Elevated Lipoprotein(a) [Lp(a)] is an independent, genetically determined risk factor for atherosclerotic cardiovascular disease (ASCVD), with levels >50mg/dL affecting 20–30% of the global population. Despite therapeutic limitations, interest in Lp(a) has increased, driven by its prognostic value and the emergence of targeted therapies. However, with increasing guideline-directed Lp(a) testing, clinician response to elevated concentrations, especially in the absence of guideline-based treatment indications, remains unclear.
In a new study and presentation at the American College of Cardiology, researchers found that elevated Lp(a) was associated with earlier and more frequent initiation of preventive pharmacotherapy. These response rates were modest in a low-risk, primary prevention study population.
Specifically, nearly 80% of patients with elevated Lp(a) > 50mg/dL did not initiate lipid-lowering therapy in the absence of other ASCVD risk factors. Drugs that drastically lower “bad” LDL cholesterol (PCSK9 inhibitors) and aspirin initiation was even less common, suggesting selective rather than systematic responses to elevated Lp(a). Together, these findings suggest that elevated Lp(a) appears to only occasionally influence prescribing behaviour – behaviour consistent with previous reports.
“While not currently a standard indication for statin therapy alone, elevated Lp(a) is increasingly used by clinicians as a “risk enhancer” to guide more aggressive, albeit often unstandardised, preventive measures,” says corresponding author Sheilah A. Bernard MD, associate professor of medicine at Boston University Chobanian & Avedisian School of Medicine.
The researchers conducted a multicentre retrospective observational cohort study evaluating initiation of preventive pharmacotherapy following Lp(a) measurement among nearly 15 000 patients at low risk for ASCVD. Within 90 days of Lp(a) measurement, lipid-lowering therapy initiation was uncommon but more frequent among patients with elevated Lp(a) compared to those with non-elevated Lp(a). PCSK9 inhibitor initiation was rare but more frequent among patients with elevated Lp(a). Similarly, aspirin initiation was uncommon but more frequent among patients with elevated Lp(a).
According to the researchers, these findings should not be interpreted as indicating that such prescribing is guideline-directed. “Current recommendations recognise Lp(a) as a risk-enhancing factor rather than as a treatment target, and no therapy is approved solely for Lp(a) elevation. Our analysis describes contemporary practice rather than appropriate management,” adds Bernard who also is a cardiologist at Boston Medical Center.
The first major update to resistance-training guidelines in 17 years delivers one clear message: any amount of resistance training improves strength, muscle size, power and physical function.
The new recommendations, published by the American College of Sports Medicine (ACSM) as a Position Stand, are based on 137 systematic reviews involving more than 30 000 participants, making them the most comprehensive resistance-training guidelines to date.
“The best resistance training programme is the one you’ll actually stick with,” says Stuart Phillips, distinguished professor in the Department of Kinesiology and an author on the Position Stand. “Training all major muscle groups at least twice a week matters far more than chasing the idea of a ‘perfect’ or complex training plan. Whether it’s barbells, bands, or bodyweight, consistency and effort drive results.”
This update has been a long time coming. ACSM last published a Position Stand on resistance training for healthy adults in 2009, predating the explosion of research on muscle health, aging and the role of strength in long-term wellbeing.
“The new document reflects that surge in evidence and expands its recommendations to include more people and more types of training than ever before,” Phillips says.
A central theme of the new Position Stand is that the most meaningful gains come from a simple shift: moving from no resistance training to any form of it. While training variables such as load, volume, or frequency can be fine-tuned, the primary goal for most adults should be to build a consistent routine.
One of the greatest changes is the recognition that meaningful results don’t require a gym. Elastic bands, bodyweight training and home-based routines offer clear and measurable improvements in strength, muscle size and functional performance.
Rigid rules and prescriptive ideal programs are no longer supported by evidence, explains Phillips. Instead, personal goals, enjoyment, and long-term adherence matter most, especially for adults looking to stay strong, healthy and functional as they age.
Athletes and highly trained individuals will still require more specialized, sport-specific programs, but for the average adult, the message is simple: find a resistance-training routine you enjoy and stick with it.
Countries like South Africa benefited in very concrete ways from multilateral forums. Photo by Kindel Media
By Marcus Low
Funding cuts over the last year or so have created a crisis for multilateral health institutions. Which institutions emerge from this crisis, and in what form, will have real consequences for the health of people in South Africa, argues Spotlight editor Marcus Low.
In recent weeks, there has been a glut of articles from global health big-hitters, all concerned with how multilateral health institutions should, or should not be re-designed. These include articles from Philippe Duneton, Executive Director of UNITAID, Sania Nishtar, CEO of GAVI, and one co-authored by, among others, Anders Nordström, a former acting Director-General of the WHO, Helen Clark, a former New Zealand Prime Minister, and Peter Piot, the driving force behind UNAIDS from the mid-90s to 2008.
