EDITORIAL

 

A critical juncture: Reimagining a unified, integrated HIV response in South Africa

 

 

On 20 January 2025, global news of the sudden withdrawal of US government funding led to rapid uncertainty about the future of HIV science and service provision.^[1] This was not the first major hurdle to challenge the HIV community. In South Africa (SA), AIDS denialism and a failure to provide evidence-based treatment for HIV led to >300 000 preventable deaths between 1999 and 2008.^[2] The XIII International AIDS Conference (9 - 14 July 2000), held in Durban at the height of AIDS denialism, was a historic turning point. The conference directly confronted denialism, generated international visibility and contributed to advocacy for access to antiretroviral therapy (ART). Within a few months, ART costs dropped. Although affordable treatment was available in the private sector, there was still limited treatment in the public sector. To support advocacy for treatment access, the organising committee of the XIII International AIDS Conference established DiraSengwe and convened the first SA AIDS Conference in 2003. This conference was a critical catalyst for the eventual rollout of ART, supported by global actors including the President's Emergency Plan for AIDS Relief (PEPFAR). In sub-Saharan Africa, ART roll-out resulted in increased life expectancy, from 56.5 years in 2010 to 62.3 years in 2024, and a decreased rate of new HIV infections.^[3-5]

SA now has the world's largest HIV programme, with the National Department of Health (NDoH) owning and funding the majority of it. This is laudable; however, donor funding, especially from PEPFAR, has made significant contributions to the HIV response over the last 20 years. In 2023, PEPFAR funded 21% of HIV expenditure and 50% of prevention expenditure.^[6] The abrupt and precipitous US funding cuts led to halted scientific discovery, service disruptions, healthcare worker retrenchments from funded non-governmental organisations, loss of employment among programme and research staff and potential long-term setbacks for HIV vaccine development, threatening HIV progress in SA and globally. Without mitigation, modelling studies have estimated that SA is likely to face up to 65 000 additional AIDS-related deaths over 3 years, and up to 712 000 additional deaths over 20 years.^[6] There has been disagreement about how this crisis should be managed, with activists describing the NDoH response to the funding cuts as a new form of denialism,^[7,8] while the Minister of Health, Dr Aaron Motsoaledi, has likened HIV activists to Afriforum.^[9]

The 12th SA AIDS conference was held in September 2025, at a critical time to unite and develop shared priorities to address the funding challenges.

 

Facing the funding cliff: Hard truths and new priorities

Dr Anna Grimsrud (senior technical advisor at the International AIDS Society) appealed to conference participants to confront challenges head on, reminding them that 'admitting to challenges is not conceding dependence; it's owning the work ahead.'^[10] She urged participants to 're-think, re-build and rise', sentiments echoed by many delegates. Speakers highlighted that the unexpected funding cuts were extremely harmful and emphasised the need to be honest about the repercussions, including significant gaps in health services and damaged trust.

It was consistently reiterated that the new funding reality is pushing SA and many other sub-Saharan African countries toward local ownership, digital innovation and more integrated health programmes. These are positive directions; however, we need to make bold, tough decisions to prioritise services, using rational and transparent processes. As a country, we should invest in key HIV and other priorities by aligning budgets to programme commitments.

 

Roadmap to 2030: Accountability, inclusion and integration

In this editorial, the Chairs and Scientific Committee of the 12th SA AIDS conference share critical insights expressed and deliberated on during the conference, and in the words of Prof. Linda-Gail Bekker, 'recalibrate the road to 2030.' The HIV response needs to be better integrated into other health programmes within the primary healthcare framework, from funding to service delivery. SA should lead more research and foster stronger scientific partnerships, shifting the balance of power and benefit toward the global south. The NDoH has the opportunity to lead a reinvigorated response, with all actors moving forward together. But re-building a unified, integrated HIV response requires a change from the current trajectory. So, what must be done?

Two evidence-based interventions stood out as being likely to contribute strongly to the HIV response in the coming year. Firstly, 6-month multi-month dispensing (6MMD) allows clinically stable clients living with HIV and other chronic illnesses to access 6 months of medication at one visit. This can decrease visit burden for clients and clinics, and improve retention.^[11,12] Secondly, lenacapavir, a 6-monthly pre-exposure prophylaxis (PrEP) injection, supports acceptable, discrete HIV prevention with only two service contacts per year and no daily tablet-taking.^[13] Encouragingly, scientists, the NDoH and civil society have embraced both interventions.

To make progress and move forward with these evidence-based interventions, we recommend:

• inclusive policy and programmatic planning comprising authentic engagement with communities, implementers and researchers

• a contextually relevant and evidence-based communications strategy, with messages co-designed with key populations and prototyped among target audiences to ensure acceptability and effectiveness

• transparent monitoring, wherein the NDoH shares key data with civil society, community organisations and researchers to promote accountability

• promotion of access and equity for integrated services - the systems and processes for differentiated service delivery that have been developed, largely through the HIV programme, should be considered an essential component of integrated service delivery

• strengthening other health programmes by using existing HIV systems and lessons from implementation: for example, the electronic medical register and other health information systems can be adapted and applied to different disease areas

• insisting on equity in research funding partnerships, and rejecting science and implementation from the global north that does not fairly benefit South Africans.

Former PEPFAR implementing partners, civil society organisations and academic and research institutions have a wealth of experience to support implementation of these recommendations. We can leverage this combined expertise to prevent repeating past mistakes and sustain SA's HIV programme. The HIV community should be able to hold the national, provincial, and district Departments of Health accountable for the implementation of 6MMD and lenacapavir, and not be seen as adversarial in doing so.

The 12th SA AIDS conference was pivotal in discussing options for accessing prevention and treatment. There was consensus that increased local ownership and integration of all aspects of the HIV programme are necessary and desirable. We need to use this moment of change to move integration forward by acknowledging and confronting our challenges with honesty, transparency and genuine community and expert consultation. Doing so can rebuild a unified, resilient and reimagined HIV response that honours the progress made, and secures the future of HIV programmes.

Acknowledgements. Thank you to Prof. Linda-Gail Bekker and Dr Anna Grimsrud for their wise words. We would also like to thank the 12th SA AIDS Conference participants for their engagement and contributions, and the FPD Secretariat for the incredible work behind the scenes.

K Rees

Anova Health Institute, Johannesburg, South Africa, and Department of Community Health, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. rees@anovahealth.co.za

G Wolvaardt

Foundation for Professional Development, Pretoria, South Africa

T Chidarikire

World Health Organization, Pretoria, South Africa

J J Dietrich

Perinatal HIV Research Unit (PHRU), Faculty ofHealth Sciences, University of the Witwatersrand, Johannesburg, South Africa

L Ibisomi

Epidemiology and Biostatistics Division, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa, and BAMMISHO Health and Demographic Surveillance System Node, Rustenburg, South Africa

T Kufa-Chakezha

Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa

T Mabuto

The Aurum Institute, Johannesburg, South Africa

G Maimela

Foundation for Professional Development, Pretoria, South Africa

E Mudimu

Department of Decision Sciences, University of South Africa, Pretoria, South Africa

L Scott

Wits Diagnostic Innovation Hub, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

P Smith

Desmond Tutu Health Foundation, Cape Town, South Africa

N Sohaba

South African National AIDS Council, Centurion, South Africa

C Chetty-Makkan

Health Economics and Epidemiology Research Office (HE²RO), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

 

References

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