Our anti-HIV jab will be rolled out in six weeks. But funding cuts hollowed out the system needed to deliver it

South Africa’s uptake of the once-every-six-month HIV prevention jab, lenacapavir (LEN), will be heavily affected by the Trump administration’s funding cuts to the country because it destroyed much of the infrastructure — such as community-based testing and field recruitment for HIV prevention services — needed to create demand for the medicine. 

That’s one of the findings of a report released on Tuesday by the US-based organisation, Physicians for Human Rights and two local non-profits, Advocacy for Prevention of HIV and Aids and Emthonjeni Counselling & Training. 

LEN is almost foolproof in stopping HIV-negative people from getting the virus through sex; scientists estimate if between one and two million people without HIV get the injection at least once a year between now and 2043, the country could prevent enough new infections to stop Aids from being a big public health threat within eight years. 

South Africa’s first two shipments — a total of 37 920 doses paid for with money from the Global Fund to Fight Aids, TB and Malaria — arrived in late March and early April and roll-out is expected to start in late May to early June. 

The report’s authors conducted in-depth interviews with 40 participants — doctors, nurses, clinical officers, peer counsellors and navigators, transgender and young people, sex workers, gay and bisexual men and government health workers — with personal experience of the funding cuts in Cape Town, Khayelitsha, Phillipi, Midrand and Johannesburg. 

Study participants’ input was collected in September through 20 individual and group oral history interviews and researchers got them to again check and, where necessary, update their quotes in March.

“The collapse of community-based prevention services and resources for community-led activities came at the precise moment that many participants in this study were preparing for lenacapavir and its game-changing potential,” the report states. 

“The damage to the health system from the funding cuts may prevent it from meeting the demand for lenacapavir.” 

Why would US funding cuts affect LEN’s roll-out? 

Pepfar funding, which the Trump administration ended most of in February 2025, made up a relatively small part — about 17% — of the money used to fight HIV in South Africa. 

But, the report points out, the kind of services that the funding paid for and the small number of districts where it was used — 27 out of the country’s 52 health districts — has resulted in a disproportionate impact on HIV prevention services, such as HIV testing and the uptake of a daily HIV prevention pill that government clinics stock for free, because there are now far fewer field workers to encourage people to use those services and to make them easy and quick to access.

Data from the international advocacy organisation, Avac, for instance, shows that the uptake of the pill decreased by a quarter between January and September last year compared to the same period in 2024. HIV testing rates in some areas in the country were also lower in 2025 than in 2024, before the funding cuts happened. 

“The impacts of funding cuts to South Africa cannot be understood simply by examining the percentage of the overall South African programme budget that was stripped away overnight,” the report authors argue. 

“While the United States provided a relatively small proportion of the total HIV response budget in South Africa, the targeted resources the United States covered most, and in some instances all, aspects of key services, many of which had not been replaced by the South African government at the time of publication.” 

Pepfar funding was channelled to South Africa through two US government agencies, the United States Agency for International Development, USAID (which was shut down in July), and the Centres for Disease Control (CDC). 

USAID-funded projects closed down early last year but CDC-funded programmes continued with what the US government calls “bridge funding”, which, at this stage, ends in June. 

Although many other African countries have signed memorandums of understanding with the US for further funding as part of its America First Global Health Strategy, which was launched in September, South Africa’s chances of this are poor.

“It appears possible, if not highly likely, that the Trump administration will cease to fund health programmes and research in South Africa at the end of this fiscal year, as a direct result of its baseless accusations of white genocide and the collapse of cooperative relations,” said the report. 

What has changed at government clinics? 

South Africa’s Pepfar funding was for the 27 health districts in the country with the highest HIV infection rates and mostly only for projects that worked with groups of people, such as sex workers, gay and bisexual men, transgender people, pregnant and breastfeeding women and teen girls and young women, with a higher chance of getting HIV than the general population. 

The funding mainly went to NGOs that helped the government to reach the goals of the country’s five-year HIV and TB plans (the latest one is our strategy for 2023 to 2028).

NGOs manned mobile clinics with nurses, peer counsellors and navigators who went to communities to make it easy for them to access HIV services and such campaigns were designed to specifically address the special needs of each high-risk group. 

