The ethics of research in developing countries

Informed recruitment in partner studies of HIV transmission: an ethical issue in couples research

BACKGROUND

Much attention has been devoted to ethical issues related to randomized controlled trials for HIV treatment and prevention. However, there has been less discussion of ethical issues surrounding families involved in observational studies of HIV transmission. This paper describes the process of ethical deliberation about how best to obtain informed consent from sex partners of injection drug users (IDUs) tested for HIV, within a recent HIV study in Eastern Europe. The study aimed to assess the amount of HIV serodiscordance among IDUs and their sexual partners, identify barriers to harm reduction, and explore ways to optimize intervention programs. Including IDUs, either HIV-positive or at high risk for HIV, and their sexual partners would help to gain a more complete understanding of barriers to and opportunities for intervention.

DISCUSSION

This paper focuses on the ethical dilemma regarding informed recruitment: whether researchers should disclose to sexual partners of IDUs that they were recruited because their partner injects drugs (i.e., their heightened risk for HIV). Disclosing risks to partners upholds the ethical value of respect for persons through informed consent. However, disclosure compromises the IDU's confidentiality, and potentially, the scientific validity of the research. Following a brief literature review, we summarize the researchers' systematic evaluation of this issue from ethical, scientific, and logistical perspectives. While the cultural context may be somewhat unique to Eastern Europe and Central Asia, the issues raised and solutions proposed here inform epidemiological research designs and their underlying ethical tensions.

SUMMARY

We present ethical arguments in favor of disclosure, discuss how cultural context shapes the ethical issues, and recommend refinement of guidance for couples research of communicable diseases to assist investigators encountering these ethical issues in the future.

Ethical, legal, and social issues related to genomics and cancer research: the impending crisis

Cancer research is a multibillion-dollar enterprise validated by the clinical trial process and increasingly defined by genomics. The continued success of the endeavor depends on the smooth functioning of the clinical trial system, which in turn depends on human subject participation. Yet human subject participation can exist only in an atmosphere of trust between research participants and research sponsors, and the advent of genomics has raised a multitude of ethical, legal, and social issues that threaten this trust. The authors examine 6 of these issues: (1) informed consent; (2) privacy, confidentiality, and family disclosure dilemmas; (3) property rights in genomic discoveries; (4) individual and institutional conflicts of interest; (5) insurance and employment issues; and (6) litigation under the federal False Claims Act. The authors conclude that failure to resolve these issues may lead to a sufficient impairment of trust in genomics-based clinical trials on the part of potential research participants that the clinical trial system may implode for lack of willing participants, thus threatening the future of cancer research.

New malaise: bioethics and human rights in the global era

Recent transnational HIV research projects have raised questions about the ethics of research in developing countries, and with good reason. Lower ethical standards are often applied in these settings, yet the field of bioethics has remained relatively quiet on the subject, concerning itself primarily with issues that only affect affluent countries. Here we call for a new focus on equity and human rights in bioethics.

Generalizability of population-based studies on AIDS: a comparison of newly and continuously surveyed villages in rural southwest Uganda

BACKGROUND

Population-based studies are thought to provide generalizable epidemiological data on the human immunodeficiency virus type 1 (HIV-1) epidemic. However, longitudinal studies are susceptible to bias from added attention caused by study activities. We compare HIV-1 prevalence in previously and newly surveyed villages in rural southwest Uganda.

METHODS

The study population resided in 25 neighbouring villages, of which 15 have been surveyed for 10 years. Respondents (>/=13 years) provided socio-demographic and sexual behaviour data and a blood sample for HIV-1 serology in private after informed consent. We tested the independent effect of residency: (1) original versus new villages; (2) proximity to main road; and (3) proximity to trading centre on HIV-1 serostatus of respondents using multivariate logistic regression.

RESULTS

There were 8,990 adults censused, 68.3% were from the original villages, 48.2% were males and 6111 (68.0%) were interviewed and had definite HIV-1 serostatus. The HIV-1 prevalence was 6.1% overall, 5.7% in the new, and 6.4% in the original villages (P = 0.25). Residency in the new or original villages did not independently predict HIV-1 serostatus of respondents (P = 0.46). Independent predictors of HIV-1 serostatus were education (primary or higher, odds ratio [OR] = 1.7 and 1.4, respectively), being separated or widowed OR = 4.2, reported previous use of a condom OR = 1.8, or reported genital ulceration OR = 3.3, and age group 25-34 and 35-44 years OR = 5.8 and OR = 4.8 (all P </= 0.001).

CONCLUSIONS

In the context of rural Uganda where there has been considerable health education about AIDS, the additional attention to HIV infection caused by this longitudinal study does not appear to have appreciably affected the prevalence of HIV-1 infection.