Brazil Is Willing to Pay for Long-Acting HIV Prevention. It Is Choosing Whose

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POLICY & MARKETS · HIV PREVENTION · OCTOBER 6, 2026 · BRAZIL

At the price GSK, through its ViiV Healthcare unit, proposed to Conitec (Comissão Nacional de Incorporação de Tecnologias), Brazil’s health technology assessment commission, whose medicines committee has provisionally recommended the drug, cabotegravir, an HIV-prevention injection given every two months, costs about R$6,660 a year per person once the first year’s loading doses are past. That is roughly 3.2 times the US$400 a year, about R$2,083, that Brazil’s health ministry offered Gilead in July for lenacapavir, a rival given twice a year (6,660 / 2,083, at the Central Bank’s PTAX rate of R$5.2079 on 1 October 2026). Gilead turned the offer down, according to Brazilian press reports; the company has not commented on the proposal.

The stand-off is usually told as the story of a middle-income country that cannot afford a new drug. The numbers say otherwise. Brazil is willing to pay for long-acting pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV-negative people to prevent infection. What it is deciding is whom to pay, and on what terms. One figure is a seller’s proposed price that the buyer’s assessors provisionally endorsed while calling its budget impact unsustainable; the other is a buyer’s bid the seller rejected. What Gilead asked has not been disclosed.

Brazil has already priced the alternative

Conitec’s preliminary report (dated June 2026; public consultation 76 opened in August) records GSK’s proposed price of R$1,110 per dose, after a 79.6% discount on the maximum government price. The first year takes seven injections, about R$7,770; later years take six. Daily oral PrEP costs the system about R$1,026 a year (R$2.81 a tablet in the manufacturer’s model; the commission’s reviewers used R$3.05). The manufacturer’s model, as reported by the commission, put the cost per quality-adjusted life year (QALY) gained at R$21,313 (the commission’s technical reviewers’ adjusted estimate was R$20,735), below the R$40,000 threshold it uses, and estimated a five-year budget impact of R$961m for men who have sex with men and transgender women aged 15 to 30. The committee called that budget impact unsustainable at the proposed price and said further price negotiation could make it viable. Its medicines committee issued a preliminary favourable recommendation on 5 August 2026; the public consultation closed in late August; the final recommendation and ministry decision are still pending.

Draurio Barreira, director of the health ministry’s HIV department, put Brazil’s offer at US$400 per person per year, according to Jornal de Brasília. Earlier reports, including by the same newspaper and by AIDS Healthcare Foundation (AHF), an advocacy group, described it as US$400 “por tratamento”. Folha de S.Paulo, reporting from the AIDS 2026 conference on 27 July, described a US$400 “por dose” figure, which the minister did not confirm; at two doses a year that would mean US$800. Gilead has not confirmed the figure.

The two drugs have not been compared head to head. The World Health Organization (WHO) says lenacapavir was shown in trials to prevent almost all HIV infections among those at risk; a meta-analysis considered by Conitec found about 79% fewer infections with cabotegravir than with oral PrEP. The figures measure different things.

Prevention will not save Brazil money, and that is not the argument

The usual case for paying now is that it saves money later. Here it does not. A cost-effectiveness study of long-acting PrEP in Brazil, funded by the US National Institutes of Health (NIH), found it improved outcomes at added cost rather than saving money (Chen et al., Journal of the International AIDS Society, May 2026). Lenacapavir was good value up to about US$740 a year for men who have sex with men. Brazil’s offer sits well inside that.

The same study complicates Brazil’s position. It puts cabotegravir’s cost-effective price at US$710 a year; the proposed price Conitec’s committee provisionally recommended is about US$1,280 (6,660 / 5.2079), about 1.8 times that. The manufacturer’s model reviewed by Conitec, which measures quality-adjusted life years rather than Chen’s life years saved, reached the opposite conclusion. Either way, Brazil’s assessors have provisionally recommended a drug priced above the NIH-funded benchmark for one supplier while holding the other below it.

The reason prevention cannot pay for itself is arithmetic. A year of first-line antiretroviral therapy (ART) costs about US$434.60 per person in Chen’s model, close to Brazil’s offer for a year of prevention. But prevention is bought for many people to stop one infection. “If we need to treat hundreds of people to avoid one infection, this medicine needs to be cheap,” Mr Barreira told a hearing of the lower house’s human rights committee on 14 April. “Even oral PrEP, which is cheap, already consumes 8% of the department’s budget” (Agência Aids, 15 April 2026, translated from Portuguese).

