PEPFAR pause destabilized South African HIV care system

On the first day of President Trump’s second term, his administration ordered a 90-day pause on foreign development assistance, effective immediately. This order included PEPFAR — the President’s Emergency Plan for AIDS Relief — an initiative launched in 2003 by then-President George W. Bush to combat HIV/AIDS around the world. Two weeks into the new term, the Trump administration issued a waiver for programs that supply HIV antiretroviral drugs and other services deemed “lifesaving,” while keeping the rest of PEPFAR shut down. The abrupt changes caused widespread confusion and disrupted HIV care worldwide. 

In South Africa, home to the largest population of people living with HIV, PEPFAR’s stoppage caused ripple effects that undermined the country’s whole HIV care system, triggering staffing and service cuts and increased wait times, even at clinics that received no direct funding from the U.S. government, according to a study by researchers at Washington University School of Public Health in St. Louis, the Human Sciences Research Council, and the University of the Witwatersrand in South Africa. The findings are reported in The Lancet Regional Health: Africa. 

 “These disruptions were felt across the entire health system, irrespective of direct receipt of funds,” said first author Lindsey Filiatreau, MPH, PhD, an assistant professor at WashU School of Public Health. “It undermines the public’s trust in the health system. If I’m seeing on the news every day that patients in Johannesburg are waiting 10 hours or told to go home, even if I haven’t had that experience myself, I’m going to worry.”

The researchers surveyed a representative sample of HIV clinics in KwaZulu-Natal province during the first half of 2025. They found that nearly 40% of clinics, serving half of all people with HIV in the province, experienced disruptions: 30% had to lay off staff, mostly data capturers and community health workers; and 10% had to cut back on patient tracing and HIV testing and treatment services. Wait times increased at 11% of clinics, and 10% of clinics — serving a quarter of all people living with HIV in the province — experienced treatment disruptions. 

These disruptions aren’t just an inconvenience; downsizing testing, tracing and operational support could have catastrophic effects on efforts to end the HIV epidemic. People with HIV who are properly treated can have normal lifespans and avoid passing the virus on to others, but first they need to know their infection status, and then they need to start and stay in treatment. Missed appointments can lead to missed prescription refills and missed doses. This can result in virus levels rising, threatening the patient’s health and making it more likely that the patient could inadvertently spread the virus to others. Inadequately staffed clinics with longer wait times make it more likely some patients will become discouraged and leave without receiving needed care. Patient tracers play an indispensable role by seeking out patients who miss visits to their clinics and persuading them to return to care. 

While the study was limited to South Africa, similar events unfolded in other countries around the world that had been receiving PEPFAR support, the researchers said. Up until January 2025, PEPFAR was providing antiretroviral drug therapy for 20.6 million people, and funding the salaries of more than 346,000 front-line health workers in 55 countries across Africa, Asia and the Americas. 

PEPFAR has since been allowed to resume its work, but with a narrower mandate largely limited to providing antiretroviral drugs to select countries via bilateral agreements. Modeling studies have predicted that the suspension and subsequent scale-back of PEPFAR will lead to 10 million extra HIV infections and 3 million deaths in the next decade. Circumscribing the program in this way reflects a fundamental misunderstanding of how PEPFAR and other U.S.-backed efforts to end the global HIV epidemic benefit the American people, Filiatreau said. 

“Almost all HIV drug trials happen in Africa, particularly South Africa,” she said. “We can’t conduct those enormous clinical trials in the U.S. because we don’t have the density of people living with HIV. Long-acting HIV prevention options, long-acting treatment options — many of those trials were in South Africa, but the reality is, the first people to benefit from innovative drugs are often Americans. We’re among the first people to gain access to new HIV prevention and treatment technologies.”

With advancements in treatment over the past few decades, HIV infection has become a manageable chronic illness. The ongoing global effort to end the HIV epidemic has yielded insights that already are being applied toward improving health care for other chronic illnesses, such as heart disease and diabetes, and beneficial insight is likely to keep coming.  

“The global response to HIV, irrespective of geography, has been incredibly effective in ways that responses to other chronic conditions haven’t necessarily been,” Filiatreau said. “There are a lot of lessons that can be drawn directly from the HIV response. Some of my own work centers around patient engagement with the health-care system over time. We’ve learned that when patients have negative experiences, they’re more likely to disengage, so we’ve identified strategies to support a friendly return to care. Those models of care delivery are now being implemented in other chronic condition settings.” 

Right place, right time

In January 2025, Filiatreau was in South Africa, gearing up to audit HIV care facilities in KwaZulu-Natal as part of a research team led by principal investigator Alastair van Heerden, PhD, then the research director of the Human Sciences Research Council Centre for Community Based Research and an associate professor at the University of the Witwatersrand, and now the research director at Wits Health Consortium. Then the presidential order came down.   

“Overnight, the site is thrown into chaos,” Filiatreau recalled. “There are a lot of questions around what sort of implications there will be for patient care-seeking, service availability, service delivery, and so on. Some people were saying it was fine, but I’m looking at the news and I’m thinking, ‘There’s no way this is fine.’ Our team made the decision to add questions to our facility audits to see what people in those clinics said was happening. Like, ‘Let’s get the information straight from the horse’s mouth.’”

The team surveyed 36 of 519 public facilities providing HIV care in KwaZulu-Natal from January to July 2025. Collectively, the clinics serve nearly 180,000 patients. Clinic operation managers were given structured surveys designed to assess the effects of the PEPFAR stop-work order on clinic operations, staffing and services. 

The study revealed widespread disruptions. Bigger clinics were more likely to be affected than smaller ones, probably because PEPFAR funding tends to be earmarked for the places with the highest burden of disease. When extrapolated to the whole province, the disruptions affected more than 800,000 people in KwaZulu-Natal, half of all people living with HIV in the area. The study did not assess the effects of later changes to the program. 

“In an ideal world, we would administer these exact same questions again this year to the same clinic providers to see what has changed since last summer,” Filiatreau said. “The challenge, of course, is that there is no capacity to do it. There have been layoffs in HIV research as well as in HIV care. We don’t have the staff to go to the clinics to ask these questions, and if we did, it would be burdensome for the clinic staff to answer them.”

The global HIV community is still adjusting to a world in which the U.S. is no longer funding 75% of HIV programs. This leadership vacuum creates an opportunity for countries to reimagine how to provide HIV care for their people, Filiatreau said. 

“While I think this is irrefutably a devastating outcome, it also presents a unique opportunity for us to rethink health-care delivery and patient-monitoring systems to make improvements moving forward,” Filiatreau said. “In some countries, data systems fell apart overnight. Services, clinics, disintegrated instantly. We have an opportunity to rebuild better. It’s going to take an enormous amount of time to get there and to restore people’s trust in the health-care system, but we can build something that’s more resilient than what we had.”

Filiatreau LM, Musiello F, Dela Tsagli D, Chibi B, Mukwekwerere ED, Essack Z, Venter WDF, Sikombe K, Mody A, Geng EH, van Heerden A. PEPFAR interrupted: real-world consequences of U.S foreign aid instability for HIV service delivery in South Africa. The Lancet Regional Health: Africa. March 24, 2026. DOI: 10.1016/j.lanafr.2026.100039

This study was supported by the Bill and Melinda Gates Foundation. 

Tamara Schneider, MPH, PhD, is the assistant director of communications and senior science writer at WashU Public Health. She holds a double bachelor’s degree in molecular biophysics & biochemistry and in sociology from Yale University, a master’s in public health from the University of California, Berkeley, and a PhD in biomedical science from the University of California, San Diego. She joined WashU as a science writer in 2016.