Healthcare and Aids activists agreed that it was time to face up to the reality of the US funding cuts – and its enormous impact on HIV treatment – and to change how South Africa plans and manages the challenges without outside assistance.
Ina Skosana, reporting for Health-e News, said delegates at the 12th South African Aids Conference spoke with one voice when they urged a proactive response to the funding cuts.
South Africans also needed to to be honest about the challenges linked to the withdrawal of American foreign aid, and stop saying “everything is fine”, warned Dr Anna Grimsrud, a senior technical adviser at the International Aids Society, speaking at the conference.
She added that eight months since funding was withdrawn, admitting challenges “is not conceding dependence; it’s owning the work ahead”.
Echoing her was Professor Yogan Pillay, director of HIV and TB research at the Gates Foundation, who said the “golden age” of donor assistance, when there was an abundance of donor aid, was over.
“It’s decreasing, not just for health, but for development broadly,” was his stark warning. “This means the only way to do it is to increase domestic financing or change how we do business.
“Instead of looking backwards and how to find more money, we should be looking forward and changing the way we run the programme and the entire primary healthcare system.”
Before the abrupt cessation of US aid, South Africa funded about 75% of its HIV programme.
Grimsrud said that external funding still made a significant contribution, with Pepfar providing R6.6bn annually and the Global Fund R3.2bn.
Pepfar supported 27 health districts in the country with a high HIV burden, providing services mainly to key populations at increased risk of infection.
Staff funded by Pepfar included data capturers, nurses, lay counsellors and pharmacist assistants. The withdrawal of funding brought all these programmes to an abrupt halt.
Writing was on the wall
However, activists say the government should have prepared for an eventual end to donor assistance.
“Pepfar was here to support the government in some of our challenges in the early days of HIV,” said Yvette Raphael, co-founder and co-director of Advocacy for Prevention of HIV and Aids (APHA).
“But some of our government officials, and our government, saw this as a way of evading their responsibility. And we are now here.”
Raphael, with a long history of activism sparked by her own HIV diagnosis in the year 2000, said Pepfar’s withdrawal from South Africa started years ago, when the organisation stopped providing food parcels and other forms of support to people with HIV.
“Pepfar was never here to stay. Our government must now step up and close the gap.”
How did we get here
South African National Aids Council (SANAC) CEO Dr Thembisile Xulu, agreed. “We all knew this day was coming.”
Xulu is chairperson of the HIV leadership forum, comprising the CEOs of the National Aids Councils from more than 40 countries. The collective has compiled a sustainability position paper reflecting on how countries became so dependent on donor funding that the withdrawal jeopardises entire programmes.
“We collectively allowed donor funds to create systems outside our own, leading to overlapping structures designed for donor requirements,” she said, adding that South Africa had also failed to leverage private sector capacity in the form of technology, innovations, and expertise to design a sustainable HIV programme.
These factors have now left countries vulnerable as Pepfar and other programmes reduce support.
What now?
Grimsrud said time was essential to minimise the impact of funding withdrawal.
“We cannot wait to make choices; waiting for stability is like waiting for a train that’s never coming.”
She said the country must identify components of HIV delivery that are essential to maintain, and figure out how to keep these services running more efficiently.
“We must build on our differentiated models of care, putting the people at the centre, supporting self-care, and using these models to drive integration and equity.”
In addition, the country’s budget must align with its commitments.
“We know that the National Department of Health has plans to expand HIV treatment coverage to 7m people as part of the 1.1m campaign,” she said.
“But the budget we saw only supports a growth from 6m to 6.5m people over the next three years. That gap between ambition and resources is exactly why prioritisation is so urgent.
“We need to plan realistically, cost honestly, protect what works, and innovate where efficiencies are possible.”
Millions outside the system
In his keynote address at the event’s opening, Deputy President Paul Mashatile had said that millions of people remained outside the formal healthcare system, despite huge progress in the country’s HIV response.
Mashatile, who also chairs SANAC, urged the government, civil society, and healthcare workers to accelerate interventions to reach those who have not started or have fallen out of HIV treatment, The Citizen reports.
“We can’t afford to leave anyone behind,” he said, highlighting the national “Close the Gap, Start and Stay on HIV Treatment” campaign, launched in February at Chris Hani Baragwanath Academic Hospital, and aimed at identifying and supporting 1.1m people with HIV who are not on ART – including those who have either discontinued treatment or never received it.
Only 78% of diagnosed individuals are on sustained treatment, he pointed out.
“This is not just a statistic – it’s a call to action,” he added, noting encouraging results from Gauteng, where 153 124 people had returned to care and initiated or reinitiated on ART by August 2025. This represents 47% of the province’s target of 325 848, he said.
Performance varied across districts, with West Rand reaching 71%, Sedibeng 68%, Tshwane 56%, Ekurhuleni 52%, and Johannesburg 35% of their respective targets.
Call for community-led healthcare
He urged a shift from clinic-based models to community-led responses, emphasising the need for integrated, inclusive, and stigma-free healthcare services.
He further highlighted the End TB Campaign, which seeks to screen 5m people during the 2025/26 financial year, as part of a broader push to improve public health outcomes under the National Strategic Plan for HIV, TB, and STIs.
The Citizen article – Mashatile demands urgent action to close HIV treatment gap (Open access)
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