Brian Honermann

Introduction: Changes in US global health policy, under the America First Global Health Strategy, have shifted US engagement away from open-ended programmatic support toward a model centered on time-bound bilateral health agreements. In Zimbabwe, negotiations over a proposed Memorandum of Understanding (MOU) have broken down, creating a credible risk of US withdrawal and HIV services disruption. Methods: Using PEPFAR performance data from 2024 to 2025, we quantify the total projected increase in new HIV infections from the disruption of PEPFAR-funded HIV testing, prevention, PMTCT, and adult treatment programs. Results: Our model estimates 75,440 (range: 30,002–122,601) new HIV infections could take place in Zimbabwe within 1 year as a consequence of full PEPFAR withdrawal and no additional government or international support, including 8939 (6953 – 10,926) new infections from loss of HIV testing programs, 19,139 (17,021 – 21,256) from loss of prevention programs, 1050 (134 – 2005) from disruptions to PMTCT, and 46,313 (5894 – 88,415) adult infections from disruption to treatment programs. Conclusions: This analysis demonstrates that policy shifts affecting PEPFAR support in Zimbabwe would have immediate epidemiological consequences. We project approximately 75,000 additional HIV infections within 1 year of complete PEPFAR withdrawal. Most of these infections (about 46,000, or 61%) are attributable to disruptions in antiretroviral treatment, as loss of viral suppression increases onward HIV transmission. An additional 19,000 infections are projected from reduced access to prevention services, including PrEP, VMMC, and programs for key populations. These findings underscore the central role of sustained treatment coverage and prevention services in maintaining epidemic control.

Introduction: On 24 January 2025, the U.S. government issued a stop‐work order freezing foreign assistance, including support for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), although a limited waiver for selected “life‐saving” interventions was subsequently granted. PEPFAR's official 2025 monitoring results, released 17 April 2026, included only fourth‐quarter data, whereas an earlier inadvertent release contained data for all four quarters of 2025. Using both datasets, we conducted a systematic facility‐level assessment of HIV programme performance while accounting for reporting disruptions. Methods: Facilities were categorized by reporting between Q1 2024 and Q4 2025 (continuous, intermittent, dropped, new). We assessed changes in HIV treatment, testing, prevention of mother‐to‐child transmission (PMTCT) and HIV prevention across facility categories. We additionally analyse changes in human resources for health (HRH) reported by PEPFAR. Results: The dataset included 31,628 facilities and community service sites. Most sites reported continuously (71.5%), while 16.7% reported intermittently, 3.9% stopped reporting, 3.1% were new in 2025 and 2.5% were community service sites. Between Q4 2024 and Q4 2025, the total number of people receiving HIV treatment declined by −1%. People on treatment increased 0.3% at continuously reporting facilities but declined −6.0% at intermittently reporting facilities. HIV testing declined by −18% overall. HIV diagnoses decreased by −13% at continuously reporting facilities, −32% in intermittently reporting facilities and −36% in community services sites. PMTCT infant testing declined by −6% at continuously reporting facilities and −60% at intermittently reporting facilities, while infant HIV diagnoses declined by −12% and −31%, respectively. Pre‐exposure prophylaxis initiations declined by −33%, and the number of direct service delivery healthcare workers declined by −62,541 (−24%). Conclusions: Although HIV treatment remained relatively stable at continuously reporting facilities, substantial declines were observed in HIV testing, HIV diagnoses, treatment initiation, prevention services and the PEPFAR‐supported workforce. These findings suggest that treatment coverage alone is an insufficient indicator of programme resilience. As countries assume greater responsibility for HIV programmes, sustained investment across the entire HIV care cascade coupled with transparent reporting and robust monitoring systems covering the full prevention, testing, treatment and health workforce landscape will be essential to maintain progress towards epidemic control.

The Office of Population Affairs’ Title X Family Planning Program (Title X) is the only federal program in the United States (US) dedicated solely to providing comprehensive family planning and rel...

Introduction: Despite international commitment to achieving the end of HIV as a public health threat, progress is off‐track and existing gaps have been exacerbated by COVID‐19's collision with existing pandemics. Born out of models of political accountability and historical healthcare advocacy led by people living with HIV, community‐led monitoring (CLM) of health service delivery holds potential as a social accountability model to increase the accessibility and quality of health systems. However, the effectiveness of the CLM model in strengthening accountability and improving service delivery relies on its alignment with evidence‐based principles for social accountability mechanisms. We propose a set of unifying principles for CLM to support the impact on the quality and availability of health services.Discussion: Building on the social accountability literature, core CLM implementation principles are defined. CLM programmes include a community‐led and independent data collection effort, in which the data tools and methodology are designed by service users and communities most vulnerable to, and most impacted by, service quality. Data are collected routinely, with an emphasis on prioritizing and protecting respondents, and are then be used to conduct routine and community‐led advocacy, with the aim of increasing duty‐bearer accountability to service users. CLM efforts should represent a broad and collective community response, led independently by impacted communities, incorporating both data collection and advocacy, and should be understood as a long‐term approach to building meaningful engagement in systems‐wide improvements rather than discrete interventions.Conclusions: The CLM model is an important social accountability mechanism for improving the responsiveness of critical health services and systems to communities. By establishing a collective understanding of CLM principles, this model paves the way for improved proliferation of CLM with fidelity of implementation approaches to core principles, rigorous examinations of CLM implementation approaches, impact assessments and evaluations of CLM's influence on service quality improvement.

Introduction: The United States President’s Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations’ response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR’s targets and resulting programming is crucial for successfully serving key populations.Methods: Publicly available PEPFAR budgets for key populations’ services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator.Results: PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019.Conclusions: Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed.