Adjusting to a Post-PEPFAR World

RIO DE JANEIRO – Zambia is hopeful that it can reach an agreement with the United States to salvage funds for its HIV programme, but South Africa remains frozen out of any new US funding for its HIV programme, government officials told journalists at a media briefing at the International AIDS Conference on Wednesday.

Last December, the US Embassy in Zambia announced that the US was on the brink of reaching a Memorandum of Undertanding (MOU) with Zambia to “unlock a substantial grant package of US support in exchange for collaboration in the mining sector and clear business sector reforms”.

No such agreement was reached, but news crept out that the US demands for access to Zambia’s minerals had been too onerous.

But Dr Lloyd Mulenga, Zambia’s National HIV Programme Coordinator, told the media briefing that the talks had resumed and he was hopeful that an MOU would be signed – but declined to elaborate on what the US had demanded to derail the talks. 

Ghana and Zimbabwe have also been unable to accept the US terms, and modelling suggests 75,000 Zimbabweans will contract HIV within the next year unless alternative funds are found.

Earlier in the week, acting US global AIDS co-ordinator Jeff Graham told a pre-conference briefing that “there are no critical minerals mentioned in any MOU”. 

But Dr Mike Reid, former chief science officer for the US President’s Emergency Plan for AIDS Relief (PEPFAR) in the US Department of State, told Health Policy Watch that he had resigned “over the Zambia issue”.

Reid, who also addressed the media briefing, resigned in April and described the “sadness and disappointment” he and colleagues felt at being forced to implement decisions “that make no public health sense”.

“When life-saving health assistance, often beyond the immediate capacity of partner countries, is conditioned on unrelated commercial or strategic objectives, something essential is lost,” Reid had written in his substack shortly before resigning.

“When access to treatment or prevention becomes entangled with access to critical minerals or geopolitical positioning, the work is no longer what it claims to be.”

No US meeting with South Africa 

Almost eight million South Africans live with HIV and, in 2024, the country was receiving around $450 million in HIV aid from the US, both via US Agency for International Development (USAID) and the US Centers for Disease Control and Prevention (CDC).

USAID funding to South Africa and other countries stopped abruptly after President Donald Trump granted Elon Musk the authority to dismantle the agency, and CDC funding ends in March 2027.

However, while the US reached out to several countries, offering to continue supporting their HIV programmes via bilateral MOUs, it has not reached out to South Africa, the country’s Deputy Health Minister, Dr Joe Phaahla, told the briefing.

“We have not been approached with any proposed new arrangement, and indications are that we are not going to be approached,” said Phaahla.

The US Ambassador to South Africa had scheduled then cancelled a meeting with South Africa’s health minister. However, Phaahla sits alongside US officials on the board of the Global Fund and “we talk offline”, he said.

“The indications are that, because of issues outside the health sector, it’s unlikely that we are going to be approached for any discussion,” said Phaahla.

Community services first to be cut

In the days after the abrupt cuts, government officials’ priority was to secure people’s antiretroviral treatment, said Mulenga. And the easiest programmes to cut to save money were those involving community-based services.

Zambia has lost $340 million in US government support – and to safeguard key ARV services, it has cut male circumcision, community testing and the DREAMS centres aimed at protecting women and girls from HIV.

While South Africa had already secured its ARV supply by wholly funding it domestically, 15,000 frontline workers administering services, particularly for “key populations” most at risk of HIV, lost their jobs. Another 10,000 jobs are set to vanish when the CDC funding ends next year.

Florence Riako Anom, co-director of the Global Network of People Living with HIV (GNP+), describes waking up on 21 January 2025 – the day after Trump announced the immediate freezing of all development aid – to a world where access to ARV treatment was no longer safe or guaranteed.

Before the Trump announcement, many African PEPFAR-funded countries had developed sustainability plans to integrate HIV services into primary healthcare to be phased in over five years – but “the disruption moved all of this into a day or two”, said Anom.

“We have a lot of tools available now [to address HIV], but because of the geopolitical environment we find ourselves in, our fear right now, particularly for African communities, is that we will go back to that point where they are not easy to access,” said Anom.

She said most community activists were tired – caught between the anxieties of communities and the fight for self-preservation.

Self-management

Most specialised programmes for key populations no longer exist, yet many feel too stigmatised to go to government clinics.

To address this, GNP+ is exploring “self-care” products that are largely self-managed – such as long-acting pre-exposure prophylaxis (PrEP) and self-tests for HIV.

Zambia is exploring whether private clinics can dispense ARVs to ease clinic congestion, said Mulenga. This model has been pioneered by South Africa.

It is also seeking community-based volunteers to assist in clinics.

“It’s going to be tough, but we have to find cheaper, sustainable options,” he concluded.