Projected Effect of US PEPFAR Withdrawal on Zimbabwe and Implications for the Global HIV Response.

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.