HIV prevention responsibilities in HIV vaccine trials: complexities facing South African researchers

Researchers should protect the welfare of research participants through providing methods to reduce their risk of acquiring HIV. This is especially important given that late-phase HIV vaccine trials enrol HIV-uninfected trial volunteers from high-risk populations. Current ethical guidelines may be difficult for stakeholders to implement, and we know very little about what prevention services researchers are currently providing to participants or their successes, best practices and challenges. We recommend that current normative guidance be systematically reviewed and actual practice at vaccine sites be documented. Adding new tools to the current package of prevention services will involve complex decision making with few set standards, and regulatory and scientific challenges. We recommend that stakeholders (including regulators) convene to consider standards of evidence for new tools, and that decision-making processes be explicitly documented and researched. A further critical ethical task is exploring the threshold at which adding new tools will compromise the validity of trial results.

Access to treatment in HIV prevention trials: perspectives from a South African community

Access to treatment, in HIV vaccine trials (HVTs), remains ethically controversial. In most prevention trials, including in South Africa, participants who seroconvert are referred to publicly funded programmes for treatment. This strategy is problematic when there is inadequate and uneven access to public sector antiretroviral therapy (ART) and support resources. The responsibilities, if any, of researchers, sponsors and public health authorities involved in HVTs has been hotly debated among academics, scholars, representatives of international organizations and sponsors. However, there is little published on community perceptions. Recent guidance asserts that communities should make inputs into treatment and care decisions. This qualitative study explored a South African community's perceptions of who should provide what to HVT participants as well as how and why this should be done. Twenty-nine adults working at or attending five primary health care clinics in two rural areas in KwaZulu-Natal participated in in-depth interviews. Respondents expressed that researchers should 'help participants to access' treatment and care 'because they are in a position to do so' and 'are in a relationship with' trial participants. Respondents suggested that researchers could help by 'facilitating referral' until such time that participants can access care and treatment on their own. We highlight a series of implications for researchers in HVTs, including their need to be aware of prospective participants' considerable trust in and respect for researchers, the responsibility that this places on them, and the need for clear communication with communities so as not to erode community trust.

Sex, lies and disclosures: Researchers and the reporting of under-age sex

Children are a vulnerable group and require legal protection due to their youth and inexperience. Resultantly, various provisions in the law ensure the care and protection of children through mechanisms such as the mandatory reporting of abuse. A recent change in the law has broadened the mandatory reporting obligations by requiring any person who is aware of a sexual offence having been committed against a child to report this to the police. Given that it is a sexual offence to have sex below the age of 16 researchers involved in research with teenagers in which they may become aware that that they are engaging in sex or sexual activity but are under the age4 of 16 will be obliged to inform the police of this fact. The issue of reporting under-age sex is very complex as in our view there are various categories of under-age sex. We argue that researchers should not comply with the mandatory reporting obligations for underage consensual, non-exploitative sexual activity but in all other cases there should be reporting. We argue that because the mandatory reporting of underage sex/ activity (even consensual and non-exploitative activity) may alienate children from services and “punish” them by reporting their conduct to the police, advocacy is needed for a change to the Sexual Offences Act to ensure consistency with the approach taken in the Children’s Act which enables such children to access sexual and reproductive services..

Enrolling adolescents in HIV vaccine trials: reflections on legal complexities from South Africa

Background

South Africa is likely to be the first country in the world to host an adolescent HIV vaccine trial. Adolescents may be enrolled in late 2007. In the development and review of adolescent HIV vaccine trial protocols there are many complexities to consider, and much work to be done if these important trials are to become a reality.

Discussion

This article sets out essential requirements for the lawful conduct of adolescent research in South Africa including compliance with consent requirements, child protection laws, and processes for the ethical and regulatory approval of research.

Summary

This article outlines likely complexities for researchers and research ethics committees, including determining that trial interventions meet current risk standards for child research. Explicit recommendations are made for role-players in other jurisdictions who may also be planning such trials. This article concludes with concrete steps for implementing these important trials in South Africa and other jurisdictions, including planning for consent processes; delineating privacy rights; compiling information necessary for ethics committees to assess risks to child participants; training trial site staff to recognize when disclosures trig mandatory reporting response; networking among relevant ethics commitees; and lobbying the National Regulatory Authority for guidance.

Research and Law - Ethical legal challenges in adolescent HIV vaccine trials

No abstract available.

