South Africa’s Dudu Dlamini (left) explains that her HIV, diabetes and hypertension are all treated at different health facilities. The Global Fund’s Vindi Singh looks on.

As the disease burden in developing countries shifts from infectious to non-communicable diseases (NCDs), governments and patient advocates are grappling with how to re-engineer healthcare systems to address both.

The extraordinary global focus on HIV has resulted in a siloed network of HIV clinics to treat the virus – but there is growing acknowledgement that countries’ HIV gains will be lost if they don’t get NCDs under control.

“People living with HIV are disproportionately affected with NCDs. It is estimated that one in three people living with HIV have either hypertension or other NCDs,” says Professor Kaushik Ramaiya, General Secretary of the Tanzania NCD Alliance and a member of the NCD Alliance Board.

“People living with HIV (PLHIV) have an increased incidence for more than 20 non-AIDS defining cancers, while women living with HIV are up to six times more likely to develop cervical cancer,” he told an event organised by the NCD Alliance at the International AIDS Conference in Munich last week.

There are almost 40 million people with HIV, mostly in developing countries, and many are succumbing prematurely to heart disease, diabetes, strokes and other NCDs. This is often because HIV programmes are so focused on their patients’ HIV that they don’t diagnose and treat these other conditions early enough.

‘I could take ARVS well and die of high blood’

South African Dudu Dlamini lives with HIV, hypertension and diabetes. As a sex worker and the advocacy officer for Sex Workers Education and Advocacy Taskforce (SWEAT), Dlamini knows what marginalisation means.

“We are criminalised,” Dlamini told the meeting. “It is not easy for me to identify as a sex worker. Our doctors don’t know about us. For my HIV, I am treated in one place. For my high blood, another place and for my blood sugar, somewhere else.”

Having three different treatment sites costs time and transport money, and sex workers default on medication “because we are not able to keep all the appointments”, says Dlamini.

“My vision is for sex workers to be helped for all the conditions at the same time; a place where we can identify freely as sex workers and get treated –  for STIs, and all other conditions – in one place. I need one folder with all my medical history and background because I might be taking antiretrovirals well but tomorrow I die from high blood.”

Her experience echoes that of several other people living with HIV and NCDs, as captured by the NCD Alliance in a collection of testimonies that makes the case for integrated care.

Global commitment to integration made back in 2021

NCD Alliance CEO Katie Dain.

At the 2021 United Nations High-Level Meeting on HIV and AIDS, global leaders committed to ensuring that “90% of people living with and affected by HIV have access to people-centred and context-specific, integrated services for HIV and other diseases, including NCDs and mental health by 2025”, NCD Alliance CEO Katie Dain told the meeting.

“This, in many ways, is one of the real frontiers of the global HIV response, recognising that people living with HIV are living longer thanks to advancements in antiretroviral antiretroviral therapy,” she added.

Ntombifuthi Ginindza, from Eswatini Ministry of Health in southern Africa, knowledges the urgency of “integrating NCD treatment into HIV setting”.

Eswatini has an estimated HIV prevalence rate of 25% in people aged 15 to 49, one of the highest rates in the world. 

It has made remarkable progress, achieving a 72% decline in HIV infections and a 55% decline in AIDS-related deaths since 2010. But its premature mortality for NCDs in moving in the opposite direction, growing from 27% in 2015 to 35% currently.

“We are integrating NCDs into HIV setting. In the spirit of client-centredness, we’re working on an integrated chronic disease framework, which is mainly focusing on integration at primary level facilities,” said Ginindza.

“We are trying to sustain the gains that we have made on HIV. There is a lot that we have achieved through HIV, so we want to leverage the resources that we have in place for HIV as we are transitioning HIV clinics to chronic disease clinics.”

Four different models of integration

PATH Kenya’s Nicolas Odiyo and WHO’s Dr Prebo Barango

Dr Nicholas Odiyo, Senior Technical Advisor for PATH Kenya, says his non-profit healthcare group has implemented various different models for HIV and NCD integration in Kenya, India, the Democratic Republic of the Congo (DRC) and Vietnam. 

One model involves screening for certain NCDs at HIV clinics, based on the patients’ assessed risk factors, particularly hypertension, diabetes and cervical cancer, said Odiyo.

The second involves community-based screening, mainly run by community health promoters with blood pressure machines and glucometers to test for hypertension and diabetes.

The third model is integrating “continuous screening for hypertension and diabetes” into HIV programmes, while the final model involves comprehensive care for all, with NCD and HIV screening for the entire population in universal healthcare.

Blood sugar levels can easily be checked with a glucometer

Some donors are on board

HIV donors are also increasingly accepting that they need to incorporate NCD care to safeguard people living with HIV.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supports the integration of hypertension in five countries that are doing well with HIV, Botswana, Eswatini, Lesotho, Namibia and Rwanda, said PEPFAR ensior advisor Ritu Pati.

“PEPFAR’s HIV hypertension integration initiative was launched in response to  Ambassador [John Nkengasong’s] keen interest to address the very high rates of uncontrolled blood pressure amongst people living with HIV (PLHIV,” said Pati.

The five countries have received supplementary funding of $5 million for a year to improve  hypertension control in PLHIV, although this funding cannot be used to buy anti-hypertensive medication. 

“Close to 30% of men and women in sub-Saharan Africa over the age of 30 have hypertension, and at the same time, only a small proportion of them have controlled blood pressure. So the idea is, is that if we can proactively address hypertension in the populations that we serve, we can then reduce the incidence of cardiovascular events and thereby reduce mortality.

‘It’s become increasingly clear that we need to address hypertension amongst PLHIV to improve their health outcomes and preserve the gains of our PEPFAR programs.”

Pati adds that the integrated service delivery model has many benefits:  “It reduces the number of clinic appointments for PLHIV, promotes early diagnosis and treatment of co-morbidities, minimises service duplication, which really may lead to cost savings, and allows [healthcare] providers to have a comprehensive view of their patients history and offer them patient-centred care.”

Better still, PEPFAR has evidence that the integration of HIV services with primary health care “can actually improve HIV clinical outcomes such as continuity of treatment and viral load suppression”.

The Global Fund includes “integrated people-centred health services” in its strategy for 2023-2028, said Vindi Singh, the fund’s senior disease advisor on HIV treatment

HIV funding in some countries incorporates cervical cancer and hypertension services, Singh noted. Kenya and South Africa have also included HIV and NCD integration in their national strategic plans for HIV.

Stigma and competition

STOPAids CEO Mike Podmore.

But as Ramaiya notes, the stigma associated with HIV means that is far easier for people living with HIV to accept NCD integration than HIV clinics than it is to integrate HIV services into non-HIV clinics.

“You need a policy cohesion that starts from the Ministry of Health and local government, because HIV is a vertical program and TB is a vertical program. So when you are trying to integrate an NCD programme within HIV, you need to have a cross communications with those other programs.”

STOPAids CEO Mike Podmore concluded the event by noting that “with a projected 71% of people living with HIV having at least one NCD by 2035”, the focus on “trailblazing quality integration is necessary and compelling”. 

But Podmore warned that “it is essential that we do not allow HIV and other health issues like NCDs to be in competition to each other in a zero-sum game of flatlined resources”.

“We need to champion quality integration and synergies across health issues that build greater equality across diseases. 

‘It is also essential that the global health community restructures and recalibrates itself to ensure that inequalities of the COVID pandemic response cannot be repeated again, and that there is much stronger coordination of external actors at country level, led by country stakeholders.”

Image Credits: Dischem.

Lab technician at Afrigen, the Cape Town-based firm hosting the WHO co-sponsored Vaccine Technology Transfer Hub.

The Argentina-based biotech firm,  Sinergium Biotech, has agreed to share know-how on the production of an mRNA vaccine for Avian influenza (H5N1) with WHO’s  Tecnology Transfer Hub so that an affordable vaccine could rapidly be produced for developing countries, WHO said Monday.

