The United States is accelerating the distribution of a revolutionary HIV prevention drug, lenacapavir, but with a notable exclusion: South Africa, the nation with the world’s highest HIV burden, will not receive US-funded doses. This decision, framed within the Trump administration’s “America First” global health strategy, raises questions about geopolitical influence over public health priorities.
The Breakthrough Drug: Lenacapavir
For decades, HIV prevention relied heavily on daily oral PrEP (pre-exposure prophylaxis). While effective, adherence remains a significant challenge, particularly in resource-limited settings. Lenacapavir offers a distinct advantage: administered as an injection just twice a year, it eliminates the need for daily pills, improving convenience and potentially reducing stigma.
Clinical trials have demonstrated remarkable efficacy: 100% protection in women and approximately 96% in men, transgender, and nonbinary individuals. The World Health Organization (WHO) endorsed the drug in July, following FDA approval in June and EU endorsement in August.
Fast-Tracked Deployment, Politically Conditioned
The speed of lenacapavir’s rollout is unprecedented. Shipments have already reached Eswatini and Zambia, bypassing the typical bureaucratic delays. However, this rapid deployment is now entangled with US foreign policy.
Just days ago, the State Department announced that US-funded lenacapavir will not be supplied to South Africa, despite its critical need. This decision stems from escalating tensions between the Trump administration and South Africa’s President Cyril Ramaphosa. The US has accused South Africa of “white genocide” and illegal land seizures, leading to diplomatic clashes and aid cuts.
PEPFAR’s Role and Shifting Priorities
Since 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been a cornerstone of global HIV treatment access. However, the Trump administration initially froze PEPFAR funding upon taking office before announcing plans to revive it with lenacapavir. The new strategy prioritizes maternal health programs, aiming to eliminate mother-to-child HIV transmission.
Critics argue this approach is ideologically driven rather than scientifically sound. While preventing infant infections is crucial, the greatest burden of new HIV cases falls on young women, gay and bisexual men, sex workers, and people who use drugs – groups potentially excluded by the administration’s narrow focus.
Gilead’s Licensing Model and Long-Term Access
Gilead Sciences, the drug’s developer, has taken an unusual step by licensing generic manufacturers to produce lenacapavir in 120 low- and lower-middle-income countries. This could accelerate access and lower costs, but upper-middle-income nations with rising infections will be excluded from the cheaper versions.
The long-term impact of this licensing deal remains uncertain, but it represents a departure from traditional pharmaceutical practices.
Conclusion
Lenacapavir holds immense promise for HIV prevention, yet its rollout is marred by political interference. The US decision to exclude South Africa highlights how geopolitical considerations can override public health needs. While the drug’s potential is undeniable, equitable access hinges on overcoming these barriers.
