Decisions about testing for HIV while in a relationship: Perspectives from an urban, convenience sample of HIV-negative male couples who have a sexual agreement

Abstract

Many HIV-negative male couples establish a sexual agreement to help manage their HIV risk, however, less is known about their decisions about testing in this context. The present study examined whether male couples discussed HIV testing and explored their decisions about testing in the context of their sexual agreement at the individual- and couple-levels. Qualitative dyadic interview data were collected from 29 HIV-negative male couples with a sexual agreement who resided in Atlanta or Detroit; the sample was stratified by agreement type. Content analysis revealed male couples’ decisions about HIV testing as routine, self assurance, reliance and assumption on partner, beginning of relationship testers, and/or trust; decisions varied between partners and by agreement type. Findings suggest prevention efforts should help male couples integrate HIV testing into their sexual agreement that matches their agreement type and associated HIV-related risk behavior, and help shift their one-sided decisions about testing to a couple’s mutually shared decision.

INTRODUCTION

Gay, bisexual and other men who have sex with men (MSM) continue to experience the highest incidence and prevalence of HIV in the U.S. (CDC, 2015). Recent estimates also indicate that between one- and two-thirds of MSM acquire HIV from their primary relationship partners (i.e., male couples) (Goodreau et al., 2012; Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Within the context of HIV-negative male couples’ relationships, HIV transmission is attributed to a number of factors: lack of confirmation of both partners’ HIV-status (as negative) before having condomless anal sex (CAS); higher number of anal sex acts; more frequent receptive roles; and/or lower rates of condom use during anal sex (Goodreau et al., 2012; Sullivan et al., 2009). While studies have noted that >80% of U.S. HIV-negative male couples practice CAS within their relationships (Chakravarty, Hoff, Neilands, & Darbes, 2012; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012; Mitchell, 2014), CAS within these relationships does not necessarily increase couples’ risk for HIV when both men test and know they are HIV-negative, refrain from having CAS with casual MSM partners outside of their relationship (i.e., “negotiated safety”) (Crawford, Rodden, Kippax, & Van de Ven, 2001; Kippax et al., 1997), and/or are using pre-exposure prophylaxis (PrEP) with sufficient adherence (Grant et al., 2010; Grohskopf et al., 2013). However, HIV-negative male couples’ risk for HIV and other STIs may increase when one of the partnered men has CAS with an outside MSM partner – either with or without the knowledge of their main partner – while CAS is practiced within the primary relationship (Chakravarty et al., 2012; Davidovich, de Wit, & Stroebe, 2000; Mitchell, 2014; Mitchell et al., 2012), and without the uptake of PrEP.

Prior research has also reported that many male couples establish a sexual agreement in their relationship (Gass, Hoff, Stephenson, & Sullivan, 2012; Hoff & Beougher, 2010; Hoff, Beougher, Chakravarty, Darbes, & Neilands, 2010; Mitchell, 2014; Mitchell et al., 2012; Stephenson, White, & Mitchell, 2015). A sexual agreement is an explicit discussion and mutual understanding between two male partners about which sexual and relational behaviors they agree to engage in within and/or outside of their relationship (Hoff & Beougher, 2010; Mitchell, 2014). While one aim of establishing and adhering to a sexual agreement is to help couples manage their risk for HIV and other STIs, agreements also help them enhance their sexual pleasure, intimacy, communication, and trust within the relationship (Darbes, Chakravarty, Neilands, Beougher, & Hoff, 2014; Hoff & Beougher, 2010; Mitchell, 2014). The types of sexual agreements that couples form vary. Some couples from a ‘closed agreement,’ in which partners only have sex with each other (e.g., CAS within the relationship), whereas other couples may form an ‘open agreement’ in which partners may engage in sex (e.g., CAS) within and outside the relationship, with or without specific guidelines (Hoff et al., 2010; Gass et al., 2012; Mitchell, 2014; Parsons, Starks, DuBois, Grov, & Golub, 2013). The types of sex and related behaviors that couples allow to occur within and/or outside of their relationship also vary (e.g., CAS vs. using condoms for anal sex with casual MSM partners) and have implications for HIV prevention. Despite these variations in types of sexual agreements and associated permitted behaviors, what remains unknown about male couples’ sexual agreements and is central for primary prevention of HIV is whether they communicate about and decide how often to test for HIV/STIs per their agreement.

