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Daily Maverick
22-07-2025
- Health
- Daily Maverick
Slow-motion denialism — our leaders are allowing the HIV response to collapse
South Africa is staging a sequel to Mbeki-era denialism, only this time the science, solutions and costs are clearer. Tragically, we have politicians showing the same disregard for despairing public health experts sounding the alarm and civil society's calls for engagement. Treasury's token contribution, President Cyril Ramaphosa's and the Government of National Unity's (GNU) silence, Deputy President Paul Mashatile's empty promises and Health Minister Dr Aaron Motsoaledi's fabricated success, mean the current child and adult deaths and unnecessary infections are mounting. Exactly six months after the abrupt withdrawal of billions of rands in support to South Africa from the US President's Emergency Plan for Aids Relief (Pepfar), there is still no plan. In May, in response to concerns about HIV service weaknesses, Motsoaledi claimed 520,000 people were initiated on HIV treatment between February and April, a number already almost halfway towards his 'Close the Gap' campaign target. This remarkable success claimed by the minister occurred during a collapse in funding, staffing and testing, and was achieved simply with 'roadshows' and unnamed community programmes. This would represent one of the most remarkable HIV global service delivery achievements yet, given three months of massive funding withdrawal and service collapse. Yet, in the past few weeks: National Health Laboratory Services data shows CD4 test volumes are down sharply from 2024. If more people were entering care, these numbers would rise. This is the clearest indicator we have that far fewer people are entering care. The minister's claim that more than 500,000 people were added to the number on HIV treatment is thus implausible; New data from Johannesburg show HIV diagnoses and people starting treatment are down nearly one-third since Pepfar's withdrawal. In Gauteng, the province with the highest HIV burden, the minister's 520,000 number should be immediately reflected in numbers like these. Yet we are seeing the numbers go down rather than up; Community monitors from Ritshidze – an organisation that monitors the ARV programme – report steep drops in testing, medicine pickups and staff capacity in government facilities offering HIV services. 'Do more with less' is not a realistic strategy to address this; Early infant diagnosis rates have somewhat recovered, too late for many. Infants with HIV have extremely high mortality. These are the bodies behind the pause the minister refuses to call a collapse; A report by Avac, an HIV advocacy organisation, showed most key population programmes have been terminated. 'Key populations' refers to groups at particularly high risk of HIV such as sex workers and men who have sex with men. The government claimed that the patient files from the clinics that provided services to key populations have been transferred to other clinics. But staff at some of the defunded organisations providing these services have told me, despairingly, that key population clinic files now sit, unopened, in overwhelmed clinics; The Clinical HIV Research Unit in Johannesburg shut its cervical cancer screening and prevention clinic in June; and The Global Fund, our significant remaining donor, cut funding to South Africa's current grants by 16%, reducing it by R1.4-billion. The Treasury 'emergency' funding announced last week amounts to roughly half of what the Global Fund cut, and only 6% of the Pepfar cut. Repeated offers of help and pleas for meetings and consultations from local experts and civil society have been ignored by the country's leaders. This includes a letter signed by numerous organisations and individuals from across the country's most respected institutions, setting 7 July as a deadline for a response. Constant promises that the 'plans' for mitigating the HIV programme will be released have not materialised. Reassurances that provinces are getting support is not being experienced by any of the provincial colleagues I speak to. Mashatile has doubled down on the 520,000 number, telling Parliament that the withdrawal of Pepfar funding 'has spurred on' the government to become more 'self-reliant', using BRICS, Lotto and domestic funding to plug the gap, with no details as to how this will happen. He claimed no patient will suffer, despite local studies warning of massive waves of new deaths and infections, multiple anecdotes in the press to the contrary, and submissions by public figures to the Portfolio Committee on Health on service interruptions. Both Mashatile and Motsoaledi have repeatedly lamented, correctly, the severe reliance of our health system on external donors, but have not acknowledged that they have been fully responsible for the health system for almost all of Pepfar's existence. Concerned academics directly responsible for shaping the Department of Health's HIV response, who have called for the minister to explain his 520,000 figure, have not been answered. This crisis is fixable. It requires immediate reinvestment in defunded organisations, the rehiring of experienced managers and an honest medium-term plan for service integration within our health system. None of this is happening. There is no urgency, no leadership and no public plan. Motsoaledi says there is 'no collapse' but patients are dying without diagnosis, and others are acquiring HIV without prevention. Call it what you want. The system is failing. The minister's claims of 'no collapse' ring hollow for the people left stranded with no services, waiting to die for want of a diagnosis and treatment, or unnecessarily contracting HIV for lack of effective prevention. Recent local modelling has shown the Pepfar collapse may result in tens of thousands of preventable deaths, if services are not replaced. The Ramaphosa-Motsoaledi-GNU era risks a ruined legacy, not for failing to stop this crisis, but for pretending it wasn't happening. DM Professor Francois Venter is a clinician researcher at Wits University. He led a large Pepfar programme until 2012 and has had a support role since then. He and his unit do not receive Pepfar, CDC or USAID funding.
