MASAKA, Uganda—Every morning for the past four years, Agnes Mutesi, 30, has taken a pill that prevents her from getting infected with HIV.
As a sex worker, the virus felt unavoidable when the only protection option was condoms: Some clients refused to use them and threatened violence if she tried to insist.
In 2020, when a health worker introduced her to the medication known as PrEP, or preexposure prophylaxis, it felt like her life had been saved. The medicine prevented HIV from reproducing and establishing itself in her body: “It is how I was sure to not get infected,” she said.
But in mid-February, Mutesi ran out of PrEP. She doesn’t know when she will be able to get more.
The clinic that she visits in Masaka, a Ugandan city just south of the equator, is run by a local organization, but most of its HIV prevention services were paid for by the U.S. government through the President’s Emergency Plan for AIDS Relief (PEPFAR). Then-President George W. Bush created the program in 2003 to address the global HIV crisis. Buoyed by bipartisan support, PEPFAR has saved more than 26 million lives by facilitating access to HIV treatment while also preventing millions more people from getting infected.
Mutesi’s clinic was forced to shut down most of its services in late January, when U.S. President Donald Trump began a freeze on foreign aid while his administration conducts a spending review. PEPFAR program operators are now waiting to learn whether they have been eliminated after the administration cut 83 percent of programs from the U.S. Agency for International Development (USAID), which administered the majority of PEPFAR initiatives.
These include Ugandan HIV programs serving high-risk communities of people who face discrimination and the persistent threat of arrest—such as gay men, sex workers, and people who inject drugs.
Among the country’s general population, 5.1 percent of adults live with HIV. But within certain marginalized communities, it is far more prevalent. An estimated 13.7 percent of men who have sex with men and live in the capital, Kampala, are infected. Across the country, the rate among women engaged in sex work soars to 37 percent, by some estimates.
Uganda has historically been a leader in fighting HIV. In the 1990s, before the discovery of treatment and prevention options, President Yoweri Museveni championed a policy of “ABC”—abstain, be faithful, or use a condom—that was later adopted globally to reduce HIV rates.
At the same time, Ugandan lawmakers have also isolated and criminalized the communities most at risk of contracting the virus. Homosexuality has been illegal in Uganda since the country’s days as a British protectorate, but the 2023 Anti-Homosexuality Act introduced the death penalty for acts of “aggravated homosexuality,” which includes sex with a minor, an elderly person, or a person who is HIV-positive. The Ugandan Parliament is also debating a law that would introduce harsher penalties for people convicted of prostitution, which is already criminalized. Drug possession is also illegal.
In this climate, members of those communities that most need HIV services are often hesitant to visit government-run clinics, fearing the consequences if they are truthful about why they are there. Instead, they rely largely on U.S.-funded, community-run clinics where they feel safe to ask for PrEP or, if they are living with HIV, to get lifesaving treatment.
Mutesi can’t get any answers about when—or if—her clinic will offer PrEP again. Even if she felt comfortable braving potential harassment at a government facility, many of those services also relied on U.S. funding and have now largely been interrupted. It seems possible that HIV treatment and prevention services may disappear for the wider population.
“How am I going to survive?” Mutesi said. “They should leave everything as it has been, because people will get infected and die.”
Members of at-risk communities fear that new infections are surging, although it’s too soon to measure a potential increase. For people already being treated for infection, an interruption in services will allow HIV to rebound, increasing the risk that the virus will mutate and become resistant to treatment. And if treatment services remain erratic, people could die.
In interviews, community leaders describe a crisis unlike anything they have ever faced, including when Uganda lawmakers passed the Anti-Homosexuality Act in 2023.
Joseph Mumbejja, who uses they/them pronouns and runs an HIV prevention and support unit for sex workers and gender minorities in Masaka, said that after that law was adopted, they “saw an increase in the funding from the U.S. government.”
That money did more than keep their organization, MAHIPSO, afloat. It was also a signal to Ugandan officials that Washington was invested in these communities.
Now, the elimination of that support “means erasing our existence,” Mumbejja said.
Experts emphasize that any efforts to curb Uganda’s epidemic must prioritize its most vulnerable communities, both because they have the highest risk of infection but also because they do not live in a vacuum. As long as the virus is circulating in those communities, it can spread elsewhere.
“Their health and well-being matter to everyone,” Christine Stegling, the deputy executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), told Foreign Policy.
Community-run drop-in clinics and outreach efforts have been a critical source of support for those groups—and for hopes of ending the AIDS epidemic by 2030, as established in the United Nations’ list of Sustainable Development Goals.
