Governments need to prioritise funding and support for midwifery to save the lives of women and babies

A return on investment of 16:1 should be irresistible. So why does midwifery keep losing the budget fight, and what would make funders and finance ministers finally move?

When a young mother in Mtendere, Lusaka, began bleeding heavily hours after delivering her baby, her life was in grave danger. Three midwives assessed her immediately, recognised she was experiencing postpartum haemorrhage and got her to specialist care in time. 

She survived. But the outcome was not luck. Postpartum haemorrhage kills tens of thousands of women every year. She survived because Mtendere Clinic is one of six facilities in Zambia where midwifery preceptors, experienced midwives who mentor and train the next generation in clinical settings, have been systematically trained and deployed in partnership with Seed Global Health. In 2025, there were zero maternal deaths in Mtendere Clinic.

Sustained investment in midwives, in training, mentorship and the environments where they work, allowed them to act decisively when it mattered most.

 This story is not unusual. Every day, in every corner of the world, investing in midwives is the difference between life and death. Yet, in too many places, that investment is lacking.

Preventable deaths

Globally, there are one million fewer midwives than needed, and this cost can be measured in the $1 trillion lost annually to the global economy from the women’s health gap. But most of these deaths are preventable. 

Governments and funders must act now – we know what works – and the cost of inaction is in lives and growth lost.

The evidence is overwhelming. Midwives deliver up to 90% of essential sexual, reproductive, maternal, newborn, and adolescent health services. 

Given the right training, support and environment, midwives can avert up to 67% of maternal deaths globally, 64% of newborn deaths and 65% of stillbirths. 

A very modest 10% increase in midwifery coverage could see over 1.3 million lives saved every year.

These lives saved do not speak only to the personal tragedies of a mother or newborn who dies during childbirth. Because when a mother dies in childbirth, the consequences extend far beyond her – children without a mother are more likely to die before their fifth birthday. Families fall into poverty. The ripple effect can last generations.

Investing in midwifery is one of the strongest actions a country can take, with an estimated return on investment of 16:1.

There are plenty of real-world examples which demonstrate what that return looks like. In Rwanda, a country that averaged 8.5% GDP growth while simultaneously halving maternal mortality in under a decade, the link between health investment and economic performance is not theoretical. It is well documented. 

Morocco and Laos show comparable gains, alongside fewer unintended pregnancies, better newborn outcomes, and more women in education and the workforce.

For ministers working within tight budgets, investing in midwives is one of the strongest ROI cases available in health or other sectors. And these benefits extend across the health system and beyond.

A midwife examines a pregnant woman in a rural community clinic in Guatemala.

For rural or marginalised populations, midwives are often the only skilled health workers easily accessible, delivering contraception, safe delivery care, immunisations, and support for survivors of gender-based violence. 

For the 4.3 billion people currently lacking access to at least one essential sexual and reproductive health service, scaling midwifery is the fastest and most cost-effective route to closing that gap.

With 93% of midwives being women, investing in the profession directly advances gender equity – in pay, in leadership, and in workforce participation. These are not secondary benefits. They are additional economic returns on the same investment.

Yet despite all this hard evidence, investment is not being made at the scale required.

Midwives’ demands

This week, 3,000 midwives, funders and officials from every region of the world have gathered in Lisbon for the 34th International Confederation of Midwives (ICM) Triennial Congress. They are not here to debate whether midwives matter. They do. They are here to demand that governments and funders finally act on the evidence.

Their demands are clear and achievable:

 Fund one million more midwives and fund them properly. The million-midwife gap costs lives, prevents economic growth and widens every year without sustained investment.

Make midwifery central to your economic strategy not on the periphery of your health budget. Ministers can no longer ignore the productivity gains, workforce participation, and the impacts investments in midwifery make on the broader health system.

Commit to ICM Global Standards on education, pay, regulation, and leadership.
 Midwives who are well-trained, fairly paid, and empowered to lead can avert up to 67% of maternal deaths globally. But only if the systems around them work. That means proper training pathways, enforceable regulation, and career structures that retain talent rather than drive it away.

Somewhere today, a family will experience a tragedy. A mother will die in childbirth. Not because her death was inevitable – it rarely is – but because the midwife who could have saved her was never trained. 

The mother was not given the information she needed to safely deliver her baby. She was not referred to a specialist service in time.

 That death is preventable. So is the next one and the one after that. The only question is whether governments or funders will finally make the investment that stops it.

Investing in midwives is an investment in the future of every country that makes it.

Anna af Ugglas is chief executive of the International Confederation of Midwives.

Dr Lwazi Manzi is head of the secretariat of the Global Leaders Network for Women, Children and Adolescent Health, Office of the President of South Africa

Dr Chikusela Sikazwe is Zambia Country Director of Seed Global Health

Rajat Khosla is executive director of the Partnership for Maternal, Newborn and Child Health

 

Image Credits: Elizabeth Poll/ MMV, International Confederation of Midwives.

Students swim across the Kemp Welch River after school in Launakalana in Papua New Guinea’s Rigo District, who risk the crossing after floods destroyed the community’s only footbridge 14 years ago, leaving the river as their only route to and from school.

A landmark UNICEF report that maps children’s exposure to overlapping climate hazards finds that almost half the world’s children – 1.1 billion kids – now contend with at least three threats at once.

To reach school each morning, 15-year-old Lorna first has to swim across the Kemp Welch River, known to locals for its strong currents and crocodile-infested waters.

The footbridge that once linked her village in Papua New Guinea’s Central Province to its only primary school and health post was washed away by extreme flooding in 2012. More than a decade later, it has not been rebuilt.

“Most of the time we swim across the river. We put our school bag and uniforms inside a dish and swim across,” Lorna told the UN children’s agency (UNICEF). “We swim across to the school side and hide in nearby bushes or behind vehicles to change. After changing, we hide our wet clothes in the bush, then we walk to school.”

During menstruation, she said, village elders forbid the girls from crossing at all, fearing the blood will draw crocodiles.

“In monsoon season, heavy currents, dead trees and debris block the river, causing injuries and deaths,” Lorna’s school’s principal added. “Children also lose their books, bags and clothes in the river. Many children fall sick from the cold river water.”

Lorna, 15, swims across the Kemp Welch River after school in Launakalana, Papua New Guinea.

Her daily crossing is one of countless adaptations charted in the Children’s Climate Risk Report 2026, released Tuesday by the UN children’s agency. 

Almost every one of the 2.3 billion children alive is now exposed to at least one climate hazard, the report finds. They range from floods, droughts and tropical storms to heatwaves, extreme heat, wildfires and sand and dust storms.

About 1.1 billion, nearly half the world’s children, face three or more overlapping hazards at once. More than four million are exposed to as many as six.

“Imagine having to swim across a fast-moving river, known for its strong currents and crocodiles, just to make it to school,” said Tom Slaymaker, who leads UNICEF’s water, climate and environment data unit.

“For these children, the impact of climate change is not an abstract or future concern. It is a reality pushing them to risk their lives to not miss out on school.”

