The fall-out from Pepfar funding cuts for HIV programmes three months ago continues to reverberate, with three specialised clinics in Cape Town serving key populations forced to shut their doors.
Now, reports Daily Maverick, NGOs representing these groups have raised the alarm about a low uptake of individuals, affected by the closures, at state health facilities.
Thousands of people who relied on the facilities lost access to services overnight, with many turning to government clinics for continued care.
But the key population NGOs say the uptake of affected people at the state facilities has been far lower than hoped.
The Cape Town Key Populations Collective – comprising the Sex Workers Education and Advocacy Taskforce (Sweat), the South African Network of People Who Use Drugs (Sanpud), the Triangle Project, Gender DynamiX and Sisonke National Sex Workers Movement – commissioned a rapid research project providing insight into the experiences of key populations trying to access healthcare since the funding cuts.
Of the 278 survey respondents who had previously relied on Pepfar-funded facilities, 37% reported not being on their medications for antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP) or hormone replacement therapy (HRT) in August 2025.
Barriers to services included long wait times at state clinics and referral problems for those coming from other points of care.
The key population NGOs have raised concerns that the reported medication disruptions could lead to illness, increased risks of HIV acquisition or transmission and more deaths due to the disease.
“Our observation is that there is a very, very low uptake of people from key populations going to government clinics,” said Eugene van Rooyen, legal and policy adviser at Sweat.
He said more than 4 000 people had been affected by the closure of the specialised clinics, which included the Ivan Toms Centre for Health and the Wits Reproductive Health and HIV Institute (Wits RHI) transgender and sex worker clinics in Cape Town.
“We were only able to reach 278 of them in our survey, and those we reached would be the people who are relatively easy to reach – not the most vulnerable people who really need help,” he added.
“If our survey reflects that 37% of them have … defaulted, we think that the number would be much higher if you were able to actually survey all of the people.”
Barriers to care
US President Donald Trump had signed (in January) an executive order imposing a 90-day freeze on all foreign development assistance, pending a review. By late February, almost all Pepfar funding provided to international and South African HIV programmes through the United States Agency for International Development (USAID) had been permanently axed.
In the Western Cape, the financial loss has been around R360m, with 10 NGOs and 700 jobs affected, according to the Cape Town Key Populations Collective study.
Many of the affected programmes served populations that are particularly vulnerable to HIV and often lack adequate access to services, like men who have sex with men, sex workers, transgender people and people who inject drugs.
While the study surveyed people from across various groups, most of the respondents (43.7%) identified as sex workers.
Of the respondents, 249 reported at least one experience at a government health facility since the closure of the Pepfar-funded clinics. Nearly a quarter (24%) reported a good experience at a state clinic. However, more than a third (33%) said they did not stay because the wait was too long, while 32% reported that clinic staff would not help them without a referral letter.
Some also reported concerns around the confidentiality of their personal information and “rude” attitudes of staff at government facilities.
One was turned away from two state clinics because of not having a referral letter, before finally managing to access ARVs at the Green Point Clinic.
Both the national and Western Cape Departments of Health have previously said the six-month dispensing of ARVs is a strategy being rolled out to ease pressure on facilities after the Pepfar cuts.
However, one respondent said that when clinic staff were asked about this, they said it was “illegal to provide them with more than three months’ supply”.
Increased patient loads
Van Rooyen acknowledged that the overnight closure of the specialised clinics had placed a “huge burden” on some state facilities, that more needed to be done to address the difficulties that accompanied this.
On referral letters, he said: “Refusing to help someone unless they have a referral letter from the clinic where they used to collect their medication is totally unnecessary, because everybody’s information is on the computer system to which all staff at government clinics have access.
“We have communicated this to the (Western Cape) Department of Health, and we’ve also been to visit numerous clinics to explain that these people are not able to provide a referral letter because the facility where they used to get their medication no longer exists. So, they need to make a plan.”
A long-standing barrier for key populations is the fear of stigma or hostile attitudes.
Emily Craven, director of Sweat, told Daily Maverick: “The idea that everyone can just walk into a state clinic and get treatment, although theoretically true, completely ignores all of the reasons why that wasn’t happening in the first place. We had dedicated population clinics because people did not feel they could do that.”
The Pepfar cuts also led to the closure of the Wits RHI mobile clinic. Carol Lennon, clinic and outreach nurse at the Triangle Project, said the loss of mobile clinics was one of her biggest concerns, as this has affected access to services for unhoused people and those living in less centralised areas.
“We’ve lost the field workers and the mobile clinics, and that has been devastating for us … It’s not easy to find people in Cape Town who live on the street, and we were getting help from Wits RHI throughout the city … in places where the services are difficult … to reach, but also (where there are issues of) stigma and discrimination,” she said.
She added that the Triangle Project was trying to trace people who had defaulted on ARVs and link them back to care. However, confidentiality requirements around patient lists and records from the closed facilities made this process challenging.
Finding a way forward
The Cape Town Key Populations Collective shared the results of its rapid survey with the Western Cape Department of Health and Wellness, said Craven, describing the outcomes as “positive”.
The study provided recommendations for national, provincial and municipal departments of health, including:
- Working with and supporting specialist NGOs to retain and re-engage clients lost to follow-up;
- Developing “clear mechanisms for transition” to ensure tailored HIV services for key populations were integrated into State health facilities;
- Providing ongoing training for department staff at Key Population Centres of Excellence in high-density, high-burden districts; and
- Ensuring key population NGOs were financially resourced and engaged to support the roll-out of sensitisation training in all facilities.
Western Cape Health aware
Western Cape Health was aware of the pressures caused by the funding terminations, particularly on NGO-run services supporting key populations, said spokesperson Dwayne Evans.
“These cuts have… placed further strain on the system and undermined the work of valued civil society partners in the fight against HIV and TB,” he added.
“While we cannot comment on … specific surveys by external organisations, we … encourage collaboration with civil society and non-profit partners through the existing structures that promote partnerships. Our approach is to integrate patients into the provincial health platform … to strengthen coordination between NGOs and government facilities.”
Evans said referral letters were not required for access to HIV treatment at primary healthcare clinics, and encouraged people to engage with the facilities directly.
Multi-month dispensing of ART remains part of the province’s strategy to decongest facilities, with dispensing volumes being guided by national policy frameworks, supply chain considerations and clinical assessments at facility level, he said.
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