Withdrawing the United States (US) President’s Emergency Plan for AIDS Relief (PEPFAR) support in South Africa without effectively transitioning to supported services will lead to an estimated 601 000 HIV-related deaths and 501 000 new infections in the next 10 years.
This is according to research co-authored by Professor Linda-Gail Bekker, the director of the Desmond Tutu HIV Centre and the chief executive officer of the Desmond Tutu Health Foundation.
UNAIDS estimates that if PEPFAR were permanently discontinued without alternatives, this could result in an additional 6.3 million AIDS-related deaths and 8.7 million new HIV infections among adults globally by 2029.
In January 2025, at the beginning of US President Donald Trump’s second term, a funding freeze was announced. Initially described as a 90-day pause on US foreign assistance to review and align global aid with US interests, the situation quickly escalated. The US State Department issued a directive for a “stop work order,” which extended the freeze to encompass all foreign aid programmes, including PEPFAR.
Bekker said the decision would have catastrophic effects, jeopardising millions of lives and could completely derail South Africa’s hard-won gains in its fight against HIV/AIDS.
Despite significant progress, nearly eight million South Africans are currently living with HIV. Among them, between one and two million are not receiving treatment, and an estimated 400 000 have never been tested and are unaware of their HIV status. Bekker emphasised that finding and supporting those living with HIV who need to start or resume treatment and stay on lifelong therapy is a challenging task. Locating these individuals is essential for reducing the annual number of HIV-related deaths, which currently stands at 50 000, along with 150 000 new infections each year.
Bekker said around 15 000 trained healthcare providers, along with data capturers and technical support staff, have been placed on furlough. As a result, some public healthcare facilities are not operating at full capacity, and many community-based outreach programmes and services have been suspended.
Additionally, with 50–60% of USAID support staff now released from their positions, clinic queues have diminished, and partner-run clinics have closed, leading to a substantial reduction in data collection.
“Prolonged treatment interruptions, new and missed HIV acquisitions and lost opportunities to intervene will result in more hospitalisations, lives lost, infections acquired and overall increased cost to the healthcare budget over time,” she said.
Together with colleagues from academia and civil society, the researchers suggest the National Department of Health urgently allocates funding in the 2025 public sector health budget to fill currently unfunded posts that are critical for delivering public sector health services, and secure additional and/or reprogramme current Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) funding with an ongoing plan to gradually reduce dependency on these funds.
Doctors Without Borders (MSF) said the issue was not only a global public health crisis, but a full-scale humanitarian catastrophe that demands immediate action, cooperation and a global approach that prioritises the lives of people above all else.
Dr Esther C. Casas, senior HIV/TB advisor, Southern Africa Medical Unit (SAMU) and Claire Waterhouse, head of Operations Support Unit/regional advocacy coordinator said MSF was deeply saddened and angered by the casual inhumanity of these decisions, which will inevitably lead to deaths, suffering, exclusion from healthcare, and the resurgence of preventable diseases.
“Global health was already drastically under-resourced and now the situation has worsened, leaving almost every partner and community group that we work with deeply affected – many have simply ceased to exist. We hear from countless scared and confused patients and research study participants who no longer know where to turn to for care. Healthcare professionals who have lost their jobs reach out to us, still distressed about the wellbeing of their communities. We are seeing the fear in the eyes of our partners previously in USAID/PEPFAR-funded community organisations and NGOs as they fight for the survival of their programmes and their patients.
“These cuts must be reversed. New funders must step in, and existing funders must step up. Affected governments must adapt quickly to mitigate these disruptions and fill critical gaps.”
The Treatment Action Campaign (TAC) said the projected 601 000 HIV-related deaths and 501 000 new infections over the next decade are not just numbers – they represent the lives of South Africans who are at risk of losing access to essential HIV treatment and prevention services.
“South Africa’s public health system, while improving, is not yet at a level where it can independently carry the burden that PEPFAR support currently provides. The risks of treatment disruptions, increased transmission rates, and a general erosion of the gains we have made are too great to ignore.”
Cape Times