HARARE, Zimbabwe — Florence Makumene clutched a plastic container filled with her HIV medication, reflecting on the possibility that it might be the last she receives. She is increasingly worried that the continent is on the brink of a devastating return to the days when AIDS claimed millions of lives across sub-Saharan Africa.
During her youth in Zimbabwe, Makumene witnessed many dear to her fall victim to HIV, a diagnosis once seen as synonymous with hopelessness. However, her life took a different trajectory after she was diagnosed in 2016, thanks to a community organization backed by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which enabled her to receive crucial HIV treatment.
“People around me, including my own children, thought I was on the verge of dying and even planned my funeral, but I recovered and became stronger,” stated the 53-year-old.
Since its inception in 2003, PEPFAR has played a vital role in saving over 26 million lives and altering the trajectory of the global AIDS epidemic. Yet, a recent 90-day suspension of foreign aid mandated by former President Donald Trump stunted what was one of the most effective responses to the disease. Although his administration later promised waivers to continue lifesaving treatment, a judge has ruled that the freeze must be lifted.
On the ground in Africa, this aid disruption has led to the layoff of thousands of U.S.-funded health workers and the closure of numerous clinics, ultimately limiting access to HIV testing and treatments. Health experts and officials across the continent have urgently called for the resumption of PEPFAR, as they fear the dismantling of services that have become integral to local healthcare systems could regress progress made over the last few decades.
“Right now, people are facing closed doors. There’s a sense of desperation,” remarked Simon Bwanya from the Zimbabwe National Network of People Living with HIV.
On a global scale, AIDS-related fatalities have decreased by 69% since their peak in 2004, while new infections have dropped by 60% since 1995, as reported by the United Nations AIDS program. Many attribute this significant change to PEPFAR, initiated by President George W. Bush, especially in sub-Saharan Africa, where the epidemic has hit hardest.
“PEPFAR represents the most effective allocation of health resources I’ve ever seen,” remarked Francois Venter, a professor at the University of the Witwatersrand in Johannesburg, who has been involved in the HIV sector for over two decades in South Africa, the country with the highest number of people living with HIV. “I challenge anyone to suggest a better use of those funds.”
The initiative particularly targets Africa, where most of the lives saved are attributable to a program that helps distribute medication controlling HIV to millions of individuals. Yet, the ability of these individuals to continue accessing their medication now hangs in the balance.
Organizations, including the one aiding Makumene, have been shuttered for weeks, mirroring the fate of nearly all PEPFAR-funded NGOs on the continent as their future remains uncertain pending decisions from Washington.
“We feel abandoned; it’s like we’re orphans,” Makumene expressed, as she worried about her limited supply of medication. “I fear a return to the old days when being HIV positive meant death.”
Makumene is one of around 20 million individuals globally who rely on antiretroviral medications (ARVs) supported by PEPFAR. These medications are essential for preventing the virus from replicating in the body; ceasing them could spark a resurgence of the virus and potentially lead to drug-resistant strains. “HIV is a straightforward illness,” Venter commented. “You discontinue your ARVs, and you develop AIDS.”
Without these vital drugs, HIV levels in an individual’s blood can spike again, increasing the risk of transmission. Winnie Byanyima, Executive Director of the United Nations AIDS program, emphasized that the funding halt could trigger a resurgence of AIDS, instilling “panic, fear, and confusion” across various African nations.
PEPFAR significantly supports numerous NGOs while also bolstering countries’ public health systems. This assistance includes funding the salaries of thousands of healthcare workers integral to national HIV initiatives. In South Africa alone, PEPFAR accounts for the salaries of 15,000 HIV-specialized health workers in public healthcare settings. Although this represents only a small fraction of the total workforce, they play a critical role in delivering ARVs and supporting community outreach. Abruptly removing these personnel dismantles the framework necessary for effective health care.
“The crucial healthcare framework is on the verge of collapse, clinics are being forced to close, and frontline workers are left unsupported while lives hang in the balance,” stated Sibongile Tshabalala, chairperson of the Treatment Action Campaign, part of a coalition of HIV advocacy groups responding to the funding freeze. Reports indicate basic HIV services are deteriorating, particularly in a major Johannesburg hospital.
The South African government is exploring options to prevent a healthcare crisis by securing funds to retain health workers. Other countries, like Kenya, confront even steeper challenges, with more than 40,000 workers at risk of layoffs due to the aid freeze. In the tiny nation of Lesotho, around 1,500 healthcare workers, representing about 7% of the total health workforce, have already been dismissed. The Lesotho Health Ministry has called upon final-year medical students and recent graduates to fill the gaps at local healthcare facilities.
On January 28, U.S. Secretary of State Marco Rubio announced waivers intended to maintain critical treatments and other aspects of PEPFAR. Rubio indicated his support for the initiative, despite raising some concerns about its implementation, and noted a desire for continuation. However, a federal judge recently mandated the administration to temporarily end the foreign funding freeze, rebuffing claims that a waiver system was operational.
Officials from the U.S. Agency for International Development, which is responsible for a significant portion of PEPFAR’s funding, alongside aid organizations, confirmed that they currently have no knowledge of any payments being processed for the program or any associated initiatives. Criticism has also emerged regarding the nature of the waivers introduced by the Trump administration, which restrict access to treatment for certain populations.
While PEPFAR funds pre-exposure prophylaxis (PrEP), a newer preventive medication, the waivers currently only permit offering PrEP to pregnant or nursing women, excluding high-risk groups such as gay men and sex workers from access. Moreover, access to contraceptive services financed through PEPFAR has also been curtailed.
“The battle against HIV is far from over,” affirmed Dr. Kebby Musokotwane, director general of the National AIDS Council in Zambia. “We’ve come a long way, yet there’s still much left to accomplish.”
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