Experts say this can be avoided if the South African government covers some of the services it has been repaid
The new model estimates that cancellations of funding from the US President’s AIDS Relief Plan (PEPFAR) could lead to hundreds of thousands of new HIV infections in South Africa by the end of 2028. South Africa lost billions of rands from US International Development (USAID) in PEPFAR funds. The US Centers for Disease Control and Prevention (CDC) PEPFAR funds are retained, but they may only last until September. The model predicts that the share of people accessing HIV treatment and preventive services will likely be significantly reduced without PEPFAR funding. This will result in at least 56,000 deaths by 2028.
Cancellation of PEPFAR funding to South Africa could cause 150,000-295,000 HIV infections by the end of 2028. This is unless the South African government covers some of the refunded services.
These are the preliminary findings of a new modelling study commissioned by the National Health Agency to investigate the impact of PEPFAR funding cuts in South Africa. It was written by researchers at the University of Cape Town (UCT) and the University of Witwatersland (WITS). Pepfar is a multi-billion-dollar US initiative supporting HIV-related services worldwide, but has been significantly reduced by the Trump administration since February.
Studies on South Africa simultaneously found that another modeling study was published in the Lancet and that Pepfer’s cancellation could cause another million HIV infections among sub-Saharan African children by 2030.
On January 20th, newly elected US President Donald Trump issued an executive order halting virtually all US foreign development support for 90 days after the review took place. As a result, the US Aid Aid Programme was led to a halt around the world, including South Africa. A waiver was announced that appears to have allowed some Pepfer-related activities to continue, but this actually had a limited effect.
Since then, some US grants have reopened, while others have been cancelled. All termination grants will be worth hundreds of billions of dollars worldwide. In South Africa, numerous awards were cancelled in 2024 from Pepfar, which provided roughly R7.5 billion to national nonprofit organizations. These organizations used money to hire and deploy healthcare workers primarily in government clinics and operated independent health facilities. Many of these are now forced to close.
There are still some active Pep-Far grants in South Africa, but it’s unclear how long these will last, as many have been approved until September. A new study focusing on South Africa models what will happen if all Pepfahl funds are eliminated.
Up to 65,000 additional deaths are expected by 2028
In 2024, approximately 78% of all people who had HIV in South Africa were undergoing antiretroviral (ARV) treatment. This figure has steadily risen over time. It was expected to rise to 81% by 2026, according to Dr. Lise Jamieson, the lead author of the local modeling study.
However, this trend is reversed when the entire PEPFAR programme is cancelled and the government is unable to intervene. Research shows that ARV coverage for people with HIV will decrease to 70% by 2026. Under the more pessimistic scenario of the model, the numbers will drop even further by 2026 – to 59%.
This is because some people living with HIV in South Africa get their ARVs directly from Pepfar-funded drop-in centres. If these centers are closed, some patients may stop taking ARV. In fact, this is exactly what happened after one centre in Pretoria stopped providing services.
The loss of the PEPFAR fund could also hamper the health system’s ability to acquire new people with HIV treatment. For example, the PEPFAR funding organization employed around 2,000 Ray counselors across South Africa that tested people with HIV. Without these staff, fewer people will be diagnosed and treatment will begin.
Research shows that ARV coverage is not only affected by reductions, but also HIV prevention services. For example, Pepfar-funded Drop Insights provided people with HIV-prevention tablets called Pre-Exposure Prevention (PREP). These services were targeted at groups that were most likely to contract and send HIV, such as sex workers. According to a new modeling study, the full end of PEPFAR would reduce PREP coverage for female sex workers by 2026 by 55%.
Because of these factors, researchers estimate that PEPFAR reductions in South Africa by 2028 will result in 56,000 to 65,000 HIV-related deaths. By 2045, this will increase to 500,000-700,000 deaths.
Almost 90% of USAID contracts have ended in South Africa
According to Jamieson, all of these results are only true if the South African government does not intervene. Modeling studies found that the government would need to spend an additional R13 to 30 billion in total to cover all PepFAR services from 2025 to 2028.
While the government is unlikely to vent this amount, according to Jamieson, the National Health Agency is taking steps to identify and support certain key services repaid by Pepfer. She hopes that the results may not be as dramatic as the research suggests.
Another caveat is that modeling studies have estimated what will happen if South Africa loses all the funds for PEPFAR. But for now, at least there are still some grants reaching domestic beneficiaries.
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The PEPFAR fund is distributed primarily by two US institutions: the US Organization for International Development (USAID) and the US Centers for Disease Control and Prevention (CDC). Both agencies suspended funds in late January after the initial suspension order, but the CDC resumed funds about two weeks later. This comes after a US federal court ruled that the Trump administration could not freeze funds allocated to Congress.
Although CDC grants appear to be active only until September (at least for South African beneficiaries), uncertainty remains about this.
USAID took a much more difficult line – funds were suspended since late January. By late February, the agency had moved from a suspension of funds to issuing a termination notice to most of its beneficiaries.
In South Africa, approximately 89% of all USAID funds have been cancelled. All cancelled funds will be worth approximately US$261 million (R5.5 billion). Only five other countries facing greater reductions in absolute terms see estimates at all national levels here). Spotlight and Groundup have confirmed that at least a portion of the remaining 11% of USAID funds have started to flow again to domestic beneficiaries.
So, small amounts of USAID funds flow to South Africa, but the CDC funds are almost completely held. It’s unclear how long it will be.
Published by Groundup and Spotlight
