By Lloyd Gideon Makonese – Public Health & HIV/AIDs Specialist

As the Southern African Development Community prepares for its forthcoming regional health dialogues, an uneasy question pulses beneath every agenda item. Can the region defend the hard-won gains toward 95–95–95 when external political currents threaten to erode the financial lifelines that have sustained treatment, prevention and community based care for nearly two decades? Or is SADC heading into an era where global decisions made thousands of kilometres away could quietly unravel local progress?

Across the region, more than twenty million people are living with HIV, a figure that represents just over half of the global burden. When combined with East and Southern Africa, SADC countries account for one of the highest concentrations of HIV in the world, carrying a disproportionate share of the pandemic’s weight. This raises a difficult and unavoidable question. How can low and middle income countries that already face fragile economies, chronic underfunding and pressure on health systems continue to carry a crisis of this scale without consistent international support? Global organisations that were established to protect poorer nations from infectious diseases, including HIV, remain essential to sustaining treatment access, strengthening laboratory capacity and supporting frontline workers. Without these partnerships, how many gains would begin to slide backwards, and how quickly would long standing inequalities widen?

With SDG 3 calling for universal access to healthcare and SDG 5 emphasising gender equality, it becomes important to ask how regional commitments will hold when the geopolitical landscape is shifting. What happens when donor behaviour becomes as unpredictable as the disease itself?

The decision by current United States President Donald Trump to scale back, and in some cases withdraw, funding from global HIV programmes continues to cast a long shadow over many SADC health ministries. For years, PEPFAR served as more than a financial mechanism. It functioned as the backbone of national HIV responses, providing antiretroviral medicines, laboratory systems, salaries for community health workers and prevention campaigns. What does it mean for SADC when a structure this critical becomes uncertain under the foreign policy choices of a sitting American president? How many clinics begin to feel the strain of reduced resources? How many community programmes quietly disappear from villages and settlements? And how many individuals, particularly young women and adolescents, fall out of care simply because the outreach teams that once supported them can no longer operate?

These concerns extend beyond financial implications. They expose a deeper vulnerability embedded in reliance on external support. Should SADC continue leaning heavily on foreign financing when global political actions can destabilise years of progress in a single policy shift? And if domestic funding is the future, what reforms, taxation strategies or innovative approaches are governments prepared to consider to protect millions who depend on lifelong treatment?

Migration adds another layer of complexity. SADC is a region defined by movement involving cross-border traders, truck drivers, mineworkers and seasonal labourers. What happens to treatment continuity when someone begins ART in Mozambique, relocates to South Africa for work and then returns home during economic hardship? Are national health systems ready for harmonised regional digital records that allow seamless continuity of care? Without such systems, how many patients silently slip through the cracks?

Digital misinformation is another emerging threat. Online rumours and conspiracy theories about HIV treatment often spread faster than carefully developed public health messages. How can governments shield communities from harmful content without violating freedoms of expression? And can public trust be restored when economic frustrations make communities more receptive to sensational misinformation?

Persistent stigma continues to weaken prevention and treatment efforts. Why do adolescents still fear entering testing centres? Why do men see illness as a sign of weakness? Why do some religious and cultural spaces remain reluctant to open meaningful conversations about HIV? These realities influence every step toward achieving the 95–95–95 targets.

Yet, despite the challenges, the horizon is not without hope. Community led testing, integration of HIV services with mental health and non communicable disease care, partnerships with traditional leaders and the use of digital innovations present new opportunities. But a fundamental question remains. Will SADC sustain these innovations as external funding becomes increasingly unpredictable? And will countries embrace this moment to build health systems that are truly resilient and self reliant?

The next phase of the regional HIV response will not be shaped solely by biomedical achievements. It will depend on political courage, regional cooperation and a willingness to confront difficult questions without hesitation. What happens if donor withdrawal becomes a recurring pattern? What safeguards must SADC establish now? And how can the region develop a common solution for a disease that continues to traverse borders freely?

In the months ahead, readers will need to remain alert. The choices made by SADC leaders will determine whether the region advances toward the SDGs with confidence or hesitates at a point of uncertainty. What kind of future will the region choose? The world is watching, and so are the millions whose lives depend on those decisions.