Next generation data on climate and children

Percentage of children exposed to at least 3 climate hazards, per UNICEF data.

For the first time, UNICEF has mapped where and how intensely those hazards converge, drawing on a new Global Child Hazard Database that pinpoints exposure down to a 100-metre grid.

The database tracks eight climate hazards: riverine and coastal floods, droughts, tropical storms, heatwaves, extreme heat, fires, and sand and dust storms. It adds two more health crises worsened by a warming planet: malaria and air pollution.

“The lives of children continue to be upended by the impact of heatwaves, wildfires, droughts and floods,” said UNICEF Executive Director Catherine Russell. “Half of the world’s children are now living with at least three overlapping climate threats shaping their daily lives.”

Successive UNICEF assessments, built on progressively more granular data, show the climate threat to children growing more critical the better it is understood. 

The agency’s first analysis, the 2021 Children’s Climate Risk Index, found around one billion children at extremely high risk and 820 million exposed to heatwaves. The new figure for heatwave exposure is 1.5 billion. Recorded exposure to air pollution has climbed from one billion to 2.3 billion.

“Children are at the forefront of the impact of climate change,” Russell said. “Across the globe, millions of children are now facing multiple climate threats without the necessary services to cope.”

“They are experiencing extreme heat that causes heatstroke and dehydration. Their homes and schools are being destroyed by storms and floods. Devastating droughts are limiting their access to food and water. And in many cases, the intensity of these hazards is increasing with each passing year.”

When the shocks overlap

Overview of the number of children exposed to climate-related hazards.

Drought, paired with extreme heat and heatwaves, is the most common climate hazard combination, affecting an estimated 296 million children, UNICEF found, feeding into one another in a loop that drives malnutrition, water scarcity and heat illness.

A second cluster, drought with extreme heat and tropical storms, affects a further 115 million children, a convergence that drives food and water scarcity, severs access to health care and schooling, and raises the risk of displacement and disease.

Drought, heatwaves and tropical storms rank third, affecting 94 million children, followed by drought, extreme heat and riverine floods at 58 million.

“When climate hazards overlap, the impacts compound,” Slaymaker said. “A drought can leave children hungry and malnourished. A flood that follows can contaminate water supplies and spread diseases like cholera. Each shock makes the next one more dangerous.”

One of the most worrying findings of the report is that the rate of overlap in climate extremes affecting children is accelerating. Between 2012 and 2021, the number of children exposed to three or more hazards rose 69% over the previous decade.

Many more children were uprooted, with climate shocks driving the equivalent of 21,000 child displacements a day between 2016 and 2023. 

Displacement is a compounding hazard that the index does not count. Children driven from home into camps or informal settlements lose access to health care, clean water and schooling, and face sharply higher risks of disease, family separation and exploitation.

“These multiple overlapping shocks are building on top of each other and reshaping children’s lives,” Slaymaker said. “Without urgent, child-focused climate action, the shocks they face today will only intensify.”

Global but unequal crisis

Seven year old Yar ul Haq walks through floodwaters after extreme rainfall submerged his village in Pakistan.

In Africa’s Sahel, more than four million children face the combined threat of heatwaves, extreme heat, and sand and dust storms. Children across Burkina Faso, Chad, Mali, Niger and South Sudan are among the most exposed anywhere, in a belt where wind-blown dust also drives meningitis, a disease the region already carries at the world’s highest rates.

All children in the world’s 24 small island developing states, including Haiti, are exposed to tropical storms that can knock out entire health and aid systems overnight. For many of these nations, and their children, the danger is existential, as the same warming that fuels hurricanes lifts sea levels that threaten to submerge countries and coastal communities. 

In Bangladesh, Myanmar and Pakistan, children are exposed to more hazards, and at greater intensity, than anywhere else on Earth. All three nations pair vast child populations with low-lying, flood-prone geography and intensifying storms and heat, exposing children to a perfect storm of simultaneous threats to their well-being. 

Zunaira, a young activist from Pakistan, told world leaders at the UN General Assembly last year that the 2022 floods that submerged a third of her country “did not just wash away houses.”

“They washed away entire communities. They washed away childhoods,” she said. “Schools collapsed or turned into shelters. Families lost homes, and children lost the spaces where they felt safe. And when the waters receded, what remained was not only destruction, it was trauma.”

“Children are living the challenges of climate change right now,” she said. “And the impacts are not just physical – they are emotional, mental and deeply personal. We are not imagining this crisis. We are living it, and it affects us more than adults can imagine.”

Even moderate climate hazards can ‘put lives at risk’

On 20 September 2025, Nyawar, 30, sits in a canoe amid flooded fields near Bentiu displacement camp in South Sudan. After losing her home and livestock to floods, she now collects water lilies to feed her children, one of the few food sources still accessible.

Yet what turns a hazard into a catastrophe is often the ability of the health and government services meant to absorb and rebuild it.

“No country is untouched by climate risks, but imagine a child in conflict-affected places, the Central African Republic, Chad, Haiti, or Sudan,” Slaymaker said. “Because they have much lower access to essential services, such as health care, nutrition, or water and sanitation, even a moderate flood or drought can put their life at risk.”

That doesn’t mean wealthy countries are wholly spared. In Italy, more than six million children are exposed to prolonged heatwaves and drought, though UNICEF held the country up as proof that adaptation spending can blunt the danger.

Heatwave exposure has seen among the sharpest increases of any hazard the agency tracks. In Europe, which is warming faster than any other continent, extreme heat has killed more than 200,000 people over the past four years, the World Health Organization (WHO) said this month, making it the region’s deadliest climate hazard.

Every child breathes air pollution

Areas exposed to air pollution around the world.

An estimated 2.3 billion children, virtually every child on the planet, breathe air that breaches the WHO guideline for safe air, ranking it as the second-leading risk factor for death among children under five, after malnutrition, according to the report.

The latest State of Global Air report, produced by the Health Effects Institute with UNICEF, links air pollution to more than 675,000 deaths in children under five and a combined 61 million healthy years of life lost among them. 

Like the greater climate crisis, air pollution’s effects are deeply unequal, with around 90% of all air-pollution deaths occurring in low- and middle-income countries. 

Extreme heat and access to safe drinking water exacerbated by climate change follow closely behind air pollution as leading threats to the health of children around the world.

The attributable number of extreme hot days of over 35°C, which are highly likely to have materialised due to human-induced climate change.

Today, 634 million children lack safe drinking water, and one billion lack safe sanitation. Those conditions are sharpening amid climate shocks, leading to “one of the biggest killers of children under five” due to the role of clean water and sanitation access in increasing the risk of diarrhoea, Slaymaker said.

Another 550 million children were exposed to additional extremely hot days in 2024 that scientists attribute directly to human-caused warming, according to Vrije Universiteit Brussel research published this year, which is mapped out in the report. 

Other, more overlooked threats compound the toll. Each 1°C rise in extreme heat lifts the odds of stillbirth by 14%, the report notes, while a further one billion children live in areas exposed to malaria, a disease whose range expands as temperatures and rainfall shift.

