Projected Impact of U.S. PEPFAR Withdrawal on Zimbabwe and Implications for the Global HIV Response

Introduction: Changes in U.S. global health policy, under the America First Global Health Strategy, have shifted U.S. engagement away from open-ended programmatic support toward a model centered on time-bound bilateral health agreements. In Zimbabwe, negotiations over a proposed Memorandum of Understanding (MOU) have broken down, creating a credible risk of U.S. withdrawal and HIV services disruption. Methods: Using PEPFAR performance data from 2024 and 2025, we quantify the total projected increase in new HIV infections from the disruption of PEPFAR-funded HIV testing, prevention, PMTCT, and adult treatment programs. Results: Our model estimates 75,440 (range: 30,002 to 122,601) new HIV infections could take place in Zimbabwe within one year as a consequence of full PEPFAR withdrawal and no additional government or international support, including 8,939 (6,953-10,926) new infections from loss of HIV testing programs, 19,139 (17,021-21,256) from loss of prevention programs, 1,050 (134- 2,005) from disruptions to PMTCT, and 46,313 (5,894-88.415) adult infections from disruption to treatment programs. Conclusions: This analysis demonstrates that policy shifts affecting PEPFAR support in Zimbabwe would have immediate epidemiological consequences. We project approximately 75,000 additional HIV infections within one year of complete PEPFAR withdrawal. Most of these infections (about 46,000, or 61%) are attributable to disruptions in antiretroviral treatment, as loss of viral suppression increases onward HIV transmission. An additional 19,000 infections are projected from reduced access to prevention services, including PrEP, VMMC, and programs for key populations. These findings underscore the central role of sustained treatment coverage and prevention services in maintaining epidemic control.