Behavioral and social issues among volunteers in a preventive HIV vaccine trial in Thailand

Social Impacts Among Participants in HIV Vaccine Trial Network (HVTN) Preventive HIV Vaccine Trials

BACKGROUND

Given the persistent stigma and discrimination against HIV worldwide, preventive HIV vaccine trials face unique challenges. Negative social impacts (NSIs)-problems that HIV vaccine trial participants face in many different spheres of their lives related to trial participation-have received a great deal of attention. Beneficial social impacts (BSIs)-perceived benefits experienced by a participant and resulting from their trial participation-are a critical component of participants' experiences, yet they have received little attention.

SETTING

All HIV Vaccine Trials Network trial participants for whom social impact data were available-8347 participants in 13 countries who enrolled in 48 phase 1, 2a, and 2b trials.

METHODS

A cross-protocol analysis to assess self-reported BSIs and NSIs related to participating in a preventive HIV vaccine trial. Data were obtained from 48 completed HIV Vaccine Trials Network vaccine trials from December 2000 to September 2017.

RESULTS

Overall, 6572 participants (81%) reported at least one BSI, and 686 participants (8%) reported 819 NSI events. Altruism/feeling good helping others was the BSI most often endorsed by study participants (43%), followed by receiving risk-reduction counseling (30%). Most NSI events (81%) were reported by US/Swiss participants, and most (79%) trial-related NSIs were negative reactions from friends, family, and partners. Of the NSIs reported, 7% were considered to have a major impact on the participant's quality of life.

CONCLUSION

Our results underscore the relatively common experiences of BSIs among preventive HIV vaccine trial participants and mirror the results of other studies that find infrequent reports of NSIs.

Social and Behavioral Consequences of Participation in HIV Preventive Vaccine Trials in the ANRS COHVAC Cohort

From 1992 to 2007, the ANRS (France Recherche Nord & Sud Sida-HIV Hépatites) set up a network of healthy volunteers at low risk of HIV infection and participating in preventive HIV vaccine phase I and II trials. The objectives of the ANRS COHVAC volunteer cohort include the social consequences of trial participation and their sexual behavior over time. For 488 volunteers who received a vaccine candidate, 462 selection files were collected, and from 2008 to 2016, 355 volunteers participated in the prospective cohort, including self-administered and face-to-face questionnaires administered annually. The volunteer population is relatively old, with social characteristics and engagement in society rather high. Most volunteers and people around them well accepted the trials, and participation in vaccine trials was not followed by increased risk-taking regarding HIV infection years later.

Potential Behavioural and Psychological Contributions to Ethical HIV Vaccine Trials in South Africa

The development of an HIV vaccine is one of the best hopes for the future of the HIV pandemic. HIV vaccine trials involve multiple disciplines and professions, including psychologists and other behavioural scientists. One of the most important aspects of HIV vaccine trials, like all clinical trials, is their ethical conduct. This article argues that many of the ethical issues in HIV vaccine trials have strong behavioural (including psychological) components and implications. The article goes on to examine three complex ethical issues, namely informed consent, harm monitoring, and adolescent participation, to illustrate the contribution that psychologists have to make to these ethical issues. First, it is argued that informed consent (IC), which is an essential ethical prerequisite for trials, relies on certain behavioural components as, for example, in determining how understanding can best be assessed. Also, behavioural research can add to the controversial debate about whether IC could be viewed as a culture-bound phenomenon, or whether first-person consent should be done away with in certain cultural contexts. Second, the issue of harms from trial participation is examined. We argue that assessing and minimising social and behavioural harms for participants — an essential demonstration of ongoing respect for participants — can be usefully informed by behavioural science assessment techniques and counselling. Third, the article addresses the role behavioural science can play in the sensitive ethical issue of adolescent participation in HIV vaccine trials. We argue that psychology can inform the complex assessment of whether adolescents are able to make informed and voluntary decisions about their participation in trials. The article concludes that the contribution of psychology to the ethical conduct of HIV vaccine trials may be seen as a novel and unique contribution of psychology to health research.

