Almost a month on from US President Donald Trump’s executive order freezing almost all foreign development assistance for 90 days, many key health HIV/AIDS programmes in South Africa have been unable to resume life-saving services for patients in need.
Many South African organisations that rely on funding from the United States President’s Emergency Plan for Aids Relief (Pepfar) have yet to receive any communication from funders that would allow them to go back to work, despite a recent ruling from a US federal judge issuing a “temporary restraining order” on US President Donald Trump’s foreign aid freeze.
On 13 February, US federal judge Amir Ali ruled in favour of the healthcare organisations Aids Vaccine Advocacy Coalition and Global Health Council (GHC) in a lawsuit against Trump and the legality of the funding freeze. The Washington-based judge ordered Trump’s administration to temporarily lift the suspension of all funding for US Agency for International Development (USAID) programmes around the world.
In a statement released by GHC, the organisation explained that the temporary restraining order effectively barred the US government from taking actions that would disrupt the country’s foreign assistance programmes.
However, the positive effects of the federal court ruling have yet to be felt on the ground in South Africa, with many organisations still unable to resume work and others only able to provide hollowed-out services.
Pepfar funds are distributed to South African implementing partners by USAID and the Centers for Disease Control and Prevention (CDC). Some CDC-supported organisations have started to receive notices allowing them to resume certain services, according to Joan (a pseudonym for a source who chose to remain anonymous out of concern for backlash), an HIV expert at a local NGO who’s seconded to the National Department of Health. However, those relying on USAID funding have not.
About half of the Pepfar-supported programmes in SA receive funding through USAID, according to Joan.
Before Ali’s ruling, US Secretary of State Marco Rubio had issued a waiver on the 90-day foreign aid freeze for “life-saving humanitarian assistance”, stating that implementers of existing life-saving programmes could continue or resume work.
Read more: Pressure mounts on Health Minister Motsoaledi to remedy ’catastrophic consequences’ of US aid freeze
Struggle to deliver services
One of those affected by the foreign aid cuts was Nonhlanhla Mazaleni, who had to cancel an HIV education workshop for young people in Diepsloot, Soweto, on Monday because of the cuts.
Through her nonprofit organisation, Tholulwazi Phakathi, which she runs from her Diepkloof home, Mazaleni offers HIV education, psychosocial counselling and ARV treatment adherence programmes for adolescents and young adults, with the assistance of USAID.
Mazaleni said USAID workers usually helped her conduct HIV rapid and self-testing, but Tholulwazi Phakathi could no longer provide these services.
“I just came from the local clinic asking them if they can send nurses who can come test the kids … because that’s what people at USAID used to do for me. The clinic said they would call me back but we will just have to wait and see. I don’t think they will be able to send people because they are also struggling,” said Mazaleni.
Mazaleni said the inability to conduct HIV tests in her community had a knock-on effect, adding that young people who depended on her services could no longer access antiretrovirals (ARVs), post-exposure prophylaxis or pre-exposure prophylaxis (PReP) from her NPO.
“The things we do are so important for the young people in my area. They always tell me that they don’t like going to the clinics because the environment is not welcoming and they are sometimes turned away because of long lines or there are not enough people working. What we do helps catch what the clinics can’t, but now I am struggling to put even one workshop together. What am I supposed to do about getting these young people their medication?” said Mazaleni.
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While Mazaleni can still provide hollowed-out services, Engage Men’s Health (EMH) has had to shutter operations entirely.
EMH, a project of the OUT-LGBT Well-being agency, provides free, specialised services to gay and bisexual men, and men who have sex with men, who are often marginalised or fall through the cracks in the public healthcare system.
On Thursday, 13 February, EMH said its clinics were open, while its national call centre would be reconnected the following day. However, on Monday the clinic announced that its services remained suspended as a result of the US order.
EMH said that while it awaited a resolution about funding, it had advised its clients to access their ARVs or PrEP at their nearest public health facility.
Strained health system
The Pepfar funding freeze has caused “a lot of chaos” when it comes to healthcare delivery on the ground, according to Joan, with Gauteng and KZN among the hardest-hit provinces.
Many services affected by the funding freeze provided support to key populations, which are groups at higher risk of HIV. Individuals who belong to these groups, such as sex workers, men who have sex with men, transgender people and people who inject drugs, often face stigma when approaching mainstream health services.
