key: cord-0965071-ov6r0k8d
authors: Ost, K.; Duquesne, L.; Duguay, C.; Traverson, L.; Mathevet, I.; Ridde, V.; Zinszer, K.
title: A rapid review of equity considerations in large-scale testing campaigns during infectious disease epidemics
date: 2021-02-23
journal: nan
DOI: 10.1101/2021.02.22.21252205
sha: 9cfdd439ce1f324c05c2622a6a406666eb59ffe5
doc_id: 965071
cord_uid: ov6r0k8d

Context: Large-scale testing is an intervention that is instrumental for infectious disease control and a central tool for the COVID-19 pandemic. Our rapid review aimed to identify if and how equity has been considered in large-scale testing initiatives. Methods: We searched Web of Science and PubMed in November 2020 and followed PRISMA recommendations for scoping reviews. Articles were analyzed using descriptive and thematic analysis. Results: Our search resulted in 291 studies of which 41 were included for data extraction after full article screening. Most of the included articles (83%) reported on HIV-related screening programs, while the remaining programs focused on other sexually transmitted infections (n=3) or COVID-19 (n=4). None of the studies presented a formal definition of (in)equity in testing, however, 23 articles did indirectly include elements of equity in the program or intervention design, largely through the justification of their target population. Conclusion: The studies included in our rapid review did not explicitly consider equity in their design or evaluation. It is imperative that equity is incorporated into the design of infectious disease testing programs and serves as an important reminder of how equity considerations are needed for SARS-CoV-2 testing and vaccination programs.

It is essential to understand how COVID-19 testing campaigns are being offered in the current pandemic situation, in order to improve their equitable implementation. Racialized and marginalized communities have been disproportionately affected by COVID-19 (1-3) and

improving equitable access to COVID-19 testing would be a vital step in reducing disease propagation (4) . Large-scale testing is instrumental for surveillance, directly informing measures of prevention, control, and mitigation of infectious diseases (5) (6) (7) (8) . The goal of large-scale testing interventions is to reduce transmission rates through detection, treatment, isolation, and any other relevant control and prevention measures (9) . Testing programs often act as a link to care and support programs, which should be provided equitably, based on risk of infection and disease burden (10) . A proportionate universalism framework-based public health program would imply two components: a universal approach of support and services available to the population as a whole, accompanied by accessible targeted initiatives for those highly vulnerable and for those least likely to benefit from the universal program (11, 12) . When applied to COVID-19 testing initiatives, a proportionate universalism approach could include a universal program for SARS-CoV-2 testing with concerted efforts to reach vulnerable groups less able to access the universal testing programs. Equity is defined by the "absence of systematic disparities in health or in major social determinants of health between groups with different levels of underlying social advantages/disadvantages'' (13, 14) whereas health inequities refer to "differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age. They are unfair, avoidable, and could be reduced by the right mix of government policies." (15, 16) . This is an important concept for understanding the differences between (in)equity from the more general term (in)equality, two words that are often confused (17,18). Health inequalities refer to the uneven distribution of health or health resources (i.e. clinics, healthcare providers, disease tests, infrastructure, clinical material) in or between populations and it is primarily a descriptive term exempt from moral perspective (17) (18) (19) . Social determinants of health play a key role in both inequality and inequity. Disparities in social determinants are found along social gradients (1) and are often avoidable as they result from deeply rooted social institutions, practices, and injustices (18). Thus, (in)equity is the politicized expression of (in)equality involving a moral commitment to social justice (18). In light of these fundamental differences, equity-sensitive public health interventions require measures of health and social determinants of health specific and sensitive to the health issue at hand (20). In our review we identify if and how equity has been considered in large-scale infectious disease testing initiatives. Identifying examples of (in)equity in these initiatives can help guide the design of largescale testing campaigns for the COVID-19 pandemic.

We chose to conduct a rapid review approach as it enabled us to synthesize, with rigor and in a relatively short period of time, the state of knowledge about our research objective (21,22). We have a detailed online protocol published elsewhere (23).

