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

Jennifer Burton; Lynae A. Darbes; Don Operario

Disclosures

AIDS and Behavior. 2010;14(1):1-10. 

In This Article

Methods

Inclusion Criteria

This review included any trials reporting evidence from prospective comparative evaluations of couple-focused interventions for the behavioral prevention of HIV, and which involved or attempted to involve both members of a self-identified couple. A couple was defined here as a dyad (two-person pair) involved in an intimate sexual relationship; length of relationship and depth of emotional commitment was unspecified in our search, and was left to be determined by primary study investigators. Studies could involve couples from anywhere in the world. Our a priori outcomes of interest were reduced biological indication of HIV or STD infection or reduced sexual risk behavior in the intervention versus the control group. We included studies measuring any biological outcomes (e.g. HIV incidence, STI incidence, pregnancy) or behavioral outcomes (e.g. unprotected vaginal, oral, or anal sex, sharing of needles) as relevant markers of HIV risk. Studies that did not report either a biological or a behavioral outcome were excluded.

We included any randomized controlled trials (RCTs), quasi-randomized controlled trials, and nonrandomized controlled studies of couples-focused interventions compared to any control group, in which participants were assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes. Programs did not need to administer treatment to both dyad members together and concurrently; however, we excluded trials of interventions that targeted just one individual in a couple.

No exclusions were made by control group condition (e.g., usual care, another HIV prevention intervention, no treatment, an attention-matched treatment, a different version of the experimental program) or by demographic characteristics, sexual orientation, HIV status, seroconcordance, or other factors. However, studies were excluded if the control did not involve a different type of intervention, such as studies in which the same intervention was administered to different populations. Additionally there were no exclusions by setting, timing, dosage, program activities or organization delivering the intervention.

Literature Search

Electronic searches of AIDSLINE, CENTRAL, CINAHL, PsycINFO and PubMed from 1980 onward were carried out by reviewers in April 2007, and searches of the International AIDS Society Abstract Archive from 2000 to 2006 were also conducted. In addition, existing reviews and primary studies were cross-referenced for further citations and we searched for unpublished literature and ongoing trials by contacting experts and active researchers in the field. The search included terms specific to HIV/AIDS, study design (e.g., control, comparative), and intervention focus (e.g., including search terms "couple," "dyad," "marital," "married"; the full search strategy is available from the authors). Although there were no linguistic or geographic search restrictions, articles were excluded if there was insufficient information available in English to interpret the study.

All articles were initially screened by three reviewers to exclude records that were not clearly relevant. Reviewers received training on the initial screening criteria using a small subset of abstracts to ensure that they reached a high (>95%) level of agreement, after which they independently screened the remaining abstracts. Reviewers were encouraged to apply a more liberal approach to the initial abstract screening, to allow for more articles to be read in their entirety alongside a more stringent screening based on review of the full text. Reviewers were not blind to the identities of study authors, funding, or any other characteristic of the primary studies. Complete texts of all potentially relevant articles were retrieved and scrutinized by two reviewers who read each study and decided on conceptual and methodological relevance by consensus. All reviewers approved the final list of included studies. Study authors were contacted to clarify trial details as needed.

Data Extraction

Reviewers extracted data including details about study design, participants, interventions delivered to the intervention and control groups, method of data collection, baseline differences, attrition, analytic procedures and treatment effects. Where data were reported on cost, adverse events, acceptability and program implementation (i.e., program design, actual delivery by clinicians, actual uptake by participants, and context), this was also extracted. If the search retrieved multiple reports of any intervention, data were extracted from all available reports.

Analysis and Assessment of Study Quality

Our overarching aim was to summarize the state of evidence on effectiveness of couples-focused HIV prevention interventions, with a secondary aim of assessing the quality of existing studies. Provided there was reasonable methodological justification for pooling results across studies, meta-analysis would have been a statistical technique for summarizing the effect size across trials. But if meta-analysis was deemed inappropriate (e.g., due to heterogeneity among study designs, outcomes, intervention processes), we aimed to provide a narrative summary and critical analysis.

We assessed the following aspects of study quality:

  1. Study design (RCT, quasi-RCT, quasi-experimental study)

  2. Method of allocating participants to trial arms

  3. Concealment of allocation sequence from trial staff and from personnel who recruit participants into the trial (for RCTs)

  4. Blinding of participants, program staff, and outcome assessors (we did not expect most studies in this field to blind participants and/or facilitators, as preliminary research suggests that these interventions often involve time and personal contact)

  5. Baseline differences between trial arms, methods of controlling for differences in analyses

  6. Attrition: percentage dropout at each follow-up, differential attrition between trial arms, and differences between dropouts and participants who are retained

  7. Method of outcome assessment (e.g., ACASI, biomarkers, self-report)

  8. Analytic procedures: Intention to treat, complete case, per-protocol, or treatment-on-the-treated

We did not make any exclusions due to study quality, but instead report these aspects of methodological quality in the review.

Comments

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