Limpopo, 27 October 2025 – One way to make staying on HIV treatment easier, while also relieving the burden on overworked clinic staff, is simply to give people more pills to go home with. This means fewer trips back to the clinic just to collect ARVs. While progress in other districts monitored by Ritshidze deteriorated, positively 98% of people living with HIV surveyed in Capricorn, and 93% in Mopani, still left the clinic with a 3 month supply of ARVs after the PEPFAR withdrawal.
In contrast however, only 55% of people reported getting a 3 month supply in Vhembe – a district never previously supported by PEPFAR, possibly indicating the impact of PEFPAR support over the years. Additionally, Limpopo is the only province that has not started rolling out 6 month supply at all, despite the many benefits to people living with HIV as well as clinics.
One person living with HIV explained how a 6 month supply could reduce the burden of waiting all day at the clinic: “I wake up to go to the clinic at 6am. When I arrive, we wait outside to queue and only leave in the afternoon at around 4pm to 5pm. I would love to get a 6 month refill. That would help a lot”. Another described the financial burden of frequent trips: “It would help a lot if I could get a 6 month supply of treatment. That way I could plan better and know how to manage my transport money”. Another person pointed out the difficulties in getting time off from work to go to the clinic: “I am currently forced to apply for sick leave each time I go to collect my HIV treatment.. I know I won’t be able to collect and then go to work due to the queues. Having 6 months worth of treatment would help reduce the number of days I take off work”.
Limpopo’s lack of progress on rolling out 6 month supply directly undermines the National Department of Health goal to get 1.1 million more people on, or back on, treatment.
ARV refill length is among a number of issues outlined in the 3rd edition of the Ritshidze State of Health report for Limpopo. Between April and June 2025, the Treatment Action Campaign (TAC) through Ritshidze carried out 6,355 surveys with public healthcare users, and spoke to facility staff to assess 60 facilities in three districts in Limpopo. The data reveal the challenges arising in our clinics following the PEPFAR withdrawal from the province.
Critical staff shortages were revealed across all three districts monitored by Ritshidze. “I arrived at 7am but got assisted at 12pm because there were only two nurses on duty. The clinic has long waiting times because of staff shortages.. the clinic needs more staff,” one public healthcare user told us. 80% of Facility Managers said there were too few staff. This was particularly severe in Vhembe, where 95% of Facility Managers raised this concern. “There is a shortage of nurses and that is why they work slowly,” another person explained.
Staff shortages can add to delays. Positively public healthcare users in Mopani and Vhembe reported reasonable waiting times (1:36 hours in Mopani, 2:09 hours in Vhembe). However, Capricorn had the third longest waits out of all 16 districts monitored by Ritshidze at 4:40 hours – 46 minutes longer than before the PEPFAR withdrawal. “No matter how early you arrive at the clinic you always go home late.. You can arrive at 7am and only leave at 3pm. Their service is too slow. You end up spending the whole day there,” one public healthcare user explained. 59% of public healthcare users surveyed in Capricorn thought that waiting times were long, compared to just 9% in Mopani and Vhembe. 17% of people in the district said waiting times had worsened following the PEPFAR withdrawal, with 72% blaming there being less staff than usual. “I really wait long hours there. The last time I went I had to wait 5 hours. It is more congested,” another community member told us.
In addition to giving out longer ARV refills, another solution to reduce overall delays and make ARV collection easier is to get people out of the clinic who do not need ongoing clinical care. “The clinic that I collect my ART from is far,” one person living with HIV explained. Another said “I work far from the clinic, and they have never offered to decant me”. However, progress in decanting people to pick-up points in the community has deteriorated. 22% fewer people reported using external pick-up points compared to January 2025. This is likely due to PEPFAR funded service providers no longer being available to manage these external pick-up point options. “I would like to be decanted because at an external pick-up point, I will collect quicker. I am currently forced to apply for sick leave each time I go to collect my treatment,” another person living with HIV told us.
