From aid dependency to health sovereignty — Africa’s urgent call to own its HIV response

The recent Second Global Edition of the African Public Square (APS) open debate, convened during King’s Africa Week at Bush House, King’s College London, on 2 March 2026, posed a question that cuts to the heart of Africa’s contemporary development predicament: “How should the resourcing of African agency be negotiated?”

Nowhere is this tension between ownership and administration more urgent than in Africa’s HIV response. The debate did not emerge in a vacuum. A cascade of structural shocks preceded it. In January 2025, the Trump administration ordered a comprehensive review that temporarily halted nearly all US foreign aid, leading to an immediate suspension of Pepfar and the rapid dismantling of USAid’s development programmes.

Combined with significant cuts in development assistance for health from other major donors, including in Europe, these actions exposed the fragility of health systems that had come to rely on continued external funding. Africa CDC estimates that Official Development Assistance for Africa’s health sector fell by around 70% between 2021 and 2025, even as multiple public health emergencies across the continent placed increasing strain on already vulnerable systems.

For the HIV response, which had been designed over two decades around sustained external financing, the consequences were immediate and severe: treatment continuity threatened, supply chains disrupted, and surveillance systems compromised. The development predicament that we find ourselves in should not be read as an aberration, but seen as the latest expression of a longer structural condition.

The forces limiting African agency have deep historical roots that financing adjustments cannot resolve alone. Commenters have argued that what is required is the deliberate cultivation of strategic state capabilities related to industrial capacity, technological infrastructure, financial institutions and the broader economic foundations that enable states to pursue independent and progressive development strategies. Without such foundations, it is asserted that political sovereignty remains largely symbolic.

Applied to the HIV response, this intellectual frame yields a clear and uncomfortable implication: the response cannot be secured by refining the terms on which external actors remain in charge. The deeper implication is that lasting progress depends on whether African states can build the institutional foundations in the fiscal, industrial, epistemic, and political spheres through which the HIV response (and related epidemics) is owned rather than merely administered.

The issue of ownership and of both individual and collective agency in the HIV response has to be a contextually informed and forward-thinking concern. More pointedly, the HIV response sits at the intersection of, among other factors, sustainable financing, the politics of health information, the local production of medicines, and the reinforcement of health infrastructure through primary healthcare.

This makes it both a critical test case and a revealing lens through which the broader argument for health sovereignty becomes concrete.

Aid architecture and structural exposure

Financing and structural dependency are where the HIV dimension is most acute. Pepfar has long been a major pillar of HIV responses in many African countries, but the 2025 funding freeze exposed how dependent some programmes had become on external support.

In South Africa, Pepfar accounted for a substantial share of the HIV response (South Africa’s HIV/Aids programme is largely funded by the government, which contributes 74%, with 7% from the Global Fund, and 17% from Pepfar); and UNAids reported that Botswana and several other countries experienced serious service disruptions after the US stop-work order.

These responses demonstrate the principle that when the external actor withdraws, the only durable alternative is domestic fiscal ownership. HIV programming is where that lesson has been learnt most painfully and most instructively. What sustainable domestic financing requires is worth pausing on.

It demands strengthened tax systems and innovative fiscal instruments, including health-related levies, sin taxes, and mechanisms that direct domestically generated revenue toward health as a matter of policy, rather than as a residual allocation. It also requires sovereign wealth funds and development banks to be mobilised toward health investment, and National Health Financing Plans to function as living governance instruments rather than donor-facing documents.

Africa CDC’s April 2025 concept paper reports that only 16 African countries (29%) have updated National Health Development Plans supported by National Health Financing Plans, which it identifies as important tools for internal resource mobilisation. The paper provides a continental framework for shifting toward stronger domestic financing, but turning that framework into practice will depend on sustained political commitment and implementation capacity.

Data, power and the politics of health

Data ownership and governance take on particular urgency in HIV because of the sensitive and potentially stigmatising nature of the data involved. These records can expose people’s status and affect their employment, relationships and safety.

The terms the US has reportedly sought in its bilateral health engagements with Zambia and Zimbabwe make this concern concrete. Harare reportedly declined to proceed after the US sought access to epidemiological data and biological samples without clear reciprocal benefits, while Lusaka objected to clauses it viewed as problematic, including a one-way, 10-year data-sharing arrangement and links to critical minerals in exchange for $1-billion in aid.

The message from both governments was clear: health data is not a commodity to be traded for aid.

Nigeria and the United States signed a five-year health MOU under which the US is expected to provide nearly $2-billion in grant funding, while Nigeria committed to allocating at least 6% of executed federal and state budgets to health, projected to mobilise nearly $3-billion in domestic financing. The agreement drew controversy over transparency and the role of faith-based providers.

Kenya’s agreement followed a different path. It faced a legal challenge, and the high court issued orders suspending implementation of the health cooperation framework, first over the data-sharing provisions and later more broadly, citing privacy, public participation, and parliamentary approval concerns.

