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South Africa’s transgender community faces a healthcare crisis after the U.S. government cut funding to HIV programs in early 2025, leaving thousands without access to gender-affirming care and HIV treatment.

The Trump administration reduced budgets by 75% and reportedly plans to end all support through the President’s Emergency Plan for AIDS Relief by March 2027. The decision, first reported by Semafor and later confirmed to NPR, was never formally communicated to South African authorities.

Funding cuts trigger clinic closures

Much of South Africa’s transgender healthcare relied on U.S.-funded NGOs. When funding stopped, clinics closed without warning. Jacqueline Pienaar, a global health expert at the Aurum Institute, said field workers left, support groups ended, and specialized services became difficult to find.

The South African National Aids Council warns that “hot and cold” US support means South Africa will have to work harder to bring transgender people into the mainstream health system. Transgender women are, on average, 20 times more likely to contract HIV than the general population, increasing the need for HIV prevention and treatment services.

Leigh-Ann van der Merwe, a transgender activist and one of South Africa’s gender equality commissioners, described the situation as dire. For many, the loss of gender-affirming care affects more than just hormones. Without it, transgender people may question whether their lives matter.

Discrimination drives people away

Even before the funding cuts, transgender people faced hostility in public clinics. Many described being misgendered, mocked, or refused service.

A Wits RHI study found that transgender people were nearly three times more likely to stay on HIV treatment when clinics provided gender-affirming care. Yet nearly a third of participants said health workers had refused to treat them, and 40% reported receiving worse care than other patients.

One woman remembered a clinic staff member shouting, “Why must the Aids patients like you be helped first instead of everyone else?” When she asked how the employee knew her HIV status, no one answered.

Van der Merwe said transgender people once traveled long distances to reach clinics where they were treated with dignity. Now, she said, conditions have worsened.

DIY hormones and desperate workarounds

With formal care disappearing, many transgender women turn to risky alternatives. Odwa Mbane and Kat’leya Serame, former outreach workers at a now-closed Hillbrow clinic, described a growing black market for hormones. Some take high doses of birth control pills to speed up physical changes. Others pretend to have menopause symptoms to get prescriptions.

Priscilla Nkomozake, a researcher in the Eastern Cape, said one woman traded sex with a

Signs of hope amid the crisis

Some progress is being made. The Aurum Institute is negotiating with the Dutch government about a €32 million program to restore transgender healthcare in six African countries, including South Africa. If approved, it would be the largest initiative of its kind on the continent.

The health department is collaborating with Wits RHI to train more healthcare workers. A recent review of 200 studies found that transgender people do well when supported, with few regretting treatment. The main challenge, researchers said, is ensuring health workers are both trained and willing to provide care.

Serame, the former outreach worker, said many providers lack knowledge about transgender issues. “Once we educate them, they become eager to learn,” she said.

For transgender people who can’t afford private healthcare, gender-affirming healthcare (GAHC) clinics at Cecilia Makiwane Hospital in Mdantsane and Duncan Village Clinic in KuGompo in Buffalo City are among the few places where they can receive care without being mocked or treated like a problem. Van der Merwe, who runs the trans support organisation She in the Eastern Cape, explains that gender-affirming care is about far more than hormones. Without it, many transgender people become so mentally worn down by the daily struggle to exist that they start asking themselves: “Is it worth investing in my life?”