{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T17:55:31Z","timestamp":1792432531392,"version":"4.5.0"},"reference-count":75,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T00:00:00Z","timestamp":1756684800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:p>Sub-Saharan Africa (SSA) faces a critical HIV financing crisis that threatens the 2030 goal of ending HIV as a public health threat. Despite accounting for 77% of weekly global new HIV infections, occurring among adolescent girls and young women, only 1% of annual global health spending is available for SSA, where 16% of the world\u2019s population resides. This disparity undermines progress toward the UNAIDS 95-95-95targets for HIV diagnosis, treatment access, and viral suppression. Multiple converging health financing gaps exacerbate this crisis: Domestic resource mobilization remains inadequate, with only three African countries meeting the Abuja Declaration\u2019s 15% health budget allocation target. Official development assistance (ODA) has declined by 70%, while reduced PEPFAR funding threatens treatment access for over 222,000 requiring daily treatment across seven high-burden countries. Health insurance coverage remains minimal, forcing up to 70% out-of-pocket health spending in some countries. Additionally, donor-driven vertical programs have fragmented health systems, while Africa produces only 3% of global pharmaceuticals despite bearing 23% of disease burden. These financing challenges extend beyond the HIV response, potentially causing 10.6 million additional tuberculosis cases and 2.2 million deaths during 2025\u20132030. Addressing this crisis requires coordinated action including strengthened domestic resource mobilization, innovative financing mechanisms, regional manufacturing capacity, and integrated health system governance. Urgent intervention is necessary to preserve decades of HIV prevention and treatment progress, particularly affecting the most vulnerable populations.<\/jats:p>","DOI":"10.3389\/fpubh.2025.1658229","type":"journal-article","created":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T05:31:34Z","timestamp":1756704694000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":17,"title":["HIV response financing challenges in Sub-Saharan Africa: barriers to achieving the 95-95-95 UNAIDS targets"],"prefix":"10.3389","volume":"13","author":[{"given":"Benard W.","family":"Kulohoma","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colette A.","family":"Wesonga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,9,1]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1007\/978-3-031-19719-2_3","volume-title":"Disease burden and mortality, healthcare and disease burden in Africa","author":"Niohuru","year":"2023"},{"key":"ref2","author":"Dattani","year":"2023"},{"key":"ref3","year":"2025"},{"key":"ref4","year":"2016"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"6235","DOI":"10.3389\/fpubh.2024.1376235","article-title":"Prevalence and determinants of HIV among reproductive-age women (15\u201349 years) in Africa from 2010 to 2019: a multilevel analysis of demographic and health survey data","volume":"12","author":"Gedefie","year":"2025","journal-title":"Front Public Health"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"e801","DOI":"10.1016\/S2214-109X(25)00102-0","article-title":"Africa's defining moment: the time to lead the HIV response is now","volume":"13","author":"Chola","year":"2025","journal-title":"Lancet Glob Health"},{"key":"ref7","year":"2024"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"29","DOI":"10.26502\/fjwhd.2644-288400118","article-title":"Sub-national disparities in indicators of maternal mortality in Kenya: insights from demographic health surveys towards attaining SDG 3","volume":"7","author":"Mwaura","year":"2024","journal-title":"J Womens Health Dev"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"e72476","DOI":"10.7759\/cureus.72476","article-title":"Bridging data gaps: predicting sub-national maternal mortality rates in Kenyan using machine learning models","volume":"16","author":"Mwaura","year":"2024","journal-title":"Cureus"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"5242","DOI":"10.3389\/fpubh.2025.1565242","article-title":"Considerable variation in the 95-95-95 targets accomplishment between children and adults might delay achievement of set targets","volume":"13","author":"Kulohoma","year":"2025","journal-title":"Front Public Health"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"8970","DOI":"10.3389\/frph.2024.1488970","article-title":"Disparities in PrEP use and unmet need across PEPFAR-supported programs: doubling down on prevention to put people first and end AIDS as a public health threat by 2030","volume":"6","author":"Mukherjee","year":"2024","journal-title":"Front Reprod Health"},{"key":"ref12","year":"2025"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1016\/j.wen.2024.11.003","article-title":"Overcoming