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Waltz M, Lyerly AD, Fisher JA. Exclusion of Women from Phase I Trials: Perspectives from Investigators and Research Oversight Officials. Ethics Hum Res 2023; 45:19-30. [PMID: 37988277 PMCID: PMC10759148 DOI: 10.1002/eahr.500170] [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: 11/23/2023]
Abstract
Over the past 30 years, progress has been made in increasing women's representation in clinical research. However, women continue to be underrepresented in phase I clinical trials-those trials that test the safety and tolerability of investigational drugs, often on healthy individuals. As sex-based differences in adverse drug reactions are often linked to drug dose, pivotal safety information in phase I trials is often insufficiently-and inequitably-captured for females. Yet there has been little attention to how clinical investigators and those charged with overseeing the ethical conduct of these trials perceive the barriers to women's inclusion in phase I trials. To address this gap, we report on 22 interviews with U.S. phase I investigators and institutional review board (IRB) members. Our findings indicate that although these investigators and IRB members acknowledged the importance of including women in clinical trials, they justified women's exclusion from phase I trials by citing the need to manage their reproductive potential. In particular, we identified four key themes that informants used to warrant women's exclusion from phase I trials: the structure of the drug-development system itself, fears about risks to potential fetuses, distrust of women to prevent pregnancy, and concerns about risks and burdens to institutions from resulting pregnancies. We argue that these rationales reflect structural and cultural barriers to women's inclusion in clinical research that ultimately fail to respect female research participants as persons, highlighting the need for broad-based solutions.
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Affiliation(s)
- Margaret Waltz
- Research scientist at the Center for Bioethics and in the Department of Social Medicine at the University of North Carolina at Chapel Hill
| | - Anne Drapkin Lyerly
- Professor of social medicine at the Center for Bioethics and in the Department of Social Medicine at the University of North Carolina at Chapel Hill
| | - Jill A Fisher
- Professor of social medicine at the Center for Bioethics and in the Department of Social Medicine at the University of North Carolina at Chapel Hill
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Sex-based differences in nuclear medicine imaging and therapy. Eur J Nucl Med Mol Imaging 2023; 50:971-974. [PMID: 36633615 DOI: 10.1007/s00259-023-06113-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
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Lyerly AD. 'Experimental pregnancy' revisited. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:253-266. [PMID: 35859087 PMCID: PMC9299403 DOI: 10.1007/s11017-022-09578-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
In this paper, I reflect on an important article by Bob Veatch in the inaugural issue of the Hastings Center Report, entitled "Experimental Pregnancy." It is a report and elegant analysis of the Goldzieher Study, in which nearly 400 women were randomized to receive hormonal contraception or placebo absent consent or disclosure about placebo use, resulting in several pregnancies. Noting the study's limited notoriety, I first consider the narratives that have instead dominated bioethics' approach to pregnancy and research: thalidomide and diethylstibesterol (DES). These narratives have facilitated a narrow focus on avoiding fetal risk, to the exclusion of other ethically relevant considerations. I then revisit "Experimental Pregnancy" and offer two ways in which Bob's analysis serves as an important corrective, first, by foregrounding research subjects (persons who are or may become pregnant), and second, by normalizing pregnancy and thus foregrounding foundational ethical considerations that are sometimes lost amidst pregnancy's presumed exceptionalism.
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Marzo-Ortega H, Navarro-Compán V, Akar S, Kiltz U, Clark Z, Nikiphorou E. The impact of gender and sex on diagnosis, treatment outcomes and health-related quality of life in patients with axial spondyloarthritis. Clin Rheumatol 2022; 41:3573-3581. [PMID: 35763155 PMCID: PMC9568456 DOI: 10.1007/s10067-022-06228-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 12/16/2022]
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic condition, historically considered a predominantly male disease. However, increasing evidence suggests a more equal prevalence between men and women. Of the limited research conducted to date, it is apparent that gender differences exist in terms of time to diagnosis, treatment outcomes and health-related quality of life (HRQoL). Despite this, women are underrepresented in clinical trials and most studies do not stratify by gender to identify potential differences in terms of disease manifestations and treatment response. In this perspectives article, we reflect on the potential biological and social factors contributing to these differences and propose three key areas of education and research that should be prioritised in order to address the unmet needs of female patients with axSpA, namely: (1) to identify ways to increase awareness of disease occurrence in female patients among healthcare professionals (HCPs), (2) to improve understanding of gender differences in disease manifestation and outcomes, and (3) to conduct gender-stratified clinical trials with a representative sample of female patients.