The immediate cause of all this debate is the stark reality that funding for multilateral health institutions have been cut dramatically in the last year, mainly, but not exclusively, due to the United States’ retreat from such international forums in favour of bilateral agreements. Even before the funding cuts, the financial outlook at entities like the World Health Organization (WHO) and UNAIDS was bleak. Over the last year, it has tipped over into outright crisis.
The WHO has already undertaken drastic organisational restructuring. Last year, a UN document raised the possibility of “sunsetting” UNAIDS by the end of 2026. It is likely that we will see several more organisations shrinking or disappearing altogether in the coming years.
Why does this matter?
The multilateral health institutions we’ve had in recent decades have not been perfect. They were often overly politicised, fraught with power imbalances, and not always capable of responding quickly and effectively to health emergencies.
But even so, it is unequivocally true that when it comes to healthcare, multilateralism has yielded many tangible benefits that are helping keep people alive. In a world where every country stands alone, these benefits will simply fall away.
There are many examples of such benefits. The WHO’s treatment guidelines for diseases like HIV and TB are public goods that are invaluable in many countries – here in South Africa they were particularly important as an antidote to the crackpot science that flourished in the period of state-sponsored AIDS denialism. The sharing of genomics data between countries was critically important at the height of the COVID-19 pandemic. Over an even longer period, the sharing of data on influenza strains has enabled the rational selection of vaccine components for each hemisphere each year. Medicines regulators in different countries increasingly share some of their work in order to speed their processes up and avoid duplication.
This year, a new HIV prevention injection containing the antiretroviral lenacapavir is being rolled out in South Africa and several other countries, largely with the help of the Global Fund, another international entity. A stable supply of low-cost lenacapavir should be available in around a year or two from now, due to market-shaping work done by UNITAID, the Gates Foundation, the Clinton Health Access Initiative, and Wits RHI. Such market-shaping often involves committing ahead of time to purchase certain volumes of a product to incentivise manufacturers to invest in production capacity, thus kick-starting the market for the product.
Then there is the recent history of how rapidly a new antiretroviral medicine called dolutegravir was rolled out in South Africa from 2019 – today over five million people here are taking it. The Geneva-based Medicines Patent Pool (MPP) negotiated licenses that allowed generic competition to start years earlier than would otherwise have been the case. That enabled the low prices and supply security that has facilitated the massive uptake of dolutegravir here and in dozens of other countries.
It is clearly in South Africa’s interest to help keep mechanisms like the above going.
But to reduce the value of these institutions to purely the technical would miss the essence of what animates them in the first place. The reality is that multilateral health institutions have often been at their most effective when people were driven by the need to address urgent health needs, as for example in the early days of UNAIDS. The belief that people’s health matter, no matter who they are, or where they live – essentially a belief in human rights – can make the difference between an ineffectual bureaucracy and a vital health movement. Our current crisis is not only one of technical capacity, but also one where the animating power of human rights-based thinking is being challenged.
How then should we think about redesigning global health?
There are some tensions between fighting to keep what we currently have and embracing big reforms. For example, on the one hand, given the aid cuts of the last year, people have good reason to be concerned about the potential closure of UNAIDS being a precursor to the further unravelling of the global HIV response. On the other hand, there are legitimate questions as to whether UNAIDS is still fit for purpose, given how the HIV epidemic has changed over the last three decades.
One of the most useful contributions in how to think about all this comes from Nordström and his co-authors. They outline four key paradigm shifts that help bring the current moment into focus. Their paper is worth reading in full for the nuances, but here is a brief paraphrasing of the four paradigm shifts:
The first shift is about recognising the fundamental changes underway in the global burden of disease and in demography. In short, while the key threats in the last three decades were the infectious diseases malaria, tuberculosis, and HIV, they are increasingly being overtaken by non-communicable diseases (like diabetes and hypertension) and mental health disorders. This shift is not yet reflected in the architecture of multilateral health institutions.
The second shift relates to the recentring of power from Geneva in Switzerland and New York and Washington in the USA to countries and regions, giving rise to an increasingly multipolar world. “This shift does not imply that multilateral cooperation is obsolete,” write the authors, “however, it requires a clarification of which future functions should be performed at the global level, and which should be performed by national and regional bodies.”
The third shift refers to the growing push to modernise the landscape of global health institutions. The authors write: “Leaders from low-income and middle-income countries have repeatedly critiqued the dearth of systemic support, the inefficiencies of vertical initiatives, and the resource-intensive bureaucratic processes that accompany them”. Considering these external and internal pressures, they argue there is a need to move from a complex and competitive system to a simpler, needs-based, and agile system.
