Contributors: Constantine Mitengo (RIATT-ESA), Professor Kaymarlin Govender (HEARD), Roseline Hwati (RIATT-ESA), Lisa MaryAnne (EANNASO)
Introduction
East and Southern Africa (ESA) now stands at a fragile crossroads in the battle against HIV/AIDS. After decades of remarkable advances in testing, antiretroviral therapy (ART), and halting new infections, the region confronts mounting threats that risk undoing hard-won progress. Sharp funding cuts from key donors like PEPFAR and the Global Fund are destabilizing HIV programs, triggering ART shortages, layoffs of frontline health workers, and disruptions in community outreach initiatives. Simultaneously, persistent human rights abuses, stigma, discrimination, and the criminalization of key populations continue to erode access to and treatment adherence. This convergence of financial instability and social exclusion exposes millions of people living with HIV (PLHIV) in ESA to heightened vulnerability. This analysis explores how funding declines and rights violations intersect to shape the trajectory of HIV/AIDS programs across the ESA countries, underscoring the urgent imperative for integrated, rights-based, and sustainable responses.
Ongoing Human Rights Struggles Impacting HIV-ART Programs
Human rights violations are a pervasive and severe obstacle to effective HIV programming in East and Southern Africa (ESA), with wide-ranging impacts that compound the region's HIV challenges. Key points outlining the extent and effects include: Persistent stigma and discrimination against people living with HIV (PLHIV), key populations such as sex workers, people who use drugs, and LGBTQI+ individuals create hostile environments that deter access to HIV prevention, care, and treatment services. In May 2025, Al Jazeera reported that in Uganda, there has been increasing hatred and violence against the LGBTQ+ community after the introduction of the anti-homosexuality law in 2023. In Tanzania, a survey conducted by 76crimes established that there is growing stigma and discrimination against queer community, which has resulted in 71% of the group avoiding seeking medical care. This discrimination is prevalent even within healthcare settings, undermining trust and uptake of services. Criminalization of key populations severely restricts their access to vital HIV-related health services. Fear of arrest, incarceration, and societal exclusion discourages these groups from seeking harm reduction programs and HIV treatment, reinforcing HIV transmission and poor health outcomes. Gender-based violence (GBV) and entrenched gender inequalities increase women's and girls' vulnerability to HIV. South Africa, with one of the highest rates of rape and femicide globally, illustrates how violence undermines women's ability to negotiate safe sex and access HIV services. Overcrowded and poorly managed prisons in ESA serve as hotspots for HIV transmission, amplified by inadequate prevention, care, and human rights protections for inmates. Conditions such as sexual violence and lack of access to condoms exacerbate the epidemic within and beyond prison walls. These human rights failings intersect with social exclusion, creating multiple vulnerabilities that interrupt continuity of antiretroviral therapy (ART) and disrupt community-based HIV response efforts. This intersection exacerbates challenges in retaining PLHIV in care and achieving epidemic control. Overall, human rights challenges in ESA critically weaken HIV programming by driving stigma, deterring service uptake, increasing vulnerability among key and affected populations, and undermining community ownership and sustainability of HIV interventions. Addressing these violations is essential to achieving greater access, retention, and adherence in HIV prevention, care, and treatment across the region.
Effects of Deepening Funding Crisis on HIV Programs
Recent and ongoing funding cuts, especially drastic reductions from the U.S.-based sources like PEPFAR and the closure of USAID, have unleashed profound and disruptive consequences across East and Southern Africa, upending HIV prevention, treatment, and care services. Programs that depend heavily on external financing have experienced disruptions in service delivery, medicine stockouts, and workforce reductions. UNAIDS (2025) reports that over 60% of people in affected areas faced challenges accessing pre-exposure prophylaxis (PrEP), and nearly half reported ART disruptions. Community health systems, often the backbone of ART adherence and psychosocial support, have been dismantled or downsized due to budget shortfalls. Malawi and Botswana have already sounded an alarm of a disrupted medical supply chain leading to shortages of critical medicines in hospitals, including ART (BBC report). This financial instability threatens to derail progress toward the UNAIDS 95-95-95 targets, with potential increases in morbidity, mortality, and new infections.
Converging crises: the synergistic impact of Human Rights Failures and Funding Cuts on HIV responses
The collision of human rights violations and funding shortfalls has heightened the danger of an escalating HIV crisis throughout East and Southern Africa. When key populations face criminalization and stigma, their access to HIV services becomes dependent on community organizations often funded by external donors. As donor resources shrink, these organizations struggle to operate, leaving already marginalized populations without support. Conversely, when funding is available but human rights are not protected, treatment uptake remains low, and retention in care suffers. This dual burden reveals that neither adequate financing nor legal reform alone is sufficient; both are essential to sustain progress. The erosion of rights-based approaches combined with resource scarcity is undermining the foundation of ART programs and the broader public health response.
Although countries such as Botswana and Rwanda have demonstrated some resilience through strong political will, stable systems, and high ART coverage, Botswana has demonstrated how fragile our health systems are through its declaration of a state of national emergency on medical supply-chain disruption. In South Africa, with its strong health system, there have also been reports of the closure of some health clinics supporting special groups in Cape Town (dailymaverick). Kenya shows mixed results, with relatively diversified funding sources but ongoing equity challenges across counties. Conversely, Malawi, Mozambique, Zambia, and Zimbabwe remain highly dependent on donor aid, facing greater risks of service interruptions. Angola, with its less stable health infrastructure, also faces pronounced vulnerabilities in logistics and human resource capacity. These disparities highlight the urgent need for regional strategies that are tailored to local realities, taking into account diverse funding mechanisms and the complex human rights landscape.
Recommendations
ESA’s HIV/AIDS response stands at a pivotal moment. Without sustained funding and stronger human rights protections, the region risks losing decades of progress. Governments must commit to increasing domestic financing, safeguarding ART supply chains, and integrating HIV services within broader health systems to improve efficiency. Legal reforms should focus on decriminalizing key populations and enforcing anti-discrimination laws to foster inclusion and trust in healthcare systems. Donors and international partners, meanwhile, must maintain their support while promoting accountability and sustainability. Only through the convergence of funding security, rights-based governance, and resilient health systems can ESA sustain its progress toward epidemic control.
Conclusion
East and Southern Africa’s HIV/AIDS response teeters on a critical precipice. Without sustained and increased domestic financing, coupled with unwavering human rights protections, decades of hard-fought progress risk unraveling. Governments must act decisively to secure funding, safeguard antiretroviral therapy (ART) supply chains, and embed HIV services within resilient, integrated health systems to enhance efficiency and reach. Legal reforms are essential to decriminalize key populations and enforce anti-discrimination laws, thereby fostering an environment of inclusion and trust that is critical for effective healthcare. Meanwhile, donors and international partners must uphold their commitments, striking a balance between immediate support and strategies that ensure accountability and sustainability. The future hinges on a powerful convergence—where financial stability, rights-based governance, and robust health systems come together to uphold access to equitable, effective ART programs. This holistic approach is the only viable path to safeguard gains and drive lasting epidemic control in ESA, ensuring that no one is left behind in the fight against HIV.
