On August 24, Lewin left his role overseeing State’s foreign assistance portfolio to become director of policy planning and a special adviser to Secretary Marco Rubio. The former DOGE staffer helped oversee one of the most consequential and controversial remakings of U.S. foreign assistance in decades. Devex reported the move this week.

The fiscal year ends September 30, barely a month from now. In an August 26 letter, 138 lawmakers warned that approximately $7.5 billion in international affairs funding remains unobligated, including more than $3 billion for global health. They demanded answers from Secretary Rubio and OMB Director Russell Vought by September 9.

So, yes, State is moving money. It is also racing to solve a problem the administration helped create, while Congress asks what has actually been obligated and what could still disappear. I return to those questions below.

Lewin’s departure is a good moment to examine the ledger. Under his watch, State announced billions through country health agreements, awards, procurement vehicles, and public-private partnerships. But announcements are not obligations, and obligations are not disbursements.

I reviewed the available announcements and tried to organize them into three buckets.

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First, the country agreements

The United States has announced approximately $14.48 billion across 34 bilateral health agreements and related country commitments.

These agreements cover HIV, tuberculosis, malaria, maternal and child health, disease surveillance, laboratory systems, supply chains, and health workforce investments.

Nigeria has the largest announced U.S. envelope at $2.1 billion, followed by Mozambique at $1.8 billion, Uganda at $1.7 billion, Kenya at $1.6 billion, and Tanzania at at $1.3 billion.

Partner governments have also promised approximately $9.17 billion in co-investment. It represents domestic resources that countries say they will mobilize alongside American assistance.

But an MOU is not the same thing as an award. Most of these commitments stretch across three to five years and remain subject to appropriations, implementation plans, and performance requirements.

Side note - but an important one - KFF estimates that proposed U.S. funding under the country agreements is $7.3 billion, or 34%, below U.S. funding for the same countries during the preceding five-year period. That changes the interpretation: the agreements may be large in absolute terms, but they also institutionalize a substantial reduction in U.S. support and shift more responsibility to partner governments.

Second, the new funding pipeline

GHSD has established an Advancing Global Health Annual Program Statement, or APS, with a ceiling of up to $4.5 billion.

The APS is basically a standing procurement platform. If that sounds familiar, it should because USAID used similar mechanisms to move money out the door. GHSD can now issue targeted “addenda” for individual countries or cross-cutting priorities without building a new funding mechanism each time. The APS includes separate tracks for funding tied to country MOUs and for priorities outside those agreements too. (see previous Stack on this)

For now, these are solicitations. State has not yet announced who will receive the money.

Third, the other big-ticket announcements

Beyond the country agreements and the APS, State has announced several other large commitments. This is where the accounting gets tricky: some appear to be standalone, while State says others will draw from existing MOU allocations.

• $600 million to Gavi, covering previously appropriated FY2025 and FY2026 funding. State and HHS announced the release jointly after reaching an agreement with Gavi on a series of policy and operational changes. Read the joint statement.

• Up to $150 million for Zipline over three years to expand drone delivery of medicines, blood, and other health products. This is a binding agreement, but “up to” matters: the final amount will depend on performance and implementation. Read the State Department announcement.

• $512 million for Ebola response: By August 5, State said its direct-assistance announcements had exceeded $512 million, including another $242 million for outbreak response, regional preparedness, and related humanitarian assistance. Because the funding comes through several accounts and bureaus, it should not be treated as a clean GHSD-only commitment. Read the State Department announcement.

• $661 million released to the Global Fund: In July, the administration released $661 million in previously appropriated funding owed from the prior replenishment cycle. Separately, the United States has pledged $4.6 billion for the Global Fund’s current cycle, subject to future appropriations and the requirement that every U.S. dollar be matched by two dollars from other donors.

• $260.5 million for procurement: On May 12, 2026, GHSD awarded the Global Fund a fully obligated $260.5 million grant to purchase HIV and malaria products through wambo.org, according to federal records. The award runs through January 2, 2028, and marks State’s shift from procurement previously managed through USAID supply-chain contracts.

• $850 million Faith and Community Initiative award involving World Vision and a consortium of faith-based organizations. World Vision has already received $250M of this amount.

• $570 million for faith-based health facilities will reportedly flow through existing bilateral health agreements. This is an allocation from the MOU envelopes, not additional funding.

• $38.3 million for Gilead Lenacapavir partnership: The State Department, PEPFAR, the Global Fund, and Gilead announced a partnership to expand access to twice-yearly lenacapavir for HIV prevention. Federal award records identify a State Department grant to the Global Fund worth up to $38.3 million for lenacapavir procurement. It remains unclear whether this represents the full U.S. commitment.

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What the funding pattern tells us

The America First Global Health Strategy made clear that State wanted to move much more U.S. assistance directly through partner governments. Some of that shift is motion. The country agreements put governments in the lead, require more domestic spending, and set out plans for them to take on staff, commodities, and services.

But follow the announcements and the picture is more complicated. State is still routing large sums through the Global Fund, contractors, companies, faith-based networks, and other outside organizations. The system taking shape looks more hybrid than purely government-to-government.

So that means a government may own the plan without necessarily controlling all the money behind it. It also means countries are taking on more risk. Some will be ready to absorb salaries, medicines, laboratories, and data systems as U.S. support declines. Others will not.

It is still too early to know who will benefit most from this new model. So far, State appears to be making fewer, larger awards to major organizations and companies. That may move money faster, but it could leave local groups working under large prime recipients rather than controlling programs themselves.

One other note here - State has also talked a lot about working with the private sector. So far, there have been fewer deals than I expected. We have not seen a major partnership on diagnostics or laboratory capacity, nor a significant digital health/AI initiative focused on surveillance, supply chains, or program delivery. That could change.

What State still needs to explain

Congress appropriated approximately $9.4 billion for Global Health Programs in FY2026. But the country agreements, APS addenda, multilateral pledges, and standalone awards overlap. They cannot simply be stacked on top of one another.

As a former congressional appropriations staffer, I can say this is an interesting time to have that job. I do not envy the staffers trying to get straight answers from State: How much has been obligated? Which appropriation funded each award? And how much remains available?

But those figures do not resolve what is happening with the expiring FY2025 balance. Devex reports that more than $3 billion in prior-year global health funding remains at issue: the White House has proposed using $1.35 billion for USAID closeout costs, while another $1.9 billion remains unobligated and could expire on September 30. Its reporting also cites an analysis of White House data showing only $262 million obligated by the end of July. Read the congressional letter.

State should publish country implementation plans, award recipients, funding periods, fiscal-year funding sources, annual obligations, and disbursements in one consistent format. Partner-government contributions should also be tracked separately from U.S. funding.

The money is moving, and that is good news for US global health support. But a substantial amount remains unreconciled, and the fiscal-year clock is running.

Congress has five questions. I have five more.

Congress is asking the urgent legal and budget questions: Where is the money, what happened to it, and will State spend it before time runs out?

I would add five more. These are less about closing out the fiscal year and more about the global health system State is building in its place.

1. How much money will State actually obligate before September 30? More than $3 billion in global health funding is nearing expiration.

2. Which awards are already included in the country agreements? State needs to show which contracts, APS awards, and commodity purchases come from MOU envelopes—and which represent additional funding.

3. How will State measure whether the transition is working? Domestic financing is only one measure. State should also track whether governments can pay health workers, prevent commodity stockouts, maintain laboratories and data systems, and sustain service coverage. What benchmarks will determine when U.S. support declines—or when the transition needs to slow down? How much money is going to civil society ?

4. Who is responsible for the data? With programs spread across governments, the Global Fund, contractors, companies, and faith-based networks, who will collect and report results, reconcile different data systems, and intervene when programs fall behind?

5. What exactly is the Innovation Fund? State has described it as a new vehicle for American-led research, market-shaping, and health technologies, but has not disclosed its size, funding source, governance, or investments. Is it a separate pool of money—or simply a label for deals financed through existing accounts?

The disconnect was hard to miss.

In Washington, much of the conversation is about protecting and preserving what PEPFAR built. And for good reason, don’t get me wrong. But In countries, the conversation has already moved on. It is about adapting programs, building new protections and deciding what can survive a very different funding future. And I think that is a good thing.

The conversation was practical and specific. They talked about rewriting clinical guidelines, consolidating supply systems, shifting costs onto national budgets and keeping skilled workers in place as donor-funded positions disappear. They were also clearly already making hard decisions about which services to protect first.

Some of the mitigation strategies were remarkable. Others left me uneasy. More about that below.

There were clear warnings about the lack of resources to expand prevention with anything close to the ambition this moment requires. I also heard blind spots around the last mile, especially the interventions needed to reach people at highest risk of acquiring HIV. Those are early warning signs. We should treat them that way.

Let me also be clear about what I mean by “post-PEPFAR.” PEPFAR is not over. Its job is not done. The latest UNAIDS data show that in 2025 the world recorded one million more new HIV infections and 400,000 more AIDS-related deaths than it would have if we were on track to meet global targets. PEPFAR remains critical even if it’s a shell of its former self.

So what are countries doing?

A view from five countries

Sierra Leone. Sulaiman Lakoh described how the country is using the funding squeeze to integrate HIV, tuberculosis and malaria more deliberately into primary care. It is aligning plans, costing, laboratories, supply chains, financing and data across 13 shared areas.

Malawi. Stephen Macheso walked through the country’s effort to simplify its national HIV guidelines. That includes reducing the number of antiretroviral therapy initiation regimens from 15 to 3 and reconsidering how often stable patients need viral load testing.

Cambodia. Vichea Ouk described a country that has achieved more than 98 percent viral suppression among people on treatment. But new infections continue, especially among key populations. Its next challenge is sustaining treatment while financing a much more ambitious prevention response.

Zimbabwe. Gerald Nyamutamba focused on the nuts and bolts: forecasting, procurement and data visibility. Better quantification has reduced stockouts and expiries and produced about $96,720 in monthly savings.

Zambia. Earlier in the week (not part of this session), Lloyd Mulenga described a minimum package for sustainable HIV service delivery across 2,885 facilities. It sets a common standard. It also forces hard choices about what to continue, what to integrate and what to stop.

None of these countries has figured it all out of course. That is partly what made the presentations so useful. They offered an honest look at decisions being made in real time.

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Here are four themes that emerged for me:

Integration as a sequence

Integration is not one decision. It is a series of decisions about services, money, workers, commodities, laboratories, data and accountability.

Each function moves at a different speed. Each carries a different risk if it fails.

Lakoh was explicit about that. Because roughly 80 percent of services in Sierra Leone are delivered through primary care, the government is redesigning programs around the place where people already receive care. It is also using common planning and costing tools to rank interventions. Its goal is to increase domestic financing for HIV from 9 percent to 20 percent by 2030.

Mulenga showed how Zambia is approaching the same challenge through its minimum package (see figure below). The government is establishing a consistent floor for HIV services while weighing what it can afford and how it will hold the system accountable.

This is what country ownership looks like: a government deciding what to integrate, how community-led services fit within the national system, what to protect and what it can realistically sustain. But integration is not a single handoff. It is a managed sequence. Some services may move into primary care quickly. Procurement, laboratories, community workers and commodity financing will take longer. Rushing that process does not make transition happen faster. It simply makes disruption more likely and harder to detect.

Efficiency and its risks

Efficiency is one of the most overused words in global health. Too often, it means doing the same work with fewer people until something quietly breaks.

That was not what Stephen Macheso described in Malawi. The country is reviewing its HIV clinical guidelines line by line to remove unnecessary complexity. That work includes reducing the number of antiretroviral therapy initiation regimens from 15 to 3 and reconsidering how frequently stable patients need viral load testing.

Those changes have practical consequences. Fewer regimens mean fewer products to forecast, procure and keep on clinic shelves. They also simplify training and make it easier for health workers to follow the guidelines consistently. Done well, simplification can lower costs while making care easier to deliver.

But Macheso drew an important line. Simplification is not the same as cutting services indiscriminately. Each proposed change had to preserve quality, equity and health outcomes. When the evidence did not support a proposal, officials reconsidered it. A process expected to take six months had already taken more than a year. See here:

The delay was worth it because Malawi was asking whether each proposed change would actually improve the program, not simply save money.

Lloyd Mulenga made the tradeoffs more explicit in Zambia. Generalized community HIV testing is being replaced with more targeted approaches designed to produce higher yield at lower cost. Prevention for adolescent girls and young women (formerly DREAMS) is being integrated into youth-friendly services instead of operating as a parallel platform. See full list below.

These choices may make sense on paper (or a slide for that matter) but they can also create new gaps. More targeted testing may produce better numbers while missing people whose risk is less visible. Integration may reduce duplication while weakening the community services that reached people the formal system never did.

The prevention warning

Cambodia has extraordinary treatment outcomes. Yet new infections continue, and prevention remains heavily dependent on external financing.

Treatment is easier to defend as an essential obligation. Prevention is more exposed. That is especially true when it is delivered through community organizations serving gay men, sex workers, people who use drugs and others pushed to the margins.

Ouk described Cambodia’s joint HIV and tuberculosis sustainability roadmap. The country is absorbing more commodity costs into the national budget and examining how twice-yearly injectable lenacapavir might fit into its prevention strategy.

Mulenga described Zambia as narrowing prevention rather than abandoning it. But the shift from broad community testing to more targeted approaches raises a basic question: who becomes harder to find?

Long-acting PrEP should be available to anyone who wants it and could benefit from it, across all populations at risk of acquiring HIV. Targeting can help programs reach people, but it should not become a barrier that determines who gets access to new prevention options.

I worry that the current financing conversation is much better developed around treatment continuity than around the prevention ambition needed to keep epidemics moving downward. Treatment continuity is non-negotiable. But if prevention becomes a causality of aid transition, new infections will rise again.

Data should govern the transition

Gerald Nyamutamba’s presentation on Zimbabwe focused on the basic workings of the supply chain: forecasting, procurement, warehouses and the movement of data between facilities and the central government.

A 2025 assessment found experienced supply-chain staff, but weak interoperability and limited visibility across the system. Zimbabwe responded by combining forecasting across disease programs, creating a Ministry of Health-led procurement and supply management group, and linking facility and central systems through its digital health blueprint. Nyamutamba reported fewer stockouts and expired products, along with about $96,720 in monthly savings.

Other countries described using data in similar ways. Zambia’s minimum package provides a benchmark for assessing service quality. Malawi reviewed the evidence behind each proposed guideline change and rejected changes that could not be supported. Sierra Leone is using shared planning and costing tools to compare interventions and decide what to prioritize.

These examples show why data needs to guide the pace of transition. Governments and donors need to know whether integration is improving services, creating new gaps or weakening access for particular communities.

A July 2026 National Academies report commissioned by the U.S. State Department recommends tracking viral suppression, retention in care, commodity availability, service quality and access throughout the process. If those indicators begin to deteriorate, governments and donors should be prepared to slow, revise or reverse parts of the transition.

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What Washington needs to hear

If you have read this far, you probably understand why this session stayed with me. Country after country described practical changes already underway. This is not the conversation we are having in Washington. It should be.

Country realities should be the starting point for transition. Integration needs to happen function by function, with evidence guiding what moves, what stays and what needs more time. Simplification can reduce costs, but it cannot come at the expense of quality or access. And workforce, community delivery, prevention, supply chains and data systems cannot be treated as secondary concerns.

Country agreements should start with the plans governments are already building. Timelines should reflect how long implementation actually takes. Donors also need to fund the transition itself. Integration costs money. So does retaining critical staff and protecting services that domestic budgets cannot absorb overnight.

The National Academies report is clear on this point. Integration is not a substitute for adequate investment. Moving HIV services into primary care without realistic costing, protected budgets and procurement capacity risks creating an unfunded mandate.

One final thought - I was keen to see how governments are beginning to use AI to strengthen efficiency planning and improve service delivery. I am eager to learn more about what is working and how these tools can be scaled responsibly.

CHAI should take this session on the road. The officials shaping PEPFAR agreements in Washington, Global Fund decisions in Geneva and aid budgets across Europe need to hear directly from the people managing these choices.

I left Rio impressed by how quickly countries are adapting but also worried about the limits of what adaptation can achieve. Countries cannot compensate indefinitely for declining resources, especially if prevention, community delivery and the last mile are treated as optional.

