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

Results

The electronic database searches initially retrieved 7,628 records (56 from AIDSLINE, 374 from CENTRAL, 919 from CINAHL, 927 from PsycINFO and 5,352 from PubMed). Cross-referencing retrieved an additional 37 records. After the removal of duplicate references in Endnote, 7,404 unique records were screened. Of these, 121 records were deemed relevant by any reviewer and marked for full-text retrieval. There was insufficient information available in English to interpret three studies and despite efforts to contact authors it proved impossible to obtain sufficient information to determine the inclusion of three other studies. Of the 115 papers retrieved, 14 were supplementary citations for included studies, 3 referred to ongoing studies and 4 studies were still awaiting assessment, their authors having been contacted for missing statistical and descriptive data. Four studies that initially appeared to meet inclusion criteria were later excluded. Two of these reported couple-focused interventions, however, neither were prospective comparative trials (Allen et al. 1992 and Parsons et al. 2000). Two further studies were excluded since they described differing risk groups that received the same intervention; Allen et al. (2003) compared HIV+ discordant couples to couples who were HIV-concordant, while Kissinger et al. (2003) compared HIV+ couples with those who had syphilis. Eighty-four further studies were excluded for reasons specified in Fig. 1.

Figure 1.

Flow diagram of included and excluded studies

Description of Included Studies

Six studies published between 2000 and 2007 reporting couple-focused behavioural interventions for HIV were included in this review (see Table 1 for characteristics of included studies). These studies ranged in size from 26 index couples (Koniak-Griffin et al. 2008) to a three-center trial including 586 index couples (Coates et al. 2000). Three studies were carried out in the United States (El-Bassel et al. 2003, 2005; Harvey et al. 2004; Koniak-Griffin et al. 2008) while two took place in Africa (Farquhar et al. 2004; Jones et al. 2005), with one further study conducted in sites in Africa and the Caribbean (Coates et al. 2000).

Intervention Design and Content

Three studies used RCTs and three used quasi-experimental designs. One RCT (Harvey et al. 2004) compared a couples-focused HIV prevention intervention with a couples-focused community educational program. Another RCT (El-Bassel et al. 2003, 2005) used a three-arm design, comparing an HIV prevention intervention given to either couples or to female partners alone, in comparison with an education control condition comprising female partners alone. A third RCT (Coates et al. 2000) delivered HIV voluntary counseling and testing (VCT) to both individuals and to couples, and compared these treatment conditions to individuals or couples who received health information only. In a quasi-experimental study, Koniak-Griffin et al. (2008) compared an enhanced couples-focused 12-h HIV prevention program with a 1.5 h didactic presentation providing standard information on HIV/AIDS. Jones et al. (2005) provided single-gender, group-based HIV prevention to women and randomly allocated their male partners to either a high or low intensity group HIV prevention intervention. Farquhar et al. (2004) compared those participants who wished to undergo VCT individually versus those who chose to complete VCT with their partner.

Definition of "couple" varied between studies. Three studies (Coates et al. 2000; El-Bassel et al. 2003, 2005; Harvey et al. 2004) included participants with a primary/main or regular sex partner (i.e., those with legal/common-law spouses or regular girl/boyfriends) whereas another defined couple relationships as 'characterised by romantic/sexual intimacy' (Koniak-Griffin et al. 2008). Jones et al. (2005) simply encouraged participants to invite 'their male partners'. In Farquhar et al. (2004) nearly all those who enrolled as couples had been married or living together for over 3 years; however, there was no explicit operational definition of a couple. Only two studies (El-Bassel et al. 2003, 2005; Koniak-Griffin et al. 2008) specified length of relationship as part of their inclusion criteria (≥6 months and 3 months, respectively). Details of other specific inclusion and exclusion for participants in trials reviewed are reported in Table 1.

There was notable heterogeneity in intervention content. Couples-focused VCT was evaluated in two separate interventions (Coates et al. 2000; Farquhar et al. 2004). The counseling intervention by El-Bassel et al. (2003) emphasized relationship context, gender roles, communication, and intimacy as contributors to unprotected sex. Jones et al. (2005) provided female participants with cognitive–behavioral skills training delivered in same-gender groups, and their partners were randomly assigned to a high or low intensity same-gender group HIV education intervention. The intervention by Harvey et al. (2004) provided Hispanic women and their male partners culturally appropriate counseling and facilitated discussions in small groups about relationship dynamics contributing to sexual risk behavior and choices about contraception. Koniak-Griffin et al. (2008) implemented a theory-based, culturally-sensitive couple focused intervention for adolescent mothers and their male partners which addressed HIV awareness, vulnerability to HIV infection, attitudes and beliefs about HIV and safer sex. Four interventions (Coates et al. 2000; Jones et al. 2005; Harvey et al. 2004; Koniak-Griffin et al. 2008) explicitly described including either condom skills or a condom demonstration, and four studies (Coates et al. 2000; Jones et al. 2005; Farquhar et al. 2004; Harvey et al. 2004) explicitly reported providing participants with free condoms.

