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Thembi Xulu is leading South Africa’s effort to produce the anti-HIV injection lenacapavir locally, calling the move vital for the country’s long-term epidemic response. As CEO of the South African National Aids Council (Sanac), she has worked with drugmakers, activists, and government officials to make it a reality.

A dealmaker in a funding crisis

Xulu arrives at this week’s International Aids Conference in Rio de Janeiro with a direct message: donor funding is ending, and South Africa cannot depend on it indefinitely. The U.S. President’s Emergency Plan for Aids Relief (Pepfar), which once funded 24% of the country’s HIV programs, will stop all support by early 2027. Prevention efforts, which rely heavily on external money, face the greatest risk.

Aside from the occasional TikTok, her family’s dance competitions days are on hold.

How a Sanac plan became a UNAids blueprint

Two weeks ago she was in Harare, presenting to the first ever meeting of the Southern African Development Community (SADC) health and finance ministers. Last week it was Geneva, for a two-day Global Fund to Fight Aids, Tuberculosis and Malaria board meeting. Now Rio, where delegates will be grappling with the burning question in HIV: how to keep country HIV programmes on track in the face of an unprecedented funding crisis, and major cutbacks to HIV programmes.

On this topic Xulu is much more than your average, hand-wringing HIV apparatchik. When she joined Sanac, which guides South Africa’s vast response to HIV, the sustainability of the country’s programmes was a subject of nervous discussion in the HIV community, as it had been ever since Donald Trump first threatened to end Pepfar in 2017 (a threat he finally made good on in June this year, when his administration confirmed to the media, but not yet the SA government, its intention to end all HIV-related assistance and Pepfar funding for the country by early 2027).

Users have reported pain and injection-site reactions, while some men who have sex with men say the drug makes wearing fitted clothing uncomfortable. Xulu acknowledges the concerns: “The people who decide if lenacapavir works aren’t in boardrooms. They’re in communities.”

For now, the priority is finalizing the deal. Sanac has arranged meetings between Gilead’s leadership and regional officials, but scaling production without donor support will be difficult.

Xulu did not plan to become a negotiator. When she took over Sanac in 2020, the agency faced internal conflicts and a reputation for political disputes. Her predecessor left amid mismanagement allegations, and some called the role a “poison chalice.” She took a different approach, emphasizing broad consultation in drafting the 2023-2027 National Strategic Plan for HIV, TB, and sexually transmitted infections.

Her leadership combines persistence with practicality. At a recent SADC meeting in Harare, she presented Sanac’s sustainability framework, which is now referenced in UNAids’ 2024 guide on country-led HIV responses. As chair of the HIV Leadership Forum, she has influenced global discussions on funding gaps but deflects personal credit. “I think I’m the one who had greatness thrust upon them,” she said, quoting Shakespeare. “I found myself here without a plan and tried to do my best.”

That humility masks a career built on adaptability. Born in KwaMashu in 1974, Xulu was raised by her great-grandmothers after her mother, a Black Consciousness activist, spent years moving between South Africa and Swaziland. She wanted to become a doctor and applied only to the University of Natal’s medical school. A last-minute opening allowed her to enroll, and she graduated in 1997.

She later joined the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital, working on clinical trials for a tuberculosis drug. The experience left her disillusioned. “You’d explain risks to patients, offer contraception, but some still got pregnant,” she said. “Having to justify that in meetings was painful.” She shifted to public health, leading a USAID-funded project that expanded HIV treatment across five provinces.

By 2010, she was one of 12 fellows selected for Yale University’s Maurice R. Greenberg World Fellows Program, where she studied alongside figures like the late Russian opposition leader Alexei Navalny. Her return to South Africa marked a new phase: moving from donor-funded programs to revenue generation. As head of Right to Care’s for-profit arm, she managed corporate clients and tender processes. “I had to earn the money I was supposed to spend,” she said. “It’s like dating—you need something to make it last.”

When she took over Sanac, she applied the same determination to a role many considered impossible. The council, formed from 1990s activism, had a history of infighting and corruption allegations. Xulu’s transparent, consultative approach won allies, but obstacles persist. Donor funding is declining, and political conditions are unstable. She remains focused. “I am not going to lie, it has been tough,” she said. “But you don’t take these jobs expecting them to be easy.”

Her daughters, now 24 and 18, paused competitive dancing to finish university—Xulu’s rule. She hasn’t. Between meetings in Geneva, Harare, and Rio, she still challenges colleagues to dance-offs. “Anytime, anyplace,” she said, laughing. The laugh, deep and unguarded, has become her trademark.

For now, the focus stays on lenacapavir. If South Africa succeeds in local production, it could set an example for how low- and middle-income nations secure essential medicines. Time is short. Donor funds are disappearing, and the next few years will decide whether the plan moves forward or falters.

Access issues like these were discussed at a recent conference in Rio, where participants highlighted barriers to treatment.