Small win for activists, but SA's HIV projects won't get reopened

TimesLIVE

24-07-2025

The $400m that US Congress hasn't cut with the rest of its funding programme doesn't undo the blow to global HIV and TB programmes
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The $400m that the US Congress took off a list of programmes from which the Trump administration will now take back previously approved but unspent funds, doesn't mean the cuts to global HIV and TB programmes in February, including those in South Africa, are now reversed.
HIV projects that have closed in South Africa, which were formerly funded by the US government, won't restart as a result of this decision.
In fact, quite the opposite.
The 'limited Pepfar waiver' that President Donald Trump announced in February remains in place. That means no HIV prevention activities, unless they intend to stop pregnant and breastfeeding women from infecting their babies, can be paid for with US government money, and projects that make it easier for teen girls and young women in Africa, trans people, sex workers, injecting drug users and gay and bisexual men — groups of people that have a higher chance to get HIV than the general population — cannot be funded.
Without a proper explanation for it, the $400m seems to be a random amount that Trump's administration picked to take back from Pepfar, a US government programme that funds Aids projects in poorer countries with high HIV infection rates, such as South Africa.
The amount is about 8.5% of Pepfar's $4.725bn budget for this financial year and was part of a larger $9.4bn 'rescissions package' — that has now been reduced to $9bn and passed as the H.R.4 Rescissions Act of 2025.
Rescissions happen when the presidential administration wants to cancel funding that was approved by Congress and then use it for something else.
What the decision to remove the $400m from the package does, however, mean is that activism could finally be starting to pay off.
Activists have had hundreds of meetings with US senators and Congress committee chairs. There have been 'Save Pepfar' social media campaigns, and plenty of media coverage about the devastating consequences of the funding cuts. Tens of modelling studies have also projected what could happen if the lost funds are not replaced.
Opposition from within Trump's Republican Party against nonevidence-based cuts to a programme that has, for two decades, been supported by both the Democrats and Republicans and has saved over 25-million lives, is now at last emerging.
'It's a small win within the bigger context, but nonetheless, a huge win for advocacy, and a reminder that activism is powerful and alive, and making an impact,' Jirair Ratevosian, a former head of staff at Pepfar and fellow at Duke University's Global Health Institute, told Bhekisisa at last week's Conference on HIV Science in Kigali.
Around $8bn of the money was for foreign aid and development programmes, including global health, and just over $1bn for public broadcast stations that the Trump administration has accused of being biased because they're too liberal.
But the Rescissions Act is, in itself, bad news.
'It opens the floodgates for the Trump administration to say 'we don't want this or that in the budget that Congress approved',' says Mitchell Warren, the head of international advocacy organisation Avac.
'It's trying to take the congressional power of the purse and put it in the executive branch to usurp the role of Congress in deciding how much money — and on what to spend it.'
So how did this all happen, and does it hold any good in the long term for South Africa? We break it down.
1. How did we get here?
In the US, Congress — it consists of the Senate and the House of Representatives — decides how much government money goes to who, just like parliament does in South Africa. Both the Senate and the House have to pass budgets.
But, as analysts at the Centre for Budget and Policy Priorities in Washington, DC point out, President Trump wants more control over how his administration's money is spent.
In March, he signed the 2025 budget that Congress approved into law. Three months later, in June, he decided he wanted to change some of that and submitted a $9.4bn rescission request, which the House of Representatives (it has five more Republican than Democrat members) passed on June 12. When it was the Senate's turn to vote on this, some Republican senators weren't happy with the $400m Pepfar cut, signalling they wouldn't sign off on the deal unless the Pepfar part was removed.
Because there was a danger of them swinging the vote, the Republicans removed the $400m from the Rescissions Bill and got the House to pass that too. All that's left is for Trump to now sign the Act.
2. What was the $400m that was removed from the Rescissions Act for?
In short, no one really knows, because the Trump administration hasn't said what it was for — or what it plans to do with it. But what we do know is that the US law that governs rescissions, the Impoundment Control Act, says that the president can only request that Congress takes back funding that it previously approved, if the money has not yet been obligated — that means funds hadn't yet been given to a particular recipient, for instance, an HIV project in South Africa.
We also know that the $400m was part of the financial budget for 2025, says Warren, but because the law gives Pepfar permission to spend money over five years, that money doesn't have to be legally spent until 2029.
3. What will the $400m now be used for?
Again, no one knows. We don't even know if it will be used, because over the past few months, the Trump administration's main strategy has 'simply been to illegally impound funds — by announcing a 'funding freeze' or 'programmatic review' with no public notice at all — and force those harmed by the impoundments to pursue relief in court', the Centre on Budget and Policy Priorities explains in an analysis.
But we do know what the money can't be used for.
Unless the rules of Trump's 'limited waiver' are changed, Pepfar funds can mostly not be spent on any of the evidence-based strategies it paid for before Trump was elected in January. Pepfar used to focus on groups of people and areas where people have the highest chance of getting infected with HIV — that way, the programme got the biggest bang for its buck.
In South Africa, for instance, Pepfar worked in the 27 districts with the highest infection rates and groups known as 'key populations' — sex workers, gay and bisexual men, trans people, injecting drug users and African women between the ages of 15 and 24 — that are much more likely to get newly infected with HIV than other South Africans.
Now those projects, which studies show stopped many new infections, have been closed down and the Trump administration says it's not prepared to buy HIV prevention medicine for any group other than pregnant and breastfeeding women. 'It used to be all about evidence,' Warren says. 'Now it's all about ideology.'
4. What do scientists and activists want the $400m to be used for?
Ratevosian says this moment should be used to gain Republican support to change the waiver rules, so that Pepfar money can cover more of the populations and services needed for HIV prevention.
Lenacapavir, a pricey twice-a-year anti-HIV jab, which scientists believe could help to stop HIV in its tracks if it's rolled out properly, could be used to convince Republican Congress members, says Ratevosian. 'Pepfar has long wanted to get countries to transition to taking more ownership [read: pay more] for their HIV responses. So now activists are arguing: 'Preventing more new infections with the jab, will make it easier for countries to take ownership because the pandemic will be easier to manage.''
In December, Pepfar said it would join another organisation, the Global Fund for HIV, TB and Malaria to buy enough lenacapavir for two-million people over three years. But in July, the Global Fund had to go ahead with the deal by itself, because Pepfar seemed to no longer be on board.
Warren says: 'If I were in charge, I would take the $400m and double the two million people the Global Fund is planning to cover, because that's how you build a market, prevent new infections more quickly and drive the price down.'
5. What will Pepfar look like in future?
Trump's funding cuts didn't kill Pepfar — at least not in theory, but it's a shell of its former self.
What it will look like, will depend on the size of its next budget (the Trump administration wants to cut it by 40% but, so far, the House hasn't agreed to that, (the Senate still needs to sit on it) and how much support Republicans who believe in Pepfar can gain to have waiver rules changed.
But, Warren points out, 'we're not going to get pre-January projects back; we have to build something different.
'This has been the most seismic shift in democracy. We didn't think we lived in an earthquake zone, but January 20 [when Trump retook office] taught us: you need to be prepared for that earthquake and you therefore need a different infrastructure.
'In an earthquake you don't build back the same thing. You build better, something that is more resilient.'
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the