COVID Testing Equity: A Reflection Based on 1.5 Years in the ACT-Accelerator

By guest contributors Dr. Fifa Rahman, Prof Brook Baker, and Dr. Carolyn Gomes

“Vaccines alone won’t get us out of this pandemic” – a statement centred by numerous actors in the global COVID response, repeatedly and loudly, often upon deaf ears. Recently, however, there have been some signs that the attitude is changing. Canadians participated in the #FreeTheRATs campaign, demanding the government provide free rapid self-tests for individuals. Omicron surges saw drastically rising demand for RATs in December 2021, with companies responding by working around the clock and investing in automation. Germany on the other hand have invested in rapid tests long before anyone else, with antigen self-tests receiving heavy subsidies, sold at pharmacies, via mobile units called ‘coronabikes’, and via vending machines.

Peter Sands, the Executive Director of the Global Fund, a multilateral global health agency delivering professional use antigen rapid tests to LMICs through the Access to COVID-19 Tools Accelerator (ACT-Accelerator), wrote that ‘if you give people unfettered access to these easy-to-use tests giving almost instant results, they will use them to protect themselves, their families and communities’. Bill Rodriguez, the CEO of the Foundation for Innovative Diagnostics (FIND), which is leading numerous projects examining feasibility, demand, and preferences of rapid tests in LMICs, said  that ‘while the roll out of vaccines must continue, it is equally important to hit the new testing targets’ in the ACT-Accelerator’s new strategy.

Representing civil society on the diagnostics and therapeutics pillars of the ACT-Accelerator, we have participated in numerous weekly and biweekly discussions since July 2020 on access to COVID-19 tools. Our role has been to distil evidence and experience from CSOs globally and bring that to tables dominated by Global North agencies, clinicians, and epidemiologists, and to centre elements of what we think an equitable pandemic response should incorporate. At all times, we have insisted on equitable access of *all* available tools to communities that need them – including via letters to WHO leadership calling out disparity in testing equity in the Global North and the Global South, demanding that their guidelines more explicitly mention community-based testing, that the guidelines include recommendations for linkage to care with self-testing, and how individuals should react in an environment with long turnaround times for PCR tests. 

We know that progress on self-tests at the ACT-Accelerator level have been extremely slow, and not for the tireless efforts of several global health agencies such as FIND and Global Fund who are trying to get rapid tests (both professional use and self-tests) to LMICs. At time of writing, we still do not have WHO guidelines on self-tests – an important prerequisite for global health agencies to deploy self-tests to LMICs at scale. The WHO has committed to establishing a Guideline Development Group (GDG) towards the development of self-test guidelines, after which companies will be invited to register to include their products under the Emergency Use Listing. Based on our discussions, our optimistic estimations on the timeline are as follows:

            Q1 2022           Guideline Development Group for self-tests established

            Q2 2022           WHO Guidelines for rapid self-tests released & EUL expressions of interest opened

            Q3-Q4 2022      Self-test product reviews

            Q1 2023           Global health agencies deploy self-test products included on EUL

When Global North countries are rapidly deploying these tests and making them accessible to all individuals, a delayed 2023 timescale for self-test deployment to the Global South is unacceptable. We will have many more deaths in LMICs from now until then.

We’ve also been disturbed by the language we’ve been hearing from some global health officials on the COVID-19 response, including that self-tests are to be recommended *only if* people can link to treatment or *only if* they are linked to public health action. These statements are problematic for two reasons; firstly because it is not the Global North that is suffering from testing inequity, these statements imply that people in the Global South would not know how to link to treatment and/or would not know how to do public health actions. These reservations are paternalistic and racist. They are reflective of approaches from the early 2000s in the HIV world – with the then-Chief of USAID saying “If we had [HIV medicines for Africa] today, we could not distribute them. We could not administer the program because we do not have the doctors, we do not have the roads, we do not have the cold chain…[Africans] do not know what watches and clocks are. They do not use western means for telling time.” Disregarding this racist slander, today we have HIV antiretroviral medicines deployed across the world including Africa (and rural Africa), and once again the Global North underestimating the Global South was proven wrong. These approaches need to be resigned to the rubbish bins of history. Furthermore, we know for example, that in Somalia, deployment of rapid antigen tests have increased testing rates by 20%. This is basic – offer rapid tests and more people will test.

Secondly, access to self-tests is part of people’s fundamental right to information about their own bodies. We don’t tell pregnant persons that they are only allowed self-tests *only if* they will be linked to public health action.

We also think that we need clearer guidance around rapid antigen tests as part of test-and-treat strategies, especially with the emergence of outpatient medicines like Paxlovid that can be used as outpatient treatments and have been shown to drastically reduce risk of hospitalisation and death. This means that in an ideal world, people could receive community-based testing or conduct a rapid self-test at home when they first exhibit symptoms, register that result with the health authorities, who would then connect them to treatments to be initiated within five days. WHO-endorsed interim recommendations now towards testing and treating could go a long way towards LMICs preparing their countries for endemicity and averting unnecessary hospitalizations, social and economic disruptions, and deaths.

ACT-Accelerator civil society representatives are not the only ones who have called for quicker guideline development.  A recent article in The Lancet called for ‘timely dissemination of updated World Health Organization testing guidelines to drive country policies. And while we welcome anyone writing on COVID testing equity, the lack of granularity is unhelpful. There is a need for action – and timely for us means now. Timely for us, means that in a pandemic, LMICs receive the same quality of services and the same access to services as those in the Global North. This means that when it comes to both professional use rapid antigen tests and self-tests, we as a global community have grossly missed the mark.

For the promise of community-based and self-testing and connection to be realized, major changes in supply, price, and equitable distribution must be realized.  Manufacturing of rapid antigen tests must be greatly expanded with greatly expanded production in all regions of the world with more supplier receiving prompt regulatory approval and emergency use permission from the WHO Prequalification Programme and national regulators.  Increased supply, more competition, subsidies, and elimination of profiteering should reduce prices to a dollar or less.  Heightened demand is rich countries should not interfere with equitable, proportionate supply to low- and middle-income countries.   And poor people and marginalized populations within countries should have guaranteed access to free testing.  All testing, including self-testing, should be considered essential to a public health response, and not privatized as the sole responsibility of individuals and dependent on ability to pay. 

Finally, demand for testing will significantly expand only if individuals and communities are exposed to culturally competent health literacy resources on the value of regular or early testing and the promise of outpatient therapies.  As the HIV response has shown us, people will flock to tests when there easily deployed treatment are readily available, resulting in huge health benefits for individuals, families, health systems, and the community at large.

We note the comments by Ellen Johnson Sirleaf and Helen Clark in PLOS Global Public Health last year, that the ‘root cause’ of vaccine equity ‘was a lack of decisive leadership directed towards cooperation and solidarity.’ In access to testing, we continue to see this lack of decisive leadership in all spheres. Something must be done to expedite the procedures to enable deployment of community-based and self-tests now. We stand as co-actors in gross inequity. And we will stand for it no further.

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