Reimagining HIV Prevention in South Africa: From innovation to access


Published 12 December

South Africa is home to the world's largest HIV epidemic, with approximately 7.8 million people living with the virus, and an estimated 170 000 new infections in 2024.1 While considerable progress has been made with expanding access to antiretroviral therapy and reducing mother-to-child-transmission,2,3 the high rate of new infections clearly indicates that the country still faces significant challenges in overcoming the epidemic. Addressing the epidemic requires not only effective treatment but also a renewed and comprehensive approach to HIV prevention.

The HIV Prevention Toolbox

The HIV prevention toolbox has grown significantly over the years, offering both behavioural and biomedical approaches.4 Behavioural strategies such as HIV education and awareness campaigns, HIV testing and risk-reduction counselling, and comprehensive sexual and reproductive health education, enable individuals to make informed choices and reduce risk. Biomedical interventions complement these approaches by directly reducing the risk of transmission through use of condoms, voluntary medical male circumcision, prevention of mother-to-child-transmission, needle-and-syringe programmes for people who inject drugs, and daily oral pre-exposure prophylaxis (PrEP).5 Recent advancements in PrEP offer greater potential for reducing HIV transmission.6 Registered PrEP modalities in South Africa include tenofovir disoproxil fumarate and emtricitabine, an oral formulation taken once daily (approved in 2015), the cabotegravir long-acting (CAB-LA) bi-monthly intramuscular injection, the monthly dapivirine vaginal ring (both approved in 2022),7 and Lenacapavir (LEN), a groundbreaking twice-yearly HIV prevention injection, registered in October 2025.8 Long-acting injectable PrEP such as LEN signifies a breakthrough in HIV prevention, especially for those who struggle with daily or even monthly adherence.

PrEP Uptake and Access

Although several PrEP options are available in South Africa, uptake is low. Since the national rollout of oral PrEP in 2016, over two million individuals have initiated PrEP.9 However, the uptake of newer HIV prevention options remains limited, with less than 1000 women using the dapivirine vaginal ring and under 5000 individuals using injectable PrEP.6 This is because oral PrEP is widely available at public clinics, whereas the other modalities are accessible through demonstration and implementation projects.10 LEN, although approved, will only be rolled out in selected public clinics in early 2026. As a result, the majority of individuals in South Africa currently have access to only a single form of PrEP. Expanding access to the dapivirine ring and long acting injectables through public clinics is therefore urgent. These long-acting formulations could overcome many of the barriers that have hindered oral PrEP use, such as sub-optimal adherence, the burden of daily pill-taking, limited access to clinics, and the stigma that still surrounds HIV.11

Advancing HIV Prevention Through Integration of Technology and Data Driven Innovation

Emerging digital health technologies can redefine how HIV prevention is delivered. Artificial intelligence and predictive analytics can help to identify individuals and communities at greatest risk, while telemedicine allows for remote PrEP consultations and follow-ups.12,13,14 Chatbots and mobile apps can be used to educate individuals on HIV prevention, encourage PrEP uptake, and offer adherence support and counseling.15 By combining these tools with real-time data systems and efficient healthcare delivery, HIV prevention can become more accessible, personalized, and effective.

Closing the HIV Prevention Gap

Closing South Africa’s HIV prevention gap requires a bold, multi-pronged approach. Breakthroughs like LEN will only matter if their benefits reach the people who need them most. To achieve this, South Africa must move beyond celebrating scientific advances and focus on equitable access, community engagement, utilization of technology and data driven innovation, and integration of new prevention tools into routine healthcare. Access to proven tools including PrEP and other emerging prevention technologies must be scaled up and be made widely available, affordable, and easy to access, especially for high-risk and underserved populations. HIV prevention services must be youth-friendly, free of stigma, and extend beyond clinics into communities, schools, broader sexual and reproductive health programmes, and digital spaces to reach people wherever they are. Long-term success also depends on building a resilient health system capable of scaling up innovations without overreliance on external donors. HIV prevention services must be informed by real-time data, community feedback, and digital health tools. This approach will enable effective monitoring of service uptake, better resource allocation, and continuous adaptation of interventions to ensure that no one is left behind.

CONCLUSION

Although effective HIV prevention tools exist, they remain out of reach for many South Africans. Innovative HIV prevention tools will have little impact if the people who need them most are unable to access them. Real progress in HIV prevention cannot be achieved through innovation alone. Reimagining prevention requires an evidence-driven approach that integrates behavioural, biomedical, and technological advances with strong community engagement. It also calls for coordinated efforts to deliver HIV prevention services locally, while ensuring equitable access and meeting the needs of communities. South Africa has already shown that large-scale HIV treatment is possible. It is now time to apply that same commitment to HIV prevention, not just by expanding options, but by ensuring that everyone can access and choose the method that works best for them.

References

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