US to end PEPFAR HIV funding for South Africa

WASHINGTON — The United States is moving to end its HIV funding for South Africa, a withdrawal that threatens treatment for millions and warns other African countries that rely on the same aid.

The decision matters because South Africa carries the world’s largest HIV burden, and the money at stake — about $400 million a year through the President’s Emergency Plan for AIDS Relief (PEPFAR) — pays for treatment and prevention that the country now has to fund itself. This story is part of Kwacha News’s continuing health coverage.

The State Department said it would phase out PEPFAR programming in South Africa, citing policy disputes and worsening relations between the two governments. Officials framed the move as pushing a middle-income country toward financing its own health system.

What is changing

PEPFAR has been the backbone of South Africa’s HIV response for two decades, contributing roughly $400 million a year and more than $8 billion since the programme was founded under President George W. Bush. The phased drawdown removes that support over time rather than all at once.

South Africa has more than eight million people living with HIV, the most of any country. PEPFAR money funds testing, antiretroviral treatment and prevention, and the gap left by its withdrawal falls on the South African budget and on the patients who depend on those services.

There will be a phased drawdown of PEPFAR programming in South Africa, which has failed to make demonstrable progress on the policy requests of the administration.

— A US State Department official, reported by Semafor

Why it matters

The health stakes are measurable. Modelling cited by researchers suggests the loss of PEPFAR funding could cause between 150,000 and 295,000 additional HIV infections in South Africa by the end of 2028, unless the government finds the money to keep the defunded services running.

South Africa is not waiting. It has begun rolling out lenacapavir, a long-acting injectable that prevents HIV with two shots a year, and is building a new funding model around the Global Fund and its own budget. The question is whether domestic money can replace a $400 million annual hole quickly enough.

The warning travels north. Zambia is itself a major PEPFAR recipient, and a US retreat from its biggest African partner is a signal about the direction of American aid. Kwacha News reported that a US health grant to Zambia is not yet signed, and how tuberculosis still kills as donor funds retreat from Africa.

Background — aid under pressure

PEPFAR is widely credited with saving millions of lives across Africa since 2003, and South Africa was one of its largest beneficiaries. The programme paid for the scale-up of antiretroviral treatment that turned HIV from a death sentence into a manageable condition for many.

The withdrawal is part of a broader cooling between Washington and Pretoria, and a wider tightening of US development spending. For African health systems built on donor money, the shift forces a hard conversation about how to fund care when external support can be cut for political reasons.

Zambia faces the same arithmetic. Kwacha News set out the fiscal case for health taxes in Zambia as governments look for domestic revenue to replace shrinking aid — a debate the South African cut makes more urgent across the region.

What to watch

The first thing to watch is how fast South Africa fills the gap. The size of any extra infections will depend on whether the government can fund treatment and prevention before PEPFAR support runs out.

The second is the lenacapavir rollout. A cheaper, twice-a-year prevention drug could blunt the impact, but only if it reaches enough people in time.

The third is the regional read-across. If Washington can end funding for its largest African partner over policy disputes, other recipients — Zambia among them — have reason to plan for a future with less American aid.

Frequently Asked Questions

These are the questions readers have been asking about the PEPFAR decision. Short answers follow, drawn from official statements and published modelling.

What is PEPFAR?

In short, PEPFAR is the US President’s Emergency Plan for AIDS Relief, launched in 2003. The answer, simply put, is that it funds HIV treatment and prevention abroad. The key is that it has been the backbone of South Africa’s HIV response for two decades.

How does the cut affect South Africa?

The answer is that it removes about $400 million a year. Data shows South Africa has more than eight million people living with HIV, so the loss falls on testing, treatment and prevention that the government must now fund itself.

Why is the US ending the funding?

Simply put, the State Department cited policy disputes and worsening relations, and said a middle-income country should finance its own programmes. Evidence from officials shows the drawdown follows South Africa’s failure to meet the administration’s policy requests.

What are the projected consequences?

According to modelling cited by researchers, the cut could cause between 150,000 and 295,000 additional HIV infections by the end of 2028, unless South Africa covers the defunded services. Analysis shows the outcome depends on how fast that money is found.

Which other countries are at risk?

Research shows other PEPFAR recipients, including Zambia, face the same exposure. The retreat from the United States’ largest African partner signals that aid elsewhere on the continent could also be cut.

Sources

Semafor: Trump administration to end PEPFAR funding for South Africa. NPR: South Africa rolls out HIV shot amid funding shortfalls. Kwacha News coverage: the unsigned US health grant to Zambia, TB and the donor retreat and the fiscal case for health taxes.