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Draucker C, Carrión A, Ott MA, Knopf A. Assessing Facilitator Fidelity to Principles of Public Deliberation: Tutorial. JMIR Form Res 2023; 7:e51202. [PMID: 38090788 PMCID: PMC10753414 DOI: 10.2196/51202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/28/2023] [Accepted: 10/13/2023] [Indexed: 12/30/2023] Open
Abstract
Public deliberation, or deliberative democracy, is a method used to elicit informed perspectives and justifiable solutions to ethically fraught or contentious issues that affect multiple stakeholder groups with conflicting interests. Deliberative events bring together stakeholders (deliberants) who are provided with empirical evidence on the central issue or concern and then asked to discuss the evidence, consider the issue from a societal perspective, and collectively work toward a justifiable resolution. There is increasing interest in this method, which warrants clear guidance for evaluating the quality of its use in research. Most of the existing literature on measuring deliberation quality emphasizes the quality of deliberants' inputs (eg, engagement and evidence of compromise) during deliberative sessions. Fewer researchers have framed quality in terms of facilitator inputs, and these researchers tend to examine inputs that are consistent with generic group processes. The theory, process, and purpose of public deliberation, however, are distinct from those of focus groups or other group-based discussions and warrant a mechanism for measuring quality in terms of facilitator fidelity to the principles and processes of deliberative democracy. In our public deliberation on ethical conflicts in minor consent for biomedical HIV prevention research, we assessed facilitator fidelity to these principles and processes because we believe that such assessments serve as a component of a comprehensive evaluation of overall deliberation quality. We examined verbatim facilitator remarks in the deliberation transcripts and determined whether they aligned with the 6 principles of public deliberation: equal participation, respect for the opinions of others, adoption of a societal perspective, reasoned justification of ideas, expression of diverse opinions, and compromise or movement toward consensus. In this tutorial, we describe the development of a blueprint to guide researchers in assessing facilitator fidelity, share 3 templates that will assist them in the task, and describe the results of our assessment of facilitator fidelity in 1 of the 4 sites in which we conducted deliberations.
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Affiliation(s)
- Claire Draucker
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Andrés Carrión
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Mary A Ott
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Amelia Knopf
- School of Nursing, Indiana University, Indianapolis, IN, United States
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MacDonald KR, Enane LA, McHenry MS, Davis NL, Whipple EC, Ott MA. Ethical Aspects of Involving Adolescents in HIV Research: A Systematic Review of the Empiric Literature. J Pediatr 2023; 262:113589. [PMID: 37399918 PMCID: PMC11119419 DOI: 10.1016/j.jpeds.2023.113589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To evaluate the ethics of involving adolescents in HIV research, we conducted a systematic review of the empiric literature. METHODS Electronic databases Ovid Medline, Embase, and CINAHL were systematically searched using controlled vocabulary terms related to ethics, HIV, specified age groups, and empiric research studies. We reviewed titles and abstracts, including studies that collected qualitative or quantitative data, evaluated ethical issues in HIV research, and included adolescents. Studies were appraised for quality, data were extracted, and studies were analyzed using narrative synthesis. RESULTS We included 41 studies: 24 qualitative, 11 quantitative, 6 mixed methods; 22 from high-income countries (HIC), 18 from low- or middle-income countries (LMIC), and 1 from both HIC and LMIC. Adolescent, parent, and community perspectives assert the benefits of involving minors in HIV research. Participants in LMIC expressed mixed views regarding parental consent requirements and confidentiality, given adolescents' both increasing autonomy and continued need for adult support. In studies in HIC, sexual or gender minority youth would not participate in research if parental consent were required or if there were confidentiality concerns. There was variation in the comprehension of research concepts, but adolescents generally demonstrated good comprehension of informed consent. Informed consent processes can be improved to increase comprehension and study accessibility. Vulnerable participants face complex social barriers that should be considered in study design. CONCLUSIONS Data support the inclusion of adolescents in HIV research. Empiric research can inform consent processes and procedural safeguards to ensure appropriate access.
