We were warned.
Remember when Donald Trump signed an executive order earlier this year cutting off a major stream of US HIV funding to South Africa? Experts cautioned it could end in catastrophe. Well now the consequences are no longer theoretical — they’re on our doorstep.
Thousands of healthcare workers have been let go, and research centres are retrenching staff and shelving vital projects. And scientific modelling studies suggest that if the funding gap left by the US is not filled, 601,000 South Africans could die unnecessarily by 2034.
South Africa has come a long way in the fight against HIV. We’ve built the world’s largest HIV treatment programme and helped millions get access to life-saving antiretroviral therapy (ART).
The President’s Emergency Plan for AIDS Relief (PEPFAR), along with USAID, has been a critical partner in South Africa’s HIV fight for over two decades. That partnership is now unravelling — and with it, twenty years of hard-won progress.
A sudden funding crisis
Since 2003, PEPFAR has invested more than $8 billion into South Africa’s HIV response, and over $110 billion globally. In 2022, the programme contributed $460 million—about 18% of our total HIV budget.
But earlier this year, USAID-managed PEPFAR projects were shut down overnight. Programmes run through the US Centres for Disease Control have survived for now, but that funding also runs out by 30 September 2025, and there’s no guarantee it’ll be renewed.
The National Health Department now says it needs R2.82 billion just to keep things going for the rest of the financial year.
The human cost and millions lost
A modelling study, published in the Annals of Internal Medicine, projects that if the cuts aren’t reversed or replaced, we could see a 38% rise in AIDS-related deaths over just four years.
What does this mean? A modelling study is basically a scientific way of forecasting the future. Researchers take real-world data — like how many people are currently on treatment, how many clinics have been affected, and how HIV spreads — and use simulations to determine what could happen under different scenarios.
In this case, they compared what would happen if funding stays the same versus if PEPFAR support disappears completely.
The consequences of these cuts are not hypothetical. The study estimated that a complete PEPFAR withdrawal could lead to 565,000 more HIV infections and 601,000 additional deaths in South Africa by 2034.
This isn’t just a health crisis—it’s an economic one too
The same study projects a $1.7 billion (about R32 billion) in increased healthcare spending over the next ten years. Why? Because when people living with HIV (PLHIV) are not on treatment, they are more likely to develop serious illnesses and opportunistic infections like TB, pneumonia, or meningitis. These require expensive, hospital-based acute care.
On the other hand, maintaining someone on ART costs around $322 per year, a cost which may seem manageable at first glance but quickly adds up when applied to the more than 8,45 million people living with HIV. (And that’s based on 2022 Stats SA data, so the real number could very well be higher today.)
While PEPFAR funding only covered about 18% of South Africa’s total HIV budget in 2022 (about $460 million out of $2.56 billion), it still played a critical role in sustaining the broader ecosystem that keeps people on treatment. It helped pay for everything from healthcare workers and mobile clinics to outreach programmes in communities that are often missed by the public sector.
So, the cuts don’t just mean more infections and deaths. They mean a sicker population that’s more expensive to care for. And that puts extra pressure on an already stretched public healthcare system.
“PEPFAR and its predecessor, a US government-funded ART programme, kickstarted the ART programme in South Africa and also kicked over the denialism and obfuscation of President Mbeki and his minister of health Dr Manto Tshabalala-Msimang,” said Dr Neil Martinson, head of the Perinatal HIV Research Unit (PHRU) at Wits University, speaking with explain. “Their delays in starting an ART programme are estimated to have caused over 300,000 deaths in SA. Surprisingly, President Zuma supported a change in national policy to provide ART.”
Martinson noted that about 10 years ago, the South African government took over control and began paying for and supplying all public sector antiretroviral treatment. PEPFAR funding then shifted to support other key areas such as voluntary medical male circumcision, support for key populations, and linking people to care.
“Between the US and SA governments, overall longevity in South Africa has overcome almost all the reductions caused by premature deaths due to HIV,” he said.
In addition to threatening lives, the funding cut has also led to widespread job losses. More than 24,000 healthcare workers, including nurses, counsellors, data capturers and youth workers, were funded through PEPFAR.
A mixed picture: South Africa is more resilient than most
It’s important to acknowledge that South Africa is not the worst hit. As a middle-income country, it has long received less international aid compared to lower-income peers. Around 90% of antiretroviral drugs are already funded domestically, according to Health Minister Dr Aaron Motsoaledi.
But while South Africa’s HIV programme is relatively well-resourced, the same cannot be said for countries in East and Southern Africa, where entire HIV programmes have been almost entirely PEPFAR-funded. There, the consequences of the US cuts are even more devastating.
A blow to research
While the funding cuts are already affecting HIV treatment and service delivery, their impact on research is equally devastating and could set South Africa’s scientific leadership in HIV and TB back by years.
PEPFAR, USAID, and the CDC didn’t just fund clinics — they also played a critical role in building South Africa’s HIV research capacity. Over the past two decades, these funding streams have supported large-scale clinical trials, surveillance programmes, and scientific training.
