Trump's HIV funding cuts will also exacerbate diabetes, cervical cancer and depression

Daily Maverick

4 days ago

The impact of the Trump administration slashing of more than half of South Africa's HIV and TB projects funded by the US government, transcends reduced access to HIV testing and HIV prevention and treatment drugs. Treatment for diabetes, high blood pressure, cervical cancer, depression and anxiety will become harder to come by too.
The impact of US President Donald Trump's administration slashing more than half of South Africa's HIV and TB projects, transcends reduced access to HIV testing and HIV prevention and treatment drugs: treatment for noncommunicable diseases (NCDs) will become harder to come by too.
As government clinics take on HIV patients who were previously treated by the President's Emergency Plan sor Aids Relief-funded projects, the treatment of diseases like diabetes and heart disease — for all people — will come under pressure.
And mental health issues such as depression and anxiety — also noncommunicable illnesses — will most likely become more common among people with HIV, because many now face extra stress, such as having to travel further to clinics for treatment, and groups like sex workers increasingly face discrimination at government clinics.
At a Bhekisisa and Southern African HIV Clinicians Society webinar in May, the health advocacy organisation Treatment Action Campaign (TAC) and the sex worker movement Sisonke, for example, reported cases where sex workers — who used to get their treatment from US government-funded clinics where health workers were trained to address their reproductive health needs — have recently been turned away from state clinics or were denied condoms.
In 2020, noncommunicable diseases were the cause of more than half of all deaths in South Africa. But, compared to HIV, funding for noncommunicable diseases has traditionally been scarce.
We look at five ways in which HIV funding cuts could affect noncommunicable diseases.
Fewer data capturers means fewer people to keep track of NCDs
Today, people over 50 make up the second-largest group of South Africa's HIV-positive population, Bhekisisa's data team has found. Twenty years ago, they were the smallest proportion.
As people age, their chances of developing health problems like high blood pressure, heart disease and diabetes rise, which means more and more people will have to be treated for these conditions — on top of getting HIV care.
Because antiretroviral drugs (ARVs) keep people healthy and increase their life expectancy, the scale-up of treatment in South Africa — public sector treatment started in 2004 and in 2025 we've got about six million people on ARVs — means that most people with HIV and who take ARVs correctly now live just as long as those without the virus.
So, as the peak of the HIV-infected population shifts into an older age band, more and more people will probably have to be treated for noncommunicable diseases like heart conditions, diabetes, overweight and high blood pressure — on top of receiving HIV care.
Studies have shown that people with HIV who are older than 50 have double the chance of having conditions like diabetes or high blood pressure than younger HIV-positive people.
But without tracking the numbers — which will be challenging with the loss of thousands of US government-funded data capturers in the wake of foreign aid cuts — putting plans in place to care for an ageing HIV population will be hard.
And with many countries' governments, including South Africa's, scrambling to find the money to replace the thousands of data capturers for HIV programmes previously funded by the US government after the abrupt halt in aid, funds for tracking the health conditions of older people with HIV will probably be a low priority.
Employing health workers to capture and manage health data would be a hard sell, said Kate Rees, a public health specialist with the Anova Health Institute, during the Bhekisisa and the Southern African HIV Clinicians Society webinar — something that, for a public health issue that might be ignored because its fallout wasn't immediately visible — could just make the problem so much worse.
Fewer people on ARVs leads to more people with diabetes
When people with HIV are not on treatment, or if they don't use their ARVs correctly, the virus gets a chance to make copies of itself in their bodies and attack their immune systems.
That's when their immune systems get weak, and some then fall ill with diseases that scientists call opportunistic infections. The most common opportunistic infection for people with untreated HIV is tuberculosis (TB).
And that's where the catch for one of the world's fastest-rising noncommunicable diseases, diabetes, lies: there's a link between TB and diabetes.
Diabetes — a condition in which someone has too much sugar in their blood because their body doesn't get or respond to the signal from the hormone insulin to absorb glucose — kills more people in South Africa than any other disease. In 2020, it claimed 32,100 lives — about 40% of them before they turned 65.
The condition is one of four noncommunicable diseases World Health Organization (WHO) member countries agreed to tackle. The goal is to lower deaths by 25% by the end of this year.
But South Africa is far off track and that goal will now be even harder to achieve.
TB changes how someone's body reacts to insulin. That's why some people with TB — who have never been diagnosed with diabetes — are found to have lots of sugar in their blood. In some cases, this is temporary and normalises after TB treatment. But the germ still increases the odds of developing diabetes later on.