The agreement marks the first time that a vaccine developer has actually volunteered know-how to the hub, which was founded by WHO in 2021 together with the Medicines Patent Pool, and is hosted by the South African firm Afrigen, based in Cape Town.

Sinergium “has developed candidate H5N1 vaccines and aims to establish proof-of-concept in preclinical models. Once the preclinical data package is concluded, the technology, materials, and expertise will be shared with other manufacturing partners, aiding the acceleration of the development of H5N1 vaccine candidates, and bolstering pandemic preparedness efforts.” said WHO in a statement.

“This initiative exemplifies why WHO established the mRNA Technology Transfer Programme – to foster greater research, development and production in low- and middle-income countries, so that when the next pandemic arrives, the world will be better prepared to mount a more effective and more equitable response,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

H5N1 is first vaccine target for the hub since COVID-19

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold) grown in MDCK cells (seen in green).

Following it’s launch, the Afrigen mRNA Technology Transfer Programme focused mostly on testing and developing an mRNA COVID-19 vaccine candidate.  Progress, however, was slow because the major mRNA vaccine manufacturers, Moderna and Pfizer, refused to share their know-how on the WHO-sponsored platform – opting to sign licencing agreements to manufacture COVID vaccines under their brand identities with other manufacturers elsewhere in Africa.

So the agreement by Sinergium to share its IP and partner directly with the WHO co-hosted hub is a breakthrough for the global health agency – which has long sought a role in the emerging mRNA vaccine market –  to reduce costs and make vaccines more accessible in low- and middle-income countries.

The new agreement signed with a Latin-American based firm also takes a small, but meaningful, step towards the ‘regionalization’ of vaccine markets, WHO officials said on Monday.

“This announcement underscores the importance of not only geographically diversifying the innovation and production of health technologies including and recognizing the capacities in Latin American and the Caribbean, but also the importance of early planning for access and the sharing of knowledge and technologies during the research and development processes,” said Dr Jarbas Barbosa, Director of the Pan American Health Organization (PAHO), WHO’s Regional Office for the Americas.

Dr Alejandro Gil, Chief Executive Officer of Sinergium, credited PAHO’s “strong support it offers to regional manufacturers in the Americas” with playing an instrumental role in the deal.

“Sinergium’s enhanced capacity and readiness to apply our expertise to H5N1 will play a vital role in this effort towards global pandemic preparedness. …We are excited to tackle this public health challenge and our R&D team will continue to work closely with the Programme Partners.”

Along with the base at Afrigen, WHO’s mRNA technology transfer hub programme includes Institut Pasteur in Senegal – and is planned to eventually includes manufacturers in over a dozen other low- and middle-income countries around the world.

Moderna also advancing a candidate vaccine with US government help

172 dairy herds in 13 states have so far been affected by the spread of avian flu in dairy cattle since the outbreak was reported in late March.

 

Moderna is reportedly at a more advanced stage in the process of developing and mRNA vaccine for the virus, which is spreading rapidly amongst dairy cattle herds in the United States.  In early July, the US government awarded the Cambridge-based firm $176 million to advance development of “an mRNA-based pandemic influenza vaccine.”

“We have successfully taken lessons learned during the COVID-19 pandemic and used them to better prepare for future public health crises. As part of that, we continue to develop new vaccines and other tools to help address influenza and bolster our pandemic response capabilities,” said HHS Secretary Xavier Becerra, at the time of the announcement.

While WHO has so far assured that the risks to humans of avian flu remain low, as long as human-to-human transmission is not occurring, the ever-widening transmission of the deadly virus amongst different animal species increases the risks that it may one day soon mutate in a way that it can more easily infect, and be transmitted, amongst humans.

And in the absence of effective vaccines, which are also widely available, that could unleash yet another pandemic on the world.

Image Credits: Afrigen, CDC/ Courtesy of Cynthia Goldsmith, CDC.

Mathias Ofoke during his routine blood sugar test at the Ezza Ofu Health Centre, Ebonyi State, Nigeria.

Fifteen-year-old Mathias Ofoke is one of four children in his family born with type 1 diabetes. Whenever his symptoms worsened, he was taken to the nearest primary healthcare (PHC) center where he was repeatedly treated for malaria. 

It wasn’t until February, when a non-governmental organization (NGO), Abby Cares Foundation, organized a clinical outreach at Ezza Ofu Health Centre that Ofoke’s condition was properly diagnosed. 

His blood sugar result of 543 mg/dL alarmed everyone when it was displayed on the glucometer screen. But the understaffed PHC facility at Ezza Ofu could not admit him as they were not properly equipped to care for him.

The NGO facilitated his admission to a secondary health facility and began sourcing insulin for his treatment.

“We frequently see cases of hypertension, diabetes, and cancer but we are not able to manage them, so we refer,” says Elizabeth Nwovu, the officer-in-charge at Ezza Ofu Health Centre. She is a community health extension worker (CHEW) who trained to be a matron.

IDF Diabetes Atlas

An estimated 27% of deaths in Nigeria are linked to diabetes, cancer, cardiovascular and chronic respiratory diseases. These four major non-communicable diseases (NCDs) are the leading causes of mortality globally, with the majority of deaths occurring in low- and middle-income countries (LMICs). 

Diabetes, characterized by elevated blood glucose levels, affects 537 million adults (20-79 years) worldwide. This number is expected to rise by 46% in 2045. 

As urbanization increases, diets change and populations age, Nigeria has also seen a surge in adults living with diabetes, from 209,400 in 2000 to 3.6 million in 2021—only South Africa had a higher prevalence in 2021. 

Diabetes is responsible for about 4.5% of deaths in people under 60 years old in Nigeria, with common complications including hyperglycemic emergencies, diabetic foot ulcers, chronic kidney disease and stroke.

PHCs prioritized in NCD management 

A national survey on NCDs conducted between 1990 and 1992 revealed that less than a quarter of the estimated 1.05 million Nigerians living with diabetes were aware of their condition. Following this survey, the Nigerian government attempted to integrate NCDs into PHC facilities, but these efforts met with minimal success.

Efforts to tackle NCDs in Nigeria were reignited in 2021 following the Brazzaville Declaration on NCDs and the subsequent political declaration at the 66th United Nations General Assembly on the Prevention and Control of NCDs. These declarations set the precedent for the WHO Global NCD Action Plan 2013-2020, which has now been extended to 2030.

Over the years, Nigeria has built on these regional and global strategies to develop several national policies for NCD prevention and control. Notable among these are the National Multi-Sectoral Action Plan for the Prevention and Control of NCDs and the National Guideline for the Prevention, Control, and Management of Diabetes Mellitus in Nigeria.

The scope of the national guideline for diabetes management was developed using the Population, Intervention, Professions, Outcomes, and Healthcare setting (PIPOH) checklist. 

The interventions outlined in the guideline emphasize the importance of integrating community health workers, such as CHEWs, and scaling-up screening, diagnosis and treatment in PHC facilities.

Task-shifting to community health workers

According to the national diabetes guideline, a key indicator of progress is the successful delegation of certain aspects of diabetes care to lower-level health professionals, such as CHEWs and lay health workers.

Similarly, the national multi-sectoral action plan, which informed sections of the diabetes guideline, recommends expansion of the Task-Shifting and Task-Sharing Policy for Essential Health Care Services to include NCD management among its priority areas. Currently, this policy focuses on maternal and child health, and communicable diseases (HIV/AIDS, malaria, and tuberculosis).

In line with this recommendation, during the technical session of the 64th National Council on Health (NCH) in November 2023, the Ministry of Health and Social Welfare announced plans for a National Task-Shifting and Task-Sharing (NTSTS) policy focused on the prevention and control of NCDs.

