1/ Today at #AIDS2026 along with @healthjusticein we presented our analysis of one of the most important HIV prevention breakthroughs of our generation - and one of its biggest ethical failures. A Breakthrough Withheld: Power, Control and the Slow Rollout of Lenacapavir. 🧵👇 2/ Lenacapavir has the potential to transform HIV prevention. But scientific innovation alone does not save lives. Access does. Our question was simple: Has the rollout honoured the commitments made to the communities whose participation made this breakthrough possible? 3/ Our conclusion: Not yet. The evidence points to a managed retreat from the ambition that accompanied lenacapavir’s launch. Promises of broad access have been replaced by cautious scarcity management 4/ The numbers tell the story. • Licensing announced for 120 countries • Initial focus on 18 priority countries • By 2026, fewer than 12 countries had confirmed deliveries • Available supply reaches only a tiny fraction of those who could benefit. 5/ In several countries, first-year supply represents less than 1% of estimated need. A scientific breakthrough with global potential has begun with volumes too small to change the course of the epidemic. 6/ The language matters. “Priority countries.” “Phased rollout.” “Early adopters.” These terms can sound like orderly implementation. In reality, they often describe the management of scarcity rather than equitable access. 7/ This is not simply a logistical problem. It is an ethical one. The communities that participated in research, carried the burden of HIV and contributed to scientific progress should not be the last to benefit at scale. 8/ Access cannot be an afterthought. It must be designed before: • clinical trials begin • regulatory pathways are established • commercial strategies are finalised. Ethics must be built into product development- not retrofitted afterwards. 9/ We argue that governments, funders and manufacturers all have responsibilities. Scientific success should be measured not only by efficacy in clinical trials, but by whether the people who need innovation can actually receive it. 10/ Our recommendations include: ✅ Expand non-exclusive licensing ✅ Commit to transparent supply allocations ✅ Establish enforceable delivery timelines ✅ Involve affected communities in access decisions ✅ Embed equitable access into future product development from day one. 11/ Lenacapavir has shown what science can achieve. Now the challenge is whether politics, financing and intellectual property systems can match that achievement. Without equitable access, innovation risks reinforcing the very inequalities it was meant to address. 12/ Thank you to our co-authors, in-country contributors and community partners across Africa and beyond whose evidence and lived experience informed this work. The conversation doesn’t end with this presentation. The next breakthrough must not be another breakthrough withheld. #AIDS2026 #HIV #Lenacapavir #GlobalHealth #HealthEquity #AccessToMedicines #IntellectualProperty #PrEP @Bhekisisa_MG @HealthJusticeIn @HealthZA @GileadSciences @AfricanAmata @MedsPatentPool @MRCza @AASciences