U.S Funding Cuts and Health System Challenges in Community-Based HIV Programmes in Rural Kwazulu-Natal, South Africa: A Qualitative Study

1. Introduction

South Africa has the largest HIV epidemic in the world, with 7.8 million people living with HIV [1]. However, the country has made substantial progress in treatment coverage, viral suppression, and prevention over the past two decades [2]. However, these gains have depended on a mixed financing architecture in which domestic resources support core treatment procurement. In contrast, donor funding, particularly through the United States (U.S) President’s Emergency Plan for AIDS Relief (PEPFAR), USAID, CDC and associated implementing partners, has supported critical complementary functions, including community outreach, tracing, counselling, key-population programming, monitoring systems, and workforce supplementation [3,4]. In 2023, the most recent year with complete expenditure data, PEPFAR contributed 21% of South Africa’s HIV spending, amounting to part of the country’s total HIV budget of $1.86 billion, while the Global Fund provided a further 3% [5]. However, donor and domestic contributions were not evenly spread across programme areas. Although the South African government financed most antiretroviral treatment (86%), PEPFAR played a much larger role in prevention, covering 50% of prevention-related expenditure, including major support for voluntary medical male circumcision (VMMC) and pre-exposure prophylaxis (PrEP) [5]. PEPFAR also funded important treatment retention activities delivered by community-based health workers, services for key populations, and broader health system strengthening efforts, including logistics, supply chain support, and data systems [4,5].

Beginning in early 2025, the abrupt suspension and termination of many U.S.-funded agreements in South Africa generated widespread concern about the continuity of HIV services. UNAIDS reported that tens of thousands of HIV response roles were affected across national and priority district systems, with disruptions in testing, outreach, PrEP services, mobile programs, data systems, and community-led monitoring [1]. By March 2025, service interruptions were already being documented nationally, while later evidence from KwaZulu-Natal showed that a large proportion of facilities experienced staffing, operational, and service disruptions linked to funding instability [6].

The relevance of these disruptions is underscored by the UNAIDS 95–95–95 targets, which call for 95% of people living with HIV to know their status, 95% of those diagnosed to receive sustained antiretroviral therapy (ART), and 95% of those on treatment to achieve viral suppression by 2025 [7]. In South Africa, the urgency of these targets was reflected in the February 2025 launch of the national “Close the Gap” campaign, which sought to identify and re-engage 1.1 million people living with HIV who knew their status but were not yet on treatment, highlighting that the largest gap in the HIV response lies in the second 95 [8]. In this context, disruptions to community-based HIV programmes are highly consequential because they weaken the outreach, linkage, adherence support, and follow-up systems that are essential for progress across all three stages of the cascade [9].

This policy context matters because community-based HIV programmes contribute directly to all three stages of the HIV cascade [10]. Community outreach and testing support strengthen the first 95; tracing, counselling, linkage, and treatment initiation support strengthen the second 95; and adherence support, follow-up, and community retention mechanisms strengthen the third 95 by helping people remain in care long enough to achieve viral suppression [9]. Funding instability that weakens these community-based functions, therefore, threatens more than programme administration; it threatens progress toward epidemic control.

These developments matter particularly in rural KwaZulu-Natal, where community-based HIV programs are often central to reaching young people, key populations, and other underserved groups who face barriers to routine facility care [3]. Recent studies from rural KwaZulu-Natal show that peer navigators, mobile services, and youth-centred community programs improve HIV testing uptake, linkage to care, ART initiation, and access to prevention by reducing the social and geographic distance between people and formal health services [11,12,13]. In settings where stigma, transport costs, and facility-level barriers remain significant [13], the contraction of community programs may therefore produce effects that extend far beyond non-government organisation (NGO) operations alone.

