Adapting ethical guidelines for adolescent health research to street-connected children and youth in low- and middle-income countries: a case study from western Kenya

Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya

BACKGROUND

Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya.

METHODS

This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention.

RESULTS

Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant.

CONCLUSIONS

This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

Ethical Aspects of Involving Adolescents in HIV Research: A Systematic Review of the Empiric Literature

OBJECTIVE

To evaluate the ethics of involving adolescents in HIV research, we conducted a systematic review of the empiric literature.

METHODS

Electronic databases Ovid Medline, Embase, and CINAHL were systematically searched using controlled vocabulary terms related to ethics, HIV, specified age groups, and empiric research studies. We reviewed titles and abstracts, including studies that collected qualitative or quantitative data, evaluated ethical issues in HIV research, and included adolescents. Studies were appraised for quality, data were extracted, and studies were analyzed using narrative synthesis.

RESULTS

We included 41 studies: 24 qualitative, 11 quantitative, 6 mixed methods; 22 from high-income countries (HIC), 18 from low- or middle-income countries (LMIC), and 1 from both HIC and LMIC. Adolescent, parent, and community perspectives assert the benefits of involving minors in HIV research. Participants in LMIC expressed mixed views regarding parental consent requirements and confidentiality, given adolescents' both increasing autonomy and continued need for adult support. In studies in HIC, sexual or gender minority youth would not participate in research if parental consent were required or if there were confidentiality concerns. There was variation in the comprehension of research concepts, but adolescents generally demonstrated good comprehension of informed consent. Informed consent processes can be improved to increase comprehension and study accessibility. Vulnerable participants face complex social barriers that should be considered in study design.

CONCLUSIONS

Data support the inclusion of adolescents in HIV research. Empiric research can inform consent processes and procedural safeguards to ensure appropriate access.

Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda

OBJECTIVES

To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study.

STUDY DESIGN

Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests.

RESULTS

Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8).

CONCLUSIONS

The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.

Using a sociological conceptualization of stigma to explore the social processes of stigma and discrimination of children in street situations in western Kenya

BACKGROUND

The leading causes of street involvement worldwide are poverty, family conflict, and abuse. A common misconception is that street involvement is due to delinquency, a belief leading to social exclusion and social inequality for children in street situations (CSS). Exploring community perceptions of CSS and the reproduction of social difference and inequalities can help reduce stigma and discrimination.

OBJECTIVE

To explore how stigma and discrimination of CSS was produced and reproduced in specific contexts of culture and power.

PARTICIPANTS AND SETTING

Social actors including CSS, healthcare providers, children's officers, and police officers in western Kenya.

METHODS

Using a sociological conceptualization of stigma, this qualitative study explored the stigmatization processes that take shape in specific contexts of culture and power. We conducted 41 in-depth interviews and 7 focus group discussions with a total of 100 participants.

RESULTS

CSS were often labeled "chokoraa" or garbage picker, a label linked to undesirable characteristics constituting "evils" in society and stereotyped beliefs that they were "delinquents," reinforcing their "otherness" and devalued social status. CSS experienced individual and structural discrimination leading to exclusion from social and economic life.

CONCLUSION

CSS were stigmatized when labeled, set apart, and linked to negative characteristics leading to their experience of status loss and discrimination. CSS's differentness and devalued status served to limit their access to societal resources and deemed them unworthy of equal rights. Interventions involving various social actors are needed to challenge negative stereotypes, reduce stigma, and uphold CSS's human rights.

Parental waivers to enable adolescent participation in certain forms of health research: lessons from a South African case study

Background

The South African legal framework requires mandatory parental/legal guardian consent for all research with children. Ethics guidelines provide some reprieve by allowing RECs to grant waivers of parental or guardianship consent in certain defined circumstances. In the first instance, consent may be provided by a proxy when parents or guardians are unavailable, for example with orphaned children. In the second instance, guidelines permit adolescent self-consent when the nature of the study justifies this approach, for example, research on sensitive issues like sexual behaviour or substance use.

Discussion

South African guidelines set several conditions that must be met for waivers to be granted. These norms overlap with those in international guidelines. However, the ethical norms, especially related to self-consent are sometimes vague. This article critically evaluates the consent norms in the national ethics guidelines and makes recommendations for reform to ethics guidelines in a way that recognises the value of child participation in research, their evolving decision-making capacity and their best interests.

Conclusion

Recommendations are made to harmonise ethics guidelines and law in a way that promotes child participation in research, to ensure additional protections for adolescents when self-consent is allowed, and to withdraw procedural requirements for the community endorsement of self-consent strategies.

Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi

Introduction:

Adolescents living with HIV (ALHIV) experience social and health challenges that warrant the provision of services and relational support to build resilience. Little is known about how social, community and health services help. We examine formal and alternative service use by and resilience of ALHIV participating in an enhanced teen-club clinic (TCC) programme.

