The abrupt halt of PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) funding to South Africa threatens the country’s fight against HIV, putting thousands of healthcare workers’ jobs at risk and disrupting treatment for millions of patients.

The big picture

With 7.8 million people living with HIV, South Africa now faces a funding shortfall of around R8 billion that could upend progress made in reducing infections and deaths.

Addressing Parliament on Thursday 6 March, Health Minister Dr Aaron Motsoaledi outlined events since US President Donald Trump initially announced a funding freeze in January, warning that reductions in PEPFAR funding could have severe consequences for South Africa’s HIV response, but is also a much needed wake-up call.

By the numbers

• 5.5 million South Africans rely on antiretroviral therapy (ART), with PEPFAR supporting services in 27 high-burden districts.
• Of the 271,606 staff working on HIV, TB, and STI programmes, 15,154 were funded by PEPFAR, primarily through NGOs and academic institutions.
• 150 NGOs depended on PEPFAR support, with 39 serving as principal implementing partners.
• 90% of ART procurement is funded by the South African government, while the remaining 10% is covered by the Global Fund.

South Africa’s response

Motsoaledi outlined a multi-pronged strategy to mitigate the impact:

• To redeploy staff from less busy areas to areas that are highly burdened;
• To initiate task-shifting to cover up the skills that might have been lost with the departure of PEPFAR-paid staff;
• To encourage as many patients as possible to get 3 months ART if they are stable. 
• To further transition to 6-month dispensing so that they only visit facilities twice in one year;
• To integrate all the vertical programmes of PEPFAR into the state primary healthcare programmes.

Funding

The Department of Health has met with the following donors:

• CHAI (Clinton Health Access Initiative);
• ELMA Foundation
• Gates Foundation
• FCDO (Foreign and Commonwealth Development Office) of the United Kingdom (UK)
• First Rand
• AFD (French Development Agency)

“All of these institutions have promised that they will see what they can do. Let us realise that there is no government or a funder who had some spare cash somewhere waiting for Trump to erupt,”-Motsoaledi.

Progress and gaps 

While South Africa has made significant strides in the fight against HIV – reducing HIV-related deaths by 51% since 2010 and lowering mother-to-child transmission by 70% – it remains short of its 95-95-95 targets, achieving 96-79-94. The biggest gap is in ART coverage, with 1.1 million diagnosed individuals still not on treatment. An intensive campaign was launched last month to find and treat these individuals by November. 

Motsoaledi said the government is committed to maintaining the progress made in reducing HIV-related deaths, mother-to-child transmission of HIV, and new TB cases. The focus remains on ensuring that no one is deprived of essential ARV treatment.

What next?

Motsoaledi challenged parliamentarians to consider the sustainability of state subsidies for private medical aid, suggesting that these funds could be redirected to bolster public healthcare during this critical period. 

“I have a challenge for this House. Each Member of this House, together with everybody who draws a salary from the State and is on a medical aid is getting a heavy subsidy from the State to stay on private medical aid. Should we continue drawing subsidies from the State under these harsh conditions for the poor?”