The cost of inaction

Parents carry their children as they walk on a flooded street in the Phillipine capital of Manila after the family left their home for safety as Typhoon Carina brought massive flooding in 2024.

Beyond the health and mortality impacts, the financial costs levied on children and economies globally are equally staggering.

Climate hazards disrupted schooling for at least 242 million students across 85 countries in 2024 alone. Lost learning in low- and middle-income countries could cost today’s students up to $11 trillion in lifetime earnings, the report estimates.

Prevention, by contrast, pays. Every $1 invested in adapting essential services for children returns more than $10 in benefits over a decade, the report says, citing the World Resources Institute.

But developing countries will need $310 billion to $365 billion a year for adaptation by 2035, the UN Environment Programme estimated in October, against just $26 billion in international public adaptation finance in 2023, a shortfall of 12 to 14 times the required amounts. 

At COP30 in Belem last year, nations agreed to a target of tripling the adaptation finance commitment made years earlier to $120 billion per year by 2035. That ambitious upping of the ante came before the world could hit its previous $40 billion target set in Glasgow, raising questions about how long it may take for the money to arrive – or whether it will materialise at all. 

‘Not a warning of what is to come’

Lorna’s classmates swim across the Kemp Welch River after school in Launakalana, Papua New Guinea.

Back in Papua New Guinea, Lorna still holds on to hope for the future.

“My dream is to become a teacher or a pilot,” she said. “We just want a new bridge, so that we can go to school safely every day.”

“Children have done the least to cause the climate crisis, yet they are paying the highest price,” Slaymaker said.

UNICEF urged governments to cut emissions, write children into national adaptation plans and disaster response, and fund fixes already proven to work: solar power to keep schools running through outages, groundwater wells as surface water dries up, and storm shelters built to last.

“This analysis can help governments and decision makers plan better and invest more effectively in resilient services,” Russell said. “When we strengthen health and education systems and improve infrastructure with children in mind, we protect them from today’s climate threats and help secure their future.”

For children like Lorna, who have already adapted once, the margin is thin, Slaymaker warned.

“They adapted to one climate shock by swimming across a river to school. But what happens when the next shock comes, the flood waters rise, the river gets faster, and a dangerous journey becomes deadly?”

“This is not a warning of what is to come. It is a recognition of our current reality,” he said. “Climate change is not only changing the planet, but also children.”

Image Credits: UNICEF, UNICEF, UNICEF.

South Africa, speaking for the Africa Group and Group for Equity at the last round of negotiations on an PABS Annex in May 2026. That failed to yield a final agreement.

What’s left to tackle in the PABS talks? As the clock ran out, and then was extended for another year, on negotiations over the Pandemic Agreement’s Annex on Pathogen Access and Benefit-Sharing (PABS), the diplomacy and the nitty-gritty of the issues faced were deeply linked This edition of the Governing Pandemics Snapshot of the Geneva Graduate Institute’s Global Health Centre focuses on both, while noting that negotiators’ increased understanding of the technical issues may help pave the way for resolving key sticking points in future rounds of talks.  

On the side of the nitty-gritty, a perennial challenge is the sheer complexity, as Suerie Moon, the Global Health Centre’s Co-Director, writes in her opening article of this four-part Snapshot series: “What has been achieved and what’s left to tackle in the PABS talks?”

One hopeful point of progress, however, is the emerging, common understanding of how genetic databases and related systems work – as well as how the proposed  WHO-coordinated laboratory networks and WHO-recognized sequence databases could play a key role. This has given negotiators a much more solid basis for actually making proposals and finding potential points of compromise.

Meanwhile, the recent outbreaks of hantavirus and Ebola Bundibugyo virus (EBV) illustrate a case of how open and more restricted gene databases work, as discussed in a narrative elaborated by Adam Strobeyko: “What Hantavirus and Ebola Outbreaks Teach Us About PABS Database Governance.”

In the case of hantavirus, Swiss-based researchers who were among the first to sequence the virus opted for an open, unrestricted sharing. Meanwhile Ugandan and DR Congo researchers who sequenced EBV shared the data openly, but chose a model that imposes restrictions upon its use. 

Researchers registering the Ebola Bundibugyo virus on Pathoplexus, a leading data base for genetic sequences, chose a restricted use model, while the gene code for the Hantavirus was published as entirely open access on the same platform.

The narrative illustrates how scientists with different needs and links with databases make different sharing choices in real time. This happens against the backdrop of an increasing number of national laws addressing sequence data. It thus remains technically and legally impossible to impose a single governance model across all pathogen databases worldwide – a fact of life that any PABS agreement will have to acknowledge.

Based on these hard facts, Daniela Morich elaborates on the concrete proposals for benefit sharing models that are emerging from the PABS negotiations, and some initial glimmers of convergence in her article: “Building Common Ground: The Evolution of Benefit-Sharing Discussions in the Pandemic Agreement.” 

Notably, there has been limited but meaningful acceptance — particularly from the European Union — that some form of structured benefit-sharing vis-à-vis products should apply not only during a Pandemic, but also during more “routine”  Public Health Emergencies of International Concern (PHEIC), such as the current Bundibugyo Ebola virus raging in central Africa. While far from fully settled, this shift suggests a potential “landing zone”.  

The European Union delegate expresses regrets over the failure of the last session of PABS negotiations in May to reach agreement; even so, hopeful signals of flexibility by both developed and developing countries could help break the logjams over the coming year.

While the 20% target for the real-time provision of products for pandemic emergencies was enshrined in the 2025 Pandemic Agreement – other types of proposed in-kind and monetary contributions have remained a sticking point in the PABS debate. But here, too, points of convergence may be emerging. 

In terms of monetary contributions, some countries favour a system in which those  contributions (presumably by pharma or other users of the pathogen data) serve exclusively to fund the operation of the PABS System, without requiring additional  payments linked to the commercial value of products developed. 

Others argue that benefit‑sharing should reflect the value added of products developed using PABS materials; they therefore support financial contribution models that tie contributions to commercial returns. 

In “Governance of the PABS Annex”, the final article in this Snapshot series, Gian Luca Burci, looks ahead to the implementation of the Pandemic Agreement. 

In particular, he points to the rather laconic references to a system of governance for the Accord, and how those might be interpreted and operationalized going forward. Elaborating further on how governance may really work in practice, is one of the next challenges that countries will face – once the PABS hurdle is really overcome. 

What has been achieved and what’s left to tackle in the PABS talks?

The fourth meeting of the Intergovernmental Working Group (IGWG) negotiating a pathogen access and benefit-sharing in December 2025. After the sixth round in May 2026 failed to yield an agreement, negotiations were extended for another year.

By Suerie Moon

In the corridors of the 79th World Health Assembly (WHA), the frustration and gloom were palpable. Delegates had missed WHA’s May 2026 deadline to deliver the Pandemic Agreement’s (PA) Annex on Pathogen Access and Benefit-Sharing (PABS) – a necessary precondition for WHO member states to begin ratification of the Pandemic Agreement reached in 2025. 

