The abrupt shifts in global health funding strategies, particularly those championed by the “America First” doctrine, have sent ripples of concern throughout the international medical community, fundamentally challenging the stability of cross-border healthcare initiatives. The landscape of global health financing underwent a significant and sudden transformation beginning in 2025, when the Trump administration initiated drastic reductions and disturbances to global health funding. This policy shift has demonstrably imperiled hard-earned public health achievements and squandered invaluable investments in essential infrastructure and collaborative initiatives for disease management, health security, and critical research endeavors.

Over a year after these disruptions commenced, by late March 2026, programs combating HIV, tuberculosis (TB), and malaria, alongside fundamental health services and numerous humanitarian efforts, continued to suffer impairments across various nations, with the African continent particularly affected. As of April 2026, the proposed frameworks of the America First Global Health Strategy—a new U.S. Department of State paradigm for foreign aid focused on American economic and security interests and requiring co-investments from recipient nations—had yet to receive financial backing or be put into practice. This strategy, unveiled in September 2025, encompasses vital health domains such as HIV, malaria, TB, polio, and broader global health security. Concerns have emerged regarding the opaque bilateral agreements or memoranda of understanding (MOUs) between the United States and funding recipients, with critics pointing to a perceived absence of evidence-based, epidemiologically robust programming and the perceived exploitative conditions imposed by the U.S. government. From an industry perspective, this unilateral approach risks undermining the very foundations of global healthcare partnerships, potentially impacting the long-term viability of certain healthcare destinations and the trust required for international patient care and cross-border healthcare initiatives.

South Africa: A Critical Healthcare Destination Under Triple Pressure

Among the numerous nations grappling with the repercussions of the Trump administration’s decisions, South Africa stands out, having faced a compounded assault on its HIV funding, research capabilities, and crucial cooperative diplomatic ties. Before 2025, South Africa received the most substantial direct funding from the National Institutes of Health (NIH) globally, outside of the United States. This was complemented by significant contributions from the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID). These financial injections cultivated a formidable research infrastructure, fostering productive collaborations between American and South African research institutions that yielded pioneering discoveries.

Tragically, the nation also bears the burden of the world’s most extensive HIV epidemic, characterized by alarmingly high and persistent incidence rates among cisgender women, especially adolescent girls and young women. Despite its status as an upper-middle-income country, South Africa’s national health system and its robust HIV program are primarily sustained by internal resources, with 16.8 percent of its annual budget allocated to domestic health priorities. While U.S. funding constituted a dominant 80 to 90 percent of some countries’ HIV programs pre-2025, its contribution to South Africa’s HIV response in recent years amounted to approximately 17 percent. Nevertheless, these resources were instrumental, often entirely supporting specialized initiatives for vulnerable demographics, including adolescent girls and young women susceptible to HIV acquisition, sex workers, and other key populations. Furthermore, these funds underpinned essential components such as pediatric HIV diagnosis, meticulous data collection and cleaning, and vital community-based services, all of which are critical for maintaining the quality of care and supporting international patient care efforts within a global healthcare framework. The withdrawal of such targeted support undeniably impacts the nation’s capacity to serve as a reliable healthcare destination, potentially affecting patient travel for specialized treatments and broader health tourism.

The Far-Reaching Consequences of Funding Disruption on Quality of Care

The cessation of vital financial support for prevention, treatment, and research infrastructure carries ramifications that extend far beyond the immediate monetary value withdrawn. The Trump administration effectively dismantled every facet of these enduring partnerships and programs. This was achieved through the elimination of USAID-backed initiatives, key components of the President’s Emergency Plan for AIDS Relief (PEPFAR)—the United States’ premier foreign aid program addressing the worldwide HIV crisis—and a specific Trump executive order that prohibited all foreign aid and assistance, simultaneously halting all research funding to South Africa based on unsubstantiated allegations of “white genocide.”