The fourth shift is linked to the declining relative importance of development assistance, coupled with countries’ rising commitments to increase domestic financing for health. Although some international support will remain essential for low-income countries and humanitarian responses, the authors argue that domestic resources must be the engine of a new ecosystem and ways of working together.
All of these shifts are now occurring within the broader geopolitical context of what Canadian Prime Minister Mark Carney recently described as a “rupture in the world order”. He stressed that the great powers have turned their backs on the rules-based world order and have “begun using economic integration as weapons, tariffs as leverage, financial infrastructure as coercion, supply chains as vulnerabilities to be exploited”. This shift can already be seen in the US’s pivot from multilateralism to bilateral health agreements.
As Carney put it: “The multilateral institutions on which the middle powers have relied – the WTO, the UN, the COP – the architecture, the very architecture of collective problem solving are under threat.”
He argues that middle-powers like Canada, and I’d argue South Africa should aspire to be part of this group, should chart a way forward where they are not overly reliant on super powers like the US and China. Avoiding such an over-reliance is of course also an obvious lesson to take from the US’s abrupt cuts to health aid last year.
Maybe a first harsh reality to come to terms with then is that the rupture that is taking place in global geopolitics is also occurring in the world of global health. To think that we can go back to the way the WHO or UNAIDS were twenty years ago, is wishful thinking. The “rupture” might take time to propagate, but it will extend all the way.
What then is to be done?
Carney also makes the point that the rules-based order wasn’t in fact working as well for everyone as we liked to pretend. To a lesser extent, something similar could be said for multilateralism in health. Getting things done was often hard, the politics was often tricky, and when it came to the crunch, say on something like patents on medicines, the US and Europe almost always held sway.
As outlined above, countries like South Africa benefited in very concrete ways from multilateral forums, but somehow those benefits were never widely appreciated. Ultimately, it is telling that so many national governments have failed to put up the money the WHO requires to do its work – even before the current US withdrawal.
Maybe then, to make a reset of multilateral health institutions a success, will require that governments reassess and newly appreciate why it is that we need multilateral health institutions in the first place.
This will require a thorough and honest assessment of what we have gained from these institutions in recent decades. Things like market-shaping, patent pooling, pooled procurement, sharing of genomics and other data, regulatory harmonisation, guideline development, research cooperation, and multilateral fund raising have all been important and will continue to be so. We must make sure that in whatever emerges in the next few years, we have multilateral mechanisms that can deliver in all these areas.
But we will have to accept that those entities might look quite different from what we’ve come to know in recent decades. There will certainly be areas in which we still need global institutions like the WHO, but for some issues we might get more done by working with coalitions of the willing, or collaborating at a regional level – as we’re already seeing with the African Medicines Agency (although South Africa rather inexplicably hasn’t yet ratified the related treaty).
The reality is that apart from governments just not being willing to spend more on health at the moment, the enabling geopolitical substructure that we’ve been relying on for decades has given way. In many respects, this has been a disaster for our common good, but it is also an opportunity to craft new and more fit-for-purpose multilateral health institutions that are animated by a shared commitment to human rights. This is an opportunity that countries like South Africa must grasp.
As Carney put it: “We know the old order is not coming back. We shouldn’t mourn it. Nostalgia is not a strategy, but we believe that from the fracture, we can build something bigger, better, stronger, more just. This is the task of the middle powers, the countries that have the most to lose from a world of fortresses and most to gain from genuine cooperation.”
*Low is the editor of Spotlight.
This article was jointly published with Health Policy Watch, a global health news platform.
Disclosure: The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
New research from a University of Cincinnati Cancer Center study found external beam radiation therapy (EBRT) is safe to administer to patients with liver cancer even after they undergo a targeted internal radiation therapy with Yttrium-90 (Y90).
Led by first author Sarah Feldkamp, MD, and senior author Jordan Kharofa, MD, the research was published in the American Journal of Clinical Oncology. Feldkamp explained that while traditional EBRT delivers radiation from a machine outside the body, Y90 provides carefully aimed treatment for liver cancer through microscopic beads injected into the blood supply.
The location and size of each tumour help clinicians decide which radiation approach to take with each patient. But following Y90, doctors questioned whether the treatment exhausted the liver’s radiation tolerance, meaning additional EBRT could lead to toxicity.
In the study, the team reviewed 94 patients with liver cancer treated with EBRT from 2016 to 2024, including 15 who were additionally treated with Y90.
