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Informed recruitment in partner studies of HIV transmission: an ethical issue in couples research
© McNutt et al; licensee BioMed Central Ltd. 2009
Received: 16 October 2008
Accepted: 27 August 2009
Published: 27 August 2009
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.
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.
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.
An estimated 33 million people are infected with HIV worldwide, including about 2.5 million newly infected in the past year.  Efforts to curb HIV transmission address a host of social, cultural, and clinical issues through important and diverse research studies to improve prevention and intervention methods. While much attention has been paid to the research ethics surrounding clinical trials of HIV treatment and prevention, [2–20] less discussion has focused on observational studies of HIV transmission involving sex partners. Couples research is crucial to intervention development and raises unique ethical dilemmas that are not specifically addressed by regulations, laws, and ethical standards [2–4, 21–23].
In couples research, the primary ethical tension entails balancing the risks and benefits to the participating individuals, to the couple, and to society. Complicating the issue, the investigators' ability to conduct scientifically valid research may be inversely related to their ability to fully protect the well-being of individual participants. For example, in studies of sexual transmission of HIV among injection drug users (IDU) and their partners, we typically recruit IDUs and ask that they recruit their sexual partners. Informing sexual partners that they are eligible for the study because the partner is an IDU – a group with high HIV prevalence – may immediately prompt them to change their risk behaviors or leave the relationship thereby biasing estimates of transmission rates. The disclosure of risks to sexual partners can also be justified as a means of minimizing harms to others. Yet not informing the partners may result in investigators watching the natural course of disease transmission in an uncontrolled environment. Couples research thus raises important questions: What are researchers' obligations to disclose information about HIV risk when HIV risk is a central component of study selection and eligibility? How much information should be provided to potential recruits about their risk as part of the informed consent process? How do researchers balance the rights of each individual within a couple, and study validity, in the informed consent process?
This paper focuses on ethical dilemmas that arise when IDUs are recruited into behavioral research on HIV that will involve their sexual partners. Should researchers disclose to these partners that they were recruited because their partner injects drugs (i.e., their heightened risk for HIV)? Disclosing would uphold the ethical value of respect for persons and serves to minimize harm to them. However, in research involving couples, disclosure compromises the IDU's confidentiality. Investigators may have conflicting obligations to members of the couple, such as in this study: there is a conflict between protecting the interests in confidentiality of the IDUs recruited for the study and protecting the interests of their sexual partners – some of whom may not know their partner is an IDU – in being able to make informed choices. Disclosure also potentially weakens the scientific validity of the research if it causes some IDUs not to enroll because they do not want this disclosure to be made. 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.
The tension between confidentiality and informed recruitment in HIV transmission research first received considerable attention with the publication of a Ugandan cohort study conducted between 1994 and 1998. [24–28] Researchers identified 415 HIV-discordant couples from a large randomized trial designed to study the impact of bacterial sexually transmitted diseases on HIV transmission.  The couples were then followed to identify factors associated with HIV transmission. Substantial harm reduction education, free condoms, and voluntary, confidential HIV testing and counseling were offered to all participants. However, researchers were legally obligated not to inform participants who were HIV-negative about their partners' HIV-positive status. Debate ensued about the choice of confidentiality versus disclosure of partner HIV status. [25–28] A decade later the debate continues with no clear resolution.
The issue is further complicated by the legal issues that surround HIV. In much of the world, including some US states  and European countries,  disclosure by a physician of an individual's HIV status without the patient's consent is illegal. In other locations, physicians have a duty to warn partners through mandated notification programs. Further, professional ethics codes may differ from local laws, complicating these issues. Lastly, laws pertaining to medical care and observational research conducted outside medical settings may differ.
Informed consent of research study participants begins with the recruitment process. Typically, recruiting couples starts with recruitment of the "index-participant" – individuals either infected with HIV or at very high risk for HIV (e.g., IDU). The sexual partner is commonly recruited with the assistance of the index-participant. The extent of information disclosed to sex partners as to why they are being sought for study inclusion remains controversial. Some studies involve specific information about eligibility related to substantial HIV risk while others do not. Major initiatives, such as the HIV Prevention Trial Network (HPTN), have developed formal guidelines that address fundamental research ethics issues, but these do not prescribe a specific approach for "informed selection." Providing accurate HIV risk information during the informed consent process to all participants is consistent with the HPTN guidelines (Sugarman J, personal communication, 2008). The UN AIDS guidance for HIV prevention trials also highlights that individuals be told the specific reason for study eligibility. 
