South Africa’s National Department of Health is still to outline a contingency plan to deal with America’s 90-day funding freeze on foreign aid programmes. The damage is being counted at multiple levels – even as some limited funding flows are being restored, writes Ulfrieda Ho for Spotlight.
The fallout – in this country – has heightened civil society’s calls for a prompt, implementable plan to fill the gaps in care and services. Also needed, they say, is clarity on longer-term strategies for greater self-sufficiency in the country’s HIV responses as donor-funded models look increasingly precarious.
Such an argument for increased independence in Africa and the global south was made by president of the South African Medical Research Council (SAMRC), Professor Ntobeko Ntusi, writing in the journal Nature.
South Africa should have been better prepared, some beneficiaries of US-funded projects told Spotlight.
The immediate need is to ensure the overburdened and under-resourced public clinic system is able to absorb the tens of thousands of people with HIV who will have to use public facilities as the NGOs on which they have relied have been forced to close shop, virtually overnight. Clinics catering to specific groups, such as men who have sex with men, have been particularly hard hit.
South Africa is the largest global recipient of the President’s Emergency Plan for Aids Relief (Pepfar) funds, channelled here via the US Agency for International Development (USAID) and the Centres for Disease Control and Prevention (CDC).
Through Pepfar, USAID has been funding and supporting local NGOs and our Department of Health for around two decades. It invested $5.6bn between 2004 and 2020 towards prevention and treatment of HIV and TB in South Africa.
Trump’s initial executive order, signed on 20 January, halted funding received via USAID – which now falls under the State Department under the leadership of Secretary of State Marco Rubio. Since taking office, Trump has slated USAID as “corrupt” and run by “radical left lunatics”.
Trump’s actions have been challenged in courts with successful temporary blocks to his orders to place 2 200 USAID workers in the US on paid leave and to reinstate 500 US-based staff who were already placed on administrative leave from when the order was first signed. Several court actions remain in progress.
Some limited relief
In South Africa, NGOs that received USAID funding remain largely in limbo. Although the US mission in South Africa confirmed that some Pepfar-funded services could continue in the country, it is subject to some relatively strict limitations and with no assurances of longer term support. As is clear from reporting by Bhekisisa, the process to get at least some funding to flow again to Pepfar-supported projects is not straightforward.
There was some good news linked to Pepfar-funding channelled through the CDC. After a court order, organisations getting these funds should, for now, be able to continue their work. However, the court process is far from over and the future prospects of NGOs depending on CDC funds remains precarious.
Spotlight understands that some large NGOs may have to close down, while others may have to drastically reduce their services. Several have appealed to the private sector for assistance.
As it stands, thousands of people employed or contracted by local NGOs face job losses, cut-backs and deepening anxiety over income security. They include community health workers, peer counsellors, patient navigators, community activists and advocates, support and administrative staff, and contract workers who keep these organisations functioning.
At stake, too, are specialised services for so-called key populations such as sex workers, men who have sex with men, the LGBTQI+ community, and drug users. Until recently, a focus on improving services for key populations was generally accepted, including by Pepfar, to be the right strategy given the disproportionate risk of HIV infection in these groups.
But under the Trump administration’s “anti-woke” agenda, it seems likely that many services will be defunded.
Crisis of fear, silence, and uncertainty
Staff of affected NGOs have been forbidden from speaking publicly about the 90-day funding freeze. Many declined to speak on the record to Spotlight, even anonymously – too afraid it might affect the decision on their funding after the 90-day review period.
According to an FAQ by the US mission in South Africa that was published on 10 February, they have been communicating with the South African government, though it is not clear when this happened. Five days earlier, Health Minister Dr Aaron Motsoaledi told Parliament’s Portfolio Committee that he had not had any official communication from the US Government on the matter.
Figures from Motsoaledi’s presentation showed that in 2023/2024, Pepfar funding to South Africa’s Health Department amounted to 17% of its spending on HIV.
Funding totals R4.6bn for staffing and R2.9bn for running costs for NGOs, which include organisations working directly with people with HIV, mobile units and youth organisations and programmes. Pepfar focuses on the 27 districts in South Africa with the highest disease burden.