A note to readers

Washington still sets much of the policy and controls much of the money. But country voices need to be much closer to the people making those decisions. That is hardly a new idea, yet somehow we have lost the plot on it.

I want to work with others committed to bringing evidence-based country stories directly to lawmakers, the State Department and other donor capitals. If that sounds like you, please reach out to me.

His company spends more than $250 million every year covering GLP-1 medications for its employees. That represents roughly 13% of Bank of America’s entire employee healthcare budget.

Moynihan did not complain about the cost. He called it a good investment.

“We see a great impact on the employees,” he told CNBC from Aspen. Some employees will leave before Bank of America captures the long-term financial benefits of their improved health. Moynihan acknowledged that reality and still said providing access is “the right thing to do.”

It was refreshing to hear a CEO talk about public health so plainly. Better health has value, even when a company cannot recover every dollar within the next quarter or assign the return neatly on a spreadsheet.

Last year, I argued that getting HIV pre-exposure prophylaxis, or PrEP, should be as easy as getting Ozempic. If telehealth companies can deliver weight-loss drugs through online consultations and home delivery, why does HIV prevention remain trapped behind stigma, unnecessary clinic visits, and confusing insurance rules?

The Bank of America story adds another lesson. PrEP should not only be as easy to access as a GLP-1. Employers should value it with the same confidence.

Employers can change the market

PrEP is one of the most effective tools we have to prevent HIV. When taken as prescribed, it reduces the risk of acquiring HIV through sex by about 99%. People can now choose from daily pills and long-acting options.

Yet access in the United States remains harder than it should be. A 2024 review of 325 private insurance plans found that 13% did not identify any PrEP drug as available without a copay. Nearly one-third did not list PrEP among their no-cost preventive services. And 66% failed to clearly explain whether essential PrEP services, such as laboratory tests and provider visits, were covered without cost sharing.

Employers have enormous leverage to change that. Employer-sponsored insurance covers about 165.6 million Americans under 65. A National Alliance report released late last year, Ending the HIV Epidemic: Employer Strategies for Impact and Support, showed how benefit design, confusing coverage rules and administrative barriers continue to limit access to PrEP. The report called on employers to audit their health plans, eliminate unnecessary prior authorization and ensure employees can access PrEP and related services without cost sharing.

One more thing - and this I love - Bank of America does more than pay GLP-1 pharmacy claims. It pairs access with health coaching and pushes drug manufacturers and pharmacy benefit managers for lower prices. Employers should bring the same seriousness to PrEP.

PrEP in the United States

The United States has made historic progress on PrEP. Use has increased every year since its approval in 2012, reaching a record 644,170 people in 2025. But growth slowed to 10% last year, the smallest annual increase in five years, and only about three in ten of the estimated 2.2 million Americans who could benefit from PrEP currently use it.

Employers can help close that gap by turning nominal coverage into simple, affordable and confidential access.

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I was also disappointed that this mistake became one of the conference’s biggest media stories. Because AIDS 2026 produced important science, serious policy analysis and real progress on issues ranging from PrEP delivery to global aid transitions.

Rather than add to the gotcha coverage, I will highlight the six stories I think that matter more.

First, a caveat. Two people can attend the same conference and have completely different journeys, conversations, partnerships and takeaways. That is one of the beauties of conference week. Yet for that one week, we come together as a family around the goal that brought us here in the first place: erasing HIV from the map. Now that is the cartographic correction that matters.

1. The HIV prevention revolution is here

The HIV prevention revolution is no longer coming. It has started.

Gilead’s lenacapavir, which showed near-complete protection in clinical trials, is now reaching people through national programs. South Africa accounts for just over half of all lenacapavir users in African national rollouts, with 31,297 of roughly 60,000 users. Among people offered a choice, 98.5% selected twice-yearly lenacapavir over daily oral PrEP. About one-third had never used PrEP before.

So Lenacapavir is not simply giving existing PrEP users a more convenient option. It is bringing new people into HIV prevention. Women represent 72% of users so far, and pregnant and breastfeeding women account for more than one-quarter. This is particularly encouraging given the disproportionate HIV risk faced by women and girls across much of sub-Saharan Africa. Read the great analysis here from Bhekisisa.

But, and this a huge but. Uptake remains strikingly low among sex workers, gay and bisexual men, transgender people and people who inject drugs. The closure of community clinics following U.S. funding cuts may be one reason. A breakthrough product cannot reach people if the trusted organizations serving them have closed their doors.

ViiV Healthcare also showed that long-acting prevention will not stop with the options available today. Its AIDS 2026 program included real-world findings on Apretude, its injectable cabotegravir product, as well as early work on a new formulation that could reduce dosing from six injections a year to three. ViiV also presented findings comparing people’s experiences with cabotegravir and lenacapavir injections. That work matters because comfort, convenience and personal preference will help determine which products people choose and continue using.

Therese three slides from Raphael Landovitz’s plenary sum it up:

Merck added another important element to the to the future. The company announced voluntary licenses with seven generic manufacturers for alimatravir, its investigational once-monthly oral PrEP pill, covering 129 countries. Three licensees are based in Kenya, Uganda and South Africa. Merck made the announcement while Phase 3 trials are still enrolling, giving manufacturers, governments and donors a chance to prepare for access before approval rather than years afterward. That represents real progress.

Still, the licensing agreement itself leaves out most of Latin America, including countries participating in the drug’s clinical trials. That is a familiar and unacceptable pattern: communities help generate the evidence but may not share promptly in its benefits. Early licensing deserves credit, but access must follow epidemiology, not geography or World Bank classifications.

The International Treatment Preparedness Coalition (ITPC) captured this contradiction brilliantly with my favorite conference display showing how companies can treat PrEP like a luxury product: innovative, desirable and available mainly to those in the right markets. See picture below. The point landed. HIV prevention is not a designer handbag.

Together, lenacapavir, cabotegravir and alimatravir could move us beyond a one-size-fits-all approach. People may soon be able to choose daily, monthly, multi-monthly or twice-yearly protection based on what works for their lives.

The science has delivered the beginnings of a prevention revolution. Now governments, companies, donors and communities must ensure that it moves at the speed of need rather than the speed of markets.

2. We need to make PrEP much, much easier to get

A prevention revolution means little if people still need to navigate a maze to participate in it.

Last year, I argued that getting PrEP should be as easy as getting Ozempic has become for some people. Rio only reinforced that view. When demand exists, health systems and markets can move quickly. HIV prevention deserves the same convenience.

“Demedicalizing PrEP” emerged as a major theme in Rio, and for good reason. PrEP is prevention, not a medical emergency. Yet we often deliver it through systems designed to manage illness: repeated clinic visits, long waits, unnecessary laboratory requirements and limited dispensing hours.

The conference offered a better blueprint. In Kenya, trained pharmacists are initiating and refilling PrEP without requiring physician visits. Brazil is testing dispensing machines in transit hubs (see picture below), allowing people to collect prevention privately and conveniently. In the United States, MISTR’s telehealth model allows people to complete consultations online and receive PrEP at home. Community-led programs in South Africa and Thailand are bringing services directly into spaces where key populations already gather and feel safe.

These models do not lower clinical standards. They remove barriers that add little medical value but drive people away. And the same principle must shape the rollout of long-acting products. A twice-yearly injection will not transform prevention if people must travel hours to an overcrowded clinic to receive it. Countries should plan now to deliver new options through pharmacies, community organizations, mobile services and other trusted settings.

The remaining barriers are no longer primarily scientific. They are operational and political: who can test, prescribe, administer and dispense PrEP; how providers get paid; how public, private and community data connect; and how programs protect quality, privacy and continued use at scale.

Countries now need a common multi-channel blueprint connecting pharmacies, community organizations, public facilities, telehealth and home delivery. That means creating adaptable regulatory pathways, building interoperable data systems, paying community partners for their work and measuring success through equitable access and continued use, not the number of pilots launched or products distributed.

The message from Rio was simple: prevention must fit into people’s lives. We cannot keep asking people to reorganize their lives around the health system.

If we can withdraw cash from a machine, order dinner from a phone and receive almost anything at our door, we can surely find easier ways to deliver PrEP.

3. Communities built the HIV response. They came with receipts.

You did not need to travel to Rio to learn that communities are the backbone of the HIV response. If you have worked in HIV for more than a few months, you should already know that. Still, some institutions apparently needed the refresher.

The conference program was rich with examples of community-led monitoring and implementation. Community leaders showed how they identify service gaps, track medicine stockouts, reach people traditional health systems miss and turn policy promises into real services. They also presented practical solutions, including peer-led testing, community delivery of HIV treatment and prevention, and digital outreach designed around the realities of young people.

At the same time, it was clear that this part of the HIV response has taken one of the greatest hits over the past year. Funding cuts have weakened community organizations (read amfAR report), disrupted monitoring and removed many community voices from decisions that directly affect them.

These organizations form part of the HIV response’s essential infrastructure. They often see problems before governments or donors do. They know when stigma drives people away from clinics, when services disappear and when a policy that looks good in Washington fails in practice.

The State Department now has some catching up to do. It must bring civil society and NGO partners back to the table, although the truth is that communities built much of that table in the first place.

Doing so would restore the transparency, accountability and visibility that have long defined PEPFAR but have been lost under the current approach. Community involvement makes HIV programs better. It identifies problems earlier, strengthens accountability and keeps policies connected to what people actually experience.

Post-Rio offers a good moment for a reset. The State Department should take stock of the first 18 months of its new approach and pause the MOU implementation process long enough to assess what is working, what is not and where communities remain absent. A course correction now could prevent much larger failures later.

As financing tightens and countries integrate HIV services into broader health systems, community leadership will become even more important. We must fund communities, share decision-making power and include their knowledge from the beginning. Integration cannot mean invisibility, especially for the people most affected by HIV.

4. AI is already part of the HIV response. Now we must make it work at scale

Izukanji Sikazwe gave one of the best presentations I heard all week. It was a showstopper, but not because she promised that AI would solve everything. Quite the opposite. She cut through the hype, named the risks and showed what responsible use could look like.

She reminded us that HIV programs have used AI-related tools for decades. UNAIDS Spectrum models support national planning in more than 170 countries. Supply-chain systems use consumption data, patient volumes and procurement timelines to forecast where medicines should go.

We did not always call this AI, but the basic idea is not new.

Her main concern was “pilotitis,” the endless cycle of promising pilots that never become real programs. A tool may work for 200 patients with a dedicated research team. That tells us very little about whether an overstretched clinic can use it every day.

“Scale is where real impact lives” was probably the most important line of her presentation. She also pointed to the Global Fund’s investments in digital health as an example of what building for scale can look like. The Global Fund now invests roughly $150 million a year in digital tools across more than 90 countries.

But Izukanji was equally clear about the risks. Scaling AI without strong governance could deepen the same inequities the HIV response has spent decades fighting. These systems can reproduce bias, exclude marginalized communities, misuse sensitive health information and destroy trust.

Presentations from Audere Africa brought some of these ideas down to earth. One analysis of Aimee, a WhatsApp-based AI companion in South Africa, included more than 9,300 adolescent girls and young women. Among those who engaged with the AI, 45% took up HIV testing, PrEP or both. That suggests AI can become a new way into care, not simply another place to find health information.

A related study found that structured HIV-risk prompts produced more complete assessments than conversations directed entirely by users, 67% compared with 6%. The lesson was not that we need a fancier model. We need to design better conversations.

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Another analysis exmined more than 300,000 interactions across Aimee, Coach mPilo and VimbAI. In the interactions reviewed, researchers found no harmful misinformation and no false negatives in detecting self-harm risk. Every identified high-risk interaction was escalated according to protocol. Automated triage also reduced clinicians’ workload while keeping people involved in the decisions that mattered.

A fourth presentation showed that AI conversations can capture more than 120 indicators covering HIV, sexual and reproductive health, mental health, behavior and social conditions. That information can help programs understand what communities are experiencing, target outreach and reduce the reporting burden on health workers.

This could become especially useful as funding cuts weaken community-led monitoring. But AI cannot become an excuse to replace or defund communities. It should help health systems hear them more clearly and respond more quickly.

The question is no longer whether AI belongs in the HIV response. It already does. The real question is whether we can use it responsibly and at scale.

The State Department can help move this work beyond pilots. Its new Advancing Global Health Annual Program Statement is designed to fund projects that complement bilateral agreements and fill implementation gaps. GHSD should issue an addendum focused on HIV and responsible AI, with funding for country-led and community-governed tools that can become part of real programs.

Izukanji ended with an image that stayed with me. We should treat AI more like a power grid than a product. It should support human interaction, not replace it. And we should judge it by outcomes that matter: infections prevented, people reached and lives kept healthy and engaged in care.

5. The tension we cannot ignore: Countries are finding solutions, but funding cuts are causing real harm

One of the most important tensions in Rio ran through several sessions.

On one side, amfAR and others presented evidence of what funding cuts have already caused: disrupted services, prevention gaps, workforce losses and rising risks for vulnerable populations.

On the other side, CHAI and country partners showed how governments are responding. Every country presented plans for reduced external funding, greater domestic financing and stronger government ownership.

Integration emerged as the dominant strategy. Countries are bringing HIV, TB and malaria programs together while consolidating laboratories, supply chains, workforce training and digital systems. They are trying to reduce fragmentation and make limited resources go further.

These reforms were not simply cuts dressed up as efficiency. Malawi described how it is simplifying treatment regimens, testing and training while protecting the quality of care.

Cambodia presented one of the clearest quantified transition plans. Faced with funding reductions and low PrEP uptake, the country selected a scenario for scaling up long-acting cabotegravir that could save an estimated $19.1 million over five years. (see below)

Zimbabwe reported nearly $967,000 in savings through integrated quantification and stronger coordination of supply chains across disease programs.

These are serious examples of countries adapting under pressure. But we should not mistake adaptation for evidence that funding cuts carry no consequences. Countries can improve efficiency, but efficiency alone cannot replace lost financing, health workers or community infrastructure.

The shared lesson was that transition takes time. Countries need phased implementation, interoperable systems, sustained technical support and realistic plans for absorbing health workers into government structures. None of that happens because an MOU sets a deadline.

This is where the State Department must focus. It should support what countries are trying to build, identify where transitions are already creating gaps and align technical assistance with country plans. It must also recognize that a government’s ability to improvise should not become an excuse to withdraw support faster.

Just a side note: The Rio Conference also drew many foundation leaders and representatives from donor governments. I was especially pleased to see the French Ministry for Europe and Foreign Affairs with such a prominent presence, a timely reminder that global HIV leadership does not begin and end with the United States.

6. We need to be more honest about “resilience”

We use the word “resilience” constantly. It appears in reports, speeches and descriptions of systems under pressure.

But in Rio, that word felt insufficient.

What I saw was struggle, improvisation, exhaustion, creativity and refusal. I saw people holding together systems that were never designed to support them in the first place.

I also saw activists turning on one another as resources disappeared. Scarcity does that, and it serves the people responsible for the cuts. We cannot allow a fight over shrinking resources to fracture the movement. We have to resist that.

Too often, we celebrate resilience when what we really mean is that people have been left to absorb the damage.

Much of the real work happened outside the official program. It happened in hallways, side events, late-night meetings and informal gatherings where people often build the true architecture of the response.

New alliances are also emerging outside traditional global health structures. I saw community organizations, private companies and nontraditional partners working together in ways that felt practical, not performative. These are not partnerships of convenience. They reflect a system under pressure. But they are also smart approaches.

“Resilience” may be too clean a word for this reality. It can hide the friction, inequity and constant negotiation required to keep services running. Worse, it can let institutions praise communities for surviving problems those institutions helped create.

The determination I saw in Rio was real. But communities should not have to prove their resilience by being asked to survive one crisis after another.

What I hope we remember from Rio

The global HIV response is not over.

In 2025, an estimated 1.2 million people acquired HIV and 570,000 died from HIV-related causes. The latest available breakdown shows that key populations and their sexual partners accounted for 49% of new infections globally in 2024. They must be the centerpiece of an evidence-informed HIV response.

At the same time, we have better prevention and treatment tools than at any previous point in the epidemic. The science keeps moving forward, but our policies, financing and delivery systems are struggling to keep pace.

Rio also reminded me that no institution or sector can close this gap alone. We need new partnerships that connect communities, governments, researchers, implementers, advocates, technology companies and the private sector. We also need people willing to move across these worlds, challenge the silos and keep everyone focused on results.

