• The United States government funds HIV prevention, treatment and research programmes across the world but especially in sub-Saharan Africa.

• US President Donald Trump issued an executive order on 20 January that halts foreign aid for 90 days.

• The order, which is not clearly worded, has left in doubt the future of many life-saving HIV programmes in Africa.

The sudden decision by United States President Donald Trump to halt and review all foreign aid for 90 days could be devastating for HIV programmes in African countries. After Trump’s inauguration on 20 January, he signed numerous executive orders. One of these suspends aid to “foreign countries and implementing non-governmental organisations, international organisations, and contractors” pending review for whether it aligns with “American interests and … values”.

The order said, “no further [US] foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States”.

Foreign aid includes the US President’s Emergency Plan for AIDS Relief, known as PEPFAR. PEPFAR has saved millions of lives since it was launched by former president George W. Bush in 2003.

PEPFAR statistics show that at the end of 2024, it was providing life-saving antiretroviral treatment to nearly 21-million people across 55 countries, many of them in sub-Saharan Africa. PEPFAR is also delivering pre-exposure prophylaxis (PrEP) — which stops people from contracting HIV — to about 2.5 million people. In 2024, PEPFAR provided HIV testing to about 84-million people. It funds HIV treatment and intervention in Uganda, Namibia, Botswana, Mozambique, Zimbabwe, and many others.

South Africa has about 5.6-million people on antiretroviral treatment. The medicines themselves are paid for by the South African government, but PEPFAR funds some of the staff at some ARV programmes. It also funds much of the prevention and information effort, including ARV user clubs, medical circumcision and public messaging.

South Africa does leading research on HIV and TB. Much of this is funded by the US National Institutes of Health. It’s unclear what the future status of this funding is.

It’s also unclear what the status is of money that has been committed. For example, some programmes get monthly tranches based on contracts that have already been signed. At least one project manager we spoke to said he wasn’t sure if commitments for February onwards would be arriving, and US government representatives who he deals with are themselves unsure.

This uncertainty is due to this phrase in the executive order, “shall immediately pause new obligations and disbursements”. It’s unclear if already-committed disbursements are affected.

Professor Linda-Gail Bekker, an infectious disease scientist at the Desmond Tutu HIV Centre at UCT, said that it’s unclear whether the PEPFAR funding will be reduced or stopped but that the outcome in African countries could be “disastrous”.

Bekker said that HIV treatment “doesn’t stand still” and that treatment, PrEP, and quality healthcare have to keep on getting to people.

Bekker also said that other countries in Africa are far more dependent on PEPFAR funding than South Africa. For example, Malawi, which has a minimal health budget.

“There is no doubt our own national governments need to step up. We know there needs to be more self-reliance,” she said, but added that the sudden stop of donor funding can be “disastrous”.

A study from 2024 looking at the rate of mortality amongst South African adults who experienced interruption in antiretroviral treatment, shows that interrupting antiretroviral treatment leads to much greater risk of death.

Over the years, Bekker says, PEPFAR funding has also gradually transitioned from where there was an emergency situation, at the height of the AIDS epidemic in the early 2000s, to helping countries’ health systems cope.

PEPFAR allocations in Malawi for 2024 and 2025 are $180-million and $178-million respectively. It is one of two of the biggest funders of HIV interventions in Malawi, along with the Global Fund, according to the National Aids Commission (NAC) of Malawi. In a recent strategic plan, the NAC noted that, “There is an urgent need to sustain and accelerate the national response between 2020 and 2025 in order to put Malawi on the path towards ending AIDS as a public health threat in Malawi by 2030.”

It is unclear how Trump’s order to pause and review foreign aid will affect PEPFAR in the future. The US Agency for International Development (USAID) media office did not respond to questions by the time of publication.

Trump also issued an executive order withdrawing the United States from the World Health Organisation (WHO). According to Reuters there is a 12-month notice period for the US, the WHO’s largest funder, to leave the organisation and stop all financial contributions to its work.