By Catherine Ho | San Francisco Chronicle
A central part of President Biden’s new COVID strategy — the so-called “test to treat” initiative to enable pharmacies, long-term care facilities and community health centers to test patients and give out antiviral pills on the spot if they test positive — is already under way at many Bay Area health care providers.
Doctors and pharmacists have essentially been operating this way for the past few months, since pills first became available, local clinics and long-term care facilities say. However, their ability to do so has been limited by scarce supply of pills, particularly the Pfizer drug Paxlovid, and the very short window of time between symptom onset and when patients must start taking the drug. So Biden’s “test to treat” plan would ostensibly expand these operations, which are still relatively small, to more locations and improve access to the medication for more people.
San Francisco’s largest skilled nursing facility, Laguna Honda, for instance, tests residents and starts them on antiviral treatment immediately if they test positive and have symptoms, said spokesperson Zoe Harris of the San Francisco Department of Public Health, which runs the facility.
“Laguna Honda is not an official ‘test to treat’ center but that’s how we’ve been operating for our residents,” she said. “We’re not part of Biden’s plan, but we’re hoping what we do here is what we’re going to be seeing in other settings.”
Other local providers have similarly been prescribing Paxlovid and molnupiravir, the antiviral pill made by Merck, to patients who have tested positive. But some caution that the “on the spot” administration of the pills proposed by Biden could gloss over a critical step: reviewing a patient’s other medications to ensure they are not taking drugs that could interact poorly with Paxlovid.
Many commonly prescribed drugs for seizures and heart conditions should be paused while taking Paxlovid, or are reason not to take Paxlovid at all, since the antiviral may render some of those medications less effective or even harmful.
To make sure this doesn’t happen, providers like Oakland’s La Clinica test their patients at one location — an outdoor testing site at the Fruitvale BART station — and send them home in case they’re infectious. Then, if patients do test positive and are a good fit for Paxlovid, a doctor or pharmacist reviews their medical history and medications and has them send a friend or family member to one of two La Clinica pharmacies to pick up the prescription. This process must be done quickly because a course of Paxlovid has to start within the first five days of symptom onset, under federal emergency use authorization guidelines.
Dr. Paul Bayard, La Clinica’s chief medical officer, said he applauds the federal push to make antiviral pills more accessible and available faster. But he is concerned not every retail pharmacy will have every patient’s full list of medications to be able to perform this critical step, especially if the patient doesn’t typically get his or her prescriptions there.
“We love the idea of getting patients medications quickly,” he said. “We don’t want there to be barriers. We applaud the intent, we just want to be careful we don’t hurt people. You absolutely have to have access to the patient’s medications list and have to have someone who understands the importance of those interactions.”
The first COVID oral antiviral prescription Bayard wrote was for an elderly patient who was on medication that should not be taken with Paxlovid, so he prescribed molnupiravir instead, he said.
For now, because of supply constraints, only high-risk patients are eligible for Paxlovid, such as those who are unvaccinated, immunocompromised, or have underlying medical conditions. This means that just dozens of patients at some Bay Area clinics have gotten the drug. During the height of the omicron surge in January, many people had to wait a few days to get their test results, which pushed them past the five-day window to start Paxlovid, further limiting its use.
But as Pfizer’s manufacturing of the pills picks up in the coming months, testing gets faster, and doctors and pharmacists get more familiar with the drug, providers hope more people will be able to get antivirals.
“I think it’s going to get better,” said Dr. Michael Stacey, chief medical officer of LifeLong Medical Care, a network of East Bay community health centers that has been administering antiviral pills to some high-risk patients.
“Because of the limited supply of those medications, the focus has been to use those medications for those that are the most complex patients,” he said. “As the supply becomes more available, you’ll be able to treat people that don’t have a lot of other medications they’re taking, and it’d be easier to make that happen quickly. And as providers become more familiar with this medication, their comfort level will increase and it’ll be easier to get it to even the most complex patients.”