Wiyeh Alison, Komba Patience, Ojong Samuel Akombeng, Wiysonge Charles S, Moki-Suh Bih, Sadate-Ngatchou Patricia, Mukumbang Ferdinand C
Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, United States of America.
Department of Global Health, University of Washington School of Public Health, Seattle, Washington, United States of America.
PLOS Glob Public Health. 2025 Apr 28;5(4):e0004440. doi: 10.1371/journal.pgph.0004440. eCollection 2025.
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has played an important role in expanding access to antiretroviral therapy (ART) and significantly reducing HIV/AIDS mortality globally. However, policy shifts in the United States(US) aimed at realigning foreign aid with US national interests have introduced significant uncertainty regarding PEPFAR funding in 2025, threatening to undermine decades of progress in the global HIV/AIDS response. Many countries that have long relied on PEPFAR funding are trapped in a cycle where sustained donor aid has limited their transition to self-reliant, country-led HIV programs. We leverage historical institutionalism to examine how past structures, especially colonial-era institutions, have constrained African nations and limited their capacity for self-determination through the phenomenon of path dependency. Foreign aid, often aligned with the geopolitical and economic interests of donor nations, has further undermined institutional resilience in aid-recipient countries. The recent halt in PEPFAR funding, marks a critical juncture in global health, with the potential to catalyze long-overdue systemic reforms in African health systems. As uncertainty around U.S. foreign aid grows, we anticipate an increase in engagement from private and philanthropic funders. Without corrective action, the persistence of inefficient institutional pathways will continue to undermine the impact of financial investments in many African institutions, jeopardizing the effectiveness and sustainability of initiatives aimed at improving national health outcomes. For sustainable reforms in former colonies, countries must first acknowledge the constraints of colonial legacies, decolonize mindsets and institutions, define their own development priorities, and establish transparent, accountable governance, alongside political stability as fundamental pillars for progress. PEPFAR is the first major global health program to be affected, and it is unlikely to be the last. How much longer will recipient countries remain dependent on donor funding to safeguard the health and lives of their populations?
美国总统防治艾滋病紧急救援计划（PEPFAR）在扩大抗逆转录病毒疗法（ART）的可及性以及大幅降低全球艾滋病毒/艾滋病死亡率方面发挥了重要作用。然而，美国旨在使对外援助与美国国家利益重新接轨的政策转变给2025年的PEPFAR资金带来了重大不确定性，有可能破坏全球应对艾滋病毒/艾滋病数十年所取得的进展。许多长期依赖PEPFAR资金的国家陷入了一个循环，持续的捐助援助限制了它们向自力更生、由国家主导的艾滋病毒项目的过渡。我们运用历史制度主义来研究过去的结构，特别是殖民时代的制度，如何通过路径依赖现象限制了非洲国家并削弱了它们的自决能力。通常与捐助国地缘政治和经济利益挂钩的对外援助，进一步削弱了受援国的制度韧性。PEPFAR资金最近的中断标志着全球卫生领域的一个关键时刻，有可能促使非洲卫生系统进行早就该进行的系统性改革。随着美国对外援助的不确定性增加，我们预计私人和慈善资助者的参与度将会提高。如果不采取纠正行动，低效的制度路径持续存在将继续削弱对许多非洲机构的金融投资的影响，危及旨在改善国家卫生成果的举措的有效性和可持续性。对于前殖民地国家的可持续改革而言，各国必须首先认识到殖民遗产的限制，使思维方式和制度非殖民化，确定自己的发展优先事项，并建立透明、负责的治理，同时将政治稳定作为进步的基本支柱。PEPFAR是首个受到影响的重大全球卫生项目，而且不太可能是最后一个。受援国还要依赖捐助资金保障其民众的健康和生命多久呢？
