Johannesburg, 22 October 2025 – “Since January, now they cut the lines of people after 11am saying it’s late and there are no staff. They say they only take a certain number of people”.
In Gauteng, the majority of Facility Managers surveyed reported critical staffing shortages with 38% blaming the sudden withdrawal of PEPFAR supported healthcare workers, or those remaining working at a reduced capacity. The situation was particularly severe in Johannesburg, where 78% of Facility Managers raised this concern. 37% of Facility Managers surveyed in the province blamed the 374 unfilled vacancies that were reported across just 38 sites – the most vacancies reported out of all six provinces monitored by Ritshidze.
Public healthcare users also felt the impact of the reduction in staff. Only 19% said there were always enough staff at the clinic – a considerable reduction from 36% in January 2025. One public healthcare user described the congestion: “Last week I spent so many hours [at the clinic]. The registration area is always packed, but also in the consultation rooms. You’ll find that there is only one doctor to assist everyone”.
Critical staff shortages are among a number of issues outlined in the 5th edition of the Ritshidze State of Health report for Gauteng. Between April and June 2025, the Treatment Action Campaign (TAC) through Ritshidze carried out 7,482 surveys with public healthcare users, and spoke to facility staff to assess 81 facilities in four districts in Gauteng. The data reveal the challenges arising in our clinics following the PEPFAR disruptions earlier in the year.
Staff shortages are only adding to the delays. Gauteng had the third longest waiting times out of all six provinces monitored by Ritshidze. A community member explained to us their frustration with the long waits: “I normally leave home at 6am… then leave the clinic around 4pm. These long waiting times are frustrating and painful, especially because sometimes you leave the clinic without being assisted and have to return the next day”. 59% of public healthcare users thought waiting times at the facility were long, and 19% reported longer delays on the day of monitoring than before the PEPFAR disruptions. “My main challenge is that we arrive as early as 4am… nurses only start attending to patients at around 10am,” another community member told us.
Long waits aren’t just frustrating – they drive people out of the system. Every extra hour in a line is another reason to miss a treatment collection, to skip a visit, or to stop coming back. “When it’s my appointment date I spend more than 6 hours at the clinic. The process is so slow.. You wait for the whole day,” one person living with HIV told us. These queues directly undermine the National Department of Health goal to get 1.1 million more people on, or back on, treatment.
Disorganised clinic filing systems also contribute to delays when files pile up waiting to be captured or refiled, and there are too few hands to keep up. This has only deteriorated with the disruption of PEPFAR support that often helped keep records up to date and files in order.
Filing systems were observed to be in a terrible state – with 67% in a bad condition in the Johannesburg (28% more than in January 2025), 65% in the City of Tshwane, and 45% in Sedibeng. When leaving the facility that day, 46% of people surveyed in Gauteng said that the delays were longer than before the PEPFAR disruptions because of filing systems being messier and files being lost.
Increased understaffing is also placing added pressure on already overstretched nurses – fueling frustration and making unfriendliness more common. People living with HIV are routinely punished in the province. “It’s worse if I am late for an appointment,” one person living with HIV told us. “I went back on Thursday, and they turned me away saying people who missed their appointments are only seen on Fridays because they are short staffed.. I spend around R60 every time I go to the clinic. When I went back on that Friday I got to the clinic at 7am and only left the clinic at 3pm”.
Instead of health workers making it easier for people to keep collecting their treatment – as reported by just 2% of people who had been late for or missed an appointment surveyed in Gauteng – 12% said staff shouted at them on return in the City of Tshwane and Sedibeng. 61% of people surveyed in Johannesburg said they were sent to the back of the queue to wait until all other patients had been seen first as punishment. “If you miss your appointment date and go on another day, you’ll be served last. Even if you arrived at 4am and were first in line.. this is unfair, especially if you explained that you couldn’t come earlier due to work obligations or other valid reasons,” another person explained to us. Yet the guidelines specifically state that no punitive actions are allowed.
Members of key populations in particular continue to be treated poorly in our clinics. “They stigmatise us as soon as we enter the facility and even say things like, “the prostitutes have arrived,” in front of other patients.. It is very painful. I cry because of the bad treatment I receive,” one sex worker told us. Only 22% of people who use drugs, 41% of trans people, 49% of sex workers, and 61% of gay, bisexual, and other men who have sex with men (GBMSM) surveyed reported that facility staff were always friendly in our last data collection.
This situation is even worse following the sudden closure of some PEPFAR-funded services, forcing people back into the public health system. One sex worker described her re-entry into the clinic: “[The nurse] was giving me a poor attitude. I hated that she went to the other room with my file and stated to her colleagues that I am a sex worker from Wits RHI and I am here to crowd the clinic. She said she now understands why Donald Trump cut the funds.. I just kept quiet.. I feel like they were happy that foreign aid was cut because they seem to think that as sex workers, we don’t deserve services”.
A person who uses drugs also explained his situation trying to get HIV treatment at the clinic: “I had tested HIV positive in January by Anova. They were supposed to come back the following week to give me medication and a letter to go to the clinic.. We waited for them.. They never came.. I tried to go to the clinic.. The nurse was rude, very rude. According to her, she can see I was positive.. she was judging me.. we ended up arguing.. they called security on me. I was chased out*.”
Denying people ARVs and other health services is unconstitutional. Yet 11% of GBMSM, 24% of sex workers, 29% of people who use drugs, and 47% of trans people surveyed in Gauteng had been denied services in the last year. On top of that 16% of people who use drugs had specifically been refused their ARVs – including 27% in the City of Tshwane, and 42% in Sedibeng.