Daily Maverick
16-07-2025
- Health
- Daily Maverick
Loaded for Bear — Pepfar looks set to be saved, showing Republicans still have a shred of decency
In the dark age of Trump, it seems US Republicans still have a shred of decency left in their political DNA. The second Trump administration has been many things: crass, chaotic, crazy and incompetent, traits that are all a reflection of its Dear and rambling Leader. It has also set new standards for cruelty, and one of the cruellest measures has been the gutting of the US President's Emergency Plan for Aids Relief (Pepfar), a programme that now looks like it may be miraculously resurrected. Launched in 2003 by former president George W Bush, Pepfar is credited with saving about 26 million lives in Africa while preventing eight million babies from developing HIV/Aids. If the Bush presidency has a noble legacy, this is it, and it has also paid huge dividends for Africa's economic development in the form of a healthier population and workforce as Aids has always taken its greatest demographic toll on people and breadwinners in the prime of their life. Pulling the plug on the programme has had an immediate and devastating impact, with a mounting death toll. An impact dashboard devised by Brooke Nichols, an infectious disease mathematical modeller and health economist at Boston University, estimated that there has been 88 deaths per hour – more than 360,000 deaths, most of them children – since funding for the programme was iced. Combined with aid reductions by the UK and EU members, modelling published in the Lancet estimated that almost three million additional HIV deaths would occur by 2030 in the wake of the slashing of Pepfar. But suddenly, US Republicans appear to have had a change of what is left of their hearts. Reuters and several other media outlets reported late on Tuesday that the White House had agreed to exempt Pepfar from a package of foreign aid and public broadcasting cuts previously approved by Congress and that Senate Republicans were on board. If the bill is given approval by the US Senate it would still need to go to the House of Representatives and then finally the White House for President Donald Trump's signature. But the political winds seem to be cautiously favourable. For more than two decades Pepfar enjoyed broad bipartisan support – a rarity on the polarised stage of US politics – but Republicans in recent months had seemed fine with putting it through the wood chipper. So, why the abrupt U-turn among Republicans? Well, back in the day, Bush's support for the initiative was rooted in his evangelical Christian faith. '… everybody has worth, everybody matters, everybody was created by the Almighty,' Bush said when Pepfar was launched. White evangelical Christians are a key component of the Republican Party's base, and Bush's spiritual moral framing of Pepfar – which represents a drop in the massive bucket of US government spending – clearly appealed to their better angels. But this movement – long known as the Religious Right – has also had plenty of dark angels and it has turned increasingly nasty and intolerant under Trump, who has unleashed the racism and misogyny that was at the core of many of its followers. Earlier this month, The Atlantic had an insightful piece by Peter Wehner on why evangelicals had turned their back on Pepfar. 'Once Pepfar was announced, a number of evangelical groups and individuals played an important role in supporting it. They understood their faith to call them to care for the sick and the poor, to advocate for the oppressed, and to demonstrate their commitment to the sanctity of life,' he writes. 'But as this human catastrophe unfolds, few American evangelical pastors, churches, denominations or para-church organisations have spoken out against the destruction of Pepfar.' Wehner discovered through his reporting that many evangelicals are simply unaware of Pepfar – the good it has done has mostly been beneath the public radar screen. Trump's intolerance and Mob Boss approach to dissent has also played a role. 'Some people in the Christian relief and development community are remaining silent because the administration has proved both capricious and volatile. They still hope to change its course but fear that public criticism could lead it to dig in,' Wehner notes. There is also a strong streak of distrust regarding government intervention among US evangelicals, who embrace the notion of 'rugged individualism' which they see as a reflection of their Protestant faith and personal relationship with God. And there is a stern moral code among the faithful that view Aids as a product of sinful promiscuity – how they fit that square peg into the round hole of Trump's adultery, it must be said, remains perplexing. But at the end of the day, Republicans seem to have changed their mind about consigning Pepfar to the dustbin of history, and I suspect that this would not have been the case without evangelical blessing. It's also possible that some Republicans realise that the success of Pepfar lifts America's standing in Africa and that China and other adversaries could swoop in to fill that void. Trump, whose ignorance is legendary (the president of Liberia speaks such good English!), would be unaware of such detail. But there may still be a few brain cells in the White House. It also shows that in the dark age of Trump, US Republicans still have a shred of decency left in their political DNA. It's not much, but millions of African lives depend on it. DM
