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][4][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.