Beyond the Checklist

OBJECTIVES

Informed consent and understanding are essential ethical requirements for clinical trial participation. Traditional binary measures of understanding may be limited and not be the best measures of level of understanding. This study designed and compared 4 measures of understanding for potential participants being prepared for enrollment in South African HIV vaccine trials, using detailed operational scoring criteria.

METHODS

Assessment of understanding of 7 key trial components was compared via self-report, checklist, vignettes, and narrative measures. Fifty-nine participants, including members of vaccine preparedness groups and 1 HIV vaccine trial, took part.

RESULTS

There were significant differences across the measures for understanding of 5 components and for overall understanding. Highest scores were obtained on self-report and checklist measures, and lowest scores were obtained for vignettes and narrative descriptions.

CONCLUSIONS

The findings suggest that levels of measured understanding are dependent on the tools used. Forced-choice measures like checklists tend to yield higher scores than open-ended measures like narratives or vignettes. Consideration should be given to complementing checklists and self-reports with open-ended measures, particularly for critical trial concepts, where the consequences of misunderstanding are potentially severe.

Provision of HIV treatment in HIV preventive vaccine trials: a developing country perspective

HIV treatment for participants who become infected during HIV vaccine trials has been the focus of ethical controversy. The obligations of sponsors to ensure that participants have access to antiretrovirals have been a particular focus of this debate. This paper presents three arguments that have been made in this regard, and some of their limitations, in anticipation of HIV vaccine trials in South Africa. The first argument is that HIV risk behaviour increases in such trials, and HIV infection can be viewed as a research-related injury, justifying sponsor provision of treatment on grounds of compensation for harm. We conclude that risk-behaviour studies to date do not show general increases in risk behaviour that could constitute the basis for a general obligation. Participation may well adversely impact on risk behaviour for some individuals, and conceivably this could be demonstrated. This argument may, therefore, have merit at the individual level; however, it seems a weak platform from which to argue that sponsors should treat all HIV infections acquired during trials. The second argument is that treatment should be provided based on distributive justice. We conclude that traditional concepts of "distributive justice" in research appear limited in justifying obligations of sponsors to ensure access to antiretrovirals. Further, using research initiatives to reduce global health care inequities is controversial, and even proponents may disagree about the fairest use of finite resources. The third argument is that sponsors should ensure antiretroviral access on grounds of beneficence; namely, the maxim that if one can do something beneficial without sacrificing anything of comparable significance, it ought to be done. Thus, sponsors should provide more interventions than those minimally required to conduct the research. However, beneficence may demand levels of altruism that exceeds what is reasonable. While the latter arguments may provide stronger justifications than the first, it is difficult to use these arguments to establish that sponsor provision of antiretrovirals to infected individuals is obligatory.

Implications of the ethical-legal framework for adolescent HIV vaccine trials--report of a consultative forum

The ethical-legal framework in South Africa is in a period of transition, with a number of new developments changing the substantive principles and procedures for health research in the country. Some of the changing dynamics include both law reform and the review of ethical guidelines. This changing environment poses many complexities for researchers, research ethics committees and participating communities involved in planning, implementing and reviewing research with child participants, including HIV vaccine trials. This paper presents the major themes and outcomes of a consultative meeting convened by the HIV AIDS Vaccines Ethics Group in July 2004 for key stakeholder groups. At this forum participants discussed the complexities posed by a transitional and sometimes contradictory ethical-legal framework and how the framework could be improved to simultaneously promote critical research and the welfare of child participants.

HIV vaccine research--South Africa's ethical-legal framework and its ability to promote the welfare of trial participants

An effective ethical-legal framework for the conduct of research is critical. We describe five essential components of such a system, review the extent to which these components have been realised in South Africa, present brief implications for the ethical conduct of clinical trials of HIV vaccines in South Africa and make recommendations. The components of an effective ethical-legal system that we propose are the existence of scientific ethical and policy-making structures that regulate research; research ethics committees (RECs) that ethically review research; national ethical guidelines and standards; laws protecting research participants; and mechanisms to enforce and monitor legal rights and ethical standards. We conclude that the ethical-legal framework has, for the most part, the necessary institutions, and certain necessary guidelines but does not have many of the laws needed to protect and promote the rights of persons participating in research, including HIV vaccine trials. Recommendations made include advocacy measures to finalise and implement legislation, development of regulations, analysis and comparison of ethical guidelines, and the development of measures to monitor ethical-legal rights at trial sites.

