South Africa has struggled for years with one of the highest HIV burdens in the world. Recent improvements in early screening and treatment coverage have led to significant improvements in reducing HIV prevalence. This change could not have happened without the tireless work of advocacy organisations on the ground, working within communities to raise awareness of medical options and how to take care of each other.
The situation on the ground
South Africa has one of the highest rates of HIV prevalence in the world. It’s estimated that around eight million people were living with HIV in 2024, which is almost 13% of the country’s population – with the condition’s burden disproportionately falling on women.
According to South Africa’s National Plan for HIV, TB and STIs, there’s high levels of HIV status awareness among people; the issue with controlling infections primarily stems from treatment access: only around 78% of people living with HIV taking antiretroviral treatment (ARV), with many struggling to remain inserted in treatment programmes.
Efforts to control bloodborne viruses were challenged last year by the sudden end to American international aid. With many African health systems supported by international aid organisations, countries like South Africa were seriously impacted. With many agencies providing HIV support for several key populations, sudden defunding ended the livelihood of thousands of key workers, including their access to essential resources like condoms, ARV medication, progress data and more.
NACOSA’s work
It’s within this context that, at the last International Network on Health and Hepatitis in Substance Users (INHSU) Conference which happened in October 2025 in Cape Town, I was introduced to the Networking HIV & AIDS Community of Southern Africa (NACOSA) and their model for health progress.
Like the entire HIV space, NACOSA was also impacted by American aid defunding. From 2019 to 2025, they had been supported by the Global Fund to manage the people who use drugs programme. They also had additional funding from corporate partners like ViiV Healthcare, which through its Positive Action plan, implemented programmes specifically designed for women who use drugs in South African provinces to improve their access to services.
NACOSA’s People Who Use Drugs programme, funded by the Global Fund, supports over 23,000 people who inject drugs through needle exchange programmes and supporting access to treatment. In 2025, it helped 2,045 people enter Opiate Substitution Therapy programmes, adding to the already 1,229 that were on methadone. The programme also successfully distributed approximately 7.5 million sterile needles and syringes – a tried and tested intervention that contributed to lowering the HIV positivity rate at end of 2025 to 8% as opposed to 17% when the programme started in 2022.
NACOSA also successfully engaged with the South African Police Service, helping produce a national directive preventing the police from confiscating sterile needles and syringes or harassing or arresting people who use drugs that are in possession of sterile needles and syringes. NACOSA was at the forefront of innovation, piloting an overdose prevention programme through the distribution of naloxone and CPR kits, and we also launched the first Digital Chest X-ray mobile clinic to screen people who use drugs for TB.
NACOSA implements South Africa’s largest youth programme. The My Journey programme supports girls and young women to take charge of their health and wellness by providing HIV prevention choices and wellbeing services in their communities. Reaching 384,284 girls and young women, the programme aims to reduce HIV by increasing HIV testing, condom use, and the use of PrEP products and increasing the number of HIV positive young women on care.
NACOSA’s Community Systems Strengthening programme built the capacity of community organisations through training, mentoring and a community grant scheme. Organisations were supported to engage communities, deliver HIV and GBV prevention activities and assist key and vulnerable populations to access HIV and TB services. Over the last Global Fund grant cycle, NACOSA provided capacity building for more than 210 community-based organisations and training for 4,000 staff. These organisations mobilised almost one million people for HIV testing services and TB screening, and 77 emerging organisations received small grants. Organisations assessed with NACOSA’s Capacity Assessment Tool showed substantial improvements in their governance, human resources management and financial accountability.
The organisation has demonstrated how to push for alternative funding streams post-US aid defunding, working with corporate partners and donor organisations through this new landscape to sustain their operations. They’ve demonstrated their value to the South African government and helped secure public funding opportunities at the provincial and national level. NACOSA has also revised their strategy to examine how their work can be expanded to more broadly support community health systems by looking at intersections of health, climate resilience and youth employment.
