UMZIMKHULU, South Africa — In a rural community located within the KwaZulu-Natal province of South Africa, 19-year-old Nozuko Majola is assessing whether she has enough funds for the hour-long journey to acquire her essential HIV medication. The delivery of this medication to her home is often hindered due to challenging and unpaved roads.
Majola represents one of the millions of individuals impacted by the freeze on global foreign aid instigated by U.S. President Donald Trump, which has raised concerns about patients discontinuing their treatments, increasing rates of infection, and a potential rise in mortality.
In a report published in 2024 by the Human Sciences Research Council, it was revealed that KwaZulu-Natal has the second-highest HIV prevalence rate in the nation, standing at 16%, with an alarming estimate of 1,300 young individuals contracting the virus weekly. The province, which had nearly 1.9 million residents living with HIV in 2022, is among the hardest hit in South Africa. The nation, in total, has over 7.5 million individuals suffering from the virus that causes AIDS, the largest number in the world.
Currently, there are approximately 5.5 million South Africans undergoing antiretroviral treatment, whose funding is now called into question following the suspension of the President’s Emergency Plan for AIDS Relief (PEPFAR). This program contributes more than $400 million annually to combat HIV in South Africa, claiming around 17% of the total funding as per health ministry analysis.
Globally, PEPFAR is recognized for its role in saving at least 26 million lives since it commenced in 2003, according to reports from the U.N. AIDS agency. Recently, a federal judge mandated that the Trump administration temporarily lift the funding freeze, and the U.S. Embassy in South Africa confirmed that PEPFAR projects would continue under a limited waiver. However, numerous aid organizations focused on HIV have already closed their doors, with notices posted on their entrances and PEPFAR-branded vehicles idling unused, redirecting patients to overstretched health facilities.
Most of the PEPFAR funding is allocated through non-governmental organizations that complement the healthcare services provided by the government, enhancing treatment and outreach efforts.
For Majola and others in the Umzimkhulu area—where unemployment is rampant and many rely on subsistence farming and government assistance—the suspension of aid has severely disrupted their lives. “Things will be tough around here, and a lot of people will default on their treatment because we really struggle with transport,” she pointed out, adding that access to mobile clinics is scarce.
The freeze has significantly impacted the various organizations that are no longer able to provide treatment, leading to a surge of patients who are now flocking to already overwhelmed public health facilities. The support services that would routinely send health personnel to the remote villages allowed many, particularly those intimidated by the social stigma surrounding HIV, to receive confidential care and testing. Alongside this, nearly 15,000 health workers, whose salaries depended on PEPFAR funding, are now uncertain about their job security.
Approximately an hour away in the Umgungundlovu district, which has the highest concentration of HIV cases in South Africa according to research from the think tank, HIV counselors met in a small office to strategize on how to best aid patients like Majola. A nearby health clinic manager expressed concern about the surging demand for administrative work that has piled up since PEPFAR-funded staff exited.
“Those managing administration and data collection, whose positions were funded by PEPFAR, have departed. We are a small facility and we are unable to handle this workload,” explained the manager, preferring to remain anonymous due to concerns about speaking to the press.
Nozuko Ngcaweni, who has been receiving HIV treatment for roughly three decades, shared the distressing impact of the funding freeze on her community, noting that many individuals have already missed crucial medical care. “Not long ago, we said we wanted to achieve an HIV-free generation by 2030. If the situation continues deteriorating, that goal will be unreachable, and we will have to confront more deaths,” she lamented.
Mzamo Zondi, a provincial manager with the Treatment Action Campaign, an organization that fights for HIV treatment access for low-income populations, has been closely monitoring the ramifications of the aid suspension in Umgungundlovu. “Our response to HIV is likely to weaken as we grapple with halting new infections,” he declared. “This situation is a matter of life and death.”
