimension. And on the other, there is an increasing demand for health autonomy in the countries of the South, which should not, nevertheless, be interpreted as a justification for the disengagement of traditional donors. For it to be fair, the restructuring of the architecture of global health cannot only consist of reducing the complexity of the current system or encouraging the transition from aid to trade. A new equilibrium must be built between international funding and domestic resources. Coalition PLUS and several international community networks stress this point: a fair, decolonial transition to autonomy implies a real transfer of resources, technology and power, and not just a simple delegation of responsibility to the most vulnerable states.
Translated from the French by Fay Guerry
Picture credit : © CICR / Phil Moore
