In the past 24 hours, various Pepfar-funded health programmes have been issued with “stop work orders”, leaving many patients living with HIV/Aids at risk of being cut off from life-saving care.
On Monday, Gauteng-based health worker *Mary woke up to an unprecedented notice from the HIV/Aids organisation where she works – she and her colleagues were not allowed to come in to perform their duties.
She couldn’t even provide telephonic support to patients with appointments that day or the state-employed health workers who would be tackling her workload. This would be considered as work, she was told.
Mary is one of many health workers affected by the “stop work orders” issued to various organisations and programmes receiving funding from the US President’s Emergency Plan for Aids Relief (Pepfar). Their work has been brought to a screeching halt as a result of US President Donald Trump’s executive order – signed on Monday, 20 January – suspending all foreign development assistance for 90 days, pending a review to determine whether they are “fully aligned” with US foreign policy.
Read more: The Trump 2.0 effect – how the barrage of executive orders could jeopardise SA’s wellbeing
“I’ve never been told not to go to work before. As a health worker who firmly believes in advocating for patients, I couldn’t sleep last night because I was trying to think of a workaround to enable me to go to work without compromising my colleagues’ future employment. It’s unbelievable,” said Mary.
“I’m breaching my Hippocratic oath to do no harm and to do good. I’m not there, which is harming people … and I take that oath very seriously.”
A statement from US State Department spokesperson Tammy Bruce on Sunday, 26 January, said that Secretary of State Marco Rubio was “initiating a review of all foreign assistance programmes to ensure they are efficient and consistent with US foreign policy under the America First agenda”, in line with Trump’s Executive Order on Reevaluating and Realigning United States Foreign Aid.
Trump’s broad foreign aid freeze includes 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). The order does not apply to military support to Israel and Egypt, or to emergency food assistance, according to a memo issued by Rubio.
Some Republican senators have campaigned for years against Pepfar’s reauthorisation, alleging that the programme promoted abortions, according to a New York Times report.
The abrupt halt of foreign aid from the US could have a devastating impact on South African health services, particularly those related to HIV/Aids treatment and support.
Several health programmes have announced a suspension of their services as a result of stop work orders issued by US funders, including the Wits Reproductive, Health and HIV Institute’s (RHI) Key Populations Programme, and Engage Men’s Health in Johannesburg.
In a notice issued on Monday, the Wits RHI Key Populations Programme team stated “our donor, USAID, has served the Wits RHI Key Populations Programme a notice to pause programme implementation. As of close of business tomorrow … we are unable to provide services until further notice. We sincerely apologise for the inconvenience this may cause and remain committed to your health and wellbeing.”
Foster Mohale, spokesperson for South Africa’s National Department of Health, told Daily Maverick that the department had yet to receive formal correspondence from the US government about the halt of Pepfar funding for local health programmes.
“The department is yet to assess the impact of this, [or] communicate implications and contingency plans,” he said.
Significant health risks
South Africa has the largest Pepfar portfolio in the world, Daily Maverick has reported. For the US financial year spanning October 2024 to September 2025, SA received about $440-million 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.
Read more: HIV/Aids initiative that was ‘an astonishing act of vision’ is all grown up, but still faces compelling challenges
Sasha Stevenson, executive director of public interest law organisation SECTION27, said that the loss of Pepfar funding had the potential to be “massively damaging” for South Africa and other African countries.
“In some countries in Africa, Pepfar and USAID and Global Fund fund the vast majority of the HIV programme. In South Africa, that’s not the case – it doesn’t fund the majority of the HIV programme but it does still fund part of our HIV programme, and often areas of the programme ... that are important... There really is just a significant risk to South Africa [and] to our neighbouring countries,” she said.
“I never thought I’d wake up in the morning and be told that I’d be banned from going to work.”
South Africa’s HIV/Aids health services haven’t faced a loss of funding on this scale before, said Stevenson, making it difficult to predict how the system would handle it.
“The two decades of investment by Pepfar and USAID and the Global Fund, together with government investment and other funders’ investments, mean that the South African HIV programme is strong and is fairly sustainable, but it’s also not flush with money. And this funding is just so important ... to maintaining the gains that we’ve made,” she noted.
It’s not only clinicians but also administrative staff in health facilities who may be affected by the stop work orders for Pepfar-funded programmes, according to Lynne Wilkinson, a Gauteng-based public health specialist in the HIV/Aids sector. The repercussions of their absence are likely to be cumulative, resulting in larger patient backlogs and greater workloads for the health workers who remain.
“[A patient] might just spend the whole day at the clinic and not be seen today, and then have to come back tomorrow. What happens with these unplanned reductions in people able to do the work is that it just starts piling up. At some point that’ll become crippling, because tomorrow you’ve got twice as many patients, and then the next day you’ve got about three times as many patients,” she said.
“Then half of those patients just decide not to come back because they can’t spend another day in the clinic, and then we’ve lost them off treatment. That means we’ve got five times as much work to try and track them, trace them, encourage them back.”
Traumatic
Mary, who deals with patients with an urgent need for immediate health interventions, described the experience of being forced to stay at home as “more traumatic” than working during the Covid-19 pandemic.
“We took our own personal risks but we still went to work. We weren’t in Covid services, so we weren’t the most exposed to all the trauma … but we were keeping the other services going and keeping five million people on HIV treatments as much as we could,” she said.
“I never thought I’d wake up in the morning and be told that I’d be banned from going to work.”
For many patients, treatment adherence is affected by their trust in the health system, according to Mary. If they miss work and spend money to travel to a health facility for care, only to be told there’s no clinician to see them, this trust is damaged.
“They take risks to come and see us, and then we’re just not there. The impact in terms of trust in the health system is just really distressing,” she said.
Mary called for a “rapid legal solution” that would allow clinicians from Pepfar-funded programmes to go back to work.
“The programme and fixing the programme can wait, but individual human beings and their families can’t,” she said.
“Trump is over there thinking that this is a high-level decision, and I don’t think he cares that there’s all these individual human beings who are going to be impacted.” DM
*Mary is a pseudonym given to a source who’s chosen to remain anonymous out of concern for professional backlash.