Personally, I left Rio seeing more clearly the silos within our field, the tension between policy and people’s lived experiences, and the disconnect between country realities and decisions made globally. That strengthened my commitment to being a bridge builder. I want to continue to bring programmatic realities into policy discussions in Washington and around the world. I left more motivated than ever to deepen my current partnerships and build new ones around the work ahead.

The map was wrong. Now let’s focus on getting the HIV response right!

Recent Stacks

I had previously identified senior State Department officials among my 10 people to watch at AIDS 2026. It was noteworthy—and important to recognize—that they showed up in Rio to explain their approach and engage directly with the HIV community. Showing up does not resolve the disagreements, but it creates an opportunity for scrutiny, accountability and dialogue.

Activists interrupted the session with chants of “Restore PEPFAR now,” challenging the administration’s entire global HIV strategy over the past year. Their intervention ([see their statement here]) forced the room to confront two urgent issues: the administration’s continued withholding of congressionally appropriated PEPFAR funding, which they described as unlawful, and mounting evidence of deteriorating clinical outcomes.

Once the presentation resumed, officials made several important announcements and policy statements. Here are the 15 that stood out to me.

1. “We are changing the model, not the mission.”

This was Jeff Graham’s central message. Officials said the United States remains committed to ending HIV but is replacing donor-managed programs with government-led systems.

The question, of course, is whether the model can change without disrupting the mission—or the people who depend on it.

2. State now has 34 bilateral agreements involving major financial commitments.

Officials said 34 agreements are in place. The United States has committed nearly $15 billion over five years, while partner governments have pledged approximately $10.2 billion.

State described the co-financing commitments as “carefully measured” against each country’s fiscal circumstances. A country-level breakdown will be essential to determine how much of the $10.2 billion represents new and additional health spending.

3. State says only 40 cents of every assistance dollar previously reached the front line.

Officials claimed that 60 cents of every dollar went to overhead, technical assistance and program management, leaving only 40 cents for frontline health workers and commodities.

That is a striking statistic—and one that deserves a published methodology. “Overhead” can conceal inefficiency, but it can also include laboratories, surveillance, training, quality assurance and other functions that keep services working.

4. Parallel PEPFAR infrastructure will be reintegrated into national systems.

State said separate supply chains, laboratories, data platforms and disease-specific workforces are inefficient and unsustainable.

The goal is to integrate them into government systems. That makes sense in principle. The risk is dismantling functioning infrastructure before national systems have the financing and capacity to absorb it.

Importantly, the State Department commissioned the National Academies to produce a rapid expert consultation on transitioning disease-specific programs into integrated, country-led health systems. I served as a reviewer. The report examines evidence and implementation considerations involving governance, financing, workforce, data, laboratories and surveillance.

It is notable that State invested in independent evidence generation during such a consequential transition. I hope State and partner governments now use that evidence to guide implementation.

5. The five-year MOU period is not necessarily a five-year transition deadline.

Officials acknowledged that they do not know how long every transition will take. Secretary Rubio has previously suggested that some countries may require seven, 10 or even 15 years.

That flexibility matters. Disease burden, debt, fiscal capacity, political instability and health-system readiness cannot be squeezed into one standardized timeline.

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6. State is holding back funds for central management.

Not all funding will flow through the bilateral agreements. State will retain several central funding “buckets” for:

• Innovation

• Performance incentives

• Transition resilience and unexpected shocks

Under innovation, officials highlighted the partnership with Gilead to expand access to lenacapavir, Zipline’s last-mile delivery model and new malaria technologies (slide below). They distinguished between product innovation and process innovation—both of which could change how countries prevent disease and deliver services.

Officials also said countries that exceed agreed targets could receive additional funding. The design, size and governance of these funds remain important unanswered questions.

7. The new APS funding mechanism is intended to bring in different partners.

State described its Annual Program Statement as a way to broaden the partner base beyond large international implementers.

Officials clarified that “quite a few” countries may receive direct government-to-government financing. Where that is not yet feasible, State will continue funding implementing partners (including some international NGOs) but with greater emphasis on local faith-based organizations, domestic provate sector and other local partners.

Decisions about implementing partners will be made jointly, although each government will retain final authority over how its own taxpayer funds are spent.

Localization could improve sustainability. But local ownership should not become code for outsourcing public responsibilities without adequate oversight.

8. State wants health data systems to be locally operated.

Officials said PEPFAR data systems briefly went offline during the past year, exposing the risks of externally operated platforms.

The new approach will shift systems toward country ownership because State believes local systems will be cheaper, more sustainable and more accessible to governments. The real test will be whether they remain timely, interoperable and capable of protecting HIV-specific visibility.

9. Aggregate data sharing will continue; specimen sharing applies only in some countries.

State said countries will still share epidemiological and financial data needed to track program targets and co-financing. Officials stressed that this does not include identifiable medical records.

They said specimen-sharing provisions appear in only a few agreements and are intended to facilitate rapid responses to disease outbreaks. These assurances should be compared with the actual legal language of each MOU.

10. State says civil society is part of implementation.

Officials said civil society will help monitor continuity, validate government data and identify communities being left behind. Some plans may include social contracting to finance community-led services.

While it was good to hear that emphasized out loud, affected communities need a seat at the table before decisions are finalized—not merely an invitation to monitor the consequences (which are also important).

11. The proposed implementation plans contain country-specific strategies for impact.

Dr. Rebecca Bunnell emphasized that the implementation plans are not meant to be financing documents alone. They reportedly contain approaches covering integration, prevention, diagnostics, technology, service delivery and health-system strengthening.

That is encouraging. These plans should all be published (as has been done previously for 20 years) so communities, researchers and legislators can assess whether the proposed changes are epidemiologically sound.

12. Triple elimination is emerging as a major integration strategy.

State highlighted efforts to address HIV, syphilis and hepatitis B together during pregnancy. Officials said approximately 120,000 children still acquire HIV each year and that 20 African implementation plans include the use of triple diagnostic tests.

This is the kind of integration that could expand impact while protecting HIV outcomes—provided countries maintain the commodities, workforce and follow-up systems needed to deliver it.

13. State views treatment as the highest-value HIV prevention intervention—but says prevention must include everyone at risk.

Officials argued that diagnosing people with HIV, initiating treatment and achieving viral suppression remain the most effective prevention investments.

They said PrEP should focus on people at the highest risk and that programs should consider the number of people who must receive PrEP to avert one infection.

Asked how prevention services would be intentionally designed for key populations, Dr. Rebecca Bunnell said the epidemic cannot be ended without including all people at risk. This was good to hear out loud!

That creates a significant accountability gap. A commitment to include everyone is important, but without specific targets and data, it will be difficult to determine whether key populations are actually being reached—or quietly left behind.

14. AI is already appearing in country implementation plans.

I was glad to see technology move beyond the buzzword stage.

State highlighted El Salvador’s use of community telehealth and Uganda’s deployment of portable, AI-supported chest X-ray systems for tuberculosis detection. Uganda reportedly plans to expand from 14 systems to 150.

These examples show where AI may add practical value: extending access, supporting health workers and finding cases earlier—not replacing health systems with chatbots and crossed fingers.

15. The future of HIV service delivery, State said, is simplification.

Officials repeatedly emphasized modernizing and simplifying service delivery. They pointed to differentiated care, less burdensome monitoring for stable patients and more efficient diagnostic and delivery systems.

They also highlighted self-care and new service-delivery models for both prevention and treatment. These approaches could include HIV self-testing, telehealth, community- and pharmacy-based services, longer medication refills and care models that require fewer routine clinic visits. The broader goal is to bring services closer to people while reducing costs and pressure on health facilities.

There will be a lot of evidence presented at AIDS 2026 on self-care, demedicalizing PrEP, differentiated treatment and new community-based delivery models. These presentations will be important to watch because they could directly inform the country implementation plans now being finalized.

Simplification should not become a euphemism for offering fewer services. Done well, it can make prevention and treatment easier to access, less medicalized and more responsive to people’s lives. The challenge is moving the evidence from conference rooms into national policy and implementation.

My bottom line

I left the session with a clearer understanding of how State sees the new model working and with a few unanswered questions. What happens in Zimbabwe, Zambia and South Africa?

There are sensible ideas here. PEPFAR has accumulated inefficiencies and parallel systems over 23 years. Country ownership cannot remain something we talk about but never achieve.

But people do not experience an aid transition through MOUs, financing formulas or organizational charts. They experience it through whether their clinic stays open, their medicines remain available and someone they trust is still there to help.

We should all want this transition to succeed. The test is simple: Are people staying on treatment? Is prevention reaching those who need it? Are new infections falling? Are communities still shaping the response?

Ultimately, that is what saves lives.

I’ve been attending since the 2008 conference in Mexico City, and there is still nothing quite like it. World leaders, scientists, activists, health workers, people living with HIV, journalists, TikTokers and other media influencers all share the same space. There is extraordinary energy—from the main stage to the Global Village—and plenty of dancing, protest and fashion that makes a statement.

This year’s conference arrives at a consequential moment for the global HIV response. Funding is under pressure. Prevention science is advancing faster than access. Key populations face renewed political attacks. Artificial intelligence is creating both excitement and anxiety.

Here are ten people—and issues—I’ll be watching in Rio.

1. Dr. Paulo Dos Santos: A New Generation Takes Its Seat

Paulo Dos Santos is the young person under 30 serving on the AIDS 2026 Organizing Committee. A 28-year-old physician from Buenos Aires, he works in infectious diseases, HIV care, key populations, research and medical education.

Young people are often invited to conferences to tell their stories. Paulo has a seat where decisions are made—and young people like him understand how to get new products to people and make those products fit into their everyday lives. It will not necessarily take a million-dollar advertising campaign. It will take talking to consumers, understanding how they think and where they spend their time, and building a genuinely consumer-driven approach to HIV prevention and care.

Catch Paulo in a scene-setting panel discussion examining what has changed in HIV prevention since AIDS 2024—and interrogating what “choice” really means for individuals, providers, funders and governments in today’s constrained landscape.

2. Dr. Beatriz Grinsztejn: Brazil Steps onto the Global Stage

For Dr. Beatriz Grinsztejn, AIDS 2026 is personal: the conference is coming to her home city of Rio de Janeiro. As IAS President and International Co-Chair, she will welcome the HIV movement to the city where she has spent decades advancing HIV research, prevention and care.

She is also working to expand access to lenacapavir in Brazil, including by leading a major implementation study exploring how the twice-yearly prevention option can fit into people’s everyday lives. We may hear important announcements in Rio about what comes next for access in Brazil and across Latin America.

Watch Beatriz for her scientific and political leadership—and, of course, her reliably chic fashion and unmistakable eyewear.

3. Yvette Raphael: Women Will Define the Future of Prevention in Africa

Yvette Raphael leads Advocates for the Prevention of HIV in Africa and co-chairs the African Women Prevention Community Accountability Board. She has spent decades ensuring that women—especially adolescent girls and young women—are not treated as an afterthought in research, policy or access.

Her leadership is also scientific. As Chair of the PURPOSE 1 Global Community Accountability Group (G-CAG), Yvette helped ensure that the landmark lenacapavir trial was ethical, inclusive and grounded in the lives of African women. Now she is pushing to ensure that the breakthrough actually reaches young women and girls in the districts where HIV risk remains highest.

South Africa, home to the world’s largest HIV epidemic, has had U.S. health support withdrawn for political reasons. That raises profound questions about national sovereignty—and about how the country protects its progress while shaping its own future. Watch Yvette to insist that South Africa can continue to lead, not only in treatment access, but also in scientific research, community-led innovation and the next generation of voices demanding choice.

4. Erika Castellanos: Key Populations Will Not Be Erased

Erika Castellanos, Executive Director of GATE, is a trans woman living with HIV who has built her career fighting for the health, dignity and rights of trans and gender-diverse people. At a moment when trans communities are being deliberately targeted—and too often pushed out of policy, funding and public life—her voice in Rio will be essential.

The warning is not rhetorical. In its new policy brief, The Disappearance of Key Populations, and Global Black Gay Men Connect document how PEPFAR data rollbacks are making key-population programming increasingly invisible—undermining prevention, treatment access and accountability.

Key populations will not be erased—not from the data, the budgets, the agreements, the prevention strategies or the future of the HIV response. Watch Erika, alongside other KP leaders, to hold the conference accountable to that promise. There is no path to ending AIDS that abandons the people most affected by it.

5. Dr. Doris Macharia: Children Cannot Be Left Behind Again

Dr. Doris Macharia, President of the Elizabeth Glaser Pediatric AIDS Foundation, will carry an urgent message into Rio: children continue to be left behind. A recent EGPAF analysis of PEPFAR data found that pediatric HIV testing fell 34% and 54,000 fewer children were receiving treatment in a single year—an alarming warning that children may be disappearing from both services and the data.

The abstract-driven programme will be key for understanding what comes next for children. Much of the research builds on previous findings, including a better understanding of long-acting PrEP during pregnancy and more targeted approaches to closing gaps in the elimination of vertical HIV transmission.

One session to watch is Closing the gaps in prevention of perinatal transmission: Leave no one behind, particularly new pregnancy-outcome data from Malawi’s PrIMO study of long-acting cabotegravir.

Watch Doris to help translate these findings into action—and to keep asking why, when we have the knowledge and tools to prevent vertical transmission, children are still being born with HIV.

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6. Dr. Nonhlanhla Ndlovu: AI Moves from Hype to Implementation

AI may be the breakout theme of AIDS 2026—and the phrase “AI-powered” may soon require its own conference badge.

Dr. Nonhlanhla Ndlovu brings the government implementation lens. South Africa is exploring how AI can support self-care, demand creation, clinical decision-making and programme intelligence within a public health system.

But she will hardly be the only AI voice in Rio. AVAC and Audere Africa have produced an AI and HIV guide for advocates, helping delegates navigate the sessions and ask better questions. As I previously reported, Dr. Izukanji Sikazwe, the Global Fund’s Head of HIV, will deliver the conference’s first-ever plenary presentation focused on AI. Dr. mike Reid () will also share emerging insights from the Lancet Global Health Commission on AI and HIV, including the stubborn gap between hundreds of promising pilots and very little national-scale deployment.

Watch Ndlovu—and this wider constellation of voices—for the question beneath the hype: Can AI improve HIV outcomes at scale while protecting equity, privacy, community trust and local control?

7. PEPFAR: America Shows Up in Rio

Historically, the U.S. Global AIDS Coordinator—the PEPFAR Ambassador—has attended the International AIDS Conference. Today, there is no PEPFAR Ambassador. Instead, a delegation of senior State Department leaders is expected in Rio.

It matters—and, after last year, should not be taken for granted—that they are coming. U.S. officials skipped last year’s IAS conference altogether, and their presence in Rio creates an important opportunity for direct conversation. We still have much to learn about what they are implementing in countries after a year of the America First Global Health Strategy. What do they have to show for it? How are they protecting the historic gains PEPFAR helped achieve? And what will American leadership on HIV now look like? The conference will also feature several early analyses of the PEPFAR funding cuts and the new bilateral health agreements, including research I will present on what these changes could mean for HIV programmes and outcomes.

The State Department’s Bureau of Global Health Security and Diplomacy is also supporting two major side events, one with FHI 360 and another with Palladium.Watch the State Department delegation for what it says about PEPFAR’s future—and for what it does not say.

PEPFAR is not the only major funder to watch: Yogan Pillay of the Gates Foundation, Anne Aslett of the Elton John AIDS Foundation, Richard Borain of CIFF and Philippe Duneton of Unitaid will have plenty to say during the all-star panel, SY06: No Retreat, No Surrender—The Future of Philanthropy in HIV.

8. Dr. LaRon Nelson: Thinking Differently About the U.S. HIV Response

Dr. LaRon Nelson of Yale University is one of the country’s leading implementation scientists, with a rare ability to connect rigorous research to the realities of people’s lives.

He co-leads, with Prof Chris Beyrer, HPTN 096, an ambitious, community-rooted study testing an integrated approach to reducing HIV incidence among Black gay and bisexual men in the U.S. South. The study goes beyond a single intervention, bringing together HIV testing, PrEP, treatment and viral suppression while partnering with Black-led organizations and confronting the structural barriers that shape health outcomes.