Although modelling and surveillance reports are beginning to quantify the effects of the 2025 funding disruption, less is known about how these cuts were experienced by those working within community-based HIV programs and how such instability affected the functioning of local health systems at the service-delivery level. This manuscript addresses that gap by drawing on qualitative findings from rural KwaZulu-Natal to examine the health system consequences of funding instability for community-based HIV programming. It asks: How did U.S funding cuts affect the functioning of community-based HIV programmes in rural KwaZulu-Natal, and what do these effects reveal about the role of such programmes within the broader health system and South Africa’s progress toward 95–95–95?

This manuscript is guided by the World Health Organisation (WHO) Health Systems Building Blocks framework, which conceptualises health systems as six core components: service delivery, health workforce, health information systems, access to essential medical products and technologies, financing, and leadership and governance [14]. The framework is useful for examining how shocks affect the functioning of a health system, not only through direct resource loss but also through disruptions to the interdependence among these components [15]. WHO’s framing emphasises that health systems are not defined solely by commodities or facilities, but by the interactions among people, processes, financing arrangements, infrastructure, information, and governance [16].

2. Methods

This manuscript draws on findings from a qualitative study exploring the experiences of youth frontline workers and other stakeholders involved in delivering HIV prevention programmes for young people in rural KwaZulu-Natal, South Africa. The broader study used an exploratory qualitative design and included in-depth interviews, focus group discussions, and key informant interviews. The current manuscript is a focused secondary analysis of data on funding instability and its effects on the health system.

The study was conducted in the uMkhanyakude district, KwaZulu-Natal, a province with a high HIV burden and a long history of donor-supported and community-based HIV programming. The setting was purposively selected because organisations in the area were implementing ongoing community-based HIV programmes targeting young people [17,18].

The study used purposive sampling to recruit 26 participants from two CBOs implementing HIV programmes in the study setting. Participants included youth frontline workers involved in community-based HIV service delivery, and programme managers responsible for implementation and service coordination.

Data were generated through multiple qualitative methods, including in-depth interviews with youth frontline workers (n = 13), two focus group discussions with youth frontline workers (n = 9), and key informant interviews with programme managers (n = 4). All interviews and focus group discussions were conducted in isiZulu at the participating CBO premises, lasted 45-60 minutes, and were audio-recorded with participants’ consent. Data collection occurred from August to October 2025, during a period when U.S funding cuts to HIV-related programmes had recently been announced. Interview and discussion guides explored participants’ roles in programme implementation, their experiences of delivering HIV services, perceived barriers and facilitators to service delivery, and their views on changes linked to financial instability. Field observations undertaken during recruitment and site engagement further enriched the dataset by documenting workforce contraction, reduced programme activity, and organisational instability.

All audio-recorded interviews and focus group discussions were transcribed verbatim and analysed using thematic analysis [19]. The analysis involved repeated reading of the transcripts to become familiar with the data, followed by coding meaningful segments and grouping related codes into broader themes and sub-themes. For this manuscript, a secondary interpretive analysis was undertaken using the WHO Health Systems Building Blocks framework to examine how funding instability affected service delivery, the health workforce, information systems, access to essential medicines and technologies, financing, and leadership and governance [14]. Field observation notes were used to complement and contextualise the interview and focus group data.

Trustworthiness was enhanced by attending to credibility, dependability, confirmability, and transferability [20]. Credibility was strengthened through multiple qualitative methods and participant groups, enabling triangulation of perspectives. Dependability was supported by a systematic, iterative analytic process that included verbatim transcription and structured coding of the data. Confirmability was enhanced with field notes to contextualise interpretations and maintain closeness to participants’ accounts. Transferability was supported by a clear description of the study setting, participants, and data collection procedures, enabling readers to assess the relevance of the findings to similar contexts.

Ethical approval for the parent study was obtained from the Institutional Research Ethics Committee [Ethics Clearance Number: IREC 139/25]. Permission to conduct the study was also obtained from the participating CBOs. All participants were informed about the purpose of the study, the voluntary nature of participation, and their right to withdraw at any stage without consequence. Written informed consent was obtained before data collection, and all interviews and focus group discussions were audio-recorded only with participants’ permission. To protect confidentiality, transcripts were anonymised, and participants are identified in this manuscript using unique study codes.

