Pepfar projects are exempted from Trump’s ban on aid for South Africa

South African projects funded through the US President’s Emergency Plan for Aids Relief (Pepfar) are exempted — at least until the end of April — from the executive order that US President Donald Trump issued on Saturday. 

The order halts all foreign aid that the US government provides to South Africa, because of what Trump describes as South Africa’s “unjust and immoral practices that harm our nation [the US]”.

According to a high-ranking US embassy official in Tshwane, who asked not to be named, “the order does not impact lifesaving and humanitarian programmes such as Pepfar”.

Such programmes therefore still qualify for a 90-day limited waiver, which will expire towards the end of April, but only for approved activities, which were announced on February 1.   

Pepfar has committed $439,537,828 to South Africa for the current US financial year, which stretches from October 1 2024 to September 30 2025. 

Bhekisisa also confirmed the exemption for Pepfar projects from a second, trusted source, who had confirmation from Pepfar in South Africa that activities may resume under the waiver, once implementing partners — so organisations funded by Pepfar — have received approval letters from their funding agencies. 

Pepfar money in South Africa is mainly channelled to projects and the health department through two agencies, the US Agency for International Development (USAID) and the Centers for Disease Control & Prevention. 

Pepfar funds make up 17% of the health department’s HIV budget; the rest of the money (most of it), goes to NGOs rolling out HIV projects in support of the health department’s goals. 

The exemption falls under section 3(b) of the latest executive order, which says: “The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate.”

Chaos and uncertainty, regardless of the waiver 

What is not sure, however, is what will happen to waiver-approved projects once the waiver and the US government’s 90-day period, during which projects will be reviewed to assess if they align with the Trump administration’s ideologies, expire. 

Trump’s ideologies include, among other things, being anti-abortion, only acknowledging two genders — male and female — and the rejection of diversity, equity and inclusion (DEI) programmes for the appointment of staff members. 

But, says Mitchell Warren of the New York-based advocacy organisation Avac, which receives Pepfar funding and runs projects in East and Southern Africa, things aren’t as simple as “yes, you qualify” or “no, you don’t qualify”. 

“The [acting] head of USAID is US secretary of state Marco Rubio,” he explains. Last week Rubio announced that he won’t be attending the G20 summit in South Africa in November because the country is using the G20 to promote “solidarity, equality and sustainability”. He added: “In other words: DEI and climate change. My job is to advance America’s national interests, not waste taxpayer money or coddle anti-Americanism.”

Warren argues: “So understanding what to do next in how to operate, whether as the government of South Africa or as an implementing partner to Pepfar, is just filled with chaos, and that chaos not only derails programmes in the short term, it also derails relationships between countries and communities.” 

What’s in and what’s out 

The waiver that was issued on February 1 says Pepfar projects can’t restart before the “implementing agency lead deputy principals” have certified that they qualify for the waiver. 

Most South African projects have not yet received such certification letters.

“So we all wonder, does the waiver apply to us or not?” says Linda-Gail Bekker, who heads up the Desmond Tutu Health Foundation at the University of Cape Town, which receives Pepfar funding. “There is a lack of clarity and communication.”

In a second memo, released by the US department of state on February 6, with more details than the first one as to which activities qualify — or not — for the waiver, it is made clear that only tasks within previously approved Pepfar country plans will be allowed. 

Salaries for health workers, laboratory and supply chain staff, who are necessary to carry out approved work, are covered. Such activities include HIV testing, care and treatment services for all population groups, including at mobile clinics or drop-in centres for people with a high chance of contracting HIV. 

It also includes services for pregnant and breastfeeding women and the screening and diagnosis of tuberculosis in people with HIV, as well as preventive TB treatment. 

What it doesn’t cover, however, is HIV prevention medication, also known as pre-exposure prophylaxis (PrEP), for groups other than pregnant and breastfeeding women. The memo states: “People other than [pregnant and breastfeeding women] who may be at high risk of HIV infection or were previously initiated on a PrEP option cannot be offered Pepfar-funded PrEP during this pause of US foreign assistance or until further notice.”

Pepfar supports more than 90% of global PrEP users; four in 10 of them live in South Africa — by the end of August 1.65-million people in the country had used the pill at least once. Though the government procures and pays for the pills, also referred to as oral PrEP, Pepfar covers some of the salaries of health workers and data capturers involved with PrEP projects, according to health minister Aaron Motsoaledi’s presentation to the portfolio health committee in parliament last week.   

Anti-HIV meds donations likely no longer happening 

Moreover, in July, Pepfar promised 231,000 doses of a two-monthly anti-HIV shot, CAB-LA, to South Africa, of which the first batch was to arrive by the end of March 2025. In December, it also committed to join hands with the Global Fund and other donors to pay for enough doses for 2-million people in poorer countries of a six-monthly HIV prevention injection, lenacapavir. The jab lowers someone’s chances of getting HIV through sex to virtually zero. 

Last week, the maker of lenacapavir, Gilead Sciences, applied to get the jab registered for PrEP use through the EU Medicines for All mechanism. South Africa’s medicine regulator, the South African Health Products Regulatory Authority (Sahpra), is part of the process and is providing some of the assessors, says CEO Boitumelo Semete-Makokotlela. Sahpra will use the results of the review process to get the medication registered in South Africa.

But Pepfar-sponsored PrEP, and other forms of HIV prevention, now seem unlikely. 

“Alarmingly, nearly all HIV prevention efforts under Pepfar — aside from programmes for the prevention of mother-to-child transmission — are currently on hold,” write the authors of a Lancet editorial published last week. “Programmes that focus on the prevention of HIV in key populations, HIV prevention services for adolescent girls and young women, voluntary male medical circumcision and support for orphans and vulnerable children are still halted.”

The February 6 memo states that population-based HIV surveys such as the Human Sciences Research Council’s household survey are also not covered by the waiver, and neither are implementation science projects (South Africa has five CAB-LA implementation studies across 16 sites, some of them supported by Pepfar).

Pepfar partners are also not allowed to use funds to plan for the next financial year. 

HIV is the only winner — it thrives in chaos

In South Africa, Pepfar-funded programmes that received stop-work orders were required to close down within two days. As a result, many clinics providing HIV treatment or prevention services have closed or scaled down services. 

The health department has not yet come up with a viable contingency plan to continue services, should the Trump administration close down Pepfar. 

“The flurry of actions really provides an unprecedented amount of whiplash, wondering each day what to do, what not to do,” says Warren. “The only true winner in the HIV response is actually the virus itself. The virus loves chaos. The virus loves instability. The virus loves conflict. 

“So in the midst of all of these orders, what’s really happening is just a pathway for infectious diseases and for instability and that is bad news, no matter what the executive orders say.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.