LaRon is also bringing fresh thinking about impact investing and innovative financing to the U.S. HIV response. As funding constraints force harder choices, watch him for ideas that move beyond simply asking for more money and instead rethink how capital, institutions and communities can work together to produce better outcomes.

Others to watch in the U.S. space include Tristan Schukraft, CEO of MISTR, who will join a panel on demedicalizing PrEP—an approach sorely needed in the United States and around the world- and Dr. who will present on what is working for PrEP implementation for Latinos in the United States?

9. Wawira Nyagah: Access Must Move as Fast as the Science

Wawira Nyagah, Executive Director of Access Bridge, will be watching the prevention pipeline with an eye on the distance between a scientific breakthrough and access in the real world. Access Bridge was incubated at AVAC, and its work helps countries and communities prepare for new products before they reach the market.

Watch everything Wawira—and her colleagues at AVAC—do and say about access to new innovations. Their work is unmatched, especially when it comes to holding companies, funders and other stakeholders accountable for their commitments.

At the last International AIDS Conference, lenacapavir dominated the prevention news. In Rio, I expect us to hear much more about Merck’s access plans for MK-8527, now called alimatravir, a potential once-monthly oral PrEP option, as well as what ViiV has in store for the next generation of long-acting PrEP formulations.

The science is moving quickly. Watch Wawira and AVAC to make sure access moves just as fast!

10. Ben Plumley: An Unsung Hero of the HIV Movement

You’ll usually find Ben Plumley and his charming English accent in the Global Village—or behind a camera recording his widely acclaimed podcast, A Shot in the Arm. Ben is one of the unsung heroes of the HIV movement: a connector, storyteller and bridge-builder who has spent decades bringing government, business, civil society and affected communities together.

Ben will be honored during SY29: Rebuilding Trust and Financing in a Fractured World—a fitting recognition for someone who has spent so much of his career building trust across government, business, civil society and affected communities.

And speaking of honors, I’ll also be watching to see who receives the Barbara Lee Political Leadership Award during the Closing Ceremony. I hear it may be an amazing legislator from Brazil. Stay tuned.

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What Connects These Ten

What connects these ten is not a title, institution, generation or geography. Each stands at one of the fault lines shaping the future of the HIV response: science and access, funding and sovereignty, visibility and erasure, innovation and implementation.

Together, they raise one defining question:

Can the HIV response reinvent itself without leaving behind those who still need it most?

AIDS 2026 will showcase extraordinary science. But the next chapter will not be written by science alone. It will be written through decisions about money, access, data and power. It will be determined by whether governments keep their promises, whether companies deliver their innovations affordably, whether institutions listen to communities and whether the movement refuses to let anyone disappear.

See you in Rio. There is work to do.

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The United States is rapidly rebuilding its global health architecture after dismantling USAID and sharply reducing the traditional role of the Centers for Disease Control and Prevention. At discussed extensively, the centre of the new approach are bilateral health memoranda of understanding, or MOUs, negotiated directly between the State Department and partner governments.

As of July 15, the United States had signed 34 agreements. But signing an MOU is not the same as delivering health services. As congressional staff heard during a briefing this week, none of the agreements had yet become fully operational. Only a handful of detailed implementation plans were nearing completion, and those plans have not been made public.

This week, I wanted to focus on one bright spot and one not-so-bright spot: Tanzania and Zimbabwe. Together, they show the two sides of this new approach.

Tanzania signs a five-year agreement

Tanzania signed its five-year health cooperation agreement with the United States on July 1. After months of speculation whether there would even be an MOU, both sides moved swiftly to completion.

The financial commitment is substantial. The United States intends to provide approximately $1.34 billion between 2026 and 2030. Tanzania has committed more than $1.8 billion in domestic resources, bringing the combined package to more than $3.1 billion. Tanzania is expected to assume increasing responsibility for health workers, medicines and laboratory services by 2030.

There are still legitimate questions about whether Tanzania can meet those commitments and whether the transition timeline is realistic. Domestic financing projections are promises, not appropriations. Governments also face debt payments, limited tax revenue and competing health needs.

But Tanzania appears to have negotiated more deliberately than several other countries. Its government says biological specimens related to outbreaks and epidemics will remain stored, tested and governed inside Tanzania. The country did not sign a specimen-sharing arrangement. Tanzanian health data will remain subject to Tanzanian law and national health information systems according to statements released by the Ministry of Health (see below).

The agreement also gives preference to Tanzanian organizations and professionals when external implementation support is required. It seeks to strengthen the country’s Medical Stores Department and connect Tanzania with pharmaceutical manufacturing, logistics and technology-transfer opportunities.

Questions about pathogen samples, health data and national sovereignty have complicated negotiations elsewhere. Tanzania appears to have shown that governments do not necessarily have to choose between continued U.S. cooperation and surrendering control over sensitive national assets.

Still, the most important work lies ahead. The two governments must now produce an implementation plan detailing the programs, milestones, funding flows and responsibilities under the agreement. Until that happens, Tanzania has a framework, not yet a functioning transition.

Zimbabwe remains outside the framework

Zimbabwe took a different path. Negotiations over a proposed U.S. health agreement worth approximately $367 million collapsed in February after Zimbabwe raised concerns about access to sensitive health information and biological samples, as well as access to products developed using that data. The United States subsequently announced that it would end health assistance to Zimbabwe.

This is not a marginal country or a low-stakes dispute. Zimbabwe has reduced HIV incidence by roughly 80 percent since 2010. Its HIV response still depends heavily on PEPFAR and Global Fund support. Walking away without a credible replacement plan could quickly reverse those gains.

My Duke colleagues and collaborators from University of Washington, Georgetown, amfAR and Pangea Zimbabwe modeled what a complete PEPFAR withdrawal could mean if no replacement support were provided. Our central estimate was approximately 75,000 additional HIV infections within one year. That included about 19,000 infections linked to the loss of prevention programs, around 9,000 from reduced testing and delayed treatment, and more than 1,000 additional infections among children.

Zimbabwe is also among the countries expected to introduce twice-yearly lenacapavir for HIV prevention. Rolling out a major new prevention product while dismantling the broader treatment, testing, workforce and community infrastructure around it makes little sense.

The United States and Zimbabwe should return to negotiations. Both sides can protect legitimate sovereignty concerns without abandoning decades of public-health investment.

Friday Bonus: What the new APS addenda cover

The State Department has released seven new addenda under the Advancing Global Health Annual Program Statement.

Six are tied directly to signed bilateral health MOUs. They cover Nigeria, Uganda, Malawi, Cameroon, Côte d’Ivoire and Mozambique. The seventh covers population-based surveys and surveillance across multiple countries.

These are funding opportunities, not awards. Organizations are being asked to submit Statements of Interest as the first step in a two-stage process. All funding remains subject to availability.

Nigeria: Up to $200 million across as many as 20 awards. The addendum supports the U.S.-Nigeria health MOU through December 2030. It covers HIV, tuberculosis, malaria, maternal and child health, immunization, nutrition, surveillance and outbreak response. It also includes faith- and community-based care, health insurance, digital systems and the transfer of health-worker costs to the Nigerian government.

Uganda: Up to $60 million across as many as 15 awards. This supports Uganda’s MOU implementation plan through December 2030. The work includes faith- and community-based services, digital health systems, power for health facilities, supply-chain tracking, district risk assessments and independent verification of government performance.

Malawi: Up to $35 million annually across as many as four awards. The addendum supports Malawi’s MOU implementation plan through December 2030. It focuses on moving service delivery and financing from implementing partners to government ministries, districts and the Central Medical Stores Trust. The work covers HIV, tuberculosis, malaria, immunization, maternal and child health, outbreak response, supply chains and health information systems.

Cameroon: Up to $5.4 million across as many as three awards. This is tied to Cameroon’s health MOU through December 2030. The focus is mainly health security, including surveillance, laboratories, emergency response teams, One Health coordination, infection prevention, supply chains, border health and cross-border information sharing.

Côte d’Ivoire: Up to $50 million across as many as three awards. The addendum is tied to the country’s health MOU through 2030. It seeks applications from local organizations and covers disease surveillance, laboratories, outbreak response, integrated services, district capacity and continued care through faith- and community-based facilities.

Mozambique: Up to $180 million across as many as 15 awards. This supports Mozambique’s MOU implementation plan through December 2030. It covers HIV, tuberculosis, malaria, maternal and child health, immunization, laboratories, data systems, supply chains, workforce transition, public financial management and government-to-government financing. It also includes support for national surveys, including a population-based HIV impact assessment.

Non country specific APS: Surveys and surveillance

The $80 million surveys and surveillance addendum seeks alternatives and improvements to established tools such as Demographic and Health Surveys, Population-based HIV Impact Assessments and TB prevalence surveys. It encourages novel sampling, routine data, new technologies, artificial intelligence and machine learning, and real-time surveillance.

That is an implicit acknowledgment that the emerging architecture still needs credible, independent data. Governments and donors cannot determine whether rapid transitions are succeeding by relying only on program reports or financial milestones. They need population-level evidence showing whether infections, deaths and inequalities are rising or falling.

The APS announcements are therefore meaningful progress. They begin to put operational detail behind agreements that have so far existed mainly on paper.

But they also sharpen the core question: will these awards protect services while building sustainable national systems, or will they simply finance an accelerated U.S. exit?

In my opinion, the answer will depend on who receives the awards, how quickly money moves, whether implementation plans are made public and whether Congress continues to demand health outcomes—not just transition milestones.

The main takeaway is simple. These notices show which parts of the signed MOUs the State Department plans to fund through outside organizations. They also give more detail on activities, transition timelines, financing and the role of governments and implementers.

Go Deeper on APS history and mechanics

Between plenaries, panels, side events, receptions, bilateral meetings, and the inevitable last-minute additions, the challenge is no longer finding something worth attending. It is deciding what matters most.

So, rather than trying to map every session, I have been looking across the public agenda for the bigger signals. What are the debates that will shape the week? Where are the real tensions? And what should those of us working in HIV policy, financing, science, advocacy, and implementation be listening for?

And next week, I’ll publish my list of the 10 People to Watch at AIDS 2026. If you haven’t already, subscribe and stay tuned. I think you’ll discover a few names you weren’t expecting.

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1. Can the global HIV response survive the funding reset?

Why this matters

This conference comes at the most consequential moment for the global HIV response in two decades. PEPFAR has entered a period of profound structural transition, NIH and CDC are under pressure, and many countries are being asked to assume greater responsibility of their HIV and health programs while simultaneously facing dramatic fiscal constraints. At the same time, UNAIDS is undergoing a major contraction with an uncertain future, while both WHO and the Global Fund are preparing for leadership changes that will shape the next chapter of the response. Rio will reveal whether the institutions at the center of the global HIV response have a credible plan for sustaining epidemic control—or whether “country ownership” is becoming shorthand for managing decline.

What I’m listening for

• Is anyone presenting a realistic roadmap to replace shrinking external financing, or are we simply hearing calls for “more domestic resources” without specifics?

• How are countries prioritizing what to protect first—treatment, prevention, surveillance, workforce, or community systems?

• What role do the private sector, philanthropy, and innovative financing realistically play, beyond conference rhetoric?

2. The prevention revolution meets the delivery bottleneck

Why this matters

Long-acting PrEP may become one of the most important biomedical advances since oral PrEP. But history shows that scientific breakthroughs do not automatically translate into population-level impact. PEPFAR, the Global Fund, the Gates Foundation, national governments, manufacturers, and delivery partners will all need to solve questions of affordability, regulation, procurement, and service delivery if these innovations are to reach the people who need them most. CHAI and Unitaid will be especially important in shaping the market, lowering prices, accelerating generic access, and helping countries translate promising products into workable delivery models. That challenge is becoming even more urgent as the world’s largest HIV donor pulls back from prevention and reduces support for populations at greatest risk of acquiring HIV.

What I’m listening for

• Are discussions focused on equitable access, or primarily on exciting new products?

• Which delivery models—pharmacies, telehealth, community-based care, self-care—are emerging as the most scalable?

• Who is paying for long-acting prevention at real scale, and what targets are achievable?

3. HIV care is leaving the clinic

Why this matters

The future of HIV services may depend less on the next new medicine than on whether we finally start designing around what people actually want. Consumers have already shown that they value convenience, privacy, speed, choice, and care that fits into their lives. The rapid uptake of GLP-1 medicines and online PrEP in the US offers lessons in how clear marketing, telemedicine, direct-to-consumer platforms, and flexible delivery can turn complex medical products into services people actively seek out. As funding tightens and health workforces shrink, PEPFAR, the Global Fund, and national governments should invest not only in clinics and commodities, but also in pharmacies, digital platforms, community-led models, home delivery, and other approaches that treat people as consumers with preferences, not simply patients expected to navigate rigid systems.

What I’m listening for

• Who is designing HIV services around what people actually want, and what implementation experience exists for pharmacy-based and community-led models?

• Which companies, governments, and community organizations are using pharmacies, telemedicine, digital platforms, or home delivery in genuinely innovative ways?

• What can the HIV response learn from the consumer experience, marketing, and rapid delivery models that have helped scale GLP-1 medicines and online PrEP?

4. AI moves from the margins to the mainstream

Why this matters

Artificial intelligence is moving rapidly into HIV prevention, care, and public health decision-making. As one of the conference track leads, I am especially excited that AIDS 2026 will feature more AI content than any previous International AIDS Conference, including, for the first time, a plenary address on AI on Friday, July 31, delivered by Dr. Izukanji Sikazwe. Rio offers a chance to move the conversation beyond novelty and ask which applications are actually improving outcomes, strengthening health systems, and reaching people more effectively. The Audere Africa–AVAC guide is a useful roadmap to the AI conversations taking place across the conference.

What I’m listening for

• Are AI discussions grounded in implementation and measurable impact, or primarily in technological optimism?

• Who owns, governs, and benefits from the data powering these tools?

• How are countries and donors identifying the most effective AI use cases and moving them from pilot projects to scale?

5. The last mile is political

Why this matters

Ending HIV has never been solely a scientific challenge. Progress depends on sustained political leadership, community trust, human rights, and long-term investment. As the world becomes more multipolar, the future of the HIV response will depend increasingly on how governments redefine international cooperation, regional leadership, and shared responsibility. At the same time, civil society organizations are facing growing financial pressure and shrinking civic space. Rio will be the first major global gathering after the 2026 UN High-Level Meeting on HIV, where countries reached a historic agreement on the next phase of the response. The question now is whether those commitments will translate into political action.

What I’m listening for

• How are community organizations adapting to funding reductions, and what support do they need most?

• Are governments strengthening partnerships with affected communities, or centralizing decisions as financing and political conditions tighten?

• What concrete commitments will protect human rights, scientific collaboration, civic space, and international cooperation over the next five years?

How I’ll be following Rio

Rather than trying to attend everything, I’ll use these five themes to guide my week in Rio. By the end of the conference, we should have a clearer sense of whether the HIV response is entering a period of reinvention—or retrenchment.

And this is just the beginning.

Next Sunday, I’ll publish my first “10 People to Watch at AIDS 2026”—a list of researchers, policymakers, advocates, innovators, and emerging leaders who I think will shape the conversations in Rio and the future of the HIV response.

If there’s someone you think belongs on the list, send me your nomination. And if you haven’t already, subscribe so you don’t miss it.

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P.S. This year’s gathering carries a different weight. Funding shifts and organizational cuts have made it impossible for many colleagues, advocates, and community leaders to travel to Rio. That makes the time we do have together in person more important, more intentional, and more precious.

Of the many reports published, I pulled out five related to global health and read them closely. Together, they answer some important questions: How does the administration define a successful global health transition? What happens in countries where no MOU is signed? What happens if national governments cannot meet their financial commitments? The answers are more revealing than I expected.

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Collectively, these reports celebrate extraordinary achievements: more than 20.6 million people on HIV treatment, millions treated for tuberculosis and malaria, millions of babies born HIV-free, and decades of investment in health systems around the world.

They also describe how the administration intends to transition those programs to greater country ownership through bilateral agreements, some major workforce shifts, and declining U.S. financial support. The clearest clues are in the language the reports repeatedly use. Consider these excerpts:

1. “Resulting in Reductions of United States Assistance.”
   This phrase appears in the title of the PEPFAR transition report.

