South Africa faces alarming drop in HIV testing rates linked to US funding withdrawal
In the wake of the withdrawal of US Pepfar funding for South Africa's HIV/Aids programme, there has been an alleged decline in HIV viral load testing across the country. One HIV expert described the situation as 'frightening but expected'.
Over March and April this year, there has been a significant decline in viral load testing for HIV in South Africa — a phenomenon that would appear to be linked to the recent withdrawal of United States funding for HIV programmes through the US President's Emergency Plan for Aids Relief (Pepfar).
The drop in viral load testing is shown in alleged National Health Laboratory Service (NHLS) data analysed by National Institute for Communicable Diseases (NICD), as part of the laboratory service's surveillance function it provides to the national Department of Health. The information was shared with Daily Maverick by a source who chose to remain anonymous out of concern for professional backlash.
At a national level, the data indicates that viral load testing for HIV was up 1% in March 2025 compared with March 2024. However, a comparison of the number of viral load tests conducted in April 2024 and April 2025, respectively, shows that testing dropped by 11.4% between the two periods, from 594,596 to 526,908.
In certain population groups, including pregnant women, infants and young people between 15 and 24 years of age, the decline in viral load testing rates has been more severe.
Daily Maverick reached out to the NICD about the data, but was told the institute was 'unable to authenticate [the] document and therefore cannot comment on its contents'. When sent a follow-up with specific questions about drops in viral load testing numbers across different population groups, the NICD referred the query to the laboratory service.
The laboratory service told Daily Maverick it would not be commenting on the situation, adding: 'Please speak to the national Department of Health.'
Daily Maverick asked the department to confirm the decline in HIV viral load testing and comment on the reasons behind it. The department responded that it was 'dangerous' to comment on data with an unknown source, and asked about authentication by the laboratory service. It did not respond to any specific questions about the alleged decline in HIV viral load testing.
A recent Reuters report appears to have been based on the same data as that seen by Daily Maverick.
Declining HIV viral load testing
According to the data, the population group that has seen the largest drop in HIV viral load testing when comparing records for April 2024 and April 2025 is pregnant women, with the number of tests declining from 14,121 to 11,111 (-21.3%) between the two periods.
Viral load testing for young people aged 15 to 24 dropped by 17.2%, from 40,227 in April 2024 to 33,305 in April 2025. Testing for infants using PCR (polymerase chain reaction) tests dropped by 19.9%, from 48,312 in April 2024 to 38,689 in April 2025.
Three health experts within the HIV sector that Daily Maverick spoke to about the data said that the decline in viral load testing was probably linked to the recent withdrawal of Pepfar funding for HIV/Aids programmes by the US, which has resulted in layoffs for 8,061 health workers across 27 high-burden HIV/Aids districts in South Africa.
Since US President Donald Trump announced the suspension of foreign development spending in January, funding cuts by the United States Agency for International Development (USAid) have pushed key Pepfar-funded programmes and facilities to close their doors in South Africa and around the world.
Pepfar funding made up R7.9-billion of South Africa's R46.8-billion HIV/Aids programme, according to Minister of Health Dr Aaron Motsoaledi.
'Frightening but expected'
HIV viral load testing for people taking antiretrovirals allows health workers to gauge whether the patients are taking their treatment correctly, and whether that treatment is suppressing the virus effectively.
Professor Francois Venter, a Wits University clinician researcher, noted that South Africa followed 'world-class guidelines' for HIV care, which required people to be tested annually once they had been established on antiretrovirals.
'It's an incredibly important quality measure of your programme, your viral loads — the number that have been taken relative to the number of people on treatment, and then what those viral loads are showing. When they start dropping like this, you start losing that quality control measure, and it starts demonstrating that something severe is happening within the programme,' said Venter.
'The fact that [the drop in viral load testing] is happening across all the provinces suggests that there's a systemic, wide thing that's gone wrong here… There's something across the board that's happening here that's fundamentally affected the programme, and the only thing that makes sense is withdrawal of the Pepfar funding and support.'
Professor Glenda Gray, a South African physician, scientist and activist specialising in the care of children and HIV medicine, described the data as 'frightening but expected'.
'If you're not going to have the people in place to do the [HIV] testing and the counselling and triaging to care, if you don't have those people who are following up on people who have missed their visits, or who are looking to see who needs viral load testing, the wheels will come off,' she said.
