Offering state HIV patients who qualify for a six-month supply of antiretroviral (ARVs) pills at a time, so that they only have to return to clinics or community pick-up points twice a year to collect their medication, is one of the goals in the health department’s contingency plan to cope with the near collapse of US-funded HIV projects.
This will lower the workload of health workers, the strategy that was sent to provincial health departments and public health facilities on 11 February says.
Until recently, the US government’s Aids fund, the President’s Emergency Plan for Aids Relief (Pepfar), funded many nonprofits in South Africa to help provincial health departments with getting people tested for HIV and putting them onto treatment. Although the government paid for the medication, Pepfar funded the salaries of the health workers such as nurses, pharmacists, data captures, and community health workers, who worked for the organisations and dispensed the drugs.
But in late January, President Donald Trump signed an executive order that froze all foreign aid, which led to many of the clinics that were run by the health workers, closing down , because their employers had no money to pay their salaries. Some of the workers operated from government clinics, which now have to do without them, until court proceedings, which order the Trump administration to temporarily unfreeze the funds, are finalised.
The department’s contingency plan aims to find ways to cope with the crisis.
Who can get ARVs for six months?
People with HIV get treated with ARVs to stop the virus from making copies of itself in their bodies and so keep it to such low levels that the virus isn’t able to attack their immune systems and is not detectable by standard tests. Once that has happened, someone is virally suppressed and unable to transmit the virus to others through sex or to their unborn babies.
The health department’s contingency plan circular says patients who qualify for a supply of six months of treatment at a time, must have a suppressed viral load for “two consecutive periods”. In South Africa, viral load testing is usually done once a year if the treatment works well for them. So patients would need to have been on ARVs for at least two years to be considered for six-monthly supplies.
The plan also says only people who already get their drugs for three months at a time, can be considered to get a six months’ supply — and that is, given that the clinic the person visits has enough stock of the entry-level three-in-one pill, TLD , to hand out.
Currently, the longest period for which government patients receive ARVs at a time is three months, the acting deputy director general for HIV, Ramphelane Morewane, told Bhekisisa .
Health department figures that Morewane shared with Bhekisisa reveal of South Africa’s 5.8-million people on ARVs, 5.417-million are state patients. Of these, 1.6-million — or around 30% — get their medicine for three months at a time.
ARVs picked up from community points
The health department’s plan also says that all clients older than six months should, during this crisis period, get an ARV supply of at least three months if they don’t experience complications with their treatment.
All HIV-negative people who would like to use the daily anti-HIV pill, should also get a three month supply, along with HIV self-tests to ensure they’re still HIV negative before continuing with the treatment for another three months — but that’s mostly already been happening, according to a health department spokesperson.
Another “coping strategy” that the plan includes, is to allow people who get their treatment from community pick-up points such as churches, mosques, private pharmacies or adherence clubs, to which provincial health departments, usually through non-profit organisations, deliver the treatment, should be allowed a 28-day grace period to fetch it. As long as they’re not more than 28 days late, they would still qualify for an automatic script renewal, without having to return to a health facility to get a new script.
Morewane says, about half — 2.7-million of the state’s 5.4-million ARV patients — received their medication outside of a health facility by the end of 2024. The goal is to increase that to 3.2-million by the end of March.
“The sudden withdrawal of Pepfar could slow us down on this goal,” Morewane says. “But it won’t cause a total disruption, because we don’t exclusively depend on Pepfar.”
How has Pepfar’s withdrawal affected the health department?
So far, says Morewane, the health department hasn’t received reports of people on ARVs being unable to get their treatment from, at the very least, a different public health facility.
Pepfar only pays for resources in about half — 27 — of South Africa’s 52 health districts. In those 27 districts, the health department has 271 606 health workers working for its HIV programmes, of which 15 154, or 5.6%, are funded through Pepfar (they are paid by nonprofits); the health department pays for the salaries of the remaining 94.4%.
What about the impact on PrEP?
But in the case of preventive treatment, also known as pre-exposure prophylaxis, or PrEP , the effect of the freeze, or of waivers for individual projects that haven’t yet been approved, is likely to be worse — especially when it comes to getting daily anti-HIV pills to groups of people, such as teen girls and young women , sex workers , gay and bisexual men and transgender women , with a higher chance of contracting the virus.
It was with high-risk groups that Pepfar particularly assisted by helping to pay for mobile clinics or drop-in centres that appealed to such groups and catered for their specific needs.
