Turn PEPFAR funding freeze crisis into opportunity

Withdrawing the United States (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.

This was according to a research article co-authored by the University of Cape Town’s (UCT) Professor Linda-Gail Bekker and published in the Annals of Medicine – a peer-reviewed medical journal, also published as an editorial in the South African Medical Journal (SAMJ) this week. Professor Bekker is the director of the Desmond Tutu HIV Centre and the CEO of the Desmond Tutu Health Foundation. She is a globally renowned physician-scientist in the field of HIV and tuberculosis (TB).

The funding freeze was announced in January 2025 at the start of President Donald Trump’s second term in office. It was said to be a 90-day pause on US foreign assistance under the condition of reviewing and aligning global assistance with US interests. But a few days after the announcement, the US State Department ordered a “stop work order” directive – expanding the pause to include a freeze on all foreign aid programmes, including PEPFAR.

This order, Bekker said, will have catastrophic effects, place millions of lives in jeopardy and could completely derail South Africa’s hard-won gains in its fight against HIV/AIDS.

Background

Speaking to UCT News, she explained that PEPFAR was first introduced by former US president George Bush in 2003. Since then, the initiative has been critical in the global fight against HIV – strengthening overall health systems in more than 50 countries globally.

“It is the largest commitment to any single disease made by any nation.”

“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,” she said.

So, this aid came at a significant time for the country – as the HIV/AIDS denialism period, prolonged by former president Thabo Mbeki – wreaked havoc on millions of lives. Bekker said, at the time, government failed to provide access to highly effective antiretroviral treatment. Effectively, South Africa was at its lowest point. As many as 3 000 women acquired HIV per week and one in three infants were born with the virus and died within two years. Further, she said, TB rates increased dramatically, and the national life expectancy decreased from 62 in 1992 to 54 in 2005. Bekker said at the time, one study estimated that the denialism period led to 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 said.

What’s more, 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.

Effects on the ground

But despite this progress, close to 8 million South Africans are living with HIV today; between 1 and 2 million of them are not on treatment and an estimated 400 000 have never been tested and don’t know their HIV status. Bekker said finding and supporting those living with HIV who need to start or restart treatment and remain on lifelong therapy is no easy task. And locating them is critical to reduce the number of HIV-related deaths per year, which currently sits at 50 000, with 150 000 new infections respectively.

“Prolonged treatment interruptions, new and missed HIV acquisitions and lost opportunities to intervene will result in more hospitalisations.”

PEPFAR funding to South Africa constitutes around 18% of the country’s HIV response. What this means, Bekker explained, is that while the bulk of treatment care and prevention is provided by the national fiscus, the funding freeze will have a significant impact on the South African programme. She said because about 15 000 trained healthcare providers, as well as data capturers and technical support staff have been placed on furlough, some public healthcare facilities are not functioning optimally and much of the community-based outreach programmes and services have been suspended. And with 50–60% of USAID support staff now released from their posts, clinic queues have diminished, and partner-run clinics have been closed, which also means a significant 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 said.

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.

Five-point plan

But turning this crisis into an opportunity is possible. To mitigate the effects of the funding freeze, Bekker said swift action is needed. And together with colleagues in 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 said.

The SAMJ article was a collaborative effort and included input from Bekker’s colleagues at Health Justice Initiative; Sisonke, the Treatment Action Campaign; Aurora, South Africa; and the International AIDS Society.