Association of race, ethnicity, and housing stability with COVID-19 testing method by investigators in underserved populations 2020-2023

Edwin Wilbur Woodhouse^1,2,3*Timothy Veldman^2,3Elizabeth Lydon³Lisa Wruck³Elizabeth Petzold^2,3Paul K Drain⁴Eyal Oren⁵Susan Kiene⁶Corinne McDaniels-Davidson⁶Lisa Gwynn⁷Krista M Perreira⁸Barrie Harper³L Gayani Tillekeratne^2,3Susanna Naggie^2,3Micah T McClain^2,3Christopher W Woods^2,3

• ¹Duke University Medical Center, Duke University, Durham, United States
• ²Division of Infectious Diseases, Department of Medicine, School of Medicine, Duke University, Durham, North Carolina, United States
• ³Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina, United States
• ⁴Department of Global Health, School of Medicine, University of Washington, Seattle, Washington, United States
• ⁵Division of Epidemiology and Biostatistics, San Diego State University, San Diego, CA, United States
• ⁶School of Public Health, San Diego State University, San Diego, California, United States
• ⁷Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, United States
• ⁸Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

Background: Expanding SARS-CoV-2 testing was a critical part of community-based health efforts during the COVID-19 pandemic. In the RADx-UP consortium, a large NIH-funded network of community-engaged researchers in the United States, investigators were able to choose between PCR-and antigen-based testing strategies in community-based research settings. Data analyzing how COVID-19 diagnostics are chosen and utilized in research of vulnerable and underserved populations is limited. Objectives: To examine the association of race, ethnicity, and housing stability with a PCR-or antigen-based testing strategy within COVID-19 testing projects in the RADx-UP consortium. Methods: Testing protocols and investigator survey data describing target populations for community-engaged research projects were analyzed for association between race, ethnicity, and housing stability with SARS-CoV-2 test type. Community-engaged research projects were included if they were funded and approved to use PCR-and/or antigen-based COVID-19 testing by the RADx-UP testing core between 2020-2023. Multivariable adjustment to assess for confounding was then performed using rurality, project size, pandemic phase, and census region. Results: Sixty-seven projects (representing 479,410 participants) were included in the analysis. Overall, 24 (36%) projects chose an antigen-only testing strategy compared to 43 (64%) that chose a PCR-based strategy. No significant differences in distribution were seen in inclusion of PCR-testing by race (16 of 21 for Black race versus 27 of 46 for non-Black race, p=0.198), ethnicity (22 of 33 for Hispanic ethnicity versus 21 of 34 for non-Hispanic ethnicity, p=0.765), or housing stability (10 of 17 for unstable housing versus 33 of 50 for stable housing, p= 0.728) within intended population. Conclusions: Race, ethnicity, and housing stability of an underlying vulnerable population was not significantly associated with the decision by community investigators regarding which COVID-19 testing strategy was most appropriate. Future research efforts should remain vigilant to offer emerging diagnostic technologies in the most equitable and appropriate ways.