They're in the wind—thousands vanished from care, not transferred elsewhere
In the span of days following the Trump administration's 2025 funding cuts, a healthcare infrastructure built over years for South Africa's transgender population collapsed, leaving thousands without hormones, HIV prevention, and the basic dignity of being seen by a system meant to serve them. The impending end of PEPFAR support by March 2027 threatens to deepen a crisis already measured not just in statistics, but in bodies changing against their will and people vanishing from the health system entirely. What is unfolding in South Africa is a parable about the fragility of care that is constitutionally promised but financially outsourced — and about what happens to the most vulnerable when geopolitical decisions are made without accounting for the human lives tethered to them.
- When US funding was cut in February 2025, clinics closed within days — one program watching its patient count fall from nearly 4,000 transgender women to just 11, with most disappearing from the health system altogether.
- Transgender women in South Africa face HIV infection rates 20 times higher than the general population, meaning the loss of gender-affirming care is not merely a matter of comfort but of survival.
- With clinics shuttered and hormones scarce, a black market in DIY hormone treatment has emerged, offering relief without medical oversight and carrying serious risks of contamination and inconsistent dosing.
- The planned phase-out of all PEPFAR support by March 2027 looms over fragile recovery efforts, threatening to complete the dismantling that the 2025 cuts began.
- Tentative lifelines are appearing — Dutch government funding talks, expanded healthcare worker training, and online education programs — but thousands of transgender people across 52 districts remain unreached.
When US government funding to South African health programs was cut in February 2025, the collapse was almost instantaneous. Clinics that had served transgender people for years closed overnight, field workers disappeared, and support networks dissolved. In one program alone, the number of transgender women receiving care fell from nearly 4,000 to just 11 — and most of those who vanished didn't transfer elsewhere. They simply left the health system entirely.
The stakes are acute. Transgender women in South Africa face HIV infection rates 20 times higher than the general population, meaning access to hormones, HIV prevention medicines, and antiretrovirals is not incidental to their wellbeing — it is central to their survival. Gender-affirming care functions as a gateway into the broader health system; when people don't feel safe or accepted, they stop seeking care at all. The planned phase-out of PEPFAR support by March 2027 threatens to finish what the 2025 cuts began.
Promise Makubalo's experience gives shape to what these numbers mean. After three years on hormone treatment, she returned to rural Peddie in the Eastern Cape to care for relatives and found local clinics unable to help her. When news of the funding cuts reached her, she stopped trying altogether. Hair grew back on her face and chest. "I saw a lady that time," she said of her reflection during treatment. "But now I see I'm becoming a guy." The reversal was as psychological as it was physical.
South Africa's Constitution guarantees transgender people the right to healthcare, but for years that care had been effectively outsourced to US-funded NGOs. A 2024 report found that 72 percent of transgender people who stopped using public clinics cited poor treatment by staff — a problem that family physician Madeleine Muller says can begin with a security guard or a reception clerk. She has spent years training healthcare workers to understand that welcoming transgender patients is not ideology — it is medicine.
With formal systems failing, a black market in DIY hormones has filled part of the void. Those who worked at now-closed clinics describe it plainly: when the system abandons people, people find other ways. The risks — inconsistent dosing, contamination, no oversight — are real, but so is the desperation.
Fragile signs of recovery are emerging. The Western Cape government has funded services at two facilities. The Aurum Institute is in talks with the Dutch government over a €32 million program that could serve 30,000 people across six African countries. Training programs and research reviews are building the evidence base and the workforce. When Makubalo heard about these developments, she didn't hesitate: "I don't even need to think about it. I want it." She is now back on hormone treatment. But she is one person — and across South Africa's 52 districts, thousands remain in the wind.
When the Trump administration cut US government funding to South African health programs in February 2025, the collapse happened in days. Clinics that had served transgender people for years closed overnight. Field workers vanished. Support groups dissolved. For a population already navigating a healthcare system that often treated them as problems rather than patients, the sudden withdrawal of American money felt like abandonment.
The damage was staggering in its speed. In one Aurum Institute program operating across five districts, the number of transgender women receiving care plummeted from nearly 4,000 to just 11. But the numbers don't capture what happened next: most of those women didn't transfer to other clinics. They disappeared from the health system entirely. "They're in the wind," is how Jacqueline Pienaar, a global health expert at the Aurum Institute, described it—a phrase that carries the weight of thousands of people simply vanishing from reach.
The timing made the crisis worse. Reports now confirm that the US government's HIV relief program, PEPFAR, plans to phase out all support to South Africa by March 2027, threatening to finish what the 2025 cuts began. For transgender people in South Africa, this matters with particular urgency. Transgender women face HIV infection rates 20 times higher than the general population, according to the 2024 UNAids Global Aids Update. They need access not just to hormones that help them feel at home in their bodies, but to HIV prevention medicines and antiretroviral drugs that keep them alive. Gender-affirming care isn't a luxury—it's a gateway into the broader health system. When people don't feel safe or accepted, they stop seeking care altogether.
