The South African government – with civil society – has the potential to turn the Pepfar funding crisis into an opportunity to reassess urgent health system demands in its HIV and TB response, while identifying strategies to enhance healthcare delivery for long-term sustainability, say local experts.
In an editorial in the SA Medical Journal, a group of the country’s foremost HIV/Aids researchers and campaigners recommend measures that should be swiftly implemented to help save millions more lives.
1. Conduct a rapid assessment of the scope of human resource, service and programmatic gaps created: this should be done collaboratively and urgently by the national and provincial health departments with their respective Pepfar-funded implementing partners;
2. Allocate funding in the 2025 public sector health budget to fill currently unfunded posts that are critical for delivering public sector health services; and
3. Secure resources and implement the most efficient mechanisms to deliver critical services, by:
• urgently mobilising acute ‘bridging’ funding;
• reducing unnecessary burdens and improving efficiencies within the health system, like enabling six-monthly ART refills and annual clinical consultations and scripting for stable clients;
• identifying the fastest service delivery mechanisms, including potentially continuing funding for existing implementing partners already set up to provide these services; and
• engaging the private and NGO sectors to supplement service delivery capacity.
4. Develop a long-term plan, with short-, medium- and long-term priorities, to restore the HIV programme and align with the 2030 goals by:
• mobilising funding through partnerships and collaboration, by exploring innovative financing mechanisms, leveraging private sector and philanthropic support and ensuring cost-effectiveness and efficiency;
• retaining, where possible, the expertise and experience of Pepfar programmes; and
• closing data collection gaps to enable real-time impact measurement, evaluation and programme adjustments.
5. Secure additional and/or reprogramming current Global Fund to Fight Aids, TB and Malaria (GFATM), funding, with an ongoing plan to gradually reduce dependency on this assistance.
Progress made
SA, with financial support from Pepfar and the GFATM, has made major strides towards overcoming its greatest public health challenge, but the ‘last mile’ efforts to reach global Aids targets by 2030 are proving to be challenging and resource-intensive, at a time when our national budget is strained, we are undergoing austerity measures, and health systems across the country are in trouble.
Of the 2m people with HIV who are not on treatment in SA, around 400 000 have never been tested, and do not know their HIV status.
Among the remaining 1.6m not on treatment, some have been tested and know their status, but have never started treatment. A substantial number of people started treatment but later interrupted it because of a combination of individual, interpersonal and structural vulnerabilities, along with life disruptions, such as unexpected travel, that affected their ability to remain in care.
Finding and supporting those who need to start or restart treatment and remain on lifelong therapy is no simple task, but it is essential to significantly reduce the current annual 50 000 HIV-related deaths and 150 000 new infections.
Actively offering quality HIV testing services annually to all public sector facility attendees is a massive undertaking. This must be supplemented with community-based testing for individuals who do not access public sector services due to concerns about stigma, discrimination, or logistical barriers.
Additionally, tracing and reaching out to individuals who have interrupted treatment, guiding them back into public sector care and providing tailored clinical and psychosocial support are crucial steps in restoring their health and ensuring long-term retention on treatment.
At the same time, the public health system must continue to support the 6m people already on treatment, ensuring they remain in care despite the challenges faced by overstretched public sector facilities that struggle to provide comprehensive, high-quality services with reduced waiting times.
The last mile will require strong government leadership, collaboration with civil society and investment in community-led solutions. While HIV science has made exciting headway in developing long-acting antiviral formulations for prevention and treatment, these can only be provided to those who stand to benefit most through reliable, robust health systems.
All of this, and ensuring impact by 2030, will need more, not fewer, resources and collaboration.
Critical role
The reduced reliance on foreign aid for our HIV response is noteworthy, but the ~20% supported by Pepfar has been critical.
Pepfar-supported partners have, in recent years, played a crucial role in addressing these hard-to-reach gaps by integrating additional staff within public sector clinics and community health programmes.
Working alongside government-employed healthcare workers, these teams have been instrumental in the tasks outlined above, providing essential client-facing service delivery functions. In addition to their direct roles in care, they have played a significant part in training and mentoring public sector staff to ensure the implementation of ever-evolving clinical and service delivery guidelines.
Apart from direct service delivery, these funded partners have seconded staff to national and provincial health departments to strengthen essential systems that underpin public HIV services.
Supporting supply chain management to prevent treatment stock-outs, maintaining patient-level monitoring and evaluation systems across 4 000 public sector health facilities and developing systems for data visualisation and use, have all been done with Pepfar-supported staff.
