By shutting South Africa out of its overseas funding for the roll-out of the revolutionary six-monthly HIV prevention jab which could potentially end Aids, the Trump administration undercuts its own stated mission for helping other African countries, says a US HIV activist.
- By shutting South Africa out of its overseas funding for the roll-out of the revolutionary six-monthly HIV prevention jab which could potentially end Aids, the Trump administration undercuts its own stated mission for helping other African countries, says a US HIV activist.
- 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 revealed its support was a " market-shaping initiative " with the goal to increase LEN production and uptake, and, in effect, bring down the price of the jab as fast as possible.
- But the US government left the country — South Africa — with the largest market for LEN, because it has the highest number of new HIV infections in the world — off the list of the 10 states it will fund, effectively betraying its own public justification for intervening at all.
- In sharp contrast, the Global Fund is allocating three-quarters of the doses it is buying for nine countries to South Africa.
By shutting South Africa out of its overseas funding for the roll-out of the revolutionary six-monthly HIV prevention jab which could potentially end Aids, the Trump administration undercuts its own stated mission for helping other African countries, warns Mitchell Warren, the head of an international advocacy organisation, Avac.
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The injection, which contains the antiretroviral drug lenacapavir and gives almost foolproof protection for HIV-negative people against contracting the virus, is like a powerful "chemical condom", says Linda-Gail Bekker of the Desmond Tutu Health Foundation and lead scientist for a study which tested the jab, known as lenacapavir (LEN), on teen girls and young women.
"But unlike latex condoms," Bekker explains, "LEN doesn't require a user to negotiate for permission from their sexual partners to use, and only has to be taken twice a year as opposed to each time they have sex."
South Africa will roll out the shot on April 1 — and possibly earlier, according to the health department — at 360 government clinics with donated jabs from the Global Fund to Fight Aids, TB and Malaria. But the 974 450 doses, which will cover around 456 00 people in 2026 and 2027, are not even 3% of what the modellers say are required to make a meaningful dent in the country's 173 000 new, yearly HIV infections.
Why it's a dumb move to exclude SA from getting Pepfar doses
In September, the US government announced that it would, through its international Aids programme, Pepfar, join the Global Fund to buy LEN for African countries with high HIV infection rates. The Trump administration revealed its support was a "market-shaping initiative" with the goal to increase LEN production and uptake, and, in effect, bring down the price of the jab as fast as possible, so that countries could eventually buy the medicine themselves.
But the US government left the country — South Africa — with the largest market for LEN, because it has the highest number of new HIV infections in the world — off the list of the 10 states it will fund, effectively betraying its own public justification for intervening at all.
In sharp contrast, the Global Fund is allocating three-quarters of the doses it is buying for nine countries to South Africa.
Warren explains: "If you want to build large volumes of a product, whether it's lenacapavir or Coca-Cola — because we know that large volumes will lower prices — you make sure you start off with the biggest market, because that's how you will shape the market the fastest and most meaningfully.
"So South Africa is the place where you'd want to be. Economically, because that's how you will build the market the quickest. Epidemiologically, because that's how you will prevent the most new infections. Practically, because that's the country with the most mature HIV prevention medication market in the world."
Almost all — 98% — government clinics in the country stock a daily HIV prevention pill. By the end of September, 2 076 501 people had used the pill at least once; that's more than any other country. In 2023, almost 40% of the world's daily pill users lived in South Africa.
South Africa therefore has established infrastructure and tried-out plans for the distribution of HIV prevention meds like the pill and LEN.
"I'm sad that ideology and politics have yet again entered one of Pepfar's initiatives, to the point that they won't work in South Africa," says Warren.
It's a huge disappointment."
How political relations feed into the US's decision
Despite Health Minister Aaron Motsoaledi announcing in mid-October that South Africa received a letter from the US government pledging R2 008-billion to carry through Pepfar-funded programmes managed by the Centres for Disease Control until March, the health department says the country has not been approached by the US government — as several other African governments have — to sign memorandums of funding for multi-year HIV funding.