Drug users' willingness to encourage social, sexual, and drug network members to receive an HIV vaccine: a social network analysis

This study examined feasibility of peer-based promotion of HIV vaccination and dyadic correlates to vaccine encouragement in risk- and non-risk networks of drug users (n = 433) in the US. Data were collected on HIV vaccine attitudes, risk compensation intentions, likelihood of encouraging vaccination, and recent (past 6 months) risk (i.e. involving sex and/or injecting drugs) and non-risk (i.e. involving co-usage of noninjected drugs and/or social support) relationships. Willingness to encourage HIV vaccination was reported in 521 and 555 risk- and non-risk relationships, respectively. However, 37 % expressed hesitancy, typically due to fear of side effects or social concerns. Encouragement was often motivated by perceived HIV risk, though 9 % were motivated by risk compensation intentions. In non-risk partnerships, encouragement was associated with drug co-usage, and in risk relationships, with perceived vaccine acceptability and encouragement by the partner. Network-based HIV vaccine promotion may be a successful strategy, but risk compensation intentions should be explored.

Will HIV vaccination reshape HIV risk behavior networks? A social network analysis of drug users' anticipated risk compensation

BACKGROUND

An HIV vaccine could substantially impact the epidemic. However, risk compensation (RC), or post-vaccination increase in risk behavior, could present a major challenge. The methodology used in previous studies of risk compensation has been almost exclusively individual-level in focus, and has not explored how increased risk behavior could affect the connectivity of risk networks. This study examined the impact of anticipated HIV vaccine-related RC on the structure of high-risk drug users' sexual and injection risk network.

METHODS

A sample of 433 rural drug users in the US provided data on their risk relationships (i.e., those involving recent unprotected sex and/or injection equipment sharing). Dyad-specific data were collected on likelihood of increasing/initiating risk behavior if they, their partner, or they and their partner received an HIV vaccine. Using these data and social network analysis, a "post-vaccination network" was constructed and compared to the current network on measures relevant to HIV transmission, including network size, cohesiveness (e.g., diameter, component structure, density), and centrality.

RESULTS

Participants reported 488 risk relationships. Few reported an intention to decrease condom use or increase equipment sharing (4% and 1%, respectively). RC intent was reported in 30 existing risk relationships and vaccination was anticipated to elicit the formation of five new relationships. RC resulted in a 5% increase in risk network size (n = 142 to n = 149) and a significant increase in network density. The initiation of risk relationships resulted in the connection of otherwise disconnected network components, with the largest doubling in size from five to ten.

CONCLUSIONS

This study demonstrates a new methodological approach to studying RC and reveals that behavior change following HIV vaccination could potentially impact risk network connectivity. These data will be valuable in parameterizing future network models that can determine if network-level change precipitated by RC would appreciably impact the vaccine's population-level effectiveness.

Experiences of social harm and changes in sexual practices among volunteers who had completed a phase I/II HIV vaccine trial employing HIV-1 DNA priming and HIV-1 MVA boosting in Dar es Salaam, Tanzania

Background

Volunteers in phase I/II HIV vaccine trials are assumed to be at low risk of acquiring HIV infection and are expected to have normal lives in the community. However, during participation in the trials, volunteers may encounter social harm and changes in their sexual behaviours. The current study aimed to study persistence of social harm and changes in sexual practices over time among phase I/II HIV vaccine immunogenicity (HIVIS03) trial volunteers in Dar es Salaam, Tanzania.

Methods and Results

A descriptive prospective cohort study was conducted among 33 out of 60 volunteers of HIVIS03 trial in Dar es Salaam, Tanzania, who had received three HIV-1 DNA injections boosted with two HIV-1 MVA doses. A structured interview was administered to collect data. Analysis was carried out using SPSS and McNemars’ chi-square (χ2) was used to test the association within-subjects. Participants reported experiencing negative comments from their colleagues about the trial; but such comments were less severe during the second follow up visits (χ2 = 8.72; P<0.001). Most of the comments were associated with discrimination (χ2 = 26.72; P<0.001), stigma (χ2 = 6.06; P<0.05), and mistrust towards the HIV vaccine trial (χ2 = 4.9; P<0.05). Having a regular sexual partner other than spouse or cohabitant declined over the two follow-up periods (χ2 = 4.45; P<0.05).