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Chi PC, Owino EA, Jao I, Bejon P, Kapulu M, Marsh V, Kamuya D. Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study. BMC Med Ethics 2022; 23:46. [PMID: 35443642 PMCID: PMC9019790 DOI: 10.1186/s12910-022-00783-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid 'undue' levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers' attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.
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Affiliation(s)
- Primus Che Chi
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Esther Awuor Owino
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Irene Jao
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Melissa Kapulu
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Vicki Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
| | - Dorcas Kamuya
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University Oxford, Oxford, UK
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Courvoisier N, Storari C, Lesage S, Vittoz L, Barbieux C, Peytremann-Bridevaux I, Gilles I, Calmy A. Facilitators and barriers of women's participation in HIV clinical research in Switzerland: A qualitative study. HIV Med 2022; 23:441-447. [PMID: 35178844 PMCID: PMC9305145 DOI: 10.1111/hiv.13259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Women are underrepresented in most HIV clinical trials in Western countries, but their participation remains crucial as the lack of information on sex- and gender-specific effects may hinder the safety and efficacy of antiretroviral treatments. The aim of this study was to identify barriers to and facilitators of women's participation in HIV clinical trials in Switzerland. METHODS We conducted semi-structured interviews among 20 women with HIV to explore factors associated with non-participation in clinical trials. The interviewer presented to participants a clinical trial's description and discussed it with them. Lexicometric analysis on transcribed interviews identified three themes and eight sub-themes related to the pros and cons of participation in HIV clinical trials. RESULTS Participants evoked mainly decision-making drivers, concerns for women living with HIV and treatment side-effects. They highlighted the need for extensive information provided by trusted healthcare professionals on the research process as central to the decision to enrol in HIV clinical trials. Familial responsibilities were clearly identified as barriers to their participation, but not pregnancy. Additional preoccupations were other health concerns and comorbidities and the consequences of stopping ongoing antiretroviral treatments. CONCLUSIONS To overcome the barriers to the participation of women living with HIV in clinical research in Western countries, healthcare professionals and researchers should increase women's research literacy by involving them in the study design and by tailoring clinical trials to their social roles and health concerns. Trust in professionals is a facilitator of enrolment of women living with HIV that should be maintained.
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Affiliation(s)
- Nelly Courvoisier
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Chiara Storari
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Saphir Lesage
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Lucie Vittoz
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Charlotte Barbieux
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Isabelle Peytremann-Bridevaux
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Ingrid Gilles
- Center for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, Lausanne, Switzerland
| | - Alexandra Calmy
- HIV/AIDS Unit, Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
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Namiba A, Kwardem L, Dhairyawan R, Hale F, McGregor Read J, Anderson J, Welbourn A. From presumptive exclusion towards fair inclusion: perspectives on the involvement of women living with HIV in clinical trials, including stakeholders’ views. Ther Adv Infect Dis 2022; 9:20499361221075454. [PMID: 35127083 PMCID: PMC8811419 DOI: 10.1177/20499361221075454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Angelina Namiba
- 15 Chow Square, London E8 2DD, UK4M Network of Mentor Mothers, London, UK
| | | | | | | | - Janine McGregor Read
- Positively UK, London, UKHomerton University Hospital NHS Foundation Trust, London, UK
| | - Jane Anderson
- Homerton University Hospital NHS Foundation Trust, London, UK
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Joseph Davey DL, Bekker LG, Bukusi EA, Chi BH, Delany-Moretlwe S, Goga A, Lyerly AD, Mgodi NM, Mugo N, Myer L, Noguchi LM, Stranix-Chibanda L, Slack C, Pintye J. Where are the pregnant and breastfeeding women in new pre-exposure prophylaxis trials? The imperative to overcome the evidence gap. THE LANCET HIV 2022; 9:e214-e222. [DOI: 10.1016/s2352-3018(21)00280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/11/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
