US Aid Freeze Exempts Pepfar, but HIV Prevention Efforts Hang in the Balance
South Africa’s HIV programs funded by the US President’s Emergency Plan for Aids Relief (Pepfar) have been temporarily exempted from a sweeping foreign aid freeze ordered by US President Donald Trump.
The freeze, announced on Saturday, targets South Africa over what Trump describes as “unjust and immoral practices” harming US interests. However, Pepfar’s lifesaving initiatives will continue under a 90-day waiver, set to expire at the end of April.
A Lifeline for South Africa’s HIV Response
Pepfar is a cornerstone of South Africa’s fight against HIV, contributing $439.5 million for the current US financial year (October 2024 to September 2025).
This funding supports critical services like HIV testing, treatment, and tuberculosis screening, as well as salaries for health workers and lab staff.
According to The Mail & Guardian, the exemption, granted under Section 3(b) of Trump’s executive order, allows agency heads to continue aid deemed “necessary or appropriate.”
However, the waiver comes with significant limitations. Anti-HIV preventive medication (PrEP) is excluded for most groups, except pregnant and breastfeeding women.
This is a major setback, as Pepfar supports over 90% of global PrEP users, with 40% residing in South Africa. Additionally, population-based HIV surveys and implementation science projects—including studies on the long-acting HIV prevention injection, CAB-LA—are not covered.
Chaos on the Ground
The exemption has left implementing partners—NGOs and agencies that receive Pepfar funding—in a state of uncertainty. Before resuming activities, these organizations must receive approval letters from their funding agencies. Most South African projects have yet to obtain these certifications, leading to widespread confusion.
“We all wonder, does the waiver apply to us or not? There is a lack of clarity and communication,”said Linda-Gail Bekker, head of the Desmond Tutu Health Foundation.
Mitchell Warren of Avac, a New York-based advocacy group, echoed these concerns.
“The only true winner in the HIV response is the virus itself. The virus loves chaos, instability, and conflict.”
Global Implications of the Aid Freeze
The pause in US foreign aid has far-reaching consequences. Pepfar had pledged 231,000 doses of CAB-LA, a two-monthly HIV prevention injection, to South Africa, with the first batch expected by March 2025.
The program also committed to funding lenacapavir, a six-monthly HIV prevention injection, in partnership with the Global Fund. These initiatives are now in jeopardy.
A recent editorial in The Lancet warned that the disruption could reverse years of progress in the global fight against HIV.
“Nearly all HIV prevention efforts under Pepfar—aside from programs for the prevention of mother-to-child transmission—are currently on hold,” the authors wrote.
What Lies Ahead?
The 90-day waiver provides a temporary reprieve, but the future of Pepfar-funded projects remains uncertain.
The Trump administration has mandated a review of all foreign aid programs to ensure alignment with its ideologies, which include opposition to abortion, rejection of diversity, equity, and inclusion (DEI) initiatives, and a binary view of gender.
For now, stakeholders are left navigating a landscape of uncertainty, hoping for a resolution that prioritizes public health over political ideologies.
As Warren aptly put it,
“In the midst of all these orders, what’s really happening is a pathway for infectious diseases and instability.”