HARARE, Zimbabwe — Florence Makumene grasped a plastic container of her HIV medication, contemplating whether it would be her last supply. This concern emerged amidst rising anxieties about a potential resurgence of a time when countless individuals in sub-Saharan Africa perished from AIDS years ago.
As a young adult in Zimbabwe, Makumene endured the painful loss of family members to HIV, a diagnosis that was often viewed as terminal. However, after testing positive in 2016, the 53-year-old was fortunate to enroll in vital treatment through a community organization backed by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). “People around me, including my children, had resigned to my fate and were preparing to say goodbye, but I returned stronger than ever,” Makumene reflected.
Since its inception in 2003, PEPFAR has been credited with saving over 26 million lives and transforming the global approach to AIDS. However, a recent 90-day suspension of foreign aid mandated by former President Donald Trump severely disrupted this impactful response. Although the administration later introduced waivers to preserve essential treatment, a judiciary ruling has compelled officials to lift the suspension.
The consequences of this aid freeze are dire in Africa, with numerous U.S.-funded health workers laid off and clinics shuttered, limiting access to critical HIV testing and treatments. Health officials and advocates from Africa urgently appeal for the restoration of PEPFAR, expressing concern that the withdrawal of services integral to healthcare systems could regress countries by decades. “Patients are facing closed doors. Their desperation is palpable,” added Simon Bwanya of the Zimbabwe National Network of People Living with HIV.
Globally, since 2004, AIDS-related fatalities have dropped by 69%, while new HIV infections have plummeted by 60% since 1995, as reported by the United Nations AIDS program. Many experts attribute this success to PEPFAR, initiated by former President George W. Bush, which has played a pivotal role in improving conditions, particularly in sub-Saharan Africa, the most impacted area.
“PEPFAR represents an unprecedented and efficient allocation of health resources,” asserted Francois Venter, a professor at the University of the Witwatersrand in Johannesburg, who has dedicated over two decades to HIV initiatives in South Africa, the nation with the highest number of HIV-positive individuals. “I challenge anyone to suggest a more effective utilization of this funding.”
Focusing primarily on Africa, PEPFAR has saved countless lives, primarily via a program that ensures medication for managing HIV is accessible to millions. However, recent actions threaten the continuity of these treatments.
Many NGOs, including the one supporting Makumene, have been shut down for weeks, along with nearly all PEPFAR-supported organizations across Africa, as their futures hang in the balance pending decisions from Washington. “We feel abandoned, like orphans. With my limited medication supplies, I fear a return to the past when being HIV positive was akin to facing death,” expressed Makumene, whose hope hangs by a thread.
She is among an estimated 20 million individuals globally who rely on antiretroviral medicines (ARVs) with the assistance of PEPFAR. These medications prevent the virus from proliferating in the body. Discontinuing them can lead to the virus regaining strength, potentially resulting in the emergence of drug-resistant strains.
“HIV is straightforward; stop your ARVs, and you develop AIDS,” Venter emphasized. Without continued medication, HIV levels can become detectable in a person’s system, consequently elevating the likelihood of transmission.
The Executive Director of the United Nations AIDS program, Winnie Byanyima, highlighted in an interview that the funding suspension could provoke a resurgence of AIDS cases, fueling panic and uncertainty across numerous African nations.
PEPFAR finances thousands of NGOs and plays a critical role in supporting national public health systems, often covering salaries for tens of thousands of healthcare workers involved in HIV programs. In South Africa, for instance, PEPFAR funds 15,000 HIV-specialized health workers in public health facilities, even though they constitute merely 5% of the overall workforce. Their removal would dismantle vital structures.
“Vital healthcare frameworks are disintegrating, clinics are closing, and frontline workers lack support—all while lives remain at stake,” lamented Sibongile Tshabalala, the chairperson of the Treatment Action Campaign, which includes a coalition of HIV advocacy groups formed in response to these funding issues. This coalition reported that basic HIV services are “crumbling” in one of Johannesburg’s primary hospitals.
The South African government is currently exploring options to mitigate the impending health crisis by securing alternative funding to sustain the health workers. However, other African nations are facing even steeper hurdles.
In Kenya, more than 40,000 workers are on the brink of layoffs as a consequence of the funding freeze, according to officials. Similarly, in the economically disadvantaged nation of Lesotho, 1,500 health workers—approximately 7% of the nation’s total health workforce—have already lost their positions, prompting the Health Ministry to seek volunteers from final-year medical students and recent graduates.
On January 28, U.S. Secretary of State Marco Rubio announced waivers aimed at maintaining pivotal treatment and other elements of PEPFAR. Rubio, although expressing support for PEPFAR, has also articulated his reservations. Last week, a federal judge mandated a temporary lifting of the funding freeze, dismissing the administration’s claims about the existence of waivers to facilitate ongoing aid flows. The ruling cited evidence indicating that such a waiver system had yet to be established.
USAID officials and aid organizations have reported no successful payments flowing for this or any associated programs. Critics have also raised concerns about the restrictive nature of the waivers released by the Trump administration, emphasizing that these limitations hinder access to treatment for marginalized demographics.
PEPFAR not only funds ARVs but also supports pre-exposure prophylaxis (PrEP), an emerging preventive treatment. However, these waivers only permit PEPFAR-funded organizations to provide PrEP to pregnant or breastfeeding women, excluding gay men and sex workers—groups that are at higher risk for HIV transmission. Furthermore, contraceptive services via PEPFAR have been halted.
“The battle against HIV is not yet over,” asserted Dr. Kebby Musokotwane, the director general of the National AIDS Council in Zambia. “Although significant progress has been achieved, there remains much work to be done.”
