Lenacapavir offers HIV prevention hope in Eswatini, but supply and gender dynamics limit impact

Precious closes her eyes and tightens her fists as the needle slides into her right thigh, then her left, delivering a yellowish-green liquid that will protect her from HIV for the next six months. It is early March in a small health clinic in Lobamba, a rural area of Eswatini, and she has just become one of the first people in the world to receive lenacapavir, an injectable administered twice yearly that offers nearly complete protection against the virus. The nurse celebrates the moment. Precious, a 32-year-old sex worker, feels relief wash over her. Several of her colleagues have tested positive recently. She tries to use condoms with her clients, but they resist. They pay more without protection—150 lilangenis instead of 100 for a fifteen-minute encounter. The math of survival is unforgiving.

Eswatini, wedged between South Africa and Mozambique, carries the heaviest HIV burden on earth. One in four residents—roughly 220,000 people—lives with the virus, the highest prevalence rate globally. The country is one of nine African nations chosen to pilot lenacapavir distribution, a decision that marks a watershed moment in the decades-long fight against AIDS. For the first time, a new HIV prevention drug has arrived in the Global South at the same moment it reached wealthy nations. The drug costs more than 10,000 euros per person annually, a price that will plummet to 34 euros once generic versions arrive in 2027. Officials speak of ending the epidemic by 2030. The World Health Organization and PEPFAR, the U.S. presidential emergency program, secured an agreement with Gilead, the drug's manufacturer, to supply two million doses across middle and lower-income countries through 2028. But the supply is already constrained. Eswatini received 4,200 units in its first allocation, with another 1,800 promised in coming weeks or months. Each clinic receives doses in irregular batches—50 one week, 100 the next, then 30. The demand far exceeds what is available.

Charles Mduli, a veteran nurse at the Lobamba clinic, has administered 147 injections so far. He watches women arrive by word of mouth, sitting on the red earth or under the shade of generous trees, calling the drug a vaccine. Most are young women, many of them sex workers or in relationships where they have little say over whether protection is used. Precious had tried daily oral PrEP pills before, but consistency was impossible. The pills were not discreet. Partners and family members asked questions. The clinic visits were frequent and visible. The injectable is different. It is administered twice a year. No one needs to know. "It is the perfect treatment," Mduli says. "It is effective and completely discreet. Women come here and decide for themselves, and they do not have to explain anything to anyone."

Yet the drug's promise collides with the economic and social realities of Eswatini, where 59 percent of the population lives in poverty and patriarchal structures shape every intimate decision. Precious left her husband two years ago after he broke her leg in a beating. She feared he would kill her. Now she supports herself, her two children, and her mother on what she earns as a sex worker. She needs 4,000 lilangenis—roughly 200 euros—each month for food, school uniforms, and materials. The economics of condom use are stark: clients will not wear them, and they will not pay the same price if they do. Princess, 27, carries the weight of her father, her two children, and her siblings. She does not think much about herself because she must bring money home. "I cannot protect myself because they do not want to use a condom," she says, tears threatening. "And I do not think much about myself because I have to take money to the house." When she arrives at a clinic for an HIV test before receiving lenacapavir, the result is negative. But she admits to unprotected sex in the past 72 hours. The virus may not yet show on a test. The nurse advises her to return in a month. Precious leaves disappointed, uncertain whether she will be able to come back.

The drug's arrival in Eswatini is shadowed by the collapse of American funding. Sixty percent of the country's HIV response was financed by PEPFAR. In December 2024, the Trump administration imposed sharp cuts. Diagnostic testing capacity has shrunk. Health worker training has stalled. Mobile clinics that brought services to remote areas have stopped operating. The government is trying to fill the gaps, but the damage is real. UNAIDS estimates that U.S. funding cuts could result in 6.6 million additional infections and 4.2 million additional deaths by 2029. In 2025 alone, the number of people who should have started oral PrEP fell 37 percent compared to 2024. The health minister of Eswatini insists the system has not collapsed and that the government is building its own capacity. In December 2025, the United States and Eswatini signed a five-year health accord committing Washington to invest up to 205 million dollars in modernizing public health data systems and disease surveillance technology. But the immediate crisis is real.

Sandra MKambule, 24, owns a small beauty salon and considers herself independent. She received her first lenacapavir injection in January because she does not trust the men she sleeps with to tell her the truth about their status. "It was my decision and no one cares," she says. "It is much more discreet than taking a pill every day. I think it is going to change the life of many young women like me." Her 15-year-old niece learned she had contracted HIV and took her own life. The weight of that loss hangs in the room. Nkululeko Dube, who represents the AIDS Healthcare Foundation in Eswatini, calls lenacapavir a milestone but urges caution. The drug protects against HIV, he reminds people, but not against syphilis or pregnancy. People must not grow complacent. He remembers not so long ago when families sold their cattle and their homes trying to save a child dying of AIDS. Young people died of pneumonia, meningitis, complications of a disease for which there was no treatment. People lay in the streets, exhausted and wasted. "It sounds like a movie," he says, "but it was like that."

The question now is whether lenacapavir can reach the scale required to bend the curve. UNAIDS estimates that roughly two million people globally take some form of PrEP, mostly daily pills. To "drastically change the trajectory of new infections and move toward ending AIDS by 2030," the organization says, 20 million people at risk would need access. Generic versions will help when they arrive in 2027. But for now, the doses are counted. Some clinics have run out. Others have enough for a few days. The shelves in Eswatini's central medicine warehouse reserved for lenacapavir hold very few boxes and much empty space. Officials have set aside 500 doses for people who received their first injection in December and need their second in May. The world needs a positive story about HIV, Mark Edington of the Global Fund said. Eswatini is trying to write one. But the ending remains uncertain.