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Kons KM, Wood ML, Peck LC, Hershberger SM, Kunselman AR, Stetter C, Legro RS, Deimling TA. Exclusion of Reproductive-aged Women in COVID-19 Vaccination and Clinical Trials. Womens Health Issues 2022; 32:557-563. [PMID: 36075817 PMCID: PMC9197956 DOI: 10.1016/j.whi.2022.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION We analyzed the exclusion of pregnant and breastfeeding individuals and those capable of pregnancy in COVID-19 vaccine and clinical treatment trials. METHODS Inclusion and exclusion criteria were extracted from all listed COVID-19 vaccine and treatment clinical trials from May 1, 2020, to October 31, 2020, using the U.S. National Library of Medicine database. We report rates of rates of exclusion for pregnant and lactating individuals and requirements for contraception for pregnancy-capable participants in COVID-19 vaccine and treatment clinical trials. The analysis included the association between clinical trial exclusion and vaccine and treatment type, study location, sponsor, and phase. RESULTS Pregnant and lactating individuals were explicitly excluded from most COVID-19 vaccine and treatment clinical trials. Of the 90 vaccine trials, 88 (97.8%) excluded pregnant individuals, 73 (81.1%) excluded lactating individuals, and 56 (62.2%) required contraception use. Of the 495 treatment trials, 350 (70.7%) excluded pregnant individuals, 269 (54.3%) excluded lactating individuals, and 91 (18.4%) required contraception use. Although vaccine type was not associated with pregnancy exclusion, it was associated with lactation exclusion (p = .01) and contraception requirement (p < .001). Treatment type was associated with pregnancy exclusion, lactation exclusion, and contraception requirement (all p < .001). CONCLUSIONS COVID-19 vaccination and treatment clinical trials mirrored historical trends restricting participation owing to pregnancy, lactation, and contraception nonuse, despite known safety profiles. People of childbearing potential should be considered for and afforded the same opportunity as males to make informed decisions on study participation, particularly in the setting of a global pandemic.
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Affiliation(s)
- Kelly M. Kons
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania
| | - Megan L. Wood
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania
| | - Lindsey C. Peck
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania
| | - Sarah M. Hershberger
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania
| | - Allen R. Kunselman
- Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Christina Stetter
- Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Richard S. Legro
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania,Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Timothy A. Deimling
- Penn State Milton S. Hershey Medical Center, Department of Obstetrics and Gynecology, Hershey, Pennsylvania,Correspondence to: Timothy A. Deimling, MD, University of Pittsburgh Physicians, Division of Gynecologic Specialties, UPMC West Shore Medical Building 1, 2025 Technology Parkway, Mechanicsburg, PA 17050. Phone: (717) 926-8563
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Lyerly AD, Beigi R, Bekker L, Chi BH, Cohn SE, Diallo DD, Eron J, Faden R, Jaffe E, Kashuba A, Kasule M, Krubiner C, Little M, Mfustso‐Bengo J, Mofenson L, Mwapasa V, Mworeko L, Myer L, Penazzato M, Rid A, Shapiro R, Singh JA, Sullivan K, Vicari M, Wambui J, White A, Wickremsinhe M, Wolf L. Ending the evidence gap for pregnancy, HIV and co-infections: ethics guidance from the PHASES project. J Int AIDS Soc 2021; 24:e25846. [PMID: 34910846 PMCID: PMC8673925 DOI: 10.1002/jia2.25846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION While pregnant people have been an important focus for HIV research, critical evidence gaps remain regarding prevention, co-infection, and safety and efficacy of new antiretroviral therapies in pregnancy. Such gaps can result in harm: without safety data, drugs used may carry unacceptable risks to the foetus or pregnant person; without pregnancy-specific dosing data, pregnant people face risks of both toxicity and undertreatment; and delays in gathering evidence can limit access to beneficial next-generation drugs. Despite recognition of the need, numerous barriers and ethical complexities have limited progress. We describe the process, ethical foundations, recommendations and applications of guidance for advancing responsible inclusion of pregnant people in HIV/co-infections research. DISCUSSION The 26-member international and interdisciplinary Pregnancy and HIV/AIDS: Seeking Equitable Study (PHASES) Working Group was convened to develop ethics-centred guidance for advancing timely, responsible HIV/co-infections research with pregnant people. Deliberations over 3 years drew on extensive qualitative research, stakeholder engagement, expert consultation and a series of workshops. The guidance, initially issued in July 2020, highlights conceptual shifts needed in framing research with pregnant people, and articulates three ethical foundations to ground recommendations: equitable protection from drug-related risks, timely access to biomedical advances and equitable respect for pregnant people's health interests. The guidance advances 12 specific recommendations, actionable within the current regulatory environment, addressing multiple stakeholders across drug development and post-approval research, and organized around four themes: building capacity, supporting inclusion, achieving priority research and ensuring respect. The recommendations describe strategies towards ethically redressing the evidence gap for pregnant people around HIV and co-infections. The guidance has informed key efforts of leading organizations working to advance needed research, and identifies further opportunities for impact by a range of stakeholder groups. CONCLUSIONS There are clear pathways towards ethical inclusion of pregnant people in the biomedical research agenda, and strong agreement across the HIV research community about the need for - and the promise of - advancing them. Those who fund, conduct, oversee and advocate for research can use the PHASES guidance to facilitate more, better and earlier evidence to optimize the health and wellbeing of pregnant people and their children.
