The abrupt decision by United States President Donald Trump to suspend and review all foreign aid for 90 days has raised serious concerns about the potential impact on HIV programmes in Africa.
After taking office on January 20, Trump signed several executive orders, including one that halts aid to “foreign countries and implementing non-governmental organisations, international organisations, and contractors” pending an evaluation of whether it aligns with “American interests and … values.”
The order states that “no further U S foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States.”
This directive encompasses the US President’s Emergency Plan for AIDS Relief which has played a critical role in saving millions of lives since it was launched by former President George W. Bush in 2003.
According to Pepfar, as of the end of 2024, the initiative was providing life-saving antiretroviral therapy to nearly 21 million people across 55 countries, many of which are in sub-Saharan Africa.
Additionally, Pepfar delivers pre-exposure prophylaxis (PrEP) to about 2.5 million people, helping to prevent new HIV infections, and facilitated HIV testing for approximately 84 million individuals in 2024.
The programme’s contributions are vital in countries such as Uganda, Namibia, Botswana, Mozambique, Zimbabwe, and others.
In South Africa, where 5.6 million people are on antiretroviral treatment, the government funds the medicines, but Pepfar supports staff for some programmes, as well as prevention and awareness initiatives like ARV user clubs, medical circumcision, and public health messaging.
South Africa’s HIV and TB research efforts, funded in part by the US National Institutes of Health, may also be at risk.
The extent of the executive order’s impact on ongoing funding commitments is unclear. For instance, while some programmes receive monthly disbursements under existing contracts, project managers have reported uncertainty about payments scheduled from February onward.
Even US government representatives involved in these programmes have no clarity due to the language in the order, which specifies that agencies must “immediately pause new obligations and disbursements.”
Professor Linda-Gail Bekker of the Desmond Tutu HIV Centre at the University of Cape Town has warned of potentially dire consequences for African countries if Pepfar funding is reduced or suspended.
“HIV treatment doesn’t stand still,” Bekker explained, stressing that continued access to treatment, PrEP, and quality healthcare is essential.
While South Africa is less dependent on Pepfar compared to other African nations, Bekker noted that countries like Malawi face far greater challenges due to limited health budgets.
“There is no doubt our own national governments need to step up. We know there needs to be more self-reliance,” she said. However, she also cautioned that a sudden cessation of donor funding could have “disastrous” consequences.
Research from 2024 demonstrates that interruptions in antiretroviral therapy significantly increase mortality rates among South African adults.
Over the years, Pepfar has evolved from addressing an emergency at the height of the AIDS epidemic in the early 2000s to strengthening health systems in affected countries.
In Malawi, Pepfar allocations for 2024 and 2025 are $180 million and $178 million, respectively, making it one of the nation’s two largest HIV intervention funders alongside the Global Fund. According to the National AIDS Commission of Malawi, the country urgently needs to sustain and accelerate its response to meet the goal of ending AIDS as a public health threat by 2030.
The future of Pepfar funding remains uncertain under the executive order.
The US Agency for International Development (USAID) did not respond to inquiries about the situation before publication.
Compounding the uncertainty, Trump also signed an executive order withdrawing the US from the World Health Organization.
Reuters reports that the US, as the WHO’s largest funder, must serve a 12-month notice period before ceasing all financial contributions to the organization.
