www.thelancet.com/hiv 第 12 卷 2025 年 7 月
2025年1月24日之後，由於美國總統防治愛滋病緊急救援計畫（PEPFAR）停止支持，全球的愛滋病防治計畫受到嚴重干擾，大部分國家陷入混亂。對 153 個 PEPFAR 受助者的調查顯示，資金凍結導致挽救生命的服務停止，儘管獲得了豁免，但大多數服務仍未恢復。例如，為重點人口服務的診所仍然關閉，導致數千人無法獲得醫療服務。包括本土非政府組織在內的醫療保健組織紛紛關閉，導致大量醫療專業人員失業。可悲的是，無數依賴這些服務的人，包括2000萬接受抗病毒治療的愛滋病毒感染者，都面臨著嚴重伺機性疾病或因此死亡的高風險。
美國政府停止對愛滋病毒的資助造成了巨大的缺口，但同時也為重新構想愛滋病毒應對措施提供了一個機會，讓非洲各國政府、社區和組織發揮帶頭作用——如果他們能夠加緊努力的話。投資並不容易，在許多國家，美國的資金很難被取代。例如，尚比亞的國民生產總值為 800 億美元，政府預算為 36 億美元，而美國在愛滋病毒方面的投資為 4 億美元，佔其整體投資的近 11%，亦佔其衛生預算的 50%。 即使在南非，愛滋病毒預算主要由國內稅收提供資金，但美國政府提供的 17% 資金也用於資助愛滋病毒檢測和數據資訊系統等重要組成部分。 關鍵外國援助資金的突然撤回和是否豁免的不確定性，將要求非洲各國政府在短期至中期內加大力度吸收相當大比例的相關成本。
非洲各國政府對其衛生系統的投資不足。儘管 2001 年《阿布賈宣言》承諾將國家年度預算的 15% 用於衛生部門，但只有少數國家實現了這一目標。1993 年世界銀行的《投資健康》報告闡明了健康與經濟成長的關係。此前，人們認為財富透過改善營養、改善環境和獲得醫療服務來創造健康，因此健康是單向的。但該報告挑戰了這種邏輯，證明對健康的投資透過健康壽命、生產力、教育和人力資本創造財富。簡而言之，維持成功的愛滋病毒計畫可能需要大量的前期成本，但會帶來長期的健康和經濟繁榮效益。
國家因應措施可加強先前受美國總統防治愛滋病緊急救援計畫捐贈模式所制約的衛生系統。總統防治愛滋病緊急救援計畫提供了透明度、凝聚力和結構，但也存在一些缺點；這些包括對平行供應鏈、臨床服務、報告結構和數據系統的需求，這些通常由外部承包商管理，並且未納入當地國國家系統。隨著國家計畫轉向擁有和領導愛滋病毒應對工作，創建覆蓋初級和三級醫療的更強大的衛生系統的機會也隨之出現。這包括利用總統防治愛滋病緊急救援計畫的基礎設施、人力資本、電子數據系統、供應鏈和其他捐款來造福衛生系統。
非洲各國政府必須迅速採取行動應對捐助環境的不穩定，因此需要採取迅速和協調的行動。 COVID-19 和其他公共衛生危機開創了先例，例如連接不同政府部門的集中事件指揮部。最初需要採取臨時措施來加強對供應鏈、人力資源和衛生系統能力的預測和規劃。財政部、教育部和衛生部必須共同努力，維持愛滋病防治計畫。
情境規劃、預測和建模方法可以幫助政府評估不同的投資策略並優化資源配置。在全球團結的基礎上，國際社會可以提供技術專長和有針對性的需求評估，以明確適合非洲政府的可持續愛滋病毒防治計畫的最佳實踐。
透過非洲聯盟、西非國家經濟共同體、南部非洲發展共同體和東非共同體等區域機構，各國政府可以倡導區域協調應對愛滋病毒。非洲聯盟的非洲藥品管理局和非洲疾病管制與預防中心在新冠疫情期間就體現了這一點。可以啟動區域融資，或許可以效法非洲的疫苗採購舉措，來維持愛滋病毒防治計畫。此外，在從區域資源中獲利的跨國公司的推動下，強勁的非洲私營部門也可以參與其中，投入資源來支持衛生系統，特別是愛滋病毒防治工作。
愛滋病計畫向國內所有權的轉變是不可避免的，但卻提供了透過數位工具實現服務交付現代化的機會。人工智慧 (AI) 驅動的預測分析可以提高患者留存率、優化供應鏈並增強有針對性的推廣，利用技術以更少的資源實現效率最大化。我們可以從新冠疫情的數位健康創新中汲取經驗教訓，例如遠距醫療、人工智慧診斷和行動健康應用程式。
轉型將是痛苦的，但混亂的規模和變化的迅速性要求做出根本性的回應。基於科學的方法可以減輕危害並指導應對措施。各國政府必須加大對衛生事業的投入。波札那和盧安達是國家自主承擔並資助其愛滋病毒計畫同時維持成果的典範。非洲各國政府應該吸取這些國家的經驗教訓，並將其作為最佳實踐的標竿。國家擁有衛生系統不僅是可能的，而且是必要的。
這是一個清算的時刻，但也是一個機會的時刻。如果非洲各國政府和全球合作夥伴能夠接受衛生系統可持續性的新願景，這種轉變將為建立更強大、更有彈性的衛生系統奠定基礎，以應對當今和未來的挑戰。
我們聲明不存在利益競爭。
*Wilbroad Mutale、Aggrey Semeere、Elizabeth A Bukusi、Dike Ojji、Francois Venter、Thomas Odeny、Roma Chilengi、Mosepele Mosepele、Elvin Geng、Izukanji Sikazwe、Samuel Bosomprah、Llyod Mulenga、Fred Simitala
wmutale@yahoo.com