Daily Maverick
11-07-2025
- Health
- Daily Maverick
Closing the funding gap — how SA can respond to US aid cuts
South Africa still lacks an action plan after the withdrawal of US aid for HIV and related health services. But when funds do arrive, how will they be managed? The answer may lie in the District Health Programme Grant. The government's extended silence on how it plans to solve the funding crisis created by the withdrawal of US aid has thrown much of the health sector in South Africa into despair. It has been five months since the withdrawal of the aid amounting to about R7-billion per year. It covered the salaries for 15,000 health workers, of whom 8,000 are community health workers, 2,000 are nurses, and 300 are doctors working in 27 of South Africa's high HIV priority districts. As a result, volumes of high-risk populations have lost access to care, while overstretched healthcare workers are facing increased pressure amid ongoing staff shortages. Recently, the Global HIV Treatment Coalition and civil society organisations wrote a strongly worded letter to the government demanding action on a fully costed emergency plan. They accused the state of not taking concerted action. They are not wrong: The government has still not made a clear plan available to the public, although there is consensus on the urgent need to strengthen the emergency response. Plans have been developed internally in the National Department of Health, and a national technical support unit has been established in the office of the health department's director-general to support the integration of services. It is understood that several provinces are being supported to develop provincial transition plans that can be translated into concrete action. But ongoing discussions with the National Treasury have made little meaningful progress in closing the funding gap. The Treasury has indicated that any new funding will either be part of the adjustment budget or as an emergency allocation. At this stage, it is still unclear how much money, if any, will be allocated. There is another challenge that is yet to be considered. When the funding does arrive, there will need to be consensus on how the money is coordinated, incubated and managed. Here, the answer may already be in our back pockets in the form of the District Health Programme Grant. The grant is a mechanism for funding South Africa's public health efforts, particularly relating to HIV, TB and other communicable diseases. As an existing instrument, this grant programme could help address issues linked to the funding gap and lay the foundation for the sustainable integration of activities previously funded by the US President's Emergency Plan for Aids Relief (Pepfar). Why the District Health Programme Grant could work The District Health Programme Grant presents an ideal mechanism that can be used to strengthen governance and ensure that the funding, plans and activities, down to a district level, align with national campaigns and priorities. The grant would need to be amended to ensure that there is improved management of the conditionalities so that the funds invested meet their purpose. Conditional grants are funds allocated to provinces with the primary purpose of ensuring that national priorities are implemented consistently across the country. They facilitate targeted service delivery, equity, accountability and performance monitoring. The District Health Programme Grant, which has a budget of about R25-billion, already has a large HIV component, so additional funding for the HIV and TB services that are needed could easily be allocated to this grant. And if the health department amended the grant mechanism to allow for the contracting in of service providers, such as the Pepfar implementing agents, which are mostly South African NGOs previously funded by the US government, the country would be able to use the capacity built up over time in these organisations to strengthen the delivery of HIV and TB services. The concern, however, is accountability. In the current set-up of the grant, provinces can act more autonomously, and the grant's conditionalities are poorly managed. For the system to be more effective, there needs to be a greater emphasis on cooperative engagement, where two-way reporting between the national and provincial levels can take place. Amending the grant to include stronger accountability mechanisms would help the health department to better coordinate and manage it. The clock is ticking The funding gap comes at a time when the health department has launched two ambitious