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Stronger Together: Results from a Randomized Controlled Efficacy Trial of a Dyadic Intervention to Improve Engagement in HIV Care Among Serodiscordant Male Couples in Three US Cities

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Abstract

Engagement in HIV care and a high level of antiretroviral therapy (ART) adherence for people living with HIV is crucial to treatment success and can minimize the population burden of the disease. Despite this, there is a critical gap in HIV prevention science around the development of interventions for serodiscordant male couples. This paper reports on the results of a randomized controlled trial to assess the efficacy of Stronger Together, a dyadic counseling intervention aimed at increasing engagement in and optimizing HIV care among serodiscordant male couples in Atlanta, GA, Boston, MA, and Chicago, IL. Between 2014 and 2017, 159 male serodiscordant couples (total N = 318) in Atlanta, GA, Boston, MA, and Chicago, IL were enrolled and equally randomized to either the Stronger Together intervention arm (a three-session dyadic intervention involving HIV testing and adherence counseling) or a standard of care (SOC) control arm. Couples completed individual study assessments via an audio computer assisted self-interviewing (ACASI) system at baseline, 6, 12 and 18 months. Primary outcomes included being prescribed and currently taking ART, and fewer missed doses of ART in the past 30 days; because the trial was not powered to examine viral suppression, we examined this as an exploratory outcome. Longitudinal data analysis was by an intention-to-treat approach. Participants ages ranged from 18 to 69 (mean = 35.9), and are predominantly white (77.5%), and college educated (68.4% earned a college degree or higher). Participants randomized to the Stronger Together arm had a significantly greater odds of being prescribed and currently taking ART over time than those in the SOC arm (at 12 months OR 2.75, 95%CI 1.35–4.67, p-value 0.020, and at 18 months OR 2.91, 95%CI 1.61–4.88, p-value 0.013). Similarly, those in the Stronger Together arm had a significantly lower odds of missing a dose of ART in the past 30 days over time compared to those in the SOC arm (at 12 months OR 0.28, 95%CI 0.09–0.81, p-value 0.019, and at 18 months OR 0.25, 95%CI 0.07–0.82, p-value 0.023). Among male couples in serodiscordant relationships, the Stronger Together intervention resulted in significantly improved HIV treatment outcomes at both 12 and 18 months of follow-up. This trial is the first to date to demonstrate evidence of efficacy for a dyadic counseling intervention and has the potential to fill a critical gap in secondary HIV prevention interventions for serodiscordant male couples.

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References

  1. Goodreau SM, Carnegie NB, Vittinghoff E, Lama JR, Sanchez J, Grinsztejn B, et al. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE. 2012;7(11):1–9. https://doi.org/10.1371/journal.pone.0050522.

    Article  CAS  Google Scholar 

  2. Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(1):1153–62. https://doi.org/10.1097/QAD.0b013e32832baa34.

    Article  PubMed  Google Scholar 

  3. Brady SS, Iantaffi A, Galos DL, Rosser BRS. Open, closed, or in between: Relationship configuration and condom use among men who use the internet to seek sex with men. AIDS Behav. 2013;17(4):1499–514. https://doi.org/10.1007/s10461-012-0316-9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Jin F, Crawford J, Prestage GP, Zablotska I, Imrie J, Kippax SC, et al. Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS. 2009;23(2):243–52. https://doi.org/10.1097/QAD.0b013e32831fb51a.

    Article  PubMed  Google Scholar 

  5. Goldenberg T, Finneran C, Andes KL, Stephenson R. ‘Sometimes people let love conquer them’: how love, intimacy, and trust in relationships between men who have sex with men influence perceptions of sexual risk and sexual decision-making. Cult Health Sex. 2015;17(5):607–22. https://doi.org/10.1080/13691058.2014.979884.

    Article  PubMed  Google Scholar 

  6. Stephenson R, White D, Mitchell J. Sexual agreements and perception of HIV prevalence among an online sample of partnered men who have sex with men. Arch Sex Behav. 2015;44(7):1813–9. https://doi.org/10.1007/s10508-015-0532-2.

