HIV/Aids projects are exempted from Trump’s ban on aid for SA

Projects funded through the President’s Emergency Plan for Aids Relief  (Pepfar) are exempted — at least until the end of April — from the executive order US President Donald Trump issued on Saturday.

The order halts all foreign aid the US government provides to SA because of what Trump describes as the country’s “unjust and immoral practices that harm our nation [the US]”.

However, according to a high ranking US embassy official in Tshwane, who asked not to be named, “the order does not impact lifesaving and humanitarian programmes such as Pepfar”.

Such programmes therefore qualify for a 90-day limited waiver which will expire towards the end of April, but only for approved activities, announced on February 1.

Pepfar has committed $439.5m (R8.1bn) to SA for the US financial year  which stretches from October 1 2024 to September 30 2025.

Bhekisisa confirmed the exemption for Pepfar projects with a second trusted source, who had confirmation from Pepfar in SA that activities may resume under the waiver once implementing partners, or organisations funded by Pepfar, have received approval letters from their funding agencies.

Pepfar money in is mainly channelled to projects and the health department through the US Agency for International Development (USAID) and the Centres for Disease Control.

Pepfar funds make up 17% of the health department’s HIV budget. The rest of the money goes to nongovernmental organisations rolling out HIV projects in support of the health department’s goals.

The exemption falls under the latest executive order, which says: “The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate.”

What is, however, not sure, is what will happen to waiver-approved projects once the waiver and the US government’s 90-day period, during which projects will be reviewed to assess if they align with the Trump administration’s ideologies, expires.

Trump’s ideologies include, among other things, being anti-abortion, only acknowledging two genders (male and female) and the rejection of diversity, equity and inclusion (DEI) programmes for the appointment of staff members.

However, Mitchell Warren from the New York-based advocacy organisation, Avac, which receives Pepfar funding and runs projects in eastern and southern Africa, said things aren’t as simple as “yes, you qualify” or “no, you don’t qualify”.

“The [acting] head of USAID is US secretary of state  Marco Rubio,” he said.

Last week Rubio announced he won’t attend the G20 summit in SA in November because the country is using the G20 to promote “solidarity, equality and sustainability”.

Warren said: “In other words: DEI and climate change. My job is to advance America’s national interests, not waste taxpayer money or coddle anti-Americanism.

“Understanding what to do next on how to operate, whether as the government of SA or as an implementing partner to Pepfar, is filled with chaos, and that chaos not only derails programmes in the short term, it also derails relationships between countries and communities.”

What’s in and what’s out

The waiver issued on 1 February said Pepfar projects can’t restart before the “implementing agency lead deputy principles” have certified they qualify for the waiver.

Most SA projects have not yet received such certification letters.

“We all wonder does the waiver apply to us or not,” said Linda-Gail Bekker, who heads the Desmond Tutu Health Foundation at the University of Cape Town which receives Pepfar funding, “because there is a lack of clarity and communication”.

In a second memo, released by the US state department on February 6, with more details about which activities do and do not qualify for the waiver, it is made clear that only tasks within previously approved Pepfar country plans will be allowed.

Salaries for health workers, laboratory and supply chain staff, who are necessary to carry out approved work, are covered. Such activities include HIV testing, care and treatment services for all population groups, including at mobile clinics or drop-in centres for people with a high chance of contracting HIV.

It also includes services for pregnant and breastfeeding women and the screening and diagnosis of tuberculosis in people with HIV, as well as preventive TB treatment.

However, what it doesn’t cover is anti-HIV preventive medication, also known as pre-exposure prophylaxis or PrEP, for groups other than pregnant and breastfeeding women (PBFW).

The memo states: “People other than PBFW who may be at high risk of HIV infection or were previously initiated on a PrEP option cannot be offered Pepfar-funded PrEP during this pause of US foreign assistance or until further notice.”

Pepfar supports more than 90% of global PrEP users. Four in 10 of them live in SA. By the end of August last year 1.65-million people in the country had used the pill at least once. Though government procures and pays for the pills, also referred to as oral PrEP, Pepfar covers some salaries of health workers and data capturers involved with PrEP projects, according to health minister Aaron Motsoaledi’s presentation to the portfolio health committee in parliament last week.

Anti-HIV meds donations likely no longer happening

Moreover, in July last year Pepfar promised 231, 000 doses of a two-monthly anti-HIV shot, CAB-LA, to SA. The first batch was to arrive by the end of March. In December  the plan also committed to join hands with the Global Fund and other donors to pay for enough doses for 2-million people in poorer countries of a six-monthly HIV prevention injection, lenacapavir. The jab lowers someone’s chances of getting HIV.

Last week the maker of lenacapavir, Gilead Sciences, applied to get the jab registered for PrEP use through a mechanism, EU Medicines for All. The SA Health Products Regulatory Authority (Sahpra) is part of the process and is providing some assessors, said CEO Boitumelo Semete-Makokotlela. Sahpra will use the results of the review process to get the medication registered in SA.

However, Pepfar-sponsored PrEP and other forms of HIV prevention now seems unlikely.

The February 5 memo stated populations-based HIV surveys such as the Human Sciences Research Council’s household survey  are also not covered by the waiver, and neither are implementation science projects. SA has five CAB-LA implementation studies across 16 sites, some of them supported by Pepfar.

Pepfar partners are also not allowed to use funds to plan for the next financial year.

In SA, Pepfar-funded programmes that received stop-work orders were required to close down within two days. As a result, many clinics providing HIV treatment and prevention services, have closed or scaled down services. The health department has not yet come up with a viable contingency plan to continue services should the Trump administration close down Pepfar.

“The flurry of actions provides an unprecedented amount of whiplash, wondering each day what to do, what not to do,” said Warren.

“The only true winner in the HIV response is the virus itself. The virus loves chaos. The virus loves instability. The virus loves conflict. In the midst of all of the orders, what's happening is a pathway for infectious diseases and instability and that is bad news, no matter what the executive orders say.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.