Elizabeth Nwovu, a community health extension worker (CHEW) and the officer-in-charge at Ezza Ofu Health Centre, Ebonyi State, Nigeria.

“This policy, if adopted, will complement the existing Task-Shifting and Task-Sharing Policy for Essential Health Care Services,” said Dr Anyaike Chukwuma, Director of Public Health, during the event.

The NTSTS policy aims to address the rising burden of NCDs in Nigeria by decentralizing preventive, diagnostic, treatment, and rehabilitative services to PHC facilities.

“By implementing this policy, the country hopes to adopt a patient-centered approach, accelerate progress towards NCD prevention and control, achieve universal health coverage, and work towards the Sustainable Development Goals,” Chukwuma added.

PHCs are ready but support is inadequate

“PHCs are not adequately supplied with medications,” said Nneka Nwankwo, founder of Abby Cares Foundation. She has over 20 years’ experience in public health and social services.

Her NGO sources Ofoke’s daily insulin injection from a tertiary hospital in the city center. Nigeria’s annual diabetes-related health expenditure per person is estimated at $499.7, which falls below the African regional average. If current trends continue, the prevalence of diabetes in the country is predicted to increase by up to 120% by 2045.

In his study on improving primary health care services for NCDs in Nigeria, Whenayon Ajisegiri found that some government stakeholders’ skepticism about the qualifications of community health workers, who constitute the majority of the PHC workforce, has been used to justify the limited supply of NCD drugs at PHCs. Ironically, NCD drugs are contained in the list of essential medicine and should be available at PHC facilities.

“When PHC facilities repeatedly fail to provide patients’ medications, it leads to frustration. And when you lose patients’ trust in the initial stages, it is difficult to regain,” said Nwankwo.

Patient flow for NCD service delivery at the PHC level, with enablers and barriers along the pathway.

A survey of 30 PHCs in Abuja, Nigeria’s capital city, reported a readiness to integrate diabetes care in terms of available paper-based health management information systems, equipment, and personnel. However, the poor availability of diabetes medications makes it impossible to harness this opportunity.

“If we can get access to testing kits and the drugs, it will improve our ability to manage patients with diabetes,” said Nwaovu.

The survey recommended a subsidized drug-revolving fund mechanism to maintain drug inventory, drawing from programs like the Hypertension Treatment in Nigeria (HTN) Program and the Academic Model Providing Access To Healthcare (AMPATH) program in Kenya.

Community health workers play an integral role

The slow progress in integrating diabetes and other NCDs into PHCs is also linked to the omission of community health workers from NCD policies.

The critical shortage and uneven distribution of skilled health workers, particularly physicians and nurses, have necessitated the deployment of community health workers to support essential health services delivery.

Prior to the introduction of the NTSTS, existing policies like the National Standing Orders, which guides the training and practice of community health workers, restricted their role to only screening and referral. Ajisegiri noted that frequent referrals to higher health facilities—secondary and tertiary—could undermine public trust in the services provided at PHCs.

Formalization of task-sharing 

Given the Nigerian government’s prioritization of PHCs to tackle NCDs, experts have advocated for capacity building, while formalizing task-sharing and task-shifting policies for NCDs among community health workers.

In a survey of 30 PHCs in Abuja, Nigeria’s capital city, only 37% reported having at least one staff member trained in diabetes diagnosis and management within the past two years. With the NTSTS for NCDs set to be adopted, Nigeria appears to be on track to address this issue. 

This task-sharing and task-shifting model has already been successfully implemented in maternal and child care, as well as in the management of infectious diseases.

While this approach is expected to help the government maximize the available health workforce for NCD management, it is crucial to allocate sufficient resources to PHC to enhance infrastructure, ensure consistent medicine supplies, and bridge the significant skill gap among community health workers. Additionally, refining the practice scope in the National Standing Orders is essential to prevent interprofessional role conflict.

Funding and political will are paramount

The national multi-sectoral action plan acknowledged the problem of medication access and called for action towards ensuring a reliable supply of essential medicines for treating diabetes and other major NCDs.

It recommended expanding the Basic Minimum Package of Health Services, funded by the Basic Healthcare Provision Fund (BHCPF), to cover comprehensive care and treatment of NCDs. The BHCPF serves as a catalytic funding source to enhance access to primary health care, particularly for poor and vulnerable groups. 

This expansion aims to reduce out-of-pocket expenses for treatment. However, funding for the BHCPF has been inconsistent. 

Nwankwo recalled that Ofoke’s father was reluctant to bring his other children living with diabetes for treatment due to the costs. Despite her offer to subsidize the insulin injections by 50%, her efforts to persuade him were unsuccessful. 

“Even with your help, I can’t afford it,” she remembered him saying. Eventually, he brought one more child for screening.

Nneka Nwankwo, founder of Abby Cares Foundation in her office in Abakiliki, Ebonyi State, Nigeria

Only half of the initial 55.1 billion naira allocated to the BHCPF in 2018 was released and by 2021, the budget had decreased to 35 billion naira. Between 2019 and 2022, it is estimated that 89 billion naira was allocated through the BHCPF, with only 7,250 out of the 35,514 Primary Healthcare Centres in the country receiving these funds.

This scenario is all too familiar for Nwankwo. “At Ezza Ofu Health Centre, the quota for the health insurance scheme is around 300 people, but it’s just a drop in the pond,” she said. During her organization’s first outreach at the PHC, over 1,000 people showed up seeking medical care. “Creating policies is not enough if they are not backed with the right resources,” she added.

Pius Ukpai contributed to this reporting from Ebonyi State, Nigeria.

Image Credits: Chimdiebube Ikechukwu, IDF Diabetes Atlas, Whenayon Ajisegiri.

An extract from the online campaign to ‘Kick Big Soda out of sport’.

Leading global health organisations have called for Coca-Cola to be removed as a major sponsor of the Olympic Games and an end to sponsorship by “Big Soda” of all other sporting events.

Sixty organisations and over 35,000 people have signed an online petition as part of the “Kick Big Soda Out of Sport “campaign, ahead of the opening of the Olympic Games in Paris on Friday (26 July).

“Sugary drinks harm people and our planet. By accepting billions from Coca-Cola to sponsor the Olympic Games, the International Olympic Committee (IOC) implicitly endorses a world where health and environmental harms are ‘sports-washed’ away, undermining commitments to use sport to create a better world,” according to the petition.

It adds that sugary drinks are a major contributor to rising rates of obesity, Type 2 diabetes and heart disease and that Coca-Cola targets children with its marketing.

The petition also says that Coca Cola is damaging the environment with “plastic pollution, carbon emissions and water depletion”.

“With continued Coca-Cola sponsorship, how does the IOC intend to meet its commitment to WHO to promote a healthy society through sport, to advance Sustainable Development Goal 3 (“Good health and well-being”) and prevent non communicable diseases (NCDs)?” it asks.

It urges the IOC to “prioritize the health and well-being of people and our planet over Big Soda’s corporate interests” by terminating Coca-Cola’s Olympic sponsorship, and committing to not accepting future sponsorship from corporations that harm public health and the environment.

“Serving as a major sponsor of the Olympics allows companies to blanket venues and events with their logos, reaching an audience of over 3 billion watching at home,” said Trish Cotter, global lead of the food policy program at Vital Strategies. 

“Alongside growing opposition to soda’s involvement in sport, athletes themselves are beginning to speak up about which companies should be permitted to sponsor sporting events. For example, at Euro 2020 Cristiano Ronaldo made a strong statement when he pointedly removed two bottles of Coca-Cola that were placed in front of him at a news conference.”

‘Contradicts IOC’s mission’

“The link between sugary beverages and chronic and largely preventable diseases such as diabetes, cancer and heart disease is well established,” said Dr. Barry Popkin, W. R. Kenan Jr. Distinguished Professor of nutrition at the University of North Carolina at Chapel Hill Gillings School of Global Public Health. 