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Affiliation(s)
- Katherine R MacDonald
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Leslie A Enane
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN
| | - Megan S McHenry
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN
| | - Neilkant L Davis
- Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Elizabeth C Whipple
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | - Mary A Ott
- Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN
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Knopf A, Draucker CB, Fortenberry JD, Ott MA, Arrington-Sanders R, Reirden D, Schneider J, Straub D, Ofner S, Bakoyannis G, Zimet G. Parental Engagement in Consent Processes for Enrollment in Biomedical HIV Prevention Trials: Implications for Minor Adolescents' Willingness to Participate. J Adolesc Health 2023; 72:703-711. [PMID: 36646563 PMCID: PMC11114099 DOI: 10.1016/j.jadohealth.2022.11.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/10/2022] [Accepted: 11/22/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Minor adolescents are often excluded from HIV prevention clinical trials due to unresolved ethical issues. Their under-representation in research leads to delayed access to new HIV prevention approaches. We examine the relationship between consent procedures, trial features, demographic and social characteristics, and minor adolescents' willingness to participate (WTP) in biomedical HIV prevention research. METHODS We recruited 14-17-year-olds at risk of HIV for this quasi-experimental study. Adolescents were randomly assigned to (1) self-consent, (2) adult permission required, or (3) parental permission required and underwent simulated consent procedures for two types of HIV prevention trials. They rated likelihood of participating in each study if offered the opportunity and completed a survey with demographic, social, and behavioral measures. RESULTS One hundred and twenty nine adolescents with diverse identities and socioeconomic status enrolled. Among the 58% of participants who identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ), 76% were out to at least one parent/guardian (outness). Mean WTP was 3.6 (of 5; 5 = definitely would participate) across all participants and both trial types. We found no evidence of an association between WTP and consent condition, LGBTQ identity, or outness. However, medical mistrust, communication with parents, and concern about HIV were associated with WTP. DISCUSSION Our results suggest adolescents are willing to participate in HIV prevention trials and parental involvement in the consent process may not be the most important deciding factor. However, variation in WTP within consent groups, and variation in other significant variables, underscores the need for individualized approaches to recruitment and consent for these trials.
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Affiliation(s)
- Amelia Knopf
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana.
| | - Claire Burke Draucker
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana
| | - J Dennis Fortenberry
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary A Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Renata Arrington-Sanders
- Division of Adolescent and Young Adult Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Reirden
- Section of Adolescent Medicine & Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colorado
| | - John Schneider
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Diane Straub
- Section of Adolescent Medicine & Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Ofner
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Giorgos Bakoyannis
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana; Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Gregory Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
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Skeen SJ, Shaw Green SK, Knopf AS. Synthesizing Adaptive Digital Bioethics to Guide the Use of Interactive Communication Technologies in Adolescent Behavioral Medicine: A Systematic Configurative Review. Pediatr Clin North Am 2022; 69:739-758. [PMID: 35934497 DOI: 10.1016/j.pcl.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Despite the continuing integration of digital outreach tools into adolescent preventive services, adaptive guidance for their ethical use remains limited. In this configurative review, we synthesize the ad hoc, applied digital bioethics developed in adolescent human immunodeficiency virus prevention science. By focusing on generalizable technological affordances, while balancing privacy and autonomy, we offer strategies for identifying potential technologically mediated harms that can transcend specific platforms, tools, or the knowledge levels of individual clinicians. Clinical vignettes illustrate the application of these strategies.
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Affiliation(s)
- Simone J Skeen
- Department of Social, Behavioral, and Population Sciences, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA 70112, USA.