尚比亞大學公共衛生學院衛生政策與管理系，盧薩卡 10101，尚比亞（WM）；南部非洲合作研究與創新組織（SAICRIO），尚比亞盧薩卡（WM）；烏干達坎帕拉馬凱雷雷大學健康科學學院傳染病研究所（AS）；肯亞內羅畢 KEMRI微生物學研究中心（EAB，TO）；奈及利亞阿布賈大學健康科學學院臨床科學系內科系（DO）；南非約翰尼斯堡威特沃特斯蘭德大學（FV）；美國密蘇里州聖路易斯華盛頓大學腫瘤科（TO）；尚比亞國家公共衛生研究所，尚比亞盧薩卡（RC）；波札那大學，哈博羅內，波札那（MM）；美國密蘇里州聖路易斯華盛頓大學醫學系（EG）；尚比亞傳染病研究中心（CIDRZ），尚比亞盧薩卡（RC、IS、SB）；尚比亞盧薩卡衛生部（LM）；烏干達坎帕拉馬凱雷雷大學醫學系和馬凱雷雷大學聯合愛滋病計畫（FS）
How can Africa sustain its HIV response amid US aid cuts?
www.thelancet.com/hiv Vol 12 July 2025
After Jan 24, 2025, globally, HIV prevention and treatment programmes were severely disrupted by cessation of support from the US President’s Emergency Plan for AIDS Relief (PEPFAR), sending most into turmoil. A survey of 153 PEPFAR recipients indicated that the funding freeze stopped life-saving services, and the majority are yet to be reinstated despite waivers. For instance, clinics serving key populations are still closed, leaving thousands without access to care. Health-care organisations, including indigenous non-governmental organisations, have closed, leaving several health professionals jobless. Tragically, countless people reliant on these services, including the 20 million people living with HIV on antiretrovirals, are at high risk of suffering debilitating opportunistic illnesses or dying as a result.
Cessation of US Government HIV funding has created a major gap, but also an opportunity to reimagine the HIV response, putting African governments, communities, and organisations in the lead—if they can step up. Investments will not be easy, and in many countries, US funding cannot easily be replaced. For example, with a gross national product of US$80 billion and a budget of $3·6 billion in Zambia, the US HIV investment of $400 million represents nearly 11% overall and 50% of the health budget. Even in South Africa, where the HIV budget is largely funded off the domestic tax base, the 17% from the US Government funds vital components including HIV testing and data information systems.3 The abrupt withdrawal of critical foreign aid funding and uncertainty with waivers demands African governments to step up to absorb a substantial proportion of related costs in the short to medium term.