Of all the countries affected by America’s shifting global health strategy, South Africa’s position is the hardest to ignore. It has one of the world’s largest HIV epidemics. Pepfar funding has accounted for a substantial share of HIV spending. While South Africa did receive a Pepfar Bridge Plan worth $115-million to sustain services through March 2026, which means there was at least a temporary transition mechanism, it has not yet been invited into the same new MOU process as other African countries, leaving it dependent on temporary bridge financing rather than a clear long-term transition plan.

What makes these disputes more than diplomatic disagreements is their real-world impact when systems fail. In 2025, Kenya’s electronic medical records system went offline after a USAid-funded server was decommissioned, disrupting treatment records, viral load monitoring and the supply-chain data that keeps antiretrovirals moving.

In the HIV context, African-controlled health data infrastructure is not an abstract governance issue; it is what prevents interruptions in care. The consequences were just as stark for prevention: when the US government cancelled Dreams funding and restricted PrEP support to pregnant and breastfeeding women, a long-built prevention platform was abruptly weakened and, in some places, dismantled.

In South Africa, this matters especially because adolescent girls and young women aged 15 to 24 account for about 35% of new HIV infections, despite making up a much smaller share of the population.

While the US-led agreements are framed as promoting African health self-reliance, the evidence suggests they may represent a significant and potentially exploitative restructuring of global health power. Health data is treated as a bargaining chip, financial conditions are imposed on governments already under pressure, democratic processes are bypassed and the systems communities depend on for accountability are weakened.

At the same time, the multilateral health architecture that many African countries have long relied on is being eroded. For the millions whose HIV treatment depends on these systems, the stakes could not be higher.

Pharmaceutical sovereignty
and local manufacturing

Local pharmaceutical sovereignty is central to HIV control because Africa still imports most of the medicines it uses and remains dependent on external suppliers for ARVs, diagnostics and key inputs such as active pharmaceutical ingredients. Building local capacity, therefore, means more than assembling finished products: it requires manufacturing infrastructure, quality control, regulatory harmonisation, technology transfer and predictable regional markets that can sustain production at scale.

Initiatives such as the South African-led Brilliant Consortium show the value of African scientific leadership, but the disruption caused by USAid’s 2025 funding freeze underscores how fragile externally funded biomedical capacity can be.

Against that backdrop, investments in African manufacturing for ARVs and newer prevention tools such as lenacapavir are not just health interventions; they are industrial and sovereignty priorities that determine whether the continent can secure its own HIV response.

The HIV-preparedness nexus

The Covid-19 pandemic made a hard lesson impossible to ignore: health systems and epidemic-response capacity take decades to build, but they can unravel quickly when funding is interrupted. What scientists warned at CROI 2026 was not just about HIV research or delivery systems in isolation, but about the real damage caused when infrastructure that has been carefully built over years is allowed to weaken.

The surveillance platforms, clinical trial sites, laboratory network and community healthworker systems developed through the HIV response are not single-purpose assets; they also form the backbone of preparedness for future outbreaks. If they are allowed to deteriorate, the loss is not temporary. It weakens the continent’s ability to respond quickly and confidently to the next health threat. Sustaining this infrastructure is therefore about more than HIV; it is about protecting long-term health security and sovereign response capacity in a post-Covid world.

Primary care: The HIV engine

The success of the UNAids 95-95-95 targets is not just a story of high-tech hospitals, but of strong primary health care and community-based delivery systems. By shifting HIV management closer to clinics and communities, countries such as Zimbabwe have shown how differentiated service delivery, community-based care, and peer support can improve retention, reduce patient costs, and decongest facilities.

These same frontline systems are now expected to do more, including integrating HIV care with NCD services and digital health tools so that no patient is lost at the last mile.

However, we also need to acknowledge the growing burden on PHC workers as they are asked to manage HIV, TB, malaria and rising rates of NCDs such as hypertension and diabetes. Integrated care can improve efficiency, but it also increases workload and risks burnout, especially in under-resourced clinics.

As people live longer with HIV, PHC workers must also manage ageing-related conditions and potential drug-drug interactions between ART and cardiovascular medicines. Much of the funding remains vertical, while the horizontal PHC system – staff, electricity, water, and supply chains – remains fragile.

If the clinic has no running water, the HIV response cannot function properly. Reaching the last mile of the 95-95-95 targets remains especially difficult because of stigma, poorer viral suppression among children and adolescents, treatment fatigue, drug resistance and supply-chain fragility. As we move toward 2030, the HIV response faces a major sustainability test, especially as donor funding declines and health-worker shortages persist.

Is Africa ready to take the next steps?

For two decades, the organising question of the HIV response has been how to sustain and grow external financing. The current debate invites a quieter but more consequential reckoning: whether African states can build the fiscal, institutional and industrial foundations to own that response themselves.

The two questions are not incompatible in the short term; transitions are rarely clean, but the direction of travel is no longer ambiguous. HIV is not a time-limited emergency programme. It requires the kind of durable, domestically anchored capacity that external funding, however generous, was never designed to provide. Reorientation is no longer optional; it is necessary. DM