The Lenacapavir Paradox: why a promising HIV prevention tool may undermine progress toward ending AIDS in Africa

Summary African HIV programs are transitioning to new MOU agreements restoring Ministry sovereignty while facing unprecedented funding cuts. Mathematical modeling examining cuts predict 60,000–74,000 excess deaths over five years. Around 5.8 million people remain unsuppressed. Despite implementation barriers, lenacapavir, a twice-yearly injectable with 100% trial efficacy, is being rapidly introduced for millions of people. Economic constraints include requirements for higher incidence that may not exist if treatment access increases, and number needed to treat in thousands that will grow as coverage and viral suppression expand. Clinical complexity requires specialized training, loading doses, pharmacovigilance, and managing injection reactions. System demands include candidate identification, supply chain management, and loading-dose costs of 20-50%. Three-year donor funding builds markets and infrastructure governments must sustain while companies capture profits from public investment. Treatment remains the foundation of epidemic control and seven African countries have achieved the 95-95-95 target. The priority must be expanding treatment to achieve viral suppression while rigorously evaluating lenacapavir's role in the overall HIV response.