Concerningly, 56% of people in Capricorn still collect from the facility after consultation and rescript with a clinician – up from just 6% before the PEPFAR withdrawal. This wastes the time of the person collecting their ARVs, as well as the clinician they must consult with. Capricorn was now one of the worst performing districts out of all 16 monitored by Ritshidze at ensuring people living with HIV were using one-stop community and facility pick-up points to make ARV collection easier.
On top of this, facility pick-up points continue to operate inefficiently. People should be in and out with only one-stop, able to collect their ARVs in less than 30 minutes. However 71% of people living with HIV told us they were required to go to other service points – such as registry, collecting their file, taking vitals, and seeing a clinician before collecting their parcel. This was particularly acute in Mopani, as reported by 88% of one-stop facility pick-up point users. These unnecessary service point attendances with less staff capacity at the clinic meant that 28% of people surveyed said it took longer to collect their parcel than before the PEPFAR withdrawal. It is extremely inefficient to increase workload for staff at a time when staff shortages are a crisis.
Another reason people stop going to the clinic is due to the levels of friendliness and professional treatment. Positively 84% of those surveyed at the Limpopo clinics reported staff are always friendly. Limpopo had the most friendly environments out of all 6 provinces monitored by Ritshidze. However, for members of key populations the experience is very different. One gay man told us: “Some [nurses] are very hostile. They look at you in a bad way. When they do assist you, they don’t do it with love or care. They don’t smile at you. They just help you quickly so that you can leave. I often feel low self-esteem and have become afraid of people because of this”.
Only 59% of trans people, 43% of gay, bisexual, and other men who have sex with men (GBMSM), 40% of sex workers, and 25% of people who use drugs reported that facility staff were always friendly. “I experience a lot of discrimination at this clinic. To the point that I am now scared to return there. When I am at the clinic, the security staff look at my ID, then look at me because I look feminine. They call other staff members to laugh at me and make silly jokes. The nurses also do the same. Some even ask me why I “pretend to be a girl” when I am a man. Other clinics are far from where I live. If I had money, I would rather use a private facility” one member of the LGBTQIA+ community explained.
For trans and gender diverse people there is a further level of disrespect. One woman described to us how clinic staff are judgemental towards her because she is trans: “It feels like they were never trained to be sensitive. They shout at us in the waiting area about the services we need, which is very embarrassing”. Only 46% of trans people surveyed said that staff were always respectful.
One trans man described to us the lack of gender affirming care at the clinic: “the staff ask me unnecessary questions before assisting me. They ask whether I am a woman or a man when I arrive at the facility. This is very painful and uncomfortable. The staff are not friendly. They are harsh with me. They ask these unnecessary questions in the waiting area where other patients are present, instead of in a private space. It is very humiliating”.
Another trans woman said: “I was traumatised by how badly they treated me. I never saw myself going back to that clinic again. Right now, I only have one bottle of ARVs left. When I went to the clinic, they told me they were out of ARVs for me and that there was no other way to help me because, according to the nurse, “Trump took his money.” The sad part was how rude the nurse was. She was shouting while saying this in front of other patients. I felt humiliated and scared because everyone was looking at me, and I felt like they were judging me”.
Additionally 11% of GBMSM, 15% of trans people, 17% of sex workers, and 35% of people who use drugs surveyed in Limpopo had been denied services in the last year, and 7% of people who use drugs had been denied their ARVs. Denying people their life saving ARVs puts them at risk of getting advanced HIV, multiple other illnesses, and even dying. It also further increases HIV transmission.
It is not only ARVs. PEP was denied to 27% of people because they are sex workers, 20% because they are trans, and 13% because they are GBMSM. 19% of people surveyed had been told they could not get STI services at the facility because they are a sex worker, and 14% because they are GBMSM. Contraceptives were also denied with 32% of people surveyed being denied contraceptives because they use drugs and 7% because they are a sex worker.
Additionally 25 people told us they or someone they knew had been denied services without an ID in this reporting period in Limpopo – and 31% of people who use drugs surveyed across the province last year had been denied access to services because they did not have an ID. Limpopo had the highest proportion of reports of people who use drugs being denied services without an ID out of all 7 provinces monitored by Ritshidze.
