South Africa has less than eight years before one of the most important sources of funding for its HIV and TB programmes falls away, so it's critical that the government accelerates its action plans, particularly when it comes to key populations, writes Ida Jooste for Bhekisisa.
In allocation letters sent in March to the countries it funds, the Global Fund to Fight Aids, TB and Malaria said its final grant to South Africa will be in the next funding cycle, grant cycle 9, which runs from April 2031 to March 2034.
The fund gives countries grants for three years at a time.
South Africa is one of the countries that will lose Global Fund backing earlier than most of the more than 100 countries the Fund supports: because it is wealthier than many of the other states the Fund considers it rich enough to pay for its own HIV programmes.
The fund told Bhekisisa it does not have a final end date for Global Fund support to other, poorer countries.
“The current move is part of a long-term shift toward ‘full domestic financing’ rather than giving a single universal deadline,” a spokesperson said.
However, much of South Africa’s Global Fund grant is used to pay for services for “key populations”.
“This news boils down to hearing we’re defunding the part of the programme that stops the most infections,” according to Francois Venter, who heads up Ezintsha, “and the plan to deal with key groups that are most likely to get HIV still hasn’t moved forward.”
The Global Fund cuts have already begun. The allocation letter also shows that in the upcoming funding period, 1 April 2028 to 31 March 2031, the second-last before the funding stops completely, South Africa will receive just under $345m for HIV programmes, roughly a quarter less than in the previous three-year cycle, which was about $464m. The reduction comes on top of significant funding losses after the withdrawal of support from the US government.
The phase-out is part of the fund’s strategic shift “to focus resources toward the poorest countries with the heaviest disease burdens” while supporting nations like South Africa in “accelerating on their path to self-reliance”, a fund spokesperson said.
Thembisile Xulu, CEO of the South African National Aids Council (SANAC), and also chairperson of the Country Co-ordinating Mechanism which helps to decide which organisations get Global Fund money, and how much, said the move is not unexpected.
“We’ve had to think ahead,” she said. “We’re using the funding we have now to prepare for what comes next. If the final grant is much smaller than what we’re used to, we don’t want to be caught off guard. We need to be ready for HIV to be fully funded by our own government, an area where we’ve actually done quite well as a country.”
The fund mostly relies on contributions from wealthy nations like the US and France, but this year it received billions of dollars less than what it had planned for. This means less money for the countries reliant on its grants.
After missing its $18bn fundraising goal the fund had to reduce the total amount of money it gives to countries to $10.78bn for the upcoming cycle.
The sharp cuts of the past 15 months in US funding for health programmes, through bilateral agreements with countries like South Africa, have been widely reported. But it’s no longer only the US that reduced or stopped direct funding to countries; other wealthy countries have followed suit.
Many analysts describe this as the end of a “golden age” of global health funding, a roughly 30-year period during which health grants from wealthy countries and a few private foundations in poorer countries grew seven-fold from $5.6bn in 1990 to more than $41bn by 2020.
On paper, the Global Fund’s eight-year timeline and the numbers for South Africa may look manageable, said health economist Gesine Meyer-Rath, “but that depends on where you look.”
Meyer-Rath said that based on data from the latest UNAids financial dashboard, which tracks where HIV money is coming from globally and how it is being used, the money South Africa receives from the Global Fund makes up only 3%-5% of its HIV budget. However, she says, that figure can be misleading.
Behind the numbers
In South Africa’s allocation letter and the documents that confirmed the news about the phase-out of our funding, the Global Fund cautioned that the government needs to increase its budget for services to key populations, because they are the most likely to be hit as outside funding falls away.
In 2023, Global Fund grants covered 33% of programmes for key populations in South Africa, while the government funded 15% and the US government’s Aids fund, PEPFAR, 52%.
With most PEPFAR funding withdrawn in early 2025, the Global Fund has now become the main supporter of non-profits providing key population services, although the exact proportions are not yet publicly available.
In South Africa, teenage girls and young women make up just under a third of the country’s 180 000 annual new HIV infections – the number of infections among this group (57 571 per year, according to the Thembisa model) being higher than for any other group with a high chance of getting infected.
