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In 2024, the global fight against human immunodeficiency virus (HIV) has had its ups and downs. The number of people receiving antiretroviral therapy (ART) and achieving viral suppression is at an all-time high. AIDS deaths are at their lowest level in two decades. However, despite these encouraging developments, the Sustainable Development Goals (SDGS) to end HIV as a public health threat by 2030 are not on track. Worryingly, the AIDS pandemic continues to spread among some populations. According to the UNAIDS 2024 World AIDS Day report, the United Nations Programme on HIV/AIDS (UNAIDS), Nine countries have already met the “95-95-95″ targets by 2025 required to end the AIDS pandemic by 2030, and ten more are on track to do so. At this critical juncture, efforts to control HIV must be intensified. A major challenge is the number of new HIV infections each year, estimated at 1.3 million in 2023. Prevention efforts in some areas have lost momentum and need to be refocused to reverse the decline.

Effective HIV prevention requires a combination of behavioral, biomedical, and structural approaches, including the use of ART to suppress the virus, condom use, needle exchange programmes, education, and policy reforms. The use of oral pre-exposure prophylaxis (PrEP) has reduced new infections in some populations, but PrEP has had a limited impact on women and adolescent girls in eastern and southern Africa who face a high HIV burden. The need for regular clinic visits and daily medication can be humiliating and inconvenient. Many women are afraid to disclose PrEP use to their intimate partners, and the difficulty of hiding pills limits PrEP use. A landmark trial published this year showed that just two subcutaneous injections of the HIV-1 capsid inhibitor lenacapavir per year were highly effective in preventing HIV infection in women and girls in South Africa and Uganda (0 cases per 100 person-years; The background incidence of daily oral emtricitabine-tenofovir disoproxil fumarate was 2.41 cases /100 person-years and 1.69 cases /100 person-years, respectively. In a trial of cisgender men and gender-diverse populations on four continents,  Lenacapavir given twice a year had a similar effect. The incredible effectiveness of long-acting drugs provides an important new tool for HIV prevention.

However, if long-acting preventive treatment is to significantly reduce new HIV infections, it must be affordable and accessible to people at high risk. Gilead, the maker of lenacapavir, has signed deals with six companies in Egypt, India, Pakistan and the United States to sell generic versions of Lenacapavir in 120 low – and lower-middle income countries. Pending the effective date of the agreement, Gilead will provide lenacapavir at a zero profit price to 18 countries with the highest HIV burden. Continuing to invest in proven integrated prevention measures is essential, but there are some difficulties. The U.S. President’s Emergency Fund for AIDS Relief (PEPFAR) and the Global Fund are expected to be the largest buyers of Lenacapavir. But in March, PEPFAR’s funding was reauthorized for only one year, rather than the usual five, and will need to be renewed by the incoming Trump administration. The Global Fund will also face funding challenges as it enters its next replenishment cycle in 2025.

In 2023, new HIV infections in sub-Saharan Africa will be overtaken by other regions for the first time, particularly Eastern Europe, Central Asia and Latin America. Outside sub-Saharan Africa, most new infections occur among men who have sex with men, people who inject drugs, sex workers and their clients. In some Latin American countries, new HIV infections are increasing. Unfortunately, oral PrEP has been slow to take effect; Better access to long-acting preventive medicines is essential. Upper-middle-income countries such as Peru, Brazil, Mexico, and Ecuador, which do not qualify for generic versions of Lenacapavir and do not qualify for Global Fund assistance, do not have the resources to purchase full-price lenacapavir (up to $44,000 per year, but less than $100 for mass production). Gilead’s decision to exclude many middle-income countries from licensing agreements, especially those involved in the Lenacapavir trial and the resurgence of HIV, would be devastating.

Despite health gains, key populations continue to face human rights abuses, stigma, discrimination, punitive laws and policies. These laws and policies discourage people from participating in HIV services. Although the number of AIDS deaths has declined since 2010, many people are still in the advanced stages of AIDS, resulting in unnecessary deaths. Scientific advances alone will not be enough to eliminate HIV as a public health threat; this is a political and financial choice. A human rights-based approach combining biomedical, behavioural and structural responses is needed to halt the HIV/ AIDS epidemic once and for all