A coalition of civil society groups has urged President Cyril Ramaphosa to lead a co-ordinated response to prevent “mass healthcare disruptions, preventable deaths, and surges in new HIV infections and drug resistance” after Donald Trump turned off the aid funding taps to the country.
“Action is critical,” said the Community Health and HIV Advocate Navigating Global Emergencies (CHANGE) coalition in a statement on the weekend.
While a few organisations delivering HIV and TB services through the US President’s Emergency Plan for Aids Relief (Pepfar) confirmed to Health Policy Watch that they had received waiver letters on Saturday exempting them from the 90-day freeze on Pepfar activities, others have seen activities cut or curtailed.
Meanwhile, the US Agency for International Development (USAID), which disburses a significant portion of the Pepfar funding, is being dismantled and Pepfar’s long-term future is in doubt as its budget comes up for consideration before the US Congress in late March.
Adding to the confusion, several other organisations have not received waivers, while forcing them to cut certain activities.
For example, at least 9 000 people have lost access to needle exchange and opioid substitution therapy (OST), according to the SA National Aids Council’s (SANAC) civil society forum.
Funding for HIV clinics catering for those most vulnerable to HIV – “key populations” including sex workers, men who have sex with men and trans people – is likely to be cut permanently.
And funding for the game-changing intervention for groups vulnerable to HIV – twice-yearly injections of lenacapivir that are 100% effective in preventing HIV infection or pre-exposure prophylaxis (PREP) – has also been cancelled, according to various reports.
Hopeful
However, Bhekisisa reports that it has confirmed exemption for Pepfar projects from a trusted source, who had confirmation from Pepfar in South Africa that activities may resume under the waiver, once implementing partners, or organisations funded by Pepfar, have received approval letters from their funding agencies.
Pepfar money in South Africa is mainly channelled to projects and the Health Department through USAID and the Centres for Disease Control (CDC).
Of the Health Department’s HIV budget, 17% comes from Pepfar: the rest of the money (most of it), goes to NGOs rolling out HIV projects in support of the department’s goals.
The exemption falls under section 3(b) of the latest executive order, which says: “The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate.”
What is not certain, though, is what will happen to waiver-approved projects once the waiver and the 90-day period expires.
The waiver issued on 1 February said Pepfar projects can’t restart before the “implementing agency lead deputy principles” have certified that they qualify for the waiver.
Most South African projects have not yet received such certification letters.
“So we all wonder, does the waiver apply to us or not,” said Linda-Gail Bekker, who heads up the Desmond Tutu Health Foundation at the University of Cape Town, which receives Pepfar funding, “because there is a lack of clarity and communication.”
In a second memo, from the US Department of State on 6 February, with more details than the first on which activities qualify – or not – for the waiver, it is made clear that only tasks within previously approved Pepfar country plans, also known as COPs, will be allowed.
Salaries for health workers, laboratory and supply chain staff, who are necessary to carry out approved work, are covered, according to Bhekisisa. Such activities include HIV testing, care and treatment services for all population groups, including at mobile clinics or drop-in centres for people with a high chance of contracting HIV.
It also includes services for pregnant and breastfeeding women and the screening and diagnosis of TB in people with HIV, as well as preventive TB treatment.
But it doesn’t cover anti-HIV preventive medication (PrEP), for groups other than pregnant and breastfeeding women (PBFW).
The memo states: “People other than PBFW who may be at high risk of HIV infection or were previously initiated on a PrEP option, cannot be offered Pepfar-funded PrEP during this pause of US foreign assistance or until further notice.”
Pepfar supports more than 90% of global PrEP users; four in 10 of them live in South Africa – by the end of August 1.65m people in the country had used the pill at least once. Although the government procures and pays for the pills (oral PrEP), Pepfar covers some of the salaries of health workers and data capturers involved with these projects.
Anti-HIV meds donations may dry up
Moreover, in July, Pepfar promised 231 000 doses of the two-monthly anti-HIV shot, CAB-LA, to South Africa –the first batch was to arrive by the end of March 2025.
In December, the Plan also committed to join hands with the Global Fund and other donors to pay for enough doses for 2m people in poorer countries of the six-monthly HIV prevention injection, lenacapavir.
Last week, the maker of lenacapavir, Gilead Sciences, applied to get the jab registered for PrEP use through EU Medicines for All.
The SA Health Products Regulatory Authority, SAHPRA, is part of the process and is providing some of the assessors, said CEO Boitumelo Semete-Makokotlela. SAHPRA will use the results of the review process to get the medication registered here.
But Pepfar-sponsored PrEP, and also other forms of HIV prevention, now seems unlikely.
“Alarmingly, nearly all HIV prevention efforts under Pepfar – aside from programmes for the prevention of mother-to-child transmission – are currently on hold,” wrote the authors of a Lancet editorial last week.
