Attitudes Towards Couples-Based HIV Testing Among MSM in Three US Cities

Abstract

Couples-based voluntary HIV counseling and testing (CVCT)—in which couples receive counseling and their HIV test results together—has been shown to be an effective strategy among heterosexual sero-discordant couples in Africa for reducing HIV transmission by initiating behavioral change. This study examined attitudes towards CVCT among men who have sex with men (MSM) in three US cities. Four focus group discussions (FGD) were held with MSM in Atlanta, Chicago, and Seattle. Although initially hesitant, participants reported an overwhelming acceptance of CVCT. CVCT was seen as a sign of commitment within a relationship and was reported to be more appropriate for men in longer-term relationships. CVCT was also seen as providing a forum for the discussion of risk-taking within the relationship. Our results suggest that there may be a demand for CVCT among MSM in the United States, but some modifications to the existing African CVCT protocol may be needed.

Introduction

Men who have sex with men (MSM) continue to be the most heavily impacted risk group in the US HIV epidemic. After 2000, MSM were the only risk group in the US with increasing HIV incidence, and, in 2006, 53% of incident HIV infections were among MSM [1]. Recently, research has shown an emerging understanding of the critical role that “couples” play in HIV prevention for MSM. For example, in the US, 68% of new HIV infections among MSM are likely attributable to sex with main partners [2]. Further, evidence from the American Community Survey estimated that the number of same-sex couples living in the US increased by 30% from 2000 to 2005—a rate of increase about six times the rate of population growth [3]. This dramatic increase in the number of same-sex couples is suggested to be, in part, a reflection of same-sex couples increased comfort in reporting their relationship status to survey takers [3], indicating the presence of an increasingly large number of visible same-sex male couples with the potential to demand and utilize couple focused services.

Few interventions currently exist that target, or recognize, MSM couples. Given that main sex partners may contribute significantly to the acquisition of HIV among MSM [2] and that MSM couples as a demographic in the US are increasing, preventive efforts that target MSM dyads may be an effective strategy in reducing HIV incidence. Couples voluntary counseling and testing (CVCT) has been shown to be effective in reducing HIV transmission and precipitating behavioral change among sero-discordant heterosexual couples in Africa where heterosexual couples represent the largest risk group for HIV infection. Thus, this approach may be used and adapted for MSM couples. This paper examines whether CVCT could be a viable and feasible approach for MSM in the US using focus group discussions with MSM in three cities (Atlanta, Chicago and Seattle) to explore MSM’s attitudes towards the possibility of a same-sex version of CVCT. An understanding of whether MSM are open to CVCT is an important first step in the adaptation of a service to meet the needs of currently under-served MSM couples in the US.

Background

The risk of acquiring HIV infection is related to an interaction of correct knowledge of one’s own HIV sero-status and the sero-status of one’s sex partner. However, knowledge of partner sero-status is a problematic issue among MSM. Although the prevalence of lifetime and recent HIV testing among US MSM is high [4], many US MSM who are HIV infected are unaware of their infection: overall 48% of MSM recruited in community venues in five US cities who were HIV tested as part of CDC’s National HIV Behavioral Surveillance (NHBS) project and were found to be HIV positive were unaware of their HIV infection [5].

Individual HIV voluntary counseling and testing (VCT) is a critical part of the HIV prevention portfolio, but its efficacy as a stand-alone HIV prevention intervention is unclear [6–9]. A meta-analysis of 27 studies, mostly conducted in North America, showed mixed results of individual VCT as an HIV prevention intervention; although individuals who received VCT and had positive HIV test results subsequently increased condom use, those who received VCT and had negative results did not change their patterns of condom use [10]. Others have shown that some MSM who receive positive HIV test results continue to engage in high-risk sexual behavior [11]. The authors of the meta-analysis called for theory-driven research into VCT, and in particular, an investigation of specific counseling approaches to optimize HIV testing as a prevention intervention.