The WHA agreed to extend the talks for up to a year – noting that if  consensus can be reached earlier a  special session of the Assembly would be convened in 2026 – and many countries formally reiterated their commitment to getting it done.

While the near total absence of ‘green text’ (indicating consensus) in the latest draft left the impression that little headway has been made, that may be misleading. A look back at countries’ original proposals, and the evolution of negotiations over the past year, shows that progress has been significant, even if deep divisions remain. 

Coming to terms with complexity

Grappling with complexity. Computer visualization of a DNA sequence with different colors for each of four base chemicals  (adenine, guanine, cytosine and thymine). Hantavirus and bundibugyo virus, however, are comprised of RNA sequences that use uracil instead of thymine.

A perennial challenge with PABS is the sheer technical complexity of the issues. Diplomats must not only master the finer points of how laboratories, databases and product R&D work, but also envision how they could work differently.

Over the past year, many delegates built a working familiarity with these topics – a necessary pre-condition to reaching agreement – and some previously-contested technical questions have largely been settled. 

For example, the idea that an individual genetic sequence can be tagged with a ‘universal persistent identifier’ now seems to be widely-accepted, even if countries disagree on the definition and purpose of such identifiers. Most importantly, after 9 months, a clearer common understanding of how the overall system could work seems to be emerging, with WHO-coordinated laboratory networks and WHO-recognized sequence databases comprising the backbone.

Seeking a middle ground with a ‘hybrid’ pathogen data registration system

The GSAID database was a dominant platform for sharing SARS-CoV-2 sequences during the pandemic. But it’s restrictive use clauses have come under fire.

In addition, after months of establishing and defending their positions, delegates have cautiously started to put on the table proposals that seek to find middle ground. For example, a ‘hybrid’ pathogen data registration system has now been proposed. This would give countries a choice of whether to share their data through open-access or registration-based databases; it aims to broker compromise between delegations wanting one or the other, an issue that  my colleague Adam Strobeyko discusses further in the second article of this series. 

The proposals for benefit-sharing during a Public Health Emergencies of International Concern (PHEIC) – and not only during (far less frequent) Pandemic Emergencies – reflect efforts to infuse more meaning into the overarching  commitments of Article 12 of the Pandemic Agreement, as my colleague Daniela Morich addresses in her analysis, the third in this series.  

Countries do not all agree on the particulars of these and other proposals put forward so far, but they reflect real efforts to find elusive ‘landing zones’ – a shift from the pure tug-of-war dynamics that marked the earlier months of PABS negotiations. Notably, the May 2026 WHA decision extending the PABS talks included in its scope of work a mandate for member states to find agreement “to develop legally binding contracts,” a priority for the Global South, even if the content of those contracts remains a point of debate. 

Financing PABS 

 A great deal of attention has focused on a few of the most contentious issues over the past year (e.g. databases, which benefits should be shared when), but other critical issues have had little air time.

For example, how will the PABS system be financed? This question involves not only flows of monetary benefits, but also where would the additional funds needed to operationalize a system come from, and how would PABS financing fit into the broader Coordinating Financial Mechanism agreed in the PA and International Health Regulations. 

Technology transfer (including but not limited to licensing of intellectual property) is critical to achieve geographically diversified manufacturing capacity. But so far, countries have only agreed on the ends, not the means to make such transfers happen. Furthermore, key provisions for governance of the overall system remain to be defined. There is broad agreement on the need to create an expert PABS Advisory Group, but disagreement persists on the scope of the Advisory Group’s mandate, and  to whom it should report, as my colleague Gian Luca Burci discusses in the final article of this series.

US bilateral agreements: ‘termites’ in the wood of PABS architecture? 

US official Brad Smith (right) at a meeting to discuss a bilateral agreement with Kenya. Nearly three dozen such deals had been signed as of late April 2026.

Finally, a new elephant in the room has emerged since negotiations began: how to design a multilateral system that can function alongside the growing number of US bilateral global health agreements – under which  countries would be obliged to  share pathogen samples and data with the US government  in exchange for health aid.  

Bilateral agreements can weaken multilateral ones if they create escape routes from multilateral obligations, which is particularly problematic for issues like pandemics where all countries are affected. Bilateral deals can be described as ‘termites’ in the wood of the multilateral PABS house that is still under construction, to borrow a phrase from the trade arena.

In brief, negotiators must resolve many issues in the months ahead, but the slow wheels of multilateral negotiations have been grinding forward and are set to continue. 

It’s also important to remember that while the PABS negotiations proceed, delegates will be  contending with at least two other political issues on the global health agenda – the race for WHO’s next Director-General and the global health architecture reform process. Contending with all three at the same time  will stretch smaller delegations even more thinly across multiple negotiations. However, these additional bargaining chips could also open new possibilities for striking grand political bargains. 

Countries have in their hands the ingredients for a PABS deal – the question is whether many cooks can make one stew, what ingredients it will contain, and how palatable it will be.

Read the entire issue of this Governing Pandemics Snapshot series here. 

_____________________

Suerie Moon is the  Co-Director of the Global Health Centre of the  Geneva Graduate Institute, where she is also a Professor of Practice. Adam Strobeyko is a Legal Advisor and Researcher at the Global Health Centre. Daniela Morich is the Global Health Centre’s Head of Policy Engagement and the Global Health Platform.  Gian Luca Burci is a Senior Visiting Professor in International Law at the Geneva Graduate Institute and Academic Advisor at the Global Health Centre. He co-leads the Governing Pandemics Initiative.

The authors thank Diana Jalea for her editorial review and Anna Bezruki for her comments on an earlier draft.

Image Credits: Pathoplexus.org , Gerald Barber, Virginia Tech (with permission of the National Science Foundation), Gisaid.org.

Passengers being evacuated from MV Hondius, the cruise ship affected by a hantavirus outbreak, in Tenerife.

Dutch, Spanish and Swiss medical experts applied slightly different criteria for discharging patients infected with Andes hantavirus during the recent outbreak on a cruise ship –  but none required a negative blood test, as this could remain positive “for months”.

This emerged during a briefing convened by the World Health Organization’s (WHO) Information Network for Epidemics (Epi-WIN) team on Tuesday, with medical experts who had treated patients.

The Netherlands had the most relaxed criteria. Two patients sought care in the Netherlands, and both were discharged after two negative saliva tests, said Karin Veldkamp, head of infection control at the University Medical Centre in Leiden, Netherlands.

“We decided that if the saliva is negative twice, that we could safely discharge the patients at home, and then we could give them additional [isolation] measures if their urine and blood are positive,” said Veldkamp, adding that advice from medical experts from Argentina and Chile, who dealt with an outbreak in 2019, had helped guide this decision.

Spain also treated two confirmed cases and managed 12 asymptomatic contacts. It required patients to have two negative PCR tests from oropharyngeal (throat) swabs and urine samples, said Octavio Garcia, from the high-level isolation unit at the Infectious Diseases Department of Hospital Central de la Defensa in Madrid.

