The US freeze in life-saving HIV and Aids programmes has detrimental effects on affected key populations. Reuters
Four days into his second administration, US President Donald Trump signed an executive order reinstating the global gag rule (GGR or Mexico City Policy). The GGR prohibits organisations receiving US foreign funding from providing or referring to abortion care, even with separate, non-US government funds.
Organisations need to make the difficult choice of whether to comply with the rule or forgo US government funding. Some, including organisations funded by the US President’s Emergency Plan for Aids Relief (Pepfar) that implement HIV/Aids programmes, do comply. But some USAid-funded organisations refuse to comply and turn down US government funding.
In the last few weeks, executive orders limiting foreign aid funding and leading to “stop-work orders” have overshadowed the gag rule and put a punitive halt on all existing foreign assistance awards, until a 90-day review can determine which services — according to the Trump administration — are deemed “appropriate to fund”. This has left many organisations providing a wide range of programmes with no choice but to temporarily shut down or scale down services, leaving many people with limited or no access to vital health care.
After much public outcry from American citizens, as well as consulates and programme implementers across the world, some programmes were eligible to apply for emergency humanitarian waivers which included a vague list of “life-saving medicines and medical services”. Pepfar programmes were one of the few that were granted waivers. But, even with these waivers, which are due to expire in April 2025, organisations have been unable to access existing funding, and future funding remains uncertain.
Although Pepfar programmes received waivers, the waivers did not apply to the full range of services offered through these programmes. These waivers included only salaries for personnel necessary to carry out approved work (laboratory staff, healthcare workers and supply-chain staff), HIV testing and treatment services for all key population groups including services for pregnant and breastfeeding women, and the screening and diagnosis of Tuberculosis (TB) in people with HIV, and preventative TB treatment.
Preventive HIV services, including the provision of HIV screenings for people seeking male circumcision, and pre- and post-exposure prophylaxis (PrEP and PEP) for groups other than pregnant and breastfeeding women, were restricted.
South Africa runs the world’s largest anti-HIV prevention and treatment programme, with 1.65 million HIV-negative people in the country having used an anti-HIV pill at least once. A freeze in life-saving HIV and Aids programmes has detrimental effects on affected key populations. It has serious implications for the livelihoods of clinic and programme workers, who have shown resilience in the past few weeks to ensure that patients are cared for despite the orders.
These policies have forced various clinics in South Africa to shut down. The Wits Reproductive Health and HIV Institute, which runs four Trans Health Centres in South Africa, sent SMSes alerting those affected that services would be placed on hold as of 28 January 2025. This left 1 800 patients and 24 staff members affected. The Anova Health Ivan Toms Centre in Cape Town placed a sign outside its building to inform patients of the temporary “pause of all services”. The centre offered HIV services to gay, bisexual and other men who have sex with men. Clients in Johannesburg, Gqeberha, and East London, also felt the effect of the stop-work order as OUT’s Engage Men’s Health closed its doors.
In addition to halting critical services, work on crucial clinical trials has been frozen, leaving some participants with medical devices inside their bodies. One such frozen study was taking place in Vulindlela, a township in KwaZulu-Natal, where a new device to prevent HIV infection and pregnancy was being tested. Like in many of the other trials that received the stop-work order, removing the device — a silicone ring which was inserted through participants’ vaginas — would violate the rules set out in the order.
Dr Leila Mansoor, one of the investigators on the trial, highlighted the ethical implications tied to leaving such devices unmonitored in people’s bodies. Mansoor and her team chose to put their participants first and remove the devices, going against the restrictions of the stop-work order. This is just one example of how the stop-work orders and funding freezes have affected research studies and participants across the country.
Over the last few weeks, we have also seen a possible threat to the provision of reproductive health services to young people and their rights, as a result of the GGR and other executive orders. In South Africa, people aged 15 to 34 make up a third of the country’s population. At a time when many youths feel forgotten by the “system”, these actions could further limit their ability to take ownership of their sexual and reproductive health and lives.
The government of South Africa recognises the reproductive health rights of its people, including abortion, and guarantees said rights to young people through its Constitution and the National Adolescent and Youth Health policy, but the GGR flies in the face of these commitments, not only threatening access to reproductive health services for young people, particularly those from historically disadvantaged backgrounds and key populations, but also violating the sovereignty of countries.
Although a US judge ordered the Trump administration to restore funding for foreign aid programmes, in the past week this information has not trickled down to affected organisations and health facilities. Many service providers remained closed, for fear of contravening the “stop-work orders” and losing the little funding left at their disposal. While some Pepfar organisations have since resumed work, others have not, and it remains unclear when services will resume.
As the saying goes, when America sneezes the rest of the world catches a cold, and ultimately, the stop-work orders, funding freezes, and the GGR affect ordinary people all over the world. Under previous US administrations that have implemented the GGR, ample evidence demonstrates the harm it has caused. While we do not yet have the evidence of the actions of the current administration, we know the effect will be far reaching. And, while it is great to see that concerned Americans whose commitment to social justice and access to universal healthcare for all is unwavering, it has also become clear that there is a conversation to be had about democratising funding.
The recent effects of these Trump administration policies highlight how countries that are heavily reliant on US foreign assistance are especially vulnerable to the US government’s actions. We must seek funding sources that are unrestricted, aligned with South African law and commitments to human rights and free from political interference.
For example, the use of UN bodies and other global mechanisms like the Global Fund for HIV, TB and Malaria, and Gavi, the Vaccine Alliance can be a possible solution, as these structures have systems in place to disperse aid, with built-in checks and balances.
But, in recent times, the UN has been shown to be subject to ideology and geopolitics as the security council veto powers ultimately determine the fate of all nations. And, the Trump administration’s withdrawal of support for the World Health Organisation and the United Nations Population Fund, alongside the dramatic cuts to US foreign aid broadly, make the chances of additional resources becoming available extremely slim.
As we reflect on World Social Justice Day on 20 February, we must continue to advocate, educate, organise and resist. Everyone deserves access to information, power and resources to build the families and live the lives they choose. We, especially those living in democratic countries that have free and fair elections, must use our power to vote for good and ensure people committed to evidence-based, high-quality, comprehensive sexual and reproductive health care lead our governments.
Duduetsang Mmeti is a communications manager and Sesona Buyeye a communications assistant for Ibis Reproductive Health.