After a year of US funding cuts across global public health, including South Africa’s hard-hit HIV programmes, new realities are settling in. We spoke to Mitchell Warren from the New York HIV advocacy organisation, Avac, to find out what that means for South Africa. Photo: Paul Botes
Health organisations that merge, more investment from the private sector, larger contributions from local governments and a much bigger focus on preventing new HIV infections.
That’s how the international health advocate, Mitchell Warren, sees HIV programmes surviving this year after the US government’s massive funding cuts in 2025. Warren heads the New York organisation, Avac, which also works in East and Southern Africa.
One thing’s for sure, the US’s money isn’t coming back, says Warren — at least not to South Africa, despite the country having the largest HIV epidemic in the world. Increasing political tension between President Donald Trump’s administration and the South African government resulted in President Trump labelling South Africa at the G20 meeting in Johannesburg in November as a country not “worthy of membership anywhere” and deservant of the US stopping “all payments and subsidies to them, effective immediately”.
Ten countries, eight of them African, will receive donations of a six-monthly HIV prevention jab, lenacapavir, from the US government’s Aids programme, Pepfar, this year. Many of the countries will also receive shots funded by the Global Fund. South Africa, on the other hand, will get donations only from the Global Fund.
Warren explains: “It’s bad for the HIV response in South Africa and around the world but it’s also just the most remarkably dumb economic policy because South Africa is the strongest economy on the continent [and the goal of Pepfar’s investment is to build a market for lenacapavir as fast as possible].”
The Trump administration’s decisions spurred some other Western governments to reduce their contributions to the Global Fund to Fight Aids,TB and Malaria.
By December, the fund had received only 63% in pledges for its $18 billion goal of contributions. The UK’s latest contribution is 15% less than its previous contribution in 2022 and Germany’s 2022 contribution was 23% higher than its 2025 contribution (the fund works in three-year cycles).
We talked to Warren about what we can expect in the Aids world this year, what we can do differently and how he thinks we should rebuild.
Following is an edited version of Mia Malan’s conversation with Warren, which was broadcast on our Bhekisisa podcast.
Mia Malan (MM): Let’s start with your work. How has your organisation changed in the past year?
Mitchell Warren (MW): We received one of those [Pepfar] stop-work orders a year ago and ended up laying off about a third of our staff. Even more difficult were decisions about sub-grants to partners all over East and Southern Africa — those grants were terminated, meaning a lot of them had to downsize and lay off staff as well. We’re about 40% smaller budget-wise and working hard to make sure we are fit for the future.
MM: What does “fit for the future” mean when you have less money? How do you become smarter? Can you give practical examples?
MW: We need to look at strategic partnerships. We are working with partners, particularly South African and other African advocacy organisations, to say: we did these things together with this much money, we have less money, you have less money — How do we get smarter?
We cannot build back to January 19 of 2025. We are not looking to bring back every project that was terminated. We had a lot of things that maybe were not core to our mission. They were not unimportant but we need to be mission critical. Maybe we both hosted a session at a conference, maybe both of us did outreach and education about PrEP [pre-exposure prophylaxis — [medicine HIV-negative people used to stop themselves from getting infected with HIV]. Now, one of us should do it with the support of the other. It’s about streamlining, looking for strategic partnerships and figuring out where each of us focuses to make sure that we divide and conquer, that we collectively complete the job.
MM: A year ago, we thought the cuts would be catastrophic. Have they been as bad as we feared?
MW: The honest answer is we don’t entirely know yet. One of the most outrageous cuts in Pepfar was to not track the data or at least not report on the data. We used to see quarterly data from Pepfar to assess performance, to realign programmes. Now we’re operating with at least one hand tied behind our back.
We expect by the end of March to begin seeing data from governments and from UNAids. Remember, World Aids Day data showed that from 2023 to 2024 the rate of new infections flatlined at 1.3 million both years — and that was before the US administration changed. The expectation is we certainly didn’t achieve great progress in 2025 and are likely going to see an uptick.
