New study finds major HIV service declines in Uganda and Zimbabwe after 2025 US aid cuts

A new study from LSE and Duke University, published in The Lancet Global Health, documents severe and sustained declines in HIV service delivery for some of the world’s most vulnerable populations at four non-governmental organisations in Uganda and Zimbabwe following the cuts to United States foreign aid in 2025.

The research, led by Dr Henry Cust, LSE Fellow in the Department of Health Policy and former Research Scientist at Duke’s Sanford School of Public Policy, is the first to measure the impact on service delivery using data from within organisations whose US-sourced funding was cut and never restored. HIV prevention, predominantly PrEP (pre-exposure prophylaxis), HIV testing and treatment (antiretroviral therapy [ART]) all fell sharply after the 2025 PEPFAR (President's Emergency Plan for AIDS Relief) and USAID (US Agency for International Development) stop-work orders and had not recovered by March 2026, despite a humanitarian waiver meant to protect life-saving services.

Key takeaways

• The study is the first to measure what happened to HIV services for the populations most vulnerable to HIV after the United States froze foreign aid and halted PEPFAR and USAID work in January 2025
• HIV service delivery dropped sharply in four non-governmental organisations in Uganda and Zimbabwe, and those losses largely persisted through to March 2026.
• Prevention, PrEP and testing saw the steepest declines, and treatment also fell despite a humanitarian waiver meant to protect life-saving services.
• The authors argue for emergency transition funding, stronger continuity plans and more stable domestic financing for HIV programmes.

The study shows that when the United States froze foreign aid in January 2025 and halted work under PEPFAR and USAID, HIV service providers in Uganda and Zimbabwe lost more than funding. They lost the systems that helped keep prevention, testing and treatment services running for people at highest risk of HIV.

Dr Cust said: “For the first time, we can put real numbers on what the US funding withdrawal actually did for those most vulnerable to HIV and at the forefront of the epidemic.

“In the organisations involved, services used successfully to tackle the HIV epidemic in sub-Saharan Africa fell by between a half and two thirds, largely remaining there through to March 2026. The safety net that was supposed to preserve life-saving treatment did not hold. The services and community trust that took decades to build were dismantled overnight.”

That erosion of trust is already visible to the organisations involved.

Byrone Chingombe, Key Populations Programme Technical Director at the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, one of the organisations in the study, said: “The vulnerable populations we take care of do not trust our services anymore. They say, ‘you went away without any notice, and you were not available, you left us with nothing.’”

The study used routine monthly and quarterly service data between January 2023 and March 2026 to track changes in prevention, PrEP, treatment and testing. Across the organisations studied, the authors found large declines in every core service area compared to 2024 averages. Prevention fell by roughly 37% to 63%, PrEP by 43% to 72%, treatment by 22% to 32% and testing by 59% to 64%.

The study adds something earlier rapid assessments and modelling studies could not provide, explained Dr Cust:

“Rapid assessments provided vital early warning, but they capture immediate, often qualitative impressions of disruption before the dust settles. Modelling studies project the long-run consequences and are important for estimating the range of possible impacts. But they rest on strong assumptions about how funding translates into infections averted and how services might respond.

“Our study measures what actually happened. Using routine service data from organisations that lost their US-sourced funding, we show that services fell sharply and remained well below previous levels more than a year later. It turns warnings and projections into measured facts. It measured loss of care, for people with nowhere else to go.”

The paper focuses on nongovernmental organisations that serve key populations (men who have sex with men, female sex workers, people who inject drugs, prisoners and transgender people) in Uganda and Zimbabwe. In both countries many of these populations are criminalised, which means they face stigma, legal barriers and limited access to health services used by the general public. Community-based care is especially important and often their only option. Dr Cust said the study should not be stretched beyond what the data can support, but it likely reflects a wider pattern among organisations that provide life-saving services that relied heavily on USAID contracts.

The findings also show the limits of the humanitarian waiver that was supposed to protect life-saving care. Even treatment services declined after the waiver took effect, suggesting that dismantling the channels that delivered funding limited the waiver’s ability to restore the staff, commodities and delivery systems needed to keep care going.

Dr Cust said: “The US released a waiver that said life-saving services could continue working, and, by implication, would continue to receive funds. That should have protected HIV treatment. However, because they dismantled the apparatus to deliver the funding and distribute the drugs, the waiver had limited impact on USAID-funded organisations. It’s a case of actions speaking louder than words.”

Dr Cust added that the study points to three urgent needs: protecting the HIV services that the most vulnerable populations rely on and that local health systems are unlikely to replace; strengthening emergency transition funding; and using this moment to build stronger and more inclusive domestic services.

He said: “The most vulnerable populations have lost a lifeline, and the urgent focus needs to be on protecting services for key populations that are crucial to fighting HIV. Not all organisations serving these populations have survived, and those still hanging on desperately need renewed funding.”

HIV service delivery following the PEPFAR and USAID HIV funding withdrawal in Uganda and Zimbabwe: an interrupted time-series study is by Dr Henry Cust and Dr Sungai T Chabata.