Public health experts and activists warn the sudden cut of US President’s Emergency Plan for AIDS Relief (PEPFAR) will strain an already overburdened public health system, with potential long-term consequences for HIV and tuberculosis (TB) response efforts.

“This is one of the worst days of my career,” says Dr Kate Rees, Public Health Medicine Specialist at Anova Health Institute, during a virtual press conference on Thursday

Overnight, organisations around the world were blindsided by emails from the United States Agency for International Development (USAID) announcing the termination of (PEPFAR) funding, citing US government interests. The decision threatens HIV and AIDS programmes that provide critical treatment, testing, and prevention services, particularly for marginalised communities.

“It is so painful that these terminations mean death to poor people of the world. Key and vulnerable populations are the most affected. These terminations happen at a time when the whole world is bewildered by these outrageous decisions by the Trump administration,” Sibongile Tshabalala, Treatment Action Campaign (TAC) national chairperson tells  Health-e News.

“Over the last 25 years of the PEPFAR programme, many, many millions of lives have been saved and many infections averted,” says Professor Linda-Gail Bekker, Chief Operating Officer of the Desmond Tutu Health Foundation.

Bekker states that South Africa is dealing with epidemics in young women and girls, and in key populations who are particularly vulnerable to HIV infection. “At the same time, they are incredibly underserved by our mainstream services in the HIV response.”

It’s estimated that over 20 million people in the world on HIV treatment were directly supported by PEPFAR. 

“This funding has been closing those specific gaps, reaching the people who may not be coming into public sector clinics because they are highly stigmatised or discriminated against,” says Bekker. 

South Africa, one of the biggest beneficiaries, receives 17% of its overall AIDS programme funding from PEPFAR, which amounts to roughly R7 billion. Experts and civil society members fear the country will be hard-pressed to fill this gap.

A recently published modelling study by Bekker and others suggests that, without PEPFAR funding, the country could see an excess of half a million unnecessary deaths, and up to half a million new infections over the next 10 years.

“I predict a huge disaster, a walk back on the investment,” says Bekker, “unless other resources can be found, and found urgently.”

Impact on public health facilities

Speaking at the virtual press conference hosted by Community Health & HIV Advocates Navigating Global Emergencies (CHANGE), public health expert, Dr Lynne Wilkinson, says that public health facilities will face further challenges. Wilkinson describes the PEPFAR funding as “complementary”, and its absence places increased strain on the system. TB services will also be negatively impacted, she says, resulting in limited screening and testing capacity, leading to undiagnosed cases and increased transmission.

She warns that pre-exposure prophylaxis (PrEP) services for HIV prevention face potential cutbacks, threatening prevention efforts for adolescent girls, young women, and pregnant women. Additionally, there will be no outreach to test individuals outside of healthcare facilities, and case management, including follow-ups for missed appointments, will be discontinued, she says.

UNAIDS suggests that more than 15 000 PEPFAR-funded staff will lose their jobs including those doing vital community-led monitoring at health facilities.  

Key populations at risk

Men, sex workers, transgender persons and people who inject drugs are among the key population groups at greater risk of suffering from the termination of PEPFAR funding.

Kholi Buthelezi, national coordinator at the sex worker movement, Sisonke, says the loss of funding creates serious health and safety concerns for sex workers. Similarly, Aurora Krotoa Moses of the Aurora Kaleidoscope Movement, shares concerns about transgender persons safely accessing services without risk of stigmatisation.

“We feel that our heads are beyond controlling the situation,” says Buthelezi.

“The Trump administration, according to our organisation, has declared war on the right to health globally, not only in South Africa,” says Yvette Raphael, executive director at Advocacy for Prevention of HIV & AIDS (APHA). “In South Africa, healthcare is a human right, and our government has an obligation to secure those rights.”

Government response

Economists that Health-e News spoke with earlier this month said South Africa could cover the funding gap. The health department had issued a circular to temporary measures to prevent service interruptions. 

In response to our questions about the latest developments, spokesperson  Foster Mohale says, “the department has noted the media reports about permanent funding withdrawal on USAID-funded projects in the country, but we have not received a formal correspondence.”

Mohale did not respond to our question about short and long-term plans to address the funding termination.  – Health-e News