“It is those facilities that are central for us to be successful in the long run,” Stegling said. “And those are the ones that are closed right now,” not just in Uganda, but in countries around the world.
Following the stop-work order, the U.S. State Department issued a waiver on Feb. 1 that allowed PEPFAR-implementing agencies to at least deliver lifesaving treatment for people who are infected with HIV, even as most prevention programs remained paused. But in many places in Uganda, no services ever resumed. With the more recent elimination of most USAID contracts, the programs may now close for good.
Some HIV centers in Uganda have managed to temporarily reopen, because they draw their PEPFAR funding through the U.S. Centers for Disease Control and Prevention (CDC), which has not been targeted by the Trump administration to the same degree as USAID. But the CDC-funded organizations have been cautioned that funds are only available through April 19, when the administration is expected to complete its 90-day foreign aid review.
Their services have been badly disrupted by the contract confusion: Community outreach workers have been put on leave, prevention services have been halted, and there is lingering uncertainty about the supply of additional treatment drugs.
MAHIPSO is one of the CDC-funded organizations that got word on Feb. 15 that it could reopen its drop-in clinic. But the group was told that the restored funds came with a new stipulation from the CDC: MAHIPSO could no longer classify its clients, meaning that the staff couldn’t keep records of whether a patient is a sex worker or a gay man, for instance.
MAHIPSO staff said the requirement, which has subsequently been removed for the organization and some other CDC recipients, seemed designed to forestall scrutiny from the Trump administration.
Joel Sendi, MAHIPSO’s programs director, said that while the requirement was in place, it made it difficult to provide specialized care. “Each community has a unique need, which really needs to be understood,” he said.
He said the requirement also renders the organization complicit with efforts to wipe away the identities of the people who they support, even as those groups remain under attack in Uganda and elsewhere. However, he saw little choice but to adhere or risk losing any future funding.
It’s not actually clear that there will be any future funding. And Uganda’s marginalized communities are beginning to struggle with what an end to that money would mean for the fight against a public health crisis that they thought they were on track to defeat.
Given the sensitivity of providing services to vulnerable communities in the country, there are no public statistics on just how many members of these groups benefit from U.S. support. But in the aftermath of the funding freeze, the degree to which their HIV services depended on Washington has become clear. PEPFAR money didn’t just fund the drop-in clinics—it also paid for HIV testing as well as medications and the logistics that delivered them to health centers across the country.
For years, Let’s Walk Uganda (LWU), a human rights organization, had received requests from members of the LGBTQ community for help with HIV services. It received UNAIDS funding for a clinic, which finally opened in January in the heart of Kampala.
As the freeze took hold weeks later, Edward Mutebi, LWU’s executive director, received a flurry of messages. Realizing that the LWU clinic was not funded by the U.S. government, members of the LGBTQ community who had suddenly lost access to their regular services pleaded with Mutebi for help.
But even LWU could not escape the impact. It had partnered with a nearby clinic that relied on U.S. support for access to the medicines that LWU needed to offer HIV prevention and treatment services. When U.S. funding froze, that partner clinic could no longer offer supplies. The LWU team is now considering just buying what it can from private providers to at least keep clients on treatment until the organization exhausts its remaining funding.
“There is panic,” Mutebi said. “We receive emails and calls asking [about] what’s going to happen. We don’t have answers.”
As it scrambles to maintain basic services, the Ugandan Health Ministry has proposed collapsing drop-in centers into the routine outpatient services offered at government-run hospitals. The proposal alarmed advocates, who worry that it indicates a lack of understanding about why—and for whom—the drop-in centers were created in the first place.
Richard Lusimbo, who runs the Uganda Key Populations Consortium, an advocacy organization for vulnerable groups, requested an emergency meeting with Health Ministry officials after they announced the plan. He told Foreign Policy that he returned with assurances that they understood the “need to ensure that there’s protection for community interventions.” But without specialized drop-in centers, there is a risk of “discrimination, isolation, and deterrence from receiving services,” he said. “For LGBTQ, sex workers, and people who inject and use drugs, lives are at stake.”
Advocates continue to press the Health Ministry to request emergency funds to help fill at least some of the gaps. Ministry officials did not respond to a request for comment.
Community leaders are not sure where else they can turn. There is now a sense that they have been abandoned to a time before PrEP or HIV treatment.
“We have survived on American support,” said Macklean Kyomya, who runs a health program for sex workers in Kampala. “We are not sure what we did to Trump. We are not sure whether this is a mission intended to sweep us away.”
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