Rumours about blood and reimbursements in a microbicide gel trial

Understanding reticence to occupy free, novel-design homes: A qualitative study in Mtwara, Southeast Tanzania

INTRODUCTION

The population of Africa set to reach 2 billion by 2050. There is therefore great demand for housing across the continent. Research on modified novel designs for housing is a priority to ensure that these homes are not sites of infection for diseases transmission such as malaria. One trial to assess the protection afforded by novel design houses is underway in Mtwara Region, southeastern Tanzania. After constructing 110 of such homes across 60 villages, project staff encountered a certain reticence of the target population to occupy the homes and were faced with accusations of having nefarious intentions. This article explores these accusations, their impacts on home occupancy and lessons for future housing studies.

METHODS

This qualitative study drew on in-depth interviews and focus group discussions with ten occupants of the intervention homes, six community leaders and a further 24 community members. Interviews were recorded, transcribed verbatim and translated to English for qualitative content analysis.

RESULTS

In communities around the Star Homes, during construction and handover, project staff were widely associated with 'Freemasons', a term used to practices, secrecy, and other conspiracy theories in rural Tanzania. These connections were attributed to other community members and explained in terms of knowledge deficit or envy, with others hoping to be allocated the home. The stories were embedded in assumptions of reciprocity and suspicions about study motives, linked to limited experience of research. The relationship between the accusations of freemasonry and reticence to occupy the houses was not straightforward, with project staff or relatives playing a role in decisions. The stakes were high, because the recipients of Star Homes were the poorest families in targeted communities.

CONCLUSION

The results indicate the need for long-term and proactive community engagement, which focuses on building relationships and providing information through recognizable voices and formats. Given the stakes at play in housing interventions, research teams should be prepared for the social upheaval the provision of free new housing can cause.

Preferences, beliefs, and attitudes about oral fluid and blood-based HIV self-testing among truck drivers in Kenya choosing not to test for HIV

Introduction

Clinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.

Methods

Participants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.

Results

The final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.

Conclusion

We found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Confluence of crises: COVID-19, "gassings", blood draws and the continued importance of community engagement in Zambia

Background: Nationally representative, household-based, health-related surveys are an invaluable source of health information, but face implementation challenges. In sub-Saharan Africa, these challenges are exacerbated when surveys include the collection of biological specimens. In this study, we describe the potential implementation challenges identified during field practice leading up to the 2020 Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, and explore the role of two crises on community mistrust of, and apprehension to, participate in the survey. Methods: Using focus group methodology to better understand the influence of crises on ZAMPHIA participation, we conducted 12 focus group discussions (FGDs) in five districts across two provinces. FGDs were conducted with three purposively sampled study groups: recognized household heads, community leaders, and young adults aged 18-24 years. We used reflexive thematic analysis to develop themes from across the FGDs. Results: We identified two key themes: the ever-present threat a stranger posed to the community is enhanced by crises, and endorsement of community awareness through sensitization can mitigate outsider challenges in medical research. Conclusion: We argue that these crises emphasized underlying mistrust that can only be addressed with substantial investment in community engagement efforts to build trust and partnership in medical research endeavors. Our findings underline the importance of prioritizing community engagement through substantial investment in varied and extensive approaches to sensitization to facilitate community engagement toward community acceptance of ZAMPHIA and similar studies.

Taking Opportunities, Taking Medicines: Antibiotic Use in Rural Eastern Uganda

The ways in which dimensions of health and healthcare intersect with economics and politics in particular contexts requires close attention. In this article we connect concerns about antibiotic overuse in Uganda to the social milieu created through policies that follow President Museveni's vision for a population who kulembeka, "tap wealth." Ethnographic fieldwork in rural Eastern Uganda illustrates how taking medicines in rural households reflects a wider landscape of everyday imperatives to "tap" opportunities in a context of acute precarity. We argue for a closer connection between medical and economic anthropology to push forward understanding of health, medicines and wellbeing in Africa.