It appears that a direct consequence of the breakdown in diplomatic cooperation is the U.S. government’s failure, thus far, to pursue a Memorandum of Understanding (MOU) with South Africa for ongoing health-related funding. While these agreements are often criticized for their self-serving nature and focus on U.S. interests, they typically offer crucial assistance and technical collaboration, aiding countries in transition planning and ensuring that previous U.S. investments through PEPFAR, USAID, and other partners are not entirely squandered by sudden cuts to global health funding. As of April 2026, this transitional mechanism was unavailable to South Africa. Instead, the United States government seemed poised to abandon nearly all its extensive investments in research, programming, and long-standing collaborations with a nation at the very heart of the global HIV pandemic and a leader in scientific innovation. This trifecta of dismantling HIV programs, cutting research funding, and severing cooperative diplomatic relations has, in essence, transformed South Africa into a testing ground for the “America First” foreign policy. From a strategic management standpoint, this represents a severe miscalculation, as it not only jeopardizes public health but also tarnishes the U.S.’s reputation as a reliable partner in global healthcare, potentially impacting its soft power and future cross-border healthcare initiatives. It is imperative to meticulously chronicle both the immediate and prospective consequences of this particular global health policy trajectory, especially concerning its effects on quality of care and the broader global healthcare ecosystem.

Throughout the preceding year, a diverse coalition of South African advocates, activists, clinicians, researchers, and individuals living with HIV meticulously documented the profound repercussions of these sudden funding cutbacks. Organizations such as Advocates for the Prevention of HIV in South Africa (APHA), Emthonjeni Counseling & Training, and PHR collaboratively spearheaded a project to record the damages, attest to the effects, and underscore the broader implications of the Trump administration’s policies. In September 2025, PHR and its partners conducted 20 in-depth oral history interviews involving 40 participants. These individuals—including South African medical doctors, nurses, clinical officers, peer counselors, peer navigators, people living with HIV, young individuals, transgender men and women, men who have sex with men, government health workers, and researchers—articulated their personal experiences of the immediate psychological, physical, and public health detriments resulting from these losses. To ensure accuracy and provide current perspectives, all participants were re-contacted in March 2026 to verify their statements and offer updates. These powerful narratives collectively illustrate how the devastating triple impact on U.S. funding for HIV initiatives, research infrastructure, and diplomatic relations with South Africa has significantly degraded the quality of HIV treatment and prevention services, placed immense pressure on the wider health system, and is effectively squandering billions of dollars of prior U.S. investment in crucial research platforms and health delivery mechanisms, particularly those focused on primary prevention. With no indication of transitional funding or the re-establishment of robust research collaborations, it is an editorial opinion that the United States has inadvertently contributed to a future surge in new HIV infections that could otherwise have been averted, thereby undermining its own stated goals for global healthcare and potentially impacting its standing as a desirable healthcare destination for collaborations.

Key Findings: Diminished Capacity and Eroding Trust in Global Health

The systematic documentation of impacts reveals a worrying trend across South Africa’s health system, affecting community outreach, clinic-based services, and critical data infrastructure. These reductions directly compromise the quality of care and the integrity of international patient care models.

In the Community: Diminished Community-Based Testing and Programming for Primary Preventive Health Care

The withdrawal of funding has severely curtailed the reach of community-based health interventions, a cornerstone of effective public health. A young cisgender woman, an HIV prevention advocate and educator, powerfully articulated the shift: “The only way to get tested for HIV now is to go inside the clinic and test. Whereas we had people that were working in the streets for the community doing just HIV testing. You didn’t need to go to the clinic, you didn’t need to wait in long queues. You just went in the tent and said, ‘I’m here for HIV testing.’ You get tested, if you’re positive, they link you to care. It’s no waiting, no… It gave dignity, in a sense. Now you need to imagine now, someone is going to have to wait for them to really get sick, so that they can say, ‘No man, I’m really sick, I need to go to the clinic.’”