| | - Sara K Shaw Green
- Center for Translational Behavioral Science, Florida State University, 2010 Levy Avenue, Research Building B, Suite B0266, Tallahassee, FL 32310, USA
| | - Amelia S Knopf
- Community and Health Systems, Indiana University School of Nursing, 600 Barnhill Drive, NU W425, Indianapolis, IN 46220, USA
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Tolley EE, Zissette S, Taylor J, Hanif H, Ju S, Schwarz J, Thurman A, Tyner D, Brache V, Doncel GF. Acceptability of a Long-Acting, Multipurpose Vaginal Ring: Findings from a Phase I Trial in the U.S. and Dominican Republic. J Womens Health (Larchmt) 2022; 31:1343-1352. [PMID: 35363574 PMCID: PMC9527051 DOI: 10.1089/jwh.2021.0394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Women worldwide face risks from pregnancy, HIV, and other sexually transmitted infections (STIs). To date, highly effective contraceptive methods provide no HIV/STI protection, and HIV prevention products, excluding condoms, provide no pregnancy protection. Intravaginal rings (IVRs) delivering antiretrovirals and contraceptives are a promising multipurpose prevention technology (MPT). Methods: Embedded within a Phase I randomized, placebo-controlled trial, we examined acceptability of continuous versus interrupted use of a 90-day MPT IVR among 47 low-risk women in Norfolk, Virginia and the Dominican Republic. A baseline survey assessed menstruation attitudes, risk perceptions and trial-related motivations. Follow-up surveys (M1/M3) examined user experiences with and preferences for IVR attributes; 18 women also participated in two in-depth interviews. Results: Most women rated the IVR's flexibility and smoothness (86%) and ease of insertion/removal (76%) as very acceptable. Fewer women similarly rated the IVR size (57%) and changes in color from menstruation (52%). Most participants experienced no changes or less bleeding. Those reporting more/heavier bleeding (20% M1, 15% M3) disliked the change. Overall, women preferred a 3-month (75%) to a 1-month IVR (7.5%) or a bimonthly injectable (10%). In qualitative interviews, women were willing to continuously use an IVR for 6–12 months, providing it did not “degrade” inside the body. Reasons for trial participation and prevention preferences, menstrual attitudes, and perceived IVR benefits and doubts varied by site. Conclusions: Findings provide strong evidence of demand for an MPT IVR that protects from pregnancy and HIV/STIs, lasts longer than 1 month, minimally disrupts menstrual bleeding, and is in women's control. numberClinicalTrials.gov: #NCT03279120.
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Affiliation(s)
- Elizabeth E Tolley
- Behavioral, Epidemiological & Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | - Seth Zissette
- Rollins School of Public Health, Emory University, Department of Epidemiology (PhD Student), Atlanta, GA, USA
| | - Jamilah Taylor
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Jill Schwarz
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Andrea Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063249. [PMID: 35328936 PMCID: PMC8953200 DOI: 10.3390/ijerph19063249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023]
Abstract
Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15-19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents' health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa.
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Gailloud L, Gonzalez-Argoti T, Philip S, Josephs LS, Mantell JE, Bauman LJ. 'How come they don't talk about it in school?' Identifying adolescent barriers to PrEP use. HEALTH EDUCATION RESEARCH 2022; 36:505-517. [PMID: 34467401 PMCID: PMC8793170 DOI: 10.1093/her/cyab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/11/2021] [Accepted: 08/27/2021] [Indexed: 06/13/2023]
Abstract
Although 21% of new human immunodeficiency virus (HIV) diagnoses in the United States are in youth aged 13-24 years, adolescent awareness and uptake of the HIV prevention medication pre-exposure prophylaxis (PrEP) are low. This study explores the attitudes and challenges that adolescents face while taking PrEP. Thirty interviews were conducted with Black and Latine (we use the gender-inclusive term Latine rather than Latinx for more appropriate Spanish pronunciation) students aged 15-17 who received care at school-based health centers (SBHCs) in the Bronx, NY. Transcripts were coded inductively and deductively using thematic analysis. Most participants were unaware of PrEP, but nearly all were enthusiastic when informed about it; a majority denied that they would feel any stigma when taking PrEP. Despite this high receptivity, multiple barriers were identified, particularly confidentiality from parents, low perceived need of PrEP and concerns about daily adherence and side effects. Adolescents overall were enthusiastic about the availability of PrEP and felt it empowered them to have control over their health. SBHCs were considered trusted sources of confidential, accessible care, and we believe that they can be uniquely positioned to mitigate barriers to PrEP distribution in the future.
