US funding cuts threaten transgender healthcare in South Africa

South Africa’s Constitution and HIV policies guarantee transgender people access to healthcare, and for years much of that care was delivered through US-funded NGOs. That system collapsed in 2025 when the Trump administration slashed US government funding for health programs in the country. Reports now indicate conditions will worsen further: initial cuts had already reduced budgets by 75%, and the US government’s HIV program, Pepfar, reportedly plans to soon end its support altogether by March 2007.

While this termination has not been formally communicated to South African authorities, Semafor first reported the plan on June 18, and US officials confirmed it to NPR on June 23. The South African National Aids Council warns that fluctuating US support forces the country to accelerate efforts integrating transgender individuals into mainstream healthcare systems.

US Funding Cuts Threaten Transgender Healthcare

The loss of US funding has already left transgender people with fewer clinics offering hormone therapy and fewer trusted healthcare providers. If all American support ends in 2007, many could be left without essential services. Trans women face a 20-fold higher HIV risk than the general population, making access to prevention tools—such as six-monthly anti-HIV injections for those without HIV and antiretroviral treatment for those with the virus—critical. With providers struggling to fill the funding gap, vulnerable populations now face even greater barriers to care.

Leigh-Ann van der Merwe, a transgender activist and gender equality commissioner, addressed a group of transgender women at She, the support organization she leads in the Eastern Cape. When asked how their lives would change if gender-affirming healthcare clinics at Cecilia Makiwane Hospital in Mdantsane and Duncan Village Clinic in KuGompo disappeared, Van der Merwe explained these facilities were among the few options for those unable to afford private care. The clinics provided hormones to align physical appearance with gender identity, along with HIV prevention and treatment—all without judgment or stigma.

Beyond hormones, gender-affirming care addresses deeper psychological needs, Van der Merwe said. Without it, many transgender individuals grow disillusioned, questioning whether their lives are worth living. Though South Africa’s Constitution and HIV policies protect their right to healthcare, day-to-day services had long relied on US-funded NGOs. Even before the 2025 funding cuts, specialized transgender care was scarce, according to Jacqueline Pienaar, a global health expert at the Aurum Institute. When the Trump administration abruptly terminated US support in February 2025, clinics shut down overnight, field workers vanished, and support networks collapsed.

State Department Confirms HIV Funding End

NPR reports it has confirmation from the US State Department that it will end all HIV funding to South Africa by March next year. The State Department linked the decision to South Africa’s lack of progress on US policy demands and what it described as bias against white South Africans. Earlier reports from Semafor had already pointed to a total withdrawal by 2007, which Pienaar says would finalise a collapse that has been looming, despite the government’s insistence that there is ‘no crisis.’ She says this claim ignores the humiliation that keeps transgender people away from public clinics.

Jirair Ratevosian, who served as acting head of Pepfar from 2021 to 2023, cautioned that rebuilding donor-funded support networks takes years. Since 2003, Pepfar has invested over $8 billion (about R132.9 billion) in South Africa’s HIV programs. He said the most affected will be those already struggling for healthcare, particularly high-risk groups like transgender people. Nelson Dlamini, spokesperson for the South African National Aids Council, described US funding fluctuations as a “hot and cold” relationship, emphasizing the urgent need for faster integration of vulnerable groups into the health system.

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As the US has stopped recognizing groups like transgender people, Dlamini says, “we were still going to sit with the problem on our hands of how to keep them in care, regardless of the latest developments [that the US could stop funding to South Africa all together].”

In a July 2025 Lancet letter, Pienaar described gender-affirming care as a vital entry point to broader healthcare engagement. Services that validate gender identity, the letter argued, are essential for encouraging further health interventions. Without acceptance and respect from providers, many transgender individuals abandon healthcare entirely.

This disconnect poses a major public health risk. The 2024 UNAIDS Global AIDS Update highlights transgender women among those with the highest HIV infection rates. Many struggle to obtain these services, worsening their vulnerability.

Patient Stories Highlight Care Loss

The treatment she had started three years earlier had helped her feel more comfortable in her skin, more like the person she had always known herself to be. “I saw a lady that time,” she says, remembering. When Bhekisisa met her, Makubalo described the loss of her former self. It’s like reversing … I don’t feel like a pretty woman.” By their meeting, hair had regrown on her chin, cheeks, and chest.

Makubalo’s experience reflects the broader impact of funding instability. Without consistent access to gender-affirming care, transgender individuals face not just physical but psychological deterioration. The impending loss of US support threatens to deepen these challenges, leaving South Africa’s most vulnerable populations without the healthcare they desperately need.

Impact of Funding Cuts on HIV and Gender-Affirming Care

Transgender people who cannot afford private healthcare rely on gender-affirming clinics. They also offer HIV prevention and treatment care. Patients receive these services without being mocked or treated like a problem.