The South African Medical Research Council's Guidelines on Ethics for Medical Research--implications for HIV-preventive vaccine trials with children

Children are at risk of HIV infection, stand to benefit from the development of HIV preventive vaccines, and therefore should be enrolled in trials of HIV vaccines in order to generate relevant safety, immunogenicity and efficacy data. In South Africa, the national vaccine initiative is considering the future conduct of trials involving children; this requires an analysis of the current ethical framework, including elements that facilitate or constrain the conduct of such trials. In this article, we examine the Medical Research Council (MRC)'s Guidelines on Ethics for Medical Research: General Principles (Book 1), and their provisions on research involving children. We argue that this set of influential guidelines includes provisions on research with children that are conceptually problematic and may prohibit critical research with healthy (but at-risk) child participants, including trials of HIV-preventive vaccines. We recommend that Book 1 provisions should be redrafted to reflect a balance between protecting children from research-related risks and testing interventions critical to their health.

How well does South Africa's National Health Act regulate research involving children?

Currently there are no laws in South Africa regulating the rights of research participants. The National Health Act is the first attempt by the legislature to use the law to protect research participants, including children. This article describes the strengths and limitations of the provisions, implications for researchers and research ethics committees, and makes recommendations. Strengths of the Section include that it enables the Minister of Health to issue regulations detailing protections for research participants, it supplements existing law on consent, it introduces the concept of the 'best interests' of the child and it creates procedural safeguards. Limitations of the Section include that it does not set an independent age for consent to research, it focuses on informed consent and not other protections, it is inconsistent with existing or draft legislation and ethical guidelines, and it retains the contested distinction between 'therapeutic' and 'non-therapeutic' research. Poor drafting and inconsistencies also impede interpretation. The implications for researchers are that it facilitates so-called 'non-therapeutic' research on children. However, procedural burdens for obtaining consent are created. Research Ethics Committees (RECs) will have to work with the 'therapeutic' and 'non-therapeutic' distinction as well as new concepts such as 'best interests' of the child, and ensure that consent procedures comply with the Act. We conclude that while the Act is an important development in the law, it is flawed in places. We recommend that amendments be made and that capacity development be provided to stakeholders.

Postmastectomy Reconstruction of the Previously Augmented Breast: Diagnosis, Staging, Methodology, and Outcome

Although many of the health and safety issues associated with breast augmentation have been thoroughly discussed over the past decade, the literature is remarkably silent regarding postmastectomy reconstruction of the previously augmented breast. A retrospective review of the senior author's reconstructive practice was performed for the years 1983 through March of 1999, revealing 21 women who underwent postmastectomy breast reconstruction after previous breast augmentation. For purposes of measuring aesthetic results, these 21 patients were matched to a carefully selected control group of 15 patients. They were also compared with other, larger populations, including 777 of the senior author's other breast reconstructions, the breast cancer registry at the Lombardi Cancer Center in Washington, D.C., and several large, published epidemiologic studies. The interval between the previous augmentation and the diagnosis of breast cancer ranged from 9 months to 18 years, with a mean of 9.3 years. None of the previous augmentation implants was ruptured at the time of mastectomy. Of the nine patients with previous subpectoral augmentation, cancer was detected mammographically in five (56 percent), whereas of the 12 patients with previous subglandular augmentation, cancer was first detected mammographically in only three (25 percent). This difference was not statistically significant (p = 0.2). Overall, eight of the study patients' tumors (38 percent) were first detected mammographically, which is similar to other published reports of breast cancer patients in the general population. Seventy-one percent of the 21 study patients were node-negative, which also compares favorably with other published series. Sixteen of the women with previous augmentation (76 percent) had purely prosthetic reconstructions. Flaps were used in the other five reconstructions (23 percent): three latissimus dorsi flaps (14 percent) and two transverse rectus abdominis musculocutaneous flaps (9 percent). All five flaps were used in patients who had undergone radiation therapy. Throughout the senior author's entire reconstructive practice history, transverse rectus abdominis musculocutaneous flaps were more frequently used [282 of 777 nonaugmented reconstructions (36 percent)], whereas latissimus dorsi flaps were less frequently used [17 of 777 nonaugmented reconstructions (2.2 percent)] (p < 0.001). The cosmetic results of the breast reconstructions in the previously augmented study group were generally good-to-excellent, with a mean score by blinded observers of 3.35 of a possible 4.0. These results were comparable to or better than those in the matched controls, who scored a mean of 3.0.

Hospital and emergency department use by young low-income children

BACKGROUND

Limited data are available concerning determinants of health care service usage by low-income young children.

