A modelling study commissioned by the National Department of Health into the impact of the Pepfar funding cuts has revealed that this could result in another 150 000 to 295 000 HIV infections in SA by the end of 2028 – unless the government covers some of the defunded services.
Business Day reports that the study was authored by researchers at the Universities of Cape Town and the Witwatersrand.
The SA research parallels a separate modelling study published in The Lancet, which found that the discontinuation of Pepfar could result in an additional 1m HIV infections among children in Sub-Saharan Africa by 2030.
The study estimates that this could trigger the deaths of about 500 000 children, while more than 2m others would be left orphaned.
Pepfar provided about R7.5bn to non-profit organisations in the country last year, primarily to employ and deploy health workers in government clinics, or to operate independent health facilities. Many have now closed.
While there are still some active Pepfar grants in SA, it is not clear for how much longer these will be retained because many are only approved until September.
Reversing
The latest study focuses on what would happen if all Pepfar funding in South Africa were eliminated.
In 2024, about 78% of all people who were HIV-positive were on antiretroviral (ARV) treatment, a percentage that has been rising steadily. By 2026, it was expected to climb to 81%, said Dr Lise Jamieson, the lead author of the local modelling study.
The trend would be reversed if the entire Pepfar programme were cancelled and the government failed to step in.
ARV coverage among people with HIV would drop to 70% by 2026, according to the study, and in a more pessimistic scenario, to 59% by 2026.
This is partly because some people with HIV get their ARVs directly from Pepfar-funded drop-in centres. If these closed, some patients might stop taking their medication altogether, as happened in Pretoria after one centre stopped providing services.
The loss of Pepfar funds could also reduce the health system’s capacity to get newly infected people on HIV treatment. For instance, Pepfar-funded organisations had employed almost 2 000 lay counsellors countrywide who tested people for infection.
Without these staff, fewer people would be diagnosed and receive treatment.
Beside ARV coverage declining due to the cuts, HIV prevention services would also be affected, according to the study. As an example, Pepfar-funded drop-in sites had been providing people with pre-exposure prophylaxis (PrEP) pills: full termination of Pepfar would lead to a reduction of as much as 55% in this coverage for female sex workers by 2026.
Because of those factors, the researchers estimate the Pepfar cuts would cause 56 000 to 65 000 additional HIV-related deaths in SA by 2028, and by 2045, that would increase to between 500 000 and 700 000 deaths.
All of these results will hold if the SA Government fails to step in, according to Jamieson.
To cover all Pepfar services from 2025 to 2028, the government would need to spend an additional R13bn to R30bn.
While it was unlikely the state would provide those amounts, Jamieson said that the NDoH was taking steps to identify and support certain key services that had been defunded by Pepfar, and she was hopeful the outcome might not be as drastic as the study suggests.
Another caveat is that the modelling study estimated what would happen if SA lost all of its Pepfar funding. But at least for now, there are still some grants reaching beneficiaries in the country.
Taking steps
While the US Agency for International Development (USAID) and the CDC – both of which distribute Pepfar funds – paused funding after the initial suspension order in late January, the CDC resumed its funding about two weeks later after a US federal court ruled that the Trump administration could not freeze congressionally appropriated funds.
CDC grants only appear to be active until September (at least for SA beneficiaries), though uncertainty remains.
USAID has taken a much harder line, issuing termination notices to most of its beneficiaries.
In SA, about 89% of all USAID funding has been cancelled. The value of all cancelled funds amounts to about $261m. Only five other countries have faced bigger cuts in absolute terms.
Spotlight and GroundUp have confirmed that at least some of the remaining 11% of USAID funding has once again started flowing to beneficiaries in SA.
Thus, a small amount of USAID funding is trickling into the country while CDC funds have largely been retained in full, though it is not clear for how much longer.
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