Sex workers in Vosloorus, Johannesburg and Springs talked to GroundUp about their struggle to access health services, particularly antiretroviral treatment, since the closures of US funded clinics. Photos: Kimberly Mutandiro
It’s afternoon on Boundary Road in Vosloorus. Sex worker Simangele (not her real name) hopes to secure her next client.
Making enough money to pay rent has always been a concern for Simangele. But now she has a new worry: how to keep up with her antiretroviral treatment.
Two months ago the closure of a mobile clinic — where Simangele and other sex workers in Vosloorus went for checkups and to collect their treatment — left her without access to the life-saving medication.
The mobile clinic was run by the Wits Reproductive Health and HIV Institute (WITS RHI) which heavily relied on US funding. The institute has been providing critical sexual and reproductive health services since 2018. The programme was one of many health facilities forced to halt services at the end of January in the wake of US funding cuts for global aid.
Speaking to GroundUp, Simangele says she ran out of antiretroviral medicines (ARVs) over a month ago and has resorted to borrowing a few tablets from a friend. “I don’t know what I will do because the tablets my friend gets give me side effects,” she says. (Antiretrovirals treat HIV. They have to be taken daily for life.)
She says the clinic closed without any warning or before they could give them transfer letters to public healthcare facilities. She is now dreading having to go to a public facility where she says sex workers are frequently discriminated against, particularly those who are undocumented.
We spoke to a dozen other sex workers in Joburg and in Springs who are worried about defaulting on their antiretroviral treatment following the closure of the Wits RHI clinics. The clinics also provided pre-exposure prophylaxis (PrEP) (to prevent HIV-negative people contracting HIV), and treatments for sexually transmitted infections, TB, sexual reproductive health services, and counselling.
A sex worker shows the last few ARVs she has left.
Another sex worker said, “The minute we go to public clinics, they will need documents, which some of us do not have … Wits made time to listen to our problems as sex workers. Even when we faced challenges with clients, they never judged us.”
Sisi (not her real name), who rents rooms and assists sex workers in Vosloorus, said she’s aware of several sex workers who have defaulted and no longer have access to condoms, lubricants, and treatment for sexually transmitted infections. “The Wits clinic did not discriminate against people without documents and would sometimes provide food, branded T-shirts, caps, and even jobs,” she said.
“Many of us will die”
We visited Zig Zag Road in Springs, where several sex workers said they were out or almost out of ARVs. When asked why they didn’t just go to a local clinic, they told GroundUp about instances where they experienced stigma while trying to access treatment at public clinics.
“I used to receive PrEP to help prevent HIV (from the Wits clinic). We would also receive birth control services. Now I can’t go to a public clinic because we are mocked for being sex workers,” said Siphesihle.
Ntombi, who waits for clients along End Street, attended one of the Wits clinics in Hillbrow which closed down. She said those on PrEP were given transfer letters before the clinic closed.
Other workers nearby told GroundUp that they now pay up to R250 for PrEP, which is more than they can afford.
Sisonke calls for urgent response to crisis
The Sisonke National Movement, which advocates for the rights of sex workers, has been raising the alarm since the closure of US-funded facilities. Before the closures, Sisonke was in talks with National Department of Health through the South African National AIDS Council about the provision of services to sex workers and other vulnerable groups, said the organisation’s spokesperson Yonela Sinqu.
She said that the department never answered activists when they asked what would happen should donor funds no longer be available for these facilities.
She said the plea for assistance without referral letters is made to all provinces, not only Gauteng. However, Gauteng is the only province that has approached us with the crisis of people without referrals, she said.
Department of Health spokesperson Foster Mohale has not responded to requests for comment.
Finding a path forward for South Africa’s healthcare workers
Donald McMillan
By Donald McMillan, Managing Director at Allmed Healthcare Professionals
06 May 2025
South Africa’s healthcare system is under serious pressure. The sudden suspension of critical US funding has resulted in the loss of around 15 000 healthcare jobs – many of them linked to HIV/AIDS programmes that served as lifelines for vulnerable communities. Combined with broader public sector budget cuts and a national hiring freeze, the situation threatens to undo decades of progress in healthcare delivery. As public hospitals struggle with fewer staff and shrinking resources, the country is at risk of losing not only jobs, but skills, infrastructure, and hope. But in the face of these challenges, there are still ways to keep services running and people employed. One of them is through Temporary Employment Services (TES), which provides a flexible staffing approach that can help stabilise the system while longer-term solutions are explored.
A healthcare system under pressure
The US aid cut has had an immediate and devastating impact. Programmes focused on HIV, tuberculosis, and reproductive health, many of which were propped up by international donor funding, have been forced to scale back or shut down entirely. Thousands of community healthcare workers, nurses, counsellors, and administrators have found themselves jobless, while patients are left facing longer wait times and reduced access to care.
At the same time, cost-cutting across the public sector has put a freeze on new hires, even in essential departments like health and the impact is already being felt. With public hospitals and clinics stretched thin, they’re unable to take on newly trained doctors and nurses. And while the private sector plays a role, it simply cannot absorb the overflow. This isn’t just a staffing issue, it’s a setback for the entire healthcare system, affecting everything from medical training to frontline care.
Young professionals left in limbo
Every year, South Africa produces thousands of highly trained doctors and healthcare workers, many of whom move into the public health system after completing their compulsory community service. These roles used to be a given but with hiring freezes and shrinking budgets, many young professionals are now finishing their training with nowhere to go. Despite their skills and frontline experience, these workers are left in limbo. This is a double blow as South Africa loses out on the return from its investment in their education, while the risk of a growing skills drain looms large. With countries like the UK, Australia, and Canada actively recruiting healthcare workers, there’s a real chance they may leave and not come back.
A flexible solution in Temporary Employment Services
In response to this crisis, temporary employment solutions have become a practical and effective solution. TES providers offer qualified healthcare professionals short- to medium-term flexible contracts, enabling them to continue working in their field while delivering essential support to overburdened healthcare facilities.
This approach offers a lifeline not just for displaced workers, but for clinics and hospitals struggling with limited resources. TES employees can be rapidly deployed where they are needed most, whether to cover staff shortages, serve remote communities, or support seasonal fluctuations in demand. Unlike permanent hires, they don’t carry long-term costs such as medical aid or pension contributions, making them a more budget-conscious option in uncertain times.
The benefits of the TES model have already been proven. During the COVID-19 pandemic, temporary staff played a key role in scaling up testing, vaccination, and treatment efforts across the sector. That same adaptability is needed now to respond to the healthcare funding crisis.
Rethinking the future of healthcare work
While temporary employment solutions cannot not solve the problem alone, it can provide an important stopgap and potentially a new way of thinking about workforce planning in the healthcare sector. Rather than relying solely on permanent positions, South Africa may need to adopt a more fluid, demand-based deployment model that allows professionals to move between roles, regions, and areas of urgent need.
Shifting to this model calls for a change in mindset. Permanent posts have traditionally been seen as the gold standard in healthcare, valued for their stability and benefits. But in a time of uncertainty, contract and locum roles – especially when managed by trusted TES providers – can offer a practical alternative, combining income, ongoing experience, and flexibility.
Retaining talent, restoring hope
Avoiding long-term damage to South Africa’s healthcare system will require urgent, coordinated action. Government departments must urgently reprioritise spending toward essential services like health and education. At the same time, private healthcare providers and staffing agencies must step up and work together to ensure that skilled professionals are not lost to the system or the country.