Participants, including government health workers, young peer educators, and individuals living with HIV, reported a substantial reduction in accessible community-based health services. These vital services included HIV and sexually transmitted infection (STI) testing, crucial linkage to pre-exposure prophylaxis (PrEP)—a biomedical strategy where HIV-negative individuals use antiretroviral medications to prevent virus acquisition—HIV treatment, and fundamental primary health services such as blood pressure monitoring, immunization catch-up programs, and body mass index testing for managing non-communicable diseases. In some instances, these services have entirely disappeared because the U.S.-funded entities providing them lost their financial support. In other cases, government-supported community outreach efforts have scaled back due to staffing shortages at physical clinic locations. This illustrates one of the many ways U.S. cuts to PEPFAR-funded programs have inadvertently degraded the quality and accessibility of care for health issues unrelated to HIV. The cessation of widespread community HIV testing jeopardizes timely diagnosis and subsequent linkage to treatment, a critical component of effective global healthcare.

An HIV diagnosis serves as the essential entry point for accessing effective health services. Individuals diagnosed with HIV should be promptly connected to antiretroviral treatment and other supportive services, while those who are HIV-negative but at risk should be linked to comprehensive HIV prevention, including PrEP. Structural impediments like prolonged wait times, travel expenses, and lost income associated with clinic-based HIV testing can significantly reduce testing uptake if convenient and community-based services are no longer available. Many participants highlighted extended clinic wait times and expressed concerns that individuals would delay testing until symptoms became unavoidable. One participant issued a stark warning: “If we do not take care of our health, we will be forced to take care of our illness.” This scenario directly impacts the overall public health landscape and can deter patient travel, including medical tourism, to regions perceived as having compromised primary care.

In the Clinic: Diminished Quality of Clinic-Based Primary Prevention and Treatment Services

While PrEP and antiretroviral therapy remain available in South African government-funded health facilities, private clinics, and through local organizations with existing CDC-PEPFAR and other funding sources, the study’s participants described a noticeable decline in the quality of clinic-based services. A cisgender woman, a PrEP user, recounted her experience: “So I went in there, so I told her [the nurse] that I wanted to return to my PrEP, and I asked her, ‘Why now there’s no counselors? […] Why are the processes not the same?’ And then she’s like, ‘Sis we have a lot of work here. We only test you when you ask, as now you are asking me to test you. If you did not ask, then I was not going to test you.’”

This account underscores the challenges: extended wait times, overburdened staff, the abandonment of standard protocols for HIV testing prior to PrEP provision, and the loss of health workers crucial for follow-up. These workers previously ensured that clients newly diagnosed with HIV and TB understood and adhered to their treatment regimens, and they re-engaged individuals with HIV who had missed appointments. PrEP, HIV, and TB treatments are effective when medications are taken consistently as prescribed, following an accurate diagnosis that the client fully comprehends. Many people living with HIV diligently take antiretrovirals, achieving virologic suppression that preserves health and reduces HIV transmission risk. However, certain populations—including newly diagnosed individuals, marginalized groups who anticipate or experience stigma at health facilities, and those facing income and housing insecurity—often struggle to initiate or maintain regular treatment. The loss of dedicated health workers to support these vulnerable segments of the population places hard-fought gains in the HIV response at significant risk, eroding the quality of care and potentially impacting international patient care efforts that rely on robust local systems. This situation could make South Africa less appealing as a healthcare destination for those seeking comprehensive patient travel support.

In the Dark: Diminished Availability of Timely, Actionable Data

Effective public health programs are fundamentally reliant on timely, accurate, evidence-based, and actionable data. In the context of HIV, this encompasses critical metrics such as:

  • The number of new HIV diagnoses (incidence) within a specified population over a given period.
  • The percentage of individuals consistently returning for their antiretroviral therapy or PrEP refills.
  • The proportion of people on antiretroviral therapy who achieve virologic suppression.
  • The percentage of individuals on antiretroviral therapy who have disengaged from care.

