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Chory A, Nyandiko W, Gillette E, Scanlon M, Aluoch J, Koros H, Munyoro D, Ashimosi C, Beigon W, Lidweye J, Nyagaya J, DeLong A, Kantor R, Vreeman R, Naanyu V. Ethical Considerations for Engaging Youth Living with HIV in Research: Perspectives from Youth, Their Caregivers and Subject Matter Experts in Kenya. J Empir Res Hum Res Ethics 2023; 18:175-188. [PMID: 37574803 PMCID: PMC11325439 DOI: 10.1177/15562646231193949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Introduction: Engaging youth living with HIV (YLWH) in research is critical to improving HIV-related outcomes, but their involvement raises unaddressed bioethical questions. Methods: This study used qualitative inquiry with Kenyan YLWH, caregivers, and subject matter experts (SMEs) to evaluate ethical considerations and strategies for research involving YLWH. Results: Interviews were conducted with 99 participants: 40 YLWH (median age 17.5, 50% female), 20 caregivers (70% female), and 39 SMEs (44% female). All participant groups discussed the need for HIV disclosure status assessment, confidentiality, and engagement of caregivers. Youth participants discussed the importance of clear protocol explanations and developing good rapport. All participant groups perceived youth under 18 to be harder to recruit due to a number of identified barriers. Clinic settings were the most acceptable place for recruitment. Conclusion: Participants provided perspectives on engaging YLWH in research that can be incorporated into protocols and regulatory guidelines.
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Affiliation(s)
- Ashley Chory
- Department of Global Health and Health Systems Design, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Winstone Nyandiko
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Emma Gillette
- Department of Global Health and Health Systems Design, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael Scanlon
- Indiana University Center for Global Health, Indianapolis, Indiana, USA
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Hillary Koros
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dennis Munyoro
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Whitney Beigon
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Janet Lidweye
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jack Nyagaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Allison DeLong
- Alpert Medical School at Brown University, Providence, RI, USA
| | - Rami Kantor
- Alpert Medical School at Brown University, Providence, RI, USA
| | - Rachel Vreeman
- Department of Global Health and Health Systems Design, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Violet Naanyu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University School of Arts and Social Sciences, Eldoret, Kenya
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Abrams EJ, Capparelli E, Ruel T, Mirochnick M. Potential of Long-Acting Products to Transform the Treatment and Prevention of Human Immunodeficiency Virus (HIV) in Infants, Children, and Adolescents. Clin Infect Dis 2022; 75:S562-S570. [PMID: 36410381 PMCID: PMC10200315 DOI: 10.1093/cid/ciac754] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Long-acting antiretroviral products have the potential to transform human immunodeficiency virus (HIV) prevention and treatment approaches in pediatric populations. Broadly neutralizing antibodies and/or long-acting antiretroviral formulations by injection could dramatically improve provision of HIV prophylaxis and/or early treatment to newborns and infants at risk of HIV infection. Challenges in daily oral antiretroviral administration to toddlers and school age children living with HIV may be relieved by use of long-acting formulations, but the pharmacokinetics and safety of these products in children must be studied before they can enter routine clinical use. Although some initial studies of broadly neutralizing antibodies and injectable long-acting agents in infants and young children are underway, more studies of these and other long-acting products are needed. For many adolescents, compliance with daily medication administration is especially challenging. Long-acting products hold particular promise for adolescents living with HIV as well as those at high risk of HIV acquisition, and adolescents can usually be included in the drug development pipeline simultaneously with adults. Long-acting products have the potential to provide alternatives to lifelong daily oral drug administration across the pediatric age spectrum, leading to more effective prevention and treatment of HIV infection in infants, children, and adolescents.
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Affiliation(s)
- Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Edmund Capparelli
- Department of Pediatrics and Clinical Pharmacy, University of California San Diego, La Jolla, California, USA
| | - Theodore Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Mark Mirochnick
- Department of Pediatrics, Boston University, Boston, Massachusetts, 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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Tucker JD, Iwelunmor J, Abrams E, Donenberg G, Wilson EC, Blachman-Demner D, Laimon L, Taiwo BO, Kuhns LM, John-Stewart GC, Kohler P, Subramanian S, Ayieko J, Gbaja-Biamila T, Oladele D, Obiezu-Umeh C, Chima KP, Jalil EM, Falcao J, Ezechi OC, Kapogiannis BG. Accelerating adolescent HIV research in low-income and middle-income countries: evidence from a research consortium. AIDS 2021; 35:2503-2511. [PMID: 34870930 PMCID: PMC8901045 DOI: 10.1097/qad.0000000000003049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Many adolescents and young adults (AYA) have unmet HIV prevention needs. We describe the Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) consortium organization, transition milestones, and youth engagement strategies. The PATC3H consortium focuses on reducing HIV incidence and related health disparities among AYA. DESIGN AND METHODS Organizational data were obtained from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and supplemented with a brief survey completed by study principal investigators. Transition from the initial phase (years 1 and 2) to the subsequent phase (years 3 and 5) was contingent on meeting prespecified milestones. We reviewed the structure and function of the research consortium, identified shared elements of transition milestones, and examined common youth engagement strategies. RESULTS The PATC3H consortium supports eight research studies through a milestone transition mechanism. The consortium includes AYA HIV research studies in seven countries - Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. The NIH request for applications required transition milestones that included early consultation with stakeholders. The transition milestones required by NIH for the eight studies included early consultation with health and policy stakeholders, pilot intervention data, and commitment from national government stakeholders. All studies provided multiple pathways for AYA engagement, including AYA advisory boards and youth-led research studies. CONCLUSION Data suggest that requiring milestones to transition to the final phase may have facilitated health and policy stakeholder engagement and enhanced formative assessment of regulatory protocols. These data have implications for designing engaged research studies in low and middle-income countries.