Despite the current turbulence, South Africa’s healthcare workers remain among the best trained and most resilient in the world and with the right support structures, including flexible employment options like TES, we can preserve our healthcare capacity and continue to serve those who need it most.
The World Health Organization warns that global health funding cuts are paving the way for a resurgence of diseases that had been brought to the brink by vaccination.
One example of prior success is Africa’s “meningitis belt”, spanning parts of sub-Saharan Africa, where vaccination campaigns had successfully eliminated meningitis A. Likewise, yellow fever and related deaths were drastically cut by improved routine immunisation and emergency vaccine stockpiles.
The WHO says that this hard-won progress is now threatened. “Funding cuts to global health have put these hard-won gains in jeopardy,” warned Tedros Adhanom Ghebreyesus, WHO Director-General.
Outbreaks on the rise
In 2023, measles cases were estimated at more than 10.3 million – a 20% year-on-year increase. In a statement marking the beginning of World Immunization Week,the WHO, UN Children’s Fund UNICEF and their partners warned that this upward trend is expected to continue into 2025.
After years of declining cases in Africa thanks to improved vaccine access, yellow fever is also making a return. The start of 2025 has already seen a rise in outbreaks across the continent, with cases also confirmed in the Americas.
The threat of vaccine misinformation
Vaccination efforts are increasingly under pressure due to a combination of misinformation, population growth, humanitarian crises, and funding cuts.
Earlier this month, a WHO review across 108 countries found that nearly half are experiencing moderate to severe disruptions to vaccination campaigns, routine immunisations, and supply chains due to falling donor support.
“The global funding crisis is severely limiting our ability to vaccinate over 15 million vulnerable children in fragile and conflict-affected countries against measles,” said Catherine Russell, Executive Director of UNICEF.
High healthcare returns on vaccination
Vaccines save around 4.2 million lives each year, protecting against 14 different diseases. Almost half of those lives are saved in Africa.
Despite this, falling investment now risks the re-emergence of diseases once thought to be under control.
Health experts emphasise that immunisation is one of the most cost-effective health interventions. Every $1 invested in vaccines brings an estimated return of $54 through better health and economic productivity.
UNICEF, WHO, and their partners are calling on parents, the public, and political leaders to support immunisation programmes and ensure long-term investment in vaccines and public health systems.
Mycobacterium tuberculosis drug susceptibility test. Photo by CDC on Unsplash
By Catherine Tomlinson
Health research in South Africa has been plunged into crisis with the abrupt termination of several large research grants from the US, with more grant terminations expected in the coming days and weeks. Professor Ntobeko Ntusi, head of the South African Medical Research Council, tells Spotlight about efforts to find alternative funding and to preserve the country’s health research capacity.
Health research in South Africa is facing an unprecedented crisis due to the termination of funding from the United States government. Though exact figures are hard to pin down, indications are that more than half of the country’s research funding has in recent years been coming from the US.
Many health research units and researchers that receive funding from the US National Institutes of Health (NIH) have in recent weeks been notified that their grants have been terminated. This funding is being slashed as part of the efforts by US President Donald Trump’s administration to reduce overall federal spending and end spending that does not align with its political priorities.
Specifically, the administration has sought to end spending supporting LGBTQ+ populations and diversity, as well as equity and inclusion. As many grants for HIV research have indicators of race, gender, and sexual orientation in their target populations and descriptions, this area of research has been particularly hard hit by the cuts. There have also been indications that certain countries, including South Africa and China, would specifically be targeted with NIH cuts.
On 7 February, President Donald Trump issued an executive order stating that the US would stop providing assistance to South Africa in part because it passed a law that allowed for the expropriation of land without compensation, and separately because the South African government took Israel to the International Court of Justice on charges of genocide in Gaza.
Prior to the NIH cuts, some local research funded through other US entities such as the US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC) were also terminated.
How much money is at risk?
“In many ways the South African health research landscape has been a victim of its own success, because for decades we have been the largest recipients of both [official development assistance] funding from the US for research [and] also the largest recipients of NIH funding outside of the US,” says president and CEO of the SAMRC Professor Ntobeko Ntusi.
Determining the exact amount of research funds we get from the US is challenging. This is because funding has come from several different US government entities and distributed across various health research organisations. But the bulk of US research funding in South Africa clearly came from the NIH, which is also the largest funder of global health research.
According to Ntusi, in previous years, the NIH invested, on average, US$150 million – or almost R3 billion – into health research in South Africa every year.
By comparison, the SAMRC’s current annual allocation from government is just under R2 billion, according to Ntusi. “Our baseline funding, which is what the national treasury reflects [approximately R850 million], is what flows to us from the [Department of Health],” he says, adding that they also have “huge allocations” from the Department of Science, Technology and Innovation. (Previous Spotlight reporting quoted the R850 million figure from Treasury’s budget documents, and did not take the additional funds into account.)
How is the SAMRC tracking US funding terminations
Ntusi and his colleagues have been trying to get a clearer picture of the exact extent and potential impacts of the cuts.
While some US funding given to research units in South Africa flows through the SAMRC, the bulk goes directly to research units from international research networks, larger studies, and direct grants. Keeping track of all this is not straight-forward, but Ntusi says the SAMRC has quite up to date information on all the terminations of US research awards and grants.
“I’ve been communicating almost daily with the deputy vice-chancellors for research in all the universities, and they send me almost daily updates,” says Ntusi. He says heads of research units are also keeping him informed.
According to him, of the approximately US$150 million in annual NIH funding, “about 40%…goes to investigator-led studies with South Africans either as [principal investigators] or as sub-awardees and then the other 60% [comes from] network studies that have mostly sub-awards in South Africa”.
Figures that Ntusi shared with Spotlight show that large tertiary institutions like the University of the Witwatersrand, the University of Cape Town, and the University of Stellenbosch, could in a worst case scenario lose over R200 million each, while leading research units, like the Desmond Tutu Health Foundation and the Centre for the AIDS Programme of Research in South Africa, could each lose tens of millions. The SAMRC figures indicate that while many grants have already been terminated, there are also a substantial number that have not been terminated.
Where will new money come from?
Ntusi says the SAMRC is coordinating efforts to secure new funding to address the crisis.
“We have been leading a significant fundraising effort, which…is not for the SAMRC, but for the universities who are most affected [and] also other independent research groups,” he says. “As the custodian of health research in the country, we are looking for solutions not just for the SAMRC but for the entire health research ecosystem.”
Ntusi explains that strategically it made more sense to have a coordinated fundraising approach rather than repeating what happened during COVID-19 when various groups competed against each other and approached the same funders.
“Even though the SAMRC is leading much of this effort, there’s collective input from many stakeholders around the country,” he says, noting that his team is in regular communication with the scientific community, the Department of Health, and Department of Science, Technology and Innovation.
The SAMRC is also asking the Independent Philanthropic Association of South Africa, and large international philanthropies for new funding. He says that some individuals and philanthropies have already reached out to the SAMRC to find out how they can anonymously support research endeavours affected by the cuts.
Can government provide additional funds?
Ntusi says that the SAMRC is in discussions with National Treasury about providing additional funds to support health researchers through the funding crisis.
The editors of Spotlight and GroundUp recently called on National Treasury to commit an extra R1 billion a year to the SAMRC to prevent the devastation of health research capacity in the country. They argued that much larger allocations have previously been made to bail out struggling state-owned entities.
Government has over the last decade spent R520 billion bailing out state-owned entities and other state organs.
How will funds raised by the SAMRC be allocated?
