Increasing representation of Black communities in COVID-19 home testing and surveillance data

Abstract Black communities in the U.S. have disproportionately experienced adverse outcomes attributable to the COVID-19 pandemic. While COVID-19 cases and deaths have declined in recent months, emergent variants continue to pose threats to the health of Black communities and others. COVID-19 testing has recently shifted from primarily point-of-care testing to widespread use of rapid home antigen tests. Home testing may be preferable to clinic-based testing for Black persons, many of whom have a high degree of well-founded, historically based mistrust of the medical system, but very little is currently known about knowledge, attitudes, and behaviors surrounding COVID-19 home testing among Black people. In addition to challenges related to affordability and accessibility of home testing, the privacy afforded by home testing comes at the expense of surveillance information. Home tests are rarely reported to public health surveillance, and specimens are unavailable for genetic sequencing and variant detection. This results in a substantial gap in public health knowledge about COVID-19 burden of disease and circulating variants, which may be particularly problematic for Black communities with higher risk for adverse outcomes. We propose a pre-post intervention study based in Black communities in Atlanta, GA to assess willingness of research participants to use a COVID-19 rapid home test and to simultaneously mail a self-collected anterior nares sample to a commercial laboratory for confirmatory PCR testing. We will provide culturally competent oral and illustrated written communication messages encouraging continued COVID-19 vigilance and home testing alongside self-collection of a specimen for mail-off testing. These messages will be packaged with a home test kit for rapid testing and self- collecting and mailing a second specimen to a laboratory. If a subset of home testers were willing to self-collect and mail a specimen for confirmatory testing, multiplier methods could be used to estimate burden of disease and circulating variants among home testers. However, people with medical mistrust may not elect to share biological specimens for surveillance purposes. We aim to understand motivations and barriers for using this type of testing modality in Black communities while also assessing general knowledge, attitudes, and behaviors related to home testing. Specific aims are to: (1) Develop culturally appropriate, empowering communications strategies underscoring the importance of home COVID-19 testing for individual and public health; (2) Assess knowledge, attitudes, and behaviors regarding COVID-19 rapid home testing among socio- demographically diverse Black communities; (3) Assess willingness to provide, in conjunction with a rapid home test, a self-collected specimen to a laboratory for confirmatory COVID-19 testing; (4) Conduct in-depth interviews with persons completing (N=10) and not completing (N=10) the study-provided home test to further improve communications strategies using participants' open-ended reflections on intervention effectiveness.