Of the roughly eight million people living with HIV in South Africa, around 6.2 million are on treatment. (Photo: Shutterstock)News & Features
15th September 2025 | Ufrieda Ho
A dire picture for HIV/Aids funding emerged at the 12th South African AIDS Conference, raising the call for resilience, adapting and also for government to raise its game.
The what-next of South Africa’s HIV response will have to be centred on getting back to basics, leveraging on advances in treatment options and learning fast about adapting in a world without US aid for health services.
These were among the key takeaways from speakers at a plenary session at the 12th Southern African Aids Conference held in Kempton Park last week.
Professor Linda-Gail Bekker, executive officer of the Desmond Tutu Health Foundation, in her address took stock of “the incredible devastation around the world” from the virtual overnight shutting off of funds and human resources as Donald Trump returned to the US presidency in January 2025.
“It was $460 million into the wood chipper for us. And the worrying thing is that it could take us back to the harrowing scenes of 2000 [the height of Aids deaths in the country],” she said.
This comes against what she called the two largest challenges for South Africa’s HIV response: sub-optimal 12-month retention in care and viral suppression. Meaning the struggle to keep patients on treatment beyond a year and helping them stay on antiretrovirals that reduce the amount of virus in the body to a minimum.
The picture painted by Bekker and others is bleak, with much uncertainty remaining as to how South Africa might plug the funding holes left by the abrupt US aid cuts.
Bekker shared research by the Health Economics and Epidemiology Research Office (HE²RO), a division of the Wits Health Consortium at the University of the Witwatersrand. Their research shows that the fallout in the next three years could see South Africa experience a 29% to 56% increase in new HIV infections, or an additional 150 000 to 295 000 cases by 2028. Unless the South African government is able to take over services, there could be a 33% to 38% increase, or an additional 56 000 to 65 000 AIDS-related deaths in that period. (Spotlight previously reported on the HE²RO modelling in more detail here.)
The modelling also suggests that government will need additional funding of between $620 million and $1.4 billion (roughly R10 billion to R24 billion) between 2025 and 2028 to replace the local services that received US government funding.
CASH INJECTION | Emergency funding will for sure soften the blow of the sudden and major US funding cuts – but the blow remains a massive one. Here’s the quick breakdown: shorturl.at/Szjlh
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— Spotlight (@spotlightnsp.bsky.social) August 15, 2025 at 10:35 AM
In July, Treasury allocated R763 million in emergency funding to fill the gap, a fraction of what the HE²RO researchers estimate is needed. In addition, the Gates Foundation and the Wellcome Trust pledged R100 million each for research to the South African Medical Research Council on condition that the South African government doubled their contributions, which government committed to over three years. This added up to an R600 million bailout for research, also a fraction of the amount of research funding that has been lost.
The shortfall remains massive. Last year, Pepfar (United States President’s Emergency Funds for AIDS Relief) funds flowing to South Africa totalled over R7.5 billion.
Calls for greater transparency
Throughout the conference, there was also strong calls from attendees and speakers for government to be more transparent about its plans to mitigate the funding cuts and to provide credible data and information about monitoring and measuring of the success of their interventions. This includes details on how it plans to provide all stable patients with enough medicines for six months at a time. Such multi-month supplies mean people have to travel less to collect medicines, thus making it easier to stay on them. Rollout of multi-month dispensing has been very uneven across the country.
Questions were also raised over a lack of full transparency regarding the price of lenacapavir, a breakthrough HIV prevention injection that provides six months of protection per shot. As we recently reported, the South African government will be paying $60 per person per year for the jab, with other donors paying the rest – it is not publicly known how much this “rest” is. The deal was setup by the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gilead Sciences – the company that makes lenacapavir – and several private donors. Last week, Spotlight published an op-ed in which activists questioned the lack of full transparency about the price.
