Rio de Janeiro, Brazil — HIV activists confronted U.S. officials before the official start of the AIDS 2026 conference over sweeping changes to Washington's global HIV strategy, accusing the Trump administration of creating a public health emergency through funding cuts, while the United States defended a new financing model that it says will build more sustainable, country-led HIV programmes.
At the centre of the debate is the America First Global Health Strategy, under which the United States is replacing traditional donor-funded programmes with five-year bilateral Memoranda of Understanding (MOUs) that require partner countries to gradually assume greater responsibility for financing and managing their HIV responses. So far, 34 countries have signed agreements committing to increase domestic health spending between 2026 and 2030 as U.S. support is gradually reduced.
Opening the pre-conference session in Rio de Janeiro on implementing the agreements, Dr Chris Akolo, Senior Technical Director for HIV at FHI 360, said the MOUs had become a central mechanism for sustaining HIV programmes and required close collaboration between governments, local implementing partners and U.S. agencies.
The session brought together representatives from partner country ministries of health, local implementing organisations and U.S. government officials to discuss country ownership, governance, domestic financing and maintaining HIV service delivery during the transition.
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Responding to criticism of the new strategy, Acting U.S. Global AIDS Coordinator Jeff Graham insisted the United States remained fully committed to ending HIV. He said the reforms were intended to strengthen, rather than weaken, the global response.
"Our commitment to ending HIV is undiminished. We are here. We are still in the leadership seat for global health. We are here leading the HIV response. We're changing the model, but not the mission," said Graham.
He said the move toward country ownership had been written into PEPFAR legislation since 2008 and was now being implemented through bilateral agreements tailored to each country's epidemiological situation, fiscal capacity and readiness to assume greater responsibility for its HIV response.
According to Graham, the United States has signed 34 MOUs under which Washington has committed nearly U.S.$15 billion in health assistance over five years, while partner governments have pledged more than U.S.$10 billion in domestic financing.
He rejected suggestions that the reforms represented a withdrawal of U.S. support, saying Washington intended to spend all of the global health funding appropriated by Congress for 2026 while directing more resources to frontline health workers, medicines and patient care and reducing administrative costs.
"We are helping countries to build the capacity to solve their own challenges instead of perpetuating dependency," said Graham.
He said the strategy would also expand partnerships with local organisations, faith-based groups and governments, while maintaining funding for frontline HIV services during the early years of the transition to avoid disruptions in care.
Expanding on how the new model will be implemented, Dr Rebecca Bunnell, deputy head of implementing the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), said implementation plans were designed to help countries assume greater ownership while safeguarding health outcomes.
She said the plans are built around four principles: improving efficiency, shared decision-making, increasing domestic co-investment and ensuring accountability.
"We need to achieve these simultaneously and these two outcomes can really reinforce each other. We can purposefully implement the transition to health sovereignty in ways that will maximize health impact," said Bunnell.
Bunnell argued that the shift to country ownership and the push to reduce HIV's toll as a public health threat are not competing priorities, but goals that reinforce one another: a country that succeeds in cutting infections is better positioned to sustain its own health system going forward. As the strategy moves through this transition, she urged the room to "keep our eyes on the prize and our eyes on the gold."
She pointed to integration as one of the clearest opportunities for impact, describing how countries are folding HIV diagnostics and service delivery into broader government health systems rather than running them as standalone programs. In Mozambique, for example, health officials are shifting from disease-specific community health workers toward a single, government-run cadre of integrated health workers. Bunnell also cited a "triple elimination" approach, combining efforts against pediatric HIV, congenital syphilis and hepatitis B, that 20 African implementation plans have already adopted.
Bunnell said closing the treatment gap remains the single most effective intervention available, since an estimated 5 million people with HIV worldwide remain undiagnosed and roughly 10 million are not virally suppressed. She described PrEP as a complement to, not a substitute for, treatment, most effective when programs are targeted at those at highest risk of infection.
"Civil society has long played a critical role in providing accountability within the HIV response," she said.
She also sees a growing role for technology and private-sector partnerships in country plans, from AI-assisted TB detection systems being scaled up in Uganda to a newly announced licensing deal expanding access to a long-acting HIV prevention drug across 129 countries. She said civil society groups remain essential to the model, both to hold governments accountable and to flag early signs of services being disrupted for hard-to-reach populations.
"We should not only ask, 'Will this prevent the most HIV infections and save the most lives?' but also, 'Will this advance country health sovereignty?'" she said. " This is the most critical work before us, and by so doing, we can achieve an end to AIDS as a public health threat."
Partner countries back transition
Officials from partner countries also welcomed the new bilateral agreements, describing them as an opportunity to strengthen national ownership while ensuring HIV programmes remain sustainable.
