A pharmacist holds a pack of Paxlovid

The Quick Start consortium will distribute 100,000 courses of the antiviral drug Paxlovid in ten countries.Credit: BJ Warnick/Yonhap/Newcom/Alamy

A programme to bring oral COVID-19 antivirals to low- and middle-income countries has launched with an initial donation of 100,000 courses of treatment, to be distributed in 9 sub-Saharan African countries and Laos.

By the end of September, the COVID Treatment Quick Start Consortium aims to begin treating people in these countries with Paxlovid (nirmatrelvir–ritonavir), an antiviral drug developed by Pfizer in New York City. The programme is backed by non-profit organizations such as the Clinton Health Access Initiative, Americares and the COVID Collaborative, along with Duke University in Durham, North Carolina, and other partners.

The size of the donation is dwarfed by the need in these ten countries: limited supplies and high costs have restricted the flow of COVID-19 antivirals to low- and middle-income regions. “It’s a diabolically horrible situation in terms of equitable access to therapies,” says Rachel Cohen, a regional executive director at the Drugs for Neglected Diseases Initiative, which is headquartered in Geneva, Switzerland. “I’m very enthusiastic about any initiative to support access.”

One potential challenge is the stringent requirement that Paxlovid be given within five days of the start of COVID-19 symptoms. Antiviral drugs are thought to be most effective when given early in an infection, but the speed with which people must be tested and then given treatment has proved difficult even in wealthy countries.

The consortium will establish pilot projects to explore how best to implement test-and-treat programmes in areas with limited healthcare infrastructure.

In Zambia, one of the ten countries targeted by Quick Start, public-health officials are evaluating how best to deploy the limited supplies of Paxlovid, said Lloyd Mulenga, director of infectious diseases for the Ministry of Health in Lusaka. This means focusing on areas with high rates of COVID-19 infection as well as more rural areas, to work out the logistics of antiviral distribution outside of urban centres. “We hope that these lessons are going to move us forward in how to roll out,” he said.

Low-cost alternatives

Over time, the consortium plans to expand the programme to more countries and transition to lower-cost, generic versions of Paxlovid, but these aren’t expected to be available until the end of this year or early 2023. In collaboration with the Medicines Patent Pool, a United Nations-backed public-health organization in Geneva, Pfizer has agreed to license its intellectual property to generics makers to supply 95 low- and middle-income countries. And in May, the Clinton Health Access Initiative negotiated a maximum price of US$25 per course of treatment for these generics.

Pfizer has also signed a supply agreement with the UN children’s charity UNICEF to provide up to 4 million courses of Paxlovid at not-for-profit prices to low-income countries. But fulfilment of that order has been delayed for months while UNICEF attempts to renegotiate some terms to “ease access” to the drugs, a spokesperson for UNICEF told Nature.

Last month, UNICEF sent its first shipment, to Cambodia, of another COVID antiviral called Lagevrio (molnupiravir), made by Merck in Rahway, New Jersey and Ridgeback Therapeutics in Miami, Florida. But questions have been raised about the drug's efficacy, and safety restrictions — including a recommendation that sexually-active people use contraception during and immediately following treatment — make it challenging to deploy.

Against this backdrop, public-health advocates worry that global interest in ensuring access to COVID-19 treatments will wane as caseloads and fatalities drop in wealthier countries, says Cohen. “As COVID moves off of everybody’s high-priority list, that’s where initiatives like this can be really helpful.”