Equitable access to cell and gene therapies in South Africa: opportunities and hurdles

The translational gap for gene therapies in low- and middle-income countries

Gene therapies are designed to address the root cause of disease. As scientific understanding of disease prevention, diagnosis, and treatment improves in tandem with technological innovation, gene therapies have the potential to become safe and effective treatment options for a wide range of genetic and nongenetic diseases. However, as the medical scope of gene therapies expands, consideration must be given to those who will benefit and what proactive steps must be taken to widen development and access potential, particularly in regions carrying a high disease burden.

Looking ahead: ethical and social challenges of somatic gene therapy for sickle cell disease in Africa

Somatic gene therapy will be one of the most exciting practices of genetic medicine in Africa and is primed to offer a "new life" for persons living with sickle cell disease (SCD). Recently, successful gene therapy trials for SCD in the USA have sparked a ray of hope within the SCD community in Africa. However, the high cost, estimated to exceed 1.5 million USD, continues to be a major concern for many stakeholders. While affordability is a key global health equity consideration, it is equally important to reflect on other ethical, legal and social issues (ELSIs) that may impact the responsible implementation of gene therapy for SCD in Africa. These include informed consent comprehension, risk of therapeutic misestimation and optimistic bias; priorities for SCD therapy trials; dearth of ethical and regulatory oversight for gene therapy in many African countries; identifying a favourable risk-benefit ratio; criteria for the selection of trial participants; decisional conflict in consent; standards of care; bounded justice; and genetic tourism. Given these ELSIs, we suggest that researchers, pharma, funders, global health agencies, ethics committees, science councils and SCD patient support/advocacy groups should work together to co-develop: (1) patient-centric governance for gene therapy in Africa, (2) public engagement and education materials, and (3) decision making toolkits for trial participants. It is also critical to establish harmonised ethical and regulatory frameworks for gene therapy in Africa, and for global health agencies to accelerate access to basic care for SCD in Africa, while simultaneously strengthening capacity for gene therapy.

Navigating equity in global access to genome therapy expanding access to potentially transformative therapies and benefiting those in need requires global policy changes

In December 2023, the US Food and Drug Administration and the UK Medicines and Healthcare Products Regulatory Agency granted the first regulatory approval for genome therapy for sickle cell disease. This approval brings hope to those suffering from this debilitating genetic disease. However, several barriers may hinder global patient access, including high treatment costs, obtaining informed consent for minors, inadequate public health infrastructure, and insufficient regulatory oversight. These barriers reflect the structural inequalities inherent in global health governance, where patient access often depends on social and institutional arrangements. This article addresses concerns around informed consent, treatment costs, and patient access, and proposes corresponding policy reforms. We argue that these discussions should be framed within a broader global context that considers social and institutional structures, global research priorities, and a commitment to health equity.

Nurses' roles in CAR-T therapy for B-cell malignancies and managing associated cytokine release syndrome

Introduction

In recent times, significant innovations have been made in cancer immunotherapy. These innovations have yielded positive outcomes, including a substantial improvement in the clinical outcomes of cancer patients, especially in the B-cell setting involving patients with B-cell malignancies.

Method

This paper explores oncology nurses' actual and expanded roles in utilizing chimeric antigen receptor T-cell (CAR-T) therapy.

Result

CAR-T therapy is an exciting innovation in cancer treatment. However, this therapy is often associated with some mild to life-threatening side effects and toxicities, including cytokine release syndrome (CRS). Unfortunately, nurses lack adequate standardized guidelines for monitoring and managing patients with CRS. This paper explains oncology nurses' actual and expanded roles in utilizing CAR-T therapy in treating B-cell malignancies based on experience and published data.

Discussion

Nurses' responsibilities for patients experiencing CAR-T toxicities with a particular focus on CRS during treatment are discussed.

Access to CAR T-cell therapy: Focus on diversity, equity and inclusion

Chimeric antigen receptor T-cell (CAR T-cell) therapy has revolutionized the treatment of hematologic malignancies in patients with relapsed or refractory disease without other treatment options. However, only a very small proportion of patients with an indication for CAR T-cell can access the treatment. The imbalance between supply and demand is magnified in minority and vulnerable populations. Limited access is multifactorial and in part a result of factors directly related to the cellular product such as cost, complex logistics and manufacturing limitations. On the other hand, the impact of diversity, equity, and inclusion (DEI) and their social and structural context are also key to understanding access barriers in cellular therapy and health care in general. CAR T-cell therapy provides us with a new opportunity to better understand and prioritize this gap, a key step towards proactively and strategically addressing access. The aim of this review is to provide an analysis of the current state of access to CAR T therapy with a focus on the influence of DEI. We will cover aspects related to the cellular product and the inseparable context of social and structural determinants. Identifying and addressing barriers is necessary to ensure equitable access to this and all future novel therapies.

