A new HIV prevention tool (lenacapavir) is said to be available to South Africans 456,000 It is the victory of the people. It is not. In a country where there are still hundreds of records new infections Day by day, partial coverage is unlikely to slow the pandemic in any meaningful way. What's worse is that not all supplies have yet reached our shores.
Announcement in 2024 The introduction of HIV prevention injections twice a year was celebrated as a scientific milestone. Celebratory media headlines followed, expert panels were convened and political statements began to emerge.
For a moment it seemed as if a corner had been turned.
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What was missing from the celebration was a serious inquiry into how South Africa intends to deploy this tool on a scale that matches the AIDS epidemic. Instead, the focus quickly moved to pilots, phases, partnerships, and timelines. It all seemed reasonable but in reality, the plan was following a familiar script.
The lencapavir roll-out is not the first HIV prevention pilot framed in the language of practicality. Oral prevention pills were also initially made available to small high-risk groups. With the benefit of hindsight, we know that even the best-intentioned, seemingly practical initiatives can repeat historical inequities. We should know better than to accept the appearance of progress without questioning the design of the project.
The gap between scientific feasibility and public health impact closes only when projects are set up to improve outcomes. It matters who was secured first, who waited longest and who was asked to accept risk in the name of feasibility.
How SAF is doing containment based on geography
South Africa's current approach to lencapavir is not implemented at the national level. Actually this is a controlled experiment. Of the more than 3,000 public clinics, just 300 clinics in 23 The districts have been lucky enough to be selected.
Access to life-saving preventive equipment has become a matter of where you live as our government has accepted an environment of limited supply rather than challenging it. It refuses to take action against any state GileadAnd the US government has instructed PEPFAR to exclude South Africa from its allocation. Overall, this public health policy is driven by politics, not evidence.
Call it targeting if you want. To those excluded, it probably feels like a judgment. Living outside the designated district now determines whether state-of-the-art HIV prevention is available to you. Living in an area labeled 'low incidence' effectively shortens your life, despite overwhelming evidence that prevention works best when it is widespread, proactive and universal. Viruses do not respect municipal boundaries at all.
This is not an unavoidable obstacle, but a design choice and a political decision of the pilot rather than scale, which leaves millions of South Africans who remain equally vulnerable to infection. This indicates that stopping transmission everywhere is less important than stopping it somewhere. It also indicates the Health Ministry being unable to deal with the 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 separated from access commitments would rekindle old injustices.
South Africa has been central in HIV research, hosting trials, contributing data and organizing communities in the service of global science.
in the matter of lencapavirSouth Africa, along with other countries in Latin America, was at the center of the success. However, trials and research participation have not guaranteed benefits; This rarely happens. Once again, communities that have enabled search are being asked to wait for access. The social contract that underpins ethical research, that those who take the risks should share in the rewards, has been quietly destroyed, without legal or other retribution.
Trust does not disappear overnight but is destroyed decision by decision.
Policy options that accommodate shortages rather than confront them
South Africa experienced no supply shortages yesterday. it bears the brunt During and even before the COVID-19 pandemic. The scale of the HIV epidemic is well known, and the number of people who will need effective prevention to interrupt transmission is enormous no secret. Yet the response has been calibrated downwards, designed to fit within the estimated limits imposed by Gilead and others. Rather than treating scale as non-negotiable, the policy is open to adjustment. Scarcity has been absorbed into planning assumptions, and limited access has been redefined as realism.
Global Fund and the politics of reallocation
The decision to reallocate substantial resources from existing health services to a narrowly targeted prevention pilot follows the same logic. In a context where eliminating the United States Agency for International Development has already weakened services for at-risk populations, this option does not expand the system and the numbers are inexcusable. Ending AIDS by 2039 will require millions of doses of lencapavir. Current approach set by obsession And the Minister of Health, with Gilead, Global Fund to Fight AIDS, Tuberculosis and Malaria, unitaid And others provide a fraction of what is required.
There is also a risk that policy conversations may be avoided. Restrictive prevention has scientific consequences. Limited supply increases the possibility of running out of stock. Dosing window is missed due to stock out. Missing windows increase the risk of resistance. This is how biology reacts to indecision. The most powerful prevention tool we ever have may be weakened not by failure to invent, but by failure to deploy.
A deliberate decision to continue the global pandemic
Modeling suggests At least two to four million people are needed for effective prevention to stop HIV transmission in South Africa, the epicenter of the global HIV epidemic.
This means that getting lencapavir is Gilead's global goal. three crores People have a sad confession.
Arbitrary limits set by the South African government and Gilead also represent the point at which risk is considered acceptable. This is a dire repeat of the scenario that played out during COVID-19. A UN expert opinion Concluded that when urgency collides with inequality, African lives are often managed rather than saved. HIV is beginning to follow the same pattern. Those most affected by the pandemic have once again been asked to wait, to accept the 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 a deliberate policy.
We have seen this pattern before and we can't say that we didn't recognize it.
Tian Johnson is the founder and strategist of the African Coalition, a pan-African health justice advocacy group. 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 from Johnson and Hassan examining the gap between scientific success and public health impact in South Africa's response to HIV with the advent of long-acting lencapavir.
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 the public discussion on health issues.