“Allowing Coca-Cola to continue as a key sponsor of the Olympic Games directly contradicts the IOC’s mission and undermines the efforts and achievements of Olympic athletes.

“The most insidious actions of the beverage industry, however, are their marketing strategies, which disproportionately target children and adolescents. These tactics perpetuate unhealthy consumption patterns, setting young people up for lifetimes of poor dietary habits and health risks.”

“This campaign is bringing much-needed attention to the ways sugary drink companies use sport to add to their bottom line,” said Nzama Mbalati, Chief Executive Officer of HEALA, a civil society coalition in South Africa advocating for a more just food system.

“This petition underscores the need for the IOC to prioritise the health of people and the sustainability of our planet over commercial interests,” said Alejandro Calvillo, Director of El Poder del Consumidor, a consumer rights nonprofit in Mexico. 

“By distancing itself from Big Soda, the IOC has an unprecedented opportunity to uphold its reputation as a beacon of integrity, excellence and social responsibility.”

“Kick Big Soda Out of Sport” is the beginning of a movement to remove all sugary beverage sponsorship from sport. The campaign is led by concerned global health organizations and advocates and highlights the harmful effects of sugary drinks on our health and the planet.

Lezzita Mphundi, a health worker in rural Malawi, HPV vaccine demand has rebounded – stockouts are now the problem.

After experiencing the distress of caring for a loved one with advanced cervical cancer, Edna Maloya vowed to take proactive measures to ensure that her family and friends would be protected. 

“I was my cousin’s caregiver. I can’t take chances with cervical cancer,” says Maloya, who lives in Blantyre, Malawi’s second largest city.

She happily supported the Ministry of Health’s (MoH) human papillomavirus (HPV) school vaccination campaign aimed at girls aged nine to 14, consenting to her 13-year-old daughter receiving the HPV vaccine.

But some of the other parents in her daughter’s class had reservations and chose not to have their daughters vaccinated -–even though they could have done so either during the school vaccination campaigns or in community health facilities. 

Maloya is firm in her views: “This is my only child. If we have an opportunity to prevent illnesses, let’s utilise it. I’m certain that those who are hesitating now will someday wish they had let their daughters have this vaccine.” 

Malawi’s HPV vaccination rates – rebounding from Pandemic era turmoil 

HPV vaccination rates plummeted during the COVID pandemic, but now have rebounded sharply.

When Malawi first introduced the HPV vaccination in 2019, the uptake was dramatic with 85% of the first group of eligible girls, nine-year-olds, getting their first dose.  

Then the COVID-19 pandemic hit, followed by Cyclone Freddy, which left more than half a million people displaced – and following that, outbreaks of polio and cholera. 

HPV coverage rates plummeted sharply to just 13% in 2021 and 2022, according to WHO’s immunization dashboard that tracks HPV vaccine uptake around the world.  

Rates are finally rebounding with  a dose of the vaccine reaching 68% of eligible nine-year-old girls in 2023.  And according to the new WHO guideline, approved in 2022, one dose is sufficient to provide lifelong protection. 

The rebounding vaccination rate is good news for Malawi, which has the world’s highest incidence and mortality rates of cervical cancer. The disease is also the leading cause of cancer deaths amongst women in the country, according to the national Cervical Cancer Strategic plan 2022-2026. About 4,000 women are diagnosed every year, while nearly 3,000 women annually die from the disease, according to WHO data. 

In 2023, the WHO African region’s HPV vaccination rate was second highest in the world 

HPV vaccination rates in Africa have rebounded in 2023 and are on an upward swing. 0

Throughout Africa, a positive trend can be observed in the 2023 HPV vaccine data, just released by the World Health Organization (WHO). 

After a slight dip in vaccination rates during the pandemic year of 2021, rates rebounded quickly reaching 40% of eligible girls.  

That places WHO’s Africa region as second only to the Americas, which had a 68% uptake, in vaccine roll-out last year. It slightly exceeds the WHO’s European Region, whose 53 member states extending from the United Kingdom to Central Asia and Russia registered a 39% rate for HPV jabs. 

These three regions remain far ahead of the others including: South-East Asia, with a 16% uptake; the Western Pacific, including China, Japan and Australia (11%); and the Eastern Mediterranean Region, extending from Tunisia to Afghanistan, which had a woeful 1% rate of HPV vaccination in 2023. 

WHO’s Africa Region has the best first-dose coverage of HPV vaccine than any other region in the world – except the Americas.

Simultaneous vaccine campaigns confused parents

Malawi’s Ministry of Health first introduced the HPV vaccine in 2019 through campaign mode focusing on schools. 

In 2021,the vaccine was incorporated into the country’s Extended Programme on Immunisation (EPI) schedule. This meant that girls can now get the vaccine in school during campaign days, which occur quarterly, or in community health facilities. 

However in 2021 and 2022, the COVID-19 pandemic led to school closures. It was followed by Cyclone Freddy, and in its wake, outbreaks of polio and cholera. These led to multiple new vaccine campaigns for older children and adults occurring at overlapping moments, something that confused and put off many parents.

“The parents literally accused us of tricking them into giving COVID-19 vaccine to their girls…. We don’t force them to receive the vaccine if they don’t want,” said Florence Nasava, a senior Disease Control Surveillance Assistant (DCSA) for the Zingwangwa Health Centre in Blantyre. 

Nasava adds that local health workers redoubled their efforts with community volunteers, traditional and religious leaders to help in demystifying the vaccine myths – and explain the difference between the HPV vaccines, COVID jabs and others to parents.

“Since its [HPV’s] introduction, Malawi has grappled with multiple and unforeseen crises such as the COVID-19 pandemic and Cyclone Freddy – which left more than half a million people displaced, and outbreaks of polio and cholera,” noted a spokesperson from Gavi, the Vaccine Alliance, which is providing the vaccines to Malawi and 38 other low-income countries worldwide.    

Stockouts are now the major problem 

A young girl receives a single dose of HPV vaccine at Lisawo primary school in Chiradzulu Malawi in 2020, just before COVID sent vaccine rates plummeting.
Florence Nasava, of Zingwangwa Health Centre vaccinates a young girl against HPV in 2024.

Nasava also perceives that demand has now rebounded, reflecting the new 2023 data. Overall, the local health centre typically sees two to three girls a day for the HPV vaccinations, she says, adding that “many more girls get vaccinated during mass school campaigns, where an average of 300 to 400 girls are vaccinated per day.” 

In rural areas, appreciation for the vaccine is also spreading  – in light of the large cervical cancer burden that exists.  

“This vaccine is a life saver for our girls’ generation. I was motivated to have my two daughters vaccinated against the disease since this is an incurable disease,” Zione Limitedi told Health Policy Watch.  She is a DCSA in Gwilima village in Malawi’s southern region.

“I know of a woman from my village who died of cervical cancer…. It’s difficult to manage in a poverty stricken rural area, so the vaccine is our only hope to protect the future,” adds Limitedi.

Lezzita Mphundi, a DCSA based in Chikwawa, a rural area about an hour’s drive from Blantyre, says parents seem to be most comfortable having their girls receive the vaccine with their classmates during school campaigns rather than going alone to the outreach clinics or at a facility.

“Many parents consented to having their girls vaccinated. I vaccinated over 200 girls before supplies ran out,” she said of a recent campaign day. That reflects a new problem. Now that demand is high, stockouts are a growing problem. 

LMICs have the highest rates of cervical cancer deaths

Dr Atupele Kapito Tembo – Malawi was an early adopter of the HPV vaccine.

