Case Study: The impact of U.S. stop work orders on TB and TB/HIV programs and people in East and Southern Africa

Case Study: The impact of U.S. stop work orders on TB and TB/HIV programs and people in East and Southern Africa

April 2025

Since the USAID stop-work orders came into effect, Bruce has been receiving direct feedback from ARASA’s partners regarding the disruptions to their work. In addition to one-on-one conversations, he has engaged with partners during advocacy meetings and working group sessions, where similar concerns have been raised. “These platforms allow us to exchange experiences, assess the impact, and clarify what’s truly happening,” Bruce explains. “There’s a lot of misinformation circulating within communities, so it’s vital that we create spaces to share accurate information and support one another.” ARASA’s partners don’t know what’s coming next; few of them have a solid understanding of the minutiae of the funding mechanisms and processes involved.

Uganda is one of the highest-burden countries for both TB and TB/HIV, with approximately 91 000 new cases each year. Most of the country’s TB funding actually came through PEPFAR,^[1] as well as USAID and the CDC. With the Executive Orders related to USAID and the funding freeze, “we see a lot happening in terms of the staff going back home, putting tools down,” Bruce says. There is also a lot happening “especially around the community targeted TB programming,” which is a real threat to TB care, prevention, early detection and contact tracing – much of which is carried out by health volunteers. The funding changes have had an impact on TB referrals and transport of samples (the latter of which has long been supported by the CDC). Treatment support for patients has been cut off as well.^[2]

Most TB-related services have now been discontinued, and the Ministry of Health has directed that these services be integrated into the Outpatient Departments of government health facilities. However, ARASA has raised concerns about the implications of this shift. Based on emerging observations, even in cases where integrated TB services are technically available, many individuals affected by TB are reluctant to seek care. This reluctance is largely due to fears of stigma and discrimination — particularly the risk of being overheard and identified by others in the facility as someone with TB. The label alone can cause significant discomfort and social isolation, often discouraging individuals from returning for continued care and treatment.

Another critical challenge is health worker fatigue. Previously, PEPFAR/USAID funding helped to bridge the human resource gap by supporting the recruitment and retention of essential healthcare personnel. However with the withdrawal of this support, even where services remain technically available, there are often insufficient staff to deliver them effectively. The few remaining health workers are overwhelmed by increased workloads, which compromises the quality of care. This strain is particularly evident in areas requiring patient follow-up and support on adherence to treatment — key components in ensuring successful outcomes.

Bruce notes with concern that the progress previously made in reducing TB-related stigma is now being eroded. He recalls a conversation with the coordinator of a drop-in centre in Mbarara City, western Uganda, who shared that they are beginning to lose clients. One such client, a businessman, explained that he has stopped collecting his TB medication because he now has to queue publicly at a government facility. In the past, he received his medication discreetly in an envelope. “I’d rather stop taking the medicine than stand in line and have everyone know what I’m collecting and what I’m suffering from,” he reportedly said. This among other anecdotal stories highlights how stigma, compounded by the loss of differentiated care, is driving people away from life-saving treatment.

Since the USAID stop-work order, Bruce has witnessed an alarming shift in the delivery of HIV and TB services in Uganda. One immediate change was the disappearance of discreet, person-centred care due to a shortage of health workers. Clinics began instructing clients to collect a six-month supply of ARVs (antiretroviral medications for HIV) in a single visit – many of the drugs nearing expiration. With little explanation or choice, people accepted the only medication available.

In one case, a young woman received ARVs that wouldn’t even last the full treatment period. Others, unable to replenish their supply, began skipping doses – a dangerous practice that heightens the risk of drug resistance, particularly for TB, where treatment adherence is already a major challenge.

Bruce is deeply concerned about the rise in drug-resistant TB due to disrupted follow-up systems, staff shortages and lapses in diagnostics – areas once supported by USAID and PEPFAR. TB diagnostic samples are now spoiling in transit due to delays, and stockouts of drugs are increasingly common. Though Uganda’s National Medical Stores and Drug Authority are still in the supply chain, USAID’s withdrawal has left many essential commodities ‘on hold.’

