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Thembi Xulu is leading South Africa’s effort to produce the HIV prevention drug lenacapavir within the country. As CEO of the South African National Aids Council (Sanac), she has spent the past year negotiating with drugmakers, governments, and activists to make local production a reality. The plan will be presented at this week’s International Aids Conference in Rio de Janeiro.

Xulu’s role extends beyond policy. She describes herself as a “hip-hop mama” who learned to dance to support her daughters’ international competition careers. During an event in Croatia, her enthusiasm reportedly prompted their instructor to issue a warning: dance moms should avoid criticizing results until they return to their rooms, as even bathrooms could have judges present.

From donor dependency to local control

When Xulu took over Sanac in 2020, the organization faced the potential loss of U.S. funding through the President’s Emergency Plan for Aids Relief (Pepfar). At the time, the program covered 24% of South Africa’s HIV initiatives, a smaller share than in many neighboring countries but still a significant risk. The Trump administration announced in June that it would end all HIV-related assistance to South Africa by early 2027, though the decision has not been formally communicated to the government.

Sanac responded by advocating for a more self-reliant approach. Its 2021 framework shifted responsibility to provincial governments, a model later highlighted by UNAids as an example for sustainability.

Local production of lenacapavir, a twice-yearly injectable HIV prevention drug, represents the next phase. South Africa began offering the jab at select public clinics in June, though donor funding covers most of the cost. With 55 million people to protect, Xulu argues that relying on external support is not a long-term solution. “Donor contributions are needed and appreciated because the budget is tight, but they won’t sustain us,” she said.

Negotiating with Gilead—and the region

Lenacapavir was developed by Gilead Sciences, which conducted many of its clinical trials in South Africa. In late 2024, the company signed voluntary licenses with six generic manufacturers to produce the drug for 120 low- and middle-income countries—but South Africa was excluded. The omission drew criticism from officials.

Xulu led negotiations with the company. Initially, Gilead insisted on end-to-end production, including manufacturing the active pharmaceutical ingredient (API) and final product locally. Her team proposed a phased approach: importing the API while completing production in South Africa until full local manufacturing becomes possible. Gilead agreed to the compromise. “They accepted the idea,” Xulu said.

The initiative has regional support. In February, health ministers from the Southern African Development Community (SADC) endorsed South Africa’s proposal, aiming to make the drug affordable and accessible across the region. If successful, the model could prevent supply chain disruptions like those seen during COVID-19, when low-income countries struggled to access vaccines and treatments.

Xulu’s role in these discussions has been more about coordination than direct negotiation. Her team arranged meetings between Gilead’s president and leaders in South Africa and SADC, positioning the country as a hub for regional production. The effort has drawn comparisons to high-stakes diplomacy, though she downplays the praise. “I think I’m the latter,” she said, quoting Shakespeare. “Some are born great, some achieve greatness, and some have greatness thrust upon ’em.”

A career built on stubborn optimism

Xulu’s path to Sanac was unconventional. Born in KwaMashu in 1974, she was raised by her great-grandmothers—one a seamstress, the other a nurse—while her mother, a young activist, moved between South Africa and Swaziland. As a child, she often skipped school to help them collect chronic medication from King Edward Hospital, soaking their feet in warm water and rubbing them with arthritis ointment. “One day, granny, I’m going to make these knees better,” she’d promise.

She nearly missed her chance at medical school. After refusing to list backup options on her application, she was initially rejected. A last-minute opening saved her. After graduating in 1997, she planned to specialize in obstetrics and gynecology until her then-husband’s job took them to Johannesburg. Instead, she joined the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital, working on clinical trials for a tuberculosis drug.

The work left her frustrated. “You’d explain the risks, offer condoms, contraception, but some participants still got pregnant,” she said. “Having to account for that in a reviewer’s meeting was hurtful.” She shifted to public health, later leading a USAID-funded project that expanded HIV treatment across five provinces. By the time she left, the team had grown from 15 to 800 people, introducing what’s now called “differentiated models of care.”

In 2010, she became a Yale World Fellow, sharing the program with the late Russian opposition leader Alexei Navalny. The experience changed her approach to leadership. “I learned not what to think, but how to think,” she said. Upon returning to South Africa, she took over a for-profit arm of Right to Care, moving from donor-funded programs to corporate HIV workplace initiatives. “I had to generate the money I was supposed to spend,” she said. “It’s like dating: you go on a first date, and for there to be a second, something has to make it stick.”

Her next challenge was Equip, a USAID-funded consortium that helped countries adopt the World Health Organization’s “test and treat” strategy—putting everyone who tests positive on HIV treatment, regardless of immune system strength. The project spanned 12 countries, from Malawi to Ukraine, requiring her to build teams from scratch in each. Tsitsi Chakauya, Sanac’s company secretary, recalled Xulu’s demanding schedule: “She’d take meetings at 3am just so others wouldn’t be inconvenienced.”

Xulu’s appointment as Sanac CEO in 2020 came with skepticism. The organization, formed amid conflict between government and civil society over HIV mismanagement in the 1990s, has a contentious history. “People asked, ‘Thembi, are you sure? There’s this tough Sanac stakeholder called South African civil society. Are you sure?’” she recalled. Her approach to the 2023-2027 National Strategic Plan (NSP) involved consulting “as widely, deeply and sincerely as she could,” Chakauya said. The result was called “the People’s NSP,” with Xulu as “the People’s CEO.”

She remains cautious about declaring success. When asked if the lenacapavir plan has community support, she highlights practical issues. “Some men who have sex with men said they couldn’t wear crop tops because of the bumps at the injection site,” she noted. “We know it’s a viscous substance. We know it’s a painful injection.” The real test, she added, will come from the people using it—not those in boardrooms.

For Xulu, the work is deeply personal. “We must keep exploring options: choice, agency, and non-medical prevention approaches,” she said. “And countries must take full ownership.”

Local production could also address broader health challenges. User account restrictions on social media have limited awareness campaigns, making community-driven solutions even more important.