The research strategy was developed in consultation with librarians from the French National

Research Institute for Sustainable Development (IRD) and the University of Montreal. We began our electronic database query in July 2020 on PubMed and Web of Science, and updated our search in November 2020 to better reflect the rapidly evolving state of COVID-19 literature. The following english and french key words were used to define our queries (Appendix 1) : "testing", "mass testing", "dépistage", "screening"; "TB", "tuberculosis", "tuberculose"; "HIV", "VIH", "human immunodeficiency virus"; "COVID-19", "SARS-CoV-2", "coronavirus"; "design", "planification", "planning"; "equit*", "equal*", "inégalités", "inégalités sociales en santé", "ISS", "social inequities in health"; "pandemi*", "epidemic", "outbreak", "endemic"; "infectious disease", "maladie infectieuse".

We followed the PRISMA extension for scoping reviews (24). We used the Automated Text Classification of Empirical Records (ATCER) (25) tool to classify abstracts with an empirical degree ≥ 80. ATCER is a tool that automatically categorizes publications indexed in bibliographic databases into (a) empirical studies (>50), and (b) non-empirical work (<50) (25). We selected the ATCER threshold of ≥ 80 to reflect articles that were "highly empirical", due to our objective of including studies with quantitative data such as program evaluation indicators. The inclusion criteria for articles were: i) a focus on an infectious disease, ii) description of the design portion of a testing or screening program, iii) published in English or in French, iv) had an empirical degree greater than 80 according to the ATCER tool, and v) published after 2010.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 

All identified studies were imported from PubMed and Web of Science into Rayyan QCRI (26), a systematic review software, for screening of the titles, abstracts, and full texts. At least two of three involved reviewers (KO, LD, CD) independently assessed the relevance of titles and abstracts based on the inclusion and exclusion criteria. The second stage of review involved two of three reviewers independently identifying potentially relevant publications based on a full article review.

Any discordance in the process was discussed among all reviewers and if no consensus was reached, an additional reviewer (LT) was consulted.

After independent full text screening was conducted by at least two reviewers, data from the retained articles were extracted and assessed. Extracted data included the following elements: characteristics (title, authors, year), context (country, disease addressed), and the consideration of health inequities or inequalities in the design of the intervention, the main results, and the discussion of the study. If the study considered health inequities, we extracted further information on which measures of equity were considered and if a specific tool or theoretical framework was used in the program design. Generally, a theoretical framework can be used to inform how a public health program is planned and what strategic and operational components were considered during the process of this planning (27). We considered equity (explicit or implicit) in the i) intervention rationale, ii) design, iii) choice of target population, and iv) final recommendations for future initiatives based on the PROGRESS-plus criteria (28). The PROGRESS Plus framework was developed and endorsed by the Campbell and Cochrane Equity Methods Group, in order to highlight a set of social determinants of health that drive variations in health outcomes and the inequalities among the social determinants of health gradient (28). The categories referred to by the acronym are: place of residence, race or ethnicity, occupation, gender, religion, educational level, socioeconomic status (SES), and social capital. Our goal, through the use of these tools, was to assess the presence or absence of the consideration of health inequities in the implementation or evaluation of testing programs.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) We used the Mixed Methods Appraisal Tool (MMAT) (29), and specifically used the section on study methodology to apply a systematic definition to the included articles. The MMAT encompasses five study design categories: i) qualitative research, ii) randomized controlled trials, iii) non-randomized studies, iv) quantitative descriptive studies, and v) mixed methods studies.

In addition, we followed the Template for Intervention Description and Replication (TIDieR-PHP) checklist and guide to assess study coherence and program reporting and evaluation completeness (30). The 12-item checklist includes categories: (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) and is an extension of the CONSORT checklist.

We initially identified 291 references with 41 peer reviewed studies being included in the review ( Figure 1 ). According to MMAT classifications, the studies were a mixture of 2 randomized studies (31,32), 17 non-randomized studies (33-50), 18 descriptive quantitative studies (51-67), and 4 mixed-methods studies (68-71) ( Table 1) . Most of the studies (83%) reported on HIV-related screening programs, while the remaining studies focused on other sexually transmitted infections (n=3) and COVID-19 (n=4). The evaluated studies were implemented in North America (n=27), Europe (n=8), Africa (n=5), and Asia (n=1).

