KwaZulu-Natal, 14 October 2025 – “They used to give me a 3 month supply of treatment, but now they are giving me a 1 a month refill from April until now, and they never explained why”.
Giving people living with HIV more pills to go home with reduces how often people must go to the clinic. Not only does this decongest facilities, but it also makes it much easier for people to stay on treatment. This is key to achieving the goal committed to by the National Department of Health – to put 1.1 million of the 2 million people living with HIV not on treatment, on or back on treatment by the end of 2025.
Before the PEPFAR disruptions, KwaZulu-Natal had made considerable progress – with 84% of people surveyed in January 2025 getting a 3 month supply or longer of ARVs including one of the best performing districts in the country, King Cetshwayo at 97%. However, after the PEPFAR disruptions only 53% of people surveyed took home a 3 month supply or longer – a worrying 31% drop.
Not only were fewer people getting a 3 month supply – but of extreme concern are the 45% of people across multiple clinics in eThekwini who took home only a 1 month supply. Shorter treatment supplies only increase the likelihood of a person interrupting treatment or them never coming back to the clinic at all.
Changes in ARV refill length are among a number of issues outlined in the 5th edition of the Ritshidze State of Health report for KwaZulu-Natal. Between April and June 2025, the Treatment Action Campaign (TAC) through Ritshidze carried out 6,629 surveys with public healthcare users, and spoke to facility staff to assess 60 facilities in 3 districts in KwaZulu-Natal. The data reveal the challenges arising in our clinics following the PEPFAR disruptions earlier in the year.
In King Cetshwayo – where PEPFAR support has been permanently withdrawn – 15% fewer public healthcare users surveyed reported there being enough staff at the facility, and 27% said staff shortages were worse compared to before the PEPFAR disruptions. In uMgungundlovu where PEPFAR support was temporarily suspended but then re-instated, 29% of people reported there never being enough staff to provide services. One public healthcare user we spoke to in the district illustrated this saying: “we often wait at the clinic until sunset without being assisted. We’re still new at our workplaces and fear losing our job”.
Staff shortages can increase the time people spend waiting for services at the clinic. While overall KwaZulu-Natal had the shortest waiting times out of all provinces monitored by Ritshidze, in King Cetshwayo 28% of people experienced a longer waiting time than usual after the PEPFAR disruptions. One reason for this is the disastrous state of filing systems in the district, observed at 89% of sites – up from 55% in January 2025. “We are often told that our files are missing or lost. They usually manage to find them later. I’m not sure whether they misplace the files or store them in different areas,” one public healthcare user explained. King Cetshwayo had the most filing systems in bad condition out of all districts monitored by Ritshidze.
One third of people surveyed in the district said it took up to an hour or more to receive their file. When people complained of increased delays since PEPFAR disruptions, 76% of people blamed these delays on filing systems being messier and files being lost.
“Files often go missing and it takes a long time to retrieve them. Even if you are next in the queue, other patients who have had their files retrieved earlier will be assisted before you if your file is missing… some patients are issued new files. Later, when they return, they end up with two files, which causes further delays,” another person told us. 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.
Increased understaffing at clinics is placing added pressure on already overstretched nurses – fueling frustration and making unfriendliness and poor service more common. Sadly, fewer people said staff were always friendly in KwaZulu-Natal after the PEPFAR disruptions – down from a commendable 81% in January 2025 to 68% in this reporting period. As one community member put it: “not all nurses are kind. There are a few who are compassionate and treat patients with humanity, but most of the nurses at this facility are rude. When you ask a question they respond rudely and even shout at you”.
The situation is even worse for members of key populations in KwaZulu-Natal. Ritshidze’s 2024 data collected in the community show that only 60% of gay, bisexual, and other men who have sex with men (GBMSM), 51% of trans people, 37% of sex workers, and 35% of people who use drugs reported that staff were always friendly – compared to 80% of public healthcare users in the same reporting period. Further 6% of GBMSM, 16% of sex workers, 19% of trans people, and 28% of people who use drugs surveyed in KwaZulu-Natal had been denied services in the last year, and 11% of people who use drugs had been denied their ARVs. One person who uses drugs recounted how he “tried using the government clinic but I didn’t get treated. Most of the time I was not allowed into the clinic by the security. They would think that I was there to do bad things. They would tell me to come back another day without a good reason”.
