Low-cost generic drugs under the President's Emergency Plan for AIDS Relief drove down treatment cost; more are needed

Market Failure, State Failure: The Political Economy of Supply Chain Strengthening to Ensure Equitable Access to Vaccines and Medicines in Low- and Middle-Income Countries

CONTEXT

Much of the existing work on the political economy of vaccine access has focused on how intellectual property rights agreements contribute to inequitable COVID-19 vaccine access between high-income and low- and middle-income countries (LMICs). The two solutions that emerged to scale up access in LMICs involved either voluntary arrangements under COVAX or a waiver of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) to allow immediate access to intellectual property. However, an additional constraint on access is weak and ineffective supply chains within LMICs that have eroded over several decades of health-sector reform.

METHODS

This article reviews the literature on the political economy of supply chain strengthening in LMICs and identifies key challenges to equitable access to emergent vaccines and other medicines emanating from market and state failures in internal supply chains.

FINDINGS

Over the past century, supply chain policies in LMICs have alternated among an emphasis on addressing market failures contributing to unaffordability of vaccines/medicines, an emphasis on state failures contributing to unavailability of vaccines/medicines, and a more recent move toward public-private hybrid arrangements to strengthen supply chains.

CONCLUSIONS

In addition to reshoring production capacity through a TRIPs waiver, the international community must address chronic weakness in internal supply chains in LMICs to ensure access to novel vaccines/medicines.

The Social, Behavioral, and Ethical Modalities of COVID-19 on HIV Care in South Africa: A Systematic Review

The profound public health impact of the novel outbreak of the SARS-CoV-2 virus in 2019 has been unparalleled in the last century. Rapid spread of the disease and a high death toll fueled the development and global rollout of effective vaccines regardless of the massive inequitable access. However, some public health measures intended to control COVID-19 have had collateral effects on the control of other infectious diseases. In this systematic review, we analyze the impact of the COVID-19 pandemic on efforts to control HIV in South Africa, emphasizing the social, ethical, and behavioral ramifications. The SCOPUS, PubMed, Ovid, PsychINFO, and Cochrane Library databases were searched for publications between March 2020 and January 2022. Of the 854 articles identified, 245 were found duplicated, and 609 were screened, 241 of which were potentially eligible, and 15 of which were ultimately included. Although no studies on the ethical implications were eligible for our study criteria due to insufficient primary data to perform an analysis on, we explored this topic in the Discussion section of this paper. We confirm declines in ART, PrEP, and HIV testing during the initial lockdown period, with slight variations across the South African provinces. Protecting routine services and reducing the disease burden on high-risk nations such as South Africa is imperative moving forward with the pandemic.

An Evaluation of US Food and Drug Administration's Program to Register HIV Drugs for Use in Resource-Constrained Settings

IMPORTANCE

The US Food and Drug Administration (FDA) program to review antiretroviral drugs for use in low-resource settings via the US President's Emergency Plan for AIDS Relief (PEPFAR) now supports treatment of more than 14 million patients with HIV. However, an in-depth evaluation of the program has not been undertaken.

OBJECTIVE

To conduct a quantitative analysis of the FDA-reviewed antiretroviral drug applications in order to assess the contributions of PEPFAR and to identify areas for improvement.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted of all PEPFAR applications submitted to the FDA from December 1, 2004, to May 31, 2018. The analyses were conducted between October 2018 and February 2019.

MAIN OUTCOMES AND MEASURES

Numbers and types of applications reviewed, how long it took for applications to obtain approval or tentative approval (time to registration), how often the FDA issued a complete response letter (CRL) identifying deficiencies precluding application approval or tentative approval and their reasons, and the association between CRLs and time to registration.

RESULTS

Overall, 260 PEPFAR applications for 327 antiretroviral therapies were reviewed by FDA, of which 216 applications (83%) for 272 drugs were authorized for use. Of the 216 authorized applications, 184 applications for 231 drugs remain in active status and, thus, are available for use. Twenty-six percent (56 of 216) of the applications were for pediatric-specific formulations or strengths; the remainder were for adults. For all 216 applications, the median (interquartile range) time to registration was 10.0 (7.0-17.5) months. Thirty-seven percent (95 of 260) of the applications received 1 or more CRLs, resulting in a total of 172 CRLs; most applications received 1 CRL, whereas some were issued up to 6 CRLs. Among all CRLs, 264 deficiency reasons were identified; the most common deficiencies were associated with manufacturing processes (155 [44%]), followed by product labeling (62 [23%]), and failing facility inspections (54 [20%]). Complete response letters were associated with an increased time to registration. Applications without CRLs had a median (interquartile range) time to registration of 9.0 (5.5-12.0) months, whereas those with at least 1 CRL took a median (interquartile range) of 22.0 (14.0-38.0) months (P < .001).