3. Findings

This section presents the findings on how recent U.S funding cuts affected community-based HIV programmes in rural KwaZulu-Natal. The findings are organised using the WHO Health Systems Building Blocks framework to illustrate how funding instability affected distinct yet interconnected dimensions of the local HIV response.

3.1. WHO Health System Building Blocks

The findings show that funding instability affected community-based HIV programmes across all six WHO health system building blocks. Rather than functioning as a single financial constraint, the U.S funding cuts produced linked disruptions across service delivery, workforce capacity, information systems, commodities and technologies, governance arrangements, and programme continuity.

3.1.1. Service Delivery Disruptions

Participants consistently reported a decline in outreach capacity and service continuity following funding cuts. Community activities were paused, scaled back, or stopped entirely, and some organisations shifted from community-based service delivery to more restricted clinic-based work. One participant explained:

“There is nothing that we are doing right now as an organisation until we get more funding. Since there are budget cuts, we are no longer going to communities.”

(KII-3)

Another stated:

“We have stopped all our outreach programmes; we only work in clinics to provide counselling because there is no funding to continue with these programmes.”

(IDI-1)

Participants also expressed concern that the suspension of programs left young people without trusted access points for prevention and support:

“It is disheartening to see that we have been supporting young people while the programme was still running, but now that it has come to an end, some are left without assistance. For example, some young people obtained their ART, condoms, and lubricants from us rather than from the clinic, and when funding is lost, the programme ends, and many of them are left without support.”

(KII-1)

Another one stated:

“After the funding ended, the programme stopped, and the people we had supported were left without help, making it seem as though our work as an organisation had been in vain.”

(FGD-2)

These findings suggest that community-based services were not peripheral add-ons, but critical components of local HIV delivery systems. When funding instability reduced outreach, access narrowed, especially for young people who did not routinely use clinic-based services.

3.1.2. Health Workforce Instability

Participants reported widespread workforce instability following funding cuts, including job losses, contract non-renewals, salary reductions, and reduced working days. Some staff had already lost their jobs by the time data collection began, while others had moved from full-time to part-time work. One participant explained:

“Some staff members had their contracts expire, and they were not renewed, and some of them were forced to take a salary cut while working from home.”

(IDI-6)

Another explained:

“Our organisation hires more youth workers, but they are not here today… since the organisation is facing financial challenges due to budget cuts, they are only here two or three days a week.”

(KII-3)

Participants emphasised that staff instability weakened continuity of care because youth frontline workers often built ongoing trust-based relationships with beneficiaries. Where workers lost employment, follow-up and relational continuity were lost.

3.1.3. Health Information and Follow-Up Systems

Although participants did not always explicitly name information systems, their accounts showed that follow-up, tracing, record flow, and continuity mechanisms were weakened when funding instability reduced staff and program activity. Participants described losing contact with beneficiaries, interruptions in program monitoring, and weakened ability to sustain engagement after programme closure. One participant reflected:

“I lost contact with some youth beneficiaries who had been enrolled in our HIV prevention programmes because budget cuts resulted in the non-renewal of youth frontline workers’ contracts.”

(KII-4)

Others indicated that community-linked support systems had effectively served as informal continuity mechanisms for young people reluctant to collect treatment or prevention commodities from clinics.

These findings suggest that information and continuity systems in community-based HIV programs were embedded in people and relationships rather than solely in formal databases.

3.1.4. Medicines, Products and Technologies

Participants reported shortages of condoms, HIV testing kits, pamphlets, and PrEP availability at community sites, which directly affected service delivery. In some cases, youth frontline workers had to borrow materials from nearby health facilities to keep functioning, as indicated below:

“With the recent funding cuts, we don’t have enough condoms, pamphlets, PrEP and HIV testing kits.”

