Three ways South Africa can make HIV treatment simpler and better
As the world's largest HIV programme, South Africa already has plenty of policies and evidence available to help simplify HIV treatment. (Photo: Shutterstock)
South Africa’s HIV programme is under profound pressure. The answer should not be to make people living with HIV work harder to stay on treatment, but to remove unnecessary visits and use scarce clinical capacity where it is needed most, argue Dr Anna Grimsrud and Lynne Wilkinson.
South Africa runs the largest HIV treatment programme in the world. In June 2026, it was reported that the United States planned a phased withdrawal of all PEPFAR support to South Africa. Whatever the timing, the direction is clear: South Africa will have to deliver more of its HIV response with domestic resources and in an already stretched healthcare system.
That makes efficiency essential. But efficiency should not mean poorer care. For people with HIV who are well, taking treatment consistently, and have a suppressed viral load, more clinic visits do not automatically mean better care. Every unnecessary visit costs transport money, time away from work or school, and hours in a queue. It also uses up clinical time that would be better spent on people who are unwell, starting treatment or struggling to stay on it.
South Africa already has much of the policy and evidence it needs to simplify HIV treatment. Three changes should now be prioritised.
1. More medicine at a time and fewer clinic trips
Give people more medicine at a time and make the process of collecting repeat prescriptions more convenient, rather than requiring a clinical consultation every time.
For adults, six-month dispensing (6MMD) is already policy. However, 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 – still less than 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. Closing that gap should be the first priority.
For people not eligible for 6MMD, or who would simply rather not collect six months of medicine at once, South Africa already has another option. Repeat prescription collection strategies (RPCs) allow people to collect refills from faster, more convenient locations such as pharmacies, adherence clubs and dedicated collection points, without seeing a clinician each time.
SCALE UP | For 1.5 million people in South Africa living with HIV, the routine of long clinic queues, missed work, and travel costs could be cut to just two clinic visits a year by March 2027.
www.spotlightnsp.co.za/2026/05/27/s…
— Spotlight (@spotlightnsp.bsky.social) May 27, 2026 at 11:35 AM
Children and adolescents living with HIV should benefit too. Younger children may still need a clinical review every six months, but they should not need one every time medicine is collected. For now referral to RPCs for children and adolescents remains low. 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. Outcomes, such as retention, improved for adolescents and were the same for children receiving their medicine pick-ups at community points.
We need longer supplies and more convenient collection points – not just at clinics – for everyone still on a shorter refill cycle in between visits.
2. A comprehensive clinic visit once a year
Rather than six-monthly clinic visits, provide one annual clinical consultation and a 12-month prescription for adults established and stable on HIV treatment, regardless of how often they collect medicine in-between.
More than a decade ago, a group of South African clinicians called for this. Then South Africa tested it. During COVID-19, emergency measures extended prescriptions to 12 months thereby reducing clinical visits to once a year.
Three South African studies – including 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 among people receiving annual rather than six-monthly clinical visits and prescriptions.
Related Posts
Annual visits are also an opportunity to improve quality. In Cape Town, where annual reviews have been the 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. Fewer visits can mean better quality visits.
A clinic visit spent mainly waiting for a new prescription is not good care. One comprehensive clinical visit a year can be.
3. A recall system that actually recalls people
Modernise recall systems so people who need to return to the clinic do, and those doing well do not come back unnecessarily.
Longer refills and fewer clinic visits depend on the health system reliably identifying who needs attention between scheduled visits. This matters most for those especially vulnerable, even with the closer follow-up they need: people newly diagnosed, sick, re-engaging in care, or struggling with adherence. When recall fails for them, the consequences can include progression to advanced HIV disease, opportunistic infections and death.
Today, the system partly compensates for unreliable recall by asking people to return for results whether those results are normal or not. The vast majority of people are doing well and making an unnecessary trip simply to hear that everything is fine, while someone with an abnormal result may not be contacted quickly enough.
The laboratory already flags abnormal results to clinics, but these sit passively until someone looks and acts. A modern results-and-recall system could change this. A better system would push alerts to both the clinic and the client, flagging abnormal results, missed follow-up tests and overdue visits, with recall at the right urgency, and track whether each alert is acted on. A normal result could trigger a message to the client confirming that no extra visit is needed. Phone numbers can be verified electronically at each visit, and messages need never contain the result itself – only a prompt to come in, or reassurance that all is well.
Digital tools – potentially including carefully designed uses of artificial intelligence – can help. But technology is not the main point. Accountability is. Every clinically important result should lead to action.
Simplification is not rationing
At a time of funding pressure, longer medicine supplies and fewer clinic visits may sound like cost-cutting. They are not. The opposite is true: simplification means reducing care people do not need so that the health system has more capacity for the care people do need.
South Africa has already done much of the hard work. Policies for longer refills and community collection largely exist, and evidence for annual prescriptions comes from South Africa’s own programmes. What is needed now is implementation at scale, policy change to enable annual clinical visits nationally, and recall systems reliable enough that simplifying care for people doing well does not mean missing those who are not.
That is what real simplification looks like: not less care, but care matched to need – making lifelong treatment easier for people doing well while focusing scarce resources on those who need more support.
*Grimsrud is Senior Technical Advisor at IAS – the International AIDS Society. Wilkinson is Technical Consultant to the IAS and researcher at the University of Cape Town’s Centre of Infectious Disease Epidemiology and Research.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.