What Do We Know?
7.2.2 Relationship-Based HIV Prevention Programs
One of the fi rst RCTs to test the effi cacy of a relationship-based HIV prevention intervention was Project Connect, conducted with low-income urban couples in the U.S. (El-Bassel et al. 2003a, 2005 ) . This study included 217 couples who reported risky sexual behavior with each other or with at least one outside partner. A woman was eligible for Project Connect if she was between 18 and 55 years of age and was involved in a relationship for at least 6 months.
The intervention emphasized relationship contexts, gender roles, communica-tion, and intimacy, all of which contribute to HIV risk behaviors among couples.
The intervention consisted of an orientation session and fi ve relationship-based ses-sions. It combined content related to safer sex practices and prevention of HIV and other STIs, as well as joint HIV testing. The intervention emphasized communica-tions, negotiation, and problem-solving skills. The goal of the intervention’s relationship-based approach was to reframe safer sex not as individual “protection,”
but rather as a way to preserve the relationship and the community, as an act of love, commitment, and intimacy. This approach highlights how relationship dynamics may be affected by gender roles and expectations. The session content pointed out the positive contribution of each participating couple to the future health of their partnership, family, and community. Consistent with the U.S. National HIV Prevention Plan (Centers for Disease Control and Prevention (CDC) 2001 ) , the intervention also directed prevention messages to HIV-positive individuals and serodiscordant couples. For example, the intervention emphasized reducing risk for any new STIs, including HIV, with a secondary prevention emphasis on HIV-infected individuals, and educated participants about drug-resistant strains of HIV.
The intervention addressed the particular susceptibility of HIV-positive individuals to infection by other STIs, and the common, incorrect belief that individuals whose viral load is undetectable pose no transmission risk to their partners.
The intervention also emphasized responsibility for self, for each other as a cou-ple, for family, and for the community. The intervention focused on a positive future orientation (for example, addressing change for preventive health, as opposed to past risky behaviors). It also emphasized the importance of individual contributions to enhancing the future health of ethnic communities hardest hit by AIDS by addressing the adverse effects of HIV in the African American and Latino commu-nities; and by linking behavior change to commitment to one’s community
(DiClemente and Wingood 1995 ; Kelly et al. 1995 ; Schilling et al. 1995 ; Van Der Straten et al. 1995 ) . Several steps were employed in order to make the intervention in Project Connect congruent with the culture, needs, and worldviews of the com-munity in which the study was conducted. The comcom-munity and consumers had con-siderable opportunities to make their voices heard during the grant preparation and conceptualization, research implementation, and dissemination. In order to strengthen the cultural congruence and gender specifi city of the intervention, focus groups were conducted with several couples from the target setting, and their input and voice were incorporated into the design of the intervention components. (For a more complete discussion, see Sormanti et al. 2001 ).
El-Bassel et al. ( 2003a, b, 2005 ) found that the HIV prevention intervention pro-vided to the couples was effi cacious in reducing unprotected sex at both the 3- and 12-month follow-up assessments. Two major factors may explain the success of the intervention. First, the content of the sessions targeted the intimate relationship as the focus of change, and defi ned the couple as the agent of change. The relationship context received primary emphasis even when a woman received the intervention without her partner. All exercises in each session and homework assignments were geared toward the woman who was asked to practice the communication, negotia-tion, and condom skills that she learned in the sessions with her partner. The inter-vention enabled women and their intimate partners to discuss sexual issues and to explore, together, how they could protect themselves from HIV and STIs.
Harvey et al. ( 2004 ) develop an intervention focused on young couples but deliv-ered in a group format. The intervention was delivdeliv-ered in a group modality with culturally appropriate counseling. It included facilitated discussions in small groups about relationship dynamics affecting sexual risk behavior and choices about contra-ception, a demonstration of proper use of condoms and assistance for couples in selecting a healthy safer-sex strategy that worked for them. Strategies were designed to consider the couple’s reproductive intentions and sexual expectations, including preventing an unintended pregnancy and having a healthy pregnancy, avoiding or controlling triggers leading to unsafe sex, and communicating with partners about sexual issues. At the end of each session, participants were given condoms. The fi ndings of the study showed that no signifi cant effects on condom use were reported at 3 and 6 months. Intervention effects were found at 3 and 6 months on self-effi cacy, and effects on health protective communication skills were found at 3 months.
Finally, we would like to discuss Project Eban, a recent RCT funded by the National Institute of Mental Health (NIMH) that involved four sites across the U.S.
