The United States (US) government has not initiated a meeting with South Africa to discuss the continuation of its HIV grant, and it won’t supply the country with the long-acting HIV prevention medication, lenacapavir, amid a deepening political row between the two countries.

While US Ambassadors throughout the continent have initiated meetings with African Health Ministers to discuss Memorandums of Understanding (MOU) for the continuation of their US President’s Emergency Plan for AIDS Relief (PEPFAR) grants from April 2026, South Africa has not received such an invitation.

“The Department of Health has not received any correspondence from the US government regarding PEPFAR discussions,” Foster Mohale, South Africa’s Health Ministry spokesperson, told Health Policy Watch.

Neither the US Embassy in South Africa nor the US State Department responded to queries about whether such a meeting is being planned or whether the US has decided to exclude South Africa from future PEPFAR grants.

However, in relation to whether the US would provide lenacapavir to South Africa, a US Embassy spokesperson provided a comment by Jeremy Lewin, Under Secretary for Foreign Assistance, Humanitarian Affairs, and Religious Freedom, stating that the US “will not be contributing doses to South Africa”.

“Obviously, we encourage every country, especially countries like South Africa, that have significant means of their own to fund doses for their own population of this innovative American-made drug that Gilead has developed. US-funded doses will not be going to South Africa,” Lewin told a media briefing on 17 November, the day the first 1,000 lenacapavir doses were delivered in Eswatini and Zambia.

Largest HIV+ population

Around eight million South Africans are living with HIV, around 13% of the population – the largest HIV positive community in the world.

In 2024, South Africa received $453 million in PEPFAR funding, and $439 million had been allocated for 2025. But this was suspended when Donald Trump became president on 20 January.

In October, the US government approved a $115 million “PEPFAR Bridge Plan” for South Africa for six months from 1 October to 31 March 2026.

Relations between the US and South Africa have been rocky since Trump took office, signing an executive order in February to “halt foreign aid or assistance delivered or provided to South Africa”.

The order incorrectly claims that South Africa is persecuting white Afrikaners, and has “taken aggressive positions towards the United States and its allies, including accusing Israel, not Hamas, of genocide in the International Court of Justice”. 

The US has offered white Afrikaners refuge in the US, and Trump has made several disparaging remarks about the country, including at a meeting at the White House with South African President Cyril Ramaphosa. 

Earlier this month, the US pulled out of the G20 meeting being hosted in South Africa this weekend, with Trump repeating incorrect claims of discrimination against whites as the reason. 

All 2026 lenacapvir stock bought

The US government and the Global Fund have bought all of Gilead’s 2026 stock of lenacapavir, a twice-a-year injectable that is almost 100% successful in preventing HIV transmission.

The Global Fund’s HIV head, Izukanji Sikazwe, told Health Policy Watch that her organisation will supply South Africa and all countries in need with lenacapavir “based on evidence of need”.

But eight patient advocacy groups described the rollout of 500 lenacapavir doses each for Eswatini and Zambia as a “public relations stunt” in a media release on Thursday.

“Africa and the Global South are being offered merely symbolic handouts, while Gilead and donors shape markets to serve corporate and geopolitical interests, not urgent public health needs,” said Fatima Hassan, director of the Health Justice Initiative (HJI).

“By procuring a minuscule number of doses, Gilead can claim that [lenacapavir] is ‘introduced’ in Africa, creating demand and laying the path for commercial bullying instead of introducing the product at actual cost and at scale. This is a profit-seeking, corporate strategy dressed up as solidarity,” she added.

Gilead announced in October 2024 that it has authorised six generic manufacturers to sell lenacapavir in 120 low- and middle-income countries, although none are from sub-Saharan Africa. It also excluded several Latin American countries including Brazil and Colombia.

The medicine is licensed in the US as Sunlenca for people with drug-resistant HIV, and currently costs $42,250 a year for two injections.

The generics are only likely to be available in 2027 at the earliest, and the advocacy groups claim Gilead is “frustrating the speed at which generic entries are possible”, as it has not yet filed an application with India’s drug regulatory authority and has prioritised registration in only 22 countries. 

‘Insulting’

The advocacy groups estimate that at least 10 million Africans need lenacapavir to achieve the global goal of a 90% reduction in new HIV infections by 2030, with two million of these being South Africans. 

However, the US will only provide doses for 325,000 people in 2026 – an “insulting” amount in comparison to the need, said Bellinda Thibela, Health GAP’s International Policy and Advocacy coordinator.

“Instead of crumbs, the US should be providing millions of lenacapavir doses, to alter the course of the HIV pandemic and to repair the harms caused by their illegal and deadly cuts to HIV programmes since January,” added Thibela.

However, Brad Smith, US Senior Advisor for the Bureau of Global Health Security and Diplomacy, told a media briefing this week that Gilead’s available volume in 2026 is 600,000 doses, but that the US and the Global Fund are committed to buying two million doses.

“We anticipate a continued increase in demand and production capability over time to enable us to meet the two million doses sometime in mid-2027,” said Smith, adding that the doses were being split 50/50 between the US and the Global Fund.

“We are working out between ourselves exactly who will distribute and procure for which country,” Smith added.

Speaking at the same media briefing, Gilead CEO Daniel O’Day said his company was able to “provide Lenacapavir at no profit to Gilead to the countries with the highest burden of HIV”.

Political decisions

Citing the US Executive Order against South Africa, the advocacy groups say that the US  has made the country “the target of harsh foreign policy decisions based on the Trump administration’s racism, lies, and conspiracy theories”.

Nigeria is also being “pushed out” of lenacapavir support “after being criticised by US government officials, including for refusing to imprison US detainees extracted during US immigration raids”, they claim.

“In contrast, Eswatini has accepted the offer of not just the 500 lenacapavir doses ahead of World AIDS Day, but also $5.1 million in funding from the US government in exchange for imprisoning US detainees,” they note.

Sibongile Tshabalala, Chairperson of the Treatment Action Campaign (TAC), called for either Gilead to license South African generic companies to make lenacapavir, or for the South African government to “use its lawful powers to issue compulsory licenses”.

“Now that the Trump administration has openly tied the global rollout of lenacapavir to a political standoff rewarding ‘compliance’ but punishing African political autonomy and sovereignty, South Africa must step forward with principled global leadership,” the groups add.

Image Credits: The Global Fund/ Saiba Sehmi, International AIDS Society, Witkoppen Clinic, Gilead.