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Slack C, Ndebele P, Allen M, Salzwedel J. Shifts in UNAIDS ethics guidance and implications for ethics review of preventive HIV vaccine trials. J Int AIDS Soc 2021; 24 Suppl 7:e25796. [PMID: 34806302 PMCID: PMC8606858 DOI: 10.1002/jia2.25796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/03/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION A major change in the ethics framework for preventive HIV vaccine trials worldwide is the release of the UNAIDS 2021 ethical considerations in HIV prevention trials. This new guidance comes at an exciting time when there are multiple HIV vaccine efficacy trials in the field. Research Ethics Committees (RECs) or Institutional Review Boards are a most likely audience for these guidelines. Our objective is to highlight shifts in ethics recommendations from the earlier 2012 UNAIDS guidance. DISCUSSION We review recommendations related to four key issues, namely standard of prevention, post-trial access to safe and effective vaccines, enrolment of adolescents and enrolment of pregnant women. We outline implications and make recommendations for the ethics review process, including suggested lines of inquiry by RECs and responses by applicants. CONCLUSIONS There have been several shifts in the UNAIDS ethics guidance with implications for HIV vaccine researchers submitting applications for initial ethics review or re-certification, and for RECs conducting such reviews. This review may assist RECs in a more efficient and consistent application of ethics recommendations. However, additional tools and training may further help stakeholders comply with new UNAIDS ethics recommendations during protocol development and ethics review.
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Affiliation(s)
- Catherine Slack
- HIV/AIDS Vaccines Ethics Group (HAVEG)School of Applied Human SciencesCollege of HumanitiesUniversity of KwaZulu‐NatalPietermaritzburgSouth Africa
| | - Paul Ndebele
- Department of Global HealthMilkenInstitute School of Public HealthThe George Washington UniversityWashingtonDCUSA
| | - Mary Allen
- National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
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Knopf AS, Krombach P, Katz AJ, Baker R, Zimet G. Measuring research mistrust in adolescents and adults: Validity and reliability of an adapted version of the Group-Based Medical Mistrust Scale. PLoS One 2021; 16:e0245783. [PMID: 33481944 PMCID: PMC7822238 DOI: 10.1371/journal.pone.0245783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
Mistrust of health care providers among persons of color is a significant barrier to engaging them in research studies. Underrepresentation of persons of color is particularly problematic when the health problem under study disproportionately affects minoritized communities. The purpose of this study was to test the validity and reliability of an abbreviated and adapted version of the Group Based Medical Mistrust Scale. The GBMMS is a 12-item scale with three subscales that assess suspicion, experiences of discrimination, and lack of support in the health care setting. To adapt for use in the research setting, we shortened the scale to six items, and replaced “health care workers” and “health care” with “medical researchers” and “medical research,” respectively. Using panelists from a market research firm, we recruited and enrolled a racially and ethnically diverse sample of American adults (N = 365) and adolescents aged 14–17 (N = 250). We administered the adapted scale in a web-based survey. We used Cronbach’s alpha to evaluate measure internal reliability of the scale and external factor analysis to evaluate the relationships between the revised scale items. Five of the six items loaded onto a single factor, with (α = 0.917) for adolescents and (α = 0.912) for adults. Mean scores for each item ranged from 2.5–2.9, and the mean summary score (range 6–25) was 13.3 for adults and 13.1 for adolescents. Among adults, Black respondents had significantly higher mean summary scores compared to whites and those in other racia/ethnic groups (p<0.001). There was a trend toward significance for Black adolescents as compared to white respondents and those in other racial/ethnic groups (p = 0.09). This five-item modified version of the GBMMS is reliable and valid for measuring research mistrust with American adults and adolescents of diverse racial and ethnic identities.
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Affiliation(s)
- Amelia S. Knopf
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Peter Krombach
- Office of Evaluation, Indiana University School of Nursing, Indianapolis, Indiana, United States of America
| | - Amy J. Katz
- Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Rebecca Baker
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, United States of America
| | - Gregory Zimet
- Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
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Landers SE, Francis JKR, Morris MC, Mauro C, Rosenthal SL. Adolescent and Parent Perceptions about Participation in Biomedical Sexual Health Trials. Ethics Hum Res 2020; 42:2-11. [PMID: 32421948 DOI: 10.1002/eahr.500048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Given the burden of HIV and other sexually transmitted infections among adolescents who are legal minors, it is critical that they be included in biomedical sexual health trials to ensure that new prevention and treatment interventions are safe, effective, and acceptable for their use. However, adolescents are often not well represented in clinical trials. We provide an overview of the available evidence regarding adolescent and parent willingness for adolescents to participate in biomedical sexual health trials, parental involvement in the permission-consent process, management of differences and discord among adolescents and parents, and parental involvement throughout the study period. We also outline recommendations for current practice and areas for future research.