Additionally 50 people told us they or someone they knew had been denied services without an ID in this reporting period in Gauteng – and 24% of people who use drugs surveyed across the province last year had been denied access to services because they did not have an ID – including 33% in the City of Tshwane, and 46% in Sedibeng. 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.
One way to relieve the burden on overworked staff members is to give people longer ARV refills. However, while before the PEPFAR disruptions Gauteng was among the better performing provinces, only 75% of people reported getting a 3 month supply or longer on the day of monitoring – including only 69% in Johannesburg and 54% in Sedibeng.
Progress is reversing just as the health department should be rolling out 6 month supply. “Having to travel to the facility every 2 months is financially straining… I would like to receive a 6 month supply, as this can help reduce transport costs,” one person living with HIV told us. Another explained: “At work I always have to explain my absence to go to the clinic. Some employers don’t like employees who frequently request time off. Getting a 6 month supply of treatment would reduce these problems”. Yet since August less than 2,400 people have been enrolled to date, in one of the highest HIV burden provinces in South Africa.
Another way to reduce the burden on healthcare workers is ensuring that people who come to collect ARVs at facility pick-up points do just that, in under 30 minutes. But instead they are operating inefficiently. 21% of facility pick-up points users in Johannesburg and 24% in Sedibeng were required to go to other service points (such as registry, collecting files, taking vitals, and seeing a clinician) before collecting their parcel – unnecessarily increasing the workload for staff at a time when staff shortages are a crisis.
It also increases the time it takes to collect your pills. One person living with HIV told us: “You have to wait while they look for your file.. You have to go into the consultation room to consult with a nurse.. Only then do they give you your ARVs”. Only 69% of people said it took under 30 minutes to collect their parcel in Johannesburg (an 11% decrease from January 2025), and just 43% in Sedibeng (a 12% decrease from January 2025).
HIV testing has also been impacted by the PEPFAR disruptions. Only 47% of people not on ART reported being offered HIV tests at a health facility visit in this reporting period. 30% of facilities in Johannesburg, 25% in the City of Tshwane, and 25% in Ekurhuleni reported that there were fewer staff to provide HIV testing following the PEPFAR disruptions. This means it is not possible to identify people who are living with HIV who need to start or restart treatment – or identify people for prevention services.
Other HIV services were also impacted in Gauteng. 24% of sites said that there are fewer or no staff to conduct viral load tests. “The facility is often overcrowded, and there are times when I’ve had to leave without drawing blood for viral load testing because of the large number of patients waiting,” one person explained. Additionally, 34% of sites said there were fewer or no staff to conduct routine clinical consultations.
PEPFAR funded services for people who use drugs were temporarily closed in the City of Tshwane for a period of 15 days during the initial chaos of the work stop orders – and 4,000 people who use and inject drugs from the City of Tshwane faced disruption in accessing needles/syringes and methadone. While these services have resumed it is limited – no new clients are being initiated on methadone. While 51% of sites in Gauteng said they refer people who want access to methadone onwards, the reality is there is nowhere to refer them. National guidelines and policies must be amended to ensure that opioid substitution therapy is made available in clinics.
Following the closure of the PEPFAR funded drop-in centre for trans women in Johannesburg, access to lifesaving hormonal care has also deteriorated. 31% of trans people wanted to access hormones at the facility in the last year – yet hormonal care is not available in primary health facilities currently. One trans woman told us: “I used to get my hormones at Aurum Institute, but now that they are closed I can’t access them anymore. We can only get them by buying them. At the clinic I am currently using, they never give us information on where to access them. They also don’t give us contraceptives. They said they are not for trans people”. A change in national policy is critical to ensure that hormones could be prescribed by doctors at primary level, just like they are by private GPs. This would expand access to many more trans and gender diverse people in need.
Overall, the reversal in progress following the PEPFAR disruptions as well as the ongoing failings in the health system contribute to slow progress towards getting everyone to start or restart, and then stay on HIV treatment. This year’s report continues to call for urgent action and reform. Gains made in the HIV response in South Africa cannot be undermined by increasingly poor quality healthcare services and denial of services.
* This person has since been supported by Anova to start ARVs at a different clinic.
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 Gauteng State of Health report is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-State-of-Health-Gauteng-2025.pdf
A summary presentation is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-Gauteng-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 four PEPFAR priority districts in Gauteng: City of Tshwane, Ekurhuleni, Johannesburg, and Sedibeng. Ritshidze monitoring has continued in all four districts. PEPFAR implementing partners are still active in the City of Tshwane and Ekurhuleni – while contracts have been terminated in Johannesburg and Sedibeng. Ritshidze data will be able to document any changes in the quality of service provision following the PEPFAR disruptions.
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 81 public health facilities in four districts: City of Tshwane (20 sites), Ekurhuleni (20 sites), Johannesburg (28 sites), and Sedibeng (11 sites). Surveys were carried out with 81 Facility Managers, 4,038 public healthcare users and 1,993 people living with HIV in the Patient survey, and 3,444 public healthcare users in the Patient Exit survey.
- Key Population service data was collected in the community between July 2024 and September 2024 in 4 districts in Gauteng: City of Tshwane, Ekurhuleni, Johannesburg, and Sedibeng. A total of 2,788 surveys were carried out in the province (including 1,132 people using public health facilities). This combined 286 gay, bisexual, and other men who have sex with men (GBMSM), 472 people who use drugs, 286 sex workers, and 88 trans people.