South Africa’s globally recognised HIV programme, once hailed as a model of success, is facing unprecedented strain. A combination of deep U.S. funding cuts and structural weaknesses has triggered a crisis in prevention, treatment, and research efforts — with potentially devastating consequences for the country that bears the world’s largest HIV burden.
A Collapse in Slow Motion
The turning point came with the 2025 suspension of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)’s decision to halt key research collaborations. These U.S. programs had, for decades, formed the backbone of South Africa’s HIV response — funding not just medicines, but the people, systems, and services that made them work.
The impact has been swift and severe. Community-based clinics have shuttered. Testing and prevention campaigns have slowed to a crawl. Stocks of life-saving antiretroviral drugs, including innovative injectable PrEP medications, sit unused as logistics networks crumble. NGOs that reached vulnerable groups — sex workers, adolescents, rural patients — have slashed operations or disappeared altogether.
We are about to see a wave of new HIV infections, sickness and death, with children born infected in record numbers.
Professor Francois Venter – Clinician researcher at University of the Witwatersrand, Johannesburg,
According to public health experts at the University of the Witwatersrand, the programme is “collapsing in plain sight”, not because South Africa cannot afford HIV care, but because vital support structures — funded almost entirely by the U.S. — are disappearing.
An Invisible Infrastructure Unravels
Contrary to public perception, most antiretroviral drugs in South Africa are indeed funded by the government. However, what U.S. support enabled was the infrastructure that delivered those drugs to people: case managers, outreach teams, home-care workers, counsellors, data systems, and research trials. This ecosystem kept millions in care and helped reduce new infections year after year.
Dr. Francois Venter, a leading HIV expert, notes: “You can have warehouses full of ARVs, but if the system that links people to treatment breaks down, it’s meaningless. We’re watching that system crumble.”
Government Response: Too Little, Too Late?
In response, Deputy President Paul Mashatile announced emergency allocations from the Treasury to cushion the impact and pledged government commitment to universal treatment. Yet critics say the state’s interventions are reactive and insufficient to plug the massive operational gap left by PEPFAR and NIH.
South Africa’s Health Minister insisted that the supply of antiretrovirals would continue uninterrupted. But frontline organisations warn that the collapse of support services means fewer people are getting tested, fewer are initiating treatment, and many may fall out of care altogether — undoing decades of progress.
Communities and Researchers Left Adrift
The research sector has also been hit hard. The NIH freeze has disrupted long-running HIV trials and vaccine studies. Collaborations with top South African universities and institutes have been paused or cancelled. Meanwhile, civil society organisations, which have historically played a vital watchdog role, are stretched beyond capacity.
What’s more, at-risk populations — young women, men who have sex with men, transgender people — are once again being left behind, despite being central to the country’s epidemic.
Towards Local Ownership — or Further Collapse?
The crisis has also reignited a larger debate about South Africa’s dependence on foreign aid. While some view this moment as a necessary pivot toward local ownership, others warn that “localisation” cannot succeed without proper planning, time, and investment.
“Sudden localisation with no money is just another way of saying abandonment,” wrote a Wits University commentary, calling the collapse “predictable, avoidable, and deadly.”
Hope Amid Uncertainty
There are, however, rays of hope. Some private sector actors — including insurers and major employers — have stepped in to support care delivery. The Global Fund continues to provide limited support. And a growing number of local researchers and advocates are mobilising to reshape the response.
Still, the road ahead is steep. Without urgent, coordinated action — including honest accounting of what’s been lost — the human toll could rise sharply.
As South Africa stands at a crossroads, the choices made in the coming months will determine whether its once-celebrated HIV programme can survive — or whether decades of progress will be undone by short-sighted geopolitics and insufficient domestic response.
