When Politics Overpowers Science: Why the US Withholds LEN from South Africa

The US's Decision to Exclude South Africa from LEN Funding

By excluding South Africa from its overseas funding for the roll-out of the revolutionary six-monthly HIV prevention jab, known as lenacapavir (LEN), the Trump administration undermines its own stated mission of helping other African countries, according to a US HIV activist. This decision has sparked significant criticism and concern within the global health community.

In September, the US government announced that it would join the Global Fund to Fight Aids, TB and Malaria, to buy LEN for African countries with high HIV infection rates. The Trump administration described its support as a "market-shaping initiative" aimed at increasing LEN production and uptake, thereby bringing down the price of the jab as quickly as possible.

However, the US government left South Africa off the list of 10 states it will fund, despite the country having the largest market for LEN due to its high number of new HIV infections. In contrast, the Global Fund is allocating three-quarters of the doses it is buying for nine countries to South Africa.

Mitchell Warren, head of an international advocacy organisation, Avac, warns that this exclusion betrays the US's public justification for intervening in the first place. The injection, which contains the antiretroviral drug lenacapavir and offers almost foolproof protection for HIV-negative people against contracting the virus, is likened to a powerful "chemical condom" by Linda-Gail Bekker of the Desmond Tutu Health Foundation.

Unlike latex condoms, LEN does not require a user to negotiate with their sexual partners and only needs to be taken twice a year. South Africa plans to roll out the shot on April 1, potentially earlier, at 360 government clinics with donated jabs from the Global Fund. However, the 974,450 doses allocated for 2026 and 2027 are less than 3% of what modellers say are needed to make a meaningful dent in the country's 173,000 new, yearly HIV infections.

Why Excluding South Africa is a Strategic Mistake

Warren explains that if you want to build large volumes of a product, you should start with the biggest market. South Africa is the ideal place for this because of its economic potential, epidemiological significance, and established infrastructure for distributing HIV prevention medications.

Almost all — 98% — government clinics in South Africa stock a daily HIV prevention pill. By the end of September, 2,076,501 people had used the pill at least once, more than any other country. In 2023, almost 40% of the world's daily pill users lived in South Africa.

Despite this, the US government has not approached South Africa to sign memorandums of funding for multi-year HIV funding, unlike several other African governments. Political relations between the US and South Africa are at an all-time low after President Donald Trump boycotted the annual G20 meeting hosted by South Africa in November.

Trump accused the South African government of "horrific human right abuses endured by Afrikaners" and branded it a country not "worthy of membership anywhere." Ramaphosa responded by stating that it was regrettable that Trump continued to apply punitive measures based on misinformation.

The Role of Political Relations in US Decisions

There is no credible evidence of human rights abuses endured by white people only in South Africa; in fact, evidence shows that crime often affects Black people worse than white people. Warren criticized the US's actions, calling it absurd that it took two decades to declare the apartheid regime racist, yet it took days for the current president to declare the new democratic SA racist.

South Africa will receive its first batch of LEN — 115,000 doses sponsored by the Global Fund — by the latest in February. However, to stop enough new infections to end Aids as a public health threat, South Africa would need millions of doses. Lise Jamieson, a modelling scientist at Wits University, calculated that South Africa would need 31 million doses between now and 2043 to reduce new infections to 65,000.

If most people on LEN use the medicine only once, South Africa would need 65 people to use the medicine to stop one new infection. If people use LEN for a year, we will avert one HIV infection for every 35 people using LEN and need 67 million doses between now and 2039.

Should South Africa Make LEN?

The US government and Global Fund delivered 500 LEN doses to Eswatini and Zambia, both countries with positive relations with the Trump administration. However, HIV activists have criticized this move as a public relations stunt. Gilead Sciences, the company that developed the drug, will stop selling doses to the two donors once generics become available in 2027.

South Africa's health department plans to produce LEN locally if local drug makers can obtain licenses from Gilead. Activists have called on the government to issue compulsory licenses, allowing local companies to make generic LEN without Gilead's permission.

"Cheap politics and zero foresight will thwart global efforts for a proper roll-out," says Yvette Raphael, co-founder of Advocacy for the Prevention of HIV and Aids. "No smart access effort can exclude South Africa in HIV prevention programming."