The SARS-CoV-2 pandemic has had a disproportionate effect on Black and Indigenous people, racial and ethnic minorities, and other historically marginalized groups.1 Two antiviral oral drugs, Paxlovid (Pfizer; nirmatrelvir copackaged with ritonavir) and molnupiravir have received emergency use authorization when taken within 5 days for symptomatic, high-risk COVID-19 infection. Paxlovid and molnupiravir reduce hospitalization by 89% and 31%, respectively.2 These drugs complement COVID-19 infusion therapeutics, eg, remdesivir and sotrovimab.2
To date, inequities have emerged in receipt of COVID-19 vaccines and monoclonal antibody (mAb) treatment.3,4 Prescription of oral antiviral drugs among primary care and other clinicians could improve access to marginalized populations by avoiding the logistic challenges associated with time-sensitive appointments at infusion centers. If equitably deployed, these new treatments could mitigate COVID-19–related inequities in hospitalizations and deaths in racial and ethnic minority communities.
Ethical principles (ie, maximize benefit, equal concern, and mitigate health inequities) and procedural fairness and transparency developed for allocation of COVID-19 vaccines are relevant to COVID-19 therapeutics.1 Operationalization of these principles involves unique challenges. These include fluctuations in patient demand based on COVID-19 surges and public awareness of therapeutic options, and time-sensitive COVID-19 testing and treatment windows, in addition to fluctuations in production and supply of therapeutics. Operationalization of these ethical principles is further hindered by current US Department of Health and Human Services (HHS) policy that allocates therapeutics to states based on population size rather than need,5 with states in turn establishing their distribution policies and public awareness campaigns.
Informed by models that highlight cascading disparities at critical steps in the care continuum, (ie, from patient awareness, demand, and care-seeking to receiving medication),6 we discuss key barriers to equity and corresponding strategies to overcome them (Table).
Patient demand is driven by pandemic dynamics, the public perceptions of risk, supply scarcity, and patient awareness of relevant symptoms, treatment options, treatment windows, and the logistics of obtaining treatment, ie, testing, obtaining appropriate care, and treatment by prescription or infusion.
Low awareness is accentuated by limited information, even online. The HHS website provides links to mAb sites but does not specifically discuss how to access oral antiviral medications. State health department websites vary widely in the breadth, depth, and usability of information they provide with few providing information on oral antiviral drugs or pharmacies that stock them. Although reliable data are lacking, clinical and prior experience suggest comparatively low awareness of novel COVID-19 therapeutics among socially disadvantaged racial and ethnic minority communities.
These awareness-related disparities can be addressed through federally funded, community-driven, culturally, linguistically, and health literacy–appropriate outreach campaigns that extend to racial and ethnic minority communities. Relevant, easily understandable information should be widely posted on health department and health care organization websites in multiple, understandable languages, including American Sign Language. This enables patients to quickly access information and share it with families and friends. Community health workers can provide outreach to places often overlooked in public health crises such as homeless shelters, jails, prisons, senior centers, and job training programs. Quarantine workers and contact tracers can assist in educating patients about antiviral treatment. Health care organizations, including academic medical centers, can promote health equity by partnering with community organizations, local news stations, and health departments to promote awareness among patients cared for in their systems and surrounding racial and ethnic minority communities.
Access to Health Care
Patient health care costs deter timely essential care. The HHS website advises patients without insurance “to call the doctor's office and tell them you do not have insurance” and “Confirm that the provider you will be seeing is willing to participate in HRSA [the Health Resources & Services Administration] Uninsured Program and bill the federal government, not you.”7 Under the Provider Relief Fund, HHS reimburses participating health care clinicians, generally at Medicare rates for COVID-19 health care for uninsured patients, ie, COVID-19 testing, treatment of patients with a COVID-19 primary diagnosis, and COVID-19 vaccines and administration. Information regarding this program and enrollment is available on the HRSA website.8 The HHS provides a list of organizations participating in HRSA’s Uninsured Program, but it is not easily searchable.7 A user-friendly list of participating practices should be posted by HHS and include the specific treatments available by practices in addition to information or links detailing exact locations of pharmacies that stock antiviral medications and provide them free to uninsured patients. Importantly, HRSA should assess the adequacy of their uninsured network and immediately fund expansion of federally qualified health centers sites to address gaps in their uninsured network, particularly in high-risk, racial and ethnic minority communities. Information on access to treatment for uninsured patients should be widely shared with state and local health departments, health care organizations, media, and community organizations and disseminated to racial and ethnic minority communities (Table).
Early reports suggest scarcity in antiviral supplies.5 In the absence of equity policies, scarcity, however time-limited, contributes to inequities when more affluent and better-connected patients use their knowledge and resources to gain preferential access. To maximize benefit and promote equity, HHS could dynamically allocate drugs based on state-wide COVID-19 hospitalizations and community effects (mortality and economic and educational disruption) while also restricting separate private purchases. States could adopt parallel allocation processes to communities experiencing high COVID-19 hospitalizations and effects. Policies should be public and transparent. Policies, such as those in New York City that allocate supplies to a single central pharmacy with home distribution, improve equitable access while minimizing public exposures to symptomatic patients.
The NIH has published guidelines on patient treatment prioritization for COVID-19 therapeutics during logistic or supply constraints.9 These guidelines aim to prioritize patients at highest risk of disease progression based on age, vaccination status, immune status, and clinical risk factors, yielding descending tiers of priority. These guidelines have been criticized for failing to effectively operationalize ethical values.10 These criticisms could be addressed through NIH updates, validation and adoption of patient risk calculators, and/or by state health departments in their guidelines. For example, some state health departments, eg, Washington State, cite social risk factors, ie, limited access to care or members of communities disproportionately affected by COVID-19, in addition to among medical considerations. Explicit treatment prioritization is critical to operationalizing fair and just treatment during scarcity. Health care organizations committed to health equity could adopt such policies and assure equitable implementation.
Transparent Data to Ensure Equity
Ensuring equity in COVID-19 antiviral treatment requires transparent monitoring of processes and corresponding corrective action. The HHS could lead by partnering with pharmaceutical companies, health plans, and pharmacy claim companies to track groups receiving COVID-19 treatment. Relevant data include patient demographic characteristics (eg, age, sex, race/ethnicity, insurance, zip code, and comorbidity), COVID-19 diagnosis, source of care, and which treatments were administered or dispensed. These data could be augmented with findings from national and state surveys to monitor inequities in awareness and demand. Collectively, these data will inform modification of equity strategies including allocation of resources to ensure people residing in high-risk communities who are themselves highest risk, receive the most effective treatment. In the absence of HHS action, states could establish comparable systems. These data should be publicly transparent to ensure trust in fair processes.
Health inequities predictably emerge in socially disadvantaged racial and ethnic minority communities following the introduction of new medical advances, such as COVID-19 life-saving therapeutics. Proactive, dynamic, transparent strategies can mitigate these inequities. Action on these strategies is urgently needed to ensure health equity.
Published: March 25, 2022. doi:10.1001/jamahealthforum.2022.0050
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Fiscella K et al. JAMA Health Forum.
Corresponding Author: Kevin Fiscella, MD, MPH, Department of Family Medicine, University of Rochester, 1381 South Ave, Rochester, NY 14620 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Fiscella K, Sanders M, Yaeger J. Strategies to Promote Equity in COVID-19 Antiviral Treatment. JAMA Health Forum. 2022;3(3):e220050. doi:10.1001/jamahealthforum.2022.0050