2. “Transitions are expected to occur over a period of two to five years.”
   The full sentence notes that some transitions may go beyond five years and should be tailored to country readiness and context. Still, this is an aggressive timeline for shifting major HIV program functions and financing.

3. “Subject to the availability of funds.”
   The MOUs may outline expected U.S. and partner government commitments, but U.S. support remains conditional. In Washington, that phrase means anything can happen.

4. “These plans do not commit the United States to funding beyond Year 1.”
   This applies to countries covered by multi-year plans rather than formal MOUs. It is still remarkable: a so-called multi-year approach with no U.S. funding commitment beyond the first year.

5. “U.S. assistance through bilateral budgets will gradually decrease over time.”
   Again, the cut is explicit. The unanswered question is whether reductions follow readiness, or whether readiness is being defined to match the reductions.

6. “Formal, non-binding arrangements.”
   The compact report describes the bilateral MOUs this way. That is a lot of strategic weight to place on documents that are formal, but not binding.

7. “U.S. funding is contingent on meeting co-investment and performance benchmarks.”
   This is presented as accountability, and accountability is important. But the question is what the benchmarks are designed to protect.

8. “Failure to meet co-investment benchmarks may trigger corrective actions or adjustments to U.S. funding.”
   That is the penalty clause. The reports explain the funding consequences more clearly than the patient consequences.

9. “Funding Adjustments: Reallocation (upward or downward) or suspension of funds if corrective actions are not implemented.”
   This makes funding suspension part of the formal contingency plan. That may be reasonable in some cases, but it also shows how the framework is built to enforce transition commitments. What is less clear is what safeguards protect patients and services if funding is reduced or suspended.

10. “The overarching measure of success in MOUs is the demonstration by partner countries that they are on a clear path toward self-reliant health systems.”
    The sentence continues by defining that path as adhering to MOU commitments, meeting co-investment targets, and assuming ownership of national health programs. Success is framed around compact compliance and cost absorption, not primarily around HIV incidence, viral suppression, prevention access, or epidemic control.

11. “The U.S. government may unilaterally reduce or cease providing funding under the MOU in future years.”
    Country ownership, yes. But with a trapdoor.

Read together, these excerpts are overwhelmingly about the mechanics of transition: MOUs, implementation plans, co-investment, funding adjustments, corrective actions, benchmarks, workforce transfer, and reductions in U.S. assistance.

There is much less discussion of incidence, viral suppression, advanced disease management, prevention gaps, community systems, or epidemic control. That doesn’t mean those things don’t matter. It suggests they are no longer the organizing principle. Now imagine these reports had been written in a different era, led by public health professionals with one overriding goal: sustain HIV epidemic control.

The dominant phrases would likely look very different. You would perhaps expect to see language like:

“Protect treatment continuity.”
”Reduce new HIV infections.”
”Maintain viral suppression.
”Expand PrEP access.”
”Protect key population services.”
”Strengthen community-led delivery.”
”Preserve laboratory and surveillance capacity.”
'“Monitor service disruption and patient outcomes.”
”Measure progress toward integration.”

That’s because a public health strategy starts with the epidemic and works backward. It asks what financing, workforce, commodities, laboratories, data systems, and community platforms are needed to keep people alive and prevent new infections. These reports confirm that the strategy seems to be to start with the transition architecture and work forward.

This comparison isn’t meant to romanticize an earlier era. Every administration has its own priorities. But organizing principles matter because they determine what leaders measure, what they reward, and ultimately what they protect. When transition becomes the primary frame, there is a risk that epidemic control becomes something assumed rather than something actively managed.

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The most revealing section is the workforce report. It says that across the first 27 bilateral MOUs, U.S.-funded frontline health worker support would fall from 196,444 full-time equivalents in FY2025 to 36,866 by FY2029. Partner governments are expected to increase their support from 54,779 to 118,647 FTEs over the same period. Even if every country meets its commitments, that still leaves a net reduction of 95,710 US-funded frontline health workers across the health system.

That is the broader point. PEPFAR was never just an HIV program. It built laboratories. It trained health workers. It strengthened supply chains. It supported surveillance systems. It financed community networks. It helped countries detect and respond to Ebola, COVID-19, mpox, cholera, and other health threats.

When those systems weaken, the consequences do not stay inside HIV budgets. They spill into maternal and child health, TB, malaria, outbreak detection, health security, and national budgets. A poorly managed HIV transition can become a global security problem. It can become a fiscal problem. It can become a trust problem between governments, communities, and donors.

None of this is an argument against country ownership. Countries should lead their own health systems, and sustainability should remain a central goal of global health policy. The question is whether the United States is supporting a transition that protects epidemic control, or whether it is shifting costs and risks faster than health systems can absorb them.

The administration can fix this by making service integration and epidemic control the real test of transition.

That means publishing country implementation plans, naming the specific services and functions being transferred, and tracking a small set of core indicators: treatment continuity, viral suppression, PrEP access, advanced HIV disease, key population services, workforce retention, laboratory capacity, stockouts, and community-led monitoring. With integration as a stated policy objective, then the administration should measure whether integration strengthens outcomes rather than simply whether programs moved into broader systems.

A successful transition should not be measured by whether the paperwork is complete, but by whether people remain alive, protected, treated, and reached.

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His reply: “A republic, if you can keep it.”

I thought about those words today as I made my way to the Great American State Fair on the National Mall. I wanted to feel inspired. Instead, I felt sad. Sad that the moment felt too politicized for many Americans to see themselves in it. And yes, angry that the story being told did not fully reflect the diversity, sacrifice, struggle, and hope that make America what it is.

But maybe that is the point. A republic does not keep itself. Each generation has to renew it, defend it, and widen its promise.

My parents came to the United States in the 1970s seeking what millions of immigrants have sought: the chance to build a better life. America gave them that opportunity. They worked hard, raised a family, and taught us that citizenship is a responsibility.

Immigrant families are not on the sidelines of the American story. We are part of its fabric. We strengthen this country not despite where we came from, but because of it.

Keeping the republic means ensuring every generation has the opportunity to contribute, belong, and build. It means building bridges, not walls. It means being kind to our neighbors, supporting one another across difference, and refusing to let fear define who belongs.

That is the America my family believed in. That is the America I will always fight for.

Happy Independence Day to all Americans.

But that is not what the 2026 High-Level Meeting on HIV/AIDS felt like.

The rooms were emptier this time. A core group of committed people showed up — mostly advocates, negotiators, UN agency staff, the hardcore faithful. The themes that echoed across side events were also very telling: integration of HIV into primary health systems, community leadership, and innovation. UNDP organized a session on community-led responses. WHO was a visible presence, framing the integration of HIV alongside hepatitis, TB and malaria elimination. UNAIDS also used its side session to put communities at the center, reminding the room that the response cannot be rebuilt through ministries and multilateral agencies alone.

But there was only one moment all week when I felt something closer to the old energy — and it was when the conversation turned to long-acting PrEP. Everything else felt like same old same old.

Does this still matter?

On June 23, the United Nations General Assembly adopted a new Political Declaration on HIV and AIDS by a vote of 149 in favor, 8 against, and 14 abstentions. Diplomats applauded. UNAIDS called it a road map. Advocates and implementors called it a floor. You can read more about what’s in here (from UNAIDS).

The countries that voted no: the United States, Russia, Israel, Burkina Faso, Burundi, North Korea, Niger, and Senegal.

Then consider the trend line: The 2021 declaration also broke consensus — Russia requested a vote and four countries voted against. But in 2021, the tally was 165 in favour, 4 against, 0 abstentions. And the United States voted yes.

The yes votes fell by 16. The no votes doubled. Fourteen countries that once voted yes now refused to commit either way. And the country that created PEPFAR, that has invested over $120 billion in the global AIDS response since 2004, crossed to the other side of the ledger.

That is not just a broken UN consensus but a collapsing political foundation on which every dollar of the global AIDS response was built.

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What a Political Declaration Is — and Isn’t

The 2001 Declaration of Commitment on HIV/AIDS helped unlock the political will and financing that built PEPFAR and the Global Fund. The 2011 and 2016 declarations produced the 90-90-90 and 95-95-95 targets that still organize the global response today. Political declarations have mattered.

But they have mattered because of what came after them . They worked when a declaration unlocked new dollars, when it moved a government to act, when it gave advocates a hook to hold power accountable. So the real question is not whether governments can still negotiate language. It is whether the global health machinery behind the AIDS response, the financing, implementation, diplomacy, and accountability system that turns declarations into action, still functions.

The Machinery Is Broken

In 2025, global development assistance for health fell by 23% — the sharpest single-year drop ever recorded. Between 2024 and 2025, HIV testing programs fell by 22% in high-burden settings. Funding for condoms was cut by more than 90% in some countries. The United States — the single largest historical funder of the global AIDS response, whose PEPFAR program has been severely transformed— arrived in New York without meaningful new financing commitments and under the shadow of its own America First Global Health Strategy, which projects a combined $4.3 billion reduction in U.S. and Global Fund support to high-burden countries between now and 2029.

The declaration itself puts a number on the financing gap: $18.7 billion was available for HIV in 2024 against a required $21.9 billion annually by 2030 — a $3.2 billion shortfall, with every indication it will widen. It is the distance between the commitments governments signed onto this week and the resources they are willing to put behind them.

And the epidemic itself is not cooperating with the narrative of steady progress. While sub-Saharan Africa has made the most substantial gains — a 59% decline in new HIV infections since 2010 — the declaration acknowledges that infections actually increased between 2010 and 2025 in three regions: the Middle East and North Africa by 77%, Latin America by 13%, and Eastern Europe and Central Asia by 15%.

Nearly nine million people living with HIV remain off treatment. Criminalization of key populations is increasing. And the declaration that just passed calls for achieving 95-95-95, universal access, long-acting prevention, and local manufacturing — all by 2030. Everyone in that room knew the math does not work.

The most clarifying thing said all week didn’t come from the General Assembly floor. It came from an op-ed published in The Guardian on the morning the meeting opened — co-authored by Dr. Jean Kaseya, Director General of Africa CDC, and HE Ambassador Amma Adomaa Twum-Amoah, the African Union Commissioner for Health. Opening with the Bundibugyo Ebola outbreak as a reminder that Africa cannot wait on distant supply chains or other people’s goodwill, they offered a ledger of hard-won progress before landing on this: “Africa has earned the right to set the terms of that fight.”

What they present is the Common Africa Position, built on the Africa Health Security and Sovereignty agenda that African heads of state have already adopted, makes three clear demands: put domestic HIV financing inside national budgets, make medicines affordable with real technology transfer and local manufacturing, and integrate HIV care into primary healthcare with community organizations and African-owned data systems at the center.

Which Brings Us Back to the United States

One thing was conspicuously absent from the HLM all week: the bilateral approach. Country-to-country health agreements, the America First framing, the model in which the U.S. negotiates directly with governments outside multilateral structures. Interestingly, none of that found traction in New York. What the room did, instead, was double down on multilateralism. The Global Fund, UNAIDS, WHO, UNDP — the architecture that the United States helped build and has recently worked to circumvent was celebrated and reinforced.

But well all know that the United States still matters. That matters to say plainly, because the temptation in this environment is to either oversell American indispensability or to write the U.S. off entirely. Neither is honest.

What the U.S. does on PEPFAR, on the Global Fund, on public-private partnerships, on community-led programming will shape the trajectory of the AIDS response in ways that no other single country’s choices will.

But here is what has to change: the U.S. needs to be honest about what works.

What works is integration — HIV services folded into primary healthcare, reaching people through systems that exist for other reasons too, that survive when a vertical program loses its funding. What works is community leadership — not as a talking point but as a financing commitment, formal standing for the organizations that actually know where people are and how to reach them. What works is real access — lenacapavir at a price that an African ministry of health can plan around, not a price that requires a donor to intercede every procurement cycle. What works is outcomes: viral suppression, incidence decline, people who know their status and stay in care.

What does not work is a sugar-coated HIV response designed to survive Washington politics. One that funds what is comfortable, reaches who is easiest to reach, and reports metrics that look good in congressional testimony while avoiding the hardest epidemiology.

Key populations — gay and bisexual men, sex workers, people who inject drugs, and transgender people — remain central to the epidemic. The declaration the U.S. voted against says this plainly: these communities and their partners account for 49% of new adult HIV acquisitions globally, and far higher shares in some regions. A response that cannot name these communities or fund programs that reach them is not serious about ending HIV.

The Promoting Human Flourishing in Foreign Assistance executive order has already restructured how U.S. foreign assistance can engage with key population programming. The most recent PEPFAR data has made those same communities nearly invisible — stripped from the reporting frameworks that once made the U.S. response accountable to the people it was supposed to serve. When U.S. Ambassador Tammy Bruce explained the no vote this week by citing “divisive topics,” she was naming, without naming, exactly this: the decision to treat the communities most affected by HIV as a political liability rather than a programmatic priority. That choice has a body count.

The irony reached its peak this same week. While the U.S. delegation stood in the General Assembly and voted against a declaration on the grounds that it strayed from the 95-95-95 targets, the State Department simultaneously announced the permanent withdrawal of PEPFAR funding from South Africa, the country with the world’s largest HIV burden, home to more than eight million people living with the virus. And the stated justifications had nothing to do with health. (read my stack last week)

You cannot claim fidelity to 95-95-95 while withdrawing $400 million a year from the country that needs it most, for reasons that have nothing to do with AIDS. The position is not principled. It is not even coherent.

So: Does It Matter?

Yes — but not for the reasons the applause suggested.

The 2026 Political Declaration matters because it keeps one thing alive: a shared standard governments can still be judged against. It matters because it gives advocates a legal and political hook. It matters because the 2031 follow-on meeting it mandates creates a five-year window in which the gap between ambition and financing either gets closed or becomes permanent.

And it matters when health ministers are fighting finance ministers over HIV line items. In those rooms, a UN Political Declaration becomes a mandate. It says: our country agreed to this, in front of the world, and now we have to write the check.

But the declaration does not matter as a driver of the next phase of the AIDS response. That phase is already being driven out of Addis Ababa, out of the 400 organizations that signed a People’s Declaration because the official one wasn’t enough. It will matter when governments return to data-informed implementation, measurable outcomes, successful country transitions, community accountability, and sustained financing.

And then there was this. In a week of mostly low energy and mostly familiar faces, the most alive I felt in any room was watching young advocates stand up and describe their governments’ responses with clarity, urgency, and zero patience for the gap between what is being promised and what is being delivered.

People like Keren Dunaway of ICW Global; Florence Riako Anam of the Global Network of People Living with HIV; Jeremy Tan of Youth LEAD Asia Pacific; Catherine Nyambura of the Athena Network; Lilian Benjamin Mwakyosi; Erika Castellanos of Gate; and Michael Ighodaro of GBGMC. These are not the architects of the current system. They are a generation that has grown up inside the AIDS response, that knows the data, that has watched the promises cycle and the gaps widen, and that is no longer asking for a seat. They have the skills, the relationships, the moral authority. What they need is the keys to the car.

What gives me something close to hope, coming out of this week, is not the declaration. It is them. It is the people who will work to make the declaration actually matter in the days and months ahead.

Work to do.

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p.s. Inside the United Nations, José Vela Zanetti’s mural Mankind’s Struggle for a Lasting Peace shows bodies under pressure: fractured, muscular, unfinished, reaching toward something larger than themselves. It is not a peaceful image. It is a reminder that peace is built through conflict, power, and choice.

That felt like the right image for this week’s High-Level Meeting on HIV/AIDS. The meeting was supposed to renew global commitment to ending AIDS. Instead, it revealed a deeper fracture: between countries willing to name the communities most affected by HIV, and those still trying to sanitize the epidemic for political comfort. Still, UNAIDS deserves credit for helping hold a fractured system together by keeping communities in the room, centering their voices in the process, and mobilizing the countries that were willing to defend a serious, evidence-based response.

The Largest HIV Program in the World

I spent several years helping oversee the South Africa program as PEPFAR Chair (an internal designation for oversight responsibilities at State Department). During that time, South Africa represented one of the largest country investments in the entire PEPFAR portfolio. The annual budget was roughly $425 million (FY 2023), accounting for nearly one in every ten PEPFAR dollars spent globally. Since 2003, the United States has invested more than $8 billion in South Africa’s HIV response. More importantly, South Africa was often where new ideas, new technologies, and new approaches were tested before they spread elsewhere.

