key: cord-1009828-ih1um9bl authors: Ferreira, Leonardo M. R.; Mostajo-Radji, Mohammed A. title: Plasma-based COVID-19 treatments in low- and middle-income nations pose a high risk of an HIV epidemic date: 2020-07-06 journal: NPJ Vaccines DOI: 10.1038/s41541-020-0209-2 sha: cba39bcabd8e039e29e0b1b379101e8dbbc18b81 doc_id: 1009828 cord_uid: ih1um9bl Convalescent plasma therapy holds promise as a transient treatment for COVID-19. Yet, blood products are important sources of HIV infection in low- and middle-income nations. Great care must be taken to prevent plasma therapy from fueling HIV epidemics in the developing world. related acute lung injury and transfusion-associated circulatory overload 6 . In fact, blood transfusions have been shown to represent an important source of HIV infection in many lowand middle-income countries, being associated with positive HIV status 7 . It is unlikely that most low-and middle-income countries will be able to secure the blood supply by universal HIV testing 7 . Even when funding is provided, access to medical materials and supplies in the international market remains difficult for the developing world 8 . For years, the United Nations Development Programme (UNDP) and the World Health Organization (WHO) have subsidized molecular testing in the developing world. One such program, the introduction of "all-in-one cartridge" systems for RNA sample isolation and PCR-based testing, has been used for HIV and tuberculosis diagnosis 9 . This technology has recently been approved for COVID-19 testing, although with significant delays in the delivery of reagents and supplies 10 . Importantly, this platform has a higher cost and lower throughput than other PCRbased approaches. It allows the processing of only up to four samples per run, severely limiting its utility for COVID-19 and HIV PCR-based testing in larger communities. Moreover, governmental laboratories with RNA testing capabilities are currently saturated in many low-and middle-income countries 11 , leaving administrators to decide between testing for COVID-19 or HIV. Regulations worldwide have forbidden paid organ and tissue donations for decades. Yet, these measures remain far from effective, particularly, in the developing world 12 . The reality of plasma donations is similar. In Bolivia, for instance, although law 1716 forbids any kind of payment for tissue donation, advertisements requesting paid plasma donations are common, even in prime time TV and national newspapers 13 . Such strategy is likely to be successful, as media coverage has been shown to positively impact organ and tissue donation rates 14 . Some regions have circulating lists of infected individuals. Plasma donations are compensated with thousands of dollars, several times the local average monthly salary, and can be performed once a week. Patients who recover following convalescent plasma infusion are then encouraged to donate their plasma. In addition to resembling a pyramid-type scheme, such practice does not have a solid scientific rationale, as these patients are highly unlikely to have developed any neutralizing antibodies against SARS-CoV-2. In fact, even among individuals who recover from SARS-CoV-2 on their own, one-third have low or undetectable neutralizing antibody titers 2 . Such a plasma black market is reminiscent of events in the 1990s in China, where an HIV epidemic began with local pay-for-plasma schemes 15 . Rapid and affordable antibody-based HIV and COVID-19 testing capacity must be escalated in the developing world. One possible strategy is to share plasmids with biomedical facilities in low-and middle-income countries, which could then locally produce the reagents for antibody-based testing, circumventing the high costs and waiting times associated with importing such tests from abroad 10 . Centers with a proven track record of testing for endemic contagious diseases in the developing world exist, some of them resulting from multinational collaborations with developed nations 16 . Furthermore, antibody-based tests generated inhouse may be more accurate and cost-effective than commercial ones 17 , so sharing parts and reagents (e.g., plasmids, purified antibodies) may be more desirable than already assembled testing kits. Importantly, conventional antibody-based HIV testing may miss early infection 18 . Hence, methods to detect viral nucleic acids directly remain desirable. Recently developed CRISPR-based methods to detect specific viral RNA sequences amenable to lyophilization, long-term storage, and reconstitution on paper represent a promising approach to detect the presence of SARS-CoV-2 and HIV, both RNA viruses, in locations with little to no healthcare infrastructures 19, 20 . More bilateral and multilateral scientific collaborations between high-and low-and middleincome countries should be encouraged to gradually foster productive scientific collaboration and build local biomedical infrastructure 21 . In summary, convalescent plasma therapy holds promise as an emergency transient treatment for critical COVID-19 patients. Nevertheless, it is of utmost importance to emphasize that, unlike chemicals, such as hydroxychloroquine, which can only harm the individual taking them, plasma therapy can endanger entire communities. In scenarios of scarce blood-borne pathogen testing capacities, few enforced regulations, and widespread misinformation and disease stigma, unregulated convalescent plasma therapy may well become a recipe for a new HIV epidemic in the developing world. 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