Paxlovid, the brand name for a combination therapy consisting of ritonavir and nirmatrelvir, is an oral antiviral medication available for the treatment of COVID-19. If taken early enough, it can significantly improve not only the patient’s outlook, but also reduce the chances of an infected person passing the disease on to others. Although it does have potentially severe interactions with some common medications, for most people Paxlovid is a safe and effective treatment with few adverse outcomes. Paxlovid can be prescribed by a physician or pharmacist to patients who quality. Roughly 75% of the adult U.S. population meets the eligibility requirements for a Paxlovid prescription due to having at least one risk factor for severe COVID-19.
Yet despite these numbers, almost no one is taking Paxlovid. Out of those eligible for the drug, only about 15% actually receive it. A recent NIH study of Paxlovid’s effectiveness against hospitalization and death found that “Paxlovid is effective in preventing hospitalization and death in at-risk COVID-19 patients,” but uptake was inconsistent and varied widely by geographic region, reaching as low as 0% in some areas and as high as 50% in others.
Because the data roughly mirrors geopolitical trends, it might be tempting to blame divisive politics and/or misinformation on the low uptake of Paxlovid, with those living in “red” states less likely to receive it. However, the NIH study found that education level, percent of the population identifying as Hispanic or African American, poverty status, and unemployment were all predictors of Paxlovid treatment. These factors are all known drivers of health inequity, and therefore Paxlovid access mirrors inequities in health care access in the U.S. Notably, these factors are also associated with a higher risk of hospitalization or death from COVID-19.
It might then also be tempting to blame Paxlovid’s poor uptake on the failings of the U.S. health care system more generally. However, poor communication between federal agencies, health departments, providers, and the general public has undoubtedly played a significant role. First, consider the issue of who is at “high risk” for hospitalization or death. The messaging of public health agencies, particularly the CDC, has consistently emphasized that COVID-19 is a serious health concern for “high-risk” individuals, but has failed to underscore the fact that approximately three quarters of the adult U.S. population falls into this category, at least as far as Paxlovid eligibility is concerned. A study published in 2023 found that only 18.5% of those eligible for oral antiviral medications believed that they were at high risk for severe disease, and only 15.9% received a prescription and took it within five days of testing positive. The same study also found that lack of awareness was not a major obstacle to uptake. About 80% of patients were aware of the medications–they simply did not believe they needed to take them.
To facilitate the use of Paxlovid and other medications for COVID-19, the federal government initiated the Test to Treat program, which aims to reduce barriers to testing and prescription; however, the program’s website is difficult to navigate, and finding a participating location can be challenging. The FDA also passed guidance allowing pharmacists to prescribe Paxlovid to eligible patients, theoretically removing the barrier of having to access a physician. However, much confusion about this guidance persists. Insurance often does not cover treatments prescribed by a pharmacist, and patients must have bloodwork documenting their kidney and liver function taken within the past year. Drug interactions are also a common concern with drugs like Paxlovid, and while many of the medications with serious interactions can safely be discontinued during the course of treatment, the prescribing physician must oversee this process. The result of this lukewarm commitment to ensuring equal access to this antiviral medication is that those at highest risk for a severe outcome are the least likely to be prescribed Paxlovid.
Unfortunately, physicians may also play a significant role in the problem. A study by the CDC, which aimed to determine why oral antivirals for COVID-19 are under-prescribed to immunocompromised patients, found that the most common reason for failing to prescribe Paxlovid was mild or absent symptoms. This is due to a misperception among clinicians that Paxlovid should only be offered in moderate or severe cases. Despite official guidance to the contrary, many providers have not been adequately educated on the proper use of these medications.
Another significant communications failure is the controversy around the so-called “Paxlovid rebound” effect, in which a patient tests positive for COVID-19 after initially testing negative and completing the full course of medication. In fact, as one author notes, it would be more accurate to call this effect “COVID rebound,” because subsequent research has found that this phenomenon is no more likely to occur if Paxlovid is taken versus no intervention, nor is it even unique to COVID-19, as the rebound effect has been observed in other viral infections. Nonetheless, this confusion is a commonly cited reason for hesitancy.
The bottom line is that if you are one of the 100 million Americans who do not have access to a primary care physician who can prescribe Paxlovid within the short timeframe in which the drug is effective, getting the drug can be both difficult and expensive, with high barriers to access in the best of circumstances. And because the public health messaging around COVID-19 has focused so much on personal risk while also failing to adequately clarify who exactly is at risk and why, most Americans simply won’t seek out this potentially life-saving medication.
While there are many larger structural issues at play, a coordinated, strategic communications plan initiated at the federal or state level, along with more funding to help low-income Americans access antiviral medication, could go a long way toward improving uptake. But failing that, we can each do our part to encourage friends and family to find out if they are eligible for Paxlovid before they test positive and help them come up with a strategy for acquiring the medication in the event that they do. The right information could be the difference between a quick recovery and a serious outcome.