Global vaccine equity for covid-19 is the defining challenge of 2021, but we cannot neglect the need for therapeutics, write Rachel Cohen and colleagues

The need for treatments at all stages of covid-19 is more pronounced than ever given inequitable access to vaccines and surging cases across different parts of the world, including in Africa, Asia, and Latin America. It is further compounded by the possible waning of immunity over time, uncertainty around the efficacy of vaccines for immune-compromised individuals, vaccine hesitancy, and the continued impact of new variants of concern.

Yet this is an area that has been relatively neglected, under-resourced, and less successful in the global response to the pandemic, with effective therapeutic innovations few and far between.

The response to covid-19 has enabled major scientific advances and the development of new health tools, particularly vaccines, at breakneck speed. We’ve been able to shorten clinical development and regulatory timelines and quickly validate platform technologies and modalities in ways that may be transformative for other diseases.

But it has also thrown into sharp relief the lack of coordination and limited commitment to prioritizing and financing research and development (R&D) in low and middle income countries (LMICs); serious power imbalances that determine who has a seat at the decision making table in global health; and the lack of transparency and globally agreed rules to ensure open sharing of knowledge, data, and technology, as well as equitable access to new health tools developed. Indeed, if there is one central lesson from the past year and a half, it is that there is urgent unfinished business when it comes to equitable access. 

Global vaccine equity for covid-19 is the defining challenge of 2021. But we cannot be satisfied with only one set of tools, and there is a narrow window of opportunity for the international community to learn the positive lessons—and avoid repeating the mistakes—of the past year when it comes to covid-19 therapeutics.

Few of the repurposing candidates that might have offered immediate and affordable treatment options have panned out, but the search continues. The availability and global impact of first generation monoclonal antibodies (mAbs) has been very limited but more affordable and adapted second generation mAbs and other biologics may hold promise. Only a handful of direct acting or host directed antiviral candidates have advanced through the research pipeline, but the pace of development has been impressive despite the lack of early prioritization, and some important new investments are finally being made.

While World Health Organization guidelines did not initially recommend the use of repurposed antivirals, mostly based on clinical dataset analysis from severe, hospitalized patients, there is a clear rationale emerging that a strong antiviral (or combination of antivirals) combined with host directed therapies could be effective during the first few days of infection to avoid severe disease and hospitalization. These treatments should be easy to take at home after rapid diagnosis—effectively enabling “test and treat” approaches at the community level.

The case for investing in research for therapeutics is clear. But how can we ensure that these new treatments are developed using a model of collaboration and knowledge sharing aimed at global equity and solidarity? 

In a recently released policy report from the Drugs for Neglected Diseases initiative (DNDi) several recommendations for immediately correcting our course are outlined. This includes the need to increase political attention, financing, collaboration, and coordination—especially for open drug discovery and development and robust testing of these options in adaptive platform trials in LMICs. 

In addition, given that policy makers are assessing options for the future of the Access to COVID-19 Tools Accelerator (ACT-A), it is critical that the ACT-A Therapeutics Partnership ensure more balanced representation from LMICs and improve transparency. This would help address concerns that ACT-A relies too heavily on an outdated international aid model driven by the “global north” and is marred by opaque decision making processes. 

In light of enormous inequities in access to vaccines globally, it is also vital that we secure specific contractual commitments and enabling policies, such as the TRIPS waiver proposed by South Africa and India. This would ensure the rapid transfer of technology, large scale manufacturing, and equitable access to new and existing covid-19 diagnostics and therapeutics in addition to other health tools.

In the longer term, there must be sustained support for end-to-end R&D for numerous infectious diseases, or those that may emerge, with epidemic or pandemic character, with clear priority given to populations and pathogens most likely to be neglected by the market; a re-imagining of global health R&D coordination, collaboration, and financing to support a more distributed, decentralized, and democratic approach; and globally agreed norms and binding rules governing R&D and equitable access to essential health tools. 

Only with renewed public leadership and new models of international cooperation focused on these goals will it be possible to achieve continued innovation for the pressing healthcare needs of all people, no matter their income or where they live.

Rachel Cohen, regional executive director, Drugs for Neglected Diseases initiative North America, New York, USA

Michelle Childs, director of policy advocacy, Drugs for Neglected Diseases initiative, Geneva, Switzerland

Monique Wasunna, director,  Drugs for Neglected Diseases initiative Africa, Nairobi, Kenya

Michel Lotrowska, regional director, Drugs for Neglected Diseases initiative Latin America, Rio de Janeiro, Brazil

Kavita Singh, regional director,  Drugs for Neglected Diseases initiative India, New Delhi, India

Nathalie Strub-Wourgaft, director of neglected tropical diseases and covid, Drugs for Neglected Diseases initiative, Geneva, Switzerland

Bernard Pécoul, executive director, Drugs for Neglected Diseases initiative, Geneva, Switzerland

Competing interests: The authors declare no competing interests. All of the authors work for the Drugs for Neglected Diseases initiative (DNDi), which is working on issues in relation to treatments for covid.