Conclusion

Participants in the phase I/II HIV vaccine trial were likely to face negative comments from relatives and colleagues after the end of the trial, but those comments decreased over time. In this study, the inherent sexual practice of having extra sexual partners other than spouse declined over time. Therefore, prolonged counselling and support appears important to minimize risky sexual behaviour among volunteers after participation in HIV Vaccine trials.

Motivators to participation in actual HIV vaccine trials

An examination of actual HIV vaccine trials can contribute to an understanding of motivators for participation in these studies. Analysis of these motivators reveals that they can be categorized as social and personal benefits. Social benefits are generally altruistic, whereas personal benefits are psychological, physical, and financial. In this systematic review, the authors performed a literature search for actual preventive HIV vaccine trials reporting motivators to participation. Of studies conducted in the Organization for Economic Co-operation and Development (OECD) countries, the authors retrieved 12 studies reporting on social benefits and seven reporting on personal benefits. From the non-OECD countries, nine studies reported on social benefits and eight studies on personal benefits. Social benefits were most frequently described on macroscopic, altruistic levels. Personal benefits were most frequently psychological in nature. Rates of participation were compared between the OECD and the non-OECD countries. Knowledge of actual motivators in specific countries and regions can help target recruitment in various types of actual HIV vaccine trials.

Issues in women's participation in a phase III community HIV vaccine trial in Thailand

To assess qualities and outcomes of women participating in a large, community-based HIV vaccine trial, the present study was conducted among female participants of the RV 144 prime-boost trial in Thailand from 2003 to 2009. Qualities of participation refer to complete vaccination, retention, and status change. Outcomes of participation refer to incident rate, adverse event, and participation impact event. A total of 6,334 (38.6%) women participated in the trial, of whom about 50% were classified as low risk and 11% as high risk. About 85% of participants completed four vaccinations and 76% were included in the per-protocol analysis of the on-time vaccination schedule. More women (88%) completed 42 months follow-up compared with men (85%). Women aged 21 and above had more adverse events compared to younger age groups. More women (5%) compared with men (3%) reported participation impact events (PIEs). High-risk women had more PIEs and a higher infection rate compared to the low-risk group. Complete vaccination and retention on last follow-up were more common in married women aged above 21, and being a housewife. Female volunteers showed the same qualities and outcomes of participation as males in the HIV vaccine trial. There was no statistically significant difference in vaccine efficacy between men and women, especially among the high-risk and married women. The study highlighted the important behavioral, social, and cultural issues that could be considered for future HIV vaccine trial designs.

Motivators to participation in medical trials: the application of social and personal categorization

The Health Belief Model provides a framework to understand motivators for volunteering for medical research. Motivators can take the form of social and personal benefits. In this systematic review of review articles, we contrast motivators of participation in actual cancer trials to those in actual HIV vaccine trials. We retrieved eight review articles from 2000 to 2012 examining motivators to participation in actual cancer trials. Personal benefits were most often psychological in nature, such as "coping with symptoms." Social benefits included "advancing research," "helping other cancer patients," and "for their family." While specific motivators vary between considerations - cancer research and HIV vaccine trials, these motivators fall into similar categories at similar frequencies. For example, personal/psychological benefits are common in each. Participant recruitment must be mindful of these categories of motivators for both cancer and HIV vaccine research.

A qualitative evaluation of volunteers' experiences in a phase I/II HIV vaccine trial in Tanzania

Background

Evaluating experiences of volunteers in an HIV vaccine trial will be useful for the conduct of future trials. The purpose of this study among volunteers who participated in a phase I/II HIV vaccine trial in Dar es Salaam, Tanzania was to assess what characterized their experiences during the trial.