A critical examination of research narratives 'rumours' and passive community resistance in medical research

Several studies in Africa have reported effects of 'rumours, misconceptions or misinformation' on medical research participation and uptake of health interventions. As such, community engagement has sometimes been used for instrumental purposes to enhance acceptability of research or interventions and prevent 'rumours'. This paper seeks to highlight the value of ongoing engagement with communities to understand research narratives 'rumours' reproduced in medical research. We demonstrate that 'rumours' are a form of divergent communication or local interpretation of medical research that needs critical attention, and we question the ethics of dismissing such divergent communication.This paper draws on experiences from ethnographical research, which aimed to understand community engagement in medical research projects conducted in Malawi. We observed that even though community meetings were held to improve participation, 'rumours' about research influenced decision making. 'Rumours' presented local critiques of medical research, legitimate concerns informed by historical experiences and local conceptualisation of health. Structural inequalities, negative outcomes or absence of visible benefits following research participation informed unmet expectations, discontent with research and consequently passive resistance. The sociocultural context where participating research communities often rely on social networks for information nurtured propagation of these divergent perspectives to inform lay discourse around medical research.We conclude that ongoing engagement, critical self-reflection and attempts to decode deeper meaning of 'rumours' throughout research implementation is necessary, to show respect and address community concerns expressed through 'rumours', enhance informed participation and adoption of future health interventions.

COVID-19 Amid Rumors and Conspiracy Theories: The Interplay Between Local and Global Worlds

Stories and narratives are part of our human sociocultural history, which are always preserved in what I call "societal memory." We construct stories to weave meanings that help us make sense of our lifeworlds. Like stories, rumors and conspiracy theories can offer deep meanings when analyzed in specific contexts. Such narratives become most prominent in times of looming uncertainties, anxieties, and fears. Thus, the challenging coronavirus disease 2019 (COVID-19) pandemic has become surrounded by plentiful rumors and conspiracy theories. These narratives reveal geopolitics when they code the pandemic as "bioengineered." They also demonstrate local concerns, as in Pakistan, people started drinking "miraculous" tea as a form of prevention, shaving their heads, and/or praying to God to undo his "punishment." Some conceptualized the pandemic as an invented "plot." These narratives seem to empower individuals to make sense of this pandemic and to deal with its multidimensional effects: they allow them to feel confident enough to go outside and earn their livelihood. In this chapter, the author builds on his long-term ethnographic fieldwork on infectious diseases, recent telephone interviews, and content analysis of the media to discuss narratives revolving around COVID-19 in Pakistan. The author argues that these rumors and conspiracy theories are social phenomena pregnant with multiple meanings that deserve to be thoroughly explored, especially by anthropologists. A dearth of understanding about COVID-19 and narratives surrounding it would substantially impede the strategies to deal with this ongoing pandemic.

Impacts of Rumors and Conspiracy Theories Surrounding COVID-19 on Preparedness Programs

Being a part of our sociocultural history, stories and narratives help us make sense of our lifeworlds. Stories, rumors, and conspiracy theories offer deep meanings when analyzed in specific contexts, and prominently appear in the face of looming uncertainties, anxieties, and fears. Similarly, many narratives have surrounded the coronavirus disease 2019 (COVID-19) pandemic at the global and local levels as people try to make sense of this invisibly spreading virus and its multidimensional effects. Drawing on the media reports, I show and analyze global-level narratives that reveal geopolitics in play. To present the local level narratives in Pakistan, I build on my long-term ethnographic fieldwork, recent telephone interviews, and content analysis to discuss why these tales emerge and spread. As the pandemic unfolded, local people started drinking "miraculous" tea as a form of prevention, shaving their heads, and/or praying to God to undo His "punishment" and conceptualizing the pandemic as an invented "plot." With my analyses, I compare the "viral rumors" with the virus and argue that these narratives are social phenomena, carrying multiple meanings that need the thorough attention of social scientists, for example, anthropologists, just as we need experts to study a virus.

