US funding cuts gutted the NGOs that provided most of South Africa's transgender healthcare overnight. Last week, things became even cloudier with news reports that the US government plans to permanently phase out its multi-billion dollar HIV relief programme in South Africa by early 2027. Now, with hormones scarce and trusted clinics gone, an already vulnerable population is being pushed further from the HIV services they urgently need.
- South Africa's Constitution and HIV policies recognise transgender people's right to healthcare, and for many years it was provided — much of it outsourced to US-funded NGOs.
- That came to an abrupt end in 2025, when the Trump administration cut US government funding to health programmes in South Africa .
- News reports and analysis say the situation will be getting worse; initial cuts had already slashed budgets by 75%, and now US government's HIV programme, Pepfar , reportedly plans to soon end its support altogether by March 2007.
- This news has not been formally communicated to South Africa ( it was published by Semafor on 18 June, and confirmed by US officials to NPR news on 23 June).
- 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.
- US funding cuts had already left transgender people with fewer places to get hormones and fewer trusted health workers. If all US support ends in 2027, more people could be pushed "into the wind".
- On average, trans women are 20 times more likely to get HIV than the general population, so they need to be able to get HIV prevention medicine, for example, the six-monthly anti-HIV jab , if they are HIV negative and antiretroviral medicines if they have HIV. As healthcare providers scramble to make up the gap, it has left many in the already vulnerable population unable to get services.
"Can I be honest? That is the start of a horror movie."
Leigh-Ann van der Merwe, a transgender activist and one of South Africa's gender equality commissioners, was answering a question Bhekisisa put to a group of transgender women gathered at the offices of She, a trans support organisation that Van der Merwe runs in the Eastern Cape.
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We asked what life would look like for transgender people if gender-affirming healthcare (GAHC) clinics at Cecilia Makiwane Hospital in Mdantsane and Duncan Village Clinic in KuGompo in Buffalo City did not exist.
For trans people who can't afford private healthcare, the GAHC clinics are one of the few places where they can receive gender-affirming healthcare , such as hormones which help their body match how they see themselves . They can also get HIV prevention and treatment care and other health needs seen to, without being mocked or treated like a problem.
Van der Merwe 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? " South Africa's Constitution and HIV policies recognise transgender people's right to healthcare, but for many years, much of the day-to-day care had effectively been outsourced to US-funded NGOs.
Specialised services for transgender people were already "few and far between", even before the funding cuts in early 2025 , says Jacqueline Pienaar, a global health expert at the Aurum Institute . When the Trump administration suddenly cut United States (US) government funding to health programmes in South Africa in February 2025, clinics closed overnight. Field workers disappeared and support groups collapsed.
For many transgender people, the result was immediate: fewer places to get hormones, fewer trusted healthcare workers and fewer reasons to keep returning to clinics they already feared.
NPR reports it has confirmation from the US State Department that it will end all HIV funding to South Africa by March next year. The State Department linked the decision to South Africa's lack of progress on US policy demands and what it described as bias against white South Africans. Earlier reports from Semafor had already pointed to a total withdrawal by 2027, which Pienaar says would finalise a collapse that has been looming, despite the government's insistence that there is 'no crisis. '
She says this claim ignores the humiliation that keeps transgender people away from public clinics.
Responding to the reports , Jirair Ratevosian , who was the acting head of staff at Pepfar from 2021 to 2023, warns that donor-funded support networks can take years to rebuild once they are lost.
The programme has invested more than $8-billion (about R132.9-billion) in South Africa's HIV programmes since 2003. He told Bhekisisa that the people who would suffer most are those who already struggle to get healthcare, especially groups with a higher chance of getting HIV, like transgender people.
Nelson Dlamini, South African National Aids Council (Sanac) spokesperson, describes the US funding uncertainty as a "hot and cold engagement". He says it's clear South Africa must move much faster to ensure groups with a higher chance to get HIV are "absorbed" into the health system.