Though CDC recommends sexually active gay, bisexual and other MSM to test for HIV at least once a year (CDC, 2015), prior studies have reported low HIV and STI testing rates among HIV-negative male couples despite their engagement in CAS within and/or outside the relationship (Chakravarty et al., 2012; Mitchell & Petroll, 2012; Stephenson, White, Darbes, Hoff, & Sullivan, 2015). Furthermore, few HIV-negative partnered men test for HIV at regular intervals (e.g., quarterly or twice a year) (Mitchell & Horvath, 2013; Stephenson et al., 2015). With respect to sexual agreements and HIV/STI testing, one study reported that HIV-negative partnered men were twice as likely to get tested every 3, 4, or 6 months when a sexual agreement was present in their relationship than those who never got tested while in their relationship. However, partners with higher levels of trustworthiness were more likely to have never been tested for HIV, suggesting that they may rely on their partners to motivate them to get tested or may deem testing as a violation of trust in their relationship (Mitchell & Horvath, 2013). In addition, Beougher et al. (2015) recently described motivations to test for HIV and associated behaviors among a sample of male couples, and noted their motivations to test were either event-related (i.e., testing after risky sexual behavior) or partner-related (i.e., testing as a response to partner’s request to get tested), suggesting that motivations to test may alter and/or depend on the dynamics between the two partners and the situations that arise while being in the relationship. These few studies indicate that different motivators may impact the frequency in which partnered men and male couples test for HIV. However, whether male couples strategically plan and discuss how often to test for HIV within the context of their sexual agreement remains largely unknown yet relevant to help increase testing frequency among this population.

Drawing on these dynamics and decision-making processes, interdependence theory posits that behaviors within couples’ relationships are interdependent because each partner has a certain amount of control and influence on the outcome in the behavioral interaction they have together (Kelley & Thibaut, 1978). This outcome is dependent upon each partner’s option, value, and assessment of the particular behavior and whether that behavior is important to their relationship. Transformation of motivation and communal coping, two key constructs of interdependence theory, help explain why members of the couple ascribe health events as meaningful for the relationship or to their partner, rather than just for oneself, and why couples’ management of a health threat shifts from an individual-level belief to a mutually shared responsibility, respectively (Lewis et al., 2006). With respect to sexual agreements and testing, each partner’s reasons for integrating testing for HIV/STIs will depend on his value of this particular behavior, and whether he believes in engaging in this behavior is important to both he and his partner as well as their relationship. As such, research which explores HIV-negative male couples’ discussions and related decisions about HIV/STI testing within the context of their sexual agreement is needed to determine how best to encourage other HIV-negative male couples – with and without sexual agreements – to bolster their HIV/STI testing behaviors.

To further our understanding of HIV-negative male couples’ discussions and decisions about HIV testing within the context of their sexual agreement, the present qualitative study sought to: 1) examine whether male couples discussed HIV testing as part of their sexual agreement, and whether partnered men concurred about having this discussion; 2) explore male couples’ decisions about HIV testing in the context of their sexual agreement at the individual- and couple-levels. Qualitative dyadic data from 29 concordant HIV-negative male couples with an established sexual agreement that resided in the Atlanta, GA or Detroit, MI metro areas were used to accomplish these aims.

METHOD

Recruitment and Eligibility

Data for this study are drawn from interviews conducted with 29 HIV-negative male couples from Atlanta and Detroit in 2014. The University of Michigan and the University of Miami Institutional Review Boards approved all study procedures. Participants were recruited via passive recruitment methods, including the distribution of flyers at local gay-identified events and venues, ads on email listservs, and business card distribution through places that provide services and/or activities to gay men and other MSM, including local AIDS service organizations and community-based organizations, bars, and coffee shops in Detroit and Atlanta metro areas. Placement of ads on Facebook were also used to target Facebook members whose profile webpage lists that they are male, 18 years of age or older, living in either of these metro areas, interested in men, and in a relationship (gender of relationship partner was clarified during the screening process). Interested men either clicked on the Facebook ad or called the number listed on the recruitment materials to learn more about the study; they were then directed to a confidential online screener. Eligible men (aged >18, resident in Atlanta or Detroit, self-reported as being HIV-negative; had been practicing CAS in their relationship for > 6 months; have reported no recent history (< 1 year) of intimate partner violence or coercion; have formed and had a sexual agreement in their relationship for at least 6 months; had always adhered to their sexual agreement were then directed to an electronic version of the informed consent document. Once consented, participants were prompted to electronically input their first name, phone number, and email address along with their partner’s first name, email address and/or phone number so that their partner could be screened for eligibility and provide consent to participate. Both members of the male couple had to meet all inclusion criteria to enroll in the study.