“Most of South Africa’s globally recognised HIV researchers have received research training in the US and then NIH research grants in South Africa. USAID and CDC also funded large research projects, and the CDC provided assistance to SA’s NICD to prepare for and prevent endemic and epidemic infections.”
Martinson, who has led studies on TB transmission and HIV in high-burden communities for over 20 years, says the impact is already being felt: “We at PHRU are retrenching one third of our research staff at the end of May,” Martinson said, highlighting the very real and immediate effect on the country’s research infrastructure. “PHRU is co-author on about 90 manuscripts per year. We think this will reduce by more than 30%.”
That’s not just a loss of jobs. It’s a loss of data, scientific momentum, and future breakthroughs. Beyond vaccine development, funding from US agencies helped South Africa lead globally in prevention science, drug resistance research, and TB/HIV coinfection studies. Much of this research has informed international guidelines, a testament to the value of homegrown science backed by global collaboration.
What’s next?
The health department has proposed several options to plug the gap, including emergency allocations from the National Treasury, a new trust fund similar to the COVID-era Solidarity Fund, and additional support from partners like the Global Fund, which has already committed R1 billion in ARV support, according to Nicholas Crisp, deputy director for National Health Insurance.
The department has also engaged with potential funders and donors, such as the Bill & Melinda Gates Foundation, French Development Agency, and others, according to Dr Motsoaledi.
“Under no circumstances will we allow this massive work performed over a period of more than a decade and a half to collapse,” said Motsoaledi. “We don’t want to go back to a time when death was the order of the day.”
But with no single donor able to replace the $439 million previously supplied by the US annually, the road ahead is uncertain. Treasury has yet to commit to covering the R2.82 billion shortfall, and time is running out. In Finance Minister Enoch Godongwana’s third attempt at the budget speech on Wednesday, he stated that Treasury “has not made provision for the allocation of (PEPFAR funding withdrawals) now… once the resources allow, we will deal with that matter.”
When explain requested for further comment from the Department of Health, we were referred back to the press statement issued by Minister Aaron Motsoaledi on 15 May 2025.
The bottom line
South Africa’s HIV response has been a global success story, driven by both domestic leadership and international partnership. The abrupt withdrawal of PEPFAR and USAID funding risks reversing this progress, with catastrophic consequences for public health, research, and economic stability.
The numbers are clear. Without swift, coordinated action to replace the lost funding, hundreds of thousands of lives may be at stake.
Emma is a freshly graduated Journalist from Stellenbosch University, who also holds an Honours in history. She joined the explain team, eager to provide thorough and truthful information and connect with her generation.
Remember Trump’s HIV funding cuts? South Africans are suffering
|
We were warned.
Remember when Donald Trump signed an executive order earlier this year cutting off a major stream of US HIV funding to South Africa? Experts cautioned it could end in catastrophe. Well now the consequences are no longer theoretical — they’re on our doorstep.
Thousands of healthcare workers have been let go, and research centres are retrenching staff and shelving vital projects. And scientific modelling studies suggest that if the funding gap left by the US is not filled, 601,000 South Africans could die unnecessarily by 2034.
South Africa has come a long way in the fight against HIV. We’ve built the world’s largest HIV treatment programme and helped millions get access to life-saving antiretroviral therapy (ART).
The President’s Emergency Plan for AIDS Relief (PEPFAR), along with USAID, has been a critical partner in South Africa’s HIV fight for over two decades. That partnership is now unravelling — and with it, twenty years of hard-won progress.
A sudden funding crisis
Since 2003, PEPFAR has invested more than $8 billion into South Africa’s HIV response, and over $110 billion globally. In 2022, the programme contributed $460 million—about 18% of our total HIV budget.
But earlier this year, USAID-managed PEPFAR projects were shut down overnight. Programmes run through the US Centres for Disease Control have survived for now, but that funding also runs out by 30 September 2025, and there’s no guarantee it’ll be renewed.
The National Health Department now says it needs R2.82 billion just to keep things going for the rest of the financial year.
The human cost and millions lost
A modelling study, published in the Annals of Internal Medicine, projects that if the cuts aren’t reversed or replaced, we could see a 38% rise in AIDS-related deaths over just four years.
What does this mean? A modelling study is basically a scientific way of forecasting the future. Researchers take real-world data — like how many people are currently on treatment, how many clinics have been affected, and how HIV spreads — and use simulations to determine what could happen under different scenarios.
In this case, they compared what would happen if funding stays the same versus if PEPFAR support disappears completely.
The consequences of these cuts are not hypothetical. The study estimated that a complete PEPFAR withdrawal could lead to 565,000 more HIV infections and 601,000 additional deaths in South Africa by 2034.
This isn’t just a health crisis—it’s an economic one too
The same study projects a $1.7 billion (about R32 billion) in increased healthcare spending over the next ten years. Why? Because when people living with HIV (PLHIV) are not on treatment, they are more likely to develop serious illnesses and opportunistic infections like TB, pneumonia, or meningitis. These require expensive, hospital-based acute care.
On the other hand, maintaining someone on ART costs around $322 per year, a cost which may seem manageable at first glance but quickly adds up when applied to the more than 8,45 million people living with HIV. (And that’s based on 2022 Stats SA data, so the real number could very well be higher today.)
