The Trump administration’s dismantling of PEPFAR and USAID global health programmes has disrupted HIV treatment and prevention services across South Africa, Mozambique, and across sub-Saharan Africa — with health workers documenting clinic closures, interrupted treatment, and the beginning of a reversal of gains that took decades and 26 million lives’ worth of effort to build.
In South Africa and Mozambique, health care providers say cancellation or redirection of US PEPFAR funding under the Trump administration have already endangered vulnerable people and cost lives.
Lucky Mazibuko, an HIV activist in Johannesburg who came of age during the worst years of South Africa’s AIDS epidemic, speaks of the crisis in visceral terms. He says that at the time of the epidemic’s peak, the country “was filled with the stench of death.” It seemed, he said, that there would be no end to the suffering. “There was no hope, there was basically no light,” he said. “And even if there was a light at the end of the tunnel, it looked like that of an oncoming train.”
PEPFAR changed that. Twenty-three years of the President’s Emergency Plan for AIDS Relief — a programme with rare bipartisan support through five presidencies — built the infrastructure that brought HIV from a death sentence to a manageable chronic condition for millions of southern Africans. The programme is estimated by the US State Department to have saved approximately 26 million lives since its 2003 inception.
Now, Mazibuko says, the stench is returning.
What PEPFAR Did — and How It Is Being Dismantled
President George W. Bush announced the President’s Emergency Plan for AIDS Relief, or PEPFAR, in January 2003. The programme is often cited as the most effective public health campaign ever. And for decades, the programme enjoyed widespread bipartisan support. But the Trump administration has radically changed the way the US delivers foreign assistance, making sharp cuts and creating uncertainty about future funding.
The Trump administration’s approach to global health aid has followed two tracks simultaneously. The first is explicit — the executive order in January 2025 banning all foreign aid and assistance and suspending funding for research to South Africa, based on what reports describe as spurious claims about the South African government. The second is structural — the broader DOGE-led elimination of USAID programmes that has removed the institutional infrastructure through which PEPFAR was delivered.
The Trump administration has disrupted every aspect of these longstanding partnerships and programmes both through the elimination of USAID-supported programmes, elements of PEPFAR, and through a Trump executive order banning all foreign aid and assistance and suspended all funding for research to South Africa based on spurious claims of white genocide.
Early 2025, a week into the president’s second term, Trump bragged about the early cuts from Elon Musk’s DOGE team: “We identified and stopped $50 million being sent to Gaza to buy condoms for Hamas.” Quick fact check here — no condoms were being sent anywhere in the Middle East. And the Gaza in question was probably Gaza Province in Mozambique, which has a high prevalence of HIV infections. It’s the only province in the country where 1 in 5 adults is living with HIV.
The specific mischaracterisation that drove the elimination of HIV programming in Gaza Province, Mozambique — a province with one of the highest HIV prevalence rates in the world — was based on a confusion between the name of a war zone and the name of a Mozambican province. That confusion produced the cancellation of programmes that were preventing transmission and treating infection in one of Africa’s most HIV-affected communities.
The Ground Reality in South Africa
South Africa has the highest absolute number of people living with HIV of any country in the world — approximately 7.5 million people. PEPFAR has been the backbone of the country’s antiretroviral treatment programme for more than two decades, supporting not just medication supply but the human infrastructure — clinicians, counsellors, data systems, community health workers — that makes treatment access possible.
In South Africa 15,000 health workers were supported by the US government. Those health workers — doctors, nurses, counsellors, community workers — are the human embodiment of PEPFAR’s reach. They are the people who conduct HIV tests, initiate antiretroviral treatment, follow up with patients who miss appointments, and connect people newly diagnosed with the support systems that make adherence possible.
When their contracts are terminated, those patients do not disappear. They disappear from care — which is a different thing.
As of late March 2026 — more than a year after the disruptions began — HIV, tuberculosis, and malaria programmes, along with basic health services and many other humanitarian programmes, remain impaired in countries around the world, and particularly in the Africa region.
