How do you persuade people to want a new medicine when there isn’t enough of it to go around? That’s the problem facing the first countries rolling out lenacapavir (LEN), the six-monthly anti-HIV injection, writes Ida Jooste for Bhekisisa Centre for Health Journalism.
The shot – which South Africa started rolling out at around one in 10 government clinics on 5 June – has sparked an excitement about HIV prevention that Mitchell Warren, executive director of the HIV advocacy organisation Avac, says he hasn’t seen in three decades.
Some experts say it’s easy to understand why. The injection offers close to complete protection against HIV and only needs to be taken twice a year.
But for now, supplies are limited, as the only doses available to South Africa are the branded product, made by LEN’s developer, Gilead Sciences, and paid and distributed through an arrangement with the Global Fund to Fight Aids, TB and Malaria, until generics become available in 2027.
Some African countries also get doses supported by Pepfar.
And therein lies a catch: countries need to create enough demand for LEN to convince drug makers there will be a market for cheaper generic versions. The bigger the market, the cheaper generic LEN will be.
But create too much demand now and people could arrive at clinics only to be told they’ve run out of stock.
Zambia, which began offering LEN in December with only 500 initial doses, has been trying to strike this balance for months. At the International Aids Conference in Rio de Janeiro in July, the country’s director of infectious diseases, Lloyd Mulenga, described during a panel discussion how clinics frequently run out of stock.
South Africa, which launched later than Zambia, but on a much larger scale, is now facing many of the same issues.
A man named Aaron walks into a clinic
“Yesterday, I saw something I’ve never seen before,” Sister Samaria Mwale told Bhekisisa at Chilenje Level One Hospital in Lusaka, to which we travelled in June.
“A man called Aaron walked into the clinic with seven women from a nearby brothel.”
Aaron had learnt about LEN through field workers and persuaded the women to come with him. He got the injection too.
“I took them because it’s for their protection,” he later told Bhekisisa. “By these women being safe, many of us are safe.”
Aaron is planning to bring another six women to the clinic.
Mwale had also chosen LEN for herself. “I thought it would be very painful, but it was manageable,” she says.
But Zambia hasn’t created this interest by waiting for people like Aaron to walk into clinics. Health workers and community organisations have been taking information about LEN into communities, sometimes literally drumming up interest.
But with doses scarce, much of the outreach has happened close to clinics where LEN is actually available.
Aaron heard about LEN this way. It’s an attempt to solve the dilemma: create demand, but create it where you have injections to offer.
Elmari Briedenhann, head of communication and engagement at Wits RHI, has helped develop community plans in South Africa, Zambia, Zimbabwe, Nigeria and Kenya. She says keeping quiet about LEN because supplies are scarce would create another problem: rumours and wrong information.
“If we don’t say something, the space is going to fill up with misinformation,” Briedenhann says.
The answer, she argues, is to tell people what LEN is – but also to be honest about where and when they can get it.
“In that sense, I’m a big fan of the truth.”
Warren compares the current situation to a small restaurant whose carrots have run out: you can’t offer carrot soup that day, it’s off the menu. Instead, clinics can then offer clients the daily HIV prevention pill.
South Africa stocks the pill, which is free, at almost all government clinics.
But countries can’t keep LEN on a tiny menu forever.
To get beyond a rationed roll-out, Warren says, manufacturers need evidence that there will be enough demand to make large quantities of cheaper generic LEN worthwhile.
HIV experts writing in the International Journal for Equity in Health show how producing more doses could bring the price down. The authors estimate that if manufacturers produce 5m to 10m doses a year, LEN could be supplied for as little as $25 per person a year.
In October 2024, Gilead Sciences gave six companies licences to make generic LEN. Two Indian manufacturers, Hetero and Dr Reddy’s, have received donor support to make it at $40 per person per year, more or less the same cost as that of the daily HIV prevention pill. Generic LEN is expected to become available in early 2027.
The South African Government and the SA National Aids Council (Sanac), are also in the process of negotiating with Gilead for licences for local drug makers to make LEN.
SA waited because it feared losing people’s trust
South Africa faced the same dilemma as Zambia before giving its first LEN injection. Fikile Ndlovu, the Health Department’s deputy director general for HIV, says the department worried that launching with too few doses could backfire.
“One of the things we grappled with … was having too few doses, because people would lose trust in us,” she told Bhekisisa.
That’s why the department delayed its launch until June when it believed it had enough stock for a launch, around 38 000 doses.
LEN is currently available in 360 public health facilities, with more to be added in phases.