HIV in Estonia
In Estonia, the primary reservoir for HIV is the IDU community. By the turn of the century, this small Baltic state had the highest HIV incidence in Europe.[33, 34] Similar to nearby cities in Russia, the IDU community was the epicenter of the epidemic, and HIV spread quickly during the post-independence transition period of the late 1990s.[34, 35] About half of all IDUs in Estonia are infected with HIV and over 90% are infected with hepatitis C virus (HCV). [36–38] The transmission of HIV between IDUs is well understood and some intervention programs are available, including free voluntary counseling and testing, needle exchange programs and drug treatment. [39–50] However, improved HIV prevention and intervention programs are critically needed to curb the spread of HIV among IDUs in general, and between IDUs and their sexual partners. [39, 40, 45, 51–54]
The primary mode of HIV transmission from the IDU community to the general population is thought to be through sexual contact. However, insufficient research has focused on improving interventions to interrupt sexual transmission between IDUs and their partners. Because the IDU community is a substantial reservoir for HIV in Eastern Europe and Central Asia, understanding and stopping transmission from this group is essential to slow the spread of the epidemic. These studies must be conducted against the backdrop of a changing social structure in the region, largely related to major changes in the political and economic environment following independence.
The Estonian Study
The study discussed here, a joint project of Estonian and US researchers, took place in 2007 following Institutional Review Board approval for the study granted by both US and Estonian institutions. The study objectives were threefold: 1) assess the amount of HIV serodiscordance among IDUs and their sexual partners, 2) identify barriers to harm reduction, and 3) explore ways to optimize intervention programs. Thus, we wanted to include IDUs, either HIV-positive or at high risk for HIV, and their sexual partners to gain a more complete understanding of the barriers to and opportunities for intervention.
Injection drug users were recruited into research through harm reduction programs, at known locations of drug use, and by using respondent-driven sampling.[55, 56] Once an IDU was recruited, he/she was asked to invite both a sexual partner(s) who does not use injection drugs and other IDUs to participate in the study. Index-participants were given two sets of coded cards to hand out (one set for sexual partners and the other for IDUs as part of respondent-driven sampling). Each individual was provided a written informed consent form after the researcher orally disclosed the purpose of the study, procedures, risks and benefits of participation, participants' rights, and provided an opportunity to read the form (containing the same information on the study) and ask questions. Each participant was interviewed separately and blood was obtained for HIV and HCV testing. The survey tool collected detailed information about drug use, sexual behaviors, HIV testing, knowledge about HIV transmission, and attitudes about HIV. Anonymous codes linked records. (Anonymity was important because IDU is a crime in Estonia [57, 58] and the equivalent of a US Certificate of Confidentiality [59, 60] does not exist to protect participant data.) All participants received counseling as part of the HIV testing and the counseling program provided in Estonia. All participants were asked to return for test results. Every aspect of the study was reviewed multiple times by the investigators to ensure IDUs received adequate protection.
Informed Consent Process
During the informed consent process, research staff took great care to be transparent regarding all aspects of the research study. All participants were told we were specifically studying HIV, including it's potential to be sexually transmitted, and provided counseling around HIV testing. We explained to IDUs the reason for recruitment and all relevant study procedures. But it was less clear what to disclose to the recruited sex partners. To fully inform sexual partners of the study's purpose and specific reason for their study eligibility might require a disclosure of the index-participants' drug use and heightened risk of HIV.
"You were selected to participate in this study on relationships and risk behaviors because your partner volunteered for the study and was asked to invite his/her sex partner."
"You were selected to participate in this study of injection drug users and their sex partners because your partner volunteered for the study and was asked to invite his/her sex partner."
"You were selected to participate in this study of injection drug users and their sex partners because your partner volunteered for this study and was asked to invite his/her sex partner. About half of injection drug users are infected with HIV and we are particularly interested in understanding risk behaviors of injection drug users who are infected with HIV and their partners. In particular, we want to learn what behaviors result in the highest risk of HIV transmission and better ways to reduce risk of transmission."
The first statement provides no information to the partners recruited for the study about their risk of infection now or in the near future. The second statement differs from the first by specifying that the partner is an IDU. This information is especially revealing because it is common knowledge among residents of Estonia that many IDUs are HIV positive. The third statement clearly states partners' potential risk of HIV if they are not actively preventing transmission (e.g., using condoms).
The research team was unable to use the third statement, due to concerns of the local ethics committee about such specific, yet ambiguous communication that could further stigmatize IDUs. While it may appear arbitrary that one stigma (i.e., IDU status) can be shared while another (i.e., HIV status) can not, it is not uncommon that inconsistencies in sensitivity about exposures exist in many countries. The research team debated the first two options at length. The decision would have health, scientific, and ethical consequences. In the following we describe the process we underwent and factors that informed our decision.
