From Donor Dependency to Sustainable National Capacity: Strengthening HIV Testing Services through permanent employment of Lay Counsellors in South Africa
1
HIV and AIDS and STI, National Department of Health, Pretoria, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1710
ABSTRACT
BACKGROUND:
Lay counsellors are central to South Africa’s HIV testing services (HTS), delivering pre and post-test counselling, HIV rapid testing and linkage to care. This cadre faced major disruptions following the United States government’s stop order directive, which led to reduced donor support. In response the National Department of Health (NdoH) initiated a sustainability driven transitioning to integrated 8803 lay counsellors in the 9 provinces into the public health force. This cadre contributed significantly to the country reaching its 1st 95 of the UNAIDS targets
AIM:
To examine the implementation and health system effect of South Africa’s permanent employment of 8803 lay counsellors by evaluating workforce sustainability, service delivery fidelity, and sustainability indicators and determining how this large-scale transition influences HIV testing performance and maintenance of the first 95 amidst declining external financing. The study will examine changes in service delivery processes, including adherence to national HTS guidelines, client flow, linkage to care, and data recording and reporting practices, to determine whether permanent employment improves or constrains service quality and operational efficiency.
RESULTS:
Of the 8803 lay counsellors nationally, 4195 (48%) has transitioned to permanent employment at the end of 2025. Facilities with permanently absorbed counsellors demonstrated stable to increased monthly outputs despite the donor transitioned period. Facilities also reported reduced staff turnover, consistent services availability and improved integration of HTS within routine healthcare workflows. Government commitment to absorb all 8803 represent one of the largest nationally funded HTS workforce sustainability transitions globally.
CONCLUSIONS:
South Africa’s absorption of lay counsellors has safeguarded the continuity and quality of HTS in the context of declining donor support. The transition strengthens national ownership of the HIV response, supports maintenance of the first 95 target, and enhances long-term workforce sustainability. Completing the absorption of all counsellors remains essential to ensuring resilient, epidemic control.
Lay counsellors are central to South Africa’s HIV testing services (HTS), delivering pre and post-test counselling, HIV rapid testing and linkage to care. This cadre faced major disruptions following the United States government’s stop order directive, which led to reduced donor support. In response the National Department of Health (NdoH) initiated a sustainability driven transitioning to integrated 8803 lay counsellors in the 9 provinces into the public health force. This cadre contributed significantly to the country reaching its 1st 95 of the UNAIDS targets
AIM:
To examine the implementation and health system effect of South Africa’s permanent employment of 8803 lay counsellors by evaluating workforce sustainability, service delivery fidelity, and sustainability indicators and determining how this large-scale transition influences HIV testing performance and maintenance of the first 95 amidst declining external financing. The study will examine changes in service delivery processes, including adherence to national HTS guidelines, client flow, linkage to care, and data recording and reporting practices, to determine whether permanent employment improves or constrains service quality and operational efficiency.
RESULTS:
Of the 8803 lay counsellors nationally, 4195 (48%) has transitioned to permanent employment at the end of 2025. Facilities with permanently absorbed counsellors demonstrated stable to increased monthly outputs despite the donor transitioned period. Facilities also reported reduced staff turnover, consistent services availability and improved integration of HTS within routine healthcare workflows. Government commitment to absorb all 8803 represent one of the largest nationally funded HTS workforce sustainability transitions globally.
CONCLUSIONS:
South Africa’s absorption of lay counsellors has safeguarded the continuity and quality of HTS in the context of declining donor support. The transition strengthens national ownership of the HIV response, supports maintenance of the first 95 target, and enhances long-term workforce sustainability. Completing the absorption of all counsellors remains essential to ensuring resilient, epidemic control.
| eISSN: | 2654-1459 |
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