New Cape Town transgender health service addresses funding gap after Pepfar cuts

The Desmond Tutu Health Foundation (DTHF) has opened an integrated service providing gender-affirming care to transgender and gender-diverse people at Groote Schuur Hospital in Cape Town, as part of an effort to bridge the gap in health services caused by the cut in the US President’s Emergency Plan for Aids Relief (Pepfar) funding earlier this year.

The service aims to assist transgender and gender-diverse people who were accessing care at donor-funded clinics that closed due to the funding cuts. Among the services it provides are access to pre-exposure prophylaxis (PrEP), antiretrovirals and hormone replacement therapy (HRT), testing for sexually transmitted infections and HIV, and psychosocial support.

“I think it’s something that’s quite groundbreaking and in some ways revolutionary... because of the growing backlash [against LGBTQIA+ individuals], globally and here in South Africa. And I think it’s our duty, especially as clinicians, to not do any harm when it comes to transgender and gender-diverse individuals, and it’s a privilege and it’s an honour to be involved in this,” said Dr Yashna Singh, principal investigator at the Desmond Tutu Health Foundation.

In January, US President Donald Trump signed an executive order imposing a 90-day freeze on all foreign development assistance, pending a review. By late February, almost all Pepfar funding provided to international and South African HIV programmes through the United States Agency for International Development (USAid) had been permanently axed.

Read more: ‘The axe has fallen’ — Trump’s USAid issues notices to terminate funding for key health programmes across SA

Read more: Key populations in Cape Town battling to access HIV state clinics after Pepfar aid cuts – study

The cut led to the closure of three specialised clinics serving key populations in Cape Town, including the Ivan Toms Centre for Health and the Wits Reproductive Health and HIV Institute (Wits RHI) transgender and sex worker clinics. Thousands of people who relied on these facilities lost access to services overnight, with many turning to state-owned clinics for continued care.

While the Western Cape Department of Health and Wellness has plans to absorb former clients of specialised clinics into public health services, the increased burden on state facilities in the wake of the abrupt foreign aid cut has presented a challenge. The Desmond Tutu Health Foundation trans health service is a temporary measure aimed at providing immediate assistance to affected individuals, while supporting the provincial health department in building long-term capacity for gender-affirming care within the public health system.

A ‘stopgap’ measure

The Desmond Tutu Health Foundation, which operates primarily as a research organisation, has a long history of providing care to queer individuals, said Bust. Its new service is supported by a grant co-funded by Elma Philanthropies and the FirstRand Empowerment Foundation.

“In terms of psychosocial support, we have a psychologist who’s there once a week, and a social worker. We also have a peer-led support group that meets once a month,” she said.

The service, which operates primarily as a research organisation, has a long history of providing care to queer individuals, said Bust. Its new service is supported by a grant co-funded by Elma Philanthropies and the FirstRand Empowerment Foundation.

“We are one of four awardees… All four organisations were doing quite different work that focuses on [vulnerable populations], so some of their work also focuses on sex workers, adolescents and young girls, men who have sex with men... A lot of the organisations are also focused on Joburg and Gauteng,” explained Bust.

“We are the only one that’s providing direct gender-affirming care services to trans and gender-diverse people.”

The programme is set to run for six months, with the expectation that the Western Cape Department of Health and Wellness will be prepared to take over the provision of these gender-affirming care services from March 2026.

“[The department has] said they are working to build their capacity and are hoping to at least have one or two Centres of Excellence or primary healthcare facilities where people can go and access those gender-affirming care services, starting in March next year. The idea is that we assist in bridging that [gap] and referring people there, if it is ready by that time,” said Bust.

Confusion in wake of cuts

Anecdotal accounts from members of key populations suggest that it’s been challenging to access gender-affirming care at state health facilities in the wake of foreign aid cuts.

Bust said: “I think every single client that we’ve spoken to, transgender or gender-diverse person, has just been like, ‘We don’t know where to go, we don’t know what the process is. We don’t know if it’s safe to go to clinics.’ Or people have gone [to clinics] and they’ve been turned away.

“For anybody trying to navigate the system, it’s incredibly confusing, especially if you don’t have access to a phone or [a place] to find out about services.”

The Groote Schuur Hospital Transgender Clinic, a public health unit facilitating access to gender-affirming care, was already at full capacity when the Pepfar-funded facilities closed, according to Bust. It has struggled to initiate new clients, with a waitlist of about three to four months.

The Desmond Tutu Health Foundation service is providing HRT medications to individuals who were previously receiving them at Pepfar-funded clinics, but people who have never received hormones before need to be referred to the endocrinology unit at Groote Schuur Hospital.

“In terms of gender-affirming hormone therapy, it is currently only endocrinologist- or specialist-initiated, so... there’s quite a lengthy referral process, specifically because there’s such a high demand. Clients have to come into Groote Schuur, get an assessment with a psychologist, and then [go on] the waiting list,” said Singh.

“Part of the work of the [trans health service] will also be easing the burden on the endocrine unit. We’ll be seeing clients for initial psychosocial assessment [and] doing baseline blood [tests].”

Bust noted that one of the “stumbling blocks” to expanding gender-affirming care services in the public health sector was that HRT medications were listed as “tertiary-level” medicines, meaning they couldn’t be issued at a primary care level.

“I think that’s one of the big delays, but globally, there’s lots of evidence to show that it can safely be provided at primary healthcare level, and that’s what a lot of the NGOs and [actors] in the private sector are doing,” she said.

Carol Lennon, clinic and outreach nurse at the Triangle Project, indicated that the organisation was aware that the Desmond Tutu Health Foundation was providing a temporary service for gender-affirming care. The Triangle Project is an LGBTQIA+ rights nonprofit based in Cape Town.

“The DTHF is taking on anyone who was previously receiving these services, so existing clients, not new. New clients still only have the option of Groote Schuur Hospital for initiation on treatment, which of course has a long waiting list. The Triangle [Project] does appreciate this service from DTHF, but ideally want these services available to all,” said Lennon.

Bust emphasised the significance of an inclusive environment for the provision of health services to LGBTQIA+ individuals, which allowed people to feel safe when accessing care.

“It’s really important for us to have trans people at the centre of that too. It’s important that we’re centring lived experiences… We have trans people on our team… It’s why we have a peer-led psychosocial support group as well, who we’ve been engaging with on this, so that when we’re thinking about providing care to trans people, they’re included in those services,” said Bust.

Daily Maverick asked the Western Cape Department of Health and Wellness about the Desmond Tutu Health Foundation trans health service. Its response will be added once it becomes available. DM