Description:

TCC is an adolescent-centred differentiated care model offering a ‘one-stop-shop’ for HIV/Sexual and Reproductive Health (SRH) services to ALHIV. A survey was conducted with 406 ALHIV to determine frequency of use and satisfaction with services. In addition, we conducted 26 in-depth interviews with ALHIV, 12 group discussions with 144 caregivers, and observations of workshops held for 35 health workers to capture multiple perspectives on service use and relational support systems for adolescent’s wellbeing.

Discussion:

About 70% of ALHIV were concurrently clients of three or more services. The multi-method analysis showed variations on risks, range of services, frequency of use and satisfaction. Interview data reflected complex factors influencing access to formal services, and caregivers and adolescents also sought alternative care from spiritual and traditional healers.

Conclusion:

Adolescent centred-approaches have the potential to enhance resilience promoting resources and outcomes. A multi-sectoral approach to service use and provision is critical to inform adolescent intervention programs and wellbeing.

What do we know about ancillary care practices in East and Southern Africa? A systematic review and meta-synthesis

Background: Despite growing calls for the provision of ancillary care to study participants during medical research, there remains a noticeable gap in ethical guidelines for medical researchers in resource-constrained settings (RCS). We reviewed recent studies to determine the extent to which ancillary care is provided in East and Southern Africa and to examine the ethical justifications researchers provide to support their views on ancillary care obligations. Methods: A systematic search for qualitative and mixed methods studies on ancillary care was conducted across MEDLINE, Embase, African Wide Information, PubMed, CINAHL Plus, and Scopus. The National Institutes of Health (NIH) Department of Bioethics and H3 Africa websites and Google Scholar were further searched. Studies conducted in East and Southern Africa between 2004 and 2020, as well as those that reported on ancillary care provided to study participants were included. All studies included in this review were evaluated for methodological quality as well as bias risk. NVivo version 12 was used for thematic analysis. Results: Overall, 4,710 articles were identified by the initial search. After the data extraction and quality assessment, 24 articles were included. Key areas presented include ancillary care approaches and the themes of researcher motivation for providing ancillary care and expectations of participants in medical research. The review shows that while some international researchers do provide ancillary care to their study participants, approaches are not standardised without consistent guidelines for ethical practice for ancillary care. We found limited empirical studies in RCS that report on ancillary care, hence findings in this review are based on single studies rather than a collection of multiple studies. Conclusions: This paper emphasizes the value of establishing ethics guidelines for medical researchers in RCS who consider provision of ancillary care to their participants, and the need to account for these ethical guidelines in medical research.

Ethical considerations for research involving pregnant women living with HIV and their young children: a systematic review of the empiric literature and discussion

BACKGROUND

The proper and ethical inclusion of PWLHIV and their young children in research is paramount to ensure valid evidence is generated to optimize treatment and care. Little empirical data exists to inform ethical considerations deemed most critical to these populations. Our study aimed to systematically review the empiric literature regarding ethical considerations for research participation of PWLHIV and their young children.

METHODS

We conducted this systematic review in partnership with a medical librarian. A search strategy was designed and performed within the following electronic databases: Ovid MEDLINE, Embase and CINAHL. We screened titles and abstracts using the following inclusion criteria: (1) a study population of PWLHIV or children under 5 years of age; and (2) collection of qualitative or quantitative data regarding ethics of research participation. Excluded were reviews, commentaries, policy statements, clinical care-related ethics concerns, abstracts, case studies, or studies unrelated to HIV research. Studies were appraised for quality, data were extracted, and studies were qualitatively analyzed using a principle-based ethical framework within the Belmont Report.

RESULTS

Of the 7470 titles identified, 538 full-text articles were reviewed for eligibility and only three articles met full criteria for inclusion within this review. While we allowed for inclusion of studies involving young children born to mothers with HIV, only articles focused on PWLHIV were identified. Within the results of these studies, four themes emerged: (1) adequacy of informed consent; (2) consideration of paternal involvement; (3) balancing risks; and (4) access to research and treatment. A strength of this review is that it included perspectives of international research investigators, community leaders, and male partners. However, only two studies collected empiric data from PWLHIV regarding their experiences participating in research CONCLUSION: Researchers and funding agencies should be aware of these considerations and appreciate the value of and critical need for formative research to ensure clinical trials involving PWLHIV promote ethical, well-informed research participation and, ultimately, improve care outcomes. More research is needed to create a comprehensive ethical framework for researchers when conducting studies with PWLHIV.