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, accusing the government of "horrific human right abuses endured by Afrikaners ... killing white people, and randomly allowing their farms to be taken from them" and branding it a country not "worthy of membership anywhere" and deservant of the US stopping "all payments and subsidies to them, effective immediately", after President Cyril Ramaphosa refused to hand over a baton, representing the G20 presidency, to the acting US ambassador at the closing ceremony.
Ramaphosa hit back in a statement saying "it is regrettable that despite the efforts and numerous attempts ... to reset the diplomatic relationship with the US, President Trump continues to be vindictive and seek to apply punitive measures against South Africa based on misinformation and distortions about our country".
There is no credible evidence of human rights abuses endured by white people only in the country; in fact, evidence shows that crime often affects Black people worse than white people, as so many Black people live in poorer areas where crime rates are higher.
"It took the US two decades to declare the apartheid regime racist, but it took our current president a matter of days to declare the new democratic SA racist," Warren says. "It's absurd."
How many people need to take LEN to stop one infection?
South Africa will receive its first batch of LEN — 115 000 doses sponsored by the Global Fund — by the latest in February, the health department told Bhekisisa.
But for South Africa to use LEN to stop enough new infections to end Aids as a public health threat, in other words, to get the rate of new infections down 0.1% (it's currently 0.32%), we'd need to reduce 2024's 172 994 new HIV infections to 65 000, Wits University Health Economics and Epidemiology Research Office (He2ro) modelling scientist, Lise Jamieson, has calculated.
And for that to happen by 2043, so within 18 years, we'd need millions of doses.
If most people on LEN use the medicine only once (so a single six-month dose), South Africa would need 65 people to use the medicine to stop one new infection — this comes to a total of 31-million doses we need between now and 2043.
If we'd like to end Aids a few years earlier, in 2039, and most people use LEN for a year (so each person would take two consecutive doses, and turn up for their second dose in time), we will avert one HIV infection for every 35 people using LEN and need a total of 67-million doses between now and 2039.
South Africa's Global Fund LEN doses therefore only constitute about 3% (974 450/31-million = 3.14%) of the total number of doses that we would need to end Aids in 2043 (the more conservative scenario that Jamieson calculated).
"That's why we need LEN to be dirt cheap and it's got to be easy to give," says Bekker. "You need to over treat with prevention, because you don't know that one person is who will get infected. You can't predict it."
Should SA make LEN?
The US government and Global Fund delivered 500 LEN doses to Eswatini and Zambia — both countries have positive relations with the Trump administration — in November. The doses which the Global Fund and Pepfar buy are from Gilead Sciences, the company which developed the drug.
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But HIV activists have criticised the November move as a public relations stunt and "symbolic handouts, while Gilead [LEN's manufacturer] and donors shape markets to serve corporate and geopolitical interests, not urgent public health needs".
Gilead told Bhekisisa it will stop selling doses to the two donors once generics from six companies it issued with licences become available in 2027. South Africa's health department will buy additional LEN when generics become available, but how many doses it will be able to afford will depend on the price of the medicine and on how eager people are to use LEN, says the national health department's Deputy Director General for HIV, Nonhlanhla Fikile Ndlovu.
The country plans to produce LEN locally, if local drug makers are able to obtain licences from Gilead which allow them to import the key ingredient as they don't have the technology to make it, like the other six companies (none of them are based in South Africa) which already have licences, would.
Although Gilead has told Bhekisisa it could potentially consider such licences, should the companies pass an evaluation, government and representatives from South Africa's National Aids Council say the process is difficult and is being dragged out.
Meanwhile, activists have called on the government to issue compulsory licences, which will allow 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. South Africa was also one of the countries that contributed to the success of LEN [by hosting trial sites] — and we should remember that HIV knows no borders and that our fight for human rights is not for sale."
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
