Nine lessons to make SA’s anti-HIV jab rollout work
In less than a month, South Africa will start rolling out the most potent HIV prevention medication the world has seen. But that alone doesn’t guarantee that HIV-negative people who need this twice-a-year injection — called lenacapavir (LEN) — will use it.
Uptake — and whether LEN contributes to lowering the country’s 170 000 new yearly HIV infections — will depend on how the health department approaches those who need it and how accessible the medicine is.
LEN is injected into the fatty layer under the skin in someone’s tummy. The injection leaves a small supply of medicine, called a depot, under the skin that slowly releases the drug over six months. (That’s why the medicine only needs to be taken once every six months.)
In a clinical trial, for which I was one of the researchers, LEN has shown perfect protection against HIV infection among teenage girls and young women between the ages of 16 and 25.
This is an important group to which LEN should be provided: about 30% of South Africa’s new HIV infections is among adolescent girls and young women, even though they constitute only 8% of the population.
But there’s something crucial we should remember: we’re targeting healthy, HIV-negative people. We need to treat them as such.
One of the key lessons I have taken from working as an HIV prevention researcher is that we have to manage people taking preventive medicine differently from patients in treatment programmes. As a medical doctor, I’ve also had to keep reminding myself of this.
When people are unwell, they come to the health system. When they are well, they don’t.
They don’t want to feel like patients and they stop using services quickly if they feel judged or lectured. Healthy people are far more likely to take up preventive services when these are introduced in environments that don’t feel like hospitals.
Our role as health providers is not to hold prevention medication in the system but to make it simple, easy to get and easy to use.
Because LEN is a long-acting injection and doesn’t require a young woman to agree on its use with a sexual partner, this prevention method fits easier into many young women’s lives than condoms or once-a-day pills (a daily HIV prevention pill is stocked for free in most government clinics).
I’ve seen effective tools come and go with the same limitations: daily adherence requirements, repeated clinic visits and having to negotiate use within complex relationships.
For many young women that has never been realistic. Long-acting prevention changes the equation. For the first time, it feels like we may have something that could actually work in the real world — but only if we roll it out right.
As a scientist who has researched HIV prevention medication over the past decade and a half, I’m sharing nine lessons I’ve learned that could help our LEN roll-out to reach the right people.
- People don’t accept new meds without step-by-step explanations
When lenacapavir became available in our studies (the results haven’t yet been published), participants chose the injection over daily pills when given the option. Our study data shows young women like the idea of a long-acting injection with most of them choosing it over the daily pill when they’re given the choice.
But that acceptability does not happen on its own. In trials, we invest time explaining the intervention, answering questions and building confidence. That is what drives uptake. Without the same effort across the 360 government clinics where lenacapavir will be rolled out this year, uptake is likely to be limited.
Part of this process is to explain LEN’s side effects.
Lenacapavir is generally well tolerated. The most common side effects are pain at the spot where it is injected, small lumps under the skin where the medicine forms a small depot and sometimes swelling. Occasionally, a small amount of fluid may be seen at the injection site immediately after the injection; this is related to the injection process rather than the medicine itself.
As a researcher, I’ve seen how these reactions can be uncomfortable, particularly with the first dose. But simple measures such as ice packs, good injection technique and preparing potential users in advance by explaining the pharmacology of the depot to help them understand what the nodule represents, can make a meaningful difference.
In our trials, I’ve also noticed how tolerability varies, with thinner people sometimes reporting more discomfort, likely reflecting differences in tissue under the skin.
These reactions become more manageable over time when expectations are set clearly. That’s why it’s important to train healthcare workers delivering lenacapavir to provide high-quality counselling, much of which can be effectively done by trained lay health workers.
2. Make giving consent easy and simple
From my experience, young women, including those under 18, can make informed decisions about how to protect themselves from HIV.
When they’re given easy-to-understand information and guidance, they understand their risk, ask relevant questions and interact meaningfully with care, often while navigating complex relationships and social situations that increase their chances of getting HIV.
Yet systems often make this harder than it needs to be, particularly through rigid consent processes and interactions that can feel judgemental. Even well-intentioned questions about parental awareness may be experienced as shaming and discourage young people from accessing care.
Where legally permissible, services should support independent adolescent consent (without the involvement of a parent), use clear, age-appropriate materials and prioritise confidential, non-judgemental engagement.
3. Don’t wait for users to come to clinics, recruit them in communities
As scientists, we never just go into a community and start our research straight away. For months before we start with a study, we build relationships.
We visit the communities we plan to work with to sit down with participants, explain how the intervention we’re studying works and answer their questions. Over time, people become more familiar with it, often hearing about it from others and seeing it used in their communities.
