Adolescent participation in HIV research: consortium experience in low and middle-income countries and scoping review

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.

Factors influencing mothers' decision to enroll their HIV-negative children in a hypothetical HIV vaccine trial

Despite advances in preventive treatments for HIV, children continue to become infected with HIV. Research has investigated adult and adolescents' willingness to participate in hypothetical HIV vaccine trials; however, maternal willingness to enroll their infants in such trials remains underexplored.

AIM

This study explored the factors influencing mothers' decision-making about enrolling their HIV negative infants in a hypothetical HIV vaccine trial. Methods: HIV infected and uninfected mothers (n = 22) were interviewed.

RESULTS

Several factors were identified as influencing the mothers' decisions, including perceptions and knowledge of HIV and vaccines.

CONCLUSION

Maternal concerns about protecting their infants from HIV were also identified and mothers indicated that they were eager to vaccinate their children. Insufficient information and reassurance regarding vaccine trial safety and efficacy influenced maternal reluctance to enroll their child.

Adolescent decision making about participation in a hypothetical HIV vaccine trial

PURPOSE

The purpose of this study was to examine the process of adolescent decision-making about participation in an HIV vaccine clinical trial, comparing it to adult models of informed consent with attention to developmental differences.

METHODS

As part of a larger study of preventive misconception in adolescent HIV vaccine trials, we interviewed 33 male and female 16-19-year-olds who have sex with men. Participants underwent a simulated HIV vaccine trial consent process, and then completed a semistructured interview about their decision making process when deciding whether or not to enroll in and HIV vaccine trial. An ethnographic content analysis approach was utilized.

RESULTS

Twelve concepts related to adolescents' decision-making about participation in an HIV vaccine trial were identified and mapped onto Appelbaum and Grisso's four components of decision making capacity including understanding of vaccines and how they work, the purpose of the study, trial procedures, and perceived trial risks and benefits, an appreciation of their own situation, the discussion and weighing of risks and benefits, discussing the need to consult with others about participation, motivations for participation, and their choice to participate.

CONCLUSION

The results of this study suggest that most adolescents at high risk for HIV demonstrate the key abilities needed to make meaningful decisions about HIV vaccine clinical trial participation.

Why is it hard to make progress in assessing children's decision-making competence?

Background

For decades, the discussion on children’s competence to consent to medical issues has concentrated around normative concerns, with little progress in clinical practices. Decision-making competence is an important condition in the informed consent model. In pediatrics, clinicians need to strike a proper balance in order to both protect children’s interests when they are not fully able to do so themselves and to respect their autonomy when they are. Children’s competence to consent, however, is currently not assessed in a standardized way. Moreover, the correlation between competence to give informed consent and age in children has never been systematically investigated, nor do we know which factors exactly contribute to children’s competence.

This article aims at identifying these gaps in knowledge and suggests options for dealing with the obstacles in empirical research in order to advance policies and practices regarding children’s medical decision-making competence.

Discussion

Understanding children’s competency is hampered by the law. Legislative regulations concerning competency are established on a strong presumption that persons older than a certain age are competent, whereas younger persons are not. Furthermore, a number of contextual factors are believed to be of influence on a child’s decision-making competence: the developmental stage of children, the influence of parents and peers, the quality of information provision, life experience, the type of medical decision, and so on. Ostensibly, these diverse and extensive barriers hinder any form of advancement in this conflicted area. Addressing these obstacles encourages the discussion on children’s competency, in which the most prominent question concerns the lack of a clear operationalization of children’s competence to consent. Empirical data are needed to substantiate the discussion.

Summary

The empirical approach offers an opportunity to give direction to the debate. Recommendations for future research include: studying a standardized assessment instrument covering all four relevant dimensions of competence (understanding, reasoning, appreciation, expressing a choice), including a study population of children covering the full age range of 7 to 18 years, improving information provision, and assessing relevant contextual data.

Behavioral considerations for engaging youth in HIV clinical research

From both scientific and ethical perspectives, it is important that youth be enrolled in biomedical HIV prevention clinical trials. At the same time, adolescents, as minors, are considered a vulnerable population requiring particular attention to the reduction of potential harm associated with participation in such trials. In this article, we review the evidence supporting enrollment of youth in HIV clinical trials, including data on HIV infection rates, sexual behavior, and cognitive, psychosocial, and neurophysiological development. Next, we address the potential risks associated with clinical trial participation, with a focus on the concept of preventive misconception, the tendencies to (1) overestimate the probability of assignment to the experimental condition, as opposed to the placebo, and (2) assume that the experimental intervention is efficacious. Finally, we discuss targeted interventions to reduce preventive misconception and the importance of developing and testing adolescent-friendly risk-reduction interventions that are tailored to the structure and time frame of a biomedical HIV prevention clinical trial. The very issues that make inclusion of youth in HIV prevention clinical trials necessary also demand that particularly intensive efforts be made to protect participating minors from the harm that could accrue from a clinical trial.

Social and behavioral science in HIV vaccine trials: a gap assessment of the literature

Social and behavioral science research is integral to the conduct of HIV vaccine trials, especially because the vaccine targets an infection laden with sensitive human issues. Although social and behavioral sciences have played a larger role in HIV vaccine clinical trials than other vaccine clinical trials to date, this role should be expanded. Fortunately, related publications, conference coverage and research proposals are on the rise; community engagement is receiving more attention during the earlier stages of product development; and collaboration between HIV vaccine scientists and social and behavioral scientists is being fostered. Greater attention to social and behavioral science issues could not only facilitate accrual, but also improve research efficiency and relevance. In this review, gaps in the literature on social and behavioral science issues in HIV vaccine clinical research, including barriers and facilitators to trial participation, enhancing feasibility of trial success, health systems, policy and monitoring social and behavioral issues, are identified and directions are suggested for filling those gaps. Development of a safe, efficacious and acceptable HIV vaccine will be nurtured by addressing the gaps through interdisciplinary collaborations.