In January, US President Donald Trump suspended the disbursement of funds from the President’s Emergency Plan for AIDS Relief (PEPFAR) for 90 days, sparking concern among public health officials and global organisations.
While the decision shocked many, it was consistent with President Trump’s campaign rhetoric of prioritising American interests over international aid.
For developing countries, particularly those in Sub-Saharan Africa, where PEPFAR plays a critical role, this policy shift raised concerns about the future of HIV intervention programmes.
PEPFAR, a US government programme combating the HIV/AIDS epidemic, has been a crucial source of funding for Nigeria’s HIV response since 2005. With approximately 1.8 million Nigerians living with HIV, any disruption in funding can significantly impact treatment and prevention efforts.
However, many experts described this development as a wake-up call for Nigeria to reduce reliance on foreign aid and take full ownership of its HIV response alongside other public health needs.
Nigeria’s response
Two days after Mr Trump’s directive, the Nigerian government, in what seemed like a nod to public demand, announced plans to strengthen its domestic HIV response.
This stance remained even after the US granted a waiver for HIV intervention.
Through the National Agency for the Control of AIDS (NACA), the Nigerian government announced plans to locally produce HIV-related medical tools, including test kits and antiretroviral drugs.
While this was seen as a proactive move, experts remain sceptical about Nigeria’s ability to fully fund and sustain the initiative.
On 3 February, the Federal Executive Council (FEC) approved $1.07 billion to finance the healthcare sector reforms under the Human Capital Opportunities for Prosperity and Equity (HOPE) programme.
It also approved N4.8 billion for HIV treatment, according to the Minister of Finance and Coordinating Minister of the Economy, Wale Edun.
As part of government efforts to address the funding gap, the Nigerian Senate also recently allocated an additional N300 billion to the health sector in the 2025 budget.
The additional allocation, equivalent to $200 million, will target health programmes such as Tuberculosis, HIV,Malaria and Polio.
Persistent underfunding of health sector
For years, Nigeria has struggled to fund its health sector. The country has repeatedly failed to meet the 2001 Abuja Declaration commitment, which requires the African Union (AU) countries to allocate at least 15 per cent of their annual budgets to the health sector. Nigeria’s average allocation remains around five per cent.
Even in 2024, when the sector received its highest-ever budget, it accounted for only 5.75 per cent of the total budget.
A significant portion of the funds goes toward salaries and administrative expenses rather than direct disease control and prevention.
In the past 11 years, 72 per cent of the health budget was spent on workforce-related expenses, leaving limited resources for critical interventions like HIV treatment and prevention.
The budget for HIV/AIDS control is even lower, with international donors covering most of the costs. According to the US Department of State, PEPFAR is Nigeria’s primary funding source for antiretroviral therapy, testing, and prevention services.
HIV/AIDS funding: PEPFAR vs NACA
Data from the US Department of State website shows that between 2015 and 2024, the US provided $2.28 billion (N3.4 trillion at an exchange rate of N1,493 per dollar) in HIV/AIDS assistance to Nigeria.
This amount is approximately 53.21 per cent of Nigeria’s total health budget from 2015 to 2024.
In 2015, Nigeria received N292.63 billion as aid for HIV/AIDS, which increased to N392.66 billion in 2016 and N358.32 billion in 2017. The support continued with N346.38 billion in 2018, N262.77 billion in 2019, and a peak of N409.08 billion in 2020.
Nigeria received N306.07 billion in 2021, N370.26 billion in 2022, N341.90 billion in 2023, and N328.46 billion in 2024.
In comparison, Nigeria’s budgetary allocation for NACA has fluctuated significantly over the years. The agency received N2.78 billion in 2015, which increased to N3.42 billion in 2016 but then dropped sharply to N738.49 million in 2017.
However, from 2018 onward, NACA’s funding increased. In 2018, the agency received N4.53 billion, and N6.70 billion in 2019. The allocation dropped slightly to N6.21 billion in 2020 before rising again to N4.51 billion in 2021.
