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Molldrem S, Smith AKJ. Health policy counterpublics: Enacting collective resistances to US molecular HIV surveillance and cluster detection and response programs. SOCIAL STUDIES OF SCIENCE 2024; 54:451-477. [PMID: 38054426 PMCID: PMC11118791 DOI: 10.1177/03063127231211933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Health policies and the problems they constitute are deeply shaped by multiple publics. In this article we conceptualize health policy counterpublics: temporally bounded socio-political forms that aim to cultivate particular modes of conduct, generally to resist trajectories set by arms of the state. These counterpublics often emerge from existing social movements and involve varied forms of activism and advocacy. We examine a health policy counterpublic that has arisen in response to new forms of HIV public health surveillance by drawing on public documents and interview data from 2021 with 26 stakeholders who were critical of key policy developments. Since 2018, the national rollout of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs in the United States has produced sustained controversies among HIV stakeholders, including among organized networks of people living with HIV. This article focuses on how a health policy counterpublic formed around MHS/CDR and how constituents problematized the policy agenda set in motion by federal health agencies, including in relation to data ethics, the meaningful involvement of affected communities, informed consent, the digitization of health systems, and HIV criminalization. Although familiar problems in HIV policymaking, concerns about these issues have been reconfigured in response to the new sociotechnical milieu proffered by MHS/CDR, generating new critical positions aiming to remake public health. Critical attention to the scenes within which health policy controversies play out ought to consider how (counter)publics are made, how problems are constituted, and the broader social movement dynamics and activist resources drawn upon to contest and reimagine policymaking in public life.
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Schuster ALR, Bollinger J, Geller G, Little SJ, Mehta SR, Sanchez T, Sugarman J, Bridges JFP. Prioritization of ethical concerns regarding HIV molecular epidemiology by public health practitioners and researchers. BMC Public Health 2024; 24:1436. [PMID: 38811963 PMCID: PMC11137925 DOI: 10.1186/s12889-024-18881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND HIV molecular epidemiology (HIV ME) can support the early detection of emerging clusters of new HIV infections by combining HIV sequence data routinely obtained during the clinical treatment of people living with HIV with behavioral, geographic, and sociodemographic information. While information about emerging clusters promises to facilitate HIV prevention and treatment efforts, the use of this data also raises several ethical concerns. We sought to assess how those working on the frontlines of HIV ME, specifically public health practitioners (PHPs) and researchers, prioritized these issues. METHODS Ethical issues were identified through literature review, qualitative in-depth interviews, and stakeholder engagement. PHPs and researchers using HIV ME prioritized the issues using best-worst scaling (BWS). A balanced incomplete block design was used to generate 11 choice tasks each consisting of a sub-set of 5 ethical concerns. In each task, respondents were asked to assess the most and least concerning issue. Data were analyzed using conditional logit, with a Swait-Louviere test of poolability. Latent class analysis was then used to explore preference heterogeneity. RESULTS In total, 57 respondents completed the BWS experiment May-June 2023 with the Swait-Louviere test indicating that researchers and PHPs could be pooled (p = 0.512). Latent class analysis identified two classes, those highlighting "Harms" (n = 29) (prioritizing concerns about potential risk of legal prosecution, individual harm, and group stigma) and those highlighting "Utility" (n = 28) (prioritizing concerns about limited evidence, resource allocation, non-disclosure of data use for HIV ME, and the potential to infer the directionality of HIV transmission). There were no differences in the characteristics of members across classes. CONCLUSIONS The ethical issues of HIV ME vary in importance among stakeholders, reflecting different perspectives on the potential impact and usefulness of the data. Knowing these differences exist can directly inform the focus of future deliberations about the policies and practices of HIV ME in the United States.
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Affiliation(s)
- Anne L R Schuster
- Department of Biomedical Informatics, The Ohio State University College of Medicine, 1800 Cannon Drive, Columbus, OH, 43016, USA.
