Scaling Up Covid-19 Vaccination in Africa — Lessons from the HIV Pandemic

 concerns regarding access to Covid-19 vaccines in Africa are like concerns raised about responding to the HIV pandemic within the mid-1990s and early 2000s when highly active antiretroviral treatment (ART) was accessible in high-income countries but had limited availability in African countries — a disparity that resulted in many preventable deaths in these high-burden settings.1 Funding for scaling up ART throughout Africa wasn't available until 2002 when the United Nations Global Fund against AIDS, Tuberculosis, and Malaria and therefore the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) began to supply it. During the Covid-19 pandemic, these programs provided a model for the planet Health Organization (WHO) and global partners to rapidly establish the COVID-19 Vaccines Global Access (COVAX) initiative to bridge the vaccine gap and ensure rapid and equitable access to vaccines in both high-income countries and low- and middle-income countries.1

The HIV pandemic taught us that ART provision alone was insufficient to realize global disease control. It highlighted the necessity to proportion health infrastructure for multiple purposes: to acquire drugs, promote ART adherence and retention in care, identify key populations in danger, overcome stigma inhibiting access to worry, and develop community support for HIV prevention and treatment. Another key need was obtaining robust data for efficacious HIV treatment in vulnerable populations, including children and pregnant women (see table).

In addition to access to Covid-19 vaccines and therapies, countries require sufficient infrastructure to receive and administer these interventions, which can be logistically challenging in rural and remote areas. Local resources for addressing these requirements, especially for vaccines, vary among urban and rural settings within the various African subregions. the present mRNA-based Covid-19 vaccines (developed by Moderna and Pfizer–BioNTech) require an endless cold chain for distribution: Moderna’s vaccine needs –20°C for shipping and storage before dilution, and Pfizer’s vaccine must be kept at –70°C, a way greater challenge in Africa. Many health care centers in African countries lack the personnel, equipment, and stable electric power for low-temperature vaccine storage. Innovative solutions for storage and transport are needed, like the high-tech, insulated, reusable container developed to stay Ebola vaccines at ultracold temperatures for up to every week. The mRNA vaccines are administered as two doses separated by 3 to 4 weeks, which presents the challenge of retaining patients long enough to finish the complete series. The Johnson and Johnson adenovirus-vector vaccine, which recently received emergency use authorization from the Food and Drug Administration, offers advantages for rollout in Africa, including single-dose administration and no need for ultracold storage. The Oxford–AstraZeneca vaccine are often stored and transported at normal refrigeration temperatures (2 to 8°C) for a minimum of 6 months.

The identification of populations at high risk for HIV and therefore the development of tailored strategies to interact with them in HIV prevention and treatment has been critical for the success of national HIV control programs. Given the limited supply of Covid-19 vaccines and therefore the surges in new cases and deaths throughout Africa, it'll be crucial to vaccinate populations at the best risk for infection and severe disease. These related challenges will vary among subregions and countries, given differences in demographic structure, the prevalence of underlying conditions, and the number of essential workers. Addressing the challenges of equitable vaccine distribution would require careful planning and global cooperation; computational models are often used for prioritization and rollout strategies.

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Furthermore, we learned that denial, stigma, and misinformation about HIV and its treatment were barriers to ART acceptance in Africa. Covid-19 vaccine acceptance is reportedly only moderate in some high-income countries, like the United States; some African countries are similarly reporting low acceptance. A 56% vaccine acceptance rate was reported among quite 4000 adults within the Democratic Republic of Congo. Disturbingly, being a health care worker was a risk factor for low acceptance during this setting.2 Public health institutions and officialdom, private companies, civil society stakeholders, and community opinion leaders must develop an evidence-based, strategic communication decides to debunk misinformation being disseminated on multiple platforms, including social media. Covid-19 vaccine messaging should leverage existing community structures and use lessons learned from past vaccine-hesitancy challenges (e.g., for polio and measles). the supply of thousands of trained doctors who are involved in implementing HIV programs provides additional resources for scaling up Covid-19 vaccination in Africa.

