Eastern Cape, 16 October 2025 – “Sometimes I don’t even want to go to the clinic because of the long waiting hours and other difficulties we face. We arrive early in the morning. Even when it’s still dark, just to queue. And we end up leaving very late. That’s one of the reasons people stop using the clinics”.
Long waiting times continue to frustrate public healthcare users who waste long hours in queues for check-ups, and even just to collect medication. “On my last visit, I waited for close to seven hours,” one public healthcare user told us. The Eastern Cape had the second longest waiting times out of the six provinces monitored by Ritshidze.
48% of people said the waiting times at the facility are long. This rose to 73% in Buffalo City. One person living with HIV explained: “when you have a clinic appointment, you have to tell yourself that you’re going to spend your whole day at the facility. It’s very painful. Sometimes I tell myself that I am not going because of all the challenges”. While PEPFAR support is still active in both districts we are monitoring in the province, 24% of people said that waiting times were longer than usual after the PEPFAR disruptions (34% in Buffalo City).
While 76% of people blamed staff shortages, 25% blamed staff not working or working slowly. As one person described: “there are enough nurses.. but they don’t work effectively. They spend time talking.. instead of assisting patients.. Some even go shopping while we are there, hungry and without money for food”. Waiting times cannot be ignored as the Department of Health aims to get 1.1 million more people on (or back on) HIV treatment by the end of 2025.
Long waiting times are among a number of issues outlined in the 5th edition of the Ritshidze State of Health report for the Eastern Cape. Between April and June 2025, the Treatment Action Campaign (TAC) through Ritshidze carried out 4,215 surveys with public healthcare users, and spoke to facility staff to assess 40 facilities in 2 districts in the Eastern Cape. The data reveal the challenges arising in our clinics following the PEPFAR disruptions earlier in the year.
Critical staff shortages continue to drive long waiting times. “The main problem is the shortage of staff.. which is why we often end up waiting for long hours to be assisted… it is very frustrating,” one person explained to us. In Buffalo City – where PEPFAR support was temporarily suspended but then re-instated – 80% of Facility Managers reported the PEPFAR partner working at reduced capacity, and 100% said there were not enough staff at their clinics. 28% of public healthcare users in the district agreed there were never enough staff, and 23% thought staff shortages had worsened since January 2025. One community member described how “the nurses at the clinic are very slow… this is painful. I often leave the facility feeling frustrated because when I leave late, I still need to get a sick note to give to my employer, even though I arrived at the clinic early.”
Paper filing systems in disarray are another cause of the delays. While the condition of the filing systems has been improving in OR Tambo, this still needs attention with 25% still reported to be in a bad condition. In contrast, Buffalo City’s filing systems are reported to be in a disastrous state with 80% reported to be in a bad condition – a worrying 43% increase from January 2025. “We usually get our files quickly, but sometimes there are unexplained delays. You can queue and move along with the line, but when it’s your turn, they keep looking for your file,” one person explained. Buffalo City had the second most reports of filing systems being in a bad condition out of the 16 districts monitored by Ritshidze.
Given that PEPFAR partners have often supported the maintenance of clinic filing systems and funded data capturers, it is sensible to think this is correlated with the PEPFAR implementing partner working at a reduced capacity, as reported by 80% of facilities in Buffalo City. One person living with HIV described how: “our files often go missing. They will tell you that they can’t find your file. Then you have to wait for them to create a temporary file, which also takes time”. 36% of people surveyed said that the delays were longer after the PEPFAR disruptions because of filing systems being messier and files being lost. Only 14% of people said it took under 30 minutes to find their file in Buffalo City – 25% less than in January 2025 – while 29% said it took over an hour.
One easy solution to reduce congestion and overall delays is to get people out of the clinic who do not need ongoing clinical care. In January 2025, the Eastern Cape was among the provinces making the slowest progress in giving out longer ARV supplies – with Alfred Nzo only giving 39% of people surveyed a 3 month supply or longer. Positively, the facilities in the province surveyed by Ritshidze managed to increase the amount of people getting a 3 month supply or longer to 88%, becoming the best performing province monitored by Ritshidze. However due to funding cuts, Ritshidze was unable to monitor either Alfred Nzo or Chris Hani – and we do not know if these districts have improved or not.
Conversely, progress in decanting people to pick-up points in the community has deteriorated. One person living with HIV who has returned to the clinic described the ease at the pick-up point: “I used to collect my treatment at Clicks, and that system was very helpful. You would get there, press “collect” on the machine, sit down, and then they’d call you to collect your treatment. The process was very quick”. However, in this reporting period 57% of people surveyed in the Eastern Cape said they had to collect their ARVs at the facility after consultation and rescript with a clinician. The Eastern Cape was the worst performing province on this. OR Tambo performed worst out of the 16 districts monitored, with 25% fewer people using external pick-up points after the PEPFAR disruptions. This while 65% of people said they would like to collect ARVs closer to their home if it were possible.
One-stop facility pick-up points continued to operate inefficiently in the Eastern Cape, requiring 42% of people living with HIV surveyed in the province to go to other service points before collecting their parcel. “There is no sense of urgency… when you go to collect your treatment, you will still leave at 4pm when they are about to close. Ideally, your treatment should already be packed so you can just collect it and leave,” one person living with HIV told us.
