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Mail & Guardian
13 hours ago
- Health
- Mail & Guardian
Dangerous fantasy: US ambassador Dybul said SA was ready to transition off Pepfar. It wasn't
In April, Ambassador Mark Dybul, a former Global Fund chief and key architect of the US President's Emergency Plan for Aids Relief (Pepfar), told the US Congress that South Africa could 'easily transition' from American HIV support within 12 months. It was a neat soundbite, delivered with the polished assurance of someone who has spent years navigating donor boardrooms. But it was also a dangerous fiction, one that we are now watching unravel in real time. Because South Africa cannot go it alone. And despite the minister of health's insistence that the gap is being closed, thousands of people are already falling through it. At the time of Dybul's statement, many in South Africa's HIV sector warned that such an accelerated transition, especially one not backed by an inclusive, resourced plan, would lead to devastation. Those warnings were dismissed as alarmist. Yet today, viral load testing is in decline, trusted clinics are closing, and thousands of health workers have been terminated. Sisonke, the national sex worker-led movement, has shut down its mobile HIV clinics. Anova Health Institute, which pioneered MSM-accessible services, has lost its lifeline. Community-based organisations, already operating at the edges of burnout, are being forced to scale back or shutter. This is not a theory. This is collapse in motion. There is a particular kind of harm caused by high-level optimism detached from ground-level truth. When someone like Dybul tells Congress that South Africa is 'ready,' that narrative travels. It echoes in donor reviews, funding allocations, and strategic plans. It creates political cover for disengagement. And it reinforces the deadly idea that once money has been invested, moral and practical responsibility ends. But HIV doesn't respond to spreadsheets. And South Africa's overburdened public health system cannot carry the full weight of this response alone, particularly not for the communities that have always been the most criminalised, stigmatised, and underserved. It's not just that the funding was cut. It's that our own government has failed to step in. As Bhekisisa recently reported, the South African government's response to this crisis has been one of denial, deflection, and delay. The health minister has downplayed the severity of the situation and accused civil society of peddling panic. Meanwhile, activists, health workers, and people living with HIV are the ones shouldering the fallout, with fewer services, fewer options, and fewer lives saved. To suggest that South Africa is independently filling the gap left by Pepfar is not just disingenuous, it's deadly. The impact on key populations is immediate and catastrophic. Sex workers, LGBTQ+ people, migrants, and people who use drugs already face hostility within public healthcare settings. They have depended on donor-funded, community-led initiatives not just for services, but for safety. When those programmes disappear, there are no public equivalents waiting in the wings. There is only the void, and the violence of being made invisible again. Without dedicated funding, programmes tailored to these communities have always struggled. Conservative gatekeepers have used moral panic to obstruct local support, leaving many initiatives in perpetual financial precarity. Now, without international investment, they are not just under threat, they are being erased. What is happening in South Africa is not transition. It is abandonment dressed in the language of efficiency. It is donor fatigue hidden behind 'local ownership.' It is austerity disguised as empowerment. We need to call this moment what it is: a reckoning. If South Africa is to truly own and sustain its HIV response, then our government must act with urgency, transparency, and humility. That means fully funding civil society partners. It means protecting and scaling up programmes that serve criminalised groups. It means ending the performance of readiness and facing the reality of fragility. And to global donors: solidarity doesn't end when the press release goes out. If you say you care about health justice, then you cannot disappear at the hardest moment and call it strategy. Dybul's statement to Congress may have come from a place of strategic optimism. But optimism, when weaponised against evidence, becomes a tool of harm. His claim was not just inaccurate, it gave donors permission to walk away and governments cover to do nothing. It created a fantasy of resilience while the system crumbled underneath it. And now, the people who fought for their right to health are being left with nothing but press briefings, vague promises, and shuttered clinics. South Africa cannot go it alone, not yet. And pretending otherwise has cost us too much already. Tian Johnson is the founder and strategist of the African Alliance, a Pan-African health justice nonprofit.
News24
26-05-2025
- Health
- News24
Trump's HIV funding cuts will hit diabetes and cervical cancer treatment hard. Here's why
The slashing of over half of SA's HIV and TB projects funded by the US government will affect more than HIV testing and HIV prevention and treatment drugs. The diagnoses and treatment of noncommunicable diseases such as diabetes, high blood pressure, cervical cancer, depression and anxiety will also become harder. We break down five ways in which HIV funding cuts are making NCDs harder to pick up. The impact of US President Donald Trump administration's slashing of over 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 Pepfar-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 such 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, NCDs were the cause of more than half of all deaths in South Africa. But, compared to HIV, funding for NCDs has traditionally been scarce. We look at five ways in which HIV funding cuts could affect NCDs: 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 chance for developing health problems like high blood pressure, heart disease and diabetes rises, 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 around 6-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 likely 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 too than what is seen in 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. ALSO READ | How hard are USAID cuts hitting Africa's healthcare? 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 health conditions of older people with HIV will likely be a low priority. Employing health workers to capture and manage health data will 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 isn't immediately visible - could just make the problem so much worse. Fewer people on ARVs leads to 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 NCDs, diabetes, lies: there's a link between TB and diabetes. Diabetes - a condition when 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. READ MORE | R2.82 billion. That's what we need to plug the US funding gap – for now The condition is one of four NCDs World Health Organisation (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. The TB germ 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 eight 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 to 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 mean 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 SA, 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 says. READ | 110 HIV researchers set to lose jobs in SA after Trump cuts, risking 'hard-won gains' 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 Africa 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 ended, 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 NCDs. 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 which 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 which 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 NCDs fall through the cracks NCDs 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 to do too many things. On top of NCDs, 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. READ | US cancels 83% of USAID programmes, impacting global aid efforts 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 NCDs. '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.'