Flow cytometry: A powerful analytical technique for characterizing the biological function of biotherapeutics and biosimilars

Biotherapeutics are complex molecules with therapeutic activity produced through biotechnology and/or genetic engineering. These medicines have clinical applications in diagnostic procedures and therapies for many disorders, including cancer, autoimmunity, and chronic degenerative diseases. Most biotherapeutics are expensive and sometimes unaffordable for low-income patients suffering from cancer or chronic illness. Biosimilars emerged in the 2000 s after patents of many innovative biotherapeutic products expired. The Biosimilar market is growing fast and demands reliable technologies for analyzing the physicochemical properties and bioactivity of products. A big challenge for biosimilar development is to prove comparable bioactivity, safety, efficacy, and toxicity profile as the innovator product. Bioactivity assessment can utilize different analytical techniques such as ELISA, flow cytometry, and surface plasmon resonance. Flow cytometry is a versatile analytical tool that can be used for the development of quantitative, reproducible, and accurate protocols suitable for routine evaluation of bioactivity in-vitro. Nevertheless, flow cytometry has been very scarcely used in comparability evaluation between biosimilar versus an originator product. Here, we review potential applications of flow cytometry to carry out functional bioassays of biotherapeutics or biosimilars.

Glucarpidase (carboxypeptidase G2): Biotechnological production, clinical application as a methotrexate antidote, and placement in targeted cancer therapy

Patients receiving high-dose methotrexate (HDMTX) for malignancies are exposed to diverse complications, including nephrotoxicity, hepatotoxicity, mucositis, myelotoxicity, neurological symptoms, and death. Glucarpidase is a recombinant carboxypeptidase G2 (CPG2) that converts MTX into nontoxic metabolites. In this study, the role of vector type, gene optimization, orientation, and host on the expression of CPG2 is investigated. The effectiveness of various therapeutic regimens containing glucarpidase is classified and perspectives on the dose adjustment based on precision medicine are provided. Conjugation with cell-penetrating peptides, human serum albumin, and polymers such as PEG and dextran for delivery, higher stability, and production of the biobetter variants of CPG2 is highlighted. Conjugation of CPG2 to F(ab՜)2 or scFv antibody fragments against tumor-specific antigens and the corresponding prodrugs for tumor-targeted drug delivery using the antibody-directed enzyme prodrug therapy (ADEPT) is communicated. Trials to reduce the off-target effects and the possibility of repeated ADEPT cycles by adding pro-domains sensitive to tumor-overexpressed proteases, antiCPG2 antibodies, CPG2 mutants with immune-system-unrecognizable epitopes, and protective polymers are reported. Intracellular cpg2 gene expression by gene-directed enzyme prodrug therapy (GDEPT) and the concerns regarding the safety and transfection efficacy of the GDEPT vectors are described. A novel bifunctional platform using engineered CAR-T cell micropharmacies, known as Synthetic Enzyme-Armed KillER (SEAKER) cells, expressing CPG2 to activate prodrugs at the tumor niche is introduced. Taken together, integrated data in this review and recruiting combinatorial strategies in novel drug delivery systems define the future directions of ADEPT, GDEPT, and SEAKER cell therapy and the placement of CPG2 therein.

Development of novel therapeutics for all individuals with CF (the future goes on)

Despite the major advances and successes in finding and establishing new treatments that tackle the basic defect in Cystic Fibrosis (CF), there is still an unmet need to bring these potentially curative therapies to all individuals with CF. Here, we review aspects of what is still missing to treat all individuals with CF by such approaches. On the one hand, we discuss novel holistic (high-throughput) approaches to elucidate mechanistic defects caused by distinct classes of mutations to identify novel drug targets. On the other hand, we examine therapeutic approaches to correct the gene in its own environment, i.e., in the genome.

Gene therapy access: Global challenges, opportunities, and views from Brazil, South Africa, and India

Gene and cell therapies for a variety of life-limiting illnesses are under investigation, and a small number of commercial products have successfully obtained regulatory approval. The cost of treatment is high, and clinical studies evaluating safety and efficacy are performed predominately in high-income countries. We reviewed the current status of gene and cell therapies in low- and middle-income countries and highlighted the need and current barriers to access. The state of product development in Brazil, South Africa, and India is discussed, including lessons learned from American Society of Gene and Cell Therapy (ASGCT)-sponsored virtual symposia in each of these countries.