The main type of study setting among the included articles were hospitals (n=16) and clinic-based (52, 54) , homeless shelters (51,58), residential homes (48), and multiple sites and settings (37). Most studies (n=38) focused on a combination of adults over the age of 18 and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) (55, 61) , with one other study focused on newborns and their mothers (41) and one on the elderly (48).

Measures of equity/inequity were assessed based on the PROGRESS-Plus framework. None of the 41 included studies evaluated whether the intervention reduced health inequity or inequalities as a study objective, nor did they include a formal definition of equity/inequity (or framework).

Elements of health equity were indirectly addressed in 23 studies (Table 2) 

This rapid review largely featured articles addressing HIV testing programs, and/or testing programs of infectious disease in North America in formal healthcare settings such as clinics or hospitals. None of the 41 studies included in this rapid review examined health equity in their interventions, however, 8 studies did consistently include elements of equity in their testing intervention, without the inclusion of any formal measurement of, or framework specifically implemented in order to address health equity. Specifically, most (n=6) of these 8 articles considered the PROGRESS-plus categories of gender and/or sex.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) To our knowledge, no prior studies have examined the equitable access, delivery, or design of COVID-19 testing programs. This review shows that implicit measures of equity have been implemented through targeting COVID-19 testing programs to high-risk populations such as health care workers (44), people living in homeless shelters (51,58,73) and long-term care facilities (48). It is largely recognized that targeted actions towards specific communities or groups imply labelling, thus stigma, and increases the risk of missing numerous infections in particularly vulnerable population groups (11, 12, 74, 75) . The current pandemic is exacerbating health inequities and testing programs need to be designed accordingly to address these inequities, which are also central to mitigating disease spread (76) (77) (78) (79) . An example of an approach that could be used in combination with existing testing infrastructure to increase equitable access to COVID-19 testing consists of the deployment of rapid antigen testing kits for in-home testing for those with faced with mobility or geographic restrictions or work and/or family obligations that do not easily coincide with testing program schedules (3) .

Numerous tools exist to support incorporating equity values within public health interventions and programs (80) (81) (82) . These tools should be used both during the design, implementation, and evaluation process, as the link between equity intention and action remains challenging (83) . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 23, 2021. ; https://doi.org/10.1101/2021.02.22.21252205 doi: medRxiv preprint

· Use tools such as PROGRESS-Plus framework to ensure explicit inclusion of health equity when in the process of designing, implementing, and/or evaluating interventions.

· Promote the use of TIDIER-PHP to systematically review public health programs and promote replicability of existing equitable programs to other settings.

Given our objective to include studies with empirical results and also to conduct the review in a timely manner, we chose an ATCER threshold of 80. This may have limited our findings and the generalizability of the results. We recommend that a full scoping review be conducted on this topic to further investigate important trends on the incorporation of health equity into infectious disease testing programs.

The results of this rapid review highlight the overall lack of consideration of equity in the design of large-scale testing interventions. This is a particularly concerning issue as social and economic inequities continue to be exacerbated by COVID-19 and there has not been any research to date that discusses how COVID-19 testing programs have been designed with equity in mind (1-3).

To achieve equity in testing and to optimize the role of testing in disease prevention and control, strategies should ensure that the probability of being tested is proportionate to the risk of being affected by the disease (85,86). We urge practitioners, decision makers, and researchers to explicitly include equity measures when designing and implementing COVID-19 large-scale testing interventions, which should also be considered in COVID-19 vaccination programs.

The authors would like to thank Laurence Goury, librarian at the IRD, and Julie Desnoyers, librarian at the University of Montreal, for their advice regarding the search strategy and the queries on the bibliographic databases.

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The copyright holder for this preprint this version posted February 23, 2021. Authors have no conflicts of interest to declare.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 23, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 23, 2021. ; To evaluate an opt-out inpatient HIV screening program administered with admission-orders written by physician house staff. These data were compared to the number of HIV tests and diagnoses as part of physician-ordered HIV testing (based on signs and symptoms) in the ED.

