South Africa is about to begin one of the most important HIV prevention drives in decades.
Earlier this month, Health Minister Aaron Motsoaledi announced the country will launch its roll-out of the once-every-six month HIV prevention injection, lenacapavir (LEN), on June 5 in Mpumalanga. Roll-out will be across South Africa, initially at 360 government clinics.
The moment matters.
LEN, an injection taken only twice a year, is one of the biggest advances in HIV prevention. When people not living with HIV take the medicine, it’s almost foolproof in stopping them from getting the virus through sex.
But new medicines alone do not stop epidemics. Health systems, political choices and funding determine whether the medication reaches the people who need it.
Until now, South Africa has had a daily HIV prevention pill that is stocked for free by most government clinics. But many people, especially young people, find it hard to take a tablet each day; the less often someone uses the pill, the less well it works.
Because it only has to be taken once every six months, LEN gives people a prevention option that may fit more easily into their lives. But the systems needed to get the injection to people are weaker than they should be — in South Africa and around the world.
That is the contradiction policymakers now face: just as one of the most powerful HIV prevention tools becomes available, many of the programmes needed to deliver it have been weakened by funding cuts and political changes.
LEN matters because it tackles one of the biggest problems with the daily pill: adherence. For young women and men without stable housing, or those worried about stigma, a six-monthly injection could be easier to use.
The Global Fund to Fight Aids, TB and Malaria, which also provides funds to South Africa, and the United States President’s Emergency Plan for Aids Relief (Pepfar), have recognised the opportunity.
Pepfar is the US government’s HIV programme, which has historically helped fund HIV treatment and prevention in many countries, including South Africa.
But in early 2025, when Donald Trump became president, Pepfar cut at least half of its funding for HIV South Africa (at this stage, the remaining funding ends in June).
As far as LEN is concerned, the Trump administration has, so far, decided not to fund South Africa. The doses that will be used in South Africa this year and most of next year, are funded by the Global Fund, and are only enough to put around 456 000 people on LEN over two years.
Modelling studies, however, show that more than eight times as many people — between one and two million people per year — have to get LEN at least once per year — if the country wants to make a big enough dent in new infections to end Aids as a public threat within the next eight years.
South Africa has the most new yearly HIV infections — 139 521 in 2025, according to the latest projections of the Thembisa model, which the national health department uses to plan its programmes — in the world. The country would therefore need more LEN doses than any other country to lower new infections.
For the world in total, around five million people per year need to access LEN to have real impact and to drive prices down low enough — we still have a road to walk to get to that number.
So far, the Global Fund and Pepfar have increased their commitment — the Global Fund supports nine countries and Pepfar 10 countries with LEN — from enough doses for two million people to enough for three million people over the next three years.
But promises on paper are not the same as getting injections into people’s bodies.
Over the past 20 years, Pepfar, the Global Fund and government spending helped to sharply reduce HIV deaths and expand access to HIV treatment across Africa. But because of funding cuts of Western countries and also multilateral donors such as the Global Fund, those funding systems are under growing pressure.
Donors are now increasingly choosing to protect treatment programmes rather than grow prevention programmes.
The trade-off is understandable. Governments and donors do not want people already on HIV treatment to lose access to lifesaving medicine. But the result is that prevention programmes are often cut back first when money becomes tight.
That is a dangerous mistake.
Recent Pepfar figures show the problem. Although treatment numbers have stayed fairly stable, HIV prevention numbers are moving in the wrong direction. HIV testing has dropped. Fewer people are being diagnosed.
Most worrying, the number of people starting on HIV prevention medication has fallen sharply by 41% — including among teenage girls and young women between the ages of 15 and 24, which is the group of people in Africa who have the most new infections.
Community programmes that work with groups with the highest chance of getting HIV — sex workers, gay and bisexual men; transgender people and injecting drug users — have been gutted by funding cuts and Pepfar doesn’t even track data for these groups any longer.
This matters because LEN cannot simply be added to a struggling system. A successful rollout depends on strong HIV testing services, trusted community programmes and health workers who can keep people connected to prevention services through reliable follow-up systems.
