Adjusting to a Post-PEPFAR World
Florence Riako Anom woke on 21 January 2025, the day after the US funding freeze was announced, to a world where access to HIV treatment was no longer guaranteed. That single morning crystallised what the abrupt halt of American development funding means in practice: millions of people across Africa suddenly uncertain whether the antiretroviral therapy keeping them alive would continue to reach them. The crisis has exposed how quickly life-saving treatment access can become precarious when international support shifts on geopolitical grounds rather than public health need.
South Africa faces the most immediate threat. Nearly eight million people in the country live with HIV, and the nation was receiving approximately $450 million annually in US HIV aid through USAID and the CDC before the freeze. That support has now evaporated, with CDC contributions scheduled to end entirely in March 2027. Deputy Health Minister Dr Joe Phaahla told journalists at the International AIDS Conference in Rio de Janeiro that South Africa has received no approach from Washington about any replacement arrangement. “We have not been approached with any proposed new arrangement, and indications are that we are not going to be approached,” he said. The US Ambassador to South Africa had scheduled, then cancelled, a planned meeting with the country’s health minister, a signal that factors well outside the health sector are driving the decision.
The human cost is already visible. South Africa has begun laying off workers: 15,000 frontline health workers administering services to the populations most vulnerable to HIV have lost their jobs, with another 10,000 expected to be dismissed when CDC funding ends next year. In Zimbabwe, modelling suggests 75,000 people will contract HIV within the next year unless alternative funding sources emerge.
Zambia occupies a different position, caught between hope and uncertainty. The country has lost $340 million in US government support, but negotiations continue with Washington over a potential Memorandum of Understanding that could unlock new funding. Dr Lloyd Mulenga, Zambia’s National HIV Programme Coordinator, expressed cautious optimism that talks would yield results, though he declined to specify what demands had previously derailed them. Reports from December indicated the US had sought access to Zambia’s mineral resources in exchange for HIV funding, though US officials have publicly denied that critical minerals feature in any MOU discussions.
Meanwhile, the uncertainty has forced immediate, painful choices on the ground. Zambia has eliminated male circumcision programmes, community-based HIV testing, and DREAMS centres designed to protect women and girls from infection. Specialised services for key populations have ceased to exist in many areas, leaving vulnerable groups without the tailored care they depend on.
The speed of the disruption shattered carefully laid plans. Many African countries receiving PEPFAR support had developed five-year sustainability strategies to integrate HIV services into primary healthcare systems. Anom, co-director of the Global Network of People Living with HIV, described how those plans collapsed almost overnight. “The disruption moved all of this into a day or two,” she said.
Dr Mike Reid, former chief science officer for PEPFAR at the US Department of State, resigned in April over what he described as the “sadness and disappointment” of implementing decisions that “make no public health sense.” He wrote that conditioning health assistance on unrelated commercial or strategic objectives undermines the fundamental purpose of the work. “When access to treatment or prevention becomes entangled with access to critical minerals or geopolitical positioning, the work is no longer what it claims to be,” Reid stated. His resignation stands as a rare public acknowledgement, from inside the system, that citizens’ health needs are being subordinated to other agendas.
Countries are now exploring survival strategies. Zambia is investigating whether private clinics can dispense antiretrovirals to reduce pressure on government facilities, a model already pioneered by South Africa. Community-based volunteers are being recruited to support clinic operations. GNP+ is exploring self-managed tools including long-acting pre-exposure prophylaxis and self-testing kits to maintain access for populations too stigmatised to seek care at government facilities. “It’s going to be tough, but we have to find cheaper, sustainable options,” Mulenga said.
The broader question facing these nations is whether makeshift solutions can sustain treatment access for millions while governments negotiate with Washington or seek funding from other sources. Whether people living with HIV in southern Africa can continue accessing the medications they depend on to survive may ultimately hinge on how quickly, and on what terms, those negotiations conclude.