The cost of waiting lands on future governments

Brazil notified 39,216 HIV infections in 2024, up 19% from 2020, a year depressed by pandemic-era testing, according to the health ministry’s 2025 epidemiological bulletin. Notifications measure diagnosis as much as transmission. About 827,000 people were on treatment in 2024, out of an estimated 1.1m living with HIV.

Each new infection commits Brazil’s public health system, the Sistema Único de Saúde (SUS), to treatment for life. At US$434.60 a year, 35 years of first-line treatment costs about US$15,200 per person before discounting (434.60 × 35; the 35 years is our illustrative assumption). The prevention budget is spent by this administration; the treatment bill for infections not prevented is paid by governments elected over the next three decades.

The modelled benefit is real but bounded. In Chen’s base case, adding lenacapavir at 20% coverage on top of oral PrEP cuts the 10-year infection risk for men who have sex with men from 14.0% to 10.8%, nearly a quarter fewer infections (3.2 / 14.0 = 22.9%). Every year without a long-acting option forgoes part of that.

Brazil sits in the region’s most expensive bracket

Lenacapavir has three reference points in the Americas. In the United States, Gilead’s list price for prevention was set at about US$28,218 a year at launch in 2025, 70 times Brazil’s offer (28,218 / 400). In the 120 countries covered by Gilead’s voluntary licence, which the company describes as high-incidence and primarily low- and lower-middle-income, and which include Bolivia, Honduras, Haiti and much of the Caribbean, a generic maker has committed to about US$40 a year, from as early as 2027 pending regulatory approval, according to the Gates Foundation. Brazil’s offer is ten times that (400 / 40).

Brazil, Mexico, Argentina, Colombia, Peru and Paraguay are among those left out of the licence. On 15 September the Pan American Health Organization (PAHO) announced an agreement with Gilead to supply 14 Latin American countries, Brazil included, through its Regional Revolving Funds, without publishing a price. “The estimated cost of production is up to 40 dollars a year, but the price reaches tens of thousands,” said Susana van der Ploeg of the intellectual property working group of the Brazilian Interdisciplinary AIDS Association (ABIA), at the April hearing (translated from Portuguese).

For Gilead, the stand-off puts a rival ahead in Brazil’s public market

A payer that can say no to one supplier because it is saying yes to another is not a payer that cannot afford innovation. Cabotegravir is further along the road to the public system: it has a preliminary recommendation, while we found no Conitec assessment of lenacapavir as of early October. Patients who start on cabotegravir become the base that any later lenacapavir offer has to win over.

At the April hearing, before the July offer, Arturo De La Rosa, Gilead’s vice-president for Latin America, said the company was “working with Fiocruz to evaluate manufacturing in Brazil” (translated from Portuguese), referring to the Oswaldo Cruz Foundation, the health ministry’s research foundation. When it turned down Brazil’s offer in July, Gilead said only that talks were continuing and that it had signed a memorandum of understanding with Fiocruz to study technology transfer, according to Jornal de Brasília. In the PAHO announcement, Gilead committed to advance a technology-transfer process in Brazil. Local production would change the price argument; no timeline has been given.

In Brazil, the price of long-acting HIV prevention is being set by the second supplier, not the first. Gilead is the loser so far: cabotegravir is likely to be offered in the public system before lenacapavir. Our prediction: lenacapavir will not reach the SUS through a direct Gilead-ministry deal in 2027; if it arrives, it will come through PAHO’s fund, and if that price is disclosed it will sit below the US$740 a year the NIH-funded model calls cost-effective for men who have sex with men. A direct deal in 2027 would prove this analysis wrong.

Why this is relevant

Sources: Conitec: preliminary report on cabotegravir (consultation 76) · Conass: public consultation 76 on cabotegravir · Jornal de Brasília: PAHO-Gilead agreement (15 Sep 2026) · Jornal de Brasília: Gilead rejects Brazil’s offer (31 Jul 2026) · Jornal de Brasília / Folha: AIDS 2026 report (27 Jul 2026) · AHF Brasil: Gilead rejects Brazil’s lenacapavir offer · Chen et al., Journal of the International AIDS Society (2026) · Agência Aids: congressional hearing on lenacapavir · Câmara dos Deputados: hearing report · Ministry of Health: HIV/Aids epidemiological bulletin 2025 · Ministry of Health: HIV clinical monitoring report 2025 · PAHO: new pathway to access lenacapavir · Gates Foundation: generic lenacapavir at US$40 a year · Gilead: access strategy for long-acting PrEP · BioPharma Dive: Yeztugo list price · WHO: recommendation on injectable lenacapavir · Poder360: injectable PrEP in the SUS · PTAX exchange rate, 1 Oct 2026