The Public Health Impact of Foreign Aid Withdrawal by the United States Government and Its Implications for ARVs, Preexposure, and Postexposure Prophylaxis Medications in South Africa and Nigeria

Abstract

HIV/AIDS remains a global public health concern, with a high prevalence in sub-Saharan Africa. The President’s Emergency Plan for AIDS Relief (PEPFAR) initiatives, including preexposure prophylaxis (PREP) and postexposure prophylaxis (PEP), significantly reduced HIV infections in South Africa and Nigeria. The suspension of United States (U.S.) foreign aid may impact these preventive measures. Although some emergency aid programs were exempted, uncertainty persists, impacting global health initiatives, especially in South Africa and Nigeria. This study investigates the public health impacts of the United States (U.S.) government’s January 2025 suspension of U.S. foreign aid, focusing on its implications for HIV prevention initiatives, such as PREP and PEP, in South Africa and Nigeria. We comprehensively searched keywords such as PEPFAR, PREP, PEP, HIV infection in South Africa or Nigeria, antiretroviral (ARV) drugs, public healthcare impact, 2025 Trump’s foreign aid withdrawal, titles, and abstracts in Google Scholar, PubMed, and Web of Science. The search results were screened from 500 to 150 included articles based on their relevance and quality assessment for inclusion. The review unveiled that Nigeria maintained a continuous increase in HIV/AIDS-related deaths and new HIV infections from 1990, reaching the climax between 1999 and 2005, showing approximately 110,000 HIV/AIDS-related deaths and 200,000 new HIV infections. Notably, due to the PEPFAR intervention in Nigeria, an improved decrease in both HIV/AIDS-related deaths (45,000) and new HIV infections (75,000) was experienced from 2010 to 2023. South Africa experienced a rapid increase between 1990 and 2003 in both HIV/AIDS-related deaths and new HIV infections, reaching the climax around the early 2000s, with about 520,000 new HIV infections and 260,000 HIV/AIDS-related deaths in 2005. Furthermore, there was a continuous decline from 2005 onwards, with 50,000 HIV/AIDS-related deaths and 150,000 new HIV infections by 2023. Therefore, the suspension of this aid threatens disruptions in ARV therapy, possible increases in HIV transmission, shortages in PREP and PEP, the retrenchment of healthcare workers, the suspension of non-governmental organization activities, and the reversal of gains in vulnerable populations, reversing progress toward the 95-95-95 vision, increasing morbidity and mortality rates and financial strain on healthcare systems in these two countries. We recommend proactive measures, such as increased budget allocations for healthcare reforms, exploring local vaccine and health product development and diversifying funding sources in Nigeria, and implementing universal healthcare coverage for South Africans to mitigate the adverse consequences of aid withdrawal.

1. Introduction

One of the global public health concerns is Human Immunodeficiency Virus (HIV), responsible for acquired immunodeficiency syndrome (AIDS). Globally, intensified campaigns and initiatives are focused on reducing new HIV infections while increasing the accessibility of therapeutics. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), there were 39.9 million people living with HIV (PLHIV) in 2023 across the world. These global statistics include 38.6 million adults above 15 years and 1.4 million children below 15 years [1]. UNAIDS further reported that, in 2023, 1.3 million new people were infected with HIV, indicating a 39% decrease in new HIV infections since 2010 and a corresponding 60% decrease since the climax in 1995. In 2023, approximately 30.7 million (77%) PLHIV had access to antiretroviral therapy (ART) worldwide [1,2]. More so, in 2023, UNAIDS estimated that East and South African regions had the most PLHIV at approximately 20.8 million, 5.1 million lived in West and Central Africa, 6.7 million lived in Asia and the Pacific, and 2.3 million lived in West and Central Europe and North America [1,3]. A summary of the 2023 statistics of PLHIV, new HIV infections, and HIV-related deaths is depicted in

Table 1. The 2023 overview of HIV epidemic globally.

	PLHIV	New HIV Infections	HIV-Related Mortality
Statistics/Total Number	39.9 million	1.3 million	630,000
Adults above 15 years	38.6 million	1.2 million	560,000
Children below 15 years	1.4 million	120,000	76,000
Men above 15 years	18.1 million	660,000	320,000
Women above 15 years	20.5 million	520,000	240,000

.

Preexposure prophylaxis (PREP) and postexposure prophylaxis (PEP) are two globally common HIV/AIDS prevention strategies. PREP and PEP play pivotal roles in the global fight against HIV/AIDS. PREP and PEP function differently but complement each other in decreasing the rate of HIV infections, particularly among vulnerable populations [4,5]. PREP is a prophylactic measure involving the use of antiretrovirals (ARVs) prior to likely exposure to HIV. PREP is usually a combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) taken daily and orally. PREP maintains the concentration of ARVs in the bloodstream, thereby preventing HIV replication in an exposed person. It further inhibits the reverse transcriptase and prevents HIV infections in the system [4,5,6]. Consequently, PEP is a contingency HIV preventive measure applied after suspected exposure to HIV infection. PEP is endorsed by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) as an important emergency measure for HIV prevention taken as a 28-day regimen [7]. PEP functions by preventing HIV replication at the initial phase prior to the viral establishment of a persistent infection. PEP involves a combination of three ARVs such as TDF, FTC, and raltegravir (RAL) or dolutegravir (DTG). Administering PEP within 72 h of likely HIV exposure decreases the infection rate by approximately 80% [7,8]. A comparative analysis of PREP and PEP is shown in

Table 2. A comparative analysis of PREP and PEP.