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Affiliation(s)
- Joseph D. Tucker
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Chapel Hill, NC, USA
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Juliet Iwelunmor
- Behavioral Science and Health Education, College for Public Health and Social Justice, St. Louis University, St. Louis, MO, USA
| | - Elaine Abrams
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
- Epidemiology Department, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Geri Donenberg
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Erin C. Wilson
- San Francisco Department of Public Health, San Francisco, CA 94102
| | - Dara Blachman-Demner
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, USA
| | | | - Babafemi O. Taiwo
- Department of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa M. Kuhns
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Grace C. John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, WA
| | - Pamela Kohler
- Department of Global Health, University of Washington, 1510 San Juan Road NE, Seattle, WA, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
| | | | - James Ayieko
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Titilola Gbaja-Biamila
- Behavioral Science and Health Education, College for Public Health and Social Justice, St. Louis University, St. Louis, MO, USA
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - David Oladele
- Behavioral Science and Health Education, College for Public Health and Social Justice, St. Louis University, St. Louis, MO, USA
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Chisom Obiezu-Umeh
- Behavioral Science and Health Education, College for Public Health and Social Justice, St. Louis University, St. Louis, MO, USA
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Kelechi P. Chima
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Emilia M. Jalil
- National Institute of Infectious Diseases, FIOCRUZ, Rio de Janeiro, Brazil
| | - Joana Falcao
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
| | - Oliver C. Ezechi
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Bill G. Kapogiannis
- Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Bonner CP, Fisher CB, Carney T, Browne FA, Gichane MW, Howard BN, Turner L, Wechsberg WM. "Because all mothers is not the same": The development and implementation of an in loco parentis informed consent procedure to enroll adolescent girls and young women to participate in HIV research. J Adolesc 2021; 93:234-244. [PMID: 34896961 PMCID: PMC10916742 DOI: 10.1016/j.adolescence.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/12/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION South Africa has one of the highest incidences of HIV among adolescent girls and young women (AGW), ages 15-24, and recent research has focused on developing interventions for HIV prevention. However, the South African National Health Act requires those under 18 years of age to obtain a guardian's permission to participate in research. Limiting research enrolment to AGYW who can obtain guardian consent may lead to non-representative findings. Therefore, innovative, inclusive consent approaches that protect AGYW from the risks of research are needed. METHODS This report details the development and implementation of an approach called the in loco parentis (in place of parent) consent procedure. In loco parentis consent provides a vehicle for adolescent participation that protects adolescents from potential social harms. The in loco parentis consent procedure does not seek to obtain independent minor consent but seeks to obtain permission for the minor to participate in research from a trusted adult who is not a minor's parent or legal guardian. This report also qualitatively explores the experiences of 31 AGYW who were recruited into a behavioral HIV prevention study using this method. RESULTS Findings suggest that the in loco parentis consent procedure is a feasible and acceptable method to inclusively AGYW in HIV research. CONCLUSIONS The in loco parentis procedure may provide a more inclusive strategy to recruit AGYW for HIV research to increase the generalizability of findings.
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Affiliation(s)
- Courtney Peasant Bonner
- Substance Use, Gender, and Applied Research Program, RTI International, Atlanta, GA, USA; Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Felicia A Browne
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC, USA
| | - Margaret W Gichane
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC, USA
| | - Brittni N Howard
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC, USA
| | - Leslie Turner
- Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC, USA
| | - Wendee M Wechsberg
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; Substance Use, Gender, and Applied Research Program, RTI International, Research Triangle Park, NC, USA; Department of Psychology, North Carolina State University, Raleigh, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Harrington EK, Casmir E, Kithao P, Kinuthia J, John-Stewart G, Drake AL, Unger JA, Ngure K. "Spoiled" girls: Understanding social influences on adolescent contraceptive decision-making in Kenya. PLoS One 2021; 16:e0255954. [PMID: 34383836 PMCID: PMC8360567 DOI: 10.1371/journal.pone.0255954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 07/27/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents' own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents. METHODS Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15-19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making. RESULTS Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk. CONCLUSIONS Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents' seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.
