Richard Amenyah | Case for making the Caribbean’s HIV response sustainable

When the Caribbean mounted its bold response to HIV in the 1990s and early 2000s, it did so with the heavy backing of external donors. Through shared responsibility and global solidarity, the World Bank, PEPFAR, the Global Fund, and other partners helped save countless lives, slow new infections, and give hope where despair once reigned. Today, AIDS-related deaths have fallen by more than half in the region compared to the peak years. This is a story of resilience and of progress that has come at great cost and is now at risk.

Now comes the harder chapter. Donor support is shifting and has dwindled significantly over the years. Major funders are tapering and tailoring their assistance, expecting Caribbean governments to assume a greater share of responsibility. Already, some countries stopped receiving such support, but that transition is no longer a distant prospect. It is already here. The funding cuts are unprecedented and radical, with disruptive immediate consequences, and the long-term costs are staggering. For instance, UNAIDS projects that global reductions in US aid could lead to an estimated 6 million new infections and 4 million AIDS-related deaths by 2029. The Caribbean cannot afford such outcomes. Hence, the question before us is stark: Will the region’s HIV response remain sustainable once donor funds recede? Or will we risk reversing hard-won gains?

The answer depends squarely on the choices Caribbean governments make now. Sustainability will not happen by default. It demands deliberate policies, financial commitments, and political leadership. This is how we secure country and regional ownership and heath sovereignty.

UNIMAGINABLE COST OF COMPLACENCY

The Caribbean still has the world’s second-highest HIV prevalence after sub-Saharan Africa. An estimated 340,000 people are living with HIV, with women and key populations most affected. Tuberculosis remains a leading opportunistic infection worldwide. At the same time, non-communicable diseases (NCDs) like diabetes, hypertension, and cardiovascular disease account for about 80 per cent of deaths in the region. HIV and NCDs now collide in the same clinics, households, and national budgets. The total domestic resources for the HIV response rose by eight per cent from 30 per cent to 38 per cent between 2023 and 2024 in the Caribbean.

If donors withdraw or funding fades drastically, without strong domestic action, the region risks fragmented services, drug stockouts, weakened community systems, and rising inequalities. Gains in treatment coverage (85 per cent of people living with HIV know their status, and 74 per cent of them on treatment, with 66 per cent achieving viral suppression) and gradual reduced new infections could unravel quickly. And as history shows, rebuilding lost ground costs far more than sustaining progress.

Sustainability won’t just happen, and it is not just about “finding money”. Caribbean governments must lead with strong policy, budgets, and planning. Here is how:

1. Show political leadership and country ownership: HIV must be treated as a national priority and balanced with the push to beat NCDs. Sustainability plans must be developed, embedded in the development agenda and need champions in Parliament and Cabinet - not just health officials. Further, National AIDS councils and Country Coordinating Mechanisms must be revitalised to provide whole-of-government oversight.

1. Prioritise integration at the primary-care level: HIV, TB, and NCDs should not be managed in silos. Integrating services reduces duplication, cuts costs, and makes care more patient-friendly. A woman living with HIV should be able to receive her diabetes check, family planning, and ART refill in the same visit, not in three separate clinics. Integration builds efficiency, and efficiency ensures sustainability.

2. Strengthen resource planning: Short-term donor cycles must give way to long-term domestic planning. Governments need transition strategies that define milestones for scaling up local financing, human resources, procurement, and supply chains. Clear accountability frameworks, time-bound transition plans led by ministries of finance, in collaboration with health, can ensure commitments translate into budget lines and disbursements. Innovative financing options such as earmarked “sin taxes” on alcohol and tobacco, health levies, or social-insurance schemes can create predictable revenue streams. These mechanisms have already shown results in countries like Barbados and Trinidad and Tobago for NCD prevention.

3. Leverage partnerships. Civil society is the hardest hit by funding cuts. Governments must include funds for outreach, peer support, stigma reduction in their sustainability plans. Engaging them in sustainability planning is not just ethical but pragmatic. Regional institutions like CARICOM, PAHO, and the OECS Commission must also coordinate efforts, pool procurement, and negotiate better drug prices on behalf of smaller economies. They can also support cross-country knowledge-sharing on integration and financing models.

MATTER OF POLITICAL WILL

At its core, this is not just a technical debate about health financing. It is a test of political will. Caribbean leaders have shown bold vision before, from spearheading the first UN high-level meeting on NCDs to advancing the Caribbean Cooperation in Health framework. That same leadership is now needed to safeguard the HIV response. Domestic investment is not charity; it is smart economics. Every dollar spent on HIV treatment saves far more in hospitalisations, lost productivity, and orphan care. Moreover, a sustainable HIV response strengthens health systems as a whole, building resilience to pandemics, hurricanes, and economic shocks.

To secure this future, governments must urgently fund core HIV services such as laboratory supplies, ART, and outreach, etc, through national budgets rather than donors. Policy reforms should drive the integration of HIV, TB, and NCDs services at the primary-care level to maximise efficiency and ensure person-centred care. Crucially, governments must also institutionalise dedicated budget lines for community-led and peer programmes, recognising civil society as indispensable partners in delivering equitable and rights-based services.

Transitions are already under way across the region. The Global Fund is tailoring its support; PEPFAR has scaled back. If we wait until donor funds disappear completely, it will be too late. Sustainability planning must happen before the lifeline is cut and not after. The window of opportunity is narrow, but it is still open.

CALL TO ACTION

The choices made today will define the health of the next Caribbean generation. This moment calls for bold leadership. It is time for Caribbean governments to say: “We own this.” Caribbean governments must act decisively. Sustainability cannot remain a conference slogan. It must be translated into budgets, clinics, and communities. It also means commitment to health laws, integration, oversight, and equitable access. Solidarity, not dependency. Resilience, not retreat. Political leaders must align words with fiscal commitments. Technical partners must support robust, data-driven transition plans. Civil society must be empowered as equal partners. And citizens must hold governments accountable for protecting lives.

Ending AIDS in the Caribbean is possible but only if we claim ownership of the response. Donors helped us build the bridge. Now it is our responsibility to cross it and ensure that the journey does not end midway.

Let this be the region’s own legacy: an HIV response built to last and led by Caribbean people, funded by Caribbean budgets, guided by Caribbean communities.

Dr Richard Amenyah is an international public-health specialist from Ghana and the director of the UNAIDS Multi-Country Office in the Caribbean. Send feedback to columns@gleanerjm.com.