Features	PREP	PEP
Aim	Prevention of HIV prior to exposure	Prevention of HIV after exposure
Medication Schedule	Continuous and daily	After exposure
Period	Prolonged as required	Only a 28-day regimen
Efficiency	About 99% on when strictly adhered to	Approximately 80% if taken within 72 h after exposure
Targets	Vulnerable populations	To be taken by everybody when exposed to HIV
Compliance	Strict daily compliance	Strict daily 28 days of compliance
Drug Reactions	Very moderate, likely liver and kidney malfunctions	Interim nauseating symptoms, stomach upset, and weakness
Availability	Usually prescribed and needs constant follow up	Only in emergencies

. The United States of America, through its President’s Emergency Plan for AIDS Relief (PEPFAR), has the highest global financial commitment as a nation in the fight against the HIV/AIDS pandemic. This review investigates the public health impacts of the United States (U.S.) government’s 20 January 2025, announced suspension of United States (U.S.) foreign aid and its implications for HIV prevention measures, including the PEPFAR initiatives, such as PREP and PEP, in South Africa and Nigeria. This study further reviews South Africa and Nigeria’s dependence on the PEPFAR initiative, assesses the immediate and long-term impacts of U.S. foreign aid withdrawal, and recommends potential measures to cushion these effects for sustainable HIV/AIDS country-driven outcomes.

2. HIV/AIDS Epidemiological Trends in South Africa and Nigeria

The HIV/AIDS epidemic continues to be an important public health challenge for both South Africa and Nigeria. However, both countries vary in their HIV/AIDS prevalence and incidence rates, as well as the infected population. While South Africa remains the greatest affected country globally by HIV/AIDS, Nigeria continues to rank the highest in the West African region [3,9]. The introduction of PREP and PEP by PEPFAR to both countries has significantly equipped them to nationally reduce HIV infections and prevalence rates.

Table 3. Summary of South Africa and Nigeria HIV epidemiology and PEPFAR interventions.

Group/Class	South Africa	Nigeria	References
HIV prevalence adults: 15–49 years	19.6%	1.3%	[10,11]
Number of PLHIV	7.8 million	1.8 million	[10,11]
Yearly new infections	150,000	75,000	[12,13]
Yearly HIV/AIDS-related mortality	45,000	51,000	[14,15]
PEPFAR ART coverage	5.5 million persons on treatment	1.7 million persons on treatment	[16,17]
Main vulnerable populations	MSM, sex workers, transgender people, people who inject drugs (PWID), adolescent girls and young women (AGYW)	MSM, sex workers, transgender people, people who inject drugs (PWID), adolescent girls and young women (AGYW)	[18,19,20,21,22]
Major contributors to HIV epidemic	Stigmatization and other socio-economic discrimination, reduced proportion of male circumcisions, high gender-based violence (GBV)	Stigmatization and other socio-economic discrimination, insufficient accessibility of HIV test kits and treatment, and gender inequality	[23,24,25]

shows a comparative analysis of HIV epidemiology in South Africa and Nigeria, including the preventive roles of PREP and PEP in each country.

3. Overview of the Contributions of United States (U.S.) Foreign Aid in the Fight Against HIV/AIDS in South Africa and Nigeria

The pivotal role of the U.S. in public health is globally recognised, especially in combating Human Immunodeficiency Virus (HIV) and acquired immunodeficiency syndrome (AIDS). The U.S.’s role is shown significantly in its global technical, financial, and medical commitments, particularly in sub-Saharan Africa, which has the highest and most alarming rates of HIV/AIDS [26,27]. The sub-Saharan Africa HIV/AIDS epidemic eruption of 1980 to the early 1990s raised a global public health alarm that necessitated U.S. intervention through awareness creation, education, and the provision of ART regimens. This initial African intervention was pioneered by the U.S. Agency for International Development (USAID) and the CDC [28,29,30,31,32].

One of the most important initiatives in the global fight against HIV/AIDS, launched in 2003 by George W. Bush, was the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR was responsible for fighting the HIV/AIDS pandemic by providing preventive measures, therapeutics, and healthcare services in sub-Saharan Africa, with an initial financial commitment of USD 15 billion for 5 years [33,34]. The aim of PEPFAR was the reduction in HIV transmission and its related mortality, expanding the accessibility of antiretroviral therapy, and strengthening the healthcare system. In 2023, the financial commitment to the PEPFAR initiative cumulatively increased to USD 110 billion, rating it as the highest financial commitment to addressing one disease or pandemic from one country/nation [35,36,37]. The initial focus of PEPFAR was on 15 countries with high prevalence rates, including South Africa and Nigeria. Recently, the coverage of PEPFAR extended to 55 countries, with the integration of HIV/AIDS with tuberculosis (TB) and maternal health, the prevention of mother-to-child transmission (PMTCT), and supporting voluntary medical male circumcision (VMMC). Furthermore, in 2013, PEPFAR adjusted its program from an emergency-response strategy to a more sustainable country-driven approach [36,37,38,39,40].

In 2022, South Africa was reported to have the highest adult (15–49 years) global prevalence rate of 19.6% or 7.8 million PLHIV [41]. The donation of USD 8 billion by PEPFAR to South Africa over the last 20 years ranks South Africa as one of the highest beneficiaries of the U.S. global health fund, with about 5.5 million people benefitting from antiretrovirals. Furthermore, South Africa’s HIV/AIDS program was supported with an additional USD 453 million from the U.S. in 2024 [42,43]. Nigeria received a total Global Fund of USD 4.8 billion from 2002 to 2024, making it the highest Global Fund recipient worldwide. Consequently, South Africa had received USD 546.8 million from the Global Fund as of March 2025 [44,45,46,47].

In addition, PEPFAR expanded the accessibility of PREP and PEP to sex workers and men who have sex with men (MSM), who are regarded as high-risk or vulnerable populations [48]. Other services provided by PEPFAR include strengthening healthcare personnel capacity and supporting youth-oriented prevention initiatives such as determined, resilient, empowered, AIDS-free, mentored, and safe (DREAMS) [49,50]. PEPFAR interventions scaled-up ART access in South Africa, tremendously reducing the HIV/AIDS-related mortality rate, as shown in Figure 1. The initiative resulted in a significant reduction in the mother-to-child HIV transmission incidence rate [51,52]. Integration therapy for HIV-TB co-infections has also enhanced the management of HIV-TB co-infected persons [53]. The monitoring, evaluation, and reporting data for South Africa can be sourced as cited in the literature [54].