Since the funding cuts, clients now have to go to government clinics to get tested or to get HIV prevention medication, where they face long queues and overstretched nurses, whom participants told the report’s researchers, are frequently insensitive to their needs. 

“People are not saying ‘I can’t get my medicine’, there’s nowhere for me to go to get it’,” Emily Bass, one of the report’s co-authors, told Bhekisisa. “Instead they’re describing huge barriers, such as long waiting times and stigma, they have to surmount when they use the general healthcare system. There’s only a ‘bare bones’ option.” 

A government nurse in charge of a township clinic told researchers that she now often deprioritises clients coming to collect HIV prevention medication, triaging patients in immediate medical need, such as a badly dehydrated child, over HIV prevention clients. 

“The sister is busy putting the drip on the rehydrating child … and now there is this person who is sitting there for hours for PrEP [HIV prevention medication]. This person is not sick and is now not a priority. The patient leaves, [even though they are] already recruited … because he’s tired of waiting. So our uptake is low.” 

The report points out that patients who already have an illness and who are experiencing symptoms and therefore need medication to treat the illness, are much more likely to tolerate long waits or stigma. 

But HIV-negative patients who visit clinics for preventive medication aren’t sick. 

“If you want people who are at risk of HIV to understand their risk, know their HIV status and take HIV prevention medication [like LEN], you can’t ask them to go to a clinic and wait from 7am to 4pm,” Bass explains. 

“They’re not going to spend their entire day waiting to be screened for something and then get an intervention that will prevent them from getting something [HIV]. You need the platform [system] that South Africa and the US has built over the past 22 years. You need a peer counsellor or navigator who talks to you frankly about side effects, who helps you to make choices and, should you decide to use the medication, helps you to get it.”

Clinics now not only have to cope with clients who formerly got their services from mobile clinics but nurses also have to do without the health workers that Pepfar-funded NGOs provided many clinics with.

In one clinic featured in the report, this has led to nurses abandoning standard HIV testing protocols, such as making sure that clients who visit the facility for HIV prevention medication refills, are tested for HIV before issuing the medication, to make sure that they’re still HIV negative. 

An HIV prevention medication client, who had to wait for his medication from 7am to 4pm, didn’t get tested and then asked a nurse: 

“Do you guys see the need for [testing], because these steps we are skipping. There are people who really were exposed [to HIV] last night, and then [when they get to the clinic for refills of the medication], you are not testing them … because of the workload. You just give them PrEP [HIV prevention medication]. What if this person was exposed?” 

Dreams got teen girls to use PrEP — what will we use for LEN?

One of the biggest losses when funding was cut, the report says, was the Pepfar-funded Dreams partnership for teen girls and young women. 

Dreams didn’t just offer HIV testing and prevention; it helped young women to develop life skills and skills to generate an income. 

In areas where Dreams operated in Pepfar-supported countries, the uptake of HIV prevention medication was 1.4 times higher than in areas where the programme wasn’t rolled out. Overall, 70% of all the teen girls and young women who started on such medication in Pepfar countries, did so in Dreams districts. 

“At the precise moment that this platform could have been used to expand access to injectable PrEP [HIV prevention medication], the US government cancelled all Dreams funding and restricted PrEP funding to services for pregnant and breastfeeding women only,” the report notes. 

“Overnight, a prevention platform constructed over years of community presence was severely damaged and, in some places, destroyed.” 

About 30% of new HIV infections in South Africa are among teen girls and young women between the ages of 15 and 25 years, even though they only comprise around 8% of the population. 

The road ahead 

The report’s authors say the government should increase its health spend — 16.8% of the country’s budget goes towards health — “to mitigate against the concerning impact of the US global health funding cuts”.

But Yvette Raphael, Advocacy for Prevention of HIV and Aids director, argues it’s time to find new donors. “We need to move away from saying we don’t take money from pharmaceutical companies. Pharma is creating this, so they need to put up a system to support this.”

Raphael is funded by Gilead Sciences, the drug maker that developed LEN, to create Zazi clubs for young people, which provide similar services to what Dreams did. 

Mitchell Warren, Avac’s executive director warns: “We’re now building lenacapavir programmes on a foundation of sand, not stone”. 

“So LEN introduction is going to be harder than it should have been. But we shouldn’t use that as an excuse to go slow or small. We need to be hyper-aware as these programmes roll out that we are truly reaching the people who could use it the most.”

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