One dilemma is that it is unlikely that all the lost funding could be replaced. This means tough decisions might have to be made about which projects are supported.
Ntusi says that the SAMRC has identified four key areas in need of support.
The first is support for post-graduate students. “There’s a large number of postgraduate students…who are on these grants” and “it’s going to be catastrophic if they all lose the opportunity to complete their PhDs,” he says.
Second is supporting young researchers who may have received their first NIH grant and rely entirely on that funding for their work and income, says Ntusi. This group is “really vulnerable [to funding terminations] and we are prioritising [their] support…to ensure that we continue to support the next generation of scientific leadership coming out of this country,” he says.
A third priority is supporting large research groups that are losing multiple sources of funding. These groups need short-term help to finish ongoing projects and to stay afloat while they apply for new grants – usually needing about 9 to 12 months of support, Ntusi explains.
The fourth priority, he says, is to raise funding to ethically end clinical and interventional studies that have lost their funding, and to make sure participants are connected to appropriate healthcare. Protecting participants is an important focus of the fundraising efforts, says Ntusi, especially since many people involved in large HIV and TB studies come from underprivileged communities.
Ultimately, he says they hope to protect health research capacity in the country to enable South African health researchers to continue to play a meaningful and leading role in their respective research fields.
“If you reflect on what I consider to be one of the greatest successes of this country, it’s been this generation of high calibre scientists who lead absolutely seminal work, and we do it across the entire value chain of research,” says Ntusi. “I would like to see…South Africa [continue to] make those meaningful and leading pioneering contributions.”
African countries face a major challenge of dealing with high rates of communicable diseases, such as malaria and HIV/Aids, and rising levels of non-communicable diseases. But the continent’s health systems don’t have the resources to provide accessible and affordable healthcare to address these challenges.
Historically, aid has played a critical role in supporting African health systems. It has funded key areas, including medical research, treatment programmes, healthcare infrastructure and workforce salaries. In 2021, half of sub-Saharan Africa’s countries relied on external financing for more than one-third of their health expenditures.
As aid dwindles, a stark reality emerges: many African governments are unable to achieve universal health coverage or address rising healthcare costs.
The reduction in aid restricts healthcare services and threatens to reverse decades of health progress on the continent. A fundamental shift in healthcare strategy is necessary to address this crisis.
The well-known maxim that “prevention is better than cure” holds not just for health outcomes but also for economic efficiency. It’s much more affordable to prevent diseases than it is to treat them.
As an infectious diseases specialist, I have seen how preventable diseases can put a financial burden on health systems and households.
For instance, each year, there are global economic losses of over US$33 billion due to neglected tropical diseases. Many conditions, such as lymphatic filariasis, often require lifelong care. This places a heavy burden on families and stretches national healthcare systems to their limits.
African nations can cut healthcare costs through disease prevention. This often requires fewer specialist health workers and less expensive interventions.
To navigate financial constraints, African nations must rethink and redesign their healthcare systems.
Three key areas where cost-effective, preventive strategies can work are: improving water, sanitation, and hygiene; expanding vaccination programmes; and making non-communicable disease prevention part of community health services.
A shift in healthcare delivery
Improving water, sanitation, and hygiene infrastructure
Many diseases prevalent in Africa are transmitted through contact with contaminated water and soil. Investing in safe water, sanitation, and hygiene (WASH) infrastructure is an opportunity. This alone can prevent a host of illnesses such as parasitic worms and diarrhoeal diseases. It can also improve infection control and strengthen epidemic and pandemic disease control.
Currently, WASH coverage in Africa remains inadequate. Millions are vulnerable to preventable illnesses. According to the World Health Organization (WHO), in 2020 alone, about 510 000 deaths in Africa could have been prevented with improved water and sanitation. Of these, 377 000 deaths were caused by diarrhoeal diseases.
Unsafe WASH conditions also contribute to secondary health issues, such as under-nutrition and parasitic infections. Around 14% of acute respiratory infections and 10% of the undernutrition disease burden – such as stunting – are linked to unsafe WASH conditions.
By investing in functional WASH infrastructure, African governments can significantly reduce the incidence of these diseases. This will lead to lower healthcare costs and improved public health outcomes.
Local production of relevant vaccines
Vaccination is one of the most cost-effective health interventions available for preventing infection. Immunisation efforts save over four million lives every year across the continent.
There is an urgent need for vaccines against diseases prevalent in Africa whose current control is heavily reliant on aid. Neglected tropical diseases are among them.
Vaccines can also prevent some non-communicable diseases. A prime example is the human papillomavirus (HPV) vaccine, which can prevent up to 85% of cervical cancer cases in Africa.
HPV vaccination is also more cost-effective than treating cervical cancer. In some African countries, the cost per vaccine dose averages just under US$20. Treatment costs can reach up to US$2,500 per patient, as seen in Tanzania.
It is vital to invest in a comprehensive vaccine ecosystem. This includes strengthening local research and building innovation hubs. Regulatory bodies across the continent must also be harmonised and markets created to attract vaccine investment.
Integrating disease prevention into community healthcare services
Historically, African healthcare systems were designed to address communicable diseases, such as tuberculosis and HIV. This left them ill-equipped to handle the rising burden of non-communicable diseases, such as type 2 diabetes and cardiovascular diseases. One cost-effective approach is to integrate the prevention and management of these diseases into existing community health programmes.
Community health workers currently provide low-cost interventions for health issues such as pneumonia and malaria. They can be trained to address non-communicable diseases as well.
In some countries, community health workers are already filling the service gap. Getting them more involved in prevention strategies will strengthen primary healthcare services in Africa. This investment will ultimately reduce the long-term financial burden of treating chronic diseases.
A treatment-over-prevention approach will not be affordable
Current estimates suggest that by 2030, an additional US$371 billion per year – roughly US$58 per person – will be required to provide basic primary healthcare services across Africa.
Adding to the challenge is the rising global cost of healthcare, projected to increase by 10.4% this year alone. This marks the third consecutive year of escalating costs. For Africa, costs also come from population growth and the rising burden of non-communicable diseases.
By shifting focus from treatment to prevention, African nations can make healthcare accessible, equitable and financially sustainable despite the decline in foreign aid.
The cancellation of PEPFAR funding to South Africa could cause between 150 000 and 295 000 additional HIV infections by the end of 2028. This is unless the South African government covers some of the defunded services.
These are the preliminary findings of a new modelling study commissioned by the National Health Department to look into the impact of PEPFAR funding cuts in South Africa. It was authored by researchers at the University of Cape Town (UCT) and University of the Witwatersrand (WITS). PEPFAR is a multi-billion dollar US initiative that supports HIV-related services globally, but which has been significantly slashed by the Trump administration since February.
The research on South Africa comes at the same time that a separate modelling study was published in The Lancet which found that the discontinuation of PEPFAR could cause an additional 1-million HIV infections among children in sub-Saharan Africa by 2030. This would lead to the deaths of about 500 000 children according to the study, while over 2-million others would be left orphaned.
On 20 January, newly-elected US president Donald Trump issued an executive order which suspended virtually all US foreign development assistance for 90 days pending a review. As a result, US-backed aid programmes were brought to a standstill across the world, including in South Africa. While a waiver was published which supposedly allowed some PEPFAR-related activities to continue, this had a limited effect in practice.
