In discussing the push to vaccinate against COVID-19 in developed economies like the US, UK, etc., what gets lost in political rhetoric is the importance of effective vaccination among the immunosuppressed, especially the HIV+ group.

In groups with underlying immunosuppression [i.e., people with hematological malignancies, people receiving immunosuppressive therapies for solid organ transplants, or other chronic medical conditions], there have been reports of prolonged COVID-19 infection. The latest one is from South Africa, where an HIV+ patient experienced persistent COVID-19 infection –of 216 days– with moderate severity. The constant shedding of the SARS-CoV-2 virus accelerated its evolution inside this patient. This is possible because suboptimal adaptive immunity delays clearance of the SARS-CoV-2 virus but provides enough selective pressure to drive the evolution of new viral variants. In this case, the mutational changes of the virus within the patient resembled the Beta variant.

The largest population of immunosuppressed [HIV+] is in South Africa. So an alternative to chasing variants like Delta and Beta after their largescale emergence or trying to convince people who reject vaccination in the Global North is to tackle super-spreading micro-epidemics of novel variants among the immunosuppressed in the Global South. Since Novovax and J&J are demonstrably ineffective among the immunosuppressed, the Moderna vaccine is the best bet to slow down the emergence of future variants.

Who has millions of unused mRNA Covid-19 vaccines that are set to go to waste? The answer is the United States. As demand dwindles across the United States and doses will likely expire this summer, why not use them in the Global South, especially South Africa, by a concerted international effort?