Switzerland’s single positive case was a 64-year-old man with other underlying conditions, said Professor Walter Zingg from the University of Zurich’s department of infectious diseases.

He was hospitalised on 4 May and discharged on 18 May after his saliva and nasopharyngeal swabs tested negative. The virus was still faintly detectable in his urine and blood.

“We decided that if the patient is clinically well, and 14 days from the beginning of the acute phase or 21 days from the beginning of the prodromal phase, we would stop isolation without further restrictions,” said Zingg.

“We just saw him last week, and he was still positive in both full blood and urine,” said Zingg, adding that his contacts were required to observe 42 days of self-isolation.

Garcia said that the PCR tests of the blood of both Spanish patients “were positive throughout the disease, even after clinical convalescence”.

“We know that in different studies, especially from our colleague Dr Marcela Ferres [from the University of Chile], full blood PCR will remain positive for a long period of time, even after more than 23 days from symptoms onset,” said Garcia.

As the virus can persist in the blood and semen, the Spanish health authorities also recommended four months of safe sex practices post-discharge.

“We recommended a monthly clinical review during the first six months after discharge to detect both clinical and psychological sequelae from these patients. They will also have a monthly blood PCR until we get a negative result,” said Garcia.

Early phase is most dangerous

All the experts agreed that the early stages of infection were the most risky for transmission.

Zingg said that their research indicated that the infectious period is two days before the first symptoms.

Colin Brown, the UK’s deputy head of epidemics and emerging infections, said that the UK conducted a big literature review, “looking at particular evidence of transmission dynamics”. 

“Because we know the Andes hantavirus is detectable before symptom onset or antibody development, and that transmission mostly occurs in the prodromal phase or asymptomatic phase, we assume that there’s a big respiratory transmission component, and that there could be a degree which is asymptomatic or indeed presymptomatic,” said Brown.

This respiratory transmission is “probably mostly in the symptomatic infected individuals and during their acute symptomatic episode”, said Brown. However, the UK recommended strict PPE guidance as “there are a lot of limitations in knowledge”.

Brown added that the UK took a case-by-case approach to the virus, given the variables displayed by different patients.

However, the UK designates the hantavirus as a “high consequence infectious disease”, based on the lack of medical countermeasures and vaccines, and its high case fatality rate.

A UK citizen who flew to Johannesburg, South Africa, after leaving the cruise ship in St Helena, was the first person to be diagnosed with the virus, prompting the UK to notify the WHO of the outbreak.

US evaluates home situation

Katherine Willet, medical director of the US National Quarantine Unit in Nebraska, said her unit is using high-level PPE, “adapting some of our prior models, very similar to our approach with COVID for quarantined individuals”. 

“Some of the US-exposed citizens are quarantining at home and not in the facility, and the approach that we’re taking there obviously is going to be variable, based on their situation,” said Willet.

Evaluating their home circumstances was important, particularly their ability to isolate from other individuals in the household. 

“The most important thing is going to be making sure that there’s airborne precaution, eye protection, and skin covering for these individuals, especially if they’re going to need to come into close contact,” she added.

Meanwhile, Health and Human Services Secretary Robert F Kennedy Jr has refused to allow one of the US citizens at the National Quarantine Unit to sit out her 42-day quarantine at home, according to Inside Medicine.

Ten of the 18 US passengers on the cruise ship have been allowed to isolate at home, while seven opted to stay in the unit. But the eighth, Angela Perryman, wanted to isolated at home but her home state of Florida refused to implement the 24-hour surveillance required by health authorities to allow this.

Last week, Dr Michael Bell, the US Centers for Disease Control and Prevention (CDC)’s quarantine medical reviewer, concluded that Perryman’s confinement was unnecessary and that home-based monitoring would be enough to protect the public.

However, Kennedy overruled this decision without giving reasons. Ironically, Kennedy and acting CDC head Dr Jay Bhattacharya were vocal critics of COVID-19 lockdowns.

Image Credits: BBC.

The recent Ebola outbreak serves as a grim reminder that nature does not wait for treaty negotiations on pandemic preparedness.
Workers erect an Ebola isolation tent on the grounds of a hospital in Ituri, DRC.

Despite claims by the United States that it has allocated over $270 million to the Ebola Bundibugyo outbreak response, countries and groups dealing with the outbreak are in the dark about where the money is going.

Washington’s directive to US health experts not to deal with World Health Organization (WHO) officials is also hampering their involvement in the response, sources told Health Policy Watch.

The Africa Centres for Disease Control and Prevention and the WHO are leading the continental Ebola response, centred in the Democratic Republic of Congo (DRC), and recently launched a joint continental preparedness and response plan.

Although Africa CDC Director General Dr Jean Kaseya described the US as “the first partner for global health security”, he acknowledged that he was unclear of the extent of the US financial contribution, as well as what funds have been disbursed so far, and to whom.

“We know that announcements [about funding] were made by the US government, and we also know that they are supporting some organisations like OCHA [the UN humanitarian affairs office]. Currently, we want to understand how much money from what the US gave to a number of partners can really go to supporting the response,” Kaseya told a media briefing last Thursday in response to a question from Health Policy Watch.

This Tuesday, the Ebola response will be discussed during a high-level meeting of African Presidents, which is being convened by the President of Burundi, chair of the African Union, said Kaseya.

“We know that the US will attend the meeting on Tuesday, [and] they will have the opportunity to give us the reliable amount that they are putting into the response,” he added.

The US State Department issued a statement last Friday stating that it had committed $270 million in “direct Ebola response money” and that, “working with Congress, intends to provide $50 million to the Coalition for Epidemic Preparedness Innovations (CEPI) to develop medical countermeasures for the Bundibugyo strain of Ebola”.

Over the past few weeks, Kaseya has criticised countries and donors for failing to turn their Ebola pledges for financial support into “real money”. By 4 June, less than $2 million had reached affected countries despite pledges of around $498 million, said Kaseya, although he declined to name the countries.

Kaseya also revealed last week that China had committed a mere $2 million to the response, less than half of South Africa’s $5 million pledge.

Non-engagement with WHO?

WHO's Dr Roseline Belzaire (centre) and Africa CDC's Dr Yap Boum on the ground in Ituri in the DRC to address Ebola.
WHO’s Dr Roseline Belzaire (centre) and Africa CDC’s Yap Boum (right), who are leading the continental response team on Ebola.

The US State Department failed to respond to Health Policy Watch queries about how officials from the US CDC and other expert health bodies were assisting the Ebola response on the ground, and whether they had been instructed not to engage with the WHO.

Sources who asked not to be named told Health Policy Watch that US officials were unable to advise or engage with WHO officials on the ground in the DRC, which had sometimes meant that they ignored them in meetings. 

The US withdrew from the WHO when Donald Trump assumed office in January 2025, although WHO member states recently refused to recognise its withdrawal until the US paid its unpaid membership fees.

Dr Chikwe Ihekweazu, WHO head of health emergencies, recently told the journal, Science, that he missed working with US scientists “at a technical level” to address the current Ebola outbreak.

