BHEKISISA: 글로벌펀드 지원 단계적 폐지로 남아프리카공화국의 고위험 HIV 인구집단 전략의 격차 노출

The Global Fund to Fight Aids, Tuberculosis and Malaria will start to cut its grant support to South Africa in just two years, with its final grant ending in eight years. Some experts are worried the government isn’t doing enough to plan for it.

South Africa has less than eight years before one of the most important sources of funding for its HIV and TB programmes falls away.

In allocation letters sent in March to the countries it funds, The Global Fund to Fight Aids, Tuberculosis and Malaria said its final grant to South Africa would be in the next funding cycle, grant cycle 9, which runs from April 2031 to March 2034.

The fund gives countries grants for three years at a time.

SA is one of the countries that will lose Global Fund backing earlier than most of the more than 100 countries the fund supports; because the country is wealthier than many of the other states the fund considers it rich enough to pay for its own HIV programmes.

The fund told Bhekisisa it does not have a final end date for Global Fund support to other, poorer countries.

“The current move is part of a long-term shift toward ‘full domestic financing’ rather than giving a single universal deadline,” a spokesperson said.

However, much of SA’s Global Fund grant is used to pay for services for groups of people with a higher chance of getting HIV than the general population. Researchers call such groups “key populations”, and they include sex workers, gay and bisexual men, transgender people and people who inject drugs. Reaching and treating key populations helps slow the spread of HIV beyond just the people directly receiving care, says Francois Venter, who heads up the health organisation Ezintsha.

“This news boils down to hearing we’re defunding the part of the programme that stops the most infections”, he says, “and the plan to deal with key groups that are most likely to get HIV still hasn’t moved forward.”

The Global Fund cuts have already begun. The allocation letter also shows that in the upcoming funding period, 1 April 2028 to 31 March 2031, the second last before the funding stops completely, SA will receive just under $345-million (about R5.7-billion) for HIV programmes. That is roughly a quarter less than in the previous three-year cycle, which was about $464-million (R7-billion). The reduction comes on top of significant funding losses for SA after the withdrawal of support from the United States (US) government.

The phase-out is part of the fund’s strategic shift “to focus resources toward the poorest countries with the heaviest disease burdens” while supporting nations like SA in “accelerating on their path to self-reliance”, a fund spokesperson told Bhekisisa.

Thembisile Xulu, CEO of the South African National Aids Council (Sanac), and also the chairperson of the country coordinating mechanism that helps to decide which organisations get Global Fund money, and how much, says the move is not unexpected.

“We’ve had to think ahead,” she says. “We’re using the funding we have now to prepare for what comes next. If the final grant is much smaller than what we’re used to, we don’t want to be caught off guard. We need to be ready for HIV to be fully funded by the South African government, an area where we’ve actually done quite well as a country.”

The fund mostly relies on contributions from wealthy nations like the US and France, but this year it received billions of dollars less than it had planned for. This means less money for the countries reliant on its grants.

After missing its $18-billion fundraising goal (R298-billion) the fund had to reduce the total amount of money it gives to countries to $10.78-billion (R180-billion) for the upcoming cycle.

The sharp cuts of the past 15 months in US funding for health programmes, through bilateral agreements with countries like SA, have been widely reported. But it’s no longer only the US that reduced or stopped direct funding to countries; other wealthy countries have followed suit.

Many analysts describe this as the end of a “golden age” of global health funding, a roughly 30-year period during which health grants from wealthy countries and a few private foundations in poorer countries grew seven-fold from $5.6-billion in 1990 (about R14.3-billion at the time) to more than $41-billion by 2020 (around R675-billion then).

On paper, the Global Fund’s eight-year timeline and the numbers for SA may look manageable, says health economist Gesine Meyer-Rath, “but that depends on where you look”.

Meyer-Rath explains that, based on data from the latest UNAids financial dashboard, which tracks where HIV money is coming from globally and how it is being used, the money SA receives from the Global Fund makes up only 3-5% of its HIV budget. However, she says, that figure can be misleading.

In South Africa’s allocation letter and the documents that confirmed the news about the phase-out of SA’s funding, the Global Fund cautioned that the government needs to increase its budget for services to key populations, because they are the most likely to be hit as outside funding falls away.

In 2023, Global Fund grants covered 33% of programmes for key populations in SA, while the government funded 15% and the US government’s Aids fund, Pepfar, 52%.

With most Pepfar funding withdrawn in early 2025, the Global Fund has now become the main supporter of nonprofits providing key population services, although the exact proportions are not yet publicly available.

Nonprofits run services within communities, but also sometimes have health workers, such as lay counsellors and data capturers, based at government clinics. These workers help nurses with HIV testing and to quickly get HIV-positive patients onto treatment and HIV-negative people on preventive medication, should they need it.

In SA, teen girls and young women make up just under a third of the country’s 180,000 annual new HIV infections — the number of infections among this group (57,571 per year, according to the Thembisa model) is higher than for any other group with a high chance of getting infected.