Since then, some US grants have resumed, while others have been cancelled. The value of all terminated grants comes to tens of billions of dollars globally. In South Africa, numerous awards have been cancelled from PEPFAR, which had provided roughly R7.5-billion to non-profit organisations in the country in 2024. These organisations primarily used the money to hire and deploy health workers in government clinics, or to operate independent health facilities. Many of these have now been forced to close.
While there are still some active PEPFAR grants in South Africa, it’s unclear how much longer these will be retained, as many are only approved until September. The new study focusing on South Africa models what would happen if all PEPFAR funding was eliminated.
Up to 65 000 additional deaths expected by 2028
In 2024 roughly 78% of all people who had HIV in South Africa were on antiretroviral (ARV) treatment. This figure has been steadily rising over time. By 2026, it was expected to climb to 81%, according to Dr Lise Jamieson, lead author of the local modelling study.
But this trend will be reversed if the entire PEPFAR programme is cancelled and the government fails to step in. ARV coverage among people with HIV would drop to 70% by 2026, according to the study. Under the model’s more pessimistic scenario, the figure would drop even lower – to 59% by 2026.
This is partly because some people living with HIV in South Africa get their ARVs directly from PEPFAR-funded drop-in centres. If these centres close down, some patients may stop taking their ARVs. Indeed, this is precisely what happened after one centre in Pretoria stopped providing services.
The loss of PEPFAR funds could also hinder the health system’s capacity to get newly-infected people on HIV treatment. For instance, PEPFAR-funded organisations had employed nearly 2000 lay counsellors across South Africa who tested people for HIV. Without these staff, fewer people will be diagnosed and get started on treatment.
Not only will ARV coverage drop due to the cuts, but HIV prevention services will also be affected, according to the study. For instance, PEPFAR-funded drop-in sites had been providing people with pills that prevent HIV, called pre-exposure prophylaxis (PrEP). These services were targeted at groups most likely to contract and transmit HIV, like sex workers. According to the new modelling study, the full termination of PEPFAR would lead to as much as a 55% reduction in PrEP coverage for female sex workers by 2026.
Because of factors like these, the researchers estimate that the PEPFAR cuts would cause between 56 000 and 65 000 additional HIV-related deaths in South Africa by 2028. By 2045, this would increase to between 500 000 and 700 000 deaths.
Nearly 90% of USAID contracts terminated in South Africa
All of these results only hold if the South African government fails to step in, according to Jamieson. The modelling study finds that to cover all PEPFAR services from 2025 to 2028, the government would need to spend an extra R13 to 30-billion in total.
It’s unlikely that the government will cough up this amount, but according to Jamieson the National Health Department is taking steps to identify and support certain key services that were defunded by PEPFAR. She is hopeful that the results may not be as drastic as what the study suggests.
Another caveat is that the modelling study estimated what would happen if South Africa lost all of its PEPFAR funding. But at least for now, there are still some grants reaching beneficiaries in the country.
PEPFAR funds are primarily distributed by two US agencies – the US Agency for International Development (USAID) and the US Centres for Disease Control and Prevention (CDC). While both agencies paused funding after the initial suspension order in late-January, the CDC resumed its funding roughly two weeks later. This was after a US federal court ruled that the Trump administration could not freeze congressionally appropriated funds.
CDC grants only appear to be active until September (at least for South African beneficiaries), though uncertainty remains about this.
USAID has taken a much harder line – funding was suspended from late January. By late-February, the agency moved from pausing funds to issuing termination notices to most of its beneficiaries.
In South Africa, roughly 89% of all USAID funding has been cancelled. The value of all cancelled funds comes to about US$261-million (R5.2-billion). Only five other countries have faced larger cuts in absolute terms (see all country-level estimates here). Spotlight and GroundUp have confirmed that at least some of the remaining 11% of USAID funding has once again begun flowing to beneficiaries in the country.
Thus, a small amount of USAID funding is trickling into South Africa, while CDC funds have largely been retained in full. Though it’s unclear for how much longer.
Finance Minister Enoch Godongwana holding a copy of the 2025 Budget Speech. (Photo: Parliament of RSA via X)
By Charles Parry, Funeka Bango, Tamara Kredo, Wanga Zembe, Michelle Galloway, Renee Street and Caradee Wright
While the 2025 national budget boosts health spending, researchers from the South African Medical Research Council stress the need for strong accountability measures. They also raise concerns about rising VAT and omissions related to US funding cuts and climate change.
The 2025 budget speech by Finance Minister Enoch Godongwana saw a welcome boost to the health budget with an increased allocation from R277 billion in 2024/2025 to R329 billion in 2027/2028. This signals a government that is responding to the dire health needs of the public sector, that serves more than 80% of the South African population.
As researchers at the South African Medical Research Council (SAMRC), we listened with interest and share our reflections on some of the critical areas of spend relevant for health and wellbeing.
We note the increase in investment in human resources for health and allocations for early childhood development and social grants. At the same time, we also raise concern about increasing VAT, with knock-on effects for the most vulnerable in our country. There were also worrying omissions in the speech, such as addressing the impact of the United States federal-funding freeze on healthcare services nationally, and a noticeable absence of comment on government’s climate-change plans.
Health and the link with social development: Recognising the importance of early childhood development
Education and specifically early childhood development (ECD) is known to have critical impacts on children’s health and wellbeing, with longstanding effects into youth and adulthood. In South Africa, eight million children go hungry every day, and more than a third of children are reported to live in households below the food poverty line, that is below the income level to meet basic food requirements, not even covering other basic essentials such as clothes.
While the increase in the number of registered ECDs is laudable, many more ECD centres in low-income areas remain unregistered, which means they do not get support from the government in terms of subsidies and oversight.
Social grants
The increase in social grants is welcomed. However, the marginal increase of the Child Support Grant (CSG) by only R30, from R530 to R560, is too little to impact on the high levels of child hunger and malnutrition. The release of the Child Poverty Review in 2023, which highlighted the eight million children going hungry every day, including CSG recipients, proposed the immediate increase of the CSG to at least the Food Poverty Line (R796 in 2024).
Social relief of distress still too small
The Social Relief of Distress (SRD) Grant is an important source of income for low-income, working-age, unemployed adults. Its continuance in 2025 is welcomed. However, it remains too small at R370 per person per month, and the stringent means-test criteria which disrupt continuous receipt from month-to-month, makes it an unreliable, unpredictable source of income for low-income individuals.
Strengthening the healthcare workforce
The Minister stated that “R28.9 billion is added to the health budget, mainly to keep about 9 300 healthcare workers in our hospitals and clinics”. It will also be used to employ 800 post-community service doctors, and to ensure that our pharmacies do not run out of medicines. The speech highlighted the necessary commitment to strengthening the healthcare system, specifically human resources for health.
Considering the pressures on resources, primarily due to the escalating disease burden and challenges within the health workforce, the proposed budget increase from R179 billion to R194 billion – an increase of 8.2% – to maintain the current workforce and employ additional healthcare workers signifies a positive step forward that will aid in addressing staff shortages.
Despite the gains in health spending, the proposed increase in VAT raises substantial concerns to partially negate the potential benefits to the health sector. As the World Bank reports that approximately 60% of people living in South Africa live below the poverty line, increases to VAT will likely drive poverty levels higher.
A focus on other forms of taxation may be better, more evidence-based, and less likely to disproportionately affect those at the highest levels of poverty.
On the issue of alcohol taxes, often mischaracterised as “sin taxes” rather than “health taxes”, the Minister has proposed excise duties of 6.75% on most products for 2025/26. This is 2% above consumer inflation, which stands at 4.75%.
