Enhancing Community Participation in HIV Prevention Research Steve Morin, Ph.D. AIDS Policy Research...
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Transcript of Enhancing Community Participation in HIV Prevention Research Steve Morin, Ph.D. AIDS Policy Research...
Enhancing Community Participation in HIV Prevention
Research
Enhancing Community Participation in HIV Prevention
Research
Steve Morin, Ph.D.Steve Morin, Ph.D.
AIDS Policy Research CenterAIDS Policy Research Center
AIDS Research InstituteAIDS Research Institute
University of California, San FranciscoUniversity of California, San Francisco
UCSF Research TeamUCSF Research Team
Stephen F. Morin
T. Anne Richards
Andre Maiorana
Marisa McLaughlin
Nicolas Sheon
Kimberly Koester
Karen Vernon
Sheri Storey
Andrew Herring
AcknowledgementsAcknowledgements
Community Working Group Co-Chairs
Janet Frohlich
Mike Shriver
Family HealthInternational
Stella Kirkendale
Wayne Wilson
Specific AimsSpecific Aims
To assess the views of CAB and research team members regarding community consultation in HIV research
To assess motivation and barriers to participation in prevention trials
BackgroundBackground
Community Advisory Boards (CABs) in AIDS Community Advisory Boards (CABs) in AIDS research have their roots in AIDS activismresearch have their roots in AIDS activism
AZT trial in 1987 pointed to need for AZT trial in 1987 pointed to need for partnership with communitypartnership with community
Educated and desperate people with HIV Educated and desperate people with HIV organize to demand a seat at the tableorganize to demand a seat at the table
NIH History of CABsNIH History of CABs
Community Constituency Group formed Community Constituency Group formed
NIH guidance to AIDS clinical trials units to NIH guidance to AIDS clinical trials units to establish local CABs establish local CABs
Role -- to provide advice and communicate Role -- to provide advice and communicate community preferencescommunity preferences
With HIVNET, CABs go internationalWith HIVNET, CABs go international
HPTN continues emphasis on community HPTN continues emphasis on community participationparticipation
QuestionsQuestions
Do CABs work….Do CABs work….
In the absence of organized activists?In the absence of organized activists?
In prevention trials v. treatment trials?In prevention trials v. treatment trials?
Rapid AssessmentRapid Assessment Goal is a preliminary, qualitative Goal is a preliminary, qualitative
understanding understanding
Field teams visit for five days to get Field teams visit for five days to get picture at one point in timepicture at one point in time
Triangulation of data sourcesTriangulation of data sources secondary reportssecondary reports
ethnographic observationsethnographic observations
semi-structured interviewssemi-structured interviews
Site Interviews Site Interviews Researchers CAB Participants Total
Birmingham 5 6 4 15
Philadelphia 5 6 5 16
Los Angeles 4 6 5 15
Chiang Mai 7 6 6 19
Harare 5 6 7 18
Lima 5 6 6 17
Total 31 36 33 100
SitesSites
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Philadelphia
Harare
Birmingham
Chiang Mai
Lima
Los Angeles
Ra
pid
As
se
ss
me
nt - 6
mo
nth
s
na
ps
ho
t
Data AnalysisData Analysis
Interviews transcribedInterviews transcribed
Data entered into EthnographData entered into Ethnograph
Reviewed for broad themes and Reviewed for broad themes and subthemessubthemes
Codes assigned and verifiedCodes assigned and verified
Summaries and cross-site analysisSummaries and cross-site analysis
Conflicting World ViewsConflicting World Views
ResearchersResearchers
Scientific questionsScientific questions
Randomized trials Randomized trials
Recruitment/retentionRecruitment/retention
CommunityCommunity
ParticipantsParticipants
Basic life needsBasic life needs
Medical care Medical care
HIV & STD screeningHIV & STD screening
ResearchResearch
World ViewWorld View
What is the role of the CAB?
CAB As BridgeCAB As Bridge
CAB Members View of RoleCAB Members View of Role
Bridge, link, go-between, liaison Bridge, link, go-between, liaison
Provide advice on protocolsProvide advice on protocols
Identify potential research ideasIdentify potential research ideas
Clearinghouse for ethical issues Clearinghouse for ethical issues
Legitimize research in communitiesLegitimize research in communities respond to misinformationrespond to misinformation
provide accessprovide access
social marketing/public relationssocial marketing/public relations
Conflict in RoleConflict in Role
““To whom is the CAB accountable? Is it to To whom is the CAB accountable? Is it to the community? Is it to the local the community? Is it to the local municipal authorities? Or, is it to the municipal authorities? Or, is it to the research programs? That is a gray area. research programs? That is a gray area. That is an area we are struggling with.” That is an area we are struggling with.”
