CHAI has released a comprehensive gap analysis to inform the response to disruptions in global HIV funding. Drawing on data from 14 low- and middle-income countries, this analysis identifies critical vulnerabilities across the HIV cascade that threaten millions of lives dependent on consistent treatment and prevention services.
The scale of the situation
• 20.6 million people living with HIV supported by PEPFAR
• US$736 million in total procurement budget (2024)
• 370,000 healthcare workers funded through PEPFAR
Critical shortages across the HIV care continuum
Prevention: Four countries risk stockouts of oral PrEP within six months, while long-acting cabotegravir (CAB-LA) introduction has already been severely disrupted. Voluntary medical male circumcision (VMMC) services and condom distribution programs have been reduced or paused.
Testing: Ten countries face imminent stockouts of early infant diagnosis commodities. Layoffs in HIV testing services have severely impacted capacity, with one country reporting termination of 53 percent of testing-focused staff.
Advanced HIV disease (AHD): Ten countries risk stockouts of critical AHD commodities. Point-of-care CD4 testing availability is threatened, alongside access to life-saving treatment and diagnosis for opportunistic infections. Some countries are already experiencing national-level shortages, which will lead to increasing preventable AIDS-related deaths.
Treatment: Eight countries face shortages of pediatric or adult antiretrovirals. Introduction of optimal pediatric formulations such as pediatric abacavir/lamivudine/dolutegravir (pALD) is in jeopardy. Recent data indicates one in five children under the age of one has died following treatment interruption, underscoring the urgency for this population.
Monitoring: Thirteen countries report impending stockouts of viral load testing commodities, which are critical for assessing treatment failure. Reduced access risks increased drug resistance and onward HIV transmission.
Supply chain disruptions
The impact extends beyond commodities. Operational suspensions at PEPFAR-supported warehouses compounded by the loss of broad government waivers, have complicated clearance processes for essential medicines. Meanwhile, workforce reductions have left gaps in service delivery, and shutdown of health information systems has disrupted real-time stock tracking.
Market destabilization
Suppliers report US$55 million worth of stock currently sitting in warehouses at risk of cancellation or non-payment. With 30 to 35 percent of ARV revenue for major Indian generic producers coming from PEPFAR-funded procurement, the uncertainty threatens supplier viability, particularly for low-volume, single-supplier products.
Path forward
As efforts to stabilize the HIV market response take shape, three priorities are clear:
- Sustainable financing: Establish long-term, government-led financing systems prioritizing efficient resource use.
- Coordinated market mechanisms: Develop country- and global-level structures supporting short-term needs while planning for long-term sustainability.
- Government-owned systems: Rebuild HIV programs prioritizing national ownership and integration with existing health systems.
