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COVID-19 challenges raise concerns over future funding for HIV

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Why the second dose of COVID-19 vaccine shouldn’t be skipped as jab hesitancy lower in poorer countries compared to developed nations

A new report from KFF (Kaiser Family Foundation) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) finds that donor government disbursements to combat HIV in low-and middle-income countries increased by $377 million in 2020, reaching $8.2 billion in 2020 compared to US$7.8 billion in 2019. Donor government funding supports HIV care and treatment, prevention, and other services in low- and middle-income countries.

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The rise in funding is almost entirely the result of an increase in United States contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which was due largely to the disbursement of prior-year funding. U.S. disbursements to the Global Fund are not expected to remain at this level in 2021.

The United States continues to be the largest donor to HIV, accounting for 76 per cent of all donor government funding, followed by the United Kingdom ($612 million, seven per cent), Japan ($258 million, three per cent), Germany ($246 million, three per cent), and France ($216 million, three per cent). As other donor governments continue to pull back bilateral funding, the United States accounts for an increasing share of overall funding for HIV from donor governments.

The report reflects prior-year political and funding decisions and does not fully capture the impact of COVID-19 on donor funding decisions.

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KFF Senior Vice President, Jen Kates, said: “ many donor governments are beginning to bounce back from the pandemic, its global impact and related recession make future funding for HIV response unpredictable.

“Not only are some low- and middle-income countries experiencing a ‘third-wave of COVID-19, vaccines remain largely out of reach, potentially leading to greater funding needs for HIV and other health services.”

Executive Director of UNAIDS, Winnie Byanyima, said: “We are at a critical stage in the AIDS response as countries are confronting the huge challenges posed by the COVID-19 pandemic.

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“But we do still have an opportunity to end the epidemic by 2030 if donors and countries alike commit to mobilize resources and prioritize health, human rights, and equality which are the key components, not only to lead us out of the pandemics of HIV and COVID-19, but they are the cornerstone to economic recovery and security.”

These data are included in a broader UNAIDS global report, which examines all sources of funding for HIV relief, including local governments, non-governmental organizations, and the private sector, and compares it to the resources needed to achieve goals related to testing and treatment.

The new report, produced as a long-standing partnership between KFF and UNAIDS for more than 15 years, provides the latest data available on donor government funding based on data provided by governments. It includes their bilateral assistance to low- and middle-income countries and contributions to the Global Fund, UNAIDS, and UNITAID. “Donor government funding” refers to disbursements, or payments, made by donors.

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Meanwhile, a study has shown why second dose of the COVID-19 vaccine should not be skipped. According to a study led by investigators at the Stanford University School of Medicine, the second dose of a COVID-19 vaccine induces a powerful boost to a part of the immune system that provides broad antiviral protection.

The finding strongly supports the view that the second shot should not be skipped.

“Despite their outstanding efficacy, little is known about how exactly RNA vaccines work,” said Bali Pulendran, PhD, professor of pathology and of microbiology and immunology. “So we probed the immune response induced by one of them in exquisite detail.”

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The study, published July 12 in Nature, was designed to find out exactly what effects the vaccine, marketed by Pfizer Inc., has on the numerous components of the immune response.

The researchers analysed blood samples from individuals inoculated with the vaccine. They counted antibodies, measured levels of immune-signaling proteins and characterized the expression of every single gene in the genome of 242,479 separate immune cells’ type and status.

“The world’s attention has recently been fixed on COVID-19 vaccines, particularly on the new RNA vaccines,” said Pulendran, the Violetta L. Horton Professor II.

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The Pfizer vaccine, like the one made by Moderna Inc., works quite differently from the classic vaccines composed of live or dead pathogens, individual proteins or carbohydrates that train the immune system to zero in on a particular microbe and wipe it out. The Pfizer and Moderna vaccines instead contain genetic recipes for manufacturing the spike protein that SARS-CoV-2, the virus that causes COVID-19, uses to latch on to cells it infects.

In December 2020, Stanford Medicine began inoculating people with the Pfizer vaccine. This spurred Pulendran’s desire to assemble a complete report card on the immune response to it.

The team selected 56 healthy volunteers and drew blood samples from them at multiple time points preceding and following the first and second shots. The researchers found that the first shot increases SARS-CoV-2-specific antibody levels, as expected, but not nearly as much as the second shot does. The second shot also does things the first shot doesn’t do, or barely does.

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Unexpectedly, Pulendran said, the vaccine — particularly the second dose — caused the massive mobilization of a newly discovered group of first-responder cells that are normally scarce and quiescent.

First identified in a recent vaccine study led by Pulendran, these cells — a small subset of generally abundant cells called monocytes that express high levels of antiviral genes — barely budge in response to actual COVID-19 infection. But Pfizer vaccine-induced them.

This special group of monocytes, which are part of the innate museum, constituted only 0.01 per cent of all circulating blood cells prior to vaccination. But after the second Pfizer vaccine shot, their numbers expanded 100-fold to account for a full one per cent of all blood cells. In addition, their disposition became less inflammatory but more intensely antiviral. They seem uniquely capable of providing broad protection against diverse viral infections, Pulendran said.

