HIV prophylaxis in Brazil: Treating instead of negotiating

I n São Paulo's queer scene, people whisper an insider tip: a drug that the UN AIDS program describes as "revolutionary." One spade, six months protection. Lenacapavir is the name of the miracle drug. It is an injectable version of pre-exposure prophylaxis, or PrEP, which in studies prevented almost all HIV infections. Instead of swallowing a pill every day, two injections a year are enough. But the drug is not yet available in Brazil, where the number of new HIV infections is rising.

The artist Solange do Nascimento Silva has found a loophole: she is already receiving the drug through a study. She heard about it in her ballroom community, a queer subculture known for performance competitions and voguing. With her long legs crossed, she is now sitting in a health administration bus at Largo do Arouche, one of the city's LGBTQ+ hotspots, and is receiving her first injection.

Do Nascimento Silva hopes that lenacapavir will make her everyday life easier. Because as a trans woman, she already has to take many different preparations every day: three hormones for gender reassignment, and then PrEP. “Four pills every day just to make me feel good – that’s a lot for the body,” she says.

233,000 Brazilians are already protecting themselves from HIV with PrEP. Lenacapavir would make your life a lot easier. And at the same time stop the increasing number of infections by simply and effectively protecting even more people from risk groups. The price for this could be around 25 to 40 dollars. According to Doctors Without Borders, this is how much an annual dose of lenacapavir costs to produce. In the USA, however, the pharmaceutical giant Gilead charges $28,000. This is hardly affordable for the Brazilian healthcare system.

In 2025, Gilead had sales of over $29 billion, with net income of more than $8 billion. The company has a patent on lenacapavir in many countries, including Brazil. This gives him the power to decide where and at what price the drug is available.

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For people like Solange do Nascimento Silva, who live with the fear of HIV, what counts is not patents or sales figures, but rather access to a medication that adapts to the reality of their lives. Lenacapavir is one such drug. It could curb the HIV epidemic in Brazil. But how does it reach those who urgently need it? And what could healthcare that serves humanity instead of profit look like?

Brazil was once considered a model student when it came to combating HIV. The state health system introduced guaranteed access to antiretroviral drugs for everyone, and the number of infections fell. But new infections have been increasing for several years, especially among young people and in queer communities. One reason for this is the weakening of HIV/AIDS policy, including by politicians like ex-President Jair Bolsonaro, who, contrary to scientific findings, relied on chastity campaigns in the fight against sexually transmitted diseases. With the recent presidential election, there could have been a return to this policy with Bolsonaro's son Flávio.

The public AIDS coordination of the city of São Paulo shows what potential the Brazilian health system has. In just a few years, the metropolis has made a name for itself as a model city for HIV prevention. Bucking the national trend, the number of new infections here is declining - between 2016 and 2025 it fell by 56 percent.

Cristina Abbate is sure that this is also due to São Paulo's prevention infrastructure, which she helped to build and coordinate. This also includes the bus on which Solange do Nascimento Silva received her first lenacapavir injection. He tours the city's LGBTQ+ hotspots several times a week, offering free testing, treatment and prevention measures. Not far from the bus, Abbate is now standing in front of a prevention center in the República subway station and talks about her impatience. “I’m known for always being in a hurry,” she says. “Because while we’re pondering here, people out there are getting infected.”

She has been pursuing a vision for a few years now: bringing HIV prevention to where the people are. She had read an article about a couple who had opened a nail salon in a subway station to make it easier for working women to get manicures. Abbate couldn't get the concept out of his head. “How often do people put off their tests because they can’t fit them into their everyday lives?” she says. As long as lenacapavir is only available to your patients in studies, alternatives must be found. Abbate decided to open a prevention clinic in the subway station. It has been in operation since June 2023. Testing for HIV, syphilis, chlamydia and gonorrhea is carried out without an appointment.

"The idea is to break out of the practical logic. Our station is open from 5 p.m. to 11 p.m., we catch people here in their routine, on the go, after work or before the party," explains Abbate. Anyone who tests positive will immediately begin free treatment. Of course there are also PrEP and condoms.

“Do you see that?” Abbate asks as she points to a framed sign above the reception desk. "This is the phone number for my personal office, for feedback and complaints. There is one like this in every practice." There has never been a complaint.

If you can't make it to the República subway station, you can also get HIV medication prescribed via video call. But that's not enough for Abbate. Your next project: the PrEPsi machine. “PrEP should be as easy to obtain as a Coca-Cola,” says Abbate. She and her colleague Carolina Marta de Matos are standing in front of such a machine at the Luz subway station. The purple paint is already coming off even though it has only been in use for a year. There are now five machines at subway stations in the city. De Matos generates a QR code using the app, holds it up to the scanner and hey presto, the machine spits out a pack of PrEP and an HIV test.

Abbate is proud of how close to everyday life the fight against HIV works in São Paulo. At the same time, she is frustrated that she still has to work with automated solutions. After all, injectable PrEP, Lenacapavir, has long been available.

It is unlikely that Abbate will be able to offer this in its subway stations in the near future. Because the negotiations between Gilead and Brazil are deadlocked. Gilead is said to have charged Brazil $1,200 per annual dose, an insider told taz. The official number is not known. According to media reports, Brazil offered a maximum of $400 - still ten times the production costs.

Because companies like Gilead also know that many countries cannot afford the moon prices paid in the USA, they grant voluntary licenses to some low-income countries. They work like this: The patent holder allows selected pharmaceutical companies to produce their patent-protected drug as a generic and sell it cheaply. In 2024, Gilead granted such licenses to six generic drug manufacturers. They are allowed to produce and sell lenacapavir for 120 low- and middle-income countries. In India, generic lenacapavir will be available from 2027 for around $40 per annual dose.

