Abstract
This paper discusses some of the ethical challenges raised by advanced clinical trials designed to assess the safety and efficacy of vaginal microbicides in protecting women from HIV infection. The ethical principles that guide clinical research involving human subjects require that all participants in such trials be provided available measures known to reduce the risk of HIV infection. However, this will reduce the ability of the study to assess the protective effect of the test microbicide. In addition, providing extensive services to trial participants may be construed as an undue inducement if the study is being conducted among vulnerable groups such as sex workers or women from disadvantaged communities. Suggestions are provided to resolve this dilemma in the planning and implementation of HIV prevention services for trial participants.
Full text
PDFSelected References
These references are in PubMed. This may not be the complete list of references from this article.
- Allen S., Serufilira A., Bogaerts J., Van de Perre P., Nsengumuremyi F., Lindan C., Carael M., Wolf W., Coates T., Hulley S. Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates. JAMA. 1992 Dec 16;268(23):3338–3343. [PubMed] [Google Scholar]
- Allen S., Tice J., Van de Perre P., Serufilira A., Hudes E., Nsengumuremyi F., Bogaerts J., Lindan C., Hulley S. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. BMJ. 1992 Jun 20;304(6842):1605–1609. doi: 10.1136/bmj.304.6842.1605. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Angell M. The ethics of clinical research in the Third World. N Engl J Med. 1997 Sep 18;337(12):847–849. doi: 10.1056/NEJM199709183371209. [DOI] [PubMed] [Google Scholar]
- Asamoah-Adu A., Weir S., Pappoe M., Kanlisi N., Neequaye A., Lamptey P. Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana. AIDS. 1994 Feb;8(2):239–246. doi: 10.1097/00002030-199402000-00012. [DOI] [PubMed] [Google Scholar]
- Barry M. Ethical considerations of human investigation in developing countries: the AIDS dilemma. N Engl J Med. 1988 Oct 20;319(16):1083–1086. doi: 10.1056/NEJM198810203191609. [DOI] [PubMed] [Google Scholar]
- Bhave G., Lindan C. P., Hudes E. S., Desai S., Wagle U., Tripathi S. P., Mandel J. S. Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India. AIDS. 1995 Jul;9 (Suppl 1):S21–S30. [PubMed] [Google Scholar]
- Cates W., Jr, Stewart F. H., Trussell J. Commentary: the quest for women's prophylactic methods--hopes vs science. Am J Public Health. 1992 Nov;82(11):1479–1482. doi: 10.2105/ajph.82.11.1479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Choi K. H., Coates T. J. Prevention of HIV infection. AIDS. 1994 Oct;8(10):1371–1389. doi: 10.1097/00002030-199410000-00003. [DOI] [PubMed] [Google Scholar]
- DiClemente R. J., Wingood G. M. A randomized controlled trial of an HIV sexual risk-reduction intervention for young African-American women. JAMA. 1995 Oct 25;274(16):1271–1276. [PubMed] [Google Scholar]
- Elias C. J., Coggins C. Female-controlled methods to prevent sexual transmission of HIV. AIDS. 1996 Dec;10 (Suppl 3):S43–S51. [PubMed] [Google Scholar]
- Elias C. J., Heise L. L. Challenges for the development of female-controlled vaginal microbicides. AIDS. 1994 Jan;8(1):1–9. doi: 10.1097/00002030-199401000-00002. [DOI] [PubMed] [Google Scholar]
- Farr G., Acosta Castro L. A., DiSantostefano R., Claassen E., Olguin F. Use of spermicide and impact of prophylactic condom use among sex workers in Santa Fe de Bogota, Colombia. Sex Transm Dis. 1996 May-Jun;23(3):206–212. doi: 10.1097/00007435-199605000-00008. [DOI] [PubMed] [Google Scholar]
- Finkelstein M. O., Levin B., Robbins H. Clinical and prophylactic trials with assured new treatment for those at greater risk: I. A design proposal. Am J Public Health. 1996 May;86(5):691–695. doi: 10.2105/ajph.86.5.691. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fox L. J., Bailey P. E., Clarke-Martínez K. L., Coello M., Ordoñez F. N., Barahona F. Condom use among high-risk women in Honduras: evaluation of an AIDS prevention program. AIDS Educ Prev. 1993 Spring;5(1):1–10. [PubMed] [Google Scholar]
- Gostin L. Ethical principles for the conduct of human subject research: population-based research and ethics. Law Med Health Care. 1991 Fall-Winter;19(3-4):191–201. doi: 10.1111/j.1748-720x.1991.tb01814.x. [DOI] [PubMed] [Google Scholar]
- Grinstead O. A. Social and behavioral issues in phase III HIV preventive vaccine trials. AIDS. 1995;9 (Suppl A):S245–S250. [PubMed] [Google Scholar]
- Grosskurth H., Mosha F., Todd J., Mwijarubi E., Klokke A., Senkoro K., Mayaud P., Changalucha J., Nicoll A., ka-Gina G. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995 Aug 26;346(8974):530–536. doi: 10.1016/s0140-6736(95)91380-7. [DOI] [PubMed] [Google Scholar]
- Gupta G. R., Weiss E. Women's lives and sex: implications for AIDS prevention. Cult Med Psychiatry. 1993 Dec;17(4):399–312. doi: 10.1007/BF01379307. [DOI] [PubMed] [Google Scholar]
