WHEN THE MONEY LEFT: HOW TASO GULU REINVENTED HIV CARE AFTER USAID CUTS

When USAID funding was slashed, many feared HIV care in northern Uganda would unravel. Instead, at TASO Gulu, the cuts triggered an unexpected transformation. Rather than trying to rebuild the old donor-funded model, the organisation began putting communities themselves at the centre of care. It is the first story in a series exploring how organisations across northern Uganda have responded to the end of USAID funding—not only by coping with the losses, but by discovering new forms of local ownership and resilience.

On the morning of 6^th July 2026, I sat with Mr Nyeko Kenneth, the acting in-charge of TASO Gulu City Branch, in his office adjacent to Gulu Regional Referral Hospital. For more than an hour, we talked about the last eighteen months; eighteen months after USAID cut funding by 42 percent, forcing staff layoffs and the end of nutrition support. Mr Nyeko described how TASO Gulu rebuilt HIV care by putting clients, savings groups, and the city government at the centre.

For more than 30 years, TASO had worked on a formula that felt permanent. Money came from USAID through PEPFAR. With that money, they paid salaries, bought test kits and ARVs, refunded clients 10,000 shillings ($3) for transport, bought beans and posho for malnourished children, fuelled the white pickups for outreach, and kept the yellow building open six days a week.

Clients came from Nwoya, Omoro, Pader, Amuru, and the parishes of Gulu City. They sat on wooden benches, waited their turn, collected drugs, talked to a counsellor, and went home. The system was not perfect, but it was steady. And then the steadiness ended.

The Turning Point

In late 2023, USAID announced realignments to its global health budget. HIV programmes in countries considered to have ‘middle capacity’ were cut by 30 to 50 percent. Uganda was on that list. For TASO Gulu, which relied on PEPFAR for about 80 percent of its annual budget, the cut landed hard.

By January 2024, eight community outreach workers had been told their contracts would not be renewed. Two drivers were laid off. The nutrition programme for children and pregnant women stopped. School outreach was reduced from four schools per month to two.

In the waiting room, the rumour mill worked overtime. ‘TASO drugs are going to finish.’ ‘The Americans have left us to die.’ Mr Nyeko spent January and February doing what he calls ‘firefighting.’ He told clients the truth in community meetings. ‘We said, ‘The drugs are here. The refund is not. If you can walk, please walk. If you cannot, tell your peer leader.’‘ Some clients stopped coming for two months. Others walked 15 to 20 kilometres.

It was in that crisis that the branch made a decision that would change everything. They would not spend the next year begging to restore the old budget. They would build a new model. Mr Nyeko calls it ‘moving from aid to agency.’

When I asked him what that meant, he leaned forward and tapped the desk. ‘It meant we stopped asking, ‘Who will give us money?’ and started asking, ‘What do we already have?‘ And what we had was people. Eight thousand people who come here every month. That is not a cost. That is a community.’

The first thing they did was look at money differently. For years, TASO had given handouts: food, transport, and soap. When that stopped, the team feared clients would collapse. Instead, with help from AVSI Foundation, they started Village Savings and Loan Associations inside the clinic compound.

A New Model

The idea was simple and already familiar in Acholi. Twenty people form a group. Every week, each person saves 5,000 shillings ($1.50). The group lends that money to members at 5 percent interest. Today, 18 months later, TASO Gulu has 43 groups linked to the clinic. There are 1,214 members, whose total savings amount to about 487 million shillings ($132,000).

Mr Nyeko told me about a 38-year-old client. ‘She used to come for a bag of posho. Initially, she was angry when we stopped, but soon after she joined a group. Now she borrows 200,000 shillings ($55), buys second-hand clothes in the market, sells them, and pays her own transport. Last month, her group gave her a loan to pay school fees.’

Each group also puts 2 percent of its profits into what it calls a health solidarity fund. That fund pays boda fare for members who are too sick to walk. It is not big money, but it is their money, and that changes how people talk about the clinic. ‘They used to say ‘TASO’s clinic.’ Now they say, ‘Our group,’’ Mr Nyeko said.

The second shift was about who does the work. With no money for fuel, weekly home visits became impossible. So TASO turned to its own clients. They identified 62 people who had been on ART for more than three years, had suppressed viral loads, and were respected in their villages.

They trained them as Expert Clients. The job description was clear: remind people of appointments, trace those who miss them, provide basic adherence counselling, and reduce stigma by being visible and positive. They are volunteers. TASO gives them a monthly data bundle worth 15,000 shillings ($5) and priority access to the savings groups.

Mr Nyeko described one male client as ‘the man who knows every footpath.’ Before the cuts, a nurse would drive out once a month, spend fuel, and maybe find three people at home. Now, he walks in the evenings and finds ten.