South Africa experienced sudden surge between 1990 and 2003 in both HIV/AIDS-related deaths and new HIV infections, reaching the most intense around the early 2000s, with about 520,000 new HIV infections and 260,000 HIV/AIDS-related deaths in 2005. South Africa experienced a continuous decrease from 2005 onwards, with 50,000 HIV/AIDS-related deaths and 150,000 new HIV infections by 2023. This pattern depicts the successful impact of increased accessibility to HIV/AIDS treatments and preventive measures after 2005; however, the sustained high infection numbers show a continuous transmission burden [55].

Nigeria ranks as the country with the highest HIV prevalence rate in West Africa, with approximately 1.8 million PLHIV [56]. Although the country’s HIV prevalence rate of 1.4% is low, the burden of HIV is high when considering the large population of the country [57]. According to the January 2018 U.S. Mission in Nigeria’s report, the U.S. government (via PEPFAR) has committed approximately USD 85 billion to the global fight against the HIV/AIDS pandemic since 2003 [58]. PEPFAR donated about USD 6 billion to support the fight against HIV/AIDS, which supported the treatment of about 1 million children and women with HIV/AIDS. Furthermore, in 2020, PEPFAR HIV/AIDS support included the provision of counselling and HIV testing services to about 8.2 million pregnant women and children, the provision of counselling to about 1.2 million HIV-positive pregnant women to prevent mother-to-child HIV transmission, the support of about 1.2 million PLHIV for the better management of TB and HIV co-infections, and extended care and services to approximately 1.3 million vulnerable children and orphans [58]. Therefore, PEPFAR interventions scaled-up ART access in Nigeria, significantly reducing the HIV/AIDS-related mortality rate and new HIV infections, as shown in Figure 2.

Nigeria experienced a continuous increase in HIV/AIDS-related deaths and new HIV infections from 1990 onwards, reaching the most intense between 1999 and 2005, with about 110,000 HIV/AIDS-related deaths and 200,000 new HIV infections. A continuous gradual decrease was experienced from 2006 to 2009 in both HIV/AIDS-related deaths and new HIV infections. Notably, an improved decrease in both HIV/AIDS-related deaths and new HIV infections was experienced from 2010 onwards, showing the positive impact of increased PEPFAR, Global Funds, and other accelerated HIV/AIDS initiatives. There was a significant decrease of 45,000 HIV/AIDS-related deaths and 75,000 new HIV infections in 2023, depicting impactful achievements, but still showing a continued burden of disease [55].

Other major PEPFAR programs in Nigeria include support for the Nigeria’s national HIV/AIDS strategic framework (NSF), the expansion of the PMTCT coverage, and encouraging the national government’s sustainability fight against HIV/AIDS through increased and diversified funding. The PEPFAR initiative has significantly reduced the number of new HIV cases in Nigeria. The program has led to the wide coverage and availability of ART, reaching about 80% of tested PLHIV. Moreover, through extensive sensitization and counselling services, PEPFAR programs have reduced the stigmatization and discrimination of PLHIV in Nigeria [38,59,60,61]. PEPFAR also developed PEPFAR monitoring, evaluation, and reporting data, which can be sourced from the cited literature [62].

Finally, PEPFAR, U.S. Agency for International Development (USAID), and Centers for Disease Control and Prevention (CDC) assist South Africa and Nigeria (

Table 4. Roles of the U.S. government and other agencies in combating HIV/AIDS in South Africa and Nigeria.

Funding Agency	Main Activities in South Africa	Main Activities in Nigeria	References
President’s Emergency Plan for AIDS Relief (PEPFAR)	Mainly funded and supported antiretroviral therapy and other HIV-preventive programs, supporting laboratory equipment and system strengthening	Mainly funded and supported antiretroviral therapy and other HIV-preventive programs, supporting laboratory equipment and system strengthening	[63,64]
U.S. Agency for International Development (USAID)	Bilateral assistance with focus on orphans, vulnerable children, prevention programs, health systems	Focus on prevention, care for vulnerable groups, supply chains, and strengthening of health systems	[65,66]
Centers for Disease Control and Prevention (CDC)	Provision of technical assistance, surveillance, monitoring, and strengthening of public health capacity	Supporting laboratory activities, data and system record keeping, epidemiology training of health workforce, and other implementation of other HIV programs	[67,68]

) in developing, strengthening, and building their capacities in some important sectors, such as human capacity development, health system strengthening, and the provision of state-of-the-art laboratories and pharmaceutical warehouses to improve South Africa and Nigeria’s healthcare for tackling HIV/AIDS and other diseases, as summarized in Table 4.

4. The 20 January 2025, U.S. Government Foreign Aid Suspension

Immediately after Trump’s swearing in and assumption of the U.S. presidency on 20 January 2025, the U.S. government signed an Executive Order (EO) that initiated a 90-day suspension of all U.S. foreign aid initiatives. This suspension is meant to allow the new administration a chance to reassess the transparency, effectiveness, and alignment of these initiatives with the Trump administration’s America First agenda [69,70]. All U.S. consulate and diplomatic offices received notices to issue suspension directives to halt the execution of all U.S global health initiatives, including PEPFAR in low- and middle-income countries (LMICs). The EO was founded on economic effectiveness and political principles. The Executive Order also included all foreign aid executed by the U.S. Department of State and the U.S. Agency for International Development (USAID). However, some foreign aid was excluded, such as emergency military and food aid to Egypt and Israel, other relief initiatives that provide emergency medications and basic necessities [70,71]. Despite the exemptions for basic amenities and emergency medical services, it remains very uncertain what specific initiatives are exempted, such as PEPFAR and other public health initiatives like the presidential program for malaria reduction. This uncertainty necessitated PEPFAR’s waiver application and subsequent approval on February 1 for specific programs, including maternal and child health, nutrition programs, and the president’s malaria initiative (PMI). PEPFAR’s temporary (90 days) waiver also includes implementing emergency life-saving HIV/AIDS therapeutic programs in line with the U.S. Secretary of State’s 28 January 2025 memo on emergency medications and basic necessities waiver [71].