Study Sample

In total, 29 male couples participated: 15 from the Detroit metro area and another 14 from the Atlanta metro area. Fifteen couples had an open sexual agreement whereas 14 male couples had a closed agreement. The mean age of the participants was 33 years (range: 19 – 65) and the average age difference between partners was 6.1 years (range: 0 – 38). Fourteen percent of couples (N=4) had been in their relationship between 6 and 12 months, 34% (N=10) between 1 and 2 years, 17% (N=5) between 2 and 5 years, 24% (N=7) between 5 and 10 years, and 10% (N=3) had been in their relationship for over 10 years. Most men identified as Non-Hispanic and/or white; 28% of the couples were mixed race (N=8).

Procedure

At the appointment, each partner was provided a copy of the consent document. Partners of each couple were interviewed simultaneously yet apart from one another (by different interviewers). Semi-structured individual-level interviews were used to record partnered men’s understandings about the history and aspects of their sexual agreement. Specifically, men were asked, “As part of your agreement, did you and your partner discuss how often you would get tested for HIV/STIs?” Follow-up prompts of “What did you decide?” and “Could you please elaborate?” were used to encourage partnered men to elaborate for further discussion. All interviews were digitally recorded, transcribed verbatim, checked for accuracy, and de-identified.

Analytic Plan

Content analysis (Hsieh & Shannon, 2005) was then employed to identify whether male couples discussed including HIV/STI testing into their sexual agreements and associated decisions. Using a step-by-step iterative process (Frost, McClelland, Clark, & Boylan, 2014), three members of the research team read all transcripts, took notes, and identified any overarching themes. These three members then met to discuss the overarching themes before rereading and coding the transcripts for these themes. During meetings, the research team compared and discussed their coding for these themes and made adjustments as needed before creating the codebook. The codebook provided a description of the themes for coding along with their corresponding definitions. Each team member then used the codebook to code the transcripts once again. This process was applied for all transcripts and each team member reviewed one another’s coding of the transcripts to ensure consistency was achieved for the themes identified. All coding was done manually.

RESULTS

Male Couples’ Discussions about HIV Testing in the Context of Their Sexual Agreement

By comparing interview responses between each relationship partner of the couple, our analysis of whether male couples discussed HIV testing in the context of their sexual agreement revealed three different groups of couples: 1) those with both partners who concurred they did not discuss HIV testing in the context of their sexual agreement; 2) those with both partners who concurred they did discuss testing in the context of their sexual agreement; and 3) those who disagreed about discussing HIV testing in the context of their sexual agreement. As noted in Table 1, nineteen couples (65%) concurred they did not discuss HIV testing, six couples (21%) concurred they did discuss testing, and four couples (14%) disagreed about discussing HIV testing in the context of their sexual agreement. Based on this dyadic comparative analysis, the majority of couples did not discuss and/or integrate HIV testing as part of their sexual agreement.

Table 1.

Dyadic analysis on whether couples discussed HIV testing within the context of their sexual agreement

Partner 1 response	Partner 2 response
	Yes, discussed	No, did not discuss
Yes, discussed	6	3
No, did not discuss	1	19

Note. Among the 4 couples who disagreed about discussing HIV testing per their sexual agreement, 3 were from Detroit and 1 was from Atlanta.

Decisions about HIV Testing within HIV-negative Male Couples’ Relationships

Analysis of the individual interviews identified several themes about partner’s HIV testing decisions: routine testing, self assurance, reliance and assumption on partner, beginning-of-relationship testing, and trust. As noted before, most partners and couples stated they did not discuss nor integrate HIV testing as part of their sexual agreement. However, themes that emerged illustrate partners’ HIV testing decisions since they have been in their current relationship. With the exception of routine testing, all other themes related to decisions about HIV testing were expressed by partners who reported not discussing HIV testing with their main partner. For some partners, more than one theme was present regarding their decisions about HIV testing; thus, themes that emerged were not mutually exclusive from one another. That is, for some partnered men, their decisions about testing for HIV in their current relationship were influenced by more than one factor (e.g., trust, reliance and assumption on partner). When examining the themes at the couple-level (i.e., between both partners of the couple), some couples had partners who reported similar reasons regarding their HIV testing decisions while other couples had partners who reported different reasons. Some couples also had multiple themes present regarding their decisions about HIV testing in their relationship.

