A young woman sits on a plastic chair in a concrete courtyard, flanked by faded blue wooden doors. It's late afternoon, and most of the narrow doors of two dark, stucco buildings are closed. Until rush hour and the night.
Pressing bright pink fingernails together, the sex worker at this brothel talks about her fear of contracting HIV now that U.S. government funds for preventive medications have been slashed and condoms are scarce. She is one of many Ugandan women increasingly without such protection, including young girls from rural areas trafficked into prostitution as well as women who face gender violence or are unsure of their partners' fidelity.
"Nowadays, we see women, they're facing a problem, a challenge of: 'Do you just go without any protection?' I'm seeing that many, many people will get infected," says Judith Babirye, who has long worked with women at this brothel behind a trucker bar on the crowded highway that links Uganda to Kenya.
Babirye is a project officer with St. Francis Health Care Services, which provides health care and related services to vulnerable populations in Eastern and Central Uganda. She translates for the 26-year-old woman, who asked not to be identified because sex work is illegal in Uganda. One of an estimated 130,000 sex workers in the country, the woman quietly talks about her seven-day workweek, sometimes with 10 clients a day. She sends money home to her mother to pay her young son's school fees and can only afford to see him each December. She dreams of starting a hair salon or raising chickens.
For four years, the St. Francis team would come to the brothel — and 79 others like it — to offer HIV testing and prevention products to sex workers. But the Trump administration directed early this year that U.S.-funded pre-exposure prophylaxis (PrEP), which reduces HIV-infection risk, be provided only to pregnant women and breastfeeding mothers. St. Francis receives minimal preventive meds and tests for its facility but can no longer offer them to the 1,500 women sex workers it serves in the community. The team also used to deliver nearly 9,000 condoms to the brothel monthly, but the U.S. government no longer provides those either.
"Now, when we don't have condoms," the young woman says, "we just give in."
Paul Mwanje, St. Francis' director of programs, has grappled with sudden dire funding cuts before. Sitting in his sparse office in St. Francis' complex of sienna buildings in the small Nile River town of Njeru, he says the 2025 cuts remind him of another shock. After the U.S. government partially cut President's Emergency Plan for AIDS Relief (PEPFAR) funding in response to Uganda's 2014 Anti-Homosexuality Act, St. Francis lost about $125,000, forcing it to lay off 18 of its 48 employees, many of whom were providing care to HIV positive patients, until funding was later restored. The experience made the St. Francis team realize the danger of relying so much on a single foreign donor.
"It was an eye-opener to us then, that this could happen," says Mwanje. The organization has since sought more private donors and increased its revenue by offering new paid services like surgery, maternal care, radiology and dental exams.
St. Francis' adaptations mirror a die-hard push by Ugandan health leaders blindsided by the shockwave cuts. The East African nation had received more than $3 billion from PEPFAR since 2004 and has been among the top low-income countries receiving decimated USAID funds. Among the African nations hit hardest, Uganda has endured thousands of layoffs in the health sector and terminated NIH and CDC research grants. Pervasive uncertainty in the battle against HIV and other infectious diseases, including malaria and tuberculosis, lingers. "Everything was so abrupt," says Dr. David Serwadda, former dean of Makerere University School of Public Health in Kampala. "So dizzyingly abrupt."
Faced with such devastating losses, Uganda's health leaders have accelerated innovations, such as shifting patients from separate, PEPFAR-supported HIV clinics into government outpatient services; tapping a large network of private clinics; and scaling up non-U.S. international collaborations, donor outreach and tech solutions, including AI.
The critical question: Will Uganda be able to fill the void left by the U.S. foreign aid shake-up?
While it's unlikely the country will be able to match the missing U.S. funds, leaders say they will have to decide which health care programs to prioritize and how to run them.
"That's a conversation we are all having," says Dr. Rhoda Wanyenze, Makerere's current public health dean. She emphasizes that collaborations should be based on country ownership: "leadership of programs right from inception and conceptualizing how they happen — including how they end."
New challenges for an underfunded system
The stakes for Uganda couldn't be higher: About 1.4 million adults and children are living with HIV. About a third of new HIV infections are among girls and young women at high risk for various reasons including gender-based violence. More than 80% of those living with HIV had been receiving antiretroviral (ARV) medications before this year. Many Ugandans are still getting ARVs — for now.
