Gauteng’s public health system is faltering, and queer and trans South Africans are among those paying the highest price.
The 5th edition of Ritshidze’s State of Health Report for Gauteng, released this week, paints a sobering picture of faltering HIV and key population services across the province following PEPFAR funding cuts earlier this year.
It documents rising delays, unfriendliness, and outright denial of care, especially for people who use drugs, sex workers, and LGBTQIA+ communities (who are included in the category of key populations, groups that face a higher risk of HIV).
Between April and June 2025, Ritshidze gathered data from 81 public health facilities across Tshwane, Ekurhuleni, Johannesburg, and Sedibeng. Surveys included 4,038 public healthcare users, 1,993 people living with HIV, and 81 facility managers.
Additional community-based surveys with 2,788 key population members, including 286 gay, bisexual and other men who have sex with men (GBMSM), 286 sex workers, and 88 trans people, revealed deepening inequities in access to respectful, friendly, and affirming healthcare.
Staff Shortages and Long Queues Drive People Out of Care
According to the report, Gauteng’s clinics are stretched to breaking point. 38% of facility managers blamed staff shortages on the sudden withdrawal of PEPFAR-supported workers, while 37% cited 374 unfilled vacancies, the highest number across all provinces monitored by Ritshidze.
One public healthcare user said:
“Since January, they cut the lines of people after 11am saying it’s late and there are no staff. They say they only take a certain number of people.”
Only 19% of respondents said there were always enough staff, down from 36% earlier this year. 59% reported long waits, and many described being at clinics for over 10 hours without receiving care.
“When it’s my appointment date I spend more than six hours at the clinic,” said one person living with HIV. “The process is so slow. You wait for the whole day.”
Every hour lost in line risks treatment interruption, undermining national goals to re-engage 1.1 million people in HIV care.
“The Prostitutes Have Arrived”: Stigma Still Rife in Public Clinics
For members of key populations, the experience of seeking healthcare remains degrading.
Only 22% of people who use drugs, 41% of trans people, 49% of sex workers, and 61% of GBMSM said clinic staff were always friendly. Just 34% of trans people said staff respected their gender identity.
Denial of care remains shockingly common:
- 47% of trans people,
- 29% of people who use drugs,
- 24% of sex workers, and
- 11% of GBMSM
reported being denied services in the past year.
A sex worker told Ritshidze:
“They stigmatise us as soon as we enter the facility and even say things like, ‘the prostitutes have arrived,’ in front of other patients. It’s very painful. I cry because of the bad treatment I receive.”
Another added:
“[The nurse] went to the other room with my file and said, ‘I understand why Donald Trump cut the funds, these sex workers are here to crowd the clinic.’ I feel like they were happy that foreign aid was cut because they think we don’t deserve services.”
This kind of hostility isn’t just unprofessional, it’s unconstitutional. The report stresses that denying people ARVs and other health services violates basic human rights.
Trans Healthcare in Crisis: “They Said Hormones Are Not for Trans People”
The closure of the PEPFAR-funded drop-in centre for trans women in Johannesburg has left a devastating gap in access to lifesaving gender-affirming care.
According to the report, 31% of trans people wanted to access hormones at public health facilities in the past year, yet none could, as hormonal care is not available at primary healthcare level.
One trans woman explained:
“I used to get my hormones at Aurum Institute, but now that they are closed, I can’t access them anymore. We can only get them by buying them. At the clinic I am currently using, they never give us information on where to access them. They also don’t give us contraceptives. They said they are not for trans people.”
Ritshidze argues that a national policy change is urgently needed to allow doctors at primary health level, not just private GPs, to prescribe hormones. Expanding this access would transform the lives of countless trans and gender-diverse people currently shut out of care.
HIV Services Sliding Backward
The report highlights sharp declines in HIV testing and treatment continuity following PEPFAR’s withdrawal:
- Only 47% of people not on ART were offered an HIV test during facility visits.
- 24% of sites had fewer or no staff for viral load testing.
- 34% had fewer staff for clinical consultations.
- Only 75% of people received a three-month ARV supply or longer, with just 54% in Sedibeng.
Patients reported increased transport costs and work conflicts due to frequent visits.
“Having to travel every two months is financially straining. I would like to receive a six-month supply,” said one person living with HIV.
Without urgent reform, the report warns, these delays will derail the country’s goal of getting more people back on treatment.
Ritshidze Calls for Culture Change and Accountability
Ritshidze urges a culture shift across health facilities to eliminate unfriendliness, breaches of confidentiality, and discrimination against key populations.
Key recommendations include:
- Establishing at least two Centres of Excellence (CoEs) per district for each population group, with trained, affirming staff and confidential services.
- Holding all staff, clinical, lay, and security, accountable for verbal abuse, denial of services, or privacy violations.
- Providing gender-affirming healthcare, including correct use of names and pronouns, gender-neutral toilets, and removal of coloured folders marking perceived gender.
- Expanding harm reduction services for people who use drugs, including sterile needles, methadone, and naloxone.
“Without making services friendlier and safer for people who use drugs, sex workers, and the LGBTQIA+ community, the Department of Health will never get everyone on ARVs or address the retention crisis,” the report warns.
Health Is a Right, Not a Privilege
The State of Health report reveals a system buckling under pressure, but also one that too often chooses stigma over service. For LGBTQIA+ people, trans and gender-diverse individuals, sex workers, and people who use drugs, the result is exclusion from lifesaving care.
“I used to feel seen when I went for my treatment,” said one trans woman. “Now, I feel like I’m not wanted there.”
Unless policymakers act urgently, the unfriendliness and neglect detailed by Ritshidze will continue to turn public clinics, once lifelines, into spaces of fear.