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Affiliation(s)
- Elizabeth K. Harrington
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Edinah Casmir
- Kenya Medical Research Institute, Center for Clinical Research, Thika, Kenya
| | - Peninah Kithao
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Jennifer A. Unger
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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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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Day S, Kapogiannis BG, Shah SK, Wilson EC, Ruel TD, Conserve DF, Strode A, Donenberg GR, Kohler P, Slack C, Ezechi O, Tucker JD. Adolescent participation in HIV research: consortium experience in low and middle-income countries and scoping review. Lancet HIV 2020; 7:e844-e852. [PMID: 33275917 PMCID: PMC8491773 DOI: 10.1016/s2352-3018(20)30269-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/10/2020] [Accepted: 09/07/2020] [Indexed: 01/09/2023]
Abstract
Adolescents in low and middle-income countries (LMICs) have a high prevalence of HIV, therefore, it is important that they are included in HIV research. However, ethical challenges regarding consent can hinder adolescent research participation. We examined examples from the Prevention and Treatment Through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) research consortium, which investigates adolescent HIV prevention and treatment in seven LMICs: Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. PATC3H researchers were asked to identify ethical and practical challenges of adolescent consent to research participation in these countries. We also did a scoping review of strategies that could improve adolescent participation in LMIC HIV studies. Examples from PATC3H research highlighted many ethical challenges that affect adolescent participation, including inconsistent or absent consent guidance, guidelines that fail to account for the full array of adolescents' lives, and variation in how ethical review committees assess adolescent studies. Our scoping review identified three consent-related strategies to expand adolescent inclusion: waiving parental consent requirements, allowing adolescents to independently consent, and implementing surrogate decision making. Our analyses suggest that these strategies should be further explored and incorporated into ethical and legal research guidance to increase adolescent inclusion in LMIC HIV research.
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Affiliation(s)
- Suzanne Day
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Bill G Kapogiannis
- Maternal and Pediatric Infectious Diseases Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Seema K Shah
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Mary Ann and J Milburn Smith Child Health Research, Outreach, and Advocacy Center, Stanley Manne Children's Research Institute, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Erin C Wilson
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Theodore D Ruel
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Donaldson F Conserve
- Department of Prevention and Community Health, The George Washington University, Washington, DC, USA
| | - Ann Strode
- School of Law, University of KwaZulu-Natal, University Road, Durban, South Africa
| | - Geri R Donenberg
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Catherine Slack
- HIV AIDS Vaccines Ethics Group, School of Applied Human Sciences, University of KwaZulu-Natal, Scottsville, Pietermaritzburg, South Africa
| | - Oliver Ezechi
- Nigerian Institute of Medical Research, Medical Compound, Yaba, Lagos, Nigeria
| | - Joseph D Tucker
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Faculty of Infectious Diseases, London School of Hygiene & Tropical Medicine
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Simons-Rudolph A, Iritani B, Odongo F, Rennie S, Gilbertson A, Kwaro D, Luseno W. Adolescent perceptions about participating in HIV-related research studies. CHILDREN AND YOUTH SERVICES REVIEW 2020; 116:105262. [PMID: 32905545 PMCID: PMC7472997 DOI: 10.1016/j.childyouth.2020.105262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The rising incidence of infection among youth in sub-Saharan Africa makes HIV-related research among younger people a top priority. There remains, however, a lack of consistent and unambiguous ethical principles and guidance for researchers wishing to conduct HIV studies with adolescents. The overarching aim of our research was to better understand youths' experiences with HIV studies. The present study explored four questions: (1) What strategies are effective for recruiting youth for HIV studies? (2) What motivates youth to participate in these studies? (3) How do study participants perceive HIV testing within the context of a research study? (4) What do participants understand about the risks of study participation? These data are essential to inform guidelines for the responsible conduct of research with young people. We interviewed 82 adolescents (aged 15-19) in Kenya taking part in a study examining ethical issues pertaining to their involvement in HIV-related research. Pursuant to our research questions, we found that direct study recruitment combined with encouragement from female relatives was the greatest facilitator to study enrolment among young people. Most young participants expressed that they were motivated to join the study in order to (1) learn their HIV status (n = 49) and (2) receive HIV-related education (n = 26), even though both are already free and widely available. Participants largely preferred testing in a place they deemed "private," although both the health clinic and home were regarded by adolescents as locations with greater privacy. Adolescents largely did not accurately perceive risks of the study two months after baseline, although they could remember the benefits with great clarity. This work can inform researchers, policymakers, and ethics review committees on approaches to maximize efficiency in recruitment and data collection, and to enhance understanding of risks and benefits in HIV-related research among adolescents. While further research is needed, these data may be used by others conducting HIV research in this region to improve recruitment strategies and more effectively engage and appeal to young people.
