The Global Fund for HIV, TB and Malaria says it will fund the roll-out of the twice-yearly anti-HIV jab, lenacapavir, for poorer countries, including SA, with or without the help of the US President’s Emergency Plan for Aids Relief( Pepfar). 

This is the fund that US President Donald Trump has halted almost all support for in the past few weeks. 

“We are still maintaining our ambition on lenacapavir for PrEP (pre-exposure prophylaxis),” Global Fund executive director Peter Sands told Bhekisisa.

“We see lenacapavir as a potential game changer in the fight against HIV as an injectable, long acting PrEP solution that is pretty well 100% effective. It's not going to be right for everybody, but we need to find out more from having people use it.”

PrEP is medicine that HIV-negative people can take to prevent themselves from contracting HIV through sex. 

In December, Pepfar and the Global Fund announced a commitment to fund the roll-out of lenacapavir in countries they support, once regulators registered the medicine as PrEP.  At the time, Pepfar funded projects in 28 developing countries with HIV infection rates, including SA . The Global Fund continues to support South Africa and more than 100 other countries.   

Pepfar and the Global Fund said they would, alongside the Children’s Investment Fund Foundation and the Gates Foundation, pay for 2-million people to get the jab at least once over three years. The shot is taken every six months. 

Lenacapavir, which is made by the drug company Gilead Sciences, made world headlines in June when trial results found that not one of the 2,134 young women who received the medicine contracted HIV. A second study showed that lenacapavir also dramatically reduced the chances of HIV infection for other groups of people – gay men, trans and non-binary people of 16 years and older, who have sex with partners classified as male at birth – by 96%.

Gilead applied for the registration of lenacapavir as PrEP with the US medicine regulator, the Food and Drug Administration in December, and the European Medicines Agency and EU Medicines for All project in February. SA's registration forms part of the latter. 

The US government has not yet made clear whether it would honour the December announcement, but many key players fear that the Trump administration’s recent termination of USAID-funded Pepfar projects – and their particular aversion to HIV prevention projects – are telling signs that Pepfar is likely to pull out of the lenacapavir deal.   

Sands, however, says he was going to ensure the Global Fund’s share of the funding happens, even if the roll-out is on a smaller scale. “We cannot afford to miss such a game-changing opportunity,” he says.

And, he argues, the US would be unwise to quit now, if the Global Fund’s new “investment case” is anything to go by. 

Since the Global Fund was founded 23 years ago, $26.6bn (R495bn) has been invested in HIV programmes alone. Every three years the fund asks donors, including the US, France, the UK, Germany, Japan, Canada and others, to replenish the coffers. The US usually puts in the lion’s share – just under a third; – and has contributed $26.31bn to the fund to date.

This year the fund's appeal is for $18bn, which they estimate will prevent 400-million new infections and cases across the three diseases, saving 23-million lives by 2029.

This time the US contribution to the fund could decrease – or disappear.

To make the case for this round’s request, the Global Fund ran the numbers with the help of Imperial College, London. Researchers found that for every dollar invested in successful health interventions, a return of $19 is expected.

Alan Whiteside, a global health policy professor at the Balsillie School of International Affairs in Canada, has spent decades researching the economic impact of HIV in SA  “Walking away from past investments just to cut losses would be pure waste,” he says.

“It directly hurts your return on investment, which is a way to measure whether spending money on something leads to benefits. Investments in health lead to much greater benefits than the initial cost." 

But, even if the pledges aren’t as high as hoped, or if a donor withdraws, “investing something is still better than investing nothing”, Whiteside says, “especially if there is so much at stake with that investment”.