A new HIV drug promises 99.9% protection. But it's making Indian health activists wary; here's why

The US Food and Drug Administration (FDA) has approved lenacapavir, a new injectable drug that claims to offer 99.9% protection against HIV. But concerns are being raised in India over its affordability and accessibility, particularly through the public healthcare system.

The injection costs around ₹24 lakh ($28,218) for two doses administered six months apart. Lenacapavir belongs to the class of HIV prevention drugs known as pre-exposure prophylaxis (PrEP). However, India’s National AIDS Control Organisation (NACO) has not included PrEP in its public programmes so far.

"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.

He added that NACO had made it mandatory for its counselling centres to provide information on PrEP a couple of years ago. He also expressed concern that 75% of the 88% people diagnosed with HIV in Mumbai in 2023–24 were from the 15–49 age group. PrEP, however, remains available only in the private sector.

Experts call for government action, tiered pricing
PrEP has existed for over a decade and is widely used in developed countries. In India, public health discussions around PrEP only began recently.

A doctor from a government hospital said, "They set up a committee, then a white paper was brought out that served as a backgrounder for guidelines that were drawn up last year. However, there has been no development since."

Dr Ishwar Gilada of the People's Health Organisation (India) said, "The govt should distribute PrEP to check the spread of the disease, which has only been increasing in recent years. The total number of HIV-positive people in India increased from 2.2 million to 2.5 million in a few years."

According to him, sexually transmitted infections have been rising in Mumbai. "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," he said.

He suggested a three-tier pricing structure: full price for those who can afford it, subsidised pricing for some, and free access for those unable to pay. NACO officials were not available for comment.

India has also not approved HIV self-testing kits. "We have self-testing kits for pregnancy, diabetes, and Covid, but policymakers fear about the mental health of people after a positive result in self-testing HIV kits," said Dr Gilada.

A senior doctor suggested that similar fears may be behind the delay in rolling out PrEP publicly, as officials worry it might encourage risky behaviour.

Hope for lower-cost versions as UNAIDS urges price drop
Bala from Bombay Gay called lenacapavir a "monumental milestone forward in HIV treatment and prevention," but added that the current price point makes it inaccessible in India. "So, we have to wait and see if prices will come down over time," he said.

Dr Gilada expressed hope that Indian manufacturers licensed by Gilead Sciences might eventually offer the injection at less than $100 per year. "India can do it," he said.

UNAIDS, in a recent statement, urged Gilead Lifesciences to reduce the price of the new drug to improve global access.

(With inputs from ToI)