Couples voluntary HIV counseling and testing (CVCT) has been used as an HIV prevention intervention in Africa for over 20 years [12–15], and is considered by CDC to be a “high leverage HIV prevention intervention” [16] in that setting. CVCT has been shown to have the potential to avert more than two-thirds of new HIV infections among urban African men and women [17]. Although the process of CVCT can vary across programs, or even across couples, in general in CVCT, couples participate in the whole cycle of VCT together: they receive pretest information together, receive pretest counseling and risk ascertainment as a couple, and receive the results of HIV testing and post-test counseling as a couple. Concordant negative couples are advised to remain monogamous with each other or to use condoms with any outside partners. Concordant positive couples are advised to use condoms with each other to prevent exposure to different strains of HIV as well as with outside partners to prevent transmission. For HIV discordant couples, where one partner is HIV positive and the other is HIV negative, correct and consistent condom use becomes the primary prevention strategy to protect the HIV negative partner from infection [18].

This paper examines attitudes towards potential CVCT services among MSM in three US cities: Atlanta, Chicago and Seattle. These cities were chosen to represent cities with differing sizes and diversities of MSM populations, and with differing prevalence of HIV. The paper illustrates the attitudes of MSM towards CVCT, and makes suggestions as to how a service that has been successful in stemming heterosexual HIV transmission in Africa could be adapted for MSM, the group at highest risk for HIV in the US.

Methods

Focus group discussions were used to examine participants’ perceptions of CVCT, comparisons of CVCT and VCT, and perceived behavioral changes that may result from CVCT. As a research technique, focus group discussions employ guided, interactional discussion as a means of generating the rich details of complex experiences and the reasoning behind an individual’s actions, beliefs, perceptions and attitudes [19]. In total four focus group discussions were held (two in Chicago and one each in Atlanta and Seattle).

Participant Recruitment

Participants were recruited through community-based organizations that had strong connections to the MSM populations in each of the cities. The target population for the groups was men aged over 18 years who self-report that they have sex with men and currently identify themselves as in a relationship with another man and are current residents of one of the cities. Participants did not have to self-identify as gay, bisexual or transgender. Members of the same couple were not eligible to be in the same focus group. Potential participants who contacted the study organizers were screened on the aforementioned criteria. Upon arrival at the focus group venue, participants first went through the consent process, and then completed a screening questionnaire (including age, race, and relationship status). The research team members reviewed the completed questionnaires and selected 10 participants to represent a diverse mix of the potential participants (e.g., a range of ages, races/ethnicities and relationship statuses).

Data Collection and Analysis

The question guide for focus group discussions included the following themes: attitudes towards HIV testing, motivation for HIV testing, attitudes towards CVCT, willingness to participate in CVCT, barriers and facilitators to CVCT use, and the impact of CVCT on relationship quality and behavioral change. Focus group participants were told that a ‘couple’ or a ‘relationship’ should be self-defined; that is, no definition of a couple/relationship was given to the participants, who were encouraged to think of what constituted a couple/relationship from their own perspective. Participants were not asked to reveal their sero-status. The analysis involved the coding and classifi-cation of the data by reviewing the transcriptions for potential conceptual categories, using the guideline questions as initial categories [19]. This process was conducted using the NUD*IST [20] software for qualitative data management and analysis; both inductive (arising from the literature on CVCT) and deductive (arising from the data) codes were applied.

Results

Four focus groups were conducted, with a total of 39 participants. The age of participants ranged from 19 to 53; 21/39 (54%) participants were African American, 18/39 (46%) were Caucasian, all participants identified as currently being in a relationship, and 20/39 (51%) reported that they had other sex partners in addition to their main partner.

Acceptability of CVCT for Same-Sex Male Couples

The discussion around the potential of providing CVCT to male couples followed the same pattern in each of the three cities. Initially participants were skeptical about the acceptability of CVCT among gay men, reporting that men would be unlikely to attend such services. This reaction, however, stemmed from a belief among the participants that such services were impossible to provide under current confidentiality laws. Once the discussion moved to a description of the process of CVCT there was almost universal acceptance of CVCT. Several participants reported previous experiences in which they had attempted to receive HIV testing with their partner, but had been denied due to confidentiality laws. Each of these participants described how the inability to test with their partner left them without a sense of support during the testing process, had made them feel ostracized as gay men, and had resulted in them having to find out their partner’s results without the aid of counseling services.