Methods

We conducted four focus group discussions with 35 out of the 60 individuals (women and men) after the five scheduled vaccinations. An interpretive description approach was applied to data analysis.

Results

As a result of the trial interventions, both men and women gained confidence in their own abilities to have safer, less risky sexual behaviour. The participants experienced the trial as a way of accessing free [insured] medical services. Most of the men said they had gone from self-medication to professional medical consultation. Despite these benefits, the participants faced various challenges during the trial. Such challenges included mistrust of the trial shown by health care providers who were not connected to the trial and discouragement from friends, colleagues and family members who questioned the safety of the trial. However, they managed to cope with these doubts by using both personal and trial related interventions.

Conclusion

We found that during the phase I/II HIV vaccine trial, participants had both the opportunities and the ability to cope with the doubts from the surrounding community. Follow up visits enhanced the opportunities and individuals' abilities to cope with the doubts during the trial. Understanding this discourse may be useful for the trial implementers when designing future trials.

Trials Registration

ISRCTN: ISRCTN90053831

Pan African Clinical Trials Registry (PACTR): ATMR2009040001075080

Conceptual framework for behavioral and social science in HIV vaccine clinical research

HIV vaccine clinical research occurs within a context where biomedical science and social issues are interlinked. Previous HIV vaccine research has considered behavioral and social issues, but often treated them as independent of clinical research processes. Systematic attention to the intersection of behavioral and social issues within a defined clinical research framework is needed to address gaps, such as those related to participation in trials, completion of trials, and the overall research experience. Rigorous attention to these issues at project inception can inform trial design and conduct by matching research approaches to the context in which trials are to be conducted. Conducting behavioral and social sciences research concurrent with vaccine clinical research is important because it can help identify potential barriers to trial implementation, as well as ultimate acceptance and dissemination of trial results. We therefore propose a conceptual framework for behavioral and social science in HIV vaccine clinical research and use examples from the behavioral and social science literature to demonstrate how the model can facilitate identification of significant areas meriting additional exploration. Standardized use of the conceptual framework could improve HIV vaccine clinical research efficiency and relevance.

Barriers of enrolment in HIV vaccine trials: a review of HIV vaccine preparedness studies

Barriers to participation in an HIV vaccine trial have been examined in many HIV vaccine preparedness studies (VPS). These barriers can be understood in terms of the locus of the barrier (personal vs. social) and the nature of the barrier (risk vs. cost). Another type of barrier is perceived misconceptions. In this systematic review, we categorize barriers, and compare these barriers between the Organization for Economic Co-operation and Development (OECD) countries and the non-OECD countries. In the OECD countries, we retrieved 25 studies reporting personal risks (PR), 9 studies reporting social risks (SR), 10 studies reporting personal costs (PC), and 16 studies reporting misconceptions. In the non-OECD countries, we retrieved 27 studies reporting PR, 19 studies reporting SR, 18 studies reporting PC, 1 study reporting social costs (SC), and 13 studies reporting misconceptions. Important PR were "adverse effects" and "vaccine-induced seropositivity", "distrust of institutions", and "temptation to have unsafe sex" in men who have sex with men (MSM). "Discrimination" was a common SR. "Time commitment" was an important PC, and "family commitments" were a SC in one non-OECD country. "HIV infection from the vaccine" was a common misconception. Both the OECD and the non-OECD countries have similar barriers, and people's decisions to participate in a clinical trial involve multiple barriers. However, these barriers apply to hypothetical HIV vaccine trials, and barriers for actual vaccine trials need further assessment.