While PEPFAR funding only covered about 18% of South Africa’s total HIV budget in 2022 (about $460 million out of $2.56 billion), it still played a critical role in sustaining the broader ecosystem that keeps people on treatment. It helped pay for everything from healthcare workers and mobile clinics to outreach programmes in communities that are often missed by the public sector.
So, the cuts don’t just mean more infections and deaths. They mean a sicker population that’s more expensive to care for. And that puts extra pressure on an already stretched public healthcare system.
“PEPFAR and its predecessor, a US government-funded ART programme, kickstarted the ART programme in South Africa and also kicked over the denialism and obfuscation of President Mbeki and his minister of health Dr Manto Tshabalala-Msimang,” said Dr Neil Martinson, head of the Perinatal HIV Research Unit (PHRU) at Wits University, speaking with explain. “Their delays in starting an ART programme are estimated to have caused over 300,000 deaths in SA. Surprisingly, President Zuma supported a change in national policy to provide ART.”
Martinson noted that about 10 years ago, the South African government took over control and began paying for and supplying all public sector antiretroviral treatment. PEPFAR funding then shifted to support other key areas such as voluntary medical male circumcision, support for key populations, and linking people to care.
“Between the US and SA governments, overall longevity in South Africa has overcome almost all the reductions caused by premature deaths due to HIV,” he said.
In addition to threatening lives, the funding cut has also led to widespread job losses. More than 24,000 healthcare workers, including nurses, counsellors, data capturers and youth workers, were funded through PEPFAR.
A mixed picture: South Africa is more resilient than most
It’s important to acknowledge that South Africa is not the worst hit. As a middle-income country, it has long received less international aid compared to lower-income peers. Around 90% of antiretroviral drugs are already funded domestically, according to Health Minister Dr Aaron Motsoaledi.
But while South Africa’s HIV programme is relatively well-resourced, the same cannot be said for countries in East and Southern Africa, where entire HIV programmes have been almost entirely PEPFAR-funded. There, the consequences of the US cuts are even more devastating.
A blow to research
While the funding cuts are already affecting HIV treatment and service delivery, their impact on research is equally devastating and could set South Africa’s scientific leadership in HIV and TB back by years.
PEPFAR, USAID, and the CDC didn’t just fund clinics — they also played a critical role in building South Africa’s HIV research capacity. Over the past two decades, these funding streams have supported large-scale clinical trials, surveillance programmes, and scientific training.
“Most of South Africa’s globally recognised HIV researchers have received research training in the US and then NIH research grants in South Africa. USAID and CDC also funded large research projects, and the CDC provided assistance to SA’s NICD to prepare for and prevent endemic and epidemic infections.”
Martinson, who has led studies on TB transmission and HIV in high-burden communities for over 20 years, says the impact is already being felt: “We at PHRU are retrenching one third of our research staff at the end of May,” Martinson said, highlighting the very real and immediate effect on the country’s research infrastructure. “PHRU is co-author on about 90 manuscripts per year. We think this will reduce by more than 30%.”
That’s not just a loss of jobs. It’s a loss of data, scientific momentum, and future breakthroughs. Beyond vaccine development, funding from US agencies helped South Africa lead globally in prevention science, drug resistance research, and TB/HIV coinfection studies. Much of this research has informed international guidelines, a testament to the value of homegrown science backed by global collaboration.
What’s next?
The health department has proposed several options to plug the gap, including emergency allocations from the National Treasury, a new trust fund similar to the COVID-era Solidarity Fund, and additional support from partners like the Global Fund, which has already committed R1 billion in ARV support, according to Nicholas Crisp, deputy director for National Health Insurance.
The department has also engaged with potential funders and donors, such as the Bill & Melinda Gates Foundation, French Development Agency, and others, according to Dr Motsoaledi.
“Under no circumstances will we allow this massive work performed over a period of more than a decade and a half to collapse,” said Motsoaledi. “We don’t want to go back to a time when death was the order of the day.”
But with no single donor able to replace the $439 million previously supplied by the US annually, the road ahead is uncertain. Treasury has yet to commit to covering the R2.82 billion shortfall, and time is running out. In Finance Minister Enoch Godongwana’s third attempt at the budget speech on Wednesday, he stated that Treasury “has not made provision for the allocation of (PEPFAR funding withdrawals) now… once the resources allow, we will deal with that matter.”
When explain requested for further comment from the Department of Health, we were referred back to the press statement issued by Minister Aaron Motsoaledi on 15 May 2025.
The bottom line
South Africa’s HIV response has been a global success story, driven by both domestic leadership and international partnership. The abrupt withdrawal of PEPFAR and USAID funding risks reversing this progress, with catastrophic consequences for public health, research, and economic stability.
The numbers are clear. Without swift, coordinated action to replace the lost funding, hundreds of thousands of lives may be at stake.
Emma Solomon
Emma is a freshly graduated Journalist from Stellenbosch University, who also holds an Honours in history. She joined the explain team, eager to provide thorough and truthful information and connect with her generation.
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