“EBRT can be delivered after Y90 without an increase in toxicity,” said Feldkamp, a resident in the Department of Radiation Oncology in UC’s College of Medicine. “These results, though not particularly surprising to our team given collective personal experience, do contradict commonly held assumptions by others in the field.”
Kharofa said the study offers “meaningful reassurance” that EBRT can be offered after Y90 when treatment is carefully individualized to each patient.
“That expands the options we can offer patients with residual or recurrent disease, and I think it will change how some clinicians approach this sequencing question,” said Kharofa, senior advisor and chair of the Protocol Review and Monitoring System at the Cancer Center and professor in the Department of Radiation Oncology in UC’s College of Medicine.
“This research suggests that having had Y90 in the past doesn’t automatically close the door on radiation as a next step,” he continued. “The key is working with a team experienced in individualizing treatment plans, and that’s exactly the kind of care we aim to provide.”
Feldkamp noted that the relatively small size of this patient population makes a follow-up study or larger clinical trial more difficult. However, other institutions conducting similar single- or multisite reviews could provide more clarity on liver toxicity following radiation treatment for liver cancer.
Cipla recently brought together doctors and blood cancer experts for an academic summit to talk about an advanced cancer treatment called CAR‑T cell therapy, and what it could mean for people in Africa in the future.
CAR‑T cell therapy is a form of personalised medicine in which a person’s own immune cells are collected and modified in a specialised laboratory so they can better recognise and attack certain blood cancers. It is used in some countries for patients with specific types of lymphoma and leukaemia when other treatments have not worked. It is only available in a few highly specialised hospitals around the world.
The cost challenge
In the same way that quality, affordable antiretrovirals changed HIV from a fatal disease to a chronic condition in the early 2000s, one of the biggest challenges now is to make CAR-T cell therapy more widely accessible as costs are prohibitively expensive.
CAR‑T cell therapy remains complex and expensive to deliver, and the cost of treatment is a major barrier to access worldwide. In many high‑income countries, the cost of a single CAR‑T treatment can reach the equivalent of hundreds of thousands of US dollars per patient. In South Africa, high‑complexity cellular and stem cell procedures can cost in the order of millions of rand per patient, which means such therapies are beyond the reach of most people in both public and private sectors.
Paul Miller, CEO of Cipla Africa, said: “Treatment costs are a major hurdle for patients. Efforts to develop scientifically rigorous, clinically validated CAR‑T therapies at more sustainable costs could, in future, be very important for patients across Africa.”
Miller added: “Globally, there is increasing focus on making cutting‑edge therapies more accessible. By developing local expertise and manufacturing capabilities, countries can reduce reliance on expensive imports and work toward lowering costs over time.”
How CAR-T cell therapy works
If a patient is eligible, CAR‑T treatment usually starts with collecting some of their white blood cells through a process similar to donating blood. In a special laboratory, these cells are genetically modified so that they can better recognise and target cancer cells. The cells are then multiplied and later given back to the patient in a single infusion.
Studies in other countries have shown that CAR‑T therapy can help some patients with difficult‑to‑treat blood cancers achieve long‑lasting remissions. However, it does not work for everyone and can cause serious side effects, so patients must be treated and monitored in experienced centres.
CAR‑T cell therapy has evolved over several decades, and current research focuses on improving precision, safety, scalability and global accessibility, with the aim of making these treatments available to more patients across more cancer types in future.
Equitable access
Africa carries a heavy burden of both infections and cancer. South Africa, for example, has one of the largest populations of people living with HIV in the world, and these patients have a higher risk of certain blood cancers. This makes access to good‑quality, proven cancer care especially important.
People living with HIV face an increased risk of B‑cell malignancies, including aggressive lymphomas, making the need for effective and equitable cancer care all the more pressing.
Even though cancer treatment has improved a lot in Europe, North America and Asia, most patients in low‑ and middle‑income countries still do not have access to the newest therapies. The main barriers are high cost, the need for advanced laboratories and equipment.
Medical experts with deep clinical experience in environments from South Africa, Morocco and India contributed to the academic programme, bringing a global perspective to an African challenge and sharing important lessons learned.
The promise of CAR-T cell therapy
CAR‑T cell therapy has shown encouraging results in certain relapsed or refractory blood cancers, with some patients achieving deep and durable responses. Internationally, thousands of patients have now received CAR‑T treatment in approved centres.
Gene and cell therapies are subject to strict regulations and rigorous quality standards in many countries. In addition to cost, logistics and the “vein‑to‑vein” traceability chain are important factors that health systems must be equipped to manage.
“Cipla is committed to partnering with healthcare professionals, policymakers and institutions to chart a clear and equitable path for CAR-T therapy access across Africa, ensuring that the most vulnerable patients are not left behind in the next chapter of cancer care,” said Miller.