Raising alcohol prices through higher excise taxes is globally recognised as an effective way to address alcohol-related harms. National Treasury is to be commended for adjusting alcohol excise tax rates above CPI in the 2025/26 Budget. This is a move in the right direction, but it does not address the current anomalies in tax rates across different products. This failure to address shortcomings in the excise tax regime is expected, given the release of a discussion document on alcohol excise taxes in December 2024 with a February 2025 response date. The earliest we can expect substantial changes in excise tax rates is in February 2026.
From a public-health perspective, it makes sense to link alcohol excise taxes to the absolute alcohol content of the product to standardise across products. Ethanol is ethanol. The current differential in excise tax rates on different alcohol products is indefensible. Specifically, it makes no sense to tax wine and beer so much less than spirits in terms of absolute alcohol content. Wine, especially bag-in-box wine, is the cheapest product on the market in South Africa, and its affordability increases consumption, leading to more societal harm.
Beer is the most consumed product in the country and is increasingly sold in larger, non-resealable containers. A 2015 SAMRC study in Gauteng found the highest level of heavy episodic drinking with beer products, largely due to their affordability, especially in larger, non-resealable containers. Heavy episodic drinking is a major public-health concern in South Africa, with 43.0% of current drinkers engaging in heavy episodic drinking at least monthly, 50.9% of male and 30.3% of female drinkers. Increasing the excise tax on beer is a powerful tool that the state can use to reduce the level of such behaviour.
Additionally, it makes sense to have lower taxes on alcohol products with lower alcohol content, as this could shift consumption to less harmful products. The current excise tax regimen does not account for this within a single product type like beer or wine, as all products are taxed at the same rate regardless of their alcohol content.
During the COVID-19 pandemic, we saw the benefits of decreased access to alcohol: fewer injuries, fewer unnatural deaths, and communities less disrupted by patrons visiting liquor outlets. While no one advocates for total liquor sales bans, increasing excise taxes on wine and beer would decrease alcohol consumption and reduce harms on drinkers, on others around them, and on society more broadly.
Acute risk to lives with knock on effects due to US federal funding cuts
We believe the South African government has a responsibility to step into the gap left by the sudden US federal funding freeze on HIV and TB services. The US President’s Emergency Plan for AIDS Relief (PEPFAR) funds 17% of HIV and TB services in South Africa and covers salaries for thousands of health workers, including the vital services of community health workers.
The implications for people living with HIV and TB and affected by the externally funded services will be devastating. It will also have ripple effects on the health system as we see inevitable increases in demand for health services to address advancing illness, effects on families caring for ill relatives or losing income.
This area needs to be addressed and clear communication from the National Department of Health is urgently awaited. The US funding cuts clearly impact on essential research funding available to institutions like the SAMRC and no indication has been given in the budget of any plans to augment or replace such funding.
National Health Insurance for South Africa’s public sector
The Minister addressed budget allocations for NHI implementation, specifically, the mid-term indirect and direct conditional grants for NHI were R8.5 billion and R1.4 billion respectively. Although these amounts in themselves are minor compared to other health-budget allocations, allocations for infrastructure (R37.4 billion over the mid-term economic framework period) and additionally allocations for digital patient health information systems, chronic medicine dispensing and distribution systems, and medicine stock surveillance systems are vital for healthcare efficiency and improved outcomes.
Least said not soonest mended: climate change – ‘no comment’?
From a climate-crisis perspective, although the budget speech did not explicitly mention climate change or its related health challenges, there seems to be positive steps being taken to address these issues. Initiatives such as clean energy projects and efforts to improve water management have the potential to benefit all sectors of society, while helping to mitigate the health risks associated with climate change.
Promising spend on health, but who will measure the impact?
Ultimately, increasing health spend is a promising step to increase access to quality health services for South Africa’s population. However, this is not enough, government must seize the opportunity to translate the budget increase into improved health outcomes. The effectiveness of the additional funds must be maximised through efficiency, transparency, and sound governance. The government can reinforce the integrity of public-health services by aligning these increases with robust accountability measures.
Government-academic partnerships represent an opportunity to share knowledge, technical skills and resources to support evidence-informed decision-making for national health decision-making and strengthen monitoring and evaluation mechanisms. There are many examples of this working well, and we trust that the SAMRC, along with the network of higher education institutions are well placed to provide the necessary support.
*Parry, Bango, Kredo, Zembe, Galloway, Street and Wright are researchers with the SAMRC.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
After the US slashed global aid, the South African government stated that only 17% of its HIV spending relied on US funding. But some experts argue that US health initiatives had more bang for buck than the government’s programmes. Jesse Copelyn looks past the 17% figure, and considers how the health system is being affected by the loss of US money.
In the wake of US funding cuts for global aid, numerous donor-funded health facilities in South Africa have shut down and government clinics have lost thousands of staff members paid for by US-funded organisations. This includes nurses, social workers, clinical associates and HIV counsellors.
Spotlight and GroundUp have obtained documents from a presentation by the National Health Department during a private meeting with PEPFAR in September. The documents show that in 2024, the US funded nearly half of all HIV counsellors working in South Africa’s public primary healthcare system. The data excludes the Northern Cape.
Counsellors test people for HIV and provide information and support to those who test positive. They also follow up with patients who have stopped taking their antiretrovirals (ARVs), so that they can get them back on treatment.
Overall, the US funded 1,931 counselors across the country, the documents show. Now that many of them have been laid off, researchers say the country will test fewer people, meaning that we’ll miss new HIV infections. It also means we’ll see more treatment interruptions, and thus more deaths.
PEPFAR also funded nearly half of all data capturers, according to the documents. This amounted to 2,669 people. Data capturers play an essential role managing and recording patient files. With many of these staff retrenched, researchers say our ability to monitor the national HIV response has been compromised.
These staff members had all been funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The funds were distributed to large South African non-government organisations (NGOs), who then hired and deployed the staff in government clinics where there is a high HIV burden. Some NGOs received PEPFAR funds to operate independent health facilities that served high-risk populations, like sex workers and LGBTQ people.
But in late January, the US paused almost all international aid funding pending a review. PEPFAR funds administered by the US Centres for Disease Control (CDC) have since resumed, but those managed by the US Agency for International Development (USAID) have largely been terminated. As a result, many of these staff have lost their jobs.
The national health department has tried to reassure the public that the country’s HIV response is mostly funded by the government, with 17% funded by PEPFAR – currently about R7.5 billion a year. But this statistic glosses over several details and obscures the full impact of the USAID cuts.
Issue 1: Some districts were heavily dependent on US funds
The first issue is that US support isn’t evenly distributed across the country. Instead, PEPFAR funding is targeted at 27 ‘high-burden districts’ – in these areas, the programme almost certainly accounted for much more than 17% of HIV spending. Some of these districts get their PEPFAR funds from the CDC, and have been less affected, but others got them exclusively from USAID. In these areas, the HIV response was heavily dependent on USAID-funded staff, all of whom disappeared overnight.
Johannesburg is one such district. A doctor at a large public hospital in this city told Spotlight and GroundUp that USAID covered a substantial proportion of the doctors, counsellors, clerks, and other administrative personnel in the hospital’s HIV clinic. “All have either had their contracts terminated or are in the process of doing so.”
The hospital’s HIV clinic lost eight counselors, eight data capturers, a clinical manager, and a medical officer (a non-specialised doctor). He said that this represented half of the clinic’s doctors and counselors, and about 80% of the data capturers.
