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Too little, too late — what a Pepfar waiver can’t do

Too little, too late — what a Pepfar waiver can’t do
Mia Malan
By Mia Malan
4 Feb 2025
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On Saturday, the US state department issued details of who qualifies for a limited waiver during the Trump administration’s 90-day pause of foreign aid. The freeze has resulted in the temporary close down of several HIV treatment clinics in South Africa. The waiver, however, doesn’t allow for US government-funded anti-HIV pills, unless they’re given to pregnant women.

In 2003, the year in which Pepfar – the US government’s Aids fund which Donald Trump brought to a halt last week – was launched, I moved to Kenya for four years, to head up an HIV radio journalism project funded by the American government. 

The programme, run by the international media development organisation I worked for, was initially funded through democracy and governance money of the US Agency for International Development, USAID. But five months into the project, Pepfar, the President’s Emergency Fund for Aids Relief, was launched.

The fund meant more resources – and longevity. Pepfar support allowed us to do what most other media programmes could only dream of: expensive, hands-on long-term mentoring.   

We had enough money to roll out week-long workshops for small groups of reporters at a time; we could provide journalists with the latest recording equipment; give them travel grants to provinces and free access to a radio newsroom with sound-editing programmes, computers, fast internet, phones and a resource centre with a wealth of HIV information. 

But most importantly, we could afford the salaries of a full-time sound technician and experienced story development and scripting mentors, with whom local journalists could work to produce their reports.   

But I was sceptical.  

It was the first time I had worked for a nonprofit. And I certainly had no experience with making a living from a project funded by the US government – and for that matter a Republican-run administration (George W Bush was president at the time).  

I was worried that Pepfar would interfere with the contents of the stories, and that there’d be an expectation for the radio inserts to glorify America’s goodwill; it was the year in which the fund started to buy antiretroviral drugs (ARVs) for countries like Kenya, and help roll them out.  

But, surprisingly, things played out very differently.

Impact that transcends the HIV field 


The quarterly meetings with Pepfar officials were new to me, and so were the donor and impact reports. But our interactions were respectful and constructive. When I explained that, to be credible, media reports had to be produced independently, and that no stories would be cleared with Pepfar before publication, they listened. 

Mostly, the only “rules” were that the radio programmes had to be of a high enough quality to make an impact, so that listeners found the information digestible enough to do something with it, such as getting tested for HIV or get onto treatment – and that the stories needed to hold the government and HIV organisations accountable for their actions.  

That investment produced remarkable results. 

Within months of the start of the media project, reporters’ HIV stories were aired in prime-time slots; mostly because they were of a considerably higher standard, and therefore more interesting, than the content radio stations produced without access to the resources reporters could use for HIV stories. 

HIV-trained journalists started to win awards, the kind political or investigative journalists had previously won; listeners began to call into radio shows, reporting HIV projects that were run badly; media consumers contacted reporters after the airing of their stories to find out where to get tested or treated; and from the second year of the project, the media professionals we worked with started to get promoted to more senior positions, such as news editors, within their newsrooms.  

When the funding for the programme eventually ended after just more than a decade (I left in year four), the training model was used for projects in other countries and ones that focused on different subjects, and mediums such as print and TV journalism. HIV-trained reporters in Kenya had become editors at influential media houses; some became communication managers or directors at health NGOs; others became journalism lecturers.

In the end, the programme’s impact transcended the field of HIV.  

Waivers can’t restore trust


That’s the case with almost all Pepfar health projects I’ve interacted with. Because they’re funded for many consecutive years, and also address the social determinants of health, the programmes contribute to far more than HIV; they build health systems, create jobs, help young people finish school and help to make our planet a safer place. 

To Mitchell Warren, the head of the New York-based advocacy organisation, Avac – one of hundreds of Pepfar-funded organisations that received stop-work orders last week – their HIV-related work in eastern and southern Africa is about “global health and development. It’s about democracy, about the way we think the world should be.”     

So when US President Donald Trump issued his executive order to freeze foreign assistance programmes for three months so they can be re-evaluated and potentially scrapped, he didn’t only interrupt lifesaving HIV services. He destroyed almost 22 years of partnerships, “literally with the stroke of a pen”, Warren explains. 

On Saturday, the US State Department issued details of who qualifies for a limited waiver during the 90-day pause – HIV treatment programmes do, but when it comes to preventive anti-HIV medication only projects dealing with the prevention-of-mother-to-child transmission are covered. 

But the waiver is likely to be too little, and way too late. “Many programmes have started to shut down and have begun with massive layoffs,” Warren says. “The abrupt freeze has also resulted in trust being broken down. And that doesn’t get undone because of a waiver.”

In South Africa, at least three Pepfar-funded programmes – transgender clinics of the Wits Reproductive Health Institute, the Anova Health Institute’s Ivan Toms Centre for Health in Green Point and OUT’s Engagement Men’s Health clinics in Gauteng and the Eastern Cape – let staff and patients know they were temporarily shutting their doors last week.

