The American, British and Dutch responses to unlinked anonymous HIV seroprevalence studies: an international comparison

Improving access to test results for participants in bio-behavioural surveys of people who inject drugs

Bio-behavioural surveys of people who inject drugs (PWID) evolved from unlinked anonymous monitoring (UAM) of human immunodeficiency virus (HIV) incidence and prevalence, which began in some high-income countries in the late 1980s. UAM was conducted purely for surveillance purposes and test results were not returned to participants. Later, the importance of collecting data on behavioural risk factors was recognised, leading to the development of bio-behavioural surveys of PWID, which today are conducted regularly in several countries. Typically, these surveys recruit participants from venues providing harm reduction services and involve behavioural questionnaires and dried blood spot (DBS) testing for HIV and hepatitis C (HCV). DBS test results are not returned to participants; instead, countries offer varied systems of on-site testing separate from the bio-behavioural testing or provide referrals to external testing services. In this commentary, we trace the history of bio-behavioural surveys of PWID from their origins to the present day to explain how the methodologies evolved, along with the ethical considerations underlying them. We highlight the dramatic improvements in treatments for HIV and HCV over the past thirty years and the corresponding need to ensure that bio-behavioural survey participants can access low-barrier and timely testing. We review the pros and cons of different strategies for providing test results to participants and argue that the return of DBS results collected as part of bio-behavioural surveys warrants consideration as an additional tool to improve testing access for participants. Any changes should be informed by the perspectives of participants, study site personnel and investigators.

Ethics and Collateral Findings in Pragmatic Clinical Trials

Pragmatic clinical trials (PCTs) offer important benefits, such as generating evidence that is suited to inform real-world health care decisions and increasing research efficiency. However, PCTs also present ethical challenges. One such challenge involves the management of information that emerges in a PCT that is unrelated to the primary research question(s), yet may have implications for the individual patients, clinicians, or health care systems from whom or within which research data were collected. We term these findings as ?pragmatic clinical trial collateral findings,? or ?PCT-CFs?. In this article, we explore the ethical considerations associated with the identification, assessment, and management of PCT-CFs, and how these considerations may vary based upon the attributes of a specific PCT. Our purpose is to map the terrain of PCT-CFs to serve as a foundation for future scholarship as well as policy-making and to facilitate careful deliberation about actual cases as they occur in practice.

A walk in the park: a case study in research ethics

Can researchers, interested in novel ways to assess HIV seroprevalence among populations which are otherwise hidden, collect condoms that have been discarded on the ground in a public sex environment and test them for HIV? Researchers, who use other types of abandoned samples, such as discarded syringes, hair or saliva samples, or excess biological samples, confront similar issues. This review evaluates whether such abandoned tissues can be studied based on U.S. Code of Federal Regulations and literature on related issues including: research involving banked tissues, blinded seroprevalence studies, and property claims that individuals might make on the samples. It also addresses broader questions of potential for stigma and risk to individuals and communities. The article concludes that the research should be permitted legally because either it does not involve human subjects, or it satisfies the requirements for waiver of consent; and that the research should also be permitted because the ethical principal of avoiding harm to individuals is fully satisfied based on a careful reading of the lessons of the tissue bank, biological property rights, and blinded seroprevalence study debates, as well as a consideration of other potential harms that might be involved.

Usefulness of information from the unlinked anonymous prevalence monitoring programme for HIV in England and Wales: survey of planners of HIV/AIDS services

The aim of this study was to evaluate whether information from the Unlinked Anonymous Prevalence Monitoring Programme for HIV in England and Wales is useful to planners of HIV/AIDS services. The study involved 2 stages: examination of 1997 AIDS Control Act Reports for England and Wales, and a telephone questionnaire survey of local planners of HIV/AIDS services. Forty-eight out of 55 health authorities (87.3%) found information from the programme to be useful in general; 37/55 (67.3%) found the information useful for targeting of health promotion; 35/55 (63.6%) found the information useful for assessing the effectiveness of preventive measures aimed at reducing the spread of HIV; and 28/55 (50.9%) found the information useful for planning of medical or social services. If information from the programme was no longer available, 36/55 (65.5%) said it would make some difference to local planning, although 12/55 (21.8%) said it would make no difference. Local planners were generally supportive of the programme, and complaints were mostly directed at funding and timeliness of the reports.