In fact, among people who have high sugar levels in their blood when getting diagnosed for TB, studies show that between 8% and 87% are eventually diagnosed with diabetes.
But, the opposite is also true: people with diabetes have a higher chance of falling ill with TB.
So, in short: when there's less money to help people with HIV get diagnosed or to make it easy for diagnosed people to get on to treatment, and stick to it, more people get TB. And when more people have TB, diabetes becomes more common, because some people with TB are more likely to get diabetes. At the same time, people with diabetes who get TB, have a higher chance of falling very ill with TB, because diabetes makes their immune systems even weaker.
Fewer women on ARVs means more with cervical cancer
Last week, the Clinical HIV Research Unit at Wits University in Johannesburg shut its cervical cancer screening and prevention clinic at Helen Joseph Hospital, one of the biggest units in the country, following the termination of US funding.
'This closure will significantly impact cervical cancer prevention efforts in South Africa, which faces one of the highest rates of cervical cancer in the world,' the unit said in a press release.
Cervical cancer is the second most common cancer among South African women, after breast cancer, but it's the leading cause of cancer-related deaths — even though it's preventable through vaccination and regular screenings such as pap smears and testing for the human papillomavirus (HPV), which causes most cervical cancer cases.
'With timely screening and early detection being key to preventing cervical cancer, the closure of this screening unit at Helen Joseph Hospital leaves a major gap in services and will further strain the health service,' the unit's communication department said.
Women with untreated HIV infection are much more likely to develop cervical cancer after being infected with cancerous forms of the HPV virus, because their immune systems are too weak to clear the virus without treatment.
Cervical cancer is the most common cancer among black South African women, who are also the group with the highest HIV infection rate in the country.
About a quarter of people with HIV in South Africa are not on antiretroviral treatment. USAid programmes that have now been discontinued helped to find them by sending community health workers into communities to test people for HIV and find people who had already been diagnosed with HIV, but fell off treatment.
The ending of USAid programmes has resulted in fewer HIV testing and treatment services, which in turn affects how many women become vulnerable to developing cervical cancer.
Depression and anxiety will become more common
Mental health conditions are also noncommunicable diseases.
If more people with HIV are left without treatment as a result of US government funding cuts, mental health conditions like depression and anxiety will likely become more common.
Why? Because Pepfar funded counsellors who would find people with HIV and get them on treatment immediately after they were tested.
Without ART, some people develop HIV encephalopathy, a condition that damages brain tissue through inflammation from the virus. Encephalopathy raises the chances of depression or anxiety because it harms the areas of the brain that control movement, emotions and memory.
People with HIV already face stigma that causes stress and anxiety that can lead to depression.
'There's still the shame, stigma and moral issues that come with HIV,' says Francois Venter, an HIV doctor and the director of Ezintsha at the University of the Witwatersrand.
Depression makes it harder for people to stick to their treatment. Studies show that people with HIV and depression are more likely to stop taking their medication — weakening their bodies and raising the chances of them dying from opportunistic infections.
Fewer nurses means noncommunicable diseases fall through the cracks
Noncommunicable diseases are underdiagnosed in South Africa, experts say.
'If we went into the community aggressively looking for high sugar and blood pressure, we would do such a better job,' says Venter. 'Instead, we sit back and wait([until people turn up at clinics), which is why we do so badly with diabetes and hypertension.'
Even at clinics, people are rarely tested, mostly because there are too few nurses at our clinics. On top of noncommunicable diseases, they also have to help treat HIV and gender-based violence, and see that pregnant women and newborn babies are healthy.
And after February's US funding cuts, we have even fewer nurses. According to health department data, Pepfar funded 2,320 nurses, of which just over half (those programmes that received their funds through USAid) have now been laid off. Right now, the rest (programmes funded through the Centres for Disease Control and Prevention), only have jobs until the end of September.
Pepfar also funded 2,705 lay counsellors, health department data shows. Without this staff who went into communities to screen people for HIV, TB and other diseases, patients now have to travel to clinics for help, which means more patients for nurses.
And when nurses have more work, they have less time to treat each patient, which, says Venter, makes it even harder to pick up on noncommunicable diseases.
'Because of that, the actual interaction would take probably an hour and a half. When you've got a mile-long queue outside your door, you just don't have that time.'
'So they (nurses) go for the absolute basic stuff.' DM