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Affiliation(s)
- Sara E Landers
- Research coordinator in the Department of Pediatrics at Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center
| | - Jenny K R Francis
- Assistant professor in the Department of Pediatrics at the University of Texas Southwestern Medical Center
| | - Marilyn C Morris
- Associate professor in the Department of Pediatrics at Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center
| | - Christine Mauro
- Assistant professor in the Department of Biostatistics at the Mailman School of Public Health at Columbia University Irving Medical Center
| | - Susan L Rosenthal
- Professor of medical psychology in the Departments of Pediatrics and Psychiatry at Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center
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Knopf A, Ott MA, Draucker CB, Fortenberry JD, Reirden DH, Arrington-Sanders R, Schneider J, Straub D, Baker R, Bakoyannis G, Zimet GD. Innovative Approaches to Obtain Minors' Consent for Biomedical HIV Prevention Trials: Multi-Site Quasi-Experimental Study of Adolescent and Parent Perspectives. JMIR Res Protoc 2020; 9:e16509. [PMID: 32224493 PMCID: PMC7154935 DOI: 10.2196/16509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite the high burden of new HIV infections in minor adolescents, they are often excluded from biomedical HIV prevention trials, largely owing to the ethical complexities of obtaining consent for enrollment. Researchers and ethics regulators have a duty to protect adolescents-as a special category of human subjects, they must have protection that extends beyond those afforded to all human subjects. Typically, additional protection includes parental consent for enrollment. However, parental consent can present a risk of harm for minor adolescents. Research involving minor adolescents indicate that they are unwilling to join biomedical trials for stigmatized health problems, such as HIV, when parental consent is required. This presents a significant barrier to progress in adolescent HIV prevention by creating delays in research and the translation of new scientific evidence generated in biomedical trials in adult populations. OBJECTIVE This protocol aims to examine how parental involvement in the consent process affects the acceptability of hypothetical participation in biomedical HIV prevention trials from the perspectives of minor adolescents and parents of minor adolescents. METHODS In this protocol, we use a quasi-experimental design that involves a simulated consent process for 2 different HIV prevention trials. The first trial is modeled after an open-label study of the use of tenofovir disoproxil fumarate and emtricitabine as preexposure prophylaxis for HIV. The second trial is modeled after a phase IIa trial of an injectable HIV integrase inhibitor. There are 2 groups in the study-minor adolescents aged 14 to 17 years, inclusive, and parents of minor adolescents in the same age range. The adolescent participants are randomized to 1 of 3 consent conditions with varying degrees of parental involvement. After undergoing a simulated consent process, they rate their willingness to participate (WTP) in each of the 2 trials if offered the opportunity. The primary outcome is WTP, given the consent condition. Parents undergo a similar process but are asked to rate the acceptability of each of the 3 consent conditions. The primary outcome is acceptability of the consent method for enrollment. The secondary outcomes include the following: capacity to consent among both participant groups, the prevalence of medical mistrust, and the effects of the study phase (eg, phase IIa vs the open-label study) and drug administration route (eg, oral vs injection) on WTP (adolescents) and acceptability (parents) of the consent method. RESULTS Enrollment began in April 2018 and ended mid-September 2019. Data are being analyzed and dissemination is expected in April 2020. CONCLUSIONS The study will provide the needed empirical data about minor adolescents' and parents' perspectives on consent methods for minors. The evidence generated can be used to guide investigators and ethics regulators in the design of consent processes for biomedical HIV prevention trials. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16509.