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Affiliation(s)
- A.P. Simons-Rudolph
- Pacific Institute for Research and Evaluation (PIRE),
Chapel Hill, USA
- Corresponding author at: PIRE, 101 Conner Dr., Ste
200, Chapel Hill, NC 27514, USA.
| | - B.J. Iritani
- Pacific Institute for Research and Evaluation (PIRE),
Chapel Hill, USA
| | - F.S. Odongo
- Kenya Medical Research Institute (KEMRI), Kisumu,
Kenya
| | - S. Rennie
- Department of Social Medicine, UNC Center for Bioethics,
University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - A. Gilbertson
- Pacific Institute for Research and Evaluation (PIRE),
Chapel Hill, USA
| | - D. Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu,
Kenya
| | - W.K. Luseno
- Pacific Institute for Research and Evaluation (PIRE),
Chapel Hill, USA
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10
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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11
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Nachman S, Townsend CL, Abrams EJ, Archary M, Capparelli E, Clayden P, Lockman S, Jean-Philippe P, Mayer K, Mirochnick M, McKenzie-White J, Struble K, Watts H, Flexner C. Long-acting or extended-release antiretroviral products for HIV treatment and prevention in infants, children, adolescents, and pregnant and breastfeeding women: knowledge gaps and research priorities. Lancet HIV 2019; 6:e552-e558. [PMID: 31307946 PMCID: PMC7152795 DOI: 10.1016/s2352-3018(19)30147-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/14/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022]
Abstract
Antiretroviral agents with long-acting properties have potential to improve treatment outcomes substantially for people living with HIV. In November 2017, the Long acting/Extended Release Antiretroviral Resource Program (LEAP) convened a workshop with the aim of shaping the research agenda and promoting early development of long-acting or extended release products for key populations: pregnant and lactating women, children aged up to 10 years, and adolescents aged 10-19 years. Goals included strategies and principles to ensure that the needs of children, adolescents, and pregnant and lactating women are considered when developing long-acting formulations. Research should focus not only on how best to transition long-acting products to these populations, but also on early engagement across sectors and among stakeholders. A parallel rather than sequential approach is needed when establishing adult, adolescent, and paediatric clinical trials and seeking regulatory approval. Pregnant and lactating women should be included in adult clinical trials. Adolescent-friendly trial design is needed to improve recruitment and retention of young people.
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Affiliation(s)
- Sharon Nachman
- Health Sciences Center, SUNY Stony Brook, Pediatrics, New York, NY, USA.
| | | | - Elaine J Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, NY, USA; Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | | | - Edmund Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | | | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Mayer
- School of Medicine, Harvard University, Cambridge, MA, USA
| | | | | | | | - Heather Watts
- Office of the Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
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12
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Marsh V, Mwangome N, Jao I, Wright K, Molyneux S, Davies A. Who should decide about children's and adolescents' participation in health research? The views of children and adults in rural Kenya. BMC Med Ethics 2019; 20:41. [PMID: 31200697 PMCID: PMC6570858 DOI: 10.1186/s12910-019-0375-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 05/22/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND International research guidance has shifted towards an increasingly proactive inclusion of children and adolescents in health research in recognition of the need for more evidence-based treatment. Strong calls have been made for the active involvement of children and adolescents in developing research proposals and policies, including in decision-making about research participation. Much evidence and debate on this topic has focused on high-income settings, while the greatest health burdens and research gaps occur in low-middle income countries, highlighting the need to take account of voices from more diverse contexts. METHODS Between January and March 2014, 56 community representatives and secondary school students were involved in eight group discussions to explore views on the acceptability of involving children and adolescents in research, and how these groups should be involved in decision-making about their own participation. Discussions were voice-recorded and transcriptions analyzed using Framework Analysis, combining deductive and inductive approaches. RESULTS Across these discussions, the idea of involving children and adolescents in decision-making about research participation was strongly supported given similar levels of responsibility carried in everyday life; existing capacity that should be recognized; the opportunity for learning involved; varying levels of parental control; and generational shifts towards greater understanding of science for adolescents than their parents. Joint decision-making processes were supported for older children and adolescents, with parental control influenced by perceptions of the risks involved in participation. CONCLUSIONS Moves towards more active involvement of children and adolescents in planning studies and in making decisions about their participation are supported by these findings from Kenya. Important emerging considerations include the need to take account of the nature of proposed studies and prevailing attitudes and understanding of research in identifying children's and adolescents' roles. More research is needed to expand diversity and develop approaches to joint assent and consent processes that would fairly represent children's and adolescents' wishes and interests, towards their long term benefit.