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Susan J Little
- Division of Infectious Disease, University of California San Diego, San Diego, CA, USA
| | - Sanjay R Mehta
- Division of Infectious Disease, University of California San Diego, San Diego, CA, USA
| | - Travis Sanchez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, 1800 Cannon Drive, Columbus, OH, 43016, USA
- Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Molldrem S, Smith AKJ, Subrahmanyam V. Toward Consent in Molecular HIV Surveillance?: Perspectives of Critical Stakeholders. AJOB Empir Bioeth 2024; 15:66-79. [PMID: 37768111 DOI: 10.1080/23294515.2023.2262967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND The emergence of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs as key features of the United States (US) HIV strategy since 2018 has caused major controversies. HIV surveillance programs that re-use individuals' routinely collected clinical HIV data do not require consent on the basis that the public benefit of these programs outweighs individuals' rights to opt out. However, criticisms of MHS/CDR have questioned whether expanded uses of HIV genetic sequence data for prevention reach beyond traditional public health ethics frameworks. This study aimed to explore views on consent within MHS/CDR among critical stakeholders. METHODS In 2021 we interviewed 26 US HIV stakeholders who identified as being critical or concerned about the rollout of MHS/CDR. Stakeholders included participants belonging to networks of people living with HIV, other advocates, academics, and public health professionals. This analysis focused on identifying the range of positions among critical and concerned stakeholders on consent affordances, opt-outs, how to best inform people living with HIV about how data about them are used in public health programs, and related ethical issues. RESULTS Participants were broadly supportive of introducing some forms of consent into MHS/CDR. However, they differed on the specifics of implementing consent. While some participants did not support introducing consent affordances, all supported the idea that people living with HIV should be informed about how HIV surveillance and prevention is conducted and how individuals' data are used. CONCLUSIONS MHS/CDR has caused sustained controversy. Among critical stakeholders, consent is generally desirable but contested, although the right for people living with HIV to be informed was centrally supported. In an era of big data-driven public health interventions and routine uses of HIV genetic sequence data in surveillance and prevention, CDC and other agencies should revisit public health ethics frameworks and consider the possibility of consent processes.
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Affiliation(s)
- Stephen Molldrem
- Institute for Bioethics and Health Humanities, The University of Texas Medical Branch, Galveston, TX, USA
| | - Anthony K J Smith
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Vishnu Subrahmanyam
- Institute for Bioethics and Health Humanities, The University of Texas Medical Branch, Galveston, TX, USA
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Molldrem S, Bagani S, Subrahmanyam V, Permar R, Matsiri O, Caiphus C, Kizito B, Modongo C, Shin SS. Botswana tuberculosis (TB) stakeholders broadly support scaling up next-generation whole genome sequencing: Ethical and practical considerations for Botswana and global health. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002479. [PMID: 37967081 PMCID: PMC10651001 DOI: 10.1371/journal.pgph.0002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 11/17/2023]
Abstract
Global health agencies are increasingly promoting the scale-up of next-generation whole genome sequencing (NG-WGS) of pathogens into infectious disease control programs, including for tuberculosis (TB). However, little is known about how stakeholders in low-to-middle income countries (LMICs) understand the ethics, benefits, and risks of these proposals. We conducted a qualitative study in Greater Gaborone, Botswana to learn how TB stakeholders there viewed a potential scale-up of NG-WGS into Botswana's TB program. We conducted 30 interviews and four deliberative dialogues with TB stakeholders based in Greater Gaborone, the country's largest city and capital. We created and showed participants an animated video series about a fictional family that experienced TB diagnosis, treatment, contact tracing, and data uses that were informed by NG-WGS. We analyzed transcripts using reflexive thematic analysis. We found broad support for the scale-up of TB NG-WGS in Botswana, owing to perceived benefits. Support was qualified with statements about ensuring adequate planning, resource-allocation, community and stakeholder engagement, capacity-building, and assessing ethical norms around publishing data. Our results suggest that scaling up NG-WGS for TB in Botswana would be supported by stakeholders there, contingent upon the government and other entities adequately investing in the initiative. These findings are relevant to other LMICs considering scale-ups of NG-WGS and related technologies for infectious diseases and suggest the need for sustained research into the acceptability of pathogen sequencing in other contexts.
