The South African Government has been slammed for its deafening silence as the largest HIV treatment programme in the world implodes, heralding a wave of new infections, sickness and death, and further strain on an already over-burdened public health system.
With President Cyril Ramaphosa being “too busy with the G20” and Health Minister Aaron Motsoaledi, equally, being missing in action, scathing critics and activists warn that the cost of doing nothing is millions of lives at risk and a shattered legacy.
What’s desperately needed is a combination of urgency, action and strategy, writes Professor Francois Venter in GroundUp, otherwise South Africa will see record numbers of children being born infected with HIV – and the country’s hard-won victories against TB being reversed.
Two decades ago, the HIV crisis was defined by denialism and delay, when President Thabo Mbeki and the late Health Minister Manto Tshabalala-Msimang presided over a period in which scientific consensus was rejected and the rollout of antiretroviral medicines was obstructed.
Preventable deaths spiralled into the hundreds of thousands, with their names now linked to one of the worst public health failures in modern history.
The consequences of today’s inaction will also be deadly.
Sadly, Motsoaledi and Ramaphosa are charting their own tragic legacy. This time, it isn’t denialism; it’s ignoring the problem, points out Venter.
Chaos has resulted from the US having 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 (ARVs), and thousands of workers across HIV programmes lost their jobs.
MatCH, an organisation which 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, while 230 000 doses of long-acting injectable medicines that prevent HIV transmission have not been released because of 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 is one of the local Health Department’s few delivery jewels.
South Africa’s HIV response has made monumental strides over two decades: 6.2m of 8m people with HIV are on treatment; life expectancy is up by more than a decade from during the peak of the HIV epidemic; new infection rates dropped from more than 500 000 infections 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 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.
Gone AWOL
But while HIV programmes now 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 current crisis, triggered by the funding withdrawal, has meant:
The destruction of the NGOs supporting the department in critical areas, including testing, HIV prevention, services tailored to key populations, bringing people interrupting treatment back into care, and technical support;
The disruption of research, and accompanying job losses; and
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’ve 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 department has been slow to request funds from National Treasury. Instead it 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 1.1m 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 Organisation (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 the President, 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, and South Africa’s HIV and TB research infrastructure is world class.
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 on 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.
New era of activism
The lack of leadership has been alarming, says Sisonke Msimang, South African writer and political scientist, who asks why, “when the funding cuts happened, there no shouting”.
Msimang was a vocal critic of the Aids denialism of the Mbeki era, supporting the health advocacy organisation TAC in what became a landmark legal victory in 2002 that secured access to lifesaving treatment for HIV-positive pregnant women, writes Ida Jooste in Bhekisisa.
Msimang is also one of 29 health rights activists featured in the Health and Human Rights Oral History Project, which launched in late March when the world scrambled to count the costs – in dollars and in lives – of the drastic funding cuts.
“We need to see urgency from the government to reverse this. We’re not seeing that,” warns Sasha Stevenson, who heads up the social justice organisation, SECTION27.
Activists say getting the government to find the money might require a back-to-basics approach to HIV advocacy.
The department told Bhekisisa the department is currently applying for emergency funding from the Treasury, via section 16 of the Public Finance Management Act.
But Fatima Hassan, founder and director of the Health Justice Initiative (HJI), says the department’s slow pace is frustrating.
She says the business community should also have stepped forward by now to acknowledge the scale of the crisis. “History will judge those with money and resources who didn’t come forward and say they’re trying to mitigate the impact.”
Additionally, she adds, some of the “noise” of activism was initially stifled; people speaking for organisations affected by cuts wouldn’t go public – or did so anonymously – so as not to poke the bear (Trump) and lose their contract.
The funding crisis is a reminder that the need to hold the state accountable never ends, activists say.
Msimang says the shutdown of USAID has exposed how civil society has not been pushing hard enough for South Africa to pay for its own health services.
Mluleki Zazini, director of the National Association of People Living with HIV and Aids, says maybe it’s time to go back to the basics.
“I think we need to go back to the streets so that we can voice our needs,” says Zazini, who also chairs the civil society forum within Sanac. “We criticise them in boardrooms … maybe they’ve forgotten that we used to mobilise people to get action.”
Professor Francois Venter is a clinician researcher at Wits University. He led a large Pepfar programme till 2012, and he has had a support role since then. He and his unit do not receive Pepfar, CDC, or USAID funding. His opinion piece was published in both GroundUp and Spotlight.
Bhekisisa article – Fighting for funds: A new era of HIV activism (Creative Commons Licence)
See more from MedicalBrief archives:
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Another 150 000 HIV infections possible by 2028 from aid cuts
US policy could impact funding of hundreds of HIV organisations