ROWEN GOVENDER: HIV fight shifts with long-acting PrEP in SA

South Africa is preparing for the most significant shift in its HIV response in more than a decade. The country has approved long-acting injectable pre-exposure prophylaxis (PrEP) and plans to roll it out in the public sector next year, which many believe could reshape prevention for people struggling with daily medication.

It is real progress, yet it exposes a deep truth: even with scientific breakthroughs, millions of South Africans still cannot access testing, treatment or prevention consistently enough to turn the epidemic around. That persistent access gap is the biggest threat to ending Aids as a public health challenge.

South Africa cannot let innovation outpace access. The country must focus on finding people who are not in care, supporting those who have fallen out of treatment, offering prevention that is easy and stigma free, and addressing the social and economic pressures that still drive thousands of new infections weekly.

Forty years after HIV first emerged, the world has made enormous progress in turning a deadly virus into a manageable chronic condition. South Africa is central to that story, with about 8-million South Africans living with HIV. The country also runs one of the largest treatment programmes globally, providing free lifelong antiretroviral therapy to more than 5.7-million people. Viral suppression rates among those on treatment are high, and South Africa has made meaningful strides toward the global 95-95-95 targets.

Yet the epidemic remains stubborn and uneven. Nearly 2-million South Africans living with HIV are not receiving treatment. Every week about 1,000 adolescent girls and young women become infected. Many young men delay testing or treatment for too long, fuelling transmission. Social inequality, gender-based violence, stigma and the unequal distribution of healthcare services remain major drivers of new infections.

The arrival of long-acting HIV prevention tools is groundbreaking and urgent. Injectable PrEP, taken twice annually, could dramatically improve adherence for people who cannot manage daily pills or who face social barriers making consistent prevention difficult.

South Africa’s rollout prioritises high-incidence districts and vulnerable groups, including communities where HIV remains entrenched despite available services. This positions SA at the forefront of prevention innovation and could become a model for other nations facing similar challenges.

But the success of long-acting PrEP depends on whether it reaches those communities most affected. Clinics must be youth friendly and accessible. Community health workers must have the support to allow them to reach people where they are. Outreach must confront stigma directly, especially in areas where privacy concerns prevent individuals from seeking help. Sustainable funding, reliable supply chains and clear communication are vital.

South Africa launched its “Close the Gap” campaign in early 2025 to bring 1.1-million more people into care, identifying individuals who were never diagnosed, those who were but never started treatment and those who dropped out. The epidemic cannot be controlled unless everyone living with HIV is supported throughout their treatment journey. Retention in care is as important as initiation.

The gendered nature of the epidemic means young women face disproportionate risk, linked to power imbalance, lack of economic opportunity and vulnerability to violence. Simultaneously, young men are often missing from healthcare systems altogether. They test later, start treatment later and have poorer outcomes, which contributes to continued transmission. South Africa’s response must prioritise youth-friendly services, school-based education and male engagement strategies.

Efforts to reduce stigma need to be persistent and grounded in community realities. Legal reforms and rights-based approaches are important steps towards creating safe environments where people feel supported to seek care.

South Africa has achieved significant success in reducing mother-to-child transmission and providing voluntary medical male circumcision. These gains show what works when community outreach, public health infrastructure and political commitment align.

As the country marks World Aids Day on Monday, South Africa is taking another step forward, but progress is fragile. Scientific advances must be matched by equitable access, reliable delivery systems and social interventions that reduce vulnerability.

The future of the HIV response will be determined not by breakthroughs alone but by whether those breakthroughs reach every South African who needs them.