HIV infection in psychiatric patients: an unlinked anonymous study

BACKGROUND

Recent surveys suggest that psychiatric patients are at increased risk of being infected with HIV, although very little information is available concerning the seroprevalence of HIV infection among this population outside the US. The aim of this study is to determine the seroprevalence of HIV-I among patients admitted to a psychiatric in-patient unit and to gather linked anonymous risk-factor information.

METHOD

An unlinked serosurvey was made, using HIV-1 antibody testing of remnant blood specimens collected for routine medical purposes, of patients consecutively admitted to an acute psychiatric unit in Madrid.

RESULTS

Blood was obtained from 390 of the 477 eligible patients (81.8%). The prevalence of HIV was 5.1% (20/390). Patients aged between 18 and 39 accounted for 63.4% of the admissions and 75% of the positive results. Of the 29 patients who presented with injecting drug use, 14 were HIV-infected (48.3%; 95% CI 29.4 67.5). Of the 51 patients for whom any risk behaviour was noted on the admission chart, 18 were HIV-infected (35.3%; 95% CI 22.4 49.9).

CONCLUSIONS

This study demonstrates that there is a substantial prevalence of HIV infection in psychiatric patients admitted to an acute in-patient unit. History of injecting drug use was strongly associated with seropositivity. Clinicians recognised risk factors for HIV infection in the majority of the HIV-infected cases.

Prevalence of HIV and Treponema pallidum infections in pregnant women in Campinas and their association with socio-demographic factors

The anonymous seroprevalence of HIV and syphilis was studied by collecting umbilical cord blood samples from 5,815 women who gave birth in Campinas' hospitals throughout a six-month period. ELISA and Western blot were used for HIV, and VDRL and TPHA for Treponema pallidum screening. While maintaining the anonymity of the women, information was recorded on the hospital of origin, divided into university (public) and private hospitals, as well as on the form of payment (social security, private insurance or direct payment), age, marital status, education, employment and place of residence. Seroprevalence was 0.42 percent for HIV and 1.16 percent for syphilis. There was a significant correlation between a positive reaction to the two infections (p = 0.02). After univariate and logistic regression analysis, only university hospitals were shown to be associated with seropositivity for HIV, whereas the same variable and an older age were associated with syphilis. All positive reactions were found either in public hospitals or among social security patients treated at private institutions. The conclusion was that HIV infection is becoming almost as prevalent as syphilis among this population, and affects primarily the lower socio-economic strata. This suggests that routine, voluntary HIV serology should be considered and discussed with patients during prenatal or delivery care whenever a population shows a seroprevalence close to or greater than 1 percent.

Estimation of the magnitude of the HIV epidemic among homosexual men: utilization of survey data in predictive models

A group of 709 randomly selected males aged 18-55 years living in the city of Amsterdam, the Netherlands, were questioned about sexual lifestyle and related behavior. A substantial proportion (10%) of these men appeared to be homo- or bisexual. Of these homo- and bisexual men, 16.5% were predicted to be HIV seropositive, using their behavioral information in logistic regression models derived from a second study among 506 homo- or bisexual volunteers who were questioned and tested for HIV antibodies as well. Generalizing the results of the sample, the magnitude of the homo- and bisexual population in Amsterdam is estimated to be 21,500 (95% confidence interval: 17,000-26,000) of whom 3500 are HIV seropositive. This is in agreement with estimations on the basis of AIDS surveillance data. The study shows that in the absence of serological data it is possible to estimate HIV prevalence, given that the relation between the presence of HIV antibodies and sexual activity or indicators for sexual activity is known. Since serological data are lacking in many occasions, this method may be of help to estimate HIV prevalence in other geographic locations and risk groups.