But even though teen girls and young women make up such a high number of new HIV infections in SA, experts say it is important to make a special effort to bring down new infections in smaller groups like sex workers, gay and bisexual men and people who inject drugs, because even though their numbers are smaller, in proportion, they are much more likely to get HIV. Ignoring them would hurt the country’s plans to bring down HIV infections overall in the country.

So, there’s a practical reason to protect health programmes for groups like sex workers, gay and bisexual men and transgender people. It’s about how HIV spreads, not paperwork, says Jacqui Pienaar, a global health specialist at the Aurum Institute, which has received funding from the Global Fund for key population care for over a decade.

In SA, about 20% of adults have HIV. But in some groups, the numbers are much higher. For example, about 62% of sex workers and 63% of transgender women live with the virus.

“These key populations are part and parcel of our social and sexual circles. They are part of the tapestry of South Africans, and we can’t ignore them,” says Pienaar.

HIV, she cautions, does not stay contained within one group, it moves through communities.

“Everybody always thinks gay people sleep only with gay people. No, they don’t. They’re sleeping with your husband. They’re sleeping with your wife.”

Specialised services often cost more because they are designed to reach people where they are – through mobile clinics or after-hours care – rather than waiting for them to come to a clinic.

Take programmes for one of the key population groups, people who inject drugs. Their health needs are more complex than health services offered to the general population, and therefore take more time and resources.

A big part of the work involves providing methadone, a lifesaving medicine that helps people stop using drugs. But methadone is strictly regulated in SA; it has to be prescribed by a doctor, which makes it harder and more expensive to provide than the country’s usual nurse-led clinic services.

“All of that makes it more expensive,” Pienaar explains. “But if you don’t provide that level of care, you lose people. The specialised key population clinics also allow for longer visits, says Pienaar, while public clinics often have only a few minutes per patient.

“Without specialised support, many in those key populations would rather stop their treatment entirely than face the judgement they experience when they go to a general public clinic.”

Meyer-Rath and her colleagues at Wits University’s HE2RO, who study health costs, have, however, shown that while specialised care often carries a higher price tag per person, the higher impact more than makes up for the cost. For instance, giving a daily HIV prevention pill to sex workers or gay and bisexual men is more cost-effective than giving it to the general population because these groups are much more likely to get HIV infected.

For example, research reveals that in places or groups of people where the incidence rate – that is, the rate at which people are getting infected — is 3% or more, 33 people need to take prevention medication to stop one new infection. But in places where the chances for new infections is lower, 200 people have to take HIV prevention drugs to stop one new infection.

Further analysis bears this out: the cost to prevent one new infection among sex workers with the pill is R10,368, and for gay and bisexual men it is R19,618. This is far more affordable than the cost for the general population, which rises to R22,797 for young women and R37,304 for young heterosexual men. And stopping the virus in these high-risk groups protects the entire population, making it the most effective way to use SA’s limited health resources.

Also, when people drop out and stop taking treatment, the virus can keep spreading, because the amount of virus in someone’s body starts to rise again. Many studies have shown that people from these groups say they are treated badly at clinics: judged, spoken to harshly, or called names. As a result, some stay away, which is why standalone services were designed for key populations.

Sanac’s Xulu says what matters most now is to ensure people keep coming back to government clinics, and for them to be kept on treatment.

“If, for instance, trans people hear it’s difficult to get [gender-affirming hormones such as testosterone] at clinics and as a result, lose faith in the system and stop taking their treatment, that would be a major concern,” she says, “for their own health and for efforts to control HIV more broadly.”

She emphasises that the country must take a clear-eyed, disciplined approach to what can realistically be delivered with the available constrained resources, “focusing on a defined package of high-impact, comprehensive TB and HIV services”.

“This will require tough, and at times uncompromising, prioritisation of fully integrated service delivery models which are designed to eliminate duplication, drive efficiencies, and maximise value for money. Difficult choices will have to be made,” she says.

If SA wants to give key populations special services and the care they need, she says, the country will have to be “realistic and very harsh” about which services it decides to pay for.

But Venter says the country should not have to be making these decisions under pressure. He argues the government has “done a shocking job” of shifting care for key populations into the public system.

Although the Department of Health commissioned a plan showing how services for key populations could be built into public clinics, which was completed in 2023, the plan still has not been approved. In the meantime, the HE2RO researchers are busy calculating what it would cost to put that key population plan into action.

“In many ways, the way we were able to support key populations with full donor funding was a Rolls-Royce service,” says Pienaar.

It was a model where patients were given dedicated time to address complex medical and psychological needs, for example specific anal care for men who have sex with men or the specialised requirements of people who inject drugs.

But that model is no longer sustainable as donor funding shrinks.

That’s why, in the next round of Global Fund funding, the Aurum Institute will apply to pass on their expertise. It is proposing to train and support staff in public clinics instead of running their own. The aim is to move what they have learned over more than a decade into the public system so people can get the care they need at their local clinic.

But this will only work if the public health system is ready to take it on, and if the government puts existing plans into action, Pienaar says.

“If we don’t do this now,” says Venter, “we will see the results, a clear rise in infections, in five years’ time.” DM

This story was produced by the Bhekisisa Centre for Health Journalism.