Health Department Faces Test as PEPFAR Support Recedes

South Africa’s National Department of Health faces a defining test of implementation. The country’s HIV programme, the largest treatment effort of its kind in the world, is preparing to absorb a reduced share of external support. In June 2026, it was reported that the United States planned a phased withdrawal of all PEPFAR support to South Africa. Whatever the exact timing, the direction of travel is clear: the state will have to carry more of the HIV response with domestic resources inside an already stretched healthcare system. For policymakers and oversight bodies, the question is no longer whether to act, but whether existing mandates and policies are being executed at the scale the moment demands.

Writing in an opinion piece published by Spotlight, Dr Anna Grimsrud, Senior Technical Advisor at IAS, the International AIDS Society, and Lynne Wilkinson, Technical Consultant to the IAS and researcher at the University of Cape Town’s Centre of Infectious Disease Epidemiology and Research, argue that the answer lies not in asking people living with HIV to work harder to stay on treatment, but in removing unnecessary clinic visits and directing scarce clinical capacity to those who need it most.

Additional reference context is available at https://www.spotlightnsp.co.za/2026/10/14/three-ways-south-africa-can-make-hiv-treatment-simpler-and-better/.

The authors’ first priority concerns the gap between policy and delivery. Six-month dispensing, known as 6MMD, is already official policy for adults. Yet more than 5 million people in South Africa still receive three, two or even one month of treatment at a time. The National Department of Health began the national rollout in August 2025, targeting 1.5 million people by March 2027, a figure that still falls short of half of those likely eligible. Spotlight reported earlier this year that implementation was running behind schedule; more recent figures suggest around 350 000 people are now receiving 6MMD. For an accountability-focused reading, this is the central compliance question: a policy exists, a rollout date was set, and the numbers indicate the state is far from its own target.

Meanwhile, for those not eligible for 6MMD, or who prefer not to collect six months of medicine at once, repeat prescription collection strategies already allow people to collect refills from pharmacies, adherence clubs and dedicated collection points without seeing a clinician each time. Children and adolescents, however, have largely been left out of these arrangements. In a new analysis from KwaZulu-Natal, only 18% of more than 32 000 eligible children and adolescents were ever referred to community pick-up points. Among those who were, clinic visits fell from six to two a year, and outcomes such as retention improved for adolescents and held steady for children.

The second proposed change sits squarely with policy-makers rather than implementers. The authors call for one comprehensive annual clinical consultation and a 12-month prescription for adults established and stable on treatment, replacing six-monthly visits. Clinicians called for this more than a decade ago. During COVID-19, emergency measures extended prescriptions to 12 months, cutting clinical visits to once a year. Three South African studies, covering more than 27 000 public-sector patients in eThekwini, nearly 430 000 clients across seven provinces and a large private-sector programme, found comparable or better retention in care and viral suppression under annual visits. In Cape Town, where annual reviews have been standard since 2011, a routine clinical audit found that more than 80% of annual visits included checks for weight, family planning, TB and STI screening. What is missing, the authors suggest, is a national policy decision to make annual clinical visits the rule.

The third change concerns the reliability of the state’s follow-up machinery. Recall systems must reliably identify who needs attention between scheduled visits, a matter of life and death for people newly diagnosed, sick, re-engaging in care or struggling with adherence. Today the system partly compensates for unreliable recall by requiring everyone to return for results, whether normal or not. The laboratory already flags abnormal results to clinics, but these sit passively until someone looks and acts. The authors propose a modern results-and-recall system that pushes alerts to both clinic and client, flags abnormal results, missed follow-up tests and overdue visits, and tracks whether each alert is acted on. Digital tools, potentially including carefully designed uses of artificial intelligence, could help, but the authors stress that technology is not the main point. Accountability is: every clinically important result should lead to action.

The authors reject the framing of simplification as rationing. Longer medicine supplies and fewer visits, they argue, reduce care people do not need so the system has more capacity for care they do. Policies largely exist and the evidence comes from South Africa’s own programmes. What remains is implementation at scale, a national policy change on annual visits, and recall systems dependable enough that simplifying care for people doing well does not mean missing those who are not.