The government has defended its progress in dealing with the US funding cuts and their crucial impact on HIV and Aids programmes in South Africa, in particular, denying that this was in any danger of collapse.
Health Minister Aaron Motsoaledi lasy week also vehemently reiterated that there was no chance of South Africa begging the United States for help, notes MedicalBrief.
His comments came a day after a Reuters report of ‘shocking’ drops in testing and monitoring of HIV patients across South Africa since the US aid cuts – with previously unpublished government data showing that viral load testing has dropped by up to 21% among key groups in the past two months, which experts said was very worrying and has major implications.
Pregnant women, infants and youth are the most affected, and these drops appeared to be linked to the loss of US funding, according to the data from the National Health Laboratory Service.
With less testing, fewer people who may transmit the virus will be identified, but missing a test can also indicate that a patient has dropped out of the system and may be missing treatment, according to the Reuters reports.
SA targeted
The Trump administration froze many foreign aid programmes early in his Presidency before reinstating some lifesaving assistance, including parts of the Pepfar global HIV initiative.
But South Africa was also specifically targeted, with an executive order cutting all funding to the country in February.
At least 15 000 health workers’ salaries were paid by Pepfar, which previously gave South Africa more than $400m a year. Most of that funding has been withdrawn, though it is unclear exactly how much.
The health workers did HIV testing and counselling in districts with a high prevalence of HIV, and followed up when patients missed a check-up or dropped off treatment.
The funding also supported NGO-run clinics, which have now closed.
The government has urged HIV patients who did check-ups at those clinics to visit public health centres instead, but public health centres often have long lines and staff are known to be unwelcoming to certain groups.
According to the data seen by Reuters, the number of viral load tests conducted for people aged 15-24 fell by 17.2% in April from April last year, after dropping 7.8% year-on-year in March. Total population testing was down 11.4% in April.
Maternal viral load testing was down 21.3% in April after falling by 9.1% in March, and early infant diagnostic testing was down 19.9% in April, after falling by 12.4% in March, the same data showed.
The percentage of people who were virally suppressed among those tested also fell nationwide, by 3.4% in March and 0.2% in April, with steeper declines for young adults, a further sign that patients may have had their treatment interrupted, the data showed. The data have not been made public.
“These are shocking figures, with profound implications for maternal and child health across the country,” said Francois Venter, executive director of the Ezintsha Research Centre in Johannesburg.
Given a summary of the data, Foster Mohale, Department of Health spokesperson, said more analysis was needed and that South Africa already had challenges with patient retention and viral load testing even before the aid cuts.
But HIV experts have said for months that the Health Ministry was downplaying the impact of the funding loss in the country, and that a drop in testing figures might be an early warning sign – followed by a rise in new cases and deaths.
“These data demonstrate what previous models have shown regarding the impact of Pepefar/USAID cuts on pregnant women and their infants,” said Dvora Joseph Davey, an epidemiologist working on maternal and infant HIV at the University of Cape Town.
She said the impact was clear at five public health clinics where she works in Cape Town, which since the US aid cuts have been under-staffed, with fewer nurses to draw blood that is needed for viral load tests.
‘Going to die’
HIV experts said that diagnostic testing was probably also affected by the funding cuts too, though those data were not available.
The counsellors who used to do rapid diagnostic HIV tests have also gone, and pregnant women are no longer being put on preventative HIV drugs (PrEP) because the counsellors used to offer that, Davey said.
In Johannesburg’s Diepsloot township, HIV activist and community leader Sophy Moatshe said it was hard to get HIV patients to seek care because of the stigma, and without health workers reaching out when they miss an appointment, many fall through the cracks.
The cuts have also hit research, including HIV vaccine trials.
Department of Health spokesperson Mohale said the government was speaking to prospective local and international donors about covering funding gaps, but declined to give details.
The data on testing in April, however, were “a good indication of what’s going to happen in the future”, said Davey.
HIV/Aids programme ‘not collapsing’
But reacting to the inference that funding cuts were behind the startling decline in viral load testing, Motsoaledi said the country’s HIV/Aids programme was not, in fact, in danger of collapsing, and that although there had been little response to the government’s appeals to various potential funders, going cap in hand to beg Trump for help was out of the question.
He listed steps taken by the Ddpartment to address the loss of aid, including assistance for members of key populations affected by the closure of Pepfar-funded clinics and new training programmes for health workers.
“Over the past three weeks there have been numerous media statements, articles and claims by prominent South Africans … within the HIV/Aids (sector). The general thrust … is that since the US announcement to withdraw funding from Pepfar, that the HIV/Aids programme has collapsed or is on the verge of collapsing.
“We wish to confirm that the fight against HIV/Aids and TB is in our villages, in our communities and townships, and even on the streets of our country, and that is where our focus is, has been and… should be.”
Motsoaledi’s words appeared to be a criticism of health experts and activists who have verbalised the urgent need for a clear emergency plan from the government to address the loss of US funding for the HIV/Aids programme.