(IDI-12)

“We didn’t have HIV testing kits on site, so we ended up borrowing from nearby health facilities, and we were able to continue working.”

(IDI-2)

Others highlighted the problem of promoting services that were not locally available:

“If we speak to young people about PrEP, we should focus on something that is actually in stock, rather than discussing products that are not available on site.”

(IDI-4)

These accounts indicate that the cuts not only reduced financing but also weakened the practical availability and credibility of community-based HIV prevention.

3.1.5. Financing and Sustainability

Participants understood funding instability not simply as a temporary shortfall, but as a threat to the very existence of community-based HIV programmes. They criticised short-term programmes that ended without transition plans and described sustainability as one of the most serious weaknesses in implementation. One participant said:

“The programmes should not be like fly by night, whereby when it’s over, it just over like that.”

(IDI-4)

Another explained:

“The problem with our programme is sustainability. We have started the programme, but due to budget cuts, the programme ends, and we must leave what we have started without seeing it to the end.”

(KII-2)

Participants were especially concerned that programmes ended while beneficiaries still had ongoing needs and queries.

3.1.6. Leadership and Governance Gaps

Participants identified significant governance weaknesses in the management of funding contractions. These included weak strategic planning for sustainability, abrupt programme closure, poor handover processes, and uneven geographic coverage of services. Relationship disruption was a recurring theme: participants argued that communities, especially children and vulnerable youth, lost trusted service providers and health professionals when organisations' funding ended. One participant explained the consequences of abrupt programme closure:

“When programmes end, or staff lose their jobs, new social workers may be introduced, creating a continuity gap that makes it difficult for children to build trust and open up to someone new.”

(KII-3)

Similarly, another participant highlighted problems with weak transition plans for sustainability:

“If such programmes are introduced, there should be a clear commitment to see them through to completion, rather than ending them halfway while people are still seeking support.”

(FGD-1)

Together, these findings show that funding instability exposed not only resource dependence, but also governance weaknesses in transition planning, accountability, and long-term programme stewardship.

4. Discussion

This study found that the instability triggered by abrupt U.S funding cuts did not simply reduce the budget envelope for community-based HIV programmes in rural KwaZulu-Natal; rather, it disrupted multiple, interdependent functions of the local HIV response. Interpreted through the WHO Health Systems Building Blocks framework, which conceptualises health systems in terms of service delivery, health workforce, health information systems, access to essential medicines and technologies, financing, and leadership or governance, the findings show that the funding shock reverberated across the full architecture of programme delivery rather than affecting one component in isolation [14]. This is consistent with emerging evidence from South Africa that instability in PEPFAR- and USAID-linked funding in 2025 generated multidimensional effects on HIV services, staffing, research, data systems, and community-based outreach, even where the government continued to finance antiretroviral medicines themselves [1,4,21].

The first and most visible effect of funding instability in this study was the weakening of service delivery, especially in the community-based and outreach-oriented components of the HIV response. Participants described interrupted outreach, reduced service visibility, and the closure or suspension of programme activities, as well as difficulty maintaining the continuity of support for young people who depended on community-based access points for prevention commodities, psychosocial support, counselling, and linkage to care. These findings echo recent national and provincial evidence showing that the 2025 U.S funding disruption affected HIV testing, tracing, outreach, mobile services, drop-in centres, and key-population programmes, with particularly severe effects on services that sit at the interface between clinics and communities rather than within routine medicine procurement systems [1,21]. In KwaZulu-Natal specifically, province-representative facility audit data showed that funding instability interrupted treatment support, patient tracing, HIV testing, and clinic operations for a substantial share of facilities and people living with HIV, demonstrating that service disruption extended well beyond isolated NGO closures [6,11]. Similarly, evidence from a multi-country survey shows that U.S. funding disruptions led to widespread interruptions in HIV-related service delivery, including counselling, testing, and prevention services, across many settings [22].

