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This antiviral pill paired with COVID vaccines offers the hope of ‘zero COVID deaths,’ officials say

San Francisco Chronicle logo San Francisco Chronicle 5/13/2022 By Catherine Ho

When Martha Smith came down with a cough that turned out to be COVID in late April, she figured she’d be able to get Paxlovid, the antiviral pill that’s now in increasingly ample supply at many pharmacies, pretty quickly.

“I thought it was going to be easy,” said Smith, who lives in Oakland. “We’ve been at this for two years, surely we’ve developed some processes around this.”

Instead, Smith spent the next two days on the phone, speaking to multiple doctors and CVS locations before tracking down the Pfizer drug at a pharmacy in Oakland. All the while, the clock was ticking because she began the process three days into her symptoms and Paxlovid must be started within the first five days of onset to properly do its job.

“You would’ve thought I was the first person to have ever asked for this, which seems like a public health education flaw, but also an organizational flaw,” said Smith, who is vaccinated and boosted and qualifies for the drug because her weight puts her at higher risk for progressing to severe disease.

Public health officials are racing to raise awareness and improve access to Paxlovid so people like Smith can halt mild COVID symptoms before they get more serious. Unlike remdesivir and monoclonal antibody infusions — treatments that have been around longer than the pills, but require people to go to a hospital or clinic — antiviral pills have been lauded as a cheap, accessible way anyone could get treatment at home by picking them up at a pharmacy.

Combined with widespread vaccination and boosting, the pills offer a promise unthinkable when the pandemic started in 2020: that almost nobody should die from COVID anymore. Experts from FDA Commissioner Dr. Robert Califf to local Bay Area health officers are now daring to talk about “zero COVID deaths,” thanks to the combined power of shots and pills.

But the health care system, as on so many other occasions during the pandemic, is struggling to catch up to this vision. Many doctors aren’t comfortable yet prescribing the new drug, in part because Paxlovid has the potential to interact harmfully with common medications and thus requires a careful review of the patient’s regimen. Many don’t know which pharmacy to send the prescription to since not all locations have it, despite the federal “Test to Treat” program adding sites each week. Meanwhile, some patients are unaware such a treatment is available, whether they qualify, or how to get it.

Smith has chronic lung issues and is used to advocating, sometimes stubbornly, for her health. She feels lucky to have a regular health care provider that she knows how to reach and that she eventually got her hands on the five-day course of 30 Paxlovid pills. Her symptoms have since faded.

“I’m fine,” she said. “But a lot of people would be sicker than me, and in life situations where they didn’t have the freedom to make six phone calls.”

In some ways, the U.S. is at a juncture that would’ve been unimaginable a year ago — in a good way. Most Americans are now vaccinated, and many are boosted, with vaccines that are extraordinarily good at reducing the risk of severe disease and death. And two antiviral pills, Pfizer’s Paxlovid and the less commonly used molnupiravir from Merck, are for the first time no longer in short supply. If anyone was looking for a sign that society can live with the virus, this is arguably it.

That makes this current swell of cases the first where the promise of antiviral pills — hailed as game-changers when they were first authorized in late 2021 — will be put to the test. During the earlier omicron surge that peaked in January, the pills were so new and scarce that only the very highest-risk people could get them and even then they were hard to find for many.


Video: Who is eligible for COVID-19 antiviral drug Paxlovid? (ABC News)

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Some progress is being made locally. Contra Costa County has set up a 24/7 phone line to help connect residents with doctors who can prescribe Paxlovid, if appropriate. Marin and San Mateo counties are opening new Test to Treat sites where residents can get tested and, if they’re positive, get a prescription on the spot. Some Bay Area residents say they’ve been able to get Paxlovid quickly and easily, in some cases on the same day with minimal effort.

“It happened without a lot of fanfare but is a key milestone in our pandemic response,” said Dr. Matt Willis, public health officer for Marin County. “For the first time since the beginning of the pandemic, we have enough medication in Marin to effectively treat everyone who should be treated with COVID-19.”

“While vaccines are our best line of defense, they aren’t 100%,” Willis added. “Paxlovid can reduce the risk of death in people at highest risk by another 90%.” When you combine the two, he says, you get “a 90% reduction in risk of dying by being infected, and on top of that, an additional 90% reduction of risk of death if you receive timely and appropriate treatment.”

The result: “For the first time, we can visualize a community with zero COVID deaths.”

Both drugs work by stopping replication of the virus in the body. Paxlovid, like HIV drugs, is a protease inhibitor that prevents production of new viral particles, while molnupiravir stops viral genetic material from being accurately copied.

Numbers aren’t available for how many people have received Paxlovid locally or in California, nor how much usage has changed over time. But health care providers say they are clearly prescribing it more in recent months. Under the FDA’s emergency use authorization guidelines, people can get Paxlovid if they are 12 or older and are at high risk for severe disease. Factors includes age, cancer, chronic kidney, lung and heart disease, diabetes, obesity and many other conditions. Initially, only those at very high risk — such as those who are severely immunocompromised — could get antiviral pills. Now, with improved supply, providers can offer it those at moderately high risk.

UCSF is dispensing about three to four times as much Paxlovid as it did in January, said Dr. Sarah Doernberg, who oversees the rollout of COVID antiviral treatments there.

Greater usage nationwide has highlighted a potential concern with Paxlovid, known as the “rebound” effect, where some people who finished their course of pills see symptoms return or later test positive again. In Pfizer’s clinical trials, this was reported at rates of 1.5% and 2%, and researchers are still trying to figure out how common it is in the real world and why it happens.

Doernberg said she has heard about this phenomenon anecdotally, but that it doesn’t discourage her from prescribing Paxlovid. “There’s definitely something out there, it’s just hard to know if people are able to test more, if it’s happening in people who don’t get treated, how often it’s happening,” she said. “All these things we need to quantify a little bit more.”

Whether antivirals will indeed be the game-changers many hoped remains unclear. One way to measure it, at the community level, is whether hospitalizations and deaths stay relatively low. On that front, things seem to be going well: hospitalizations are rising less steeply, proportionally to cases, than in previous surges. That metric, however, is influenced by so many other factors — how omicron subvariants are behaving, how many people are vaccinated and boosted, how many people have some natural immunity — that it’s hard so far to attribute it to treatments alone.

It may be, however, that antiviral pills have the power to shape behavior at the individual level, giving people like Smith some comfort in taking reasonable risks, aware that if she does fall ill, she can get an effective treatment.

“Knowing I had options, Paxlovid and a few other ones, and that the hospitals are pretty good around here, I felt like I had a good game plan that’d allow me to feel life is not risk-free, but taking sensible risks and understanding the risks I’m taking,” Smith said.

The Paxlovid rollout is still relatively new, but public health officials and providers assume the drug will eventually become normal in COVID care protocols.

“At some point it’ll kind of be the standard thing we do,” Doernberg said. “It’ll still require that level of thought because of the (drug) interactions. I do think with practice it will get easier for people.”

Catherine Ho (she/her) is a San Francisco Chronicle staff writer. Email: cho@sfchronicle.com Twitter: @Cat_Ho

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