As South Africa grapples with the implications of a sudden 90-day suspension of funding from the United States President’s Emergency Plan for AIDS Relief (PEPFAR), health experts and government officials are urgently seeking solutions to address the impending shortfall.
This funding freeze poses a significant threat to the treatment and prevention of HIV/AIDS in a country that is home to nearly 8 million people living with the disease.
Funding overview
The Institute of Security Studies (ISS) reported on Thursday that in 2024 alone, the US provided R8.5 billion in direct funding to South Africa under PEPFAR, with a projected US$439 million (R8.2 billion) in 2025.
The US Agency for International Development (USAID), through PEPFAR, has since 2003 supported several countries in a global HIV/AIDS response.
The Department of Health said there are 7.8 million South Africans living with HIV/AIDS, which is the highest number globally.
Government response
Minister of Health, Aaron Motsoaledi, told the Portfolio Committee on Health on Thursday that PEPFAR funding has been instrumental in addressing the needs of the 27 high-burden districts, which were selected for support based on specific criteria.
Committee members raised concerns that suspending PEPFAR funding could disrupt HIV prevention and treatment in the 27 high-burden districts. They also questioned how the government would address the funding shortfall and ensure HIV patients receive necessary care.
They stressed that South Africa needs to become more self-reliant in health matters by decreasing its dependence on foreign funding. They suggested that the Minister investigate alternative funding models that could support health initiatives without relying on foreign aid.
Expert opinions
Professor Salim Abdool Karim, director of the Centre for the Aids Programme of Research in South Africa (Caprisa), said when there was an evaluation being done of PEPFAR some time ago, it was recommended that it should put in place a programme to steadily withdraw and hand over activities to the local country.
“My view is not that PEPFAR should close down but have a strategic plan that hands over to the South African government all its activities," he said.
He noted that in South Africa, this makes good sense because the government had already taken over all treatment programmes, purchasing of drugs and diagnostic tests, among others.
PEPFAR has been an aid that supports and enhances South Africa’s treatment programme, he said.
“We don't depend on the US taxpayer and US charity for treating diabetic patients or hypertension patients; why should we depend on that for AIDS treatment? We should really take care of our own people, in my view. If the US government would like to support the country, it should provide training and other kinds of support activities but it should not be treating our patients,” he emphasised.
Abdool Karim said South Africa can perform this function, but that this does not apply to other countries like Mozambique or Malawi. “In South Africa, it can be a short transition of three to five years.”
He believes that this must be done in a very systematic way.
“Now the way not to do it is to wake up one morning and say, 'that's it, we are stopping the PEPFAR programme’. That’s just catastrophic and it is going to make things worse. There should be a much more carefully planned set of transitional arrangements,” said Abdool Karim.
Ready or not, Abdool Karim said the South African government has to take over the PEPFAR-funded programmes. “Currently, PEPFAR’s support, particularly for NGOs, should all systematically be scaled back. The government needs to decide if those programmes are worth keeping, and we must pay for it.”
He said some may have to close down or seek other funding.
“We should never be in a situation where if we don't get external support, then our patients will die,” he said.
Current uncertainties
Abdool Karim said based on his understanding, all USAID activities have been frozen, and PEPFAR is one of the activities under USAID.
He said it was not clear whether people can restart treatment because even though there was an exemption for life-saving treatment, it is not clear if this applies to AIDS patients.
“They are just seeking clarity, but in short, it looks like the way Elon Musk is driving these changes for the US government, his approach is basically to shut down USAID, in which case PEPFAR would need to find another way to continue its funding or PEPFAR itself might need to shut down,” said Abdool Karim.
Impact on NGOs
Founding member of the Treatment Action Campaign (TAC), Mark Heywood, who sits on the organisation’s board of directors, said the 17% of US funding that the country receives has the potential to have a disproportionate impact on the HIV programme.
“That 17% is health professionals and others who are supporting high HIV prevalence districts, but it’s also big research institutions that do really important monitoring, trials on new drugs, new interventions, and the handicapping of those institutions comes at a very high cost,” he said.
For example, he said an organisation called Right to Care, based in Helen Joseph Hospital, has 2,000 employees, which include clinicians, experienced nurses, among others, and 90% of their funding comes from these sources.
He said the TAC is also in a difficult position because the biggest programme around clinic monitoring that it runs is PEPFAR-funded.
“The success of HIV programmes isn't just about buying medicines; it's monitoring health systems, and it's continued civil society advocacy to make sure that drug regimens are improved,” said Heywood, adding that there were a million people who dropped off the ARV programme in South Africa over the last few years.
Heywood said this area that receives US funding is a critical part of the engine. “If you break this part of the engine, there are ramifications that go much further.”
This is not a short-term crisis according to Heywood, and while the US has spoken about a 90-day pause and a waiver, the reality is that these programmes have come to a halt, and it will be very difficult to get them up and running again.
