Source: The Conversation – Africa – By Paul Bowen, Professor Emeritus and Senior Research Scholar in the Department of Construction Economics and Management, University of Cape Town
The first shipment of Lenacapavir, a long-acting injectable that prevents HIV with two shots a year, arrived in South Africa from the United States in early April 2026. Clinical trials showed close to 100% efficacy. The rollout, expected to begin in June 2026, prioritises adolescent girls and young women, pregnant and breastfeeding women, transgender people, sex workers, men who have sex with men, and people who inject drugs.
These are the right populations to start with. But one group repeatedly slips through the cracks: adult, employed men in mobile, male-dominated industries, who move between work sites and home, between long-term partners and casual or paid encounters. In epidemiology, they are a “bridging population”: people whose sexual networks connect higher-prevalence groups to lower-prevalence groups.
In 2017, UNAIDS named the problem in its Blind Spot report, showing that men across sub-Saharan Africa are less likely than women to test for HIV, less likely to be on treatment, and more likely to die of Aids-related illness. A 2022 meta-analysis of 168 studies confirmed that across sub-Saharan Africa, men remain missing along the HIV care continuum, and South Africa, with the world’s largest HIV burden, is a particular concern. South African men are less likely than women to know their HIV status, link to treatment less often, and are 27% more likely to die from HIV.
For decades, South Africa’s HIV campaigns have focused on awareness. That work has largely succeeded: in our work on HIV-related risk behaviour and condom use among male construction workers, spanning 2008 to date, nearly all participants understood how HIV is transmitted and what condoms do. The problem is that this knowledge does not translate into consistent behaviour. We are researchers working in the field of HIV/Aids in the South African construction industry since 2008, with a particular focus on the psycho-social aspects of the disease. We focus primarily on site-based construction workers.
Like the military, mining and trucking industries, construction work is highly mobile and male-dominated. Workers move between sites, spend long periods away from long-term partners, and live in worker hostels where shebeens and sex work flourish. These conditions are linked to multiple and overlapping partnerships, long identified as a key driver of transmission.
In our 2023 study, we showed how condom use varies by partner type: participants were far more likely to use condoms with sex workers and casual partners than with long-term partners. A follow-up study of participants reporting concurrent relationships confirmed that what predicted consistent use was not awareness, but how much men felt they could insist on and use a condom, and how much at risk they felt.
Attitudes to condoms matter
In our most recent study of male construction workers who self-reported that they were clients of sex workers, the same pattern held: how much men felt they could insist on and use a condom (perceived control), and their attitudes towards condoms, mattered far more than awareness. Men in this group were also relatively more likely to use condoms with sex workers, and less so with long-term partners. It looks like sensible risk management, and at the individual level it is. But HIV prevalence among female sex workers in South Africa is around 62%.
It only takes one unprotected encounter to acquire the virus, and once a man does acquire it, his steady partner becomes his highest-probability transmission target: not because she is high risk in the abstract, but because the sex is unprotected.
The evidence on this is consistent.
A KwaZulu-Natal study found HIV prevalence of 21% among rural partners of migrant men and 26% among the men themselves, with modelling suggesting that migration accounts for a tenfold increase in HIV among migrants’ female partners. Similarly, female partners of migrant miners in the southern African region have been found to be 8% more likely to be HIV positive than partners of non-migrants, and miners themselves are 15% more likely to be HIV positive.
Because condoms are associated with risky sex, introducing one into a marriage may import a meaning of infidelity. Research with married couples in rural South Africa has documented the pattern directly. Married women who suggested condom use described being beaten after raising it. Others said persistence risked the husband seeking sex outside the marriage. The rational choice for a woman in a long-term relationship who suspects her husband is at risk is often to say nothing, even when saying nothing may be the choice that infects her.
Age-disparate relationships
Relationships where young women have partners five or more years older have become more common over the past two decades. A report by the Human Sciences Research Council shows such partnerships among adolescents rose from around 39% in 2005 to nearly 48% in 2017.
A recent national study found that young women in relationships with men who were five or more years older faced higher rates of HIV, sexually transmitted infections, intimate partner violence and pregnancy than peers not in such partnerships. The age gap and financial dependence which often accompanies such partnerships leave little room to negotiate condom use. As one participant put it: “When he says no condom, I can’t say no to him.”
Why this matters for the Lenacapavir rollout
Who is reached matters as much as how many. Clinics, schools and maternal health programmes do not easily accommodate men who spend up to ten hours a day on site, change sites every few months, and distrust formal health settings.
The priority groups for the Lenacapavir rollout are the right ones. These are the populations at highest risk of acquiring HIV.
But the rollout still has a gap. Protecting people who are likely to acquire HIV is one half of prevention; reaching the people who transmit it is the other. A 36 year old woman in a rural area, who is not pregnant, not breast feeding and not a sex worker, is not a priority, but she is at risk every time her migrant husband comes home. The husband himself, older, employed, heterosexual, and likely having casual or paid sexual encounters during his time away, fits no category the rollout names, even though he is the one who acquires and transmits HIV.
Estimates indicate that sex between clients of female sex workers and their long-term partners accounted for 42% of new infections in South Africa between 2010 and 2019. Female sex workers are in the priority list, their clients are not. A strategy that does not address who transmits HIV will always have a gap.
Two practical shifts would help.
First, prevention services, PrEP, post-exposure prophylaxis, testing and, where appropriate, Lenacapavir, must reach men where they already are: construction sites, transport hubs, taxi ranks, and mining hostels. The Test@Work model, piloted in the UK and adaptable in South Africa, shows opt-in workplace testing in general health checks achieves high uptake among men who rarely visit clinics.
Second, men who are clients of sex workers, and older men in age-disparate relationships with young women, should be named explicitly in the national prevention framework. They are a bridging population into otherwise low risk groups, including adolescent and young women.
Kamal Yakubu is a co-author on this article.
– HIV in South Africa: why rolling out a groundbreaking new shot will miss a critical group of men
– https://theconversation.com/hiv-in-south-africa-why-rolling-out-a-groundbreaking-new-shot-will-miss-a-critical-group-of-men-282618
