JOHANNESBURG – The future of South Africa's fight against HIV/AIDS, a battle in which it has made significant strides, is now hanging in the balance as US President Donald Trump's administration enacts a foreign aid freeze and threatens to cut off all funding to the country.
The move has sparked widespread panic and uncertainty among healthcare providers and the millions of South Africans living with HIV, potentially reversing years of progress in combating the epidemic.
South Africa is home to one of the world's most severe HIV/AIDS epidemics, with at least 8.5 million people living with HIV – a quarter of all cases worldwide. Widespread, free access to antiretroviral treatment in southern Africa was propelled by the introduction of George W. Bush's US President Emergency Plan for AIDS Relief (PEPFAR) in 2003. PEPFAR is considered one of the most successful foreign aid programmes in history, and South Africa is the largest recipient of its funds.
Trump's initial executive order, signed on the day of his second inauguration, froze foreign aid for a 90-day period, a decision currently being challenged in court by federal employee unions who claim it represents "unconstitutional and illegal actions" creating a "global humanitarian crisis".
However, the order is already having an immediate impact on South Africa's most vulnerable.
The situation has been further exacerbated by Trump's recent announcement that he will cut off all future funding to South Africa, citing the country's land expropriation law as a "massive Human Rights VIOLATION".
"South Africa is confiscating land, and treating certain classes of people VERY BADLY," Trump wrote on his Truth Social platform. "A massive Human Rights VIOLATION, at a minimum, is happening for all to see."
The immediate consequences of the aid freeze are already being felt on the ground. A woman seeking her regular sexual health screenings and Pre-Exposure Prophylaxis (PrEP) at a USAID-funded clinic in Johannesburg's inner city was turned away, only to discover that the clinic had been shuttered. "Like many sex workers in town, free sexual health clinics are her lifeline," she explained, her eyes welling up as she grappled with the news.
An HIV-positive sex worker shared her patient transfer letter from the same closed clinic and told Sky News with panic that she is still waiting to be registered at an alternative facility.
The closure of this clinic, built by Witwatersrand University to research reproductive health and cater to vulnerable and marginalised communities, falls under the categories excluded by a recent waiver issued by US Secretary of State Marco Rubio. The waiver, while continuing life-saving assistance, explicitly excludes "activities that involve abortions, family planning, gender or diversity, equality and inclusion ideology programmes, transgender surgeries or other non-life saving assistance".
An activist and healthcare worker at a transgender clinic tells us everyone she knows is utterly afraid. "Corner to corner, you hear people talking about this. There are people living with chronic diseases who don't have faith anymore because they don't know where they are ending up," says Ambrose, a healthcare worker and activist. "People keep asking corner to corner – 'why don't you go here, why don't you go there?' People are crying – they want to be assisted."
South African civil society organisations have responded with alarm, issuing a joint open letter calling for their government to provide a coordinated response to address the healthcare emergency created by the US foreign aid freeze.
The letter states that close to a million patients living with HIV have been directly impacted by stop-work orders. Signatories stressed the need for an increased budget for healthcare services, as the temporary suspension of the US President’s Emergency Plan for Aids Relief (Pepfar) continues to affect the work of key health programmes in SA.
“The current situation has sowed incredible chaos and confusion as Pepfar-supported programmes remain ‘paused’, jeopardising the health, lives and livelihoods of thousands of people, especially key at-risk populations with HIV, TB and cancer,” stated the letter.
“We do not know what steps you have taken to start to remedy the catastrophic consequences of the Executive Order, if any. Minister Motsoaledi … what is the plan, both for now and the future?”
The letter was addressed to Minister of Health Aaron Motsoaledi, Minister of Finance Enoch Godongwana, Minister of International Relations and Cooperation Ronald Lamola and President Cyril Ramaphosa.
Among the organisations behind the letter are the Health Justice Initiative, the Treatment Action Campaign, SECTION27, Sweat, African Alliance, Cancer Alliance and the Public Service Accountability Monitor at Rhodes University.
“Despite the Waiver, we understand that most Pepfar implementing partners have not received any direct or complete communications from the United States Government about the implications of the Executive Order and the Waiver, leading to ongoing uncertainty. News reports also indicate that senior USAID officials have resigned or been placed on leave,” stated the letter from civil society stakeholders.
“These developments are likely to delay communication to implementing partners and lead to legal challenges against the decisions taken by the Trump administration.”
In the long term, the funding shortfall caused by the loss of Pepfar may affect antiretroviral therapy (ART) for adults and children; HIV prevention programmes; the livelihoods and jobs of direct clinical and care providers; and linkage to care for communities affected by HIV, TB and even cancer, warned the organisations behind the letter.
Nelly Zulu, an activist and mother living with HIV in Soweto, vividly recalls the dark days of AIDS denialism and the struggle to access treatment. "That time, there was no medication. The government would tell us to take beetroot and garlic. It was very difficult for the government to give us treatment but we fought very hard to win this battle. Now, the challenge is that we are going back to the struggle," she says.
Nelly credits access to free treatment with saving her life and that of her 21-year-old son, who tested positive for HIV at four years old. "It helped me so much because if I didn't get the treatment, I don't think I would be alive – even my son. My concern is for pregnant women. I don't want them to go through what I went through – the life I was facing before. I'm scared we will go back to that crisis."
The potential disruption caused by the US funding freeze is undeniable, despite the Ministry of Health's insistence that only 17% of all HIV/AIDs funding comes from PEPFAR.
A demand much harder to execute than declare. "There is already a shortage of the medication – even if you ask for three months' treatment, they will give you one or two months worth then you have to go back," says Nelly. "Now, it is worse because you can see the funding has been cut off."
On Monday, Minister of Health Dr Aaron Motsoaledi met with US charge d'affaires for South Africa, Dana Brown, to discuss bilateral health cooperation and new US policy for assistance.
A statement following the meeting says: "Communication channels are open between the Ministry and the Embassy, and we continue to discuss our life-saving health partnership moving forward. Until details are available the minister called on all persons on antiretrovirals (ARVs) to under no circumstances stop this life-saving treatment."
