Donor dependence and domestic resource mobilization for HIV programmes in sub-Saharan Africa and trade-offs in policy financing models and their implications for programme performance and sustainability

Abstract

Sub-Saharan Africa has the highest global burden of the human immunodeficiency virus (HIV) infection. As an effort to control the HIV epidemic, international donor organizations, including the United States President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, contributed enormous financial resources to curb the spread of the virus. This narrative review explores the policy trade-offs between domestic and donor funding for HIV programmes in sub-Saharan Africa and evaluates their impact on programme performance and sustainability. We searched electronic databases such as PubMed, Scopus, and Google Scholar, as well as grey literature from reports of international organizations, to include relevant evidence. The evidence included literature published between January 2010 and May 2026. Donor-funded initiatives made it possible to scale up antiretroviral therapy and prevention services across sub-Saharan Africa. However, following the January 2025 United States funding freeze on foreign aid, which reduced PEPFAR-supported programme funding, at least 18 countries in sub-Saharan Africa were affected, constituting a challenge to the continuity of HIV programmes. Closing this funding gap is an immediate priority; without it, any conversation about long-term sustainability remains largely theoretical. Integration of HIV funding into the national health budget and health systems would enhance sustainability.