This had been particularly devastating because it was so abrupt, he said. An instruction by the US government in late-January required all grantees to stop their work immediately.
“There was no warning about this, had we had time, we could have made contingency plans and things wouldn’t be so bad,” he explained. “But if it happens literally overnight, it’s extremely unfair on the patients and remaining staff. The loss of capacity is significant.”
He said that nurses have started to take on some of the tasks that were previously performed by counselors, such as HIV testing. But these services haven’t recovered fully and things were still “chaotic”.
He added, “It’s not as if the department has any excess capacity, so [when] nurses are diverted to do the testing and counselling, then other parts of care suffer.”
Issue 2: PEPFAR programmes got bang for buck
Secondly, while PEPFAR may only have contributed 17% of the country’s total HIV spend, some researchers believe that it achieved more per dollar than many of the health department’s programmes.
Professor Francois Venter, who runs the Ezintsha research centre at WITS university, argued that PEPFAR programmes were comparatively efficient because they were run by NGOs that needed to compete for US funding.
“PEPFAR is a monster to work for,” said Venter, who has previously worked for PEPFAR-funded groups. “They put targets in front of these organisations and say: ‘if you don’t meet them in the next month, we’ll just give the money to your competitors’ and you’ll be out on the streets … So there’s no messing around.”
US funding agencies, he said, would closely monitor progress to see if organisations were meeting these targets.
“You don’t see that with the rest of the health system, which just bumbles along with no real metrics,” said Venter.
“The health system in South Africa, like most health systems, is not terribly well monitored or well directed. When you look at what you get with every single health dollar spent on the PEPFAR program, it’s incredibly good value for money,” he said.
Not only were the programmes arguably well managed, but PEPFAR funds were also strategically targeted. Public health specialist Lynne Wilkinson provided the example of the differentiated service delivery programme. This is run by the health department, but supported by PEPFAR in one key way.
Wilkinson explained that once patients are clinically stable and virally suppressed they don’t need to pick up their ARVs from a health facility each month as it’s too time-consuming both for them and the facility. As a result, the health department created a system of “differentiated service delivery”, in which patients instead pick up their medication from external sites (like pharmacies) without going through a clinical evaluation each time. But Wilkinson noted that before someone can be enrolled in that service delivery model, clinicians need to check that patients are eligible.
“Because [the enrollment process] was going very slowly … this was supplemented by PEPFAR-funded clinicians who would go into a clinic and review a lot of clients, and get them into that system”. By doing this, PEPFAR-funded staff successfully resolved a major bottleneck in the system, she said, reducing the number of people in clinics, and thus cutting down on waiting times.
Not everyone is as confident about the overall PEPFAR model. The former deputy director of the national health department, Dr Yogan Pillay, told Spotlight and GroundUp that we don’t have data on how efficient PEPFAR programmes are at the national level. This needs to be investigated before the health department spends its limited resources on trying to revive or replicate the programmes, argued Pillay who is now the director for HIV and TB delivery at the Gates Foundation.
While he said that many PEPFAR-funded initiatives were providing crucial services, Pillay also argued that “the management structure of the [recipient] NGOs is too top-heavy and too expensive” for the government to fund. Ultimately, we need to consider and evaluate a variety of HIV delivery models instead of rushing to replicate the PEPFAR ones, he said.
Issue 3: PEPFAR supported groups that the government doesn’t reach
An additional issue obscured by the 17% figure is that PEPFAR specifically targeted groups of people that are most likely to contract and transmit HIV, like people who inject drugs, sex workers, and the LGBTQ community. These groups, called key populations, require specialised services that the government struggles to provide.
Historically, PEPFAR has given NGOs money so that they could help key populations from drop-in centres and mobile clinics, or via outreach services. All of this operated outside of government clinics, because key populations often face stigma in these settings and are thus unwilling to go there.
For instance, while about 90% of surveyed sex workers say that staff at key populations centres are always friendly and professional, only a quarter feel the same way about staff at government clinics. This is according to a 2024 report, which also found that many key populations are mistreated and discriminated against at public health facilities. (Ironically, health system monitoring organisation Ritshidze, which conducted the survey, has been gutted by US funding cuts.)
While the key populations centres funded by the CDC are still operational, those funded by USAID have closed. The health department has urged patients that were relying on these services to go to government health facilities, but researchers argue that many simply won’t do this.
Venter explained: “For years, I ran the sex worker program [at WITS RHI, which was funded by PEPFAR] … Because sex workers don’t come to [health facilities], you had to provide outreach services at the brothels. This meant … we had to deal with violence issues, we had to deal with the brothel owners, and work out which days of the week, and hours of the day we could provide the care. Logistically, it’s much more complex than sitting on your bum and waiting for them to come and visit you at the clinic.
“So you can put up your hand and say: ‘Oh they can just come to the clinics’ – like the minister said. Well, then you won’t be treating any sex workers.” Venter said this would result in a public health disaster.
He argued that one of the most crucial services that key populations may lose access to is pre-exposure prophylaxis (PrEP), a daily pill that prevents HIV.
While the vast majority of government clinics have PrEP on hand, they often fail to inform people about it. For instance, a survey of people who are at high-risk of contracting HIV in KwaZulu-Natal found that only 15% were even aware that their clinic stocked PrEP.
Another large survey found that at government facilities, only 19% of sex workers had been offered PrEP. By contrast, at the drop-in centres for key populations, the figure was more than double this, at 40%. Without these centres, the health system may lose its ability to create demand for the drug among the most high-risk groups.
One health department official told Spotlight and GroundUp that the bulk of the PrEP rollout would continue despite the US funding cuts. “The majority of the PrEP is offered through the [government] clinics,” she said, 96% of which have the drug.
However, she conceded that specific high-risk groups like sex workers have primarily gotten PrEP from the key populations centres, rather than the clinics. “This is the biggest area where we are going to see a major decline in uptake for [PrEP] services,” she said.
600 000 dead without PEPFAR?
Overall, the USAID funding cuts have severely hindered the HIV testing programmes, data capturing services, PrEP roll-out, and follow-up services for people who interrupt ARV treatment. And the patients who are most affected by this are those that are most likely to further transmit the virus.
So what will the impacts be? According to one modelling study, recently published in the Annals of Medicine, the complete loss of all PEPFAR funds could lead to over 600 000 deaths in South Africa over the next decade.
While South Africa still retains some PEPFAR funding that comes from the CDC, beneficiaries are bracing for this to end. According to Wilkinson, the PEPFAR grants of most CDC-funded organisations end in September and future grants are uncertain. For some organisations, the money stops at the end of this month.
Meanwhile, if the government has any clear plan for how to manage the crisis, it’s certainly not making this public.
In response to our questions about whether the health department would be supporting key populations centres, the department’s spokesperson, Foster Mohale, said: “For now we urge all people living with HIV/AIDS and TB to continue with treatment at public health facilities.”
When pressed for details about the department’s plans for dealing with the US cuts, Mohale simply said that they could not reveal specifics at this stage and that “this is a work in progress”.
In his budget speech in Parliament on Wednesday, Finance Minister Enoch Godongwana did not announce any funding to cover the gap left by the abrupt end of US support for the country’s HIV response. Prior to the speech, Godongwana told reporters in a briefing that the Department of Health would assist with some of the shortfall, but no further information could be provided.
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/
By Ufrieda Ho
Amid major disruptions caused by aid cuts from the United States government, the health department aims to enrol a record number – an additional 1.1 million – of people living with HIV on life-saving antiretroviral medicine this year. Experts tell Spotlight it can’t be business as usual if this ambitious programme is to have a chance of succeeding.