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Affiliation(s)
- Stephen Molldrem
- Institute for Bioethics and Health Humanities, University of Texas Medical Branch, Galveston, Texas, United States of America
| | | | - Vishnu Subrahmanyam
- Institute for Bioethics and Health Humanities, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Rebecca Permar
- Program for Leadership and Character, Office of Academic Advising, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | | | | | | | | | - Sanghyuk S. Shin
- Sue & Bill Gross School of Nursing, University of California, Irvine, California, United States of America
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Garcia M, Devlin S, Kerman J, Fujimoto K, Hirschhorn LR, Phillips II G, Schneider J, McNulty MC. Ending the HIV Epidemic: Identifying Barriers and Facilitators to Implement Molecular HIV Surveillance to Develop Real-Time Cluster Detection and Response Interventions for Local Communities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3269. [PMID: 36833963 PMCID: PMC9964218 DOI: 10.3390/ijerph20043269] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 06/18/2023]
Abstract
The rapid implementation of molecular HIV surveillance (MHS) has resulted in significant challenges for local health departments to develop real-time cluster detection and response (CDR) interventions for priority populations impacted by HIV. This study is among the first to explore professionals' strategies to implement MHS and develop CDR interventions in real-world public health settings. Methods: Semi-structured qualitative interviews were completed by 21 public health stakeholders in the United States' southern and midwestern regions throughout 2020-2022 to identify themes related to the implementation and development of MHS and CDR. Results for the thematic analysis revealed (1) strengths and limitations in utilizing HIV surveillance data for real-time CDR; (2) limitations of MHS data due to medical provider and staff concerns related to CDR; (3) divergent perspectives on the effectiveness of partner services; (4) optimism, but reluctance about the social network strategy; and (5) enhanced partnerships with community stakeholders to address MHS-related concerns. Conclusions: Enhancing MHS and CDR efforts requires a centralized system for staff to access public health data from multiple databases to develop CDR interventions; designating staff dedicated to CDR interventions; and establishing equitable meaningful partnerships with local community stakeholders to address MHS concerns and develop culturally informed CDR interventions.
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Affiliation(s)
- Moctezuma Garcia
- Department of Social Work, College of Health & Sciences, San José State University, San Jose, CA 95112, USA
| | - Samantha Devlin
- The Chicago Center for HIV Elimination, University of Chicago, Chicago, IL 60637, USA
| | - Jared Kerman
- The Chicago Center for HIV Elimination, University of Chicago, Chicago, IL 60637, USA
| | - Kayo Fujimoto
- Department of Health Promotion & Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX 77030, USA
| | - Lisa R. Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Gregory Phillips II
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - John Schneider
- The Chicago Center for HIV Elimination, University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Moira C. McNulty
- The Chicago Center for HIV Elimination, University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Buchbinder M, Juengst E, Rennie S, Blue C, Rosen DL. Advancing a Data Justice Framework for Public Health Surveillance. AJOB Empir Bioeth 2022; 13:205-213. [PMID: 35442141 PMCID: PMC10777676 DOI: 10.1080/23294515.2022.2063997] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Bioethical debates about privacy, big data, and public health surveillance have not sufficiently engaged the perspectives of those being surveilled. The data justice framework suggests that big data applications have the potential to create disproportionate harm for socially marginalized groups. Using examples from our research on HIV surveillance for individuals incarcerated in jails, we analyze ethical issues in deploying big data in public health surveillance. METHODS We conducted qualitative, semi-structured interviews with 24 people living with HIV who had been previously incarcerated in county jails about their perspectives on and experiences with HIV surveillance, as part of a larger study to characterize ethical considerations in leveraging big data techniques to enhance continuity of care for incarcerated people living with HIV. RESULTS Most participants expressed support for the state health department tracking HIV testing results and viral load data. Several viewed HIV surveillance as a violation of privacy, and several had actively avoided contact from state public health outreach workers. Participants were most likely to express reservations about surveillance when they viewed the state's motives as self-interested. Perspectives highlight the mistrust that structurally vulnerable people may have in the state's capacity to act as an agent of welfare. Findings suggest that adopting a nuanced, context-sensitive view on surveillance is essential. CONCLUSIONS Establishing trustworthiness through interpersonal interactions with public health personnel is important to reversing historical legacies of harm to racial minorities and structurally vulnerable groups. Empowering stakeholders to participate in the design and implementation of data infrastructure and governance is critical for advancing a data justice agenda, and can offset privacy concerns. The next steps in advancing the data justice framework in public health surveillance will be to innovate ways to represent the voices of structurally vulnerable groups in the design and governance of big data initiatives.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, Center for Bioethics, UNC—Chapel Hill