Since any major disruption in ARV availability risks plunging people into severe illness and even death, the Uganda Ministry of Health faces a critical challenge: How to protect lives with available government funds. Following the cuts from the U.S., the ministry issued its own order on Feb. 7: "Standalone HIV/TB clinics MUST be phased out and integrated into general outpatient services." The decision has raised concerns about health care staff untrained in the nuances of HIV care, and staff or community stigma against those with HIV. A key issue: How can an underfunded health system realistically handle a vast surge of new patients?
Some regional health leaders are working hard on the daunting task. "We are struggling, but our clients are still getting the services," says Dr. Fredrick Isabirye, health officer for Jinja, a city of about 280,000 that's 60 miles east of Kampala.
His staff of 350 was cut by 100. Patients, who typically got care in HIV clinics open just two days each week, can now be seen more often at hospital outpatient departments and health centers, Isabirye says. Yet, wide concerns remain about future funding and overburdened health workers. By midsummer, staff orientation on integration of HIV and primary care was rolled out in his region, Isabirye adds, including at the Jinja Regional Referral Hospital and 10 health centers.
There had been a glimmer of hope soon after the initial U.S. freeze in aid in January. The U.S. Department of State announced a waiver to allow PEPFAR funding for "life-saving HIV services," but that has proven inconsistent, noted a Sept. 3 Physicians for Human Rights report. A major problem: Moving ARVs from Uganda's central and district stores to distant clinics because of cutbacks in transport systems and layoffs of health workers, according to Mwanje and UNAIDS. (The U.S. Department of State did not respond to requests for comment for this story on the U.S. funding cuts and their impacts on Ugandans.)
Given expected dwindling PEPFAR support over the next several years, a longtime goal of eliminating AIDS as a public health threat likely remains at grave risk.
"PEPFAR's renewal is vital to prevent further backsliding," noted the Physicians for Human Rights report, "and to uphold the right to health for millions of people who rely on it."
A long walk, an optimistic outcome
Hadija Lukowe, a single mother of four, walked from her village near the Nile River to a nearby clinic one day more than 10 years ago. She arrived emaciated and dying. Lukowe was having trouble getting HIV meds. She and her children were facing starvation.
"I was traumatized because of the situation I was going through," recalls Lukowe, who is HIV positive. "I was thinking, 'Maybe I can't live any longer.' At that time, I did not have any support at all, so even getting food to eat was very hard."
The Soft Power Health clinic in Kyabirwa provided Lukowe with rides to a Ugandan government clinic for free HIV meds. Clinic team members treated her family for malaria and malnutrition. They arranged ARVs for her child who tested positive for HIV and brought a mattress to her home so Lukowe could sleep better.
As her health improved with ongoing ARV medications, Lukowe learned about organic gardening from the nonprofit, which also offers health education and services to 15,000 Ugandans annually within communities near Jinja. She planted her own garden, which provides the family with beans, potatoes and bananas today.
"I feel strong, stronger than I used to be," says Lukowe, standing tall beside the clinic's thriving garden in a long dress of swirling black and green covering her slight frame.
A collection of bright yellow-orange and red buildings, Soft Power Health provided care for 50,000 patients in the clinic and the field last year with a $699,000 annual budget funded mostly by private foundations and individual donors. The nonprofit, with an outdoor waiting room sheltered by large thatched roofs, has resources beyond the dreams of many public health centers in Uganda, including electronic medical records, 100% solar power, 100 staff members and an organic garden.
Such private health centers have long bolstered Uganda's health care system as unofficial partners. A 2018 Ministry of Health report tallied 6,937 health facilities in the country, with more than half private. Many have fees — nonprofits typically charge less. Soft Power Health charges a flat fee for visits, labs and meds equivalent to $7, affordable to most patients, organizers say. (Lukowe was among higher-need patients treated for free.) The fees cover 18% of treatment costs, and fundraising covers the rest.
In the current era, the government health system might need to rely more on private health care facilities, especially to help tackle other surging diseases like malaria, already rising in Southern Africa. Jessie Stone, the U.S. physician who founded Soft Power Health in 2004, leads other malaria-prevention efforts. The nonprofit, for example, is selling 1,500 heavily subsidized mosquito nets each year for $1.12 each. The U.S. halted tens of millions in malaria-related USAID funding early this year, and future antimalarial support remains unclear, with reduced U.S. overall funding still projected for FY 2026. "We all have to collaborate in a resource-poor setting," Stone says, "because there's so much need."
One such need: tracking antibiotic-resistant tuberculosis strains circulating in patients, so treatments could possibly be adapted. When the nearby Budondo Health Center lost funding for this work several months ago, it gave its high-tech GeneXpert machine to Soft Power Health's staff to help conduct the testing. The results are already confirming both centers' concerns about the continual spread of drug-resistant TB.
