US funding cuts could cause over 150,000 additional HIV infections in SA by 2028 — new study

The cancellation of the US President’s Emergency Plan for Aids Relief (Pepfar) funding to South Africa could cause between 150,000 and 295,000 additional HIV infections by the end of 2028. This is unless the South African government covers some of the defunded services.

These are the preliminary findings of a new modelling study commissioned by the national health department to look into the impact of Pepfar funding cuts in South Africa. It was authored by researchers at the University of Cape Town (UCT) and Wits University. Pepfar is a multibillion-dollar US initiative that supports HIV-related services globally, but which has been significantly slashed by the Trump administration since February.

The research on South Africa comes at the same time that a separate modelling study was published in The Lancet which found that the discontinuation of Pepfar could cause an additional 1-million HIV infections among children in Sub-Saharan Africa by 2030. This would lead to the deaths of about 500,000 children, according to the study, while more than 2-million others would be left orphaned.

On January 20, US President Donald Trump, issued an executive order which suspended virtually all US foreign development assistance for 90 days pending a review. As a result, US-backed aid programmes were brought to a standstill across the world, including in South Africa. While a waiver was published which supposedly allowed some Pepfar-related activities to continue, this had a limited effect in practice.

Since then, some US grants have resumed, while others have been cancelled. The value of all terminated grants comes to tens of billions of dollars globally. In South Africa, numerous awards have been cancelled from Pepfar, which provided roughly R7.5bn to nonprofits in the country in 2024. These organisations primarily used the money to hire and deploy health workers in government clinics, or to operate independent health facilities. Many of these have now been forced to close.

While there are still some active Pepfar grants in South Africa, it’s unclear how much longer these will be retained, as many are approved only until September. The new study focusing on South Africa models what would happen if all Pepfar funding was eliminated.

Up to 65,000 additional deaths expected by 2028

In 2024, roughly 78% of all people who had HIV in South Africa were on antiretroviral (ARV) treatment. This figure has been steadily rising over time. By 2026, it was expected to climb to 81%, according to Dr Lise Jamieson, lead author of the local modelling study.

But this trend will be reversed if the entire Pepfar programme is cancelled and the government fails to step in. ARV coverage among people with HIV would drop to 70% by 2026, according to the study. Under the model’s more pessimistic scenario, the figure would drop even lower — to 59% by 2026.

This is partly because some people living with HIV in South Africa get their ARVs directly from Pepfar-funded drop-in centres. If these centres close down, some patients may stop taking their ARVs. Indeed, this is precisely what happened after one centre in Pretoria stopped providing services.

The loss of Pepfar funds could also hinder the health system’s capacity to get newly infected people on HIV treatment. For instance, Pepfar-funded organisations had employed nearly 2,000 lay counsellors across South Africa who tested people for HIV. Without these staff, fewer people will be diagnosed and get started on treatment.

Not only will ARV coverage drop due to the cuts, but HIV prevention services will also be affected, according to the study. For instance, Pepfar-funded drop-in sites had been providing people with pills that prevent HIV, called pre-exposure prophylaxis (PrEP). These services were targeted at groups most likely to contract and transmit HIV, like sex workers. According to the new modelling study, the full termination of Pepfar would lead to as much as a 55% reduction in PrEP coverage for female sex workers by 2026.

Because of factors like these, the researchers estimate that the Pepfar cuts would cause between 56,000 and 65,000 additional HIV-related deaths in South Africa by 2028. By 2045, this would increase to between 500,000 and 700,000 deaths.

89% of USAID contracts terminated in South Africa

All of these results only hold if the South African government fails to step in, according to Jamieson. The modelling study finds that to cover all Pepfar services from 2025 to 2028, the government would need to spend an extra R13bn-R30bn in total.

It’s unlikely that the government will cough up this amount, but Jamieson says the health department is taking steps to identify and support certain key services that were defunded by Pepfar. She is thus hopeful that the results may not be as drastic as what the study suggests.

Another caveat is that the modelling study estimated what would happen if South Africa lost all its Pepfar funding. But, at least for now, there are still some grants reaching beneficiaries in the country.

Pepfar funds are primarily distributed by two US agencies — the US Agency for International Development (USAID) and the US Centers for Disease Control & Prevention (CDC). While both agencies paused funding after the initial suspension order in late January, the CDC resumed its funding roughly two weeks later. This was after a US federal court ruled that the Trump administration could not freeze congressionally appropriated funds.

CDC grants appear to be active only until September (at least for South African beneficiaries), though uncertainty remains about this.

USAID has taken a much harder line — funding was suspended from late January, and by late February, the agency moved from pausing funds to issuing termination notices to most of its beneficiaries.

In South Africa, roughly 89% of all USAID funding has been cancelled. The value of all cancelled funds comes to about $261m million. Only five other countries have faced larger cuts in absolute terms (see all country-level estimates here). Spotlight and GroundUp have confirmed that at least some of the remaining 11% of USAID funding has once again begun flowing to beneficiaries in the country.

Thus, a small amount of USAID funding is trickling into South Africa, while CDC funds have largely been retained in full. But it’s unclear for how much longer.

* This article was produced by Spotlight and GroundUp.