Evaluating equitable access based on sociodemographic predictors of nirmatrelvir-ritonavir use during the first year of availability in Ontario, Canada: A population-based ecological study.

Abstract

Objectives: Nirmatrelvir-ritonavir is recommended to prevent severe outcomes due to SARS-CoV-2 infection in high-risk patients. Our objective was to determine if inequities existed in access to nirmatrelvir-ritonavir across sociodemographic groups.

Methods: We conducted a population-based ecological study of nirmatrelvir-ritonavir dispenses in Ontario, Canada, forward sortation areas (FSA) from April 4, 2022, to April 3, 2023. Our primary outcome was the FSA-level dispense rate of nirmatrelvir-ritonavir per 100,000 population. A negative binomial model was used to calculate crude and adjusted rate ratios with 95% confidence intervals (CIs) for nine sociodemographic variables (income, visible minority, essential worker, household size, education, citizenship, employment rate, social assistance, and language proficiency), adjusted for seven demographic/clinical population-level variables (age, sex, comorbidities, immunocompromised, COVID-19 vaccination, long-term care residents, and percent SARS-CoV-2 PCR test positivity).

Results: The final cohort included 513 FSAs, 12,911,594 residents-127,123 (0.98%) who received and 12,784,471 (99.02%) who did not receive nirmatrelvir-ritonavir. There was an 18-fold variation across FSAs, 133-2417 prescriptions per 100,000 population. In the adjusted model, dispensing rates were significantly lower in regions with higher proportions of residents with low income (adjusted rate ratio (RR_adj) = 0.98 (95% CI 0.97, 1.00, p = 0.014)) and less post-secondary education (RR_adj = 0.98 (95% CI 0.97, 1.00, p = 0.044)). Other sociodemographic variables did not have significantly lower nirmatrelvir-ritonavir use.

Conclusion: This province-wide study revealed small inequities in nirmatrelvir-ritonavir dispensing across Ontario neighborhoods with lower income and lower post-secondary education populations associated with less nirmatrelvir-ritonavir use. The findings highlight the importance of addressing barriers for equitable access to therapeutics for future pandemics.