These data points are essential for triggering targeted problem-solving interventions, ranging from a home visit for a client who missed a refill to customized community engagements in areas with high rates of new infections. Data facilitates the judicious allocation of scarce resources and provides early warning signs when programs are underperforming. In this study, participants detailed data-entry backlogs resulting from U.S. foreign aid cuts, which meant clinic staff had limited real-time information regarding key indicators of HIV program success. They often could not ascertain whether clients recorded as “disengaged” (having missed one or more refill appointments) had, in fact, received their refill without the visit being logged in the system that generates usable data reports.

A government-employed data quality officer, a cisgender woman, expressed her profound concern: “I’m waiting for a big bomb to blow on our face at any time. Because people, the truth is people are not taking the treatment. And because we can’t see that they’re not taking it. And even when they come, we don’t have time for them because we are overwhelmed. I’m here today for a meeting to look at why is this clinic not seeing the [same] number of patients.”

Collectively, the disruption of community-based services, the degradation of facility-based primary prevention quality, and the diminished timeliness and quality of data create conditions conducive to potential surges of new HIV infections. Critically, these surges could occur without adequate awareness and prompt action from public health stakeholders, including front-line health workers, affected communities, and leadership at local, subnational, and national levels. This lack of data transparency and operational efficiency profoundly impacts the ability to deliver quality of care and maintain a reliable global healthcare system.

Irretrievable Waste: Squandered Investments in Research Infrastructure and Global Healthcare Innovation

Beyond the immediate service delivery impacts, the funding cuts represent a catastrophic squandering of long-term investments in research infrastructure, severely hindering South Africa’s role as a medical tourism and healthcare destination for innovation.

A staff member at a major research institution, a cisgender woman, lamented the direct consequences: “The worst part is I’m currently recruiting for a study that requires clinic assistants. They are not there, the people in the clinics [formerly employed by PEPFAR]. The clinics are in crisis…I work with many clinics here. The [health workers] that I would go and know that they’ll be there: data capturers, there will be counselors, I will be able to interact with this person and that person, they are not here.”

Prior to 2025, South Africa received an estimated $100 to $150 million annually in direct grants from the NIH, with the total reaching approximately $400 million when including sub-grants, in addition to PEPFAR funds. Much of this crucial funding evaporated over the past year due to the termination of research and grant funding by the NIH, the non-renewal of awards for ongoing clinical trials, and an NIH directive prohibiting foreign sub-award grants. South African researchers have unequivocally described these financial losses as catastrophic, jeopardizing years of progress in global healthcare.

It is vital to recognize that the United States itself was a direct beneficiary of these robust research collaborations, which led to significant advancements, including products developed by U.S. private sector companies such as the injectable PrEP medication, lenacapavir. South Africa has also played an indispensable role in assessing effective strategies for treating and preventing TB, contributing to the development of the Xpert MTB/RIF diagnostic test (capable of detecting Mycobacterium tuberculosis and rifampicin resistance), genomic research identifying human genetic variations linked to increased TB susceptibility, and pioneering TB vaccine research.

The cost-effective and efficient development of new drugs and preventive measures necessitates clinical trials conducted in communities with high rates of new infections and/or a high prevalence of the disease in question. Without these specific epidemiological conditions, clinical trials for, for example, a novel HIV PrEP strategy would demand enormous participant enrollments, extended timelines, and prohibitive costs. South Africa’s persistently high rates of HIV, TB, and other infections, coupled with its exceptional research infrastructure, have historically made efficient, ethical research possible, yielding worldwide benefits, including for populations within the United States. The dismantling of this infrastructure not only undermines South Africa’s standing as a healthcare destination for research but also impedes global progress in medical innovation.

Overall, this report concludes with an editorial opinion that the Trump administration’s “America First” foreign policy approach, as implemented in South Africa through cuts to HIV programs, research, and civil diplomatic relations, is profoundly counterproductive. It demonstrably wastes resources, undermines decades of progress against HIV/AIDS, and ultimately diminishes both U.S. national and global health security. The long-term implications for cross-border healthcare and international patient care are severe.