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Affiliation(s)
- Vicki Marsh
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
| | - Nancy Mwangome
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
| | - Irene Jao
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
| | - Katharine Wright
- UK Nuffield Council on Bioethics, 28 Bedford Square, London, WC1B 3JS UK
| | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
| | - Alun Davies
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
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Abstract
Purpose of review Many of the almost 2 million HIV infections that occurred globally in the last year occurred among adolescents and young people, particularly those from East and Southern Africa and within key populations. Global HIV epidemic control will require that new infections among these youth populations be curtailed. This review examines the most effective prevention approaches to reach these adolescent populations in the next 5 years. Recent findings Adolescents are in transition and are developmentally unique. They have specific needs and challenges, which if not addressed will result in less than successful interventions. Tailored, layered, combination prevention packages that take into account specific adolescent needs and involve biomedical, behavioural and structural components are recommended. These packages should be designed for and with the meaningful input of adolescents, and involve their peers in their implementation and execution. Where possible, age-appropriate health and social interventions that go beyond HIV should be bundled and offered in a variety of community-based venues that are already acceptable to and frequented by adolescents. Summary It is urgent that we reach adolescents globally with the most effective HIV prevention approaches. HIV prevention investment in this population has immediate and longer-term benefits.
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Abstract
PURPOSE OF REVIEW The goal of this paper is to review recent data on biomedical, behavioral, and structural HIV prevention interventions for adolescents and young adults. RECENT FINDINGS While it is accepted that HIV prevention interventions must take an integrated approach to achieve maximum effectiveness, to date, there have been limited, rigorously evaluated combination prevention interventions for adolescents. There are currently a range of effective biomedical, behavioral, and structural approaches that can be integrated into prevention packages to address the prevention needs of adolescents, including oral PrEP, male circumcision, rapid HIV testing, numerous behavioral interventions, and structural interventions such as cash transfers and community mobilization to address gender-based violence. There is still a need for rigorously evaluated, innovative combination prevention packages for adolescents. Prevention approaches must take into account the context of young people's lives and address the multiple levels of influence on their lives including parents, partners, and communities.
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Affiliation(s)
- Sybil Hosek
- Department of Psychiatry, John Stroger Hospital of Cook County, 1900 W. Polk Street, Ste. 854, Chicago, IL, 60612, USA.
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
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15
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Hejoaka F, Varloteaux M, Desclaux-Sall C, Ndiaye SM, Diop K, Diack A, Niasse F, Cames C. Improving the informed consent process among HIV-infected undisclosed minors participating in a biomedical research: insights from the multicentre nutritional SNACS study in Senegal. Trop Med Int Health 2019; 24:294-303. [PMID: 30624827 DOI: 10.1111/tmi.13202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Providing research information in a manner accessible to minors participating in biomedical research is a major challenge. Guidance is dramatically lacking regarding best practices for seeking informed consent among undisclosed minors enrolled in HIV-related research. We implemented an improved informed consent process (IICP) and identified factors associated with understanding of the information presented to HIV-infected minors prior to their enrolment in a study. METHODS We enrolled study participants attending 12 paediatric HIV clinics in Senegal. Children ≥7 years were provided with standardised research information using the IICP, which involves viewing a video and taking part in extended group discussions. Understanding was assessed by seven basic questions scored 1 or 2 points, with a maximum score of 11 points. A score of 9 or more points was defined as satisfactory understanding. Factors associated with understanding were identified using a stepwise logistic regression model. RESULTS Overall, 112 children, with a median age of 12.9 years (IQR: 10.2-15.0), participated in the IICP, of whom 37% were HIV disclosed. 71% achieved a satisfactory understanding score and all gave consent to participate in the research. HIV-disclosed children were more likely to demonstrate satisfactory understanding than undisclosed children (aOR = 3.2, 95% CI: 1.1-9.6). Age, study setting and education level were not associated with satisfactory understanding. CONCLUSION These findings provide practical guidance for the development of improved and friendly informed consent processes in research involving minors. The implementation of the paediatric HIV research agenda will require a standardised and operational definition of informed consent, integrating the issue of HIV disclosure.