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Affiliation(s)
- Anne Drapkin Lyerly
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Richard Beigi
- Department of ObstetricsGynecology & Reproductive SciencesUPMC Magee‐Women's HospitalPittsburghPennsylvaniaUSA
| | - Linda‐Gail Bekker
- Desmond Tutu HIV Centre and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Susan E. Cohn
- Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | | | - Joseph Eron
- Department of Medicine and Center for AIDS ResearchUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Ruth Faden
- Johns Hopkins Berman Institute of BioethicsBaltimoreMarylandUSA
| | - Elana Jaffe
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Angela Kashuba
- Eshelman School of Pharmacy and Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary Kasule
- Botswana‐Baylor Centre for Clinical ExcellenceGabaroneBotswana
| | | | - Maggie Little
- Kennedy Institute for Ethics and Department of PhilosophyGeorgetown UniversityWashingtonDCUSA
| | - Joseph Mfustso‐Bengo
- Center of Bioethics for Eastern & Southern Africa and Department of Health Systems and PolicyCollege of MedicineUniversity of MalawiZombaMalawi
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS FoundationWashingtonDCUSA
| | | | - Lillian Mworeko
- International Community of Women Living with HIV Eastern AfricaKampalaUganda
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Annette Rid
- Department of BioethicsThe Clinical CenterNational Institutes of HealthBethesdaMarylandUSA
| | - Roger Shapiro
- Department of Immunology and Infectious DiseasesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Jerome Amir Singh
- Howard College School of LawUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Dalla Lana School of Public Health Sciences, University of TorontoTorontoOntarioCanada
| | - Kristen Sullivan
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | | | - Jacque Wambui
- National Empowerment Network of People Living with HIV and AIDS in Kenya (NEPHAK)African Communities Advisory Board (AfroCAB)LusakaZambia
| | - Amina White
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Marisha Wickremsinhe
- Ethox Centre and Wellcome Centre for Ethics and HumanitiesUniversity of OxfordOxfordUK
| | - Leslie Wolf
- Center for LawHealth & Society and College of Law and School of Public HealthGeorgia State UniversityAtlantaGeorgiaUSA
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Balkus JE, Dionne-Odom J, Wiesenfeld HC. Contraception Requirements in Clinical Trials: Considerations From Studies on Sexually Transmitted Infections. JAMA 2021; 326:2007-2008. [PMID: 34730777 DOI: 10.1001/jama.2021.19473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle
| | - Jodie Dionne-Odom
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham
| | - Harold C Wiesenfeld
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
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Spach NC, Jaffe EF, Sullivan KA, Goldfarb IT, Anderson JR, Coleman J, Gilbert SZ, Gross MS, Rahangdale L, Faden RR, Lyerly AD. Pregnant Individuals' Views on Fetal Tissue Research in the United States. Obstet Gynecol 2021; 138:755-761. [PMID: 34619743 PMCID: PMC8542627 DOI: 10.1097/aog.0000000000004576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fetal tissue research has driven significant medical advances but remains publicly contentious in the United States. The views of pregnant individuals in the United States regarding the donation of fetal tissue offer an important and previously unexplored perspective on this issue. METHODS We conducted a secondary analysis of data from two separate, broader qualitative studies. Pregnant and recently pregnant individuals (N=79) from clinical sites at the University of North Carolina at Chapel Hill, Johns Hopkins University, and Massachusetts General Hospital were interviewed individually using a semi-structured guide addressing a range of issues related to infectious disease research and pregnancy, including the acceptability of fetal tissue research. Interviews were transcribed, coded, and analyzed for emergent themes. RESULTS Among this sample of predominantly Black (61%), reproductive-aged pregnant and recently pregnant participants, the majority (72%) generally supported fetal tissue research. The following three themes were identified: choice, respect, and meaning. Respondents discussed the deeply personal nature of decisions surrounding fetal tissue research, emphasizing the importance of informed consent and respect for the person's emotional state when approaching for consent. The ways in which participants regarded how to respectfully handle fetal tissue also shaped views about the acceptability of donation, both for and against. For many participants, fetal tissue donation to research represented one way of ascribing meaning to pregnancy termination or loss. CONCLUSION Among this diverse sample of pregnant and recently pregnant individuals, most were supportive of fetal tissue donation for research. A better understanding of pregnant individuals' views on this topic may lead to policies and practices that are congruent with the needs and values of people facing decisions regarding the disposition of fetal remains.