Supported staff have also played a key role in sustaining critical service providers such as the Central Chronic Medicine Dispensing and Distribution programme, which facilitates the distribution of pre-packed multi-month treatment refills at convenient facility and out-of-facility collection points – a system that serves ~50% of the 6m people on HIV treatment in SA, as well as people with other chronic diseases.
Notably, they have also funded the critical role of community-led monitoring of public sector HIV services, ensuring accountability and improving the quality of care provided by both government and Pepfar-funded partners.
Immediate removal of these services has already left a major gap in programming, with >15 000 trained healthcare providers across all cadres, as well as data capturers and technical support staff, put on furlough last month.
With an estimated 50%-60% of USAID support staff suddenly laid off, there are longer clinic queues, closed partner-run clinics, and significant reductions in data collection, the timely identification and management of people with advanced HIV disease (Aids), gender-affirming healthcare, HIV testing, HIV treatment literacy, and treatment initiations and re-initiations for people re-engaging in care.
Prolonged treatment interruptions, new and missed HIV acquisitions and lost opportunities to intervene will result in more hospitalisations, lives lost and infections acquired, and overall costs to the health budget over time, as predicted by a recently published model.
Largest commitment in the world
First announced by President George W Bush in 2003, and re-authorised four times since with bipartisan support in Congress, Pepfar has been critical in the global response to the HIV epidemic, and strengthening overall health systems in >50 countries worldwide.
It is the largest commitment to any single disease by any nation, and in 2003, when it started, South Africa was in the grips of an unfolding HIV epidemic that would grow into the largest national HIV epidemic globally, with nearly 8m people with HIV today.
This was three years after hosting the International Aids conference in Durban, where 11-year-old Nkosi Johnson courageously called out then-President Mbeki and his administration for their Aids denialism and failure to provide South Africans with access to highly effective antiretroviral treatment (ART).
At SA’s lowest point, as many as 3 000 young women were acquiring HIV a week, one in three of their infants were born with the virus and dying within two years, TB rates had increased sixfold, and the national life expectancy had decreased from 62 years in 1992 to 54 in 2005.
It was subsequently estimated that this denialism was responsible for the death of >300 000 South Africans.
Pepfar offered SA, and its neighbouring countries, a critical lifeline. With < $8bn invested in SA and $120bn worldwide since then, Pepfar has supported >20m people with HIV treatment in 55 countries, including half a million children.
In addition, it has reached 2.3m adolescent girls and young women with comprehensive HIV prevention services, prevented 5.5m babies from being born with HIV, supported 6.6m million, vulnerable children and caregivers, enrolled 2.5m people on HIV pre-exposure prophylaxis (PrEP), provided 83.8m people with HIV testing services, and directly supported 342 000 health workers.
In 2022, the $460m from Pepfar represented 18% of SA’s $2.56bn annual HIV budget.
Over Pepfar’s 22-year history, the global HIV epidemic has evolved, and significant progress has been made. HIV treatment is now very effective, and provided in a single, once-a-day pill. Life expectancy for people with HIV who are on treatment is comparable with those without HIV.
In the absence of an effective HIV vaccine, antiretroviral PrEP – where a single pill is taken regularly before HIV exposure – can effectively prevent HIV acquisition. Besides oral PrEP, we can now offer less-frequently dosed and longer-acting PrEP modalities, which add even more capability in reducing transmission.
With >6m people with HIV in SA on treatment, the largest HIV treatment programme in the world, the national fiscus funds almost all HIV treatment and the majority of core public sector HIV services.
With the new US administration, there is huge vulnerability in our HIV programmes, and an urgency to ensure we do not lose the progress of the past two decades.
A recent modelling study estimates that eliminating Pepfar support in SA without transitioning the supported services will lead to 601 000 HIV-related deaths and 565 000 new HIV infections over the next 10 years alone.
Additionally, population-level healthcare expenditure will increase by $1.7bn, due to an increase in HIV prevalence and a less healthy population.
There is no time to lose.
A Grimsrud, International Aids Society; L Wilkinson, School of Public Health, University of Cape Town, and Advocates for the Prevention in HIV in Africa; Y Raphael, Advocates for the Prevention in HIV in Africa; S Tshabalala, Treatment Action Campaign; A K Moses, Aurora Kaleidoscope Movement, South Africa; F Hassan, Health Justice Initiative; K Buthelezi, Sisonke; K Rees. Anova Health Institute, and Department of Community Health, School of Public Health, University of the Witwatersrand; L-G Bekker, The Desmond Tutu HIV Centre, University of Cape Town.
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