Africa: Long-Lasting Protection – The Future of HIV Prevention in Africa

Lima, Peru — Imagine a world where an HIV prevention method lasts for six months, offering protection without the daily hassle of taking a pill. This could soon be a reality as new long-acting HIV prevention tools move through the research pipeline.

These prevention tools are designed to transform the fight against HIV, particularly in places where daily oral pre-exposure prophylaxis (PrEP) has been difficult to implement.

Professor Nelly Mugo from the Kenya Medical Research Institute (KEMRI) considers what would happen if “all college students, all teenagers (were) on these products”.

“… because think about it, that is the time when most people get HIV. We need to bridge people through this period of their life, when their hormones are raging, when they’re settling into themselves, when they’re settling down in life, they can settle into their sexual lives in a safer way,” Mugo says.

“We know the peak period that people get HIV is 18 to 24 right? And then for some at 30 and a few more later in life. So if you have this product that lasts for long durations of period you can protect people. The less HIV we have in the population, the lower the risk of getting infection,” the KEMRI scientist and medical doctor says.

Breaking New Ground with Long-Acting HIV Prevention

Long-acting HIV prevention solutions are gaining traction as innovative alternatives to daily pills, with products like the dapivirine vaginal ring, the lenacapavir injection, and CAB-LA leading the charge.

Unlike oral PrEP , which requires daily adherence, the dapivirine ring is an intravaginal device that can be placed in the cervix and provides protection for an entire month.

This topical product is designed to deliver medication directly where it’s needed, minimizing systemic absorption and enhancing safety. Despite its approval, the ring is still not widely adopted in many countries, partly due to unfamiliarity with such health products and cultural hesitations surrounding their use.

However, early adopters have reported positive experiences, sparking hope for broader acceptance as awareness increases.

The dapivirine ring is a flexible silicone ring inserted into the vagina, where it releases HIV-preventing medication locally for a month. It’s been proven as safe and effective but faces cultural and logistical challenges in its adoption.

“There’s a contraceptive ring in the market, but it’s never really come to Africa because it’s a bit more expensive, and also people are a little bit shy about introducing things in their private parts, but those who use it really like it. So it’s my hope, as we women become more familiar with that ring, that we will use it more often,” says Mugo.

The “nice thing” about topical products, she says, is that they’re “very safe: “… because you don’t get a lot of the drug your body in your blood system, the drug stays in the area where the risk happens, in the vaginal canal”.

Other innovations in this area, for example Matrix’s Fast Dissolving Vaginal Insert and Dual-Purpose Vaginal Film, are still under investigation. These thin films dissolve upon insertion and offer a promising option for monthly protection without removal.

Another promising long-acting HIV prevention option is the CAB-LA injection, a form of PrEP, administered every two months by healthcare providers. It has shown great potential in community studies, with many expressing enthusiasm for a solution that eliminates the need for daily medication.

Additionally, lenacapavir, a first-in-class antiretroviral, offers six months of protection and is undergoing regulatory processes. Lenacapavir is indicated for adults with multidrug-resistant HIV-1 strains, where existing therapies have failed due to resistance or intolerance.

This subcutaneous injection – administered under the skin – though still in early research, has the potential to drastically change HIV prevention by offering even longer-term protection.

“… lenacapavir is not yet available, because it’s only in July that we had the results announced of PURPOSE 1, and I think last month in this conference, we heard about the results of PURPOSE 2. So first results was amongst women, and now it’s amongst gay populations,” says Mugo.

While its high cost poses challenges for accessibility, efforts are underway to transition it to a more affordable generic option by 2026. These long-acting products are paving the way for a more effective and manageable approach to HIV prevention, particularly in regions where adherence to daily medication remains a significant barrier.

“So those two long active products (lenacapavir and CAB-LA) still need to be given by healthcare providers. The ring you can insert yourself – once a woman is taught how to do it, it’s easy to do,” says Mugo.

Ensuring Access to Those Who Need It Most

While these long-acting tools hold great promise, one of the biggest challenges is ensuring that they reach the communities that need them the most, particularly in rural and underserved areas. This will require a coordinated effort among healthcare providers, researchers, governments, and local communities, Mugo says.

“There’s no single organization that can do this alone,” says Mugo. “KEMRI is involved in the research, but delivery is the responsibility of programs like LVCT Health, the Ministry of Health, and other partners.”

In Kenya, LVCT Health, an NGO known for implementing health programmes at scale, has already introduced the dapivirine ring, engaging with community members, policymakers, and healthcare providers to build awareness and acceptance of the product.

However, the challenge of access is not just logistical—it’s also cultural.

“Introducing new products, especially those involving sexual health, can be met with resistance, particularly in conservative communities,” says Mugo.

“Well, you know, when things are new, people hesitate, when you’re introducing something that’s unfamiliar, and their male partners also would need to know about it. The ring can be used discreetly, but women are concerned about using it without their partner’s knowledge … For some people, it’s good, they want to use a product without having to disclose to their partners.”

The Role of Policy and Regulation

Another barrier to the widespread adoption of these long-acting HIV prevention tools is the regulatory environment. In Kenya, for example, the approval of CAB-LA by the Kenya Pharmacy and Poisons Board took a long time to be approved for research purposes.

“We need to streamline the regulatory process, so these products can move more quickly through the pipeline and become available to those who need them,” says Mugo.

Mugo also stresses the need for policy changes that facilitate the approval of multipurpose prevention technologies (MPTs) that can simultaneously prevent HIV, pregnancy, and sexually transmitted infections (STIs).

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“The only multi-purpose technology product we have is the condom. The condom actually does all three, protects pregnancies, HIV and STIs. But you know the challenges is, it’s a man who uses a condom, unless it’s a female condom. So maybe we need to do more work to reintroduce the female condom,” says Mugo.

Shaping the Future of HIV Prevention

As research continues, the future of HIV prevention in Africa looks bright. Developing long-acting, easy-to-use prevention tools could dramatically reduce the incidence of new infections, particularly among young people, who are most at risk.

“If we can get these products into the hands of young people, we can protect an entire generation, says Mugo.

The potential for reducing community viral loads is also a game-changer.

“The fewer people with HIV in a community, the lower the risk of new infections,” Mugo says. “By providing long-acting prevention tools to as many people as possible, we can create a ripple effect that reduces the overall number of infections and moves us closer to eliminating HIV.”

With continued research, collaboration, and community engagement, the dream of a world with fewer HIV infections and ultimately, no HIV at all—may soon become a reality.

Sethi Ncube interviewed Prof Mugo during HIVR4P 2024, the 5th HIV Research for Prevention Conference in Lima, Peru, after receiving a scholarship from the IAS.
Read more of Ncube’s work from HIVR4P 2024 here.

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