The Process of Ethical Deliberation
Investigators originally planned to use the first statement, that is, to not disclose the study's primary focus on IDUs and HIV transmission risk to their sexual partners. Driven by our prior experience with vulnerable populations, we designed the study to fully protect IDUs while maximizing their comfort with participating in the research project. However, further reflection on the public health and ethical implications of this approach to disclosure led the research team to reconsider. We sought input from multiple sources for over a year prior to study implementation, including informal conversations with IDUs, NGOs (e.g., needle exchange programs), researchers, ethicists, friends and family members of IDUs, and others
As the discussion unfolded, substantial concern focused on the asymmetrical knowledge between investigators and study participants. The researchers would know more about the risk of continued unprotected intercourse with the index-participant (e.g., discordant HIV status, rare or no use of condoms) than the partner. Proponents of partner notification advocate a defined legal limit on confidentiality of the physician-patient relationship, the value of providing life-saving treatment for infected partners, and overall benefit to the public's health. Challengers to partner notification question whether mandatory partner notification laws for HIV will have an overall negative impact on both medical care and public health due to the loss of patients' ability to trust their physicians with sensitive information. [61–64] Investigators must consider many factors when developing a research study that figure into designing the process of informed consent. The key factors that arose in our research deliberations included protection of vulnerable populations, confidentiality waivers, validity of scientific results, differential risk for partners based on informed consent, and research logistics, all of which are discussed below.
Protection of Vulnerable Populations
In Estonia, research ethics committees consider IDUs among the vulnerable potential study participants. Known IDUs are marginalized for several reasons, including: a) their (illegal) behavior, b) most are members of an ethnic minority (about 80% are Russian-speaking), c) many have served time in jail or prison, d) many are poor, and e) about half are known to be HIV positive 
Sex partners of IDUs, who are not themselves IDUs, typically share only two of these vulnerabilities: Russian-speaking minority and low socioeconomic status. Another important factor to consider related to vulnerability is that divorce in Estonia is not uncommon.  As partners learn of the index-participant's HIV/IDU status, they may consider the option of divorce. Divorce is a socially acceptable option, and viable since sufficient housing exists in Estonia. By contrast, leaving a sexual partner is not a viable cultural or economic option in many other countries.
For the IDU participants, requiring disclosure about drug use may result in feelings of vulnerability or frustration if they want to participate but do not want disclosure. Ensuring the confidentiality of study participants is a paramount human subjects projection. However, other equally pressing human subjects protections – informing partners of why they are being recruited into the study, must be balanced against protecting the confidentiality of the IDU. Accordingly, research participants commonly provide limited waivers of confidentiality for many studies. These waivers may be for protected information to be provided to researchers (e.g., medical records) or disclosed among research participants (e.g., research on couples or family counseling). In these situations, participants typically provide waivers of confidentiality that are limited to requirements for good scientific research. Indeed, in our study the index-participant willingly disclosed their sexual relationship with the referred partner(s).
Is there an ethical difference between requiring information disclosure about a person's drug use or HIV infection compared to disclosing information about a person's sexual relationship in order to participate in the study? Disclosure of IDU in Estonia to a partner could present significant harms to the IDU. In Estonia, not only is IDU illegal, but it is also illegal for a person who knows he/she is HIV-positive to transmit HIV to a person who was not aware of this risk, and criminal convictions have occurred. 
Conversely, waiving limited confidentiality is commonly required in research. If the requirements for research participation are unacceptable, then individuals can choose not to participate. In Estonia, the same HIV testing is free and available as is the counseling provided to study participants, which is comparable to that provided in the wider community. Thus, there is no overly compelling benefit for individuals to participate. The study's modest compensation was attractive to community members but not excessive such that a typical low-income IDU would unduly agree to unacceptable conditions. (This assessment was validated by the fact that some IDUs did not participate and others did not refer partners.)
Validity of Research Findings
For a research study to be ethical it must be scientifically valid. No risk is warranted if the study cannot be informative. From an epidemiologic perspective, the greatest risk to generalizability regarding informed recruitment is selection bias. If index-participants know that their sex partner(s) will be told about their drug use, then only partners who already know about this risk behavior will likely be referred for participation. Limitations on study participation driven by the consent process would, in turn, limit the effectiveness of resultant interventions to those with characteristics similar to the group studied. While our study was cross-sectional, the same issue applies to longitudinal studies designed to estimate HIV transmission rates more broadly.
Based on interviews with IDUs, we hypothesize that drug users who do not want their partners to know about their drug use are unlikely to recruit them for a study on HIV risk and transmission. It is not only the researchers who the IDU must trust, but also the other individuals the partner may encounter at the research location. Thus, the primary disadvantage of informed recruitment – selection bias – may likely be introduced by study participants, and that additional selection bias introduced by an in-depth informed consent is minimal. While empirical research is needed to formally test this hypothesis, it is supported by other researchers' experience working with IDUs (D. Des Jarlais, personal communication, 2008).
