RESUMO
Although significant progress has been made in achieving goals for COVID-19 vaccine access, the quest for equity and justice remains an unfinished agenda. Vaccine nationalism has prompted calls for new approaches to achieve equitable access and justice not only for vaccines but also for vaccination. This includes ensuring country and community participation in global discussions and that local needs to strengthen health systems, address issues related to social determinants of health, build trust and leverage acceptance to vaccines, are addressed. Regional vaccine technology and manufacturing hubs are promising approaches to address access challenges and must be integrated with efforts to ensure demand. The current situation underlines the need for access, demand and system strengthening to be addressed along with local priorities for justice to be achieved. Innovations to improve accountability and leverage existing platforms are also needed. Sustained political will and investment is required to ensure ongoing production of non-pandemic vaccines and sustained demand, particularly when perceived threat of disease appears to be waning. Several recommendations are made to govern towards justice including codesigning the path forward with low-income and middle-income countries; establishing stronger accountability measures; establishing dedicated groups to engage with countries and manufacturing hubs to ensure that the affordable supply and predictable demand are in balance; addressing country needs for health system strengthening through leveraging existing health and development platforms and delivering on product presentations informed by country needs. Even if difficult, we must converge on a definition of justice well in advance of the next pandemic.
Assuntos
COVID-19 , Vacinas , Humanos , Vacinas contra COVID-19 , COVID-19/prevenção & controle , Vacinação , Justiça SocialRESUMO
Salim Abdool Karim, Segenet Kelemu and Cheryl Baxter discuss COVID-19 impacts and adaptations in Africa.
Assuntos
COVID-19/epidemiologia , Desenvolvimento Sustentável , África/epidemiologia , Segurança Alimentar , Abastecimento de Alimentos , Recursos em Saúde , HumanosRESUMO
BACKGROUND: The number of people on antiretroviral therapy (ART) requiring treatment monitoring in low-resource settings is rapidly increasing. Point-of-care (POC) testing for ART monitoring might alleviate burden on centralised laboratories and improve clinical outcomes, but its cost-effectiveness is unknown. METHODS: We used cost and effectiveness data from the STREAM trial in South Africa (February, 2017-October, 2018), which evaluated POC testing for viral load, CD4 count, and creatinine, with task shifting from professional to lower-cadre registered nurses compared with laboratory-based testing without task shifting (standard of care). We parameterised an agent-based network model, EMOD-HIV, to project the impact of implementing this intervention in South Africa over 20 years, simulating approximately 175â000 individuals per run. We assumed POC monitoring increased viral suppression by 9 percentage points, enrolment into community-based ART delivery by 25 percentage points, and switching to second-line ART by 1 percentage point compared with standard of care, as reported in the STREAM trial. We evaluated POC implementation in varying clinic sizes (10-50 patient initiating ART per month). We calculated incremental cost-effectiveness ratios (ICERs) and report the mean and 90% model variability of 250 runs, using a cost-effectiveness threshold of US$500 per disability-adjusted life-year (DALY) averted for our main analysis. FINDINGS: POC testing at 70% coverage of patients on ART was projected to reduce HIV infections by 4·5% (90% model variability 1·6 to 7·6) and HIV-related deaths by 3·9% (2·0 to 6·0). In clinics with 30 ART initiations per month, the intervention had an ICER of $197 (90% model variability -27 to 863) per DALY averted; results remained cost-effective when varying background viral suppression, ART dropout, intervention effectiveness, and reduction in HIV transmissibility. At higher clinic volumes (≥40 ART initiations per month), POC testing was cost-saving and at lower clinic volumes (20 ART initiations per month) the ICER was $734 (93 to 2569). A scenario that assumed POC testing did not increase enrolment into community ART delivery produced ICERs that exceeded the cost-effectiveness threshold for all clinic volumes. INTERPRETATION: POC testing is a promising strategy to cost-effectively improve patient outcomes in moderately sized clinics in South Africa. Results are most sensitive to changes in intervention impact on enrolment into community-based ART delivery. FUNDING: National Institutes of Health.