But even in South Africa, clinics have run out of stock. In July, a woman who follows Bhekisisa on TikTok said she was turned away at three Gauteng clinics. At Lyttelton clinic in Centurion she was asked to make a booking first: “They told me to call on a Monday to make an appointment,” she said.
Bhekisisa reported this to Ndlovu, who then did a Zoom interview with our TikTok producer to explain why some clinics had run out of stock and when new stock would arrive. She also explained that LEN clinics cannot ask clients for appointments, and sent a Health Department official to the Lyttelton clinic the next day to clarify the procedure.
Ndlovu said: “If we are having an honest conversation, explaining the doses we have, where we have them, and the limitations, that minimises uncertainty about where and when people can find them.”
Getting LEN to people who need it most
Demand has been striking. In the first six weeks, 31 297 people started, as Bhekisisa reported. Among people offered a choice between LEN and a daily HIV prevention pill, 98.5% chose the injection.
About a third of LEN users were new to HIV prevention medication while 28% were men – almost three times the proportion historically reached when only the pill was available, Bhekisisa’s data team’s analysis showed.
But those headline figures expose another problem with the idea of “demand”.
Having enough injections in the country doesn’t necessarily mean that the people who need them most can get them.
Only 705 of the first 31 297 LEN users were sex workers, 419 were gay and bisexual men, 33 people who inject drugs, and 31 were transgender people.
These groups, also called key populations, have a far higher chance of getting HIV than the general population.
Jacqueline Pienaar of the Aurum Institute, says such groups’ low uptake isn’t because they don’t want LEN.
“The issue is that [groups with a higher chance of getting HIV] don’t want to go to clinics because they are treated badly because of discrimination against, for instance their sexuality, gender identity or profession, or have to wait five to six hours.”
Before the US government’s HIV funding cuts in 2025, Pepfar funded separate clinics with tailor-made services for high-risk groups. But most of those clinics, which were run by NGOs, have since closed down.
It has left these groups with no other option than to go to public health clinics where some health workers aren’t sensitive to their needs.
For such groups, making LEN available only at general public clinics can turn theoretical availability into practical inaccessibility.
So the challenge isn’t simply creating enough demand. It’s making sure doses are in the places where people who want them can actually get them.
What Zambia’s numbers tell us
Zambia’s roll-out now covers 106 public clinics in 13 districts. Health officials there have tried to tackle the same problem faced by South Africa: the stigma facing high-risk groups at clinics.
“We’ve had trainings for every cadre … from the cleaners to security guards to clinical personnel,” says Mundia Mwitumwa, an HIV prevention technical adviser at Zambia’s health ministry.
Seven and a half months into the country’s roll-out, 4 382 people had started LEN in Zambia, according to health ministry figures. Of those, almost three-quarters – 3 137 people – had never used HIV prevention medicine before.
The oldest LEN recipient so far is 72. At the other end are girls as young as 14.
Mwitumwa says mothers have brought their teenage daughters to clinics because they know they’re sexually active and want to protect them against HIV.
“We then hold private sessions away from the parent,” she said: “We say, ‘Do you understand why mom has brought you here? Do you agree?’”
For Mwitumwa, these conversations suggest that a prevention option people want can sometimes open up conversations about HIV and sex that were previously difficult to have.
Numbers have to add up
Back in South Africa, arithmetic remains difficult. So far, the country has received 114 720 LEN doses (37 920 in March/April, 19 800 in May and 57 000 in June), paid for with its Global Fund grant.
Of those, 42 947 doses had been used by 17 August. The rest of the 71 773 doses have all been distributed to clinics, the health department says.
The department and Sanac are still developing a national plan for creating demand for LEN.
For now, Ndlovu says the approach is simple: tell people honestly how much LEN is available and where they can get it. If one clinic runs out while another has injections sitting unused, doses can be shifted between facilities or districts, she says.
But moving scarce doses around can only take South Africa so far. Modelling scientists say for the country to make a meaningful dent in new HIV infections within the next two decades, between 1m and 2m people need to take LEN at least once a year.
The long-term solution is getting millions of LEN doses at a price the country can afford.
That’s why the demand-and-supply balancing act matters.
Countries need enough injections to meet the demand they’re creating. But manufacturers of cheaper generic LEN also need confidence that millions of people will want to produce before producing it at scale.
And South Africa’s early figures suggest that appetite is not going to be a problem.
“If we don’t get the generics,” Ndlovu says, ”we are going to run into serious problems.”
Additional reporting by Mia Malan
See more from MedicalBrief archives:
South Africans rush to receive LEN jab
Minister promises SA-made generic as LEN rollout begins
Gilead inks deal for generic HIV drug supply to low-income nations
LEN rollout will miss a critical group of South African men