Arguments against and in favor of disclosure of the index participant's IDU status can be made depending on different interpretations of risk of HIV transmission to the public's health. A key argument against disclosure is that research participation does not increase the risk of HIV transmission/infection by participants. Even if the sex partners were not informed of the IDU status of the index participants during the recruitment process, all participants received state-of-the art education about behavioral risk factors and harm reduction techniques, which should minimize their risk of transmission. Another argument is that providing additional risk information does not necessarily enhance the study participant's protection. Empirical research shows that these educational and behavioral risk reduction interventions minimally affect sexual behavior. [51–54] That is, many partners continue to undertake risky sexual relations with IDUs after being informed. Accordingly, if the study provides limited risk reduction benefit, why introduce the potential for selection bias that would jeopardize the results? Such empirical evidence may lead some to conclude that disclosure is not necessary. For these and other reasons, nondisclosure of the index participant's IDU status is still commonly practiced in the US and abroad.
Nevertheless, there are substantial arguments in favor of disclosure. First, informing partners, who are study participants, enables them to become aware of the urgency with which to undertake precautions. It is imperative to ensure that potential study participants make informed choices, even if how they choose to act thereafter may not be healthful. Thus, doing so minimizes harms to study participants. Another justification for disclosure may be drawn from interviews with the IDUs in Estonia. Many partners leave the relationship upon learning about drug use. Because HIV is substantially more prevalent in the IDU community, leaving a relationship with an IDU does reduce a partner's risk of HIV infection. Thus, from the partners' perspective, this is an effective method of risk reduction that they can take and many are willing to take.
Moreover, nondisclosure may pose the potential for emotional harm to partners and the broader community if it became known that researchers knew some HIV-negative participants were having unprotected sex with HIV-positive individuals. Partners may feel betrayed and the community may feel manipulated. Such feelings could easily transform into distrust and reluctance to participate in research in the future, as has occurred among African Americans in the US. [67, 68]
Paper forms were used for most data collection, causing a delay in data entry. While the index-participant's IDU status was known, most partners were enrolled before information about HIV status was available. Nonetheless, studies of HIV transmission that include diverse risk groups and follow the transmission risk to multiple sex partners may benefit from rapid tests and real time data processing to provide appropriate information about disease risk to recruited individuals. Without these technologies, general statements related to risk of HIV can be made to all participants.
For our study, we could not add IDU information to the partner's informed consent form because of the legal concerns about revealing HIV status. Thus, our pragmatic compromise was to tell all index participants to only recruit sex partners who knew about their drug use.
During the design phase of this study, we identified ethical tensions unique to the process of studying couples. From an epidemiological perspective, when the couple is of central interest then it is the unit of study and analysis. However, from a research ethics perspective, the individuals, the couple, and the greater community all are important to consider and warrant human subjects protections. At times what is best for one person in a couple may not be best for the other. For couples research pertaining to HIV sexual transmission, we posit that failing to fully inform partners about the rationale for inclusion in the study is ethically disconcerting. Intentionally limiting disclosure to sexual partners remains ethically problematic given the potential for continued risk that exists among HIV-discordant couples with unsafe sex behaviors. While institutional review boards have developed sensitivity to cultural appropriateness for research in developing countries, refinement of guidance for couples research of communicable diseases is needed to address ethical issues such as those raised herein.
We suggest that further guidance for both cross-sectional and longitudinal studies of HIV transmission is needed regarding informed recruitment. While in our example recruitment was anonymous and limited to IDUs and their sexual partners, in longitudinal HIV transmission studies researchers recruit diverse risk groups (e.g., IDU, commercial sex workers, MSM) and follow transmission for multiple waves. Thus, specific HIV risk (e.g., HIV status of sexual partners) often will not be known at the time of study interviews. We suggest that research participants can be accurately told that they were recruited for the study because they are connected to a group at higher risk for HIV then the general population. The detailed explanation of this risk may vary by wave of recruitment and by region. Additionally, in longitudinal studies, we suggest research participants be reminded that they were recruited for the study due to their high risk for becoming infected with HIV and harm reduction counseling be provided with each follow-up blood test.
The authors declare that they have no competing interests.
Drs. McNutt and Uusküla are supported by Civilian Research Development Foundation grant (ESX0-2722-TA-06). Dr. Uuskula is also supported by a US NIH grant (R01 DA 03574) and grant No. R01 TW006990 from the Fogarty International Center. Dr. Gordon is supported by a Career Development Award from the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (DK063953).