“In the past, they would be part and parcel of any response, and just working without them is painful for me. I know it’s also painful for them, because we’re still friends and they’re just unable to engage as they would like to,” said Ihekweazu.

Kaseya did not respond to Health Policy Watch’s question about the nature of US interaction with WHO officials engaged in the response.

‘Unpredictable and unprofessional’

However, Lawrence Gostin, distinguished professor of global health at Georgetown University in Washington DC, said that Trump’s “instruction” to “US public health agencies, particularly the CDC, not to communicate directly with the WHO” has been handled “flexibly, if not bizarrely”.

“Sometimes, [US] CDC officials participate in WHO activities and communicate with WHO scientists. Other times, CDC officials refuse to attend WHO programs and activities, and do not communicate with the WHO,” Gostin told Health Policy Watch.

“Most bizarrely, I’ve heard that CDC officials are in the room but do not speak. This is an unpredictable, unhelpful, and unprofessional way to conduct business, especially when it involves life-and-death decisions,” added Gostin, who also directs the WHO Collaborating Center on National and Global Health Law.

“Collaborations are neither predictable nor professional. Very senior WHO and [US Health and Human Services] leaders do talk. I have firsthand knowledge of this. I also know that technical communication and sharing of scientific data occur at the field level. But all of this is inconsistent and erratic.

“CDC officials feel constrained and cautious in their interactions with WHO counterparts. Often, the sharing of scientific or epidemiologic information is mostly one-way: from the WHO to the CDC. This inconsistency, unpredictability, and constrained collaboration significantly impedes the response to the Ebola outbreak in the DRC.”

Gostin added that there was “incomplete and grudging communication” between US government offices and other UN agencies such as UNICEF.

“When you combine the political constraints placed on the CDC with lost funding and staffing, it is obvious that the US has lost its global health leadership role. And the US is often seen as an obstacle to overcome in global health, rather than an invaluable partner,” Gostin concluded.

Image Credits: Joël Lumbala/ WHO.

WHO Director-General Dr Tedros Adhanom Ghebreyesus, wearing green to encourage consensus during the last round of PABS talks. 

World leaders need to finalise the Pandemic Agreement by applying political will at the “highest level”, a spirit of equity and a sense of urgency.

This is the call made by World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus and Brazilian President Luiz Inácio Lula da Silva in an open letter published on Monday ahead of the G7 summit in France.

Talks on the outstanding annex to the Pandemic Agreement, on a pathogen access and benefit sharing (PABS) system, have deadlocked, with negotiations due to resume between 6 and 17 July.

Reminding leaders that around 20 million people died during the COVID-19 pandemic, the letter notes: “To respond to future pandemics in time, countries must be able to quickly identify pathogens with pandemic potential and share their genetic information and material so scientists can develop tools: the tests, the treatments, the vaccines that decide who lives and who does not. 

“The system that makes this possible, fairly and on equal footing, is the PABS annex. It is the last piece of the puzzle, not only for the Pandemic Agreement but for everything WHO and member states have built from the hard lessons of COVID-19. Until it is finished, the agreement cannot enter into force. The promise stays unkept.”

The deadlock is mainly between developed countries, led by Europe and Japan, and developing countries.

“The hardest questions, including how the benefits of shared pathogens are defined and shared, how the system is governed, and how equity is guaranteed on equal footing, are difficult for a reason,” the letter notes. 

“They are the very questions that went unanswered last time, while people who could have been protected were not. The world is wrestling with them now precisely because they matter so much.”

Three steps forward

Tedros and Lula da Silva propose three urgent steps forward:

First, the clear signal that “only a head of government can give: that finishing this annex is a national priority”.

“Second, a spirit of equity. The PABS system rests on a simple, fair bargain: those who share dangerous pathogens quickly must be able to trust that the vaccines and treatments born from that sharing will reach their own people too.” 

Third, a sense of urgency – particularly as scientists predict a close to one-in-four chance of another pandemic within the coming decade.

The letter notes that a PABS system is not “charity”, but will enable pathogens with pandemic potential to be identified and addressed at their source. It will establish a system for countries to speedily identify and share genetic information of these pathogens,  and get swift access to tests, treatments and vaccines to address these.

“Today, the rules for accessing a pathogen and sharing what flows from it are improvised case by case, often mid-crisis. PABS replaces that with a single framework known in advance, stable rules that let laboratories and partners across the world move at the speed an outbreak demands,” the letter notes.

It also reassures leaders that neither the Pandemic Agreement nor the PABS annex will undermine national sovereignty.

“Nothing in the Agreement gives WHO any authority to direct or alter a country’s laws or policies, or to require measures such as lockdowns, travel restrictions or vaccination mandates.

“Those decisions remain with sovereign states. So we ask you, concretely, to instruct your negotiators to come to the July session ready to conclude, and to give them the flexibility to close the remaining gaps and finalise the annex in this round.”

“Those are people who are being killed socially.”

​That is how Dr. Marcus Lacerda, Director of the WHO-hosted Special Programme for Research and Training in Tropical Diseases (TDR), describes children whose futures are shaped by repeated bouts of vivax malaria.

​

​Lacerda, who joined TDR in March 2026, has spent more than 25 years studying infectious diseases in the Brazilian Amazon. He is perhaps best known as a driving force behind tafenoquine, the first single-dose radical cure for Plasmodium vivax malaria approved in four decades.

​Speaking on the latest episode of Trailblazers with Garry, hosted by Dr. Garry Aslanyan, Lacerda reflected on the experiences that have shaped his career and the lessons he has learned over decades of work in tropical medicine.

​His path began as a young medical student when Catholic missionaries invited him to visit remote communities in the Amazon.

​”I fell in love [with] the population, I fell in love [with] the geography,” he recalled. He ultimately became convinced that his life’s calling was to practice medicine, particularly focusing on the diseases prevalent in the Amazon.

​That decision led him to focus on vivax malaria, a disease often overshadowed by more deadly infections but one that carries profound social consequences.

​One study conducted by a master’s student in the Amazon followed hundreds of children and found that those who had experienced at least one episode of vivax malaria performed worse in school than their peers.

​”Malaria sometimes kills, but sometimes it kills you in the sense of not allowing those kids to go to the university,” Lacerda said.

​Despite major advances in diagnostics, treatment and prevention, Lacerda argues that scientific innovation alone will not eliminate malaria.

​”So now we have the tools, but we don’t have the same appetite for eradication,” he said, noting that competing national priorities have pushed malaria down the global agenda.

​For Lacerda, the challenge ahead is not only developing new solutions but ensuring countries have the support and determination needed to put existing ones into practice.

Listen to the full episode >>

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Image Credits: https://www.buzzsprout.com/1632040/episodes/19280656.

“It wasn’t unusual for shells and missiles to smash through the upper floors, leaving sizeable holes. Every time we were hit, we’d wonder if we should close the hospital.”

