documentBy Kerry Cullinan
Donor cuts and a shake-up in the HIV/AIDS sector are having a major impact on HIV/AIDS services countrywide.
Many patients who previously got their antiretroviral (ARV) treatment from well run non-governmental organisations are being transferred to already overcrowded public health facilities.
A number of HIV/AIDS support organisations, including those supporting orphans, are either closing or cutting back on staff.
Some donors, such as the Royal Netherlands Embassy, are pulling out altogether. Others, including the biggest funder - the US President's Emergency Plan for AIDS Relief (Pepfar) - are "reprioritising".
During Thabo Mbeki's presidency, the government's failure to provide adequate treatment and support for people with HIV/AIDS resulted in donors supporting projects that were run by churches and NGOs.
But now that the Zuma government has shed Mbeki's AIDS denialism, most donors are reluctant to fund life-long ARV treatment and want the government to assume this responsibility.
Pepfar announced six months ago that it was moving from "primarily implementing programmes to providing technical assistance and capacity building to the South Africa government".
The impact of Pepfar's change is being felt most acutely by projects that received funds for ARV treatment, which was almost 40 percent of Pepfar's operating budget.
The list of cutbacks is long and growing.
The SA Catholic Bishop's Conference (SACBC), which has 14 ARV treatment sites serving 20 000 patients, is in the process of transferring patients to government clinics wherever possible.
An SACBC employee who declined to be named confirmed that their HIV/AIDS programme was facing "substantial cuts" in Pepfar funds and that they had already retrenched a number of staff countrywide.
In Johannesburg, the SACBC's Nazareth House is in the process of transferring all 2000 patients to the Hillbrow Clinic.
The SACBC is also closing its big ARV sites in Mtubatuba in northern KwaZulu-Natal.
However, in some areas the SACBC has managed to keep sites open by getting the provincial health departments to supply ARVs, which account for two-thirds of the costs of each site.
This has saved a number of Limpopo sites, two sites in KwaZulu-Natal, one in Botshabelo in the Free State and Winterton in Gauteng.
Pepfar has also cut funds to programmes that paid private doctors to start and monitor poor patients on ARVs, particularly in places were government treatment sites were far away including Mpumalanga and the North West.
The Aurum Institute monitored a network of private doctors with over 7 000 patients on ARVs, but these patients have all been transferred to government clinics.
In the Eastern Cape, two Pepfar-funded clinics in Duncan Village have closed and redirected over 3000 patients to the over-crowded local clinic.
Three PrimeCure ARV sites in Bloemfontein with a total of 2 500 patients closed in July 2010.
Meanwhile, the Society for Family Health's New Start programme, which offers HIV testing, has closed its offices in Durban and Cape Town and Mussina.
In the Free State, Care International pulled out of the Motheo district this year, taking with it funding for AIDS orphans in the district, which includes Bloemfontein and Botshabelo.
Started by US president George W Bush in 2003, Pepfar has donated over R19-billion to South Africa since 2004, working through some 600 partners and supporting 20 000 jobs.
However, US President Barak Obama has other spending priorities and Pepfar is being scaled down and reorganised over a period of five years.
In theory, the move towards government provision of health services will prevent the duplication of scarce resources, particularly doctors and professional nurses.
But in practice, in many areas of the country, government health facilities are simply unable to cope with patient numbers as they lack the staff, resources and management capacity to do so. Staff in the church- and NGO-run clinics also often have a better work ethic.
Professor Francois Venter, head of the Southern African HIV Clinicians' Society, said that while he supported the reorganisation so that government took control over service delivery, this "must not happen at patients' expense".
"I am worried about the outlying and rural areas where particularly the Catholic Church, provides the only ARV treatment service for miles," said Venter. "I am very sad to hear that their sites are closing, particularly Nazareth House, which provides a very caring, empathetic service."
Lynne Wilkinson, deputy country director for Medicins sans Frontieres (MSF), echoed Venter's fears about the possible impact on patients.
"MSF is requesting the Department of Health to commit to ensuring that changes in donor funding policies, such as that of Pepfar, do not result in HIV positive patients receiving reduced continuity or quality in care and treatment or public sector facilities being further overloaded without increased resource allocation," said Wilkinson.
However, the situation is not completely gloomy. Venter emphasized that South Africa was in a far better position than other African countries that receive Pepfar funds, as 83 percent of our HIV/AIDS programme was government funded.
Countries such as Malawi, Mozambique and Uganda are reported to be battling with looming Pepfar cuts.
Meanwhile health economist Professor Gesine Meyer-Rath said that the government had been able to reduce the costs of ARV drugs by 26 percent when awarding its recent ARV tender, and that it was also looking at "task-shifting" from doctors and nurses to lower levels of healthworkers to save more money to build the sustainability of the country's HIV treatment programme.