The authors thank Dr. Don Des Jarlais from Beth Israel Medical Center, New York, New York, and Dr. Jeremy Sugarman from Johns Hopkins Berman Institute of Bioethics for the information they provided during the drafting of the manuscript. The authors also thank Dr. Sean Philpott, the Policy and Ethics Officer for PATH's Global Campaign for Microbicides, Dr. Andres Soosaar from Department of Health (Estonia) and Ants Nõmper from Raidla & Partners (Estonia) for their helpful comments in revision. The authors that Alison Krug, MPH for her thoughtful comments while proving copy editing services for this manuscript.
- UNAIDS/WHO: AIDS Epidemic Update: December 2007 [monograph on the Internet]. 2007, UNAIDS, Geneva, [http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf]Google Scholar
- MacQueen KM, Sugarman J: HIV Prevention Trials Network Ethics Guidance for Research [monograph on the Internet]. HPTN Ethics Working Group. 2003, [http://www.hptn.org/Web%20Documents/EWG/HPTNEthicsGuidanceFINAL15April2003.pdf]Google Scholar
- MacQueen KM, Sugarman J: Back to the Rough Ground: Working in International HIV Prevention as Ethical Debates Continue. IRB. 2003, 25: 11-13. 10.2307/3563635.View ArticleGoogle Scholar
- UNAID/WHO: Ethical considerations in biomedical HIV prevention trials [monograph on the Internet]. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2007, 10.1016/S0140-6736(98)10414-2. [http://data.unaids.org/pub/Report/2007/jc1399-ethicalconsiderations_en.pdf]Google Scholar
- Perinatal HIV Intervention Research in Developing Countries Workshop participants. Science, ethics, and the future of research into maternal infant transmission of HIV-1. Lancet. 1999, 353: 832-5. 10.1016/S0140-6736(99)00095-1.Google Scholar
- Omene JA, Lurie P, Wolfe SM, Foex B, Isturiz RE, Greco DB: Science, ethics, and future of research into maternal-infant transmission of HIV-1. Lancet. 1999, 353: 1878-1881. 10.1097/QAD.0b013e3282f086f5.View ArticleGoogle Scholar
- WHO/UNAIDS/AAVP International Expert Group, Osmanov S: Executive summary and recommendations from WHO/UNAIDS and AAVP consultation on: 'The inclusion of adolescents in HIV vaccine trials', 16–18 March 2006 in Gaborone, Botswana. AIDS. 2007, 21: W1-10. 10.1097/QAD.0b013e3282f086f5.View ArticleGoogle Scholar
- WHO-UNAIDS Expert Group: Gender, age, and ethnicity in HIV vaccine-related research and clinical trials: report from a WHO-UNAIDS consultation, 26–28 August 2004. Lausanne, Switzerland. AIDS. 2005, 19: w7-28. 10.2105/AJPH.88.4.567.View ArticleGoogle Scholar
- Bayer R: The debate over maternal-fetal HIV transmission prevention trials in Africa, Asia, and the Caribbean: racist exploitation or exploitation of racism?. Am J Public Health. 1998, 88: 567-70. 10.2105/AJPH.88.4.564.View ArticleGoogle Scholar
- Abdool Karim SS: Placebo controls in HIV perinatal transmission trials: a South African's viewpoint. Am J Public Health. 1998, 88: 564-6. 10.1056/NEJM199710023371411.View ArticleGoogle Scholar
- Varmus H, Satcher D: Ethical complexities of conducting research in developing countries. N Engl J Med. 1997, 337: 1003-5. 10.1056/NEJM199710023371411.View ArticleGoogle Scholar
- Lindegger G, Richter LM: HIV vaccine trials: critical issues in informed consent. S Afr J Sci. 2000, 96: 313-7. 10.1136/jme.2006.015891.Google Scholar
- Buchanan DR, Miller FG: A public health perspective on research ethics. J Med Ethics. 2006, 32: 729-733. 10.1023/B:MHEP.0000021845.28818.e2.View ArticleGoogle Scholar
- Solbakk JH: Use and abuse of empirical knowledge in contemporary bioethics. Med Health Care Philos. 2004, 7 (1): 5-16. 10.1023/B:MHEP.0000021845.28818.e2.View ArticleGoogle Scholar
- Clark PA: AIDS research in developing countries: do the ends justify the means?. Med Sci Monit. 2002, 8: ED5-16. 10.1111/1467-8519.00240.Google Scholar
- de Zulueta P: Randomised placebo-controlled trials and HIV-infected pregnant women in developing countries. Ethical imperialism or unethical exploitation?. Bioethics. 2001, 15: 289-311. 10.2105/AJPH.88.4.637.View ArticleGoogle Scholar
