COVID-19, the disease caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), has led to a global pandemic and has exacerbated existing health inequities among vulnerable populations. Despite higher rates of COVID-19 in Black and Latinx individuals compared to White individuals, rates of testing in predominately non-White, low-income communities are significantly lower than in high-income areas. Strategies to increase COVID-19 testing rates in underserved populations are thus urgently needed. Self-testing, where individuals collect their own samples, is now feasible for the detection of SARS-CoV-2. Self-testing can increase testing convenience and privacy and has been effectively leveraged to expand testing for other infections, such as HIV, in key populations across a broad spectrum of contexts. However, self-testing may be limited to those with access to health services, without reaching individuals underserved by existing medical systems. One promising approach to increase test uptake is the secondary distribution of self-testing kits, where an individual distributes tests to contacts in their social network and encourages them to self-test. A significant advantage of a secondary distribution strategy is that by decentralizing a health care process, individuals may be more likely to access services if delivered by social network peers, rather than health professionals. In addition, secondary distribution can enhance contact tracing efforts, as individuals diagnosed with COVID-19 can distribute self-tests to close contacts to identify additional cases. Given high levels of COVID-19 misinformation, stigma, and medical mistrust among vulnerable populations, this peer-driven test distribution strategy holds significant promise in increasing the reach of COVID-19 testing among underserved populations. In collaboration with our community-based partner, Public Health Management Corporation, we will conduct a 1:1 randomized trial with 1048 individuals cared for at Federally Qualified Health Centers to evaluate whether secondary distribution of SARS-CoV-2 self-tests increases test uptake compared with referrals among underserved populations in Philadelphia (Aim 1). We will also assess whether the secondary distribution of self-tests to close contacts among individuals with COVID-19 facilitates case detection (Aim 2). Additionally, we will use a mixed methods strategy to identify key social, ethical, economic, and behavioral barriers and facilitators to secondary distribution to inform its future modifications, implementation, and scale-up (Aim 3). We will engage our relationship with community partners to reach underserved individuals with housing instability, immigrants, and those with significant medical comorbidities including HIV, viral hepatitis, and substance use disorders, in order to increase COVID-19 test uptake in these populations. As more rapid and user-friendly diagnostic tests emerge, this secondary distribution model may become even more impactful. The proposed project may establish a new paradigm for expanding COVID-19 testing and contact tracing.
Strategies to rapidly disseminate COVID-19 testing are urgently needed, particularly to address increasing health disparities among underserved communities. This study will engage community partners and leverage SARS-CoV-2 self-testing technologies in order to evaluate a novel secondary distribution strategy to disseminate testing among underserved populations.