​That is how Dr. Amani Ballour, a Syrian paediatrician and the first female director of a hospital in a Syrian war zone, recalls working in an underground medical facility during the Syrian civil war. Yet despite repeated attacks, “the people kept coming, and we kept working. We never did close the cave.”

​Speaking on the Global Health Matters “Dialogues” podcast, Ballour described six years spent treating civilians under siege in Eastern Ghouta, where hospitals became targets and medical workers struggled to provide care with dwindling resources. The underground facility known as “The Cave” cared not only for war injuries but also for children suffering from hunger, disease and a lack of basic medicines.

​Among the most traumatic moments was the August 2013 chemical attack on Ghouta. Arriving at the hospital in the middle of the night, Ballour found hundreds of victims struggling to breathe.

​”The hardest thing was to choose how to begin,” she recalled. “The people whom we will start helping will live, but other people will die. So we have to choose who’s going to live and who’s going to die.”

​The siege also created a public health catastrophe. Food, medicines and infant formula were scarce. Ballour remembered treating children whose primary complaint was hunger.

​”The first question I asked them was, ‘What are they suffering from? What they have, they said, ‘I’m hungry, I need to eat.'”

​Today, Ballour serves as Programme Advocacy Officer at the Syrian American Medical Society and continues to advocate for accountability for attacks on healthcare.

​”International humanitarian law is already protecting the health workers and the medical facilities,” she said. “There must be stronger enforcement mechanisms, like independent investigations, and real consequences for those who target healthcare.”

​For Ballour, preserving the stories of those lost remains essential.

​”Silence allows injustice to be normal,” she said. “Keeping their stories alive is a way of honoring their lives.”

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Image Credits: Global Health Matters Podcast.

The Panchachuli peaks, part of the Himalaya range between India and Nepal.

Home to 1 in 4 people globally, the region should brace for “multi-hazards” and poor air quality apart from heat and water stress, according to a new report. The authors called on countries in the fractious neighbourhood to cooperate on data and form common solutions.

The monsoon season this year is likely to bring more water and heat stress, rather than relief, to South Asia, home to over two billion people – a quarter of the world’s population. 

This preliminary assessment comes from the Hindu Kush Himalaya Monsoon Outlook 2026 for June to September, which draws on global and regional climate outlooks for South Asia. 

The countries covered include Afghanistan, Bangladesh, Bhutan, China (the Xizang/Tibet Autonomous Region), India, Myanmar, Nepal, and Pakistan. Of these, much of Afghanistan and Myanmar are forecast to have a better, even above normal, monsoon in parts than the other countries. 

By contrast, the India Meteorological Department has forecast a below normal monsoon, at 92% average levels of 87 centimetres during 1971–2020 with a 5-percentage point error margin. 

The eight countries are members of the International Centre for Integrated Mountain Development (ICIMOD) based in Nepal, which produced this report; the other authors are from the Institute of Atmospheric Physics, Chinese Academy of Sciences (IAP-CAS). 

Worryingly, the ICIMOD’s report forecasts that temperatures will be about 0.5 to 2° above normal compared to a recent 15-year period, 2010-2024, which saw many of the hottest years on record. 

Threat of multi-hazards

Twin peaks of Nanda Devi, in the Himalaya range between India and Nepal.

A weaker monsoon does not reduce disaster risks, however, the report said. 

Floods account for a significant proportion of disasters in the Hindu Kush Himalaya region. The threat of floods and other water-induced hazards may be further amplified by the cascading nature of multi-hazards. 

In the HKH in particular, warmer temperatures, reduced snowfall, declining water availability, and lower river flows are likely to place additional stress on communities directly dependent on the monsoon. Erratic rainfall, especially after prolonged dry spells, can still trigger landslides and flash floods in mountain regions. 

In India, for example, between 2024 and 2025, more than 8,000 lives were lost due to disasters across Himalayan states, including Assam, Arunachal Pradesh, Himachal Pradesh, and Jammu and Kashmir.

The monsoon outlook “gives disaster management authorities a critical window to prepare,” said Navneet Yadav, Team Lead for Disaster Risk Reduction and Climate Resilience at Palladium India.

Air quality is also likely to take a hit. It is “logical” that a weaker monsoon will remove fewer pollutants from the air, the report’s authors said in response to a question from Health Policy Watch. 

“Warmer and drier conditions favour wildfires. Dust, ozone formation, et cetera,” said Saswata Sanyal, Disaster Risk Reduction Manager at ICIMOD. “So should the region be preparing for a poor air quality season, along with heat and water stress? Absolutely.”

The region is home to almost all of the world’s top 100 most polluted cities, making the waterfall effect on poor air pollution particularly dangerous. 

Impact of drier, hotter monsoon

RMC = Regional Member Countries of ICIMOD.

The impacts are likely to extend beyond the mountains. 

Increasing temperatures, both maximum temperatures and night-time temperatures, may adversely affect human health due to heat stress people may face during heatwaves, particularly when combined with higher humidity. 

Heat stress occurs when the body cannot dissipate excess heat; when that happens, the body’s core temperature rises and the heart rate increases. 

Livelihoods will also be adversely impacted, according to the report. In agriculture, for instance, higher temperatures and lower water availability can lead to heat stress in crops and livestock, reduce yields, and shorten growing seasons, particularly in already marginal mountain farming systems. 

Elevated temperatures can also intensify evapotranspiration – evaporation from water bodies and transpiration from plants – and the loss of soil moisture, further compounding the impacts of droughts. 

Hydropower generation is also likely to decline, particularly in Nepal and Bhutan, which may further exacerbate existing stresses on national and regional energy supplies.

Can South Asia work together?

The risks are high, and so are tensions among several of the countries. ICIMOD may include representatives of all the region’s countries, but it is “apolitical”. The authors acknowledge that all countries “need to be on board” for data sharing to work.  

ICIMOD says it is trying to provide a platform where data generated by a monsoon or snow outlook can be used across borders, and be a space for countries to discuss these challenges and “form common solutions”.

Given the risk of hazards intensifying through the combination of above-normal temperatures and erratic rainfall, the report calls for better coordination to share relevant information quickly with disaster management networks.

“There is always some inhibition among the countries to share data openly with each other,” Sanyal said. “Obviously, you understand there’s a lot of politics involved.” 

Image Credits: Chetan Bhattacharji.

Prevention programmes have borne the biggest brunt of the cuts, while The number of people receiving pre-exposure prophylaxis (PrEP) at least once in the year fell 38% between 2024 and 2025, the report shows. 

The global HIV response is facing its “biggest storm” since the world united against the epidemic, UNAIDS warned Friday, as it published new data showing donor funding for HIV/AID prevention and community services critical to containing infections dropped by almost one quarter last year.

The Global AIDS Brief is being published just 10 days ahead of the United Nations High-Level Meeting (HLM)  in New York City, where member states are due to adopt a new Political Declaration on ending HIV/AIDS as a public health threat by 2030.

It is the first comprehensive damage assessment of the funding shock that hit HIV response and the entire array of global health crises in 2025.

External development assistance to HIV/AIDS programmes fell by 23% last year, the sharpest drop on record, the report reveals. 