PHR and its collaborators present compelling narrative evidence that the Trump administration’s cuts to global health funding and its halt of foreign aid and assistance to South Africa have had several critical negative impacts:

  • Wasted Investments in Prevention: Hundreds of millions of dollars of investments have been squandered by abandoning primary prevention programs and technologies designed to support large-scale prevention efforts, including the innovative new PrEP drug lenacapavir. This represents a significant setback for wellness tourism initiatives that often leverage robust public health systems.
  • Squandered Research Infrastructure: Hundreds of millions of dollars of investments have been squandered by failing to continue engagement with a unique collaborative research infrastructure, encompassing laboratories, advanced data systems, clinical trial platforms, and highly skilled personnel. This undermines South Africa’s potential as a leading healthcare destination for medical research.
  • Reckless Disregard for Human Life: There has been a reckless disregard for the dramatic consequences of failing to maintain funding to reduce new HIV infections among infants, young people, and adults, and preventing unnecessary suffering and death among people living with HIV. This ultimately leaves populations worldwide, including in the United States, less secure and more vulnerable to illness, impacting the fundamental quality of care globally.

In essence, while the America First Global Health Strategy ostensibly aims to reduce perceived inefficiencies and waste in foreign assistance through mechanisms like bilateral health agreements, the abrupt cuts to global health aid themselves have paradoxically generated inefficiencies and introduced risks of waste, fraud, and abuse. This directly contradicts the strategy’s stated objectives. These disruptions and reductions in aid jeopardize decades of U.S. investment in HIV prevention and response infrastructure. Primary prevention initiatives and clinical trials, along with the broader research ecosystem—established in South Africa over many years through billions of dollars in funding—are particularly vulnerable. These cuts not only weaken the resilience and durability of local health systems, thereby impacting the quality of care available to international patients, but also dismantle the critical clinical research pipeline in South Africa upon which the United States has historically relied for innovations in treatment, prevention, and disease management. The disruption of these programs threatens both ongoing research and the capacity to generate new scientific knowledge, ultimately undermining the long-term effectiveness of U.S. foreign assistance, U.S. national security, and the global fight against HIV.

Strategic Recommendations for Rebuilding Global Health Resilience and Quality of Care

This report unequivocally demonstrates that the elimination of crucial funding for prevention, treatment, and research systems carries consequences that extend far beyond the immediate financial impact. These findings underscore the urgent imperative to restore investments in prevention, rebuild community-based outreach, reignite HIV research, and re-establish robust data tracking mechanisms to prevent further damage to South Africa’s and the global HIV response. The report also identifies critical shifts that are undermining the availability, accessibility, acceptability, and quality of HIV prevention and treatment services, particularly for key populations, signaling a clear regression in the realization of the right to health and other fundamental human rights.

Key Recommendations for a Sustainable Global Healthcare Future

To the United States Government:

  1. Mobilize and Safeguard Funding: Actively mobilize, safeguard, and appropriately allocate funding appropriations for HIV prevention, treatment, primary health care, and collaborative HIV and TB research.
  2. Extend Transitional Support: Extend the Bridge Plan through the end of FY2026 at levels commensurate with appropriation, providing options for countries to transition as memoranda of understanding with aid recipient countries are successfully signed.
  3. Ensure Timely Fund Transfers: Ensure that appropriated funds necessary for programmatic implementation still performed by the CDC and Department of Defense are transferred with sufficient buffer time and funding for budget reserve and planning.
  4. Preserve Investment Value: Ensure that shifts in global health policy do not undermine decades of prior investment, especially in building robust healthcare destinations.
  5. Ground Engagements in Human Rights: Ensure that global health engagements and aid agreements with partner countries are fundamentally grounded in human rights, equity, and mutual accountability, promoting ethical cross-border healthcare.
  6. Reinvest in Community Health Workers: Reinvest substantially in funding for community health workers, peer educators, health ambassadors, and other community outreach professionals globally, recognizing their role in accessible quality of care.
  7. Sustain Rights-Based Programming: Ensure sustained, rights-based funding and programming for key populations, critical for equitable international patient care.
  8. Lift Research Restrictions: Immediately lift the existing restriction on U.S. federal funding for research in South Africa.
  9. Enhance Transparency: Ensure transparency and data access by publicly releasing disaggregated programmatic and financial data on a regular basis, fostering trust and accountability in global healthcare.

