A lifeline in freefall: Inaction could cost a million lives over 10 years if Pepfar disappears

As South Africa’s diplomatic relationship with the United States sours, the country’s political leaders have braved the crosswinds of a superpower’s racist tirade, but their failure to act poses a grave risk for the country, which is home to the world’s largest HIV epidemic.

President Cyril Ramaphosa and Health Minister Aaron Motsoaledi have both signalled that they’re aware of the dire implications for South Africa’s HIV and TB project if the US President’s Emergency Plan for Aids Relief (Pepfar) pulls out for good, but to date, neither have offered a concrete alternative to continue with all the services that Pepfar funded.

President Cyril Ramaphosa. (Photo: Jairus Mmutle)

Minister of Health Aaron Motsoaledi. (Photo: Gallo Images / Lee Warren)

We need an alternative, fast, because lives, livelihoods and health services are at risk.

Even though most Pepfar donor dollars came to South Africa through non-profit projects, the 17% it provided of South Africa’s HIV budget represented both a patch that plugged crucial gaps in the health system and a pillar that reinforced the system as a whole.

Over the past two decades, civil society across South Africa has worked closely with the health department to understand the country’s HIV epidemic and to make sure that projects don’t duplicate the services that are already available in state clinics and hospitals. Specialised queer-friendly clinics, for instance, are entirely led by non-profits.

At the same time, civil society has seconded staff to parts of the health system, such as supply chain management to prevent stockouts, where their expertise made a huge difference.

They have set up the Central Chronic Medicine Dispensing and Distribution (CCMDD) system, which allows people to pick up several months of their HIV treatment pre-packed and available at convenient collection points. The system has helped about three million people skip long clinic queues and avoid discrimination.

The CCMDD is already showing the first signs of trouble.

In Limpopo, a panicked patient living with HIV, Maite Letsoalo, told the Treatment Action Campaign that since thousands of non-profit workers were fired in February, she has not heard from the pharmacy where she has usually picked up a three-month supply of her antiretroviral (ARV) pills since 2021.

“I am very worried. Right now, I am using pills from some extras from the days I have missed my tablets. I am also sharing pills with my partner.”

How is South Africa’s HIV project faring?

Even with all these supporting elements in place, and despite the recent launch of a “last mile” campaign, South Africa’s HIV epidemic is not controlled.

Notwithstanding a vast HIV testing and treatment infrastructure and Pepfar support, more than half of people diagnosed with HIV in 2020 already had quite advanced HIV disease with weakened immune systems, with a third having progressed to Aids, for which treatment is more complicated and less likely to be life-saving.

Far fewer babies are born with HIV if their mother knew their status before falling pregnant, but those who become infected during pregnancy or while they are breastfeeding are still falling through the cracks, resulting in transmission to their children. Finding those children and ensuring they are tested and kept in care remains challenging for the health system.

What’s more, about one in four people with HIV are not on treatment, which means they are more likely to fall ill or pass the infection on to others. The government is distributing fewer condoms and young people are using them less frequently, too.

South Africa recorded about 150,000 new HIV infections in 2023 and is lagging on 2030 targets to eliminate the disease as a public health threat (also called virtual elimination).

Taken together, it should not have come as a surprise when a new study found that 25 years on, HIV is still the leading cause of death in South Africa.

That was the reality before Trump’s inauguration on 20 January 2025.

About half of the money South Africa got through Pepfar has fallen away. This money was cut because it was being disbursed by the United States Agency for International Aid and Development (USAid), which Trump’s right-hand man, Elon Musk, spent February “feeding into the woodchipper”.

South Africa was not alone — more than 5,000 projects were axed worldwide.

The other half of the country’s Pepfar funding comes through the Centers for Disease Control and Prevention (CDC). For now, some of these projects are up and running again, thanks to a US court order, though experts told GroundUp that CDC grants beyond September 2025 are not a given.

The National Institutes for Health (NIH), which funds more research in South Africa than any other institute, could be reconsidering its South African grants too.

The life cycle of an epidemic 

South Africa has come a long way since the dark days of Aids denialism, when Thabo Mbeki’s refusal to provide treatment led to at least 300,000 estimated preventable deaths.

Today, antiretroviral treatment (ARVs) and highly effective oral pre-exposure prophylaxis (PrEP) (prevention) are available free in South Africa’s government clinics. People living with HIV who stay on treatment now live about as long as those without HIV.

But it would be unfair not to acknowledge that this progress was not only about providing treatment, it was also about creating the conditions for treatment to succeed, and here, the US government support played a prominent role.

Early on, when ARVs were available only to those who had Aids, it was already clear that medicines or ARVs alone would not be enough to save lives. US donor funding also helped support the community-led monitoring work of the Treatment Action Campaign (TAC), whose radical self-disclosure campaigns and treatment literacy projects turned the jargon of immunology such as “CD4 count” and “virally suppressed” into public discourse.