First, opt-out inpatient HIV screening was associated with markedly lower per test positivity rates when compared to targeted testing in the ED, and these newly HIV diagnosed patients were not typically tested through physician-directed testing in the ED. Second, uptake of screening was limited when physicians were responsible for opt-out screening during routine care, with limited time resources seemingly the major barrier. To describe Wisconsin's social networks testing program and outcomes.

Although social networks testing did not yield a higher new positivity rate compared to other testing strategies, it proved to be successful at reaching high risk individuals who may not otherwise engage in HIV testing.

To examine the results of implementing counselor-based HIV testing and linkage to care components in five urban, NYC pharmacies located in communities highly affected by HIV, in areas with some of the highest rates of poverty in the United States.

Participants were satisfied with a counselorbased rapid HIV testing program in community-based pharmacies. Expansion of HIV screening initiatives into community pharmacies is one way to increase access to HIV testing for individuals who might not otherwise interact with the healthcare system Mixed methods Couples HIV testing and counseling implemented in antenatal care settings helps identify more HIV-positive men whose partners were negative than previous practice, with high acceptability among hospital staff. To evaluate a community-based an HIV testing program for its capacity to reach men who have sex with men (MSM) and successfully refer HIVpositive patients to treatment.

Easily accessible, community walk-in clinics and targeted testing in high-risk settings are convenient for populations of MSM less likely to seek out the established health care system. Check-point diagnosed 37 new HIV cases, posed no barrier to successful link-age to care, was noninferior in quickly reducing community viral load, was cost-effective, reached younger MSM, and proved an ideal plat-form for trying out new interventions and test forms, which conventional health care providers have not yet embraced. To determine the characteristics of those more likely to undergo frequent (HIV) testing.

We found that providers need to strengthen practices to identify persons who have had multiple HIV tests and provide enhanced behavioral interventions for those with persistent risks. This might mean referral to other prevention and support services in order to effect sustainable risk reduction. The results also suggest that some risk behaviors (i.e. injection drug use, MSM and multiple sexual partners) are appropriately recognized as markers for more frequent HIV testing Early implementation of the NACHC model in our setting posed challenges in terms of time involved in initial planning, consistent data collection and reporting, and patient flow. In spite of these challenges, 100 patients were screened for HIV infection who might not have been screened otherwise, and they were given HIV risk reduction handouts after testing, an education intervention that may raise awareness and lead to behavior changes. Younger patients were more likely to undergo testing. The majority of patients who were tested, African American women, represented a high-risk group in North Carolina and the South, and yet African American MSM, those with the highest risk, were underrepresented in our sample. To describe adolescent attitudes and preferences toward rapid HIV testing in a Pediatric Emergency Department.

This study offers valuable new insights into adolescent attitudes and preferences for rapid HIV testing in a PED. Adolescents gave high ratings for the location, testing, and counseling process. Our data support the importance of structured counseling, which is contrary to current published perspectives of counseling efficacy. In addition, we found that the PED was a highly preferred location for rapid HIV testing, which supports the need for increased development of prevention and testing programs in this setting. To (i) evaluate a multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males (especially those of color) aged 13 to 24 years; and (ii) link youths to appropriate prevention services after receipt of their test results.

The findings suggest that community-based targeted approaches to HIV testing are more effective than universal screening for reaching young sexual minority males (especially males of color), identifying previously undiagnosed HIV-positive youths, and linking HIVnegative youths to relevant prevention services. Targeted, community-based HIV testing strategies hold promise as a scalable and effective means to identify high-risk youths who are unaware of their HIV status. To evaluate the impact of a focused emergency nurse partnership with a long-standing HIV testing program, by analyzing a successive series of nurse-driven strategies focused on optimizing rates of HIV testing.

The emergency department is a prime location for public health interventions such as HIV screening. To incorporate these initiatives, strong nursing engagement and leveraging existing resources is key to success. In addition, true sustainability requires integration into the clinical workflow, including optimizing the 24-hour nature of the emergency department to ensure screening reaches all parts of the population. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 23, 2021. ; https://doi.org/10.1101/2021.02.22.21252205 doi: medRxiv preprint

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