Decolonising research methodologies: lessons from a qualitative research project, Cape Town, South Africa

Background: It is becoming increasingly important for researchers to critically reflect on approaches that can have a positive impact on the health outcomes of indigenous people. Such issues are of great importance and perhaps of special relevance to researchers in the Global South, and to the African context in which we work.

Objective:To share some lessons learned from our fieldwork to contribute to current knowledge and conversations on decolonising research process.

Methods: We used an African lens to critically reflect upon some issues raised from individual interviews and focus group discussions with our participants which we deem to be important for consideration in a decolonising research process.

Results: The major issues that we raise are about important structures such as power, trust, cultural competence, respectful and legitimate research practice and recognition of individual and communities’ health assets in a decolonising research process.

Conclusions: Our paper argues for alternative approaches which are culturally appropriate for health research and for improved health outcomes of marginalised groups. In addition, we argue that participatory and transformative research methods which recognises individual and communities’ assets are needed. We hope that the lessons that we share in this paper can contribute towards a respectful and good research practice among the marginalised population groups in our context.

"Why Don't You Go Into Suburbs? Why Are You Targeting Us?": Trust and Mistrust in HIV Vaccine Trials in South Africa

Trust is a key element of high-quality stakeholder relations, which are themselves essential for the success of HIV vaccine trials. Where trust is absent, community stakeholders might not volunteer to become involved in key trial activities, and potential participants might not volunteer for enrollment. We explored site staff and Community Advisory Board (CAB) members’ experiences of trust/mistrust among community members and potential participants. We analyzed 10 focus group discussions with site staff and CAB members at two active South African HIV vaccine trial sites. We report on key characteristics perceived to contribute to the trustworthiness of communicators, as well as factors associated with mistrust. Attributes associated with trustworthy communicators included shared racial identity, competence, and independence (not being “captured”). Key foci for mistrust included explanations about site selection, stored samples, vaccination, and Vaccine Induced Sero-Positivity (VISP). Our findings suggest that community members’ trust is not necessarily global, in which trials are trusted or not; rather, it appears fairly nuanced and is impacted by various perceived attributes of communicators and the information they provide. We make recommendations for clinical trial site stakeholders invested in building trust and for future research into trust at these sites.

"It Was Not My Aim to Sleep There": The Impact of Timing and Location of Sex on Adherence to Coitally-Dependent HIV Pre-exposure Prophylaxis

The FACTS 001 trial found that vaginal pre- and post-coital application of 1% tenofovir gel did not prevent HIV-1 infection amongst young South African women. The trial included a multi-faceted approach to adherence support and collected objective and self-reported adherence measures. Using qualitative data collected from a random sub-set of FACTS 001 participants (135 in-depth interviews at product discontinuation and 13 focus group discussions at dissemination of trial results), we explore the importance of 'place' and 'timing' in shaping acts of sexual intimacy and product adherence. Demographically, this qualitative sub-sample is similar to the trial cohort of predominantly young, unemployed women living with parents or other family members. Sexual intimacy was largely unpredictable and happened across multiple locations in which women had limited privacy, autonomy, or control over the timing of sex. This made adherence to the dosing strategy challenging. Findings may inform the development of future event-driven pre-exposure prophylaxis regimens or products.

'Hold on' (Bambelela)! Lyrical interpretations of participation in an HIV prevention clinical trial

During a five-day workshop, former clinical trial participants and local musicians wrote the lyrics and recorded a song about an HIV prevention trial. Born of concerns about misconceptions regarding experimental drug trials, the aim was to engender engagement with medical researchers and open dialogue about the risks and benefits of trial participation. Composing lyrics that highlighted their credibility as communicators of medical scientific knowledge and their selfless sacrifice to stem the transmission of HIV, women performed their social positioning and cultural authority in contrast to men as well as other women not part of the trial. While involvement in HIV prevention initiatives often attracts stigma, scorn and criticism, the song's lyrics highlighted women's new-found identities as heroines searching for a solution to the spread of HIV, challenging these stereotypes. Methodologically, the paper describes a novel approach that uses artistic expression for public engagement with biomedical research.

