HARARE, Zimbabwe — Florence Makumene clutched a plastic container filled with her HIV medication, anxiously pondering whether it might be her last supply. Concern has grown over a potential regression to the days when millions succumbed to AIDS across sub-Saharan Africa.
As a young adult in Zimbabwe, Makumene witnessed friends and family members fall victim to the HIV virus, which was perceived as a dire and fatal diagnosis back then. Though she also received a positive test result in 2016, the 53-year-old’s situation was different; a community organization supported by the U.S. President’s Emergency Plan for AIDS Relief, known as PEPFAR, helped her access crucial medical assistance.
“People around me, including my own children, had written me off and were preparing to bury me, but I bounced back stronger,” said Makumene.
Since its launch in 2003, PEPFAR has been credited with saving over 26 million lives and transforming the global response to AIDS. However, a 90-day freeze on foreign aid instituted by former U.S. President Donald Trump stunted one of the most effective global health initiatives, although his administration later assured that exceptions would be made to maintain treatment programs. A court ruling has mandated the administration to lift the freeze.
In various parts of Africa, the freeze has led to layoffs of thousands of U.S.-funded health workers and closures of clinics, which has greatly limited access to HIV testing and treatments. Health officials and experts are urgently urging a resumption of PEPFAR funding, fearing a dismantling of vital services that could push countries backward decades in their healthcare advancements.
“People are finding doors closed. They are desperate,” remarked Simon Bwanya from the Zimbabwe National Network of People Living with HIV.
Globally, AIDS-related deaths have decreased by 69% since peaking in 2004, and new HIV infections have dropped by 60% since 1995, according to the United Nations AIDS program. Many specialists attribute a significant portion of this success to PEPFAR, introduced by former Republican President George W. Bush, especially in the heavily impacted region of sub-Saharan Africa.
“PEPFAR is the most efficient deployment of health resources I have seen,” stated Francois Venter, a professor at the University of the Witwatersrand in Johannesburg, who has spent over two decades involved with HIV initiatives in South Africa, the country with the highest number of individuals living with HIV. “I challenge anyone to tell me how we could have used the money better.”
PEPFAR’s primary objective has been in Africa, where a substantial number of lives have been saved through a program that provides essential antiretroviral therapy (ART) to millions. However, the current situation puts the continuation of this treatment at risk.
The nonprofit organization assisting Makumene has been non-operational for several weeks, paralleling the fate of nearly every PEPFAR-funded NGO in Africa as their future hangs in the balance in Washington.
“We are like orphans; we have no one to turn to,” expressed Makumene, who has managed to stockpile a limited supply of medication. “I fear we might be going back to the old days when being HIV (positive) was equated with death.”
Makumene is among approximately 20 million people around the world who rely on antiretroviral drugs (ARVs) facilitated by PEPFAR. These medications prevent the progression of HIV within the body; discontinuing them could allow the virus to resurrect and cause the appearance of drug-resistant strains.
“HIV is a simple disease,” said Venter. “You stop your ARVs, you get AIDS.”
Without consistent access to these medications, the HIV virus could rebound to detectable levels in individuals, heightening the risk of transmission.
Winnie Byanyima, the Executive Director of the United Nations AIDS program, remarked that the funding halt could trigger a resurgence of AIDS cases, leading to “panic, fear, and confusion” across several African nations.
PEPFAR finances countless NGOs while also directly supporting public health systems in various countries, typically covering salaries for thousands of health workers integral to national HIV strategies. In South Africa, PEPFAR funds around 15,000 specialized HIV workers in public hospitals and clinics. Although they only constitute 5% of the overall HIV healthcare workforce, their roles are critical in providing ARVs, counseling, and outreach services to those distant from healthcare facilities. Removing this segment would severely disrupt the system.
“Critical health care infrastructure is being dismantled, clinics forced to close, frontline workers without support, all while lives hang in the balance,” warned Sibongile Tshabalala, chair of the Treatment Action Campaign, a coalition of HIV advocacy groups formed in response to the funding freeze.
The coalition highlighted a sharp deterioration in basic HIV services like testing and treatment at one of the key hospitals in Johannesburg.
The South African government is actively devising strategies to mitigate a crisis by securing financing to maintain its healthcare workforce. Other countries in Africa are encountering even more daunting challenges.
In Kenya, more than 40,000 health workers are facing potential lay-offs due to the funding freeze, while in Lesotho—a small nation in southern Africa—1,500 health staff, roughly 7% of the country’s total medical personnel, have already lost their positions. Lesotho’s Health Ministry has called upon final-year medical students and recent graduates to assist at local health centers to fill the void.
On January 28, U.S. Secretary of State Marco Rubio announced new waivers to sustain lifesaving treatments and other PEPFAR services. Although he claims to support PEPFAR, Rubio has expressed reservations. Following a federal court ruling, the administration was instructed to lift the foreign funding freeze temporarily, ruling against claims that waivers were effectively sustaining funding. Testimonies indicated that such a waiver system had yet to be put in place.
Officials from the U.S. Agency for International Development, which manages much of PEPFAR funding, along with aid organizations, have reported that no payments were flowing through for this program or others.
Moreover, health experts and activists have expressed concerns about the limitations imposed by the waivers released by the Trump administration. These waivers restrict treatment accessibility for certain groups.
In addition to ARVs, PEPFAR funds pre-exposure prophylaxis (PrEP), a preventative therapy. Nevertheless, the waivers permit PEPFAR-supported NGOs to administer PrEP only to pregnant or breastfeeding women, excluding high-risk groups like gay men and sex workers who are vulnerable to HIV transmission. Funding for contraception services via PEPFAR has also been discontinued.
“The fight against HIV is not over yet,” declared Dr. Kebby Musokotwane, director general of the National AIDS Council in Zambia. “There’s a lot of progress that has been made, but there’s still a lot that needs to be done.”
