It’s been nearly a year since the first vaccines for the coronavirus were administered, promising a way out of a horrid pandemic that has, at the time of publication, claimed the lives of more than 5.1 million people globally. On their own, vaccines haven’t been enough to end the pandemic—thanks primarily to hesitancy and the lack of global availability—so the public health toolkit needed something new. Enter two pills.
Pfizer and Merck have both produced antivirals for COVID-19 that are expected to receive FDA approval in the near future. The pills are five-day treatment courses that, according to clinical studies, dramatically reduce the risk of hospitalization and death. They’re also easier for patients to take than the primary, currently available treatments for COVID-19: monoclonal antibodies and remdesivir, which are delivered through infusion or injection in a clinical setting. And both pills are being tested to see if they can prevent infection, too.
It’s a testament to how biomedical science has risen to meet the many challenges of the pandemic. But will people who are reluctant to take a Pfizer COVID vaccine now happily take a Pfizer COVID pill—whether for treatment or prevention? And if they don’t object to the pill, does that mean we have found a way out of the vaccine wars?
Well, it depends, according to the experts who spoke with Slate. Until Pfizer and Merck release data on how it could be used to prevent infection, both antivirals should be considered as companions to the vaccines, remdesivir, and monoclonal antibody treatments.
“These all complement the vaccines,” said David Carlisle, the president of Charles R. Drew University of Medicine and Science, “for the vaccines prevent the risk of acquisition of the infection and these treatments prevent people from getting sicker once they get the infection. And so both are very good and very important. And it’s certainly nice that we have two more highly effective arrows in the quiver against COVID-19.”
Some people sick with COVID are currently refusing medical interventions like inhaled steroids and blood thinners in favor of dubious treatments promoted by anti-vaxxers online. For them, the antivirals could be beneficial (especially compared with something like ivermectin, which is ineffective but popular among COVID skeptics).
Immanuel Carrothers, an unvaccinated 28-year-old, said as much: “I think if it was a pill, that would be easier to internalize not only physically but physiologically because we relate a pill with temporary metabolic breakdown … whereas an injection of whatever could have lasting effects,” he said in response to a social media callout.
The experts I spoke to said that the science behind Carrothers’ thinking, while understandable, isn’t quite right. Long-term effects from the COVID vaccines are extremely unlikely. And Carlisle pointed out that many medications consumed orally can have long-lasting effects even if most of them don’t. Adam Ratner, director of pediatric infectious diseases at NYU Langone Health, added that all vaccines, including those that aren’t given through injection, are gone from the body quite quickly.
“I’m not aiming to delegitimize the feeling that this person is expressing,” he said. “I just don’t think that it is necessarily based on solid data.”
But perhaps the psychology really is what’s important here. The hope is that anyone who is injection-hesitant will be more open to a medication that reduces their risk of severe COVID. As an example, Ratner pointed to the Orthodox Jewish community in New York City. Many community members have been resistant to the COVID vaccine—but they largely seem to accept monoclonal antibody therapy.
“The goal with overcoming vaccine hesitancy is to get people to take up the safest course of action for their health and the health of our wider community,” said Rachel Moran, a researcher at the University of Washington who studies online misinformation. “If we did have a non-injection based way to give people the same safe and lasting immunity that the COVID-19 vaccine affords then that would be great, especially for those of us who are afraid of needles.”
But, she added, “the COVID-19 vaccines that we have are currently the best tool to get us towards the level of immunity that will end the pandemic and save lives, so we have to focus on vaccine hesitancy.”
As for using it for a preventative? There are reasons why we generally don’t take pills to prevent disease, said Paul Auwaerter, the clinical director for the division of infectious diseases at Johns Hopkins University School of Medicine.* (The most notable exception here, of course, is PrEP, the anti-HIV medication.) Take the flu. If someone at high risk for a severe bout of the flu can’t mount a proper immune response or get the flu vaccine for some reason, they could be prescribed something like TamiFlu as a preventative. But it has to be targeted. “[O]veruse might lead to emergence of resistance,” said Auwaerter. “Simply put, immunization is such a more simple and less expensive option that it’s almost never done, except for people in whom immunization can’t be carried out rather than a voluntary decision.”
Indeed, the new antivirals are pricey. A five-day treatment course is $529 for Pfizer and $700 for Merck. And using this as a preventative will be highly dependent upon access to healthcare, a problem in underserved populations, whereas the vaccines for COVID-19 are increasingly ubiquitous and free.
But the truth is that many who haven’t yet been vaccinated against COVID may be unmovable at this point. Vaccine adverseness is complicated. It’s a combination of mistrust and distrust in the government advocating for the vaccine, the companies producing it, the ingredients, and the scientific processes behind it. For many of them, the pills may literally be more palatable, especially if they help address specific concerns. For instance, Moran thinks it could potentially appeal to the subset of folks who won’t take the vaccine based on religious grounds, because they believe there’s fetal tissue in it. (None of the vaccines contain fetal cells. They were only used in the development process to help make sure the vaccines worked in humans.) But that will only apply to people who genuinely refuse the vaccine for religious reasons, as opposed to those who are actually using religious claims to mask political objections.
Plus, on a basic level: “It’s just human nature that people are more amenable to an oral medication,” said Carlisle. “I’m sure that there will be people who will say ‘I’m not going to get vaccinated because this oral medication is available,’ but I want to make it clear that is not the correct judgment on the part of individuals. Everyone should get vaccinated. You don’t want to have to get treated for COVID-19.”
*Correction, Nov. 23, 2021: This article originally misspelled Paul Auwaerter’s last name.
Update, Nov. 23, 2021: This article was updated to clarify Adam Ratner’s professional affiliation.