Donor funding transitions as system shocks: Implications for paediatric HIV equity and health system sustainability in sub-Saharan Africa
1
Department of Health and Society, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
2
Academic Model Providing Access to Healthcare (AMPATH), Moi University, Eldoret, Kenya
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
Equitable access to HIV services for children remains a persistent global health challenge, especially in settings heavily dependent on external donor financing. In sub-Saharan Africa, paediatric HIV programmes have relied on donor-supported systems, particularly through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Recent donor funding transitions and policy realignments have raised concerns about the continuity, equity, and sustainability of HIV testing and treatment services for children.
METHODS:
A scoping review was conducted in line with Joanna Briggs Institute methodology and reported according to PRISMA-ScR guidelines. Peer-reviewed and grey literature published between 2005 and 2025 were identified across multiple databases and organisational sources. Eligible studies examined donor funding disruptions affecting HIV service delivery in sub-Saharan Africa, with paediatric relevance inferred through shared service platforms.
RESULTS:
Nine studies spanning 19 donor-supported African countries met the inclusion criteria. Six interrelated themes were identified: (1) nature and drivers of donor funding disruptions; (2) service delivery disruptions in paediatric HIV care; (3) health system capacity challenges; (4) financial dependency and sustainability constraints; (5) consequences for paediatric outcomes and equity; and (6) resilience, adaptation, and mitigation strategies. Donor transitions were consistently associated with paediatric ART interruptions, delayed early infant diagnosis, workforce attrition, weakened outreach and retention support. These effects were most pronounced in rural and low-volume facilities, exacerbating geographic and socio-economic inequities.
CONCLUSIONS:
Donor funding transitions function as system shocks rather than neutral budgetary adjustments, disproportionately placing children at risk and widening inequities in access to HIV care. Strengthening age-disaggregated monitoring, embedding child-sensitive safeguards into transition planning, and investing in sustainable health system financing are essential to advancing equitable and resilient paediatric HIV responses in sub-Saharan Africa.
Equitable access to HIV services for children remains a persistent global health challenge, especially in settings heavily dependent on external donor financing. In sub-Saharan Africa, paediatric HIV programmes have relied on donor-supported systems, particularly through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Recent donor funding transitions and policy realignments have raised concerns about the continuity, equity, and sustainability of HIV testing and treatment services for children.
METHODS:
A scoping review was conducted in line with Joanna Briggs Institute methodology and reported according to PRISMA-ScR guidelines. Peer-reviewed and grey literature published between 2005 and 2025 were identified across multiple databases and organisational sources. Eligible studies examined donor funding disruptions affecting HIV service delivery in sub-Saharan Africa, with paediatric relevance inferred through shared service platforms.
RESULTS:
Nine studies spanning 19 donor-supported African countries met the inclusion criteria. Six interrelated themes were identified: (1) nature and drivers of donor funding disruptions; (2) service delivery disruptions in paediatric HIV care; (3) health system capacity challenges; (4) financial dependency and sustainability constraints; (5) consequences for paediatric outcomes and equity; and (6) resilience, adaptation, and mitigation strategies. Donor transitions were consistently associated with paediatric ART interruptions, delayed early infant diagnosis, workforce attrition, weakened outreach and retention support. These effects were most pronounced in rural and low-volume facilities, exacerbating geographic and socio-economic inequities.
CONCLUSIONS:
Donor funding transitions function as system shocks rather than neutral budgetary adjustments, disproportionately placing children at risk and widening inequities in access to HIV care. Strengthening age-disaggregated monitoring, embedding child-sensitive safeguards into transition planning, and investing in sustainable health system financing are essential to advancing equitable and resilient paediatric HIV responses in sub-Saharan Africa.
| eISSN: | 2654-1459 |
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