This followed on the Trump administration dismantled USAID and slashed contributions to the HIV response the United States had anchored for two decades. The result is an HIV response that is collapsing.

Most serious disruption in decades

Winnie Byanyima, UNAIDS executive director, said the disruption is unquestionably the most serious the HIV response has faced since the late 1990s, when the world came together to fight the disease with the creation of UNAIDS, followed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Emergency Plan for AIDS Relief (PEPFAR)  and the WHO 3×5 initiative. 

Today’s shrinking civic space and the spreading criminalization of marginalized communities is converging into “the biggest storm the HIV response has ever seen,” Byanyima warned.

Alongside malaria, HIV has been among the best-funded causes in the history of international health development, with the US pouring more than $100 billion into PEPFAR since 2003, the largest commitment ever made by one nation against a single disease.

Together with the Global Fund, US Funding channeled via PEPFAR and USAID accounted for roughly 86% of all donor financing for HIV in 2024. What was built on that money is now unravelling with it.

Some 1.2 million people acquired HIV in 2025, a dramatic 43% decline since 2010 – and reflective of the results the combined efforts have yielded on the ground.

AIDS-related deaths fell 57% over the same period to 570,000. And of the 40.9 million people living with HIV worldwide, 32.1 million were on treatment last year.

But the world missed every one of its 2025 targets, and the new numbers may be a final snapshot before the cuts register in the epidemiological record.

The report describes 2025 as “a profound shock to global health financing” that destabilized HIV responses across many countries, disrupting service delivery, supply chains and community systems. The full effects, it warns, will only become evident over the next few years.

Byanyima said the response now stands at the most perilous moment in its history, with decades of hard-won gains at risk of unravelling just as the tools to end the epidemic have finally come within reach.

Prevention programmes 80% donor dependent in disarray

The deepest cuts are in prevention which only received 11% of HIV  funding overall in 2024. In sub-Saharan Africa, prevention programmes depended on donors for 83% of their funding when the cuts hit, the UNAIDS report found.  Globally, two-thirds of prevention programmes were funded by external donors.

The number of people receiving pre-exposure prophylaxis (PrEP) at least once in the year fell 38% between 2024 and 2025 across 62 countries reporting to UNAIDS, including in countries with the highest HIV burdens.

Data from PEPFAR, the US bilateral programme, show HIV testing declined 22% in high-burden countries over the same period. Funding for condom programming fell 93%, and support for programmes ensuring people can actually reach services, such as supportive laws and policies, dropped 80%.

Every week, 3,000 adolescent girls and young women in sub-Saharan Africa acquire HIV. Incidence in this group runs three to four times higher than among their male peers, and women account for six in ten new infections in the region, according to the report data.

The HIV response collapse comes at a moment when science has delivered the most powerful prevention tools in the epidemic’s history. Lenacapavir, a twice-yearly injection that almost completely blocks HIV transmission, is a life-changing drug that isn’t reaching the people who need it most.

Lenacapavir reached just over 6,000 people across five sub-Saharan African countries by the end of March, against the 20 million people UNAIDS estimates need antiretroviral-based prevention. The gulf between the potential of the medicine and access for those who need it is one of the starkest examples in global health of how innovation and science are not solutions on their own to solving medicines access issues.

Rights in retreat

For decades, the slow drift of HIV-related law around the world moved in only one direction: toward decriminalization. That tide has now turned. For the first time since UNAIDS began tracking the data, criminalization of the marginalized populations most at risk of HIV is increasing.

Two countries introduced new criminal laws targeting same-sex sexual activity or gender expression in 2025, and one increased penalties for same-sex relations in 2026. The report does not name the countries, but Burkina Faso criminalized same-sex relations for the first time in its history last September, with sentences of two to five years in prison plus fines, while Trinidad and Tobago’s Court of Appeal reinstated its colonial-era buggery laws in March 2025. Neighbouring Mali had criminalized homosexuality months earlier, in its December 2024 penal code.

Just seven of 193 countries do not criminalize at least one of same-sex sexual activity, sex work, possession of small amounts of drugs, transgender people, or HIV non-disclosure, exposure or transmission. Outside Chile, Colombia, the Netherlands, Paraguay, Slovenia, Uruguay and Venezuela, at least one of the populations most at risk of HIV lives on the wrong side of the law everywhere on Earth.

Sex work is criminalized in 168 countries and drug possession in 152. Same-sex sexual activity is illegal in 66 countries, more than half of them in Africa, where penalties range from heavy fines to 14-year sentences in Nigeria, Kenya and Malawi, life imprisonment in Tanzania, Zambia, Sierra Leone and The Gambia, and the death penalty for “aggravated homosexuality” under Uganda’s 2023 law.

Epidemics accelerate wherever human rights protections collapse, Byanyima warned, describing the global rollback of rights and civic space as organized, political, and devastating for public health.

When people fear arrest or discrimination, they do not test and do not seek care. CIVICUS, the civil society monitor, found civic space narrowed, obstructed, repressed or closed in 159 of 198 countries and territories in 2025, leaving just 7% of the world’s population living in countries where civic space is open or relatively open.

“No country seems immune from this deeply worrying trend,” said Mandeep Tiwana, CIVICUS secretary general, presenting the findings in December.

The last declaration before the SDG 2030 deadline

Next week’s UN High-Level Meeting will produce the final Political Declaration before the 2030 deadline that world leaders set under the Sustainable Development Goals to end AIDS as a public health threat. 

The goal is not actual eradication of the virus, but reducing new infections and deaths by 90% compared to 2010, shrinking the epidemic to a scale health systems can manage.

This year’s declaration will set new targets drawn from the Global AIDS Strategy 2026-2031: 

  • 40 million people on ARV treatment 
  • 20 million accessing antiretroviral prevention, 
  • and HIV services free of stigma and discrimination for all.

Meeting those targets would avert 3.2 million new infections and 1.2 million deaths by 2030, according to UNAIDS modelling. See related story. 

Fighting for its own survival 

The declaration will be negotiated around an agency fighting for its own survival. UN Secretary-General António Guterres proposed sunsetting UNAIDS by the end of 2026 in his UN80 reform plan last September, triggering an outcry from member states and more than 1,000 civil society organizations, as Health Policy Watch reported in October.  See related story.

https://healthpolicy-watch.news/with-future-of-unaids-in-question-top-official-says-very-difficult-to-envision-2026-shutdown/

UNAIDS is already cutting its secretariat staff by 54% and consolidating country offices from 85 to 54 under its own board-approved restructuring.

“I’m seeing death, real people dying,” Byanyima told the World Health Summit in Berlin last October, as UNAIDS modelling projected the funding collapse could cause an additional 6.6 million new HIV infections and 4.2 million AIDS-related deaths by 2029 if services are not restored.

The world has the science, the medicines and the experience to end AIDS by 2030, Byanyima said. What remains, she argued, is a political choice for the leaders gathering in New York: invest in finishing the job, or retreat and watch it come undone.

Image Credits: Wikimedia Foundation.