America’s “Test to Treat” has failed. Here’s how to fix it.

We can still make distributing antivirals for COVID-19 a success.

A US government initiative designed to increase access to potentially life-saving oral antivirals for COVID-19 is failing. 

These drugs, especially Pfizer’s Paxlovid pill, are incredibly effective — Paxlovid cut the risk of death or hospitalization by about 90% in a phase 3 trial — but most high-risk patients never get them. 

Here’s how we can fix it and bring one of our best weapons against COVID-19 back to the frontlines.

The challenge: We now have effective antiviral pills for COVID-19, including Merck’s molnupiravir and Paxlovid, that can prevent severe illness and hospitalization. The US government purchased hundreds of thousands of courses of these meds and shipped them to pharmacies to distribute for free.

In theory, most high-risk patients who need the drugs should be getting them, but that’s not the case. A big part of the problem is that antivirals for COVID-19 must be taken within days of symptoms appearing to be most effective.

“The drugs clearly are not getting to people at high enough rates to have their maximum impact.”

Amesh Adalja

Most people don’t test for COVID-19 until they start to feel sick. If the test results are slow, the window of effectiveness has often passed by the time they get a positive result, see their doctor for a prescription, and actually obtain the meds.

As a result, many of these potentially life-saving antivirals for COVID-19 have been sitting unused on pharmacy shelves.

​​”There’s an assumption that there’s not enough of [these drugs] around, but it does seem when you look at the numbers that there is a lot around — it’s just not being used,” Amesh Adalja, an infectious disease physician at the Johns Hopkins Center for Health Security, told NPR

“They clearly are not getting to people at high enough rates to have their maximum impact,” he continued.

“Test to treat is exactly what we should be doing at this point. But the implementation simply has not worked.”

Mara Aspinall

Test to Treat: To try to increase access, the government launched the Test to Treat initiative in March. People can go to a website to find a site where they can get tested for COVID-19 and, if they qualify, receive free antivirals for COVID-19 at the same time.

Unfortunately, large numbers of the meds are still going unused.

“Test to treat is exactly what we should be doing at this point. But the implementation simply has not worked,” Mara Aspinall, a biomedical diagnostics professor at Arizona State University, told the Financial Times

One problem with the initiative is regulations that require a doctor to make the prescription, and most pharmacies don’t have someone capable of writing prescriptions on site.

Of the tens of thousands of pharmacies in the US that have antivirals in stock, the vast majority can’t participate in Test to Treat. In North Dakota — a state that’s the size of all of New England combined — there are only three Test to Treat locations.

Most pharmacies don’t have someone capable of writing prescriptions on site.

Another problem is that many people are taking rapid tests at home, not at labs, and doctors may insist on a PCR test before prescribing.

In addition, when tests happen at clinics, there’s an opportunity for a healthcare professional to let a patient know about their treatment options — that opportunity is lost with at-home tests. But even when people are told about antivirals for COVID-19, some simply turn down the meds.

“When a patient comes to us and they’re COVID positive and they have some mild symptoms, we offer them some of these drugs if they fit the criteria,” Phyllis Tien, an infectious disease physician at UC San Francisco, told NPR. “But some of them don’t want to take the drugs.”

Looking ahead: It’s hard to say what might convince people who don’t want the treatment, but there are several ways to make Test to Treat more effective. 

The Department of Health and Human Services could authorize pharmacists to dispense the antivirals, which would allow any pharmacy to participate in the program.

“We’ve put tests into everyone’s homes. Now let’s link those tests to telemedicine and treatment.”

Michael Mina

The US could also eliminate the need to visit a pharmacy altogether.

Patients could take an at-home test, show a healthcare provider their results via video chat, and then have antivirals for COVID-19 delivered right to their home — if needed, the provider can even virtually supervise the testing process. 

“All of a sudden, you can massively decrease barriers to people getting treated for COVID-19,” Michael Mina, CSO of the health software company eMed, told TIME. “We’ve put tests into everyone’s homes. Now let’s link those tests to telemedicine and treatment.”

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