It really sucked the process I went through back then. I went to get a test, my partner went to get a test, I found out my results were positive right away and he had to wait longer, maybe another three or four days, and I had to find out over the phone because he called me because he went down to get the results by himself, they wouldn’t have the both of us go together, but that really was a horrible process because what was the first thing we did – we got together right after that to talk about it and deal with the whole thing

We had been in a relationship together for six months, and I was thinking that it was going to be just like any other doctors appointment and I could go in with him, and I got there, and it hit me, and I thought ‘Ok, gay rights, cool’; I asked the nurse if I could go in with him and she told me no it was confidential, and my boyfriend was actually really shaking and nervous and it was hard for me to be out there. I got angry

A common reason for the acceptability of CVCT for gay men was that it would validate the acceptability of same-sex male relationships and would make homosexual couples more equal to heterosexual couples. Participants reported that undergoing CVCT would be seen as a declaration of commitment to a relationship, similar to a marriage ceremony for heterosexual couples. Some participants also reported a misconception that heterosexual couples were allowed to undergo CVCT, and extending CVCT to same-sex couples would be a way of creating equity.

A commitment, like this is it, you and me, that’s it baby, I am not looking for anyone else…it’s almost like a marriage, cuz like in actual heterosexual marriages they have to get tested by law before they can marry

I think for me the way I look at our relationship is that it is like being in a marriage and I find particularly degrading when health care providers look at us differently…and I wish that the health care system would go to that point that there would be the same degree of privilege and confidentiality granted to partners as there is to spouses

Relationships are normally defined by society’s rules, and it may become more acceptable as more people see men testing together, then that type of relationship become more acceptable for all

CVCT as a Means of Disclosing Sero-Status

One of the main reasons participants reported for the acceptability of CVCT was the potential for CVCT to provide a means for couples to disclose their sero-status to each other. Several HIV-positive participants reported that CVCT would provide an opportunity for them to inform their new partner of their positive status in the company of a trained counselor. One participant reported that he had gone through testing and shared his results with his partner, even though he knew he was HIV-positive, as a method for revealing his status to his new partner.

I knew I was HIV positive and I didn’t know how to tell him, we hadn’t had sex yet, we were just flirting around with each other. But he was so damn persistent about being tested, but for whatever reason back then I just couldn’t say it, so I said let’s just go get tested. And I remember we were in a waiting room and they called me first, and I go back there and they told me I was positive. Even though I knew I was positive it was still an emotional toll and I couldn’t stop crying

Similarly, several participants reported that CVCT would provide a forum for the discussion of results among couples, and would remove the difficulty of having to inform a partner of a newly detected HIV-positive sero-status. Participants often talked about the benefits of the “open communication” that they perceived would be provided by CVCT.

I think it is a great idea, I think what happens is when one person tests positive, at least in my experience, it is hard to communicate that to the other person, so if you are both in the room together it kind of nips that in the bud and creates dialogue

The Roles of Trust and Honesty

Many participants talked about the increased potential for honest disclosure of HIV test results that CVCT services would provide.

Then there is the honesty part (if you tested separately), you tested separately, I am negative and he is positive, are they really gonna tell me they are HIV positive? They ain’t got to tell me, the doctors can’t tell me

I think it would knock off the dishonesty part, if you decide leaving home that is what you wanna do, and you get there and you know what is ahead and what might happen, I think it is an excellent idea

Similarly, several participants noted that CVCT services would provide a forum for partners to be honest about their sexual behaviors, and it was perceived that each partner would be expected to disclose any sexual activity that had taken place outside of the relationship. However, the CVCT process used in Africa does not currently require participants to report this.

It could also complicate the situation too. I am very faithful to my partner, but if you in the room and the partner says he has other casual partners and you don’t know about them, then you got to be prepared to hear things like that

When talking about the decision to test together, participants often referred to “trust” in a relationship, stating that undergoing CVCT would require couples to have developed trust in their relationship and their partner. Many participants felt that the decision for a couple to undergo CVCT would be a declaration of their trust of each other, and their willingness to be open to full disclosure of their partner’s sero-status and behaviors.

