Understanding of Informed Consent

HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University

Understanding of Informed Consent and Motivators for Participation Among MSM HIV Vaccine Trial

Participants

Lisa Chin, JD, EdD, MPH, MA

HIV Center Grand RoundsJune 30, 2011


Why do people participate in HIV vaccine trials (HVT) and do they know what they are getting into?


Background HIV Vaccine Development

HIV vaccines are critical for comprehensive prevention strategy against HIV/AIDS

Human subject testing is essential aspect of HIV vaccine development


Recruitment Issues in HVTs

Many participants are needed to ensure power to assess a vaccine’s safety and efficacy

Willingness to participate in a HVT varied from 22% to 79%

In practice only 20% of participants actually enrolled (Buchbinder et al., 2004)

Understanding motivations to participate can help to improve recruitment


Participants’ Understanding of HVTInformed Consent Information

Ethical implications for informed consento Concerns about therapeutic misconception

Most studies among non-HVT study populationso Vaccine preparedness o Vaccine feasibility o Longitudinal epidemiological

Few studies with actual HVT participantso South African HVT o US IDU HVT participantso North American HVT – vaccine efficacy


Pilot Study

Qualitative Study with high- and low-risk participants in HVT

Formative Research for Quantitative Instrument Development

Quantitative Assessment with HVT Participants


Qualitative Part of Pilot Study

Domains of interest:• Understanding of HVT informed consent

information• Perceptions of HVT informed consent process• Potential therapeutic misconception• Motivators for participating

Study participants:

• High-risk individuals HVT participants (20 MSMs)• Low-risk individuals HVT participants (20 women

& men)


Parent HVT for Pilot Study

Phase II Trial -- Double Blind Vaccine vs. Placebo Study aims are to assess:

• Vaccine safety and immunogenicity• Reduction of viral load upon HIV acquisition

Vaccines not made from HIV virus Recruited from 2 research sites in NYC


Participants’ Demographics

Age range: 23-48 yrs (mean = 35.8) Ethnicity

• 7 White• 10 African-American• 1 Hispanic• 1 Asian• 1 Mixed

Education (Highest Level)• 1 <HS• 11 HS degrees• 6 BA degrees• 2 MA degrees


Qualitative Probes

Motivators for participation• Decision to get involved• Other factors involved• Family or friends who are healthcare

professionals• Role of payment• Role of HIV concerns

Understanding of informed consent• Study goals• What study involves• Possible risks and benefits• Inputs/pressure to participate


Study Analysis

Qualitative interviews• 1-2 hour interviews• Transcribed and Coded• 2 Coders

Coding themes• Understanding/misunderstanding-misconception of

HVTo Study purpose/goalso Study designo Vaccine and placebo

• Perspectives on risks and benefits of participation• Understanding of voluntariness of participation• Motivators for participation

o Sources for motivationso Role of compensation as a motivator


Motivators for Enrolling into and Staying in Study

Altruism

Compensation


Altruistic Motives from Various Sources

• Familial: Values taught that helping others is important• Cultural/Community: Emphasis on giving back to the

community or the desire to help

• Religious: Personal religious values/beliefs opposing observed hypocrisy

• Experiential: Personal experiences with HIV/AIDS

• Professional: Being a healthcare professional or having family members who are

• Political: Activism in response to the HIV/AIDS epidemic

• Moral: Making up for past wrongs

• Existential: Provides a sense of meaning and purpose

• Psychological: Obtaining gratification


Participants’ Altruistic Motives

Emphasis giving back to the community or the desire to help the community

I am helping my community, as far as gay men, black gay men…the community I live in. (AA, age 41)

Obtaining gratification

It’s very fulfilling for me. I’m very proud of being in this. (W, age 23)


Compensation as a Motivator

Sole motivator (n=1) Important but not sole motivator (n=4) Added bonus but not motivator (n=5) Compensation not a motivator (n=10)


Compensation Important but not Sole Motivator

At the beginning, it was pretty much for extra cash. But I chose this particular study because my parents have had friends that had HIV. It’s pretty much a win-win. Win-win as in I would be doing something that I support and I would make a few extra bucks from it. (AA, age 23)

I’m unemployed. I need the money. I’m not going to lie about that. And the same thing is I know a lot of people with HIV. (AA, age 39)


Compensation as an Added Bonus

To maintain follow-up visits/adherence

I probably would have done it for free, but that definitely gets [you] to the appointment. (AA, age 28)

It motivates you to show up on time. If you feel like you’re not getting paid, you can start taking liberties with the responsibilities that you have. (W, age 43)

Acknowledgement of participant’s time

The amount of money that I end up getting from this study is not even really pocket change. It definitely does make me feel that my time is valuable at least. (W, age 23)


Compensation not a Factor

I’ve probably would’ve still participated even they weren’t paying me. (W, age 27)

