The disruption to SA’s HIV/Aids programmes in the wake of US President Donald Trump’s shock freeze on foreign aid is a stark reminder of the inherent dangers in the government’s continued reliance on donor funding.
About a fifth of SA’s total HIV/Aids spending is provided by foreign donors, the biggest of which is the US President’s Emergency Plan for HIV/Aids Relief (Pepfar). Launched by former US president George Bush with bipartisan support in 2003, Pepfar has since poured $140bn into SA.
Lest we forget, Pepfar was initiated during the grim era when former president Thabo Mbeki and health minister Manto Tshabalala-Msimang were fiercely opposed to the provision of life-saving antiretroviral (ARV) treatment. Hospital wards were overflowing with Aids patients and the classified sections of the newspapers were filled with death notices. Pepfar and other donors such as the Global Fund to Fight HIV/Aids, Tuberculosis and Malaria, have played a vital role in combating SA’s epidemic, providing medicines, staff and technical support.
Much has changed since the end of Mbeki’s administration, and the government now champions scientifically sound, evidence-based strategies for preventing and treating HIV. But SA’s relationship with Pepfar and the US administration remains vital as it grapples with the world’s biggest HIV burden, with an estimated 8-million people living with the disease.
Pepfar, which allocated $448m to SA for this US fiscal year, supports a number of well-established NGOs that operate in the 27 health districts worst affected by HIV. It funds 270,000 healthcare professionals and technical experts who work alongside state employees to provide testing, counselling and care.
That support now hangs in the balance.
Within hours of his inauguration on January 20, Trump signed an executive order pausing all foreign assistance for three months, pending a review to determine whether supported projects align with his agenda. This was swiftly followed by “stop-work” orders on existing operations, which brought Pepfar’s work in 54 countries to an abrupt halt. Clinics were shuttered, staff sent home and the distribution of ARVs stopped.
While it is not uncommon for a new administration to review its spending priorities and change tack on health policy, the speed and ferocity of Trump’s actions left the international HIV/Aids community reeling.
The World Health Organisation, UNAids and the International Aids Society swiftly sounded the alarm about the harm unleashed on HIV patients, who risk developing drug resistance if there is even a short break in their treatment. Governments of the Pepfar-supported nations have largely remained quiet, fearful no doubt of drawing Trump’s ire. Even SA’s usually outspoken health minister, Aaron Motsoaledi, has said little more than that he was “baffled” by the news, offering little reassurance to patients.
US secretary of state Marco Rubio’s subsequent waiver for life-saving humanitarian assistance has offered a partial reprieve, as it is expected to allow Pepfar-supported projects to restore some services. The relief may, however, be short-lived.
Despite Pepfar’s success — it has saved an estimated 26-million lives and prevented millions of infections — the scheme is under growing pressure from conservative Republicans, who have already reduced its five-year authorisation from Congress to just one year. Its future under the new Trump administration is far from certain.
US politicians would do well to remember that jettisoning Pepfar would not just harm patients in recipient countries but will hurt Americans too. Few of the high-HIV burden countries that receive Pepfar assistance — aside perhaps from SA and Botswana — have the means to quickly step into the breach should funding end. This would leave millions of HIV patients without treatment, quickly reversing the hard-won gains of the past two decades. Not only would infection rates rise, but lack of treatment would fuel the emergence of new drug-resistant strains that know no borders.
They should remember too that the US has profited from the research funding provided to SA scientists by the National Institutes of Health (NIH), its key agency for medical research. The NIH invested $40.6m in grants to SA researchers in 2022, more than a third of the $108.2m provided to low- and middle-income countries that year. The NIH’s long-running support to SA’s research base has fostered global scientific collaboration and helped devise better treatments and prevention strategies that benefit US citizens as much as South Africans.
This is a fraught and turbulent time. One can only hope that good sense prevails.
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