The immediate debate will focus on HIV services, and understandably so. South Africa is home to the largest HIV epidemic in the world, with roughly eight million people living with HIV. Although South Africa finances most of its HIV response from domestic resources, the massive annual PEPFAR investment has historically supported health worker salaries, community-based organizations, prevention programs, surveillance systems, and other supportive care and treatment programs. According to PEPFAR’s own data, 72.84% of people living with HIV are on treatment with support from PEPFAR as shown here from amfAR.

A Transition Already Underway

The reality is that this transition has already been underway for months. Earlier this year, South Africa was notably excluded from the bilateral agreements and memoranda of understanding that the administration pursued with several PEPFAR countries. Instead, South Africa received a much smaller bridge funding arrangement that represented roughly one-quarter of its previous annual PEPFAR budget ($115 million), a dramatic reduction from historical levels. I suspect – based on inclusion in a recent congressional notification – they are expecting another roughly $100 million to support existing commitments through the end of the fiscal year, and workforce obligations through early 2027 as reported, and necessary closeout activities.

See trend chart below:

It is also important to understand what PEPFAR funded in South Africa. Unlike many countries, South Africa largely finances its own HIV treatment program and purchases most of its own antiretroviral medicines. PEPFAR support was concentrated in areas that are often harder to absorb quickly, including HIV prevention, voluntary medical male circumcision (VMMC), DREAMS programs for adolescent girls and young women, orphans and vulnerable children (OVC) programs, community-based services, surveillance, and portions of the health workforce. Those are precisely the areas most vulnerable when external funding declines and often the hardest to rebuild once lost.

The Clinical and Community Research Ecosystem at Risk

For years, South Africa has served as one of the world’s most important engines of biomedical innovation. Some of the leading HIV researchers, epidemiologists, laboratory scientists, and clinical trial networks are based there. Many of the breakthroughs that have shaped the modern HIV response were developed, tested, or validated in partnership with South African institutions.

And yes, that includes lenacapavir, the twice-yearly HIV prevention injection that many believe could fundamentally change the trajectory of the epidemic. The landmark PURPOSE trials that demonstrated extraordinary efficacy were conducted in South Africa and neighboring countries. The same research ecosystem is expected to play a major role in evaluating future prevention technologies, including Merck’s monthly oral prevention candidate, MK-8527, and whatever comes next after that.

South Africa’s research leadership is closely tied to its ability to conduct large, well-powered studies and generate answers quickly. That combination of scientific expertise, clinical infrastructure, community engagement, and participant recruitment has made the country one of the most important centers of HIV research in the world.

The irony is hard to miss. Earlier this month, global leaders traveled to South Africa to celebrate the rollout of the world’s first lenacapavir injections. Among them were Gilead CEO Daniel O’Day, Global Fund Executive Director Peter Sands, government officials, scientists, and advocates. They came to celebrate a breakthrough that was made possible, in part, by the very research ecosystem that decades of U.S. and global investment helped build. Only weeks later, we are discussing the withdrawal of one of the largest partnerships that helped create it.

The Omicron Lesson

The world got a reminder of this in late 2021 when South African scientists identified and rapidly characterized the Omicron variant. Their ability to do so reflected years of investment in laboratories, surveillance systems, genomic sequencing, and scientific talent. Much of that capacity was strengthened through HIV programs and related public health investments.

Global health security is often discussed as though it exists separately from disease-specific programs. In reality, the opposite is true. The laboratories that monitor HIV frequently support tuberculosis surveillance. The scientists who study HIV often contribute to pandemic preparedness. The data systems built for one disease become the foundation for detecting the next threat.

The Missing Transition Plan

To be clear, there is a legitimate discussion to be had about sustainability. PEPFAR was never intended to last forever. South Africa is a middle-income country and has assumed increasing responsibility for financing its own HIV response. That trend will continue regardless of who occupies the White House.

The question is not whether transition should happen.

The question is whether it is being managed responsibly.

That concern becomes more pressing because the United States is not the only donor reducing support. The Global Fund recently informed South Africa that its next allocation will fall from approximately $464 million to about $345 million, a reduction of roughly 26 percent. Multiple streams of external financing are shrinking at the same time, creating a much different environment than previous transition discussions.

That assessment should examine South Africa’s fiscal capacity, workforce needs, research infrastructure, surveillance systems, and prevention programs. It should evaluate what other donors are doing and identify where financing gaps are likely to emerge. It should also consider the implications for scientific research, pharmaceutical development, and global health security.

If the administration believes South Africa can absorb these responsibilities, it should show the evidence.

What Are We Prepared to Lose?

The United States has every right to redefine its relationship with South Africa. But a decision with consequences this large deserves more than a press leak.

This decision affects the country that remains home to the world’s largest HIV program, represents roughly one-tenth of the global PEPFAR portfolio, has received more than $8 billion in historic U.S. investment, houses some of the world’s leading HIV research institutions, helped validate breakthrough prevention tools such as lenacapavir, and contributed to the scientific infrastructure that alerted the world to the Omicron variant.

For more than twenty years, South Africa has been one of the most important partners in the global HIV response. It has also been one of the world’s most important contributors to public health science.

Before we walk away from that partnership, we should understand exactly what we are leaving behind.

Inspired by Rahman-Shepherd et al.’s satire on how (not) to organise a panel at a global health conference, Nelson Aghogho Evaborhene, Rosemary Mburu, Levi Singh and I decided to take a similar approach to a much bigger target: global health architecture.

The result is our tongue-in-cheek guide to how not to pursue global health architecture reform. Have a read and let us know what you think. And if you like it, give it a share!

How (not) to design the future of global health architecture

If recent actions toward reform are any indication, there is a clear and consistent way to ensure that global health architecture evolves just enough to sound different, while remaining fundamentally the same.

A proven starting point is to convene the same architects who built the current system. Former leaders from multilaterals, bilateral agencies, and large implementing partners are best positioned to reimagine the structures they helped create.

Anchor the conversation in familiar reform agendas: replenishments, governance tweaks, coordination platforms, and financing instruments. There is no need to question whether the architecture itself—its incentives, fragmentation, or delivery pathways—is fit for purpose.

Above all, avoid asking whether fragmentation is itself part of the problem. Instead, create new initiatives to coordinate existing initiatives, launch additional financing platforms to streamline older financing platforms, and establish fresh governance mechanisms to improve coordination among previous governance mechanisms. If done correctly, each reform layer will generate enough institutional overlap to justify another reform process within five years.

Prioritise experience above all else. The future is complex, so it is only logical to rely on those who built the current system. Prioritise titles that signal authority—former ambassadors, ministers, and presidents are ideal. These roles guarantee expertise across any topic, regardless of how far removed they may be from current delivery realities. Their presence reassures the room that the conversation is sufficiently high-level.

Be deliberate about who is not in the room. Exclude mid-career professionals with 20 years of experience running programs, managing supply chains, or navigating country-level implementation. They tend to bring operational detail and a bias toward execution. Prefer candidates with a single-sector pedigree. Career politicians and career diplomats are ideal. Cross-sector operators—those who have worked across public, private, and community systems—often introduce nuance that slows consensus.

If you want to signal boldness, float a structural shake-up—perhaps merging or even collapsing a United Nations agency. Suggest combining UNAIDS with the World Health Organization or merging the The Global Fund and Gavi, the Vaccine Alliance. If you are pressed for time, simply collapse an entire aid agency overnight, as the U.S. government effectively did, without a transition plan, a successor structure, or any account of what happens to the programs or the people it serves mid-delivery. It will look decisive and reform-oriented.

Keep discussions comfortably abstract. If the topic turns to country ownership or transition under bilateral frameworks, stay at the conceptual level. Avoid deep dives into what happens when funding declines, prevention programs contract, or community systems lose support. These operational realities complicate the narrative.

And be sure to keep the focus away from the populations most affected. Children, vulnerable communities, sexual minorities, migrants, and refugees tend to introduce specificity—raising questions about access, equity, and whether global systems actually work for those at the margins. Better to reference them in principle, if at all, rather than center their realities in the design.

If younger voices must be included, position them tokenistically within performative dialogue spaces where the parameters of engagement, acceptable critiques, and intended by the “adult experts” outcomes have largely been predetermined. At best, they are invited to validate agendas they had little to no role in shaping

And for the sake of coherence, forget the private sector. Despite their role in manufacturing, supply chains, digital platforms, and licensing agreements that often determine access at scale, they add unnecessary complexity to reform discussions. If the private sector does come up, default to the age-old concern about conflicts of interest. It is a reliable way to sideline their role without engaging the substance.

And be equally disciplined about keeping global health program implementers at arm’s length. Organisations that actually deliver programs at scale—those navigating procurement, workforce constraints, community trust, and real-world trade-offs—bring a level of specificity that can derail a clean reform narrative. Better to design the architecture without them and invite their feedback once the parameters are already set.

Be cautious about inviting community leaders, scientists or public health researchers from high-burden settings. They may raise questions about whether the current architecture actually delivers for the populations it intends to serve. These are valid questions, but not necessarily helpful for a clean reform narrative. And if you are going to organise a panel to discuss all of this, make sure to include only heads of state and heads of UN agencies. It reinforces the importance of the topic and ensures the conversation remains appropriately elevated.

If possible, create parallel reform initiatives with overlapping mandates and slightly different acronyms. This ensures that only actors with dedicated policy teams, permanent Geneva representation, and substantial travel budgets can participate consistently across all forums. Smaller states and overstretched ministries may struggle to keep up, but this is a reasonable trade-off for maintaining momentum.

Most importantly, treat fragmentation as a temporary governance failure rather than a structural feature of the system itself. Otherwise, the conversation may drift toward uncomfortable questions about dependency, financing, manufacturing power, and who benefits from keeping global health governance fragmented in the first place.

Congratulations! You have successfully redesigned global health architecture while ensuring that power, priorities, and decision-making remain exactly where they were before.

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References:

1. Rahman-Shepherd A, Chozom T, Kantiana ID, Kaushik A, Lakhotia D, Cook AR. How (not) to organise a panel at a global health conference. Lancet Glob Health. Published online May 2, 2026. doi:10.1016/j.langlo.2026.103956.

2. Bulc B, Al-Wahdani B, Bustreo F, et al. Urgency for transformation: youth engagement in global health. Lancet Glob Health. 2019;7(7):e839-e840. doi:10.1016/S2214-109X(19)30221-9.

3. Cyril S, Smith BJ, Possamai-Inesedy A, Renzaho AMN. Exploring the role of community engagement in improving the health of disadvantaged populations: a systematic review. Glob Health Action. 2015;8(1):29842. doi:10.3402/gha.v8.29842.

I've been thinking about that anniversary in a personal way. For as long as I've been alive, HIV has been there in the background—sometimes distant, sometimes impossible to ignore. Before I fully understood what it was, it was shaping the world around me—touching communities I belonged to, influencing how my generation thought about sex, health, and loss, and eventually leading me into a career I never could have imagined when I was younger.

Whenever I find myself reflecting on the history of HIV, I often come back to Keith Haring. As my readers know, I’ve long admired his art, but over the years I’ve come to appreciate it for another reason. His work offers a window into what it felt like to live through that moment in history. The fear. The anger. The urgency. The determination of people who refused to be invisible.

By the time Haring was covering New York with his unmistakable figures, HIV was spreading rapidly through communities while stigma spread almost as fast. The epidemic exposed deep fault lines in American society. Many political and societal leaders looked away. Ronald Reagan would not publicly say the word AIDS until 1985, after thousands of Americans had already died.

What I find inspiring - especially today - is the response that eventually emerged.

Artists found ways to make people pay attention. Activists demanded action. Gay communities cared for one another when few others would. People living with HIV organized and refused to be defined by the disease. Researchers, healthcare workers, and community leaders pushed forward despite enormous obstacles.

Long before I worked in HIV, I benefited from the results of that response.

The early treatments, the research institutions, the rights and protections that many of us now take for granted were not inevitable. They were won. I understand that the opportunities and freedoms I inherited were built by people who fought through some of the epidemic’s darkest years.

My own connection to that legacy began in 2003. When I entered this field, many of the people I admired were already legends. , Mark Harrington, , Zackie Achmat, A. Cornelius Baker, Sandy Thurman, Phill Wilson and Tony Fauci had each shaped the HIV response in different ways. Some fought in the streets. Some challenged scientific institutions. Some helped transform research into lifesaving treatments. Nancy Pelosi, Maxine Waters, and my former boss, Barbara Lee, were fighting in Congress to sustain America’s commitment to the global response.

Shortly after graduating from college (go Bruins!), I traveled to South Africa. PEPFAR had just been announced. The Global Fund was barely born. Being in South Africa that year, I saw how entire communities were carrying the weight of HIV, but there was also a sense that something was changing.

PEPFAR was America’s promise to help confront the global AIDS crisis. Led by the State Department and carried out through US agencies including USAID and the CDC, it helped bring HIV treatment, testing, and prevention to millions of people. USAID and its partners turned much of that commitment into reality by supporting clinics, training health workers, strengthening supply chains, and partnering with local organizations. Together, these efforts transformed HIV from a death sentence into a manageable condition for millions and became one of the most successful global health initiatives in history.

That trip changed the course of my life.

What drew me in was the fight for dignity. The belief that where you live, who you love, or how much money you have should not determine whether you receive lifesaving care.

Over the years, I had the privilege of working alongside many of them. One of the unexpected gifts of a career in HIV has been realizing that the people who shaped history were not larger-than-life figures. They were ordinary people who refused to accept the status quo. They pushed institutions to move faster, demanded accountability, and insisted that the lives of people living with HIV mattered.

Forty-five years later, our responsibility is not simply to celebrate that progress. It is to decide whether we will protect it.

Forty-five years later, our responsibility is not simply to celebrate that progress. It is to decide whether we will protect it.

We have tools that earlier generations could barely imagine. People can live long and healthy lives with HIV. We finally have prevention options capable of transforming the epidemic. We have U=U. At the same time, a new generation of long-term survivors is aging with HIV. Their needs extend beyond antiretroviral therapy to include mental health services, chronic disease management, social support, and systems designed to help people thrive across the life course.

So I suspect Keith Haring would remind us that progress is not the same thing as victory. He understood that public health is about more than medicine. It is about visibility. It is about human rights. It is about whose lives count and whose stories get told.

Haring’s art was part of that struggle. I think he would marvel at the scientific progress we have made. But he would not be satisfied.

Looking around today, I know I’m not. In just the past year, we’ve seen cuts to HIV programs, cancelling of important research trials and partnerships, growing pressure on public health institutions, undoing the parts of PEPFAR that made it impactful, and renewed debates about whose health is worth investing in.

Haring understood that visibility matters. That stigma matters. That politics matters. Most of all, he understood that progress only happens when people demand it.

That may be the most enduring lesson of the HIV response. Not what science achieved, important as that has been, but what communities achieved when they organized, fought back, cared for one another, and refused to accept that some lives were worth less than others.

The people who came before us fought for the world we inherited. Forty-five years later, our task is to make sure the next generation can say the same about us.

And yet every so often, if you are lucky, someone enters your life who stays. Across the moves. Across versions of yourself. Across ambition, heartbreak, and time.

For me, that person was Amanda Cary.

I met Amanda twenty years ago in Boston. I was in graduate school and interviewing for a job at Physicians for Human Rights. I remember trying desperately to impress her because I really wanted the position.

Amanda was shy. Almost painfully so. She barely made eye contact. She wore oversized black glasses that seemed to swallow half her face. But there were clues. The colorful African bead necklace. The tattoos. The hints that underneath that reserved exterior was someone deeply interesting.

Amanda carried contradictions beautifully.

She could be nurturing and savage in the same conversation. Tender and fiercely opinionated. Deeply caring but hilariously irreverent. Watching her slowly grow into herself over the years was one of the great privileges of my life.

I got the job.

Soon after, we became inseparable.

We shared offices. Wrote advocacy papers. Planned trips. We believed, with the conviction of people in their twenties, that we were going to help change the world.

Then came our great adventure.

Amanda and I packed a truck and moved from Boston to Washington.

We arrived convinced we were entering our own version of The West Wing. Smart people. Big ideas. Public service.

Reality, of course, was messier.

