Richard Amenyah | Revolutionising HIV prevention in the Caribbean

The Caribbean has made remarkable progress in the fight against HIV – leading the world in reducing AIDS-related deaths by more than 60 per cent since 2010. But with an adult HIV prevalence of up to 1.2 per cent – second only to sub-Saharan Africa – and roughly 15,000 new infections each year, ending AIDS as a public health threat remains out of reach.

Every week, 290 people acquire HIV in the Caribbean – 70 of them are 15–24 year olds. Gaps in prevention services including sexual reproductive health services, combined with stigma and discrimination, are keeping these numbers stubbornly high.

A breakthrough is now within reach through medical innovation with long acting injectable antiretroviral drugs for HIV prevention. Lenacapavir (LEN) – a twice-yearly injectable pre-exposure prophylaxis (PrEP), with its 99.99 per cent efficacy rate, which was approved by the US Food & Drug Administration (FDA) in June 2025 and recommended by the World Health Organisation (WHO) in July – offers a real chance to change this trajectory. The modelling studies indicate LEN can be cost-effective, particularly if annual per person costs remain below US$ 213 in higher prevalence settings. Similarly, LEN can be cost-effective per disability-adjusted life-year (DALY) averted where coverage and adherence are high and service delivery focuses on those at greatest risk for HIV acquisition.

However, without bold, homegrown action from governments, civil society, communities, technical partners, and the private sector, this game-changer innovation could remain underused while infections continue to rise. Administering injections every six months could offer a valuable prevention option for people who find it difficult to take a daily pill, helping to promote greater equity in HIV services. However, if delivery is centralized, access could be unintentionally restricted unless complemented by community-based or decentralized approaches — underscoring the importance of inclusive implementation strategies.

With global funding for HIV under pressure Caribbean nations must mobilize domestic resources to introduce and scale up long-acting PrEP. Drawing on lessons from past HIV innovations, here’s what it will take to make lenacapavir a reality and achieve lasting impact in the Caribbean.

NOT SCIENCE ALONE

Lenacapavir’s potential will be determined by policy, price, and politics – not science alone.

If we want ambition to translate into lives saved, Caribbean governments and people must act now on a few non-negotiables:

1. Commit to ambitious goals. Set clear, measurable targets – reduce new infections by 90 per cent by 2030 – with lenacapavir as a cornerstone alongside other cost-effective interventions, such as condoms. Integrate it into national HIV strategies now, even before supplies ramp up in early 2026. Don’t wait for donors – allocate domestic budgets for training, outreach, and distribution, building on gains like the 66 per cent viral suppression rate.

2. Secure affordability from the outset. Negotiate early with Gilead – which has pledged no-profit supply for low-income countries – and leverage the PAHO Strategic Fund as well as agreements like the Global Fund’s commitment for up to two million people over three years. Through CARICOM and other regional bodies, push for pooled procurement, volume guarantees, and generic licensing to avoid delays.

3. Accelerate generics and manufacturing. Promote technology transfer to local or regional producers (e.g in Brazil or Mexico), aiming for affordable generics within two to three years. This builds self-reliance, strengthens economies, and ensures uninterrupted supply.

4. Fast-track approvals and guidelines. Health ministries should expedite regulatory processes in line with WHO’s guidance, updating national protocols to include lenacapavir. Budget for rapid reviews, training, and capacity building.

5. Integrate services smartly. Embed lenacapavir into existing HIV, sexual, and reproductive health services – no need for stand-alone clinics. Use community health workers including pharmacists and task-shifting to extend reach, especially to remote islands and underserved areas.

6. Prioritize fairness and choice. Offer lenacapavir alongside oral PrEP, targeting high-incidence groups like young women, men who have sex with men, and migrants. Invest in anti-stigma campaigns to ensure equitable access.

7. Build demand from the ground up. Empower CSOs and centre communities to lead awareness and service delivery. Lessons from oral PrEP implementation show that mistrust limits uptake – peer-led delivery systems, stigma-reduction outreach and user choice are essential for successful rollout.

8. Strengthen monitoring and evaluation. Track safety, drug resistance, uptake, and effectiveness in real-world settings, sharing data regionally. Use modelling and real-time data to target impact and ensure equity in who gets access first. Adjust strategies based on evidence, including addressing gender disparities (54 per cent of new infections among adolescents occur in girls).

9. Secure sustainable financing. With external aid declining, governments must prioritize prevention in national budgets – reallocating resources where needed and forging partnerships with the private sector, especially in tourism and other key industries.

Lenacapavir is more than a drug – it’s an opportunity to end HIV as a public health threat in the Caribbean. Governments must act decisively. Civil society and communities must hold leaders accountable. The private sector and partners must invest in a healthy, thriving region.

If we act now, we can turn this breakthrough into lasting control of HIV – saving lives, protecting families, and safeguarding economies. Delays will cost another generation dearly.

Dr Richard Amenyah is an international public health specialist from Ghana and the Director of the UNAIDS Multi-Country Office in the Caribbean. Send feedback to columns@gleanerjm.com