For over two decades, South Africa’s fight against HIV and AIDS stood as a global success story. From dusty townships to inner-city clinics, millions of lives were saved thanks in part to one foreign aid programme: the United States President’s Emergency Plan for AIDS Relief (PEPFAR). But in a sharp reversal, Washington has now pulled the plug—and the silence from the government in Pretoria is as deafening as the cries from abandoned patients.
Across South Africa, clinics that once bustled with outreach workers, stockrooms, and queues of hopeful patients are shuttering doors. The American decision to stop funding key programmes, especially those focused on vulnerable populations like sex workers, drug users, and transgender people, has left thousands without access to antiretroviral therapy. “We are back where we started,” says Lindiwe Mokgoro, a nurse who worked at a Johannesburg clinic that closed last week. “All that progress—they’re pulling it out by the roots.”
At the heart of the crisis is a policy shift driven by politics in the United States. Officials claim it’s about making partner countries take “ownership” of their healthcare systems. But health advocates say the move is driven by a growing backlash in US domestic politics against funding reproductive health and harm reduction services abroad. “Let’s be honest,” says Nomvula Sithole, a rights activist in Cape Town. “This isn’t about sustainability—it’s about ideology.”
South Africa has the largest HIV-positive population in the world, with more than 7.5 million people living with the virus. While the national government does fund a large portion of the response, it has long relied on international aid to plug critical gaps. The US alone contributed over $800 million annually in recent years, supporting not just medication but education, community outreach, and treatment for marginalised groups.
Now, NGOs that depended on these funds are downsizing or disappearing. Outreach to vulnerable communities has collapsed. One mobile health unit in KwaZulu-Natal that tested thousands of sex workers every month is now a rusting van with deflated tyres. “We’re losing people every day,” says Sipho Dlamini, who ran a community testing programme in eThekwini. “And no one is counting the bodies.”
The national government’s response has been puzzling. While President Cyril Ramaphosa’s office acknowledged the funding gap in April, no detailed rescue plan has been shared since. Insiders say internal political battles and economic pressures have paralysed the cabinet. “It’s as if the state is hoping civil society will fix this with bake sales,” said one health policy researcher.
For many affected, the crisis isn’t abstract—it’s terrifyingly real. Thulani, a 26-year-old sex worker living with HIV, was turned away from his clinic this week. “They said I should go to a hospital, but that’s four taxis and a full day’s travel,” he said. “I don’t have that kind of money.”
The collapse of these programmes threatens more than individual lives—it risks reversing national progress. South Africa’s HIV prevalence rate has stabilised in recent years, and new infections have been declining. That trend is now under threat. “It’s like cutting parachutes halfway through a skydive,” says Dr. Tania van Rensburg, a public health expert at Wits University. “The plane’s gone. And we’re in freefall.”
International organisations are watching closely. UNAIDS has expressed “grave concern,” and the Global Fund has signalled possible emergency reallocation of resources. But stopgaps won’t fix a long-term rupture. “What’s needed is political will,” says Sithole. “Pretoria must decide—do they let their people die for pride, or do they step up?”
Some analysts see this as a wake-up call for South Africa to take fuller ownership of its public health response. Others fear it will simply be the poor who pay the price. Either way, one thing is clear: in the communities hardest hit, the pandemic is far from over.
“The virus didn’t get the memo,” says Mokgoro, bitterly. “It’s still here. But the help is gone.”
