As US cash dries up South Africa's fight to stop Aids gets harder

The impact of a flourish of the US president's pen in Washington a year ago continues to be felt on individual lives some 13,000km (8,000 miles) away in South Africa.

There was a collective gulp among some in the health sector here when, hours after he was inaugurated, President Donald Trump signed an executive order freezing US aid commitments.

For South Africa that meant the potential loss of an estimated $400m (£295m) that the US contributed each year to the country's HIV programmes – representing about a fifth of what it was spending on the issue.

Last year, the government provided $46m in response to the US decision - just 11.5% of what was lost.

The US also agreed a "bridge plan" of $115m that will last until the end of March in place of regular funding from the US President's Emergency Fund for Aids Relief (Pepfar).

Since being set up by President George W Bush in 2003, the US government has invested over $110bn in the global HIV-Aids response through Pepfar, saving 26 million lives, according to the state department.

Many of those lives were in South Africa as around 13% of the population are living with HIV, making it the country with the largest number of HIV-positive people in the world.

Enormous advances in treatment and prevention over the decades have ensured many are alive who would not be otherwise but these are expensive and the loss of funding could put many at risk.

Prof Linda-Gail Bekker, the head and co-founder of the Desmond Tutu Health Foundation and one of the world's top HIV researchers, says there is no doubt there has been a reduction in testing and gaps in services.

Forty per cent of her funding – around $8m - came from the US government.

"This money was significant in carrying out a large number of what I call last-mile activities," she tells the BBC.

"Things like finding people who haven't come in for care, providing services for people who don't find it easy to go into the public-sector clinics. The South African government did mobilise some emergency funding, but it was really a drop in the ocean compared to what we have lost."

Among other services, the Tutu Foundation uses its money to fund mobile clinics for people unable or unwilling to go to government-funded ones.

It has been able to keep them going even though other charities have closed theirs.

On a bright summer day, a small group of women are sitting under a small awning outside one of their mobile clinics in Philippi, one of Cape Town's most dangerous townships.

They listen intently as a health worker from the foundation lists different types of preventative HIV medication. Those who have turned up do not want to add to the country's HIV statistics.

"I want to take preventative medicine because anything can happen," says 28-year-old Esethu. She's here to get a second shot of Cabotegravir, commonly known as CAB-LA, an injectable form of pre-exposure prophylaxis (Prep) which reduces the chances of catching HIV by almost 80%.

"Guys can take advantage; you can't even trust the guys you're dating now. Even if you use a condom, the condom can disappoint. With this I know I'm safe all the time."

She says she first heard about the cuts to US funding on social media last year and was worried it would lead to the closure of services in Philippi.

"The mobile clinics are very helpful because you don't have to walk that much to get to them or spend money on taxis.

"They are also very important for young people because when you go to the government clinics, you get people that are your mother's age, so you can't open up to them. Here you get young people the same as you, so you can open up and tell them anything."

Nineteen-year-old Okuhle is here to find out about Lenecapavir, a new preventative shot to be taken twice a year. It has been described as a game-changer in the fight against HIV, and Okuhle worries that if more mobile clinics were to shut down, many young people and township residents would stop taking preventative medicine.

"That will be a big problem, because a lot of people don't like going to the public clinic. And the risk of people getting HIV will get higher."

Health Minister Dr Aaron Motsoaledi hopes his government will announce more HIV funding in its next budget. It is also working with other donors to fill the gap left by the US.

Through the Global Fund, it has secured 900,000 doses of Lenacapvir – enough for 450,000 people, which is due to be rolled out within months. But researchers say more will be needed to stop new infections from growing.

"We are a country that has rolled out more oral prep than any country in the world," explains Bekker.

"Around three million people have been offered oral prep: a daily pill. But we find young people struggle to take something daily when they're healthy and well. And so Lenacapavir brings great hope of far more effective prevention.

"But it means we have to reach those kinds of numbers. Certainly millions of South Africans would need to be offered Lenacapavir in order to avert the number of infections we need to in this country."

She adds that there were 180,000 new HIV infections in the country last year, but that they don't know how many they'll be seeing this year because of the cuts.

Prof Helen Rees, founder and executive director of Wits RHI, one of the world's leading HIV research institutes, says "the impact of the cuts was profound, because it was so sudden" and fears the knock-on effects.

"If you stop testing, if you stop giving prevention, and if you are unable to sustain treatment, you're inevitably going to get more cases."

Ironically, the full effects of the loss of funding are not fully known because one of the things it supported was data collection.

"If you don't have [this], you don't know your hotspots, you don't know who you need to focus on and how. We will need to know how many people as a result of these cuts are defaulting from treatment while we try and re-establish services. So data is incredibly important, and it has been affected."

In the meantime, there is little sign that American funding of South Africa's HIV response will return.

"You are aware that the US has moved," Motsoaledi told the BBC. "There's no chance of them going back. They have adopted a new policy called America First Global Health Strategy, which I believe, frankly speaking, no nation on earth that respects itself should accede to."

He was referring to the bilateral health deals that the US has now entered into with several countries including Kenya, Malawi and Nigeria.

HIV research could also be affected by the funding cuts which will have implications beyond South Africa.

Researchers here are global leaders in the field, partly due to US funding.

For Bekker from the Desmond Tutu Foundation it is important to remember the connection between South Africa and the rest of the world.

"I often say to people, in order to end the epidemic for the world, we really do need to end the epidemic in South Africa. If we do not contain it, close it down, shut it down, we stand the huge risk of it continuing for decades."

Additional reporting by Ed Habershon

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