Promise Makubalo's story illustrates what this looks like on the ground. She had been taking hormone treatment for three years, a medication that made her feel like herself. When she moved from the city back to rural Peddie in the Eastern Cape to care for relatives, the local clinics couldn't provide what she needed. After hearing about the funding cuts, she stopped trying. Hair began growing back on her chin, cheeks, and chest. "I saw a lady that time," she said, remembering her reflection when hormones were available. "But now I see I'm becoming a guy. It's like reversing... I don't feel like a pretty woman." The reversal wasn't just physical. It was psychological, a daily reminder that the system had abandoned her.
The Constitution and South Africa's HIV policies recognize transgender people's right to healthcare. But for years, much of that care had been outsourced to US-funded NGOs. When those organizations lost funding, the gap between constitutional promise and lived reality became impossible to ignore. A 2024 Ritshidze report found that 72 percent of transgender people who stopped using public clinics blamed poor treatment by staff. Madeleine Muller, a family physician who runs gender-affirming care units at Cecilia Makiwane Hospital and the Duncan Village Clinic, knows the problem starts before anyone reaches a doctor. "It can start with the security guard. Or with the clerk at the reception desk." She has spent years training healthcare workers to understand that welcoming transgender patients isn't about ideology—it's about keeping people alive.
The informal economy has filled some of the void. With hormones scarce and clinics closed, a thriving black market in DIY hormones has emerged. Odwa Mbane and Kat'leya Serame, both trans women who worked at the now-closed Hillbrow transgender clinic in Johannesburg, described it plainly: when the system fails, people find other ways. "You can't blame people for looking for options to make them feel like the person that they are," Pienaar said. But DIY hormones carry risks—inconsistent dosing, contamination, no medical oversight.
There are fragile signs of recovery. The Western Cape government stepped in to fund transgender health services at Groote Schuur Hospital and the Green Point Community Health Centre. The Aurum Institute is in talks with the Dutch government about a €32 million program that would serve at least 30,000 people from high-risk groups across six African countries, including South Africa. Wits RHI is working with the health department to train more healthcare workers. Pathsa, South Africa's professional association for transgender health, has created 22 online training videos covering everything from understanding transgender people to hormone therapy protocols. The evidence is also becoming clearer: a February 2026 Pathsa review of over 200 research studies found that transgender young people do better when supported, that few regret treatment, and that being forced to wait for care harms their mental health.
When Makubalo learned about these training programs and the possibility of restarting her hormones, her answer was immediate: "I don't even need to think about it. I want it... I'm ready." She contacted Muller, arranged a consultation, and is now back on hormone treatment with a prescription in hand. But she is one person. Across South Africa's 52 districts, thousands of transgender people remain in the wind, waiting for a health system that has not yet learned to see them.
Citas Notables
They're in the wind— Jacqueline Pienaar, global health expert at Aurum Institute, describing transgender women who disappeared from the health system after funding cuts
I saw a lady that time. But now I see I'm becoming a guy. It's like reversing... I don't feel like a pretty woman.— Promise Makubalo, describing the physical and psychological effects of losing access to hormone treatment
La Conversación del Hearth Otra perspectiva de la historia
Why does gender-affirming care matter so much for HIV prevention? It seems like separate issues.
Because if you don't feel safe or accepted in a clinic, you stop going. A transgender woman might need HIV prevention medicine or treatment, but if the receptionist misgenders her or the doctor treats her like a problem, she leaves and doesn't come back. The care itself is the gateway.
So the funding cuts didn't just remove hormones—they removed trust.
Exactly. In one program, 4,000 women went to 11. The rest didn't move elsewhere. They disappeared. When you've been turned away or humiliated enough times, you stop trying.
What happens to someone like Promise Makubalo when the hormones stop?
The physical changes reverse. Hair grows back. But it's not just that. It's the psychological weight of it—seeing yourself becoming someone you're not, knowing the system has abandoned you. Some people start asking if it's worth investing in their life at all.
Is there a black market for these hormones?
Yes. When the formal system fails, people find informal ways. DIY hormones, unregulated sources. It's not ideal—there's no medical oversight, no consistency—but people do what they have to do to survive.
What would actually fix this?
Training more family doctors and GPs to prescribe hormones confidently. Making clinics welcoming at every level—security, reception, clinical staff. And funding that doesn't disappear overnight. The Dutch government funding being discussed could help, but it depends on approval.
Do healthcare workers actually want to learn this, or is there resistance?
Serame said most workers simply didn't know much about transgender issues. Once she talks to them and answers their questions, the response is surprisingly positive. It's not ideology—it's education and willingness.