Access criteria for COVID-19 antivirals: determine priority by need

There are two COVID-19 antivirals currently available in New Zealand; nirmatrelvir with ritonavir (Paxlovid; oral) and remdesivir (Veklury; IV, hospital use), and these are funded for groups at high risk of severe outcomes from COVID-19 (see: “Factors that increase risk of severe outcomes from COVID-19”).¹

The access criteria for funded COVID-19 antivirals for people aged 50 – 64 years are amended from 1^st September, 2025, to include all people aged 50 years and over with COVID-19 who are considered by their healthcare professional to be at high risk of hospitalisation or death from COVID-19 infection.¹ Previously, access was restricted to people aged ≥ 50 years if they were of Māori or Pacific ethnicity or had not yet completed a primary course of COVID-19 vaccination.¹

This change is intended to give healthcare professionals more discretion as to which patients they consider to be at high risk due to factors not covered in other aspects of the access criteria (see below). Healthcare professionals can use their clinical judgement, including knowledge of COVID-19 epidemiology and risk factors, to prescribe COVID-19 antivirals to patients aged ≥ 50 years based on need.¹ This may include consideration of the patient’s medical, personal and/or social factors and circumstances, such as ethnicity and access to healthcare, e.g. social or geographical isolation, lack of transport, unreliable phone or internet connection, housing issues (see: “Demographic factors, vaccination status and co-morbidities influence risk”).

People aged 65 years and over remain eligible for funded COVID-19 antiviral treatment based on age alone. People of any age can also access funded COVID-19 antivirals if they meet other criteria, e.g. if they are immunocompromised, have previously required care in the intensive care or high dependency unit for COVID-19, people with a disability or severe vulnerability due to medical conditions or a combination of risk factors (see box).¹

Factors that increase risk of severe outcomes from COVID-19

People with certain factors or within specific population groups have been identified as being at increased risk of hospitalisation and death from COVID-19, and are, therefore, likely to benefit from COVID-19 antiviral treatment. This could be due to medical, personal or social factors. It is possible that recommendations may be revised over time as further evidence emerges. Table 1 lists medical co-morbidities and independent factors that increase the risk of severe COVID-19.

Demographic factors, vaccination status and co-morbidities influence risk

Age. Increasing age is a predominant risk factor for severe outcomes (i.e. hospitalisation and death) from COVID-19.^{2, 3} This risk is reported to be particularly high in people aged over 70 years in New Zealand, compared to those who are younger.⁴

Ethnicity. Numerous New Zealand-based studies have shown that people of Māori and Pacific ethnicity experience higher hospitalisations and mortality due to COVID-19.^{2, 3, 5} The effect remains after controlling for variables, e.g. age, co-morbidities, socioeconomic deprivation.^{2, 3} Therefore, ethnicity is an important independent factor in determining patients at risk of more severe outcomes from COVID-19.

High socioeconomic deprivation is associated with an increased hospitalisation and mortality risk due to COVID-19.^{2, 6} An effect is also observed independent of age, co-morbidities and ethnicity.² This may include people living in overcrowded homes, no fixed home, who are unemployed, have a lack of transport or an unreliable phone or internet connection. Specifically, people who do not have a stable setting in which to recover from COVID-19, or a reliable means of caring for themselves, seeking help or responding to follow up are likely to be at high risk.

Data supporting ethnicity and socioeconomic deprivation as independent risk factors for severe outcomes from COVID-19 will be covered in more detail in an upcoming comprehensive article on COVID-19 antivirals.

Vaccination status influences the risk of progression to severe COVID-19.^{7, 8} People who were not fully vaccinated^* against COVID-19 have been shown to be at greater risk of hospitalisation and mortality due to COVID-19 compared to those who were.^{2, 4} While most of the eligible population in New Zealand are vaccinated to some degree against COVID-19,⁹ there will be a very small group who in addition to never being vaccinated, have not been exposed to SARS-CoV-2 and will, therefore, have no COVID-19 immunity.⁴ This will likely result in more severe illness if infected with COVID-19.

* Considered to be those who had not received at least two primary doses of COVID-19 vaccine (a single dose of the Comirnaty JN.1 COVID-19 vaccine is now considered a primary course)

Medical co-morbidities. People with co-morbidities, e.g. cardiovascular or respiratory disease, immunocompromise, experience poorer outcomes associated with COVID-19.^{7, 8} Data from New Zealand has shown that people with any co-morbidity had more than six times the risk of COVID-19 mortality than people without.² See Table 1 for a list of medical co-morbidities that are associated with a high risk of severe COVID-19.¹⁰

Table 1. Medical co-morbidities and independent factors that increase risk of COVID-19 severity.^{2, 10}

So, how do you determine who is at high risk to meet criteria 4.2?

When deciding whether a patient needs a COVID-19 antiviral, if they clearly meet the listed access criteria, then treatment is appropriate, e.g. are aged ≥ 65 years, have three or more co-morbidities in Table 1. The decision to prescribe a COVID-19 antiviral to patients aged 50 years or over who are at high risk of hospitalisation or death due to factors not covered in other aspects of the criteria (i.e. to meet access criteria 4.2) comes down to clinical judgement of the individual circumstances of the patient. In general, consider COVID-19 antivirals in a patient aged 50 – 64 years if they have any of the following factors:

• Māori or Pacific ethnicity
• Socioeconomic deprivation that means they do not have a stable setting in which to recover from COVID-19, or a reliable means of caring for themselves, seeking help or responding to follow up
• Are not fully vaccinated against COVID-19 (primary course) and never had COVID-19 before
• One or two of the medical co-morbidities from Table 1 if there is clinical concern about the effect on recovery from COVID-19