Trump’s executive orders spark chaos — South Africa's vital HIV programmes face uncertain future

5 Feb 2025

Are Pepfar-funded programmes able to deliver life-saving care? Why are South Africa’s HIV/Aids services still using US aid? Is our foreign policy to blame for the funding freeze? Daily Maverick tackles key questions about the 90-day pause on US foreign aid.

US President Donald Trump’s first two weeks in office have been characterised by a chaotic barrage of executive orders, sweeping statements and legal challenges. Keeping up with events coming out of Washington would constitute a full-time job, and even at this early stage, your average global citizen could be forgiven for having a measure of “Trump fatigue”.

These rapid policy changes have widespread implications for South Africa, however – particularly in the health sector. Daily Maverick has been tracking developments around the freeze on funding for the US President’s Emergency Plan for Aids Relief (Pepfar), which came into effect after Trump signed an executive order on 20 January suspending all foreign development assistance for 90 days, pending a review to determine whether they were “fully aligned” with US foreign policy.

Read more: ‘I’m breaching my Hippocratic oath’ – Trump’s foreign aid freeze halts key HIV programmes

Read more: US State Department grants waiver on aid freeze for ‘life-saving humanitarian’ assistance

As HIV/Aids organisations scramble to keep up with rapid policy shifts, the future of Pepfar has become a key concern for activists and policymakers around the world. It plays an important role in health security for South Africa, our neighbouring countries – and even the US itself.

What’s happening with Rubio’s waiver on ‘life-saving care’?

Trump’s broad foreign aid freeze included Pepfar, the global health programme started by George W Bush, and all US foreign assistance funded by or through the State Department and US Agency for International Development (USAID). As a result, HIV/Aids programmes around the world were issued with “stop work orders” last week, bringing their work to a screeching halt.

The executive order did not apply to military support to Israel and Egypt, or to emergency food assistance. On 28 January, US Secretary of State Marco Rubio issued an additional waiver on the 90-day freeze for “life-saving humanitarian assistance”, stating that implementers of existing life-saving programmes could continue or resume work.

Instead of being a reprieve for organisations providing HIV/Aids treatment and support, the waiver caused widespread confusion as nonprofits around the world tried to establish whether Pepfar-funded activities fell under the umbrella of life-saving aid.

It was only on 1 February, four days later, that the US State Department issued additional details of the waiver, clarifying that Pepfar was able to implement “urgent life-saving HIV treatment services”, subject to certain limitations.

Pepfar activities that could resume during the 90-day pause included:

Life-saving HIV care and treatment services, including HIV testing and counselling, prevention and treatment of opportunistic infections including TB, laboratory services, and procurement and supply chain for commodities or medicines;

Prevention of mother-to-child transmission services, including test kits, medicines and pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women; and

Reasonable implementing agency and implementing partner administrative costs strictly necessary to deliver and provide oversight of this assistance, including “related country-based data activities and portions of Pepfar’s central data platform used for clinical monitoring and program management”.

However, many Pepfar-funded programmes in South Africa have yet to receive instructions from funders that would allow them to resume their work.

Lynne Wilkinson, a Gauteng-based public health specialist in the HIV/Aids sector, noted that even if some Pepfar-funded programmes were given the go-ahead to resume, the waiver was very limited.

“For HIV prevention, it only clearly covers… prevention of mother to child transmission" putting Pepfar-funded GBV services at risk which "provide post-exposure prophylaxis (PEP) to prevent HIV acquisition after rape,” she said.

Pepfar funds are distributed to South African organisations by USAID and the Centers for Disease Control and Prevention (CDC), according to Wilkinson.

“As no one from USAID or CDC is formally communicating the application of the waiver to the South African NGOs and their subcontracted CBOs [community-based organisations] who provide these services, their hands remain tied and they cannot resume the services that the waiver may cover without risking falling foul of their contractual obligations,” Wilkinson said.

“At the moment, the majority of the operating funds for these South African NGOs comes through contractually regulated grants with USAID or CDC. The last communication to them was that they’re not allowed to spend these funds in their bank accounts because of the stop-work order. Of course, USAID and CDC may not easily be able to do so due to the hollowing out of these institutions at the US level.”

Many South African NGOs and community-based organisations have been forced to start retrenchment processes for their staff, with no guarantee of when – or even if – they will be able to pay salaries, according to Wilkinson.

“They have to balance their lack of funding right now and meeting South African labour law requirements… This means many big NGOs are retrenching thousands of staff, effective at the end of the month,” she said.

Speaking at a joint press briefing with Costa Rican President Rodrigo Chaves Robles on 4 February, Rubio emphasised that he had issued a “blanket waiver” on life-saving programmes, adding that he didn’t know “how much more clear we can be with that”.