The 'experimental public' in longitudinal health research: views of local leaders and service providers in rural South Africa

BACKGROUND

The concept of 'experimental public' has been recently applied to publics involved in clinical trials. This term could also be applied to publics involved in longitudinal research such as health and demographic surveillance systems. The ethics of practice and public engagement with these experimental publics are of key importance and include issues of informed consent, confidentiality, collection of body tissue samples and fair local benefit.

METHODS

Individual (n = 11) and focus group (n = 5) qualitative semi-structured interviews were conducted with 56 local leaders and service providers regarding their views about research activities in a longitudinal health research study site run by the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in rural South Africa. Deductive and inductive thematic analysis was undertaken using NVivo software to identify the emergent themes.

RESULTS

There was an understanding of the usefulness of collecting demographic data, but reasons for gathering other contextual data such as on food security, as well as the reasons for collection of blood was less clear. While appreciation was expressed for feedback of individual results such as blood pressure levels during home-based data collection, there were requests for more results from biomarkers, and for these to be given at home, rather than at the clinic. There were reports of indirect refusals, and offers by leaders to assist in reducing refusal rates. There were concerns about confidentiality, especially in the publication of results. Some leaders would have liked to receive more individual level data for planning of services, although they understood this would breach confidentiality. Service providers were concerned about the withdrawal of some services post intervention trials.

CONCLUSIONS

This experimental public has, over time, developed a nuanced understanding of the reasons for research and the procedures undertaken. Discussions concerning fair benefit ranged from requests for more individual clinically-relevant results for participants, to understanding how research results could assist in planning of public health services at local and national levels. The concerns illustrate the complexity of the ethics of practice which has implications for policy, practice and governance for those working in longitudinal health research sites globally.

Barriers to uptake of antenatal maternal screening tests in Senegal

Background

Evidence exists that selective antenatal maternal screening tests contribute to the reduction of maternal morbidity and mortality. However, data are lacking on coverage with the complete set of recommended tests. The study aimed to identify barriers to uptake of the complete set of tests recommended by the Ministry of Health in Senegal.

Methods

Data were collected in communities, antenatal care (ANC) clinics and the laboratories of 11 public health care facilities across Senegal. Mixed-methods included ethnography (observations and informal conversations), in-depth interviews and workshops at the health facilities; structured interviews with 283 women receiving antenatal tests (“women in the lab”); in-depth interviews with 81 women in communities who were pregnant or had recently delivered (“community women”).

Results

Only 13% of community women and 22% of women in the lab had received the complete set of tests. For various social, financial and antenatal care-related reasons 38% of community women who visited antenatal care facilities did not access a laboratory. The lowest test uptake was in women receiving antenatal care at health posts. Barriers at the laboratory level were the cost of the test, stock-outs of reagents, and broken equipment. Midwives were the main gatekeepers of the laboratory, not requesting (all) tests because of assumptions about women's financial problems and reliance on clinical symptoms.

Conclusion

In Senegal, recommended antenatal maternal screening tests are substantially underutilized. Efforts to increase test uptake should include accessible testing guidelines, reducing the cost of tests, raising awareness about the reasons for tests, and making the complete test set in point-of-care format accessible in peripheral health posts. National and international antenatal care policies and programs should facilitate access to maternal screening tests as a contribution to reducing maternal and infant morbidity and mortality.

•

Only 13% of pregnant women receive a complete set of antenatal maternal tests.

•

Financial problems and gender relations constrain women's access to laboratories.

•

Midwives as gatekeepers to the laboratory often request an incomplete test-set.

•

High price, reagent stock-out and faulty machines are barriers at the laboratory.

•

Understanding the multi-level barriers to test uptake should inform interventions.

