African leaders are rising to challenge of aid cuts, but debt holds them back

In 2019, I met a young woman in Kenya called Juliana who was diagnosed with HIV as a teenager. She worked for a USAID-funded project, providing advice and support to pregnant women newly diagnosed with HIV. When we spoke again recently, her project had received a stop work order from the American government, and all staff had been put on unpaid leave. 

The mothers who use the service panicked. Fearing running out, they started going to multiple clinics to stockpile medicines. Juliana said she had to put on a "plastic smile" to try to reassure them. But, still breastfeeding a four-month-old baby of her own, she needs to stay on treatment herself to prevent transmitting the virus to her child.

So now, Juliana is supporting her community without any income or safety for her own family.

Losing control of AIDS pandemic

We are seeing a humanitarian disaster unfold simultaneously at breakneck speed and in slow motion.

The sudden implementation of stop work orders has seen clinics shut and services disrupted almost overnight.

But, as Sibongile Tshabalala from South Africa's Treatment Action Campaign said: "The crisis in our clinics is only going to get worse, and many more people might stop treatment…and the long-lasting impact will be of increased deaths and more HIV infections."

I lead the Joint United Nations Programme on HIV/AIDS (UNAIDS).  In 2023, 3,500 people acquired HIV every day. According to our latest estimates, if the US President's Emergency Plan for AIDS Relief (PEPFAR) is not reinstated, and nothing comes in its place, that figure will grow to 5,800.

The world will see 4 million more AIDS-related illnesses and 6 million more HIV infections by 2029.

Put simply, we will lose control of the AIDS pandemic.

Domestic resources already account for more than 60% of the HIV response – and in South Africa it is more than 80%. But, facing such a catastrophic outcome, African leaders are stepping up, mobilising more resources to take greater ownership of HIV programming.

Zambia's Ministry of Health has developed a plan to provide a minimum package of HIV services for 12 months. Malawi, Ethiopia, Mali, Kenya, and many others are doing all they can to provide more domestic HIV funding, while governments across the continent are shifting work from US-funded staff to domestic health workers.

In South Africa, Health Minister Aaron Motsoaledi has vowed that no one will be denied antiretroviral medicines following aid cuts, and he is confident the country can get an additional 1.1 million people living with HIV on treatment.

Meanwhile, South Africa is leading efforts to secure ongoing international funding, co-hosting this year's replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has helped to save 65 million lives.

Even before this latest crisis, UNAIDS was working with the governments of more than 35 low and middle-income countries to develop detailed transition plans towards domestic ownership of their HIV responses. That work is more critical now than ever.

But time after time, we are coming up against the same problem: how can a government increase domestic HIV funding when budgets are being drained by unsustainable debt repayments?

Debt relief urgently needed

Of Africa's 54 countries, 34 now spend more on debt than on healthcare.

We cannot address the aid crisis if we do not address the debt crisis.

This week, governments have an opportunity to take decisive steps to change that. Finance ministers from around the world are travelling to the United States for the Spring Meetings of the institutions that sit at the heart of our global economy: the International Monetary Fund (IMF) and the World Bank.

As the historic first African President of the G20, South Africa can play a leading role. Already, South Africa has established a G20 working group on African debt.

And when South Africa's Minister Enoch Godongwana lands in DC, he will convene a meeting of all finance ministers of G20 countries on the sidelines of the international financial institutions.

His task is to unite them around an ambitious agenda that can relieve the burden of excessive payments to service debt, enabling investment in health and social protection services.

First, the poorest countries in greatest need should have their debts cancelled. These are low-income countries in or close to debt distress, many facing default.

Fragile public services are already barely able to keep people alive, but debt obligations could force governments to gut what remains.

The world has a moral duty to act in solidarity.

Second, lower-middle income countries that have faced multiple shocks need breathing space to recover and invest in their economies.

African countries are facing debt interest payments up to nine times higher than those paid by wealthy countries. For these countries, debt restructuring is needed to curb interest rates and reschedule payments into realistic timelines.

During the Covid-19 pandemic, the G20 established a mechanism called the Common Framework to provide debt restructuring and relief, but after nearly four years of disorganised and dysfunctional negotiations, only three countries have received support.

We need a faster, more effective system to deal with the problem of unaffordable debts.

Third, African governments must ramp up efforts to increase revenues through progressive taxation. Africa loses $89 billion every year to illicit financial flows, mostly aggressive tax planning enabled by tax incentives, exemptions, and loopholes. Health levies on tobacco, alcohol, and sugary beverages pose an opportunity to generate short-term revenue, while helping to curb unhealthy behaviours.

But the richest should shoulder the greatest burden, and that can only be achieved through taxing wealth, corporate profits, inheritance, and capital gains.

African leaders are rising to the moment

Aid, debt, and taxation might seem abstract financial concepts, far removed from our daily lives.

However, for people like Juliana and her children, securing the resources to fund health programmes is a matter of safety. For many, it is one of life and death.

If Africa cannot take ownership of the HIV responses in the face of cuts, our continent could return to the darkest days of AIDS.

African leaders are rising to meet this critical moment with action. But the scale of the challenge means that we cannot simply reallocate existing budgets – we need more money in government coffers.

Ultimately, tackling debt and taxation head-on is the only path forward.

Courage and cooperation are required to relieve crushing debt, ensure fair taxation, and invest in humanity - because the cost of inaction will be counted in lives lost.

Winnie Byanyima is UNAIDS Executive Director and Under-Secretary-General of the United Nations..

Follow Ms. Byanyima at: LinkedIn, X (Twitter), Instagram.

A version of this article was originally published by News24, 21 April 2025.