"As the US has stopped recognising groups like transgender people", Dlamini says, "we were still going to sit with the problem on our hands of how to keep them in care, regardless of the latest developments [that the US could stop funding to South Africa all together] ."
"What do these transgender terms mean"
Research shows : T ransgender people who receive hormone therapy as well as HIV treatment are almost three times more likely to stay on their medication and keep their HIV under control.
Writing in The Lancet in July 2025, Pienaar co-authored a letter describing gender-affirming care as a vital "gateway" into the rest of the health system for transgender people. Receiving services that validate a person's gender identity, she wrote, is "essential to their willingness to engage in further health interventions".
In other words, transgender people are more likely to return to clinics when health workers acknowledge and respect who they are. If they don't feel accepted or understood, many stop using healthcare services altogether .
This, explains Pienaar, is a big problem. The 2024 UNAids Global Aids Update on HIV and Transgender People shows transgender women are among the groups with the highest HIV infection rates. Their chance of getting HIV is 20 times higher than that of the general population, so they need to be able to get HIV prevention medicines, such as the six-monthly anti-HIV injection , if they are HIV negative and antiretroviral drugs if they have HIV. One of the reasons HIV rates are so high among transgender women is that many struggle to get the healthcare they need, including HIV prevention services.
Pienaar says gender-affirming care quite literally saves lives. A 2024 study in Canada found that nearly two-thirds of transgender and gender-diverse people had had thoughts of suicide at some point in their lives, compared with about one in ten other people. Pienaar found even higher rates across South Africa based on research conducted among transgender women in 2025, which will be published later this year.
For Promise Makubalo, the crisis began before the funding cuts. When she moved from KuGompo back to Peddie in the rural Eastern Cape to care for relatives, she could no longer get the hormone treatment she had been taking. Bhekisisa heard from other transgender women in the province that Makubalo had begun to "de-transition", meaning some of the physical changes brought about by the hormones were starting to reverse. We asked to see her.
After hearing about the cuts, Makubalo says she knew there was little point even trying to get hormones through the local clinics in Peddie. The treatment she had started three years earlier had helped her feel more comfortable in her skin, more like the person she had always known herself to be.
"I saw a lady that time," she says, remembering the reflection she used to see in the mirror when she still had a steady supply of hormones. "But now I see I'm becoming a guy. It's like reversing ... I don't feel like a pretty woman."
When we met her, hair had begun growing back on Makubalo's chin, cheeks and chest.
Between rights and reality
The 2024 Ritshidze State of Healthcare for Key Populations report , based on interviews with nearly 14 000 sex workers, people who use drugs, gay and bisexual men and transgender people across South Africa, found 72% of transgender people who stopped using public clinics blamed poor treatment by staff.
In interviews with Bhekisisa, transgender people in the Eastern Cape, Western Cape and Gauteng described something similar: a gap between the rights the Constitution promises and what they experienced in everyday life.
Christi Kruger, director of the Centre for Sexualities, Aids and Gender at the University of Pretoria , says the goal of anti-transgender movements, which are on the rise in the US, is to create a climate where "people don't even try to get the healthcare they need, and will just sort of give up and disappear".
Although South Africa's laws are different, some of the transgender people Bhekisisa spoke to described a similar result: after being treated badly, embarrassed or ignored by healthcare workers again and again, they stopped going to health facilities.
For Theo Tahu, a non-binary trans man in Cape Town, that has meant going to a hospital to find out about top surgery , only to be called by his "dead name" — the term transgender people use for the name they were given at birth, which they no longer use.
For Tahu and others, the problem often starts before they even enter the clinic. Madeleine Muller, a family physician at Cecilia Makiwane Hospital who runs the GAHC units there and in the Buffalo City clinic , explains: "It can start with the security guard. Or with the clerk at the reception desk."
Through Pathsa , South Africa's professional association for transgender health, Muller trains healthcare workers across the country to provide gender-affirming care. She also teaches them how to make clinics welcoming places where transgender people feel safe enough to want to come back.