The disruption to HIV data management has been particularly damaging to the programme’s ability to monitor and respond to emerging crises. HIV data management has been hugely affected; 20% of the 271 electronic medical record systems established at service sites were down during assessments in February. An electronic medical record system that is down does not know which patients are missing doses, which patients have developed drug resistance, or which communities have seen increases in new infections.
The Ground Reality in Mozambique
Mozambique’s situation is in some ways more acute than South Africa’s — the country has fewer resources to compensate for the loss of US funding.
In Mozambique more than 21,000 health workers were supported by the US government, and HIV data management has been hugely affected.
Mozambique has the second-largest AIDS epidemic in the world, according to the US Embassy in Maputo. The country’s public health system is significantly less developed than South Africa’s — less infrastructure, fewer trained clinicians, less domestic funding available to replace lost US support.
Mozambique is a lot poorer than South Africa, but the country has negotiated a deal with the US State Department to preserve some global health aid. That partial preservation — a bilateral negotiation with State rather than through the USAID mechanism — represents one country’s ability to secure continued support through diplomatic channels. Most countries affected by the PEPFAR cuts have not had the same success.
The Scale of the Projected Damage
The projections from public health research institutions are stark.
The Institute of Security Studies projected that the cuts could push 5.7 million more Africans into extreme poverty by 2026. Separately, the Africa Centre for Disease Control and Prevention estimated that two to four million additional Africans are likely to die annually as a result of reduced global aid budgets. Within South Africa alone, cuts to HIV/AIDS programmes could result in an additional 500,000 deaths over the next decade, according to the Desmond Tutu HIV Center.
These projections — 500,000 additional deaths in South Africa over ten years; 2-4 million additional annual deaths across Africa from reduced aid — are not speculative. They are based on documented relationships between treatment coverage and mortality, applied to the treatment coverage gaps that the funding cuts are producing.
The gap between the scope of this crisis and the coverage it receives in global media is itself a significant story. The Iran war, which has dominated international headlines for 100 days, has killed thousands. The PEPFAR crisis, unfolding quietly in clinics and communities across southern Africa, is projected to kill millions. Both deserve reporting. One is receiving it. The other is not.
What Has Not Been Cut — and Why
The Trump administration has maintained some global health aid, particularly in countries that have negotiated bilateral agreements with the State Department under the new America First Global Health Strategy framework. That framework prioritises programmes that advance “American economic and security interests” and secures co-investments from recipient countries.
The framework’s logic — that US aid should produce tangible returns for US interests — is not without precedent. But its application to HIV programming produces outcomes that contradict the framework’s stated objectives: reducing infectious disease burden globally reduces the probability of pandemic emergence that threatens the United States; maintaining the infrastructure of health systems in fragile states reduces instability that costs the US in other ways. The short-term savings from cutting PEPFAR produce long-term costs that the framework does not adequately account for.
What Happens Next
The political window for reversing the PEPFAR cuts in the current administration is not wide. The White House has not signalled any reversal of the broader foreign aid reduction strategy. Congressional efforts to restore funding have not produced legislative action. International partners — the Gates Foundation, European governments, PEPFAR’s other bilateral donors — have increased their own contributions where possible, but cannot fully replace the scale of US funding.
For the patients in Johannesburg and Maputo who lost access to clinics that no longer exist, the political timeline is irrelevant. The question is whether the drugs that were making their infection manageable are still accessible. For many, the answer is increasingly: not reliably.
“The stench of death is returning,” said Lucky Mazibuko.
He has lived through it before. He knows what it smells like.
LoudFact.com is an independent global news and explainer platform. This report is based on reporting from NPR’s Juana Summers, KPBS, WUNC, the Africa Practice analysis, UNAIDS, PHR’s April 2026 report, and USAID programme documentation as of June 7-8, 2026.
