Ruann moved to Walvis Bay for the same reason many other trans women are attracted to the Namibian port city: to find work. The city sits where the Namib desert meets the Atlantic Ocean, and its natural harbour brings about 900 ships each year — and with them potential clients for Ruann, a sex worker.
“We are pushed to have unprotected sex,” Ruann told the Thomson Reuters Foundation, declining to give her surname. “How will I ask my client, 'What is your status?'”
Ruann relies on a clinic specialising in trans healthcare to get tested for HIV and receive regular doses of pre-exposure prophylaxis, or PrEP, to prevent infection. But the clinic is funded by the US, and Ruann's access to care hangs in the balance as President Donald Trump's administration dismantles the US Agency for International Development (USAID), which administers foreign aid.
“It's going to be terrifying for me if I can't access health services,” she said.
High Risk
The country of 3-million people is considered one of the most progressive on the continent for LGBTQ+ rights. But transgender people in Namibia are still left behind in healthcare.
When Ruann was 18, she suffered an acid burn that led to a stay in hospital. While bathing her, a male nurse pointed to her genitals as proof of her “real” gender, then cut her hair, even though the burn was on her arm.
“That's when I decided I'm not going back to any state facility,” Ruann said.
But as a trans sex worker, Ruann is at high risk of contracting HIV. Sex workers are four times more likely to contract HIV/Aids compared to the general population, and transgender people are 14 times more likely, according to UNAids, the UN agency working on the epidemic.
That's why international donors have focused on the two groups, called “key populations”.
The US has invested $110bn (R2-trillion) in 55 countries under the President's Emergency Plan for Aids Relief (Pepfar), launched by George W Bush in 2003.
Pepfar has saved more than 26-million lives, provided 83-million HIV tests and helped 7.8-million babies be born HIV-free.
“Pepfar has been the primary support for those types of clinics where governments have not stepped in,” said Beirne Roose-Snyder, a Washington-based senior policy fellow with the Council for Global Equality.
HIV and Aids remain the leading cause of death in Namibia, where some 230,000 people have the disease. But new infections fell by 54% between 2010 and 2022, UNAids said.
If I'm not protected … you are putting the entire country at risk. We are engaging in sexual activities with the general population
— Pitti Peter, trans woman and member of the Namibian Sex Workers Alliance
Experts credit community-focused HIV prevention and treatment for part of the success.
A case worker with a Pepfar-funded project first brought Ruann to a discreet clinic in a converted shipping container, tucked behind a tall wall in an industrial part of town.
At the Walvis Bay Corridor Group clinic, Ruann began PrEP and had other health screenings, services funded by Pepfar and USAID and implemented by a local NGO, IntraHealth Namibia.
Brihana, a 28-year-old trans woman, receives care at a branch in the capital Windhoek. She had previously encountered medical staff who questioned her gender, leading her to avoid healthcare services altogether.
The Walvis Bay Corridor Group provides taxis to reach appointments and ensures trans patients do not have to sit in waiting rooms with other patients.
“They were the ones that actually put me back together, and that's when I felt very safe,” Brihana said.
Minimising visibility is a priority at a time when trans Namibians face a dangerous backlash to recent court decisions that expanded rights for same-sex couples. Since 2023, six trans Namibians have been killed, according to rights groups.
Now the funding that keeps trans-specific medical services available is in jeopardy.
'Weaponising' Pepfar
Even before Trump froze humanitarian assistance as part of his “America First” foreign policy, members of his Republican party had expressed opposition to Pepfar and reduced its funding cycle to one year from five. It expires in March.
“There has been a very concerted effort to weaponise and target Pepfar by political actors in the US,” said Roose-Snyder.
Conservative lawmakers and anti-abortion groups have claimed Pepfar-backed groups promote abortion. By law, Pepfar cannot fund abortions, but four cases in Mozambique of nurses performing them in Pepfar-funded facilities were uncovered, the only such cases ever found, according to US officials in January.
The suspension of US aid poses a bigger threat to Pepfar.
Despite a waiver on life-saving assistance, clinics have already shut down. The Walvis Bay Corridor Group closed three of its eight clinics by the end of December when a funding agreement ended. Initially, it expected bridge funding to get to the end of March.
That means patients have gone for more than two months without testing, counselling and treatment.
“If I'm not protected ... you are putting the entire country at risk,” said Pitti Peter of the Namibian Sex Workers Alliance who helped Ruann get healthcare and is a trans woman herself.
“We are engaging in sexual activities with the general population.”
Advocates said Namibia is not ready to go cold turkey.
“If non-government organisations are not helping, then the government will be overwhelmed, and the burden will be too much,” said Maria Nghishoongele, a Walvis Bay Corridor Group nurse.
Namibia is close to reaching the UNAids target of 95-95-95 for 2025, in which 95% of people carrying HIV/Aids know their status, 95% of those who know their status are on medication, and 95% of them have a suppressed viral load.
Leaving out vulnerable groups could roll back these gains.
“We can't reach any of those goals without the inclusion and leadership of transgender people,” said Roose-Snyder, adding that their exclusion in healthcare will only “drive the HIV epidemic.”
The Thomson Reuters Foundation is the charitable arm of Thomson Reuters.
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