South Africa’s HIV gains are under threat as donor cash shrinks — and the clock is ticking
Scientists, clinicians, activists and people living with HIV gathered in Gauteng last week sounded an unusually stark alarm: years of hard-won progress against HIV could unravel unless funding and strategy change urgently. Delegates at the 12th South African AIDS Conference warned that with U.S. donor support falling, the country could see as many as 295,000 new infections and 60,000 AIDS-related deaths by 2028 if nothing is done.
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The projections are blunt. They forced a question many in the room had long tried to avoid: how do you sustain a public-health triumph when the money that helped build it is ebbing away?
A fragile recovery
South Africa has been at the center of the global HIV response for two decades. The country’s scale-up of antiretroviral therapy (ART) is credited with reducing mortality, restoring life expectancy and stabilizing the epidemic in many communities. Clinics once overflowing with grief now hold lines of people receiving life-extending drugs, while children born to HIV-positive mothers in many places are growing up HIV-free.
But public health wins are not permanent without investment. “We are living on borrowed time,” said a clinician from a Johannesburg hospital at the conference. “ART keeps people alive, but prevention, testing and the systems that deliver care need consistent funding. When that dries up, everything else follows.”
The concern is not hypothetical. Much of South Africa’s HIV programme was expanded with the help of international donors — notably U.S. government initiatives and the Global Fund. As Washington and other traditional donors shift priorities and budgets face pressure from new geopolitical crises and domestic spending demands, the plug risks being pulled on programmes that are expensive but essential.
Where the gaps will be felt first
Prevention work is particularly vulnerable. Condom distribution, community outreach, adolescent programmes, and newer biomedical prevention tools such as long-acting injectable PrEP are costly to scale and sustain. Activists warned at the conference that loss of funding will disproportionately hurt young women and girls, who already account for a large share of new infections in South Africa.
“Prevention is invisible until it fails,” said a community advocate. “When programmes vanish, infections rise slowly and then all at once.”
Testing and retention in care are also at risk. Funding shortfalls can mean fewer mobile testing units in rural areas, longer waits at clinics, and reduced capacity for tracing and supporting people who stop treatment. Interruptions in ART are not just clinical setbacks — they increase the risk of resistance and make the epidemic harder and costlier to control over time.
Hard choices: austerity, reallocation or innovation?
Delegates sketched a range of responses. One obvious answer is domestic financing: countries must pick up more of the tab. But that is easier said than done. South Africa faces competing fiscal pressures — from rebuilding an economy battered by the pandemic, to providing social grants and investing in infrastructure. Increasing health spending substantially requires political will and sometimes painful trade-offs.
Another option is smarter spending: targeting interventions to where they will have the biggest impact, investing in community-led delivery models that can reach key populations cheaply and effectively, and adopting cost-saving technologies. For example, shifting to differentiated models of care for stable patients can reduce clinic congestion and free up health workers for prevention and for complex cases.
New biomedical tools offer promise but also new costs. Long-acting injectable cabotegravir for HIV prevention has shown superior efficacy for some populations versus daily oral PrEP, but scaling it requires cold-chain logistics, regular clinic visits and reliable funding. If international donors step back, rolling out these innovations at scale could stall.
What the global picture says
South Africa’s dilemma mirrors a broader challenge: the post-2008 model of development assistance is fraying. Donor fatigue, competing crises from conflict to climate change, and geopolitical realignments are reshaping global health financing. For health systems that grew dependent on external aid, the transformation can be destabilizing.
Yet the stakes are not merely national. South Africa is home to one of the world’s largest HIV epidemics, and setbacks there reverberate across the region. An uptick in infections or the emergence of drug resistance can cross borders. That makes this more than a domestic policy problem — it is a test of global solidarity and strategy.
Voices from the ground
At the conference, a woman living with HIV described balancing motherhood, employment and daily pill-taking. “I have a job now because the drugs work,” she said. “But if the clinic stops offering support groups, if outreach declines, people will stop coming. I don’t want to see my community go back to where we were.”
A young activist from Gauteng, who organizes peer-led prevention sessions, warned that supply disruptions would hit the most marginalized hardest. “It’s always the people with the least who pay the price,” she said. “We need prevention, but we also need jobs, education and dignity.”
Decisions ahead
The conference left delegates with a clear imperative: adapt quickly or risk backsliding. That means governments, donors and communities must negotiate a new compact — one that strengthens domestic financing, prioritizes high-impact prevention, and leverages innovations while protecting the delivery systems that keep people in care.
It also raises broader ethical questions about how the world funds long-term public health victories. Are global health investments a temporary charitable act or an enduring partnership? When a life-saving program matures, who bears the responsibility for sustaining it?
Those are not easy questions. But the choices will be answered in clinics, classrooms and households across South Africa in the coming years. The projections presented in Gauteng serve as a warning: the fight against HIV is not over simply because death rates fell. It is an ongoing commitment, one that requires money, political will and the kind of social solidarity that turns treatment into prevention and survival into thriving.
What kind of global compact will we choose — and who will be held to account if we fail?
By News-room
Axadle Times international–Monitoring.