These disruptions are especially important in rural KwaZulu-Natal, where community-based HIV programmes often perform critical functions that clinic-based services alone cannot absorb. Recent work from rural KwaZulu-Natal has shown that peer navigators and mobile, youth-centred HIV services improve uptake of testing, ART initiation, and prevention services by reducing the geographic, social, and symbolic distance between young people and formal health services [12]. More broadly, integrated community-based models have been shown to strengthen linkage and viral suppression among youth in settings where routine facility care does not adequately meet demand or address social barriers to care [23]. In the current study, funding instability therefore threatened the very service-delivery modalities that make HIV programmes reachable and acceptable in underserved rural settings.

The findings also point to severe strain on the health workforce, the second WHO building block. Participants reported contract non-renewals, reduced working days, salary cuts, redeployment of responsibilities, and loss of trusted relationships between youth workers and beneficiaries. These experiences are strongly supported by national data indicating that the U.S. funding freeze affected more than 15,000 PEPFAR-funded HIV-response staff across South Africa’s priority districts [1], while official briefings later confirmed that at least 8,061 jobs had already been lost by mid-May 2025 [24]. Additional evidence similarly describes retrenchments concentrated among counsellors, community health workers, data capturers, and outreach personnel, the very cadres that keep community-based HIV programmes functioning and connected to public facilities [4]. Evidence from Uganda shows that the funding freeze resulted in the loss of PEPFAR-supported health workers, including counsellors, data clerks, and community outreach staff, with ripple effects on clinic operations and service continuity [25].

What makes the workforce disruption especially significant is that South Africa’s HIV programme is often described as “domestically funded” because the state finances most antiretroviral medicines; yet donor financing has long underwritten a substantial portion of the human infrastructure that supports adherence, tracing, counselling, differentiated service delivery, key population programming, and data management [4,5]. The present findings align with this distinction. Participants did not primarily describe stock-outs of government-funded ART; rather, they described losing the people and relational systems that enable young people to find, start, understand, continue, and return to care. This distinction matters because health systems do not function solely through medicines. As the WHO framework makes clear, the workforce is not an optional add-on to service delivery; it is one of the system’s core pillars [14].

A third major implication concerns the health information system. Although participants in this study spoke more often about visible operational losses, such as outreach, tracing, and commodities, their accounts of reduced reporting, weaker continuity, and the breakdown of follow-up reflect deeper information-system disruptions. This interpretation is consistent with national reporting from UNAIDS and provincial data from KwaZulu-Natal, both of which show that funding disruptions affected data entry, filing, dashboards, stock visibility systems, and community-led monitoring systems used to track service gaps and support programme accountability [1,6]. The suspension of Ritshidze’s community-led monitoring and the weakening of stock-visibility and data-support systems further underscore that information systems are embedded in community-based HIV programmes, not only in formal government databases [6,11].

For community-based HIV programmes, these data systems are central to continuity of care. They support patient tracing, identification of missed visits, linkage to ART, outreach planning, hotspot mapping, and monitoring of access to prevention [6]. Once they are disrupted, the system loses not only administrative efficiency but also the ability to identify where gaps are widening. Recent literature on community health systems has argued that the classical WHO building blocks need to be understood in a decentralised, community-based way, as community interventions depend on interactions among local actors, data flows, supervision, and programme inputs rather than on facilities alone [26]. The present study supports that argument: when funding cuts affected information support roles and community monitoring, they weakened not just paperwork, but system intelligence and responsiveness [26].