Brazil was excluded from the voluntary license even though it, like many other Latin American countries, participated in Gilead's lenacapavir trial. This makes Susana van der Ploeg from the Brazilian AIDS Association Abia angry. “Imagine that I have the solution to a health crisis that affects you and thousands of others - but you only get access if you can afford it,” she says in an interview with taz.

Just a few weeks ago, the lawyer and activist who specializes in patent law protested against Gilead's patent policy at the AIDS conference in Rio de Janeiro. With a raised fist and a megaphone, she called for a compulsory license for lenacapavir. Activists next to her held signs that read, "Lenacapavir: Tested in Brazil. Withheld from Brazilians."

Gilead justifies Brazil's exclusion from the voluntary license by saying that the license is intended for countries with high HIV incidence and limited resources. This is met with criticism in Brazil. While new HIV infections have been declining worldwide since 2010, here they have increased by over 20 percent in the same period.

Van der Ploeg has a different explanation: Brazil is a huge market with a single buyer, the state healthcare system. In addition, the country willingly grants patents - and, as van der Ploeg believes, against its own interests. Gilead would have an easy time in Brazil. If it weren't for Brazilian civil society; People like themselves who put pressure on. “Healthcare should not be organized according to the rules of the market – and certainly not according to what Gilead would like to earn,” says van der Ploeg.

If she had her way, we would live in a world without patents. She lists examples in history in which medical innovations were not patented: such as the BCG vaccination against tuberculosis in 1921. Or the smallpox vaccination in 1796. And when the inventor of the first polio vaccine, Jonas Salks, was asked in 1955 who owned the patent for his vaccine, he is said to have replied: "Well, to people, I would say. There is no patent. You can, for example, the sun patent?”

For Susana van der Ploeg there is currently only one solution: the compulsory license. The patent holder retains his patent and must be appropriately compensated, but the state allows the product to be manufactured and imported without the patent holder's consent. This procedure is quite common. Just two years ago, Colombia issued a compulsory license for the HIV drug dolutegravir. Malaysia did the same in 2017 for the hepatitis C drug sofosbuvir and Russia in 2020 for Gilead's Covid drug remdesivir.

But headwinds are to be expected, from pharmaceutical companies themselves, but also from governments that represent their interests. When Thailand issued several compulsory licenses between 2006 and 2008, the United States placed it on a trade list of countries it said did not adequately protect intellectual property. The US pharmaceutical industry pushed for sanctions, and the manufacturer Abbott decided to initially stop introducing new drugs on the Thai market.

It would not be the first compulsory license for Brazil: in 2007, President Lula da Silva issued a compulsory license for the AIDS drug efavirenz by decree without the consent of the US pharmaceutical company Merck. Brazil was then able to obtain a generic from India: instead of $1.59, the tablet only cost 45 cents.

Susana van der Ploeg wants Lula, strengthened by his re-election, to use this drug again with lenacapavir. The timing is good because Brazil is already under trade sanctions from the USA. Donald Trump is obviously interfering in Brazilian democracy. That's why, says van der Ploeg: "Right now it would be crucial for Lula to say to Trump: Not with us."

Othoman Mellouk, an expert on drug patents and access to HIV medicines at the NGO ITPC Global, agrees. Gilead would be under massive pressure from Brazilian civil society anyway. “You can’t use Brazilians as test subjects for drugs and then say: I don’t care about you,” he says. “Brazil could issue a compulsory license, produce the drug itself and supply it to other countries in the region – and much cheaper.”

In mid-September, the pressure on Gilead led to its first small success: the Pan American Health Organization Paho announced a new “pathway” for access to lenacapavir in Latin America and the Caribbean. Together with Gilead, Paho wants to make the syringe available in 14 countries, including Brazil, through a regional procurement fund.

The taz asked Paho and Gilead at what price lenacapavir should be offered under the new deal, what purchase quantities were agreed and when the syringe will be available in Brazil. Paho did not respond by press time. Gilead said in writing that the pricing terms of the agreement are confidential and that the company differentiates country prices based on economic strength, HIV burden and health system context.

Othoman Mellouk and Doctors Without Borders criticize the lack of transparency in the agreement. “As long as the price, quantities and delivery date are not communicated transparently, we cannot say what the deal means for access to lenacapavir,” says Mellouk. But the secrecy could also have tactical reasons. Because if Gilead agrees to and announces a lower price with Brazil, other countries could also demand a better price.

In order to prevent their negotiating position on the global market from being weakened, pharmaceutical companies use the common practice of “confidential discounts”: Instead of publicly committing to $400, for example, a pharmaceutical company offers a “buy one, get two for free” discount.

The buyer then pays $1,200 for one unit and receives two units “for free”. This means that the pharmaceutical company does not have to admit that it is effectively selling the drug for $400, while the buyer gets the product at their maximum bid. This tactic allows pharmaceutical companies to differentiate their prices and is criticized by the WHO and OECD as being non-transparent. Through individual negotiations, pharmaceutical companies can always give in if too much pressure builds up against them - without changing the basic distribution of power.

For Solange do Nascimento Silva, the price negotiations are far away; what matters to her is her access to the medication. That evening, after her first dose of lenacapavir, she remains under observation on the city government bus for a few hours. She later said that she tolerated the first injection well.

If lenacapavir is not yet available in Brazil after the study's waiting period has expired, do Nascimento Silva would have to switch back to tablets. The injection simply makes more sense for her and many other trans people, she explains: “It reduces the burden that the body has to carry.”