water, sanitation, and hygiene challenges in critical regions of the global community","volume":"7","author":"Bose","year":"2024","journal-title":"Water-Energy Nexus"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1371\/journal.pstr.0000020","article-title":"Investment needs to achieve SDGs: an overview","volume":"1","author":"McKenzie","year":"2022","journal-title":"PLoS Sustain Transform"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1382","DOI":"10.1016\/j.oneear.2025.101382","article-title":"Accelerating progress on the SDGs: policy guidance from the global modeling literature","volume":"8","author":"Allen","year":"2025","journal-title":"One Earth"},{"key":"ref16","year":"2025"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"e807","DOI":"10.1016\/S2352-3018(24)00212-1","article-title":"Global, regional, and national burden of HIV\/AIDS, 1990\u20132021, and forecasts to 2050, for 204 countries and territories: the global burden of disease study 2021","volume":"11","author":"Carter","year":"2024","journal-title":"Lancet HIV"},{"key":"ref18","year":"2025"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"e0291371","DOI":"10.1371\/journal.pone.0291371","article-title":"Financing health system elements in Africa: a scoping review","volume":"18","author":"Behzadifar","year":"2023","journal-title":"PLoS One"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"e0003433","DOI":"10.1371\/journal.pgph.0003433","article-title":"Financing health in Sub-Saharan Africa 1990\u20132050: donor dependence and expected domestic health spending","volume":"4","author":"Gr\u00e9pin","year":"2024","journal-title":"PLoS Glob Public Health"},{"key":"ref21","year":"2025"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"956","DOI":"10.1186\/1471-2458-14-956","article-title":"Where will the money come from? Alternative mechanisms to HIV donor funding","volume":"14","author":"Katz","year":"2014","journal-title":"BMC Public Health"},{"key":"ref23","author":"Raji","year":"2025"},{"key":"ref24","year":"2025"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"S2","DOI":"10.1186\/1753-6561-5-S5-S2","article-title":"Health financing in Africa: overview of a dialogue among high level policy makers","volume":"5","author":"Sambo","year":"2011","journal-title":"BMC Proc"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"235","DOI":"10.1016\/S0140-6736(25)01037-2","article-title":"Global, regional, and national trends in routine childhood vaccination coverage from 1980 to 2023 with forecasts to 2030: a systematic analysis for the global burden of disease study 2023","volume":"406","author":"Haeuser","year":"2025","journal-title":"Lancet"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"e26431","DOI":"10.1002\/jia2.26431","article-title":"By executive order: the likely deadly consequences associated with a 90-day pause in PEPFAR funding","volume":"28","author":"Tram","year":"2025","journal-title":"J Int AIDS Soc"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"302","DOI":"10.1186\/s12913-021-06316-4","article-title":"The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda","volume":"21","author":"Zakumumpa","year":"2021","journal-title":"BMC Health Serv Res"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1080\/23744235.2025.2464857","article-title":"A pause that hurts: the global impact of halting PEPFAR funding for HIV\/AIDS programs","volume":"57","author":"Akingbola","year":"2025","journal-title":"Infect Dis"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"291","DOI":"10.1016\/S2468-1253(25)00045-7","article-title":"Pathogens don't respect politicians: US federal disruption poses a new threat to global public health","volume":"10","author":"Wang","year":"2025","journal-title":"Lancet Gastroenterol Hepatol"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"103233","DOI":"10.1016\/j.eclinm.2025.103233","article-title":"The impact of the PEPFAR funding freeze on HIV deaths and infections: a mathematical modelling study of seven countries in Sub-Saharan Africa","volume":"83","author":"Hontelez","year":"2025","journal-title":"eClinicalMedicine"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"e346","DOI":"10.1016\/S2352-3018(25)00074-8","article-title":"Impact of an international HIV funding crisis on HIV infections and mortality in low-income and middle-income countries: a modelling study","volume":"12","author":"Brink","year":"2025","journal-title":"Lancet HIV"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"e629","DOI":"10.1016\/S2352-3018(20)30211-3","article-title":"Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models","volume":"7","author":"Jewell","year":"2020","journal-title":"Lancet HIV"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"283","DOI":"10.1016\/S0140-6736(25)01186-9","article-title":"Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis","volume":"406","author":"Cavalcanti","year":"2025","journal-title":"Lancet"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"8054","DOI":"10.1080\/16549716.2020.1868054","article-title":"Strategies