A new chapter in HIV prevention is opening, with oral pre-exposure prophylaxis (PrEP) and other approved oral agents reshaping how sexually active people protect themselves.
For SA — and the Eastern Cape in particular, which bears a deep burden of HIV — these medicines offer powerful tools to reduce new infections. Yet medicines alone cannot finish the job: socioeconomic realities, persistent stigma, and the urgent need for curative research must remain central to our response.
Oral prevention drugs work by blocking HIV’s ability to establish infection after exposure. Taken as a daily pill or in some cases as event-driven dosing, these drugs reduce the risk of sexual transmission by large margins when used correctly.
Recent developments have improved tolerability, reduced interactions with other medications, and expanded eligibility — making prevention more accessible to a wider range of people, including adolescents and women of reproductive age.
Lenacapavir is the new drug, available as once six monthly injections to HIV negative individuals. It can be used in Post Exposure Prophylaxis in needle stick injuries among doctors and nurses working in hospitals and clinics. It has been provided free of cost in South African hospitals and clinics.
Effective use of oral prophylaxis requires a mix of clinical access, education, and adherence support. For sexually active individuals, PrEP offers autonomy and confidentiality: you can take control of prevention without relying on partner negotiation.
Clinics, community health workers, and pharmacies play complementary roles in counselling, testing for HIV and other STIs, monitoring for side effects, and reinforcing adherence. Importantly, routine HIV testing must remain standard — oral prevention is intended for HIV-negative people and must be stopped if someone acquires HIV until confirmatory testing and appropriate treatment initiation.
The Eastern Cape faces structural challenges: poverty, uneven health services, transport barriers, and high unemployment. Introducing oral prevention at scale can produce several socioeconomic effects:
• Health system strain and investment needs: Scaling PrEP requires laboratory capacity, trained staff, supply chains, and outreach programmes;
• Reduced long-term treatment costs: Preventing new infections lowers future spending on lifelong antiretroviral therapy (ART), hospital admissions, and management of opportunistic infections;
• Workforce and productivity gains: Fewer new infections in working-age adults preserves household incomes, reduces caregiving burdens, and supports community resilience;
• Equity concerns: Without deliberate policy, uptake may skew toward relatively advantaged groups (urban, educated, younger). Targeted outreach — mobile clinics, community-based distribution, school and youth programmes — is essential to reach rural and marginalised populations; and
• Economic multiplier through demand: Local implementation creates jobs for health workers, counsellors, transport logistics, and community educators.
In settings where oral PrEP has been scaled effectively, many regions report declines in new infections among high-risk groups. However, measurable population-level impact depends on coverage, retention, and combination with other prevention strategies (condoms, voluntary medical male circumcision, harm-reduction programmes for people who inject drugs, and treatment-as-prevention where people living with HIV are virally suppressed).
Early South African data and global experiences suggest:
• Rapid reductions in new infections in concentrated populations (e.g., sex workers, men who have sex with men, serodiscordant couples) when programmes are well supported;
• Slower, uneven declines across the general population without high coverage; and
• Continued importance of STI surveillance, since some STIs can increase HIV transmission risk even when PrEP is used.
While prevention and ART have transformed HIV from a fatal disease to a manageable chronic condition for those with access to care, a definitive cure remains the holy grail. A cure would eliminate lifelong medication, reduce stigma embedded in chronic diagnosis, and end transmission from people living with HIV.
Scientific advances offer promise, but years of research and ethically rigorous trials lie ahead.
A paradox persists: better treatments and preventive options coexist with persistent stigma. Misunderstandings about HIV fuel discrimination that drives people away from testing and care.
Messaging must correct two dangerous misperceptions:
• That HIV is untreatable. Modern ART suppresses virus to undetectable levels, preserving health and preventing transmission (U=U: undetectable = untransmittable).
• That prevention pills alone replace the need for broader care. PrEP prevents HIV but does not treat other STIs or the social determinants that increase vulnerability.
Communities must hear that while a universal cure is not yet available, people living with HIV can live long, healthy lives with treatment; likewise, those at risk can protect themselves today with proven tools.
To translate the promise of oral prophylaxis into lasting impact, policymakers and civil society should prioritise:
• Accessible delivery: integrate PrEP into primary healthcare, mobile clinics, and community programmes; reduce clinic visit burdens with decentralised models;
• Equity-focused outreach: target youth, rural communities, sex workers, and people in informal settlements with culturally appropriate messaging;
• Adherence support: use SMS reminders, peer navigators, and flexible refill options to improve retention;
• Integrative services: combine HIV prevention with reproductive health, mental health support, and social services;
• Data-driven scale-up: monitor uptake, discontinuation reasons, seroconversions, and STI trends to adapt programs quickly;
• Anti-stigma campaigns: partner with local leaders, schools, and media to humanize people living with HIV and elevate prevention success stories; and
• Sustain research funding: balance immediate programmatic needs with long-term investment in cure science.
Lenacapavir remains a preventive drug which represent a major advance in our collective toolkit. For sexually active people in SA, these medicines offer agency and hope. But true success depends on combining pharmacology with fair access, robust health systems, socio-economic supports, stigma reduction, and continued pursuit of a cure.
Until we eradicate HIV entirely, we must use every available measure — prevention, treatment, and human compassion — to protect lives and restore dignity.
Dr Amitabh Mitra, retired orthopaedic surgeon, emergency medicine expert, poet and visual artist, SA