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“The extraordinary increase in the frequency of these cells, just a day following booster immunization, is surprising,” Pulendran said. “It’s possible that these cells may be able to mount a holding action against not only SARS-CoV-2 but against other viruses as well.”

Meanwhile, new research published in Nature Medicine revealed a willingness to get a COVID-19 vaccine was considerably higher in developing countries (80 per cent of respondents) than in the United States (65 per cent) and Russia (30 per cent).

The study provides one of the first insights into vaccine acceptance and hesitancy in a broad selection of low- and-middle income countries (LMIC), covering over 20,000 survey respondents and bringing together researchers from over 30 institutions including the International Growth Centre (IGC), Innovations for Poverty Action (IPA), WZB Berlin Social Science Center, the Yale Institute for Global Health, the Yale Research Initiative on Innovation and Scale (Y-RISE), and HSE University (Moscow, Russia).

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Personal protection against COVID-19 was the main reason given for vaccine acceptance among LMIC respondents (91 per cent), and concern about side effects (44 per cent) was the most common reason for vaccine hesitancy. Health workers were considered the most trusted sources of information about COVID-19 vaccines.

The study comes at a critical juncture when vaccine shipments are still slow to arrive at the majority of the world’s population, and COVID-19 cases are surging in many parts of Africa, Asia, and Latin America. The findings suggest that prioritizing vaccine distribution to low- and middle-income countries should yield high returns in expanding global immunization coverage.

The researchers, who conducted the surveys between June 2020 and January 2021, point out that vaccine acceptance may vary with time and with the information that people have available to them. While the evidence on the safety and efficacy of available COVID-19 vaccines has become more clear in the last six months, severe, but rare, side effects may have undermined public confidence.

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Also, WHO has welcomed new findings presented, last week, at the International Pediatric HIV Workshop on the superiority of dolutegravir (DTG)-based regimens in young children.

Children living with HIV continue to be left behind by the global AIDS response. In 2020, only 54 per cent of the 1.7 million children living with HIV received antiretroviral therapy compared to 74 per cent among adults living with HIV. Among the focus countries, only 40 per cent of children living with HIV (or 74 per cent of children receiving antiretroviral therapy) achieved viral suppression in 2020.

The ODYSSEY trial, a multi-country randomised trial sponsored by Penta, has previously demonstrated superior treatment efficacy for DTG plus two nucleoside analogs versus standard-of-care (SOC) in 707 children ≥14kg (median age 12 years) starting first- or second-line ART. An additional cohort of 85 children <14kg, enrolled from Uganda, Zimbabwe, and South Africa, completed 96 weeks follow-up on 28 June 2021. [ad] Among these children, with median age of 1.4 years, an estimated 28 per cent had treatment failure by 96 weeks in the DTG arm vs 48 per cent in the SOC arm. DTG-based ART was superior to SOC (predominantly protease inhibitor-based ART) in young children starting first or second-line therapy, judged on treatment failure by 96 weeks. The treatment benefit for DTG in the <14kg cohort was consistent with that observed in children enrolled ≥14kg. There were no safety concerns on DTG. At 96 weeks, 76 per cent of children in the DTG arm had VL<50copies/mL compared with 50 per cent in SOC; corresponding proportions with VL<400copies/mL were 91 per cent vs. 71 per cent. WHO has recommended DTG-based HIV treatment for all infants and children since 2018 and provided dosing recommendations for infants and children over four weeks of age and more than 3kg in July 2020. Upcoming WHO 2021 consolidated guidelines on HIV and the newly released policy brief on transitioning to the 2021 optimal formulary for antiretroviral drugs for children provide further guidance on how to transition DTG-containing regimens as well as how to best dose it when treatment for tuberculosis is required. Two generic formulations of DTG 10 mg dispersible tablets have been approved by the United States Federal Drug Administration (US FDA). This approval was swiftly followed by the announcement on World AIDS Day of a ground-breaking agreement negotiated by Unitaid and the Clinton Health Access Initiative that reduces the cost of HIV treatment by 75 per cent for children in low- and middle-income countries where the DTG 10 mg dispersible tablet will be available at a cost of $4.50 for a 90-count bottle. [ad] These new findings from the ODYSSEY trial confirm that DTG-based regimens can significantly improve virological suppression in young children and country programmes are encouraged to plan a rapid introduction of DTG-containing HIV treatment as the preferred first-line regimen for all infants and children who are as young as four weeks of age and weighing more than 3kg. WHO and partners are committed to supporting national governments as they develop rapid transition plans to DTG-based treatments, change policies and guidelines, quantify their needs, budget for and procure the appropriate stocks of medicines, organize distribution, train health care workers and sensitize and engage affected communities to ensure demand, treatment literacy for caregivers and children and smooth uptake of these new formulations. [ad]


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