Foregrounding possibilities and backgrounding exploitation in transnational medical research projects in Lusaka, Zambia

Today medical research funded by resourceful commercial companies and philanthropic organizations increasingly takes place in much less resourceful settings across the globe. Recent academic studies of this trend have observed how global inequalities have shaped the movements of this research, and how human subjects who make their blood and bodies available are at risk of exploitation. In Lusaka, people expressed their fears of being used by transnational medical research projects in various idioms of concern. While such concerns were always latent, people were generally eager to join the projects. Concerns were often backgrounded in favor of pragmatic attention to—and active creation of—possibilities that might stretch well beyond the purpose and time limit of individual research projects. The article illuminates how intimately the ambiguities and possible scenarios of exploitation inherent in transnational medical research projects are intertwined with scenarios of possibility.

Broad Consent for Genomic Research and Biobanking: Perspectives from Low- and Middle-Income Countries

Genomic research and biobanking are increasingly being conducted in the context of collaborations between researchers in high-income countries and those in low- and middle-income countries. Although these scientific advancements have presented unique opportunities for researchers to contribute to cutting-edge scientific projects and address important health problems, they have also challenged existing ethical and regulatory frameworks, particularly in sub-Saharan Africa. Broad consent is a model that allows the use of human biological samples and associated data in future research that may be unrelated to the original study. Drawing on emerging perspectives in low- and middle-income countries, we argue that broad consent is equivalent to consent to governance and that a robust governance framework for genomics and biobanking should seek to promote global health and research equity and take into account five key elements: respect, authentic community engagement and trust building, the preservation of privacy and confidentiality, feedback of results, and capacity strengthening.

Taking culture seriously in biomedical HIV prevention trials: a meta-synthesis of qualitative studies

A substantial gap exists between widespread acknowledgement of the importance of incorporating cultural sensitivity in biomedical HIV prevention trials and empirical evidence to guide the operationalization of cultural sensitivity in these trials. We conducted a systematic literature search and qualitative meta-synthesis to explore how culture is conceptualized and operationalized in global biomedical HIV prevention trials. Across 29 studies, the majority (n = 17) were conducted in resource-limited settings. We identified four overarching themes: (1) semantic cultural sensitivity - challenges in communicating scientific terminology into local vernaculars; (2) instrumental cultural sensitivity - understanding historical experiences to guide tailoring of trial activities; (3) budgetary, logistical, and personnel implications of operationalizing cultural sensitivity; and (4) culture as an asset. Future investigations should address how sociocultural considerations are operationalized across the spectrum of trial preparedness, implementation, and dissemination in particular sociocultural contexts, including intervention studies and evaluations of the effectiveness of methods used to operationalize culturally sensitive practices.

Community and research staff collaboration for development of materials to inform microbicide study participants in Africa

INTRODUCTION

Clinical trials of new vaginal products require careful communication with participants about trial requirements. Most microbicide trials have been multi-site studies conducted among women in sub-Saharan Africa, where literacy levels and understanding of scientific methods differ from those designing and conducting the trials. Microbicide trials require women to insert objects in their vagina and ensure they are present in the vagina during sex. For many women, this is a novel behaviour. These behaviours take place within the context of clinical trial participation, which is an additional novelty. Research teams must develop informational materials to help participants understand the clinical trial and input from local research staff and community members can improve the content and format of these materials.

METHODS

This paper discusses the development of illustrated materials developed for microbicide trial participants, presenting examples from two studies. In both studies, research staff and community advisory groups collaborated to review and revise materials.

RESULTS

Collaborative efforts revealed insights about how to convey information about clinical trial participation and microbicide use. These insights highlighted realities of the local context, details that might be misunderstood, illustrations of a sensitive nature and concerns about blood testing. In particular, information about blood testing and product use instructions required careful consideration. Although the research team anticipated needing advice on how best to convey information on these topics to participants, some aspects of potential participant concerns about these topics were also new to the research team. Community advisors and local research staff suggested better ways to convey this information, and provided guidance on how to use the materials.

CONCLUSIONS

The collaboration served to develop informational materials for microbicide trial participants. Furthermore, staff gained a better understanding of issues and concerns that could influence trial participation. A collaborative engagement process can provide important insights into local culture and knowledge beyond what is needed for development of clinical trial participant information materials. Research teams should be sensitive to this possibility, avail themselves of information and take appropriate action.