I would think that anyone who are that far with, anyone you are going through that with, should be someone you can trust, I would hope so…if you have that issue you probably shouldn’t be together anyway It’s a matter of relationships going further, I trust you, we trust each other, love and commitment and all that good stuff

Relationship Quality and Commitment

The most often stated reason for a male couple to undergo CVCT was that it would be considered a sign of commitment in the relationship. Participants reported that CVCT could be viewed as a “rite of passage” for a couple, and would be understood to be clear declaration of commitment to the relationship. Participants also reported that CVCT would develop a sense of responsibility for the relationship; by testing together individuals would know each other’s sero-status and would be able to adopt behavioral practices to safe guard their partner. Undergoing CVCT was also seen as an indication of the seriousness of the relationship and would be seen as a sign that the couple intended to remain together.

When my partner and I got tested we decided together, it was a decision we made together, I didn’t really think I was positive and I didn’t really think I had put myself at that kind of risk, and he didn’t really think he was positive, but in coming together in this relationship I think we both felt that it was just something, a safe guard, a kind of etiquette, something to do together to know that we were not going to put each other at risk

It’s like taking responsibility for the relationship, if you are going to take responsibility for the relationship and be committed

That’s the key word, commitment, people don’t do it ‘cos they are really not committed to that person, they are still out there messing around, so what good would it do for me to take a partner to get tested and still be sleeping around with four, five other guys?

Sexual Quality and Condom Use

In addition to acting as a declaration of the seriousness of a relationship, several participants noted that couples may undergo CVCT as a means of moving away from condom use. Participants reported that there were natural stages in a relationship, once a couple had decided to be monogamous, that the couple would want to stop using condoms. CVCT was reported to be a useful tool for this stage of the relationship, providing male couples with a forum to jointly learn their HIV status and to receive counseling on safer sexual behavior as a couple.

And then when you just really wanna settle down, and you say this is it, we gonna be together, I am gonna be committed to you, you gonna be committed to me, then yeah, that will prompt you to go get tested, then you know if the test come out negative then you got nothing to worry about ‘cos you not sleeping around, and I ain’t got to worry about slipping on no condom

Providing Emotional Support

Participants universally reported that CVCT would allow a person receiving their HIV test results to receive emotional support from their partner. Several participants noted that while they had appreciated the support of the provider, this was no substitute for the support that could be gained from the presence of a partner.

But your counselor is a stranger, and I am sure they are a very nice person, but if I am getting bad news I would rather have someone that I am in a relationship with, there is no substitute for that

Initially it is like a comfort level, because I know that whenever I go to a doctor and get a major test or something, I am usually like all nervous, and I think if my partner were in that room with me I would feel more comfortable at first…but I think if the results are not what you are wanting then it could be even more tense later

Several participants reported previous testing experiences in which they or their partner had received their results individually. Each of these participants noted the greater emotional support that they could have provided or received if they had been able to be with their partner when the results were given.

I think it would’ve been a lot better, during that time all I wanted to do was to hold someone’s hand, I just knew it was really emotional for him, and I knew it would be a lot better for him if I were in the room and able to calm him down

We came here together because we wanted to share that information with each other, and we really wanted to share this experience of being tested together, so if there had been some bad news I would have wanted him there to be supportive

Reasons Against CVCT

Although participants in the focus groups were supportive of the provision of CVCT to male couples, participants were able to identify some reasons why other MSM may not be open to CVCT. Several participants suggested that the CVCT process would force couples to reveal their recent sexual behaviors and that this fear of disclosure may be a barrier preventing men from attending CVCT.

A lot of people probably wouldn’t want to get tested together ‘cos it would show that they had been creeping around

Similarly, some participants noted that the disclosure of sero-status may lead to violence or abandonment. This was seen to be a concern for couples who proved to be sero-discordant during the CVCT process, with the HIV-positive partner seen to be at risk of being abandoned by their partner or experiencing violence from their partner.