‘People open up to him because he is also living with HIV,’ Mr Nyeko said. The cost of outreach dropped by more than 70 percent. The default rate remained at 8 percent, lower than the national average of approximately 12 percent. ‘We lost staff,’ Mr Nyeko said. ‘But we gained trust.’

Inside the clinic, the way medicine was dispensed also changed. Monthly refills had created a crowd during the first week of every month. People would spend a day and 20,000 shillings ($6) on transport to collect a three-month supply. TASO moved all stable clients to three-month and six-month refills.

Communities Lead

They also set up Community Drug Distribution Points. Once a month, a nurse and an Expert Client drive to Omoro, Nwoya, Pader, and Amuru with a locked box. They meet clients under a tree or at a Health Centre II. The client signs, collects the drugs, and goes home. ‘We cut the client’s cost and our fuel cost at the same time,’ Mr Nyeko said.

Technology filled the gap left by fewer staff. Every parish now has a ‘TASO Connect’ WhatsApp group with 40 to 80 members. Peer leaders post: ‘Those with appointments on Friday, please come early.’ Nurses answer questions about rashes and dizziness. Lab results are photographed and sent with names redacted.

Every Thursday at 7 p.m., a nurse runs ‘Ask the Nurse’ on Zoom. Thirty to forty people join to ask about side effects. ‘One nurse handles what used to take five people in a hall,’ Mr Nyeko said. He knows the limits. Many elderly clients do not have smartphones. So, the branch is now training grandmothers to use basic phones and receive voice calls instead of text messages.

Data also changed how outreach was planned. Instead of conducting blanket visits, the team pulled reports from DHIS2 and their own registers. They mapped the 12 villages with the highest number of missed appointments.

Outreach trips were cut by 40 percent, yet the number of defaulters traced increased because teams were going where the problem was. ‘When fuel was free, we visited everywhere and found nothing,’ Mr Nyeko said. ‘Now fuel is expensive, so we visit wisely, and we find people.’

Eighteen months after the cuts, TASO Gulu is serving 8,103 clients on ART, up from 7,842. Retention at 12 months has risen from 89 percent to 92 percent. Viral suppression stands at 93 percent.

The cost of caring for one client per year has dropped from about 440,000 shillings ($120), to about 315,000 shillings ($85). There has not been a single ARV stock-out. The clinic has not closed for a single day.

I asked him if he considered this a success. He shook his head. ‘Success would be if we did not lose anything. We lost. Children no longer get therapeutic food. We used to provide mental health counselling every week. Now it is once a month. Staff are tired. They are doing two people’s work. Teenagers ask, ‘Where are the school books you used to give us?’ I have no answer.’ He paused. ‘But we also gained. We gained owners.’

He told me about a meeting in Laroo in March this year. A client stood up and said, ‘This is not USAID’s clinic. This is our group. If we do not save, no one will save for us.’ Mr Nyeko said that sentence has stayed with him.

‘For 30 years, accountability went one way: to Washington. Now it goes three ways: to the savings group, to Gulu City, and to the peer leader. When you own something, you protect it.’

Beyond Donors

The branch now has a three-year plan. First, grow the savings groups to 2,500 members and register them as a cooperative so they can buy maize and beans in bulk and sell them at a profit. Second, hand over 50 percent of stable clients to public health centres under the Differentiated Service Delivery model so that TASO can focus on newly diagnosed clients and those who are struggling.

Third, open a ‘TASO Social Enterprise’ pharmacy and laboratory that will serve the general public. Profits will go back into peer support and transport for the sickest. ‘We will still write grants,’ Mr Nyeko said. ‘PEPFAR will still buy the drugs. But our budget will not assume that money will be there forever.’

When I asked what advice he had for other NGOs facing the same cuts, he did not hesitate. ‘Do not chase the donor to bring back the old money. It will not come. Sit with your clients and ask, ‘What can we do together?’ Go to government early, not when you are broke. And use technology. A WhatsApp group is cheaper than a pickup.’

The cuts made by USAID were detrimental. In other districts, clinics closed. People defaulted. Children missed meals. But in Gulu, the pressure forced a question that had long been avoided: who owns the HIV response? The answer is no longer in Washington. It is in the savings book that a peer leader carries. It is in the memorandum signed by the city mayor. It is in the Zoom call on Thursday night. It is in the pharmacy receipt for 5,000 shillings.

‘Thirty years ago, we started because people were dying and had no one,’ Mr Nyeko said as we ended the interview. ‘Today, we are here because people are living, and they have each other. The money left. The people did not, and we hold a mandate to serve them.’