The WHO says nearly 94% of the cervical cancer deaths in 2022 occurred in low- and middle-income countries (LMICs), where the burden of cervical cancer is greatest, due to limited access to routine screening tools and treatment services for the disease at early stage. These are almost universally available in developed countries. 

That’s what makes HPV vaccination, which sharply reduces risks of developing cervical cancer from the most common cause, human papillomavirus, all the more important in Malawi and other African countries.

Rwanda was the first African country to implement the HPV vaccination program successfully in 2011, followed by Zambia in 2013, then South Africa in 2014, which even managed to maintain an 80% vaccination rate through the pandemic years.  In November 2023, Togo became the latest country to introduce the HPV vaccine, following Nigeria, in October. 

All in all,  27 African countries have incorporated the HPV vaccine into their routine immunization programmes, with a primary focus on girls aged 9-14.  

Malawi was also an early adopter, launching an HPV vaccination pilot program for adolescent girls in Rumphi, a district of northern Malawi, and Zomba, in the country’s eastern region. That scored an early success, achieving 80% coverage, said  Dr Atupele Kapito-Tembo, epidemiologist and public health specialist at Kamuzu University of Health Sciences (KUHes).  

“This demonstrated the country’s capacity and ability to cover the targeted population,” she observed.

As for the sharp decline seen during the pandemic years, she said, “In my view and experience, Malawi needs more engagement with stakeholders since girls and their caregivers may not be fully aware of their HPV vaccine eligibility and benefits.

“They might have heard about the vaccine or cervical cancer, but made no initiative to get screened or have their daughters vaccinated because they haven’t been exposed to enough information.”

“There’s a need for more sensitisation to restore confidence in vaccines,” she urges.

Cancer also takes time to manifest and therefore it can be difficult to appreciate the impacts of the vaccine right away, Tembo observes.

“If we compare with high income countries, they introduced this vaccine in the 1990s and the impact is seen now. For us it may take a decade or two from 2017/2018 [when vaccination began] to see the impact.”

MOH aims to reach 90% coverage goal 

HPV vaccine

In 2020, the World Health Assembly approved a global strategy to eliminate cervical cancer by 2030, setting out the so-called ‘90-70-90’ targets. Those aim to have 90% of girls worldwide fully vaccinated with HPV vaccine by age 15; 70% of women are screened with a high-performance test by age 35; and 90% of women identified with cervical cancer receiving treatment.  

Last March, governments, donors and other partners pledged some $600 million at the first-ever global forum on cervical cancer in Cartagena de Indias, Colombia – putting those  goals closer than ever within reach.

In Malawi’s Ministry of Health, EPI Programme Manager Dr Mike Chisema says the ministry aims to reach the 90 percent vaccination coverage target by 2030, perceiving it as a key lever in the country’s cervical cancer elimination strategy. 

Additionally, if cervical cancer deaths can be reduced, that can also help reduce HIV-related deaths insofar as there are significant co-morbidities, he points out. 

At the same time, vaccines need to be deployed alongside screening and treatment for women, he notes saying: “we have to control for other factors such as HIV prevalence and [other] risk factors for developing cervical cancer.”

Important to sustain demand despite occasional stockouts

Chisema says that vaccine stock outs observed recently, especially in rural Malawi, are largely due to district internal logistical challenges and not necessarily due to inadequate vaccines at central level.

He said that it remains critical, however, for girls to continue coming forward – so that valuable supplies of the vaccine do not expire. 

In recognition of this, Chisema says that the Ministry of Health has come up with several initiatives including expansion of the age eligibility for the vaccine from 9-14 years old, enabling multi-cohort vaccination and more attention to stockouts in the “last mile”. 

The Ministry is also gearing up for a major multi-age campaign in 2025 or earlier working with both primary and secondary school teachers to identify eligible children. Although the results will be reaped decades later, Malawi sees that as a long-term investment in women’s health. 

“We just need to continuously review our health system and strengthen it accordingly, evaluating what works for us or not,” Chisema says.

Image Credits: Nadia Marini/ MSF , Josephine Chinele , WHO, Josephine Chinele.

António Guterres delivering a video message during the launch of the State of Food Security and Nutrition report Wednesday.

Global levels of hunger remain stagnant at the highest rates seen in over a decade, as one in 11 people worldwide (8.9%) faced hunger, or undernourishment, in 2023, according to the latest State of Food Security and Nutrition (SOFI) report, released on Wednesday.

The report, a collaboration between the Food and Agriculture Organization (FAO), International Fund for Agricultural Development (IFAD), UNICEF, the World Food Programme (WFP) and the World Health Organization, summarizes the lackluster progress made toward the second Sustainable Development Goal (SDG2): “No Hunger.”

In 2023, nearly one-third (28.9%) of the global population was food insecure, lacking regular access to adequate food. A third of the world’s people ran out of food at certain times during the year, and went an entire day or more without eating, the report found.

That’s in comparison to 21.5% of people facing moderate or severe food insecurity in 2015, when the Sustainable Development Goals were first adopted.  

That growing number is a combined result of climate change, regional conflicts, economic downturns, and other destabilizing factors, found in many low- and middle-income countries. Amongst the countries with high levels of food insecurity,  74% were affected by one or more such drivers.

Regional rates of food insecurity have increased since 2020 in Africa, remained largely unchanged in Asia, and declined in Latin America – but not to 2015 levels.

“Hunger, food insecurity and malnutrition remain a global crisis,” said Antonio Guterres, United Nations’ Secretary-General, during the report launch at the G20 meeting in Brazil on Wednesday. But “we can solve this crisis and finance is the key.”

Progress made towards eradicating hunger, made in the years of the Millennium Development Goals, slumped in 2015 – paradoxically that was the same year that the 2030 Sustainable Development Goals, including SDG2, No Hunger, was adopted. Hunger rates climbed even higher during the COVID pandemic, remaining stagnant ever since. 

Overall, estimated 713-757 million people are hungry or “undernourished” – defined as habitually consuming insufficient food to provide energy levels needed for a normal active and healthy life, according to the SOFI report. 

And in Africa, the number of people who are chronically undernourished rose in 2023 to 20.4% of the continent’s population. In Asia, levels of hunger remained unchanged (8%), while hunger levels in Latin America and the Caribbean declined somewhat to (6%).

Most countries off track in reaching SDG nutrition goals as well

Few countries are on track to meet global nutrition targets: maximising exclusive breastfeeding and minimising low birthweight, stunting and wasting, anemia, and overweight.

In terms of seven nutrition goals that are also asociated with the SDG2, there has been some moderate progress on infants and children – even though most countries remain off track with respect to the goals overall.

Rates of stunting and wasting (one indicator of progress for SDG 2.2) – which means children failing to reach their height or muscle volume – declined among children younger than five years old over the last decade.

Similarly, progress has been made in exclusive breastfeeding of infants under six months of age: a practice long-recommended by the WHO because of its beneficial effects for mother and child health. 

In 2022, 48% of infants under the age of six months were exclusively breast fed only, as compared to 37.1% in 2012. 

Among children younger than five years of age, stunting and wasting rates have declined. The number of infants breastfed during their first six months increased.

The improved numbers are “showing that investments in maternal and child nutrition pay off,” stated Catherine Russell, the Executive Director of UNICEF, noting that the economic benefits of breastfeeding support programmes are just as large as health-related ones, with $35 return of every dollar invested.

Healthy diet unaffordable for a third of the world’s population

For children as well as adults, an adequate caloric intake still does not equal good nutrition. More than a third of the world’s population, 2.8 billion people, could not afford a healthy diet in 2022, falling back to pre-pandemic levels. In low-income countries, the rate of “malnutrition” was as high as 71.5%. 

Rising rates of obesity, often coexisting with under-nourishment, constitute a double burden for national health systems. “This is a […] cost for the society because overweight and obesity will create non-communicable diseases that will affect our finances: we will spend significantly more on health,” said Maximo Torero, FAO’s Chief Economist, at the report’s launch Wednesday.

