The United States Is Ending PEPFAR in South Africa. Here's What That Could Mean.
Why This Decision Matters Beyond HIV
This week, reports emerged that the Trump administration plans to phase out PEPFAR support for South Africa, with program awards winding down and remaining support ending by early 2027. If fully implemented, it would mark one of the most consequential shifts in U.S. global health policy since PEPFAR was created more than two decades ago.
The Largest HIV Program in the World
I spent several years helping oversee the South Africa program as PEPFAR Chair (an internal designation for oversight responsibilities at State Department). During that time, South Africa represented one of the largest country investments in the entire PEPFAR portfolio. The annual budget was roughly $425 million (FY 2023), accounting for nearly one in every ten PEPFAR dollars spent globally. Since 2003, the United States has invested more than $8 billion in South Africa’s HIV response. More importantly, South Africa was often where new ideas, new technologies, and new approaches were tested before they spread elsewhere.
The immediate debate will focus on HIV services, and understandably so. South Africa is home to the largest HIV epidemic in the world, with roughly eight million people living with HIV. Although South Africa finances most of its HIV response from domestic resources, the massive annual PEPFAR investment has historically supported health worker salaries, community-based organizations, prevention programs, surveillance systems, and other supportive care and treatment programs. According to PEPFAR’s own data, 72.84% of people living with HIV are on treatment with support from PEPFAR as shown here from amfAR.
A Transition Already Underway
The reality is that this transition has already been underway for months. Earlier this year, South Africa was notably excluded from the bilateral agreements and memoranda of understanding that the administration pursued with several PEPFAR countries. Instead, South Africa received a much smaller bridge funding arrangement that represented roughly one-quarter of its previous annual PEPFAR budget ($115 million), a dramatic reduction from historical levels. I suspect – based on inclusion in a recent congressional notification – they are expecting another roughly $100 million to support existing commitments through the end of the fiscal year, and workforce obligations through early 2027 as reported, and necessary closeout activities.
See trend chart below:
It is also important to understand what PEPFAR funded in South Africa. Unlike many countries, South Africa largely finances its own HIV treatment program and purchases most of its own antiretroviral medicines. PEPFAR support was concentrated in areas that are often harder to absorb quickly, including HIV prevention, voluntary medical male circumcision (VMMC), DREAMS programs for adolescent girls and young women, orphans and vulnerable children (OVC) programs, community-based services, surveillance, and portions of the health workforce. Those are precisely the areas most vulnerable when external funding declines and often the hardest to rebuild once lost.
But focusing only on HIV misses the larger story.
The Clinical and Community Research Ecosystem at Risk
For years, South Africa has served as one of the world’s most important engines of biomedical innovation. Some of the leading HIV researchers, epidemiologists, laboratory scientists, and clinical trial networks are based there. Many of the breakthroughs that have shaped the modern HIV response were developed, tested, or validated in partnership with South African institutions.
And yes, that includes lenacapavir, the twice-yearly HIV prevention injection that many believe could fundamentally change the trajectory of the epidemic. The landmark PURPOSE trials that demonstrated extraordinary efficacy were conducted in South Africa and neighboring countries. The same research ecosystem is expected to play a major role in evaluating future prevention technologies, including Merck’s monthly oral prevention candidate, MK-8527, and whatever comes next after that.
When people hear the phrase “foreign aid,” they often picture money leaving the United States. What they miss is that much of this investment helped create scientific infrastructure that American universities, pharmaceutical companies, and biotechnology firms rely upon today.
South Africa’s research leadership is closely tied to its ability to conduct large, well-powered studies and generate answers quickly. That combination of scientific expertise, clinical infrastructure, community engagement, and participant recruitment has made the country one of the most important centers of HIV research in the world.
The irony is hard to miss. Earlier this month, global leaders traveled to South Africa to celebrate the rollout of the world’s first lenacapavir injections. Among them were Gilead CEO Daniel O’Day, Global Fund Executive Director Peter Sands, government officials, scientists, and advocates. They came to celebrate a breakthrough that was made possible, in part, by the very research ecosystem that decades of U.S. and global investment helped build. Only weeks later, we are discussing the withdrawal of one of the largest partnerships that helped create it.
The Omicron Lesson
The world got a reminder of this in late 2021 when South African scientists identified and rapidly characterized the Omicron variant. Their ability to do so reflected years of investment in laboratories, surveillance systems, genomic sequencing, and scientific talent. Much of that capacity was strengthened through HIV programs and related public health investments.
Global health security is often discussed as though it exists separately from disease-specific programs. In reality, the opposite is true. The laboratories that monitor HIV frequently support tuberculosis surveillance. The scientists who study HIV often contribute to pandemic preparedness. The data systems built for one disease become the foundation for detecting the next threat.
The Missing Transition Plan
To be clear, there is a legitimate discussion to be had about sustainability. PEPFAR was never intended to last forever. South Africa is a middle-income country and has assumed increasing responsibility for financing its own HIV response. That trend will continue regardless of who occupies the White House.
The question is not whether transition should happen.
The question is whether it is being managed responsibly.
That concern becomes more pressing because the United States is not the only donor reducing support. The Global Fund recently informed South Africa that its next allocation will fall from approximately $464 million to about $345 million, a reduction of roughly 26 percent. Multiple streams of external financing are shrinking at the same time, creating a much different environment than previous transition discussions.
Before implementing a decision of this magnitude, the State Department should publish a transition plan and a public impact assessment.
That assessment should examine South Africa’s fiscal capacity, workforce needs, research infrastructure, surveillance systems, and prevention programs. It should evaluate what other donors are doing and identify where financing gaps are likely to emerge. It should also consider the implications for scientific research, pharmaceutical development, and global health security.
If the administration believes South Africa can absorb these responsibilities, it should show the evidence.
What Are We Prepared to Lose?
The United States has every right to redefine its relationship with South Africa. But a decision with consequences this large deserves more than a press leak.
This decision affects the country that remains home to the world’s largest HIV program, represents roughly one-tenth of the global PEPFAR portfolio, has received more than $8 billion in historic U.S. investment, houses some of the world’s leading HIV research institutions, helped validate breakthrough prevention tools such as lenacapavir, and contributed to the scientific infrastructure that alerted the world to the Omicron variant.
For more than twenty years, South Africa has been one of the most important partners in the global HIV response. It has also been one of the world’s most important contributors to public health science.
Before we walk away from that partnership, we should understand exactly what we are leaving behind.