The fourth building block, access to essential medicines, products, and technologies, was reflected in participants’ accounts of shortages of condoms, pamphlets, HIV test kits, and PrEP availability at community sites, even where government-funded ART continued to exist in the broader public system. This distinction is consistent with a growing body of South African evidence that suggests that the most immediate effect of the 2025 U.S funding disruption was not the wholesale collapse of national antiretroviral procurement, because South Africa’s HIV treatment programme is largely domestically financed, and the government continues to fund most ARV medicines [5]. Instead, the earliest and most visible effects were seen in last-mile service functions, including patient tracing, community outreach, data capture and filing, HIV testing, reduced refill lengths, prevention access, and other ancillary and community-based services that are more dependent on donor-supported personnel and programme infrastructure [6].

This matters particularly for PrEP and prevention services, which often rely more heavily than ART on community outreach, demand creation, and low-threshold access points. UNAIDS has reported that after the freeze, many programmes serving adolescent girls, young women, LGBTQI+ communities, and other key populations experienced disruptions in PrEP provision and community-based prevention, even where patients could theoretically be referred to public clinics [21]. Yet referral does not automatically guarantee access, especially in rural contexts marked by stigma, transport costs, long queues, and fear of discrimination. In this sense, funding instability weakened the technological and commodity ecosystem of community programmes by hollowing out the social and operational infrastructure that connects people to products.

The fifth building block, financing, sits at the centre of this manuscript’s argument. Participants’ accounts show that funding instability operated not simply as a financial shortfall, but as a system shock with cascading effects across other building blocks. South Africa’s HIV response is often cited as being largely domestically financed, yet donor funding has remained strategically concentrated in areas that are disproportionately important for prevention, key populations, community outreach, monitoring, workforce supplementation, and implementation support. According to UNAIDS and other assessments, PEPFAR funding represented roughly 17–18% of South Africa’s HIV response before the 2025 disruption, but it was highly concentrated in 27 priority districts and in functions that could not be quickly substituted by the state [1,27]. This explains why a relatively small share of total financing can still generate outsized disruption to the health system when withdrawn abruptly. A rapid survey across 32 countries on the impact of U.S funding cuts on the HIV response highlights how reductions in global HIV financing can destabilise multiple components of the health system simultaneously, rather than affecting only a single programme area [22].

Recent modelling reinforces the seriousness of this dependence. National simulations suggest that cessation of PEPFAR-supported services in South Africa could reverse hard-won gains in HIV incidence and mortality unless the government rapidly substitutes both funding and service functions [5]. Abrupt USAID and CDC cuts could significantly increase infections and deaths if services are not restored, even though the country remains one of the strongest-performing parts of the national ART programme [28]. While modelling should be interpreted cautiously, it complements the current qualitative findings by showing that participants’ concerns about interrupted tracing, weakened prevention, and workforce collapse point to wider epidemiological and systems risks.

The sixth WHO building block, leadership and governance, is also revealed in the current study. Participants described a lack of transition planning, weak communication, incomplete projects, uneven geographical coverage, and abrupt programme closure without clear handover arrangements. These governance weaknesses meant that funding shocks were not buffered through contingency systems; instead, they were transferred downward to youth workers and communities. This aligns with broader national debates in South Africa, where the 2025 funding crisis exposed longstanding dependence on external financing for key health functions and renewed calls for stronger domestic stewardship, transition planning, and health sovereignty [3,4,28].

At the same time, governance responses were mixed. South Africa’s Department of Health emphasised that the public sector continued to finance most ART and moved to mitigate disruptions through six-month ART dispensing for eligible patients, emergency staffing allocations, and campaigns to close the treatment gap [29]. Yet these actions did not fully replace the community-based, relational, and prevention-oriented functions that were lost when CBOs and donor-supported programmes contracted. The current findings, therefore, suggest that governance challenges were not only about public-sector ownership but also about managing the interface between state systems, donor-supported community programmes, and civil society delivery platforms. From a building blocks perspective, leadership and governance determine whether financing shocks are absorbed, adapted to, or amplified through the rest of the system. In this case, governance gaps appear to have amplified them.