The overall impact of foreign aid suspension on global public health systems will probably be exacerbated within the 90-day period, given that more initiatives and projects without exemption (waiver) might be obligated to wind down and downsize, resulting in many unattended persons being affected. The ongoing review of the U.S. government’s global foreign aid might result in the continuation/discontinuation and adjustment of some programs. However, controversies and some legal issues surround the temporary suspension of U.S. foreign aid. It has been reported and speculated that there might be an imminent legal challenge to the suspension of foreign aid EO, which might result in the U.S. Congress stepping in, as Congress has oversight of some foreign aid initiatives. Hitherto, it appears to be only Democratic Senators who have spoken out about foreign aid suspension [70,72,73].

5. The Impact of Foreign Aid Suspension on Ongoing HIV/AIDS Prevention Initiatives, Specific Programs Affected, and Populations at Risk in South Africa and Nigeria

There is a phrase that says “prevention is better than cure”, and HIV prevention measures are important, as there is no cure for HIV [74,75]. HIV prevention strategies have been developed over the years, with some being successful in reducing the rate of HIV infection within the population. These interventions have impacted the behaviour of people by promoting condom use, increased HIV testing, voluntary male circumcision, and the increased use of PREP and PEP medications [76,77]. However, recent developments in the withdrawal of the PEPFAR fund may drastically affect South Africa, where the HIV rates are high, by causing a surge in the number of HIV infections due to limited access to drugs. The suspension of foreign aid might slow reaching the targets from the 95-95-95 vision. This 95-95-95 vision aims at attaining the goals of ensuring that 95% of people living with HIV know their HIV status, 95% of people who know that they have HIV are on ART, and 95% of people who are on treatment are virally suppressed by 2030 [78,79].

Since the launch of PEPFAR in 2003, it has saved several million people by supporting programs for HIV prevention, treatment, care, and support in about 55 countries [80]. The HIV/AIDS expenditure data for Nigeria and South Africa, as shown in Figure 3 and Figure 4, depict Nigeria’s increased HIV/AIDS expenditure in 2006 from USD 19 million to USD 500 million by 2010, revealing accelerated and scaled-up HIV/AIDS interventions. Expenditure was maintained and stable between 2010 and 2011, reaching the most intense point of USD 574 million in 2012. Post-2012 witnessed a reduced expenditure from USD 502 million in 2015 to USD 438 million in 2021, depicting changes in financial landscapes and the initiatives’ priorities. On the other hand, South Africa had an appreciable increase in expenditure of USD 611 million in 2006 to USD 2.3 billion in 2009, depicting the accelerated national fund and donor-assisted investments in HIV/AIDS initiatives. Funding was slightly decreased to USD 1.85 billion in 2014 and continuously increased from USD 2.43 billion (billion is represented as B in Figure 4) in 2017 to USD 2.55 billion in 2019. There was slight stable expenditure from USD 2.41 billion in 2020 to USD 2.47 billion in 2021, before a decrease to USD 1.8 billion in 2023, suggesting a shift in the initiative’s allocation and prioritization [55].

The sudden pause issued by the United States Government in U.S. foreign aid will drastically affect PEPFAR’s ability to continue with programs and services that are offered to PLHIV. UNAIDS is aware of the damage that will result from halted foreign aid and, therefore, they are collaborating with different stakeholders to create new partnerships with governments and communities to ensure that important HIV services continue during this 90-day pause and that updated information on HIV epidemiology is provided. UNAIDS pledges that PLHIV will continue accessing the services needed. Figure 5 shows the projection for 2029 according to UNAIDS if the PEPFAR initiative is permanently stopped. This projected increase in the number of new HIV infection cases poses an obstacle to ending HIV/AIDS as a public health threat by 2030, and also makes the goal of reaching 95-95-95 just a fantasy [79].

In recent years, most low- and middle-income countries have been immensely supported by PEPFAR in the prevention and treatment of HIV/AIDS. However, due to political issues and policy changes, partial funding cuts were made, thereby negatively affecting vulnerable populations and PLHIV in these countries [81]. Previously, the U.S. government cut the U.S foreign aid budget for countries such as Botswana and South Africa, which affected more than USD 6.7 billion earmarked for HIV/AIDS prevention, care, and research under PEPFAR, including the Global Fund to Fight HIV, Tuberculosis and Malaria, the National Institutes of Health, the Centres for Disease Control and Prevention, and the U.S. Agency for International Development [82].

South Africa is one of the largest beneficiaries of PEPFAR aid, and the funds are administered by USAID and the CDC [83,84]. From the years 2016 to 2023, South Africa benefitted greatly from USAID, with about 700,000 USAID-supported PREP programs. USAID reported that beneficiaries included a higher number of females within the reproductive age range compared to their male counterparts in the general population. Furthermore, MSM and other vulnerable populations are among the highest beneficiaries of the PREP program in South Africa [85]. Local non-governmental organisations (NGOs) and the Department of Health (DOH) have been recipients of USAID funds through PEPFAR. USAID also reported that, between 2004 and 2020, South Africa received about USD 5.6 billion at the current rand/dollar exchange rate towards preventing and treating HIV and TB [86,87]. In addition, there is a different budget for HIV programs in South Africa. The extent to which South Africa relies on U.S. funding varies by program. For example, 56% of the funding was reported to be spent on prevention, including youth and workplace interventions, condom distribution, and an independent human papillomavirus vaccination program [88].