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Affiliation(s)
- Natalie C Spach
- Center for Bioethics, the Department of Social Medicine, and the Department of Obstetrics and Gynecology, UNC School of Medicine, and the UNC Gillings School of Global Public Health, Chapel Hill, North Carolina; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, and Harvard Medical School, Cambridge, Massachusetts; the Berman Institute of Bioethics and the Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburg, Pennsylvania
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Stranix-Chibanda L, Yu C, Isaacs MB, Allen M, Andriesen J, Walsh SR. A retrospective analysis of incident pregnancy in phase 1 and 2a HIV-1 vaccine study participants does not support concern for adverse pregnancy or birth outcomes. BMC Infect Dis 2021; 21:802. [PMID: 34380464 PMCID: PMC8356543 DOI: 10.1186/s12879-021-06431-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pregnancies occur during HIV-1 vaccine clinical trials, despite requirements for women of reproductive potential to use effective contraception. Deployment of an effective HIV-1 vaccine regimen will likely target adolescents and young adults and therefore safety for pregnant and breastfeeding women will need to be addressed. Methods We performed a retrospective, cross-protocol analysis to identify and compare pregnancy outcomes reported in 53 Phase 1 and Phase 2a HIV-1 vaccine clinical trials conducted by the HIV Vaccine Trials Network (HVTN). Results Two thousand six hundred seventy-three women of reproductive potential were identified and 193 pregnancies were reported. 39 of 53 (74%) studies had at least one pregnancy reported with an overall pregnancy rate of 3.15 per 100 woman-years (w-yr). While active contraception use was required during study participation, 13 of the 53 studies also contained a long-term follow up period during which pregnancy was no longer discouraged. The pregnancy rate during main study participation was 3.09 per 100 w-yr, while pregnancies occurred at a slightly greater rate in the long-term follow up period (3.22 per 100 w-yr). Adverse pregnancy outcomes were reported at similar rates between vaccinees and placebo recipients when vaccine vectors, adjuvant used, or geographic region were examined. Conclusion Although there is considerable heterogeneity amongst the different vaccine trials, there appears to be no obvious indication of increased risk of adverse pregnancy or birth outcomes in these early phase HIV-1 vaccine studies. More complete data on pregnancy outcomes should be collected in early phase HIV-1 vaccine clinical trials to better inform subsequent efficacy trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06431-x.
