Johannesburg, 10 October 2025 – Between April and June 2025, a scaled down team at the Treatment Action Campaign (TAC) began monitoring through Ritshidze to assess the state of our clinics. During the three months we carried out 32,530 surveys with public healthcare users, and spoke to facility staff to assess 326 facilities in 16 districts, across 6 provinces. The data reveal the impact of the PEPFAR disruptions following the U.S funding cuts earlier in the year.
48% of public health facilities monitored reported reduced capacity after the PEPFAR disruptions. The loss of health workers is only adding to the pressures on already overburdened staff. 85% of facilities reported not having enough staff to meet the needs of patients, with 21% blaming these gaps on PEPFAR partners no longer working or working at reduced capacity at the facility. 62% of public healthcare users surveyed also reported too few staff, with 19% of people saying these shortages have only gotten worse following the PEPFAR disruptions.
The ripple effect of the impact of the PEPFAR disruptions is apparent in the quality of HIV services currently being provided, together with increasing levels of dysfunction in our clinics.
Waiting times have worsened in a number of districts – frustrating public healthcare users who waste long hours in queues for check-ups and even just to collect medication. “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,” one person living with HIV told us. 22% of public healthcare users surveyed said waiting times were longer than usual after the PEPFAR disruptions, with 68% blaming the delays on fewer staff working than usual. Waiting times cannot be ignored as the Department of Health aims to get 1.1 million more people on HIV treatment – including those who have disengaged because of poor conditions at the clinic.
Another reason for the increased delays is the worsening in the state of clinic filing systems. As many as 80% of sites or more in some districts have filing systems in disarray, leading to people waiting longer to receive their files. 54% of people surveyed blamed the longer waiting times on it taking longer to find their files than usual. 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 disruptions.
An easy solution to reduce congestion and overall delays is to get people out of the clinic who do not need ongoing clinical care. This can be done by giving out longer medicine supplies and letting people collect ARVs at external pick-up points closer to home. Easier and quicker ARV collection with fewer visits to clinics makes space for the 1.1 million people who still need to start, or restart, treatment by the end of 2025. However progress has plateaued in some districts and reversed in many following the PEPFAR disruptions. 9% fewer people reported getting a 3 month supply of ARVs compared to January 2025, with decreases across all provinces except the Eastern Cape. 8% more people reported only getting a 1 month supply, with worrying increases in the Free State and KwaZulu-Natal. Shorter treatment supplies only increase the likelihood of a person interrupting treatment or them never coming back to the clinic.
While a lot of what we find through community-led monitoring are issues that must be resolved at the local, district, and provincial levels, there are systemic issues that the National Department of Health must resolve. For example, TAC and Ritshidze have been pushing for people to be given a 6 month supply of ARVs at a time for many years, based on evidence from many other countries. A commitment was made on World AIDS Day last year from the Minister of Health and Deputy President to begin rollout, and ensure at least 30% of people eligible are receiving 6 months supply. However implementation only started in August outside of the Western Cape with less than 10,000 people enrolled to date. Very low targets were also set in the first place that are inequitable and far too slow – only 10 facilities per province until end March 2026. The National Department of Health must adjust targets to ensure that phase 1 and 2 implementation from now until end March 2026 includes a minimum of 50% of all facilities – with full roll out during the last phase.
Since the PEPFAR cuts, 35% of people living with HIV report it now takes longer to collect their ARVs. Use of external pick-up points has dropped by 8% – a direct result of PEPFAR partners no longer managing many of them. One person told us: “at the external pick-up point you are in and out. Now I have to wake up early to be at the clinic at 7am and I will be there for three hours just to collect ARVs.” TAC has been calling for more pick-up points for years – not fewer. The solution is simple: many community based organisations (CBOs) are ready to run pick-up points in their own communities. But the current funding model is designed for large private pharmacy networks serving thousands, not small CBOs supporting 50–100 people. The National Department of Health and National Treasury must create a dedicated CBO-friendly model – one that makes it easy to register, contract, and fund community-led pick-up points. It is time to leverage community partners – because they do not just hand out ARVs, they are also there when someone is struggling to stay on treatment.
HIV testing – the entry point to treatment and prevention – has also been hit hard. One in five facilities now report having no or fewer staff to do testing, largely due to the loss of PEPFAR-funded counsellors. With fewer staff, finding the 1.1 million people who need to start or restart treatment becomes an even harder task. Many people going to the clinics are not being tested. Only 47% of people not on ART said they were offered an HIV test while at the clinic – dropping below 30% in some districts. Every person attending a facility must be tested for HIV at least once a year – and counsellors must be funded to make that possible.
Since the PEPFAR disruptions, more people surveyed reported that staff were unfriendly compared to January 2025. Understaffed clinics are placing added pressure on already overstretched nurses – fueling frustration and making unfriendliness and poor service more common. Public healthcare users are left to face long waits and unfriendly staff.