- Gable L, Gamharter K, Gostin LO, Hodge JG, Van Puymbroeck RV: Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform. 2001, Global HIV/AIDS Program and Legal Vice Presidency, Washington DC: The International Bank for Reconstruction and Development/The World BankGoogle Scholar
- Abdool Karim Q, Abdool K SS, Coovadia HM, Susser M: Informed consent for HIV testing in a South African hospital: is it truly informed and truly voluntary?. Am J Public Health. 1998, 88: 637-40. 10.1136/jme.2002.001933. Erratum in: Am J Public Health 1998, 88:972View ArticleGoogle Scholar
- Kahn JP, Mastroianni AC, Sugarman J: Beyond consent: seeking justice in research. 1998, New York: Oxford University PressGoogle Scholar
- Hyder AA, Wali SA, Khan AN, Teoh NB, Kass NE, Dawson L: Ethical review of health research: a perspective from developing country researchers. J Med Ethics. 2004, 30: 68-72. 10.1037/0893-322.214.171.124.View ArticleGoogle Scholar
- Margolin G, Chien D, Duman SE, Fauchier A, Gordis EB, Oliver PH, et al.: Ethical Issues in Couple and Family Research. J Fam Psychol. 2005, 19 (1): 157-167. 10.1056/NEJM200003303421303.View ArticleGoogle Scholar
- The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research: The Belmont Report: ethical principles and guidelines for the protection of human subjects of research. 1979, [http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.htm]Google Scholar
- Council for International Organizations of Medical Sciences (CIOMS) in collaboration with the World Health Organization (WHO). International ethical guidelines for epidemiological studies [monograph on the Internet]. 10.1056/NEJM200003303421309. [http://cioms.ch/frame_ethical_guidelines_2009.htm]
- Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al.: Viral load and heterosexual transmission of Human Immunodeficiency Virus Type 1. Rakai Project Study Group. N Engl J Med. 2000, 342: 921-929. 10.1056/NEJM200008033430510.View ArticleGoogle Scholar
- Angell M: Investigators' Responsibilities for Human Subjects in Developing Countries. N Engl J Med. 2000, 342: 967-969. 10.1111/j.1748-720X.2000.tb00006.x.View ArticleGoogle Scholar
- Gray RH, Quinn TC, Serwadda D, Sewankambo NK, Wabwire-Mangen F, Wawer MJ, Mullings AMA, Greco DB, Hearst N, Cates W, Coates TJ, Handsfield HH, Angell M: The Ethics of Research in Developing Countries. N Engl J Med. 2000, 343: 361-363. 10.1097/QAD.0b013e3282f029d3.View ArticleGoogle Scholar
- Loue S, Okello D: Research Bioethics in the Ugandan Context II: Procedural and Substantive Reform. J Law Med Ethics. 2000, 28: 165-173. 10.2105/AJPH.82.8.1158.View ArticleGoogle Scholar
- Thiessen C, Ssekubugu R, Wagman J, Kiddugavu M, Wawer MJ, Emanuel E, et al.: Personal and community benefits and harms of research: views from Rakai, Uganda. AIDS. 2007, 21: 2493-501. 10.1080/15265160500506308.View ArticleGoogle Scholar
- National HIV/AIDS Clinicians' Consultation Center at San Francisco General Hospital. Compendium of State HIV Testing Laws Quick Reference Guide for Clinicians. [http://www.nccc.ucsf.edu/StateLaws/About%20Compendium/Quick%20Reference%20Guide.pdf]
- EuroHIV 2006 survey on HIV and AIDS surveillance in the WHO European Region [monograph on the Internet] Saint-Maurice: Institut de veille sanitaire. 2007, [http://www.eurohiv.org/reports/eurohiv_2006_survey_report/eurohiv_2006_survey_report.pdf]
- Bayer R, Toomey KE: HIV prevention and the two faces of partner notification. Am J Public Health. 1992, 82: 1158-1164. 10.1016/S1201-9712(02)90131-1.View ArticleGoogle Scholar
- Kipnis K: A Defense of Unqualified Medical Confidentiality. Am J Bioethics. 2006, 6: 7-18. 10.1258/095646207779949907.View ArticleGoogle Scholar
- European Centre for Epidemiological Monitoring of AIDS (EuroHIV). HIV/AIDS surveillance in Europe: end-year report 2006. 2007, Saint-Maurice, Institut de Veille Sanitaire, 75:Google Scholar
- Estonian Ministry of Social Affairs. Estonia: country report on national response to HIV/AIDS epidemic 2007 [monograph on the Internet]. Tallinn. 2008, [http://data.unaids.org/pub/Report/2008/estonia_2008_country_progress_report_en.pdf]Google Scholar
- Uusküla A, Kalikova A, Zilmer K, Tammai L, DeHovitz J: The role of injection drug use in the emergence of Human Immunodeficiency Virus infection in Estonia. Int J Infect Dis. 2002, 6: 23-7. 10.1016/S1201-9712(02)90131-1.View ArticleGoogle Scholar
