The best move amid aid cuts is to direct remaining funds to communities

South Africa has made significant progress in its response to HIV and AIDS, reducing mother-to-child HIV transmission and increasing life expectancy with the help of the global community. With new developments such as long-acting injectable prevention and treatment options, ending AIDS could still be possible. But not without community organizations. The international community cannot abandon the community response now. The decision by the U.S. government to drastically cut aid to developing countries has set in motion a domino effect where other governments have not only reduced funding, but are deprioritizing remaining funding to local community-based organisations. These organizations have been the bedrock of the response to HIV and AIDS in poorer countries over decades and have proven, cost-effective methods to stop the spread of infection while at the same time addressing complex and deep-seated inequality and poverty that drive the spread of HIV. South Africa has been hit hard by the funding cuts, with the loss of around $261 million to nonprofits in the country, resulting in the termination of 15,374 roles and disruption to services for an estimated 222,000 people living with HIV, including 7,445 children under 15 years old. A modeling study commissioned by the South African health department estimates the cuts will cause between 150,000 and 296,000 additional HIV infections and between 56,000 and 65,000 additional HIV-related deaths by the end of 2028. While some local funders have rallied resources and South Africa’s Treasury mobilized 753.5 million rands (around $43.8 million) to plug gaps, the future for independent civil society remains precarious. The HIV and AIDS networking organization NACOSA that I run recently surveyed its members — mostly small, community-based organizations working in health and social development in South Africa. The results paint a worrying picture of the state of community-based organizations in the wake of funding cuts, shrinking budgets, and an economy under increasing strain after the collapse of foreign aid and the imposition of tariffs. Over a third of organizations reported having less than two months of funding to continue operations. Almost a quarter have already lost more than half of their funding, while nearly half are feeling indirect impacts through reduced or delayed partner disbursements. A quarter of organizations have been forced to restructure or lay off staff — with some cutting up to 75% of their workforce. Community organizations have played a critical part in South Africa’s HIV response since the start, working with government, donors, and scientists to bring testing, treatment, and support to millions of people. The progress has been undeniable: Life expectancy surged from 54 years in 2006 to over 65 in 2017, driving economic growth as more people lead productive lives. Recognizing the undeniable fact of their contribution and centrality in saving lives, the work of communities in leading, managing, and delivering their own response to HIV has received widespread recognition from global funders and multilateral agencies. These institutions place communities at the center of policy and plans, but the reprioritized budgets of donor governments and development institutions are not translating into funding where it is needed and can be most useful. Spending is directed to big-ticket, heavily controlled and monitored budget lines, overlooking hardworking frontline staff — the very people who have held the response together over the last few decades and also helped get us through COVID-19 in Africa. Unless community-based organizations, who are the last line of defense in poorer communities, are urgently resourced, they may have to shut their doors, and the health outcomes for poorer South Africans are going to be catastrophic. The impact of the cuts are already being felt at facility level. The Ritshidze Gauteng State of Health report found critical staff shortages, exceptionally long waiting times, delays in finding files, and missed appointments at public health facilities in South Africa’s most populous province. Of particular concern is the disengagement of key populations now that specialist services have stopped — sex workers, people who use drugs, and people from the LGBTQ+ community report unfriendliness, lack of confidentiality, and even denial of services. A recent analysis of data from the National Health Laboratory Service found that the number of HIV viral load tests is significantly lower than expected across South Africa — an indicator that either HIV-positive patients are being lost to the system, or they are not being properly monitored, or the data system for recording viral load tests is less accurate. With foreign aid declining and government budgets shrinking, NACOSA’s network organizations are reporting their struggle to sustain programs and retain skilled staff. While many recognize the need for sustainability planning, only less than half currently have an up-to-date sustainability plan. Fundraising remains the most significant challenge reported, with nearly 90% of organizations finding it difficult. Organizations need flexible funding and sustained, long-term support to build partnerships and develop sustainability mechanisms. This requires a trust-based approach to support the work of frontline people and organizations that have built community health systems over decades.