Forty years ago, the world recorded the first known cases of Aids. Today, that pandemic holds essential lessons for the latest disease outbreak — and in particular, the quest for an equitable — and effective — global Covid-19 vaccine roll-out.
Four decades ago, five men presented with a then-mysterious set of illnesses at three hospitals in Los Angeles. They would become the first documented cases of Aids.
It would be another 15 “searing” years before treatment was available in 1996, writes Johns Hopkins University Epidemiology Professor and former International Aids Society president, Chris Beyrer, in a recent edition of The Lancet.
In 2001 alone, UNAids estimated that as many as 18 000 people died of Aids-related illnesses in the United States (US). Still, the advent of antiretrovirals had more than halved annual Aids deaths in the US in just seven years.
But in Zimbabwe — where treatment was not available — the estimated death toll from Aids in 2001 was as much as 190 000.
History is, in many ways, repeating.
Today, the number of people who have received a Covid-19 vaccine in the United States as of 6 July is almost five times the amount of people inoculated in the entirety of Africa.
Lesson 1: The role of funding in an equitable pandemic response
Infectious diseases are global — that was one of HIV’s most important lessons. What happens in one country affects us all. In the HIV pandemic, delays in the global roll-out of HIV treatment led to deaths the world could have prevented. It also made it more difficult — and costly — to prevent new cases. The same could now be said about the stark inequality in global Covid-19 vaccine distribution: lives that could have been saved will be lost.
But the importance of equity in a pandemic response is not the only teaching HIV holds for the fight against Covid-19, as my co-authors and I recently highlighted in a New England Medical Journal article.
The HIV pandemic has shown us that international donor funding can play a vital role in catalysing a global response and increasing access to treatment. But access to medicine was not enough to curb national HIV epidemics. Antiretroviral therapy, we found, only worked when coupled with health systems fit for purpose that could support people to be diagnosed, and to start treatment and stay on it. Similarly, today equitable access to vaccines must be an urgent start, but it alone is not enough.
International funding must support the healthcare systems that ensure treatment and vaccines reach those who need them most.
Lesson 2: Going beyond access to support local delivery systems
The creation of international funding bodies to fund the HIV response — notably the Global Fund to Fight Aids, TB and Malaria and the US President’s Emergency Plan for AIDS Relief (Pepfar) in the early 2000s — acted as a catalyst for increased funding to fight the disease, particularly in Africa.
Today, institutions like these have been a model for the World Health Organisation’s Covid-19 Vaccines Global Access (COVAX) initiative, which is trying to ensure equitable access to Covid-19 immunisations globally.
The world must urgently ensure equitable access to Covid-19 vaccine doses. We must also make certain that national health systems, particularly in resource-poor countries, are supported to deliver them. However, just 14% of development aid globally in 2019 went to this kind of health systems strengthening, according to a 2020 report by the research centre, Institute for Health Metrics and Evaluation.
Lesson 3: Countering secrecy and fear, a fight against misinformation
But HIV also revealed that disease thrives in secrecy that is fuelled by fear, misinformation and stigma. Working with local communities is the most critical factor in combatting this and messages that work in one place may not succeed in another.
Evidence-based communication is needed to ensure that myths and misconceptions about Covid-19 vaccines do not fuel vaccine hesitancy and delay national roll-outs. Debunking these untruths must be done through channels that leverage existing and trusted community structures, such as local leaders.
New data from South Africa, for instance, shows encouragingly that 76% of people surveyed nationally said they would consider getting a Covid-19 vaccine if it was available. Among those who still did not fully accept vaccines, half said they would be convinced to use a vaccine if local community leaders did so first.
In our work, we’ve found the influence of community leaders equally valuable — and a powerful public health tool. In Nigeria, for instance, Egpaf partnered with churches and religious leaders to help pregnant women and their partners to get tested for HIV, and if they tested positive, could access treatment to prevent their babies from contracting HIV before, during or after birth.
And in Uganda, we drew on the knowledge of our trained expert HIV patients to follow up on patients who were unable to collect medication during the country’s Covid-19 lockdown. Expert patients are people with HIV who have been trained to counsel, educate, and provide peer psychosocial support to other HIV-positive people and link them to care. One solution such patients came up with was for counsellors to group antiretroviral drug refill dates so that clients could pick up their medication for several months at one time. For clients who couldn’t access clinics, health workers arrange to have their drugs delivered in the community.
Lesson 4: Know your epidemic and address data gaps
Although women and children were not initially included in Covid-19 clinical trials, this pandemic has learned from HIV — and years of advocacy on this — to correct the situation quickly.
For some Covid vaccines, such as those from Pfizer and Moderna, early data is now, for instance, available to show the jabs are safe for use in pregnant women. Pfizer and Moderna have also been clinically tested, or are in the process of being tested, on adolescents and younger children in the US.
This move is underpinned by an important recognition: As a society, we protect women and their children by including them in research to develop medicines and vaccines that work for them — not by excluding them from studies.
Fundamentally, HIV has taught us that we must know our epidemics — and who they affect and how — in order to fight them effectively.
But gaps remain.
Strong data, for instance, on how widely and severely Covid-19 affects children and adolescents — particularly in Africa — is lacking, as colleagues showed in February research published in the journal of Clinical Infectious Diseases. Generally, data on outcomes of childhood Covid-19 and Covid-19 in pregnancy have not been regularly reported by countries — many of which have struggled with standardising data and reporting.
Today, there are promising signals that the international community has begun to appreciate not just the moral imperative of rolling out life-saving vaccines in places like Africa but also the real risk that inaction will prolong the impact of the pandemic everywhere.
Still, it bears remembering that it took transforming the fight to end Aids into a global cause with significant amounts of political support and resources to get meaningful and sustainable progress to take hold.
Dr Lynne Mofenson is the senior HIV technical advisor for the Elizabeth Glaser Paediatric AIDS Foundation. Follow the foundation on Twitter @EGPAF.