| | - Eric Juengst
- Department of Social Medicine, Center for Bioethics, UNC—Chapel Hill
| | - Stuart Rennie
- Department of Social Medicine, Center for Bioethics, UNC—Chapel Hill
| | - Colleen Blue
- Institute for Global Health and Infectious Diseases, UNC—Chapel Hill
| | - David L. Rosen
- Division of Infectious Diseases, Department of Medicine, UNC—Chapel Hill
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Rich SN, Richards VL, Mavian CN, Switzer WM, Rife Magalis B, Poschman K, Geary S, Broadway SE, Bennett SB, Blanton J, Leitner T, Boatwright JL, Stetten NE, Cook RL, Spencer EC, Salemi M, Prosperi M. Employing Molecular Phylodynamic Methods to Identify and Forecast HIV Transmission Clusters in Public Health Settings: A Qualitative Study. Viruses 2020; 12:E921. [PMID: 32842636 PMCID: PMC7551766 DOI: 10.3390/v12090921] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 01/19/2023] Open
Abstract
Molecular HIV surveillance is a promising public health strategy for curbing the HIV epidemic. Clustering technologies used by health departments to date are limited in their ability to infer/forecast cluster growth trajectories. Resolution of the spatiotemporal dynamics of clusters, through phylodynamic and phylogeographic modelling, is one potential strategy to develop a forecasting tool; however, the projected utility of this approach needs assessment. Prior to incorporating novel phylodynamic-based molecular surveillance tools, we sought to identify possible issues related to their feasibility, acceptability, interpretation, and utility. Qualitative data were collected via focus groups among field experts (n = 17, 52.9% female) using semi-structured, open-ended questions. Data were coded using an iterative process, first through the development of provisional themes and subthemes, followed by independent line-by-line coding by two coders. Most participants routinely used molecular methods for HIV surveillance. All agreed that linking molecular sequences to epidemiological data is important for improving HIV surveillance. We found that, in addition to methodological challenges, a variety of implementation barriers are expected in relation to the uptake of phylodynamic methods for HIV surveillance. The participants identified several opportunities to enhance current methods, as well as increase the usability and utility of promising works-in-progress.
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Affiliation(s)
- Shannan N. Rich
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA; (V.L.R.); (N.E.S.); (R.L.C.); (M.P.)
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
| | - Veronica L. Richards
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA; (V.L.R.); (N.E.S.); (R.L.C.); (M.P.)
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
| | - Carla N. Mavian
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - William M. Switzer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30322, USA; (W.M.S.); (K.P.)
| | - Brittany Rife Magalis
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Karalee Poschman
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30322, USA; (W.M.S.); (K.P.)
- Florida Department of Health, Division of Disease Control and Health Protection, Bureau of Communicable Diseases, HIV/AIDS Section, Tallahassee, FL 32399, USA; (S.E.B.); (E.C.S.)
| | - Shana Geary
- Division of Public Health, Injury and Violence Prevention Branch, North Carolina Department of Health and Human Services, Raleigh, NC 27699, USA;
| | - Steven E. Broadway
- Florida Department of Health, Division of Disease Control and Health Protection, Bureau of Communicable Diseases, HIV/AIDS Section, Tallahassee, FL 32399, USA; (S.E.B.); (E.C.S.)
| | - Spencer B. Bennett
- Florida Department of Health, Bureau of Public Health Laboratories, Jacksonville, FL 32202, USA; (S.B.B.); (J.B.)
| | - Jason Blanton
- Florida Department of Health, Bureau of Public Health Laboratories, Jacksonville, FL 32202, USA; (S.B.B.); (J.B.)
| | - Thomas Leitner
- Theoretical Biology & Biophysics Group, Los Alamos National Laboratory, Los Alamos, NM 87545, USA;
| | - J. Lucas Boatwright
- Department of Plant and Environmental Sciences, Clemson University, Clemson, SC 29634, USA;
- Advanced Plant Technology Program, Clemson University, Clemson, SC 29634, USA
| | - Nichole E. Stetten
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA; (V.L.R.); (N.E.S.); (R.L.C.); (M.P.)
| | - Robert L. Cook
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA; (V.L.R.); (N.E.S.); (R.L.C.); (M.P.)
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
| | - Emma C. Spencer
- Florida Department of Health, Division of Disease Control and Health Protection, Bureau of Communicable Diseases, HIV/AIDS Section, Tallahassee, FL 32399, USA; (S.E.B.); (E.C.S.)
| | - Marco Salemi
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA; (C.N.M.); (B.R.M.); (M.S.)
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA; (V.L.R.); (N.E.S.); (R.L.C.); (M.P.)
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