When comparing partners’ decisions about HIV testing within their relationship (Table 2), many variations in theme combinations existed with respect to couples’ HIV testing decisions. For instance, some couples were categorized as “routine – routine testers” while other couples were categorized as “reliance and assumption on partner – beginning of relationship testers.” To illustrate these different combinations of themes, exemplary quotes from both partners of the couple are provided and described below.

Table 2.

Couple’s decisions about HIV testing: Comparing both relationship partners responses

Theme identified in partner 1’s response - Theme identified in partner 2’s response	Number of couples
Routine - Routine	14
Self assurance – Self assurance	4
Reliance and assumption on partner - Reliance and assumption on partner	5
Beginning of relationship testers – Beginning of relationship testers	2
Trust - Trust	4
Routine – Self assurance	18
Routine – Reliance and assumption on partner	11
Routine – Beginning of relationship testers	0
Routine – Trust	5
Self assurance - Reliance and assumption on partner	9
Self assurance – Beginning of relationship testers	1
Self assurance - Trust	1
Reliance and assumption on partner – Beginning of relationship testers	6
Reliance and assumption on partner - Trust	1
Beginning of relationship testers – Trust	3

Note. Our analyses detected that there were multiple themes embedded in the participants’ responses. Because of this overlap in responses, the total number of couples do not equal to 29.

Routine – routine testers

Many couples had partners who were both routine testers. In these cases, partners had already implemented a routine interval of testing for HIV either through annual check-ups or opportunities at local gay establishments. For example, this male couple, who have been together for 5–10 years, had one partner who included testing for HIV as part of his yearly medical check-up while the other partner would often get tested at their local gay bar:

[Partner 1]: Whenever I would go in for a health screening or my annual health checkup or something like that, I’m like, ‘Oh, while I’m here, let’s do this.’ (42 years old, Non-Hispanic, White, open agreement)

[Partner 2]: … an event like on the weekend, say at a local gay bar or club… sometimes there are testing’s that happen or they’re giving out information… and generally testing is a part of it. So when we see the opportunity is there, we generally will go ahead and do it. (28 year old, Non-Hispanic, White, open agreement)

Routine – trust testers

Several couples had one partner who routinely tested for HIV while the other partner based his decision to test on how well he trusted his partner. For this particular couple (relationship length: 2–5 years), the partner’s trust was based on him perceiving that his partner would not have sex outside of their relationship, thereby reinforcing his reasoning for not testing for HIV while in the relationship. Thus, many partners felt it was unnecessary to test based on this level of trust. This couple illustrates these perceptions:

[Partner 1]: So I do mine every 12 months when I go to my physical… I don’t know if I know exactly when he does his. I think he does it with his physical, but I’m not a hundred percent sure. And I just associate with my physical ‘cause it’s just the easiest thing for me to remember to do it. (30 year old, Hispanic, White, closed agreement)

[Partner 2]: … you know, I trust him enough to – to know that he’s not going outside the relationship, but stupidly or not… I mean, I really don’t know anyone that is, like, as connected as we are that’s in a relationship. (26 year old, Non-Hispanic, White, closed agreement)

Reliance and assumption on main partner – routine testers

In addition, some couples had partners who not only tested for HIV routinely but also relied and assumed that the other partner was doing the same without explicitly discussing it. Both partners of this couple (relationship length: 6 months – 1 year) describe their individual testing routine while under the assumption that their partner was doing the same:

[Partner 2]: Actually, we have not talked about that. I think both of us had done like every six months before, and I think that’s more of an assumption that that would be something we would continue to do, but we actually have not actually discussed that specifically. (28 year old, Non-Hispanic, White, closed agreement)

[Partner 1]: I think both of us get tested regularly. So I don’t [know for sure but], I guess that didn’t change. (29 year old, Non-Hispanic, African American, closed agreement)

