Couple-Based HIV Prevention in the United States: Advantages, Gaps, and Future Directions

Core Components of Couple-Based HIV Prevention in the United States

There is a notable heterogeneity in HIV intervention content in couple-based studies.⁷ Most studies explore knowledge of HIV and STIs; technical skills in condom use; couple skills in communication and negotiation as well as problem solving and goal setting; couple power imbalances associated with sexual decision making⁷; and ways to promote and maintain a healthy relationship. Other content of HIV interventions addresses couple HIV counseling and testing, family planning, a review of cultural values to reinforce commitment to protect one's partner and community, and changing couples' peer norms regarding safer sex practices.^7,12–15 This combination of couple-based skills and intervention content are illustrated in 3 studies conducted in the United States by the authors of this paper.

Project Connect, with 217 heterosexual couples, was the first study funded by the National Institute of Mental Health of the National Institutes of Health to test a relationship-based HIV/STI risk reduction intervention. The intervention, a series of 6 once-weekly sessions (delivered to couples in one study arm and to women alone in another), was found to be efficacious in increasing condom use, compared to the third study arm, the control—a single HIV/STI information session.^12,13,15 The weekly sessions targeted the relationship context, and all exercises and homework assignments were geared toward the male study partner; all women attending these sessions were asked to practice the communication, negotiation, and condom skills that they learned in the weekly sessions with their partners. Connect is currently being disseminated by the Centers for Disease Control and Prevention as a DEBI (Diffusion of Effective Behavioral Interventions) and tested for adoption by 80 New York State agencies.¹⁶

Project Eban, with 535 African American serodiscordant couples in 4 US cities, was recently completed.^14,17 Couples assigned to the Eban Couples Risk Reduction Intervention compared to a Health Promotion comparison condition were more likely to increase condom use over the 12-month period.¹⁷

Project Connect with Pride, an adaptation of Connect that was targeted to African American MSM couples composed of at least one methamphetamine user, was recently piloted with 34 MSM dyads with promising results.¹⁸

Couple-based prevention research on drug-related HIV risks is emerging. Specific core components of drug-related interventions include syringe disinfection skills, triggers for drug use, gender imbalances in HIV risks associated with a couple's drug-using contexts, and improved access to harm reduction programs.¹⁹

Addressing treatment adherence within a couple has the potential advantage of not only improving the health of persons living with HIV, but also reducing the risk of transmission within the pair by reducing the viral load of the infected partner and thus the risk of HIV transmission.^9,20 Core components of interventions to promote adherence include enhancing a couple's commitment to maintain a steady supply of medications, helping to identify and resolve ongoing barriers to adherence, improving communication and mutual caretaking, promoting sexual risk reduction skills, and encouraging regular HIV testing for uninfected partners. In prevention of mother-to-child transmission interventions, couple sessions also focus on HIV testing for the male partner.¹⁰

Gaps in the Science of Couple-Based Research

Since the HIV epidemic began, only 7 couple-based studies have been conducted in the United States.^{9,15,17,18,21,22} Six of these focused on sexual risk reduction; 1 included both sexual risk reduction and adherence to antiretroviral therapy where HIV prevention was incorporated into treatment and care.⁹ Two included MSM,^9,18 and of these, 1 was conducted with MSM who use drugs.¹⁸ None were conducted solely with drug-using, non-MSM populations. None have focused on primary prevention among HIV-noninfected couples who engage in HIV risks or among HIV-infected seroconcordant couples.⁷

Existing models vary in their definition of a “couple.” In studies conducted by the authors, couples include ongoing dyadic heterosexual or same-sex relationships, which may include but are not limited to relationships between spouses, common-law spouses, intimate partners, lovers, and casual sexual partners. Most couple intervention models allow the index participant to identify his or her partner. Several have more stringent criteria, such as length of the relationship, level of commitment, and sexual orientation.^15,17 Thus, key questions remain unanswered: To what extent are the findings generalizable? For whom are the interventions particularly efficacious?

Most couple-based studies are limited by one or more methodological drawbacks, including relatively small sample sizes, lack of a randomized control design, and/or the lack of biologically confirmed STIs as an outcome variable.⁷ None of the couple-based studies to date have been sufficiently powered to examine new STI and HIV infections as outcomes.

To date, few studies have examined whether couple-level interventions are effective in reducing extradyadic sexual relationships among partners. This is an important outcome to consider, as partner concurrency has been found to increase HIV risk within a partner's sexual networks as well as within the dyad.²³ It is unclear whether existing couple-based HIV prevention approaches reduce HIV risk with extradyadic partners.

Couple-based HIV prevention approaches have used different modalities to deliver their intervention. The science of couple-based HIV prevention has yet to tell us which modality works better. Are interventions more effective when sessions are delivered to each couple individually? When the sessions bring a group of couples together? Or when some sessions are delivered in small, single-gender groups? Future research should address the question of which is most efficacious and/or cost-effective.

The particular mechanisms that lead to behavior change remain unspecified. To advance the science of HIV prevention intervention with couples, there is a need to identify mediators. Moreover, greater attention must be given to the use of relationship-based theories that move beyond social cognitive theory, which has guided most couple-based studies.⁷ Statistical techniques using data collected from couples also need to be developed more thoroughly. Examples of areas to be targeted for development include: Is the unit of analysis the individual or the couple? What is a conservative way to handle discrepant reports from partners on conjoint behaviors?

A number of challenges need to be highlighted in couple-based interventions. Although some evidence suggests that couple-based HIV prevention interventions may not work as well for couples experiencing severe conflict or intimate partner violence,^24,25 research has yet to identify whether the effects of couple-based interventions are moderated by certain relationship characteristics (eg, length and type of relationship, relationship satisfaction level, history of intimate partner violence). Another challenge is that couple-based interventions require more clinical training and skills than individual-based interventions. Agency clinical staff also tend to be more comfortable conducting individual interventions and may take more time to feel comfortable delivering couple-based sessions.