LATEST As South Africa’s top HIV scientists worked urgently on rescue plans, including a possible alternative 'solidarity fund' with business support, to plug the gaping holes that President Donald Trump’s foreign funding ban has left in SA’s HIV/AIDS and TB prevention and treatment programmes, affected organisations yesterday got a first glimpse of who would be spared after days of uncertainty and anxiety.
An instructive note from the Centre for Disease Control and Prevention (CDC) explaining a “limited waiver,” finally landed among implementing partners in South Africa, reports Chris Bateman for MedicalBrief. The memo is in line with Rubio's earlier waiver memo, which tersely specified, “lifesaving, immediate, urgent humanitarian,” aid as exceptions to Trump’s foreign funding withdrawal.
For the first time USAID and CDC partners abroad have insight into what activities qualify for the limited waiver.
The detailed CDC note – seen by MedicalBrief – is believed to have been sent to all CDC partners in South Africa.
In line with Trump’s conservative world view, it excludes any activities that involve abortions, family planning, conferences, gender or DEI, (Diversity, Equity and Inclusion), “ideology programmes”, transgender surgeries, and administrative costs other than those listed, or other non-life saving assistance.
This waiver does not include until-now highly successful HIV prevention interventions like PrEP, VMMC (Voluntary Medical Male Circumcision), and harm reduction including opiate agonist therapy for people who use drugs or OVC (Orphans and Vulnerable Children), programmes.
It applies to:
• Delivery of life-saving HIV care and treatment services through support for health workers (doctors, nurses, and other clinical and community health workers, etc.) delivering or monitoring HIV care and treatment to ensure continuity of service provision. These workers deliver care at hospitals, primary healthcare clinics, faith-based clinics, and community settings.
• Provision of HIV testing for adults and children in community and facility settings.
• Provision of HIV drugs and support to prevent treatment interruptions for adults and children in community and facility settings.
• Provision of care for advanced HIV disease, including CD4 testing (immune function test), prevention and treatment of opportunistic infections, and HIV treatment adherence support.
• Provision of HIV viral load testing, which allows patient monitoring to ensure that HIV drug treatments are effective.
• Provision of tuberculosis preventive therapy (TPT) and Tuberculosis Treatment, as TB is the largest killer of people living with HIV.
• Support for transportation, storage, distribution, and management of HIV care and treatment commodity supply chain to ensure timely provision of medications and tests to patients.
• Procurement of HIV medicines and other commodities required for provision of HIV care and treatment services to prevent stockouts in national HIV programs (e.g., HIV drugs, HIV test kits, early infant HIV tests, viral load tests and lab equipment for clinical monitoring, TB prevention and treatment drugs, opportunistic infection medicines for advanced HIV disease).
• Prevention of Mother-to-Child Transmission of HIV, which consists of testing and re-testing pregnant and breastfeeding women, providing HIV prevention services for (pregnant) women who are HIV negative including Pre-exposure Prophylaxis (PrEP) and HIV treatment drugs for [pregnant] women who are positive, HIV testing for partners, early infant diagnosis tests, and comprehensive care for infants.
• Support for transportation, storage, distribution and management of HIV commodity supply chain to ensure timely provision of medications for PMTCT.
• Focused data and systems maintenance activities in support of the above areas.
• Reasonable administrative costs as necessary to deliver such assistance and provide oversight and compliance.
This memo follows radio silence encountered by two top local HIV scientists from their US funders in trying to find out what constitutes “lifesaving, immediate, urgent humanitarian” work as specified in an earlier US ‘reprieve’ from US Secretary of State, Marco Rubio.
Rubio has ensconced himself as head of the multi-billion-dollar UNAIDS programme to ensure alignment with Trump’s ‘stop work’ foreign funding directive. SA’s top HIV/AIDS and TB researchers said they’re getting no response from Pepfar, the National Institute of Health and UNAIDS officials in the USA (also see USAID memo to staff below).
Earlier this week, Professor Glenda Gray, former Medical Research Council CEO and director of the Infectious Disease and Oncology Research Institute at Wits University, said: “I don’t know of a single reprieve order in South Africa so far. This is a disaster for us, but it’s even worse in neighbouring and other African countries who rely far more on foreign funding.”
“It’s almost like starting again. If you wipe out USAID with all the contracting and accounting officials suspended or gone, including PEPFAR who underpin 17% of our HIV/AIDS and TB work, it will reverse all the gains we’ve made.”
On Tuesday night, the who’s-who of HIV scientists and researchers in SA met to brainstorm alternative funding solutions and, said Gray, “gauge the temperature and address this situation where everybody’s now scrambling for support”.
Her co-investigator in the promising seven-African country HIV vaccine trial (halted by the ban), Professor Linda-Gail Bekker, deputy director and chief operating officer of the Desmond Tutu HIV Centre and past president of the International AIDS Society, added: “We’re paralysed by the surreal nature of this thing. We want to see what we can do in the short term while it’s all being cleared up.”
Bekker said UNAIDS and Pepfar workers were ‘being retrenched or thrown out of their offices. We keep sending messages but hear nothing back. There’s simply nobody at the end of the line. There are also no specific instructions around the waiver.”
Others who attended Tuesday night’s emergency meeting were Professor Francois Venter executive director of Ezintsha, (peer-reviewed, worldwide research projects for chronic diseases including HIV and AIDS, TB, vaccine trials, medical technologies), at the University of the Witwatersrand, Professor James McIntyre, international vice-chair of the US NIH-funded International Maternal Paediatric and Adolescent AIDS Clinical Trials (IMPAACT) Network, (the leading global collaborative HIV research network in women and children), and Treatment Action Campaign founder Zackie Achmat.
