Lessons learned from the rapid rollout of nirmatrelvir/ritonavir for COVID-19 treatment in high-risk patients in Zambia

Authors: Shanti Narayanasamy, Mwaba Mulenga, Prudence Haimbe, Hilda Shakwelele, Lloyd Mulenga, Jessica Joseph, and Nellie Bristol on behalf of the COVID Treatment QuickStart Consortium

Although nirmatrelvir/ritonavir was strongly recommended more than a year ago by the World Health Organization for rapid treatment of COVID-19, the medication and the technical assistance needed to administer it are still only available in a handful of low- and middle-income countries (LMICs). As COVID-19 continues to circulate globally, ensuring equitable access to the drug and other oral antivirals has been a challenge.

The COVID Treatment QuickStart Consortium is in partnership with ten countries in Africa and Asia to address this inequity. Launched in September 2022, QuickStart brings together Duke University, Americares, the Clinton Health Access Initiative (CHAI), and the COVID Collaborative as implementing partners, with support from the Open Society Foundations, Pfizer, and the Conrad N. Hilton Foundation. QuickStart is supporting governments to introduce and scale up access to COVID-19 testing and treatment for high-risk populations—older individuals and those with underlying health conditions—reducing their risk of hospitalization and death. In addition to protecting those most vulnerable to severe disease, QuickStart lowers the burden of COVID-19 management on health personnel and services while building capacity within primary care to respond to future emerging infections.

Zambia was the first country to receive a 1,000-course donation of nirmatrelvir/ritonavir in December 2022, coinciding with its 5^th wave of COVID-19 infections. Over the next six weeks, health officials successfully integrated the drug into national treatment guidelines, trained healthcare personnel on appropriate use and side effects, and distributed nirmatrelvir/ritonavir across the country. The arrival of effective treatment spurred greater testing and 8,758 cases were reported in January and February compared to 693 recorded in the last quarter of 2022. The Zambia Ministry of Health’s (MoH) swift launch of test-and-treat programs resulted in treatment initiation for 434 cases during that two-month period. 

Zambia’s experience is a clear example of how health officials can quickly and effectively deploy new medical countermeasures if they have the necessary tools and partners in place to provide technical assistance. Several characteristics of the response provide key lessons for other LMICs as they launch their own test-and-treat programs.

1. Every program needs a champion

Prior to Zambia’s fifth COVID-19 wave in December 2022, cases had declined markedly and there was a growing perception globally that COVID was ‘over’. In this climate, and faced with other pressing health priorities, advocating for resources to integrate nirmatrelvir/ritonavir into standard-of-care treatment for high-risk patients with mild to moderate COVID-19 was daunting. Dr. Nyuma Mbewe, National COVID-19 Case Management Specialist in the Ministry of Health, drove awareness of the continued threat and its long-term impacts and emphasized the importance of test-and-treat as a fundamental tool in containing spread of the virus. Working closely with health care professionals, policymakers, and community leaders she led development of the program and integration into existing public health services. She also played a crucial role in communicating the significance of testing to the public, building trust in the new treatment, and encouraging widespread participation in the program. Dr. Mbewe’s actions epitomized the high-level political will and program ownership driven by MoH leadership and government officials. Having a well-placed, locally trusted champion willing to advocate for program implementation was crucial to creating a receptive climate and integral to the successful test-and-treat rollout.

2. Leveraging established organizational structures to integrate COVID-19 disease management into existing programs and management

The test-and-treat program in Zambia was launched through existing patient pathways and points of contact within the national public health system. COVID-19 testing was offered at all hospital clinical entry points for any patients showing symptoms. Patients testing positive had a specific record created and were referred to the COVID-19 center within the hospital. COVID-19 centers have been integrated into existing tuberculosis (TB) programs in Zambia, a crucial part of their success and sustainability. Recognizing the overlapping symptoms and transmission routes of the diseases, this allowed health systems to use well-established TB infrastructure, resources, and expertise to diagnose and manage both diseases simultaneously. The approach has also prevented siloing of COVID-19 testing and treatment and ensured the ongoing viability of the program.

3. A whole-of-team approach to programmatic training

Introducing nirmatrelvir/ritonavir in Zambia during a COVID-19 wave required rapid training of clinical providers. To expedite the process, different cadres of providers were all trained together rather than in individual groups, previously the norm. This was both a more efficient training model and facilitated conversation among providers on potential challenges during the roll-out of a new therapeutic product.

4. Taking a holistic approach to patient care

People at highest risk of severe COVID-19 disease are those with other medical comorbidities. Some high-risk factors, such as diabetes, cardiovascular disease, chronic respiratory diseases, and hypertension–conditions known as non-communicable diseases (NCDs)—are not as well known or diagnosed in LMICs despite being a leading cause of death. In Zambia, screening for COVID-19 and NCDs has now become bi-directional, meaning that people testing positive for COVID-19 are now also being assessed for NCDs, while COVID-19 testing is also now occurring at NCD clinics. This new process has been a direct result of the QuickStart program.

COVID-19 is here to stay. Integrating effective test and treat programs into existing health services is critical to containing outbreaks, protecting health resources, and building capacities for primary care and future emergencies. The QuickStart Consortium is dedicated to addressing therapeutics inequities as well as collecting and disseminating implementation lessons to aid other countries in improving test-and-treat programs.

Photo credit: Training/information session with QuickStart data collectors at the TB Clinic at University Teaching Hospital in Lusaka.