Guest blog by Natasha Davies, MD
It is difficult to comprehend the scope of senseless chaos and harm the current US administration's freeze on foreign aid has already wrought in barely eight weeks. In South Africa – setting for the world's largest HIV epidemic, as well as decades of progress made possible in part by funds through PEPFAR (US President's Emergency Plan for AIDS Relief) – the administration permanently rescinded PEPFAR commitments funded by USAID (United States Agency for International Development) on February 27, 2025.
Natasha Davies, MD, a Johannesburg-based colleague of The Well Project, has served thousands of women living with HIV, including pregnant and breastfeeding women in extraordinarily challenging circumstances. Davies was among the many thousands of individuals who were recently forced out of essential jobs in the HIV sector as a result of the abrupt and unconscionable cancellation of this funding. This blog entry compiles some of Davies' own observations in the final weeks of February of this devastating experience and its impact.
It's been a hell of a couple of weeks.
Twenty-one years of working as an HIV clinician and then suddenly to be told I can't provide care has been incredibly hard. I've tried pushing back and asking to volunteer but even that isn't allowed.
I am so incredibly worried about the patients I was looking after. Some of them were not doing well at all and were far along in their pregnancies and only just starting to trust me and open up and then I just vanished. Wednesdays are worst, because I know there is no one there. If I'm not there, then these women will be seen by an obstetrician only who has no HIV experience at all. It's just heartbreaking.
[My] kids don't really understand how a president on the other side of the world can stop me working nor why he would want to. To be honest, neither do I.
I received a call from a mother I looked after when she was newly diagnosed during her pregnancy. She doubted her diagnosis, having been with the same partner, who tested HIV-negative, for 21 years. It took me several visits and advanced additional testing to convince her she had HIV and needed to take antiretroviral therapy (ART). She eventually accepted her diagnosis and reached suppression by delivery and now has a healthy, thus far, HIV-[negative] son. But she called me today from another province saying she moved home to the rural area and went to the clinic and they are refusing her treatment because she doesn't have a transfer letter. Ordinarily, through a network of PEPFAR partners linking to nurses and counsellors, I would have been able to sort it out, connect her with a named person who could advocate for her, get her the treatment she deserves. But now, nothing; I'm powerless. No network. No protection. No advocacy. All I could say was go back to clinic and if they still refuse, call me and try to get them to take the phone so I can talk to them. The real impact on the ground being felt by so many people.
My organization was, for example, supporting so many postnatal clubs, with about 5,000 mother-baby pairs having benefits from the support across three different provinces. We had seen only one transmission in those clubs over the past two years (and that in a mum who disengaged) compared with a national breastfeeding transmission rate of around 3% by end of feeding. So now we don't know what has happened to those clubs because they were run by PEPFAR-employed facilitators at many facilities. We have also lost the staff who tracked the positive test results for infants so, where an infant does acquire HIV, we don't know who will track the mom to bring baby back for ART initiation.
Also, obviously, my work of supporting particularly high-risk mothers has stopped and I can no longer provide telephonic support to nurses asking for guidance for women they are seeing who are not doing well. It's an absolute catastrophe and I have no doubt that mothers and infants will be affected with maternal deaths, newly acquired HIV (no PrEP service support) for moms and babies and infant deaths where babies don't get urgently linked to care.
My thoughts are just full of worry for the 2,800 colleagues for whom today is their last day of employment. No more work. No more income. And so, so many of them are low earning counsellors and data staff on whom entire extended families depend because of high unemployment in the country. This isn't just about the impact on a programme, or numbers, or even people living with HIV, there is also a massive individual impact on individual healthcare workers.
People keep talking about how for South Africa this is "only" 17% of the total HIV budget and the department of health keeps saying they will manage the transition. But it's not about a percentage of a budget; it's about the 8 million lives that will be affected by disrupted services. PEPFAR funded partners worked in the priority districts, the areas of the country with the highest HIV burden and the poorest outcomes. They also focused on the most vulnerable - men, pregnant and breastfeeding women, children and adolescents, new and reengaging clients, those with comorbidities including tuberculosis or mental health challenges, those who had missed appointments, mobile populations and migrants, key populations. All these groups that the government health services were not managing to service optimally have to fit in and manage to keep themselves stable with an inbuilt resilience to overcome the inherent barriers in a broken system full of burnt out staff. That's what people aren't realising. The percentage, proportion, total monetary value doesn't even come close to representing just how much we did for these most vulnerable individuals who will now be at such high risk of poor outcomes in a system that just cannot cope with their specific needs.
Hear Davies speak with South African media outlets regarding PEPFAR funding cancellation:
- Trump's USAID Cuts: A crisis for HIV services in South Africa? (Primedia+)
- USAID cuts leave beneficiaries and aid workers in desperate situation (ENews Channel Africa)