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Affiliation(s)
- Fabienne Hejoaka
- Institut de recherche pour le développement, UMI233 TransVIHmi, U1175 INSERM, Université de Montpellier, Montpellier, France
| | - Marie Varloteaux
- Institut de recherche pour le développement, UMI233 TransVIHmi, U1175 INSERM, Université de Montpellier, Montpellier, France
| | - Caroline Desclaux-Sall
- Institut de recherche pour le développement, UMI233 TransVIHmi, U1175 INSERM, Université de Montpellier, Montpellier, France
| | - Sidy Mokhtar Ndiaye
- Centre régional de recherche et de formation à la prise en charge clinique, Dakar, Sénégal
| | - Karim Diop
- Centre régional de recherche et de formation à la prise en charge clinique, Dakar, Sénégal.,Division de lutte contre le sida et les IST/Ministère de la santé et de l'action sociale, Dakar, Sénégal
| | - Aminata Diack
- Centre hospitalier national d'enfants Albert Royer, Dakar, Sénégal
| | - Fatou Niasse
- Conseil national de lutte contre le sida, Dakar, Sénégal
| | - Cécile Cames
- Institut de recherche pour le développement, UMI233 TransVIHmi, U1175 INSERM, Université de Montpellier, Montpellier, France
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16
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Colom M, Rohloff P. Cultural considerations for informed consent in paediatric research in low/middle-income countries: a scoping review. BMJ Paediatr Open 2018; 2:e000298. [PMID: 30613801 PMCID: PMC6307601 DOI: 10.1136/bmjpo-2018-000298] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Conducting research with children in low/middle-income countries (LMIC) requires consideration of socioeconomic inequalities and cultural and linguistic differences. Our objective was to survey the literature on informed consent in paediatric LMIC research, assessing for practical guidance for culturally and linguistically appropriate procedures. METHODS We conducted a scoping review on informed consent in paediatric LMIC research searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were published in English, from any date range, of any study design or format. RESULTS The search identified 2027 references, of which 50 were included in the analysis following full-text review. Reviewed guidelines emphasised individual, informed and voluntary consent from parents and caregivers. Reviewed articles provided detailed practical guidance on adapting these guiding principles to LMIC settings, including considerations for community engagement, verbal or other alternative consent procedures for low-literacy settings or less commonly spoken languages and guarding against therapeutic misconception by caregivers. There was uncertainty, however, on how to best protect individual autonomy, especially when influenced by gender dynamics, leadership hierarchies or the social status of researchers themselves. There was, furthermore, limited research discussing the special case of research involving adolescents or of procedures for documenting assent by participating children. CONCLUSIONS A scoping review of paediatric research in LMICs revealed substantial guidance on several features of culturally appropriate informed consent. However, additional research and guidance is needed, especially in the areas of gender imbalances, research with adolescents and children's own assent to participate in research.
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Affiliation(s)
- Marcela Colom
- Centre for Research in Indigenous Health, Wuqu’ Kawoq | Maya Health Alliance, Tecpán, Guatemala
| | - Peter Rohloff
- Centre for Research in Indigenous Health, Wuqu’ Kawoq | Maya Health Alliance, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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17
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Hodes R, Vale B, Toska E, Cluver L, Dowse R, Ashorn M. 'Yummy or crummy?' The multisensory components of medicines-taking among HIV-positive youth. Glob Public Health 2018; 14:284-299. [PMID: 30067457 DOI: 10.1080/17441692.2018.1504103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The global rollout of Antiretroviral Treatment (ART) has revealed an urgent need to understand the medicines-taking practices of HIV-positive adolescents. In the last decade, the literature on the social determinants of health has broadened the evidence-base on ART adherence. Interdisciplinary studies have expanded conceptions of medicines-taking beyond clinical or health systems frameworks, recognising the importance of socio-structural conditions and of patients' beliefs and experiences. Participatory research techniques which foreground the perspectives of adolescents provide greater insights still into their adherence. This article explores the use of participatory methods within a broader study on the social determinants of ART adherence among HIV-positive adolescents in South Africa. We describe how participatory methods were incorporated into this study (n = 1,059 in the quantitative baseline). We focus on an exercise, 'Yummy or crummy?', that explored the multisensory dimensions of medicines-taking, including their colour, smell, shape, and delivery mechanism. We describe two principal findings: first, adolescents' preference for greater understanding of the chemical workings of medicines, manifested in their preferences for colour, taste and shape of medicines; and second, the vital relationship between sensory preferences and the social imperatives of discretion and confidentiality regarding HIV-status.
