Systemic barriers block access to HIV prevention breakthrough Lenacapavir despite its potential to end epidemics

Indigenous and traditional health systems have historically provided culturally resonant HIV prevention and care, often with lower costs and higher trust among communities. For example, the *Temazcal* (sweat lodge) ceremonies in Mexico are used to address stigma and mental health alongside biomedical treatment. These systems are sidelined by a biomedical monopoly that prioritizes patented drugs like Lenacapavir over proven, low-cost alternatives. Integrating indigenous knowledge could reduce reliance on corporate pricing while improving cultural acceptance.

The HIV epidemic is deeply tied to colonial legacies, including the extraction of resources and the disruption of local health systems in Africa and Asia. Structural adjustment policies in the 1980s-90s forced cuts to public health budgets, exacerbating vulnerability to HIV. The current patent regime, enshrined in TRIPS, mirrors colonial-era resource extraction by prioritizing corporate profits over global health. Historical parallels include the 19th-century cholera epidemics, where colonial powers blamed local practices rather than systemic water infrastructure failures.

Cross-cultural comparisons reveal that countries like Cuba and Thailand achieved HIV control through community-based programs and price controls, not market-based solutions. In Thailand, the '100% Condom Program' combined public health campaigns with sex worker-led outreach, reducing new infections by 90% in a decade. Meanwhile, Brazil’s use of compulsory licensing for HIV drugs in the 1990s demonstrated how public investment can bypass patent barriers. These models contrast sharply with the subscription pricing narrative, which assumes corporate benevolence.

Lenacapavir’s efficacy is well-documented in clinical trials, but its real-world impact is limited by delivery systems that fail to reach marginalized populations. Studies show that adherence to HIV prevention is higher when integrated into existing community health programs, not corporate-run subscription models. The scientific consensus also highlights that patent monopolies inflate prices by 10-100x above production costs, a phenomenon documented in WHO reports. Without addressing these structural barriers, even breakthrough drugs will have limited reach.

Artistic and spiritual traditions often frame health as a collective responsibility, contrasting with the individualistic 'subscription' model. For instance, the South African concept of *Ubuntu*—'I am because we are'—underpins community health initiatives that reduce stigma and improve outcomes. In Brazil, Afro-Brazilian *Candomblé* and *Umbanda* traditions incorporate healing rituals that address the spiritual dimensions of illness, which are often ignored in biomedical approaches. These perspectives suggest that prevention must engage with cultural identity, not just pharmacology.

Future scenarios show that without decolonizing HIV prevention, Lenacapavir will remain inaccessible to those most at risk, prolonging the epidemic. A 2030 projection by UNAIDS indicates that patent-driven pricing could leave 60% of people in low-income countries without access to long-acting prevention by 2035. Conversely, a scenario where public funding and technology transfer enable local production could reduce costs by 90% and achieve 95% coverage in a decade. The subscription model risks locking in corporate control, while a commons-based approach could create resilient, equitable systems.

Marginalized groups—sex workers, LGBTQ+ individuals, people in prisons, and racial minorities—are systematically excluded from HIV prevention discussions despite bearing the highest burdens. In the U.S., Black women account for 60% of new HIV diagnoses among women, yet receive only 10% of prevention funding. Global South communities, where 60% of new infections occur, are treated as passive recipients rather than partners in solution design. Their exclusion from pricing debates reflects a broader pattern of epistemic injustice, where their knowledge and needs are rendered invisible.