OBJECTIVES

To explore predictors of hospitalization and emergency department (ED) use by young children of low-income families by using the Aday and Andersen Access Framework.

METHODS

Low-income women (n = 474) with a child younger than 6 years completed a structured face-to-face interview at human service offices or Women, Infants, and Children (WIC) clinics in four central Ohio counties. Women were considered low-income if they or their child were Medicaid eligible or uninsured. Data were collected for both the mother and the index child on sociodemographic status, health services use, health status, and access to care.

RESULTS

Fifteen percent of the children had been hospitalized the previous year, and half had an ED visit. Hospitalization was significantly related to maternal hospitalization the previous year (OR = 2.5), child age younger than 1 year old (OR = 2.1) and more than two chronic conditions (OR = 2.2). Maternal ED usage in the last year (OR = 2.2), Medicaid fee for service plan (OR = 1.7), and rural residence (OR = 2.0) were predictive of ED use.

CONCLUSIONS

Predisposing characteristics (maternal hospital/ED use) were predictive of both hospitalization and ED use by the index child. Enabling characteristics (fee-for-service Medicaid plan, rurality) were only predictive of ED use, and need characteristics (child's health) were only predictive of hospitalization. Further research to explore linkages between maternal and child use of health care services as well as the effect of changes in health care access, managed care, and other innovations on hospitalization and ED use in young, low-income children is recommended.

Ethical issues in HIV vaccine trials in South Africa

In this review we describe the ethical issues central to local and international debates about HIV vaccine trials. These issues include the physiological and psycho-social risks of trial participation, the preventative interventions to be provided to participants, access to treatment for participants who seroconvert, access to an effective vaccine after the trial, the role of placebo-controlled trials, and obtaining informed consent.

Rearrangement of extracellular matrix during cluster formation by human luteinising granulosa cells in culture

Human ovarian granulosa cells were cultured on a basement membrane preparation (Matrigel) to investigate the role of extracellular matrix components in granulosa cell cluster formation. Time-lapse videomicroscopy of these cultures revealed a rapid aggregation of cells which was initiated during the first 2-4 h of culture so that by 8 h most of the granulosa cells were incorporated into clusters. Further amalgamation then occurred with the transfer of cells along 'bridges' between combining clusters. The clustering process, which was complete by about 24 h, was accompanied by reorganisation of matrix which was visualised by immunolabelling of laminin. Clustering cells appeared to gather matrix which became distributed around the clusters. Confocal microscopy showed matrix to be present over the surface of each cluster as well as around the base apparently anchoring the aggregate to the culture surface. Results suggest the potential for active rearrangement of matrix by granulosa-derived cells during corpus luteum development.

Self-reported health status of low-income mothers

PURPOSE

To determine the self-reported health status of low-income mothers before major health and welfare policy reform in the state of Ohio, to compare the health status of this group with the general population age-based norms, and to examine differences in health status among insurance and racial subgroups. Policy makers and others have a need for key health-status information about low-income mothers, a topic for which little empirical data currently exist.

DESIGN

Descriptive using a cross-sectional survey with convenience sampling; 502 women were interviewed at intake sites in four countries in central Ohio, 1995 to 1996.

METHODS

Health status was measured using the general health status index developed by J. E. Ware and colleagues (1995). Two summary measures, one indicating physical health and one indicating mental health, were used and compared with published norms. Multivariate logistic models were examined for depression and physical health status.

FINDINGS

A significant level of depression in the population of low-income mothers was found as were differences in physical health scores by insurance group. People insured privately had the highest physical health scores, while those enrolled in fee-for-service Medicaid had scores indicating the poorest health. No significant difference was found between racial groups in self-reported health status.

CONCLUSIONS

Self-reported mental health status is low among some low-income female populations. Physical health is worse for the Medicaid-enrolled group compared to both uninsured and privately insured groups. This poor state of health will likely diminish the success of welfare reform to improve the economic self-sufficiency of these women unless comprehensive health services are available.

