Community involvement in UK-based clinical research on HIV vaccines, microbicides and other new prevention technologies Julian Meldrum – www.julian-meldrum.net
Questions for discussion • What kinds of community involvement are possible, desirable or necessary, especially here in the UK? • When to separate and when to mix vaccines, microbicides, PEP? • What forums or other organisational structures exist now or should be developed to support UK community involvement?
Defining community • “Community is the group of people who will participate in or are likely to be affected by or have an influence on the conduct of the research.” – Community Working Group of the US-funded HIV Prevention Trials Network (www.hptn.org)
UK clinical trials • Phase I (no UK Phase III) but on scale too large to recruit from health staff and academic community alone • Multi-sponsor (MRC, IAVI, EuroVac) • Multi-centre (London, Oxford, Wales) • Overlaps between vaccine and microbicide trial research teams • Further trials overseas (Africa, Asia?)
Models for UK involvement in HIV prevention research • Outreach to potential trial volunteers • Mobilising to advocate for new prevention methods • Monitoring impact of (perceived) new technologies on HIV prevention efforts (gay men, African communities in UK) • Options for ‘community expert’ and trial volunteer input to research process, e.g. on standards of care
Vaccines vs Microbicides • Both sexes vs women as volunteers? • One-off trial participation vs option to volunteer for a series of trials? • Level of active participation needed? • Level of involvement of positive people: different underlying reasons? • Stage of development (components vs formulated products)?
Vaccines + Microbicides • Prospect of partial efficacy and testing in combination with other prevention methods = complex messages • Potential impact on future treatment and/or prevention options for individuals and communities • Potential social hazards for ‘low risk’ Phase I volunteers due to HIV stigma
Use of ARVs in prevention • Post-exposure prophylaxis – could be made available now but RCT not possible; economics & logistics? • Pre-exposure prophylaxis (tenofovir) –RCT possible and essential; issues of targeting, economics & logistics? • Use in microbicides – tenofovir, NNRTIs: need to target HIV-ve users, evaluate resistance risks, logistics?
Community Advisory Boards • Driven by needs of Phase III trials, where role is: • Liaison between community and researchers. • Advise [on] the development and implementation of research. • Identify potential research ideas. (HIV Prevention Trials Network)
What is the role for a UK Community Advisory Board? • Clearly, not to prepare for a Phase III trial. So is it needed at all? • This presentation sets out the case for an important role which needs to be differentiated, however, from those of other forums for community involvement in HIV prevention technology research
Outreach and trial volunteer support (1 of 3) • Recruiting volunteers to a small one-off trial is possible without reference to community or volunteer experience • Recruiting thousands for a research programme over several years is unlikely to be possible without serious attention to community issues and the volunteers’ experience in the trials
Outreach and trial volunteer support (2 of 3) • Trial investigators must be responsible for volunteer recruitment, retention and support • However, a media, outreach and volunteer support strategy for each trial/trial series could benefit from access to a Community Advisory Board that includes past trial volunteers and HIV community groups
Outreach and trial volunteer support (3 of 3) • Volunteers should be encouraged to see themselves as part of a process beyond the immediate trial; they should be able to comment on their experiences of involvement (positive as well as negative) and be given an opportunity to be kept informed about the research after the trial
Mobilising communities for advocacy (1 of 2) • Advocacy issues related to microbicides, vaccines and use of ARVs for prevention are distinct and may be best kept separate • Advocacy needs alter as options move nearer to adoption in practice (or appear to move away, with greater awareness of technical challenges)
Mobilising communities for advocacy (2 of 2) • The existence of the UK Campaign for Microbicides does not reduce the need for a CAB to consider trial design, volunteer support, etc • Such campaigns and any CAB would need to exchange information on a regular basis but separating out the roles is mutually beneficial
Monitoring impacts on HIV prevention • Existing forums (CHAPS, African HIV Prevention Network) are the best place to discuss these issues • The THT ‘Expert Seminar’ model which invites stakeholders to discuss an issue is the best pattern for now • A CAB and campaign groups can and should help to identify issues to discuss and take to those forums
Proposal for UK-CAB • The proposal is, that the UK-CAB should extend its work on treatment research and access to cover research on HIV prevention technologies – in a well-defined and sustainable way, taking full account of the existence and need for other forums for community involvement
Proposal for UK-CAB • Use of ARVs for prevention is an obvious area for the UK-CAB to explore, as it builds on the experience of treatment advocates in relation to the use of ARVs for treatment. In fact, the relationship is so close that it might best be integrated with other work on ARVs.
Proposal for UK-CAB • Microbicide trials are already recruiting HIV positive women for initial safety and acceptability studies. It is obviously appropriate for the UK CAB to be considering the need for training and support to those involved in that process. The use of ARVs as microbicides could further strengthen the case for UK CAB involvement.
Proposal for UK-CAB • While there is important UK-based HIV vaccine research, it may be at a greater remove from direct clinical application than ARV or microbicide prevention research • However, there is real value for both community organisations and researchers in having a dialogue …
Proposal for UK-CAB • Issues for UK trials may include: • Media strategy to place trials in broader context and prevent damaging hype • Rationale for (not) pursuing potential therapeutic use in HIV positive people • Communicating other exclusion criteria • Managing seropositivity (if applicable) • Reviewing protocols and volunteer info, including feedback options during/after trial