Pricing pivotal as HIV drug advances offer ‘choice’

[RIO DE JANEIRO] After decades of asking people to prevent HIV with a pill every day, scientists may finally have found numerous options to make HIV prevention and treatment fit around people’s lives instead of asking lives to fit around medicines.

At the 26th International AIDS Conference (AIDS 2026) in Rio de Janeiro, new evidence from the PURPOSE 1 and PURPOSE 2 studies reinforced the promise of twice-yearly injectable lenacapavir for HIV prevention.

Meanwhile, ISLEND-1 and ISLEND-2 trials showed that a once-weekly oral combination of islatravir and lenacapavir could offer people living with HIV an effective alternative to daily treatment.

Together, the findings suggest HIV prevention and treatment may be entering an era defined by long-acting options rather than daily pills.

Unlike the PURPOSE studies, which evaluated lenacapavir as a preventive medicine (pre-exposure prophylaxis, or PrEP) for people without HIV, the ISLEND studies represent a different kind of breakthrough for treatment. Rather than preventing HIV infection, they offer people already living with HIV the possibility of replacing 365 tablets each year with just 52.

HIV treatment typically combines two or more antiretroviral medicines to suppress the virus and reduce the risk of drug resistance, which is why lenacapavir was paired with islatravir rather than used alone. Lenacapavir has already proved effective as a standalone preventative medicine.

Nyaradzo Mgodi, a Zimbabwean clinical trials specialist and HIV prevention researcher, told SciDev.Net: “The findings represent a significant shift in both HIV prevention and HIV treatment.

“They demonstrate that long-acting PrEP [HIV prevention medicine] and treatment options can achieve high protection with less frequent dosing, directly addressing adherence challenges we have seen with oral PrEP and antiretroviral therapy.”

In Africa, adolescent girls and young women make up 63 per cent of new HIV infections, according to UNAIDS. Mgodi believes the easier-to-use medicines could improve adherence and accelerate progress towards epidemic control. They mark a shift away from a “one-size-fits-all” model towards person-centred HIV care, she says.

However, through the conference, speakers repeatedly stressed that scientific breakthroughs alone will not end the epidemic.

Whether these innovations transform HIV control in low- and middle-income countries will depend less on laboratory success than on affordability, political commitment, strong health systems and distribution to those most in need, experts told SciDev.Net.

Questions answered

New PURPOSE data answers practical questions that policymakers and public health programmes have been waiting to see resolved. Participants overwhelmingly chose to continue receiving the six-monthly injection rather than return to daily oral PrEP, adherence remained above 90 per cent in the “open-label” extension trial where patients knew the treatment they were receiving, and protection against HIV remained exceptionally high, the conference heard.

Mitchell Warren, executive director of HIV non-profit AVAC, says the findings move the conversation beyond whether the medicine works.

“The PURPOSE studies answered three critical questions,” Warren told SciDev.Net. “Would people choose injectable PrEP? Would they continue returning every six months? And would the high efficacy continue? The answer to all three is yes.”

With lenacapavir already being rolled out in several African countries including Zambia and Zimbabwe, Warren believes governments should have greater confidence to expand implementation but he cautions that clinical evidence alone will not change the epidemic.

“The field needs to move with even greater speed, scale and equity in translating these results into public health impact,” he said.

Speaking to SciDev.Net, Eliav Barr, senior vice president, head of global clinical development and chief medical officer at Merck Research Laboratories (MSD), which developed the drug islatravir, says reducing treatment frequency could significantly improve quality of life.

“Once-a-day therapy is difficult for people,” Barr told SciDev.Net. “Instead of taking tablets every day, you take one pill once a week. You can fit it into your own life.”

The weekly regimen, he added, also reduces the constant reminder of living with HIV.

“Every time an individual takes tablets, they have to remember, ‘I have HIV.’ With a once-weekly pill they only have to think about that once a week.”

Barr stressed that the weekly pill should not be viewed as competing with other treatment options, but as an expansion of HIV treatments options available to patients.