The Health Department did not respond to questions on contingencies, or details of next steps to fill the funding gaps or how capacity and resources will be redirected to avert catastrophe. Motsoaledi did not give any of these details in his presentation to Parliament either.
What he did say was that since Trump’s executive order came into place, the department had hosted a meeting with the provincial leads on HIV and TB; conducted assessments on the immediate impacts of the executive order; met people with HIV and engaged with SANAC to finalise a sustainability framework.
A collective of activist organisations, including the Health Justice Initiative, SECTION27, the Cancer Alliance, Treatment Action Campaign, Sweat, PSAM and the African Alliance, have pressed the department to create an “urgent co-ordinated emergency plan” along with an increased budget to avert a looming disaster.
The activists highlighted that despite the Trump administration saying some NGOs could apply for a waiver, many had no practical way to do so without ways to communicate with their USAID contacts. Also, USAID employees had been placed under a work stop order and were locked out of their offices and denied access to their work emails.
The appeal from the collective also extends to protecting the work of academic and clinical research in the fields of HIV, TB, and cervical cancer that will also be affected by the funding freeze. Around 28% of the South African Medical Research Council’s budget for 2025/2026 was to come from the US government.
An ‘unreal world’
Professor Linda-Gail Bekker, chief executive officer at the Desmond Tutu Health Foundation, said Trump’s actions put in jeopardy the goal to finally have epidemic control of HIV – and right at the final hurdles.
“We have made amazing progress. And thank you to Pepfar that helped us to get this far, but the work is not over. For the US to pull out at this point is a massive loss of investment; it’s also regression. It’s like getting to the end of a book but having the last chapters torn out before you can read it,” said Bekker.
She said Pepfar funding has made it possible to build a formidable cohort of lay and professional people trained and dedicated to their roles that supported public healthcare in the most critical ways.
“These are individuals who distribute antiretrovirals, distribute pre-exposure prophylaxis, find and trace individuals who've been lost to care. They take services into communities, to outside the health facilities, and made the effort to go the last mile to find those people – that is how you close down the epidemic,” she said.
Her caution too is that loosening a grip on HIV control means potential surges in tuberculosis. “HIV and TB track together all the time, and an HIV epidemic that is once again out of control almost certainly means what will follow is a TB epidemic that is out of control.”
Trump has created an “unreal world”, said Dr Andy Gray of the University of KwaZulu-Natal, who has also worked with the World Health Organisation (WHO) in various capacities over two decades. “People are being held to ransom; and scared.
“We have always been used to the oscillation between the United States’ Republican and Democratic administrations; things may be a little uncomfortable or there may be some disruption, but not this ‘let’s burn down the house’ approach taken by the Trump administration,” he said.
“There is no consideration of human rights or for human beings anywhere in the world, including America,” he added, pointing out, too, that the CDC has, for the first time in 60 years, been instructed to cease publishing weekly mortality and morbidity data, despite an outbreak of avian flu (H5) in that country.
South Africa’s strategic health response should be to shift from a donor-funded model, added Gray. His concern, however, is that with a stretched purse and with competing priorities, the HIV response will slip down the list.
He said better self-sufficiency comes from eliminating waste, investing in employing the right people in the right jobs as well as investing in efficient systems.
National Treasury would have to redirect money for the interim shortfall left by the US funding freeze, and provinces would have to step up by getting their houses in order, he said.
South Africa, he warned, should ready itself for the “worst case scenario” once the 90-day review period is up.
SANAC response
The South African National Aids Council (SANAC) is meant to bring together government, civil society and the private sector to create a collective response to HIV, TB and STIs in South Africa. But if there is a crisis strategy from the council, it has not yet been announced.
SANAC head of communications Nelson Dlamini said that they are in a position of not being able to engage publicly because they haven’t had any direct communication with Pepfar’s and USAID representatives based in Pretoria.
“Pepfar is a government-to-government agreement and there ought to be official communication with the Government of South Africa so we know what this means for our working relationship, but nothing has been forthcoming,” he said.
“SANAC is a co-ordinator so we have to still co-ordinate. We are engaging … with relevant structures but we can’t say we are doing X, Y, Z till we have a sit down with Pepfar.”
*This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.
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