While the South African public health system is under strain, scapegoating migrants diverts attention away from the real challenges – decreasing budgets and lack of investment, the withdrawal of PEPFAR resources, overworked healthcare workers, mismanagement, corruption – that have plagued the public health system. Denying migrants health services does not alleviate this crisis. Furthermore, an estimated 12% of people born in South Africa do not have identity documentation.
Overall Limpopo – and Capricorn, Mopani, and Vhembe individually – did outperform other provinces and districts monitored by Ritshidze across several aspects of health and HIV service delivery which is commendable – especially friendliness, critical to keeping people in care. However, even staff friendliness cannot make up for unnecessary long waiting times and we simply cannot get everyone on HIV treatment or prevent new infections while denying people entry to clinics or access to services, making conditions intolerable for some, or by failing to implement simple and proven interventions to make ARV collection quicker and easier, including ‘one-stop’ pick-up points and giving out a 6 month supply of ARVs. Now is time for the provincial and district health departments to focus on addressing the remaining challenges that still create barriers to people accessing healthcare and HIV services. This is the only serious way to get another 1.1 million people to start, or restart HIV treatment.
For more information or to arrange interviews contact:
Ngqabutho Mpofu | +27 72 225 9675 | ngqabutho.mpofu@tac.org.za
Lotti Rutter | +27 82 065 5842 | lotti@healthgap.org
Notes:
The Limpopo State of Health report is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-State-of-Health-Limpopo-2025.pdf
A summary presentation is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-Limpopo-State-of-Health-October-2025.pdf
What is Ritshidze?
Ritshidze is a community-led monitoring (CLM) system implemented by the Treatment Action Campaign (TAC). Through Ritshidze, community members systematically collect data at clinics and in the community that are analysed, and then used to generate solutions to problems that are put to duty bearers for action. Community-led monitoring is an indispensable strategy for improving the state of our public healthcare system, and getting more people on ARVs.
How does Ritshidze collect data?
Ritshidze collects both quantitative and qualitative data through observations, as well as through the implementation of standardised surveys and in depth interviews with healthcare users (public healthcare users, people living with HIV, members of key populations) and healthcare providers (Facility Managers, pharmacists/pharmacist assistants). All Ritshidze’s data collection tools, our data dashboard, and all raw data are available through our website.
What changes have been made in where Ritshidze collects data following the PEPFAR disruptions?
Prior to the end of January 2025, Ritshidze data was collected across sites in two PEPFAR priority districts in Limpopo: Capricorn and Mopani. While Ritshidze monitoring will continue in these districts, PEPFAR implementing partners have now had their contracts terminated in both districts – the province is no longer receiving PEPFAR support. Ritshidze data will be able to document any changes in the quality of service provision following the PEPFAR disruptions. From this reporting period, Ritshidze data will also be collected in Vhembe, a non-PEPFAR priority district. By moving beyond only monitoring PEPFAR priority districts, Ritshidze aims to understand the quality of service provision in the next layer of high demand/high burden districts.
What changes were made to data collection to determine the impact of PEPFAR funding cuts on HIV services?
A new tool was developed in this reporting period to survey patients as they exit the clinic. This was to gather evidence to the state of service provision that day – to better understand the impact of the PEPFAR disruptions on clinics. All monitoring tools are available here: https://ritshidze.org.za/category/tools/
Data collection periods and locations
- Facility level data was collected between April 2025 and June 2025 at 60 public health facilities in three districts: Capricorn (20 sites), Mopani (20 sites), and Vhembe (20 sites). Surveys were carried out with 60 Facility Managers, 3,155 public healthcare users and 1,514 people living with HIV in the Patient survey, and 3,200 public healthcare users in the Patient Exit survey.
- Key Population service data was collected in the community between July 2024 and September 2024 in three districts in Limpopo: Capricorn, Mopani, and Vhembe. A total of 1,679 surveys were carried out in the province (including 1,367 people using public health facilities). This combined 264 gay, bisexual, and other men who have sex with men (GBMSM), 603 people who use drugs, 299 sex workers, and 201 trans people.