Nongovernmental organisations (NGOs) supported by the US President’s Emergency Plan for Aids Relief (Pepfar) in SA were on Monday still waiting for formal guidance on how to implement the limited waiver granted to the Trump administration’s freeze on foreign aid.
Just hours after his inauguration on January 20, US President Donald Trump signed an executive order pausing all foreign aid for 90 days pending a review to determine whether it aligned with his “America First” foreign policy agenda.
This was swiftly followed by a “stop-work” order that seeded panic and alarm as HIV/Aids programmes supported by Pepfar in more than 50 countries ground to a halt. Clinics were shut, medicines remained in warehouses and healthcare workers and technical support staff were told to stay at home.
Pepfar provides 17% of SA’s HIV/Aids funding, allocating it $448.5m in the 2025 US fiscal year, in recognition of the vital role SA plays in combating the pandemic. SA has the world’s biggest HIV burden, with about 7.8-million people living with the disease in 2023.
Pepfar has supported SA’s efforts to combat HIV/Aids for the past 20 years and pays the salaries of thousands of healthcare workers who work in public hospitals and clinics, as well as experts who provide technical assistance to government departments and agencies.
A partial waiver to the aid freeze for “emergency humanitarian assistance” was signed by US secretary of state Marco Rubio on January 28, but the details of which Pepfar programmes would be allowed to continue under this instruction emerged only at the weekend. A February 1 memo from the head of the US state department’s bureau of global health security and diplomacy, Jeff Graham, to Pepfar implementing agencies and country heads, which Business Day has seen, sets out which activities may resume.
These include “life-saving HIV care and treatment services”, which it says includes HIV testing; counselling and treatment; the prevention and treatment of opportunistic infections, including tuberculosis; laboratory services; and the procurement and supply chain management of commodities and medicines.
It permits the resumption of services to prevent mother-to-child transmission of HIV, including commodities, test kits, medicines and pre-exposure prophylaxis for pregnant and breast-feeding women, and gives the go-ahead for “reasonable” administrative costs to deliver and oversee these programmes.
But large parts of Pepfar’s work remain on hold: the limited waiver does not apply to voluntary male circumcision, transgender clinics, such as those run by the Wits Reproductive Health and HIV Institute, or clinics specifically aimed at men who have sex with men, provided by organisations such as the Anova Health Institute.
The memo specifically excludes from the waiver activities that apply to abortions, family planning, gender, or “diversity equity and inclusion” programmes, and says that any other activities not specified in the guidance may not be resumed without express approval.
Mitchell Warren, executive director of the HIV advocacy group Avac, said it was unclear who would provide direction to Pepfar’s implementing partners as the Trump administration had shuttered the US Agency for International Development’s (USAID) headquarters in Washington.
USAID has until now played a key role in channelling funds and overseeing programmes supported by Pepfar.
Billionaire Elon Musk, who is leading Trump’s drive to shrink the federal government, said on Monday that work was under way to shut down USAID, according to a Reuters report.
USAID’s infrastructure had been “gutted” to such an extent that it was unclear who would provide guidance to Pepfar’s implementing partners about which programmes could resume under the partial waiver.
“No-one knows … who’s making the decisions, or on what basis they are making them. It’s clearly not going to come from anyone with technical expertise, because all of the technical expertise has either been fired or locked out,” he said.