The project was led by investigators with demonstrated leadership in culturally con-gruent HIV/STI prevention interventions. It showed powerful intervention effects on increasing condom use. The intervention, focusing on a single ethnic group (African Americans), was guided by an Afrocentric paradigm (Karenga 1994 ) , and concentrated on the within-ethnic group strengths of people of African descent, as well as on the beliefs and practices that can shape an individual’s understanding and worldview (Kambon 1992 ) . The structure of the intervention promoted the indi-vidualism essential to self-protection, as well as the collectivism necessary to sup-port relationship building and peer supsup-port for behavior change (Karenga 1988 ;
Triandis 1994 ) . It was guided by the well-known paradigm of Nguzo Saba (Karenga 1994 ) . Seven principles of Nguzo Saba (unity, self-determination, collective work and responsibility, cooperative economics, purpose, creativity, and faith) guide the Afrocentric worldview and belief systems of native groups of Africa (Karenga 1988 ) . In the context of this study, these seven principles guided the content of the intervention, the style of delivery, and the study design. The use of these principles sanctions the ethnic matching of facilitators and participants, essential to the peer support and modeling needed in a culturally congruent intervention.
Nguzo Saba informs HIV prevention guidelines that bring couples, families, and communities together. The principles promote respect for traditions, and highlight the sociopolitical and racial realities that African-descended people affected by HIV continue to face. The intervention consisted of eight weekly 2-h sessions. It included four sessions with individual couples and four sessions with groups of three to fi ve couples (NIMH Multiside HIV prevention trial group 2008a ) . Positive outcomes of the Eban study demonstrate the success of another culturally congruent adaptation of the original Connect intervention, in increasing condom use at 12 months (NIMH Multiside HIV prevention trial group 2008b ) .
The only couple-based HIV prevention study for injection drug users (IDUs) that has been developed outside of the USA is a HIV/STI risk-reduction intervention for IDU couples conducted in Kazak hstan (Gilbert et al. 2010 ). The study was con-ducted at a needle exchange program (NEP) site in Shu, Kazakhstan, a small city of approximately 34,000 situated along a major drug traffi cking route originating in Afghanistan. The study examined the preliminary effects of a couple-based sexual risk-reduction intervention (CHSR). This pilot trial demonstrated the feasibility and preliminary effects of the CHSR in reducing sexual and drug-related HIV risks. The content of all the CHSR sessions was couple based and focused on (1) identifying HIV risks encountered by the couple and (2) introducing, modeling, and practicing couple communication and problem-solving skills, which both partners could use to reduce their transmission risks. Materials and exercises incorporated social cogni-tive skill-building strategies, including couple sexual communication skills, problem-solving and assertiveness skills, technical condom use, and syringe disinfection skills (Centers for Disease Control and Prevention CDC 2004 ) . As the preferred method of reducing injection risks, participants were encouraged to obtain new needles from the NEP and not share drug use equipment. Participants were also taught problem-solving and assertiveness skills to identify and avoid triggers for unsafe sex and injection practices. Other activities included participating in games, brainstorming, role playing, and small group discussions to build group cohesion and to increase knowledge of HIV/STIs and transmission risks.
The CHSR intervention was tailored to the realities of drug-involved couples in Kazakhstan. The sessions began and ended with a ritual, such as listening to an inspi-rational Kazakh song, poem, or quote. At the end of each session, participants were asked to set a risk-reduction goal for the week; progress with respect to each goal was reviewed at the next session. The content for the fi rst three single-gender groups for male and female partners was identical, except for a component that was added to ses-sions 2 and 3 in the female gender groups, designed to help women anticipate and manage negative partner reactions to requests to use condoms or not to share needles.
Participants were signifi cantly more likely to increase condom use and decrease unsafe injection acts at the 3-month follow-up. This pilot trial demonstrates the preliminary benefi ts for a couple-based approach for reducing sexual and drug-related HIV risks. The study fi ndings also suggest some preliminary evidence of the short-term effects of the CHSR intervention in increasing HIV/STI knowledge, con-dom negotiation self-effi cacy, and couple’s risk-reduction communication. These positive effects suggest that the modifi ed approach of delivering the CHSR inter-vention using a mixed modality of single-gender group sessions and an individual couple session was effective in promoting change in the core mediators of original couple-based HIV prevention (El-Bassel et al. 2003b, 2005 ) .
Few couple-focused Antiretroviral Therapy (ART) adherence interventions have been tested, even though it is well established that social support is one of the most consistent correlates of adherence across a wide range of populations and diseases (Kaplan et al. 1997 ) .