不要再對COVID-19的反應中重複來自HIV的錯誤
資料來源：剌胳針愛滋病毒期刊www.thelancet.com/hiv；2021年2月8日
自第一批愛滋病毒感染被發現後40年來，我們經常在本刊這些頁面中反映出與該疾病鬥爭所取得的巨大進步。從2021年的優勢點出發，有很多地方值得慶祝：已鑑定、分類和定序了一個未知的病毒，開發和精進治療方法，並強化衛生系統以提供這些治療；一個對應愛滋病的反應已經形塑了整個衛生系統和全球衛生。但是，當我們與對應嚴重急性呼吸道症候群冠狀病毒2（SARS-CoV-2）和COVID-19的快速反應一併考量時，HIV反應似乎特別呆滯緩慢。
在僅僅一年的時間裡，已經鑑定並分類確定了導致當今世界大流行的病毒，並已採取了治療方法（儘管不完善）以挽救生命，並且至關重要的是，在2021年初，經由驚人的快速發展幾種疫苗已經被推出，透過臨床試驗過程並已獲得批准。現在，在2021年的前幾週內，數百萬人已經接受了第一劑疫苗，以保護其對抗病毒並將開始去降低COVID-19的發生率且挽救生命。例如，在以色列，大約有900萬人（佔成年人口的四分之一）已經接種了輝瑞疫苗，人們希望很快就能看到疫苗接種對這一流行病的影響。但是，隨著許多人在慶祝對抗SARS-CoV-2方面取得的顯著進展時，一種令人擔憂的模式開始出現，這對從事愛滋病毒工作的人來說太熟悉了：分配不均。
儘管現在全球範圍內的愛滋病毒計劃在獲得治療上都迅速擴大，但情況並非總是如此。不到十年前，獲得治療的機會大大偏向了疾病負擔較低的高收入國家之民眾；甚至在擴大治療機會的同時，已開發國家的愛滋病毒感染者可以獲得最新，最有效，危害最小的治療，而最貧窮國家的人們獲得的治療通常很零星，有時甚至是過時的療法。甚至在今天，在獲得治療、預防、照護和檢驗等方面仍然存在著不平等現象。
在冠狀病毒疫苗接種的初期，於撰寫本文時已出現了類似的失衡現象。例如，儘管有25％持有以色列身份證的人已經接種了輝瑞疫苗，但400萬巴勒斯坦人中沒有人接種過一劑疫苗。在世界範圍內，大約有4,500萬人已接種疫苗，但到目前為止，幾乎每一劑這種疫苗者都施打在高收入國家/地區中。
世衛組織秘書長譚德塞博士Tedros Adhanom Ghebreyesus在世衛組織第148次執行委員會議上發表講話時警告說，「世界正處於災難性道德淪喪的邊緣，這種失敗的代價將由世界上最貧窮國家的生命和生計中支付」。當各國爭相搶購取得疫苗，希望擺脫疫情暴發的循環、經濟上的破壞性封鎖和冠狀病毒所造成的高死亡率時，隨著富裕國家試圖排在前列，疫苗價格可能會被推高。」 譚德塞表示，「這種以我為優先的方法將會是弄巧成拙的」。
去年四月，詹姆斯 · 哈格里夫斯（James Hargreaves）及其同事寫了一篇評論，《從HIV大流行對COVID-19反應的三個教訓》，發表在本雜誌上。第一個教訓是預期和應對不公平的反應，並特別提到公平獲得疫苗的需求。世衛組織的COVAX計劃旨在確保到2021年年底，全球20億最貧困的人口能夠獲得疫苗。
但是儘管有明確的警告和努力確保公平獲得疫苗，但疫苗採購在開始時即有偏差，澳大利亞和加拿大等國家/地區購買的疫苗數量超出其人口所需的數量，且和以色列一樣，其他國家/地區（例如，
巴林，阿拉伯聯合大公國、英國和美國在疫苗交貨方面已經脫穎而出。資金更多的國家可以更直接地獲得疫苗。
在過去的12個月中，SARS-CoV-2已對世界造成了巨大損失，超過200萬人喪生。但是，如果有一線希望，疫苗的反應和驚人的開發速度也可能會對疫苗批准體系產生持久影響，從而在適當時候使HIV領域受益。
但是，如果不聽從愛滋病毒應對工作上的明確教訓，讓富裕的國家在疫苗接種方面處於領先地位，同時又將世界上最貧窮的國家排除在外，那將是不可原諒的。最富有國家政府的國際發展和援助部門必須立即採取行動，確保在冠狀病毒疫苗推出過程中沒有任何人是落後掉隊的。
Do not repeat mistakes from HIV in COVID-19 response
40 years since the first cases of HIV were identified, we often reflect in these pages about the enormous advances that have been made to combat the disease. From the vantage point of 2021 there is a lot to celebrate: an unknown virus identified, characterised, and sequenced; treatments developed and refined; health systems strengthened to deliver those treatments; an HIV response that has shaped health systems and global health. However, when considered alongside the rapid response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19 the HIV response seems practically sluggish.