The budget rose to N6.42 billion in 2022 and to N8.28 billion in 2023. By 2024, it reached N10.04 billion, and for 2025, a proposed allocation of N19.03 billion has been made, marking the highest in recent years.
Despite this upward trend, experts argue that Nigeria needs a much larger and more consistent financial commitment to effectively combat HIV/AIDS.
Domestic funding
Meanwhile, the US, through PEPFAR, attempted to help Nigeria and other African countries reduce dependency on external funding and strengthen domestic ownership of HIV programmes.
Between 2011 and 2015, the programme instituted a reduction of about $83 million in yearly programme support to Nigeria. At the time, the programme’s focus shifted from emergency response to sustainability and country ownership. However, this effort failed.
Multiple reports and studies showed that the government struggled to increase domestic funding enough to cover the gap the reduction created. Key areas of the HIV response suffered, such as the availability of antiretroviral drugs, testing services, and healthcare infrastructure.
These gaps in funding led to disruptions in treatment for persons living with HIV, increased stockouts of essential medications, and limited access to care, particularly in rural and underserved areas.
What Nigeria needs to do — Expert
Victor Adepoju, director of HIV, Viral Hepatitis, and Infectious Diseases at Jhpiego, an affiliate of Johns Hopkins University, believes that Nigeria will need a different funding model to sustain its HIV/AIDS response if PEPFAR funding is withdrawn.
According to Mr Adepoju, one significant step the country has taken is establishing an integrated Technical Working Group (TWG) for HIV, TB, and Malaria.
He argued that while Western donors previously funded these programmes separately, the approach made them less efficient and more costly. He noted that by integrating efforts, Nigeria can cut costs and improve programme efficiency.
Mr Adepoju also highlights the need for local production of TB, HIV, and malaria drugs, which could lower treatment costs and enhance sustainability. However, he cautions that Nigeria may still struggle to independently fund the HIV response given its current national budget.
“Nigeria won’t be able to fully sustain (the programme) given the need, but will be able to salvage some,” he said.
For instance, he noted that Nigeria recently approved the procurement of HIV drugs for 150,000 people, while over one million people rely on treatment.
“Many will still die,” he warned, emphasising that the government must adopt a different approach to HIV/AIDS funding.
While strategies like local drug manufacturing could enhance long-term sustainability, he stressed that they are still future-focused solutions and do not address the immediate funding gap that would arise if PEPFAR pulls out.
To bridge this gap, he suggested expanding health insurance, attracting private sector investment, and creating a safety net for vulnerable populations who cannot afford treatment.
Similarly, Dan Onwujekwe, a former principal investigator at PEPFAR and research fellow at the Nigerian Institute of Medical Research (NIMR), revealed that international donor agencies had warned Nigeria as far back as 2012 to prepare for a potential pullout.
Mr Onwujekwe, a TB/HIV specialist, noted in an earlier interview with Punch newspaper that between 2012 and 2015, PEPFAR repeatedly engaged with Nigerian health authorities, advising them on strategies for transitioning to domestic ownership of diagnostics, drugs, equipment, and infrastructure.
Despite these warnings, he said, little was done, leading to current shortages of TB/HIV drugs, especially for persons over 40 years old living with HIV/AIDS.
“It is going to be a big challenge despite the early warnings,” he said. “They (PEPFAR) gave Nigeria three years of notice, holding multiple meetings on the transition process and suggesting ways to take ownership.”
He warned that losing donor support could cripple Nigeria’s HIV/AIDS control efforts and called for urgent government action at all levels.
He urged the authorities to designate a specific tax allocation —such as a portion of stamp duty — to fund TB and HIV programmes, emphasising that failure to act would be disastrous for a country with one of the highest burdens of TB and HIV globally.
PREMIUM TIMES
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