South Africa runs the world’s largest HIV programme, supporting 7.8 million people living with the virus. While the majority of the programme is managed by South Africa’s government, key receive support from external donors, including U.S. funding. The dividends we enjoy today have been built on an aid-dependent system that is in jeopardy. The abrupt withdrawal of U.S. government funding could unravel decades of hard-won gains, pushing an already strained healthcare system to the brink of collapse. While there are signs that certain aspects of PEPFAR might be reinstated, the damage is already done – treatment has been disrupted, and trust has been broken.
Many U.S.-funded clinics and community programmes – the backbone of epidemic control – have already shut. Staff were sent home, and some have already been dismissed permanently. The safety net for thousands of vulnerable people who relied on these services is vanishing as we watch the unravelling of key funding mechanisms for our most at-risk and HIV affected populations.
Among these marginalised and vulnerable populations, we estimate that over the U.S. 90-day review period, at least 20,000 individuals could be experiencing a daily treatment interruption. That’s a staggering 1.8 million people facing an imminent break in treatment due to their belonging to high-risk population groups. Overall, PEPFAR funding supported around 4 million people in accessing care, and while some of the existing programmes may be reinstated, it is unlikely that every programme will be. The consequences for our key populations would be catastrophic for South Africa.
The domino effect of cutting funding
The interruption of treatment will have a number of immediate impacts:
When access to antiretroviral treatment (ART) is interrupted, viral rebound happens in as little as 2-4 weeks. HIV can progress to AIDS within 6 to 18 months, and the risk of new infections – including mother-to-child transmission – will skyrocket. Worse, drug-resistant HIV strains could emerge, rendering first-line treatments useless. As HIV drug resistance can be sexually transmitted, there is an added risk to new infections – first-line therapies won’t work, and our existing clinic setup is not sufficiently resourced to pick these cases up quickly, further compounding the situation.
With public-private partnerships collapsing – particularly for key populations, thousands of people risk being turned away from government clinics that are already at full capacity. The crisis won’t stop at HIV. South Africa’s fragile health system is also battling tuberculosis (TB), the leading cause of death in the country, and drug-resistant infections. With a new wave of HIV infections and potential AIDS related illnesses, we run the risk that TB becomes an even greater burden on our communities and health systems.
The U.S. government has every right to determine its funding priorities, but a withdrawal of this scale – without notice or mitigation measures – is a recipe for disaster. While the full long-term implications remain uncertain, the immediate consequences are clear: a potential tidal wave of rising HIV and opportunistic infections, coupled with deep social and economic ripple effects, driven by a poorly managed transition in services. Even if some HIV funding is eventually reinstated, this shift signals a broader trend of donor fatigue and evolving global aid disbursement models, putting the sustainability of HIV programmes at risk.
South Africa, like other affected countries, must urgently develop contingency strategies, integrating long-term management plans to ensure service continuity. In the interim, a five-year local reinvestment in critical programmes is essential, particularly where ideological concerns may block future funding. This is not an act of charity—it is a matter of responsibility and upholding the fundamental right to health. Without immediate action and strategic planning for the eventual cessation of aid, we risk an unprecedented collapse that could reverse decades of progress in HIV control, with consequences that will be felt for generations.
The time to act is now.
Dr Jenny Coetzee & Minja Milovanovic are the founding partners of African Potential, a social impact and sustainability focused public benefit organisation. They have over 35 years collective experience on the frontlines of the HIV, violence and TB epidemics in South Africa, working among some of the country’s most marginalised and vulnerable populations.