CONCLUSIONS AND RELEVANCE

The FDA's PEPFAR program has made many antiretroviral drugs available for global use. However, FDA and the pharmaceutical companies could take steps to improve the quality of applications submitted to prevent avoidable deficiencies in manufacturing processes and labeling. Further efforts to develop better, easier to use pediatric-specific therapies are needed.

The influence of constraints on the efficient allocation of resources for HIV prevention

OBJECTIVE

To investigate how 'real-world' constraints on the allocative and technical efficiency of HIV prevention programmes affect resource allocation and the number of infections averted.

DESIGN

Epidemiological modelling and economic analyses in Benin, South Africa and Tanzania.

METHODS

We simulated different HIV prevention programmes, and first determined the most efficient allocation of resources, in which the HIV prevention budget is shared among specific interventions, risk-groups and provinces to maximize the number of infections averted. We then identified the efficient allocation of resources and achievable impact given the following constraints to allocative efficiency: earmarking [provinces with budgets fund pre-exposure prophylaxis (PrEP) for low-risk women first], meeting targets [provinces with budgets fund universal test-and-treat (UTT) first] and minimizing changes in the geographical distribution of funds. We modelled technical inefficiencies as a reduction in the coverage of PrEP or UTT, which were factored into the resource allocation process or took effect following the allocation. Each scenario was investigated over a range of budgets, such that the impact reaches its maximum.

RESULTS

The 'earmarking', 'meeting targets' and 'minimizing change' constraints reduce the potential impact of HIV prevention programmes, but at the higher budgets these constraints have little to no effect (approximately 35 billion US$ in Tanzania). Over-estimating technical efficiency can result in a loss of impact compared to what would be possible if technical efficiencies were known accurately.

CONCLUSION

Failing to account for constraints on allocative and technical efficiency can result in the overestimation of the health gains possible, and for technical inefficiencies the allocation of an inefficient strategy.

Impact of the US Food and Drug Administration registration of antiretroviral drugs on global access to HIV treatment

Background

Since 2004, the US Food and Drug Administration's (USFDA) dedicated drug review process in support of President's Emergency Plan for AIDS Relief (PEPFAR) has made safe, effective and quality antiretrovirals (ARVs) available for millions of patients. Furthermore, the WHO and Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) can add the USFDA-reviewed products to their respective formularies, through a novel process of 'one-way reliance'. We assessed the number of ARVs made available through WHO and Global Fund based on the USFDA review.

Methods

We conducted a cross-sectional study of all the USFDA-reviewed PEPFAR drugs between 1 December 2014 and 20 March 2017 to determine 1) the percentage that are included on the WHO and Global Fund formularies; 2) the number of the USFDA ARVs supporting the WHO HIV treatment guidelines, and their uptake by WHO and Global Fund and 3) time between the USFDA review and WHO review of the same ARVs.

Findings

Overall, 91% (204/224) of the USFDA products appeared on either the WHO/Prequalification of Medicines Programme (PQP) or the Global Fund ARV lists. Forty-five per cent (100/224) and 83% (184/224) appear on WHO/PQP and Global Fund formularies through one-way reliance, respectively. Forty-one per cent (91/224) of the USFDA products support the WHO-preferred first-line HIV treatment options. Of these 91 products, 38% and 85% of products were adopted by WHO/PQP and Global Fund through one-way reliance, respectively. Sixty-six products that were fully reviewed and registered by WHO (vs one-way reliance) had also undergone the USFDA review; 46 of these were registered by WHO after the USFDA review was complete (median delay of 559 days (IQR 233-798 days)).

Conclusions

The USFDA's PEPFAR process is making safe and effective ARVs available worldwide, in part because the major global ARV procurement organisations rely on the USFDA registration as proof of quality. There is room for improved information sharing and collaboration to reduce duplication of effort, save resources and further expedite access to ARVs.

The US Food and Drug Administration's tentative approval process and the global fight against HIV

INTRODUCTION

In 2004, the US government began to utilize the Food and Drug Administration's (USFDA) tentative approval process (tFDA) as a basis to determine which HIV drugs are appropriate to be purchased and used in resource-constrained settings. This process permits products that are not approved for marketing in the US, including medicines with active patents or marketing restrictions in the US, to be purchased and distributed in resource-constrained settings. Although the tFDA was originally intended to support the United States' President's Emergency Plan for AIDS Relief (PEPFAR), the USFDA list has become a cornerstone of international HIV programmes that support procurement of ARVs, such as the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Our objective in this article is to help the global HIV policy makers and implementers of HIV programmes better understand the benefits and limitations of the tFDA by providing an in-depth review of the relevant legal and regulatory processes.

