South African NGOs are already feeling the squeeze as US President Donald Trump’s planned suspension of all foreign development assistance begins to take effect, putting hundreds of millions of dollars in aid at risk of drying up and threatening critical health programmes, writes MedicalBrief.
The order to suspend the aid came amid a slew of other hard-hitting announcements by Trump, including a withdrawal from the WHO (see story below), new immigration policies and another declaring that male and female gender identities are “not changeable”, and the banning of transgenders from the military.
Trump ordered a pause on United States foreign assistance for 90 days, pending a review to determine whether they are “fully aligned” with US foreign policy as his administration promoted its “America First” agenda.
He announced on Monday that “We get tired of giving massive amounts of money to countries that hate us, don’t we?”
However, BusinessLIVE reports that yestrday US Secretary of State Marco Rubio issued a waiver partially lifting the Trump administration’s freeze on foreign aid, potentially offering a reprieve for US-funded HIV/Aids programmes that provide life-saving treatment.
The waiver for “life-saving humanitarian assistance” includes “core life-saving medicine, medical services, food, shelter and subsistence assistance, as well as supplies and reasonable administrative costs” and directs organisations implementing life-saving humanitarian assistance to resume work if they have stopped, according to US media reports.
For SA, the development means NGOs funded by the US President’s Emergency Plan for Aids Relief (Pepfar) is likely to resume some of their activities. However, the details have yet to be communicated to Pepfar’s implementing partners, which earlier this week received letters from the Trump administration directing them to stop work.
Similar instructions were sent to US-funded staff working in the public health sector. By noon on Wednesday they were still in the dark as to exactly which services they would be permitted to resume while the review is under way.
Rubio’s waiver explicitly excludes activities that involve abortions, family planning conferences, gender or diversity, equity and inclusivity ideology programmes, transgender surgeries, and non-life-saving assistance”.
The Citizen reports that in 2024, the US provided nearly $6.6bn in humanitarian assistance across sub-Saharan Africa.
Its formal instructions on Monday to the HIV/Aids organisations it funds in SA to immediately stop work confirmed their worst fears, they said, and puts pressure on the National Department of Health to step into the breach.
“I am 100% supportive of a comprehensive review of foreign aid, however, it can be done in a manner that is reasonable and does not cause mass harm,” said a person in a leadership role at a President’s Emergency Plan for Aids Relief (Pepfar) implementing partner.
The source told BusinessLIVE: “Being asked to put an immediate pause of any duration to the world’s largest HIV and TB treatment programmes will cause irreparable harm.
“The provision of life-saving services and medicines will stop and public facilities will immediately face a patient management crisis of unprecedented magnitude – all because they trusted the US Government to follow through on its commitments.”
SA has received more than R8bn to fight HIV/Aid through Pepfar since its inception in 2003.
President and chairperson of the Southern African HIV Clinicians Society Dr Ndiviwe Mphothulo said they were five years away from reaching the 95-95-95 targets set by the UN Joint Programme on HIV/Aids by 2030.
“Funding is very important in seeking to achieve those targets. It’s essential.”
While South Africa also relied on domestic funding for these efforts, it was simply not enough, he added.
He said if funding were to be permanently cut, the situation would be “dire”.
Professor Francois Venter, who heads up the Ezintsha research and policy unit at Wits, said in South Africa, Pepfar funds were often used to trace HIV-positive people who had stopped treatment and to help them get back on track.
If this funding were discontinued and these individuals fell through the cracks, the consequences could be devastating.
Life or death
Putting a stop to Pepfar’s work, even briefly, will jeopardise HIV prevention and treatment programmes worldwide, and is a matter of life or death, said International Aids Society President Beatriz Grinsztejn.
“Pepfar provides lifesaving antiretrovirals for more than 20m people – and stopping its funding essentially stops their HIV treatment. If that happens, people are going to die and HIV will resurge.”
But Health Department spokesperson Foster Mohale said there’s been no formal communication from Pepfar about the issue, writes Ina Skosana for Health-e News. He said the department would communicate the implications of such a decision once it receives formal correspondence.
Pepfar has been working in South Africa since 2004, funding more than 1 250 community-based organisations that provide a range of HIV and TB services.
