Despite countries having instituted sustainability plans to increase domestic responsibility over the coming five years period for PEPFAR supported programmes, allowing for a careful and well-prepared handover, they are now being pushed off a cliff through the abruptness of this action said Dr Kate Rees, an epidemiologist with South Africa’s Anova Health Institute. Even South Africa, which already covers 83% of its HIV programme will struggle to match and meet investment needs while twenty-five countries across Africa remain heavily reliant on PEPFAR and USAID (covering anything from 30 to as much as 90% of their HIV programme). It is for this reason that Prof Linda-Gail Bekker, CEO of the Desmond Tutu Foundation, in an online press conference ‘predicts a huge disaster, unless other sources can be found urgently’.

Following the initial Stop Work Order late in January, with subsequent funding cuts made to WHO and UNAIDS, and the recent termination of USAID and PEPFAR awards to hundreds of implementing partners, the global and local HIV response is being hit hard. From across the PATA network, and despite government contingency plans, we are receiving reports that many dedicated and committed health providers, stretching from peer supporters, mentor mothers, data captures, counsellors, testers and sample drivers to nurses, clinicians and specialists, have been retrenched and their livelihoods threatened, with almost no notice. Clinics that were lifelines for HIV care, ARV distribution, and maternal and child health services or specialist care and mobile services to key and vulnerable populations, have been shut down overnight. In some countries, the ARV supply chains, and availability of test-kits and other reagents are already under strain, potentially leaving hundreds of thousands without the treatment and quality care needed to survive and thrive.

For patients and communities, critical services have already been impacted, including HIV testing, following up on positive HIV tests for babies, or managing advanced HIV disease in children. Adolescent girls and young women, pregnant and breast-feeding women are at risk of not receiving HIV prevention prophylaxis, with vertical transmission prevention strategies, antenatal and postnatal care, and follow-up faltering. Community-led monitoring systems, as well as wrap-around psychosocial, OVC and GBV support and differentiated service delivery options for prevention and treatment in the community, have been heavily impacted. This will limit linkage to services, and undermines community-led efforts in strengthening retentions in care and treatment adherence while also tackling stigma and discrimination.

Many of the health systems strengthening processes, infrastructure, and capacity supported by PEPFAR and already integrated into the national health system, if removed abruptly, will lead to severe gaps, and, in some instances, could even result in the entire HIV programme and related health system collapsing. At a minimum this will place existing health systems under increased stress, while an already overstretched workforce will be faced with increased responsibilities, amidst a severe lack of capacity, a depletion of skills, and a growing scarcity of commodities and other tools needed to effect quality care. Across several countries, and from local partner reports, health information systems are also at risk. We have seen an exodus of data capturers, with data not being recorded or being done by busy clinic staff. The loss of data quality will have a direct impact on our ability to effectively monitor and manage cases or timeously follow up on those who have missed appointments. This will also have a direct impact on national HIV surveillance overall, undermining the accuracy of data that can effectively guide decision making decision-making and track progress along the HIV cascade against established targets.

According to the Anderson Office of Public Policy there were more than 20 million people supported by PEPFAR on antiretroviral treatment. Based on FY2024 dispensing data, globally this means there are 222,333 people, including 7,445 children under the age of 15, receiving treatment and picking up new supplies of ARVs every single day. The majority of people on treatment supported by PEPFAR reside in Africa, with the PEPFAR Impact Tacker estimating that the funding freeze and now termination of awards has already resulted in 16,309 adult deaths, and 1,736 child deaths, as of the 3rd March 2025, with this increasing daily. In South Africa alone, according to Prof Linda-Gail Bekker this may result in half a million new infections and AIDS related deaths over the coming decade.

In the words of Winne Byanyima, UNAIDS Director, ‘Without funding for the HIVE response, we risk reversing progress and face a resurgent AIDS pandemic. If we want national governments to plug the gap, we must give them the means to do so. While many countries and affected governments have responded and shown commitment to secure additional domestic resources and have put in place contingency plans, with efforts to rapidly integrate services, the financing and operational procedures to implement this, to offset current disruptions have not been applied with the urgency required.

In an open letter to all African Heads of State, sent by the CHANGE Network, highlighting that the US Government’s shift in Foreign Aid policy will leave two-thirds of health programs, particularly those targeting HIV, TB, and malaria, in limbo, initiating a dangerous setback for health progress and exacerbating health inequities across Africa. The open letter calls upon Presidents and all Heads of State of Africa, to take immediate and concrete action to address the health financing crisis and prioritise investments in sustainable health systems. These recommendations provide several practical and measurable actions that include increasing domestic financing, increasing health budget allocations, and restructuring debt whilst also taking immediate steps to address the current crisis, and provide a bold emergency response that must move beyond rhetoric and act now to close the current funding crisis, strengthen health systems, and protect millions of lives. This emergency response must ensure that it makes the necessary emergency funding available, devises an emergency plan with key stakeholders and implementing partners that can, in the short and medium term, ensure that services are not interrupted, commodities are secured, systems are maintained, and health capacity is increased and deployed to meet operational and procedure guidelines, while not compromising quality standards and care.

Luann Hatane
Executive Director