Couples-focused Behavioral Interventions for Prevention of HIV: Systematic Review of the State of Evidence

Jennifer Burton; Lynae A. Darbes; Don Operario


AIDS and Behavior. 2010;14(1):1-10. 

In This Article

Abstract and Introduction


HIV is frequently transmitted in the context of partners in a committed relationship, thus couples-focused HIV prevention interventions are a potentially promising modality for reducing infection. We conducted a systematic review of studies testing whether couples-focused behavioral prevention interventions reduce HIV transmission and risk behavior. We included studies using randomized controlled trial designs, quasi-randomized controlled trials, and nonrandomized controlled studies. We searched five electronic databases and screened 7,628 records. Six studies enrolling 1,084 index couples met inclusion criteria and were included in this review. Results across studies consistently indicated that couples-focused programs reduced unprotected sexual intercourse and increased condom use compared with control groups. However, studies were heterogeneous in population, type of intervention, comparison groups, and outcomes measures, and so meta-analysis to calculate pooled effects was inappropriate. Although couples-focused approaches to HIV prevention appear initially promising, additional research is necessary to build a stronger theoretical and methodological basis for couples-focused HIV prevention, and future interventions must pay closer attention to same-sex couples, adolescents, and young people in relationships.


Sexual transmission of HIV occurs frequently in the context of a primary relationship between two consenting partners. However, HIV prevention interventions generally focus on individuals rather than specifying couples as a unit of change and analysis, neglecting the potentially crucial role that partners may play in sexual behavior (Allen et al. 2003; Painter 2001). Underpinning the dominant interventional focus on the individual, HIV prevention tends to be based on theoretical models emphasizing individual determinants of sexual risk behavior, such as the AIDS Risk Reduction Model (Catania et al. 1990), Health Belief Model (Becker 1974), Information-Motivation-Behavior Model (Fisher and Fisher 2002), and Theory of Reasoned Action (Ajzen et al. 2007). These approaches generally focus on the role of cognitive and motivational processes that operate at the level of the individual such as self-efficacy, personal beliefs and intentions, and perceived norms toward condoms (Albarracin et al. 2005). Interpersonal dynamics between partners tend to be overlooked in HIV prevention models. However, examining the broader literature on partner influences in health behavior demonstrates that partners and accompanying relationship factors need to be included in how we conceptualize health behavior change (House et al. 1988; Lewis et al. 2006). This may be especially relevant with regard to HIV-related sexual behaviors.

There is a growing consensus that HIV prevention research should address couples as a unit of behavior change and intervention (Harmann and Amico 2008). Earlier studies provided preliminary evidence for the feasibility of couples-focused interventions for HIV—particularly the role of couples-focused voluntary counseling and testing (Allen et al. 1992; Higgins et al. 1991; Padian et al. 1993). Moving beyond the context of HIV testing and counseling, more general couples-focused HIV prevention programs may differ from individual-focused HIV prevention programs by addressing the ongoing dynamic and interactional forces within dyads that contribute to sexual risk behavior, including gender roles, power imbalances, communication styles, child-bearing intentions, and quality of relationship issues (e.g., commitment, satisfaction, intimacy). Optimal modes for delivering couples-focused HIV prevention programs may differ from modes for intervening with individuals, for example by including couples counseling and exercises that involve both members of the dyad. Couples-focused programs might simultaneously include both dyad members, or might address each member separately and alone, or might involve a combination of both modalities. Evaluation of couples-focused HIV prevention programs might also differ from individual-focused programs, for example by evaluating patterns of sexual behavior within the dyad, disaggregating sexual behavior with primary versus secondary partners, and deriving composite measures of couple-level risk using algorithms based on each partners' individual behavior within and outside the relationship.

Although couples-focused HIV prevention interventions have been promoted as a potentially promising strategy, there exists no known synthesis of the research on the effectiveness of these programs. Based on a comprehensive literature search of all high-quality evaluations of couples-focused HIV prevention programs, the aims of this paper were to (a) describe and synthesize findings from identified studies, and (b) conduct a critical analysis of the state of this research.


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