In an opinion piece for Spotlight in late April, Wits researcher Venter had said Motsolaedi had showed a lack of “leadership, communication or urgency” in the crisis, adding that “South African health and political leadership has not produced a plan, despite civil society repeatedly pleading for transparency”.
Daily Maverick reports that other health activists have spoken out about the Health Department’s slow pace of enacting contingency plans.
Plugging the Pepfar gap
Pepfar funding made up R7.9bn of South Africa’s R46.8bn HIV/Aids programme, and supported the Health Department in 27 high-burden HIV/Aids districts, according to Motsoaledi.
Across these districts there were 12 NGO-managed, specialised clinics serving key populations through Pepfar funding, which supported 63 322 people, he said.
“When the Pepfar-funded clinics were closed, we transferred those patients’ files to the nearest public health facilities… all 63 322 files were moved.”
He said 34 facilities funded by the Global Fund and four NGOs supported by the South African government had continued to provide uninterrupted services for members of key populations with HIV/Aids.
Of the 271 606 people working in the HIV/Aids programme across the 27 districts, 15 539 were funded by Pepfar.
“Unfortunately, 8 061 are out of their jobs. The remaining 7 478… are still employed because they are funded through Centres of Disease Control, or CDC, at least until September this year.”
There is no plan to absorb the 8 061 unemployed health workers into the public health system at this stage.
Other steps taken by the department to address the loss of Pepfar funding included:
• A sensitisation training programme for healthcare workers on the barriers affecting access to healthcare by key populations, which had reached 1 012 clinicians and 2 377 non-clinicians in seven provinces;
• The establishment of “roving teams, specifically for patient monitoring and data capturing”, by eight provinces in which Pepfar was active;
• Weekly meetings between the Department of Health and provincial health departments to verify reports around HIV counselling and testing; and
• Numerous meetings with potential donors about additional funding to fill the gap left by Pepfar.
Among those with whom Motsoaledi said he had engaged regarding the loss of Pepfar funding were private sector representatives; former US President Bill Clinton; the CEO of the Gates Foundation; and Minister of Finance Enoch Godongwana.
“There’s a long list of funders we have met and not a single one who said, ‘No, we won’t help’. But up to today. there’s not a single one who came to the party, either private funders or governments around the world,” he said.
He noted that the exception was the Global Fund, which pledged an additional R1bn for the procurement of antiretrovirals.
“As we said before, we procure 90% of our ARVs from our own government fiscals, and this is supported by 10% from Global Fund. And the Global Fund, after… the pullout of Pepfar, pledged R1bn for more ARVs to be procured.”
Close the Gap campaign
The Close the Gap campaign, launched by the government, UNAIDS and other stakeholders on 25 February to identify and support 1.1m people with HIV who know their status but are not yet on treatment, had made progress, he said.
UNAIDS had set 95-95-95 targets for 2030, calling on member states to ensure that 95% of people with HIV know their HIV status, 95% of people who know their status are receiving HIV treatment, and 95% of people on treatment are virally suppressed.
According to Motsoaledi, the numbers in South Africa stand at 96-79-94.
“While the plan (for the Close the Gap campaign) was to reach 1.1m more people by the end of December 2025 … we have been able to reach 520 700 people with HIV and Aids, and initiated them on treatment,” he said.
“This was made possible by the budget reprioritisation of R659m from HIV/Aids conditional grants.”
He added that it was inconceivable “that out of R46.8bn spent by the country on the HIV/Aids programme, the withdrawal of R7.9bn by President Trump will immediately lead to a collapse of the entire programme”.
“We want to put this categorically clear that under no circumstances will we allow this massive work performed over a period of over a decade and a half to collapse and go up in smoke because President Trump has decided to do what he has done.”
Testing declines
But despite the reassurances from the Minister, Claire Waterhouse, head of Operational Support Unit at Doctors Without Borders (MSF), Southern Africa, told the Cape Times the organisation was “very concerned” by the data from the NHLS showing declines in HIV testing and monitoring in South Africa.
“If this is the case, we continue to urge … the South African government in particular, and other potential donor countries and organisations, to step up … to prevent the reversal of decades of progress in the fight against HIV.”
Treatment Action Campaign co-founder and anti-Aids activist Zackie Achmat disrupted a scheduled meeting of the Portfolio Committee on Health to highlight concerns regarding service delivery disruptions stemming from the withdrawal of Pepfar funds.
In a statement later, committee chairperson Dr Sibongiseni Dhlomo said MPs acknowledged the gravity of the concerns Achmat raised, and said the committee intended to meet with him in the coming weeks.
Trials at risk
At least 39 TB and HIV clinical research sites are under threat from the funding cuts, jeopardising at least 27 HIV trials and 20 TB trials, according to an analysis by the Treatment Action Group (TAG) and MSF drawn mostly from the NIH’s Division of Aids (DAIDS) presented last week.
TB trials at risk include testing potential vaccines and new drugs; shorter, safer regimens, and the best treatment for TB meningitis.
Health Policy Watch reports that the HIV trials include cure-related treatments involving broadly neutralising antibodies (bNAbs); vaccines designed to prime the body to make bNAbs; the impact of hormone treatment on women with HIV and treatment options for pre-exposure prophylaxis to prevent HIV.
