By Ifeoluwa Akinola, Lagos
The decision by President Donald Trump’s administration to cut the vast majority of its foreign aid programs has devastated the global HIV/AIDS effort—and left its leaders seething. South Africa’s HIV/AIDS program, the world’s largest, has been thrown into turmoil, researchers, clinicians, and advocates said yesterday during an impassioned press conference. And the fate of the Joint United Nations Programme on HIV/AIDS (UNAIDS), which relies on U.S. funds to help track and coordinate the global response, is in jeopardy.
“It is a huge crisis,” says epidemiologist Peter Piot, who ran UNAIDS from its inception in 1995 until 2008 and is now at the London School of Hygiene & Tropical Medicine. Zimbabwe, Zambia, and other hard-hit countries in Africa may soon run out of anti-HIV drugs as a result of the cuts, Piot says.
On Tuesday, the U.S. Department of State said it was terminating 5800 of 6300 foreign aid contracts issued by the U.S. Agency for International Development (USAID), which the Trump administration has effectively closed down. Many in the global health and development community are still trying to get a complete picture of the damage impact.
There had been some hope that global HIV/AID efforts backed by USAID would be spared. In response to loud protests against the freeze on U.S. foreign aid, announced by Trump on 20 January, the State Department offered waivers to “life-saving” projects 4 days later. People running such projects complained the waiver program was badly flawed, but they held out hope that funding would be restored after a 90-day review of all foreign aid programs the U.S. government said it would undertake.
This week’s terminations signal that the review has been completed. “The whole story is now over,” said Linda-Gail Bekker, an HIV/AIDS researcher at the University of Cape Town who spoke at the press conference.
For South Africa, which has 8 million people living with HIV and 150,000 new infections each year, the effects could be dramatic. The country is the largest recipient of USAID’s President’s Emergency Plan for AIDS Relief (PEPFAR), receiving $462 million in fiscal year 2023. (PEPFAR, which operates in more than 50 countries, has been credited with saving some 26 million lives since its creation in 2003 under then-President George W. Bush.)
South Africa is already paying for 83% of its HIV/AIDS efforts itself, and PEPFAR, which has been pushing countries to “own their epidemics,” intended to phase out most funding in about 5 years. But global health experts doubt the country, which has many other health care demands, can find the funds to fill the gap faster. “Instead of a careful handover, we’re being pushed off a cliff,” said Kate Rees, an epidemiologist with South Africa’s Anova Health Institute, which has also seen its funding terminated.
Bekker, who runs many South African programs to treat people living with the virus and to prevent its spread, was equally pessimistic at the press briefing “I predict a huge disaster,” she said. If PEPFAR’s funding is not replaced, South Africa could have 565,000 additional new HIV infections and 601,000 more deaths from the virus by 2034, Bekker and colleagues reported in the Annals of Internal Medicine on 11 February. The extra health care required would cost $1.7 billion. “I look to our own South African government urgently to say: How do we ensure that we fill the gaps so that lives are not lost and infections are not incurred?” Bekker said yesterday.
Other speakers at yesterday’s press conference also warned about the harm the cuts may do. “As an activist, as a person living openly with HIV, I just want to say here that I’m very hurt with what is happening, and it’s very sad,” said Sibongile Tshabalala, chair of the Treatment Action Campaign, the country’s leading HIV/AIDS advocacy organization. “How am I going to survive?”
The PEPFAR cuts will have profound knock-on effects, said Lynne Wilkinson, who helps deliver HIV services in Cape Town for the International AIDS Society. For example, because tuberculosis (TB) is the leading cause of death from people who develop AIDS, care for the two diseases is intertwined. “This is the entire HIV and TB program put at risk of unraveling,” Wilkinson said.
PEPFAR also supports South Africa’s public health facilities, she noted, providing funds for the monitoring and evaluation of clinics and counselors who do HIV testing. Losing this money “means we don’t know who has come for treatment and who hasn’t, and so we can’t find the people who have missed their appointments and help them back,” Wilkinson noted. This, in turn, can lead to people taking suboptimal treatment doses, which can lead to drug resistance.
Other top PEPFAR beneficiaries in the region—including Tanzania, Mozambique, Zambia, Zimbabwe, and Malawi—have much weaker economies and face even larger challenges to replace PEPFAR support.
UNAIDS, which tracks the epidemic and provides technical and advocacy support to all countries, saw its PEPFAR support—good for half of the agency’s $200 million budget—disappear as well. “It was a shock,” says epidemiologist Angeli Achrekar, UNAIDS’s deputy director. “We expected a 90-day review would take place, as had been described earlier.” Achrekar says it’s not yet clear whether UNAIDS will have to lay off some of its roughly 600 employees.
Many of the groups UNAIDS works with have also received termination notices, Achrekar says. “This not only impacts UNAIDS, but the entire global HIV response,” she says. “I don’t know how that squares with the fact that just a couple of days ago, they were issued the go ahead per the waiver to implement these essential, lifesaving services.”
PEPFAR had a $6.5 billion budget in fiscal year 2024, $4.8 billion of which was “bilateral aid” that went directly to countries. Some 60% of that flowed through USAID, whereas the rest went to the U.S. Centers for Disease Control and Prevention and the Department of Defense. It’s unclear whether or how long those non-USAID funds will continue to flow and how cutting USAID will disrupt those interconnected programs. (Most of the remaining $1.7 billion in PEPFAR’s budget goes to the Global Fund to Fight HIV, AIDS and Malaria, which has not yet been trimmed but could still be a target.)
“These are not mere programs to be switched on and off by decree,” says Jirair Ratevosian of the Duke Global Health Institute, former chief of staff at PEPFAR. “This will be a bloodbath. Millions will suffer as a result of these actions, and global health—and the very notion of solidarity—will be unrecognizable.”
Piot is similarly gloomy. “If it were not so abrupt, countries could explore alternative funding, but not in a few weeks,” he says. As to UNAIDS, he adds, “I don’t see how it can survive.”