Self assurance – reliance and assumption on main partner testers

Several couples had one partner who would test for self assurance while the other partner would assume and rely that other was testing for HIV. Usually, the men who would test did so as an act of reassurance, while their partner would assume and rely on their testing behaviors. This couple, who has been together 5 to 10 years, illustrates this balance of men relying on their partners desire to test for self assurance:

[Partner 1]: I get tested yearly so I know my own status. (34 year old, Non-Hispanic, White, closed agreement)

[Partner 2]: Well, he’s in the medical profession so he gets tested often. He’s sort of in a risk category… being in the kind of profession he’s in. I’m not worried about it [testing for HIV] with him. (47 year old, Non-Hispanic, White, closed agreement).

Beginning of relationship – reliance and assumption on main partner testers

Some couples had one or both partners who got tested for HIV at the beginning of their relationship and as such, partners relied and assumed on one another to tell the other whether they should get tested for HIV again in their relationship. This reliance and assumption was based on that their sexual behaviors would remain the same (i.e. unchanged) as their relationship progressed, and as such, indicated that they would not have a reason to test for HIV again. Both partners of this male couple (relationship length: 6 months – 1 year) shared similar perceptions of their own and their partner’s testing behaviors within this particular context:

[Partner 1]: Well, it was right in the beginning. He didn’t get tested right at the beginning. He was tested before and he said that he hasn’t had sex with anyone between when he got tested and he started to date me… And I did it right in the beginning because… I had sex before having sex with him, so he wanted me to do it… And then we haven’t talked about it really since because we just both assume that, I mean, I think that right now, none of us have had sex with any other people, to my knowledge. (19 year old, Non-Hispanic, White, closed agreement)

[Partner 2]: Not a how often thing, just we both did get tested though, when we started having sex. And then, I guess we trust each other so we don’t have it in the agreement during the relationship. (29 year old, Non-Hispanic, White, closed agreement)

Trust – trust testers

Some couples, particularly those who had an open agreement, shared that building and maintaining trust in their relationship was essential and also influenced their testing behaviors. For instance, men expressed trust in different ways, ranging from sex-related decisions and/or perceiving their partner would test if someone in the relationship was at risk for HIV. This couple, who have been together 2 to 5 years, illustrates these two expressions of trust regarding HIV testing in their relationship:

[Partner 1]: The thing is, we don’t use condoms [at all], and anybody that I’m going to be engaging with outside the relationship is somebody that I trust enough. And it’s kind of one of those things, where it’s just not really an issue for us, and I know that from whatever perspective it’s probably not the safest thing in the world, but we trust each other enough and we trust our judgment enough to, you know, not worry about it. I get tested every six months, and, I mean, it’s very reliable and I’ve been fine. (30 year old, Non-Hispanic, White, open agreement)

[Partner 2]: … we’ve never really kind of sat down and talked about that [HIV testing]. But I think it all comes down to trust and common sense-type of issues… If there is – something comes up unexpectedly, such as… someone – like a partner calls and says, ‘Well, they found this out. I – you should probably get tested.’ – there’s no judgment in that – we would immediately get tested, and work through whatever. (31 year old, Non-Hispanic, White, open agreement)

Comparing partners’ HIV testing decisions by their relationship sexual agreement type

Although most couples in this convenience sample indicated they did not include or integrate HIV testing into their sexual agreement, some themes captured from the interviews were more present among those who had a closed sexual agreement while others were more present among those who had an open sexual agreement (Table 3). For example, routine and self assurance testers were endorsed more among partners who established an open sexual agreement in their relationship, whereas beginning of relationship and trust testers were endorsed more among partners who established a closed sexual agreement in their relationship. Reliance and assumption on partner testers were equally represented among those with a closed agreement and those with an open sexual agreement.

Table 3.

Themes of partnered men’s decisions about HIV testing, by type of sexual agreement

	Formed a closed sexual agreement	Formed an open sexual agreement
Routine	n = 12	n = 21
Self assurance	n = 4	n = 11
Reliance and assumption on partner	n = 6	n = 6
Beginning of relationship testers	n = 8	n = 1
Trust	n = 12	n = 3

Note. Our analyses detected that there were multiple themes embedded in the participants’ responses. Because of this overlap in responses, the number of partnered men do not equal to 58.