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Affiliation(s)
- Amelia Knopf
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Mary A Ott
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Claire Burke Draucker
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - J Dennis Fortenberry
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Daniel H Reirden
- Children's Hospital Colorado, School of Medicine, The University of Colorado, Aurora, CO, United States
| | - Renata Arrington-Sanders
- Division of General Pediatrics & Adolescent Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - John Schneider
- Department of Medicine, The University of Chicago, Chicago, IL, United States
| | - Diane Straub
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Rebecca Baker
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Giorgos Bakoyannis
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Gregory D Zimet
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
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Bauman LJ, Mellins CA, Klitzman R. Whether to Waive Parental Permission in HIV Prevention Research Among Adolescents: Ethical and Legal Considerations. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:188-201. [PMID: 32342775 PMCID: PMC8367279 DOI: 10.1177/1073110520917010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Critical ethical questions arise concerning whether studies among adolescents of new behavioral and biomedical HIV preventive interventions such as Pre-Exposure Prophylaxis (PrEP) should obtain parental permission. This paper examines the relevant regulations and ethical guidance concerning waivers of parental permission, and arguments for and against such waivers. Opponents of such waivers may argue that adolescent decision-making is "too immature" and that parents always have rights to decide how to protect their children. Yet requiring parental permission may put adolescents at risk, and/or limit adolescent participation, jeopardizing study findings' validity. This paper presents recommendations on when researchers and Institutional Review Boards (IRB) should waive parental permission, and what special protections should be adopted for adolescents who consent for themselves, e.g., assuring adolescent privacy and confidentiality, screening for capacity to consent, and identifying adolescents who are at elevated risk from study participation. We also present a series of specific areas for future research to design tools to help make these assessments, and to inform researcher and IRB decisions. These recommendations can help ensure that research is conducted that can aid adolescents at risk for HIV, while minimizing risks and protecting these individuals' rights as much as possible.
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Affiliation(s)
- Laurie J Bauman
- Laurie J. Bauman, Ph.D., is Professor of Pediatrics and Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, where she also serves as Director of the Preventive Intervention Research Center and of the Behavioral Science Core of the Einstein-Rockefeller-CUNY Center for AIDS Research. She is also Director of the Bio-Behavioral Core of the HIV Center for Clinical and Behavioral Studies. Her research addresses HIV prevention among adolescents, including behavioral interventions and adoption of PrEP. Claude Ann Mellins, Ph.D., is a clinical psychologist and Professor of Medical Psychology in Psychiatry and Sociomedical Sciences at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University. She is the co-director of the HIV Center with 28 years of clinical and research experience working globally with youth and families affected by HIV. Robert Klitzman, M.D., is a professor of psychiatry at the Vagelos College of Physicians and Surgeons and the Mailman School of Public Health, and the Director of the online and in-person Bioethics Masters and Certificate Programs at Columbia University. He has published over 150 scientific journal articles and nine books on ethical issues concerning HIV, genetics, research, and other areas
| | - Claude Ann Mellins
- Laurie J. Bauman, Ph.D., is Professor of Pediatrics and Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, where she also serves as Director of the Preventive Intervention Research Center and of the Behavioral Science Core of the Einstein-Rockefeller-CUNY Center for AIDS Research. She is also Director of the Bio-Behavioral Core of the HIV Center for Clinical and Behavioral Studies. Her research addresses HIV prevention among adolescents, including behavioral interventions and adoption of PrEP. Claude Ann Mellins, Ph.D., is a clinical psychologist and Professor of Medical Psychology in Psychiatry and Sociomedical Sciences at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University. She is the co-director of the HIV Center with 28 years of clinical and research experience working globally with youth and families affected by HIV. Robert Klitzman, M.D., is a professor of psychiatry at the Vagelos College of Physicians and Surgeons and the Mailman School of Public Health, and the Director of the online and in-person Bioethics Masters and Certificate Programs at Columbia University. He has published over 150 scientific journal articles and nine books on ethical issues concerning HIV, genetics, research, and other areas
| | - Robert Klitzman
- Laurie J. Bauman, Ph.D., is Professor of Pediatrics and Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, where she also serves as Director of the Preventive Intervention Research Center and of the Behavioral Science Core of the Einstein-Rockefeller-CUNY Center for AIDS Research. She is also Director of the Bio-Behavioral Core of the HIV Center for Clinical and Behavioral Studies. Her research addresses HIV prevention among adolescents, including behavioral interventions and adoption of PrEP. Claude Ann Mellins, Ph.D., is a clinical psychologist and Professor of Medical Psychology in Psychiatry and Sociomedical Sciences at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University. She is the co-director of the HIV Center with 28 years of clinical and research experience working globally with youth and families affected by HIV. Robert Klitzman, M.D., is a professor of psychiatry at the Vagelos College of Physicians and Surgeons and the Mailman School of Public Health, and the Director of the online and in-person Bioethics Masters and Certificate Programs at Columbia University. He has published over 150 scientific journal articles and nine books on ethical issues concerning HIV, genetics, research, and other areas
