SA could face up to 65,000 additional Aids deaths and almost 300,000 extra HIV infections by 2028 if the US completely withdraws funding and the government does not step in, a modelling study has found.
Commissioned by the health department, the study is expected to help it build its business case for increasing domestic HIV/Aids funding, an effort that has taken on new urgency after the Treasury said scrapping its plans to raise VAT would leave a R75bn hole in the budget over the next three years.
It warns that the government risks losing more than a decade’s worth of hard-won gains against the HIV epidemic if it does not fully fund interventions previously supported by the US President’s Emergency Plan for Aids Relief (Pepfar).
Aids deaths and new HIV infections have been steadily falling for over a decade, and stood at 51,900 and 173,000 respectively in 2024, according to the latest Thembisa model estimates.
If all Pepfar funding ceases, the government will need to spend an additional $710m (R13.4bn) to $1.5bn (R28.4bn) between 2025 and 2028 to sustain HIV/Aids services, finds the study. It used the 2024 average rand-dollar exchange rate of R18.84 to the dollar.
US President Donald Trump’s administration has dealt a series of blows to foreign assistance worldwide, leading to the cessation of most Pepfar-supported services in SA and an uncertain future for the rest.
“We were so close to ending Aids. We had decreased incidence dramatically, we were finally turning the curve on prevalence, and now we have this situation where we could be back where we were 10, 13, 15 years ago,” said the study’s principal author Gesine Meyer-Rath, professor at Boston University School of Public Health and a researcher at the Wits Health Economics and Epidemiology Research Office.
“It’s a real blow, a punch to the stomach,” she said.
We were so close to ending Aids. We had decreased incidence dramatically, we were finally turning the curve on prevalence, and now we have this situation where we could be back where we were 10, 13, 15 years ago
— Gesine Meyer-Rath professor at Boston University School of Public Health
The scale of the additional deaths that could arise if Pepfar funding ceased completely and the government did not close the gap would be akin to the death surge seen during the Covid-19 pandemic, she said. “We all know how that felt and how horrible it was. It could be as bad as that if we do nothing,” she said.
Unlike most other countries with high HIV prevalence, SA funds the lion’s share of its public sector HIV programmes from the fiscus. But the sheer scale of SA’s epidemic — at least 7.8-million people are now estimated to be living with the disease — means it has for the past 20 years relied on significant support from donors, including Pepfar and the Global Fund to fight HIV/Aids, tuberculosis and malaria.
Pepfar accounted for 21% of SA’s total $1.85bn (R34.85bn) HIV/Aids expenditure in 2023, the latest year for which data is available, according to the study, published in the preprint server MedRx earlier this week. Pre-print servers carry research that has not yet been peer-reviewed.
The government funded 96% of antiretroviral treatment for HIV, but Pepfar funded 50% of HIV prevention services. Pepfar also funded health strengthening programmes, paid the salaries of thousands of community health workers who helped people stick with their treatment, and supported interventions tailored for people who frequently face stigma and discrimination at public health facilities, such as sex workers, men who have sex with men, and transgender people.
The study assessed the cost-effectiveness of various interventions and concluded that maintaining HIV treatment services and providing oral pre-exposure prophylaxis (pills to prevent HIV transmission) should be prioritised in a budget-constrained environment.
The modelling work is broadly in line with previously published studies that quantified the impact of the complete withdrawal of Pepfar funding to SA.
A study published in the Annals of Internal Medicine in February estimated that HIV infections would increase by 565,000 over the next 10 years, while a study published in the Lancet in March estimated there could be up to 492,000 additional Aids deaths in SA between 2025 and 2030.
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