Interventions were carried out by a variety of trained HIV prevention educators and health professionals. The number of intervention sessions delivered to participants also differed between studies. VCT interventions included both pre and post-test counseling and offered additional counseling sessions at follow-up. Other programs provided between two and six intervention sessions which were delivered over a range of time periods. Follow-up assessments took place from 6 to 14 months after intervention.

Participant satisfaction with the intervention was described for three trials included in the review (El-Bassel et al. 2003, 2005; Jones et al. 2005; Koniak-Griffin et al. 2008), and were generally positive. Cost effectiveness was reported for only one trial (Coates et al. (2000). Implementation data, including delivery, was reported for three studies (Coates et al. 2000; El-Bassel et al. 2003, 2005; Harvey et al. 2004).

Methodological Quality

The methodological quality of the studies was variable. Only one of the three randomized controlled studies reported secure allocation concealment (Coates et al. 2000). Allocation concealment was compromised in one study (El-Bassel et al. 2003, 2005) when it was discovered that a few random assignment allocation envelopes had been omitted accidentally. Harvey et al. (2004) reported that their method of group allocation was not blind. One further study (Jones et al. 2005), where randomization was used to allocate partners to high or low intensity intervention, did not report their method of allocation. Given the nature of the interventions undertaken, it was impossible to blind participants or intervention providers to treatment conditions in any of the included trials. The remaining quasi-experimental studies did not randomly assign participants to condition, which might have permitted uncontrolled and unrecognized biases between treatment groups.

Summary of Study Findings

There was considerable heterogeneity among studies in terms of trial characteristics, participants included, intervention content, and behavioral and biological outcomes measured. As a result, meta-analysis was considered inappropriate.

All trials included in this review described outcomes on either unprotected/protected sex or sex with/without condoms as a behavioral indicator of program effect. However, the unit of analysis (couples or individuals), time intervals, type of sexual encounter (oral, vaginal, or anal), and type of protection (male or female condom) varied between studies.

The most commonly described measure, episodes of unprotected/protected sex, was reported by four studies (El-Bassel et al. 2003, 2005; Coates et al. 2000; Harvey et al. 2004; Koniak-Griffin et al. 2008). El-Bassel et al. (2003, 2005) reported a significant increase in protected sexual encounters in both enhanced treatment groups—couples-focused and women alone—compared with the standard education condition. Coates et al. (2000) reported that couples assigned to VCT significantly reduced unprotected intercourse with enrolment partners compared with those couples assigned to the standard health information condition. Harvey et al. (2004) compared enhanced couples-focused counseling versus standard couples-focused education, and found no differences between the intervention and comparison group in condom use at 3 months, but did detect a significant difference between baseline and 3 month follow-up for both conditions. This lack of significant differences between the intervention and comparison groups prompted the authors to suggest that the couples-focused modality improved outcomes in both trial arms. Koniak-Griffin et al. (2008) found reduced unprotected sex at 6 month evaluation in the treatment group compared with the comparison group. Jones et al. (2005) found higher condom use among women whose partners received high intensity counseling. Farquhar et al. (2004), reported a marginal increase in women reporting condom use after undergoing couple-counseling compared to individual counseling.

A variety of other behavioral outcomes, reflecting the differing primary aims of the studies, were reported (see Table 1). Coates et al. (2000) found that couples in which one or both members was HIV-positive at baseline reported reduced unprotected intercourse with primary partners but not with non-primary partners; this effect was observed for couples in both VCT and standard treatment conditions. Farquhar et al. (2004) found that women counseled with their partners were more likely to receive nevirapine during follow-up and to avoid breast-feeding their infants compared to women counseled individually. Harvey et al. (2004) found both treatment and control groups increased use of effective contraceptive methods.

Measures related to biological outcomes were described in two studies. Coates et al. (2000) found that, among couples assigned to VCT, unprotected intercourse with non-enrollment partners was associated with a significant increase in STD incidence; this was not observed among couples assigned to standard education. El-Bassel et al. (2003) reported fewer mean STD symptoms among participants in the control group compared with those in either intervention groups, but this difference was eliminated after adjusting for baseline STDs. HIV serostatus was not reported as an outcome measure in any of the studies in this review.

Adverse events were described in two studies. In the Coates et al. (2000) trial, couple members who were assigned to receive couples-focused VCT reported a higher likelihood of being neglected or disowned by their families at the first follow-up, compared with couple members in the comparison group (reported in Grinstead et al. 2001). In Farquhar et al. (2004), partners of women who tested seronegative for HIV reported a lower rather than higher likelihood of condom use at post-test, ostensibly due to a belief that partners were in a seronegative concordant relationship.

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