Hidden harms: women's narratives of intimate partner violence in a microbicide trial, South Africa

In a context of high rates of intimate partner violence (IPV), trials of female-controlled technologies for HIV prevention such as microbicides may increase the possibility of social harms. Seeking to explore the relationship between IPV and microbicide use further, this paper documents women's narratives of participating in the Microbicide Development Program (MDP) trial in Johannesburg, South Africa, and experiences of partner violence and conflict. A social science sub-study, nested within the trial, was conducted between September 2005 and August 2009, and 401 serial in-depth-interviews were undertaken with 150 women. Using coded interview transcripts, we describe the distribution of IPV and the possible association thereof with microbicide gel use and trial participation. More than a third of these 150 women reported IPV, of which half the cases were related to involvement in the trial. In their narratives, those women reporting IPV cast their partners as authoritarian, controlling and suspicious and reported verbal abuse, abandonment, and in some cases, beatings. Shared experiences of everyday violence shaped women's feelings of unease about revealing their participation in the trial to intimate partners and attempted concealment further contributed to strains and conflict within relationships. Our findings point to the role of social scientific enquiry in identifying the less obvious, hidden negative impacts of participation in a clinical trial therefore exposing limitations in the biomedical construction of 'social harms', as well as the implications thereof for potential future use outside the clinical trial setting.

Women's experiences with oral and vaginal pre-exposure prophylaxis: the VOICE-C qualitative study in Johannesburg, South Africa

Background

In VOICE, a multisite HIV pre-exposure prophylaxis (PrEP) trial, plasma drug levels pointed to widespread product nonuse, despite high adherence estimated by self-reports and clinic product counts. Using a socio-ecological framework (SEF), we explored socio-cultural and contextual factors that influenced participants’ experience of daily vaginal gel and oral tablet regimens in VOICE.

Methods

In Johannesburg, a qualitative ancillary study was concurrently conducted among randomly selected VOICE participants assigned to in-depth interviews (n = 41), serial ethnographic interviews (n = 21), or focus group discussions (n = 40). Audiotaped interviews were transcribed, translated, and coded thematically for analysis.

Results

Of the 102 participants, the mean age was 27 years, and 96% had a primary sex partner with whom 43% cohabitated. Few women reported lasting nonuse, which they typically attributed to missed visits, lack of product replenishments, and family-related travel or work. Women acknowledged occasionally skipping or mistiming doses because they forgot, were busy, felt lazy or bored, feared or experienced side effects. However, nearly all knew or heard of other study participants who did not use products daily. Three overarching themes emerged from further analyses: ambivalence toward research, preserving a healthy status, and managing social relationships. These themes highlighted the profound and complex meanings associated with participating in a blinded HIV PrEP trial and taking antiretroviral-based products. The unknown efficacy of products, their connection with HIV infection, challenges with daily regimen given social risks, lack of support–from partners and significant others–and the relationship tradeoffs entailed by using the products appear to discourage adequate product use.

Conclusions

Personal acknowledgment of product nonuse was challenging. This qualitative inquiry highlighted key influences at all SEF levels that shaped women’s perceptions of trial participation and experiences with investigational products. Whether these impacted women’s behaviors and may have contributed to ineffective trial results warrants further investigation.

Acceptability and feasibility of cash transfers for HIV prevention among adolescent South African women

Women are at increased risk of HIV infection in much of sub-Saharan Africa. Longitudinal and cross-sectional studies have found an association between school attendance and reduced HIV risk. We report feasibility and acceptability results from a pilot of a cash transfer intervention conditional on school attendance paid to young women and their families in rural Mpumalanga, South Africa for the prevention of HIV infection. Twenty-nine young women were randomised to intervention or control and a cash payment based on school attendance made over a 2-month period. Quantitative (survey) and qualitative (focus group and interview) data collection was undertaken with young women, parents, teachers and young men in the same school. Qualitative analysis was conducted in Atlas.ti using a framework approach and basic descriptive analysis in Excel was conducted on the quantitative data. Results indicate it was both feasible and acceptable to introduce such an intervention among this population in rural South Africa. There was good understanding of the process of randomisation and the aims of the study, although some rumours developed in the study community. We address some of the changes necessary to ensure acceptability and feasibility of the main trial.

