January 22, 2026
Over the course of the past year, the story of injectable lenacapavir (LEN) for PrEP has been a stark illustration of what’s at stake for global health as the US government defunds and dismantles fundamental programs within the HIV response. A profound contrast can be seen in this moment—on the one hand, there is a historic opportunity of every six-month LEN injections, which provide near perfect protection, and the speed at which the world can move with this intervention. On the other and, the field is facing unprecedented attacks on the infrastructure required to deliver LEN and other HIV prevention options. Science is breaking through formidable barriers in understanding HIV and how to prevent it, just as the infrastructure for delivering groundbreaking technology is defunded and destabilized.
2025 was a year of extremes. The field reached important milestones in accelerating access to LEN and advancing HIV prevention science. LEN moved with unprecedented speed from regulatory approvals and guidelines to real-world introduction. South Africa and Zambia authorized LEN within months of US and EU regulatory approvals and the World Health Organization (WHO) rapidly issued guidance and prequalification. Initial LEN delivery has now begun in Brazil, Eswatini, South Africa, and Zambia, setting the stage for expanded access as the year ahead unfolds. Each of these efforts reflect a global commitment to learn critical lessons from the all-too-slow rollout of oral PrEP and injectable cabotegravir and get rollout right this time.
Yet this momentum occurred as the new US administration launched an extensive assault on global health and the systems that make it possible. One of its first actions was the dissolution of the United States Agency for International Development (USAID). Damaging policies imposed on the President’s Emergency Plan for AIDS Relief (PEPFAR) soon followed, including threats that prevention would be restricted to narrow populations at risk. Of equally deep concern, PEPFAR has not released program data since 2024. Data-driven programming, and inclusion of gay men and other men who have sex with men (MSM), transgender people, and other key populations in PEPFAR-supported PrEP programs is essential to the end-goal of achieving epidemic control. AVAC Executive Director Mitchell Warren calls it a time of erasure, “people in greatest need of lenacapavir are not being tracked, counted or engaged by PEPFAR.”
In its place, the US is driving a nationalistic “America First” Global Health Strategy, signing bilateral memorandums of understanding (MOUs) country by country. The process is short on transparency, excludes civil society and rolls back decades of hard-fought wins aimed at ensuring community priorities, and evidence, inform national strategies and spending on HIV prevention. Some MOUs have come under criticism and court challenge for provisions that advantage American interests at the expense of the partner country and at the expense of a genuine effort to advance global health.
In the meantime, other major institutions that advance global health priorities are struggling to maintain momentum. WHO and UNAIDS are confronting steep funding cuts. The Global Fund, which is playing an instrumental role in supplying LEN for PrEP, fell short of its $18 billion goal, securing pledges so far of only $11.34 billion, with several major donors, including the US, pledging lower amounts than in previous years.
Restrictive, underfunded, siloed or shuttered programming for LEN for PrEP (and other HIV prevention options) threatens this once-in-a-generation opportunity to bend the curve of the epidemic. Moreover, gains the field has fought decades to achieve are threatened. Instead of taking a giant step forward, the world is at risk of tumbling backwards. Instead of ignoring or reinforcing barriers faced by key populations, programs must diversify, decentralize, train and empower providers and peer educators, and innovative to reach marginalized communities with a choice in PrEP options—including LEN for PrEP. Instead of reduced funding to major providers of LEN for PrEP, such as the Global Fund, donors must seize this opportunity to fully fund robust, comprehensive, coordinated efforts to scale it up. Instead of gutting normative agencies such as the WHO and UNAIDS that set targets and standards for achieving impact, international coordination should be reinforced as the foundation for success at a global level.
Global health champions stand at a bend in the road. It’s time to reimagine an HIV response that reaches beyond past success and never backs down in its demand for speed, scale, and equity. Moving forward into this new reality, health leaders, scientists and communities must accept nothing less than a new architecture for global health that brings effective HIV prevention, including LEN for PrEP, and access to care to everyone who needs it.