By Dr Puni Mamdoo
Dr Mamdoo is a Public Health Medicine Specialist Physician contracted to the Department of Public Health at Nelson Mandela University.
With this abrupt cessation of US funding through PEPFAR, USAID and other agencies, we have lost a massive resource that aligned with government to strengthen the HIV/TB programme.
World AIDS Day 2025 is being used to advocate for more funding but it is also the opportune time to rethink donor funding across the continent.
Funding is fickle – this is the lesson we learned so bitterly this year. Some of us in the development sector already recognised this vulnerability to politics and expected NGO leadership to build sustainability into their workplans, considering the scale of funding over the past 25 years.
The lesson here is for leaders of donor-funded organisations to adopt public health principles, like equity, quality, sustainability and systems, thinking when negotiating with funders. Public Health Medicine Specialist Physicians in South Africa possess the specific training, skills and expertise to lead, manage and operationalise population-level interventions and programmes.
We also need to rethink the regulation of NGOs. One gaping need is for NGOs to be more accountable to the provincial departments of health but this requires the capacity to manage and regulate NGO partnerships. Regardless of size, NGOs and other funded initiatives, such as Corporate Social Investment (CSI) projects, should be transparent about how they spend their money in health, so that their work aligns with the needs of the South African health system.
Unifying among all countries in the post-USAID and PEPFAR funding withdrawal, is that sustained funding will be necessary to eliminate HIV/TB as a threat. A major question is whether governments of low- and middle-income countries can provide for such medicines and services in their fiscus to avoid donor dependence.
I have witnessed first-hand the power -distance and lack of agency of NGOs and ranked health officials alike, when communicating local population health needs and priorities to international donors.
Our development in South Africa must be democratised and pluralistic, so in the next wave of funding, we want to avoid centralised funding to only a few large NGOs. The last 30 years of funding has shown that this model must be improved, if we are to meet the challenge of comprehensive primary healthcare for all in South Africa.
Those NGOs with grassroots campaigns, strong leadership in public health medicine and the all-important capacity to implement, will allow more resources to find its way to the bottom of the pyramid.
South Africa has achieved significant progress in stemming the HIV epidemic since the early 2000s, with all the funding and the resources spent thus far.
The activism of World AIDS Day is to re-emphasise the current goals for the HIV/Aids programme: 95% of people living with HIV must be diagnosed; 95% of those diagnosed must be treated and 95% of those on treatment must achieve a state of chronic stable health (called “virally suppressed”). While we have not yet achieved all these targets, we have a pathway towards this goal.
South Africa should be really proud: we have the biggest rollout of antiretrovirals (ARVs), which means that we have the greatest number of HIV positive people on treatment in the world. This is our first achievement.
The second achievement is that we have reduced to less than 1%, the chance of vertical transmission of HIV from mother to child. This is a huge win for South Africa because it means that pregnant women do not transfer HIV to their babies. Prior to this achievement, babies born with HIV suffered poor health and low life expectancy. We have managed to nearly eliminate this as a source of HIV infection.
After the initial AIDS denialism, there is no doubt that the South African government has been taking the lion's share of the responsibility in providing ARVs (a combination of three drugs in one tablet, taken once a day).
Internationally donor-funded organisations have played a role as well, in the ARV programme, doing direct service delivery before 2010, and later transitioning to “technical assistance”, which means, in practical terms, supporting government in the HIV/TB programme through, for example ex training, staffing and resources.
Our third achievement is in recognising that the South African government must be credited for the provision of ARVs and essential medicines in the fiscus even though this provision is marred by stock-outs..
HIV and TB are a dual epidemic – having either of these conditions enhances your susceptibility for the other. Our fourth achievement is to have recognised and addressed this double-pronged threat to population health, although there is still work to be done here.
The advocacy around World Aids Day is meaningful and important because we lost many South African lives due to the disease. In the early 2000s the average life expectancy at birth for a South African was just 57 years. With the advent of HIV/TB programme we have realised our fifth achievement, which is an increase in average life expectancy to about 66 years in 2025..
The HIV/TB epidemic looks different even among low- and middle-income countries. Over the past decade key populations like IV drug users (IVD), men who have sex with men (MSM) or sex workers have been targeted to achieve coverage of screening, diagnosis, treatment and retention in care. In South Africa, the HIV/TB epidemic is showing a concerning trend – new cases are mainly seen in adolescent girls and young women (AGYW) aged 15 to 49.
The South African Health Products Regulatory Authority (SAHPRA) approved recently Lenacapavir, a twice-yearly injection, which is a game-changer in HIV prevention, but innovations do not exist alone – they require responsive systems to proliferate.
This World Aids Day 2025, our advocacy is not only about funding but a need for concerted and coordinated funded public health medicine approaches to health systems to eliminate the HIV/TB epidemic, recognising the hard-won gains and preparing ourselves for sustainable Public Health Medicine.