{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T08:04:12Z","timestamp":1784880252013,"version":"3.55.0"},"reference-count":30,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T00:00:00Z","timestamp":1784851200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Int. J. Environ. Res. Public Health","IJERPH"],"abstract":"<jats:p>Community-based organisations (CBOs) play a critical role in implementing HIV programmes, many of which have historically relied on United States (U.S.) donor funding. Recent U.S. funding cuts have disrupted community-based HIV programmes, underscoring the need to understand implementers\u2019 experiences to support sustainable service delivery. This study explored how funding instability affected community-based HIV programmes in rural KwaZulu-Natal, South Africa. A qualitative, exploratory design was employed using interviews and focus group discussions with purposively selected youth frontline workers and programme managers (n = 26). The Health Systems Building Blocks framework guided thematic analysis. Participants described disruptions in outreach and prevention services, contract terminations and reduced working hours among frontline personnel, weakened data and follow-up systems, shortages or reduced local availability of HIV prevention commodities, lack of transition planning, and abrupt program closure without sustainability measures. U.S. funding cuts disrupted essential community-based HIV services in rural KwaZulu-Natal, exposing vulnerabilities in prevention, outreach, workforce, and monitoring systems. Sustainable financing and stronger integration of community organisations into health systems are needed to protect HIV service continuity.<\/jats:p>","DOI":"10.3390\/ijerph23080951","type":"journal-article","created":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T07:36:13Z","timestamp":1784878573000},"page":"951","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["U.S. Funding Cuts and Health System Challenges in Community-Based HIV Programmes in Rural KwaZulu-Natal, South Africa: A Qualitative Study"],"prefix":"10.3390","volume":"23","author":[{"given":"Siphelele Thamsanqa","family":"Ngubane","sequence":"first","affiliation":[{"name":"Faculty of Health Sciences, Durban University of Technology, Durban 4001, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8628-5726","authenticated-orcid":false,"given":"Dumile","family":"Gumede","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, Durban University of Technology, Durban 4001, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,24]]},"reference":[{"key":"ref_1","unstructured":"UNAIDS (2025). Impact of PEPFAR Pause in South Africa, UNAIDS."},{"key":"ref_2","unstructured":"UNAIDS (2026, May 13). UNAIDS Global AIDS Update 2025, Available online: https:\/\/www.unaids.org\/en\/UNAIDS-global-AIDS-update-2025."},{"key":"ref_3","first-page":"5","article-title":"Securing our HIV response: The PEPFAR crisis in South Africa","volume":"15","author":"Grimsrud","year":"2025","journal-title":"S. Afr. Med. J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1080\/09540121.2025.2592251","article-title":"The human cost of US foreign aid cuts: Implications for HIV service delivery, research and innovation in South Africa","volume":"38","author":"Makusha","year":"2025","journal-title":"AIDS Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1476","DOI":"10.1097\/QAD.0000000000004272","article-title":"The cost of the plunge: The impact and cost of a cessation of PEPFAR-supported services in South Africa","volume":"39","author":"Jamieson","year":"2025","journal-title":"AIDS"},{"key":"ref_6","first-page":"100039","article-title":"PEPFAR interrupted: Real-world consequences of U.S foreign aid instability for HIV service delivery in South Africa","volume":"4","author":"Filiatreau","year":"2026","journal-title":"Lancet Reg. Health-Afr."},{"key":"ref_7","unstructured":"UNAIDS (2025). 2025 AIDS TARGETS, UNAIDS."},{"key":"ref_8","unstructured":"WHO (2026, May 13). South Africa Launches 1.1 Million HIV Campaign to Close Treatment Gap. Available online: https:\/\/www.afro.who.int\/countries\/south-africa\/news\/south-africa-launches-11-million-hiv-campaign-close-treatment-gap-0."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/s12981-025-00792-y","article-title":"At a crossroads: Confronting setbacks and advancing the 95-95-95 HIV targets in sub-Saharan Africa","volume":"22","author":"Mukuku","year":"2025","journal-title":"AIDS Res. Ther."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Sabapathy, K., Hensen, B., Varsaneux, O., Floyd, S., Fidler, S., and Hayes, R. (2018). The cascade of care following community-based detection of HIV in sub-Saharan Africa\u2014A systematic review with 90-90-90 targets in sight. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0200737"},{"key":"ref_11","unstructured":"(2025). KwaZulu-Natal State of Health: How the PEPFAR Disruptions Have Impacted Public Health Services, Ritshidze."