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South Africa has made tremendous strides in the fight against HIV, coming closer than ever to meeting the UNAIDS 95-95-95 targets—where in 2024, 94% of people with HIV (PWH) in South Africa were aware of their status, 80% of those were receiving antiretroviral therapy (ART), and 89% of PWH receiving ART were virally suppressed. These successes didn’t happen by accident. They are the result of sustained investment, both from within South Africa and from key international partners like the President’s Emergency Plan for AIDS Relief (PEPFAR).
PEPFAR provides crucial support to over 20 million people living with HIV across 55 countries. In 2022, PEPFAR contributed $460 million, making up 18% of South Africa’s $2.56 billion HIV budget. But what happens if that funding is suddenly slashed or eliminated? A new study co-authored by leading HIV researchers—including DTHF’s own Linda-Gail Bekker—paints a grim picture. Using advanced mathematical modeling, the researchers explored the impact of cutting $460 million of PEPFAR funding from South Africa’s HIV budget. The results? A potential public health and economic catastrophe.
More Infections, More Deaths, More Costs
PEPFAR isn’t just about treatment—it also funds HIV prevention programmes, including HIV testing, Pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. HIV prevention is the first line of defense against new infections —but without funding, South Africa will see an HIV resurgence. If PEPFAR funding remains intact, the study estimates that 1.19 million people will acquire HIV in South Africa over the next 10 years. That’s already a daunting number. But if PEPFAR is cut in half, 286,000 additional HIV infections will occur. If PEPFAR disappears entirely, that number skyrockets to 565,000 additional infections.
It gets worse. HIV-related deaths will also increase dramatically. Currently, South Africa is projected to see 1.58 million deaths from HIV over the next decade. A 50% funding cut would add 315,000 more deaths, while a full cut would push that number up by 601,000—a 38% increase.
The Economic “Savings” Myth
Cutting PEPFAR might sound like a way to reduce spending, but in reality, it is short-term thinking at its worst. People with untreated HIV progress to advanced stages of the disease, requiring expensive hospital-based care, which will further strain the already overburdened health system. The modelling found that while immediate treatment costs might drop slightly (by $620 per person for a 50% cut, and $1,140 for a full cut), these savings would be wiped out by the long-term costs of a sicker, more infectious population.
In fact, the total healthcare costs for South Africa’s HIV response would increase—by $880 million over 10 years for a 50% cut, and by a staggering $1.7 billion if PEPFAR funding disappears altogether.
The Bigger Picture: A Global Warning
South Africa has a relatively strong domestic HIV response, but many other countries rely even more on PEPFAR. If funding is abruptly withdrawn, countries with weaker health systems could experience an even sharper rise in new infections and deaths.
The researchers highlight that in places like Zimbabwe, where PEPFAR funds a much larger share of HIV programmes, a cut could lead to three times more new infections and lost lives. This is not just a South African problem—it’s a global crisis in the making.
A Call to Action
PEPFAR has been one of the most successful global health initiatives in history. Since its launch in 2003, it has saved millions of lives and helped control the HIV epidemic worldwide. But its future is now uncertain, as political shifts and misinformation threaten bipartisan support in the U.S. Congress.
If these cuts go through, the consequences will be devastating—not just for those living with HIV, but for entire economies and health systems. We must act now to protect the progress made and ensure that equitable, life-saving HIV care remains a reality. We cannot afford to let short-term political decisions erase decades of progress. The choice is clear: sustained investment in HIV treatment and prevention will save lives and money in the long run.
Here is the link to the full article this blog post is based on, which is also the source of the diagram above.
https://www.acpjournals.org/doi/10.7326/ANNALS-24-01104