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Affiliation(s)
| | - Chenchen Yu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Mary Allen
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jessica Andriesen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stephen R Walsh
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Barr E, Dubé K, Swaminathan S, Del Rio C, Campbell DM, Paez-Quinde M, Cohn SE. Impact of dedicated women's outreach workers (WOWs) on recruitment of women in ACTG clinical studies. HIV Res Clin Pract 2021; 22:37-45. [PMID: 34143949 DOI: 10.1080/25787489.2021.1938825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite efforts by the AIDS Clinical Trials Group (ACTG) to enroll representative numbers of diverse women, participation in ACTG studies in the United States remains largely white and male. To address this gap in women's participation in ACTG research, a one-year pilot study of dedicated women's outreach workers (WOWs) was proposed. OBJECTIVES included demonstrating that targeted recruitment efforts can expand community awareness of ACTG research and ensuring successful enrollment of women at the respective clinical research sites. METHODS The pilot study was conducted at two U.S. sites (Rutgers New Jersey Medical School and Emory Ponce de Leon Center in Atlanta, Georgia). The WOWs worked with site personnel to identify and reach out to women living with HIV and/or Hepatitis B or C at their respective sites and encourage them to join a clinical trial registry for those interested in participating in future clinical trials. RESULTS The Rutgers WOW approached 127 potential participants (of whom 100 joined the WOW registry) and screened 35 participants for open ACTG studies. The Emory WOW approached 120 participants, enrolling 86 into the WOW registry, and screened 51 potential participants for open ACTG studies during the WOW's tenure. The majority of women screened at both sites were women of color. CONCLUSIONS The WOW study team identified several lessons learned that can inform future efforts to engage women living with HIV in clinical research. First, success in engaging women is proportional to level of funding and institutional support. Second, there is a need for a more gender-inclusive scientific agenda as women are more likely to participate if studies address topics of interest to them. Third, meaningful engagement is a two-way street.
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Affiliation(s)
- Elizabeth Barr
- AIDS Clinical Trials Group (ACTG) Community Scientific Subcommittee (CSS), Baltimore, MD, USA.,Department of Gender, Women's, & Sexuality Studies, UMBC, Baltimore, MD, USA
| | - Karine Dubé
- UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Shobha Swaminathan
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Carlos Del Rio
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle M Campbell
- College of Medicine, Department of Preventive and Social Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.,David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Marta Paez-Quinde
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Susan E Cohn
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Raciti CG, Enane LA, MacDonald KR, Whipple EC, Ott MA, McHenry MS. Ethical considerations for research involving pregnant women living with HIV and their young children: a systematic review of the empiric literature and discussion. BMC Med Ethics 2021; 22:38. [PMID: 33794891 PMCID: PMC8017748 DOI: 10.1186/s12910-021-00601-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Catherine G Raciti
- Indiana University-Purdue University - Indianapolis, Indianapolis, IN, USA
| | - Leslie A Enane
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA
| | - Katherine R MacDonald
- Department of Adolescent and Young Adult Medicine, Children's National Hospital, Washington, DC, USA
| | - Elizabeth C Whipple
- Indiana University School of Medicine, Ruth Lilly Medical Library, Indianapolis, IN, USA
| | - Mary A Ott
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Megan S McHenry
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA.
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Erb-Zohar K, Sourgens H, Breithaupt-Groegler K, Klipping C. Unintended drug exposure during pregnancy in clinical trials - a survey in early drug development. Int J Clin Pharmacol Ther 2021; 59:26-30. [PMID: 33141016 PMCID: PMC7737523 DOI: 10.5414/cp203788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 12/16/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To collect information on unintended drug exposure during pregnancy in early clinical drug development. MATERIALS AND METHODS Questionnaire mailed in autumn 2015 to members of human pharmacology societies in Europe for anonymous responses via the online tool SurveyMonkey. RESULTS 53 of the ~ 700 addressees participated in the survey. 23 female trial participants and 11 female partners of male trial participants were exposed to investigational medicinal products during unintended pregnancies in a clinical trial. Most survey respondents confirmed adequate contraceptive methods by in/exclusion criteria and the use of pregnancy tests in female trial participants at screening and before the first dose. The last menstrual period was documented less frequently (at screening: 28 of 44, before first dose: 5 of 44 respondents). A considerable proportion of respondents denied the routine use of compliance checks about the appropriate use of contraceptive methods, had no procedures in place if contraceptive methods failed, and did not train physicians in instructing trial participants about the appropriate use of contraceptive methods. CONCLUSION The methods to avoid unintended pregnancies during participation in a clinical trial need improvement and should include (i) pregnancy tests, (ii) documentation of last menstrual period before the first dose, (iii) compliance checks of the appropriate use of contraceptive methods, and (iv) training of trial physicians. Procedures should be in place for what to do if contraceptive methods fail.