Healthy, nutritious food is often unavailable locally or may be unaffordable because of income inequalities. Should nothing change, 582 million people are projected to be chronically undernourished at the end of the decade, the SOFI report warns.

“We’re standing still,” said FAO’s Director-General, Qu Dongyu, during the report launch. A “real change of agrifood systems is the only way to address the major drivers of food insecurity.” Climate change, conflicts and other factors make agriculture more unpredictable, highlighting the need to build more resilient farming systems. “I appeal to donors and other international partners to be more risk-tolerant,” Dongyu continued. “We need to be ready for the unforeseen.”

Shift in the financing of agrifood systems needed to end hunger ‘in our lifetime’                                                        

The global prevalence of hunger, declining until 2014, has stalled, then increased again during the pandemic.

Between 2005 and 2014, steady progress was made in reducing hunger – from 12.2% to 7.3% of the global population. Then, from 2015 to 2019, hunger levels fluctuated only slightly between 7.7% and 7.5% of the global population – rising sharply at the start of the pandemic and still remaining higher than any time since 2008. 

Yet, agencies involved in making the report remain optimistic about reaching the SDG goals. 

“The elimination of hunger and malnutrition is not just a vague ambition,” but rather “something that can be achieved absolutely in our lifetime,” said Francesco Branca, WHO Director Nutrition and Food Safety Department, during a press conference Monday.

What’s needed to eliminate hunger is “a shift in the way we are financing Food Security and Nutrition,” said Sara Savastano, Director of IFAD’s Research and Impact Assessment Division. More long-term projects which look at food security more holistically, beyond sector boundaries are necessary to address the core drivers of the crisis instead of simply applying bandaids to crises, she said.

Consensus on such shared financial goals is needed so as to better use existing funds, SOFI’s authors emphasized at an earlier, pre-launch briefing on 18 July, on the sidelines of the UN Economic and Social Council (ECOSOC) High-Level Political Forum in New York City.

New UN Report Calls for Fresh Approach to Ending Food Insecurity and Hunger

Expand scope of food security investments 

To quantify and evaluate the programmes aimed at enhancing food security, the SOFI report says that aid and investments in food security needs to move beyond consumer-based food supports, to agri-food systems. 

Financial resources need to be “directed towards strengthening the resilience of agrifood systems to the major drivers and underlying structural factors of hunger, food insecurity and malnutrition,” the report states.

And for that to happen, a more coherent definition of a food security investments, as well as an overarching strategy, needs to be articulated for reaching the “no hunger” goal.

“Right now it’s impossible to determine how much financing is going to end hunger and malnutrition,” said Saskia Depee, Senior Nutrition Advisor at the WFP during a press briefing Monday, just just before the report’s release. 

But policies and interventions needed to end hunger and malnutrition could amount to several trillion US dollars over many years, experts agree.

“Nutrition and food security, and especially nutrition, are long term behavioral changes… requiring time and investment,” Sevastano said. 

Supporting small holder farmers 

Alvaro Lario, President of IFAD, during the SOFI report launch.

Much more funding needs to be invested in strengthening agrifood systems, which are ultimately responsible for food production, the report’s authors agree.

“The world of agrifood systems … is where most hunger is, [it is also] …a world that will be facing uncertainties because of climate change,” highlighted Torero. Donors also need to accept uncertainty in food security investments, counting on the significant benefits in case of success.

As part of investing in more sustainable agricultural systems, support for food producers that are pushed to the sides by agri-business investors should be a priority.  

Funds for women in agriculture, grants for Indigenous Peoples, or smallholder farmers could increase their crops and boost their financial independence. 

”Small farms under five hectares produce almost half of our food on less than one fifth of the farmland,” said Alvaro Lario, President of IFAD during the ECOSOC meeting. “Imagine what they could achieve if we invested in them much more.”

Image Credits: SOFI 2024.

Professor Linda-Gail Bekker from South Africa presents the results of the PURPOSE 1 trial at the conference.

MUNICH – Delegates at the International AIDS conference leapt to their feet in delight after results from one of the most promising HIV prevention trial in the history of the epidemic – a twice-yearly injection of lenacapavir that prevented 100% of new HIV infections – were presented on Wednesday.

Principal investigator Professor Linda-Gail Bekker from South Africa told the conference that none of the 2,134 women aged 16 to 25 who had received lenacapavir on the PURPOSE 1 trial contracted HIV.

The results, also published in the New England Journal of Medicine, compared the injectable lenacapavir with two regimens involving daily pills that have previously proven to be effective as HIV pre-exposure prophylaxis (PrEP).


However, by the end of the trial, the 3,204 women in the two pill groups reported HIV cases similar to projected population-based HIV acquisition – not because the pills didn’t work but because participants’ adherence was “low”.

Young people generally find it difficult to take daily pills because they fear being questioned about it, according to another trial from Uganda due to be presented at the conference.

Describing the results as “stellar”, Bekker said that the medicine offers “a highly effective, tolerable and discreet choice that could potentially improve PrEP uptake and persistence, helping us to reduce HIV in cisgender women globally”.

“PURPOSE 1 also sets a new standard for person-centered HIV prevention trials, demonstrating what can happen when a thoughtful scientific and community-focused trial design, a promising drug candidate and an inclusive trial implementation plan come together,” added Bekker, who is director of the Desmond Tutu HIV Center at the University of Cape Town. 

Results from the PURPOSE 2 trial testing lenacapavir in men, transgender and non-binary people who have sex with men in Argentina, Brazil, Mexico, Peru, South Africa, Thailand and the US is expected by early 2025. 

International AIDS Society president Sharon Lewin described the trial results as “a breakthrough advance with huge public health potential”.

“If approved and delivered – rapidly, affordably, and equitably – to those who need or want it, this long-acting tool could help accelerate global progress in HIV prevention. We all owe a debt of gratitude to the thousands of young women in South Africa and Uganda who volunteered to be part of this study,” said Lewin.

Gilead under pressure to lower price

Activists at AIDS2024 protest against the high price of lenacapavir

HIV leaders, activists and researchers have called on lenacapavir producer Gilead to make its medicine widely accessible.

“We still have 1.3 million new HIV infections per year. UNAIDS wants this ‘miracle’ prevention drug to reach all those who need it, now, not in six years’ time,” said UNAIDS executive director Winnie Byanyima at a media briefing on Wednesday.

She urged Gilead to “move quickly to licence lenacapavir to generic producers” via the Medicines Patent Pool.

“Generic producers bring prices down and serve all countries where the majority of people who are at risk live,” added Byanyima.

On Tuesday, activists protested at Gilead’s conference booth demanding that the company make the medicine 100% accessible.

At present, lenacapavir is licensed in the US as Sunlenca for people with drug-resistant HIV and sells for $42,000 a year – yet generic companies can make it for as little as $40, according to research conducted by Dr Andrew Hill. 

Doctors, researchers and activists all want easy access for those who need lenacapavir for HIV prevention – and that means lower prices.

AIDS Healthcare Foundation (AHF), which supports two million patients in 47 countries, said that Gilead’s failure to make its HIV medicines accessible is “costing lives”.

AHF associate advocacy director John Farina described Gilead’s pricing as “arbitrary”, aimed at profiteering rather than protecting lives.

“What is the point of 100% efficacy if nobody can access it?” asked AHF India director Dr Sam Prasad at a media briefing on Tuesday.

“The US has the high price of $42,000 for the package [of two shots]. How many people can afford it?” added Prasad, who warned Gilead not to “come to India with lawyers and try to influence our patent laws”.

Dr Helen Bygrave of Medecins sans Frontieres (MSF) Access Campaign said that lenacapavir could be “life-changing for people at risk of getting HIV and could reverse the epidemic if it is made affordable in the countries with the highest rate of new infections”.

