Introduction
The emergence of antiretroviral-based HIV prevention tools marks a new turning point in the HIV response. In 2024, a clinical trial showed that lenacapavir when injected every six months, offers almost 100 percent protection from HIV infection. Other long-lasting prevention options are in the pipeline.
These new tools are game changers. Yet as we know from other scientific breakthroughs, medicine alone is not enough. Many of the people most affected by HIV in southern Africa and other parts of the world face extraordinary hurdles in accessing safe healthcare services. As countries across southern Africa roll out long-acting HIV prevention tools, meaningful engagement of communities and recognition of their expertise will be essential to ensuring these interventions are effective, equitable, and responsive to local needs.
In January 2026, UNDP awarded 22 grants to key population-led organizations in Malawi, South Africa and Zimbabwe through its Power of Prevention project. Now grantees are educating communities about long-acting prevention, connecting marginalized groups to services, and lobbying their governments and other decision-makers to distribute prevention tools to those who need them most.
This Manifesto offers a glimpse into what communities are seeing on the ground. It is a living document, updated every six months, to reflect the perspectives and realities of communities driving prevention access across three countries in Southern Africa.
Manifesto
This is what we need for equitable prevention access.
Education from trusted peers or outreach workers. Key populations are often best positioned to reach their peers and can help inform communities on long-acting HIV prevention to enable demand generation, advocacy for policy reform, and address inequities in prevention access. For example, for transgender communities, there are concerns about possible drug-drug interactions between long-acting PrEP and hormone replacement therapy (HRT), despite that many PrEP formulations have demonstrated few to no clinically significant interactions. In Zimbabwe, communities who use and inject drugs at first misunderstood lenacapavir as a cure for HIV. In all cases, education must be provided by trained peers or outreach workers who have the trust of the populations that they’re working with.
Target information on all available HIV services, including injectable PrEP, to different communities: Ensure that information about clinics and services is available in multiple languages, formats and platforms so that communities can make informed decisions. For example in Malawi, most female sex workers do not currently know where to access injectable PrEP.
Include community organizations and key population networks in training and sustainability initiatives: Community groups often step in to fill the gap if there are disruptions in services. Peer educators and outreach workers should receive training for the sustainability of prevention outreach and other activities in case of funding cuts so that they can continue serving their community.
Flexibility of service delivery models: In some countries, HIV prevention services remain operationally fragmented, with long-acting prevention delivered through vertical, donor-supported programmes rather than embedded within routine primary healthcare. For example, key populations may access HIV testing at a public clinic but must travel to a separate, often donor-funded site for PrEP initiation or continuation. A balance must be struck between integration into primary healthcare while also not forcing clients into mainstream facilities that cannot provide tailored services.
Key populations often need to be able to access prevention health services outside of fixed clinic times. Countries can explore hosting special clinic hours once a week or monthly weekend clinics at drop-in centers, evening and weekend outreach clinics to accommodate work schedules, and night outreach. Service design must also account for hidden populations, such as younger key populations, and the working-class key population community who may not self-identify with traditional labels or spaces. For outreach in rural areas, community focal persons can act as important links, generating demand and facilitating direct access to services within their own communities. Similarly, peer-led ART refill and PrEP adherence groups reduce clinic visits and improve treatment retention. Finally, healthcare workers need to be trained to ensure friendly and welcoming attitudes towards key populations or access will stall.
Rebuilding linkages to disrupted service and care: Communities can strengthen referral pathways and ensure people who need long acting prevention access it. This can include providing recommendations for trusted service providers, accompanying people to services or helping with transport. This is particularly important in cities such as Cape Town, where three PEPFAR funded clinics abruptly closed down in 2025, leaving many key population communities without access to services. According to SWEAT, almost 50% of the people who used to receive medication from one of these clinics have defaulted for more than two months. It is also important for marginalized groups such as intersex persons, who are often excluded from major health programs.
Equitable distribution of HIV prevention services: While geographic targeting of programs may aim to reach specific populations with long acting prevention, it can also have the opposite effect, allowing urban dwellers to access prevention tools while those in rural areas are cut off. Community-based distribution models are minimal or absent outside major cities. All people who are interested in taking long acting prevention must have a pathway to access.
Key-populations drive effective policy reform: Prevention policy design must include key population organizations and networks to design useful policies and programs. For example, in July 2025, the Sexual Rights Centre in Zimbabwe convened an inaugural Parliamentary Key Population Champions (KP) Caucus, engaging 12 parliamentarians, including the Chairperson of the Health Committee, to secure legislative support for sustained key population programming. Participating parliamentarians pledged to advocate for increased domestic investment in key population-focused HIV programs and integrating their health needs into public health financing frameworks. This model can be continued to help with PrEP integration and rollout.
Sustainable financing and supply: We are working to educate and mobilize communities on the ground, but this education is pointless if prevention tools are out of stock, or if supply disruptions threaten adherence. Advance sustainable HIV prevention financing through community-driven policy and budget analysis to identify gaps in access and financing. To enable community support of lenacapavir’s rollout, for example, consider social contracting frameworks to enable community organizations to access domestic resources. At the national level, demystify existing levies or taxes and create a clear "fiscal map" for earmarked health funding.
Holistic and sustainable prevention strategies: Prevention via PrEP is not a one-off – it is an investment in long-term health equity for key populations. Fostering collaboration between communities, policymakers, and service providers ensures a sustainable, inclusive, and equitable HIV response.
Equitable distribution of resources/Funding: Community-led networks of key populations also need access to resources to support the rollout of new prevention tools, regardless of the size of the organization – some smaller networks might be better positioned to support due to their ties with key population communities.
Mind the gaps
Access and uptake need supportive legal, policy and financing environments.
Funding*:
Malawi: Prevention funding gap: $64,267,932.
For PrEP: $16,822,389
South Africa: Prevention funding gap: $222 million
For PrEP: $446 million
Zimbabwe: Prevention funding gap: $16.1 million
For PrEP: $13.1 million
Laws and policies
A major barrier to access remains service design: Across medical facilities in Southern Africa, there remains incomplete service integration, insufficient provider readiness, and limited clinical capacity for long acting prevention. Long waiting times at public facilities can also affect service access, as key populations may feel exposed waiting in a crowded public hallway, opting instead to forgo the service to remain anonymous.In South Africa, which is rolling out lenacapavir, many services are clinic-centred, following traditional Department of Health models, which often overlook opportunities to leverage peer-led or community-driven approaches.
Provider readiness: Many healthcare workers are not yet up to speed on long-acting injectables (e.g., dosing schedules, eligibility criteria) and remain unskilled at working for key populations. In practice, this manifests as poor services, unnecessary questioning, or breaches of confidentiality. These provider-level barriers directly contribute to low uptake, poor adherence, and weak retention in prevention programmes.
Harmful legal and social environments: In Malawi, the outdated Penal Code, which criminalizes same-sex relationships, remains a primary barrier to service uptake along with laws criminalizing drug use. In South Africa, the criminalisation of sex work and drug use remains a significant structural barrier. In Zimbabwe, the criminalisation of sex work, drug use and same-sex relationships prevents key populations for accessing services.
Difficult in accessing sexual and reproductive health services, including HIV prevention: Many key populations lack information on basic SRH and HIV prevention services, let alone have awareness about long acting prevention options. In addition, recent funding cuts have decimated prevention services. For example, female sex workers in Malawi can no longer access free services in public institutions, and are now asked to purchase their own condoms.
Stigma and discrimination towards key populations: Many key populations in southern Africa continue to face discrimination from service providers as well as community members which bars them from clinics and other health facilities.
*As of February 2026
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