DISCUSSION

The present study sought to examine whether HIV-negative male couples discussed HIV testing as part of their sexual agreement, and to explore their decisions about HIV testing in the context of their sexual agreement at both the individual- and couple-levels. The methodology used to address these aims is innovative because it allowed us to analyze and compare both partners of the couple responses. Our findings also have important implications for improving HIV testing behaviors among HIV-negative male couples as well as toward the development of future sexual health and HIV prevention interventions targeting this population.

When comparing each partner’s response of whether or not they discussed HIV testing in the context of their sexual agreement, many of the couples concurred about having or not having discussed testing per their agreement while four disagreed about having this discussion. This discordance may indicate a few things. First, recall bias may play a role in this discordance as couples’ relationship duration ranged from 6 months to over 10 years; their memory and/or details of this conversation (or not) may be a reflection of this time lapse. Another possibility is the extent of how well both partners communication with one another about sex and prevention topics. These communication patterns have been noted in prior studies with male couples as being important relationship dynamics to bolster for HIV prevention (Darbes et al., 2014; Mitchell et al., 2012).

Furthermore, our findings indicated that most couples did not discuss HIV testing in the context of their sexual agreement. The lack of communication about testing is of concern. First, HIV testing rates among HIV-negative male couples remains low despite their engagement in CAS within the relationship, and for some, also outside the relationship with casual MSM partners (Chakravarty et al., 2012; Mitchell & Petroll, 2012). In addition, male couples form a variety of sexual agreements that permit a wide range of sexual behaviors (Hoff & Beougher, 2010; Mitchell, 2014), thereby reinforcing the need to discuss HIV testing that matches each partner’s and couples’ risk for HIV. We recommend male couples to discuss and consider integrating HIV testing into their sexual agreement in their relationship, and to revisit this conversation on a periodic basis. To help facilitate this recommendation, tools could be developed through mHealth (i.e., apps on smartphones or tablets) or eHealth (e.g., interactive web-based program) to encourage male couples to integrate HIV and STI testing into their sexual agreements that matches their agreement type and associated sexual risk behaviors (e.g., closed agreement with CAS and test once a year). These tools should aim to encourage male couples to develop skills and strategies of how best to communicate about testing within their relationship and within the context of their sexual agreement. In addition, these tools, once developed, could be promoted by a wide variety of professionals ranging from researchers to therapists to practitioners.

When examining decisions about HIV testing, several themes emerged from what partnered men shared in their interview. Many partnered men viewed testing as a way of self assurance [to know their status] while others thought certain dynamics of their relationship may impede them from getting tested (e.g., trust, reliance and assumption on partner). Similar findings from other studies have recently been reported (Beougher et al., 2015; Mitchell & Horvath, 2013). For instance, Beougher and colleagues (2015) described some male couples motivations to test for HIV were partner-related, and that some partnered men would not test for HIV due to some of the dynamics that were present in their relationship (e.g., trust and intimacy). They argued for the need to help both partners of the couple shift their attitudes about HIV testing toward a shared, interdependent (i.e., “we”) decision to test instead of viewing it as a one-sided decision to test. We note similar themes from our sample. Extending upon this rationale, we agree and also argue that encouraging male couples to adopt a “we” orientation of shared decision-making about HIV testing would help alleviate potential signs of mistrust or false assumptions that some have reported as reasons for not testing within the context of their sexual agreement and relationship.

To help achieve this shift toward a shared sense of decision-making about testing for HIV, future HIV prevention programs and interventions should incorporate activities to encourage male couples to ascribe HIV testing as an important behavior in their relationship (i.e., transformation of motivation and communal coping). Furthermore, some partnered men’s decisions about testing differed by the type of sexual agreement they had with their main partner. For example, trust appeared to be more of a barrier to testing among those with a closed sexual agreement, and testing for HIV as a form of self-assurance was more indicative of those with an open sexual agreement. As such, future HIV prevention programs should acknowledge the commonality and variations of sexual agreements among male couples’ relationships and explore how sexual agreements can be leveraged to encourage uptake of testing via a shared, decision-making process even amongst couples who have a closed sexual agreement. Though one such program already exists, couples-based HIV testing and counseling (CHTC) (Stephenson et al., 2011; Sullivan et al., 2014) and includes transformation of motivation and communal coping from the interdependence theory (Lewis et al., 2006), additional efforts are needed to help prevent new HIV infections within this population.