Mogau Makitla, the media officer at the LGBTI+ advocacy organisation Iranti, said that Pepfar-funded services filled a gap within South Africa’s strained health system.
“People who are familiar with the advocacy work that [Iranti does] ... often approach us and say, ‘I’m struggling with this and this and this’. And Iranti will refer them to an organisation that is a service provider. One of the biggest challenges that we’re facing right now is that a lot of the organisations or spaces that we would refer people to have shut down, so now they don’t know where to go, and we don’t know where to refer them,” said Makitla.
“We want to have more financial commitments from the government to supplement all these services that have closed down… We really do need them to step up in certain ways, because these organisations were filling a gap ... in terms of what the state was not providing.”
Linda-Gail Bekker, the CEO of the Desmond Tutu HIV Foundation and director of the Desmond Tutu HIV Centre at the University of Cape Town, noted that the loss of care, treatment and prevention services for key populations would allow “concentrated epidemics” to spill over into the generalised population.
“Half of the 1.3-million infections that are currently occurring on the globe, are happening in … key populations, people who are particularly vulnerable — either because of stigmatisation, discrimination or their particular lifestyle practices — to HIV. Yet they are underserved by the mainstream services that we currently provide,” she said.
“Aside from what I believe is the moral and justice issue of making sure that everybody everywhere gets the care and treatment and prevention they need, if you want to get it down to a transactional level, if we leave these populations behind, we will see the whole epidemic, the global epidemic, lose ground in the future.”
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Other areas that had been hard hit by the Pepfar funding cuts were data capture and the tracing of patients for HIV services, said Joan.
“The number one … problem is the data capture — a lot of the data capturers were paid by Pepfar,” she explained, adding that while other workers in the public health system might be tasked with taking over these roles, they often lacked proper training and support.
“For a lot of patients, even though they may be seen and are waiting in incredibly long queues, the correct information is not going to be captured in the system, or even going to be captured at all. Their files may be lost. [Health workers are] going to be opening up new files because they don’t have the time to go and look for their files. So, we’re losing patient history.”
South Africa has the largest Pepfar portfolio in the world, Daily Maverick has reported. For the US financial year spanning October 2024 to September 2025, South Africa was allocated about $440-million from Pepfar.
Pepfar spending constituted 17% of South Africa’s R44.4-billion campaign for HIV counselling and testing, according to Health Minister Dr Aaron Motsoaledi. The programme supported 15,374 workers in the health sector at a cost of R4.6-billion.
USAID in peril
While USAID-supported organisations in South Africa wait for the green light to resume operations, the agency is facing a crisis of its own. The Trump administration is attempting to merge USAID with the State Department — a move that democratic legislators have criticised as illegal and unconstitutional.
On Friday, 7 February, US District Judge Carl Nichols blocked the Trump administration from placing 2,200 employees of USAID on paid leave, after two federal employee associations took the issue to court, according to a report in The Guardian.
Nathan, a former senior USAID official, told Daily Maverick, “USAID is in the process of being dismantled. You have some staff who are being let go… Although the foreign service staff may still be working because … there’s a court case that has held in abeyance the recall of staff from overseas, those staff are working under an instruction that limits their ability to communicate.”
Nathan (a pseudonym for a source who chose to remain anonymous out of concern for backlash) described a state of chaos in the Pepfar programme, as developments such as Rubio’s waiver on life-saving assistance came into conflict with the US Department of Government Efficiency’s efforts to dismantle USAID.
“What I’m being told is there’s no leadership and people don’t know from whom they should be taking orders, and therefore USAID staff are reluctant to communicate. And so I would speculate that this culture of confusion and chaos has filtered down into South Africa, and that’s why the Pepfar staff are either unwilling or unable to communicate effectively with the organisations that are actually implementing the programme,” he said.
The US Congress passed a law establishing USAID as a separate, independent entity in 1998, meaning the agency can only be dissolved by an act of Congress, according to Nathan.
“The top administration is basically ignoring that legal requirement, and they are dismantling and reorganising USAid by stealth — doing it in an unofficial way,” he explained. “Because they control the administrative state, which is the executive branch of government, they can keep USAid in existence only on paper.” DM