Middle powers ‘step up’ as global health funding shifts, says UNAids chief

The head of the global agency tackling Aids says that middle powers are “stepping up” to increase their contributions to fight diseases, amid a rapidly changing global funding landscape.

Winnie Byanyima, the executive director of UNAids, said in a world where faith in multilateralism is deteriorating, these countries are increasingly “the strongest defenders” of multilateralism and institutions of global governance and trade.

The middle powers are influential countries, including major Southeast Asian nations, the United Arab Emirates and larger Middle Eastern countries, the European Union, Canada, Australia and South Africa, that have shared values and enough legitimacy to negotiate and lead. They lie between the three “great powers” — the US, China and Russia — a “mezzanine tier” of five former and emerging great powers — the UK, France, Germany, Japan and India — and the rest of the global community, political analyst Richard Calland wrote for Daily Maverick.

“We see that they [middle powers] also are stepping up, and increasing their contributions in the multilateral effort to fight diseases on global health. This is positive. These are middle-sized countries … stating very clearly that they have faith in multilateralism; that they believe that certain global challenges have to be solved through the multilateral system,” Byanyima told Daily Maverick in an interview ahead of the G20 Leaders’ Summit on Friday, 21 November.

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Asked why she believed middle powers were stepping up at this specific moment, Byanyima said: “Because faith in multilateralism has been weakening, particularly by the very countries who created the United Nations and the Bretton Woods institutions — they themselves have been weakening in their defence and promotion of multilateralism.

“We’ve seen them in terms of their resourcing, but we also see the paralysis in decision-making, the inability to end wars together — the Security Council not being able to end conflicts [and] keep peace in the world.”

Changing funding landscape

According to Byanyima, the global funding landscape has shifted.

“We are seeing a rapid decline in aid. For example, we expect that this year the aid that comes to global health may reduce by up to 40%, and that’s because the traditional donors are stretched between many development challenges,” she said.

Byanyima said the agency had seen funding cuts for HIV/Aids every year for the last five years, which had become “more dramatic in the last two years, as countries who are major donors multiplied their defence spending by several times.

“The quantity and the nature of aid is changing, and developing countries that were depending a lot on aid for their Aids responses have to move quickly towards more domestic financing and also, as a region, Africa needs to move towards regional manufacturing of medicines so that they are affordable on the continent.”

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In February, US President Donald Trump abruptly halted aid funding for HIV programmes around the world, including support provided through the US President’s Emergency Plan for Aids Relief (Pepfar). The move left health systems in developing countries such as Mozambique in ruin, and led to the deaths of many HIV-positive children.

Byanyima said the US’s funding pause was “the biggest disruption” that had ever occurred since the construction of the global HIV/Aids response.

The US government decided to restore that funding, she said, referring to a later waiver on certain parts of Pepfar funding, “but not to the same level, and with more restrictions on what it can do”.

“That is a challenge, because some of the restrictions are around the very things that account for the success, like innovative ways of getting services to reach those who are criminalised [and] those who are stigmatised and marginalised,” said Byanyima.

However, she said, “It’s also not a reason to be very despondent. There is funding from other donors, like the Europeans, the UK, Japan and others, that has always been put behind what works; that supports human rights-centred [and] community-centred responses. So, while one donor might not favour the centring of women’s rights [and] human rights, there are others who understand its importance and whose money can go right there where it’s needed,” said Byanyima.

China’s multimillion-rand contribution

Ahead of the G20 Leaders’ Summit, on Thursday, 20 November, China pledged $3.49-million (R60-million) to support access to HIV prevention services for young people in South Africa for the next two years under a partnership facilitated by UNAids.

Around eight million people are living with HIV in South Africa. Before Trump’s aid pause, Pepfar constituted 17% of South Africa’s R44.4-billion campaign for HIV counselling and testing, reported Daily Maverick.

This is the first time that China has contributed to SA’s HIV response — a clear move to help fill the gap left by the US.

China’s contribution towards HIV prevention services will focus particularly on young people and people who inject drugs as two of the groups most at risk of HIV infection, according to a statement from UNAids. It will reach 54,000 adolescents and young people in Technical and Vocational Education and Training (TVET) colleges across seven provinces, and support 500 people who inject drugs through therapy programmes in Gauteng, it said.

“This particular project in South Africa is on HIV prevention. This is where the whole world is lagging behind,” said Byanyima.

My especial thanks to @AmbWuPeng @cidcaofficial 🇨🇳 and Minister Aaron Motsoaledi @HealthZA 🇿🇦, for your belief and commitment to South-South cooperation and transforming global health. https://t.co/EDx05xA9b3 pic.twitter.com/5eb28D0F3o

— Winnie Byanyima (@Winnie_Byanyima) November 22, 2025

“China has been promoting and has been a champion of south-south cooperation… China proposes a model that is more about exchanging skills, [and] know-how that has less conditionalities, as they are often known around aid floors,” she added.

UNAids data indicate that 1,000 adolescent girls and women aged 15 to 24 years were infected every week in 2024, according to Byanyima.

“China has come in to offer support at the right time and for the right group of people,” she said. DM