The cost of the plunge: the impact and cost of a cessation of PEPFAR-supported services in South Africa
File(s)
Published version
Author(s)
Meyer-Rath, Gesine
Jamieson, Lise
Mudimu, Edinah
Imai-Eaton, Jeffrey W
Johnson, Leigh F
Type
Journal Article
Abstract
Background:
Globally, shifts in United States foreign-aid policy have put HIV funding under duress. South Africa is unique in the region because its HIV program is largely domestically funded, although donor funds and partnerships support key components. We estimated the potential epidemiological impact of ceasing provision of services currently supported by PEPFAR and the costs and cost-effectiveness to the South African government (SAG) of potentially taking over these services.
Methods:
We used a costed version of Thembisa, a South African HIV transmission model, to simulate four scenarios: a minimum scenario assuming intervention coverage reducing proportional to PEPFAR's funding share of specific activities in 2023; a maximum scenario assuming additional health system impacts; and sub-scenarios either with 3-year recovery (2029–2031) or no recovery to previous coverage. HIV program costs were estimated from the provider perspective (SAG) in 2024/25 US dollars.
Results:
Over 2025–2028, discontinuing activities currently funded by PEPFAR in South Africa without replacement by SAG would result in 150 000–296 000 additional new HIV infections (29–56% increase) and 56 000–65 000 additional AIDS-related deaths (33–38%). Permanent discontinuation of currently PEPFAR-supported services over the next 20 years increases this to 1.1–2.1 million additional new HIV infections and 519 000–712 000 additional AIDS-related deaths. Sustaining these services would cost an additional $620 million to $1.4 billion between 2025 and 2028. Under a reduced budget, the most cost-effective interventions to preserve are ART and PrEP for key populations.
Conclusion:
Unmanaged PEPFAR exit from South Africa threatens to undo a decade of progress unless services are taken over by other funders, including SAG.
Globally, shifts in United States foreign-aid policy have put HIV funding under duress. South Africa is unique in the region because its HIV program is largely domestically funded, although donor funds and partnerships support key components. We estimated the potential epidemiological impact of ceasing provision of services currently supported by PEPFAR and the costs and cost-effectiveness to the South African government (SAG) of potentially taking over these services.
Methods:
We used a costed version of Thembisa, a South African HIV transmission model, to simulate four scenarios: a minimum scenario assuming intervention coverage reducing proportional to PEPFAR's funding share of specific activities in 2023; a maximum scenario assuming additional health system impacts; and sub-scenarios either with 3-year recovery (2029–2031) or no recovery to previous coverage. HIV program costs were estimated from the provider perspective (SAG) in 2024/25 US dollars.
Results:
Over 2025–2028, discontinuing activities currently funded by PEPFAR in South Africa without replacement by SAG would result in 150 000–296 000 additional new HIV infections (29–56% increase) and 56 000–65 000 additional AIDS-related deaths (33–38%). Permanent discontinuation of currently PEPFAR-supported services over the next 20 years increases this to 1.1–2.1 million additional new HIV infections and 519 000–712 000 additional AIDS-related deaths. Sustaining these services would cost an additional $620 million to $1.4 billion between 2025 and 2028. Under a reduced budget, the most cost-effective interventions to preserve are ART and PrEP for key populations.
Conclusion:
Unmanaged PEPFAR exit from South Africa threatens to undo a decade of progress unless services are taken over by other funders, including SAG.
Date Issued
2025-08-01
Date Acceptance
2025-06-05
Citation
AIDS, 2025, 39 (10), pp.1476-1480
ISSN
0269-9370
Publisher
Lippincott, Williams & Wilkins
Start Page
1476
End Page
1480
Journal / Book Title
AIDS
Volume
39
Issue
10
Copyright Statement
Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
10.1097/QAD.0000000000004272
Subjects
antiretroviral treatment
budget impact
cost
cost-effectiveness
defunding
HIV
HIV testing services
medical male circumcision
preexposure prophylaxis
Publication Status
Published
Date Publish Online
2025-06-20