Lenacapavir is the first of a new family of antiretrovirals that inhibit HIV capsid formation. It is a molecule that can be administered orally (daily or weekly) or parenterally subcutaneously every six months. A major study published in 2024 shows that subcutaneous administration of lenacapavir every six months prevents 100% of potential HIV infection. In the clinical development of lenacapavir, its use in prophylaxis and treatment of infected people (in combination with other antiretrovirals) is foreseen. Because of the impact this could have on controlling the HIV pandemic, it certainly deserves to be considered this year's most important medical breakthrough.

The long-acting prevention tools (CAB-LA and LEN) have the potential to change the way both HIV prevention and treatment are approached. In that sense, the article is correct. However, I would make three points that I think are important to make in this type of editorial.

The first is the lack of commentary on the determinants in which the discovery of lenacapavir happens. At a time when there are treatments and prevention tools such as lenacapavir that can help meet UNAIDS targets, these tools remain (and will remain if nothing changes) inaccessible to millions of people in need. Thus, the author of the editorial neglects ‘the systems, practices and pathways through which commercial actors influence health and equity’ or commercial determinants of health, and defines the success of lenacapavir, without commenting on the fact that the drug costs around $40,000 per person per year, despite studies showing that it can be produced for $40 per person per year. Or that the treatment is not registered in the vast majority of countries. Or that the marketing company's access strategy leaves out countries that should be included for public health reasons.

The second point I would make is the article's ‘over-focus’ on the role of the US as a key player in expanding global access to HIV treatment. The access results we have right now are thanks to a much broader and more complex network of actors, created and sponsored by individual countries (as in the case of PEPFAR), but also by philanthropic organisations (Global Fund) or the United Nations (Unitaid, UNAIDS), NGOs (Médecins Sans Frontières), and so on. Attributing the results to a single organisation or country is therefore a mistake. Of course, the systematic opposition of high-income countries (especially the US and the EU) to the relaxation of intellectual property rights in international law or the promotion of abstinence in PEPFAR programmes has done little to reduce the burden of disease or stigmatisation.

Finally, I wanted to make one last point. In his penultimate paragraph, the author acknowledges the work of scientists who have contributed to the response to HIV. This, while true, is incomplete. To secure the scientific breakthroughs that have made possible the development of HIV therapies, the struggle of thousands of HIV patients and members of communities most affected by HIV (such as the LGTBIQ+ community, people who use drugs or communities in multiple countries in sub-Saharan Africa) was crucial. Campaigns such as those organised by ACT UP helped to reduce stigma, raise awareness of the problem and increase the suffering of communities. But they were also instrumental in loosening regulatory procedures, changing the design of clinical trials and expanding global access. Not recognising the efforts of all these communities in improving access and the development of new therapies contributes to the marginalisation and stigmatisation of which the author himself complains, as, by omission, it ends up portraying these communities as passive subjects, simple recipients of innovation, rather than as subjects of rights (and the right to health is a human right) and an essential part of making the system work in a fairer and more equitable way.