HIV services plunge at four providers in Uganda and Zimbabwe after U.S. aid cuts
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A new study from the London School of Economics and Political Science (LSE) and Duke University, published in The Lancet Global Health, documents severe and sustained declines in HIV service delivery for some of the world's most vulnerable populations at four nongovernmental organizations in Uganda and Zimbabwe following the cuts to U.S. foreign aid in 2025.
The research, led by Dr. Henry Cust, LSE fellow in the Department of Health Policy and former research scientist at Duke's Sanford School of Public Policy, is the first to measure the impact on service delivery using data from within organizations whose U.S.-sourced funding was cut and never restored.
Services collapsed after funding withdrawal
HIV prevention, predominantly PrEP (pre-exposure prophylaxis), HIV testing and treatment (antiretroviral therapy; ART) all fell sharply after the 2025 PEPFAR (President's Emergency Plan for AIDS Relief) and USAID (US Agency for International Development) stop-work orders and had not recovered by March 2026, despite a humanitarian waiver meant to protect lifesaving services.
The study shows that when the United States froze foreign aid in January 2025 and halted work under PEPFAR and USAID, HIV service providers in Uganda and Zimbabwe lost more than funding. They lost the systems that helped keep prevention, testing and treatment services running for people at highest risk of HIV.
Cust said, "For the first time, we can put real numbers on what the U.S. funding withdrawal actually did for those most vulnerable to HIV and at the forefront of the epidemic.
"In the organizations involved, services used successfully to tackle the HIV epidemic in sub-Saharan Africa fell by between a half and two-thirds, largely remaining there through March 2026. The safety net that was supposed to preserve lifesaving treatment did not hold. The services and community trust that took decades to build were dismantled overnight."
That erosion of trust is already visible to the organizations involved.
Byrone Chingombe, key populations program technical director at the Center for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, one of the organizations in the study, said, "The vulnerable populations we take care of do not trust our services anymore. They say, 'You went away without any notice, and you were not available, you left us with nothing.'"
Service losses persisted for over a year
The study used routine monthly and quarterly service data between January 2023 and March 2026 to track changes in prevention, PrEP, treatment and testing. Across the organizations studied, the authors found large declines in every core service area compared with 2024 averages. Prevention fell by roughly 37% to 63%, PrEP by 43% to 72%, treatment by 22% to 32% and testing by 59% to 64%.
The study adds something earlier rapid assessments and modeling studies could not provide, explained Cust. "Rapid assessments provided vital early warning, but they capture immediate, often qualitative impressions of disruption before the dust settles. Modeling studies project the long-run consequences and are important for estimating the range of possible impacts. But they rest on strong assumptions about how funding translates into infections averted and how services might respond.
"Our study measures what actually happened. Using routine service data from organizations that lost their U.S.-sourced funding, we show that services fell sharply and remained well below previous levels more than a year later. It turns warnings and projections into measured facts. It measured loss of care, for people with nowhere else to go."
Community care for criminalized populations
The paper focuses on nongovernmental organizations that serve key populations (men who have sex with men, female sex workers, people who inject drugs, prisoners and transgender people) in Uganda and Zimbabwe.
In both countries, many of these populations are criminalized, which means they face stigma, legal barriers and limited access to health services used by the general public. Community-based care is especially important and often their only option.
Cust said the study should not be stretched beyond what the data can support, but it likely reflects a wider pattern among organizations that provide lifesaving services that relied heavily on USAID contracts.
Waiver failed to protect treatment
The findings also show the limits of the humanitarian waiver that was supposed to protect lifesaving care. Even treatment services declined after the waiver took effect, suggesting that dismantling the channels that delivered funding limited the waiver's ability to restore the staff, commodities and delivery systems needed to keep care going.
Cust said, "The U.S. released a waiver that said lifesaving services could continue working, and, by implication, would continue to receive funds. That should have protected HIV treatment. However, because they dismantled the apparatus to deliver the funding and distribute the drugs, the waiver had limited impact on USAID-funded organizations. It's a case of actions speaking louder than words."
Cust added that the study points to three urgent needs: protecting the HIV services that the most vulnerable populations rely on and that local health systems are unlikely to replace; strengthening emergency transition funding; and using this moment to build stronger and more inclusive domestic services.
He said, "The most vulnerable populations have lost a lifeline, and the urgent focus needs to be on protecting services for key populations that are crucial to fighting HIV. Not all organizations serving these populations have survived, and those still hanging on desperately need renewed funding."
Publication details
Henry Cust et al, HIV service delivery after the PEPFAR and USAID HIV funding withdrawal in Uganda and Zimbabwe: an interrupted time-series study, The Lancet Global Health (2026). DOI: 10.1016/j.langlo.2026.104061
Journal information: The Lancet Global Health
Key medical concepts
HIVAntiretroviral TherapyHIV TestingPre-Exposure Prophylaxis Provided by London School of Economics Who's behind this story?
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