HIV seroprevalence in sexually transmitted disease clients in a low-prevalence southern state. Evidence of endemic sexual transmission

We studied human immunodeficiency virus (HIV) seroprevalence and risk factors in 3052 clients attending three large public, sexually transmitted disease (STD) clinics in central North Carolina in mid-1988. Anonymous self-administered questionnaires linked to HIV serologies obtained by testing extra blood from syphilis serologies without personal identifiers showed the following characteristics of the respondents: 60% were men, 81% were black, the median age was 24 years, 5% were injecting drug users since 1978, 7% reported a history of syphilis, and 8% of men were homosexual or bisexual. HIV seropositivity was found in 76 subjects (2.5%), including 46% of the homosexual men, 25% of the bisexual men, 1.6% of the heterosexual men, and 0.6% of the women. Elevated HIV seroprevalence rates were found in subjects with a history of or seroreactivity for syphilis (HIV-positive rate of 53% in homosexual or bisexual men, 9% in heterosexual men, 3% in women) and with histories of gonorrhea (HIV-positive rate of 37% in homosexual or bisexual men, 2.6% in heterosexual men, 1% in women), and intercourse (41% in homosexual or bisexual men, 2% in women), prostitute contact (5% in heterosexual men), and sex with casual partners (2% in women). Even a state with a low incidence of acquired immunodeficiency syndrome can include subpopulations with a high HIV seroprevalence, apparently disseminated endemically in association with bacterial STDs.

Is the worst of the epidemic over? Back calculation of HIV seroprevalence in The Netherlands

This article calculates back the HIV seroprevalence in the Netherlands from AIDS cases notified 1982-1990 and rates of progression from HIV to AIDS adopted from American studies. It discusses a number of problems, such as changing AIDS definitions and the possible impact of AZT treatment. We estimate that the Netherlands had approximately 6762 HIV seropositives by the end of 1988, which is considerably lower than earlier expectations. When a hypothetical decrease of 10% in the manifestation of AIDS cases due to AZT treatment was incorporated, the estimate for the end of 1988 becomes 7549. After deduction of the AIDS patients who had died by the beginning of 1989 from this estimate, the HIV seroprevalence by the end of 1988 is approximately 7000. The distribution of seroincidence over time suggests that the HIV epidemic in our country has passed its summit and that the HIV incidence is falling quickly. The question arises as to how far this fortunate development may be considered a success of the Dutch AIDS policy, a policy characterised by more openness than in many other countries. The material studied here, however, allows no definite answer to this intriguing question.

HIV disease: present status and future directions

This review of the human immunodeficiency virus (HIV) epidemic shows that HIV has had and will have a major impact on dentistry, just as it has had on so many other aspects of medical practice and society. These areas include the prevention of HIV transmission in the dental care workplace, the early and safe care and treatment of those who are infected, and the protection of those who are vulnerable or made more vulnerable because of HIV infection. To do this, the dental professional must be educated about HIV and its diseases, their treatment, and what must be done to prevent HIV transmission. Early recognition and treatment of HIV-related oral diseases have become the norms of practice today. Although more and more dentists face potential exposure to HIV, excellent dental care can be provided while minimizing this risk.

Informed consent: some challenges to the universal validity of the Western model

This paper presents first an account of informed consent as it is envisioned and ethically grounded in the Western world. Next there is a discussion of why the Western model is unsuitable in much of the remainder of the world where the concept of “person” differs substantially from that of Western societies. This is followed by some comments on the current controversy on whether ethical standards should be regarded as universally applicable or, rather, whether some degree of ethical and cultural relativism is to be regarded as legitimate. After providing preliminary responses to some questions posed by the Conference Programme Committee, the paper concludes with a proposal for a procedural approach to the resolution of problems with informed consent.