South Africa’s HIV programme is collapsing

8 May 2025 - Francois Venter

We are about to see a wave of new HIV infections, sickness and death, with children born infected in record numbers.

We will see our public hospitals further overwhelmed, and our hard-won victories against TB reversed.

It is all preventable.

Two decades ago, South Africa’s HIV crisis was defined by denialism and delay. Then president Thabo Mbeki and the late health minister Manto Tshabalala-Msimang presided over a period in which scientific consensus was rejected and the roll-out of antiretroviral medicines was obstructed, and preventable deaths spiralled into the hundreds of thousands. Their names are now linked to one of the worst public health failures in modern history.

The consequences of today’s inaction will also be deadly.

Sadly, Health Minister Aaron Motsoaledi and President Cyril Ramaphosa are charting their own tragic legacy. This time, it isn’t denialism; it’s ignoring the problem.

The US has abruptly suspended almost all foreign development assistance globally, including the President’s Emergency Plan for Aids Relief (Pepfar) and National Institutes of Health (NIH) research grants.

In South Africa, NGO-led clinics closed overnight, stockouts were reported of antiretrovirals, and thousands of workers across HIV programmes lost their jobs. MatCH, an organisation that provides vital HIV services, entered business rescue. Anova, also a major service provider, retrenched 2,000 staff. TAC/Ritshidze, which monitors the HIV programme, retrenched 75% of its team. And 230,000 doses of long-acting injectable medicines that prevent HIV transmission have not been released due to the funding freeze.

Pepfar progress on the brink

You notice a system was working well when it is suddenly removed. Many South Africans may realise HIV hasn’t been on their minds or in the media much for the past 15 years. That is because the HIV response in South Africa is one of the Health Department’s few delivery jewels.

South Africa’s HIV response has made monumental strides over the past two decades:

• 6.2 million of eight million people with HIV are on treatment;
• Life expectancy is up by more than a decade from where it was at the peak of the HIV epidemic;
• New infections dropped from more than 500,000 a year to about 170 000; and
• Mother-to-child transmission of HIV is now an unusual event.

Central to that success was Pepfar, which funded a critical part of the system that held much of the HIV response together, built around the Health Department’s functional primary care clinic system.

The Pepfar programme was efficient. Targets for testing were set, and more than 200 technical experts were funded by Pepfar to support the national and provincial health departments.

This pressure pushing a sluggish Health Department was essential. The competition and accountability mechanisms created the urgency needed to keep the system responsive and moving forward.

Missing in action

While HIV programmes unravel and lives are lost, Ramaphosa and the government of national unity (GNU) are nowhere to be seen. Motsoaledi, once praised for his HIV leadership, offers no leadership, communication or urgency.

The triggered by the US government funding withdrawal has meant:

1. The destruction of the nongovernmental organisations (NGOs) supporting the Health Department in critical areas, including testing, HIV prevention, services tailored to key populations, bringing people interrupting treatment back into care, and technical support;
2. The disruption of research, and accompanying job losses, from the funding withdrawal; and
3. The collapse of health systems and key economic support areas in our neighbouring countries.

HIV testing programmes have all but collapsed. Clear evidence from the Covid epidemic shows that fewer tests means far fewer people start treatment. Services to trace people who have fallen out of care are now halted. Key populations have effectively been abandoned. Community monitoring systems have been turned off. HIV data systems are dark. ARV supply chains are faltering. Programmes have been gutted that were advancing long-acting pre-exposure prophylaxis (PrEP), community outreach and disease surveillance. Our world-class HIV and TB research cadre has been severely damaged.

And still, South African health and political leadership has not produced a plan, despite civil society repeatedly pleading for transparency. Help has been offered – by the private sector and donors – but spurned. The Health Department has been slow to request funds from National Treasury. Instead the department has sent out a thin emergency circular that appears not to have been implemented at any level.

Motsoaledi announced a grand plan to get an additional 1.1 million people on treatment by the end of the year, but with no operational plan, no reprioritisation and no budget.

It is difficult not to feel despair. I have seen the recent data on HIV testing, the PrEP numbers, the infant diagnostic stats and, most shockingly, the viral load suppression figures, and they all paint the picture of a rapidly decaying system. I am seeing the consequences in Johannesburg’s inner city where I work.

‘He was too busy with the G20’

A study commissioned by the Health Department suggests there will be between 56,000 and 65,000 additional deaths and 150,000 new infections in just three years from the US withdrawal. TB experts predict 580,000 fewer people screened and 35,000 fewer people on TB treatment in 2025. The World Health Organization (WHO) estimates that health damage within Africa from the current funding cut is already, in just three months, the equivalent of 75% of Covid’s peak damage.

Yet, I was told at a meeting of my senior university leadership to discuss the massive funding and job cuts, that Ramaphosa, who appeared weekly on television during Covid, was “too busy with the G20” meeting to meet them. Civil society’s leading organisations confirmed to me last weekend that the President and ministers have not responded to formal letters asking for a plan, despite emails pleading with them to do so, beyond acknowledgements of receipt. Motsoaledi has had one meeting with the NGOs and only with selected partners.

The loss of hard-working NGO jobs was not met with concern, outrage or even a word of thanks by the Health Department, but with a hostile press statement.

What are the pluses?

We are not where we were in 2004, at the height of Mbeki denialism, and it is good to remind ourselves of the many strengths of the HIV response and public health within our country:

• Our nurses, doctors, and other health workers now have significant experience in treating HIV;
• The backbones of the system – the treatment algorithm, tests, the medication, the laboratory systems – are all world-class;
• We have significant internal expertise, within the government and within the academic, civil society and private sectors – all deeply committed to making the public health system work at its best;
• Recent data suggest patients negotiate the convoluted clinic webs to remain in care, and are not “lost” or fall out of the system nearly as commonly as we thought;
• Despite the delay by the Health Department in responding to the mass retrenchments, there is the possibility that the organisations could be rebuilt to be better integrated within the broader health system;
• Some basic data systems are still functional;
• Our current low rate of new infections will protect us for a brief period;
• South Africa’s HIV and TB research infrastructure is world-class; and
• Our history of HIV leadership involving every sector of society and many brave people inside and outside government in the 2000s is recent enough to hopefully inspire something similar now.

Where to from here?

We should have little patience for further delay and silence from our government. We cannot have a Health Department with no plan and, critically, no communication as to what is being done. Get the experts into the room, and get a plan together – with actual priorities, funding, targets and partners. We don’t need perfection, but we do need urgency.

The health system that is delivering HIV care is unravelling now. A combination of action, strategy and urgency can save us.

It will be hard. But the cost of doing nothing is millions of lives and a shattered legacy.

Professor Francois Venter is a clinician researcher at Wits University. He led a large Pepfar programme until 2012 and has had a support role since then. He and his unit do not receive Pepfar, CDC or USAID funding. This article has assistance from ChatGPT regarding referencing and suggested editing, and the author takes full responsibility for the content and fact-checking. This opinion piece was published by Spotlight and GroundUp.