The Shift in South Africa’s HIV Response: Adapting to a New Reality
South Africa has made remarkable progress in its fight against HIV, with the country now home to the world's largest HIV treatment programme. However, this achievement would not have been possible without significant donor support over the years. As international funding begins to decline, the country faces a critical juncture in how it manages its HIV response.
The golden age of health development assistance is coming to an end. This shift presents both challenges and opportunities for South Africa to rethink its approach to HIV care. By integrating HIV management into primary healthcare, the country can better address the growing burden of noncommunicable diseases (NCDs) while maintaining effective HIV services.
A Changing Landscape of Funding
Earlier this month, South Africa received R2-billion in bridging funds from the United States' President's Emergency Plan for AIDS Relief (Pepfar). This funding is intended to ensure uninterrupted HIV service delivery until the end of March next year. However, this amount represents only a quarter of South Africa's FY2024/5 Pepfar grant and is part of a broader phase-out plan by the U.S. government.
This reduction in aid has had a ripple effect across the global donor landscape. For instance, the Global Fund for HIV, TB, and Malaria, which previously contributed roughly a third of the yearly amount from Pepfar, will now provide about R2.3-billion less over the next three years due to reduced contributions from wealthy governments.
Over the past 25 years, international funding has played a crucial role in the roll-out of South Africa’s HIV programme. It has supported essential research, including large national surveys that tracked the picture of HIV in the country. These efforts were particularly vital during the height of Aids denialism.
The Impact of Declining Donor Support
Despite the progress made, the loss of donor funding poses a serious threat to South Africa’s HIV response. If Pepfar funding stops without being replaced by government money, projections suggest between 150,000 and 296,000 additional new HIV infections and between 56,000 and 65,000 HIV-linked deaths could occur by 2028. Additionally, many health workers employed by Pepfar-funded NGOs may lose their jobs.
The reality is that the golden age of health development assistance is over. But can there be opportunity in adversity?
Rethinking Business as Usual
National statistics show a significant drop in HIV-related deaths, from 169,076 in 2010 to 77,639 in 2025. While this represents a 54% decrease, it still falls short of the UNAids target of reducing deaths to 10% of 2010 levels by 2030.
Moreover, life expectancy has climbed from around 57 to 67 years in the last decade, and about a fifth of the population is older than 50. Deaths from NCDs now far exceed those from infectious diseases, with the crossover occurring around 2009 when access to ARVs was expanded.
This changing health landscape necessitates a rethinking of how South Africa responds to HIV within the context of declining donor funding.
Do More with Less
An immediate reaction might be to protect and increase funding for the HIV programme. This could involve increasing the health budget and channeling extra money to HIV projects. However, this approach has downsides, such as continuing inefficient services and missing the chance to review what works and what doesn't.
Instead, South Africa could use the current situation to take seriously that HIV is a chronic disease and integrate its management into primary healthcare. For example, research shows that people over 50 on ARVs are up to four times more likely to have another chronic condition like high blood pressure or diabetes.
A More Integrated Approach
What could a more integrated approach to HIV services look like? One solution could be to make HIV services part of routine health checks for pregnant women, vaccinations for children, or sexual and reproductive health advice. This can help end mother-to-child transmission and lower infections among teenage girls.
Adapting services to specific client groups, as done in differentiated care for HIV, is also key. Patients with well-controlled conditions could receive several months' worth of medicine at once, improving efficiency and adherence.
Using data from these systems can help flag when people are not taking their medication consistently. Artificial intelligence can turn this data into meaningful insights, making programmes run more efficiently and empowering patients to take charge of their care.
The Most Bang for Limited Bucks
However, caution is needed to ensure that people receiving HIV prevention or treatment are not left worse off. Overworked staff, longer waiting times, and a drop in quality of care are risks if integration is not carefully managed. Stigma and distrust could also increase, especially for key populations.
Donors often fund standalone programmes and require solid data to report on their impact. Integrating HIV services into primary care could compromise this data, making donors reluctant to continue funding. However, this challenge can be overcome by directing donor funding to government institutions rather than NGOs, as seen in Zambia.
In conclusion, rethinking how to handle dwindling international aid could benefit not only South Africa’s HIV response but also programmes dealing with the surging burden of NCDs. This approach can help make healthcare more accessible and equitable for all.