One persistent problem within the HIV pandemic response has been delays within the evaluation of medicine in pregnant women and youngsters. Although women, mostly of reproductive age, constitute 51% of adults living with HIV globally, pregnancy has generally been an exclusion criterion in ART trials. Safety and pharmacokinetic data for pregnant patients became available only years after initial regulatory approval, which meant long delays in improved treatment for pregnant patients with HIV.3,4 Data on Covid-19 in pregnant African women also are limited. Reports from high-resource settings indicate that SARS-CoV-2 infection in pregnant women, as compared with nonpregnant women within the same age range, is related to increased risk for admission to the medical care unit, need for invasive ventilation, or extracorporeal membrane oxygenation, and death.4 Nevertheless, pregnancy was an exclusion criterion for Covid-19 treatment trials and therefore the first vaccine trials. After approval of the Pfizer–BioNTech and Moderna Covid-19 vaccines, the WHO initially recommended that the vaccines not tend to pregnant women, despite this group’s higher risk of severe illness and death from Covid-19. This recommendation was subsequently modified to allow use in pregnant women at “high risk of exposure” to SARS-CoV-2, like doctors, who were to be vaccinated “in consultation with their healthcare provider.” A phase 2–3 clinical test of the Pfizer–BioNTech vaccine in women during the trimester of pregnancy has just begun.

Similarly, studies of ART in children living with HIV generally didn't begin until after therapies had gained initial regulatory approval for adults, with development and approval of pediatric formulations lagging 8 to 10 years behind. Since children with Covid-19 are often asymptomatic or mildly symptomatic, they're less likely to present for health care or to undergo SARS-CoV-2 testing, which ends up in underestimation of the burden of pediatric infection. Children can become infected with SARS-CoV-2, transmit the virus to others, and develop severe complications. during a large cohort of youngsters with Covid-19 in South Africa, approximately one-third required hospitalization.5 Data on Covid-19 in children from other African countries are limited. The evidence gap observed for brand spanking new interventions for pediatric HIV treatment and prevention is echoed in Covid-19 research: children are excluded from clinical trials of the latest Covid-19 therapies, despite their potential to possess the severe disease. Trials of the Pfizer–BioNTech, Moderna, and Oxford–AstraZeneca Covid-19 vaccines were initiated in older children (12 to 17 years of age) and younger children (6 months to 11 years of age) in late 2020 and early 2021, but results aren't expected until mid to late 2021.

As we've learned from the HIV pandemic, biomedical advances alone are insufficient to sustainably control an epidemic. Considerations associated with health infrastructure, local epidemiology, and responsiveness to local concerns and beliefs are critical for ending the Covid-19 pandemic — not only in Africa but also globally. Each country will have its own unique challenges in vaccine distribution, which should be addressed with careful planning, including leveraging computational models of prioritization and rollout strategies and applying methods from implementation science to maximize local impact. Addressing these differences is important if we are to regulate current and future pandemics.

Author Affiliations

From the Departments of Epidemiology and of Infectious Diseases and Microbiology and therefore the Center for Global Health, University of Pittsburgh grad school of Public Health (J.B.N.); and therefore the Division of Infectious Diseases, Department of drugs , University of Pittsburgh School of drugs (J.W.M.) — both in Pittsburgh; the Department of drugs and therefore the Center for Infectious Diseases, Stellenbosch University, Faculty of drugs and Health Sciences, Cape Town, South Africa (J.B.N.); the Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health (J.B.N.), and therefore the refore the Department of Pediatrics and the Institute of Human Virology, University of Maryland School of drugs (N.A.S.-A.) — both in Baltimore; the Pediatric/Adolescent HIV Unit and International research facility of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria (N.A.S.-A.); the Department of Pediatrics and Child Health, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana (N.A.S.-A.); the Division of Infection and Immunity, University College London, and therefore the NIHR Biomedical Research Centre, University College London Hospitals — both in London (A.Z.); the African Forum for Research and Education in Health, Kumasi, Ghana (J.B.N., N.A.S.-A., A.Z.); and therefore the Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC (L.M.M.).

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