MM: South Africa is in a difficult position because of the Trump administration’s declaration that we’re a “racist state”. What are the implications of the US not working with the country that has the world’s largest HIV epidemic?
MW: It’s bad for the HIV response in South Africa and around the world but it’s also just the most remarkably dumb economic policy because South Africa is the strongest economy on the continent. When Pepfar announced they would provide lenacapavir through the Global Fund, they said they wouldn’t provide it in South Africa. The craziest thing was they said “this is a market shaping investment“. Well, you cannot shape a market for antiretrovirals without South Africa. It is the largest country with respect to infection, it has the largest market for treatment and it has the largest, most successful PrEP programme in the entire world.
Everybody benefits by working in South Africa, both in public health and in economic terms. The faster we build the market of big volumes, the faster the price from generics, which are coming in 2027, is going to drop for the whole world.
MM: How should South Africa respond?
MW: South Africa needs to dig deep, both in its ability to be smart and strategic and it needs to dig deep into its pocketbook. [The six-monthly HIV prevention jab] lenacapavir is a priority. It’s going to be harder without Pepfar in the short term but South Africa can dictate the terms of its response. Civil society needs to step up and advocate for what’s right for the epidemic response in the country, in the region and ultimately, globally.
MM: The Global Fund didn’t reach its $18 billion fundraising goal, with countries like the UK cutting their support by more than 20%. What’s the impact?
MW: The impact is huge. Germany made a great pledge but it was down by more than 15%. This is not just a US problem. The Global Fund is hugely impactful. One of the greatest success stories in multilateralism and we need countries to step up. It is going to be operating with a smaller resource envelope than its investment case of $18bn.
We have to look at every programme, every investment and see how we accomplish the goals with fewer resources. Are they going to do even more with lenacapavir to drive infections down faster? Will they make sure that certain programmes that focused on key populations [groups of people, such as sex workers, injecting drug users, transgender people and young women in Africa, who have a higher chance of getting HIV through sex] that Pepfar used to support get sustained through the Global Fund? We need to make sure that every dollar, rand, euro, pound is spent to best effect.
MM: Are we going to see organisations merging?
MW: We’re going to see a fundamental restructuring. You’ve got, in many countries, Global Fund and Pepfar but you also have Gavi doing vaccine programming. Do we need every global health organisation? Do we need every global advocacy organisation?
After an earthquake, architects don’t build the same building again — they build something far more resilient. This coming year has to be one of strategic rebuilding, building something different, not building back but building forward. That means a different architecture at the country level, at the community level, at the regional level and at the global level. A year from now, I suspect we’ll see fewer acronyms but hopefully we’ll see the ones that are there are stronger than any before.
MM: You’ve said before that the private sector needs to step up. What does that mean in practice?
MW: It’s on a number of levels. Over the next several years, South Africa and other countries in Africa are going to be economic engines. Companies like ViiV and Gilead, which develop HIV drugs, shouldn’t just be looking to the Global Fund and Pepfar — they should be thinking: Is there a private sector market for some of these products as African countries move into middle- and upper-middle-income status? As they make money, they can put that back into other areas.
But there’s also the private sector that isn’t in the health system — fast-moving consumer goods, agriculture, banking, telecommunications. A number of African countries are going to increasingly be moving into middle-income status. Companies need to be investing. A healthy Africa is a healthy market for future economies. We need to see this as a virtuous cycle — getting the private sector to see Africa as a growing market and making sure that we have a health system that supports healthy people in that growing economy.
MM: What’s the biggest lesson from this past year?
MW: The real lesson is don’t depend on the US. Don’t depend on anybody else. A degree of self-reliance — that was a conversation over many administrations but there was an accelerator to say: we’ve really got to step up and do it ourselves. For 21 years, Pepfar was seen as America at its greatest and people trusted America as a partner.
The honest truth is America was not a trustworthy partner. But here’s what matters: a year later, I’m still standing. We, as a community, are still standing. Lenacapavir is now in countries and being delivered to people. We are going to succeed in global health and development not because of what happened in the last year but in spite of it.
Additional reporting by Danny Booysen and Nicole Ludolph.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.