Unemployed 19-year-old Nozuko Majola is attempting to figure out if she has enough money for the one-hour journey to collect her much-needed HIV medication, which is regularly delivered to her house but is difficult to access owing to rough, untarred roads.

Majola is one of millions of South African patients affected by US President Donald Trump’s worldwide foreign assistance block, which has raised concerns about HIV patients failing to receive medication, infection rates rising, and, ultimately, an increase in mortality.

In 2024, think tank Human Sciences Research Council released figures showing that Majola’s province recorded the second-highest HIV prevalence in the country, at 16%, with at least 1,300 young people estimated to contract the disease every week.

KwaZulu-Natal also had the highest number of people living with HIV in South Africa in 2022, about 1.9 million. The country counts more than 7.5 million people infected with the virus that causes AIDS — more than any other nation.

There are 5.5 million South Africans receiving antiretroviral treatment, whose funding is now in question after Trump suspended the President’s Emergency Plan for AIDS Relief, or PEPFAR. It contributes more than $400 million a year to South Africa’s HIV programs and nongovernmental organizations, about 17% of the total funding, according to the Health Ministry.

Globally, PEPFAR is credited with saving at least 26 million lives since its inception in 2003, according to the U.N. AIDS agency.

Last week, a federal judge ordered the Trump administration to temporarily lift the funding freeze, while the U.S. Embassy in South Africa said PEPFAR projects would resume under a limited waiver. However, aid groups dealing with HIV have already shuttered with closure notices hanging at the entrances and PEPFAR-branded vehicles standing idle, with patients diverted to struggling health facilities.

Most of the PEPFAR funding is channeled through non-governmental organizations, which run programs that compliment health care services provided by the government.

‘Influx of patients’

For Majola and other HIV patients in the Umzimkhulu region, where unemployment is rife and most people rely on subsistence farming and government welfare grants, the aid freeze has disrupted their lives.

“Things will be tough around here, and a lot of people will default on their treatment because we really struggle with transport,” she said. “The mobile clinics hardly come here.”

The freeze has hurt various groups that can no longer provide treatment, causing an influx of patients to already overstretched public facilities. Along with the medication, these programs also allowed health personnel to test HIV patients in far-flung villages, which has been a lifeline for many, especially those afraid to visit public facilities due to the social stigma attached to HIV.

In addition, nearly 15,000 health workers whose salaries are funded through PEPFAR are left wondering if they have lost their livelihoods.

About an hour away in the district of Umgungundlovu, which the think tank says has the highest number of HIV cases in South Africa, HIV counselors gathered in a small office discussing how best to assist patients like Majola. A manager at a nearby health clinic wondered how to handle the administrative work that is piling up after PEPFAR-funded workers withdrew.

“People who were doing administration and data capturing, whose salaries were funded by PEPFAR, have left. We are a small facility and we cannot handle such a workload,” said the manager, who spoke on condition of anonymity because they were not authorized to speak to the press.

‘Matter of life and death’

Nozuko Ngcaweni has been on HIV treatment for about 30 years. One of her children was also infected and died at age 17. She said the aid suspension already impacted her community and many missed their treatment.

“Not long ago, we said by 2030, we want to see an HIV-free generation. But if things remain as is, we will not achieve that. We will have to deal with deaths,” she said.

Mzamo Zondi, a provincial manager of the Treatment Action Campaign, which advocates for access to HIV treatment for the poor, has been monitoring the impact of the aid freeze in Umgungudlovu.

“Our response (to HIV) is likely to falter as we struggle to stop newly infected cases,” he said. “This is a matter of life and death.”