There are a lot of worries about what would happen to an HIV-stricken country like South Africa. The cash flow that contributes to a lot of public health programs, especially from the U.S. government, has been halted. This might result in some NGOs’ frustration and financial difficulty that might even result in closure if this suspension continues beyond 90 days. The work of people working in these NGOs will be under threat, which might exacerbate societal distress.

Moreover, community health workers, peer counsellors, patient navigators, community activists and advocates, and support and administrative staff members who play a pivotal role in HIV programs might lose their jobs [89]. Following the announcement by President Trump, the South African Wits Reproductive Health and HIV Institute (RHI) Trans Health Centre closed its Key Populations Programme clinic, which was carrying out work sponsored by PEPFAR funds. Additionally, the South African Medical Research Council’s grant writing workshop was cancelled due to suspended funds through the U.S. National Institutes of Health (NIH) after announcements by the U.S. president [90]. Recipients of funding through PEPFAR received a notification to stop all activities, including the provision of antiretroviral medicine for HIV. This will lead to additional unemployment problems, because contract workers who keep these organizations functioning will be immensely affected by these uncertainties. More so, employees of PEPFAR-funded initiatives such as laboratory scientists, counsellors, nurses, and outreach and care coordinators who constitute the healthcare workforce will be thrown out of work due to the PEPFAR suspension or even permanent cessation. Consequently, their termination would lead to the disruption of services, decreased HIV testing and treatment services, weakened community outreach, and increased patient drop out from antiretroviral therapy. This upsurge in unemployment would further result in economic downturn and undermining HIV/AIDS prevention, testing, treatment, and follow-up services, thereby resulting in increased new HIV cases and HIV/AIDS-related deaths, aligning closely with the study’s primary focus on the public health consequences of foreign aid suspension.

The recent suspension of PEPFAR funding has also significantly disrupted HIV/AIDS programs in South Africa, particularly affecting specific initiatives and vulnerable populations. Employees in the health sectors who receive salaries from PEPFAR funds will face the consequences of the funding suspension, and the insecurities and uncertainties may affect their productivity and subsequently affect the healthcare system as a whole [91]. Non-Profit Clinics and organizations such as Engage Men’s Health, offering free HIV testing and treatment, have been forced to cease operations due to the funding suspension. PLHIV who are taking the antiretroviral therapies (ARTs) will experience deteriorations in health, thus leading to a high morbidity and mortality [92]. The key populations who are the main users of ARTs and prevention medication, including MSM, transgender individuals, sex workers, and residents of provinces where HIV is most prevalent, will be affected. The suspension affects South Africa’s 27 high-burden districts that depend heavily on PEPFAR support, leading to significant disruptions in HIV prevention and treatment services [79]. The funding suspension threatens to reverse progress made in combating HIV/AIDS in South Africa, underscoring the need for immediate action to restore support and ensure the continuity of essential health services. In a parliament session held on the 6th of February 2025, the South African Minister of Health, while responding to concerns raised by committee members about the immediate and long-term impacts of the PEPFAR suspension, highlighted the active role that PEPFAR has played in the fight against HIV/AIDS in South Africa. He reiterated that South Africa relies primarily on its own budget for ARVs, with approximately 90% of the medication being locally funded. This implies that more funding will be required to scale up the already nationally manufactured ARVs and diversify and strengthen other PEPFAR programs to cushion the effects of the suspension [93].

Nigeria is one of the other African countries that benefits from U.S. foreign aid. The current suspension of PEPFAR aid has contributed to struggles regarding how Nigeria will continue to carry out HIV prevention and treatment. The over USD 7.8 billion in funding received has been important in the fight against HIV/AIDS. Moreover, these funds have been used for prevention, care, and treatment services, including antiretroviral therapies to approximately 1.8 million PLHIV in Nigeria [94]. The withdrawal of these funds will be detrimental to the health of people infected and affected by HIV. Previously, a study conducted by Banigbe et al. [95] illustrated the magnitude of how a change in the policy of PEPFAR, which resulted in partial funding cuts, had affected some vulnerable populations in Nigeria [95]. The authors reported a drastic decline in staff employment, laboratory viral load testing, and prevention measures, which inadvertently affected the quality of the healthcare system in the country [95].

The current suspension of U.S. funds will cause interruptions in distribution logistics, particularly in how ART will reach PLHIV. The disturbance in supply due to the suspension of PEPFAR funds will negatively affect PLHIV. There will be issues of adherence to medications, resulting in relapse and resistance to drugs that are already developed. Studies show that when ARVs are not continuously and religiously taken by PLHIV, it affects their health and that of the community living with them, thereby increasing the chances of new infections [96,97,98]. This will cause clinics and hospitals to be overwhelmed by people who become sick, and the whole health system will be badly affected. Prevention initiatives such as educational campaigns and the distribution of free preventative resources such as condoms, PREP, and PEP will be suspended, resulting in a disturbance in reaching the goals of preventing HIV to people who are not infected by the disease [79]. One of the most crucial services of the PEPFAR program is medication for maternal and child health services. The PMTCT has reduced and prevented the MTCT of HIV. The total suspension of PEPFAR funding will significantly impact the recorded success of the PMTCT by resulting in a lot of neonatal infections and mortality and a surge in HIV infections [99].

