South Africa's HIV Fight Faces Reckoning as U.S. Aid Freeze Exposes Health System Gaps

Mnotho Ngcobo grew up in South Africa relying on the public health system. He knows what it is to sit in those queues. That personal history is what made January 2025 feel, to him, like something more than a budget problem.

When the United States froze foreign aid that month, it carved out a single exception: HIV treatment would continue. The decision seemed to protect what mattered most. What followed revealed something no carve-out could prevent: the collapse of everything else that keeps people alive.

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Clinics closed almost overnight. Health workers lost their jobs with no transition plan. Testing services vanished. Prevention programs, already fragile in systems stretched thin, simply disappeared. In Kenya, adolescent dropout rates from HIV care climbed as high as 55%. In South Africa, community organizations like Anova laid off thousands of health workers while delivery of PrEP, a prevention medication, was gutted. An mRNA HIV vaccine trial at the University of Cape Town was halted days before it was due to begin.

These were not abstract budget cuts. They were the difference between someone staying in care and vanishing from it.

Ngcobo, an assistant professor of law at the University of Louisville Brandeis School of Law, watched this unfold and recognized something deeper than a funding crisis. He presented his research at the AIDS 2026 conference in Rio de Janeiro, examining what the withdrawal of American support revealed about how African nations protect the right to health when the money that built their systems suddenly stops.

“Everyone was calling it a funding crisis, a budget problem,” Ngcobo said. “As a lawyer, that framing bothered me. Underneath the money was a legal and ethical failure nobody was naming. There was no framework anywhere governing how a donor exits a relationship that millions of lives depend on.”

For two decades, donor funding from initiatives such as PEPFAR, USAID, and the Global Fund had shaped Africa’s response to HIV. These programs rolled out antiretroviral therapy at scale, launched prevention initiatives, and helped reduce AIDS-related deaths across sub-Saharan Africa. The funding was so central that it became invisible. Governments and communities built their entire health infrastructure around it. When that money left, the infrastructure collapsed, and no legal mechanism existed to manage the transition.

Ngcobo’s research focused on South Africa and Kenya, two countries that built decades of their AIDS response around American money. His findings challenge a widespread assumption: that stronger constitutional protections guarantee resilience.

Kenya’s constitution contains more ambitious health rights language than South Africa’s. Article 43 of the Kenyan constitution is stronger on paper, and Kenyan courts have been willing to enforce those rights. Yet Kenya suffered far worse harm from PEPFAR’s withdrawal because it was structurally more dependent on the funding. PEPFAR covered more than half of Kenya’s entire HIV budget. South Africa, by contrast, relied on the United States for roughly 17% of its response and could put emergency money on the table. Constitutional strength did not predict who coped better. Structural dependence did.

The deeper problem, Ngcobo found, was that two decades of external funding had quietly built parallel health systems running alongside government services. In Kenya especially, those structures became so entrenched that they obscured the government’s own constitutional duty until the money left. A state cannot outsource a constitutional duty to a donor, he argued. The obligation remains the government’s, whether or not the state is the one writing the cheque.

Neither South Africa nor Kenya had any law or policy governing what happens when a donor exits. Responsibility for keeping services running was scattered across institutions with no real accountability mechanism. Termination letters arrived, some signed off “God bless America,” leaving affected communities with no legal remedy at all. The right to health existed on paper, but its real content depended entirely on decisions made in Washington by people who owed nothing to a patient in KwaZulu-Natal.

The consequences fell hardest on people already on the margins. PrEP access for key populations, youth-friendly clinics, and community outreach were disproportionately funded by PEPFAR and were the first things to disappear. A KwaZulu-Natal audit found that facilities serving over half the province’s people living with HIV were disrupted, including clinics that had never received a cent of direct PEPFAR money. Studies project more than half a million additional HIV deaths in South Africa over a decade if services are not restored. UNAIDS estimates that a full collapse of US-supported services could mean around 6.6 million additional infections by 2029.

“Later, when I started travelling and experiencing healthcare elsewhere, the contrast was hard to miss,” Ngcobo said. “You notice the long waits and the stockouts back home, and then you notice systems that put real weight on prevention, on catching things before they become emergencies.” That experience shaped how he came to see health as a question of law, not just medicine.

The most immediate danger, he said, is that treatment survives while prevention quietly disappears. Under fiscal pressure, governments protect patients already on antiretrovirals, and prevention programs are what gets cut. “If you let prevention slide, you’re simply manufacturing the next wave of infections, and the bill comes due a few years later,” he said. Section27’s assessment in South Africa confirmed this pattern.

Ngcobo now believes African governments have an opportunity to fundamentally reshape how donor transitions are managed. His recommendations are concrete.

Governments should turn donor exit into something governed by statute rather than left to chance. Withdrawal should never be an overnight administrative decision. It should be a managed legal process built around minimum notice periods, mandatory joint transition planning, and an enforceable duty to maintain continuity of access. Governments should also integrate donor-funded health workers and delivery systems into national health services rather than allowing parallel structures to persist indefinitely. As long as delivery lives in a parallel structure, the state’s obligation and the state’s actual capacity do not line up, and one policy change away from collapse is too close. Donor exits, Ngcobo argues, should also undergo ethical review comparable to that required for clinical research. If trial sponsors must account for the harm of closing a study, a donor dismantling a life-saving programme should face review proportionate to the foreseeable harm, binding both the donor and the recipient government.

Domestic financing remains essential. South Africa already funds around 77% of its own AIDS response and has built in above-inflation budget increases, which Ngcobo sees as the right direction, provided it is real money and not a line in a budget that never arrives. The deeper obstacle is that it cannot be done while debt repayments swallow the health budget, a structural trap most of the continent is in.

Meanwhile, there are reasons for cautious optimism. Civil society organizations in South Africa, including Section27 and APHA, have systematically documented the harm as it happened. South Africa put emergency money in and redirected patients to public facilities. Kenya stood up a crisis team and pushed on domestic antiretroviral manufacturing. At the continental level, twenty-two African countries are now building transition plans, and eleven have actually increased their national HIV budgets for 2026.

The trajectory remains precarious. The US has announced it is ending PEPFAR support to South Africa, with funding expected to run out by early 2027. This is not a reduction. It is a full exit from the country with the largest epidemic in the world. At the UN this year, the new political declaration on AIDS passed without consensus for the first time since 2001, with the US voting against it. The global solidarity that carried this response for twenty years is fracturing in real time.

The gains hold only if governments treat continuity as a legal duty rather than a policy preference, if the transition to domestic financing is managed rather than forced by a shock, and if new tools actually reach people. Lenacapavir, the twice-yearly injection, could genuinely change the trajectory of new infections, but too few manufacturers are currently licensed to make a generic, and it is not reaching the people who need it.

“The science to end AIDS exists,” Ngcobo said.