If you ask me to come get tested, and I don’t wanna lose you as a lover, because you good at what you doing, plus you probably got good money and I don’t wanna let that go, but I know I am not being loyal to you..if you ask me to come and get tested and I say no, then that’s a problem, I might say yes ‘cos I don’t wanna loose you. But then if I find out I am positive, then what?

CVCT and Relationship Progression

Most participants reported that it was very unlikely that CVCT would take place early in a relationship, or before initiating sexual activity. The decision to undergo CVCT was seen as a decision that would take place at the same time a couple decided that they were in a relationship, and was seen as a declaration of a level of commitment and trust between two individuals.

Often times we say we are in a relationship, but we have to define the relationship, and for me at least, you meet someone and you together a week or two and you call it a relationship, how healthy is that? So for me if I am with someone for only a few weeks I would question taking that test with them –but I am in a long-term, healthy, committed relationship then I would be more apt to say let’s test together

The fear of loss of a partner was the main reason many felt that CVCT would not occur early in a relationship; participants reported that the identification of sero-discordant results early on in a relationship would lead to the dissolution of the relationship.

Obviously at an early stage in the relationship if one tests positive and one doesn’t then it could be more dangerous and could kind of lead the relationship apart, but once you have reached a certain level of commitment then maybe that supportive element would come into play, wanting to be there for each other, and even this obstacle is not going to stand in the way of your relationship, because you love each other so much

Perceived Effects of CVCT on Relationship Quality

Participants felt that undergoing the CVCT process could have both positive and negative effects on a relationship, and that the effects were moderated by the length and quality of the relationship. Many participants reported that if the couple were in a long-term, stable and loving relationship that the results shared during the CVCT process should not harm the relationship.

Depends on where y’all at in your relationship, how he feels about you and how you feel about him, does he really love you? Cos if he really loves you, then they will understand that and try and help you out, they will still try and be with you

However, it was felt that the disclosure of sero-discordance early on in a relationship may lead to relationship dissolution; the main reasons being the fear of HIV transmission, the effects on quality of sexual activity, and the perception of creating dependency within a relationship.

Sometimes couples will have fear of, you know, when you go test and yours is negative and his is positive and he probably says now since we got this test done I am really having second thoughts about this relationship

If one comes out positive and the other doesn’t it means, like you said, we really need to think about this, especially for the positive person, cos this is totally going to make our sexual experience uncomfortable from here on out, cos now I am going to be constantly worried about you…that could kill the relationship

Adaptation of CVCT Services

Participants were asked how the CVCT process as conducted in Africa would need to be adapted for male couples in the US. Participants were in favor of the entire counseling and testing process being couple-focused, and did not report a need for individual counseling to be part of the process. Some participants, however, suggested the potential for one partner to coerce another into CVCT, and thus suggested that screening procedures be in place to identify possible coercion. Participants also suggested that CVCT could be included as part of a larger package of services that catered to male couples, to include relationship counseling and financial planning.

Sometimes when couples get tested you may have one who is like I am the dominant partner and I want to know what your results are….if they do some kind of screening process to find out are you legitimately doing this together, do you really care about each other?” “The whole idea of this holistic service, it’s not just get tested for HIV but you can also have relationship, financial counseling…and then that supports relationships in our community, something we don’t do

Discussion

Despite increases in options for HIV testing, including the development of oral and rapid HIV testing technologies, and a greatly expanded pharmacopoeia for disease management, the number of people undergoing HIV testing in the US has remained relatively stable at approximately 2.6 million per year [21, 22]. As a result, significant numbers of MSM are not currently accessing HIV testing services. Painter [16] reports that CVCT represents a high leverage HIV prevention intervention for African countries, where heterosexual couples represent the most at-risk group for HIV transmission [17]. Targeting couples in HIV prevention efforts—in particular couples-based HIV counseling and testing—has been shown to be effective in reducing transmission between sero-discordant couples, increasing condom use, and reducing sexual risk-taking [23–25]. However, HIV counseling and testing procedures in the US remain largely individually focused, although some prevention efforts have focused on couples through encouraging partner discussion of sexual behavior and disclosure of sero-status. Additionally, epidemiological research on HIV risk has moved beyond an individual, egocentric data approach, and has more recently began to include data on partners and sexual networks [26]; thus, although HIV research has began to recognize the importance of the dyad in shaping sexual risk-taking and HIV testing, service delivery for the most part remains stubbornly focused on the individual.