-- CAB -- CAB MemberMember
Representation:How do you put a
CAB together?
Broad Community ModelBroad Community Model Cross-section of larger community Cross-section of larger community
(Zimbabwe & Thailand)(Zimbabwe & Thailand) government officialsgovernment officials
educatorseducators
religious leadersreligious leaders
NGO representativesNGO representatives
people living with HIVpeople living with HIV
Long term view of missionLong term view of mission
Want sustainabilityWant sustainability
Population Specific ModelPopulation Specific Model
Needs of a specific group Needs of a specific group African AmericansAfrican Americans
WomenWomen
IDUsIDUs
MSMMSM
Protocol driven (Philadelphia, Birmingham) Protocol driven (Philadelphia, Birmingham)
Preparedness driven (LA, Peru)Preparedness driven (LA, Peru)
Recruitment & Retention:
Why do people serve on CABs?
CAB MotivationCAB Motivation Concern about impact of HIV on their Concern about impact of HIV on their
community or populationcommunity or population
Personal experience. e.g., HIV-infectedPersonal experience. e.g., HIV-infected
Opportunity to learn about other Opportunity to learn about other agencies, research, influence policyagencies, research, influence policy
Reimbursement -- lunch, tokens, travel Reimbursement -- lunch, tokens, travel and stipends and stipends
Prestige -- self worth; having something Prestige -- self worth; having something to contributeto contribute
Self Worth & MeaningSelf Worth & Meaning
““Just being part of something that Just being part of something that means something. Sometimes when means something. Sometimes when you are a drug user or ex-drug user. you are a drug user or ex-drug user. You know, being a part of something You know, being a part of something good and right means something.” good and right means something.”
-- CAB Member-- CAB Member
CAB Barriers -- RecruitmentCAB Barriers -- Recruitment
Site needs to decide on a modelSite needs to decide on a model
Need to recruit accordinglyNeed to recruit accordingly Find community leaders with time to Find community leaders with time to
commit to the projectcommit to the project
Identify and retain members from Identify and retain members from marginalized populationsmarginalized populations
CAB Barriers -- RetentionCAB Barriers -- Retention
Disparities in knowledgeDisparities in knowledge
Practical concerns -- e.g. time, Practical concerns -- e.g. time, transportation, child care transportation, child care
Illness -- people living with HIVIllness -- people living with HIV
Setting reasonable expectations Setting reasonable expectations
Disparities in KnowledgeDisparities in Knowledge
““It’s frustrating when you got to It’s frustrating when you got to keep interrupting to tell them keep interrupting to tell them could you explain that? Or, could could you explain that? Or, could you talk in layman’s terms? They you talk in layman’s terms? They make you feel stupid.” make you feel stupid.”
-- CAB Member-- CAB Member
What do CAB and research team members want
from each other?
Research Team WantsResearch Team Wants
Feedback -- constructive criticism to help Feedback -- constructive criticism to help improve protocolsimprove protocols
Limits -- help in clarifying to participants Limits -- help in clarifying to participants what will not be providedwhat will not be provided
Understanding -- why people do or do not Understanding -- why people do or do not participate in protocolparticipate in protocol
Access -- ability to move research into new Access -- ability to move research into new areas -- access to communities, populationsareas -- access to communities, populations
CAB WantsCAB Wants Validation - respect for their expertise and Validation - respect for their expertise and
recommendations recommendations
Standing -- to be seen as resource for Standing -- to be seen as resource for information in communityinformation in community
Training -- HIV, research details, translating Training -- HIV, research details, translating scientific languagescientific language
Feedback -- research findings to Feedback -- research findings to community community
Action -- impatient to act nowAction -- impatient to act now
Why do people participate in
prevention trials?
MotivationsMotivations
Altruism - desire to help communityAltruism - desire to help community
Reimbursements -- need moneyReimbursements -- need money
Access to HIV & STD testingAccess to HIV & STD testing
Access to quality medical care Access to quality medical care
Support networksSupport networks
Gain knowledge about HIVGain knowledge about HIV
BarriersBarriers Lack of knowledge about researchLack of knowledge about research
Distrust of medical establishmentDistrust of medical establishment
Distrust of researchersDistrust of researchers
Fear of HIV testingFear of HIV testing
Fear of needlesFear of needles
HIV-related stigmaHIV-related stigma
Fear of being identified with a Fear of being identified with a stigmatized groupstigmatized group
What is the role of the CAB in
identifying and resolving ethical
issues?