I didn’t even know you got paid for it, so that wasn’t a factor…Just the fact I wanted to help. (W, age 28)


Understanding of Informed Consent (1)

Participants had basic understanding of HVT Several misunderstandings/misconceptions about

study elements and concepts• Study purpose

o Many said “cure” or “prevent HIV acquisition”, not decrease viral load or examine vaccine safety

• Process of randomizationo What worked best for the participant

I think the doctors after they look at my file, they found out what was best after they did all the blood work and all that. (AA, age 44)

o Based on participant’s behaviorI think it’s based on what you’re going in and telling them. It has to be based on some type of activity. (AA, age 39)


Understanding of Informed Consent (2)

Some confusion about role of placebo

It prevents people from changing behavior or lying about or overstating symptoms. [Participants] also lie about their symptoms. Like, are you really going to have nausea off a placebo? It’s to keep people honest. If I’m deciding not to be honest and say, “I’m feeling nauseous”, [the staff] will say, “Hold on, something’s up because you’re just taking a placebo.” So, it’s pretty much just to keep people honest. (AA, age 23)


Participants’ Interpretation of HVT Concepts

Randomizationo Interpreted literally as a “coin toss” (i.e., an actual coin

was usedDo y’all toss a coin and decide which shot you’re going to give me? (AA, age 42)

What is in the vaccineo Synthetic HIV = “fake HIV”o “Crippling” actual HIV virus

How the vaccine workso Taking a snapshot of virus or antibodies of virus…It’s

kind of like a security guard having a picture of a wanted man. If that wanted man comes to the building, he knows. (AA, age 23)


Summary

Various motives for participation

Altruism is a multi-dimensional phenomena (instead of single dimension)

Compensation appears not to be the sole motivator for HVT participation

Overall basic understanding of HVT

Some difficulties in understanding more technical elements/components of HVT (e.g., randomization, placebo, vaccine)


Implications

Use of altruism as a marketing strategy for HVT recruitment

Strategies are needed to help participants better understand components of HVT

•Simplify written patient education materials about HVT

•Use of multi-media technology as an educational tool

•Review informed consent information with participants at various points of HVT trial


Study Limitations

Study population limited to MSM: Motivations with other populations may differ

Participants interviewed after enrollment: Issue of recall bias

Participants interviewed only once: Views on motivation may change over time


Future Research

Among different populations and with larger samples, future studies can examine:•Frequencies of types of altruism and possible associations with entrance and retention into study, and adherence to protocol•The role and importance of study compensation as a motivator (weighing of altruistic benefits against compensation)•Frequencies of types of misunderstandings and predictors (education, other socio-demographic variables, cultural factors and beliefs)•Effects of types of misunderstandings on entrance and retention into study, and adherence to protocol


Acknowledgments

Robert Klitzman, MD, Scientific Mentor HIV Center Pilot Studies Program (Pat Warne, PhD) HIV Center (PI: Anke Ehrhardt, PhD) HIV Center Ethics and Policy Core, Development

Core, IRMC, and HIV Center Administration HIV Center T32 Postdoctoral Training Fellowship

Program (PI: Theo Sandfort, PhD) Scott Hammer, MD, and CUMC HIV Vaccine Trial

Clinic and Beryl Koblin, PhD, and New York Blood Center Project Achieve

Jacqueline Berenson, MD (Clinical Forensic Psychiatry Program, NYSPI/CU)


Thank you



Familial – family values taught that helping others is important

It’s really important that everybody does something to give back to the community, which is something my mother instilled in me. (W, age 27)

Professional – Being a healthcare professional or having family members who are healthcare professional

I think [family members who are healthcare professionals] learn a lot from studies like this, a lot about diseases and how to prevent them, like how to find cures. (Asian, age 32)



Religious values/beliefs opposing observed hypocrisy

I was a closeted person. I was raised Italian Catholic. There was a lot shame around that. And I have a lot resentment toward the Catholic Church how they treat the LGBTQ community… So it’s very personal to me. It’s not about me or my future, but more about the future of the next generation to follow, if I can help out in any way. (W, age 45)



Existential, providing a sense of meaning and purpose

I wanted to be part of something that’s going to help. Be part of something that we need. Part of something that could help cure millions of people. (AA, age 44)



Moral – Making up for past wrongs

I did too much wrong, and if I could give back to the community, I did my part. (AA, age 44)



Personal experiences with HIV/AIDS

I chose that particular study because my parents have had friends that had HIV. I’ve been around it. (AA, age 23)

Political activism in response to the HIV/AIDS epidemic

I started working more formally in [HIV/AIDS outreach], trying to educate people, and just helping out people…participating in [the HIV vaccine trial] was like a next step… Somebody has to do it. (AA, age 28)

Documents

Understanding of Informed Consent