To Other Donor Governments:

  1. Increase Bilateral Support: Urgently increase bilateral HIV and primary health care support in high-burden countries to address prevention and primary care gaps, bolstering their capacity as healthcare destinations.
  2. Plan Phased Transitions: Collaborate with recipient countries to gradually transition them from reliance on donor funding through carefully planned, phased reductions, ensuring continuity of essential health services and minimizing disruptions to care, particularly for patient travel needs.

To the Government of South Africa and Other Governments Responding to HIV Epidemics in the Context of Diminished Donor Financing:

  1. Prioritize Domestic Health Funding: Prioritize prevention, treatment, and primary care as integral parts of the HIV response within domestic budgets.
  2. Act on Stress Signals: Act on warning signs of stress placed on domestic HIV programs by systematically collecting data to understand the full extent of the impact of the funding cuts.
  3. Exceed Abuja Declaration: Reaffirm, fully implement, and surpass the Abuja Declaration commitment to allocate at least 15 percent of national budgets to health, and adopt progressive increases beyond 15 percent to reflect current funding realities.
  4. Ring-Fence Prevention Funding: Prioritize ring-fenced funding specifically for HIV prevention, especially for adolescent girls and young women and other key populations.
  5. Diversify Funding Sources: Reduce reliance on a single donor by actively expanding domestic resource mobilization.
  6. Fulfill Constitutional Duties: Explicitly fulfill constitutional duties by taking proactive steps to ensure equitable access to essential health services for all populations, particularly key populations, thereby improving the overall quality of care.
  7. Insulate Critical Programs: Insulate critical programs from external shocks by strengthening the resilience of HIV and key population programs to funding fluctuations.
  8. Ensure Provincial Accountability: Hold provincial health departments accountable for delivering services, ensuring that their resource allocations meet minimum service levels and reflect the progressive realization of the right to health as required under the constitution.
  9. Integrate Anti-Discrimination Measures: Implement explicit protections to safeguard marginalized and vulnerable populations through anti-discrimination and equity measures.
  10. Monitor and Report Impact: Require transparent, regular reporting on access gaps, service disruptions, and health outcomes for key populations to monitor and publicly report impact.

To the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Health Organization, Africa CDC, the African Union, and Other Multilateral Entities:

  1. Prioritize Prevention Funding: Ensure that prevention remains a core funding priority and invest robustly in community health workers and peer-led models, which are vital for local health tourism.
  2. Strengthen Surveillance Systems: Strengthen global and regional surveillance and reporting systems to document impacts associated with funding disruptions, ensuring a clear picture of global healthcare challenges.
  3. Expand HIV Research: Sustain and actively expand funding for HIV research, preserving critical infrastructure for future innovations.
  4. Establish African Emergency Mechanism: Establish an Africa-wide HIV emergency coordination mechanism.
  5. Lead African Financing Framework: Lead the development of an African HIV financing transition framework.
  6. Coordinate Procurement and Manufacturing: Coordinate pooled procurement and regional manufacturing of HIV commodities in Africa, enhancing self-sufficiency and quality of care.

To International and Human Rights Mechanisms and Bodies, including the United Nations, African Union, and World Health Assembly:

  1. Monitor Human Rights Impacts: Continuously monitor the human rights impacts of global shifts in funding, advocating for equitable cross-border healthcare.

The news signal for this article was referred from: https://phr.org/our-work/resources/wasted-investments-looming-crisis-the-impact-of-u-s-global-health-funding-cuts-on-hiv-in-south-africa/