In just 1 year, the virus responsible for the pandemic that currently grips the world has been identified and characterised, treatments (albeit imperfect) have been implemented to save lives, and, crucially, at the start of 2021, several vaccines are being rolled out after astonishingly rapid development, progress through the clinical-trial process, and approval. Now, a few weeks into 2021, millions of people have received their first doses and protection against the virus will begin to drive down incidence of COVID-19 and save lives. In Israel, for example, where almost 9 million people, a quarter of the adult population, have received the Pfizer vaccine, people expect to begin to see the effects of vaccination on the epidemic soon. But as many celebrate the remarkable progress in combatting SARS-CoV-2, a concerning pattern is beginning to emerge that is all too familiar to those who have worked in HIV: inequitable distribution.
Although HIV programmes worldwide are now seeing rapid scale-up of treatment access, this was not always the case. Less than a decade ago, access to treatment was massively skewed in favour of people in high-income countries with lower burden; and even as treatment access was scaled up, while people with HIV in richer countries had access to the newest, most effective, and least harmful treatments, people in the poorest countries had patchy access, sometimes to outdated treatments. And even today, inequalities remain in access to treatment, prevention, care, and testing.
Similar imbalances are emerging at the time of writing in the early days of coronavirus vaccination. For example, whereas 25% of people with Israeli identity cards have received the Pfizer vaccine, none of 4 million Palestinians has received a dose of vaccine. Worldwide, around 45 million people have received vaccine, but so far, almost every single one has been given in high-income countries.
Speaking on the day of the 148th Executive Board meeting of WHO, Director General Dr Tedros Adhanom Ghebreyesus warned that the “world is on the brink of a catastrophic moral failure, and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries”. As countries scramble for access to vaccines with the hope of breaking out of the cycles of epidemic flare-ups and economically damaging lockdowns and high mortality from coronavirus, vaccine prices could be pushed up as richer countries try to jump to the front of the queue. A “me-first approach would be self-defeating”, said Ghebreyesus.
In April last year, James Hargreaves and colleagues wrote a Comment, Three lessons for the COVID-19 response from pandemic HIV, published in this journal. The first lesson was to anticipate and address inequitable responses and specifically referenced the need for fair access to vaccines. WHO’s COVAX programme was set up to ensure that 2 billion of the world’s poorest people will have access to vaccines by the end of 2021.
But despite clear warnings and efforts to ensure equitable access, vaccine procurement is off to a biased start. Countries such as Australia and Canada have purchased many more vaccines than their populations need, and alongside Israel, other countries such as Bahrain, the United Arab Emirates, the UK, and the USA have raced out of the gates in terms of vaccine delivery. Countries with more money have more immediate access to vaccines.
SARS-CoV-2 has taken an enormous toll on the world in the past 12 months, claiming more than 2 million lives. But, if there is a silver lining, the response and the incredible speed of development of vaccines will also likely have a lasting impact on the systems of vaccine approval that may benefit the HIV field in due course.
However, it would be unforgivable not to heed the clear lessons from the HIV response and for richer nations to race ahead in vaccination while excluding the world’s poorest. The international development and aid arms of governments in the richest countries must act now to ensure that no-one is left behind in coronavirus vaccine roll-out.
■ The Lancet HIV
www.thelancet.com/hiv Vol 8 February 2021