'I think that's… what the [Pepfar] implementing partners did… They were the part of the programme that added the quality that is needed for the ability to do [HIV] testing and counselling and retention in care and triage into programmes to get antiretrovirals. If you take that away, you will rapidly see the loss of quality of your programme.'
The data seen by Daily Maverick also showed a drop in viral suppression rates among pregnant women and 15 to 24-year-olds.
For the general population at a national level, viral suppression rates were shown to have dropped by 3.4% between March 2024 (77.2%) and March 2025 (74.6%). There was a drop of only 0.2%, year-on-year, between April 2024 and 2025.
In this data, viral load suppression was defined as patients with less than 50 copies/ml, which meant their viral load was not detectable in testing.
Lynne Wilkinson, a Gauteng-based public health specialist in the HIV/Aids sector, explained that viral load suppression rates were more difficult to interpret when fewer tests were done, as suppression was only being measured among those coming into health facilities to be tested.
'If your number of viral load [tests] goes down, you're not taking viral loads for a whole group of people. Now, who are those people? [Maybe] they're coming in, they're at the clinic, they're taking their treatment but the healthcare worker doesn't have the capacity because she's overburdened. Or you're not having [a viral load test] taken because you're not actually at the clinic,' she said.
Concerns around vulnerable populations
A decline in viral load testing for pregnant women would be a 'big problem', said Gray, as there was a 'direct correlation between viral load and perinatal transmission'.
'If women… aren't getting [HIV] tested, or if they're not getting on to care, they will transmit, and they will transmit during pregnancy, labour, delivery and postnatally. So, you'll start to see a reversal in control of paediatric HIV,' she said.
For the infant population, a decline in HIV testing means infants might only be diagnosed once they are already in hospital for other conditions like pneumonia and TB, according to Gray.
'When you're an infant [with HIV], and you get sick and you land up in hospital, it means that you're already immunocompromised. And so basically, kids will start treatment later; some kids may never get on to treatment, and die,' she said.
Need for action
In recent months, many health experts and activists have been vocal about the need for the South African government to produce a clear emergency plan to address the loss of US funding for the HIV/Aids programme in South Africa.
'The Department of Health, senior people — including the minister — all said, 'No, this is going to be fine,' and it's not fine. It's unravelling, and they can reverse it, but they're going to have to acknowledge there's… a problem, and… simply throwing a whole lot of money at the problem is not going to solve it,' said Venter.
'You're going to have to have a plan for how you're going to replace what was an incredibly efficient service that was in place.'
Venter said that the crisis caused by the loss of the Pepfar funding was 'fixable', if the response was swift and purposeful.
'It's not something that's going to be resolved by some international white horse coming over the mountain with lots and lots of money. It's not going to come from a donor. It's not going to come from anywhere other than within the Department of Health, with the help of lots of experts,' he said.
'They're not going to solve it by themselves. If they think they can solve it by themselves, by just bunkering down, they are going to fail, and it's going to be… another Aids tragedy, 20 years after the last one.'
On Thursday, 15 May 2025, Motsoaledi assured South Africans that the country's HIV/Aids programme was not at risk of collapsing due to the withdrawal of US funding.
Speaking at a media briefing in Pretoria, he listed steps taken by the Department of Health to address the loss of aid, including:
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.
Moving the files of 63,322 HIV patients from key populations to alternative public health facilities after the Pepfar-funded clinics they relied on closed down.
Numerous meetings with potential donors about additional funding to fill the gap left by Pepfar.
According to Motsoaledi, there is currently no plan to absorb the 8,061 health workers who lost jobs due to the Pepfar cut into the public health system, though he described them as 'people of interest' in the Health Department's talks with potential funders and the National Treasury.
At the media briefing, a Reuters reporter asked Motsoaledi about the alleged drop in viral load testing across the country.
'If viral load testing has dropped, does it mean the collapse of the [HIV/Aids] campaign by any stretch of the imagination? No. We expected that some of these problems would occur, but we are sitting with them every day. Simply because a problem is occurring, to go and announce that the HIV/Aids programme has collapsed, it's wrong, and I will remain believing that it's wrong,' said Motsoaledi in his response.
'I want to state it very clearly that I've never said everything is fine… All I said is that it's wrong to say the… HIV/Aids programme in South Africa is collapsing, because it's not.' DM
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