But experts say it is important to make a special effort to bring down new infections in other (smaller) groups like sex workers, gay and bisexual men and drug users, because in proportion, they are more likely to get HIV. Ignoring them will hurt plans to slash HIV infections overall.
Small groups, big impact on HIV
So, there’s a practical reason to protect health programmes for vulnerable groups – but it’s about how HIV spreads, not paperwork, said Jacqui Pienaar, a global health specialist at the Aurum Institute, which has received funding from the Global Fund for key population care for more than a decade.
In South Africa, about 20% of adults have HIV. But in some groups, the numbers are much higher. For example, about 62% of sex workers and 63% of transgender women are HIV+.
“These key populations are part and parcel of our social and sexual circles. They are part of the tapestry of South Africans, and we can’t ignore them,” said Pienaar.
HIV, she cautioned, does not stay contained within one group, it moves through communities.
Key population services cost more
Specialised services often cost more because they are designed to reach people where they are — through mobile clinics or after-hours care — rather than waiting for them to come to a clinic.
The health needs of people who inject drugs, for instance, are more complex than services offered to the general population, taking more time and resources.
A big part of the work involves providing methadone, but because this is strictly regulated, and has to be prescribed by a doctor, it makes it harder and more expensive to provide than the country’s usual nurse-led clinic services, said Pienaar.
“All of that makes it more expensive. But if you don’t provide that level of care, you lose people. The specialised key population clinics also allow for longer visits, while public clinics often have only a few minutes per patient.”
Meyer-Rath and her colleagues at Wits University’s HE2RO, who study health costs, have, however, shown that while specialised care often carries a higher price tag per person, the higher impact more than compensates for the cost.
For instance, giving a daily HIV prevention pill to sex workers or gay and bisexual men is more cost-effective than giving it to the general population because these groups are likelier to get HIV infected.
Research reveals that in places or groups of people where the incidence rate is 3% or more, 33 people need to take prevention medication to stop one new infection. But in places where the chances for new infections is lower, 200 people have to take HIV prevention drugs to stop one new infection.
Further analysis bears this out: the cost to prevent one new infection among sex workers with the pill is R10 368, and for gay and bisexual men R19 618. This is far more affordable than the cost for the general population, which rises to R22 797 for young women and R37 304 for young heterosexual men.
And stopping the virus in these high-risk groups protects the entire population, making it the most effective way to use limited health resources.
Sanac’s Xulu said what matters most now is to ensure people keep coming back to government clinics, and for them to stay on treatment.
She added that the country must take a clear-eyed, disciplined approach to what can realistically be delivered with the available constrained resources, “focusing on a defined package of high-impact, comprehensive TB and HIV services”.
“This will require tough, and at times uncompromising, prioritisation of fully integrated service delivery models designed to eliminate duplication, drive efficiencies, and maximise value for money. Difficult choices will have to be made,” she observed.
If South Africa wants to give key populations special services and the care they need, she said, it will have to be “realistic and very harsh” about which services it decides to pay for.
Already a realistic plan – but it’s stalled
But Venter said the country should not have to make these decisions under pressure. He argued that the government has “done a shocking job” of shifting care for key populations into the public system.
Although the Department of Health commissioned a plan showing how services for key populations could be built into public clinics, which was completed in 2023, it still has not been approved. In the meantime, the HE2RO researchers are busy calculating what it would cost to put that plan into action.
“In many ways, the way we were able to support key populations with full donor funding was a Rolls-Royce service,” said Pienaar.
It was a model where patients were given dedicated time to address complex medical and psychological needs, but it’s no longer sustainable as donor funding shrinks.
That’s why, in the next round of Global Fund funding, the Aurum Institute will apply to pass on its expertise. It is proposing to train and support staff in public clinics instead of running their own. The aim is to move what has been learned over more than a decade into the public system so people can get the care they need at their local clinic.
But this will only work if the public health system is ready to take it on, and if the government puts existing plans into action, Pienaar warned.
“If we don’t do this now,” said Venter, “we will see the results – a clear rise in infections, in five years’ time.”
See more from MedicalBrief archives:
Aids denialism deja vu as government denies funding crisis
Ramaphosa urged to escalate action on US funding crisis
Trump’s funding freeze threatens to paralyse SA NGOs