Studies suggest couple-based HIV/STD prevention interventions for African Americans

A risk reduction program focused on African American heterosexual couples appears to diminish risky sexual behaviors among couples in which one partner is HIV-positive and the other is not, according to a report posted online today that will appear in the September 27 print issue of Archives of Internal Medicine, one of the JAMA/Archives journals. The study was published online today in advance of its upcoming presentation at the International AIDS Conference in Vienna, Austria.

Rates of new HIV infections are about seven times higher among African Americans than among white individuals, according to background information in the article. Although African Americans represented only about 12 percent of the U.S. population in 2006, 45 percent of new HIV infections that year occurred in this population. Heterosexual exposure was the most common source of HIV transmission among African American women, and the second most common among African American men; studies have documented infrequent condom use among African Americans with steady partners. "This low prevalence of condom use among couples and high rate of heterosexual transmission suggest a need for couple-based HIV/sexually transmitted disease (STD) prevention interventions for African Americans," the authors write.

Nabila El-Bassel, D.S.W., of Columbia University School of Social Work, New York, and colleagues in the National Institute of Mental Health (NIMH) Multisite HIV/STD Prevention Trial for African American Couples tested one such intervention between 2003 and 2007. A total of 535 serodiscordant (differing in HIV status) couples enrolled at four sites. Of these, 260 were randomly assigned to the Eban HIV/STD risk-reduction intervention, which incorporates a traditional African concept meaning "fence" and invoking safety, security and love within one's family and relationship space. Couples attended eight weekly structured two-hour sessions, four with individual couples and four with groups of couples, that addressed communication, problem solving and other interpersonal factors associated with sexual risk reduction.

The other 275 couples were assigned to a comparison group. They participated in an intervention that was structurally similar but designed to increase fruit and vegetable consumption, physical activity and adherence to medical treatments, including HIV treatments. All couples reported their sexual behavior and supplied biological specimens for STD assessments at the beginning of the study, immediately after the intervention and six and 12 months later.

Attendance at the sessions of both interventions was high—on average, couples in the Eban intervention attended 91.4 percent of the sessions and those in the comparison group attended 84.1 percent. After the intervention, including at the six- and 12-month follow-ups, couples in the Eban group reported more consistent use of condoms (63 percent of the couples used condoms consistently, vs. 48 percent in the comparison group). In addition, the average number of unprotected intercourse acts was lower in the intervention group than in the comparison group (an average of 1.5 fewer).

The cumulative incidence of STDs did not differ between the two groups over the 12-month follow-up. Of the partners who began the study HIV-negative, two in the intervention group and three in the comparison group became HIV-positive during the study, an overall rate that translates to 935 per 100,000.

"Public health scientists have urged a shift beyond individual-level HIV interventions to prevention strategies that have an impact on social structures and context to curb the epidemic among African Americans," the authors write. "The intervention used here, in structure and content, was relationship based and redirected the focus to changing the relationship factors that influence sexual decision making and increasing the likelihood that risk reduction will be stable over time. Individual, couple and group formats were used to maximize discussion of relationships and communication about risk reduction."

The rate of conversion to HIV was substantially larger than the overall incidence estimate for African Americans, 83.8 per 100,000, suggesting that HIV-negative African Americans in serodiscordant relationships are at high risk for acquiring HIV even if their relationships are stable. "Future studies must explore the generalizability of the findings to couples irrespective of serostatus and in settings where individuals and couples are not aware of their risks for HIV transmission, but whose relationships can be supported as they learn to minimize risks for themselves and each other," the authors conclude. "Moreover, the approach of engaging couples should be tested elsewhere in the United States and in other parts of the world, including sub-Saharan Africa, where sex-based power imbalances make it especially difficult for women in couples to reduce their risk of heterosexual exposure to HIV and other STDs."