An innovative programme that forms a core part of the South African government’s health services tailored to the needs of men who have sex with men (MSM) is at risk of closing much of its operations because the US government has stopped its funding, writes Marcus Low in a Spotlight report.
Health4Men, a programme of the Anova Health Institute and the Department of Health, was notified last week that its main funder, the United States President’s Emergency Plan for Aids Relief (PEPFAR), working through the United States Agency for International Development (USAID), would not be giving it a new grant.
Low says the funding cuts mean that men who have been receiving MSM-tailored care from Health4Men facilities in Cape Town and Johannesburg will have to return to normal public-sector clinics to receive care should last minute fund-raising efforts be unsuccessful.
Since funding under the current grant will run out in a matter of months, the process of de-escalating the programme has already started. According to Dr Kevin Rebe, specialist medical consultant at Anova, they have already started notifying clients that changes are imminent. “It is very tragic that an effective locally developed MSM health model, which is admired internationally and has been replicated in many African countries, is coming to an end in our own country. This is sad news for our patients and unfortunately I believe this might negatively affect their access to enabling health services,” says Rebe.
Low writes that Health4Men operates two so-called centres of excellence clinics in Cape Town and Johannesburg – both set to be impacted by the funding cuts. They work in an additional nine Department of Health facilities, one in each of South Africa’s nine provinces. The funding cuts mean that they will have to withdraw their clinical staff from five of these nine facilities. Similarly, withdrawal from five provinces means that instead of providing ongoing training and monitoring at 400 public sector facilities, they will in future only be able to provide this support in around 175 facilities.
“The Health4Men Initiative is a broad one consisting of community engagement activities, training of health providers, an ongoing clinical mentoring programme as well as the direct service clinics,” says James McIntyre, CEO of Anova Health. “The programme is currently funded by USAID in five provinces and by the Global Fund in the other four. Loss of the USAID funding will impact all aspects of the initiative in the USAID supported provinces (Western Cape, Gauteng, Limpopo, Mpumalanga and North West). Work in the Global Fund supported provinces will continue until the end of this grant cycle (March 2019).”
Rebe says that the Health4Men programme has directly provided clinical services to around 15,000 men in the ten years since its launch in 2008. Currently around 650 men who are not living with HIV are receiving pre-exposure prophylaxis (PrEP) through Health4Men’s programmes in order to prevent HIV infection. Rebe explains that since PrEP is not currently being provided at normal public-sector clinics, there is nowhere where they can refer these men to continue receiving PrEP and as it stands these men are at risk of losing access.
While there are other programmes working with MSM, Rebe says in the report that in some areas Health4Men is the only programme providing clinical services, including PrEP, that caters specifically for the needs of MSM.
Low writes that the specific needs of MSM include promotion of knowledge about reducing their risk of HIV and STIs, providing access to commodities such as condoms, lubricants PrEP and antiretroviral therapy, and access to trained staff who are sensitive to diversity and have the clinical skills to detect and treat conditions that improve health outcomes specifically in this population. “All of this needs to be provided in an enabling, non-judgmental environment and also needs to be founded on engagement with MSM communities who will use the service,” says Rebe.
Since being founded in 2008, Health4Men has been at the forefront of service provision to MSM in South Africa. In 2015 they conducted the first demonstration programme in South Africa to test the provision of PrEP to prevent MSM from contracting HIV. Four of their sites are currently listed as Department of Health PrEP scale-up sites.
“We believe that the centre is a critical resource in MSM care for both South Africa and the region: in addition to all the South African training, both government staff and NGO’s from ten African countries have been trained by Anova over the past few years either on site at the clinic, or by Health4Men trainers in their countries, and we believe that this is worth maintaining, in addition to the expert service provision for our community,” says McIntyre.
Earlier this year Anova Health applied to USAID – one of the entities through which PEPFAR provides funding – for a new grant to continue the work. Their application was unsuccessful. Rebe stresses that they are not interested in blaming USAID for not getting a new grant and that their concern is simply with ensuring their patients continue to receive quality and appropriate treatment and care. So far Health4Men has received no indication that any other organisation will be taking over the clinical services that they have been providing.
Low writes that Anova Health is currently pursuing alternative funding to keep at least The Ivan Toms Clinic (one of the centres of excellence) in Cape Town open in the short term, while looking at other solutions longer term, says McIntyre. “As we presume a new USAID partner will provide alternative community outreach services in the USAID target cities, the most impact on the community in Cape Town and Johannesburg is likely to be the loss of the dedicated clinical services platform. Anova is pursuing other avenues to maintain the Centres of Excellence, but if we were unable to negotiate a way forward with alternative funding and the relevant Provincial Departments of Health, the direct service provision at these sites would close.”
According to Cynthia Harvey, US Embassy spokesperson, USAID “remains committed to supporting excellent and expanded health services to men who have sex with men (MSM) in South Africa” and is committed to ensuring a smooth transition between its implementers. “USAID and the successful applicant will work closely with government officials and civil society stakeholders to ensure this smooth transition,” says Harvey.
USAID is conducting a “competitive process to select an implementer for the next phase of activities related to the MSM population in SA,” says Harvey. According to her the successful applicant will “provide a comprehensive package of services for MSM in the City of Johannesburg, City of Cape Town Metro, Buffalo City Metro and Nelson Mandela Bay Metro, which will include empowerment-based, peer-led outreach, provision of condoms and lubricant, referrals or services for treatment of STIs, HIV testing services (including linkage to ART for those testing positive), ART for HIV-positive individuals (including adherence support) and PrEP services.”
Harvey also said that targets for the upcoming US government fiscal year (starting in October 1st) have increased significantly from the current year, demonstrating USAID’s commitment to providing expanded coverage.
Low writes that questions sent to the Department of Health had not been responded to at the time of publication. According to Rebe, Anova Health will be meeting with the Department of Health in the next few days to discuss the way forward.
The Anova Health Institute said that it “is sad to announce that funding from USAID for sections of our Health4Men programme will be coming to an end, effective the 30th September 2018. This funding allowed us to establish Centres of Excellence with dedicated clinical services for the men who have sex with men (MSM) community in Cape Town and Johannesburg.
“Health4Men is funded by multiple donors, so the loss of USAID funding will primarily affect clinical services in Johannesburg and Cape Town, however, national Health4Men activities, supported by our other funders, will continue. Our most immediate concern is for the many MSM clients that are utilising these services.”
Professor James McIntyre, CEO of Anova Health Institute said: “The Health4Men programme started with USAID funding in 2008, at a time when there were limited services and little attention to the needs of MSM in South Africa. As a testament to the close collaboration between the programme and the MSM community, it has achieved remarkable results and global influence, which will be the ongoing legacy of the programme.”
“Anova’s national Health4Men programme has put MSM healthcare on the public health agenda. High-level clinical expertise developed within the programme has been central to the development of national and international evidence-based policies and guidelines.
Since its inception, Health4Men has had many landmark achievements. Over the last 10 years, around 26,000 MSM have accessed and benefited from Health4Men Centres of Excellence. With support from multiple donors, Health4Men also sensitised and trained over 16,000 health workers in over 400 clinics nationwide and contributed to setting up similar services in many other countries.
“As Health4Men services are embedded within public health clinics in the public sector, we are working closely with the Departments of Health and other stakeholders in these cities. We are also exploring other funding opportunities and service options. Our priority is to ensure continued services for our MSM clients and community.
“As a governing organisation overseeing numerous projects and programmes, Anova Health Institute will continue to pioneer sexual health awareness within the MSM community with our successful We The Brave and Yellow Dot Doctor campaigns.”