In Nigeria, the different regions affected by the HIV/AIDS pandemic receive different services provided by PEPFAR. PEPFAR aid is the major vehicle for HIV prevention programs, treatment with ARTs, and care services in the country. If there is a suspension of funds beyond the 90-day pause, communities in this country will be badly affected. There will be high rates of HIV transmission due to reduced access to ARTs. Moreover, there might be higher viral loads and a decline in people with weak immune systems due to a decline in CD4 counts, which might lead to opportunistic infections such as TB and other sexually transmitted diseases. The holistic public health impact will include increases in morbidity and mortality, which have been relatively controlled over the years due to PEPFAR programs. Prevention programs such as the use of condoms, PMTCT, PREP, and PEP will be stopped if suspension exceeds the 90-day window. Unfortunately, PEPFAR supports the healthcare infrastructure in Nigeria and many people who work in these clinics, hospitals, and research institutes will be greatly affected. HIV/AIDS centres and community programs will be affected due to saturation in hospitals, leading to a lower supply of ambulances and beds at hospitals, resulting in poor service provision. Moreover, vulnerable populations, including rural communities, sex workers, MSM, younger and older women, orphans, PWID, and healthcare providers, will be at a high risk of HIV infection [4,9,100,101,102,103,104]. Nigeria is a significant recipient of U.S. foreign aid, receiving the naira equivalent of USD 1.2 billion to assist its important roles in HIV/AIDS treatment, maternal and childcare, and disease prevention efforts in 2023. Considering that Nigeria has the highest HIV/AIDS rate in West Africa, recently, the Nigeria government has taken a proactive sustainable measure in response to foreign aid suspension. The Nigerian Federal Executive Council, on Monday 3 February 2025, approved the sum of NGN 4.9 billion for healthcare reforms and appropriated another naira equivalent of USD 3.2 million to purchase 150,000 HIV treatment packs over the next 4 months. These additional funds will help to improve primary healthcare services, maternal and child healthcare, and the training of healthcare providers [105]. Furthermore, the Nigerian government has approved an additional naira equivalent of USD 200 million for the health sector in this year’s (2025) budget. They are planning to develop vaccines for HIV, and this is to try and reduce the magnitude of the impact of U.S. aid withdrawal [106].

6. Comprehensive Public Health Impacts of the U.S. Foreign Aid Suspension

The withdrawal of foreign aid by the Trump administration will significantly impact HIV prevention and treatment programs in Nigeria and South Africa, two of the countries with the highest HIV burdens in the world [107,108]. These impacts will include reduced funding for antiretroviral drugs, such as PREP and PEP, and the risk of increasing HIV incidence, leading to a major public health burden [101]. Aid withdrawal will lead to treatment disruptions, resulting in poor adherence to ARVs, which may increase the risk of viral rebound and onward transmission. Individuals who stop taking ARVs may develop drug-resistant strains of HIV, further complicating treatment efforts [109].

South Africa and Nigeria are affected by the aid suspension. Uncertainty in future funding leaves both providers and recipients unsure about continued access to essential medications like ARVs [110,111]. The decline in PREP, a key HIV prevention strategy, will greatly affect the high-risk populations, such as sex workers, MSM, and serodiscordant couples (where one partner is HIV-positive while the other is negative). Reduced funding entails that fewer individuals will be able to access PREP, thereby increasing their vulnerability to HIV infection [112]. At the same time, PEP, used to prevent HIV after potential exposure, will be less accessible due to budget cuts. These cuts will also negatively affect victims of sexual assault, healthcare workers exposed to HIV, and individuals at a high risk of infection. Studies have shown that, without timely access to PEP, there is a high tendency for the number of new infections to increase [112,113,114]. Funding shortages can result in setbacks in PMTCT programs, which ensure that HIV-positive pregnant women receive ARVs to prevent transmission to their babies [115]. In Nigeria, where mother-to-child transmission (MTCT) rates are already high, the situation will become worsened, as fewer women will be able to access prenatal HIV care, leading to an increase in HIV-positive births [116]. South Africa, which has made significant progress in reducing MTCT, also faces setbacks, as outreach programs and health services for pregnant women struggle to maintain operations [117].

The reduction in foreign aid will significantly impact HIV awareness campaigns, condom distribution, and community outreach programs, which are essential in educating the public on prevention. Following the reduction in funding, these awareness initiatives will be reduced, leading to declined or poor knowledge about safe sex practices, thereby increasing risky behaviours among some vulnerable populations [118]. The absence of these preventive measures will contribute to a potential surge in new HIV cases, reversing the progress made in curbing the epidemic. Sustained international support is crucial to maintaining these life-saving interventions and reducing the overburdening of healthcare systems [119].

Overburdened healthcare systems will struggle with rising cases of HIV and opportunistic infections like TB [120]. National governments, already financially strained, might not fully compensate for the funding gap. Overall, the withdrawal of aid will reverse progress in HIV/AIDS control, emphasizing the importance of sustained international support to prevent further public health crises.

Foreign aid plays a crucial role in providing antiretroviral drugs and funding for HIV-preventive measures such as PREP and PEP in countries like Nigeria and South Africa. These medications are essential for preventing the transmission of HIV and ensuring that individuals living with the virus can maintain their health [38,121]. However, the withdrawal of U.S. funding, particularly from programs like PEPFAR, will severely affect the availability and accessibility of these medications [1,38]. Furthermore, local healthcare systems will be overwhelmed and struggle to source and distribute ARVs. Interruptions in treatment increase the risk of drug resistance and higher mortality rates among those affected [105].

The reduction in foreign aid will lead to a decline in preventive healthcare services, including immunization programs, maternal health initiatives, and essential health education. In both Nigeria and South Africa, these cuts will make it more difficult to combat ongoing public health challenges such as TB, malaria, and other infectious diseases [109,122]. Healthcare infrastructure that is heavily reliant on foreign aid will face significant setbacks, with many HIV clinics and health facilities reducing their services or shutting down entirely due to a lack of funds [123].

Local governments, already constrained by limited healthcare budgets and resources, will be forced to find alternative means to bridge the funding gap. This will result in overstretched health systems, inadequate medical supply chains, and a shortage of healthcare workers [124]. In South Africa, where government resources are comparatively larger, some adjustments need to be made to accommodate the increased spending on HIV programs [125]. However, the reduction in external funding will still lead to service gaps, particularly in rural and underserved regions, where foreign aid previously played a vital role [126].