Kenya's Director-General for Health, Dr Patrick Amoth, welcomed the new government-to-government partnership, saying it marked a shift from donor dependency towards nationally owned and sustainable health systems. He said Kenya was the first country to sign both the Health Cooperation Framework and the accompanying Strategic Objective Agreement under the new model and expected to be the first to fully implement it.
"The new health cooperation framework builds upon that legacy and will deliver a shifting centre of gravity towards country ownership, stronger institutions and long-term sustainability," Amoth said.
He said the five-year framework represents a combined investment of about US$2.8 billion from the United States and the Kenyan government. While HIV accounts for more than 90% of the funding, the agreement also supports tuberculosis, malaria, maternal and child health, polio and broader health-system strengthening. He said the plan is built around government-run architecture rather than parallel donor systems, with oversight from a Joint Oversight Committee chaired by Kenya's Cabinet Secretary for Health, and that the country's implementation plan is set to roll out in mid-May 2026.
Kenya aims to assume full responsibility for programme management, commodity procurement, financing and digital health systems by 2030, describing the process as a deliberate, milestone-based transition rather than an abrupt handover.
"This is not about an abrupt transfer, but a carefully sequenced transition built around milestones, shared accountability and mutual trust," he said.
Nigeria, which also signed an MOU with the United States, said it was taking similar steps to prepare for the transition.
Nigeria prepares for country-led transition
Nigeria also backed the new approach. It signed its memorandum of understanding with the United States in December 2025. Dr Temitope Ilori, Director-General of the National Agency for the Control of AIDS, said Nigeria was finalising implementation plans, strengthening government institutions and preparing agencies to manage funding under the new framework.
"We have actually started our discussions by appreciating the U.S. government for their assistance in the HIV response... Over the last two decades, they've been a partner in progress," she said.
She said Nigeria's government has identified five agencies that would be involved in direct government-to-government financing, but that only two currently have experience managing U.S. government funds, so the country is working through a risk assessment and training process before those agencies can take on that role. She said negotiators are also developing performance milestones to track implementation, with oversight provided by a joint steering committee co-chaired by Nigeria's Coordinating Minister for Health and the U.S. Ambassador to Nigeria, alongside a technical committee and a management unit handling day-to-day coordination.
"We intend to have a country-owned, country-led programme that will strengthen our existing structures and strengthen governance and management practices," said Dr Ilori.
Activists push back
The policy shift has, however, sparked growing concern among HIV advocates, who argue that many countries are not yet ready to replace declining donor support and warn that the changes could undermine decades of progress against HIV.
Those concerns spilled into the conference hall when HIV activists interrupted a presentation by Graham, accusing the Trump administration of dismantling the global HIV response through cuts to PEPFAR and wider foreign assistance.
Health GAP Executive Director Asia Russell accused the U.S. government of creating a public health emergency through changes to PEPFAR and global health funding. She argued that the disruptions had reduced access to HIV prevention, testing and treatment for some of the world's most vulnerable populations.
"The last 16 months have been a public health emergency caused by your government's deadly disruptions in PEPFAR programming and global health aid, and we will not allow this fact to be erased," said Russell.
She argued that communities had experienced the impact of the funding changes long before official data became available and said recent PEPFAR programme data confirmed those concerns.
Russell also criticised the bilateral MOUs, arguing that while they were presented as promoting country ownership and self-reliance, they excluded people living with HIV and civil society from decision-making and linked health assistance to broader U.S. foreign policy objectives.
"Today, you're talking about memoranda of understanding with nice words like country ownership and self-reliance. But let's be honest. These are coercive bilateral deals that expel people with HIV from the negotiating table," she said.
Yvette Raphael, co-founder and co-director of the Advocacy for Prevention of HIV and AIDS (APHA) in South Africa, accused the United States of attempting to divide African countries through its policies.
"South Africa is part of Africa. You will not divide and rule us with your racist agenda," said Raphael.
She said South Africa had played a central role in generating the scientific evidence that has shaped the global HIV response and should continue to be treated as an equal partner in decisions affecting HIV programmes.
Health GAP also criticised the America First Global Health Strategy, arguing that the MOUs shift greater responsibility for HIV programmes to governments while accelerating the transition away from PEPFAR support before some countries are ready. The organisation said the agreements lacked transparency, excluded meaningful participation by independent civil society and attached conditions unrelated to health funding.
Citing data presented at AIDS 2026, Health GAP said the changes had coincided with declining HIV services following the closure of more than 1,700 treatment sites. The organisation pointed to reductions in HIV testing, diagnosis and treatment, including a 42% decline in PrEP enrolment and a 12.4% drop in the number of children receiving HIV treatment. In South Africa, it said treatment for HIV-positive children had fallen by 45%.
The contrasting messages at AIDS 2026 revealed the debate surrounding the future of PEPFAR. The United States and several partner governments believe the new agreements will lead to stronger, country-led HIV programs that can maintain long-term progress. However, activists argue that the shift is already causing service disruptions and threatening decades of progress in the fight against HIV.