for financing social health insurance schemes for providing universal health care: a comparative analysis of five countries","volume":"14","author":"Fenny","year":"2021","journal-title":"Glob Health Action"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"e004712","DOI":"10.1136\/bmjgh-2020-004712","article-title":"Examining the level and inequality in health insurance coverage in 36 Sub-Saharan African countries","volume":"6","author":"Barasa","year":"2021","journal-title":"BMJ Glob Health"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"e008219","DOI":"10.1136\/bmjgh-2021-008219","article-title":"Universal health insurance in Africa: a narrative review of the literature on institutional models","volume":"7","author":"Ly","year":"2022","journal-title":"BMJ Glob Health"},{"key":"ref38","year":"2017"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"6397","DOI":"10.3389\/fpubh.2022.856397","article-title":"COVID-19 and health systems functioning in Sub-Saharan Africa using the \u201cWHO building blocks\u201d: the challenges and responses","volume":"10","author":"Amu","year":"2022","journal-title":"Front Public Health"},{"key":"ref40","year":"2024"},{"key":"ref41","author":"Demeshko","year":"2025"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1186\/s41256-021-00190-7","article-title":"Health financing for universal health coverage in Sub-Saharan Africa: a systematic review","volume":"6","author":"Ifeagwu","year":"2021","journal-title":"Glob Health Res Policy"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"e9","DOI":"10.1002\/puh2.9","article-title":"Revisiting the issue of access to medicines in Africa: challenges and recommendations","volume":"1","author":"Adebisi","year":"2022","journal-title":"Public Health Chall"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"126829","DOI":"10.1016\/j.vaccine.2025.126829","article-title":"Advancing local manufacturing capacities for vaccines within Africa \u2013 opportunities, priorities and challenges","volume":"50","author":"Doua","year":"2025","journal-title":"Vaccine"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"1146","DOI":"10.1016\/j.lana.2025.101146","article-title":"Lenacapavir: a potential game changer for HIV prevention in the Americas, if the game is played equitably","volume":"47","author":"Cantos","year":"2025","journal-title":"Lancet Reg Health"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1093\/cid\/ciaf116","article-title":"Lenacapavir for human immunodeficiency virus (HIV) prevention: a commitment to equitable access and partnership by Gilead Sciences","volume":"9","author":"Baeten","year":"2025","journal-title":"Clin Infect Dis"},{"key":"ref47","year":"2025"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"e012664","DOI":"10.1136\/bmjgh-2023-012664","article-title":"Approaches for improving linkage to HIV care among HIV self-testing individuals in Sub-Saharan Africa","volume":"8","author":"Hlongwa","year":"2023","journal-title":"BMJ Glob Health"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"9743","DOI":"10.3389\/fpubh.2025.1609743","article-title":"Barriers to ART adherence in Sub-Saharan Africa: a scoping review toward achieving UNAIDS 95-95-95 targets","volume":"13","author":"Magura","year":"2025","journal-title":"Front Public Health"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1007\/s10461-017-1754-1","article-title":"Monitoring HIV treatment and the health sector Cascade: from treatment numbers to impact","volume":"21","author":"Low-Beer","year":"2017","journal-title":"AIDS Behav"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"688","DOI":"10.1097\/QAI.0000000000002628","article-title":"Brief report: financial incentives and real-time adherence monitoring to promote daily adherence to HIV treatment and viral suppression among people living with HIV: a pilot study","volume":"87","author":"Bien-Gund","year":"2021","journal-title":"J Acquir Immune Defic Syndr"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"S161","DOI":"10.1097\/01.aids.0000327637.59672.02","article-title":"Free care at the point of service delivery: a key component for reaching universal access to HIV\/AIDS treatment in developing countries","volume":"22","author":"Souteyrand","year":"2008","journal-title":"AIDS"},{"key":"ref53","first-page":"2025.03.04.25323340","article-title":"A deadly equation: The global toll of us tb funding cuts","volume-title":"medRxiv","author":"Mandal","year":"2025"},{"key":"ref54","first-page":"2025.04.23.25326313","article-title":"The potential impact of reductions in international donor funding on tuberculosis in low- and middle-income countries","volume-title":"medRxiv","author":"Clark","year":"2025"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"e00948","DOI":"10.1016\/j.sciaf.2021.e00948","article-title":"COVID-19 risk factors: the