THESE are anxious times for Thelma Magudulela, a resident of Orange Farm, south of Johannesburg. For the past 12 years, the 43-year-old unemployed mother of three has been receiving state-of-the-art HIV care from a clinic run by the independent Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital in Soweto. But the unit’s funding from the US government comes to an end next month, and she and the other 4,000 patients under its care will soon be relying on state facilities for their monthly treatments.
The prospect fills her with dread, she says, speaking through an interpreter. Her husband was transferred to their local clinic four months ago, where he now faces long queues, filthy toilets and rushed staff. Worst of all, the couple is convinced his medication has been switched to include pills that make him feel ill, and so she has been sharing the drugs she gets from her clinic instead.
"Ask the government why they don’t pay this clinic to keep treating us", she says.
Her question goes to the very heart of the complex and delicate transition under way as the US government scales back its HIV/AIDS support to South Africa, shifting from an emergency response focused on treatment to investments in technical support.
While both the US and South African governments have promised that no patient will be worse off, the change has many people worried.
"It’s essential the patients don’t get lost. Sites need to be monitored to make sure patients are moved into a health system that can take care of them and give them the drugs they need," says Francois Venter, past president of the Southern African HIV Clinicians’ Society.
If it goes wrong for even a few patients, the consequences will be grave: HIV patients risk developing drug-resistant strains of the virus if there is even a short break in their treatment, and uncontrolled HIV increases their risk of catching and spreading tuberculosis.
The US government has been providing HIV/AIDS support to South Africa since 2003, when former US president George Bush launched the President’s Emergency Plan for AIDS Relief (Pepfar), an initiative that provided assistance to 15 of the world’s countries hardest hit by HIV. Despite being a middle-income country with significant financial resources of its own, South Africa was earmarked for aid because of the severity of its epidemic, which currently affects a 10th of the population.
Pepfar began work in South Africa during the height of the denialism that characterised former president Thabo Mbeki’s administration, providing funds to non-governmental organisations (NGOs) offering treatment to HIV patients long before it was widely available in the state sector. The money it has provided to South Africa has gone to organisations operating in rural areas were there were no health services, to clinics providing treatment to specialised groups of patients such as children, and to private sector GPs. Pepfar has also paid for NGOs to train and mentor staff, and improve drug supply-chain management.
Pepfar’s annual support to South Africa will roughly halve by 2017, dropping to $250m from this year’s budget of $484m.
Donors, including Pepfar, contribute about 24% of South Africa’s total HIV/AIDS budget of R22.7 bn for the current fiscal year, according to the Treasury. It says it will find the extra money to ensure South Africa meets its treatment targets.
Although Pepfar’s budget cuts in the first two or three years are modest, there is already a significant shift in the nature of the projects getting support, with money switching from direct service delivery to longer-term investments in the public health system. While many observers believe the rationale is sound, the speed with which it is happening has them worried.
"This withdrawal risks fundamentally weakening the AIDS response in South Africa because the Department of Health is not ready and does not have the capacity to (take over)," says Brian Brink, chief medical officer of mining group Anglo American.
Contrary to widespread perception that provincial health departments need to tender for NGO services, the Treasury’s director for social services, Mark Blecher, says provincial authorities can make transfer payments these organisations. Adjustments to provincial health budgets can be made in October, if needed, he says.
But within the NGO sector there is deep scepticism about the capacity of provincial health authorities to step up to the plate. It is no secret that the Eastern Cape has failed to pay some of its doctors for months at a time. Mpumalanga has struggled with high staff turnover and medicine shortages, and Limpopo’s health department is under national administration.
Fareed Abdullah, CEO of the South African National AIDS Council, concedes the transition poses challenges: "We have built up a huge capacity … through NGOs, and we would not like to see this capacity being downgraded. We need all the (help) we can get, and we should not underestimate the complexity of transitioning patients from NGO-run services to provincial health provinces, especially in those where there are already many challenges."
Ndlovu Care CEO Hugo Tempelman says his NGO has only enough money to last until January, and fears the 7,000 patients it cares for in some of the poorest districts in Limpopo and Mpumalanga will be left stranded unless the provincial authorities agree to contract their services.
"There are clinics nearby but they don’t have the infrastructure or the knowledge to take over. Hardly anyone in rural areas like these have been trained to provide paediatric HIV treatment," he says.
In the provinces with relatively efficient health departments, the transition appears to be easier. In the Western Cape, Keth’impilo has trained and mentored staff in 28 clinics, and many of these personnel now have jobs with the provincial health department.
"But some provinces are just not that organised and it can take months to exit sites," says Keth’impilo CEO Ashraf Grimwood. "There are some communities we work in where 50% of the kids and 30% of the adults don’t have paperwork (such as birth certificates and identity documents). For a disease that affects 10% of the population, you need a huge investment in management."
Father Gérard Lagleder from the Brotherhood of Blessed Gerard in Mandeni, 100km from Durban, says his fears that patients would be stranded after Pepfar funding for drugs ended last year turned out to be unfounded. Much to his relief, the KwaZulu-Natal provincial health department’s promise to pay for the medication needed by the 600 patients using his facilities was fulfilled. "We were anticipating problems, but it didn’t happen. It wasn’t a difficult change at all," he says.
Gustaaf Wolvaardt of the Foundation for Professional Development, which trains staff, believes Pepfar’s strategy is appropriate, but suggests the transition is likely to be more complex than the US and South African governments initially anticipated. "From our perspective things are going smoothly, but we are a big organisation and have been planning this for 18 months," he says. "At least the Americans are staying. Many other donors are pulling out completely."
The stakes are high , not just for patients, but also for the two governments involved: the US health investment in South Africa is the biggest of its kind worldwide.
What unfolds in South Africa in the months and years to come will have implications in many of the other countries where the US intends to hand back responsibility for managing their HIV epidemics.