- Heise L. L., Elias C. Transforming aids prevention to meet women's needs: a focus on developing countries. Soc Sci Med. 1995 Apr;40(7):931–943. doi: 10.1016/0277-9536(94)00165-p. [DOI] [PubMed] [Google Scholar]
- Hira S. K., Feldblum P. J., Kamanga J., Mukelabai G., Weir S. S., Thomas J. C. Condom and nonoxynol-9 use and the incidence of HIV infection in serodiscordant couples in Zambia. Int J STD AIDS. 1997 Apr;8(4):243–250. doi: 10.1258/0956462971919994. [DOI] [PubMed] [Google Scholar]
- Kamenga M., Ryder R. W., Jingu M., Mbuyi N., Mbu L., Behets F., Brown C., Heyward W. L. Evidence of marked sexual behavior change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counselling center in Zaire. AIDS. 1991 Jan;5(1):61–67. doi: 10.1097/00002030-199101000-00009. [DOI] [PubMed] [Google Scholar]
- Kelly J. A., Murphy D. A., Washington C. D., Wilson T. S., Koob J. J., Davis D. R., Ledezma G., Davantes B. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. Am J Public Health. 1994 Dec;84(12):1918–1922. doi: 10.2105/ajph.84.12.1918. [DOI] [PMC free article] [PubMed] [Google Scholar]
- King R., Allen S., Serufilira A., Karita E., Van de Perre P. Voluntary confidential HIV testing for couples in Kigali, Rwanda. AIDS. 1993 Oct;7(10):1393–1394. doi: 10.1097/00002030-199310000-00018. [DOI] [PubMed] [Google Scholar]
- Laga M., Alary M., Nzila N., Manoka A. T., Tuliza M., Behets F., Goeman J., St Louis M., Piot P. Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers. Lancet. 1994 Jul 23;344(8917):246–248. doi: 10.1016/s0140-6736(94)93005-8. [DOI] [PubMed] [Google Scholar]
- Levine Carol, Dubler Nancy Neveloff, Levine Robert J. Building a new consensus: ethical principles and policies for clinical research on HIV/AIDS. IRB. 1991 Jan-Apr;13(1-2):1–17. [PubMed] [Google Scholar]
- Lurie P., Bishaw M., Chesney M. A., Cooke M., Fernandes M. E., Hearst N., Katongole-Mbidde E., Koetsawang S., Lindan C. P., Mandel J. Ethical, behavioral, and social aspects of HIV vaccine trials in developing countries. JAMA. 1994 Jan 26;271(4):295–301. [PubMed] [Google Scholar]
- Lurie P., Wolfe S. M. Unethical trials of interventions to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Engl J Med. 1997 Sep 18;337(12):853–856. doi: 10.1056/NEJM199709183371212. [DOI] [PubMed] [Google Scholar]
- Melton G. B., Levine R. J., Koocher G. P., Rosenthal R., Thompson W. C. Community consultation in socially sensitive research. Lessons from clinical trials of treatments for AIDS. Am Psychol. 1988 Jul;43(7):573–581. doi: 10.1037//0003-066x.43.7.573. [DOI] [PubMed] [Google Scholar]
- Padian N. S., O'Brien T. R., Chang Y., Glass S., Francis D. P. Prevention of heterosexual transmission of human immunodeficiency virus through couple counseling. J Acquir Immune Defic Syndr. 1993 Sep;6(9):1043–1048. [PubMed] [Google Scholar]
- Rojanapithayakorn W., Hanenberg R. The 100% condom program in Thailand. AIDS. 1996 Jan;10(1):1–7. doi: 10.1097/00002030-199601000-00001. [DOI] [PubMed] [Google Scholar]
- Rowe P. M. Nonoxynol-9 fails to protect against HIV-1. Lancet. 1997 Apr 12;349(9058):1074–1074. doi: 10.1016/S0140-6736(05)62299-4. [DOI] [PubMed] [Google Scholar]
- Stein Z. A. HIV prevention: the need for methods women can use. Am J Public Health. 1990 Apr;80(4):460–462. doi: 10.2105/ajph.80.4.460. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sweat M. D., Denison J. A. Reducing HIV incidence in developing countries with structural and environmental interventions. AIDS. 1995;9 (Suppl A):S251–S257. [PubMed] [Google Scholar]
- Tawil O., Verster A., O'Reilly K. R. Enabling approaches for HIV/AIDS prevention: can we modify the environment and minimize the risk? AIDS. 1995 Dec;9(12):1299–1306. [PubMed] [Google Scholar]
- Varmus H., Satcher D. Ethical complexities of conducting research in developing countries. N Engl J Med. 1997 Oct 2;337(14):1003–1005. doi: 10.1056/NEJM199710023371411. [DOI] [PubMed] [Google Scholar]
- Visrutaratna S., Lindan C. P., Sirhorachai A., Mandel J. S. 'Superstar' and 'model brothel': developing and evaluating a condom promotion program for sex establishments in Chiang Mai, Thailand. AIDS. 1995 Jul;9 (Suppl 1):S69–S75. [PubMed] [Google Scholar]
- Williams E., Lamson N., Efem S., Weir S., Lamptey P. Implementation of an AIDS prevention program among prostitutes in the Cross River State of Nigeria. AIDS. 1992 Feb;6(2):229–230. [PubMed] [Google Scholar]
- Zekeng L., Feldblum P. J., Oliver R. M., Kaptue L. Barrier contraceptive use and HIV infection among high-risk women in Cameroon. AIDS. 1993 May;7(5):725–731. doi: 10.1097/00002030-199305000-00018. [DOI] [PubMed] [Google Scholar]
- de Zoysa I., Sweat M. D., Denison J. A. Faithful but fearful: reducing HIV transmission in stable relationships. AIDS. 1996;10 (Suppl A):S197–S203. [PubMed] [Google Scholar]