Among the weapons in the government’s pandemic arsenal, COVID-19 treatments like Paxlovid have proven particularly effective. But despite a Biden administration push to get the antiviral to more Americans, large swaths of the country — primarily rural areas — have become “Paxlovid deserts.”

According to a new report from GoodRx Research, wide gaps remain in access to Paxlovid. The company tracked the drug’s distribution between January and March 2022 and found that some counties were given enough courses to treat all COVID-19 cases — while others didn’t receive any Paxlovid at all.

The researchers estimated that up to 42% of U.S. counties — making up about 26 million people — were Paxlovid deserts. The report drew from Department of Health and Human Services data.

In March, the Biden administration released a COVID-19 plan that focused on four key areas: treating COVID-19 with antiviral pills and other drugs, preparing for new variants, preventing business and school shutdowns, and ongoing vaccination. As part of that plan, the federal government bought 20 million courses of Paxlovid from Pfizer, then allocated them to state governments. States were left to decide how to distribute the pills; in most cases, local health departments shared the courses with hospitals and pharmacies.

“The Biden administration distributed Paxlovid directly to states, which had autonomy to disseminate the medication on their own as they saw fit for their populations,” explained Tori Marsh, director of GoodRx Research. “It’s hard to say why some counties did not receive any Paxlovid. It could be due to the small size of the population, or it could be a distribution decision made by the state that we don’t have visibility into.”

The report revealed, however, that Paxlovid distribution was equitable for racial groups, including Blacks, Hispanics and Asian American/Pacific Islanders populations. Among the counties that received their share of Paxlovid, many had higher populations of Hispanic, Black, and Asian people receiving the pills. This was particularly true in urban areas, where there is often more access to health systems and clinics than in rural areas.

Marsh said that In order for Paxlovid to be distributed more equitably and effectively, there needs to be improved health infrastructure in the country — in short, more pharmacies, hospitals and clinics. Up to 9% of U.S. counties are considered primary care provider deserts, while 40% are deemed pharmacy deserts.

“In these areas, it’s much more difficult to prescribe and dispense Paxlovid,” Marsh noted.

Since the Paxlovid rollout began, the White House has moved to address some of these pitfalls. The Biden administration announced  its “Test to Treat” program in March, which allowed people to test for COVID-19 at pharmacies and secure a prescription, then receive the pills in the same visit.

But part of the issue is an ongoing lack of awareness. One recent study found that while 66% of hospitalized patients with COVID-19 were aware of treatments like Paxlovid, only 36% sought them out and a minuscule 2% were actually receiving them.

Marsh noted that primary care providers must work with patients to devise COVID-19 treatment plans. In rural communities, that means mobile clinics, telemedicine and pill delivery should be used to boost access among the isolated individuals. Transportation and financial services for people who need to travel to access a pharmacy could supplement those efforts.

“Public health education campaigns can inform people how to get Paxlovid,” Marsh said. “Mobile clinics, telemedicine and delivery options in Paxlovid deserts could also solve for some disparities.”