The Global Fund will reduce its HIV, tuberculosis and malaria grant to South Africa by about 25 % in the 2028‑2031 funding cycle and will cease all support after the 2031‑2034 cycle. The cut, announced in allocation letters sent in March, means the country will receive just under US$345 million (approximately R5.7 billion) in the next three‑year period, down from US$464 million (R7 billion) in the previous cycle. The final grant, scheduled for the 2031‑2034 cycle, will be the Fund’s last contribution to South Africa’s health programmes.
The reduction disproportionately affects services for “key populations” – sex workers, gay and bisexual men, transgender women and people who inject drugs – who have a markedly higher risk of HIV infection and rely heavily on donor‑funded, specialised care. In 2023, Global Fund financing covered 33 % of key‑population programmes, compared with 15 % from the South African government and 52 % from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). With most PEPFAR funding withdrawn in early 2025, the Global Fund has become the principal external supporter of these services.
Cost‑effectiveness analyses show that preventing a new HIV infection with daily pre‑exposure prophylaxis (PrEP) costs R10 368 for sex workers and R19 618 for gay and bisexual men, considerably less than the R22 797–R37 304 required for the general population. Experts warn that the loss of donor funding could lead to a measurable rise in new infections within five years if the transition to domestic financing is not completed.
A government‑commissioned plan to integrate key‑population services into public clinics was completed in 2023 but has not yet been approved. The South African National AIDS Council (SANAC) CEO Thembisile Xulu said the country must prepare for full domestic financing and avoid a funding gap. “We need to be realistic and very harsh about which services we can afford,” she said, emphasizing the need for integrated, high‑impact TB and HIV service delivery.
The Global Fund’s shift reflects a broader strategic move to concentrate resources on the poorest countries with the highest disease burdens. While South Africa’s overall HIV budget receives only 3–5 % of its funding from the Global Fund, the proportion dedicated to key populations is much higher, making the impending cuts especially consequential.
Health economists note that specialised services, though more expensive per client, deliver greater epidemiological impact by targeting groups with the highest incidence rates. Without sustained support, these groups risk reduced access to care, potentially undermining national HIV control efforts.
The next steps involve government approval of the integration plan and the transfer of expertise from NGOs, such as the Aurum Institute, to public health facilities. Failure to implement these measures could result in increased HIV transmission, according to researchers at the University of the Witwatersrand’s HE2RO centre.