Over time, anyone diagnosed with HIV could start ARVs immediately. Still, activists and researchers pushed for the system to recognise a harsher truth, which is that HIV was still moving freely through South Africa’s strained social fabric, exploiting inequalities and taboos.

And so, with the backing of funders like Pepfar and USAid, projects were launched to reach sex workers, queer communities, drug users, young women and survivors of abuse – all those hit hardest by the epidemic and who are least served by the public health system.

We learnt the same lesson over and over: the public health system could provide treatment, but it lacked the reach and often, the time it takes to generate the ‘’warmth’’ to make that treatment truly work.

It was these types of donor-funded programmes that had the funding and flexibility to bring HIV services to patients that the formal system struggled to reach or refused to support explicitly, ensuring that prevention and care were not just available on paper, but were truly accessible.

These programmes were developed in cooperation with the government.

The plans drafted to limit South Africa’s donor dependency and to enable a careful handover of these non-profit projects to the health department have now been sent into a nosedive because of the Trump administration, and in South Africa, it will cost at least 15,000 jobs.

What did we really get ‘from the American people’?

It is tempting to say that what these US-funded projects bought was kindness and empathy.

By paying for logistics, donor-funded projects also bought the luxury of time, which in turn, facilitated respectful care more often than not.

They funded a nurse who had the breathing room to explain an HIV diagnosis with gentle patience, rather than rushing through another overloaded clinic queue.

They created clinics where a queer teenager could speak openly about their fears without judgment.

Without this funding, there would have been no harm reduction counsellors who saw past addiction to the person underneath, there would have been no extended clinic hours to make care possible for working mothers. These services are now terminated. The gap is yet to be filled.

Another darker reality to consider is that donor-funded projects were only barely keeping the consequences of years of austerity health budgets at bay.

Those who serve South Africa’s chronically under-resourced public health sector have been in survival mode for years and there is ample evidence of the dehumanising impact this has had on health workers and those in their care.

How a broken system breaks the people who serve and use it 

Health workers are often forced to watch their patients die unnecessarily due to staff shortages, stockouts and equipment failures, and often they are prevented from speaking out.

The TAC’s 2024 national report into the state of South Africa’s 4,000 clinics was published just a few months before Trump started gutting aid. The document, notably compiled with support from USAid, paints a dark picture. It doubles as a compendium of anecdotes about what happens when health workers are pushed beyond their limits. The TAC found that:

• Key populations face widespread homophobia and mistreatment at government clinics. “[The nurses] support each other in chasing us away from the clinic,” as one drug user put it.


• The smallest misstep can derail care for patients regardless of their orientation or their healthcare needs. Those who miss an appointment to pick up their ARVs or show up late face the schoolyard punishment of being sent to the “back of the queue’’. Failing to bring the right paperwork can result in much worse.


• Health workers also chase people away if they do not have SA ID documents or ‘’transfer letters’’, even threatening to call the police in one instance.

One patient from Mpumalanga explained: “I walked out crying. I could not get contraceptives. When I came back I discovered I was pregnant. I was shouted at too.”

The silence before the storm 

Although TB is curable, the disease kills 150 people a day in South Africa. (Photo: EPA / Daniel Irungu)

We are already witnessing the fabric of South Africa’s HIV and TB programmes unravel. Data capturers were among the first people to be let go because of the cuts, which means we will soon have to navigate the impact of the crisis without it. The consequences will be severe:

• Follow-up appointments and adherence support will soon disappear as clinics battle to track patients. Skipping doses would lead to a rise in cases of treatment resistance.


• HIV testing services are collapsing too, even in hospitals, and services such as maternal and child health screenings, specialised HIV care, and services offering PrEP for young women are disappearing.


• TB screening is already minimal, fuelling transmission and mortality.


• Case management programmes are shutting down and leaving thousands without peer support.


• Key populations have lost access to HIV testing, treatment and harm reduction services.


• Gender-based violence prevention and support services are at risk. In just one instance, services for 33,000 GBV survivors will soon vanish, cruelly cutting off post-rape HIV prevention, psychosocial support and legal aid for those in crisis in future, too.

Without these services, more people will contract HIV and TB, treatment failures will rise and the most vulnerable will be left without care.

Recent modelling published in the Annals of Medicine suggests South Africa’s health system will initially save money on HIV because fewer people will test and require lifelong treatment. In the long run though, the government will have to spend more on treatment as more people require hospitalisation and more complicated care regimens.

The models show that the funding crisis could cost South Africa between 600,000 and a million lives over 10 years, depending on how quickly the health system responds.

Our country’s HIV response has a long way to go, but we have come too far to once again measure the cost of fragmented health services in lives lost.

Tian Johnson is the founder and strategist of health advocacy group African Alliance. Fatima Hassan is the director of the legal non-profit Health Justice Initiative. Sibongile Tshabalala chairs the Treatment Action Campaign.