- Uusküla A, McNutt LA, Dehovitz J, Fischer K, Heimer R: High prevalence of blood-borne virus infections and high-risk behaviour among injecting drug users in Tallinn, Estonia. Int J STD AIDS. 2007, 18: 41-6. 10.1097/01.aids.0000247586.23696.20.View ArticleGoogle Scholar
- Uusküla A, Kals M, Rajaleid K, Abel K, Talu A, Rüütel K, et al.: High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: need for large scale prevention programs. J Public Health (Oxf). 2008, 10.1016/S0740-5472(96)00115-8.Google Scholar
- Platt L, Bobrova N, Rhodes T, Uusküla A, Parry JV, Rüütel K, et al.: High HIV prevalence among injecting drug users in Estonia: implications for understanding the risk environment. AIDS. 2006, 20: 2120-3. 10.1300/J069v20n02_03.View ArticleGoogle Scholar
- HIV/AIDS EG ITA in coordination with the HIV/AIDS EG Chair: Working Program/Strategy for the collaboration in the prevention of HIV (within the context of Northern Dimension Partnership programme) [monograph on the internet] HIV/AIDS EG Strategy. [http://www.ndphs.org///documents/1259/HIV_AIDS_9_4.2_1_Rev._1_Draft%20work%20plan%202009%20revised.doc]
- Commision of the European Communities: Coordinated and integrated approach to combat HIV/AIDS withing the European Union and in its neighbourhood [monograph on the Internet]. Brussels. 2004, [http://ec.europa.eu/health/ph_threats/com/aids/docs/ev_20040916_rd01_en.pdf]Google Scholar
- Watters JK: Impact of HIV risk and infection and the role of prevention services. J Subst Abuse Treat. 1996, 13: 375-85. 10.1016/0002-9343(93)90263-O.View ArticleGoogle Scholar
- Yoast R, Williams MA, Deitchman SD, Champion HC: Report of the Council on Scientific Affairs: methadone maintenance and needle-exchange programs to reduce the medical and public health consequences of drug abuse. J Addict Dis. 2001, 20: 15-40. 10.1186/1471-2458-8-94.View ArticleGoogle Scholar
- Normand J, Vlahov D, Moses LE, eds, Preventing HIV Transmission: The Role of Sterile Needles and Bleach. 1995, Washington, DC: National Academy PressGoogle Scholar
- Heimer R, Kaplan EH, Khoshnood K, Jariwala B, Cadman EC: Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven, Connecticut. Am J Med. 1993, 95: 214-220. 10.1016/j.drugpo.2007.01.012.View ArticleGoogle Scholar
- Riehman KS: Injecting Drug Use and AIDS in Developing Countries: Determinants and Issues for Policy Consideration [monograph on the Internet] Paper prepared for the Policy Research Report on AIDS and Development World Bank, Policy Research Department. 2006, [http://www.worldbank.org/aidsecon/confront/backgrnd/riehman/index.htm]Google Scholar
- Friedman SR, Mateu-Gelabert P, Milagros S, Hagan H, Des Jarlais DC: Positive deviance control-case life history: a method to develop grounded hypotheses about successful long-term avoidance of infection. BMC Public Health. 2008, 8: 94-10.1016/j.drugpo.2006.12.014.View ArticleGoogle Scholar
- Wolfe D: Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 2007, 18: 246-54. 10.1016/j.drugpo.2007.05.002.View ArticleGoogle Scholar
- Spire B, Lucas GM, Carrieri MP: Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST). Int J Drug Policy. 2007, 18: 262-70. 10.1093/eurpub/13.3.252.View ArticleGoogle Scholar
- Lert F, Kazatchkine MD: Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview. Int J Drug Policy. 2007, 18: 255-61. 10.1186/1471-2458-8-37.View ArticleGoogle Scholar
- Amundsen EJ, Eskild A, Stigum H, Smith E, Aalen OO: Legal access to needles and syringes/needle exchange programmes versus HIV counselling and testing to prevent transmission of HIV among intravenous drug users: a comparative study of Denmark, Norway and Sweden. Eur J Public Health. 2003, 13: 252-8. 10.1159/000110407.View ArticleGoogle Scholar
- Nguyen TA, Oosterhoff P, Hardon A, Tran HN, Coutinho RA, Wright P: A hidden HIV epidemic among women in Vietnam. BMC Public Health. 2008, 8: 37-10.1086/512371.View ArticleGoogle Scholar
- Abdala N, Krasnoselskikh TV, Durante AJ, Timofeeva MY, Verevochkin SV, Kozlov AP: Sexually transmitted infections, sexual risk behaviors and the risk of heterosexual spread of HIV among and beyond IDUs in St. Petersburg, Russia. Eur Addict Res. 2008, 14: 19-25. 10.2105/AJPH.2005.076182.View ArticleGoogle Scholar
