by Melanie A. Bisnauth, PhD, University of the Witwatersrand
In January 2025, the dismantling of the United States Agency for International Development (USAID) began as President Donald Trump signed an executive order that would see the freeze and eventual withdrawal of funding to critical health research and programmes around the world.
Over US$400 million was rescinded from PEPFAR, and USAID was rapidly restructured, slashing its global footprint. By March, 83% of USAID initiatives had been cut. Its workforce collapsed from over 10,000 employees to fewer than 300.
People living with HIV were among the hardest hit.
The U.S. withdrawal triggered cascading cuts across international aid programmes, exposing long-standing cracks in health systems worldwide. By May, an estimated 233,818 development workers across 159 humanitarian agencies lost their jobs. Although global figures remain difficult to quantify, modelling data projects excess deaths due to the funding cuts.
A 2025 study published in The Lancet shows that between 2001-2021, USAID-funded interventions prevented around 91 million deaths, including 30 million deaths among children under five. USAID funds were associated with a 65% reduction in AIDS-related deaths, a 51% reduction in malaria deaths, and a 50% decline in deaths from neglected tropical diseases. Continued defunding could reverse these gains, resulting in more than 14 million additional deaths by 2030, including 4.5 million children under five.
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The funding collapse reverberates across sectors, impacting nutrition, water and sanitation, education, and humanitarian aid – all of which are important to keeping a healthy population. Emergency response capacity to disease outbreak surveillance has become weakened.
This came as a dual shock for the healthcare system in South Africa – already strained by COVID-19 backlogs, ultimately leaving many living with HIV, particularly mobile populations, without the care they needed.
Outreach teams providing HIV testing, adherence counselling and prevention services dissolved. Peer educators and community health workers – the first point of contact for many patients – were laid off. Major strides in HIV care stalled, and gender-based empowerment programmes lost momentum. The impacts rippled quickly. UNAIDS modelling warns of more than 150,000 additional HIV infections in South Africa by 2028 if replacement funding isn’t secured.
Insights from the ground
In June 2025, I decided to circulate a rapid, semi-structured questionnaire to HIV programme implementers in South Africa to better understand the impact, and checked in with several USAID partners. Respondents included medical providers, programme managers, monitoring and evaluation officers, technical advisors, finance/grant officers, data capturers and research and training consultants. Over half had more than 6 years of USAID experience.
- 86% reported delays, freezes, redirections or cancellations in funding.
- 86% reported severe workforce losses.
- 71% saw disruptions in HIV testing, counselling, monitoring and reporting.
- 57% identified ART provision and supply chains as the most affected.
- 43% experienced cuts to mental health services; 29% to PrEP programme initiatives.
- 40% reported entire HIV projects cancelled or repurposed.
All of the respondents felt there was no support for service continuity and urged clear communication, sustained funding cycles and contingency plans. A programme manager from Gauteng states:
“This was abrupt and mostly unclear as to how we were expected to implement changes. We couldn’t maintain ART adherence support for many. There was no time to adapt before services were pulled.”
Local institutions tried to absorb the shock, but capacity was limited. The message from the field remains clear: funding cuts without continuity plans unravel trust, services, and lives.
Where the bulk of HIV services are covered by USAID, patients described walking hours to clinics only to find no staff available; this erosion of trust and continuity risks long-term setbacks. Clinics struggled to keep ART stock flowing to rural communities.
A roadmap for resilience
These cuts were not merely budgetary; they reflected an ideological agenda. They remind us that global politics are not abstract but shape survival for the most vulnerable. Without more resilient systems, the same mistakes can happen again.
To protect progress, aid-receiving countries must work to secure their local and abroad networks and embed such practices into long-term strategies. We must build systems that fit the realities of mobility and political change, meaning:
- Resilient financing mechanisms and diversified funding sources that buffer services against political cycles, corruption and precipitous donor withdrawals
- Design differentiated service delivery models that tailor care to people’s mobility
- Incorporate digital health technologies, including AI for portable health records that follow patients across provinces and borders
Above all, governments must take accountability and coordinate with frontline providers, allowing time and resources for adaptation, not collapse when policies shift.
Health systems must be agile, inclusive, and resilient to disruption and disinvestment. People living with HIV – especially mobile populations – were left stranded not by chance, but by design. Stable funding, political will, and systems responsive to mobility and inequality are essential, as global politics should never decide who can access lifesaving treatment. In fragile settings, political disinvestment and procurement failures sound a clear alarm: action must be strategic and collective.
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Dr Melanie Bisnauth is a public health professional dedicated to advancing equitable healthcare, particularly HIV/AIDS programmes, and migration-related healthcare access in South Africa and Canada. She brings deep expertise in research, data-driven policy insights, and program leadership, supported by her PhD in Public Health and work across international health organisations.
The views and opinions expressed in this opinion piece are those of the author, who is not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.
