^{Florent Jouinot from Swiss AIDS Federation reports on AFRAVIH 2026 in Lausanne.}

From universal recommendations to personalised treatment

The global success of dolutegravir has shown that widespread access to innovative treatments is possible. In just a few years, 129 countries have adopted regimens containing dolutegravir, thanks to a combination of factors that are rarely found together: voluntary licences, price negotiations, WHO recommendations, international funding, generic medicines and community mobilisation.

This success has also changed the way we think about treatment. We no longer speak solely of first-, second- or third-line treatments. The focus is now on individualised therapeutic optimisation: choosing the right treatment based on real-life circumstances, needs, co-infections, side effects, pregnancy, resistance, preferences and quality of life.

This shift is essential. People living with HIV are not just asking for effective treatment. They are asking for treatments that are manageable.

‘Long-acting’ drugs: potential ‘game changers’

Long-acting drugs could transform the therapeutic and preventive treatment of HIV. For PrEP, options are diversifying rapidly: a daily tablet, a (multi-)monthly vaginal ring, cabotegravir injections every two or four months, lenacapavir every six or twelve months, and perhaps soon monthly oral formulations.

The principle is simple: the best PrEP is the one that the person can actually use.

Oral PrEP is highly effective, but it relies on regular intake, which can sometimes be difficult to maintain over the long term. Medication fatigue, stigma, lack of confidentiality or life constraints can reduce its effectiveness in real-world settings. Long-acting formulations therefore offer a significant solution, particularly for those most at risk and/or furthest from healthcare services.

But this innovation also creates new challenges: staff training, administering injections, managing schedules and potential delays, detecting possible HIV infections, and providing support when treatment is stopped. Long-acting injections can improve adherence, but they can also re-medicalise prevention if systems are not adapted.

An innovation pipeline that is (too?) concentrated

The pipeline is active, but not necessarily diverse. A large proportion of innovations is concentrated within a few therapeutic classes and depends on a very small number of pharmaceutical companies. This concentration gives manufacturers considerable power over research priorities, prices, access timelines and the countries served. This is a critical issue.

International guidelines can open up markets, but they are not enough. If products are not authorised in certain countries, if they remain too expensive, or if they are not rolled out across regions and made accessible to all population groups—particularly the most marginalised—then they will not have the expected impact.

The example of injectable cabotegravir is telling: its inclusion in guidelines may send a signal to generic manufacturers, but the arrival of affordable versions takes years. Hence the importance of anticipating access from the development phase onwards, even before patents expire.

The risk of a two-tier innovation system

New drugs do not automatically meet the needs of everyone. Certain strategies still too often exclude pregnant people, those co-infected with hepatitis B, people living with viruses less sensitive to certain antibodies, or populations under-represented in trials (age, sex/gender, height/weight, ethnicity, etc.).

This is one of Alexandra Calmy’s key messages: clinical trials do not always include the people who will need the medicines most once they are on the market.

Innovation must therefore be evaluated in the contexts where it will be deployed. This requires more inclusive, participatory and transdisciplinary research, with genuine community involvement from the very design of the protocols.

Research thus also becomes a lever for equity and a form of activism.

Choice is not just about having an option

The word “choice” is central. But a choice is only real if several conditions are met: availability of multiple products, affordable pricing and/or coverage, geographical and cultural proximity of services, appropriate information, absence of stigma, community support and the possibility of switching methods.

Having an approved injectable PrEP is not enough if it is only accessible to a few people. Having a long-acting treatment is not enough if services cannot administer it. Having a WHO recommendation is not enough if governments do not fund its implementation.

The choice must be practical, not merely theoretical.

What this means for Switzerland

For Switzerland, these presentations raise several important questions. The country has an efficient healthcare system, but actual access still depends on the availability of treatments, cost and coverage, accessibility, and the ability to reach the most at-risk and/or marginalised populations.

At present, only daily oral HIV PrEP is available, and only one generic version is covered by the NHS, at least until the end of 2026. A recent supply disruption highlights the fragility of the system. Uncertainties regarding the continuation of coverage and the lack of an application for authorisation for CAB-LA do not bode well for the near future of HIV PrEP in Switzerland.

For Swiss AIDS Aid, the issue is clear: defending freedom of choice. This involves supporting access to different forms of preventive and therapeutic treatments, supporting people in their preferences, strengthening community-based initiatives, and ensuring that innovations are accessible to everyone who could benefit from them.

Community organisations have a vital role to play here: creating demand, providing information, offering support, breaking down barriers, and reaching out to and supporting people who do not spontaneously seek out traditional medical services.

The responsibility of governments

Finally, these two presentations serve as a reminder that access to innovations cannot be left solely to the market.

Governments must take responsibility: negotiate with pharmaceutical companies, fund the treatments chosen by individuals, support health services, invest in community initiatives and ensure equitable access for their entire populations.

The 2030 goal of ending HIV transmission will only be achieved through a range of interventions, particularly treatments that are available and truly accessible. 

It will require political will, sufficient and sustainable funding, and an organisation capable of transforming scientific innovation into real impact.

The tools exist. More are on the way. The question is no longer simply whether we can end the HIV epidemic, but whether and when we wish to achieve this.