In other words, LEN needs a strong foundation. But in many places, that foundation is cracking.
South Africa’s LEN launch, therefore, comes at both an exciting and risky moment. The country has the scientific knowledge, medicine regulator and public health experience to lead the world in rolling out LEN.
But without strong investment in prevention services — in South Africa and the other eight African countries who are rolling out LEN with Global Fund and Pepfar money -— the roll-out could end up being much smaller and slower than it should be.
The lesson for policymakers is simple: prevention cannot be treated as less important than treatment. The two go together.
Every HIV infection prevented today means fewer people will need lifelong treatment in future. Failing to invest in prevention will place even more pressure on health systems later.
That means donors and governments need to rethink how they fund and implement prevention. Here are at least four steps they can take now:
- Protect money set aside for introducing new HIV prevention tools such as LEN
Prevention should not be the first thing cut when budgets shrink. Rolling out LEN is not a side project — it is an investment in bringing down new HIV infections over the long term. It’s a strategic investment; not a luxury.
- Governments must take charge of their roll-out plans — and fund them
Instead of waiting for donors to lead, countries should include LEN in their HIV plans, and decide who most needs the injection based on infection data rather than politics.
Governments should work this into their budget lines — even if the amounts are small at first. This could encourage more donors to help fund roll-outs. To buy LEN at cheaper prices, governments should use pooled procurement mechanisms or place orders at a regional level through the African Union.
3. Drive demand by getting community groups and the people most affected by HIV to shape roll-out plans
HIV prevention programmes work best when communities trust them and ask for them. Young women in Mpumalanga, sex workers in Durban and gay men in Johannesburg should help decide how LEN is provided — whether through clinics, mobile services or community programmes. A clinic-only approach will not reach enough people.
4. Commit to eight million doses over two years — enough for four million LEN users
Although the Global Fund and Pepfar’s increased investment from two million to three million people over three years is progress, it is not enough to sharply reduce new HIV infections or lower prices quickly enough.
The HIV world should aim much higher. A meaningful commitment of eight million doses over two years is needed — and possible. Bigger roll-outs help lower prices, strengthen supply systems and encourage manufacturers to produce more stock.
Some people will say this is unrealistic at a time when aid funding is shrinking and governments face many competing health needs. But the alternative is worse: plateauing rates in new infections that don’t bend incidence curves.
Additionally, rising treatment costs and a lost chance to give people a simpler and highly effective prevention option.
The world has seen before how scientific breakthroughs created huge excitement, but weak funding and slow roll-out reduced their impact.
That should not happen again with LEN.
The urgency is even greater because other long-acting HIV prevention products are already being developed.
If we build an effective platform for LEN, other preventive medicines, such as MK-8527 — a pill taken once a month that is currently being tested in two large studies of which the results are expected in late 2027 — can be phased in through the already established services.
Countries therefore need to build stronger HIV prevention services now so they can introduce new products more quickly in future. Otherwise, the world could end up with good prevention options that health systems are too weak to deliver.
LEN is not a magic solution, and it will not suit everyone. Some people will still prefer daily HIV prevention pills or other methods. But that is exactly why it matters: having more choices helps more people find prevention that works for their lives.
South Africa’s June launch can become more than a symbolic event. It can show what serious HIV prevention leadership looks like at a time when donor funding is shrinking and global uncertainty is growing.
But success will depend on whether governments, donors and community groups treat prevention as essential — not optional.
The science is ready. The question is whether the money and political will are ready too.
Mitchell Warren is the executive director of the international health advocacy organisation, Avac. Wawira Nyagah is the executive director of Access Bridge, a Kenya-based African organisation fighting for equitable services.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
On 5 June, South Africa is about to begin one of its most important HIV prevention drives in decades. The country will start to roll out an HIV prevention injection that has to be taken only twice a year. Will the launch become more than a symbolic event that shows what serious HIV prevention leadership looks like at a time when donor funding is shrinking and global uncertainty is growing?
