At the beginning of 2025, bright white trucks would rumble into communities across South Africa on a set day each week. The trucks had fridges, medication, and staff who knew the people in need. People who use drugs, sex workers, people living with HIV; everyone knew when and where the trucks would be arriving. The trucks were Anova mobile clinics that provided HIV testing, support and counselling services, and for these people, they were a lifeline.
In 2026, “that is no more,” a government-employed health promotion officer told researchers from Physicians for Human Rights (PHR). Almost all of the trucks disappeared when the Trump administration cut funding to the President’s Emergency Plan for AIDS Relief (PEPFAR) on 20 January 2025, and froze grants from the National Institutes of Health (NIH) a few months later in March.
This was part of the president’s ‘America First’ aid policy, which supporters argued would encourage recipient countries to become self-reliant. Opposition to the cuts argued that essential services would immediately shut down. An emergency waiver for essential treatment was granted in late January, and South Africa was put into a ‘bridge plan’, intended to wean the country off of PEPFAR support. What that meant was that PEPFAR funding fell from around $450m in 2024 to just $115m in 2026, a roughly 75% decrease.
It wasn’t just the mobile clinics that vanished. Needle exchange programmes, outreach clinics, and community support networks also vanished. When the cuts came, South Africa’s harm reduction system was thrown into crisis almost overnight. In just KwaZulu-Natal Province alone, more than 800,000 people have experienced disruption in their HIV support over the last year. It is now estimated that, if the cuts are maintained, there will be an additional 56, 000–65, 000 AIDS-related deaths in South Africa between now and 2028. That’s an increase of almost 40%.
“This year has been very difficult,” Dr Andrew Scheibe, a harm reduction researcher at the University of Pretoria, told TalkingDrugs. Stacey Doorly-Jones, CEO of South African harm reduction organisation Stand, similarly struggled to find words for the impact of the cuts: “It’s unspeakable,” she said, “it’s a calamity.”
To put human faces on that calamity, a new report from PHR documents what the cuts have meant in a country suffering from the world’s largest HIV epidemic – an estimated 7.2 million people currently live with HIV in South Africa. What it finds is a harm reduction crisis that is being exacerbated by a government unwilling to help, leaving people who use drugs and other vulnerable populations with nowhere to turn for support.
System Disconnect
Since 2003, PEPFAR money has supported a network of clinics and community services specifically designed for populations at the highest risk of HIV: queer people, sex workers, transgender people, and people who use drugs. Using PEPFAR money, South Africa had built some of the most sophisticated community-based HIV prevention infrastructure anywhere in the world, consisting tens of thousands of community health workers, a vast network of community-led monitoring systems, specialised clinics for key populations, and localised programs for HIV testing, counselling, and PrEP distribution.
By necessity, this harm reduction infrastructure existed outside of the mainstream healthcare system. It did the essential work that an abstinence-obsessed government refused to engage in, explained Doorly-Jones, no matter its lip service to harm reduction.
When funding was cut, the disconnect between the two systems caused harm reduction to go into freefall. The government didn’t step in to fill the gap because there wasn’t the political appetite to help, according to Doorly-Jones.
“It wasn’t simply about reduced programming,” she told TalkingDrugs, “these life-saving services for people who use drugs were never ever properly absorbed into the public health system.”
Within the first 90 days of the cuts, 8,493 frontline posts tied to PEPFAR were eliminated. The remaining staff are on shorter hours with reduced days in the field, explained Julie Mac Donnell, a harm reduction specialist at the South African Network of People Who Use Drugs (SANPUD).
According to the PHR report, some people who lost treatment access were referred to general government facilities. What they found there was not equivalent care. The government system is ill-equipped, overwhelmed, and staffed by health workers with no time, no resources, and no training to respond to the needs of vulnerable populations.
One bisexual man living with HIV went three weeks without his medication after the clinic he used to go to for support closed in January 2025. He knew, he said, how serious that was. But at the government clinic he was sent to, the staff were completely overwhelmed.
“They’re too busy to look you in the eye,” he told PHR.
Still, the people who managed to get access to government healthcare were the lucky ones. Most didn’t, and still haven’t. They’ve been left without support, with no safety net at all.
“People don’t wait for a system to restart,” Doorly-Jones said. “People who are using drugs go into withdrawal, they share equipment, and we lose contact with them as the harms spiral out of control.”
Flying Blind
Losing PEPFAR didn’t just close clinics, it also dismantled the connective tissue of the harm reduction infrastructure. “Peer educators, outreach workers, navigators, community-led monitors, they were the invisible system. When they were cut, the entire system became blind,” said Doorly-Jones.
PEPFAR funded the health information systems, data capturers, and programme staff that fed South Africa’s national HIV patient database. Without these funds, clinics are running with mounting data entry backlogs and cannot keep track of the people using their harm reduction services. The cuts have created a data crisis that makes it impossible to track or accurately asses how bad the situation has become or people’s needs and the impacts on people’s lives.
“PEPFAR enabled and supported strong programmatic data collection, which provided evidence on the need and effectiveness of tailored responses for people who inject drugs. Without PEPFAR, these surveillance systems will not continue,” Dr Scheibe explained.
“I’m waiting for a big bomb to blow on our face at any time,” one government-employed data quality officer told PHR.
Without data, even the best-intentioned interventions may be entirely missing the mark. But the consequences run even deeper than that. If organisations want to apply for grants, they need data to convince donors to fund their programs. In its absence, the last of the money supporting harm reduction is in a perilous position.
“The harm reduction community is in crisis mode. Many organisations, particularly those that are community-based, face closure – not just because of PEPFAR funding reductions but as a result of overall reduced donor funding,” explained Dr Scheibe.
In a final insult to injury, the Trump administration compounded the crisis by failing to submit the annual PEPFAR report to Congress required by law, and by withholding datasets that previously informed independent analysis of South Africa’s situation.
Crisis Mode
Despite almost a year to save harm reduction after losing PEPFAR, when the PHR followed up its contact with participants in March 2026, they said that things had gotten worse, not better.
PHR’s recommendations are direct: the US should restore community health worker funding, reinstate rights-based programming for key populations, including people who use drugs, and lift the freeze on grants. The South African government, for its part, has obligations to its people that donor dependency does not excuse.
“If we do not domestically finance harm reduction, every donor shock is going to continue to become a public health emergency every single time,” Doorly-Jones insisted.
But there is hope. Dr Scheibe is supporting the launch of a coalition focusing on decriminalising drugs for personal purposes. He hopes that will enable South Africa to make better use of its increasingly scarce resources, encouraging the government to take practical steps towards harm reduction.
Mac Donnell and Doorly-Jones echoed that hope, saying that the government could and should step into the gap and prioritise harm reduction immediately. There are pathways to providing these services in South Africa, they said, but every lost day brings consequences that cannot be undone.
“If we do not address this crisis, we are undoing decades of progress in reducing deaths,” warned Doorly-Jones. “Now, we’re not only rescuing gains, but, ultimately, we’re losing more and more people to preventable tragedies.”