More so, a lack of funding will have a direct impact on health outcomes, with higher mortality rates due to untreated diseases, particularly HIV/AIDS. Limited funding entails that only a few individuals will access ARVs and HIV/AIDS preventive measures like PREP and PEP, resulting in worsening overall public health conditions [127,128]. In the long term, the withdrawal of foreign aid will have far-reaching consequences for the broader healthcare systems in Nigeria and South Africa. The lack of resources for medical research, infrastructure development, and basic healthcare services hinders the progress in addressing major health crises. Finally, both South Africa and Nigeria will be compelled to explore sustainable domestic financing mechanisms, but these solutions may be slow to implement. Many essential health programs may also struggle to survive during this transition period, leading to setbacks in the fight against HIV/AIDS and other public health challenges [129,130].

7. Mitigation Strategies to Be Adopted by South Africa and Nigeria

South Africa and Nigeria should explore various mitigation strategies to address the funding shortfall caused by aid withdrawal. South Africa considers health to be a human right as a national policy. The Oslo Declaration refers to human rights several times, accepting that ‘health is a fundamental right of every human being’ and, in line with legal scholarship, that ‘life is the most fundamental of human rights, and that life and health are the most precious assets’ [131]. The South African government has increased access to ARV drugs to cover universal treatment for all HIV-positive residents [132]. This was achieved by the government renegotiating for reduced ARV costs and reforming the pharmaceutical supply chain, resulting in ARV prices dropping globally and a reduction in the mortality rate of opportunistic diseases such as TB over five years in South Africa from 2009 to 2014 [133,134,135,136,137].

Notably, Nigeria’s budgetary allocation to the health sector is very low, suggesting government unwillingness and non-commitment to the fight against HIV/AIDS [138]. Funding for HIV/AIDS programs largely depends on donors such as USAID and WHO [131]. Aid interventions have achieved a remarkable feat in combatting against the HIV burden in Nigeria. Nigeria’s government must take up the sole responsibility for sustainable mitigation strategies for the HIV/AIDS health burden in the nation through partnerships with other funders such as religious groups [139]. The governments of South Africa and Nigeria can collaborate in sourcing generics from ARV drug manufacturers through BRICS alliance group member states. South Africa achieved the generic licensing of TDF by removing regulations hindering generic competition through voluntary licensing agreements with Indian generic manufacturers, thereby reducing the exports of generic medicines to South Africa [140]. The Nigerian government can adopt a similar modality by removing restrictions on medicine registration (through quality assurance and ensuring the affordability and availability of generic ARV drugs) and the harmonization of patent holders [137]. The bottom-up approach to preventing HIV nationwide involves establishing HIV projects at the community level and then scaling these activities up to include civil society organizations (CSOs), businesses, and public health initiatives [141]. CSOs can harness the power of the law and governing institutions to create space for policy reform. Policy reform resulted in the integration of local public health issues (such as access to ARVs and azidothymidine to prevent MTCT in South Africa [139,142]. This approach may result in a decrease in MTCT and improvements in average life expectancy [137,143]. The President of the Republic of South Africa recently signed the National Health Insurance Act (NHI Act) into law on May 15, 2024. One of the main objectives of the act is to allow universal healthcare coverage for all residents of South Africa without extra costs to recipients. It requires an individual to be registered to become an NHI user [144]. Nevertheless, the details of some benefits and their implementation are not precise. The act’s implementation will be carried out in the following two phases: phase 1 is from 2023 to 2026, and phase 2 is from 2026 to 2028. The NHI is not yet fully operational, but will come into effect in the future [144]. The Nigerian government can adopt and expand social health insurance (SHI), which enables healthcare to be borne by all pool members (individuals, households, business organizations, and the government), not individual contributors only [138]. A collective activist organization should advocate for the DOH to develop an urgent, coordinated emergency plan and allocate an increased budget to prevent a looming disaster. This includes mobilizing resources and establishing communication channels among stakeholders to facilitate swift response to the crisis [145]. Some organizations are exploring avenues to apply for waivers that would allow them to continue receiving some level of U.S. funding despite the freeze. However, they face challenges due to limited communication with USAID and operational restrictions placed on USAID employees from 20 January 2025, which will continue for the next 90 days [145].

8. Recommendations for Ensuring National Widespread Availability and Adherence to HIV Initiatives

Intensifying and increasing the awareness of available PREP and PEP medications and services by the DOH and other collaborative agencies and institutions involved in the fight against the HIV epidemic will strengthen the South African government’s efforts in reducing the HIV pandemic. Also, reducing the cost of accessing PREP and PEP and developing sustainable non-USAID-dependent HIV/AIDS prevention plans will foster the national widespread availability and affordability of HIV prevention drugs. More so, developing national awareness and sensitization strategies to reduce stigmatization and discrimination, which will enhance increased voluntary HIV testing and treatment in South Africa, is highly recommended.

Consequently, the Nigerian government will have to increase their budget allocation for HIV/AIDS prevention and treatment programs. They will need to collaborate with different stakeholders to achieve this mandate. Companies such as the National Health Insurance Scheme (NHIS) need to be more robust in funding more HIV programs and services. This will result in continuous care for PLHIV and those who are affected by the disease. There is a need for more NGOs and community-based organizations to mobilize and attract more funding from other organizations in the private sector or even from other continents. Within communities, there can be fundraising and voluntary services such as peer education, voluntary counselling, and support systems. One of the barriers to Nigeria’s ART distribution is its total reliance on other countries’ production and supply of ARTs. Nigeria’s reliance on other countries to produce its ARTs and other HIV/AIDS preventive medications, kits, and programs is counterproductive, as this will further delay the country’s ability to adapt and recover from the impacts of PEPFAR suspension [146]. There should be local companies or pharmaceutical companies that can manufacture ARTs and also find alternative ways to combat HIV to stop the dependence on international companies. This will also create jobs and boost the economy of Nigeria. HIV programs should be part of primary healthcare for people to easily assess treatments and counselling, thereby reducing the associated stigma.

