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As thousands of scientists, activists, and policymakers gather in Rio de Janeiro for the 26th International Aids Conference, much of the discussion will focus on protecting decades of progress against HIV in the face of devastating global funding cuts.

But one of the most important lessons from the HIV response reaches far beyond HIV itself, and that’s how to treat obesity, according to Four of South Africa’s most influential HIV activists.

South Africa has already lived through one epidemic in which stigma kept people away from effective treatment, and the country shouldn’t repeat those mistakes as obesity emerges as one of its biggest health challenges.

A woman at an HIV research site in Yeoville, Johannesburg, understood this dilemma long before most people did, when she asked her doctor a question through tears: “Why can’t I stop gaining weight?”

Her HIV treatment was working exactly as it should, but the control of her HIV with her new medicines meant she was putting on weight fast, and her doctors encouraged her to eat less and exercise more, but nothing seemed to help.

Her story captures a challenge South Africa is only beginning to confront, as obesity rates rise and demand for exorbitantly-priced weight-loss medicines grows, and the public is increasingly turning to unsafe and illegal copies of registered products sold on social media.

Weight loss injections, such as “Reta”, which is still in trial, are now widely marketed on WhatsApp, Instagram, and TikTok, often at prices that make them attractive to people who have few safe alternatives.

Desperation, fueled by stigma and a lack of access to evidence-based care, creates a market in which false hope can flourish, and South Africans have seen this pattern before, when dramatic weight loss was widely regarded as a tell-tale sign of HIV.

Today, South Africa faces a different form of stigma, but one built on remarkably similar assumptions, as weight stigma rests on a set of ugly assumptions: that people in larger bodies lack self-control, eat too much and the “wrong” foods, and are too lazy to exercise.

Research now shows that obesity, like high blood pressure or raised blood sugar, is a progressive disease that often requires treatment and reflects genes, environment, and a changing food supply — not simply bad choices.

Society, and much of medicine, has not caught up, and higher-weight people are still imagined as greedy or weak, their illness treated as a deserved consequence rather than a condition worthy of care.

The lesson from HIV is not that prevention and treatment are rivals — it’s that you need to do both at once, and withholding effective treatment from people who need it now, especially poorer people, causes avoidable harm.

The government needs to take control of both sides of this: strong regulation and enforcement to address the upstream causes of weight gain, alongside better medical care for people already living with obesity, and that lesson is especially important for people living with HIV.

In South Africa, many of those most affected by ART-associated weight gain are women using public sector services, yet medicines that could help people manage that weight gain are not available through South Africa’s public health system.

This is a cruel irony: lifesaving ARVs are available, but support for one of its commonest side effects is not, and patients are left alone with a problem that is medical, social and deeply personal.

There is another lesson South Africa should borrow from the HIV response: let affected communities lead, and HIV activism changed the country because people living with HIV, and the organisations that stood with them, refused to be treated as passive recipients of policy.

Today, South Africa stands at a fork in the road, and doing better would mean three things: regulators need to clamp down on illegal and unsafe products, while giving the public clear guidance on which treatments actually work.

The health department and medical aids should provide access to stem cell therapy and other obesity care within HIV services, for those at highest risk — alongside, not instead of, stronger food and prevention policies, and training for HIV nurses and doctors must treat weight stigma as a clinical harm.

Civil society needs to start demanding the kind of systems-level change that made mass delivery of HIV treatment possible in South Africa, and the new obesity medicines are every bit as transformational as antiretrovirals were, and may have benefits reaching well beyond weight loss, into diabetes and other chronic diseases.

Most of all, we need a government committed to doing this: one that keeps fast-food companies out of schools, and has a properly funded plan to fix a food system that currently leaves people with no real choice but an unhealthy one.

HIV activism taught South Africa that stigma kills and treatment saves lives, and as delegates in Rio spend this coming week trying to rethink, rebuild and rise for the next phase of the HIV response, they’d do well to apply the same lesson to obesity — before we replay the same mistakes on a new group of people whose bodies have already been judged enough.