Stone says, "We are going backwards from a public health perspective in Uganda and globally thanks to these cuts, but we continue to do our best."
Forging new paths with new technologies
Cutting-edge tech might offer some opportunities, depending on how the new world order of health funding plays out.
With a burgeoning Ugandan population more than doubling in just 25 years to 50 million today, health care for the most vulnerable children, for example, is increasingly a waiting game. In various hospitals, families can be seen crowded next to narrow hospital beds, or sick children rest on pallets on the floor.
For children with sepsis, a potentially lethal reaction by the body to infection that causes 20% of deaths worldwide, the wait can prove deadly. At various hospitals and clinics, high patient numbers, as well as limited medical equipment or staff training, can make triage flawed or nonexistent.
If a child needing medical attention has no clear emergency symptom like unconsciousness, or since pre-sepsis can mimic milder ailments, a first-come, first-served model can occur in some settings. "The nurse comes, takes the blood pressure, temperature, height, body weight, [then] says, 'Please sit in the line,'" says Dr. Ronald Kasyaba, assistant executive secretary with the Uganda Catholic Medical Bureau (UCMB). "A child could die just because they are waiting in the queue."
New technologies like AI could speed up treatment: Health care workers can use apps that flag high-risk patients, recent research indicates. UCMB, the nation's largest faith-based not-for-profit health care network, coordinates a wide range of health facilities, including 33 hospitals. Since 2020, UCMB and hospitals in Kenya have partnered with researchers at the University of British Columbia to develop and test Smart Triage, a research project funded mostly by the Canadian government.
Health workers use an Android phone, outfitted with a pulse oximeter, to detect blood oxygen saturation, and an app to document varied symptoms, such as malnutrition and respiratory rate. An advanced algorithm creates a sepsis risk score, and health data is fed into a real-time dashboard for physicians. Children determined high risk are prioritized for immediate treatment, which can include a sepsis bundle — IV antimicrobials, fluids and oxygen.
Challenges remain with training and implementation, though an ongoing study at one major pediatric hospital, Holy Innocents Children's Hospital in Mbarara in Western Uganda, indicates children are receiving treatment for sepsis in about 45 minutes versus three-hour or more waiting times, researchers note.
Yet in an age of canceled aid, some research projects might languish. For example, a U.S. National Cancer Institute-funded five-year study on cancer diagnosis in HIV-positive patients, part of wider research on AI in health, ended in August. Yet any continued funding appears unlikely in the current NIH-related grant environment, say researchers searching for other grants. Among the project goals: a machine learning algorithm to determine whether large, complex lung masses are tuberculosis or cancer, which can look similar on typically used X-rays. TB, common in Uganda, is often the diagnosis. Meanwhile, lung cancer is now the leading cause of cancer-related death for Ugandans.
Says Dr. Margaret Mbabazi, a consultant thoracic radiologist at Makerere University Lung Institute and elsewhere, who is collecting and analyzing the project's images: "If lung cancer is caught early for patients, we can do something. They shouldn't all have to die."
Even the production of drugs is anticipated to change. Ugandans are taking steps toward self-reliance by producing drugs locally. One example is Quality Chemical Industries Limited (Qcil), a largely African-owned pharmaceutical company that manufactures ARVs and other meds for malaria, hepatitis and other illnesses for Uganda and 13 other African nations.
Qcil has been manufacturing more than half of HIV antiretrovirals distributed by the Ugandan government for years, say company officials. At its state-of-the-art facility in Kampala, workers in clean room suits and headgear known as snoods sift and mix precise ingredients. Qcil is set to increase production from 1.4 billion tablets annually to 2.4 billion by mid-2027, with plans to also produce the landmark drug lenacapavir, the twice-yearly injectable recently proven highly effective against HIV, according to studies in Uganda and elsewhere.
Whether all goes well depends on money. Will Uganda's government, for example, have funds to buy meds? George Baguma, a Qcil co-founder and director, feels the uncertainty, yet focuses on Ugandans' evolving health needs: "We should be investing where it hurts us most."
In the end, Wanyenze, the public health dean, says, "We shall still survive. We'll be here, and we need to continue. The world needs us more than ever, and we are going to see true leadership emerge."
Brian Simpson, MPH, is a Pulitzer Center grantee and freelance journalist whose articles have appeared in NPR, Smithsonian, The Baltimore Sun and other venues.
Joanne Cavanaugh Simpson, MFA, is a two-time Pulitzer Center grantee and adviser. Her work has appeared in The Washington Post, Miami Herald and Scientific American, among other venues.
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