Preventive HIV vaccine acceptability and behavioral risk compensation among high-risk men who have sex with men and transgenders in Thailand

Thailand, with the highest number of volunteers to have participated in preventive HIV-1 vaccine trials globally, may be an early adopter of HIV vaccines. We conducted a mixed methods investigation, including 30 in-depth interviews and a venue-based survey. We used a structured questionnaire including conjoint analysis and a fractional factorial experimental design to assess preventive HIV vaccine acceptability and risk compensation among 255 high-risk men who have sex with men (MSM) and transgenders (mean age=26.6 years). HIV vaccine acceptability ranged from 31.6 to 73.8 on a 100-point scale; mean=58.3 (SD=17.1). Vaccine-induced seropositivity (VISP) had the greatest impact on acceptability, followed by efficacy, side effects, duration of protection, out-of-pocket cost and social saturation. Over one-third (34.6%) reported intentions to increase post-vaccination risk behaviors in response to a highly efficacious HIV vaccine. Social and structural interventions to promote HIV vaccine uptake as a prosocial behavior, provide accessible assays to detect VISP, and subsidize vaccine costs, and support for uptake of partially efficacious vaccines in the context of combination prevention, will facilitate HIV vaccine dissemination in Thailand.

What should South African HIV vaccine trials do about social harms?

Phase I and II HIV vaccine trials are currently underway in South Africa. Sites are being prepared for Phase III vaccine trials. Participants in these trials risk exposure to 'social harms' that may impact on participant enrolment and retention and threaten their welfare. Potential social harms should be prevented, minimised and/or addressed. This paper examines the literature on potential social harms in HIV vaccine trials. It outlines the type and severity and frequency of potential social harms and ways these have been monitored in settings in the developed world and Thailand. We argue that many of these social harms are likely to manifest in South African trials, however, it is also likely social harms may manifest differently in our setting, such as domestic violence. Therefore careful formative research is required to identify what constitutes a social harm in our setting. Measures should be carefully tailored to record such events and methods established to prevent or address these.

Negative Social Impacts Among Volunteers in an HIV Vaccine Efficacy Trial

OBJECTIVE

Describe the negative social impacts (NSIs) and their predictors in an HIV vaccine efficacy trial.

METHODS

Volunteers in the North American phase 3 trial of AIDSVAX B/B vaccine were questioned semiannually about NSIs. Multivariable logistic models identified independent predictors of NSI reporting.

RESULTS

Of 5417 volunteers (94% male), 18% reported at least 1 NSI. Most events occurred early during trial participation and involved concerns by family and friends that the volunteer was HIV-infected or at risk for infection. Problems with disability/life insurance and employment occurred less frequently (<1%). Individuals who became HIV-infected reported NSIs similar to HIV-negative volunteers. In multipredictor analysis of male volunteers, NSI reporters were younger (adjusted odds ratio [OR(Adj)] = 1.6, 95% confidence interval [CI]: 1.2 to 2.1 and OR(Adj) = 1.4, 95% CI: 1.1 to 1.8 for ages 18 to 25 years and 26 to 35 years vs. > or =46 years, respectively), enrolled at sites with 50 or fewer volunteers (OR(Adj) = 2.3, 95% CI: 1.7 to 3.1), or lived in cities with high AIDS case rates (OR(Adj) = 1.4, 95% CI: 1.1 to 1.8).

CONCLUSIONS

A modest proportion of vaccine efficacy trial volunteers reported problems in interpersonal relationships from trial participation. Serious harms involving insurance and employment were rare. Strategies to prevent harm from disclosure, particularly for younger volunteers and those from high seroincidence sites, may reduce NSIs in future trials.

Starting from scratch: program development and lessons learned from HIV vaccine trial counseling in Thailand

Counseling for participants in preventive HIV vaccine trials has been an area of continuing concern because of the need to address possible behavioral side effects (e.g., increased risk behavior because trial participants believe they may have received an active, effective vaccine) and social harms (e.g., discrimination in health care or employment because of vaccine-induced seropositivity on commercial HIV tests). Yet, the data on behavioral effects and social harms are limited and rather little detail has been provided regarding the counseling provided in current or past trials. This paper summarizes conceptual, cultural, and practical considerations in the development of a counseling program for HIV vaccine trials and provides examples from work done in the context of Phase I/II vaccine trials in Thailand.