“Gilead has a long track record of undermining global access by excluding middle-income countries from voluntary licensing deals and artificially restricting licensees,” said Health GAP’s Asia Russell. “We call on governments to break Gilead’s monopoly, by issuing non-voluntary licenses, wherever Gilead’s patents present a barrier.” 

HIV community organizations in India, Argentina, Thailand and Vietnam – the Thai Network of People living with HIV (TNP+), DNP+, Fundación Grupo Efecto Positivo, and the Vietnam Network of People living with HIV (VNP+) – have already filed eight oppositions against Gilead’s lenacapavir patent applications.

Gilead promises ‘access price’

UNAIDS executive director Winnie Byanyima (2nd right) and Gilead Vice President Jared Baeten (2nd right) address a media briefing.

Addressing a media briefing on Wednesday, Gilead Vice President Jared Baeten said that lenacapavir will be available for generic production and promised that in the interim, his company would make high-volume orders for an “access price”.

The company noted in a press release on Wednesday that “lenacapavir for HIV prevention remains an investigational drug until approved by regulatory authorities”, and it is “too early to state the price of lenacapavir for HIV prevention”.  It is currently only licensed in the US for drug-resistant HIV.

“Gilead is committed to access pricing for high-incidence, resource-limited countries. The current price for the approved indication in the heavily treated HIV population will not be our reference,” it added.

“Gilead will ensure dedicated supply of lenacapavir for HIV prevention in the countries where the need is greatest until voluntary licensing partners are able to supply high-quality, low-cost versions of lenacapavir,” the company noted, adding that it is “developing a robust direct voluntary licensing program to expedite access to those versions of lenacapavir in high-incidence, resource-limited countries”. 

However, Baeten did not comment on whether his company would work through the Medicines Patent Pool to licence generics.

Image Credits: IAS.

Almost half of the world’s population suffers from a neurological condition, yet in low-income countries, most lack access to medicines needed for treatment.

Nearly half of the world’s population suffers from some form of neurological condition ranging from simple migraines to Alzheimers. And yet in low-income countries, more than 75% of people needing neurological treatment cannot access care, according to a new World Health Organization report released on Tuesday, World Brain Day.  

The treatment gap – the difference between the number of people with a condition and those receiving treatment for it – is the combined result of misconceptions about neurological diseases, low diagnostic capacity and limited access to medicines.

“Most people with neurological disorders struggle to access the treatment they need for their conditions because these medicines do not reach them or are too expensive,” said Dévora Kestel, Director of WHO’s Department of Mental Health, Brain Health and Substance Use in a press statement. 

Should that change, “the impact of neurological disorders can be significantly decreased and quality of life improved.”

Using epilepsy and Parkinson’s disease as tracer conditions, the new WHO report identifies bottlenecks in existing treatments, particularly access to care in remote and rural areas.  

Affordability, procurement and availability of specialists are among the main barriers of access to neurological treatment.

The report also advocates for more education about neurological disorders to reduce stigma. And it recommends that neurological treatments  be integrated more completely into the essential medicines lists (EMLs) of national authorities as well as WHO’s own recommended essential medicines listing.

Finally, local healthcare systems need to budget for procurement of such medications – while international donors and agencies consider how to make treatments more affordable – including through donor-supported funding. 

Treatment access, but also prevention programmes, “will take a whole of society approach, especially given that the whole of society is impacted either directly or indirectly by these diseases,” said Dr David Dodick, co-chair of World Brain Day, at a briefing Monday, just ahead of the WHO report launch.

Nearly half of the world’s population suffers from a neurological condition 

In 2021, almost half of the world’s population, or 3.4 billion individuals suffered from a neurological condition, including side effects from a stroke, Alzheimer’s disease, neonatal brain injury, or chronic migraines, according to the Institute for Health Metrics and Evaluation (IHME) data. 

But the burden is distributed unevenly, with over 80% of the deaths related to neurological conditions, as well as losses in healthy life years, occurring in low- and middle-income countries.

Burden of neurological disorders amount for a total of 443 million years of healthy life years lost globally.

Neurological conditions are a leading cause of healthy life years lost (disability-adjusted life years, or DALYs) in 2021, ahead of cardiovascular diseases. In 2021, that amounted to a total of 443 million healthy life years lost due to a  chronic  illness, disability, or premature death.

Over the last three decades, DALYs associated with neurological conditions rose by 18% – and that is likely to increase further as a result of aging populations as well as lifestyle and environmental risks.

Over 80% of premature deaths from neurological conditions occurs in low- and middle-income countries – which have only 0.1 neurologist, on average, per 100,000 people. 

That is in comparison to 7.1 neurologists per 100,000 people in high-income countries, said Dodick.

On a more positive note, when diagnosis and treatment are available, then some 90% of strokes, 40% of dementia cases, and 30% of epilepsies are preventable. 

“We know what the modifiable risk factors are for some of the most prevalent and disabling neurological conditions, like stroke and Alzheimer’s disease, for example,” Dodick said.

Barriers to reaching global goals set out by WHA in 2022

The report identifies barriers limiting attainment of goals set by the World Health Assembly in 2022 to improve access to neurological care and treatment by 2031. 

The goals, laid out in the Intersectional global plan on epilepsy (IGAP), aim to have four out of five countries providing essential medicines and technologies to manage neurological disorders in primary health care settings within the coming decade. 

Disability-adjusted life years (DALYs) lost to neurological conditions: 80% of the global DALYs occur in low- and middle-income countries.

Even when treatment methods for neurological conditions are theoretically available, patients face many obstacles to accessing care. 

In African and Eastern Mediterranean regions, for instance, children with epilepsy are less likely to attend school because of the stigma surrounding the disorder. As the report shows, lack of knowledge about Parkinson’s and epilepsy, and exclusionary practices around people with those conditions, are common issues.

More regional manufacturing of medicines can bolster supply chains

The paucity of medicines available in pharmacies and clinics also was highlighted by country-level surveys included in the WHO report. 

In Ghana, for instance, out of 180 drug stores surveyed, levitiracetam, which is used to treat epilepsy, was available in only 50% of urban pharmacies and not at all in rural areas. Similarly, another epilepsy medicine, phenobarbital, was only available in roughly every second urban drug stores and in one in three rural pharmacies.

The report highlights the need for regional manufacturing of such medicines as well as more robust supply chains, overall, to ensure that such essential drugs are accessible. 

Consistent regulatory authorization of essential neurological medicines and ensuring their inclusion in national essential medicines lists, could also lead to more state financing support, improving treatment affordability.

Finally, the report also identifies the need for more specialised healthcare staff, particularly in rural areas, as well as more systematic data collection to improve surveillance. 

Neurological health access should be “inclusive and equitable”, also on the prevention level, said Prof. Tissa Wijeratne, Co-Chair, World Brain Day, during the webinar. “Access to preventative measures at community level, grassroot level, individual level, […] should be available to everybody across the world.”

Image Credits: WHO, IHME.

Bavarian troupe of gay traditional folk dancers provide entertainment at the opening of the International AIDS Conference.

MUNICH – German Chancellor Olaf Scholz reaffirmed his government’s commitment to the global campaign against AIDS, including the Global Fund, at the opening of the international AIDS Conference – and appealed to other global powers to do the same.

The Ukraine war is draining Germany’s resources, and on the far right, the substantial and growing influence of the anti-immigrant, anti-global Alternative for Germany (AfD) party is also influencing German spending and policies.

The budget of the government’s development ministry (BMZ), largely responsible for overseas development aid, was cut by 7% earlier this year sparking fears that Germany may retreat from its leading role in global health.

“As one of the largest donors, Germany contributes €1.3 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria,” Scholz told the packed conference, which is being attended by over 10,000 delegates.