Ritshidze’s community-led monitoring over the last eight years has shown that people living with HIV who move are routinely denied care and access to services when nurses demand that they produce a transfer letter from their previous clinic. This remains a critical challenge. Instead of immediately providing the person with ARVs and ensuring they do not interrupt treatment unnecessarily, nurses are turning people away for paperwork. 320 people told us they or someone they knew had been denied services without a transfer letter in the last 3 months – something that is not required by ART guidelines to start or restart your ARVs. The situation has been made worse by the sudden closure of some PEPFAR-funded services for members of key populations. This left people with no referrals and definitely no transfer letters – yet transfer letters are still being demanded at their new clinics. “I am very scared to go there without a transfer letter; I’m scared they will turn me away,” one person told us.
Other key HIV services have also been impacted since the PEPFAR disruptions. 12% of facilities reported fewer or no staff to perform viral load testing, 20% reported fewer or no staff to perform routine clinical consultations, and 20% reported fewer or no staff to provide psychosocial support services. 22% fewer people living with HIV were even aware of psychosocial support services available at the facility following the PEPFAR disruptions.
HIV prevention has also been impacted. 9% of facilities monitored had no external condoms available – down from January 2025. Sites not providing external condoms is unacceptable as the provision of condoms is known to be the cheapest and most cost effective HIV prevention intervention. 27% of sites also did not have internal condoms (13% less than before the PEPFAR disruptions), and 49% did not have lubricants (14% less than before the PEPFAR disruptions). While PEPFAR was not procuring these commodities, ensuring they were easily available to take at clinics was likely part of their role. On top of this, 13% of sites reported fewer or no staff to provide PrEP services – and 45% of PrEP users said it took longer to collect their PrEP than before the PEPFAR disruptions, and 9% were given a shorter supply. 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.
Progress on the development of Centres of Excellence (CoEs) for people who use drugs, sex workers, and queer and trans people has also ground to a halt. This is especially critical as more people have been forced back into the public health system following the closure of some drop-in centres and mobile services. CoEs are public health facilities that are identified as places members of key populations can go to access competent, quality, non-discriminatory, non-judgemental health services by healthcare workers with specialised training on the health needs of these populations. However, without additional staffing – to not only provide the expertise and specialised clinical services required, but also to instill culture change and improve attitudes towards members of key populations – as well as the provision of additional key services such as opioid substitution therapy and hormonal care, this intervention will fail.
The National Department of Health has a critical role to play in ensuring that members of key populations receive appropriate, compassionate, and non-judgemental care. That means moving beyond outdated thinking and prioritising services that work — like harm reduction and gender-affirming care. It is time to amend policies and implement existing national guidelines so that public health facilities and community outreach across South Africa can offer services that meet people where they are, not push them away.
Ritshidze is particularly concerned by the poor quality of services in Mangaung, where waiting times were among the worst recorded, filing systems were in complete disarray, and staffing shortages were acute. This is one of the country’s high HIV burden districts that has never received PEPFAR support – offering a clear picture of what the long-term absence of that support looks like. The situation in Mangaung is a warning. It doesn’t help to only tell the Free State to fix it – this is a national problem. PEPFAR support clearly contributed to better outcomes in other districts, and without urgent action, gaps left behind will deepen inequalities. The National Department of Health must step in to fill those gaps and ensure high burden districts like Mangaung receive the staff, systems, and support they need. We call for special monitoring of the situation in Mangaung at both the national and provincial levels.
Despite the loss of all funding for Ritshidze, TAC remains committed to monitoring both existing and emerging issues in our primary health system, and advocating for improvements. Over the next few weeks, six in-depth Ritshidze State of Health reports will be released documenting the impact of the cuts to HIV funding across six provinces in the country. Starting with KwaZulu-Natal next week, the reports will highlight the impact of the PEPFAR disruptions, whether good or bad, together with key areas that need rapid action by duty bearers.
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:
A presentation with the full data set and recommendations is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-National-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 being collected across sites in 26 PEPFAR priority districts. Following the PEPFAR funding cuts, monitoring is now continuing in 17 districts:
- 6 PEPFAR priority districts: OR Tambo (EC), Buffalo City (EC), City of Tshwane (GP), Ekurhuleni (GP), eThekwini (KZN), and uMgungundlovu (KZN).
- 8 previously PEPFAR supported districts where contracts have now been terminated: Lejweleputswa (FS), Thabo Mofutsanyana (FS), Johannesburg (GP), Sedibeng (GP), King Cetshwayo (KZN), Capricorn (LP), Mopani (LP), and Ehlanzeni (MP). Ritshidze data will be able to document any changes in the quality of service provision following the PEPFAR withdrawal.
- From this reporting period, Ritshidze data will also be collected in 2 non-PEPFAR priority districts: Mangaung (FS), and Vhembe (LP). 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 326 public health facilities in 16 districts across Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo, and Mpumalanga. Surveys were carried out with 321 Facility Managers, 16,781 public healthcare users and 8,363 people living with HIV in the Patient survey, and 15,479 public healthcare users in the Patient Exit survey.
- Key Population service data was collected in the community between July 2024 and September 2024 in 26 districts in 7 provinces. A total of 16,995 surveys were carried out (including 10,923 people using public health facilities). This combined 3,475 gay, bisexual, and other men who have sex with men (GBMSM), 6,515 people who use drugs, 4,719 sex workers, and 1,271 trans people.