DISCUSSION

USFDA's dedicated tFDA process for ARVs used by the PEPFAR programme has a wide impact globally; however, the implementation and the regulatory processes governing the programme have not been thoroughly described in the medical literature. This paper seeks to help stakeholders better understand the legal and regulatory aspects associated with review of ARVs under the tFDA by describing the following: (1) the tFDA and its importance to global ARV procurement; (2) the regulatory pathways for applications under tFDA for the PEPFAR programme, including modifications to applications, review timelines and costs; (3) the role of US patents, US marketing exclusivity rights, and the Medicines Patents Pool in tFDA; and (4) an overview of how applications for PEPFAR programme are processed through the USFDA. We also provide a case study of a new ARV, tenofovir alafenamide fumarate (TAF), not yet reviewed by USFDA for PEPFAR use.

CONCLUSIONS

In this paper, we describe the importance and implementation of USFDA's tentative approval process to review ARVs for resource-constrained settings. We also highlight the impact of patents and exclusivities on review of HIV drugs under tFDA and illustrate the concepts using a new HIV drug as an example.

The 90 90 90 strategy to end the HIV Pandemic by 2030: Can the supply chain handle it?

Introduction

UNAIDS “90-90-90” strategy calls for 90% of HIV-infected individuals to be diagnosed by 2020, 90% of whom will be on anti-retroviral therapy (ART) and 90% of whom will achieve sustained virologic suppression. Reaching these targets by 2020 will reduce the HIV epidemic to a low-level endemic disease by 2030. However, moving the global response towards this universal test and treat model will pose huge challenges to public health systems in resource-limited settings, including global and local supply chain systems. These challenges are especially acute in Africa, which accounts for over 70% of the persons affected by HIV.

Discussion

From a supply chain perspective, each of the “90's” has possible complications and roadblocks towards realizing the promise envisioned by 90-90-90. For instance, ensuring that 90% of HIV-infected persons know their status will require a large increase in access to HIV tests compared with what is currently available. To ensure that there are enough anti-retrovirals available to treat the nearly 25 million people that will require them by 2020 represents a near doubling of the ARV supplied to treat the 13 million currently on treatment. Similarly, to monitor those on treatment means an unprecedented scale-up of viral load testing throughout Africa.

Conclusions

Larger issues include whether the capacity exists at the local level to handle these commodities when they arrive in the most severely affected countries, including considerations of the human resources and costs needed to make this strategy effective. We believe that such “real world” analysis of proposed strategies and policies is essential to ensure their most effective implementation.

Correlates of Antiretroviral Therapy Adherence among HIV-Infected Older Adults

BACKGROUND

Despite the success of antiretroviral therapy (ART), HIV-infected older African Americans experience higher mortality rates compared to their white counterparts. This disparity may be partly attributable to the differences in ART adherence by different racial and gender groups. The purpose of this study was to describe demographic, psychosocial, and HIV disease-related factors that influence ART adherence and to determine whether race and gender impact ART adherence among HIV-infected adults aged 50 years and older.

METHODS

This descriptive study involved a secondary analysis of baseline data from 426 participants in "PRIME," a telephone-based ART adherence and quality-of-life intervention trial. Logistic regression was used to examine the association between independent variables and ART adherence.

RESULTS

Higher annual income and increased self-efficacy were associated with being ≥95% ART adherent. Race and gender were not associated with ART adherence.

CONCLUSION

These findings indicated that improvements in self-efficacy for taking ART may be an effective strategy to improve adherence regardless of race or gender.

HIV integrase inhibitors: 20-year landmark and challenges

Since the discovery of HIV as the cause for AIDS 30 years ago, major progress has been made, including the discovery of drugs that now control the disease. Here, we review the integrase (IN) inhibitors from the discovery of the first compounds 20 years ago to the approval of two highly effective IN strand transfer inhibitors (INSTIs), raltegravir (Isentress) and elvitegravir (Stribild), and the promising clinical activity of dolutegravir. After summarizing the molecular mechanism of action of the INSTIs as interfacial inhibitors, we discuss the remaining challenges. Those include: overcoming resistance to clinical INSTIs, long-term safety of INSTIs, cost of therapy, place of the INSTIs in prophylactic treatments, and the development of new classes of inhibitors (the LEDGINs) targeting IN outside its catalytic site. We also discuss the role of chromatin and host DNA repair factor for the completion of integration.