“Programmes focusing on the prevention of HIV in key populations, HIV prevention services for adolescent girls and young women, voluntary male medical circumcision and support for orphans and vulnerable children are still halted.”
The 6 February memo states that population-based HIV surveys like the Human Sciences Research Council’s household survey, are also not covered by the waiver, neither are implementation science projects (SA has five CAB-LA implementation studies across 16 sites, some supported by Pepfar).
Pepfar partners are also not allowed to use funds to plan for the next financial year.
HIV the only winner – it thrives in chaos
The national Department of Health has not yet devised a viable contingency plan to continue services should the Trump administration close down Pepfar.
Pepfar had committed $439 537 828 to South Africa for the current US financial year, which stretches from 1 October 2024 to 30 September 2025.
But, said Mitchell Warren from the New York-based advocacy organisation, Avac, which receives Pepfar funding and runs projects in eastern and southern Africa, things aren’t as simple as “yes, you qualify” or “no, you don’t qualify”.
“And understanding … what to do next … how to operate, whether as the government of South Africa or as an implementing partner to Pepfar, is filled with chaos – which not only derails programmes in the short term, it also derails relationships between countries and communities.
“The only true winner in the HIV response is actually the virus itself,” he told Bhekisisa’s Mia Malan. “The virus loves chaos. The virus loves instability. The virus loves conflict.
“In the midst of all of these orders, what’s really happening is just a pathway for infectious diseases and for instability and that is bad news, no matter what the executive orders say.”
Ramaphosa ‘must intervene’
Ramaphosa has been urged by the coalition CHANGE to “personally intervene before the situation worsens and to ensure a whole-of-government and civil society response”.
“The reckless freezing of aid is … a death sentence for thousands of people,” warned Sibongile Tshabalala, chairperson of the Treatment Action Campaign (TAC) which advocates for people with HIV.
“We are watching decades of progress on HIV being decimated.”
“Health workers and people have no idea what is happening … People are going to start dying soon. Can you imagine being dependent on treatment to save your life, and having it snatched away from you like this, with no alternative?” said HIV clinician Dr Francois Venter, who directs the Ezintsha research centre in Johannesburg.
Fatima Hassan, head of Health Justice Initiative (HJI), said that “the issue is still the concern about key populations and what the waiver seeks to cruelly limit”.
“The loss of US Government funding has left sex workers without life-saving healthcare, HIV prevention, and critical support. Without these services, they face higher risks of violence, stigma, and disease, pushing them further into isolation and vulnerability,” Kholi Buthelezi of the National Sex Worker Movement of SA, told Health Policy Watch.
“Without urgent funding, these lifelines will disappear, leaving sex workers more isolated and at risk than ever,” said Buthelezi.
Communities are urging Ramaphosa to use “all available domestic, as well as compulsory measures,” to ensure life-saving tools and medicines reach all who need them.
Reuters reports that Africa’s leading public health official wrote to America’s Secretary of State last week, reiterating how the US aid freeze was threatening the lives of people across the continent as well as efforts to contain disease outbreaks that could ultimately impact people in the United States.
Jean Kaseya, head of the Africa Centres for Disease Control and Prevention (CDC), also highlighted concerns with Marco Rubio about the impact on patients with diseases like HIV and the risk of an mpox pandemic also fuelled by conflict in eastern Congo, he told Reuters.
Kaseya also wrote to African leaders over the weekend warning that without urgent intervention to plug the financial gaps caused by the US freeze and other governments cutting aid budgets, there could be an additional 2.4m deaths from preventable diseases every year on the continent.
He also warned that disease outbreaks would spread further without fully-funded efforts to stop them.
In both letter, he added that conflict was also threatening the health response in parts of Africa.
He said fighting in the eastern Democratic Republic of Congo had affected the mpox response as well as measles and cholera outbreaks: millions of doses of mpox vaccines, including doses donated by Japan for children, are stuck in Kinshasa because of the security situation in Goma.
Kaseya said that lessons from Covid should not be forgotten.
“When you don’t open your eyes to something ongoing in Africa, we can have a mutation of the virus that will become a pandemic and affect all of us.”
The US aid pause and funding freeze means Africa CDC is now short of about $200m for its efforts to fight mpox, he said, part of the $1.1bn originally pledged.
For this and other efforts, the aid freeze must be lifted quickly, he said, although he thanked Rubio for the waiver for lifesaving aid and Pepfar.
The Lancet article – PEPFAR under review: what’s at stake for PEPFAR's future (Open access)
Reuters – Africa's top health official presses US to resume health aid
See more from MedicalBrief archives:
Top SA health experts rally to counter Trump’s funding block
Trump’s funding freeze threatens to paralyse SA NGOs
African activists fear Trump will cut birth control funds