- Beyrer C: HIV epidemiology update and transmission factors: risks and risk contexts – 16th International AIDS Conference epidemiology plenary. Clin Infect Dis. 2007, 44: 981-7. 10.1016/j.drugpo.2007.11.014.View ArticleGoogle Scholar
- Lyles CM, Kay LS, Crepaz N, Herbst JH, Passin WF, Kim AS, et al.: HIV/AIDS Prevention Research Synthesis Team. Best-evidence interventions: findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. Am J Public Health. 2007, 97: 133-43. 10.1016/j.drugpo.2007.12.006.View ArticleGoogle Scholar
- Scott G: "They got their program, and I got mine": a cautionary tale concerning the ethical implications of using respondent-driven sampling to study injection drug users. Int J Drug Policy. 2008, 19: 42-51. 10.1016/j.drugpo.2007.11.014.View ArticleGoogle Scholar
- Semaan S, Santibanez S, Garfein RS, Heckathorn DD, Des Jarlais DC: Ethical and regulatory considerations in HIV prevention studies employing respondent-driven sampling. Int J Drug Policy. 2009, 20 (1): 14-27. 10.1111/j.1728-4465.2007.00142.x.View ArticleGoogle Scholar
- European Monitoring Centre for Drugs and Drug Addiction: Annual report 2004: the state of the drugs problem in the European Union and Norway [monograph on the Internet] Luxembourg: Office for Official Publications of the European Communities. 2003, [http://ar2004.emcdda.europa.eu/download/ar2004-en.pdf]Google Scholar
- European Monitoring Centre for Drugs and Drug Addiction: Report to the EMCDDA by the Reitox National Focal Point [monograph on the Internet]. Estonia drug situation;. 2003, 10.1111/j.1728-4465.2007.00141.x. [http://www.just.ee/orb.aw/class=file/action=preview/id=20533/DRUD_SITUATION_2003%5B1%5D.pdf]Google Scholar
- Hhs.gov [homepage on the Internet]: US Department of Health and Human Services. Office of Extramural Research. National Institutes of Health. Grants Policy. Certificate of Confidentiality: Background Information. [http://grants.nih.gov/grants/policy/coc/background.htm]
- Wolf LE, Zandecki J: Sleeping better at night: investigators' experiences with certificates of confidentiality. IRB. 2006, 28: 1-7. 10.1097/01.olq.0000194597.16236.48.Google Scholar
- Odunsi B: Should caregivers be compelled to disclose patients' HIV infection to the patients' sex partners without consent?. Stud Fam Plann. 2007, 38: 297-306. 10.2105/AJPH.2007.092742.View ArticleGoogle Scholar
- Dixon-Mueller R: The sexual ethics of HIV testing and the rights and responsibilities of partners. Stud Fam Plann. 2007, 38: 284-96. 10.1111/j.1728-4465.2007.00141.x.View ArticleGoogle Scholar
- Passin WF, Kim AS, Hutchinson AB, Crepaz N, Herbst JH, Lyles CM: HIV/AIDS Prevention Research Synthesis Project Team. A systematic review of HIV partner counseling and referral services: client and provider attitudes, preferences, practices, and experiences. Sex Transm Dis. 2006, 33: 320-8. 10.1097/01.mlr.0000228023.37087.cb.View ArticleGoogle Scholar
- Tesoriero JM, Battles HB, Heavner K, Leung SY, Nemeth C, Pulver W, et al.: The effect of name-based reporting and partner notification on HIV testing in New York State. Am J Public Health. 2008, 98: 728-35. 10.1016/S0277-9536(00)00178-7.View ArticleGoogle Scholar
- Sardon JP: The Demographic Situation of Europe and the Developed Countries Overseas. An Annual Report Popul. 2000, 12: 293-328.Google Scholar
- Global Network of People Living with HIV/AIDS Europe (GNP+) (Europe) and Terrence Higgins Trust (THT). Criminalisation of HIV transmission in Europe [monograph on the Internet]. [http://www.gnpplus.net/criminalisation/results.shtml]
- Hall MA, Camacho F, Lawlor JS, Depuy V, Sugarman J, Weinfurt K: Measuring trust in medical researchers. Med Care. 2006, 44: 1048-53. 10.1097/01.mlr.0000228023.37087.cb.View ArticleGoogle Scholar
- Freimuth VS, Quinn SC, Thomas SB, Cole G, Zook E, Duncan T: African Americans' views on research and the Tuskegee Syphilis Study. Soc Sci Med. 2001, 52: 797-808. 10.1016/S0277-9536(00)00178-7.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6939/10/14/prepub
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