Brazil Demands Equitable Access to Long-Acting HIV Prevention Drugs

Rio de Janeiro hosted the International AIDS Conference this week, and Brazil arrived with a grievance that cuts to the heart of global health equity: the country is being priced out of the very HIV prevention drugs it helped test. Two years ago, when Gilead announced that lenacapavir—an injection given twice yearly—had prevented nearly all HIV infections in clinical trials, the news rippled through the sector as a potential turning point. But for Brazil, access has remained out of reach, blocked by pricing that Gilead set at ten times what Indonesia and Thailand pay.

The exclusion stings because Brazil carries real weight in this fight. Nearly 830,000 Brazilians live with HIV, and transmission continues to climb among the groups most vulnerable to the virus: men who have sex with men, transgender people, sex workers, people who inject drugs, and incarcerated individuals. Yet Brazil's classification as an upper-middle-income country has become a trap. It earns too much to qualify for the lowest-priced generics and licensing deals, but too little to absorb the prices pharmaceutical companies demand from wealthier markets. Health Minister Alexandre Padilha put it plainly at the conference opening: "Innovation without access is injustice."

Gilead's approach has left Latin America largely in the cold. The company signed voluntary licensing agreements with six generic manufacturers in October 2024, enabling production in select markets, but the geographic footprint excludes most of the region. Meanwhile, Gilead charges $28,000 annually for lenacapavir in the United States. The company says it is rolling out the drug in ten African countries and projects 600,000 users globally by year's end. Jared Baeten, speaking for Gilead at the conference, acknowledged that trial participants would retain access to lenacapavir, but only until they could obtain it through their own health systems—a condition that rings hollow for countries locked out of affordable supply.

Brazil has responded by turning to an alternative. ViiV Healthcare's cabotegravir, injected every two months, became the country's choice for expanding its pre-exposure prophylaxis program after ViiV offered what Padilha called "an acceptable price." Yet even this compromise reveals the problem. ViiV and the Medicines Patent Pool signed a licensing agreement covering 90 countries, but most Latin American nations were excluded from that deal as well. The message was clear: the region's needs ranked below other markets in pharmaceutical strategy.

Activists from Brazil, Argentina, and Peru staged protests at the conference, pointing out that their countries had participated in lenacapavir's clinical trials and deserved access to the results. The argument carries moral weight and practical logic: if a nation's citizens bore the risk of testing a drug, they should not be locked out when it works. Gilead's response—that trial participants would keep access—sidesteps the larger question of what happens to the broader population once trials end.

Merck has taken a different path, one that may signal a shift in how pharmaceutical companies approach these negotiations. The company is testing alimatravir, a monthly pill for HIV prevention, and last week announced voluntary licenses with seven generic manufacturers across sub-Saharan Africa and India, covering 129 low- and middle-income countries. Latin America was initially absent from that list. But on Tuesday morning, Merck announced a memorandum of understanding with Brazil's Oswaldo Cruz Foundation, the government's biomedical research and production agency. The agreement commits both parties to negotiate access terms should alimatravir prove effective in phase 3 trials, expected to conclude in the second half of 2027. Merck's Eliav Barr framed it as forward planning: "We are trying to reach agreements now to avoid limited supply at launch."

The difference is instructive. Merck is negotiating before the drug is approved, building supply chains and access pathways into the product's trajectory from the start. Gilead and ViiV, by contrast, locked in their licensing geography before Latin America could make its case. Brazil's push at this conference—backed by the weight of its HIV burden and the legitimacy of having hosted clinical trials—may be reshaping how pharmaceutical companies think about upper-middle-income countries. The question now is whether this moment becomes a precedent or an exception.