This is how demand is created in practice. It is built, not assumed. It needs to be active and deliberate and requires teams who are skilled in connecting with communities, building trust, communicating clearly and using simple approaches such as community talks, peer educators and locally tailored messaging through WhatsApp groups or community radio can raise awareness and generate interest.
In clinical trials, we call this recruitment. Without this work, LEN’s uptake is unlikely to match what we see in trial settings.
4. Put salespeople on your team — they know how to promote medicine
The way you engage — and who does it — matters.
A successful roll-out of new medicine like LEN requires expertise beyond the clinic: people who understand communication and marketing, as well as the language and culture of the communities they’re working with.
Reaching young people today may mean using TikTok, not Facebook. It is a humbling moment when you realise your carefully worded Facebook post is not getting much traction.
In our studies we have moved towards using short videos between 30 and 60 seconds, WhatsApp sharing and peer-led content, which tend to resonate better with young people.
The public sector cannot do this alone; there is real value in drawing on expertise from communications, media and marketing experts to reach people more effectively.
5. Sell prevention as something positive, rather than “know your risk”
As doctors, we’ve seen the devastation of the HIV epidemic and we understand the urgency of doing something about it. It is natural to think that if we explain the risks clearly, people will change their behaviour.
But in practice, it’s not that simple.
For many young people, being told they’re at risk of HIV infection can be off-putting rather than motivating. It can shut down the conversation rather than open it.
What works better is moving away from fear-based messaging towards positive, empowering messages about prevention, framed around staying healthy, maintaining control and choosing what works for your life.
Tone matters more than we realise.
6. Send reminders for follow-up doses — and find those who don’t return
Long-acting doesn’t mean self-sustaining.
In clinical trials, retention is engineered through tracking, reminders and follow-up to ensure participants return for subsequent doses. In public health clinics, these systems are limited or absent.
Experience with injectable contraception shows us that, even with long-acting options, people often don’t turn up for repeat doses. Without deliberate recall systems, missed doses become the norm.
In HIV prevention, this is not a trivial gap.
Missing or delaying doses reduces protection and increases the chance of getting HIV. If someone becomes infected during this time, when there is still some medicine in the body but not enough to fully protect them, there is a risk that the virus could become resistant to treatment.
Long-acting prevention does not replace a weak health system; it depends on one that can keep track of people and help them come back for their next dose. In practice, this means simple follow-up systems such as SMS reminders, WhatsApp messages and basic tracking tools.
It also requires rebuilding frontline support. The loss of community health workers, lay counsellors and data capturers following the withdrawal of US government funding has removed much of the support needed to deliver and sustain HIV prevention.
An April report found that the roll-out of lenacapavir will be heavily affected by these cuts, particularly the loss of community-based testing and outreach needed to raise awareness and bring people into services.
This gap must be filled.
7. Re-think how LEN is delivered
If we deliver LEN through existing systems only, we will limit its impact. Delivery models need to change. In clinical trials, administering LEN injections involves doctors, nurses and pharmacists, making the process labour-intensive and difficult to scale.
This is not a realistic model for a large roll-out in public health clinics.
LEN is given through a subcutaneous injection (into the layer of fat just under the skin). Such jabs are not difficult to give and patients with conditions such as diabetes mostly self-administer their insulin injections.
It’s important that we do this with LEN too: Task shifting, supported self-administration and pharmacy-based delivery is both feasible and necessary. Without this shift, access will remain constrained by clinic-based services.
8. Stop looking for a silver bullet: we need choices
When something new comes along, it is tempting to believe it will solve everything. It will not.
There is no single answer to an immensely complex condition such as HIV. We need to move quickly to roll out LEN, while being clear about its limits.
This is why choice matters. When people are offered a range of choices that fit their lives — in the case of HIV prevention: condoms, a daily pill, a twice-a-year injection, a potential yearly injection and monthly pill — uptake improves.
We’ve seen that happen with contraception. In the end, people will use what works for them.
9. Move services right into communities
For population-level impact, lenacapavir must be delivered in communities, not only in clinics.
This means mobile clinics, community health workers, lay counsellors, peer supporters and nurses reaching people where they are, explaining the medicine and making access simple and convenient.
If we do not do this and do not address the gaps left by funding cuts, much of the supply will remain on pharmacy shelves, far from those who need it most.
Dr Katherine Gill is a medical doctor and senior researcher at the Desmond Tutu Health Foundation in South Africa. She leads HIV prevention trials and programmes, with extensive experience in community-based research and the roll-out of new prevention technologies.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.