South Africa’s HIV Prevention Injection Faces Uptake Hurdles

South Africa has introduced lenacapavir (LEN), a six-month HIV prevention injection that offers near-total protection against the virus. However, the rollout faces a critical challenge: uptake remains far below the millions who could benefit. Lenacapavir, which requires only two administrations annually, is nearly 100% effective when used correctly. The government began distributing it through 360 clinics in June, with plans to expand dramatically once generic versions become available in 2024.

Health economists at Wits University’s Health Economics and Epidemiology Office (HE2RO) warn that simply making the medicine free and accessible will not ensure widespread use. Past experiences with daily oral PrEP pills—also free and widely stocked—reveal that awareness and desire drive uptake, not availability alone. To date, just over 71,000 people have received LEN by October, despite modeling suggesting that 1–2 million annual users could end AIDS as a public health threat by 2043.

Creating Demand Through Trusted Messengers

HE2RO’s analysis of HIV prevention pill programs highlights the importance of personal contact in driving uptake. In 2022, Gates Foundation-funded projects tested multiple outreach strategies, including peer educators, community radio, and social media. Of 1,038 first-time users interviewed, 46% learned about prevention medication through direct conversations with peer navigators or healthcare workers, while another 35% heard from friends or family. Only 5% cited mass media like billboards or TV as their initial source. These findings suggest that awareness does not arise organically; it requires intentional effort.

Funding the Push for Awareness and Access

Health economists emphasize that demand creation represents a significant portion of HIV prevention program costs. Activities to inform and engage potential users account for 14% to 40% of total expenses per prevention visit, depending on outreach scale and approach. Without dedicated funding for these efforts, even effective treatments like LEN may fail to reach those in need.

The shift from donor-supported to government-funded initiatives poses unique challenges for community-based outreach. Previous programs relied on international donors to cover peer educators, transportation, and social media campaigns. LEN’s rollout occurs amid reduced global health funding, requiring South Africa’s government to secure sustainable financing for demand creation alongside medicine procurement and clinic services.

Local peer educators and community conversations remain central to driving uptake, particularly among priority populations. These efforts require compensation for outreach workers, funding for events, and resources to produce accessible content. Policymakers must prioritize budgeting for these critical components to ensure LEN reaches its potential impact.

Community Outreach Drives Immediate Action

Initiatives using peer-led outreach showed remarkable success in converting interest into action. One initiative relying on community-based peer navigators achieved a 46–50% immediate uptake rate among those who learn about the medication through these conversations. In contrast, programs without such personalized outreach saw only 21–34% start using right away. Peer educators, often from the communities they serve, proved critical in answering practical questions and building trust. A transgender individual might address different concerns than a sex worker, and those who have used LEN themselves could provide relatable guidance. Broadcast media alone, while useful for normalization, cannot replace the personal connection needed to drive behavior change.

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Eliminating Delays in Access

Another key finding was the importance of immediate action once interest is sparked. Many potential users abandoned the process when faced with delays or uncertainty. When peer navigators guided individuals directly to clinics ready to administer the injection, or accompanied them to appointments, the gap between interest and receipt of medication narrowed significantly.

Clinics must ensure stock availability and streamline processes to avoid situations where someone travels to a facility only to find no doses available. Such barriers risk eroding trust and discouraging future engagement with prevention services.

This starkly underperforms compared to the 2.3 million who had ever taken daily oral PrEP by June, despite similar efforts. Such a contrast highlights that even the most effective medicine cannot succeed without a coordinated strategy to connect it with those who need it.

The sixth and final lesson from the research centers on accountability through measurement. Health officials must track which specific outreach methods translate into clinic visits and actual LEN administration. Counting broad exposure metrics like social media impressions provides limited insight compared to monitoring conversion rates from awareness to vaccination. This data allows resources to flow toward most effective strategies while reducing investment in approaches that generate interest without delivery.

Targeted campaigns yield the strongest returns. Rather than pursuing mass awareness, efforts should concentrate on communities with highest HIV risk where LEN can prevent the most transmissions. Priority groups benefit from peer-led conversations and community-based programs that address specific concerns and build confidence in the preventive injection. These focused approaches align outreach intensity with greatest public health impact.

Supply Must Meet Promotion

Local campaigns create demand only when clinics can fulfill it. South Africa begins LEN rollout with limited quantities funded by the Global Fund, making geographic coordination essential. Promoting availability in areas with insufficient stock risks disappointing potential users and eroding trust in prevention services. Outreach teams must verify clinic readiness before advocating for the injection in their communities.

The health system needs mechanisms to match interest with inventory. When someone decides to pursue LEN after peer education or community discussion, they should encounter available doses and streamlined processes. This requires real-time communication between outreach workers and clinic pharmacists, ensuring promotional activities don’t outpace supply chains. Success depends on aligning demand creation with actual service capacity at each facility.