Key populations in Cape Town battling to access HIV state clinics after Pepfar aid cuts – study

The cut by Donald Trump in the US President’s Emergency Plan for Aids Relief (Pepfar) funding that took place earlier this year led to the closure of three specialised clinics in Cape Town that were serving members of key populations. Thousands of people who relied on these facilities lost access to services overnight, with many turning to state-owned clinics for continued care.

However, key population NGOs in Cape Town report that the uptake of affected individuals at government facilities has been far lower than initially hoped. 

The Cape Town Key Populations Collective – made up of the Sex Workers Education and Advocacy Taskforce (Sweat), the South African Network of People Who Use Drugs (Sanpud), the Triangle Project, Gender DynamiX and Sisonke National Sex Workers Movement – commissioned a rapid research project providing insight into the experiences of key populations trying to access healthcare following the funding cuts.

Of the 278 survey respondents who had previously relied on Pepfar-funded facilities, 37% reported not being on their medications for antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP) or hormone replacement therapy (HRT) in August 2025. Barriers to services included long wait times at state clinics and referral problems for those coming from other points of care.

The key population NGOs have raised concerns that the reported medication disruptions could lead to illness, increased risks of HIV acquisition or transmission and more deaths due to the disease.

“Our observation in the field is that there is a very, very low uptake of people who belong to key populations going to government clinics,” said Eugene van Rooyen, legal and policy adviser at Sweat.

He pointed out that more than 4,000 people had been affected by the closure of the specialised clinics, which included the Ivan Toms Centre for Health and the Wits Reproductive Health and HIV Institute (Wits RHI) transgender and sex worker clinics in Cape Town.

“We were only able to reach 278 of them in our survey, and the people who we reached would be the people who are relatively easy to reach – not the most vulnerable people who really need help,” said Van Rooyen.

“If our survey reflects that 37% of them have ... defaulted, we think that the number would be much higher if you were able to actually survey all the people.”

Barriers to care for key populations

In January, US President Donald Trump signed an executive order imposing a 90-day freeze on all foreign development assistance, pending a review. By late February, almost all Pepfar funding provided to international and South African HIV programmes through the United States Agency for International Development (USAID) had been permanently axed.

Read more: ‘The axe has fallen’ — Trump’s USAID issues notices to terminate funding for key health programmes across SA

Read more: Pepfar funding cut ends Cape Town programme supporting vulnerable children living with HIV

In the Western Cape, the financial loss has been around R360-million, with 10 NGOs and 700 jobs affected, according to the Cape Town Key Populations Collective study.

Many of the affected programmes served key populations that are particularly vulnerable to HIV and often lack adequate access to services, such as men who have sex with men, sex workers, transgender people and people who inject drugs.

While the Cape Town Key Populations Collective study surveyed people from across various groups, the majority of respondents (43.7%) identified as sex workers.

Of the respondents, 249 individuals reported at least one experience at a government health facility since the closure of the Pepfar-funded clinics. Nearly a quarter (24%) reported having a good experience at a state clinic. However, over a third of respondents (33%) indicated that they did not stay because the wait was too long, while 32% reported that clinic staff would not help them without a referral letter.

Some respondents also reported concerns around the confidentiality of their personal information and “rude” attitudes of staff at government facilities.

One member of a key population group who previously relied on a specialised clinic in Cape Town shared their experience with Daily Maverick on condition of anonymity to maintain their health privacy. They said they were turned away from two state clinics because they didn’t have a referral letter, before finally managing to access antiretrovirals (ARVs) at the Green Point Clinic.

Both the national and Western Cape departments of health have previously stated that six-month dispensing of ARVs is one strategy being rolled out to ease pressure on facilities in the wake of Pepfar cuts. However, the anonymous source said that when they asked clinic staff about accessing six-months of ARVs, they were told it was illegal to provide them with more than three months’ supply.