The department’s goal is to get around 700 000 new HIV-negative people to use the anti-HIV pill at least once, a health department spokesperson says. Pepfar, through the Centres for Disease Control (CDC) and US Agency for International Aid, USAID, supports about 520 000 of these “initiations”, the health department’s data shows.
But, provincial health departments pay for the medication, so although things like the salaries of some of the health workers who dispense the drugs were paid for by Pepfar, it doesn’t mean that the medicine wouldn’t be unavailable — just harder to get. So people may, for instance, have to queue for longer at clinics because there will, at least for a while, be fewer health workers to help them.
Moreover, South Africa has 16 research sites testing the best ways to roll out different forms of PrEP, which includes the pill, a monthly vaginal ring and a two-monthly injection containing an antiretroviral drug, cabotegravir, released in someone’s body over two months. Six of those sites — two in Johannesburg and four in Lejweleputswa inthe Free State — which are part of a study called Catalyst, were funded by Pepfar via USAID. Those sites, a health department spokesperson confirmed, have closed down.
The two Johannesburg clinics, a sex worker and transgender clinic, have physically closed; the Free State sites were run from government facilities, so those facilities, but not the studies, continue to run, and trial participants who chose the ring and injection, are now being offered the pill.
Francois Venter, an HIV researcher who heads up the organisation Ezintsha at Wits University, and which doesn’t receive Pepfar funding, says: “Stopping such studies so abruptly is unethical, a huge waste of time and resources, and a violation of trust. It’s extremely complicated — and expensive — to restart them.”
What’s up with the court cases against Trump?
In South Africa, Pepfar projects funded through USAID are all still closed down. Last week, they were told to apply for waivers to continue with, in short, HIV treatment, but not prevention, activities. But after resubmitting workplans and reduced budgets on short notice, none of them had heard back from the US government by the end of Monday.
Devex reports that even in cases in other countries, where waivers had been approved, the Trump administration hasn’t made the funds for those activities available (the online payment system was disabled or the USAID staff who were left, had been locked out of their emails, leaving them unable to respond to questions of organisations whose grants they managed).
In the meantime, a court ruling late Thursday, instructed President Trump’s administration to temporarily unfreeze all foreign assistance funding, including Pepfar funds, which get to projects through USAID. That judgment effectively cancelled the waivers and allowed for projects to revert to their original grants.
But in practice, it means very little — at least for now.
“The finding itself does not restart foreign assistance,” says Mitchell Warren, who heads up the New York-based advocacy organisation, Avac, one of the organisations that brought the case against the Trump administration. “Sadly, these programmes don't have on off switches, and even if they did, the legal order telling the government to turn the switch back on does not yet come with formal approval from USAID to begin work again.
“We know that this administration seems to be beholden only to their own thinking and not to the rule of law.”
"A major challenge has been the absence of clear leadership"
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Meanwhile, Pepfar projects funded through the CDC, which is hosted by the US health department, restarted last week, after a federal judge enforced a temporary restraining order blocking President Trump’s administration from freezing federal grants.
In South Africa, those projects have been able to access their funds and have sent dismissed employees letters, which Bhekisisa has seen copies of, asking them to return to work.
But even in these cases, the transition has been anything but seamless.
“A major challenge has been the absence of clear leadership — not just from the national health department, but also from Pepfar,” says a manager at one organisation, who spoke to Bhekisisa on the condition of anonymity.
“Instead of a structured, coordinated approach, implementation partners have been left to navigate an uncertain landscape with little direction, forced to answer difficult questions from provincial health officials; questions that, in many cases, simply have no clear answers.”
The organisation Right to Care , which has been allowed to restart their voluntary medical male circumcision programme (VMMC) in all 27 Pepfar-supported districts, distributed a guidance document to their workers and provincial health departments on how to behave.
Throughout, it warns workers to keep a low profile — and to effectively self-sensor.
One person explains: “When the USAID stop-work order landed in our inboxes, it came with clear instructions: remain silent. No media, no social posts.
“The fear was that speaking out would trigger retaliation and jeopardise any further funding. My gut said the opposite—speak out, but I remained silent, not for myself, but to protect our staff and partners.
“Yet, that silence felt and still feels like complicity and I’m battling shame about adhering to collective silence. Can we truly call ourselves humanitarians if we choose the safe, comfortable corner of silence over solidarity with the communities we serve?”
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
