Returnee crisis puts Zimbabwe's HIV gains at risk

Memory Shoko carefully cradles a small white sachet containing just five days' worth of antiretroviral (ARV) medication — a fragile lifeline that health experts warn may not be enough to prevent dangerous interruptions in treatment for thousands of Zimbabweans returning from South Africa.

The 35-year-old mother of two is among a growing number of Zimbabweans arriving home after fleeing xenophobic violence or being deported amid intensified immigration enforcement in South Africa. She left behind the life she had built in Johannesburg with little more than one bag and a five-day emergency supply of medication issued at the Beitbridge border post.

"For the journey home, Amai," a nurse tells her as she hands over the medication. "Register at your clinic when you get there. Don't miss a day."

For health authorities, the sachet symbolises both a critical intervention and an emerging public health challenge.

More than 99 000 Zimbabweans have been screened at ports of entry since deportations from South Africa intensified, according to figures presented in Parliament. While authorities have not disclosed how many are living with HIV, officials acknowledge that a significant proportion require uninterrupted antiretroviral therapy.

Many returnees fled South Africa abruptly as xenophobic attacks spread through communities, abandoning homes, jobs and, in some cases, life-saving medication. Others were detained before they could collect their next prescription.

Some reportedly left their medication behind to avoid revealing their HIV status while escaping attacks.

The influx now threatens to test Zimbabwe's internationally recognised HIV programme, which has spent more than two decades expanding treatment access and improving patient outcomes.

According to the Ministry of Health and Child Care, more than 1.2 million Zimbabweans are living with HIV. The country has achieved the UNAIDS 95-95-95 Fast-Track targets for adults, meaning that 95% of people living with HIV know their status, 95% of those diagnosed are receiving treatment and 95% of those on treatment have achieved viral suppression.

Zimbabwe has also introduced newer HIV prevention options, including long-acting injectable cabotegravir (CAB-LA), reflecting continued progress in the country's response to the epidemic.

However, the sudden return of thousands of people requiring continuity of care presents a new challenge.

Health Minister Douglas Mombeshora recently told Parliament that border health facilities are currently able to provide only emergency supplies of medication.

"We can provide treatment for at least five days. Then they must go to their districts to register for long-term care," Mombeshora said.

He explained that managing returning patients involves more than simply issuing medication.

"We need baseline tests, like viral load, which cannot be done at the port of entry. We need baseline tests, and we need them to be in the system properly," he said.

The challenge is further complicated by differences between South African and Zimbabwean HIV treatment regimens.

"We have to take them on board with our own regimes here," Mombeshora said. "We really have to monitor and do a series of tests to make sure that they are now compatible."

The minister acknowledged that Zimbabwe currently lacks the technological capacity to rapidly match treatment regimens between the two countries after MP Darlington Chigumbu asked whether such systems existed.

"The short answer is no, we do not have those models," Mombeshora admitted.

Questions have also been raised over whether district health facilities have received sufficient additional drug supplies to accommodate the influx of returnees.

Health advocates say the five-day emergency supply offers only a narrow window for patients to reconnect with long-term treatment.

Muchanyara Cynthia Mukamuri, executive director of the Self Help Development Foundation and chairperson of the Women's Coalition, warned that vulnerable returnees face significant barriers after crossing the border.

"Five days may not be sufficient, particularly for vulnerable returnees," Mukamuri said.

"We need adequate time for assessment, counselling, enrolment and uninterrupted access. For a mother who has just crossed with three children and no money, five days is nothing. She needs to be assessed, counselled and linked immediately. Otherwise, she will disappear from the system."

Mukamuri called for formal cross-border referral systems that would allow patient records to move electronically between South African and Zimbabwean health facilities before patients arrive.

Such systems, she said, would reduce treatment interruptions and improve continuity of care.

Beyond the medical challenges, returnees also face stigma.

Stanley Takaona of the Zimbabwe HIV/AIDS Activist Union said many people fear attending opportunistic infection (OI) clinics in their home communities after returning from South Africa.

"Some of them are our peers. The transitions were somehow perfect before. Now there's stigma on who is taking ART and how they will be integrated in OI clinics," he said.

"People are asking if I go to the Opportunistic Infection clinic here, will my neighbours know? Will I be labelled?"

Takaona said deportation has left many people traumatised after losing homes, employment and social networks, only to face fears of discrimination upon returning home.

HIV advocate Evelyn Lyn Chamisa warned that even short interruptions in treatment could have long-term consequences.

"Missing ARVs for just 48 hours, or three to four days, gives HIV space to rebound and develop drug resistance," she said.

She noted that some returnees had been receiving older South African treatment regimens that differ from Zimbabwe's current first-line dolutegravir (DTG)-based therapies, making careful clinical assessment essential before treatment changes are made.

"Second- and third-line drugs are extremely expensive and in short supply," Chamisa said.

"The government must treat ART continuity as a red flag. Any delay pushes patients to costlier regimens and threatens Zimbabwe's hard-won gains."

Zimbabwe's HIV programme currently records viral suppression among approximately 93% of people receiving treatment, making it one of the strongest performers in sub-Saharan Africa.

Public health experts warn that widespread treatment interruptions among returnees could reverse years of progress by increasing the risk of drug-resistant HIV strains, which are significantly more difficult and expensive to treat.

For now, the burden falls on border health workers trying to bridge the gap between emergency assistance and long-term care.

At Beitbridge, nurses continue handing out five-day supplies of medication to exhausted returnees arriving from South Africa each day.

The sachets were never intended to be a permanent solution.

They were meant to buy time.

Whether that time proves enough may determine whether Zimbabwe preserves one of Africa's most successful HIV treatment programmes—or watches years of progress unravel one missed dose at a time.