Gray and Bekker highlighted the ‘enormous progress’ made in fighting paediatric HIV, which they say is now on the verge of being entirely preventable. However, the withdrawal of Pepfar meant that the labour-intensive work of identifying HIV-positive pregnant women and getting them onto Prevention of Mother to Child HIV Transmission (PMTCT) programmes would be derailed. It is uncertain how the funding ban will affect the roll-out of Lencapivir, the six-month prophylactic ARV injection which stands to dramatically boost HIV containment.
Meanwhile, a senior healthcare sector member of Business Unity SA (Busa), Dr Stavros Nicolaou, Aspen Pharmaceutical’s senior executive responsible for Strategic Trade Development, said any health funding failure poses a global risk of infectious disease spread, citing how Covid emergency funding and unprecedented vaccine development helped mitigate that threat. Speaking from an African CDC regional manufacturing initiative in Cairo, attended by the WHO, African Health Ministers, Unicef and the Global Alliance for Vaccines and Immunisation, Nicolaou said the Trump funding stoppage dominated a previously set agenda.
“I did not get a good impression of the impact on Africa, not to mention the globe – the assumption is that most of the funding will dry up and have to be found elsewhere,” he said.
Nicolaou said a proper audit of all funding was vital so that any alternative funding was based on a realistic figure.
“This is partly where the Trump administration is coming from. They’re dispersing billions of dollars but there doesn’t seem to be proper accountability. There are a whole lot of consultants involved.”
SA had to take control of its own destiny
“It’s just too risky to rely on an external funder on a permanent basis. You’re always at risk. Our Treasury or a public private partnership need to know what they’re in for via an audit,” he added.
Nicolaou said that while the anonymous architect of an alternative SA ‘solidarity fund,” had called and spoken to him, big business in SA was prioritising (with government), the logistics supply chain, safety and energy security and “potentially adding in water”.
“We can’t keep stepping in – this will probably have to be sorted differently – there is no proposal at Busa board level, nor an appetite for this,” he said.
Bekker and Gray remain enthusiastic about a solidarity-type HIV/AIDS and TB treatment and prevention fund and the independence it promises, agreeing with its well-placed architect that getting Trump to match it and claim credit for fast forwarding the 2030 UNAIDS 95-95-95 goals in South Africa was a smart tactical move. The proposer of the idea is intimately involved in foreign funding projects to SA and is talking to both Busa and Health Minister, Dr Aaron Motsoaledi. He’s declined to be identified, citing the ‘political sensitivity’ of his position.
However, Dr Aslam Dasoo, spokesperson for the Universal Healthcare Access Coalition, which represents 80% of SA’s healthcare stakeholders, rejected the local alternative funding proposal, saying the SA Government has ‘spectacularly abrogated its funding responsibilities.’
He said the annual R12bn of ‘halted’ Pepfar funding was less than the average amount mis-spent or stolen by a single province in their allocated health budgets (R8bn), with the exception of the Western Cape.
“It’s elementary; we need to change the system of financial accountability and appoint competent leadership and reporting lines. That way we could save R60bn between the eight provinces who’ve had qualified audits for 10 or more years. Our Pepfar financial support is chump change compared to what our government is allowing to be wasted or pilfered. We could support the whole of Africa with that saving,” he added.
Gray said it was crucial that the Organisation of African Unity becomes involved as soon as possible, especially given the seven-African nation HIV vaccine initiative she and Bekker are involved in.
The SA Government funds 74% of HIV/AIDS and TB programmes (ARVs) while NGOs plus Pepfar and UNAIDS fund and run vital high incidence area interventions and adherence and testing programmes that help keep population viral loads, (and thus infections), down.
The HIV scientists fear an exponential rise in infections and the intimately linked TB programmes collapsing.
Bekker said one estimate puts the lives saved by Pepfar since it was initiated by President George Bush in 2003 at 22m.
Update: Chris Bateman reports for MedicalBrief that all USAID “direct hire" staff will be placed on administrative leave globally from noon (Eastern Standard Time), tomorrow (Friday, 7 February), according to an USAID internal memo. The memo, seen by MedicalBrief, helps explain why puzzled and alarmed SA’s top HIV/AIDS and TB researchers reported getting no response from not just USAIDS officials, but also Pepfar and the National Institute of Health, NHI, in the USA. The memo says the only exceptions will be “designated personnel responsible for mission-critical functions, core leadership and specially designated programs”. It adds that essential staff expected to continue working will be informed by “Agency leadership,” by 3pm (EST) on Thursday 5 February. For all staff outside the USA, the Agency, in co-ordination with missions and the Department of State, was "preparing a plan in accordance with all applicable requirements and laws". Under this the agency would arrange and pay for return travel to the US within 30 days and provide for the termination of (PSC and ISC*) contracts which were "not determined to be essential”. The agency would consider case by case exceptions and return travel extensions based on personal or family hardship, mobility, or safety concerns, "or other reasons”. According to Professor Linda-Gail Bekker, the Centre for Disease Control's implementing partners received operational instructions to the waiver on 6 February.
• ISC – Integrated Food Security Phase Classification, a methodology used by USAID and a way to analyse food insecurity and malnutrition by combining evidence from various sources.