Trump’s executive orders spark chaos – South Africa’s vital HIV programmes face uncertain future

ARE Pepfar-funded programmes able to deliver life-saving care? Why are South Africa’s HIV-Aids services still using United States (US) aid? Is our foreign policy to blame for the funding freeze? Daily Maverick tackles key questions about the 90-day pause on US foreign aid.

US president Donald Trump’s first two weeks in office have been characterised by a chaotic barrage of executive orders, sweeping statements and legal challenges. Keeping up with events coming out of Washington would constitute a full-time job and even at this early stage, your average global citizen could be forgiven for having a measure of “Trump fatigue”.

These rapid policy changes have widespread implications for South Africa, however – particularly in the health sector. Daily Maverick has been tracking developments around the freeze on funding for the US President’s Emergency Plan for Aids Relief (Pepfar), which came into effect after Trump signed an executive order on 20 January suspending all foreign development assistance for 90 days, pending a review to determine whether they were “fully aligned” with US foreign policy.

As HIV-Aids organisations scramble to keep up with rapid policy shifts, the future of Pepfar has become a key concern for activists and policymakers around the world. It plays an important role in health security for South Africa, our neighbouring countries – and even the US itself.

What’s happening with Rubio’s waiver on ‘life-saving care’?

Trump’s broad foreign aid freeze included Pepfar, the global health programme started by George W Bush and all US foreign assistance funded by or through the state department and US Agency for International Development (USAID). As a result, HIV-Aids programmes around the world were issued with “stop work orders” last week, bringing their work to a screeching halt.

The executive order did not apply to military support to Israel and Egypt, or to emergency food assistance. On 28 January, US Secretary of state Marco Rubio issued an additional waiver on the 90-day freeze for “life-saving humanitarian assistance”, stating that implementers of existing life-saving programmes could continue or resume work.

Instead of being a reprieve for organisations providing HIV-Aids treatment and support, the waiver caused widespread confusion as nonprofits around the world tried to establish whether Pepfar-funded activities fell under the umbrella of life-saving aid.

It was only on 1 February, four days later, that the US state department issued additional details of the waiver, clarifying that Pepfar was able to implement “urgent life-saving HIV treatment services”, subject to certain limitations.

Pepfar activities that could resume during the 90-day pause included:

• Life-saving HIV care and treatment services, including HIV testing and counselling, prevention and treatment of opportunistic infections including tuberculosis, laboratory services and procurement and supply chain for commodities or medicines;
• Prevention of mother-to-child transmission services, including test kits, medicines and pre-exposure prophylaxis for pregnant and breastfeeding women; and
• Reasonable implementing agency and implementing partner administrative costs strictly necessary to deliver and provide oversight of this assistance, including “related country-based data activities and portions of Pepfar’s central data platform used for clinical monitoring and programme management”.

However, many Pepfar-funded programmes in South Africa have yet to receive instructions from funders that would allow them to resume their work.

Lynne Wilkinson, a Gauteng-based public health specialist in the HIV-AIDS sector, notes that even if some Pepfar-funded programmes were given the go-ahead to resume, the waiver was very limited.

“For HIV prevention, it only clearly covers… prevention of mother to child transmission” putting Pepfar-funded gender-based violence services at risk which “provide post-exposure prophylaxis to prevent HIV acquisition after rape,” she says.

Pepfar funds are distributed to South African organisations by USAID and the Centers for Disease Control and Prevention (CDC), according to Wilkinson.

“As no one from USAID or CDC is formally communicating the application of the waiver to the South African non-governmental organization (NGO) and their subcontracted community-based organisations (CBOs) who provide these services, their hands remain tied and they cannot resume the services that the waiver may cover without risking falling foul of their contractual obligations,” Wilkinson says.

“At the moment, the majority of the operating funds for these South African NGOs comes through contractually regulated grants with USAID or CDC. The last communication to them was that they’re not allowed to spend these funds in their bank accounts because of the stop-work order. Of course, USAID and CDC may not easily be able to do so due to the hollowing out of these institutions at the US level.”

Many South African NGOs and CBO’s have been forced to start retrenchment processes for their staff, with no guarantee of when – or if – they will pay their salaries, according to Wilkinson.

“They have to balance their lack of funding right now and meeting South African labour law requirements… This means many big NGOs are retrenching thousands of staff, effective at the end of the month,” she says.

Speaking at a joint press briefing with Costa Rican president Rodrigo Chaves Robles on 4 February, Rubio emphasised that he had issued a “blanket waiver” on life-saving programmes, adding that he didn’t know “how much more clear we can be with that”.

“I would say if some organisation is receiving funds from the US and does not know how to apply a waiver, then I have real questions about the competence of that organisation, or I wonder whether they’re deliberately sabotaging it for purposes of making a political point,” he said.

Wilkinson tells Daily Maverick: “It is no easy decision but it may now be time to stop waiting for direct communication, which may not be possible from USAID/CDC and go back to providing the explicit services covered by the waiver. We must create solidarity among implementing partners following Rubio’s instructions – of course, this does require having funds in bank accounts.”

Is South Africa at fault for being dependent on US aid?

South Africa has the largest Pepfar portfolio in the world. For the US financial year spanning October 2024 to September 2025, South Africa received about US$440-million about N$7.4 billion from Pepfar.

According to the Andelson Office of Public Policy at the Foundation for Aids Research, Pepfar supported 13 815 individual direct clinical providers in South Africa in the 2024 financial year, including 178 doctors or clinical officers; 1 984 nurses and midwives; and 199 pharmacists or pharmacy assistants.

– Daily Maverick