Improving livelihoods and gender equitable attitudes of street-connected young people in Eldoret, Kenya: Results from a pilot evidence-based intervention

Street-connected young people (SCY) in Eldoret, Kenya, experience substantial gender inequities, economic marginalization and are highly vulnerable to acquiring HIV. This study sought to explain and explore how participation in a pilot-adapted evidence-based intervention, Stepping Stones and Creating Futures, integrated with matched savings, changed SCY's economic resources, livelihoods and gender equitable attitudes. We piloted our adapted intervention using a convergent mixed-methods design measuring outcomes pre- and post-intervention with 80 SCY in four age- and gender-stratified groups of 20 participants per group (young women aged 16-19 years and 20-24 years, young men aged 16-19 years and 20-24 years). The pilot occurred at MTRH-Rafiki Centre for Excellence in Adolescent Health in Eldoret, Kenya, from September 2017 to January 2018. Through street outreach, Peer Facilitators created four age- and gender-stratified sampling lists of SCY whom met the eligibility criteria and whom indicated their interest in participating in the intervention during outreach sessions. Simple random sampling was used to select eligible participants who indicated their interest in participating in the intervention. The adapted intervention, Stepping Stones ya Mshefa na Kujijenga Kimaisha, included 24 sessions that occurred over 14 weeks, focused on sexual and reproductive health, gender norms in society, livelihoods and included a matched-savings programme conditional on attendance. The primary outcome of interest was gender equitable attitudes measured using the Gender Equitable Men scale and secondary outcomes included economic resources and livelihoods. Participants had a significant change in gender equitable attitudes from pre- to post-intervention from 43 (IQR 38-48) to 47 (IQR 42-51) (p < .001). Quantitatively and qualitatively participants reported increases in daily earnings, changes in street involvement, housing and livelihood activities. Overall, this study demonstrated that the adapted programme might be effective at changing gender equitable attitudes and improving livelihood circumstances for SCY in Kenya.

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.

Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study

BACKGROUND

Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17.

METHODS

This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC.

RESULTS

Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population.

CONCLUSIONS

SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed.

A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya

Research suggests a burden of HIV among street-connected youth (SCY) in Kenya. We piloted the use of peer navigators (PNs), individuals of mixed HIV serostatus and with direct experience of being street-connected, to link SCY to HIV testing and care. From January 2015 to October 2017, PNs engaged 781 SCY (585 male, 196 female), median age 16 (IQR 13-20). At initial encounter, 52 (6.6%) were known HIV-positive and 647 (88.8%) agreed to HIV testing. Overall, 63/781 (8.1%) SCY engaged in this program were HIV-positive; 4.6% males and 18.4% females (p < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.

Acceptability of a Pilot Intervention of Voluntary Medical Male Circumcision and HIV Education for Street-Connected Youth in Western Kenya

PURPOSE

Street-connected youth (SCY) in Kenya and elsewhere in sub-Saharan Africa are at high risk of HIV. Voluntary Male Medical Circumcision (VMMC) reduces the risk of female-to-male HIV transmission. Circumcision is also a traditional coming-of-age process in many Kenyan ethnic groups. This paper describes the acceptability of VMMC delivered as part of a ten-day healing, educational, and 'coming-of-age' retreat implemented as a pilot with SCY.

METHODS

Male SCY aged between 12 and 24 living on the street for more than 3 months were eligible to participate. The study took place over 10 days. After medical circumcision, youth participated in education modules. Data collected included qualitative semi-structured exit interviews featuring structured and open-ended questions about factors relevant to this intervention's acceptability.

RESULTS

There were 116 SCY (median age 14, IQR 13-15) who participated in the study. All were circumcised successfully, with no major complications. The majority of participants (81%) agreed that the circumcision procedure was uncomplicated, and 99% agreed the education was an important part of the initiation process. Thematic analysis of interview data highlighted four factors important to the program's acceptability: providing food, shelter, security; providing a safe place to heal; including traditional elements; and being with peers.

CONCLUSIONS

This novel implementation of VMMC was found to be acceptable to SCY participants and could likely be adapted and scaled for HIV prevention and education with SCY elsewhere in Kenya and sub-Saharan Africa where circumcision is part of traditional coming-of-age processes.

HIV prevalence in young people and children living on the streets, Kenya

OBJECTIVE

To obtain an estimate of the size of, and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya.

METHODS

We counted young people and children using a point-in-time approach, ensuring we reached our target population by engaging relevant community leaders during the planning of the study. We acquired point-in-time count data over a period of 1 week between the hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a fingerprint (to avoid double-counting) and were encouraged to speak with an HIV counsellor and undergo HIV testing. We used a logistic regression model to test for an association between age or sex and uptake of HIV testing and seropositivity.

FINDINGS

Of the 1419 eligible participants counted, 1049 (73.9%) were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during our study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% (19/698) for males and 8.9% (23/259) for females. We observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females.

CONCLUSION

By counting young people and children living on the streets and offering them HIV counselling and testing, we could obtain population-based estimates of HIV prevalence.

Cultural considerations for informed consent in paediatric research in low/middle-income countries: a scoping review

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.