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


This review included six evaluation studies of couples-focused behavioral interventions conducted in five countries—three African countries (Kenya, Tanzania, Zambia), one Caribbean country (Trinidad), and the United States enrolling a total of 1,084 couples. Each of these studies showed that participation in couples-focused intervention programs was associated with improvements in HIV prevention behaviors, generally indicated by reduced unprotected sex. Meta-analysis of pooled effects was not permissible due to study heterogeneity. However, examination of trends across studies indicates promising effects for HIV prevention programs that address couples and dyadic relationship issues.

Strengths of this review included a comprehensive search without restriction due to country, inclusion of only high-quality evaluations which used randomized or quasi-experimental designs, and assessment of study methodology. This is the first known systematic review of couples-focused HIV behavioral prevention interventions.

Due to our inability to compute an overall effect size for these interventions, this review cannot conclude whether couples-focused HIV prevention interventions are more or equally effective as other common—and perhaps less complex—HIV prevention modalities supported in previous reviews, such as mass media interventions (Vidanapathirana et al. 2006) and individual or small group programs for HIV prevention (Kelly and Kalichman 2002). Notably, one systematic review by Foss et al. (2007) of condom promotion interventions in sub-Saharan Africa and Asia found that behavioral HIV prevention interventions have been more effective for sex workers, who are likely to view sexual activity as a business transaction, and less effective outside the context of sex work, in which sexual activity may be a reflection of intimacy, trust, relationship bonding, power, or reproductive intentions. Conclusions from that review highlight the need for developing innovative HIV prevention techniques that address dyadic and relationship dynamics between partners that contribute to unprotected sex and other HIV risk behaviors.

Based on results from this review, we cannot conclude whether behavior changes associated with couples-focused interventions actually translate into reduced HIV transmission. None of the included studies examined HIV incidence as an outcome. Though two studies assessed STD incidence, only Coates et al. (2000) showed an association between increased STD incidence and unprotected sex with non-primary partners among participants receiving couples-focused interventions. This finding underscores a need for HIV prevention programs—whether individual or couples-focused—to encourage safer sex with primary as well as non-primary (e.g., casual sex) partners. This is especially crucial given findings showing that having multiple concurrent partners increases transmission of HIV across sexual networks (Halperin and Epstein 2004). Plausibility of reducing HIV infection must be explored in future trials of couples-focused interventions.

Sources of heterogeneity should be noted. Studies varied in their definition of a "couple", with some providing stringent criteria about relationship duration and living arrangements, and other studies allowing index participants to identify their partner themselves. Intervention components differed substantially, with two studies evaluating couples-focused VCT and the remainder evaluating educational and counseling programs which addressed HIV risk and sexual behavior in the context of a primary relationship. In addition, although the context of a primary relationship was considered, the intervention content varied in how much they focused on relationship dynamics. Although all studies involved testing an intervention addressing both members of the dyad, they varied in the extent of inclusion of male partners and in their modality of providing the intervention—either to both partners together, to each partner separately and individually, or to partners separately and in small same-gender groups. Furthermore, the sexual behavior outcomes were often only evaluated for women, and no study utilized dyadic data analytic techniques.

Notably, all studies included heterosexual couples. No interventions for homosexual couples were identified that met inclusion criteria. Also lacking were studies in Asia, South or Central America, Eastern Europe, and many African countries highly impacted by HIV. Study sites in the United States were restricted to Los Angeles and New York. Only one program for adolescent couples was identified (Koniak-Griffin et al. 2008).

Limitations of this review may challenge the generalizability of findings. The lack of a shared definition of being a couple might have introduced additional variability across studies, and prevents conclusions about types of couples and other factors related to relationship status that might promote intervention effectiveness. Participants and couples included in these six studies might not be indicative of most couples and relationships in their respective settings. Many studies recruited women seeking health services as index participants, and these women referred their male partners to the study. Couples-focused intervention modalities might not be appropriate for couples in which male partners are less willing to take part, younger adolescent couples, same-sex couples, and couples outside of HIV epicenters. Specific active intervention ingredients and mechanisms of behaviour change were not specified for the included studies, and so it is not possible to describe the processes by which couples-focused interventions might reduce HIV risk. Finally, despite our systematic and comprehensive attempt to search the literature, this review might not have identified all relevant studies such as unpublished reports and non-English language papers.

Couples-focused approaches to HIV prevention are still in an early phase of development. Additional methodological and measurement advances are necessary to improve on the state of science for couples-focused HIV prevention. Future investigations of couples-focused to HIV prevention should utilize analytic techniques that illuminate dynamics both within and between couples (e.g., Actor Partner Independence Model; Kenny et al. 2006), rather than comparing individual intervention participants to control participants. High-quality evaluations of programs are urgently needed for other populations, such as homosexual men and younger adolescents, and in both urban and rural settings in the developing world and the developed world. There have been examinations of the role of relationship factors in these populations (Lescano et al. 2006; Prestage et al. 2006), which suggest that contextual considerations such as intimacy are significantly associated with condom use. It is recommended that scientists in this topic area identify appropriate outcome measures for indicating behavior change among partners within the couple context and with outside sex partners, in order to reduce measurement heterogeneity and to facilitate future meta-analysis. Assessing incidence of biological outcomes is important to determine effectiveness of minimizing transmission of HIV and STDs.

Future couples-focused interventions for HIV prevention must be based on a stronger conceptual and theoretical understanding of the relationship dynamics that might contribute to sexual risk behaviors among couples, including gender roles, power, communication, intimacy, fidelity, reproduction goals, and family responsibilities. These factors are likely to be culturally determined and tied to norms around gender and sexuality. For example, gendered relationship and family dynamics might pose barriers to enacting safer sex intentions in more traditional cultures, and norms in some same-sex or youth communities might support more frequent high-risk sexual behaviors. Cultural and community normative beliefs and values may also differ in the extent to which individuals have multiple concurrent partners which may substantially influence risk for HIV transmission within and outside the primary relationship dynamic. As noted, concurrent partnerships have been posited to have contributed to the scale of the epidemic in Sub-Saharan Africa and in homosexual communities (Gorbach and Holmes 2003; Halperin and Epstein 2004; Kalichman et al. 2007), as well as increased incidence of HIV in African Americans in the southern United States (Adimora et al. 2003). This suggests that future interventions may need to address the issue of communication about concurrent partnerships, which would include communication about condom use with outside partners. Content of future couples-focused interventions must also incorporate information about biological factors that may determine risk for HIV transmission among primary partners including partners' HIV serostatus, HIV-seropositive concordance or discondance among partners, as well as viral load and co-infection with other STDs.

Thus, given the complex context of primary relationships and the levels of analysis by which couples may face risk for HIV transmission (individual, dyadic, network, and biological levels), models of intervention must follow from a stronger understanding of couples and relationship issues, rather than solely employ individual-focused models of health behaviour change and decision making which might be inappropriate for framing couples-focused HIV prevention programs.


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