Richard Amenyah | The Caribbean at crossroads

The Caribbean has long been a leader in the global HIV response, making significant strides in reducing new infections, expanding treatment access and retention, and strengthening health systems. However, these hard-won gains are now at risk.

The recent pause and stop-work order on US government (USG) -funded programmes, including crucial technical assistance under the US President’s Emergency Plan for AIDS Relief (PEPFAR), has exposed vulnerabilities in the region’s HIV response. While humanitarian waivers have allowed some services to continue, critically needed technical assistance programmes remain in jeopardy.

Decisive action is needed to ensure that the region remains on track to end AIDS as a public health threat by 2030. This requires not only urgent advocacy for the reinstatement of international support, but a strategic push for domestic funding.

LIFELINE OF TECHNICAL ASSISTANCE

While financial assistance from international donors has been instrumental in sustaining HIV programmes, technical assistance has been equally – if not more – transformational. UNAIDS, via its Technical Support Mechanism, with funding from USAID and other partners, has played a pivotal role in coordinating and providing technical support to the Caribbean. This support has been essential in a) strengthening data systems for more effective HIV monitoring and reporting, b) developing investment cases and tracking HIV expenditure, c) enhancing sustainability planning and resource mobilisation, d) monitoring and addressing stigma and discrimination and e) strengthening community-led responses and multisectoral coordination, among others.

If the support is not reinstated after the 90-day review period, the Caribbean will struggle to identify alternative funding sources. Without this support, governments’ ability to track and respond to the epidemic effectively will be significantly weakened.

THE DATA DILEMMA

One of the most immediate casualties of the funding pause has been the stigma index surveys, which are at varying stages of implementation in Trinidad and Tobago, Guyana, and Jamaica. These surveys, led by people living with HIV, provide insights into how the community experiences stigma in their workplaces, clinics, communities, and homes. The findings are essential for tracking progress toward the global 10-10-10 targets, which aims to reduce punitive laws, stigma and discrimination and gender-based violence to less than 10 per cent. Without this critical data, Caribbean countries risk making uninformed decisions, hindering their ability to design targeted interventions to address stigma and discrimination – one of the greatest obstacles to achieving an AIDS-free generation in the region.

SUSTAINABILITY AT STAKE

Even before the funding pause, countries faced an urgent need to transition from donor-dependent HIV responses to more sustainable, domestically financed models. With the Global Fund preparing to transition out of many countries in the region, governments planned to develop or refine sustainability plans. However, these efforts have now stalled. Without structured technical assistance to guide the transition, many countries could experience fragmented, inefficient HIV responses, jeopardising service delivery continuity.

THE IMPACT ON CIVIL SOCIETY

Civil society organisations (CSOs) have been at the heart of the Caribbean’s HIV response, particularly in reaching vulnerable and marginalised groups such as sex workers, men who have sex with men, and people who use drugs. These groups often depend on these organisations to support their access to health and other services and provide them with empowerment and capacity building. CSOs rely heavily on international funding, lots of which comes from the US government, through various mechanisms, to sustain their prevention, care, and advocacy work. The sudden disruption threatens to weaken community-based HIV efforts, increasing the risk of new infections and poorer health outcomes among people living with, and most affected by, HIV.

CALL TO ACTION

With the 90-day pause to end in April, the Caribbean must act decisively to prevent any long-term setbacks, even with a humanitarian waiver in place. Governments, policymakers, and development partners must come together to:

1. Advocate for reinstatement of technical assistance: Caribbean leaders must underscore the vital role technical assistance plays in sustaining the region’s HIV response. The strategic support provided through UNAIDS, PAHO, PEPFAR and other partners must be recognised as essential to improve health outcomes.

2. Strengthen domestic resource mobilisation and foster resilient, sustainable health systems: To reduce reliance on external funding, governments must scale up domestic investments in HIV programmes and the broader health system. They should explore innovative financing models, such as having HIV treatment as part of national health insurance schemes, HIV trust funds, and public-private partnerships. By creating fiscal space through innovative approaches, countries can enhance universal health coverage, integrate service delivery, and invest in workforce capacity-building, ensuring long-term sustainability of public health programmes, especially at the primary healthcare level.

3. Protect and expand civil society engagement: Governments should establish sustainable financing mechanisms for CSOs. By integrating these organisations into national health budgets and exploring public-private partnerships, social contracting, and domestic resource mobilisation, governments can ensure they continue providing essential services.

4. Invest in research and robust data systems: Governments must urgently prioritise and expand on stigma index surveys and other critical data collection efforts. Strengthening national health information systems will ensure that decision-making remains data-driven and evidence-based.

5. Strengthen multisectoral partnerships: The HIV response must be aligned with broader health, social protection, and development agendas related to the Sustainable Development Goals. Governments should collaborate with the private sector, academia, and international organisations to drive innovation and efficiency.

TIME TO ACT IS NOW

The Caribbean’s fight against HIV has been a demonstration of resilience, collaboration, and innovation. The progress made over the past two decades is too valuable to lose. To stay on track to end AIDS as a public health threat by 2030, governments must fill funding gaps, secure sustainability, and advocate for the reinstatement of essential technical support.

The stakes are high: UNAIDS estimates that a permanent halt to PEPFAR funding could result in 8.7 million new HIV infections (a seven-fold increase), 6.3 million additional AIDS-related deaths globally (a 10-fold increase), and about 3.4 million orphans by 2029. For the Caribbean, backsliding is not an option. With decisive action, the region can protect its gains, achieve the 2030 targets, and build a healthier, more equitable future for all. The choices made today by our policymakers will determine whether the Caribbean’s HIV response continues to be a global success story – or a cautionary tale of missed opportunities. The time for action is now.

Dr Richard Amenyah is a medical doctor and public health specialist. He is the director for the UNAIDS multicountry office for the Caribbean. Follow him on X (formerly Twitter) at @RichardAmenyah or @UNAIDSCaribbean. Send feedback to jamaica@unaids.org