The cancellation of US funding to could lead to between 150,000 and 295,000 additional HIV infections in SA by the end of 2028 unless the government covers some of the defunded services.
That’s one of the preliminary findings of a new modelling study commissioned by the national health department to look into the effect of funding cuts to the US President’s Emergency Plan For Aids Relief (Pepfar) in SA.
It was authored by researchers at the universities of Cape Town and the Witwatersrand. Pepfar is a multibillion-dollar US initiative that supports HIV-related services globally, but which has been slashed by the Trump administration since February.
The research on SA comes at the same time that a separate modelling study was published in The Lancet, which found that the discontinuation of Pepfar could result in an additional
1-million HIV infections among children in Sub-Saharan Africa by 2030.
That would lead to the deaths of about 500,000 children according to the study, while more than 2-million others would be left orphaned.
On 20 January, US president Donald Trump issued an executive order suspending virtually all US foreign development assistance for 90 days pending a review.
As a result, US-backed aid programmes were brought to a standstill across the world. Though a waiver was published that supposedly allowed some Pepfar-related activities to continue, this had a limited effect in practice.
Since then, some US grants have resumed, while others have been cancelled. The value of all terminated grants comes to tens of billions of dollars globally.
In SA, numerous awards have been cancelled from Pepfar, which had provided about R7.5bn to nonprofit organisations in the country in 2024. These organisations primarily used the money to hire and deploy health workers in government clinics, or to operate independent health facilities. Many of these have since been forced to close.
While there are still some active Pepfar grants in SA, it’s unclear how much longer these will be retained because many are only approved until September. The new study focusing on SA models what would happen if all Pepfar funding was eliminated.
In 2024 about 78% of all people who were HIV-positive in SA were on antiretroviral (ARV) treatment. That figure has been steadily rising. By 2026, it was expected to climb to 81%, according to Dr Lise Jamieson, lead author of the local modelling study.
REVERSING THE TREND
The trend would be reversed if the entire Pepfar programme is cancelled and the government fails to step in. ARV coverage among people with HIV would drop to 70% by 2026, according to the study. Under the model’s more pessimistic scenario, the figure would drop to 59% by 2026.
This is partly because some people living with HIV in SA get their ARVs directly from Pepfar-funded drop-in centres. If these centres close some patients may stop taking their ARVs. Indeed, this is what happened after one centre in Pretoria stopped providing services.
The loss of Pepfar funds could also hinder the health system’s capacity to get newly infected people on HIV treatment. For instance, Pepfar-funded organisations had employed almost 2,000 lay counsellors across SA who tested people for HIV. Without these staff, fewer people will be diagnosed and receive treatment.
Beside ARV coverage declining due to the cuts, HIV prevention services will also be affected, according to the study. For instance, Pepfar-funded drop-in sites had been providing people with pills that prevent HIV, called pre-exposure prophylaxis (PrEP).
Those services were targeted at groups most likely to contract and transmit HIV, such as sex workers. According to the new modelling study, the full termination of Pepfar would lead to a reduction of as much as a 55% in PrEP coverage for female sex workers by 2026.
Because of those factors, the researchers estimate the Pepfar cuts would cause between 56,000 and 65,000 additional HIV-related deaths in SA by 2028. By 2045, that would increase to between 500,000 and 700,000 deaths.
All of these results only hold if the SA government fails to step in, according to Jamieson. The modelling study finds that to cover all Pepfar services from 2025 to 2028, the government would need to spend an additional R13bn to R30bn in total.
TAKING STEPS
It’s unlikely that the government will provide those amounts, but Jamieson said the national health department is taking steps to identify and support certain key services that were defunded by Pepfar. She is hopeful the results may not be as drastic as the study suggests.
Another caveat is that the modelling study estimated what would happen if SA lost all of its Pepfar funding. But at least for now, there are still some grants reaching beneficiaries in the country.
Pepfar funds are primarily distributed by two US agencies — the US Agency for International Development (USAID) and the US Centres for Disease Control and Prevention (CDC).
While both agencies paused funding after the initial suspension order in late January, the CDC resumed its funding about two weeks later after a US federal court ruled that the Trump administration could not freeze congressionally appropriated funds.
CDC grants only appear to be active until September (at least for SA beneficiaries), though uncertainty remains.
USAID has taken a much harder line — funding was suspended late in January. By late February, the agency moved from pausing funds to issuing termination notices to most of its beneficiaries.
In SA, about 89% of all USAID funding has been cancelled. The value of all cancelled funds amount to about $261m. Only five other countries have faced bigger cuts in absolute terms (see all country-level estimates here).
Spotlight and GroundUp have confirmed that at least some of the remaining 11% of USAID funding has once again started flowing to beneficiaries in SA.
Thus, a small amount of USAID funding is trickling into the country while CDC funds have largely been retained in full, though it’s unclear for how much longer.
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