“There is no reason to believe that the Trump administration is going to fund them again because in America they have disabled the administration that runs these programmes.”
Seeking solutions
When asked what the possible solutions are, Heywood said: “We don't know what the answer is. These sums of money are not easy to come by, and like TAC, we are trying to make a plan, but we don't have an answer at the moment. TAC faces retrenchment of nearly 200 people.”
Heywood said discussions with the government about taking over PEPFAR-funded programmes had been mooted.
“The national and provincial health departments are shambolic and incapable in many respects. They can take over funding for the purchase of meds and so on, but they are not competent to take over management of complex systems, that are working.”
He added that the government is unlikely to be interested in putting up money for NGOs or research institutes, which are a nuisance to them a lot of the time.
“The independence of the big research institutes like Right to Care and the Wits Reproductive Institute is crucial,” he emphasised.
Academic perspectives
Professor Thumbi Ndung’u, who is the Scientific Director of the HIV Pathogenesis Programme and a Professor in HIV/TB Research at the University of KwaZulu-Natal, said the pause or stoppage of this funding will be devastating unless alternatives can be found.
He said the 17% PEPFAR contribution to the South African HIV/AIDS programme budget is not insignificant. “Moreover, even if temporary, the disruption in services could have a major impact”.
Ndung’u said the solution may be for other funders, including the government, to step in and make up for the shortfall.
“This may be challenging for the government because the processes to release additional funds may not be straightforward, and resources are scarce,” he said.
Overall, Ndung’u said the US government’s decision is disappointing.
“Governments have the right to reconsider their priorities, but to dismantle overnight programmes that have existed for more than half a century is irresponsible.”
Non-profit sector challenges
An employee of a non-profit organisation that receives 20% of its funding from PEPFAR and who requested anonymity, said immediately after US President Donald Trump ordered a three-month funding freeze, all the aid partners started receiving stop work orders.
“To protect the rest of the organisation, we had to send some people home with no pay because the orders were explicit that we cannot claim any expenses,” he said.
He said it is impossible at such short notice to try and get the respective provincial departments to absorb the work that these workers do. “That's an unrealistic expectation from the government.”
He said the organisation has been looking at where it could find a funding supplement and remains optimistic that based on the work that they do, 90% of their funding would be approved after the three-month freeze.
NGOs are frantically trying to find solutions for the communities in which they work and the staff, he said.
“The implications of these grants for South Africa, the African continent, and significant parts of the developing Asian economies are horrendous; 20 years of investments in HIV will be wiped out in months because everybody is going to be exactly where they were before we started these programmes if they are not going to get access to funding,” he said.
The source said that while the expectation is that the government is going to intervene, it would be naive to think that this would be a priority in light of the current public health crisis in the country where hundreds of doctors are unemployed.
“The intention was always that the government must absorb these programmes into the normal health system, and we have been talking about that for more than a decade, but the reality at this time is that there is no transition plan for that.
According to the source, some of these programmes can easily be transitioned into the public health system as the people, systems, and infrastructure are there, but he questioned where the money would come from. “We have got to have a phased approach.”
He described the situation as colliding crises that are compounded by 24-hour decisions that they have to make. “If we had 24 months or even 24 weeks, it would be a little different.”
He emphasised that as reasonable people dealing with a democratic government, they were expecting reasonable actions to be taken.
“For instance, it's perfectly reasonable for any new government to determine its own policies, its own priorities and allocate resources accordingly. Our government has done that; governments all over the world have done that, but you do that with new projects or projects in the pipeline and not projects that were approved two years ago.”
He emphasised that the activities that are conducted by these funds cannot be switched off and on and expected to be the same after 90 days.
Conclusion
The Nelson Mandela Children’s Fund (NMCF), which advocates for children's health, expressed its disappointment with the limited waiver announced regarding PEPFAR.
The fund explained that the limited waiver excludes activities involving family planning, abortions, conferences, administrative costs, transgender surgeries, and other non-life-saving assistance.
The absence of coverage for these services has left some organisations uncertain about their future.
NMCF's chief programmes officer, Karl Muller, stated, “This development is unfortunate and arises at a time when such funding, particularly from PEPFAR, is essential across our communities. We hope that once everything is reviewed, organisations working in this sector can fully resume their work and concentrate on the important tasks they undertake.”
Muller also warned that this decision would worsen the country's high unemployment rate, as some workers from institutions that depended on PEPFAR funding are already at home and uncertain about their future.
He noted that in recent years, the international funding pool has decreased due to budget cuts and, in some cases, funding has been suspended for various reasons.
“All funding needs to be properly accounted for; however, what we are witnessing with this limited waiver from PEPFAR is becoming increasingly stringent—a challenge we hope to overcome together. Thousands of South Africans have benefited from this funding over the years, which must not be taken for granted, yet we behave as though it’s business as usual,” said Muller.