Muller wrote a guide to help family doctors care for transgender patients. The goal is to make this type of care available at local clinics, so people don't have to rely on a few specialist centres and can get care closer to where they live.
Tahu's experience is familiar to many transgender people. That's one reason researchers from Wits RHI launched the Jabula Uzibone study in 2023/2024. The team wanted to understand whether transgender people were more likely to stay in HIV care when clinics met their broader health needs, including access to gender-affirming care.
The answer is yes. The study found that transgender people who received hormone therapy alongside HIV treatment were close to three times more likely to stay on their medication and keep their HIV under control.
The study also asked people about their experiences at clinics. Many described treatment that made them reluctant to come back. Among the 669 participants from Buffalo City, Cape Town, Johannesburg and Nelson Mandela Bay, nearly a third said health workers had been unwilling to care for them. About four in 10 said they had received poorer treatment than others or heard health workers speak badly about transgender people. Almost a third said staff had shared information about their transgender identity without their permission.
One person said when she arrived at a clinic to collect her medicine, a staff member loudly said: "Why must the Aids moffies be helped first instead of all the other patients who have been waiting for a while?"
Afterwards, the woman later asked clinic staff how the employee knew her HIV status. No one could give her an answer.
Van der Merwe says even when there was still funding for specialised care, trans people travelled far — sometimes across a province — to get to a clinic where they'd be treated with dignity. "Otherwise, you had to swallow your pride and had to be misgendered in exchange for getting healthcare.
She concludes: "Now, without funding, it's hell for most."
'They're in the wind': The status of transgender care now
The scale of the collapse is difficult to grasp, says Pienaar. Prior to the US funding cuts, services in the public sector were mostly provided by specialised gender-affirming clinics based at Groote Schuur Hospital in Cape Town and Steve Biko Academic Hospital in Pretoria, as well as a few NGO-run sites, which worked with provincial and district governments to provide the service on their behalf. Most of these NGO-led services closed with the funding cuts.
In one of Aurum's programmes in five districts, the number of transgender women receiving care dropped from nearly 4 000 to just 11 after the US funding cuts.
Pienaar says most of the women who stopped receiving care did not move to other clinics. Instead, they disappeared from the health system and became difficult for healthcare workers to reach.
"They're in the wind," she says.
In Johannesburg, a Wits RHI transgender clinic in Hillbrow, which had been US-funded, has permanently closed. A small number of former patients still get their hormones and HIV treatment through a clinic at Charlotte Maxeke Johannesburg Academic Hospital, but it can only support the group of former clients who were transferred there.
Transgender people can still get tested for HIV, HIV prevention medicine and HIV treatment if they're HIV positive, at a handful of trans-friendly clinics supported by the Global Fund , but hormone services have mostly disappeared in Gauteng.
In the Western Cape, some transgender health services have found new homes. With funding of the Elma Philanthropies Foundation and the FirstRand Empowerment Foundation, the Desmond Tutu Health Foundation now runs a transgender health clinic at Groote Schuur Hospital for people who previously received care through programmes such as Wits RHI. This clinic operates alongside the government's transgender clinic at the hospital.
Green Point Community Health Centre also continues to provide hormone treatment to people who were receiving care through donor-funded clinics. The Western Cape government stepped in to make sure the service could continue.
Groote Schuur remains one of the country's main centres for specialised transgender healthcare, including gender-affirming surgery. But patients can wait up to twenty years for surgery .
Durban has a government-run clinic with special services for groups of people who have a higher chance of getting HIV at Addington Gateway clinic, while the Eastern Cape has the two clinics run by Muller.
Although gender-affirming hormones have been on South Africa's essential medicines list since 2019, they are still very difficult to get. In many parts of the country, transgender people have to see a specialist before they can get a prescription.
Muller says that needs to change.
If more family doctors and GPs were trained and felt confident prescribing hormones, transgender people could get treatment, HIV testing, HIV prevention medicine and other health services closer to where they live.
DIY hormones when the system fails
"You can't blame people for looking for options to make them feel like the person that they are," says Pienaar. She says most trans women who can't get hormones make a plan of sorts.
