We are managing HIV with selective lenacapavir roll-out, not ending it

By Tian Johnson, African Alliance, and Fatima Hassan, Health Justice Initiative

South Africans are being told that providing a new HIV prevention tool (lenacapavir) to just about 456,000 people is a victory. It is not. In a country that still records hundreds of new infections every day, partial coverage is unlikely to slow the epidemic in any meaningful way. Worse still, all of the supplies have not yet reached our shores.  

The announcement in 2024 of a twice-yearly HIV prevention injection was rightly celebrated as a scientific milestone. Celebratory media headlines followed, expert panels convened, and political statements flowed. 

For a moment, it felt like a corner had been turned.

What was missing from the celebration was any serious interrogation of how South Africa intended to deploy this tool at a scale that matches the AIDS epidemic it faces. Instead, attention moved quickly to pilots, phases, partnership, and timelines. All of it sounded reasonable but in reality, the plan followed a familiar script. 

The lenacapavir roll-out is not the first HIV prevention pilot framed in the language of pragmatism. Oral prevention pills were also made available to small high-risk groups initially. With the benefit of hindsight, we know that even the most well-intentioned, seemingly practical initiatives can repeat historical inequities. We should know better than to accept the appearance of progress without questioning the project’s design. 

The gap between scientific possibility and public health impact is only closed when projects are set up to improve outcomes. It matters who is protected first, who waited longest and who was told to accept risk in the name of feasibility. 

How SAf is rationing prevention by geography 

South Africa’s current approach to lenacapavir is not a national rollout. It is in effect, a controlled experiment. Out of more than 3,000 public clinics, just 300 clinics across 23 districts have been lucky enough to be selected.

Access to a life-saving prevention tool has been turned into a matter of where you live because our government has accepted a limited-supply environment rather than challenging it. It refuses to take any state action against Gilead, and the US government has instructed PEPFAR to exclude South Africa from its allocations. Put together, this is public health policy driven by politics, not evidence. 

Call it targeted if you like. For the people excluded, it probably feels like a verdict. Living outside a designated district now determines whether the state-of-the-art HIV prevention is available to you at all. Living in an area labelled ‘low incidence’ effectively deprioritises your life, despite overwhelming evidence that prevention works best when it is widespread, proactive, and universal. Viruses simply do not respect municipal boundaries.

This is not an unavoidable constraint but a design choice and the political decision to pilot rather than scale, which abandons millions of South Africans who remain equally vulnerable to infection. It signals that preventing transmission everywhere is less important than containing it somewhere. It also signals a Health Ministry unable to tackle absurdly high levels of pharma power. 

Activism, research, and the broken social contract

For more than a decade, communities, activists, and researchers have warned that scientific breakthroughs divorced from access commitments would reproduce old injustices. 

South Africa has been central to HIV research, hosting trials, contributing data, and mobilising communities in the service of global science.

In the case of lenacapavir, South Africa, with other countries in Latin America, was central to the breakthrough. Trial and research participation, however, has not guaranteed benefit; it hardly ever does. Once again, communities that enabled discovery are being asked to wait for access. The social contract that underpins ethical research, that those who bear the risks should share in the rewards, has been quietly eroded, without legal or other censure. 

Trust does not disappear overnight but is worn down decision by decision.

Policy choices that accommodate scarcity instead of confronting it

South Africa did not discover supply scarcity yesterday. It bore the brunt during the  COVID-19 pandemic and well before. The scale of the HIV epidemic is well known, and the number of people who would need effective prevention to interrupt transmission is not a secret. Yet the response has been calibrated downward, designed to fit within assumed limits imposed by Gilead and others. Instead of treating scale as non-negotiable, the policy has settled for accommodation. Scarcity has been absorbed into planning assumptions, and limited reach has been reframed as realism.  

The Global Fund and the politics of reallocation

The decision to reallocate substantial resources from existing health services into a narrowly targeted prevention pilot follows the same logic. In a context where services for at-risk populations have already been weakened by the dismantling of the United States Agency for International Development, this choice did not expand the system and the numbers are unforgiving. Ending AIDS by 2039 will require tens of millions of doses of lenacapavir. The current approach as set out by SANAC and the Health Minister, with Gilead, The Global Fund to Fight AIDS, Tuberculosis and Malaria, UNITAID and others, delivers a fraction of what is required. 

There is also a risk the policy conversation avoids. Restricted prevention carries scientific consequences. Limited supply increases the likelihood of stockouts. Stockouts lead to missed dosing windows. Missed windows increase the risk of resistance. This is how biology responds to indecision. The most powerful prevention tool we have ever had can be weakened not by failure to invent, but by failure to deploy.

A deliberate decision to let a global epidemic continue

Modelling suggests that South Africa, the epicentre of the global HIV epidemic, requires at least two to four million people on effective prevention to interrupt HIV transmission. 

That means that Gilead’s global goal to get lenacapavir to three million people is a tragic admission. 

The arbitrary ceilings set by South Africa’s government and by Gilead also represent the point at which exposure is deemed acceptable. It’s an eerie repetition of the scenario that unfolded during COVID-19. A United Nations expert opinion reached the conclusion that when urgency collides with inequality, African lives are the ones most often managed rather than saved. HIV is beginning to follow the same pattern. The people most impacted by the epidemic are once again told to wait, to accept pilots, to be grateful for partial protection. In a country with the knowledge, infrastructure, and experience to do better, this cannot be explained away as a technical limitation.

This is deliberate policy design. 

We have seen this pattern before, and we will not be able to say we did not recognise it.

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Tian Johnson is the founder and strategist of the Pan-African health justice advocacy group, African Alliance. Fatima Hassan, is a South African human rights lawyer and social justice activist, and founder of the Health Justice Initiative. This is part 1 of a two-part opinion series by Johnson and Hassan examining the gap between scientific breakthrough and public health impact in South Africa’s response to HIV with the arrival of long-acting lenacapavir.

The views and opinions expressed in this opinion piece are those of the author, who is not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.