People living with HIV continue to face additional punishment if they are late for an appointment – despite the national guidelines specifically stating that no punitive actions are allowed. Almost all reports originated in uMgungundlovu where 29% said staff shouted at them on return, and 11% said they were sent to the back of the queue to wait until all other patients had been seen. “If you miss your appointment and go the next day, they make you wait until everyone else is helped. Even if your reason for missing was valid, like a family death,” explained one person living with HIV.
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, only 9% said staff asked how they could help make it easier in the future. This is despite KwaZulu-Natal already implementing longer ARV supplies and treatment collection points closer to people’s homes or work, as recommended in the national guidelines.
Without providing compassion and support at our clinics, the government will continue to lose people from treatment at unacceptable rates and will never create the welcoming, safe and non-judgemental environment needed to encourage people to come back after missing an appointment and interrupting treatment.
Viral load testing services are another critical component of the HIV response – however 13% of facility managers reported no or fewer staff to perform and explain tests, and 12% fewer people living with HIV said a healthcare worker explained their test results. KwaZulu-Natal performed worst out of all provinces monitored on this. The effect of this can be seen in deteriorating treatment literacy understanding. In this reporting period 11% of people did not know that ARVs were good for their health, and 20% did not know that having an undetectable viral load meant a person cannot transmit HIV. KwaZulu-Natal used to have the highest treatment literacy levels – now the province has fallen into second last place.
In addition, 15% of sites reported no or fewer staff to provide PrEP services following the PEPFAR withdrawal – and 23% of PrEP users surveyed said it took longer than usual to collect PrEP, and 23% were given a shorter supply. One PrEP user described how: “I went there to fetch [PrEP], they said it was out of stock and gave me another date to come. When I went back on the date they had given me, once again they told me it was out of stock and they would call me once they have it. Since then I’m still waiting for the call. I even quit taking it”. Longer PrEP supply or fast track collection systems are urgently required to reduce workload on overstretched staff and ensure people do not discontinue PrEP. Unnecessary discontinuations put people vulnerable to getting HIV at risk, and waste intensive work done to find, test, and start people benefitting from PrEP.
The latest Ritshidze State of Health report reveals the impact the PEPFAR disruptions are having on the quality of HIV service delivery – as well as the overall functioning of our clinics in the province. In previous years KwaZulu-Natal had often outperformed other provinces, however since January 2025 we have witnessed a number of setbacks that must be urgently attended to. Without rapid action by duty bearers, the critical gains that had been made in the HIV response in the province will be lost.
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 KwaZulu-Natal State of Health report is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-State-of-Health-KwaZulu-Natal-2025.pdf
A summary presentation is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-KwaZulu-Natal-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 six PEPFAR priority districts in KwaZulu-Natal: eThekwini, King Cetshwayo, Ugu, uMgungundlovu, uThukela, and Zululand. Following cuts in funding, Ritshidze monitoring has continued in eThekwini, King Cetshwayo, and uMgungundlovu only. PEPFAR implementing partners are still active in eThekwini, Harry Gwala, uMgungundlovu, uThukela, and Zululand – while contracts have been terminated in King Cetshwayo and Ugu. Ritshidze data will be able to document any changes in the quality of service provision following the PEPFAR disruptions in the districts we are monitoring.
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: eThekwini (20 sites), King Cetshwayo (20 sites), uMgungundlovu (20 sites). Surveys were carried out with 60 Facility Managers, 3,204 public healthcare users and 1,593 people living with HIV in the Patient survey, and 3,425 public healthcare users in the Patient Exit survey.
- Key Population service data was collected in the community between July 2024 and September 2024 in 6 districts in KwaZulu-Natal. A total of 4,252 surveys were carried out (including 2,456 people using public health facilities). This combined 497 gay, bisexual, and other men who have sex with men (GBMSM), 1,257 people who use drugs, 471 sex workers, and 231 trans people.