campaigns to tackle HIV and TB. The Close the Gap campaign aims to enrol a record number — an additional 1.1 million — of people living with HIV on life-saving antiretroviral medicine this year. Along with teenage girls and young women, the initiative prioritises an estimated 600,000 men who know their status but are not on treatment. This campaign aligns with the country's strategy to end TB by 2030. This year, the health department also hopes to accelerate TB case-finding by scaling up testing to five million TB tests to reduce the high rate of infections and deaths. The linkages between the campaigns make sense. TB is the leading comorbidity for people living with HIV. HIV is also the leading contributor to TB mortality, accounting for an estimated 55% of TB deaths, according to the World Health Organization's data on TB in South Africa. The campaigns are evidence-informed and well considered. However, the ambition is not matched by budgets that can support and ultimately enable its success. In addition to the R7-billion Pepfar funding gap, there is a funding gap of at least R600-million in TB to sufficiently fund the required five million tests needed for the campaign. Funding pressures at the provincial level are also constraining the scaling up of the capacity required to administer the tests. A recent analysis by the South African National Aids Council situation room, which every month evaluates the HIV response as part of the Close the Gap campaign, suggests that while there are increases in the number of people being initiated on HIV treatment, the pace is not fast enough to mitigate the losses SA experiences in retaining patients in care. This has resulted in negative growth in many high-prevalence districts. Similarly, in the first TB provincial managers' programme meeting coordinated by the national TB programme, reports of poor performance against the testing targets underpinned the underlying frustrations many are experiencing. South Africa has made incredible progress in expanding access to healthcare in the last 30 years. These include significant declines in maternal mortality, decreases in the under-5 mortality rates, and significant declines in the incidence of TB. Much of this success, particularly in the last decade, is the result of the mass rollout of lifesaving antiretroviral treatment to about six million of the estimated eight million people in SA living with HIV. The abrupt withdrawal of US aid has put at least some of this progress under threat. As we look to the mid-year adjustments budget, we don't just need new money to plug the gap; we also need a sensible framework for spending that money. Channelling the funds through a tweaked District Health Programme Grant is a financial solution that will both provide some quick relief and mitigate the impact that the funding gap will have on universal health coverage more broadly in the long run.
IOL News
10-07-2025
- Health
- IOL News
Motsoaledi: SA's HIV/AIDS programme will not collapse despite US funding cuts
Health Minister Aaron Motsoaledi says South Africa's HIV/AIDS programme remains secure, with Treasury and global partners stepping in after the withdrawal of US funding. Health Minister Dr. Aaron Motsoaledi says South Africa's world-leading HIV/Aids programme 'will not collapse' following the withdrawal of US President's Emergency Plan for Aids Relief (Pepfar) funding earlier this year. This as the National Treasury injected R753 million into the programme with global partners pledging a further R600 million to support treatment and research. Earlier this year, US President Donald Trump's administration announced it would halt all Pepfar funding, following previous global health aid cuts under the same administration. The decision by USAID to withdraw support has left a significant funding gap, particularly for countries like South Africa, where approximately 17% of the HIV/AIDS response was funded by Pepfar. Presenting the Department of Health's 2025/26 budget in Parliament on Wednesday, Motsoaledi outlined the National Department of Health's three key priorities: strengthening the public health system in preparation for National Health Insurance (NHI), eliminating key diseases such as HIV/AIDS and TB, and implementing long-overdue reforms in the private health sector. 'There is no way we are going to allow the world's biggest HIV/AIDS Programme to collapse- never.' He described claims of a collapse as premature and inaccurate, insisting the department had developed clear plans to bridge the funding gap. 'In South Africa we seem to like the word 'collapse'. Every time something meets headwinds, it is said to have collapsed,' he said. Motsoaledi told Parliament, emphasising that despite funding cuts, government and partners are stepping in. 'We presented our plans to National Treasury and asked for help. At the same time we approached other funders, both domestic and globally.' Motsoaledi revealed that National Treasury had responded to the department's request for support by releasing R753,528,000.
