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Inequity in COVID-19 testing in the US: Lessons from DC’s response to HIV/AIDS

Without proper access to healthcare facilities and testing, the pandemic will stretch the inequality which already exists, especially for women, youth, and other vulnerable groups in Nigeria. Vulnerable groups are groups that experience higher social and economic exclusion when compared to the general population. In Nigeria, some vulnerable groups include children, the ill or malnourished, women, the elderly (aged 65 and above), the disabled, youth (aged 15 – 35), and communities in poor local government areas, especially in states like Sokoto, Taraba, and Jigawa with poverty rates above 80 per cent.

The unequal impact of COVID-19 is present in several other countries. The response to HIV/AIDs in Washington DC presents opportunities to address the likely unequal impact of the pandemic.

COVID-19 is disproportionately impacting lower-income people of colour across the US. In Washington DC, 46 per cent of COVID-19 cases and 75 per cent of deaths have occurred among black people, who account for 44 per cent of the overall population. Only 15 per cent of cases and 11 per cent of deaths are among whites who comprise 46 per cent of the overall population.

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But initial data suggests that expanded testing access is not on track to reach the communities that could benefit most. In Washington DC, despite a rapid response to the pandemic that showed promise, the neighbourhoods most impacted by COVID-19 are majority lower-income black neighbourhoods – and this burden may not be addressed with widespread scaling-up of testing. Other cities in the US echo this trend. 69 per cent of cases and 73 per cent of deaths in St Louis are among black people, who make up 46 per cent of the population.

At the root of the problem are longstanding disparities in access to medical care and historical mistrust of the healthcare system due to racism in medicine. This is further complicated by racism’s contribution to the high prevalence of risk factors among people of colour, including underlying health conditions, type of work, and living conditions, which result in a higher risk of infection and worse illness.

Lessons from the HIV epidemic: Systemic solutions create equity

The response of DC to an over two-decade battle against HIV/AIDS – heralded as a model by the nation – may offer lessons for COVID-19 response. DC successfully devised approaches over time to target those most affected by the HIV/AIDS epidemic – predominantly lower-income black residents. Significantly, testing facilities were concentrated per local authority area – or ward – according to the burden. Programmes ranged from collaborating with community-based organizations to providing services across the care continuum, including the expansion of support services such as food vouchers and transportation to appointments and use of mobile testing facilities

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The results were significant. From 2004-2008, DC saw a 415 per cent increase in HIV testing among black people. Testing progress coupled with a connection to medical care and provision of support services led to overall improvements in HIV/AIDS outcomes in DC, including decreases in new diagnoses.

Race reflective data and equitable testing: two steps to overcome inequity

In a research paper, Dalberg draws on lessons from DC’s HIV/AIDS response and identifies two initial steps to help overcome the disproportionate impact of COVID-19 on people of colour, and some of these recommendations are applicable to address inequality in Nigeria.

One is the availability of routine data that reflects race, with data on testing, confirmed cases and deaths by race informing programming and decision making. This data is not widely available. Currently, race-disaggregated testing is reported in only four US  states, while confirmed cases are reported in 47 states, and death data in 42 states.

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In Nigeria, one of the most affluent LGAs, Eti-Osa, has had one of the highest numbers of tests and confirmed cases. Reflective data might signal a need for more accessible testing for Nigeria’s poorer LGAs in hotspots such as Lagos – providing a key tool for decision making. Similarly, reflective data that shows the economic impact of COVID-19 on women, youth, and the disabled might support the allocation of funds to reach high-risk segments.

Equitable testing is another step – the provision of the expanded testing access necessary for communities most affected by COVID-19. In communities of higher risk, testing facilities near convenient hours and fewer restrictions such as primary care referrals, are more accessible and will improve access to testing as well as serve as a critical entry point connecting those with COVID-19 to healthcare resources.

With these two steps in place, cities would be better able to direct resources towards communities with the highest-burden, target policy and put in place stronger containment measures. Individuals who test positive can be cautioned on how to prevent infecting family members and the community.

Better testing access could be vital for people of colour who are more likely to have co-morbidities and need hospital care sooner. Equitable testing can be hampered in several ways.

For instance, in DC’s majority-black, low-income areas with higher levels of COVID-19 cases, deaths and higher-risk population, there are fewer testing sites, inconvenient testing hours for low-income and/or essential workers, and other requirements; all of which prevent access. This picture of the potential for inequitable access to testing in DC can be applied to other cities across the world.

What does this mean for Nigeria?

There is a need for disaggregated data to address the nuances in COVID-19 impact on women, youth, and other vulnerable communities. We know that more testing is needed, especially for the most vulnerable, and we must turn to new models to level out access to care.

It’s time to create data-informed strategies to decrease access burden and engage hard-to-reach populations through partnerships and community activations with proper public health infrastructure and creative programming – with a focus on holistic community-based care.

Let’s come together to create a transparent picture of who has access to the vital information that could help change the course of the crisis. Drawing from the lessons in other countries, we can implement the strategies, policies, and connections between organizations needed to provide help where it is needed most.

This article was originally published at length on Dalberg’s official website. Click here to read the Dalberg-authored research paper on this topic.

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