Government’s new “Close the Gap” campaign launched at the end of February has set a bold target of putting an additional 1.1 million people living with HIV on antiretroviral treatment by the end of 2025.
Around 7.8 million people are living with HIV in the country and of these, 5.9 million are on treatment, according to the National Department of Health. The target is therefore to have a total of seven million people on treatment by the end of the year. Specific targets have also been set for each of the nine provinces.
The initiative is aimed at meeting the UNAIDS 95–95–95 HIV testing, treatment and viral suppression targets that have been endorsed in South Africa’s National Strategic Plan for HIV, TB, and STIs 2023 – 2028. The targets are that by 2030, 95% of people living with HIV should know their HIV status, 95% of people who know their status should be on treatment, and 95% of people on treatment should be virally suppressed (meaning there is so little HIV in their bodily fluids that they are non-infectious).
Currently, South Africa stands at 96–79–94 against these targets, according to the South African National Aids Council (SANAC). This indicates that the biggest gap in the country’s HIV response lies with those who have tested positive but are not on treatment – the second 95 target.
But adding 1.1 million people to South Africa’s HIV treatment programme in just ten months would be unprecedented. The highest number of people who started antiretroviral treatment in a year was the roughly 730 000 in 2011. In each of the last five years, the number has been under 300 000, according to figures from Thembisa, the leading mathematical model of HIV in South Africa. According to our calculations, if South Africa successfully adds 1.1 million people to the HIV treatment programme by the end of 2025, the score on the second target would rise to just above 90%.
The record for the most people starting antiretroviral treatment in a single year was approximately 730 000 in 2011. (Graph by Spotlight, based on Tembisa data.)
The ambitious new campaign launches at a moment of crisis in South Africa’s HIV response. Abrupt funding cuts from the United States government – the PEPFAR funding – has meant that the work of several service-delivery NGOs have ground to a halt in recent weeks.
These NGOs played an important role in getting people tested and in helping find people and supporting them to start and restart treatment. The focus of many of these NGOs was on people in marginalised but high-risk groups, including sex workers, people who use drugs and those in the LGBTQI community. As yet, government has not presented a clear plan for how these specialised services might continue.
“We will need bridging finance for many of these NGOs to contain and preserve the essential work that they were doing till we can confer these roles and responsibilities to others,” says Professor Francois Venter, of the Ezintsha Research Centre at the University of the Witwatersrand.
He says good investment in targeted funding for NGOs is a necessary buffer to minimise “risks to the entire South African HIV programme” and the looming consequences of rising numbers of new HIV cases, more hospitalisations, and inevitably deaths.
Disengaging from care
South Africa’s underperformance on the second 95 target is partly due to people stopping their treatment. The reasons for such disengagement from HIV care can be complex. Research has shown it is linked to factors like frequent relocations, which means people have to restart treatment at different clinics over and over. They also have to navigate an inflexible healthcare system. A systematic review identified factors including mental health challenges, lack of family or social support, long waiting times at clinics, work commitments, and transportation costs.
Venter adds that while people are disengaged from care, they are likely transmitting the virus. The addition of new infections for an already pressured HIV response contributes to South Africa’s sluggish creep forward in meeting the UNAIDS targets.
The health department has not been strong on locating people who have been “lost” to care, says Venter. This role was largely carried out by PEPFAR-supported NGOs that are now unable to continue their work due to the withdrawal of crucial US foreign aid.
Inexpensive interventions
Other experts working in the HIV sector, say the success of the Close the Gap campaign will come down to scrapping programmes and approaches that have not yielded success, using resources more efficiently, strategic investment, and introducing creative interventions to meet the service delivery demands of HIV patients.
Key among these interventions, is to improve levels of professionalism in clinics so patients can trust the clinics enough to restart treatment.
Professor Graeme Meintjes of the Department of Medicine at the University of Cape Town says issues like improving staff attitudes and updating public messaging and communications are inexpensive interventions that can boost “welcome back” programmes.
“The Close the Gap campaign must utilise media platforms and social media platforms to send out a clear message, so people know the risks of disengagement and the importance of returning to care. The longer someone interrupts their treatment and the more times this happens, the more they are at risk of opportunistic infections, severe complications, getting very sick and needing costly hospitalisations,” he says.
Clinics need to provide friendly, professional services that encourage people to return to and stay on treatment, Meintjes says, and services need to be flexible. These could include more external medicine pick-up points, scripts filled for longer periods, later clinic operating hours, and mobile clinic services.
“We need to make services as flexible as possible. People can’t be scolded for missing an appointment – life happens. Putting these interventions in place are not particularly costly, in fact it is good clinical practice and make sense in terms of health economics by avoiding hospitalisations that result from prolonged treatment interruptions,” he says.
The Close the Gap campaign, Meintjes adds, should reassure people that HIV treatment has advanced substantially over the decades. The drugs work well and now have far fewer side effects, with less risk of developing resistance. More patients are stable on the treatment for longer and most adults manage their single tablet once-a-day regime easily.
Insights from our experiences
Professor Linda-Gail Bekker, Chief Executive Officer at the Desmond Tutu Health Foundation, says to get closer to the target of 1.1 million people on treatment by year-end will mean using resources better.
“Additional funding is always welcome, so are new campaigns that catalyse and energise. But we also need to stop doing the things we know don’t have good returns. For instance, testing populations of people who have been tested multiple times and aren’t showing evidence of new infections occurring in those populations,” she says.
There is also a need for better data collection and more strategic use of data, Bekker says. Additionally, she suggests a status-neutral approach, meaning that if someone tests positive, they are referred for treatment, while those who test negative are directed to effective prevention programmes, including access to pre-exposure prophylaxis (PrEP) for people at high risk of exposure through sex or injection drug use.
But Bekker adds: “We need to be absolutely clear; these people aren’t going to come to us in our health facilities, or we would have found them already. We have to do the work that many of the PEPFAR-funded NGOs were doing and that is going to the last mile to find the last patient and to bring them to care.”
She says the impact of the PEPFAR funding cuts can therefore not be downplayed. “The job is going to get harder with fewer resources that were specifically directed at solving this problem.”
Venter names another approach that has not worked. This, he says, is the persistence of treating HIV within an integrated health system. Overburdened clinics have simply not coped, he adds, with being able to fulfil the ideal of a “one-stop-shop” model of healthcare.
Citing an example, he says: “Someone might come into a clinic with a stomach ache and be vomiting, they might be treated for that but there’s no investigation or follow-up to find out if it might be HIV-related, for instance. And once that person is out of the door, they’re gone.”
Campaign specifics still lacking
The Department of Health did not answer Spotlight’s questions about funding for the Close the Gap campaign; what specific projects in the campaign will look like; or how clinics and clinic staff will be equipped or supported in order to find the 1.1 million people. There is also scant details of the specifics of the campaign online.
Speaking to the public broadcaster after the 25 February campaign launch, Health Minister Dr Aaron Motsoaledi said South Africa is still seeing 150 000 new infections every year. He said they will reach their 1.1 million target through a province-by-province approach. He used the Eastern Cape as an example.
“When you look at the 1.1 million, it can be scary – it’s quite big. But if you go to the provinces – the Eastern Cape needs to look for 140 000 people. Then you come to their seven districts, that number becomes much less. So, one clinic could be looking for just three people,” he said.