The Independent
17-06-2025
- Politics
- The Independent
Congress should be ashamed over helping Trump cutting foreign aid, activists say
The US Congress should be ashamed by its role in helping Donald Trump claw back billions of dollars in foreign aid funding already allocated to projects around the world, activists have said. The House of Representatives recently narrowly voted through a request to claw back $9.4 billion (£7bn) of funds – known as rescissions – with $8bn of that coming from foreign aid. It is the first step to making these cuts permanent. Programmes operating in 14 African countries have told The Independent they have been denied ring-fenced funding since Trump re-entered the White House in January and issued executive orders to slash aid spending, something HIV advocacy group, the Aids Vaccine Advocacy Coalition (AVAC) has claimed was 'illegal' and 'immoral'. Each year, US legislators vote through a budget setting out what the government must spend on different activities. By not spending money already allocated by Congress on foreign aid projects, Trump had been acted beyond the powers of the presidency, said Prof Lawrence Gostin, a law professor at Georgetown University. A federal judge ruled in Marc h that Trump had overstepped in withholding funds and that his government owed aid recipients money for work done in the first few weeks of his presidency, before contracts were cancelled. That case is currently being appealed by the government. 'The president has no power to unilaterally withhold funding already allocated by Congress,' he said. However, using a 'rare vote of Congress to rescind the funds it has already allocated' allows Trump to withhold the promised money legally. 'And to its shame, the House of Representatives has done just that,' Prof Gostin said. The package of cuts must now go to the Senate for a vote before becoming law. It has been suggested that he Senate will pick up the bill next month, but may try to tweak the contents. Thursday's vote was a, 'pretty clear example that [lawmakers] are happy to roll over and give the president what he wants,' said Mitchell Warren, executive director of AVAC which sued the government. 'They still acted illegally and immorally,' Mr Warren claimed. 'This process does not change that'. Until it was allowed to expire at the end of March, the US President's Emergency Plan for Aids Relief (Pepfar), which forms the backbone of the world's HIV response, set out in law that 10 per cent of its funds must be spent on orphans and vulnerable children. But since January, projects across Sub-Saharan Africa have not seen any of the promised funds, The Independent has learned, leaving vulnerable children without vital services to prevent HIV, access nutrition and report sexual violence. It's one example of the cuts which look set to become permanent, through claw backs of existing funds and a new budget proposed this month. Based on Trump's proposed budget for next year, the majority of specialised support for orphans and vulnerable children (OVC) aside from basic medical treatment, are likely to be permanently excluded from receiving future US funds. These wider support services have been shown to protect children from contracting HIV and successfully link HIV-positive children to treatment. Project Hope in Namibia, which linked children in rural communities with HIV treatment and prevention, is another programme to have its OVC funding under Pepfar withheld since January. Early data showed children with HIV enrolled in Project Hope Namibia's programme were more likely to have the levels of virus in their blood brought down to undetectable levels – 96 per cent in January compared with 85 per cent the previous September. Suppressing the virus means they won't get sick or be able to infect others. 'They don't understand those programmes are lifesaving,' Leila Nimatallah, vice president of US advocacy group First Focus on Children, said. More than half of children with untreated HIV will die before their second birthday. 'Illegal and immoral' A State Department official said Pepfar continued to support 'lifesaving HIV testing, care and treatment' including for orphans and vulnerable children, but that all other services are currently being reviewed. But that's not how people working on the ground see things playing out. 'We will expect children to be dying who are not supposed to be dying,' said Desmond Otieno, project coordinator at HIV service the Integrated Development Facility in Kenya. The US has withheld money previously promised to IDF Kenya for services including medication counselling and psychological support since Trump took office, and the facility has already recorded deaths of children who were no longer able to access medication. 'That is the most outrageous [thing]' Mr Otieno said. The State Department spokesperson added that all foreign assistance programmes 'should be reduced over time' as they achieve their mission and move countries 'toward self-reliance". Project Hope in Namibia says its plan to make sure its services could be maintained by the local government by 2028 had been scuppered by the programmes abrupt ending, however. The process of transferring responsibility over including training up local staff will now be a lot harder, achieving exactly the opposite of this goal. Ms Nimatallah said she was calling on the Senate to 'reject this cruel rescissions package'. 'By passing this bill, Congress is taking back funding that it had already appropriated for the prevention of suffering and death of children under five from dirty water, infectious disease, and malnutrition,' she said, as well as funds 'set aside to protect Aids orphans from hunger and sex trafficking. 'The long and short of it is that the United States has turned its back on these children that it has promised to care for'.