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Ott MA, Knopf AS. Avoiding a Tyranny of the Majority: Public Deliberation as Citizen Science, Sensitive Issues, and Vulnerable Populations. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:28-31. [PMID: 31544636 PMCID: PMC7286601 DOI: 10.1080/15265161.2019.1619870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Mustanski B, Macapagal K, Thomann M, Feinstein BA, Newcomb ME, Motley D, Fisher CB. Parents' Perspectives About Adolescent Boys' Involvement in Biomedical HIV Prevention Research. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:1923-1935. [PMID: 28875351 PMCID: PMC5837896 DOI: 10.1007/s10508-017-1035-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/27/2017] [Accepted: 07/06/2017] [Indexed: 05/12/2023]
Abstract
Research on the use of pre-exposure prophylaxis (PrEP) among adolescents at high risk for HIV is urgently needed, and parents' perspectives on these studies are essential for guiding the responsible conduct of adolescent PrEP research. We conducted interviews with 30 parents of adolescent boys (50% known/presumed heterosexual; 50% sexual minority) to understand their views of research risks and benefits and parental permission regarding their son's involvement in a hypothetical PrEP adherence trial. Parents identified several health and educational benefits of the study and expressed that waiving parental permission would overcome barriers to accessing PrEP, particularly for youth who may benefit most. Among their concerns were medication non-adherence and risk compensation. Parents provided suggestions to facilitate informed, rational, and voluntary participation decisions and protect youth's safety if parental permission was waived. These findings can inform ways to increase parental trust in PrEP research and create adequate protections for adolescent participants.
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Affiliation(s)
- Brian Mustanski
- Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Suite 2700, Chicago, IL, 60611, USA.
| | - Kathryn Macapagal
- Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Suite 2700, Chicago, IL, 60611, USA
| | - Matthew Thomann
- Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Suite 2700, Chicago, IL, 60611, USA
- Department of Anthropology and Sociology, Kalamazoo College, Kalamazoo, MI, USA
| | - Brian A Feinstein
- Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Suite 2700, Chicago, IL, 60611, USA
| | - Michael E Newcomb
- Department of Medical Social Sciences, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Suite 2700, Chicago, IL, 60611, USA
| | - Darnell Motley
- Psychology Service, Edward Hines, Jr. VA Medical Center, Hines, IL, USA
| | - Celia B Fisher
- Department of Psychology, Center for Ethics Education, Fordham University, Bronx, NY, USA
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Rosenthal SL, Morris MC, Hoffman LF, Zimet GD. Inclusion of Adolescents in STI/HIV Biomedical Prevention Trials: Autonomy, Decision Making, and Parental Involvement. CLINICAL PRACTICE IN PEDIATRIC PSYCHOLOGY 2018; 6:299-307. [PMID: 30393589 DOI: 10.1037/cpp0000209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Susan L Rosenthal
- Department of Pediatrics, Columbia University Medical Center - College of Physicians and Surgeons, New York, New York, United States.,Department of Psychiatry, Columbia University Medical Center - College of Physicians and Surgeons, New York, New York, United States.,NewYork Presbyterian Hospital, New York, New York, United States
| | - Marilyn C Morris
- Department of Pediatrics, Columbia University Medical Center - College of Physicians and Surgeons, New York, New York, United States.,NewYork Presbyterian Hospital, New York, New York, United States
| | - Lily F Hoffman
- Department of Pediatrics, Columbia University Medical Center - College of Physicians and Surgeons, New York, New York, United States
| | - Gregory D Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, United States
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Hume M, Lewis LL, Nelson RM. Meeting the goal of concurrent adolescent and adult licensure of HIV prevention and treatment strategies. JOURNAL OF MEDICAL ETHICS 2017; 43:857-860. [PMID: 28507222 PMCID: PMC5685924 DOI: 10.1136/medethics-2016-103600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 03/23/2017] [Accepted: 04/18/2017] [Indexed: 06/07/2023]
Abstract
The ability of adolescents to access safe and effective new products for HIV prevention and treatment is optimised by adolescent licensure at the same time these products are approved and marketed for adults. Many adolescent product development programmes for HIV prevention or treatment products may proceed simultaneously with adult phase III development programmes. Appropriately implemented, this strategy is not expected to delay licensure as information regarding product efficacy can often be extrapolated from adults to adolescents, and pharmacokinetic properties of drugs in adolescents are expected to be similar to those in adults. Finally, adolescents enrolled in therapeutic HIV prevention and treatment research can be considered adults, based on US Food and Drug Administration (FDA) regulations and the appropriate application of state law. The FDA permits local jurisdictions to apply state and local HIV/sexually transmitted infection minor treatment laws so that adolescents who are HIV-positive or at risk of contracting HIV may be enrolled in therapeutic or prevention trials without obtaining parental permission.