Many of these trials are global, with South Africans making up 30%-50% of global trial participants and 50%-90% of trials on interventions for children and pregnant women, said Lindsay McKenna, TAG’s TB project co-director.
She estimates that the average investment in each trial participant is $12 000 – potentially all wasted if the trials are discontinued, and some have been going for several years already.
For some 30 years, South African clinical studies have provided global guidance on issues including prevention of mother-to-child HIV infection, when to start children on antiretroviral treatment, how to simultaneously treat TB and HIV, as well as the safety of HIV and TB treatments. Meanwhile, operational research, such task-shifting from HIV doctors to nurses, has led to more efficiency and cost-cutting.
“NIH funding is not aid. It’s competitive funding that researchers here competed for that went through stringent NIH processes and committees,” pointed out Marcus Low, epidemiologist and editor of Spotlight.
Impact on institutions
“South African academic and research institutes could lose about 30% of their annual income and may be forced to lay off hundreds of staff as a result of US funding cuts,” the analysis notes.
It warns of “the potential collapse of TB and HIV research and development capacity” in the country, with global impact in light of “the substantial contributions of South African research centres to advancements in TB and HIV prevention, treatment, and care worldwide”.
Professor Ntobeko Ntusi, head of the SA Medical Research Council (SAMRC), said the country had been disproportionately affected both because of its high burden of HIV and TB and the excellence of its scientific community – making it a preferred site for research.
“Universities are now beginning retrenchments at scale,” said Ntusi, adding that affected scientists also provide postgraduate training.
“Hundreds of master’s, doctoral and post-doctoral fellows, whose stipends and research costs are dependent on these grants, find themselves in a position of inordinate precarity,” said Ntusi.
‘Ethical nightmare’
Professor Ian Sanne, co-principal investigator of the Wits HIV Research Group Clinical Trials Unit, describes navigating the US funding cuts as a “major regulatory and ethics nightmare”.
NIH investment in South African HIV and TB research “amounts to almost $2bn over 20 years”, according to Sanne. Wits along stands to lose $150m to $180m in NIH funding.
Sanne’s unit lost US funding with immediate effect on 21 March – but it then had to embark on retrenchment procedures in terms of South African law, draining the reserves of the unit.
Expertise and infrastructure lost
Professor Linda-Gail Bekker, director of the Desmond Tutu HIV Centre at the University of Cape Town, says her centre will lose $6.9m out of $10m in NIH funds.
Earlier in the year, the centre lost a HIV vaccine grant worth $45m over five years from USAID that would have seen five trials in eight southern African countries “contributing to the global quest to find an effective HIV vaccine”, she added.
The centre employs 400 people and will have to retrench “one-third to half our workforce”, said Bekker, whose ground-breaking research on a twice-yearly injection to prevent HIV infection earned her a standing ovation at the International Aids Conference in Munch last year.
“We have an incredible critical mass of very experienced and very well-established research organisations in the country, and the infrastructure that has been built over the past 30 years has established an extraordinary clinical trial infrastructure,” she said.
South Africa was able to use this expertise and infrastructure during the pandemic to “pivot to test at great speed, new Covid-related vaccines”.
Impact on other African countries
Dr Tom Ellman, director of MSF’s Southern Africa Medical Unit, said that MSF has applied the “pragmatic” HIV and TB research generated in South Africa in resource-poor settings throughout the continent.
Recently back from the Democratic Republic of Congo (DRC), Ellman said it was able to draw on the “self-managed, fixed-combination antiretroviral treatment regimen” developed in South Africa for people with HIV in the conflict zone in South Kivu.
MSF’s large HIV programme in Kinshasa relies on dolutegravir – “a basic, simple, effective drug enabled by South African research”, said Ellman, who listed several other drugs that had been trialled in South Africa before hitting the global market.
“The best science leads to impact in the most difficult settings. There’s no question that South African science has transformed access to HIV, TB and other disease responses across Africa and across the world.”
Ellman said the funds cut is “particularly awful” as “we are closer than ever to finding ways out of the HIV, TB and malaria pandemics”.
Appeal for support
TAG, MSF and the SAMRC have appealed for “alternative funds to sustain TB and HIV research in South Africa”.
Ntusi says numerous donors and governments have offered support and solidarity, but most wish to remain anonymous at present.
The researchers all agreed that the most urgent need is to provide immediate support to clinical research sites to ensure continuity of care and follow-up for study participants.
“South African trial participants must be supported to complete treatments safely and, in cases of treatment failure, be offered appropriate alternatives, and research sites must be supported to complete data collection and analysis,” said TAG and MSF.
Cape Times PressReader article – SA won't beg USA for funding – Motsoaledi (Open access)
See more from MedicalBrief archives:
Government inaction over HIV funding cuts puts millions at risk
Another 150 000 HIV infections possible by 2028 from aid cuts
Trump’s aid cuts halt crucial SA-led HIV vaccine trials
PEPFAR cuts may cost 9m years of lost life in SA and Ivory Coast