Recent research co-authored by Professor Linda-Gail Bekker from the University of Cape Town (UCT) showed that withdrawing the US President’s Emergency Plan for AIDS Relief (PEPFAR) support in South Africa without effectively transitioning to supported services will lead to an estimated 601 000 HIV-related deaths and 501 000 new infections in the next 10 years.
The research is published in the Annals of Medicine, a peer-reviewed medical journal, and as an editorial in the South African Medical Journal (SAMJ).
In January 2025, at the beginning of President Donald Trump’s second term, a funding freeze was announced. Initially described as a 90-day pause on US foreign assistance to review and align global aid with US interests, the situation quickly escalated. A few days after the announcement, the US State Department issued a directive for a “stop work order”, which extended the freeze to encompass all foreign aid programmes, including Pepfar.
Professor Bekker, the director of the Desmond Tutu HIV Centre and the chief executive officer of the Desmond Tutu Health Foundation, stated that the order would have catastrophic effects, jeopardising millions of lives and could completely derail South Africa’s hard-won gains in its fight against HIV/AIDS.
Pepfarwas introduced by former US president George W. Bush in 2003. Since its inception, the initiative has been crucial in the global fight against HIV, enhancing overall health systems in more than 50 countries worldwide.
“It is the largest commitment to any single disease made by any nation. In 2003, when Pepfar started, South Africa was in the grips of an unfolding HIV epidemic that would grow into the largest national HIV epidemic globally,” says Bekker.
The aid arrived at a critical moment for the country, as the period of HIV/AIDS denialism caused significant suffering for millions. Bekker noted that the government failed to provide access to highly effective antiretroviral treatments during this time.
South Africa was at its lowest point: approximately 3 000 women were acquiring HIV per week, and one in three infants born with the virus died within two years.
Additionally, Bekker says that TB rates surged dramatically, and the national life expectancy plummeted from 62 years in 1992 to just 54 years in 2005. Bekker mentions that one study estimated this period of denialism resulted in more than 300 000 deaths.
“But Pepfar offered South Africa and its neighbouring countries a critical lifeline. Over the past two decades, the global HIV pandemic has evolved, and significant progress has been made. HIV treatment is now highly effective and is even provided in a single once-a-day pill,” she says.
Today, the life expectancy for people living with HIV who are on treatment is comparable with those without HIV. And people living with HIV who are on treatment and have an undetectable viral load, have zero risk of transmitting the virus to sexual partners and there’s minimal risk of mother-to-child transmission as well.
Despite significant progress, nearly eight million South Africans are currently living with HIV. Among them, between 1-million and 2-million are not receiving treatment, and an estimated 400 000 have never been tested and are unaware of their HIV status.
Bekker emphasises that finding and supporting those living with HIV who need to start or resume treatment and stay on lifelong therapy is a challenging task. Locating these individuals is essential for reducing the annual number of HIV-related deaths, which currently stands at 50 000, along with 150 000 new infections each year.
Pepfar funding constitutes for approximately 18% of South Africa’s HIV response.
According to Bekker, this means that although the majority of treatment, care and prevention services are provided by the national budget, the funding freeze will significantly impact the South African programme. She notes that around 15 000 trained healthcare providers, along with data capturers and technical support staff, have been placed on furlough.
As a result, some public healthcare facilities are not operating at full capacity, and many community-based outreach programmes and services have been suspended.
Additionally, with 50% to 60% of USAID support staff now released from their positions, clinic queues have diminished, and partner-run clinics have closed, leading to a substantial reduction in data collection.
“Prolonged treatment interruptions, new and missed HIV acquisitions and lost opportunities to intervene will result in more hospitalisations, lives lost, infections acquired and overall increased cost to the healthcare budget over time,” she says.
Consequently, efforts to pedal through the last mile and attain global AIDS targets by 2030 (to end HIV/AIDS as a public health threat, achieve zero new infections, zero HIV/AIDS-related deaths and zero stigma and discrimination) will be challenging.
But turning this crisis into an opportunity is possible. To mitigate the effects of the funding freeze, Bekker noted that swift action was needed.
Together with colleagues from academia and civil society, they have proposed a five-point plan, which suggests the National Department of Health implement urgently:
- Conduct a rapid assessment of the scope of human resources, services and programmatic gaps. It should be initiated urgently and collaboratively by the national and provincial departments of health and Pepfar-funded partners.
- Allocate funding in the 2025 public sector health budget to fill currently unfunded posts that are critical for delivering public sector health services.
- Secure resources and implement the most efficient mechanisms to deliver critical services by mobilising acute bridging funding; reducing unnecessary burdens and improving inefficiencies in the healthcare system; identifying the fastest service delivery mechanisms; and engaging the private and non-governmental sectors to supplement service delivery capacity.
- Develop a longer-term plan, with short-, medium- and long-term priorities, to restore the HIV programme and align with the 2030 goals.
- Secure additional and/or reprogramme current Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) funding with an ongoing plan to gradually reduce dependency on these funds.
“Home to the world’s largest HIV epidemic, the South African government, in partnership with civil society, has the potential to turn this crisis into an opportunity – collectively reassessing urgent health system demands while urgently securing our HIV and TB response and identifying strategies to enhance healthcare delivery for long-term sustainability,” Bekker says.