Other partnered men’s decisions about testing were related to starting a new relationship (i.e., beginning of relationship testers). Deciding to test only at the beginning of their relationship is problematic for HIV prevention as their perception of risk – at the beginning and throughout the relationship – may not equate to their actual risk for HIV. This finding is also of concern because some of these beginning of relationship testers had partners who relied and assumed that the other would tell them if then needed to get tested for HIV while in the relationship. Stephenson and colleagues (2015) noted that men in relationships reported lower perceived risk and higher confidence in remaining HIV-negative compared to single MSM, suggesting that coupled men perceive their relationship to be a protective barrier to HIV transmission and acquisition (Stephenson et al., 2015). While this may be true for some HIV-negative male couples, other evidence indicates many HIV-negative male couples practice CAS within their relationship, some of these partnered men also engage in concurrent CAS, and in general, their HIV testing behaviors range from nonexistent to infrequent (Chakravarty et al., 2012; Mitchell & Petroll, 2012). As such, partnered men’s perceived risk could be misinformed, including how HIV is acquired and/or transmitted. Thus, HIV prevention efforts (e.g., CHTC) that help increase HIV-negative male couples’ awareness and knowledge about HIV transmission and related behaviors are needed to shift their perceptions of risk to an informed understanding of HIV risk.

Our findings also illuminated that approximately half of male couples in this sample reported they routinely tested for HIV. Although the interviews did not capture in detail the interval in which men tested (i.e., specific frequency), this finding is similar to what has been reported from an online, nation-wide study of 275 HIV-negative male couples (Mitchell & Horvath, 2013). In that study, approximately a quarter of the partnered men tested for HIV every 3, 4 or 6 months while another quarter tested on a yearly basis (Mitchell & Horvath, 2013). In addition, a number of other male couples in our sample had at least one partner who routinely tested for HIV; for these couples, the other partner’s decision about testing ranged from of self assurance to relying and assuming his partner would tell him if he needed to be tested. There were also a few couples with both partners who concurred on their decisions about testing, such as ‘trust – trust’ and ‘reliance and assumption on partner – reliance and assumption on partner’. These within couple differences and similarities on testing decisions are important to capture as they further illustrate the need for current and future prevention efforts to help encourage male couples to attribute HIV testing as a meaningful event and a mutually shared responsibility for their relationship.

Limitations

This study has limitations. The study sample was a non-generalized, convenience sample of HIV-negative male couples that resided in either the Detroit or Atlanta metro areas, thus these findings may not be representative of all male couples who resided in other regions of the U.S. Selection bias is another limitation to consider because the study recruited male couples who had already established a sexual agreement in their relationship and had kept it for at least six months prior to the partners being interviewed. Thus, this sample’s decisions about HIV testing may differ from other couples who formed an agreement but did not adhere to it, as well as couples who do not have an agreement at all. Furthermore, other factors, such as power dynamics within the relationship, potential recent history of coercion, gender expression, internalized homophobia, structural issues (e.g., poverty), and knowledge about HIV risk and transmission, could have influenced male couples discussion(s) and/or decisions about HIV testing in the context of their sexual agreement. Additionally, the study could have been improved by using better structured qualitative questions. While our sample size was relatively small, this sample was diverse in terms of age, relationship length, sexual agreement type, and to a lesser extent, by race and ethnicity. Additional research that includes a larger regionally and racial/ethnically diverse sample size and explores how different relationship dynamics may influence couples’ discussion and decisions about HIV testing under the context of their sexual agreement is warranted, as well as studies, which include samples of HIV-discordant male couples. Future research should also investigate how culture (e.g., Latino) and religion may influence male couples’ decisions to test for HIV.

Conclusion

Our findings suggest additional HIV prevention efforts, including further study, are needed to encourage male couples to: 1) integrate HIV testing into their relationship and/or sexual agreement that matches their agreement type and associated HIV-related risk behaviors; 2) shift their one-sided decisions about testing to a couple’s mutually shared decision about testing. Current progress is being made toward achieving these recommendations, including the dissemination of CHTC throughout the U.S., however, the development of other HIV preventative interventions for male couples is needed to help prevent new HIV infections within this population.