Our apartment sat in a neighborhood long before it became trendy. On our first night, too nervous to venture outside, we sat surrounded by moving boxes eating cereal together with two bowls and one spoon.

And somehow, we were unbelievably happy.

That house became our sanctuary.

We grocery shopped together. Complained about work together. Drank cheap bottles of Malbec together. Created traditions that became sacred over time. We built chosen family before I fully understood what chosen family meant.

Amanda was an easy friend to have in your life. If things got busy, there was no guilt. No keeping track of who called last. No tally of effort or time. You could pick right back up where you left off.

That feels increasingly rare as we get older.

Maybe because adulthood pushes us toward productivity. Achievement. Constant motion.

Amanda resisted all of that.

She prioritized people.

And she brought that same philosophy into healthcare.

Over her career, Amanda left fingerprints across institutions dedicated to justice, dignity, and care. From Physicians for Human Rights to American Jewish World Service to Whitman-Walker Health and later Callen-Lorde, systems improved because she was there.

At Whitman-Walker Health, she strengthened HIV and sexual health services. During COVID, she helped adapt systems quickly to keep people connected to HIV and STI care. During the DC mpox outbreak, she became one of the steady clinical leaders helping communities navigate uncertainty. Patients trusted her. Colleagues trusted her. Healthcare systems needed her.

In public health, we often talks about systems, financing, delivery models, and innovation. Those things matter. But progress also depends on people showing up every day and doing extraordinarily hard work well.

In HIV care especially, doctors, nurses, case managers, peer navigators, social workers, outreach workers, and frontline clinical staff create the trust that keeps people connected to care. They help people navigate stigma, fear, unstable housing, insurance barriers, and the thousand small obstacles that stand between someone and health.

And we often celebrate advancement in medicines, technologies, and scientific breakthroughs. We should. But progress has always depended on people willing to show up day after day for communities too often overlooked.

Across healthcare and public health, burnout, workforce shortages, administrative burden, and years of sustained strain have pushed too many talented providers to the edge. If we are serious about ending HIV as a public health threat, we must invest in people too.

That means investing in nurses. In HIV providers. In retention. In workforce development. In mental health support. In building systems that sustain caregivers with the same seriousness we bring to sustaining care itself.

Amanda understood that instinctively.

Somehow she knew trust itself was an intervention.

Looking back now, I think Amanda showed me something I’m still trying to get better at. Friendship takes intention. Showing up for people takes time. But those relationships become the thing that carries us when life gets hard.

I have been thinking about that a lot since losing my best friend on April 8, 2026.

Amanda carried more quietly than many of us understood. I think about how easy it is to assume that the capable people are fine. The always funny people. The dependable people. The ones who care for others.

Because we move quickly through life, we mistake competence for wellness. We reward productivity while missing struggle.

Amanda gave me many things over two decades of friendship. To hold onto chosen family. To create warmth in hard places.

She also left me with a quieter lesson.

Slow down.

Look closer.

Check on people.

Adult friendship may be harder to maintain than ever. But when we invest in it fully, it gives us something increasingly rare:

More life.

Read more about Amanda Cary:

Amanda Meaghan Cary Obituary

In honor of Amanda’s extraordinary life and contributions to HIV care, nursing, and public health, Whitman-Walker Health will host a celebration of life and impact on June 12, 2026, in Washington, D.C. Friends, colleagues, patients, and community members are invited to gather in remembrance of Amanda and the countless lives she touched. RSVP is requested.

POZ Magazine: The Providers We’re Losing: Remembering Amanda Cary

What has received less attention are the countries that remain outside the current MOU approach.

I want to examine this question through the lens of HIV and assess how the current MOUs stack up against the epidemiological realities of the global HIV epidemic.

According to KFF’s MOU tracking dashboard, more than 30 countries have already signed bilateral health MOUs with the United States covering the 2026-2030 period. These agreements represent more than $20 billion in planned health financing commitments, including approximately $12.8 billion from the United States and $7.5 billion in country co-investment commitments. While most of the agreements include HIV/AIDS components, many also span broader program areas including malaria, tuberculosis, polio, and global health security.

To better understand the epidemiological implications of the current landscape, it is useful to focus on the nine African countries with more than one million people living with HIV. These countries represent the largest share of HIV burden in Africa and remain central to global progress toward HIV epidemic control.

Those nine countries are South Africa, Mozambique, Nigeria, Tanzania, Uganda, Kenya, Zimbabwe, Zambia, and Malawi. Among those nine countries, four do not currently have publicly reported MOUs with the United States: South Africa, Tanzania, Zimbabwe, and Zambia. See chart below.

Together, Zambia + Zimbabwe + South Africa + Tanzania account for approximately 61% of people living with HIV and nearly 47% of new HIV infections across the top nine high-burden African HIV epidemics. South Africa alone remains the largest HIV epidemic globally, with an estimated 7.9 million people living with HIV and roughly 150,000 new infections annually. It is important to note that several other high HIV burden countries have signed MOUs, including Nigeria, Mozambique, Kenya, Uganda, and Malawi.

Why this matters

Using current UNAIDS global estimates (~39.9 million people living with HIV

globally):

The four non-MOU countries:

• South Africa (~7.9M)

• Tanzania (~1.8M)

• Zimbabwe (~1.3M)

• Zambia (~1.3M)

Combined:
≈ 12.3 million PLHIV

That means those four countries alone represent roughly:

• ~31% of all people living with HIV globally

• ~45-47% of people living with HIV in sub-Saharan Africa

• ~42% of new HIV infections among the top nine African burden countries

Epidemiological priorities matter because many HIV indicators globally remain fragile. While treatment continuity has generally remained stable, there are growing concerns around prevention, testing, surveillance systems, workforce retention, and community-led programming in many settings. See my recent PEPFAR data summary here. Several countries continue to face significant pressure on the broader systems that support long-term epidemic control.

Against that backdrop, there has been extensive focus on the mechanics of the MOU process itself, but comparatively little public articulation of the broader HIV elimination strategy surrounding it. Also, there has been limited discussion from the State Department about how the current bilateral MOU approach contributes to long-term epidemiological goals, including sustaining progress toward ending HIV as a public health threat and avoiding backsliding in high-burden settings.

Importantly, several countries without publicly reported MOUs, including Zimbabwe and Zambia, have made substantial progress toward UNAIDS 95-95-95 targets, while others continue to face persistent gaps in testing, treatment coverage, viral suppression, or prevention outcomes. Transitions in global health financing and program ownership inherently carry risk, particularly in high-burden settings where prevention systems and community-based infrastructure remain fragile. That reality makes a clear, coherent, and epidemiologically grounded global HIV strategy even more needed during this period of transition.

The same broader strategic questions apply across other disease areas as well, including TB and malaria.

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Over time, the success of the current U.S. bilateral framework will depend on whether high-burden countries continue reducing new infections, sustaining treatment continuity, strengthening prevention systems, and maintaining the public health infrastructure needed to prevent epidemic reversals in the years ahead.

Lastly, this remains a dynamic landscape. Some agreements may still be under negotiation or not yet publicly released, which also underscores broader concerns around transparency and visibility into the evolving framework. There may very well be ongoing engagement with several countries behind the scenes, and I hope there is progress in those discussions. But bilateral engagement alone cannot substitute for a clear and concerted global HIV strategy led by the world’s largest financier of HIV programs. Ultimately, we should ask whether the overall strategy and financing remains aligned with the broader epidemiological goal that Congress, public health leaders, and affected communities have consistently articulated: sustained progress toward ending HIV as a public health threat without backsliding in the years ahead.

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Congressional leaders are already raising alarms. In a recent letter to the State Department, they warned that “holding lifesaving assistance hostage for American access to Zambian copper mines is a disturbing break from the long held bipartisan support for PEPFAR.”

At the same time, a petition (see below) filed in the Constitutional Court of Zambia challenges the government’s handling of these bilateral agreements, arguing that they were negotiated and advanced without proper parliamentary scrutiny and public transparency.

The petition, brought by civil society organizations, raises concerns that the agreements may include provisions related not only to health assistance but also to access to Zambia’s natural resources and sensitive health data. It further argues that conditioning health aid in this way could undermine constitutional protections around sovereignty, accountability, and public participation.

For more than two decades, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has operated with a clear premise: lifesaving health services should not be contingent on unrelated political or economic objectives. That approach has enabled scale, trust, and measurable results. Zambia is a clear example. The country has made substantial progress toward epidemic control, expanded access to treatment, and improved life expectancy over the past two decades.

At the same time, Zambia has emerged as a leader in the next phase of HIV prevention. In February 2024, Zambia became the first country in sub-Saharan Africa to introduce long-acting injectable PrEP—cabotegravir—outside of a study setting. This was a significant milestone for global HIV prevention. The rollout of cabotegravir required meaningful system adaptation. Health workers needed training, procurement and supply chains had to adjust, and communities had to build trust in a new prevention modality. Zambian health officials – who were actively sharing their implementation experience at HIV meetings - have already navigated these challenges and, in doing so, developed real-world experience in delivering long-acting prevention at scale.

That experience now positions the country to take the next step with lenacapavir. Its potential impact depends not only on the product itself but on the strength of the systems that deliver it. Zambia’s experience with cabotegravir means it is not starting from scratch. It is among the few countries positioned to transition relatively quickly from introduction to broader scale.

This makes the current standoff particularly scary. The U.S. government has been actively elevating lenacapavir as a cornerstone of the next phase of the HIV response—framing it as a breakthrough that could accelerate progress toward epidemic control. Senior officials have repeatedly highlighted its potential and the importance of rapid, equitable rollout across high-burden countries

Side note: I can’t help but feel that the heavy emphasis on lenacapavir is starting to outpace a broader strategy—leaning into future innovation while some of the core service delivery challenges in front of us remain unresolved.

But that ambition depends on continuity. It depends on stable partnerships, predictable financing, and trust between governments and communities. Countries like Zambia—early adopters that have already done the hard work of building delivery platforms—are central to whether lenacapavir succeeds or stalls.

As I noted in a recent piece on Zimbabwe—another early adopter of lenacapavir—even short disruptions to HIV programs can rapidly reverse progress. Modeling from that context shows that interruptions measured in months, not years, can lead to substantial increases in infections and deaths.

At the start of 2025, approximately 84% of Zambia’s HIV program funding came from PEPFAR. This level of support has enabled the country’s progress, but it also means that disruptions, even temporary ones, carry significant risk.

A recent mathematical modeling study published in Open Forum Infectious Diseases underscores just how quickly those risks materialize. A disruption lasting three months could result in more than 50,000 additional infections and over 30,000 additional deaths. If the disruption extends to one year, the impacts increase substantially. Over longer time horizons, the projections point to a full resurgence of the epidemic, with hundreds of thousands of additional deaths.

The underlying dynamics are well understood—and increasingly visible in the latest PEPFAR data (see more on that here). Prevention services tend to be affected first, with declines in testing, reduced access to PrEP, and interruptions in outreach. As a result, infections begin to rise quickly. Treatment programs may initially appear stable, but that stability erodes over time as new infections go undiagnosed and health system functions weaken. Mortality follows with a lag, but the trajectory becomes increasingly difficult to reverse.

It is also important to recognize that PEPFAR supports far more than commodities. It underpins the broader health system architecture, including laboratory networks, data systems, supply chains, and community-based service delivery. When these systems are disrupted, the effects are not isolated. And in Zambia, these risks are already visible. Recent disruptions have affected service delivery, including clinic operations, prevention programs, and laboratory systems.

The implications extend well beyond Zambia. How this moment is handled will signal to partners around the world whether U.S. health assistance remains a stable, long-term investment—or becomes subject to geopolitical negotiation. Many civil servants and civil society leaders are working intensively behind the scenes to reach a path forward, and their efforts matter.

Health programs should not be used as leverage in non-health negotiations when lives are directly at stake. Doing so introduces avoidable risk into systems that depend on continuity and trust. Ultimately, it risks undermining the administration’s own “America First” global health approach, which depends on credible, durable partnerships to succeed—whether they like to admit it or not.

References:

• The Aid Report: Zambia

• AVAC PrEP Watch

• Mulenga LB, Musokotwane K, Sivile S, Zyambo KD, Chilengi R, Lishimpi K, Sinyangwe G, Fwoloshi S, Phiri C, Phiri H, Kampamba D, Kaftan DJ, Nyimbili S, Citron DT, Kim HY, Bershteyn A. Impacts of US Bilateral Aid Disruptions on HIV Resurgence in Zambia: A Mathematical Modeling Study. Open Forum Infect Dis. 2025 Sep 11;12(9):ofaf511. doi: 10.1093/ofid/ofaf511. PMID: 41018701; PMCID: PMC12461847.

It is important to note that the State Department release reflects fourth-quarter results, which offer a snapshot rather than a full-year view. Broader analyses of 2024–2025 data show sharper declines across testing and prevention than what is visible in Q4 alone.

Overall, two things seem to be true. First, these are impressive achievements and should be acknowledged. Second—and just as important—they do not fully capture what is happening within the system.

When you look underneath the topline numbers, the trends shift quickly. HIV testing declined substantially over the year. Diagnoses fell across settings, with the steepest drops in community-based programs.

PrEP initiations also declined overall, even as targeted increases were observed among pregnant and breastfeeding women. At the same time, the workforce supporting service delivery contracted. These patterns emerge from full-year comparisons and facility-level analyses, which provide a more complete picture than quarterly snapshots alone, particularly in a year marked by reporting disruptions.

What is emerging is not a system that has failed, but one that is beginning to thin at the margins. In the HIV response, those margins are not negligible—they are where people are first tested, where they enter care, and where prevention reaches populations at highest risk of HIV acquisition. Changes in these areas often precede shifts in more visible indicators.

PEPFAR has been tested in similar ways before. Across past crises, it has functioned less like a narrow disease program and more like a broader health platform capable of absorbing shocks. During COVID-19, treatment continuity largely held, while testing and case finding declined. A similar pattern was observed during the Ebola outbreak, where treatment and PMTCT services proved more durable than upstream functions. These experiences suggest that the system has an inherent capacity to preserve core services when under stress.

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This pattern also helps explain what we are seeing now. Following the PEPFAR funding freeze—and the subsequent waiver limited to a narrow set of lifesaving services—the program has effectively shifted into preservation mode. Treatment has been prioritized and largely protected, but many of the activities that identify and bring new people into care have been scaled back or outright cancelled. That includes programs like DREAMS, prevention for key populations, voluntary medical male circumcision, and much of the community outreach that drives testing and linkage. As a result, the system is maintaining continuity for those already on treatment, while the front end of the response is weakening. Over time, this creates a divergence between what treatment numbers suggest and what is actually happening across the broader HIV response. This is concerning because it risks reversing progress on case finding and prevention, ultimately increasing the likelihood of new infections and undermining long-term epidemic control.

One reason treatment appears so stable—even in the face of disruption—is that PEPFAR has deliberately built resilience into how treatment is delivered. Over the past several years, especially during COVID-19, programs scaled up multi-month dispensing, meaning many patients now receive two, three, or even up to six months of antiretroviral medication at a time. That shift reduced the need for frequent clinic visits and created a buffer against short-term disruptions. When funding pauses or service delivery is interrupted, people do not immediately fall out of care because they often still have medication in hand. At the same time, many patients have established relationships with providers, community health workers, or clinics, which allows them to stay connected even when systems are under strain. These features of the system are not incidental—they reflect years of programmatic evolution grounded in evidence and experience. But they also explain why treatment can appear stable even as other parts of the system begin to weaken.

The challenge is that HIV control programs do not run on treatment alone. They depend on a continuous flow of people entering care through testing, diagnosis, and linkage services. When testing declines and fewer people are diagnosed, that pipeline slows. The data suggest that this is already happening. Declines in testing and prevention are not immediately visible in treatment numbers, but they shape what those numbers will look like in the future. This is why treatment is a lagging indicator. By the time changes show up there, the underlying dynamics have already shifted.

A related issue is what might be described as the scaffolding of the response. Over time, PEPFAR investments have built systems that extend well beyond clinical care—community outreach, peer navigation, and civil society partnerships. These systems are particularly important for reaching populations that are not well served by formal health facilities, because they are often the entry point into care. The current data suggest that these parts of the system are where the greatest strain is occurring. Declines are most pronounced in community-based services and in sites with less consistent support, which raises concerns about how effectively the system is continuing to reach those populations—often the very groups at highest risk of HIV acquisition.