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Affiliation(s)
- Rebecca Hodes
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.,Department of Social Policy and Intervention, Oxford University, Oxford, UK
| | - Beth Vale
- Mapungubwe Institute for Strategic Reflection, Centre for African Studies, University of Cape Town, Cape Town, South Africa
| | - Elona Toska
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.,Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Lucie Cluver
- Department of Social Policy and Intervention, Oxford University, Oxford, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Ros Dowse
- Faculty of Pharmacy, Rhodes University, Grahamstown, South Africa
| | - Mikael Ashorn
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
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18
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Shah SK, Allison SM, Kapogiannis BG, Black R, Dawson L, Erbelding E. Advancing independent adolescent consent for participation in HIV prevention research. JOURNAL OF MEDICAL ETHICS 2018; 44:431-433. [PMID: 29895555 DOI: 10.1136/medethics-2018-104959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Seema K Shah
- University of Washington Medical School Department of Pediatrics, Division of Bioethics, Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington, USA
| | - Susannah M Allison
- Division of AIDS Research, National Institute of Mental Health, NIH, Bethesda, Maryland, USA
| | - Bill G Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Roberta Black
- Division of AIDS, National Institute of Allergy & Infectious Diseases, Bethesda, Maryland, USA
| | - Liza Dawson
- Division of AIDS, National Institute of Allergy & Infectious Diseases, Bethesda, Maryland, USA
| | - Emily Erbelding
- Division of Microbiology and Infectious Diseases, National Institute of Allergy & Infectious Diseases, Bethesda, Maryland, USA
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19
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Fletcher FE, Fisher C, Buchberg MK, Floyd B, Hotton A, Ehioba A, Donenberg G. "Where Did This [PrEP] Come From?" African American Mother/Daughter Perceptions Related to Adolescent Preexposure Prophylaxis (PrEP) Utilization and Clinical Trial Participation. J Empir Res Hum Res Ethics 2018; 13:173-184. [PMID: 29471706 DOI: 10.1177/1556264618755919] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the demonstrated effectiveness of preexposure prophylaxis (PrEP) to reduce incident HIV infections, PrEP's potential as an HIV prevention strategy for adolescent populations is unknown. This study assessed perceptions of adolescent PrEP use and clinical trial participation among African American women and their adolescent daughters. We conducted focus group discussions with 15 African American mother/daughter pairs ( N = 30). Findings suggest a general lack of PrEP awareness, favorable attitudes toward adolescent PrEP use, altruistic attitudes regarding research participation among daughters, and less favorable attitudes toward adolescent clinical trial participation among mothers. Study findings have the potential to inform strategies that provide equitable access to HIV scientific advances among African American women and girls and promote informed parent-child research decision making.
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20
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Rennie S, Groves AK, Hallfors DD, Iritani BJ, Odongo FS, Luseno WK. The Significance of Benefit Perceptions for the Ethics of HIV Research Involving Adolescents in Kenya. J Empir Res Hum Res Ethics 2017; 12:269-279. [PMID: 28728497 DOI: 10.1177/1556264617721556] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Assessment of benefits is traditionally regarded as crucial to the ethical evaluation of research involving human participants. We conducted focus group discussions (FGDs) with health and other professionals engaged with adolescents, caregivers/parents, and adolescents in Siaya County, Kenya, to solicit opinions about appropriate ways of conducting HIV research with adolescents. Our data revealed that many focus group participants have a profoundly positive conception of participation in health research, including studies conferring seemingly few benefits. In this article, we identify and analyze five different but interrelated types of benefits as perceived by Kenyan adolescent and adult stakeholders in HIV research, and discuss their ethical significance. Our findings suggest that future empirical and conceptual research should concentrate on factors that may trigger researcher obligations to improve benefit perceptions among research participants.
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Affiliation(s)
- Stuart Rennie
- 1 The University of North Carolina at Chapel Hill, NC, USA
| | | | | | - Bonita J Iritani
- 3 Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA
| | | | - Winnie K Luseno
- 3 Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA
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"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya. AIDS 2017; 31 Suppl 3:S213-S220. [PMID: 28665879 PMCID: PMC5497781 DOI: 10.1097/qad.0000000000001513] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text Objectives: Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs. Design: We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13–18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya. Methods: Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices. Results: All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents’ wishes. Conclusion: Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining ‘90-90-90’ targets for adolescents.
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22
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Seeking wider access to HIV testing for adolescents in sub-Saharan Africa. Pediatr Res 2016; 79:838-45. [PMID: 26882367 DOI: 10.1038/pr.2016.28] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 12/13/2015] [Indexed: 11/08/2022]
Abstract
More than 80% of the HIV-infected adolescents live in sub-Saharan Africa. Acquired immune deficiency syndrome (AIDS)-related mortality has increased among adolescents 10-19 y old. The impact is highest in sub-Saharan Africa, where >80% of HIV-infected adolescents live. The World Health Organization has cited inadequate access to HIV testing and counseling (HTC) as a contributing factor to AIDS-related adolescent deaths, most of which occur in sub-Saharan Africa. This review focuses on studies conducted in high adolescent HIV-burden countries targeted by the "All In to End Adolescent AIDS" initiative, and describes barriers to adolescent HTC uptake and coverage. Fear of stigma and family reaction, fear of the impact of a positive diagnosis, perceived risk with respect to sexual exposure, poor attitudes of healthcare providers, and parental consent requirements are identified as major impediments. Most-at-risk adolescents for HIV infection and missed opportunities for testing include, those perinatally infected, those with early sexual debut, high mobility and multiple/older partners, and pregnant and nonpregnant females. Regional analyses show relatively low adolescent testing rates and more restrictive consent requirements for HTC in West and Central Africa as compared to East and southern Africa. Actionable recommendations for widening adolescent access to HTC and therefore timely care include minimizing legal consent barriers, healthcare provider training, parental education and involvement, and expanding testing beyond healthcare facilities.
