A wave of relief has washed over South Africa and Africa at large following the Trump administration's reversal of its near-total freeze on US foreign aid.
The decision, announced late last month, reinstates funding for crucial HIV/AIDS programs, including the provision of antiretroviral (ARV) drugs and the salaries of US-funded nurses in the Southern African country. This marks a significant turnaround after days of uncertainty and anxiety amongst patients and healthcare workers who feared a catastrophic disruption to vital medical services.
The consequences of the initial freeze were dire. A manager at a local clinic described the anxiety felt by both patients and healthcare providers as the distribution of ARVs was temporarily halted. "We will now continue providing antiretrovirals to our patients without interruption," the manager stated, expressing profound relief.
"This is a huge relief for everyone involved. Many patients rely on these medicines to stay alive, and the suspension had caused a lot of anxiety." The temporary halt to ARV distribution highlighted the precarious position of those reliant on PEPFAR for life-saving medication.
The situation was further exacerbated by the suspension of salaries for nurses funded by the US government.
An official from the Ministry of Health emphasised the critical role these nurses play in the healthcare system, stating, “These U.S.-funded nurses are crucial because, without them, there would be significant gaps in the distribution of medicines. They are a key part of our healthcare system, and their work directly impacts the lives of thousands of patients.” The reinstatement of their salaries is expected to restore morale and ensure the continued delivery of essential medical services.
However, the initial relief was tempered by uncertainty. US Secretary of State Marco Rubio's announcement that "life-saving humanitarian assistance" would continue during the 90-day review period did little to alleviate widespread confusion.
A memo issued by Rubio clarified that the waiver applied to "core life-saving medicine, medical services, food, shelter, and subsistence assistance, as well as supplies and reasonable administrative costs as necessary to deliver such assistance". Crucially, the memo excluded programmes involving "abortions, family planning conferences… gender or DEI (diversity, equity and inclusion) ideology programs, transgender surgeries, or other non-life-saving assistance".
This vagueness caused significant concern amongst health organisations across the world. Anele Yawa, general secretary of the Treatment Action Campaign (TAC), welcomed the news regarding life-saving medication but expressed uncertainty about the details. "
We welcome this announcement in terms of issues related to life-saving medication, based on the fact that already, over the past couple of days, we have seen some of the challenges on the ground with regards to access to treatment. But we do not know, as it stands, what the details of this waiver are.
"We are unsure of what it will entail and… who it involves, and who is excluded in terms of this waiver and what services will be provided in terms of life-saving medication, because when you’re talking about life-saving medication in response to HIV, you cannot leave prevention out of that.”
Lynne Wilkinson, a Gauteng-based public health specialist, echoed these concerns, highlighting the confusion within the South African health sector. While there was some confidence that US-funded antiretroviral therapy service delivery would resume, the impacts on HIV testing, prevention and community-led monitoring were less certain.
"My opinion is that HIV programmes should fall under life-saving humanitarian assistance. People living with HIV will get sick and die, with an increase in transmission and incidence," she stressed.
The impact of the initial freeze extended far beyond the provision of ARVs. The suspension of PEPFAR, which supports over 20 million people on antiretroviral treatment worldwide, raised alarm bells globally. In South Africa alone, PEPFAR contributed approximately 17% of the R44.4-billion spent on the country's massive HIV counselling and testing campaign, reaching 5.5 million people on ARVs – a scale unmatched anywhere else in the world. South African Health Minister Dr Aaron Motsoaledi described the world's reaction to Trump's review as "baffled".
The consequences of the funding halt, even temporarily, were potentially devastating. The Foundation for AIDS Research (amFAR) warned of increased suffering and transmission rates if PEPFAR-supported programs were abruptly ceased. The sudden halt threatened to disrupt essential HIV treatment services, testing, and prevention efforts, impacting over 190,000 clinicians and healthcare workers worldwide who rely on PEPFAR support. amFAR highlighted the scale of PEPFAR's contribution: antiretroviral treatments for 222,000 people annually, HIV tests for more than 224,000 individuals, over 7,000 cervical cancer screenings per year, and care for more than 3,500 women experiencing gender-based violence.
The freeze also impacted USAID's TB programs, which have invested $4.7 billion since 2000. The suspension threatened to severely hinder progress against TB, one of the world's deadliest infectious diseases. Sasha Stevenson, executive director of SECTION27, highlighted the interconnectedness of HIV and TB services within the health system, emphasising the significant impact on both.
"What this administration is doing is making the world less safe for all of us who are affected by the matters that affect global health, like, for example, Covid-19 and other global health disasters — essentially making the world less safe for everybody," she warned.
Furthermore, the reinstatement of the "Mexico City Policy" or "global gag rule" added another layer of complexity. This policy restricts US foreign assistance to organisations providing, counselling or advocating for legal abortion services, even if the funds for these services are provided by non-US donors. Stevenson noted that this policy "is making the world less safe for women by removing access to abortion in countries where the government has decided that it is lawful, such as the case in South Africa.”
The temporary nature of the waiver, however, leaves lingering uncertainty. While the immediate crisis has been averted in Zimbabwe and the resumption of ARV distribution and nurse salaries provides essential relief, the 90-day review period continues to cast a shadow over the future of US foreign aid and its vital role in combating HIV/AIDS and other global health challenges in the country and across Africa.
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