A key implication of these findings is that community-based HIV programmes should not be treated as peripheral to the health system. Rather, they are part of the system’s functional architecture, especially in high-burden rural settings like KwaZulu-Natal. Recent WHO-oriented community systems scholarship has argued that classical health systems thinking often underestimates the role of community actors, networks, and decentralised delivery platforms in making formal services effective at scale [26]. Likewise, UNAIDS continues to emphasise that community responses are essential to reaching people whom formal systems struggle to serve, and that community-led services should be integrated into planning, budgeting, implementation, and monitoring, rather than treated as externally funded extras [30]. The present study strongly supports this perspective. The funding shock was so damaging precisely because community-based programmes were performing indispensable health system functions while not always being sustainably financed.

Funding instability has serious implications for rural KwaZulu-Natal. The province carries one of the largest HIV burdens in the country and relies on layered models of facility care, community outreach, peer navigation, tracing, prevention education, and targeted services for youth and key populations. The current findings suggest that when funding instability disrupts these layers, the result is not merely a scaled-back programme but a weakened rural HIV service ecology. In such settings, community-based HIV programmes often compensate for transport barriers, stigma in public clinics, poor male engagement, adolescent disengagement, and the need for differentiated support. Their contraction, therefore, widens existing inequities by disproportionately affecting those least likely to navigate standard clinic systems successfully. Recent findings from rural KwaZulu-Natal on peer-navigator mobilisation and from Ritshidze monitoring in the province reinforce this point, showing that community-linked systems are central to both prevention uptake and sustained treatment engagement [11,12].

4.1. Study Limitations

This study has several limitations that should be considered when interpreting the findings. First, because data collection occurred amid rapidly evolving programme uncertainty, participants’ accounts may have been influenced by immediate concerns about job insecurity, organisational instability, and possible programme closure, potentially amplifying perceptions of disruption and risk while also reflecting the lived reality of the funding shock. Second, the WHO Health Systems Building Blocks framework was used as an interpretive lens rather than as the basis for a full health systems assessment. Third, the study did not include routine service or financial data, so it is better suited to explaining the experiences of funding instability than measuring its scale. Finally, the study did not directly measure HIV cascade outcomes, but instead inferred implications for the 95–95–95 targets from disruptions in outreach, linkage, follow-up, and adherence support.

4.2. Recommendations

Although antiretroviral treatment in South Africa is largely domestically financed, donor support remains critical for prevention, community-based staffing, data systems, and retention support. Therefore, stronger contingency financing and transition planning are needed to protect these functions during funding shocks. In addition, national strategies to close the HIV treatment gap should invest more deliberately in community tracing, re-engagement, and adherence support, since these are essential for improving treatment coverage and viral suppression in line with the 95–95–95 targets.

Future research should assess how disruptions in community-based HIV programmes affect HIV cascade outcomes, including testing uptake, treatment initiation, retention in care, and viral suppression, to better quantify their implications for progress toward 95–95–95. Furthermore, studies are needed to examine how young people, key populations, and other service users experience interruptions in outreach, prevention access, refill continuity, and referral systems when donor-supported programmes contract.

5. Conclusions

This study shows that U.S funding cuts functioned as a systemic stressor for community-based HIV programmes in rural KwaZulu-Natal. Through the lens of the WHO Health Systems Building Blocks framework, funding instability disrupted service delivery, depleted the workforce, weakened information systems, reduced the effective availability of prevention commodities and technologies, exposed financing dependence, and revealed governance gaps in transition and accountability. The findings suggest that the resilience of South Africa’s HIV response cannot be judged only by whether ARV medicines remain nationally procured; it must also be judged by whether the broader system can sustain the community-based, relational, and operational functions that enable people to access and remain engaged in care. Strengthening that resilience will require financing reforms, protection of community-based delivery systems, better transition planning, stronger data and monitoring systems, and explicit recognition that community HIV programmes are part of the health system itself, not external to it.