Associate Director: CAPRISA - Centre for the AIDS Programme of Research in SADirector: CU-SA Fogarty AITRP

Presented at the:Presented at the:GCM and HAVEG Consultation on ethical-legal concerns GCM and HAVEG Consultation on ethical-legal concerns

in HIV vaccine and microbicide trials, Durban September 2006in HIV vaccine and microbicide trials, Durban September 2006

Adolescents in trials: An ethical-Adolescents in trials: An ethical-legal analysislegal analysis

Quarraisha Abdool KarimQuarraisha Abdool Karim

CENTRE FOR THE AIDS PROGRAMME OF CENTRE FOR THE AIDS PROGRAMME OF RESEARCH IN SOUTH AFRICARESEARCH IN SOUTH AFRICACCAPRISAAPRISA CAPRISA is a UNAIDS CAPRISA is a UNAIDS

Collaborating Centre for Collaborating Centre for HIV Prevention ResearchHIV Prevention Research

OverviewOverview

Why focus on adolescentsWhy focus on adolescents

Opportunities through inclusion of adolescentsOpportunities through inclusion of adolescents

Context of research in adolescentsContext of research in adolescents

Concerns about enrolling young peopleConcerns about enrolling young people Ethical and Legal concernsEthical and Legal concerns

Effective interventions vs Trial GoalsEffective interventions vs Trial Goals

A way forward?A way forward?

National prevalence of HIV by sex and National prevalence of HIV by sex and age in 2002age in 2002 : Young Women at Risk : Young Women at Risk

05

10152025303540

0 10 20 30 40 50 60

Age (years)

HIV

Pre

vale

nce

(%

)

men

women

Note: Log-normal curves were fitted to data collected from the Nelson Mandela / HSRC study of HIV/AIDS

Age and gender distribution of HIV infection Age and gender distribution of HIV infection among 15–24 year olds in South Africa 2003:among 15–24 year olds in South Africa 2003:

Source: Pettifora AE, Reesa HV, Kleinschmidt I, Steffensond AE, MacPhaila C, Hlongwa-Madikizelaa L, Vermaake K, Padian NS. AIDS 2005, 19:1525–1534

Source: Carrara HRO, Abdool Karim Q, Latka MH, Frohlich JA, Makhaye G, Kharsany ABM, Zuma M, Abdool Karim SS. Submitted to JAIDS

Specific HIV Prevalence Trends in Women Specific HIV Prevalence Trends in Women Attending Prenatal Clinics in Rural KwaZulu Attending Prenatal Clinics in Rural KwaZulu

Natal, 2001-2005 Natal, 2001-2005

0

10

20

30

40

50

60

2001 2002 2003 2004 2005

Year

Pre

vale

nce

(%

)

<20 years

20-29

≥30 years

High HIV incidence rates by age in Durban & High HIV incidence rates by age in Durban & VulindlelaVulindlela

7.25 (5.3–9.2)7.25 (5.3–9.2)51.2%51.2%28172817TotalTotal

4.0 4.0 (0–11.8) (0–11.8)29.029.0313150+50+

6.4 6.4 (0.8–12.1) (0.8–12.1)39.439.414214240-4940-49

12.012.0 (4.5–19.4) (4.5–19.4)58.158.126026030-3930-39

6.56.5 (1.3–11.6) (1.3–11.6)60.960.924824825-2925-29

8.5 8.5 (4.7–12.3) (4.7–12.3)45.645.642542520-2420-24

5.0 5.0 (1.9–8.0) (1.9–8.0)26.426.4360360<20<20

Incidence Rate# Incidence Rate# (95% CI)(95% CI)

HIV HIV prevalence (%)prevalence (%)

NNAge group Age group (years)(years)

# Rates per 100 person-years from cohorts in 2005 & 2006

Source: CAPRISA Vulindlela Women & AIDS Programme

Opportunities from enrolling minors in Opportunities from enrolling minors in HIV Prevention TrialsHIV Prevention Trials