In addition, Nigeria should be more self-reliant, with community-based projects and support from the country’s funds to achieve the goal of winning the fight against HIV/AIDS. Different governmental agencies and ministries should seek and intensify collaborations with other international donors such as the Global fund, World Health Organisation (WHO), and the Bill & Melinda Gates Foundation to replenish the funding that has been stopped. Sadly, if the U.S. funding suspension continues even after the 90-day pause, this will affect the livelihoods of people residing in Nigeria, because they will have to pay from their own funds for laboratory tests, treatment, and prevention medications. A disturbance in medication for people who are consuming it can have detrimental effects on their viral load, and this will put their families and community at a high risk of contracting HIV.

Lastly, South Africa and Nigeria should implement robust monitoring frameworks that incorporate both qualitative and quantitative metrics to evaluate program effectiveness and identify gaps for improvement [147,148]. Furthermore, such frameworks would enable policymakers to access real-time progress data and determine annual funding allocations. Enhanced transparency is expected to foster trust among partners, ensure accountability among fund recipients, and encourage further investments in effective interventions, thereby strengthening national health systems [149,150]. Ultimately, these measures may improve livelihoods and maintain robust health systems even during catastrophic events.

9. Discussion and Conclusions

Over the years, HIV prevention and treatment programs have contributed to decreases in global morbidities and mortalities associated with HIV/AIDS [151]. Sub-Saharan African countries such as South Africa and Nigeria have been the main beneficiaries of PEPFAR funds, since HIV is more prevalent in these countries [35].

Recently, after Trump’s swearing in as the 47th president of the U.S. on 20 January 2025, the U.S. government signed an EO that initiates a 90-day suspension of all U.S. foreign aid initiatives. This suspension is to reevaluate the transparency, effectiveness, and alignment of these initiatives with the Trump administration’s ‘America First’ agenda. Although some waivers have been granted, the intensity of these funding halts will reduce salaries and wages, and jobs will be lost at local clinics and hospitals, negatively affecting service delivery [152,153]. Politics change the way things function in a country, and the U.S., for the past two decades, has been supporting many countries in fighting the HIV/AIDS pandemic. South Africa does not solely rely on PEPFAR because the national government funds some of HIV programs. This might help to keep the country afloat while the goal is to search for other alternative funders. However, it might cause issues for SA taxpayers and worsen if the suspension goes beyond 90 days [154]. This study investigated the public health impacts of the U.S. government’s January 2025 suspension of U.S. foreign aid, focusing on its implications for HIV prevention initiatives, such as PREP and PEP, in South Africa and Nigeria. We examined the dependence of these countries on U.S. aid for HIV programs, investigated the immediate and projected impacts of aid withdrawal, and explored potential approaches to mitigate adverse consequences.

Different strategies can be employed to recover from crises that hit countries relying on U.S. funds. There should be a broadening of funding sources, because total reliance on funding from one source can be dangerous. There should be innovation in programs that will attract funding from the government, private sector partnerships, and community-based contributions that might assist in acquiring more funds for HIV/AIDS programs [155]. The integration of HIV programs into the primary healthcare sector will not only remove the stigma surrounding HIV/AIDS, but will also assist in sourcing funding under the umbrella of reproductive health and primary care [156,157]. The utilization of funds should be properly audited to ensure that donations are used for the programs they are meant for as requested [158,159]. Unfortunately, South Africa and Nigeria have been victims of individuals who use funds for relief for personal use. The Global Fund and the U.S. Department of State, in collaboration with the Office of the Inspector General in Nigeria, reported the fraudulent mismanagement and embezzlement of over USD 3.8 million in PEPFAR funds in 2018. In addition, there was a suspected case of fraud in the PEPFAR fund 2020 audit report in South Africa. These reported fraudulent activities further highlight the significance of the controlled monitoring and accountability of foreign aid programs [160,161]. Different communities can lead their healthcare and promote it by investing in their own clinic and hospital infrastructures through their local municipalities or local governments, especially in South Africa and Nigeria [162]. There is an urgent need to create robust policy frameworks to secure funds through national governments (South Africa and Nigeria) by commitments to funding HIV prevention programs and other pandemic initiatives. This will prevent these countries from being stranded at the start of any pandemic. We live in a very digitalized world, and this can be a benefit, as countries can create innovative ways to put health in the hands of their people, and there are opportunities for online awareness, mobile health files, and telemedicine. This can be shared in a data-free mode so that it does not cause more stress to communities.

9.1. Limitations

This narrative review is focused on the assessment of the projected impacts on HIV/AIDS outcomes due to the suspension of PEPFAR and U.S. government foreign aid to Nigeria and South Africa. However, the limitations of the study include the availability and reliability of secondary data, potential political and economic changes not accounted for in projections, and the inherent difficulty of isolating the effects of foreign aid cuts from other health system factors such as domestic funding shifts, global health trends, or emerging public health crises like COVID-19. More so, the projected impacts may oversimplify complex social, behavioural, and epidemiological dynamics, and future outcomes could vary significantly subject to national government responses, alternative funding sources, and international collaborations.

9.2. Epilogue

While this review was being conducted, on 26 February 2025, all USAID and PEPFAR initiatives in South Africa were permanently terminated [163,164,165,166,167]. This development could not be included in this review and analysis. The final termination of USAID funding for HIV organizations in South Africa by the Trump administration will result in the shutdown of critical programs. This experience strengthens our recommendation for the importance of sustainable and resilient healthcare systems in the face of geopolitical uncertainties. As the global health landscape continues to evolve, the lessons from this episode will remain crucial for policymakers in navigating the complex interplay between politics, aid, and public health.