SA’s HIV response will collapse without US funding — unless we act urgently

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 lifelong 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 hospital admissions, new infections in adults and children and death. Unless the 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 10 years – 2025 will end much more like 2004, when we started our HIV treatment programme.

Many fail to recognise 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 about 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 recognise how US funding has supported HIV care. The money is largely allocated to a network of nongovernmental organisations through a competitive, focused and rigorously monitored programme 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 to find 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 programmes 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; and


• 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.

• We have a government not in denial about HIV being a problem nor encouraging pseudoscience or crackpots;


• Our frontline health workers, in more than 3,000 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; and


• Data systems suggest that the majority of “lost” patients are in care, often simply in another clinic.

• 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; and


• Accept that certain key functions and clinics may best be sited outside of the Health Department.