MUST READ | As delegates convene at the SA AIDS Conference, they must publicly call out the demand for price secrecy from Gilead and the Global Fund for what it is: bullying, write Fatima Hassan, Leena Menghaney, and Bellinda Nkoana.
www.spotlightnsp.co.za/2025/09/09/a…
— Spotlight (@spotlightnsp.bsky.social) September 9, 2025 at 9:33 AM
Dr Sandile Buthelezi, director-general for the National Department of Health, told attendees about the possibility of bringing forward the rollout date for lenacapavir from April next year, to possibly as soon as November this year. He did not answer questions about the price negotiations. He did however confirm that negotiations with The Global Fund has seen them commit to ringfencing US$29 million for procurement of lenacapavir over the next two and a half years.
Doing more with less
Having to do more with less, Bekker said at the conference, will mean the need to build a “resilience bridge”. For her, this means preserving the “two most important interventions” of providing continued access to antiretroviral treatment and to HIV prevention treatments – both long-acting injections and prevention pills.
She added that it also means better efforts to reach the population of people living with HIV who have been diagnosed but are not on treatment. In February 2025, government launched its ‘Close the Gap’ campaign aimed at placing an additional 1.1 million people on treatment by the end of this year. Bekker said the number of people living with HIV who are not on treatment is closer to 2 million people. According to Thembisa, the leading mathematical model of HIV in the country, of the roughly eight million people living with HIV in South Africa, around 6.2 million are on treatment.
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How South Africa is progressing against the 1.1 million target is not clear. Figures previously shared by Health Minister Dr Aaron Motsoaledi indicated that over half a million people had been initiated on treatment in a matter of months. This raised eyebrows since, on the face of it, it means that people had been started on treatment this year more quickly than at any other time in South Africa’s HIV response. It also wasn’t clear whether the number of people who had stopped treatment had been subtracted from the number starting treatment. Questions Spotlight previously sent to the health department seeking clarification of the numbers went unanswered. Similar questions were also raised in an open letter and an op-ed published by Spotlight and GroundUp. As yet, Spotlight has not seen answers to the questions raised about the numbers shared by the Minister.
“We need to make services [more] amenable to retention so it means multi-month dispensing and differentiated care,” Bekker said. Differentiated care refers to treating people differently based on their needs – for example by not requiring healthy people living with HIV to visit the clinic as often as sicker people.
“Bad policies that reflect ideology and bias, mean the most vulnerable are deterred from assessing the services they need, and this includes our key populations,” she added of the challenges that people like sex workers, members of the LGBTQI+ community and people who use drugs face in clinics where they are judged, harassed or discriminated against.
Speaking at #saaids2025 @DrTedros welcomed South Africa’s commitment to resilient health financing & innovation in HIV prevention, underscoring @WHO support alongside government & partners to ending AIDS as a public health threat.@HealthZA @RSAAIDSConf pic.twitter.com/MlPzF0Chzp
— WHO South Africa (@WHOSouthAfrica) September 8, 2025
Dr Lise Jamieson, a senior researcher at HE²RO, echoed Bekker’s sentiments and said a first priority remains to arrest any backsliding of care as South Africa restructures its HIV programme to match the money it has currently. “It is clear that the one thing that we absolutely cannot drop is our HIV treatment programme – it saves lives,” she said.
For Yvette Raphael, the co-founder and co-director of Advocacy for the Prevention of HIV and Aids (APHA), the undergirding socio-economic factors that have given HIV its stranglehold in South Africa remain largely unchanged.
She said: “I am one of the people who are ageing with HIV and suffering from other non-communicable diseases that come with this”, highlighting the need to address the evolving nature of HIV in the country and the need to address it alongside conditions such as diabetes and heart disease.
But she added that it is still teen girls and young women who are at a disproportionately high risk of acquiring HIV. Her message was for better youth-targeted responses that are community-level responses not top-down strategies.
“Make HIV a priority sustained by local and district government structures, not up here in our national and province centres,” she said.
“Make HIV prevention harder to ignore and weave HIV intervention services with skills training and income generating programmes. We know that employment in this country is low, so young people cannot be expected to continue a healthy life without spaces where they can generate income for themselves, this will [in turn] reduce their vulnerability and dependency on older men.”
She added that government had to step up to what should always have been their role as Pepfar funding was never meant to substitute the work of government. Raphael said: “Pepfar was here to support the government in the early days of HIV. However, some of our government officials saw that as a way of evading their responsibility, and we are now here.”
Note: The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council and subject to the South African Press Code.
