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Background. In January 2025, U.S. government funding cuts halted the majority of USAID-supported HIV programs in South Africa, removing approximately $436 million annually, about 17% of the country’s national HIV expenditure. While South Africa funds most of its HIV response, external funding has played a critical role in community-based prevention, key population services, workforce support, and data systems. Quantitative models project substantial increases in HIV infections over the coming decades, yet there is limited qualitative evidence from those directly affected.

Methods. We conducted 22 semi-structured interviews with stakeholders across South Africa between March and April 2026, using purposive and snowball sampling. Participants included program implementers, NGO and civil society leaders, clinicians, researchers, policymakers, advocates, and individuals with lived experience of HIV services. Interviews were audio-recorded, transcribed, anonymized, and analyzed using a hybrid deductive–inductive coding approach in Dedoose.

Results. Preliminary analysis of 17 transcripts identified five dominant themes. First, service disruptions were immediate and multidimensional, with rapid workforce losses, program and clinic closures, and breakdowns in data systems within days of the stop-work orders. Second, key populations, including MSM, sex workers, transgender individuals, and people who inject drugs, were disproportionately affected, as their community-based services were almost entirely PEPFAR-funded with no government equivalent. Third, spillover effects extended deeply into South Africa's research sector – previously the largest recipient of NIH funding outside the United States – with widespread job losses, the abrupt cessation of active clinical trials raising serious ethical concerns, and the interruption of critical studies including work on HIV vaccination and lenacapavir scale-up that had been years in development. Fourth, participants described a profound psychological toll across the sector; health workers, researchers, and advocates described emotional exhaustion, moral distress, and an existential reckoning with the meaning of their work, compounded by a desire to maintain services with diminished resources. Finally, while stakeholders described meaningful adaptation, including emergency government responses, new partnerships, and community-led innovations, these efforts were widely viewed as insufficient to offset the scale and abruptness of the funding withdrawal. Many participants also reflected on the structural vulnerabilities created by long-term dependence on external funding.

Conclusions. The abrupt withdrawal of U.S. HIV funding has triggered a rapid, system-wide disruption of HIV service delivery in South Africa, disproportionately affecting vulnerable populations. The impacts extend beyond clinical outcomes to workforce stability, research capacity, and community-based infrastructure. These findings underscore the need for more diversified and coordinated approaches to global health funding to prevent large-scale service disruption.