Ethics and International Collaborations

1. Ethics and International Collaborations Jeremy Sugarman, MD, MPH, MA Harvey M. Meyerhoff Professor of Bioethics & Medicine Berman Institute of Bioethics and Department of Medicine Johns Hopkins University Baltimore, Maryland USA

2. Multinational Clinical Research *Mean cost of Ph I-III. Gale Group, 2006. • Registration • Participation rates • Treatment naïve populations • Research costs* • US: $125 million • India: $70 million • Meet global health care needs

3. A Growing Epidemic Baltimore Sun, 11-22-06 • 39.5 million people infected with HIV • In 2006 • 2.9 million people died of AIDS related illnesses • 4.3 million people were infected with HIV

4. UNAIDS 2006 Report on the Global AIDS Epidemic

5. Efforts Scandalized • Popular culture • The Constant Gardner • Popular media • Washington Post series: The Body Hunters • Professional journals • NEJM concerning placebo-controls in the vertical transmission of HIV

6. Overview • Using data to inform debates and policy • Perspectives on multinational collaboration • Ethics guidance for research

7. An Empirical Imperative Lavori, Controlled Clinical Trials 1999; 20:187-193. Clinical research is predicated on the notion that we need data to determine ‘truth’ and facilitate sound decision-making Ironically, methods of clinical research, including those designed to protect participants such as conclusions about appropriate trial design in particular cases and informed consent, are introduced without data regarding safety or efficacy Where relevant we need to evaluate these protections as we would any proposed clinical intervention

8. Ethical Oversight • Multiple bodies recognize the need for guidelines • World Medical Association • CIOMS • International Conference on Harmonization • Nuffield Trust • National Bioethics Advisory Commission • Lack of consensus and conflicting guidance

9. International Perspectives on Protecting Human Subjects Jeremy Sugarman, MD, MPH, MA Benjamin Popkin, JD, MPH Judith Fortney, PhD Roberto Rivera, MD [ISBN 1-931022-14-3]. Bethesda, MD: National Bioethics Advisory Commission, May 2001, E1-30.

10. Empirical Projects to Inform NBAC’s Deliberations Ethnographic study Quantitative survey Focused site visits

11. Focused Site Visits Chile Guatemala Haiti Kenya Mexico Taiwan Thailand United Kingdom

12. Process • Key respondent in each site • Identify others with relevant experience and knowledge • Investigators • IRB members (local, regional, and national) • Persons who obtain informed consent • Oral informed consent • Standardized discussion guidelines

13. Discussion Guidelines Experiences with US regulations regarding research (e.g., how they function, who carries them out, and the relevance of standard US elements of informed consent) How US regulations correspond to international investigators’ own moral rules and how situations of conflict are reconciled Recommendations for changes or improvements in current US regulations and research practices

14. Analysis • Qualitative analysis • Site visit reports • Group debriefing sessions • Domains • Informed Consent • Institutional Review Boards • Justice • Research Design • Contrasting Approaches to Oversight • Trust

15. Overall Findings There is a high degree of commitment to conducting ethically sound research. There is much consonance between the values of international researchers and US guidelines. When there is discordance, local researchers and IRB members tended to see these as opportunities for negotiation and compromise. However, their well intentioned offers for negotiation and compromise can be met with a lack of trust.

16. On the Review Process The review process is rather burdensome – time consuming and often quite difficult, despite its importance in doing research. The specific procedures outlined in US regulations regarding how this review should take place and be documented posed substantial challenges due to staffing, space, and resources. It is sometimes perceived that there is almost no flexibility in the face of cultural variability.

17. On Informed Consent There was widespread concern that US regulations regarding informed consent place undue emphasis on detailed documentation formulated to serve foreign rather than local needs

18. Recommendations to NBAC • Work with local colleagues to make the research relevant to local issues and priorities. • In designing research, assess whether there are any relevant cultural barriers (such as whether placebos are culturally appropriate) to conducting it in a given location. • Develop informed consent documents in collaboration with local colleagues paying particular attention to potential problems in translation of particular concepts.

19. Recommendations to NBAC • Exercise a degree of flexibility with regard to written consent documents which might be awkward for research participants unaccustomed to receiving documentation of any important transaction. • Develop means of simplifying requirements for documentation that retain the ability to audit, both for the oversight of research (initial review, direct oversight, and continuing review) and for informed consent.

20. Recommendations to NBAC • Consider having a local ombudsman available to answer subjects’ concerns about the study as well as their rights as research subjects. • Encourage international discussion about the role of trusting the integrity of local investigators and those charged with the oversight of research to adopt and enforce mechanisms for ensuring that the rights and interests of human subjects are protected.

21. Recommendations to NBAC • Provide education and training for local investigators and IRB members about US regulatory requirements that includes information about the rationale for them.

22. Incorporating Findings Design research in accord with local priorities Distinguish substance and procedures of obtaining informed consent Culturally appropriate means of disclosure Support research about appropriate mechanisms of obtaining consent Consult with community leaders while recognizing the individuals involved Waivers for written documentation of consent for minimal risk research

23. Evolving Science, Evolving Guidance Research in HIV prevention and treatment is associated with an array of ethical issues Guidance, rhetoric, and scholarship have been responsive to both successes and failures Unfortunately, these efforts may conflict and/or may be inadequately sufficiently sensitive to facts and nuance

25. Format 15 guidance points span the continuum of research Unlike other guidance documents, some of the points are morally required, while others are aspirational, reflecting the realities and constraints inherent to practice Each point identifies those accountable for it

26. Before Research Ensuring high-quality scientific and ethical research Setting research objectives and priorities Engaging communities Building local capacity and partnerships Ethical issues in study design Consent, assent, permission and re-consent Addressing vulnerabilities Ethical review of research

27. During Research Standard of prevention Standards of care and treatment Independent data safety and monitoring

28. After Research Disseminating research results Sustaining capacity-building and infrastructure into the future Continuing care for research participants Provision of successful research interventions

29. Concluding Comments International collaborative research will involve practical and ethical challenges Explicit deliberation, informed where possible by data, about these issues across the continuum of research promises to enhance collaborations