The US Food and Drug Administration has approved lenacapavir, a groundbreaking injectable drug that demonstrates 99.9% efficacy in preventing HIV infection. However, the drug's substantial cost of ₹24 lakh ($28,218) for two doses administered six months apart has sparked concerns among Indian health activists about accessibility through the country's public healthcare system.
Current HIV Prevention Landscape in India
Lenacapavir belongs to the class of HIV prevention drugs known as pre-exposure prophylaxis (PrEP), which has been available for over a decade and is widely used in developed countries. Despite this established track record, India's National AIDS Control Organisation (NACO) has not incorporated PrEP into its public health programs.
"Our govt distributes condoms to break HIV transmission, it provides antiretroviral therapy drugs to prevent parent-to-child transmission of HIV, but it hasn't ever given PrEP to youngsters who are likely to indulge in high-risk behaviour," said health activist Ganesh Acharya.
The situation is particularly concerning given that 75% of the 88% of people diagnosed with HIV in Mumbai during 2023-24 were from the 15-49 age group. Currently, PrEP remains available only through private sector healthcare providers.
Rising HIV Burden and Policy Gaps
Dr. Ishwar Gilada of the People's Health Organisation (India) highlighted the increasing HIV burden in the country, noting that "the total number of HIV-positive people in India increased from 2.2 million to 2.5 million in a few years."
The problem extends beyond HIV to other sexually transmitted infections. According to Dr. Gilada, "A recent survey in Mumbai among men who have sex with men found that 60% of them were positive for the human papilloma virus. While gonorrhoea and chlamydia vanished 25 years ago, their numbers are shooting up."
India's approach to HIV prevention policy has been cautious. A doctor from a government hospital explained that while authorities "set up a committee, then a white paper was brought out that served as a backgrounder for guidelines that were drawn up last year," there has been no development since.
Expert Recommendations for Improved Access
Health experts are calling for comprehensive government action to address the accessibility crisis. Dr. Gilada proposed a three-tier pricing structure: "Charge full cost from those who can afford it, subsidy for some, and free for those who cannot afford medications."
The policy hesitation extends to other HIV prevention tools. India has not approved HIV self-testing kits, despite having self-testing options for pregnancy, diabetes, and COVID-19. "Policymakers fear about the mental health of people after a positive result in self-testing HIV kits," Dr. Gilada explained.
A senior doctor suggested that similar concerns may be driving delays in PrEP implementation, as some public health officials worry that providing PrEP might encourage risky behavior.
Hope for Future Accessibility
Despite current challenges, there is optimism about eventual access to lenacapavir in India. Bala from Bombay Gay described lenacapavir as a "monumental milestone forward in HIV treatment and prevention," while acknowledging that "its pricing makes it inaccessible to Indian patients."
Dr. Gilada expressed confidence that Indian generic pharmaceutical companies licensed by Gilead Sciences could eventually offer the injection at less than $100 per year. "India can do it," he stated.
The international community is also applying pressure for improved access. UNAIDS recently issued a statement urging Gilead Sciences to reduce the price of lenacapavir to improve global accessibility.
Clinical Significance and Future Outlook
The approval of lenacapavir represents a significant advancement in HIV prevention technology, offering unprecedented protection rates with a convenient dosing schedule of just two injections per year. However, the drug's clinical promise must be balanced against real-world accessibility challenges, particularly in resource-limited settings like India.
As the global health community continues to advocate for equitable access to this breakthrough prevention tool, the focus remains on developing sustainable pricing models and policy frameworks that can translate scientific innovation into meaningful public health impact.
