By Catherine Tembo and Wycliffe Njiragoma
James Edward (not a real name) has learned to live carefully. Every new client carries risk. Every decision about protection can shape his future.
So when he heard about an HIV prevention injection that works for six months at a time, hope came quickly for the 28-year-old male sex worker in Mzuzu. Understanding, however, did not.
“I have only heard people talking about it,” Edward says. “I need more information before I can decide whether to use it.”His uncertainty reflects a wider national dilemma.
Malawi is preparing to introduce Lenacapavir, a long-acting HIV prevention injection this April, yet awareness among communities and even some health workers remains limited.
Developed by Gilead Sciences, Lenacapavir is administered as two injections once every six months for adults and adolescents weighing at least 35 kilograms.
Clinical trials showed near-total effectiveness in preventing HIV infection, prompting global health experts to describe it as one of the most significant prevention breakthroughs since antiretroviral therapy.
Unlike daily oral pre-exposure prophylaxis (PrEP), which requires strict adherence, the twice-yearly injection is designed for people who struggle with daily pills due to stigma, mobility or inconsistent access to health services.
Malawi joins a small group of early African adopters after approval by the Pharmacy and Medicines Regulatory Authority late last year. But while policy milestones are being met, readiness at ground level appears uneven.
Member of key populations and HIV advocate, Electrazie, worries that awareness remains dangerously low.
My worry is about awareness remains dangerously low- Electrazie
“Many people still don’t understand it and so can’t make informed choices,” Electrazie says, adding that trained health workers will be critical to building trust.Yet frontline preparedness remains a concern.
At Kawale Health Centre in Lilongwe, health worker Andrew Mphongolo admits he has not received formal training on the injection. A nurse at Bwaila Hospital similarly acknowledged limited knowledge about the drug’s purpose.
A rapid assessment by Community Health Rights Advocacy (Chera) under the UNDP-supported “Power of Prevention” project found similar gaps.
Programme Manager Alex Kaomba warns that many medics remain unfamiliar with Ministry of Health guidelines as the rollout timeline approaches.
Kaomba
“We are worried given the short timeframe before the first consignment arrives,” he lamented.
National AIDS Commission Chief Executive Officer Dr. Beatrice Matanje maintains that preparations are progressing.
“Clinical guidelines, communication materials and training curricula have been developed, with provider training expected to begin in March,” she said adding that the US Government, working through global HIV programmes alongside the Global Fund, has committed support targeting about 38 000 beneficiaries annually during initial phases.
Globally negotiated access agreements mean the drug will be supplied to low-income countries at roughly US$40 per person annually, a dramatic reduction from prices exceeding US$20 000 in high-income markets.
Early rollout funding is largely donor-supported, placing pressure on governments to plan for long-term sustainability once external financing declines.
Lenacapavir will initially target populations at highest risk of infection, including sex workers, men who have sex with men and adolescent girls and young women in high-incidence areas.
While Malawi’s national HIV prevalence has fallen to about 7–9 percent, infection rates remain disproportionately high among key populations.
Studies estimate HIV prevalence among female sex workers at over 50 percent, helping explain the decision to prioritise targeted delivery rather than nationwide access.
Malawi already provides daily oral PrEP and recently introduced Cabotegravir, an injectable prevention given every two months in Lilongwe and Blantyre.
Lenacapavir is thus expected to expand prevention choice rather than replace existing options.Still, critical questions remain unresolved.
The Ministry of Health did not clarify concerns about readiness, long-term financing or sustainability of the intervention. Ministry spokesperson Adrian Chikumbe had not responded to our questionnaire by press time.
While Malawi has made significant progress in HIV treatment, with nearly one million people living with HIV and treatment coverage approaching global targets, the remaining battle lies in prevention, with roughly 11 000 new infections recorded annually.
For people like Edward, the success of Lenacapavir will depend less on scientific promise than on understanding and trust.“If I understand it properly,” he says, “then I can decide.”
As things stand, one of the world’s most advanced HIV prevention tools risks arriving before the country is fully ready to use it.