Nelson Dlamini, SANAC’s communications manager, says the focus will be to bring into care 650 000 men, as men are known to have poor health-seeking habits. Added to this will be a focus on adolescents and children who are living with HIV.
He says funding for the Close the Gap campaign will not be shouldered by the health department alone.
“This is a multisectoral campaign. Other departments have a role to play, these include social development, basic education, higher education and training, etc, and civil society themselves,” Dlamini says.
The province-by-province approach to reach the target of finding 1.1 million additional people is guided by new data sources.
“Last year, SANAC launched the SANAC Situation Room, a data hub which pulls data from multiple sources in order for us to have the most accurate picture on the status of the epidemic,” says Dlamini.
These include the Thembisa and Naomi model outputs and data from the District Health Information System and Human Sciences Research Council, he says adding that SANAC is working to secure data sharing agreements with other sectors too.
Dlamini however says the health department, rather than SANAC, will provide progress reports on the 10-month project.
South Africa faces its worst health crisis in 20 years. Worse than COVID, and one that will overshadow diabetes as a major killer, while pouring petrol on a dwindling TB fire. But it is preventable if our government steps up urgently.
Nearly eight-million people have HIV in South Africa; they need life-long antiretroviral medicines to stay healthy.
The near-total removal of US government funding last week, a programme called PEPFAR, will see every important measure of the HIV programme worsen, including hospitalisations, new infections in adults and children, and death. Unless government meaningfully steps in to continue funding the network of highly efficient organisations that currently fill key gaps in national care, an epidemic that was tantalisingly close to coming under control will again be out of our reach. Millions of people in South Africa will become infected with HIV and hundreds of thousands more will die in the next ten years. 2025 will end much more like 2004, when we started our HIV treatment programme.
Many fail to recognize the danger. Commentators, public health officials, and government spokespeople have downplayed the US financial contributions to the HIV response, suggesting services can be absorbed within current services. The funding cuts amount to approximately 17% of the entire budget for HIV and largely go to salaries for health staff. On the face of it, this indeed seems replaceable. So why are the consequences so deadly?
To understand the impact, one must recognize how US funding has supported HIV care. The money is largely allocated to a network of non-government organisations through a competitive, focused, and rigorously monitored program in four key areas:
Active case finding: The best way to prevent new cases of HIV is find everyone with the disease early on, and get them on treatment. These organisations deploy people in high-risk areas, to test for HIV and screen for TB, and shepherd people who test positive to treatment programmes. People are almost always healthy when they start treatment, and remain healthy, with greatly reduced time to transmit the virus, and much less chance of ever “burdening” the health sector with an opportunistic infection. They are hugely cost-effective.
Tracing people who disappear from care: Patients on antiretrovirals fall out of care for many reasons, ranging from changing their address, to life chaos such as losing their job or mental illness. Or they are simply mixed up in the filing dysfunction within clinics. The US supported programmes helped finding people ‘lost from care’, maintaining systems able to track who has not come back, and how to contact them, often spending considerable time cleaning redundant records as people move between facilities.
Vulnerable population programmes: Services include those for sex workers, LGBTQ+ people, adolescents, people who use drugs, and victims of gender violence. These programs are for people who need tailored services beyond the straightforward HIV care offered in state clinics. They are often discriminated against in routine services and also at significant risk of contracting HIV.
Supporting parts of the health system: This includes technical positions supporting medicine supply lines, laboratories and large information systems, as well as organisations doing advocacy or monitoring the quality of services. All of this keeps the health system ticking over.
In central Johannesburg, where I work, HIV testing services have collapsed. The people who fell out of programmes are not coming back. HIV prevention and TB screening have largely stopped.
Reassurances that state clinics will pick up testing are empty – the staff do not exist, and testing has not resumed. State clinics do not trace people who fall out of care for any illness, let alone for HIV. The data systems maintained by PEPFAR-supported organisations are now gone.
What happens now? The first hard sign that things are failing will be a large drop in the number of people starting treatment, versus what happened in the same month one year ago. The next metric to watch will be hospitalisations for tuberculosis and other infections associated with untreated HIV infection. This will happen towards the end of the year, as immune systems fail. Not long after, death rates will rise. We will see that in death certificates among younger people – the parents and younger adults.
Unfortunately, much of this information will not be available to the health department for at least a year or two, because among the staff laid off in this crisis are the data collectors for the programmes that tracked vital metrics.
The above should come as no surprise, especially to the public health commentators and health department, which is why it is so surprising to hear how certain they are that the PEPFAR programme can easily be absorbed into the state services. The timing of this crisis could not be worse, with huge budget holes in provincial health departments.
Why should this be a priority? After starting the HIV programme in 2004, we spent the next few years muddling through how to deliver antiretrovirals to millions of people in primary care, before we realised we also needed to diagnose them earlier. In 2004, the average CD4 count (a measure of immune strength) at initiation of treatment was about 80 cells/ul, devastatingly low – normal is > 500 cells/ul. A quarter were ill with TB.
This CD4 count average took years to go up, but only by pushing testing into clinic queues, communities, and special services for key populations, not waiting till they were sick. Recently, the average initiation CD4 count was about 400 cells/ul, stopping years of transmission, with most people healthy, and only a small number with TB.
There are many reasons to criticise the relationship between PEPFAR and the health department. It suited both parties to have a symbiotic relationship that meant each got on with their job and ticked their respective output boxes, but neither had to tussle with the messiness of trying to move the PEPFAR deliverables into the health department. As we move forward, learning from these fragilities to plan for the future of the HIV care programme, and for other diseases, will be critical.
Since the suspension of funding, many people have said, “We don’t hear much about HIV anymore”. That is because when the system works well, you don’t hear about it. Some things are far better compared to 2004:
We have a government not in denial about HIV being a problem nor encouraging pseudoscience or crackpots.
Our frontline health workers, in over 3000 clinics, have vast experience initiating and maintaining antiretrovirals.
Antiretrovirals are cheaper, more potent, more durable, and safer.
Treatment protocols are simpler.
New infection rates are way down.
Government delivery systems have improved.
Data systems suggest that the majority of ‘lost’ patients are in care, often simply in another clinic.
A sensible emergency plan would do this:
Fund existing programmes for a limited time, understanding that the level of reach and expertise is impossible for the health department to replicate at short notice.
Couple this with a plan to make posts more sustainable over the next year or two.
Learn from the PEPFAR programme that rigorously held organisations accountable, so that provinces can similarly be answerable for their HIV metrics.
Ask hard questions why single patient identifiers, and government information systems, that could easily be linked to laboratory, pharmacy and radiology databases, are still not integrated within the public systems, as they are throughout the private health system.
Accept that certain key functions and clinics may best be sited outside of the health department.
This will not save the large and valuable research programmes, which need other help. Much of the rest of Africa needs a Marshall Plan to rescue their entire HIV service, as they are almost totally dependent on US government funding.
But ideas like the above will preserve the current South African HIV response and allow us to imagine interventions that could end the disease as a threat for future generations.
No one disputes we need a move away from donor-assisted health programmes. But the scale and immense urgency of this oncoming emergency needs to be understood. We need a plan and a budget, and fast. Or we will have an overwhelmed hospital system and busy funeral services again.
Professor Francois Venter works for Ezintsha, a policy and research unit at Wits. He has been involved in the HIV programme since 2001, and ran several large PEPFAR programmes till 2012. Venter and his unit do not receive funding from PEPFAR, USAID or CDC. Thank you to several experts for supplying analysis and ideas for the initial draft of the article.
