The U.S. State Department is phasing out support for South Africa’s HIV programs under the President’s Emergency Plan for AIDS Relief (PEPFAR), with most funding slated to end by September 30. Experts warn this withdrawal, which represents a loss of roughly $400 million in annual aid, threatens to reverse progress in HIV prevention, treatment, and patient retention across the nation with the world’s largest HIV epidemic.
Financial Gaps and Healthcare Infrastructure
While the South African government established a $45 million emergency fund last year, it remains a fraction of the $400 million annual shortfall created by the PEPFAR drawdown, according to Roger Shapiro, a professor of immunology and infectious diseases at the Harvard T.H. Chan School of Public Health. Shapiro notes that while antiretroviral treatment programs are likely to be prioritized, the funding gap will manifest in diagnostics, prevention services, and outreach to high-risk populations.
The transition is already impacting local service delivery. Twelve specialized clinics serving sex workers and other marginalized groups have closed, forcing over 60,000 patients into the public health system. This migration risks overwhelming state facilities, where Shapiro points to concerns regarding stigma, longer wait times, and weaker follow-up care that could lead to patients dropping out of treatment.
Did you know?
PEPFAR has been credited with saving an estimated 26 million lives across more than 50 countries since its inception in 2003.
Impact on HIV Prevention and New Medications
The loss of funding complicates the rollout of newer medical interventions, including the long-acting HIV prevention drug lenacapavir. Although South Africa launched lenacapavir in June 2026, its success relies on a complex support system—including HIV testing, counseling, and regular follow-ups—that was historically bolstered by PEPFAR and USAID resources.
Shapiro warns that the current trend points toward a deterioration in the “HIV care cascade.” This includes fewer viral load tests, delayed diagnoses, and reduced uptake of pre-exposure prophylaxis (PrEP). Modeling cited by researchers suggests that without adequate replacement funding, South Africa could face between 56,000 and 65,000 additional AIDS-related deaths between 2025 and 2028, with the potential for over a million additional infections over the next two decades.
Research and System Resilience
The broader health system in South Africa faces a loss of data-driven coordination. PEPFAR provided not only direct care but also the infrastructure to monitor the implementation of HIV services nationwide. The withdrawal of support further complicates the environment for clinical trials, particularly as South African researchers also navigate challenges related to U.S. National Institutes of Health (NIH) grant funding.
Despite these systemic pressures, some specialized research programs have shown resilience. Shapiro’s own pediatric HIV cure program in Botswana, for instance, utilized private donations to bridge funding gaps during 2025. This research has successfully demonstrated that broadly neutralizing antibodies can maintain viral suppression in children, offering a potential path toward HIV remission.
Frequently Asked Questions
Why is PEPFAR funding ending in South Africa?
The U.S. State Department announced a formal phased drawdown of PEPFAR support for South Africa. This follows a period of budget fluctuations, including foreign aid cuts during the 2025 fiscal year.
What is the risk to HIV patients during this transition?
According to Roger Shapiro, the primary risk is a “deterioration in the HIV care cascade.” This means fewer people will receive testing, start treatment, or maintain viral load monitoring, potentially leading to higher infection and mortality rates.
How does this affect the rollout of new drugs like lenacapavir?
While lenacapavir is available in some public clinics, the drug requires consistent counseling, follow-up, and laboratory testing. The reduction in community-based services makes it significantly harder to sustain the infrastructure needed for these treatments.
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