NGAA MUROMBEDZI

South Africa’s introduction of long-acting injectable HIV pre-exposure prophylaxis (PrEP), lenacapavir, is a welcome addition to the choices people have to protect against HIV. It signals scientific progress and renews hope in a country that remains at the heart of the global HIV epidemic.

With approximately 7.8-million people living with HIV and an estimated 170,000 new infections recorded in 2024, our prevention response must be bold, people‑centred and grounded in lived realities.

Lenacapavir offers particular promise for:

adolescent girls and young women;
pregnant and breastfeeding mothers; and
key and vulnerable populations who continue to face disproportionate HIV risk.

For individuals who have struggled with daily oral PrEP adherence, a twice‑yearly injectable option could be life‑changing. Choice matters. Innovation matters. But innovation must never come at the expense of the fundamentals that have carried SA’s HIV response forward for decades.

Lenacapavir is PrEP, but it is not comprehensive prevention. It protects against HIV, not against sexually transmitted infections (STIs) or unintended pregnancy. That distinction is not academic; it is critical in a country already burdened by some of the highest STI rates globally and persistently high levels of adolescent pregnancy.

At this moment of biomedical progress, we must be clear: injectable PrEP does not replace condoms. Condoms remain the only prevention tool that simultaneously protects against HIV, STIs and unplanned pregnancy — and they remain the most cost‑effective intervention available to the public health system.

Rising untreated STIs and ongoing high rates of teenage pregnancy are not side issues; they are core indicators of whether our HIV prevention approach is working

Yet condom use, particularly among young women and within longer‑term or age‑disparate relationships, remains uneven.

These patterns are not driven by lack of knowledge alone; they reflect entrenched gender norms, power imbalances, economic vulnerability and limited negotiation autonomy. Any prevention strategy that ignores these demographic and social realities is destined to fall short.

This is why the rollout of lenacapavir must strengthen — not weaken — condom promotion and access. In a context of constrained resources and competing health priorities, narrowing prevention messaging risks creating new pressures elsewhere in the system.

Rising untreated STIs and ongoing high rates of teenage pregnancy are not side issues; they are core indicators of whether our HIV prevention approach is working. Community engagement must therefore be non‑negotiable. Biomedical innovation does not succeed in isolation.

Communities must fully understand what lenacapavir is, how it works, how often it must be taken and — crucially — what it does not protect against.

We need ongoing, community‑led consultations that listen to people’s experiences, from access barriers and service quality to perceptions of risk and protection. One‑off messaging is not enough; listening must be continuous.

SA’s progress against HIV has always been strongest when communities were not treated as passive recipients but as drivers of change. We must return to that principle now. To stem the tide of HIV infections among key and vulnerable populations — while also reversing increases in STIs and teenage pregnancy — we need a deliberate behaviour shift anchored in co‑creation.

Condoms, community leadership and integrated sexual and reproductive health services are not optional add‑ons; they are essential

The ask is clear. The government, donors and implementing partners must:

position key and vulnerable populations as drivers of prevention, not merely as targets of it;
embed meaningful community engagement at every point of the lenacapavir rollout;
integrate routine STI screening and contraception counselling into all HIV prevention encounters;
invest in communication strategies that reflect real‑world relationships, risks and constraints; and
actively and consistently engage men and boys, recognising that prevention responsibility cannot continue to rest disproportionately on women and girls.

We can welcome innovation without losing our foundations. Lenacapavir expands the prevention toolbox — but combination prevention remains the backbone of an effective response. Condoms, community leadership and integrated sexual and reproductive health services are not optional add‑ons; they are essential.

As the Aids Healthcare Foundation in Southern Africa, we believe this moment can either strengthen our prevention architecture or unintentionally weaken it. The difference lies in whether we choose to lead with communities, protect proven interventions and balance biomedical ambition with social realities.

If we do that, innovation will accelerate progress rather than compromise it — and SA will be closer to ending new HIV infections while safeguarding broader sexual and reproductive health for all.