Assuntos
Monitoramento de Medicamentos/economia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Testes Imediatos/economia , Fármacos Anti-HIV/economia , Fármacos Anti-HIV/uso terapêutico , Contagem de Linfócito CD4 , Análise Custo-Benefício , Creatinina/sangue , Monitoramento de Medicamentos/enfermagem , Monitoramento de Medicamentos/normas , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Humanos , Modelos Teóricos , África do Sul/epidemiologia , Resposta Viral Sustentada , Carga Viral/efeitos dos fármacosRESUMO
A new first-line antiretroviral therapy (ART) regimen containing dolutegravir is being rolled out in low-income and middle-income countries (LMICs). In studies from predominantly high-income settings, dolutegravir-based regimens had superior efficacy, tolerability, and durability compared with existing first-line regimens. However, several questions remain about the roll out of dolutegravir in LMICs, where most people with HIV are women of reproductive age, tuberculosis prevalence can be high, and access to viral load and HIV drug resistance testing is limited. Findings from cohort studies suggest that dolutegravir is safe when initiated in pregnancy, but more data are needed to determine the risk of adverse birth outcomes when dolutegravir-based regimens are initiated before conception. Increasing access to viral load testing to monitor the effectiveness of dolutegravir remains crucial, but the best strategy to manage patients with viraemia is unclear. Furthermore, evidence to support the effectiveness of dolutegravir when given with tuberculosis treatment is scarce, particularly in programmatic settings in LMICs. Lastly, whether nucleoside reverse transcriptase inhibitor resistance will affect the long-term efficacy of dolutegravir-based regimens in first-line, and potentially second-line, ART is unknown. Clinical trials, cohorts, and surveillance of HIV drug resistance will be necessary to answer these questions and to maximise the benefits of this new regimen.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , HIV-1/efeitos dos fármacos , Compostos Heterocíclicos com 3 Anéis/uso terapêutico , Adulto , Farmacorresistência Viral , Infecções por HIV/epidemiologia , Inibidores de Integrase de HIV/uso terapêutico , Compostos Heterocíclicos com 3 Anéis/economia , Humanos , Oxazinas , Piperazinas , Pobreza , Prevalência , Piridonas , Pesquisa , Inibidores da Transcriptase Reversa/uso terapêutico , Tuberculose/epidemiologia , Carga Viral/efeitos dos fármacos , Viremia/tratamento farmacológicoAssuntos
Síndrome da Imunodeficiência Adquirida/prevenção & controle , Saúde Global , Síndrome da Imunodeficiência Adquirida/economia , Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/transmissão , Pesquisa Biomédica/métodos , Epidemias , Medicina Baseada em Evidências/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Participação do PacienteRESUMO
Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the world's largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.
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Serviços de Saúde/tendências , Criança , Proteção da Criança/tendências , Doença Crônica/prevenção & controle , Difusão de Inovações , Feminino , Organização do Financiamento , Infecções por HIV/prevenção & controle , Política de Saúde , Pesquisa sobre Serviços de Saúde , Inquéritos Epidemiológicos , Disparidades em Assistência à Saúde/tendências , Programas Gente Saudável/tendências , Humanos , Serviços de Saúde Materna/tendências , Transtornos Mentais/prevenção & controle , Gravidez , Setor Privado , Setor Público , África do Sul , Tuberculose/prevenção & controle , Cobertura Universal do Seguro de Saúde/tendências , Violência/prevenção & controle , Ferimentos e Lesões/prevenção & controleRESUMO
Human immunodeficiency virus (HIV) prevention tools that women can use and control are urgently needed. Microbicides are chemical products applied to the vagina or rectum to prevent the sexual transmission of HIV. Four classes of candidate microbicides have been tested to date: those that (1) enhance the natural defences in the vagina to inactivate HIV; (2) inactivate HIV in the vagina; (3) prevent HIV from attaching to, and fusing with, the host cells; and (4) prevent HIV from replicating in genital tract host cells. Despite numerous disappointing efficacy trial results over the past 20 years, substantial progress is now being made in microbicide development after the release of the CAPRISA 004 trial, which provided proof-of-concept that topical antiretroviral microbicides can prevent sexual transmission of HIV and herpes simplex type-2 infection. Microbicides, which fill an important gap for women-controlled prevention methods, have the potential to alter the course of the HIV pandemic.
Assuntos
Anti-Infecciosos/uso terapêutico , Infecções por HIV/prevenção & controle , HIV , Adenina/análogos & derivados , Adenina/uso terapêutico , Fármacos Anti-HIV/uso terapêutico , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/classificação , Ensaios Clínicos como Assunto/economia , Ensaios Clínicos como Assunto/ética , Feminino , Humanos , Organofosfonatos/uso terapêutico , TenofovirRESUMO
BACKGROUND: Tenofovir gel, an antiretroviral-based vaginal microbicide, reduced HIV acquisition by 39% in women in a recent randomized controlled clinical trial in South Africa. METHODS: To inform policy, we used a dynamical model of HIV transmission, calibrated to the epidemic in South Africa, to determine the population-level impact of this microbicide on HIV incidence, prevalence, and deaths and to evaluate its cost-effectiveness. RESULTS: If women use tenofovir gel in 80% or more of sexual encounters (high coverage), it could avert 2.33 (0.12 to 4.63) million new infections and save 1.30 (0.07 to 2.42) million lives and if used in 25% of sexual encounters (low coverage), it could avert 0.50 (0.04 to 0.77) million new infections and save 0.29 (0.02 to 0.44) million deaths, over the next 20 years. At US $0.50 per application, the cost per infection averted at low coverage is US $2392 (US $562 to US $4222) and the cost per disability-adjusted life year saved is US $104 (US $27 to US $181); at high coverage the costs are about 30% less. CONCLUSIONS: Over 20 years, the use of tenofovir gel in South Africa could avert up to 2 million new infections and 1 million AIDS deaths. Even with low rates of gel use, it is highly cost-effective and compares favorably with other control methods. This female-controlled prevention method could have a significant impact on the epidemic of HIV in South Africa. Programs should aim to achieve gel use in more than 25% of sexual encounters to significantly alter the course of the epidemic.
