The sorry fate of primary prevention in America's global HIV plans
A lone mention of PrEP amidst thousands of words speaks volumes
The search is over! After reading nearly 150 pages of Memoranda of Understanding, Implementation Planning Tool, its Companion1 and assorted other documents, I’ve finally found the word “PrEP,” an abbreviation for pre-exposure prophylaxis that refers to the use of medications and other agents to prevent people who are HIV-negative from acquiring the virus.
I’ve been looking for a mention of PrEP because the newest PrEP agent, injectable lenacapavir, is a darling of the architects of AFGHS. The way they talk about it, you’d expect it to be peppered (PrEPpered?) all over the place in their plans and companions to those plans.
“The Department expects lenacapavir to be an important tool in achieving the Administration’s goal of ending mother-to-child transmission of HIV during President Trump’s second term,” read a November press release announcing lenacapavir roll out in Eswatini and Zambia. Quoted in that same release, Senior Official for Foreign Assistance, Humanitarian Affairs, and Religious Freedom Jeremy Lewin said, “The United States is proud to champion this biomedical achievement.”2
Lenacapavir is indeed a biomedical achievement. With two injections delivered on schedule over the course of a year, a person’s risk of acquiring HIV goes to zero. The other injectable available needs to be administered every two months; pills, which are also highly effective when taken correctly, require daily dosing. As effective as all PrEP is when taken properly, the strategy hasn’t reached nearly everyone who needs it—even though the world is far off the mark in reducing rates of new infections. In 2024, there were 1.4 million new HIV diagnoses worldwide—far more than the 500,000 target set by UNAIDS.3
No single prevention strategy is a perfect fix. Some people will want an injection, others will want pills. For many people HIV risk is compounded by sexual and gender-based violence, poverty, income and housing instability. No medicine eliminates these forces of structural violence. Even so, the Trump Administration continuation of a Biden-era commitment to support lenacapvir roll out in partnership with the Global Fund and Gilead Sciences was a wee bright spot in last year’s meander through the dark wood, where lost really was the only right direction.
Alt text: To End a Plague: Again exclusive - a doodle from the desk of a Trump appointee who loves PrEP, condoms, the dapivirine vaginal ring and harm reduction. Oh wait. Nope. That’s really not what this is. It’s me and my old friend the screenshot. Do I know there are easier ways to annotate a pdf? I do. But you can tell me anyway if you want. Full doc at the bottom. Doodles not included.
So yes. I was excited to see both oral and injectable PrEP listed in the Excel sheet for planning commodities procurement as part of the implementation planning phase for activities funded under the America First Global Health Strategy that does not, as of yet, have its own companion.
And I led with that because, hey, who couldn’t use a little good news right now? Because now we’re back at it. (How dense the wood. How difficult the course.)
As nice as it is to see PrEP appear, finally, in these documents, the cameo is cause for alarm, not celebration.
This product, which Lewin said could “bend the curve” of the HIV epidemic in some countries, is not mentioned anywhere else in any planning tool, any Memorandum of Understanding, any companion or gentleman friend or partner. It isn’t there at all. Nor is PrEP in general. There are no targets for people to be reached by PrEP. There aren’t even any process outcomes related to primary prevention (prevention in people who do not have HIV) for anyone over 12 months of age in any of the documents.
The lone allusion to lenacapavir in the tiny cell of the commodities Excel sheet reinforces the extent to which the architects of the AFGHS do not, in fact, care whether the funds spent have a public health impact at all. It’s not just that this is the only mention of PrEP—it’s also that in this one small section that scopes the supplies needed for effective primary prevention, the mainstays of condoms and lubricant are not mentioned at all. Nor is equipment for voluntary medical male circumcision, a highly effective, simple surgery that reduces men’s risk of acquiring HIV and, at high population coverage levels, reduces HIV risk for women.
Primary prevention including attention to the structural drivers of risk like poverty, lack of education and employment opportunity, social norms, stigma and discrimination used to be a mainstay of national HIV programs. Not because the US government wanted it, but because the people in the communities wanted it. On a recent trip to South Africa, in which I collected oral histories from people on the frontlines of the foreign aid transition, I met a young woman who had been providing education on HIV prevention and sexual health for adolescent girls and young women in her community. When she lost the funding, the girls kept showing up, asking if there would be a talk today. Embarrassed and at a loss, she stayed at her desk and the young women eager to know about their options for staying safe and healthy eventually went home.
The sole mention of PrEP in the entire raft of documents provided by the United States and completed by countries shows just how much primary prevention has fallen as a priority for the US government. In spite of the press releases and photo ops surrounding lenacapavir launch are, the AFGHS planning process will let countries dial in orders for oral and injectable PrEP without any connection to an over-arching prevention strategy that looks at areas of high incidence and potential high impact.
Once again: host countries can care even though the US government doesn’t.
These documents do not ask for a strategy for preventing new infections in young people and adults. Countries can still provide one. Uganda and Kenya are both on the list of ‘early access’ countries prioritized for lenacapavir by the Global Fund and US government initiative—no mention of this is made in their Memoranda of Understanding. Maybe there’s another annex to the plan? Nay, even a companion?
For now, countries that have set milestones for new HIV infections over the next five years, and promised to bring those numbers down, have no obligation to explain to the American funders how the breakthrough American innovation will be used, if at all. It seems a strangely nonchalant approach to tout American scientific knowhow, and then take no care in measuring whether it is having an impact. Or perhaps it is neglect, nonchalant’s edgier long-time friend.
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https://www.state.gov/releases/2025/11/driving-global-health-progress-through-american-innovation-and-burden-sharing-the-first-doses-of-lenacapavir-arrive-in-eswatini-and-zambia/
https://www.unaids.org/sites/default/files/2025-12/PCB%2057%20Thematic%20Background%20Note%20-%20FINAL%20-%205Dec2023.pdf