curious case of Africa's governance and preparedness","volume":"13","author":"Kulohoma","year":"2021","journal-title":"Sci Afr"},{"key":"ref56","year":"2016"},{"key":"ref57","year":"2022"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"954","DOI":"10.1377\/hlthaff.2014.0945","article-title":"A public-private partnership improves clinical performance in a hospital network in Lesotho","volume":"34","author":"McIntosh","year":"2015","journal-title":"Health Aff"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"1217","DOI":"10.1136\/bmjgh-2018-001217","article-title":"Are public\u2013private partnerships the future of healthcare delivery in Sub-Saharan Africa? Lessons from Lesotho","volume":"4","author":"Hellowell","year":"2019","journal-title":"BMJ Glob Health"},{"key":"ref60","doi-asserted-by":"publisher","first-page":"100139","DOI":"10.1016\/j.hpopen.2025.100139","article-title":"Public-private partnership (PPP) and health service delivery in Malawi: the case of Christian health Association of Malawi (CHAM) facilities in Mzimba district","volume":"8","author":"Salangwa","year":"2025","journal-title":"Health Policy Open"},{"key":"ref61","doi-asserted-by":"publisher","first-page":"5739","DOI":"10.3389\/fpubh.2022.1045739","article-title":"Healthcare system development in the Middle East and North Africa region: challenges, endeavors and prospective opportunities","volume":"10","author":"Katoue","year":"2022","journal-title":"Front Public Health"},{"key":"ref62","doi-asserted-by":"publisher","first-page":"S7","DOI":"10.1016\/S0140-6736(13)60293-7","article-title":"Universal health coverage in Rwanda: a report of innovations to increase enrolment in community-based health insurance","volume":"380","author":"Makaka","year":"2012","journal-title":"Lancet"},{"key":"ref63","doi-asserted-by":"publisher","first-page":"49","DOI":"10.2105\/AJPH.2015.302913","article-title":"Community-based health financing and child stunting in rural Rwanda","volume":"106","author":"Lu","year":"2016","journal-title":"Am J Public Health"},{"key":"ref64","first-page":"189","article-title":"Rwanda: performance-based financing in the public sector","volume-title":"Performance incentives for Global Health: Potential and pitfalls","author":"Rusa","year":"2009"},{"key":"ref65","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1017\/S1744133116000426","article-title":"Raising more domestic money for health: prospects for low- and middle-income countries","volume":"12","author":"Elovainio","year":"2017","journal-title":"Health Econ Policy Law"},{"key":"ref66","volume-title":"Mobilising tax revenues to finance the health system in C\u00f4te d\u2019Ivoire","year":"2020"},{"key":"ref67","volume-title":"The future of health financing in Africa: the role of health taxes","author":"Dao","year":"2025"},{"key":"ref68","year":"2021"},{"key":"ref69","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1186\/s12961-018-0303-3","article-title":"An evaluation of South Africa\u2019s public\u2013private partnership for the localisation of vaccine research, manufacture and distribution","volume":"16","author":"Walwyn","year":"2018","journal-title":"Health Res Policy Syst"},{"key":"ref70","year":"2025"},{"key":"ref71","year":"2022"},{"key":"ref72","doi-asserted-by":"publisher","first-page":"100499","DOI":"10.1016\/j.jvacx.2024.100499","article-title":"How the African vaccine manufacturing accelerator can assist in strengthening Africa's response to global health challenges","volume":"19","author":"Omojuyigbe","year":"2024","journal-title":"Vaccine"},{"key":"ref73","doi-asserted-by":"publisher","first-page":"135","DOI":"10.21955\/aasopenres.1115135.1","article-title":"Securing Africa\u2019s health sovereignty: why investing in science and innovation matters","volume":"3","author":"Mugabe","year":"2020","journal-title":"AAS Open Res"},{"key":"ref74","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1007\/978-3-030-14857-7_11","article-title":"Prioritising health systems to achieve SDGs in Africa: a review of scientific evidence","volume-title":"Africa and the sustainable development goals. Sustainable development goals series","author":"Wesonga","year":"2020"},{"key":"ref75","doi-asserted-by":"publisher","first-page":"e75624","DOI":"10.1371\/journal.pone.0075624","article-title":"Individual-based simulation models of HIV transmission: reporting quality and recommendations","volume":"8","author":"Colijn","year":"2013","journal-title":"PLoS One"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1658229\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T05:31:36Z","timestamp":1756704696000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1658229\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,1]]},"references-count":75,"alternative-id":["10.3389\/fpubh.2025.1658229"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2025.1658229","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,1]]},"article-number":"1658229"}}