The focus groups demonstrate clear support for the concept of couples-based HIV counseling and testing among MSM. The results of the focus group discussions suggest that the provision of CVCT could surmount several known barriers to HIV testing among MSM. Previous studies of HIV testing behavior among MSM in the US have demonstrated several characteristics associated with the counseling and testing process that act as barriers to service uptake [22]. For example, fears associated with the testing process, the waiting time for results and fears over a positive result are all known to prevent MSM from attending HIV testing [22]. Focus group participants reported that CVCT would allow MSM to undergo testing with a partner, from whom they could draw emotional support, suggesting that several of the fears associated with individual HIV testing could be eased by CVCT. Several studies have also shown that desire for intimacy in a relationship is a risk factor for unprotected sex, particularly among sero-discordant couples [27]. However, MSM in the focus groups reported that CVCT would provide an opportunity for couples to talk openly about sexual behavior and to make a plan for safer sexual practices. In particular, participants reported that CVCT would provide an opportunity for sero-positive MSM to disclose their sero-status to their partner. Knowledge of sero-status has been shown to reduce the risk of unprotected anal intercourse, particularly among sero-positive individuals [28]. Studies of the impact of CVCT in Africa have shown that CVCT increases condom use among sero-discordant couples [12, 25]. Thus, through providing a forum in which couples can learn and share their sero-status, CVCT may provide a forum for couples to be counseled on developing plans for behavioral change, and provide an opportunity to increase condom use and decrease risk-taking behaviors.

In order for CVCT to be successfully adapted for MSM in the US, several misconceptions need to be addressed. Many focus group participants believed that heterosexual couples were currently able to undergo CVCT, and that the provision of CVCT to MSM would provide greater equity. Additionally, several participants felt that the need to disclose sexual behaviors outside of the partnership—either to a counselor or to a partner—would prevent many MSM from attending CVCT. CVCT does not require couples to disclose sexual behavior outside of the partnership, rather to talk about sexual practices and develop guidelines for safer sexual behavior in the relationship. The promotion of CVCT services to MSM must make this distinction clear, and does not necessarily need to involve the disclosure of sexual behavior among couples. Moreover, CVCT may not be appropriate for all MSM “couples”, and training curricula for CVCT for MSM must recognize the variations in couple’s needs that may occur with relationship duration and type of relationship. The adaptation of CVCT for MSM in the US also requires services to work within the confines of HIPAA regulations: HIPAA prevents private health information from being shared with others without the client’s consent, thus, the CVCT process would need to ensure that the express consent for the sharing of HIV test results of each individual in the couple is sought and documented.

The key limitation to this research is that focus group participants were self-selected, and thus may be more interested in or motivated to participate in CVCT or other HIV prevention interventions than the general population of MSM in these cities. The results are thus not necessarily generalizable to all MSM in these cities.

Conclusion

Despite years of interventions, HIV prevalence remains high among MSM in the US, and there are significant numbers of MSM who are not integrating routine HIV testing into their lives. While research efforts are shifting towards a focus on the MSM dyad, services remain individually focused. CVCT provides an opportunity for MSM to talk about sex, and to make plans for safer sexual behavior as a couple in the presence of a counselor; participants reported that these are highly desirable characteristics of CVCT. CVCT also provides a forum for sero-status disclosure, which has the potential to precipitate behavioral change in a couple. The present results are based on a small sample of MSM from three diverse cities: more information is now needed from a larger, more generalizable sample to identify the extent to which CVCT is acceptable among the broader US MSM population. However, the initial results presented here are encouraging. CVCT is an acceptable format for HIV counseling and testing among MSM in this study, and if it is adapted and promoted well, could fill a significant gap in couples-based services for US MSM.