“I would say if some organisation is receiving funds from the United States and does not know how to apply a waiver, then I have real questions about the competence of that organisation, or I wonder whether they’re deliberately sabotaging it for purposes of making a political point,” he said.

Wilkinson told Daily Maverick: “It is no easy decision but it may now be time to stop waiting for direct communication, which may not be possible from USAID/CDC, and go back to providing the explicit services covered by the waiver. We must create solidarity among implementing partners following Rubio’s instructions – of course, this does require having funds in bank accounts.”

Is South Africa at fault for being dependent on US aid?

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 received about $440-million from Pepfar.

According to the Andelson Office of Public Policy at the Foundation for Aids Research, Pepfar supported 13,815 individual direct clinical providers in South Africa in the 2024 financial year, including 178 doctors or clinical officers; 1,984 nurses and midwives; and 199 pharmacists or pharmacy assistants.

However, Pepfar spending only constitutes 17% of South Africa’s R44.4-billion campaign for HIV counselling and testing, according to South African Health Minister Dr Aaron Motsoaledi.

Wilkinson said South Africa had done a “great job” of building up its HIV services, with 70% to 80% of the programme self-funded. In most other African countries the HIV programmes are largely dependent on US funding.

“But we must remember that South Africa still has the biggest HIV epidemic crisis in the world, with 8.5 million people living with HIV. We have close to a quarter of all people living with HIV in South Africa,” she said.

“Because of that, we need additional technical support and more hands on the ground. The government is paying for and providing the core public sector HIV service, and doing that fairly well, especially with so many people needing services. But if we’re going to continue along the path we were on towards stopping the HIV epidemic in South Africa, we need to continue getting additional support to do more, quickly and intensively.”

In South Africa, about 50,000 people die of Aids each year, while another 150,000 acquire HIV, according to Wilkinson. Close to six million people are on treatment, constituting 79% of people living with HIV. However, 31% of people are not on treatment and can transmit the virus, resulting in high numbers of new infections each year.

“Pepfar-funded South African NGOs and CBOs have also been instrumental in working outside of health facilities in communities. Ensuring we provide HIV testing to people who don’t come to health facilities, bringing people into the clinics, tracing people when they miss their appointment for their ARV refills are examples of the extra hand-holding that government funding isn’t able to fully support, but is key to ensuring people living with HIV start and continue their treatment,” Wilkinson said.

Has South Africa been specifically targeted because of its foreign policy decisions?

When it comes to Trump’s executive order suspending foreign aid on 20 January, it’s safe to say that it was not motivated by any South Africa-specific grievances. The order applied to almost all US foreign development funding, including Pepfar-supported programmes across the world.

That said, there has been some bad blood between South Africa and the US over the past few years, spurred on by factors such as ties between the ANC-led administration and global powers such as China and Russia, and the case brought by South Africa to the International Court of Justice in 2023, seeking to prove that long-time US ally Israel had violated the genocide convention during its assault on Gaza.

At this stage, it’s difficult to predict how these tensions might affect America’s funding commitments to South Africa during the next four years of Trump’s presidency.

Read more: Pretoria walks tense tightrope on US relations under shadow of Russia, Iran, China alignment

In a 2024 op-ed by Peter Fabricius, Daily Maverick reporter and Institute for Security Studies (ISS) Pretoria consultant, he noted: “As long as Biden is in office, it’s likely that… the US government will hold the line on relations with South Africa, even if that line stretches taut at times. The worrying prospect for South Africa, though, is that if Donald Trump wins the November election, then all bets will be off.”

On Sunday, 4 February, Trump threatened to cut off all future funding to South Africa pending an investigation into its land reform policies. In a post on his social media platform, Truth Social, he claimed – without providing evidence – that South Africa was “confiscating land” and “treating certain classes of people very badly”.

Trump’s claims come after President Cyril Ramaphosa signed the Expropriation Bill into law last month.

Read more: Ramaphosa seeks Trump meeting to discuss SA’s land reform policy after ‘land confiscation’ claims

The South African Presidency has since issued a statement denying the Act was a confiscation instrument, and expressing Ramaphosa’s willingness to engage with Trump over “issues of bilateral interest and concern”.

“The US remains a key strategic political and trade partner for South Africa. With the exception of Pepfar Aid, which constitutes 17% of South Africa’s HIV/Aids programme, there is no other funding that is received by South Africa from the United States,” it said. DM

Read Part 2 of this two-part explainer.

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Politics

What’s happening with Rubio’s waiver on ‘life-saving care’?

Is South Africa at fault for being dependent on US aid?

Has South Africa been specifically targeted because of its foreign policy decisions?