Tackling increased patient loads

Van Rooyen acknowledged that the overnight closure of the specialised clinics had placed a “huge burden” on some state health facilities, but emphasised that more needed to be done to address the difficulties that came with increased case loads at these sites.

On the issue of referral letters, he said: “Government clinics refuse to help someone unless they have a referral letter from the clinic where they used to collect their medication. This is totally unnecessary, because everybody’s information is on the computer system that all the staff at government clinics have access to.

“We have communicated this to the [Western Cape] Department of Health, and we’ve also been to visit numerous clinics to explain to the staff that these people are not able to provide a referral letter because the facility where they used to get their medication no longer exists. So, you need to make a plan.”

One of the long-standing barriers to accessing mainstream health services for key populations is the fear of stigma or hostile attitudes in these spaces.

Emily Craven, director of Sweat, told Daily Maverick: “The idea that everyone can just walk into a state clinic and get treatment, although theoretically true, completely ignores all the reasons why that wasn’t happening in the first place. We had dedicated population clinics because people did not feel like they could do that.”

The Pepfar cuts also led to the closure of the Wits RHI mobile clinic. Carol Lennon, clinic and outreach nurse at the Triangle Project, said the loss of mobile clinics was one of her biggest concerns, as this has affected access to services for unhoused people and those living in less centralised areas.

“We’ve lost the field workers and we’ve lost the mobile clinics, and that has been devastating for us … It’s not easy to find people in Cape Town that live on the street, and we were getting help from Wits RHI throughout the city … in places where the services are difficult ... to reach, but also [where there are issues of] stigma and discrimination,” she said.

Lennon noted that the Triangle Project was working to trace people who had defaulted on ARVs and link them back to care. However, confidentiality requirements around patient lists and records from the closed facilities made this process challenging.

Finding a way forward

The Cape Town Key Populations Collective shared the results of its rapid survey with the Western Cape Department of Health and Wellness, according to Craven. She described the department’s engagement with the outcomes as “positive”.

The study provided recommendations for national, provincial and municipal departments of health, including:

• Working with and supporting specialist NGOs to retain and re-engage clients lost to follow-up;
• Developing “clear mechanisms for transition” to ensure tailored HIV services for key populations were integrated into state health facilities;
• Providing ongoing training for staff of departments of health at Key Population Centres of Excellence in high-density, high-burden districts to ensure staff retained “clinical competence and sensitivity previously supported through US government funding”; and
• Ensuring that key population NGOs were financially resourced and engaged to support the rollout of sensitisation training in all health facilities.

“Particularly in the Western Cape, there is a certain level of privilege in terms of access to services that you wouldn’t find in the rural Northern Cape or Eastern Cape, but if you’re not thinking about [key population access] as a problem, then all you’re doing is getting deeper into the problem,” said Craven.

She emphasised that the decriminalisation of sex work through legal reform would also go a long way in reducing barriers to accessing health services for this group.

Western Cape Department of Health

The Western Cape Department of Health and Wellness was aware of the significant pressures caused by the termination of Pepfar and USAID funding, particularly on NGO-run services that were supporting key populations, said Dwayne Evans, spokesperson for the department.

“These cuts have, understandably, placed further strain on the health system and undermined the work of valued civil society partners in the fight against HIV and TB,” he added.

“While we cannot provide comment on the details of specific surveys undertaken by external organisations, we continue to welcome and encourage collaboration with civil society and nonprofit partners through the existing structures that promote partnerships. Our approach is to integrate patients into the provincial health platform to ensure access to care, and to strengthen coordination between NGOs and government facilities.”

Evans said that referral letters were not required for access to HIV treatment at primary healthcare clinics, and encouraged community members and affected groups to engage with the facilities directly.

“Multimonth dispensing of ART for clinically stable patients remains part of the province’s strategy to decongest facilities and support adherence, and this is being implemented at scale as part of our broader system redesign. However, dispensing volumes are guided by national policy frameworks, supply chain considerations and clinical assessments at facility level,” he said in response to a question about six-month dispensing of ARVs. DM