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Grimsrud A, Lesosky M, Kalombo C, Bekker LG, Myer L. Implementation and Operational Research: Community-Based Adherence Clubs for the Management of Stable Antiretroviral Therapy Patients in Cape Town, South Africa: A Cohort Study. J Acquir Immune Defic Syndr 2016; 71:e16-23. [PMID: 26473798 DOI: 10.1097/qai.0000000000000863] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Community-based models of antiretroviral therapy (ART) delivery are widely discussed as a priority in the expansion of HIV treatment services, but data on their effectiveness are limited. We examined outcomes of ART patients decentralized to community-based adherence clubs (CACs) in Cape Town, South Africa and compared these to patients managed in the community health center. METHODS The analysis included 8150 adults initiating ART from 2002 to 2012 in a public sector service followed until the end of 2013. From June 2012, stable patients (on ART >12 months, suppressed viral load) were referred to CACs. Loss to follow-up (LTFU) was compared between services using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation. FINDINGS Of the 2113 CAC patients (71% female, 7% youth ages ≤ 24 years), 94% were retained on ART after 12 months. Among CAC patients, LTFU [adjusted hazard ratio (aHR): 2.17, 95% confidence interval (CI): 1.26 to 3.73 ] and viral rebound (aHR 2.24, 95% CI: 1.00 to 5.04) were twice as likely in youth (16-24 years old) compared with older patients, but no difference in the risk of LTFU or viral rebound was observed by sex (P-values 0.613 and 0.278, respectively). CAC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27 to 0.40) compared with community health centre, and this association persisted when stratified by patient demographic and clinic characteristics. INTERPRETATION CACs are associated with reduced risk of LTFU compared with facility-based care. Community-based models represent an important development to facilitate ART delivery and possibly improve patient outcomes.
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Affiliation(s)
- Anna Grimsrud
- *Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;†Department of Medicine, University of Cape Town, Cape Town, South Africa;‡Gugulethu Community Health Centre, Provincial Government of the Western Cape, Cape Town, South Africa; and§The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Pettifor A, Nguyen NL, Celum C, Cowan FM, Go V, Hightow-Weidman L. Tailored combination prevention packages and PrEP for young key populations. J Int AIDS Soc 2015; 18:19434. [PMID: 25724507 PMCID: PMC4344537 DOI: 10.7448/ias.18.2.19434] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/16/2014] [Accepted: 01/02/2015] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations. OBJECTIVE In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages. METHODS We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular. RESULTS AND DISCUSSION Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure. CONCLUSIONS Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.
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Affiliation(s)
- Audrey Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa;
| | - Nadia L Nguyen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Connie Celum
- International Clinical Research Center, University of Washington, Seattle, WA, USA
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe
- Department of Infection and Population Health, University College London, London, United Kingdom
| | - Vivian Go
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lisa Hightow-Weidman
- Department of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Improving ethical and participatory practice for marginalized populations in biomedical HIV prevention trials: lessons from Thailand. PLoS One 2014; 9:e100058. [PMID: 24949864 PMCID: PMC4064984 DOI: 10.1371/journal.pone.0100058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/21/2014] [Indexed: 12/02/2022] Open
Abstract
Background This paper presents findings from a qualitative investigation of ethical and participatory issues related to the conduct of biomedical HIV prevention trials among marginalized populations in Thailand. This research was deemed important to conduct, as several large-scale biomedical HIV prevention trials among marginalized populations had closed prematurely in other countries, and a better understanding of how to prevent similar trial closures from occurring in the future was desired. Methods In-depth key informant interviews were held in Bangkok and Chiang Mai, Thailand. Interviews were audio recorded, transcribed, translated and thematically analyzed. The Good Participatory Practice Guidelines for Biomedical HIV Prevention Trials (GPP) guided this work. Results Fourteen interviews were conducted: 10 with policymakers, academic and community-based researchers and trial staff and four with representatives of non-governmental organizations (NGOs). Suggested ways to improve ethical and participatory practice centered on standards of HIV prevention, informed consent, communication and human rights. In particular, the need to overcome language and literacy differences was identified. Key informants felt communication was the basis of ethical understanding and trust within biomedical HIV prevention trial contexts, and thus fundamental to trial participants' ability to exercise free will. Discussion Biomedical HIV prevention trials present opportunities for inclusive and productive ethical and participatory practice. Key informants suggested that efforts to improve practice could result in better relationships between research stakeholders and research investigative teams and by extension, better, more ethical participatory trials. This research took place in Thailand and its findings apply primarily to Thailand. However, given the universality of many ethical considerations, the results of this study can inform the improvement of ethical and participatory practice in other parts of the world where biomedical HIV prevention trials occur, and where clinical trials in marginalized populations continue.
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