Even the national Stop TB Partnership – a key local coordination body – is on the brink of collapse. Amid this crisis, community motivation is eroding and mental health concerns are rising. Bruce describes a wave of fatigue and abandonment sweeping through communities, reminiscent of the darkest days of the COVID-19 pandemic. Without urgent action, both lives and years of progress are at risk.

All this will be a burden to the health system, but also to community systems, because the PEPFAR sites where the health workers were employed now have to be integrated into the national system or facilities. The Global Fund, which also supports some of the TB work, has to now take on the sites that were previously under USAID/PEPFAR; Bruce thinks that this is going to take a long time since the Global Fund funding is already earmarked. 

In light of the global goal to end TB by 2030, Bruce reflects that “we are hitting a hard rock in the current environment’’. While other disease areas have witnessed significant advancements in treatment, access, affordability, and technology over the years, TB has historically lagged behind. It has also received comparatively less attention and support from partner organisations. However, recent progress – particularly in improved medications and case management for drug-resistant TB – offered a glimmer of hope.

ARASA is currently focused on intensifying advocacy for increased domestic health financing, urging governments to take ownership of health budgets to ensure sustainability. Civil society has been working to meet bureaucratic and political figures in the Ministry of Health and the Uganda AIDS Commission (which oversees joint HIV-TB programming). But it will be a real challenge to demonstrate the funding gap that now exists and to push for an increased budget allocation, given what is realistically available. 

Alongside these efforts, there remains an urgent need for community mobilisation and awareness-raising around TB. Bruce emphasises that TB literacy is still very low, even among parliamentarians and policymakers. Without widespread understanding and visibility, TB will continue to be underfunded and deprioritised; awareness is therefore critical – not just for prevention and treatment, but also for unlocking the necessary political will and resources to meet global targets. What worries Bruce even more right now is the fate of key populations^[3] affected by TB: for example, in talking about TB and HIV, he and his colleagues have to take account of sexual health and rights – and at the moment, all sexual health-related services have been curtailed. 

Above all, Bruce believes these stories need to be heard and amplified. “Some of us are driven by passion, commitment and that sense of fulfillment when someone who was once struggling with adherence calls to say, ‘I’m actually fine now – I don’t need any more medication.’ That feeling fuels us. But now… the fatigue is real.”

He speaks of the cascading impact of the funding freeze: “From job losses, to telling staff to pack their bags and go home – not knowing for how long – to not even being able to pay them for the work they’ve done that month. And then there’s the human cost.” Bruce shares stories of people being forced to ration medication, skipping doses to make their supply last longer. In some cases clients are even sharing their doses with partners, cutting a three-month supply in half. “And what happens next? Drug resistance. Toxicity. The cycle we’ve worked so hard to break is re-emerging.”

His message is clear: if TB-related support structures collapse, the consequences are not just operational – they are deeply personal, and dangerously far-reaching.

^[1] The President’s Emergency Plan for AIDS Relief (PEPFAR), founded by President George W. Bush, is the largest commitment in history by any nation to address a single disease, enabled by strong bipartisan support across ten U.S. Congresses and four {residential administrations, and through the American people’s generosity. Since PEPFAR’s inception in 2003, the US government has invested over US$100 billion in the global HIV/AIDS response, saving over 25 million lives (https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar).

^[2] ‘Treatment support’ is when another person – either a healthcare worker or a lay person – helps a person with TB take their TB medications, provides emotional support and intervenes medically (or recognises when medical intervention is needed) in the case of the person not responding to therapy or having adverse effects from their treatment (https://tbksp.who.int/en/node/2321#). 

^[3] Key populations for any disease are those groups that might be particularly at risk, or where action to find and treat people affected may have particular impact. TB mainly affects people with reduced immunity (for example, young children or people with HIV), people with certain other health conditions (such as malnutrition, diabetes or silicosis) and those who smoke or have a substance-use disorder. TB also disproportionately affects people whose health is compromised because of their socio-economic circumstances (for instance, poverty, poor housing or imprisonment) (https://www.who.int/teams/global-tuberculosis-programme/populations-comorbidities).