This report, Breaking Point: The Impact of US Funding Cuts on Harm Reduction in South Africa, documents the consequences of sudden donor withdrawals on essential harm reduction services. It is the product of a rapid country survey led by Harm Reduction International (HRI) in partnership with the South African Network of People Who Use Drugs (SANPUD), and with contributions from civil society, service providers, and communities directly affected by the funding crisis. The study was financially supported by Elton John AIDS Foundation.

South Africa has long relied on international donors, particularly the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund, to finance HIV prevention and harm reduction. Roughly US$400 million (R7.6bn) annually invested into South Africa’s HIV response prior to 2025, including prevention/KP services.

While government has increasingly funded treatment, prevention interventions for key populations remain almost entirely donor dependent. The abrupt withdrawal of U.S.government funding through PEPFAR in early 2025, combined with a 16% reduction in Global Fundallocations under Grant Cycle 7 (GC7), has triggered a public health crisis with immediate anddevastating consequences. South Africa’s harm reduction system stands at a breaking point.

The Global Fund CCM increased GC7 allocations for prevention programmes for people who inject drugs and their partners to approximately US$25.3m was reduced to US$16.7m after repriorisation. The move from NACOSA to Aurum raised concerns about reduced community ownership and fewer people who use drugs SRs (from six to four).

Within weeks of the U.S. executive orders, nearly 40 USAID-funded projects were terminated, leading to the retrenchment of over 8,000 frontline HIV staff and the collapse of prevention and harm-reduction services, with service closures concentrated in six metros/districts with large key populations (Johannesburg, Cape Town, Tshwane, Ekurhuleni, Nelson Mandela Bay, Vhembe). In these areas, an estimated 166,354 key populations clients lost prevention or treatment access (navigation, PrEP/ART, outreach).

OST Sites in Tshwane and Ehlanzeni closed or curtailed services, and >5,000 people who use drugs lost access to opioid substitution therapy (OST), needle and syringe programmes (NSPs), HIV testing, and other lifesaving interventions, leaving thousands without care and treatment.

The collapse of services has already produced visible health consequences amongst people who inject drugs. Disrupted OST increased overdose risk; community-led monitoring and facility reports documented reduced HIV-testing offers and shortened ART refills during the freeze.

Among men having sex with men, the closure of OUT’s Engage Men’s Health clinic cut off ART for 2,000 clients and PrEP for 4,000. Sex workers reported rising violence, stigma, and treatment interruptions as prevention and rights-based services collapsed. If unaddressed, modelling projects up to 150,000 new HIV infections and 56,000 AIDS-related deaths by 2028.

Despite these setbacks, resilience has been evident.

• The Community-Oriented Substance Use Programme (COSUP) in Tshwane, funded by the District Municipality and implemented with the University of Pretoria, continued to deliver comprehensive harm reduction, providing a proof-of- concept for scalable domestic models.
• Civil society organisations, including SANPUD, Triangle Project, Anova, SWEAT, and TAC, rapidly pivoted to emergency measures while intensifying advocacy.
• Peer networks redistributed supplies via WhatsApp groups, and philanthropic contributions, most notably from the Elton John AIDS Foundation, sustaining chemsex-related interventions and improved ART retention among men having sex with men(MSM) from 42% to 83%.

Yet these are stopgaps, not systemic solutions.

Urgent action is required. To safeguard hard-won HIV gains, South Africa must:

• Establish dedicated Treasury budget lines for harm reduction.
• Integrate OST and NSP into the National Public Health System (NPHS) and budgets.
• Replicate COSUP across metropolitan areas.
• Protect and expand Global Fund allocations for prevention, with explicit, ring-fenced amounts to reach coverage targets for NSP (≥200–300 syringes/people who inject drugs/year) and OST.
• Without decisive domestic financing and political leadership, South Africa risks reversing decades of progress in the fight against HIV, TB, and viral hepatitis.

Final Word

The evidence is compelling, the innovations viable, and the urgency real. One path is inaction, continued dependence on volatile donors, recurring service collapses, and rising HIV, TB, and overdose deaths. South Africa must shift from a cycle of crisis and external dependency to decisive action: institutionalising harm reduction, protecting lives, and building a resilient, domestically owned system that no foreign election or aid freeze can dismantle. A harm reduction system that is democratically governed, fiscally secure, and accountable to the people it serves.