Barr said the weekly pill should be seen as another option for people living with HIV, rather than as competing with other existing treatments.

“Some people will like injections. Some people will like the once-weekly pill. Some people will prefer a daily pill. Options are always good options.”

Expanding choice on prevention

That emphasis on choice is shared by African HIV researchers working on the frontline of HIV prevention. Asked which regimen African countries should prioritise, Mgodi rejected the idea that there should be a single winner.

“Choice is critical,” she told SciDev.Net.

She argues that HIV prevention should offer the same flexibility as family planning, allowing people to choose products that fit different stages of their lives.

“Some will like oral PrEP. Some will like an injection every two months. Others every six months. It’s about choice.”

But expanding choice may create a new challenge. Health systems that previously delivered one prevention product may now have to support several options, each with different supply chains, counselling needs and delivery models.

Adaobi Lisa Olisa, Nigerian pharmacy expert and project lead for Root to Rise, said countries are attempting to introduce lenacapavir at one of the most difficult moments in the history of the HIV response, amid US and other international funding cuts.

“We are in an unprecedented situation,” she told SciDev.Net. “There was a crisis at the same time there was the best scientific innovation. It’s a paradox.”

Olisa explained that many countries lost community delivery platforms and HIV prevention systems following the US funding disruptions.

Consequently, governments are increasingly integrating HIV prevention into primary healthcare systems, rebuilding supply chains and retraining healthcare workers.

“Integration, integration, integration,” Olisa said, describing the approach many countries are now adopting.

Healthcare providers also require new skills to guide patients through the choices.

“The providers just needed capacity building,” she said. “Provider training is one of the building blocks for success.”

Affordability

Experts say access is becoming a bigger challenge than the science itself.

Unlike previous generations of HIV medicines, the success of these innovations will depend not only on regulatory approval, but also on whether countries can afford them, whether generic manufacturers can produce them quickly enough and whether health systems can integrate them into routine care, Olisa said.

Pricing, Olisa argued, now influences almost every decision governments make.

“Pricing impacts access,” said Olisa. “Governments have to invest now. Price is very important.”

For many low- and middle-income countries, affordability will determine whether they can offer genuine choice or be forced to prioritise one intervention over another.

Jared Baeten is senior vice president for clinical development, virology therapeutic area head at Gilead Sciences, the maker of lenacapavir told SciDev.Net that the company recognised from the outset the need for an ambitious access strategy.

That included accelerated regulatory pathways, partnerships with the Global Fund and PEPFAR, voluntary licensing agreements to expand generic manufacturing, investment in implementation science, and medicine supply.

Voluntary licensing agreements are expected to expand generic manufacturing in many low- and lower-middle-income countries. But Mgodi, Olisa and other experts agree licensing alone will not guarantee equitable access. Affordability, national financing, regulatory approvals and implementation capacity, they say, will ultimately determine how quickly these medicines reach the people who need them most.

Community integration

Baeten acknowledged that successful rollout depends on more than simply delivering medicines.

“Just because a pallet of vials lands in Harare doesn’t mean it’s going to be used and used well,” he said. “We have to understand how it fits within health systems.”

He said one encouraging finding from early rollout is that lenacapavir is attracting people who had never previously used PrEP and bringing more people into HIV testing and care.

“Community is the key,” Baeten said. “Community voice built lenacapavir. Community voice builds implementation now.”

Despite the optimism surrounding PURPOSE and ISLEND, researchers agreed the work is far from complete.

Warren said further innovation remains essential, including additional long-acting prevention options and new treatment approaches. He argued the tools already available must be delivered with urgency, equity and sustained investment.

For Mgodi, success will be measured by whether these medicines reach the communities that stand to benefit most.

“We now have powerful tools,” she said. “The next phase will depend on how effectively we deliver them at scale, equitably and in ways that reflect the realities of those most at risk.”

This piece was produced by SciDev.Net’s Global desk.