Molecular cloning of the human gene, PNKP, encoding a polynucleotide kinase 3'-phosphatase and evidence for its role in repair of DNA strand breaks caused by oxidative damage

Mammalian polynucleotide kinases catalyze the 5'-phosphorylation of nucleic acids and can have associated 3'-phosphatase activity, predictive of an important function in DNA repair following ionizing radiation or oxidative damage. The sequences of three tryptic peptides from a bovine 60-kDa polypeptide that correlated with 5'-DNA kinase and 3'-phosphatase activities identified human and murine dbEST clones. The 57.1-kDa conceptual translation product of this gene, polynucleotide kinase 3'-phosphatase (PNKP), contained a putative ATP binding site and a potential 3'-phosphatase domain with similarity to L-2-haloacid dehalogenases. BLAST searches identified possible homologs in Caenorhabditis elegans, Schizosaccharomyces pombe, and Drosophila melanogaster. The gene was localized to chromosome 19q13.3-13.4. Northern analysis indicated a 2-kilobase mRNA in eight human tissues. A glutathione S-transferase-PNKP fusion protein displayed 5'-DNA kinase and 3'-phosphatase activities. PNKP is the first gene for a DNA-specific kinase from any organism. PNKP expression partially rescued the sensitivity to oxidative damaging agents of the Escherichia coli DNA repair-deficient xth nfo double mutant. PNKP gene function restored termini suitable for DNA polymerase, consistent with in vivo removal of 3'-phosphate groups, facilitating DNA repair.

Purification of a polynucleotide kinase from calf thymus, comparison of its 3'-phosphatase domain with T4 polynucleotide kinase, and investigation of its effect on DNA replication in vitro

Mammalian polynucleotide kinases (PNKs) carry out 5'-phosphorylation of nucleic acids. Although the cellular function(s) of these enzymes remain to be delineated, important suggestions have included a role in DNA repair and, more recently, in DNA replication. Like T4 PNK, some preparations of mammalian PNKs have been reported to have an associated 3'-phosphatase activity. Previously, we have identified in calf thymus glands an apparently novel PNK with a neutral to alkaline pH optimum that lacked 3'-phosphatase activity. In this report, we describe purification of another bovine PNK, SNQI-PNK, with a slightly acidic pH optimum that copurifies with a 3'-phosphatase activity. The enzyme appears to be a monomer of 60 kDa. Mammalian DNA replication reactions were supplemented with T4 PNK or SNQI-PNK, and no significant effect on DNA replication in vitro was observed. Database searches support the earlier mapping of the 3'-phosphatase activity of T4 PNK to the C-terminus and suggest that the 3'-phosphatase domain of T4 PNK is related to the protein superfamily of L-2-haloacid dehalogenases. Exopeptidase digestion experiments were carried out to compare the SNQI-PNK enzyme with T4 PNK and led to the inference that the domain organization of the bovine polypeptide may differ from that of the T4 enzyme.

Preventive health counseling reported by uninsured women with limited access to care

Low-income women in the childbearing years are at an increasing risk of becoming uninsured as welfare reforms are enacted and women enter minimum-wage jobs without insurance benefits. This study contrasts preventive counseling reported by low-income uninsured mothers and mothers insured through Medicaid. Low-income women attending Women, Infant, and Children (WIC) clinics and human services offices who had received health care during the previous 12 months (N = 406) were asked if they had received counseling from a health provider regarding any of seven types of preventive health behaviors. Uninsured women were less than half as likely to receive counseling on three or more preventive topics (OR = 0.42) as were mothers on Medicaid. Risk estimates were stable on bivariate analyses and logistic regression models. Findings indicate that opportunities for preventive health counseling need to be maximized for this group already experiencing compromised access to care.

Thoracic paraplegia after lumbar spinal surgery

Two cases of thoracic level paraplegia after lumbar spinal surgery were retrospectively reviewed after 1 year of follow-up. Charts and perioperative records were reviewed in an effort to determine the possible etiology of this rare and devastating complication. We were unable to find any reports in the English-language literature regarding thoracic-level paraplegia in an isolated lumbar procedure (in the absence of preexisting structural instability or thoracic level lesion). We found 23 reported cases of acute spontaneous paraplegia or quadriplegia from fibrocartilaginous (disk) emboli to the spinal cord. This was a retrospective review specifically seeking possible predisposing conditions, intra- or postoperative hypotension, or technical errors that might have led to the complication of paraplegia. No preoperative thoracic level intracanal lesions were identified. There were no episodes of profound hypotension noted perioperatively. The specific pattern of paralysis found in these two patients did not correlate with the level of the surgery performed. Both patients had findings consistent with cord edema and spinal cord infarct in the thoracic region. We believe that these two cases represent acute spinal cord infarcts in the "watershed" region of the thoracic cord, the exact cause of which could not be determined. A theory of an embolic phenomenon is proposed as a possible etiology.