Assuntos
Adenina/análogos & derivados , Fármacos Anti-HIV/administração & dosagem , Infecções por HIV/prevenção & controle , Organofosfonatos/administração & dosagem , Adenina/administração & dosagem , Adenina/uso terapêutico , Fármacos Anti-HIV/uso terapêutico , Análise Custo-Benefício , Feminino , Infecções por HIV/economia , Infecções por HIV/mortalidade , Infecções por HIV/transmissão , Humanos , Incidência , Modelos Biológicos , Organofosfonatos/uso terapêutico , Prevalência , África do Sul/epidemiologia , Tenofovir , Cremes, Espumas e Géis VaginaisRESUMO
One of the greatest challenges facing post-apartheid South Africa is the control of the concomitant HIV and tuberculosis epidemics. HIV continues to spread relentlessly, and tuberculosis has been declared a national emergency. In 2007, South Africa, with 0.7% of the world's population, had 17% of the global burden of HIV infection, and one of the world's worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Until recently, the South African Government's response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes. Nonetheless, there have been notable achievements in disease management, including substantial improvements in access to condoms, expansion of tuberculosis control efforts, and scale-up of free antiretroviral therapy (ART). Care for acutely ill AIDS patients and long-term provision of ART are two issues that dominate medical practice and the health-care system. Decisive action is needed to implement evidence-based priorities for the control of the HIV and tuberculosis epidemics. By use of the framework of the Strategic Plans for South Africa for tuberculosis and HIV/AIDS, we provide prioritised four-step approaches for tuberculosis control, HIV prevention, and HIV treatment. Strong leadership, political will, social mobilisation, adequate human and financial resources, and sustainable development of health-care services are needed for successful implementation of these approaches.
Assuntos
Infecções por HIV , Planejamento em Saúde/organização & administração , Prioridades em Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/organização & administração , Saúde Pública , Tuberculose , Terapia Antirretroviral de Alta Atividade/métodos , Controle de Doenças Transmissíveis/métodos , Comorbidade , Resistência a Medicamentos , Prática Clínica Baseada em Evidências , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Disparidades nos Níveis de Saúde , Humanos , Liderança , Política , Vigilância da População , Saúde Pública/métodos , Fatores Socioeconômicos , África do Sul/epidemiologia , Tuberculose/complicações , Tuberculose/epidemiologia , Tuberculose/prevenção & controleRESUMO
The use of antiretrovirals for preexposure prophylaxis is being widely investigated. What if it's found to be safe and effective?
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Fármacos Anti-HIV/administração & dosagem , Infecções por HIV/prevenção & controle , Fármacos Anti-HIV/economia , Farmacorresistência Viral , Feminino , Humanos , Masculino , Cooperação do Paciente , Assunção de RiscosRESUMO
OBJECTIVE: To assess the potential impact over 10 years of a partially effective HIV vaccine in a cohort of 15-year-old adolescent girls in South Africa in terms of HIV infections and deaths prevented in mothers and infants. METHODS: A computer simulation was constructed using a population of all 15-year-old adolescent girls in South Africa followed for 10 years. A partially effective vaccine is introduced into this population with the ability to reduce the HIV incidence rates of the adolescents and vertical transmission to their infants through birth and breast-feeding. At the end of this 10 year period, the number of HIV infections and death prevented in adolescents and infants is analyzed. RESULTS: Using a 5% HIV incidence rate, a 50% effective vaccine decreases the number of HIV cases among adolescents by 57,653 (28.7%) and the number of cases among infants by 13,765 (28.9%) over 10 years. In addition, assuming a vaccine cost of $20 per dose, the vaccination program can save approximately $120 million for the South African government over 10 years. CONCLUSION: A partially effective HIV vaccine has an important role in HIV prevention in adolescents and infants in South Africa irrespective of other public policy implementations.