Sasha Stevenson, executive director of public interest law organisation SECTION27, told Daily Maverick:“In some countries in Africa, Pepfar and USAid and Global Fund fund the vast majority of the HIV programme. In South Africa, that’s not the case – it doesn’t fund the majority of the HIV programme but it does still fund part of our HIV programme, and often areas of the programme … that are important… There really is just a significant risk to South Africa [and] to our neighbouring countries.”
South Africa’s HIV/Aids health services haven’t faced a loss of funding on this scale before, said Stevenson, making it difficult to predict how the system would handle it.
“The two decades of investment by Pepfar and USAid and the Global Fund, along with government investment and other funders’ investments, mean the South African HIV programme is strong and is fairly sustainable, but it’s also not flush with money. And this funding is just so important … to maintaining the gains we’ve made,” she noted.
It’s not only clinicians but also administrative staff in health facilities who may be affected by the stop work orders for Pepfar-funded programmes, according to Lynne Wilkinson, a Gauteng-based public health specialist in the HIV/Aids sector. The repercussions of their absence are likely to be cumulative, resulting in larger patient backlogs and greater workloads for the health workers who remain.Traumatic
Concerning policy shift
The “stop order communication” to the Wits Reproductive Health and HIV Institute (RHI) – Pepfar’s biggest grant recipient in SA – was confirmed by Professor Shabir Madhi, dean of the Faculty of Health Sciences.
Pepfar does not directly finance its implementing partners, but channels funds through US Government agencies like USAid and the Centres for Disease Control.
Wits RHI focuses on HIV, sexual and reproductive health and vaccine-preventable diseases, reports News24, and the order requires that all related activities must now cease and that no further expenditure may accrue.
In an urgent message to clients on Monday, the institute revealed that USAid had served its Key Populations Programme a notice to pause programme implementation.
“As of close of business on Tuesday, 28 January, we are unable to provide services until further notice. We sincerely apologise for the inconvenience this may cause and remain committed to your health and well-being.”
The institute urged its clients to visit the clinic on Tuesday to collect any medication they may need before 4pm.
“The impact on patient care is being reviewed, and mitigation plans are being developed and deployed,” Madhi said, adding that the government must assume control of local health programmes that may be affected by Trump’s order.
The stop orders had not affected all US-funded programmes, however.
“Currently, there are very specific programmes where stop orders have been issued… largely, programmes that have got an element of diversity, equity and inclusion,” said Madhi – which is why there is concern surrounding the Wits RHI Trans Health Centre, he added.
“The Trans Health Centre is an example that forms part of diversity equity and inclusion, and that is something specific the Trump administration seems to be targeting with its stop-work orders.
“So the rest of the programmes, there haven’t been stop work orders issued, but rather there’s been a postponement in terms of further activity until such time that the powers that be in the US have decided whether they will continue to be prioritised,” he told The Citizen.
According to ForeignAssistance.gov – through which the US Government makes available its foreign assistance data – more than $17m was earmarked for various Wits programmes in 2024.
Madhi said there was a potential for other programmes to be affected, but it’s unclear at this stage whether they will be affected.
“I think it’s important to emphasise that it is eventually the responsibility of government to assume control of these programmes and to ensure they continue.”
He said it was difficult to gauge the full impact of the stop orders on local health programmes.
“Many of these are actually integrated in government facilities, and what we hope is that if there is disruption, government actually steps in to address the disruption …meaning that the staff currently employed through the US-funded grants, their activities will need to be shifted to government employees.
“Certainly, government has been assisted by the US, but at the same time, it can’t be a dependency on the US to ensure that the health of our citizens is protected.
“So, government has to come to the fore in terms of ensuring it puts in place mitigation to actually minimise disruption to services.”
Pepfar in jeopardy
Professor Hassan Mahomed, a public health medicine specialist at Stellenbosch University, said if the suspension of funding signals a shift towards a US policy to no longer fund global initiatives, the ramifications would be far-reaching.
“The worst case scenario is that we will see job losses within the next year in the sector, which will add to our huge unemployment problem, and that’s going to be tragic,” he said.
The news that research grant reviews at the US National Institutes of Health (NIH) have also been suspended was received with shock by the international research community, he added.
The NIH is the world’s largest public funder of biomedical research, which includes research on HIV and TB in South Africa. Many research groups at some of the country’s top universities are likely to now face a funding gap, which will have a detrimental effect on their work.