This becomes especially important when thinking about prevention. Reductions in testing and PrEP are not just short-term service gaps; they have implications for future transmission dynamics. When fewer people are tested, fewer diagnoses are made. When fewer people initiate PrEP, fewer infections are prevented. The State Department notes that more than 103,000 pregnant and breastfeeding women were newly enrolled on PrEP, which is an important achievement. But beyond that, there is limited visibility into other populations being reached or prioritized.

Historically, PEPFAR has shown that prevention programs are most effective when resources are explicitly targeted and sustained for specific populations at highest risk. Without that focus, coverage becomes diffuse and impact declines. These effects accumulate over time and are often only visible later, when incidence begins to change. In other words, cutting prevention is a ticking time bomb—the consequences are delayed, but they will come.

Looking ahead

The State Department’s release emphasizes improvements in Q4 data completeness and signals a transition toward reporting that is more closely aligned with national systems and bilateral agreements. While this shift is consistent with a broader emphasis on country ownership, it also introduces important tradeoffs. Historically, PEPFAR has provided detailed, continuous, publicly accessible data that allowed for granular analysis across countries and programs. That level of visibility has been central to how the program has been managed and held accountable.

As reporting evolves, it is likely that both the frequency and the granularity of available data will change. Greater reliance on national reporting systems may mean less standardized data and, in some cases, reduced public access. While this transition may improve alignment with country systems, it also introduces variability in how indicators are defined, collected, and shared, complicating cross-country comparisons and independent analysis.

Looking ahead, this shift in how data are generated and shared will require a corresponding shift in how oversight is conducted. As the U.S. moves toward a more integrated, bilateral framework, expectations around transparency, data sharing, and accountability will need to be clearly defined within those arrangements. Otherwise, there is a risk that emerging challenges—particularly in areas like prevention and community engagement—will be less visible until they are more difficult to address. More fundamentally, this transition signals a different kind of HIV response—one I have written about previously—where the tools we have relied on to track progress, identify gaps, and course-correct in real time may no longer function in the same way.

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The PEPFAR Panorama Spotlight dashboard provides a high-level snapshot of program performance in the final quarter of FY25, highlighting key indicators across testing, treatment, viral suppression, and prevention. It shows the scale of services delivered—including tens of millions of people tested and on treatment, high levels of viral suppression, and targeted prevention efforts such as PrEP for pregnant and breastfeeding women. While these figures underscore the continued reach of the program, they represent a point-in-time view and should be interpreted within the broader context of year-over-year trends and shifts in program delivery.

There appears to be a discrepancy in the headline treatment figures that warrants clarification. The State Department press release reports 20.6 million people on treatment, but when I look through the publicly available dashboards, the total comes closer to 20.3 million. See screenshot below. This may reflect differences in methodology, reporting periods, or data inclusion—but without clear documentation, it raises avoidable confusion. Given the stakes, the State Department should reconcile these figures and release the underlying data and definitions to enable full, independent interpretation.

Technical note on data interpretation: Some changes in reported results may reflect both real service disruptions and shifts in what is captured within PEPFAR-supported systems. In some cases, services may continue even as they fall out of formal reporting structures, making trends more difficult to interpret.

References

• Harris TG, Rabkin M, El-Sadr WM. Achieving the HIV care continuum during the COVID-19 pandemic: PEPFAR program adaptations. MMWR Morb Mortal Wkly Rep. 2022;71(12):1-7. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7112a2.htm

• Lecher SL, Ellenberger D, Kim AA, et al. Scale-up of HIV viral load monitoring — PEPFAR-supported countries, 2019–2020. MMWR Morb Mortal Wkly Rep. 2021;70(21):794-800. Available at: https://www.cdc.gov/mmwr/volumes/70/wr/mm7021a3.htm

• Ly J, Sathananthan V, Griffith B, et al. Facility-based delivery of HIV services during the Ebola virus disease outbreak in Liberia: an analysis of service disruption and recovery. PLoS Med. 2016;13(8):e1002096. doi:10.1371/journal.pmed.1002096

• Ratevosian J, Beyrer C. Fundamental PEPFAR reform risks a period of structural vulnerability in the HIV response. Lancet. 2026;407(10533):1035-1038. doi:10.1016/S0140-6736(26)00369-7

Taken together, the APS, addenda, and Q&A offer a more complete picture of how funding, timelines, and program design are expected to work. And what more we can expect in the coming months.

Below is a consolidated update based on those materials.

1. Current funding available

The Rapid Outbreak Response addendum confirms that up to $290 million is currently available, with up to 10 awards anticipated. Projects are expected to run for a period of up to five years.

In addition, the newly released Addendum C: Advancing Integrated and Sustainable Health Systems in the Philippines introduces a separate funding envelope of up to $200 million, with up to 6 awards anticipated.

These figures reflect funding tied to currently released addenda. Additional funding opportunities may be released over time through future addenda.

2. APS structure: phased and addendum-based

The APS is being implemented as a multi-addendum mechanism, rather than a single, standalone funding opportunity. Each addendum defines a specific technical or programmatic focus area.

The Q&A document makes clear that additional addenda will be released over time. Some addenda may be country-specific and aligned closely with bilateral agreements, while others may focus on cross-cutting services or technical areas.

At this stage, the APS includes both global/thematic addenda and now a country-specific addendum:

• Orphans and Vulnerable Children (OVC) / Child Protection

• Global Health Security / Rapid Outbreak Response

• Addendum C: Philippines (integrated health systems and bilateral health security)

This expansion signals how the APS is being used across different levels—from global priorities to targeted country investments. I would expect to see more country-specific addendums in the future.

3. Application process: two-stage approach

The APS uses a two-step application process.

In Phase 1, applicants submit a Statement of Interest (SOI). The SOI narrative is limited to five pages, although tables, charts, and annexes are allowed and do not count toward this limit within defined parameters.

Following review, a subset of applicants will be invited to move forward. These applicants may either proceed directly to Phase 2 or participate in a consultative program design process before submitting a full application.

In Phase 2, selected applicants will receive additional instructions and submit a full proposal. Not all applicants will receive feedback if they are not selected to advance.

4. Timeline and review process

The APS operates on a quarterly submission and review cycle. All SOIs submitted within a given window are reviewed after that window closes.

The review process includes a technical eligibility screening, a merit review panel, and internal clearance and decision-making steps.

The Q&A notes that the full process—from SOI submission to potential award—may take several months. Timelines may vary depending on the number of submissions and operational factors.

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5. Relationship to bilateral MOUs

The APS is designed to function alongside bilateral Memoranda of Understanding (MOUs), which are a central component of the broader U.S. global health strategy. While the State Department has not consolidated these MOUs in a single, easily accessible location—which would significantly improve transparency and stakeholder engagement—the most up-to-date information is currently available through the Kaiser Family Foundation (KFF) website.

According to the Q&A, APS-funded projects may either support the implementation of MOUs or complement MOU priorities without being directly tied to them. Some addenda may be linked to MOU funding, while others may be funded through separate channels.

Importantly, the State Department notes that applicants do not need detailed knowledge of specific MOUs in order to submit a competitive SOI.

6. Geographic scope

The Q&A initially indicated that APS-funded activities are not limited to countries with signed MOUs and that there are no designated priority countries across the early addenda.

Applicants may propose projects in any country eligible for U.S. foreign assistance, and proposals may be designed as single-country or multi-country efforts.

At the same time, the release of Addendum C focused on the Philippines demonstrates that the APS is also being used for targeted, country-specific investments aligned with bilateral priorities. I expect to see more of this in the coming months.

Taken together, the current structure allows for both:

• Broad geographic flexibility across global and regional proposals

• More defined, country-level opportunities through specific addenda

7. Program design flexibility

Across multiple sections of the Q&A, the State Department emphasizes flexibility in program design.

Applicants may choose to address one or multiple objectives within a given addendum. There is no requirement to use a specific implementation model, and proposals may include a range of approaches such as service delivery, systems strengthening, policy reform, or technical assistance.

Organizations are encouraged to submit concepts that clearly align with the scope and objectives outlined in each addendum.

8. Focus of the outbreak response addendum

The Rapid Outbreak Response addendum focuses on enabling early detection and rapid containment of infectious disease outbreaks.

The document highlights the importance of supporting response activities in the first days and weeks of an outbreak, including surveillance, laboratory capacity, infection prevention and control, case management, logistics, and coordination.

Projects are expected to be time-bound, operationally focused, and capable of adapting to changing outbreak conditions. At the same time, they should contribute to strengthening longer-term national systems for outbreak detection and response.

9. What else is new

The newly released Philippines addendum reflects a more targeted, bilateral approach within the APS.

The program focuses on strengthening disease surveillance, integrating service delivery across programs, expanding domestic financing capacity, and building performance and accountability systems.

In parallel, there is also a pipeline of forecasted global health security funding opportunities expected from the Centers for Disease Control and Prevention. These are not part of the State Department APS, but they are closely aligned in focus and timing.

The forecasted opportunities include:

• A global mechanism on strengthening outbreak detection, notification, and response capacity (CDC-RFA-JG-26-0056; ~8 awards expected)

• Country-specific programs in:

  • Kenya (4 awards)

  • Senegal (4 awards)

  • Ethiopia (3 awards)

  • Indonesia (2 awards)

  • Tanzania (3 awards)

  • Uganda (3 awards)

  • Côte d’Ivoire (2 awards)

  • Ghana (4 awards)

  • Nigeria (3 awards)

  • Sierra Leone (3 awards)

  • Democratic Republic of the Congo (4 awards)

  • India (multiple opportunities, including outbreak response and HIV/TB systems strengthening)

• Regional programming, including:

  • Central America (2 awards focused on HIV, TB, and broader health priorities)

• Cross-cutting technical investments such as:

  • Surveillance systems and early warning capacity (CDC-RFA-JG-26-0113)

  • Laboratory systems, diagnostics, and pathogen sequencing (CDC-RFA-JG-26-0058)

All of these opportunities are currently listed as forecasted, with timelines and funding levels still to be confirmed.

Bottom line

The APS is being implemented as a phased, addendum-driven funding mechanism with a defined initial funding envelope and additional opportunities expected over time.

Recent updates—including the Q&A and the addition of the Philippines addendum—show a model that combines global thematic funding windows with more targeted, country-specific investments. At the same time, parallel funding pipelines from other agencies suggest that additional resources for global health security are likely to emerge in the coming months.

While some have criticized this approach as a return to a more traditional, USAID-style model of fragmented funding streams, the reality is that the State Department is now firmly in the lead on global health strategy and implementation. The APS is not a temporary instrument—it is likely to remain a central mechanism for how these programs are funded and operationalized.

This shift also raises important questions for Congress, particularly around how progress will be tracked, how funds are allocated across disease priorities, and whether reporting will maintain the clarity and accountability that have historically underpinned bipartisan support for programs like PEPFAR.

Stakeholders will need to monitor both APS addenda and related funding announcements—as well as evolving oversight and reporting expectations—as this landscape continues to evolve.

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To read more - see my Substack on the original APS here:

This shift carries real human consequences. When diplomatic disputes spill into public health programming, they disrupt systems that millions of people depend on. In the case of HIV programs, the consequences can unfold quickly—and last for years.

Zimbabwe: An HIV Success Story at Risk

Over the past two decades, Zimbabwe has achieved one of the most significant HIV control successes in sub-Saharan Africa. With sustained support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and other partners, the country has dramatically reduced HIV transmission and expanded access to treatment.

HIV incidence has fallen by roughly 80% since 2010, and life expectancy has risen from 46 years in 2000 to about 62 years today. Those gains were built through sustained cooperation between the United States, Zimbabwe’s Ministry of Health, implementing partners, and communities across the country.

Researchers recently examined what could happen if PEPFAR funding were significantly reduced or interrupted. Using a validated HIV transmission model developed with Zimbabwe’s Ministry of Health, they simulated the impact of different funding scenarios through 2030.

If funding cuts persist through 2030, Zimbabwe could experience:

• A 78% increase in HIV incidence

• Approximately 85,000 additional infections

• About 25,000 additional HIV-related deaths

Even temporary disruptions carry serious consequences.

A 12-month interruption could still lead to 35,000 additional infections and roughly 10,000 deaths, while a three-month disruption could generate 15,000 new infections and 4,000 deaths.

Public health systems depend on continuity. When treatment supply chains break, prevention services pause, or community health programs lose support, restarting them is difficult. The system loses momentum—and the virus regains it.

The modeling also shows why disruptions have such a large impact. About 60% of additional infections would stem from interruptions in antiretroviral therapy. Treatment is not only lifesaving—it also prevents transmission. When people living with HIV maintain viral suppression, they cannot pass the virus to others. Interrupt treatment, and viral suppression declines, allowing the epidemic to expand again.

Impact on Lenacapavir Rollout

The timing of these diplomatic tensions is striking. Zimbabwe recently became one of the first countries in the world to begin rolling out lenacapavir, a long-acting HIV prevention injection administered twice a year. The drug represents one of the most promising advances in HIV prevention in decades and is a major priority for the global HIV response, and the US State Department.

The rollout initially targets thousands of people at high risk and depends on the same health systems and partnerships that PEPFAR helped build. Lenacapavir requires coordinated supply chains, trained providers, patient follow-up systems, and stable financing to scale effectively. In other words, just as countries begin deploying the next generation of HIV prevention tools, the diplomatic foundations supporting those programs are becoming unstable.

PEPFAR Historical Context

Zimbabwe’s HIV response relies heavily on international partnership. Through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the United States has invested more than $1.7 billion in Zimbabwe since 2006 to combat HIV/AIDS. Annual support has consistently exceeded $200 million, with approximately $239.6 million allocated to HIV programs as of early 2026.

These investments support far more than medication.

PEPFAR funding has helped build the backbone of Zimbabwe’s HIV response: laboratory networks, national HIV testing systems, prevention programs such as voluntary medical male circumcision, and community outreach initiatives that connect people to care. It also funds adherence support programs that help patients remain on treatment and maintain viral suppression.

Destabilizing that support does not simply reduce services—it risks undermining the entire system that keeps the HIV response functioning.

The Chilling Effect of Diplomatic Disputes

Global health programs work best when governments cooperate closely. Bilateral negotiations help align priorities, focus resources on high-burden districts, and ensure taxpayer dollars are used effectively. But when negotiations become high-profile diplomatic disputes, the effects ripple quickly through the system.

From my experience managing cooperation across large U.S. government teams and government counterparts abroad, these partnerships depend on stability and trust. Staff on both sides must plan multi-year programs, coordinate supply chains, and manage complex implementation systems. When headlines suggest partnerships could collapse, uncertainty spreads quickly. Programs planning slows down. Staff hesitate to make long-term commitments. In public health, uncertainty is rarely neutral—it is disruptive.

And this uncertainty is arriving on top of disruptions Zimbabwe has already faced following earlier U.S. funding cuts. Reporting compiled by The Aid Report documents how those reductions have already begun reshaping programs on the ground. A Zimbabwean NGO providing care to orphans reportedly lost major funding and had to lay off 140 of its 160 staff members. Community health programs have also been affected: one local provider halted outreach efforts that identified women for cervical cancer screening, interrupting preventive care for vulnerable populations.

These disruptions do not stay contained within individual programs. They weaken the networks of organizations, health workers, and community systems that sustain broader public health efforts.

A Dangerous Trend

The tensions now emerging with Zimbabwe and Zambia (see new reporting today from Stephanie Nolan) raise an important strategic question: should life-saving health programs become bargaining tools in foreign policy negotiations?

The United States has legitimate diplomatic interests and many arenas in which to pursue them. But HIV programs operate on thin margins. They require predictable funding, stable partnerships, and long-term planning.

Using these programs as leverage risks undermining one of the greatest public health success stories of the past generation—and the very systems that help keep Americans safe at home.

Diplomacy should reinforce the partnerships that sustain public health progress, not threaten them. Walking away from negotiations—or allowing geopolitical disputes to dominate them—risks reversing decades of progress.

Reference: Apollo T, Yeo YR, Mugurungi OM, et al. Case study of PEPFAR funding cuts on HIV infections and deaths: reversing hard-won gains. AIDS. 2025;39(14):2143-2146. doi:10.1097/QAD.0000000000004302