Evaluate efficacy/effectiveness Evaluate efficacy/effectiveness Assess AcceptabilityAssess Acceptability Determine SafetyDetermine Safety Identify adherence issuesIdentify adherence issues Ideal conditions for identifying and resolving Ideal conditions for identifying and resolving

potential problemspotential problems ? Licensure – HPV Vaccine? Licensure – HPV Vaccine

Context of research in minorsContext of research in minors

Caution about inclusionCaution about inclusion

Reluctance by IRBs/ECs, Regulatory Bodies, and Reluctance by IRBs/ECs, Regulatory Bodies, and Scientists to enrol in biomedical prevention trialsScientists to enrol in biomedical prevention trials

Behavioural context for young people Behavioural context for young people • delay onset of sexual debut &/or abstinence delay onset of sexual debut &/or abstinence • Already high HIV prevalence that need to be Already high HIV prevalence that need to be

addressed vs Reliance on untested & restrictive addressed vs Reliance on untested & restrictive abstinence messages abstinence messages

Context – General Context – General Access to care vs research (therapeutic vs Access to care vs research (therapeutic vs

preventive)preventive) Ethical Dilemmas not resolvable by definition – Ethical Dilemmas not resolvable by definition –

define an acceptable approachdefine an acceptable approach Ethics guidance – not cast in granite (dialogue)Ethics guidance – not cast in granite (dialogue) Law vs Ethics --- blind adherence to the law? Sex Law vs Ethics --- blind adherence to the law? Sex

work is illegal – research conducted work is illegal – research conducted Adolescents vs young people - <18 years vs <24 Adolescents vs young people - <18 years vs <24

yearsyears Assent vs Consent (UNAIDS Ethics Guidance)Assent vs Consent (UNAIDS Ethics Guidance) Emancipated minors (CIOMS)Emancipated minors (CIOMS)

UNAIDS Ethics Guidance on UNAIDS Ethics Guidance on inclusion of Children & Adolescents inclusion of Children & Adolescents

UNAIDS - children, including infants and UNAIDS - children, including infants and adolescents, should be eligible for enrolment in HIV adolescents, should be eligible for enrolment in HIV preventive vaccine trialspreventive vaccine trials• As a matter of equity As a matter of equity • Young adolescents and children are at high risk of Young adolescents and children are at high risk of

HIV infection.HIV infection. No discernment on Adolescent participation with No discernment on Adolescent participation with

parental consent vs autonomous participation of parental consent vs autonomous participation of adolescents adolescents

CIOMS and Mature MinorsCIOMS and Mature Minors

In some jurisdictions, individuals who In some jurisdictions, individuals who are below the general age of consent are below the general age of consent are regarded as "emancipated" or are regarded as "emancipated" or "mature" minors and are authorized to "mature" minors and are authorized to consent without the agreement or even consent without the agreement or even the awareness of their parents or the awareness of their parents or guardians.guardians.

CIOMS, “Mature Minors” and CIOMS, “Mature Minors” and ECs/IRBsECs/IRBs

Some studies involve investigation of Some studies involve investigation of adolescents’ beliefs and behaviour regarding adolescents’ beliefs and behaviour regarding sexuality or use of recreational drugs; other sexuality or use of recreational drugs; other research addresses domestic violence or research addresses domestic violence or child abuse. For studies on these topics, child abuse. For studies on these topics, ethical review committees may waive ethical review committees may waive parental permission if, for example, parental parental permission if, for example, parental knowledge of the subject matter may place knowledge of the subject matter may place the adolescents at some risk of questioning the adolescents at some risk of questioning or even intimidation by their parents.or even intimidation by their parents.

Enrolling minors in trials – ethical Enrolling minors in trials – ethical concernsconcerns

Vulnerable population Vulnerable population • Experiential maturityExperiential maturity• Physical maturityPhysical maturity• Diminished autonomyDiminished autonomy• Legal and social challengesLegal and social challenges• Confidentiality and Right to PrivacyConfidentiality and Right to Privacy

HIV specific challengesHIV specific challenges• Ability to adopt safer sex practicesAbility to adopt safer sex practices

Assent vs Consent: Confidentiality & Assent vs Consent: Confidentiality & Privacy Privacy

