South Africa received its first shipment of lenacapavir—a long-acting injectable that prevents HIV with close to 100% efficacy and requires just two shots per year—in early April 2026, with rollout expected to begin in June. It's a breakthrough moment for one of the world's most burdened HIV epidemics. Yet as rollout plans prioritize adolescent girls, young women, sex workers, and other key populations, researchers warn that the strategy risks overlooking a critical group: mobile, employed men in construction, mining, and similar industries whose sexual networks unwittingly connect high-prevalence populations to lower-prevalence ones.
These men are what epidemiologists call a "bridging population"—and they have been slipping through the cracks of HIV prevention for decades. A 2017 UNAIDS report highlighted the pattern across sub-Saharan Africa: men are less likely than women to test for HIV, less likely to be on treatment, and more likely to die from AIDS-related illness. In South Africa specifically, research from 168 studies shows the gap is stark. 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.
The problem isn't ignorance. Researchers working with male construction workers since 2008 found that nearly all participants understood how HIV is transmitted and what condoms do. The disconnect lies elsewhere. In a 2023 study, the same team showed that knowledge didn't predict behavior—instead, consistent condom use depended on whether men felt they could actually insist on using one, and their attitudes toward condoms themselves. Men in mobile industries spend long periods away from home, live in worker hostels, and move between long-term partners and casual or paid encounters. They tend to use condoms with sex workers and casual partners but not with their steady partners—a pattern that looks like sensible risk management at the individual level but masks a dangerous transmission pathway.
The numbers reveal why. HIV prevalence among female sex workers in South Africa is around 62%. It takes only one unprotected encounter to acquire the virus. Once a man does, his steady partner becomes his highest-probability transmission target—not because she is inherently high-risk, but because sex with her goes unprotected. A KwaZulu-Natal study found HIV prevalence of 21% among rural partners of migrant men and 26% among the men themselves, with modeling suggesting migration accounts for a tenfold increase in HIV among migrants' female partners. Similarly, female partners of migrant miners across the southern African region are 8% more likely to be HIV positive than partners of non-migrants, while miners themselves are 15% more likely to be HIV positive.
Lenacapavir's arrival offers a chance to break this pattern—but only if the rollout strategy evolves to reach men whose mobility, industry, and social context have kept them invisible in HIV prevention efforts. The vaccine's near-perfect efficacy means nothing if the populations most likely to transmit the virus to their partners never access it.