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Affiliation(s)
- Michelle Hume
- Department of Psychiatry, University of Wisconsin, Madison, Wisconsin, USA
| | - Linda L Lewis
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Robert M Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
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17
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Hosek SG, Landovitz RJ, Kapogiannis B, Siberry GK, Rudy B, Rutledge B, Liu N, Harris DR, Mulligan K, Zimet G, Mayer KH, Anderson P, Kiser JJ, Lally M, Brothers J, Bojan K, Rooney J, Wilson CM. Safety and Feasibility of Antiretroviral Preexposure Prophylaxis for Adolescent Men Who Have Sex With Men Aged 15 to 17 Years in the United States. JAMA Pediatr 2017; 171:1063-1071. [PMID: 28873128 PMCID: PMC5710370 DOI: 10.1001/jamapediatrics.2017.2007] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Adolescents represent a key population for implementing preexposure prophylaxis (PrEP) interventions worldwide, yet tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for PrEP is only licensed for adults. OBJECTIVE To examine the safety of and adherence to PrEP along with changes in sexual risk behavior among adolescent men who have sex with men (MSM). DESIGN, SETTING, AND PARTICIPANTS Adolescent Medicine Trials Network for HIV/AIDS Interventions 113 (Project PrEPare) was a PrEP demonstration project that evaluated the safety, tolerability, and acceptability of TDF/FTC and patterns of use, rates of adherence, and patterns of sexual risk behavior among healthy young MSM aged 15 to 17 years. Participants were recruited from adolescent medicine clinics and their community partners in 6 US cities, had negative test results for human immunodeficiency virus (HIV) but were at high risk for acquiring an infection, and were willing to participate in a behavioral intervention and accept TDF/FTC as PrEP. EXPOSURES All participants completed an individualized evidence-based behavioral intervention and were provided with daily TDF/FTC as PrEP for 48 weeks. MAIN OUTCOMES AND MEASURES The main objectives were to: (1) provide additional safety data regarding TDF/FTC use among young MSM who had negative test results for HIV; (2) examine the acceptability, patterns of use, rates of adherence, and measured levels of tenofovir diphosphate in dried blood spots; and (3) examine patterns of risk behavior when young MSM were provided with a behavioral intervention in conjunction with open-label TDF/FTC. RESULTS Among 2864 individuals screened (from August 2013 to September 2014), 260 were eligible and 78 were enrolled (mean [SD] age, 16.5 [0.73] years), of whom 2 (3%) were Asian/Pacific Islander, 23 (29%) were black/African American, 11 (14%) were white, 16 (21%) were white Hispanic, and 26 (33%) were other/mixed race/ethnicity. Over 48 weeks of PrEP use, 23 sexually transmitted infections were diagnosed in 12 participants. The HIV seroconversion rate was 6.4 (95% CI: 1.3-18.7) per 100 person-years. Tenofovir diphosphate levels consistent with a high degree of anti-HIV protection (>700 fmol/punch) were found in 42 (54%), 37 (47%), 38 (49%), 22 (28%), 13 (17%), and 17 (22%) participants at weeks 4, 8, 12, 24, 36, and 48, respectively. CONCLUSIONS AND RELEVANCE Adolescent Medicine Trials Network for HIV/AIDS Interventions 113 enrolled a diverse sample of adolescent MSM at risk for HIV who consented to study participation. Approximately half achieved protective drug levels during the monthly visits, but adherence decreased with quarterly visits. Youth may need additional contact with clinical staff members to maintain high adherence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01769456.
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Affiliation(s)
| | | | - Bill Kapogiannis
- National Institute of Child Health and Human Development, Bethesda, Maryland
| | - George K. Siberry
- National Institute of Child Health and Human Development, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | - Kelly Bojan
- Ruth Rothstein CORE Center, Chicago, Illinois
| | - Jim Rooney
- Gilead Sciences, Foster City, California
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