While it should take less than 30 minutes to collect your parcel, only 48% of people said it did, down from 77% in January 2025. 15% of people surveyed in OR Tambo and 29% of people in Buffalo City said it took longer to collect their parcel than before the PEPFAR disruptions. One person living with HIV explained: “we wait for long hours.. even if we are just here to collect treatment. There has never been a day at this facility when I could just collect my treatment and leave. This is frustrating because I have temporary jobs that I need to attend to as well”. It is extremely inefficient to increase workload for staff at a time when staff shortages are a crisis.
Changing between clinics remains difficult in the Eastern Cape. 26 people told us they or someone they knew had been denied services without a transfer letter in the last 3 months, all in Buffalo City – something that is not required by national ART guidelines to start or restart your ARVs. On top of that 56 people told us they or someone they knew had been denied services without an ID – accounting for 19% of the 291 people who reported this across all provinces monitored by Ritshidze. 18% of people who use drugs surveyed across the province had been denied access to services because they did not have an ID.
Members of key populations had also been refused access to health services. “Some staff members at the clinic are very homophobic. When they see someone is part of the LGBTIQ community, they sometimes refuse to assist them,” one member of the LGBTQIA+ community told us. 12% of gay, bisexual, and other men who have sex with men (GBMSM), 15% of trans people, 19% of people who use drugs, and 21% of sex workers we surveyed had been denied services in the last year, and 9% of people who use drugs had been denied their ARVs.
The report also finds that health workers continue to treat members of key populations poorly – let alone be sensitive to or knowledgeable of the health services they need. As one gay man explained: “when I disclose that I’m gay or that I have sex with men to a healthcare worker, they sometimes shout or make inappropriate remarks, such as, “anal sex is painful; how do you do it?”. Only 28% of trans people, 21% of GBMSM, 17% of sex workers, and 15% of people who use drugs surveyed thought staff were always friendly. People in the Eastern Cape reported some of the worst attitudes towards members of key populations out of all provinces monitored by Ritshidze.
Another challenge in the report is an ingrained culture of punishing those who are late for appointments. One person living with HIV explained: “If you’ve missed your appointment at the clinic, they don’t help you at all. If you decide to stay, they might help you collect your treatment, but after seven hours, when everyone else has been assisted”.
Health workers must recognise that people living with HIV might miss appointments and may even miss taking some pills. That is normal. When they return to the clinic they should be met with support and encouragement, not punishment. Yet in Buffalo City, 60% of those who had been late for/missed appointments said staff shouted at them, and 22% were sent to the back of the queue. “Some nurses shout at you if you’ve missed your appointment date. They even tell you they will assist you last, even if you were next in line. So you’re forced to go to the back of the queue. This is very stressful, but I wait patiently because I need my ARVs,” another person living with HIV told us. The guidelines specifically state that no punitive actions are allowed. Instead the majority of people re-engaging in care need it to be made easier to collect treatment. Yet of people surveyed across the province, 0% said staff asked how they could help make it easier in the future.
HIV prevention has also been impacted. Only 75% of sites monitored in OR Tambo had external condoms available – this is unacceptable as the provision of condoms is known to be the cheapest and most cost effective HIV prevention intervention. Only 48% of sites had lubricant available. One gay man living with HIV describes the pain in asking for lubricants: “At the drop-in centre, we used to get lubricant freely. But at the facility, you have to ask because it is not displayed. This makes me feel ashamed. The last time I asked, the staff said.. they don’t think they’re meant for people like us. Since then, I’ve stopped asking for them’’.
51% of PrEP users said it took longer than usual to collect PrEP, and 5% had to return because of the queues. In OR Tambo less than half of facilities were even prioritising offering PrEP to members of key populations. PEP has been routinely denied to members of key populations – of those who tried to access it only 56% of trans people, 34% of sex workers, and 19% of GBMSM said they were always able to get PEP in the last year. Further, sterile needles and syringes remain out of reach for people who inject drugs, with clinics either providing no information or referring people to private pharmacies to buy needles themselves, or to hospitals that do not provide them. Just 7% of people who use drugs said they were given any information about where to get these commodities.
43% of trans people wanted to access hormones at the facility in the last year – however hormonal care remains unavailable in primary health facilities. Following the closure of two PEPFAR funded drop-in centres for trans women in the Eastern Cape, this situation is only going to worsen.
What is clear is that government cannot get everyone on HIV treatment while denying people health services, or by making conditions intolerable. The failures in the health system are key reasons why people struggle to stay on ARVs, or access HIV prevention. Without making changes, the government will continue to lose people at unacceptable rates. This year’s report continues to call for urgent action to improve health services – that have only deteriorated following the PEPFAR disruptions in the Eastern Cape.
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 Eastern Cape State of Health report is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-State-of-Health-Eastern-Cape-2025.pdf
A summary presentation is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-Eastern-Cape-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 the Eastern Cape: Alfred Nzo, Buffalo City, Chris Hani, and OR Tambo. Following cuts in funding, Ritshidze monitoring has continued in Buffalo City and OR Tambo only. PEPFAR implementing partners are still active in both districts. 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 40 public health facilities in two districts: Buffalo City (20 sites), and OR Tambo (20 sites). Surveys were carried out with 40 Facility Managers, 2,107 public healthcare users and 1,150 people living with HIV in the Patient survey, and 2,108 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 the Eastern Cape: Amathole, Buffalo City, Nelson Mandela Bay, and OR Tambo. A total of 3,149 surveys were carried out in the province (including 2,196 people using public health facilities). This combined 542 gay, bisexual, and other men who have sex with men (GBMSM), 834 people who use drugs, 605 sex workers, and 215 trans people.