“And we will continue to support it because programmes sponsored by the Global Fund have saved 59 million lives,” he added to applause.

“We also support UNAIDS and the World Health Organization and will continue to be a reliable partner. Together with France and Norway, Germany supports the WHO Replenishment Round as a co-host for the European Union. Because the WHO needs more support. It is the chain that holds different threads of global health together.

“I would like to call on other donors for stronger support,” Scholz added. 

German Chancellor Olaf Scholz speaking at the Opening Session.

PEPFAR jitters

As Russia’s war on Ukraine drains European resources, the possibility of a victory by Donald Trump in the US presidential campaign is triggering fears that a drastic reduction in the US President’s Emergency Plan for AIDS Relief (PEPFAR) could then follow. Through PEPFAR, the US has been the world’s largest single historical sponsor of antiretroviral medication in Africa, and other game-changing innovations in HIV/AIDS prevention and treatment since 2003.  

However, Chris Collins, CEO of Friends of the Global Fight, said at a pre-conference media briefing that “bipartisan commitment to the program remains solid in the United States.”  That, despite the fact that what he described as “misinformation” held up the five-year reauthorization of PEPFAR by the US Congress in 2024 – with Congress ultimately agreeing only to a one year authorisation, until 2025. 

Addressing the same briefing, PEPFAR’s head, Ambassador John Nkengasong, warned that “now is not the time to sit back; we must sustain the gains we have all worked so hard to make against this pandemic and accelerate our efforts to end it.”

Sharon Lewin, IAS President and International Chair, opening the session.

International AIDS Society president and chair of the conference Sharon Lewin warned against “regressive policies, attacks on human rights, the spread of misinformation, cuts to global health funding, and waning trust in international institutions”.

 “We’ve seen incredible breakthroughs at AIDS 2024, including a new case of long-term HIV remission and a promising twice-yearly injection [lenacapavir] to prevent HIV,” added Lewin.

“To end HIV as a threat to public health and individual well-being, we need an evidence-based HIV response and a political climate that respects science.”

Debt relief call

UNAIDS executive director Winnie Byanyima.

UNAIDS Executive Director Winnie Byanyima called for debt relief for low-income countries that are unable to meet their citizens’ needs – including HIV prevention and treatment – and service their debt.

“In Angola, Kenya, Malawi, Rwanda, Uganda and Zambia, debt servicing is more than 60% of all the government revenue that is collected. Sierra Leone spends 15 times more on public debt servicing than on the health of its people,” said Byanyima.

“The choking debate must be restructured and restricted now.”

Appeal to Gilead to allow generic production of ‘miracle drug’ lenacapavir

She also called on Gilead, the manufacturer of the “miracle drug” lenacapavir – the twice-yearly injection that protected 100% of women from HIV infection in a recent trial – to “make history” by licensing generic manufacturers to produce it more affordably through mechanisms such as the Medicines Patent Pool (MPP).

“Gilead has an opportunity to take us closer to ending AIDS as a public health threat,” Byanyima told AFP in an interview at UNAIDS’ headquarters in Geneva.

“Those people hiding from the law — gay men, trans women — who could come out just twice a year to get their injection and be safe,” she said. So could young women in Africa, fearing stigma and domestic violence.

Lenacapavir was approved for use in 2022 for HIV patients in the United States and the European Union. But its cost of around $40,000 a year in the US currently puts it out of reach for most low- and middle-income countries.

Ukrainian leader urges action 

Ukraine’s Andrew Klepikov received a standing ovation at the opening session.

The AIDS 2024 conference includes a special focus on eastern Europe and central Asia, a region with one of the fastest-growing HIV epidemics in the world. 

“While most other regions around the globe have managed to stabilise their HIV epidemics, in eastern Europe and central Asia, it is rapidly increasing,” Andriy Klepikov, AIDS 2024 Regional Co-Chair, told delegates to the event.

“Only half of people living in our region are on antiretroviral therapy, nowhere near the global target of 95%. At the root of the region’s epidemic are drug use, stigma and harmful policies – exacerbated by violent conflict.”

Klepikov asked delegates to imagine the sound of air raid sirens, which he described as the background soundtrack of daily life in Ukraine.

“I would like to sound a siren today about the [HIV and AIDS] danger in eastern Europe and central Asia,” he added.

“Progress will require major change and innovation, removing policy barriers and respecting the rights of the communities most affected by HIV.”

Impact of Uganda’s anti-LGBTQ law

Trans man Jay Mulucha, head of Fem Alliance Uganda, speaking to delegates at the 2024 International AIDS conference.

Trans man Jay Mulucha, head of Fem Alliance Uganda, gave a moving address about the impact of Uganda’s 2023 Anti-Homosexuality Act, which introduces harsh penalties for a range of same-sex activities.

He said that being HIV positive and trans meant that “we are always discriminated against when we go for treatment” and face “corrective rape”.

His organisation’s Uganda office had been closed down, as has the homeless shelter it provided for trans people, “meaning that we are unable to supply HIV and social services for our community.”

Mulucha said his life is constantly in danger and Uganda’s LGBTQ community remains “isolated and vulnerable” – despite recent international pressure on the government of Yoweri Kaguta Museveni, who has now been in power since 1986.

“The sanctions and penalties being placed by the international community on the Ugandan government are working, but the lifting of these sanctions needs to be contingent not on changes in policy, but on evidence of changes in implementation,” said Mulucha. 

“You need to listen to the communities and hear what we are saying. We are still suffering and need your support more than ever. So the funding that is being denied to the government should be funnelled directly into LGBTIQ organizations and communities in Uganda.”

Image Credits: Steve Forrest / IAS, Steve Forrest / IAS, teve Forrest / IAS.

WHO’s Dr Prebo Barango at the NCD Alliance event at AIDS 2024

MUNICH – Despite a global commitment to cut deaths from non-communicable diseases (NCDs) by a third by 2030, virtually all countries are off-track  – and the NCD Alliance is appealing to allied organizations to help pressure governments to take action.

“NCDs cause three out of four deaths globally, and 80% of premature mortality from NCDs – deaths before the age of 70 – take place in low- and middle-income countries,” the World Health Organization’s (WHO) Dr Prebo Barango told an NCD Alliance satellite event shortly before the opening of the international AIDS conference in Munich.

“We also know that HIV mortality is worse in low and middle-income countries and that so there is a colliding epidemic of HIV and NCD,” added Barango.

Aside from the global goal to cut NCD deaths, which is one of the Social Development Goals (SDGs), global leaders made another commitment, NCD Alliance CEO Katie Dain said the meeting.

HIV High-Level Meeting

They committed at the 2021 United Nations High-Level Meeting on HIV and AIDS to ensure that “90% of people living with, and affected by, HIV have access to people-centred and context-specific, integrated services for HIV and other diseases, including NCDs and mental health by 2025,” said Dain.

“This, in many ways, is one of the real frontiers of the global HIV response, recognising that people living with HIV are living longer thanks to advancements in antiretroviral antiretroviral therapy,” she added.

But slow progress to achieve this 90% goal has prompted the NCD Alliance to issue a call for action to world leaders – and they have appealed to HIV organisations to sign the open letter.

The letter calls on all governments to “fulfil their commitments to tackle the NCD burden” by the time they attend the UN High-level Meeting on NCDs in September next year. They are calling for three key actions:  mobilising more investment, accelerating the implementation of policies to reduce NCDs and monitoring the progress made.

“NCDs such as diabetes, cancer, cardiovascular diseases, chronic respiratory conditions, neurological conditions, and mental ill health, are the leading cause of death and disability worldwide,” the letter notes.

“We urge governments to fulfil their responsibility to protect current and future generations from the risk factors that cause NCDs and provide healthcare for those who need it.”

Image Credits: Marcus Rose/ IAS.