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Contraception methods used among women with HIV starting antiretroviral therapy in a large United States clinical trial, 2009-2011. Contraception 2020; 103:225-231. [PMID: 33189709 DOI: 10.1016/j.contraception.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE(S) We describe contraception and dual method use among women with HIV initiating antiretroviral therapy (ART) in a U.S. clinical trial and examine associated factors. STUDY DESIGN We analyzed data from ART-naïve women aged 45 years and under initiating one of 3 regimens as part of A5257 (May 2009-June 2011) which required that women at risk for pregnancy use contraception. We classified self-reported methods as more effective (Tier 1 [intrauterine device, hysterectomy, permanent contraception] and Tier 2 [hormonal rings, patches, injections, pills]) versus less effective (Tier 3 [condoms alone] and Tier 4 [withdrawal, none]). We used logistic regression models to assess associations with use of (a) more effective, and (b) dual methods (condoms with a more effective method). RESULTS Of 285 women, majority were Black (59%), had annual income <$20,000 (54%), and had government insurance (68%). The most common contraceptive methods reported at baseline were permanent contraception (37%), male condoms alone (31%), and injectable progestin (8%); 41% and 16% reported Tier 1 and 2 use, respectively; 36% reported dual method use. Use of more effective and dual methods did not change 48 and 96 weeks after ART initiation (p > 0.05). In multivariable analyses, baseline use of more effective and dual methods was associated with age at least 40 years versus 18 to 29 years (odds ratio [OR] 4.46, 95% confidence interval [CI] 2.12, 9.35) and having at least one child (OR 2.31, 95%CI 1.27, 4.20). CONCLUSIONS In women initiating modern ART in a clinical trial, permanent contraception was common, while use of other more effective contraceptive methods was low and did not change after ART initiation. Efforts are needed to improve integration of family planning services for women within the context of HIV clinical trials. IMPLICATIONS The findings highlight the importance of improving integration of HIV and family planning services, including in the context of clinical trials.
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Rojo P, Carpenter D, Venter F, Turkova A, Penazzato M. The HIV drug optimization agenda: promoting standards for earlier investigation and approvals of antiretroviral drugs for use in adolescents living with HIV. J Int AIDS Soc 2020; 23 Suppl 5:e25576. [PMID: 32869500 PMCID: PMC7459170 DOI: 10.1002/jia2.25576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Most clinical trials for new antiretroviral (ARV) agents are conducted among narrowly defined adult populations. Only after safety and efficacy have been clearly demonstrated among adults living with HIV are trials including adolescents, children and infants conducted. This approach contributes to significant delays in the availability of optimal new ARV regimens for infants, children and adolescents. This commentary discusses issues related to the inclusion of adolescents aged 12 to 18 years in initial HIV clinical phase 3 trials of novel antiretrovirals (ARVs) or conducting parallel phase 3 clinical trials among adolescents. DISCUSSION The absorption, metabolic and excretion or elimination pathways for drugs do not significantly differ between adolescents and adults. In fact, dosing recommendations for ARVs are the same for adults and adolescents who meet the age and weight criteria. Although conducting clinical trials among adolescents present special challenges (e.g. consenting minors and concerns about trial completion and contraception), these challenges can be addressed to obtain high-quality trial results. Importantly, new agents and optimized combinations have more favourable dosing schedules and side-effect profiles and are more effective ARV agents with higher HIV drug resistance thresholds, which would be extremely beneficial to improve outcomes among HIV-positive adolescents. CONCLUSIONS Adolescents may not present with significantly different pharmacokinetic characteristics from those in adults. Including HIV-positive adolescents in phase 3 ARV clinical trials, either with adults or in specific adolescent studies conducted in parallel, would allow adolescents to access promising, more effective treatment for HIV years earlier than with the current stepwise approach.
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Affiliation(s)
- Pablo Rojo
- Pediatric Infectious Diseases UnitDepartment of PediatricsHospital 12 de OctubreUniversidad ComplutenseMadridSpain
| | - Deborah Carpenter
- Maternal and Child Health BranchDivision of Global HIV and TuberculosisCenter for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - François Venter
- Wits Reproductive Health and HIV InstituteUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Anna Turkova
- MRC Clinical Trials Unit at UCLInstitute of Clinical Trials & MethodologyLondonUnited Kingdom
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Correction: Women's views about contraception requirements for biomedical research participation. PLoS One 2019; 14:e0218424. [PMID: 31188882 PMCID: PMC6561573 DOI: 10.1371/journal.pone.0218424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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