Implications of an HIV-positive test result Implications of an HIV-positive test result • Negative connotationNegative connotation• Stigma &. DiscriminationStigma &. Discrimination• Violence and social ostracization Violence and social ostracization • Gender bias and not restricted to minors Gender bias and not restricted to minors

Willingness to participateWillingness to participate• Will HIV status will be disclosed to the parentsWill HIV status will be disclosed to the parents• Obligations of HCWS vs participant right to privacy & Obligations of HCWS vs participant right to privacy &

confidentiality confidentiality ? Implications for health seeking behaviours ? Implications for health seeking behaviours Respect for an adolescent participant’s autonomy and right to Respect for an adolescent participant’s autonomy and right to

confidentialityconfidentiality• Parental consent nullifies obligation Parental consent nullifies obligation

Legal challengesLegal challenges

Variation between nationsVariation between nations <18 years = minor<18 years = minor Ethical and legal safeguards – protect their interest but also Ethical and legal safeguards – protect their interest but also

diminish their autonomydiminish their autonomy SA – parental consent required for research participationSA – parental consent required for research participation > minimal risk requires consent from both parents> minimal risk requires consent from both parents

• No parents/guardians – cannot participate in researchNo parents/guardians – cannot participate in research• Restrictions eliminate participation by minors from child-headed Restrictions eliminate participation by minors from child-headed

households, absent father households and grandmother headed households, absent father households and grandmother headed householdshouseholds

• Moral judgements about sexuality – unlikely that teenagers will Moral judgements about sexuality – unlikely that teenagers will seek parental guidance and permission for participation in HIV seek parental guidance and permission for participation in HIV prevention researchprevention research

Counter concernsCounter concerns

Social autonomy for fully informed consent vs skills Social autonomy for fully informed consent vs skills or competencies for independent decision-makingor competencies for independent decision-making

Limited life experience complicates balancing risks Limited life experience complicates balancing risks and benefitsand benefits

Cognitive skills especially for younger adolescents – Cognitive skills especially for younger adolescents – not fully developed - ? Adequacy for some research not fully developed - ? Adequacy for some research related decision-makingrelated decision-making

Effective interventionsEffective interventions Multiple levels, highly complex nature of HIV Multiple levels, highly complex nature of HIV

epidemicepidemic Biomedical interventions – great promise but do not Biomedical interventions – great promise but do not

address fundamental structural driversaddress fundamental structural drivers NB of integrating science and society – community NB of integrating science and society – community

partnerships and engagement processespartnerships and engagement processes• Advocacy and policy supportAdvocacy and policy support• Community and civil society participationCommunity and civil society participation• Clinical research enterpriseClinical research enterprise• AcceptabilityAcceptability• Policy and Program developmentPolicy and Program development

Components of the Prevention Science Research Continuum

Stage 1 Conceptual Stage 2 Experimental Stage 3 Applied

Phase 4Effectiveness

Community Ownership

Long-term Acceptability

Program Implementation

Phase 2 Phase 3Conceptual Development

Theory/Biological Plausibility

Phase 1Safety

Community Engagement

Community Awareness

FormativeOperations

Program Modeling

Hypothetical Acceptability

Experiential Acceptability

ClinicalAcceptability

PolicyApplicationAdvocacy

PolicyDevelopment

MacQueen KM, Cates W. AJPM 2005;28(5)::491-5.

SummarySummary

Notwithstanding underlying variability between Notwithstanding underlying variability between regions vulnerability of youth is global regions vulnerability of youth is global

Toll on youth globally and adolescent women Toll on youth globally and adolescent women imperative to protect them from HIV infectionimperative to protect them from HIV infection

Social, political and economic drivers of risk and Social, political and economic drivers of risk and vulnerability need to be simultaneously addressedvulnerability need to be simultaneously addressed

Several options for addressing challenges – 5 Several options for addressing challenges – 5 pronged approachpronged approach

Develop and evaluate effective models for Develop and evaluate effective models for collaborative, participatory and interdisciplinary collaborative, participatory and interdisciplinary approachesapproaches

Support stakeholders to respond to emerging issuesSupport stakeholders to respond to emerging issues Enhance efforts at trust building, communication and Enhance efforts at trust building, communication and

fair benefits for research communitiesfair benefits for research communities