Identifying Ethical IssuesIdentifying Ethical Issues Ethical issues permeated interviews Ethical issues permeated interviews
with both CAB members and research with both CAB members and research team membersteam members
CABs view themselves as protecting CABs view themselves as protecting vulnerable peoplevulnerable people
Participants and CAB members often Participants and CAB members often from poor or stigmatized groupsfrom poor or stigmatized groups
Respect for Persons --Informed Consent
Respect for Persons --Informed Consent
CABs worked to assure that participants CABs worked to assure that participants had adequate information about had adequate information about procedures and risksprocedures and risks
““People must know what are the People must know what are the consequences and advantages are consequences and advantages are before going into the study”before going into the study”
Problems with Informed Consent Problems with Informed Consent
Emphasis on forms rather than processEmphasis on forms rather than process
Individual autonomy may be a culturally Individual autonomy may be a culturally bound conceptbound concept
CABs see their role as protecting CABs see their role as protecting vulnerable people, rather than individuals vulnerable people, rather than individuals protecting themselvesprotecting themselves
Little discussion of extent to which Little discussion of extent to which participation is voluntary; often viewed participation is voluntary; often viewed no real alternativesno real alternatives
Beneficence --Risk/BenefitsBeneficence --Risk/Benefits
Established CABs have been involved in Established CABs have been involved in debate about risks and benefits of debate about risks and benefits of participation studiesparticipation studies
But emerging CABs have not But emerging CABs have not
HPTN Problem HPTN Problem
CABs identified problem of lack of CABs identified problem of lack of treatment or social support for people treatment or social support for people who are diagnosed with HIV and not who are diagnosed with HIV and not eligible for trialeligible for trial
-- “We open that Pandora’s Box and -- “We open that Pandora’s Box and that person is positive. What then?”that person is positive. What then?”
-- CAB Member-- CAB Member
Distributive Justice Distributive Justice
““Guinea pig” term was used by Guinea pig” term was used by participants or CAB members at 4 sitesparticipants or CAB members at 4 sites
--- “Why is a vaccine study being --- “Why is a vaccine study being conducted in Peru since they might not conducted in Peru since they might not see benefit from it.” see benefit from it.”
--- “Are we being sacrificed in order to --- “Are we being sacrificed in order to develop a better product?”develop a better product?”
International Sites International Sites
Research must be practical for host Research must be practical for host country -- need to leave something country -- need to leave something behind behind
-- “Historically researchers came in, -- “Historically researchers came in, drew blood and left to write their drew blood and left to write their papers.”papers.”
An ExampleAn Example Important debatable question brought to Important debatable question brought to
CAB -- Should participants be give the CAB -- Should participants be give the results of CCR-5 testing?results of CCR-5 testing?
Briefing provided by research team Briefing provided by research team member in lay language with Q & Amember in lay language with Q & A
CAB debates and outlines many reasons CAB debates and outlines many reasons not to give feedbacknot to give feedback
““In the end, the CAB said you’ve got to tell In the end, the CAB said you’ve got to tell people.”people.”
Right to KnowRight to Know
““...the issue wasn’t about can we predict how ...the issue wasn’t about can we predict how people are gonna react, but do people have people are gonna react, but do people have a right to know. ...if you’re testing a right to know. ...if you’re testing something from their bodies … these are something from their bodies … these are not just people who are here for you to draw not just people who are here for you to draw specimens from.”specimens from.”
RecommendationsRecommendations Develop strategies to make CAB meetings Develop strategies to make CAB meetings
more productivemore productive Bring debatable issues to the tableBring debatable issues to the table
Bring participants into meetingsBring participants into meetings
Continuous formal and informal training to Continuous formal and informal training to respond to disparities in knowledgerespond to disparities in knowledge cross site networking for CAB memberscross site networking for CAB members
Train researchers in talking to communityTrain researchers in talking to community
RecommendationsRecommendations
Work with CABs to develop alternative Work with CABs to develop alternative methods of genuine informed consentmethods of genuine informed consent Greater emphasis on processGreater emphasis on process
Increase attention on voluntary participationIncrease attention on voluntary participation
Community building and leadership Community building and leadership training as part of CAB developmenttraining as part of CAB development Before organizing a meeting, may need to Before organizing a meeting, may need to
organize a communityorganize a community
RecommendationsRecommendations
Stipends to support CAB service Stipends to support CAB service Need to remove disincentives Need to remove disincentives
Develop plans for timely feedback of Develop plans for timely feedback of research findings to communitiesresearch findings to communities
Develop plans for sustainabilityDevelop plans for sustainability