“It requires a nice healthy demand to ensure that for each of the generic companies, it’s going to be worth their while,” says Bekker. “We are all hoping that governments [across sub-Saharan Africa] are writing the generic product into their budgets for the future, but the reality is that in the interim, we were relying on donor funding. Even my country, South Africa, which has a good GDP and funds 80 percent of its HIV response, is already purchasing antiretrovirals for 6 million individuals annually. I would imagine it will take them some years to be able to mobilize the money for lenacapavir as well.”
With PEPFAR seemingly now focused primarily on the treatment of existing patients, at the expense of prevention, clinicians like Nomathemba Chandiwana, a physician-scientist at the Desmond Tutu Health Foundation in South Africa, are concerned that the infection rate will begin to rise rather than fall, something which will have a marked public health impact across the African continent and beyond.
Speaking at last week’s NCD Alliance Forum in Kigali, Chandiwana explained that the consequences of new infections are not solely related to HIV itself. Research is increasingly showing that people living with long-term HIV infections, even those controlled by antiretroviral treatment, are at a greater risk of developing metabolic conditions such as hypertension, obesity and type 2 diabetes, a disease burden which is already on the rise in sub-Saharan Africa. “HIV itself disrupts your metabolism, as do many of the antiretrovirals,” says Chandiwana. “We see the same chronic diseases in people living with HIV as we do in the general population, but at an earlier age and in an accelerated fashion.”
Because of this, there is also a need for a new generation of HIV treatments, and one concept being explored was to use lenacapavir as a foundation of future combination therapies for those already with the virus. As well as potentially alleviating some of the metabolic side effects, it was hoped that this could lead to treatment protocols that did not require HIV-infected individuals to take daily medication.
“Various ideas have been mooted,” says Bekker. “Could you combine bimonthly cabotegravir with a six-monthly lenacapavir injection [as a form of viral suppression], so you’d only come in six times a year for treatment, and it would all be injectable? There’s a weekly antiretroviral pill in the works, and could you combine that with a six-monthly injectable? This could be very liberating for people, as they tell us all the time how stigmatizing it is to need to take daily medication.”
Yet many of these studies are now in doubt, as Bekker says they were expected to be funded by US resources. “It’s not just PEPFAR; we’re also worried about restrictions being placed on other sorts of research funding, such as the National Institutes of Health,” she says. “It’s just going to get harder to innovate and move progress forward.”
According to Ngure, there is still hope that other donors may emerge who can support The Global Fund in procuring lenacapavir, while Bekker says she is exploring new options for funding HIV prevention and research through European agencies, and possibly donor funding from sources in Scandinavia, Japan, and Australia. At the same time, she believes that the events of the past month have illustrated that African countries need to become capable of funding more preventative efforts themselves.
“Somehow Africa needs to step up and contribute to the fight,” she says. “I think that’s the big question. How much we can also contribute on this continent through countries which haven’t necessarily been able to cover a big amount of research and development but in the future need to.”
At the same time, she is afraid that without the same resources coming from the US, the unique opportunity provided by lenacapavir could be lost.
“It’s incredible that this has happened just as we’ve had the breakthrough,” she says. “I think this is going to set us back many years and ultimately cost a lot more in public health spending. Because ultimately, if we can bring this epidemic under control more quickly, it’s going to save the planet more money in the long run, and save lives too.”