Odwa Mbane and Kat'leya Serame are trans women who were both on the community outreach staff at the Hillbrow transgender clinic, which closed after funding cuts. They say there's a thriving informal market in DIY hormones.
"How do you do it yourself? Many take oral contraceptives — as is — or some overdose on them," says Serame. Mbane says she, too, was getting hormones "here and there". She had no idea of the dosage to take. "Taking it the right way means being checked and guided by doctors, so that you get the proper benefits and stay healthy."
Because birth control pills contain small amounts of the hormone oestrogen, some people take far more than the recommended dose to try and speed up changes such as breast growth. Doctors warn that this can be risky because the pills were not designed for this purpose, and little research has been done on their effects when used this way.
Van der Merwe says some trans women pretend to be not transgender and say they have "pre-menopausal symptoms" to try to get a script for menopause hormones, which also contain oestrogen, but also the wrong dose.
Priscilla Nkomozake, who is a consultant researcher on trans issues in the Eastern Cape, told Bhekisisa about a "sickening" experience where she exchanged sex with a doctor intern in return for the hormone medication that the public health system is supposed to provide.
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Since the 2025 funding cuts, Nkomozake says, the biggest need is for clinic staff to change how they think about transgender people. But she says that won't be easy.
South Africa has about 180 000 transgender people . While many live in cities, others rely on public clinics in small towns and rural areas. Yet only a few facilities know how to provide transgender-specific care.
The challenge is to make clinics and hospitals across all 52 districts in the country places where transgender people can get the right care, no matter where they live.
Looking in the mirror
But there are some signs that things may improve. Over the past few weeks, transgender people have received new reasons for hope, including the possibility of new funding and plans to train more government health workers to provide the care they need.
Pienaar told Bhekisisa that the Aurum Institute is in talks with the Dutch government about funding for a new project in six African countries, including South Africa. The programme would reach at least 30 000 people from groups of people with a high chance of getting HIV, including transgender women.
The aim is to restore and expand services that were lost after funding shifts. If approved, it would be the largest programme for transgender people in Africa with funding of approximately 32-million euros.
Wits RHI is working with the health department to train healthcare workers so that transgender people can get respectful and appropriate care.
Part of that is Muller's Pathsa training programme, which has grown to 22 online videos, with six hours of content . About half of the course focuses on understanding transgender people and the challenges they face, while the other half covers clinical care, including hormone therapy.
The training is part of the health department's efforts to improve HIV services and to put South Africa's National Strategic Plan for HIV, TB and Sexually Transmitted Infections into practice. The department wants more clinics to offer transgender-friendly services, giving them "safe spaces" where they can get healthcare without fear of being mocked or turned away.
The evidence for gender-affirming care is becoming clearer, too.
In February 2026, Pathsa completed a review of research that analysed findings from more than 200 pieces of research on transgender care published between 2021 and 2025. The study found that transgender and gender-diverse young people generally do better when they are supported, that very few regret treatment and that being made to wait for care can harm their mental health. The review found it is still difficult to make sure health workers are both trained and comfortable providing this kind of care.
Serame says many health workers simply don't know much about transgender issues. Once she starts talking to them and they get their questions answered, the response is mostly surprisingly positive. "As soon as we sensitise them, they are keen and want to learn more," she says.
The Ritshidze, Jabula Uzibone studies and Pathsa rapid review all reveal that transgender people also need something much simpler than hormones and surgery: health staff who know something about the subject and who will treat them with dignity and respect. Bothma says it's simple: "Just be a good person."
For Makubalo, looking into the mirror is full of possibility again. When told about Muller's training programme and a chance to get hormones, her answer was immediate: "I don't even need to think about it. I want it ... I'm ready." After our interview, Makubalo made contact with Muller and arranged a consultation.
She is now back on hormone treatment and has a prescription for the hormone medication she needs.
This story is the result of a Wits Centre for Journalism health reporting grant awarded to Ida Jooste, one of 24 journalists selected from across Africa.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