“The grants we get from our local funding sources are a lot smaller than what we get from the NIH. A significant percentage of income for academic institutions comes from research funding,” said Mahomed. “But it’s not just about the funding, it’s about the collaborations that go with that funding.”
External communication has also been paused, which means that NIH scientists can’t travel or take part in global meetings or make public appearances until at least the beginning of February.
While these developments are tragic for the people involved, Mahomed said they present an opportunity to re-examine Africa’s dependence on external funding.
“We can also see it as an opportunity to strengthen the voice of the Global South and tap into the expertise in our own country and others, like Brazil, Russia and China.”
Health Minister Aaron Motsoaledi said the world was baffled by Trump’s announcements.
“We have been fighting the scourge of HIV/Aids, TB and malaria together for more than 20 years as a global community, and depending very much on global funding,” he said.
“Total spending on this campaign is R44.4bn, and Pepfar contributes 17% of it,” Motsoaledi said.
He added that work was under way to determine the impact of the stop work orders, and once this was finalised, he intended to meet Finance Minister Enoch Godongwana.
Sexual and gender minority health policy
More broadly, Trump’s hardline stance doesn’t augur well for the rights of sexual and gender minority (SGM) people either, according to a viewpoint in JAMA Internal Medicine, which unpacks concerns for this sector.
Sahil Sandhu, Michael Liu and Alex Keuroghlian fear that intensified threats are looming, reflecting a pattern of increasing policy attacks on SGM healthcare in recent years.
They write that in 2023, at least 137 anti-SGM healthcare Bills were introduced in US state legislatures, a nearly four-fold increase from the previous year.
Already, 26 US states prohibit medically necessary care for transgender and gender-diverse youth.
They believe renewed efforts will unfold over the next four years to roll back measures by the Biden-Harris administration to safeguard SGM health.
They write that Project 2025 provides insights into what may be forthcoming in the Trump administration. Also known as the 2025 Presidential Transition Project, the 900-page report provides a detailed roadmap and specific action plan for each federal agency.
Although the Trump campaign distanced itself from Project 2025, the author list boasts several Cabinet Secretaries, senior advisers, and White House officials from the first Trump administration.
Major themes from the policy proposals, many of which represent more extreme versions of those implemented during the first Trump administration, raise worrying possibilities.
Among the programmes at risk, are critical sexual orientation and gender identity (SOGI) data collection and equity initiatives, and the Centres for Disease Control and Prevention (CDC) could face calls to end SOGI data collection in its surveys altogether.
For example, the Behavioural Risk Factor Surveillance System and the National Health Interview Survey administered by the CDC are among the only available health datasets with SOGI modules allowing researchers to understand the state of SGM health nationwide.
The National Institutes of Health (NIH) also faces threats to its scientific and equity initiatives.
Policy proposals include abolishing the NIH Office of Equity, Diversity, and Inclusion, which helps to ensure the agency recruits and maintains a diverse workforce, including SGM people. Additionally, the NIH may be directed to no longer fund SGM-focused research – historically underfunded – and even be pressured to fund biased studies presuming adverse effects of gender-affirming care, including pubertal suppression, hormone therapy, and surgery.
Erasing sexual, gender minority protections
The proposed policies also include systematic removal of protections for SGM health. The first Trump administration reversed the Obama-era interpretation that sex discrimination includes discrimination based on gender identity.
In 2024, however, the DHHS released a final rule to restore and expand the original Obama-era interpretation, explicitly extending protections to sexual orientation and physical sex characteristics in addition to gender identity.
A second Trump administration would probably eliminate these protections, and allow insurers and clinicians to engage in discriminatory marketing practices or deny SGM people access to essential health services.
Proposed policies also include changes to restrict access to medically necessary care for SGM people across federal programmes, and withdraw recommendations and support for gender-affirming care.
The authors say it is more important than ever for the health sector to commit itself to delivering evidence-based care and creating safe environments for SGM populations.
BusinessLIVE – Partial waiver on US foreign aid freeze offers some reprieve to HIV/Aids programmes
See more from MedicalBrief archives:
African activists fear Trump will cut birth control funds
Progress on the 3rd 90-target not a reliable guide to transmission potential
Pepfar chief pushes for extension of programme
‘Colossal impact’ fears as US anti-abortion lobby threatens to kill Pepfar