African governments have insufficiently invested in their health systems. Despite the 2001 Abuja Declaration entailing a commitment of 15% of the national annual budget to the health sector, only a handful of nations have reached this target.4 The 1993 World Bank Investing in Health report5 clarified the relationship between health and economic growth. Previously considered unidirectional, since wealth creates health through better nutrition, improved environment, and access to care, the report challenged this logic by demonstrating that investments in health generate wealth via healthy life-years, productivity, education, and human capital. In short, maintaining successful HIV programmes may require substantial upfront costs but yield long-term health and economic prosperity gains.
National responses can strengthen health systems previously constrained under PEPFAR’s donor model. PEPFAR has provided transparency, cohesion, and structure, but with some downsides; these include the need for parallel supply chains, clinical services, reporting structures, and data systems, often managed by external contractors and unintegrated into national systems. As national programmes pivot to owning and leading their HIV response, an opportunity to create stronger health systems covering primary and tertiary care emerges. This includes leveraging the PEPFAR infrastructure, human capital, electronic data systems, supply chain, and other contributions to benefit the health system.
African governments must act rapidly in response to the instability of the donor environment, hence the need for swift and coordinated action. COVID-19 and other public health crises set precedents such as a centralised incident command connecting different government sectors.6 Temporary measures are initially needed to enhance forecasting and planning for supply chains, human resources, and health system capacity. Ministries of finance, education, and health must work together to sustain HIV programming.
Scenario planning, forecasting, and modelling approaches can help governments assess different investment strategies and optimise resource allocation. Building off global solidarity, the international community can provide technical expertise and targeted needs assessments to clarify best practices for sustainable HIV programmes customised to African governments.
Through regional bodies such as the African Union, the Economic Community of West African States, the Southern African Development Community, and the East African Community, governments can advocate for a coordinated regional HIV response. The African Union’s African Medicines Agency and Africa Centres for Disease Control and Prevention exemplified this during the COVID-19 pandemic. Regional financing, perhaps modelled on Africa’s vaccine procurement initiatives, could be initiated to sustain HIV programmes.7,8 Furthermore, the robust African private sector, driven by multinational corporations that profit from regional resources, could also be engaged to commit resources to support health systems, in particular the HIV response.
The transition to domestic HIV programme ownership is inevitable but provides an opportunity to modernise service delivery through digital tools. Artificial intelligence (AI)-powered predictive analytics can improve patient retention, optimise supply chains, and enhance targeted outreaches, leveraging technology to maximise efficiency with fewer resources. We can draw lessons from COVID-19’s digital health innovations, such as telemedicine, AI-powered diagnostics, and mobile health applications.9,10
Transition will be painful, but the scale of the disruption and the rapid nature of the changes demand a fundamental response. A science-based approach can mitigate harm and guide the response. Governments must step up and invest heavily in health. Botswana and Rwanda are exemplars of countries taking ownership and funding of their HIV programmes while sustaining the gains. African governments should draw lessons from those countries, and use them to benchmark best practices. National ownership of health systems is not only possible but necessary.
This is a moment of reckoning, but it is also a moment of opportunity. If African governments and global partners can embrace a new vision for health system sustainability, this transition can lay the foundation for stronger, more resilient health systems capable of meeting the challenges of today and the future.
We declare no competing interests.
*Wilbroad Mutale, Aggrey Semeere, Elizabeth A Bukusi, Dike Ojji, Francois Venter, Thomas Odeny, Roma Chilengi, Mosepele Mosepele, Elvin Geng, Izukanji Sikazwe, Samuel Bosomprah, Llyod Mulenga, Fred Simitala
wmutale@yahoo.com
Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka 10101, Zambia (WM); Southern Africa Institute for Collaborative Research and Innovation Organisation (SAICRIO), Lusaka, Zambia (WM); Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda (AS); Center for Microbiology Research, KEMRI, Nairobi, Kenya (EAB, TO); Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Abuja, Nigeria (DO); University of the Witwatersrand, Johannesburg, South Africa (FV); Division of Oncology, Washington University, St Louis, MO, USA (TO); Zambian National Public Health Institute, Lusaka, Zambia (RC); University of Botswana, Gaborone, Botswana (MM); Department of Medicine, Washington University in St Louis, St Louis, MO, USA (EG); Center for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia (RC, IS, SB); Ministry of Health, Lusaka, Zambia (LM); Department of Medicine and Makerere University Joint AIDS Program, Makerere University, Kampala, Uganda (FS)