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e70032","DOI":"10.1002\/jia2.70032","article-title":"Person-centred HIV care and prevention for youth in rural South Africa: Preliminary implementation findings from Thetha Nami ngithethe nawe stepped-wedge trial of peer-navigator mobilization into mobile sexual health services","volume":"28","author":"Busang","year":"2025","journal-title":"J. Int. AIDS Soc."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Mathole, T., Nicol, J.U., Hlongwa, M., Turawa, E., Basera, W., Funani, N., and Nicol, E. (2025). A primary health care Re-Engineering approach to enhance PrEP initiation and adherence among high-risk, sexually active adolescents and young adults in KwaZulu-Natal, South Africa. BMC Public Health, 25.","DOI":"10.1186\/s12889-025-25698-2"},{"key":"ref_14","unstructured":"WHO (2010). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies, World Health Organization."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1093\/heapol\/czx183","article-title":"Towards an understanding of resilience: Responding to health systems shocks","volume":"33","author":"Hanefeld","year":"2018","journal-title":"Health Policy Plan."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1337","DOI":"10.1093\/heapol\/czx083","article-title":"Institutional analysis of health system governance","volume":"32","author":"Abimbola","year":"2017","journal-title":"Health Policy Plan."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Gumede, D., Meyer-Weitz, A., Zuma, T., Shahmanesh, M., and Seeley, J. (2022). A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa. PLoS Glob. Public Health, 2.","DOI":"10.1371\/journal.pgph.0000369"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"100138","DOI":"10.1016\/j.ssmqr.2022.100138","article-title":"A socio-ecological approach to understanding experiences and perceptions of a multilevel HIV prevention intervention: The determined, resilient, empowered, AIDS-free, mentored, and safe (DREAMS) partnership in uMkhanyakude, KwaZulu-Natal, South Africa","volume":"2","author":"Zuma","year":"2022","journal-title":"SSM-Qual. Res. Health"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","year":"2006","journal-title":"Qual. Res. Psychol."},{"key":"ref_20","unstructured":"Denzin, N.K., and Lincoln, Y.S. (1994). The SAGE Handbook of Qualitative Research, SAGE."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e008493","DOI":"10.1136\/bmjgh-2022-008493","article-title":"The building blocks of community health systems: A systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions","volume":"7","author":"Karim","year":"2022","journal-title":"BMJ Glob. Health"},{"key":"ref_22","unstructured":"UNAIDS (2026). Sustaining HIV Community-Led Responses: Technical Guidelines for Costing and Budgeting, UNAIDS."},{"key":"ref_23","unstructured":"NDoH (2025). Closing 1.1 Million HIV Treatment Gap: Communication Toolkit, NdoH."},{"key":"ref_24","unstructured":"UNAIDS (2026, May 16). Comprehensive Update on HIV Programmes in South Africa. Available online: https:\/\/www.unaids.org\/en\/resources\/presscentre\/featurestories\/2025\/february\/20250225_south-africa-fs."},{"key":"ref_25","first-page":"qxag020","article-title":"Impact of US government funding freezes on the HIV response: Findings from a rapid survey in 32 countries","volume":"4","author":"Brazier","year":"2026","journal-title":"Health Aff. Sch."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Ugbaja, S.C., Setlhare, B., Atiba, P.M., Kumalo, H.M., Ngcobo, M., and Gqaleni, N. (2025). The Public Health Impact of Foreign Aid Withdrawal by the United States Government and Its Implications for ARVs, Preexposure, and Postexposure Prophylaxis Medications in South Africa and Nigeria. World, 6.","DOI":"10.3390\/world6020074"},{"key":"ref_27","unstructured":"The Global Fund (2024). Sustainability, Transition and Co-Financing Policy, The Global Fund to Fight AIDS, Tuberculosis and Malaria."},{"key":"ref_28","unstructured":"WHO (2018). WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes, World Health Organization."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Zakumumpa, H., Adolf, A., Kiplagat, J., Cherop, F., Bosire, V., and Buregyeya, E. (2026). Early impacts of PEPFAR funding freeze on HIV service delivery in mid-Western Uganda. BMC Health Serv. Res., 26.","DOI":"10.1186\/s12913-026-14165-2"},{"key":"ref_30","unstructured":"Africa Centres for Disease Control and Prevention (2023). Africa CDC Strategic Plan 2023\u20132027, Africa CDC."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/8\/951\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T07:39:43Z","timestamp":1784878783000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/8\/951"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,24]]},"references-count":30,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["ijerph23080951"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23080951","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,24]]}}}