Over the past two decades, U.S. leadership in global health, anchored by more than $100 billion in funding for PEPFAR, the U.S. global AIDS initiative, has played a decisive role in controlling the global HIV epidemic. That foundation is crumbling, with implications that extend far beyond HIV. Where do we go from here in sustaining global health systems?

Launched by President George W. Bush in 2003, the President’s Emergency Plan for AIDS Relief, or PEPFAR, has been a lifeline for millions, delivering antiretroviral treatment at scale that helped bend the trajectory of the epidemic. In 2023, the United States accounted for 73% of all donor spending on HIV, investing more than $5.7 billion — a level of support that cast the U.S. as the central architect of the global response.

But those dollars are drying up, leaving us to imagine different ways to sustain global health systems. Funding reductions have already been announced, and countries are entering into compacts that require them to assume a much larger share of financing and full control over programmatic decisions.

The consequences are staggering. A Viewpoint article published in The Lancet in August 2025, which I coauthored with colleagues, argued that the effects will extend to maternal and child health as well as tuberculosis and malaria programs. Some estimates suggest that an additional 6.3 million AIDS-related deaths could occur by 2029 if funding cuts are not reversed, demonstrating the urgent need to sustain global health systems.

Yet the problem runs deeper than budget lines. Donor funding has long been the backbone of HIV control, but it has also produced a largely vertical treatment system. That model delivered extraordinary progress and saved millions of lives, but it fostered dependency and left health systems fragile and difficult to sustain. When donor support recedes, entire programs risk collapse.

For too long, sustaining global health systems has been defined narrowly as financial solvency. The implicit assumption was that if countries eventually replaced donor dollars with domestic ones, services would continue. In reality, sustainability is about resilience. Durable health systems rest on three pillars: sound financial planning, strong institutions, and public trust. Without all three, progress proves illusory.

Read the full article about sustaining global health systems by A.K. Nandakumar at Devex.