Malicious whites, greedy women, and virtuous volunteers: negotiating social relations through clinical trial narratives in South Africa

As clinical trial research increasingly permeates sub-Saharan Africa, tales of purposeful HIV infection, blood theft, and other harmful outcomes are widely reported by participants and community members. Examining responses to the Microbicide Development Programme 301-a randomized, double-blind, placebo-controlled microbicide trial-we investigate the ways in which these accounts embed medical research within postcolonial contexts. We explore three popular narratives circulating around the Johannesburg trial site: malicious whites killing participants and selling their blood, greedy women enrolling in the trial solely for financial gain, and virtuous volunteers attempting to ensure their health and aid others through trial participation. We argue that trial participants and community members transform medical research into a meaningful tool that alternately affirms, debates, and challenges contemporary social relations.

'She's my sister-in-law, my visitor, my friend' -- challenges of staff identity in home follow-up in an HIV trial in Western Kenya

Identities ascribed to research staff in face-to-face encounters with participants have been raised as key ethical challenge in transnational health research. ‘Misattributed’ identities that do not just deviate from researchers' self-image, but obscure unequivocal aspects of researcher identity – e.g. that they are researchers – are a case of such ethical problem. Yet, the reasonable expectation of unconcealed identity can conflict with another ethical premise: confidentiality; this poses challenges to staff visiting participants at home. We explore these around a case study of ‘follow-up’ staff, observed during an ethnographic study of a Kenyan HIV ‘trial community’, which included participant observation, conversations, and interviews with staff (n = 79) and participants (n = 89). We found that because of the need to maintain confidentiality and because of some suspicions towards researchers, research staff drew upon alternative identities – presenting themselves to non-participants as relatives or friends, rather than as researchers. Several staff experienced this as necessary but uncomfortable. Simultaneously, staff and participants forged close relations in line with their fictional identities, which however also posed challenges because they entailed personal responsibilities that were difficult to live up to, due to limited resources, and the trial's limited duration. Similar challenges may arise in transnational HIV treatment programmes and should be explored further in that context.

Critically engaging: integrating the social and the biomedical in international microbicides research

Randomized controlled trials and critical social theory are known not to be happy bedfellows. Such trials are embedded in a positivist view of the world, seeking definitive answers to testable questions; critical social theory questions the methods by which we deem the world knowable and may consider experiments in the biomedical sciences as social artifacts. Yet both of these epistemologically and methodologically divergent fields offer potentially important advances in HIV research. In this paper, we describe collaboration between social and biomedical researchers on a large, publicly funded programme to develop vaginal microbicides for HIV prevention. In terms of critical engagement, having integrated and qualitative social science components in the protocol meant potentially nesting alternative epistemologies at the heart of the randomized controlled trial. The social science research highlighted the fallibility and fragility of trial data by demonstrating inconsistencies in key behavioural measurements. It also foregrounded the disjuncture between biomedical conceptions of microbicides and the meanings and uses of the study gel in the context of users’ everyday lives. These findings were communicated to the clinical and epidemiological members of the team on an ongoing basis via a feedback loop, through which new issues of concern could also be debated and, in theory, data collection adjusted to the changing needs of the programme. Although critical findings were taken on board by the trialists, a hierarchy of evidence nonetheless remained that limited the utility of some social science findings. This was in spite of mutual respect between clinical epidemiologists and social scientists, equal representation in management and coordination bodies, and equity in funding for the different disciplines. We discuss the positive role that social science integrated into an HIV prevention trial can play, but nonetheless highlight tensions that remain where a hierarchy of epistemologies exists alongside competing paradigms and priorities.