Pepfar pays for 17% of the Health Department’s annual HIV budget, Health Minister Aaron Motsoaledi says. Cutting those funds could lead to 15,000 health workers losing their jobs.**  

Pepfar’s annual meeting with the Health Department and South African organisations that they fund, during which the country’s operational plans are finalised – the event was scheduled for May – is now highly unlikely to take place, Warren says. 

Instead, by then, organisations would have heard whether the Trump administration will continue to fund them at all. 

Change was coming, regardless – but not like this 


It’s not that Pepfar-funded organisations weren’t prepared for change. They knew the fund was going to become smaller, regardless of who was in charge of the US government. 

It is, after all, an emergency fund, and, with access to treatment, HIV has become a manageable disease over the past two decades, despite the epidemic being far from over. 

In 2024, one of the most obvious warning signs emerged when the US Congress authorised only one year of Pepfar funding – which ends in March 2025 – as opposed to the normal five years. That meant projects could only be funded – and could plan – for a year at a time. 

“It’s not about the fact that the Trump administration wants to re-evaluate projects,” Warren says. “It’s about the cruel display of inhumanity. You don’t just replace hundreds of millions of dollars of investments in a country by turning to the minister of finance to say, ‘Oh, Pepfar withdrew yesterday. Can you fill our coffers?’ It doesn’t work that way. And that’s why these transitions need to take time and do it responsibly and strategically.” 

Ironically, scientists and activists were hoping they could convince Congress to authorise the fund for five years again in 2025 – in line with the five years that are left to achieve the United Nations Sustainable Development Goal of ending Aids as a global health threat by 2030. “We expected and hoped this administration would be responsible and identify a five-year strategy to begin to decline investment,” Warren says. 

What’s more is that projects have no idea how they will be evaluated – and by who and for what. Only that the US government would check they’re “efficient and consistent with US foreign policy under the America First agenda”.  

“We need to know what the metric is,” Warren says. If the metric is loyalty to the new president, many programmes will be evaluated quite negatively.

“It’s almost like giving people an exam, but not telling them how you’ll grade them. The professor just says, ‘Oh, I don’t like you, you get an F, or I like you, you get an A’”. 

Pepfar IS what makes America great 


Ironically, says Linda-Gail Bekker, who heads the Desmond Tutu Health Foundation at the University of Cape Town, which receives US government funding for HIV research, Pepfar is exactly what makes America great. “It’s about global security, global diplomacy and global wellbeing. 

“To undermine that legacy at this point, and in many ways the investment, I would hope is something the Trump administration would think carefully about.”

But, as things stand right now, it seems as if Donald Trump is prepared to do exactly the opposite. 

A few years ago, the Pepfar programme refocused its funding, based on scientific research, to zoom in on population groups with the highest chance of getting HIV. “It’s how you get the biggest bang for your buck,” Bekker explains. “And how you have the greatest impact: you go where the epidemic is.”

This meant specific grants for high-risk groups such as transgender people, gay and bisexual men, sex workers, injecting drug users and, in Africa, teen girls and young women. 

But the Trump administration now believes there are only two genders – male and female – and everything else is socially engineered.

“Good public health interventions require us to go to the source of the problem and intervene in a way that makes sense. That often requires that we understand population groups with the highest infection rates and that we put our prejudices aside,” Bekker says. “Otherwise we drive those individuals underground and they disappear from our public health purview. And that makes no sense: not economic sense, not public health sense and it certainly doesn’t help the HIV response.”

We can’t allow the US government to derail the HIV fight


In late December, Pepfar, along with the Global Fund for HIV, TB and Malaria and other donors, announced that, once the medicine had been approved by regulators, it would “enable access” to a twice-a-year anti-HIV injection, lenacapavir, “in countries supported by Pepfar and the Global Fund”. 

A study, led by Bekker, showed that lenacapavir fully prevented HIV infection among young women in South Africa and Uganda. It was almost as effective in a second study conducted among gay and bisexual men, as well as transgender and non-binary people.  

But that announcement may now not be honoured. “This terrific innovation could result in significant reduction in new infections, particularly amongst adolescent girls and young women in Africa,” Bekker says. “And suddenly it looks like it might not happen. For the first time we’ve got the tools to make it happen, to bring the epidemic under control, but now it seems like they may evaporate.”

But there is at least some hope. If there’s one thing the HIV community knows how to do, it’s fight back – and this time around, they may even have some of their former enemies on their side: Big Pharma. 

During the late Nineties and early 2000s HIV activists fought the industry for lower ARV prices. They won. But part of why that happened is economies of scale – donors like Pepfar and the Global Fund committed to buying huge amounts of doses for poorer countries. Pepfar alone still pays for the ARVs of more than 20 million people each year. 

Now drug manufacturers stand to lose those doses, unless someone else steps in and offers to pay for them. 

“We’ve got to be the smartest and most strategic policymakers and activists right now to deal with issues that are being thrown our way,” Warren says. “It’s clear that the Trump administration is flexing its muscles. They’re showing off. They’re saying ‘we’re in charge’. 

“We can’t allow the US government to derail the HIV fight. We have to make sure they don’t control this. We have to step up and do our jobs – and fight back.” DM

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.




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