The arrival of the first doses of lenacapavir in the Kingdom of Eswatini this week was a moment heavy with symbolism for Africa. For decades, lifesaving HIV medicines reached African communities long after being introduced in wealthier nations, a delay that cost countless lives and deepened inequities in the global response to HIV. This time is different.
Lenacapavir, a two-dose-per-year HIV prevention injection shown to offer near-complete protection, is reaching African patients at the same time as those in high-income countries—a milestone that many see as a long overdue shift.
Gilead Sciences, the drug’s developer, presented the distribution as a sign of a new approach to global access. The company’s chief executive, Daniel O’Day, described the moment as “unforgettable,” saying it represented the outcome of scientific work that began many years ago.
But while the symbolism carries enormous weight, the rollout itself has prompted sharp criticism. The United States government, Gilead, and the Global Fund to Fight AIDS, Tuberculosis and Malaria announced the delivery of just 500 donated doses each for Eswatini and Zambia ahead of World AIDS Day. For many activists, that number was far too small for a region that accounts for the majority of new HIV infections worldwide.
“Africa and the Global South are being offered merely symbolic handouts,” said Fatima Hassan, Director of the Health Justice Initiative, arguing that a handful of doses allows the company and its partners to claim early access without delivering meaningful public health impact. She warned that by entering markets at low volume, Gilead may shape future pricing and supply on terms that favour commercial interests over access.
Demand for lenacapavir is enormous. At least 10 million people in Africa alone are expected to need the injection, particularly adolescent girls and young women, who remain disproportionately affected by HIV. But U.S. officials have said current plans will cover just 300,000 people globally by 2026, a figure campaigners say falls dramatically short of the scale required to change the trajectory of the epidemic.
“Protection for only 300,000 people is insulting,” said Bellinda Thibela of Health GAP, noting that the drug has shown superiority to oral PrEP in clinical trials. “Instead of crumbs, the U.S. should be providing millions of doses to alter the course of the HIV pandemic.”
Critics also accuse the U.S. government of undermining HIV programmes elsewhere. Since January, civil society groups say reductions in PEPFAR funding have led to cuts in HIV testing and treatment services in several African countries. Some activists claim newly negotiated memoranda of understanding in 18 countries are allowing these cuts to proceed despite Congressional disapproval, while also restricting prevention services, particularly for key populations.
These geopolitical dimensions are shaping the rollout of lenacapavir. South Africa—home to 14% of the world’s new HIV infections—was excluded from the initial donation. Activists allege the decision reflects broader strains in U.S.–South Africa relations, while others point to the challenges of delivering a scarce medicine in a country where more than two million people might benefit annually.
South Africa has been promised doses through the Global Fund, but only enough for around 480,000 people between 2026 and 2028, a scale that modelling suggests will have limited impact on national infection rates.
At the centre of the dispute is the question of who will produce lenacapavir and at what price. Campaigners note that the drug could cost as little as US$25 per year once manufactured at scale, but argue that delays in generic licensing and limited registration in low- and middle-income countries risk keeping prices high and supply constrained. No major African manufacturer has yet received a voluntary license from Gilead, despite the continent’s established capacity for sterile injectable medicines.
“South Africa has domestic companies that can manufacture quality-assured lenacapavir,” said Sibongile Tshabalala, Chairperson of the Treatment Action Campaign. She and others are urging the South African government to consider compulsory licensing if voluntary agreements do not expand.
The stakes are high. Whether lenacapavir becomes a transformative tool in the fight against HIV—or another innovation that reaches Africa slowly and only at limited scale—may depend on decisions made in the coming months on pricing, licensing and procurement.
Eswatini’s first shipment marks both a breakthrough and a reminder that scientific progress means little unless the people most affected can benefit from it.
