America still needs more COVID treatments

State of play: Pfizer's oral antiviral, Paxlovid, is highly effective, and its use has significantly increased over the last couple of months. But the way it interacts with other drugs makes it a non-starter for some people, and recent cases of the virus rebounding in patients who took the pills have raised concerns.

• Merck's antiviral, Molnupiravir, is widely considered an inferior option to Paxlovid and can't be taken by pregnant people.
• Although several effective monoclonal antibodies have been developed for treatment over the course of the pandemic, only one — manufactured by Eli Lilly — is effective against the current Omicron variant and being distributed by the federal government.
• Another monoclonal antibody, Evusheld, can be taken prior to infection to prevent COVID, but it isn't authorized for treatment.

The catch: Experts warn that having only one good antiviral is precarious, with the virus capable of evolving to resist treatments. It's much safer to have several options or to combine them into a drug cocktail, they say.

• "We certainly need additional options, because if there's anything other viruses like HIV have taught us, it's that monotherapies put you at risk of resistance," said Celine Gounder, an infectious disease specialist and Kaiser Health News editor-at-large.
• And the virus has proven that it only takes a new variant to render a monoclonal antibody obsolete.

Where it stands: Congress and the Biden administration have been in a standoff for months over new pandemic funding, and the administration has warned that it doesn't have enough money to buy more of the existing treatments and vaccines for the fall.

• The uncertainty of a federal purchaser has prompted questions about whether the existing products can quickly transition to the commercial market and remain widely accessible. But even if they do, there's the risk that those drugs don't work if the virus evolves.
• "One good oral antiviral and uncertainty about updated vaccines is not a good position at all to be in heading into the fall and winter," said Walid Gellad, professor of medicine and health policy at the University of Pittsburgh.
• "While other countries move ahead and secure next generation resources, the U.S. cannot because of congressional inaction," said a senior administration official. "There are very real consequences to this inaction and they have been repeatedly communicated to Congress. The virus is not waiting for Congress to act."

The intrigue: The political showdown isn't about the importance of further federal investment in new treatments.

• Republicans working on the COVID package agree that the government should be invested in next-generation treatments, according to a senior GOP Senate aide.

The big question is whether new treatments will come to market without government incentives, and whether they'll do so in time to keep up with the health threat.

• Throughout the pandemic, the federal government has invested in the drug development process in different ways to speed up the process, alleviate financial risk and ensure manufacturers will have a predictable market.
• "While there may be more demand for COVID antiviral drugs than some of our other antimicrobials, this is historically a place where we've had problems with market failure — in other words, not having enough of a profit incentive to invest in and develop new drugs," Gounder said.
• COVID drugs may have already lost their moneymaking luster. As demand has plateaued, supplies have increased and the pandemic has entered a new phase: The "gold rush for drugmakers making COVID-19 vaccines and treatments might be over," the WSJ recently reported.

The other side: Some economists say that the market for COVID drugs has proven predictable enough to spur private innovation without more public funding.

• "The idea that we need the government to pay for these things at this point is ignoring some of the market reality," said Craig Garthwaite, a professor at Northwestern University's Kellogg School of Management. "It's hard to imagine a world over the next several years where people aren’t concerned in some degree about getting COVID."

What we're watching: "There's so many different promising drugs that aren't being pursued, or they're being pursued by small companies" that don't have adequate support, said Eric Topol, executive vice president of Scripps Research.

• A major upside of these products are that they're variant-proof, Topol said, which means they'll continue to work against the virus as it evolves.