    Article  PubMed  Google Scholar 

  7. Mitchell J, Petroll A. Patterns of HIV and STI testing among MSM couples in the U.S. Sex Trans Dis. 2012;39(11):871–6. https://doi.org/10.1097/OLQ.0b013e3182649135.

    Article  Google Scholar 

  8. Stephenson R, White D, Darbes L, Hoff C, Sullivan P. HIV testing behaviors and perceptions of risk of HIV infection among MSM with main partners. AIDS Behav. 2015;19(1):553–60. https://doi.org/10.1007/s10461-014-0862-4.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Patterson S, Carter A, Nicholson V, et al. Condomless sex among virally suppressed women with HIV with regular HIV-serodiscordant sexual partners in the era of treatment as prevention. J Acquir Immune Defic Syndr. 2017;76(4):372–81.

    Article  Google Scholar 

  10. Bavinton BR, Jin F, Prestage G, et al. O20.3 HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. Sex Trans Infect. 2015;91(Suppl 2):A70–1. https://doi.org/10.1136/sextrans-2015-052270.189.

    Article  Google Scholar 

  11. Attia S, Egger M, Müller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23(11):1397–404. https://doi.org/10.1097/qad.0b013e32832b7dca.

    Article  PubMed  Google Scholar 

  12. Rodger AJ, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet. 2019. https://doi.org/10.1016/S0140-6736(19)30418-0.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.

    Article  CAS  Google Scholar 

  14. Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316:171–81.

    Article  Google Scholar 

  15. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375:830–9.

    Article  CAS  Google Scholar 

  16. Singh N, Berman SM, Swindells S, Justis JC, Mohr JA, Squier C, Wagener MM. Adherence of human immunodeficiency virus-infected patients to antiretroviral therapy. Clin Infect Dis. 1999;29(4):824–30.

    Article  CAS  Google Scholar 

  17. Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, Squier C, Wagener MM, Singh N. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133(1):21.

    Article  CAS  Google Scholar 

  18. Bartlett JA. Addressing the challenges of adherence. JAIDS J Acquir Immune Defic Syndr. 2002;29:S2–10.

    Article  Google Scholar 

  19. Bavinton B, Pinto A, Phanuphak N, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018;5:e438–47.

    Article  Google Scholar 

  20. Mannheimer SB, Matts J, Telzak E, Chesney M, Child C, Wu AW, Friedland G, Terry Beirn Community Programs for Clinical Research on AIDS. Quality of life in HIV-infected individuals receiving antiretroviral therapy is related to adherence. AIDS Care. 2005;17(1):10–22.

    Article  CAS  Google Scholar 

  21. Golin CE, Liu H, Hays RD, Miller LG, Beck CK, Ickovics J, Kaplan AH, Wenger NS. A prospective study of predictors of adherence to combination antiretroviral medication. J Gen Intern Med. 2002;17(10):756–65.

    Article  Google Scholar 

  22. Bangsberg DR, Hecht FM, Charlebois ED, Zolopa AR, Holodniy M, Sheiner L, Bamberger JD, Chesney MA, Moss A. Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population. AIDS. 2000;14(4):357–66.

    Article  CAS  Google Scholar 

  23. Wagner GJ, Kanouse DE, Koegel P, Sullivan G. Adherence to HIV antiretrovirals among persons with serious mental illness. AIDS Patient Care STDs. 2003;17(4):179–86.

    Article  Google Scholar 

  24. Howard AA, Arnsten JH, Lo Y, Vlahov D, Rich JD, Schuman P, Stone VE, Smith DK, Schoenbaum EE, HER Study Group. A prospective study of adherence and viral load in a large multi-center cohort of HIV-infected women. AIDS. 2002;16(16):2175–82.

    Article  CAS  Google Scholar 

  25. McNabb J, Ross Jack W, Abriola K, Turley C, Nightingale Charles H, Nicolau DP. Adherence to highly active antiretroviral therapy predicts virologic outcome at an inner-city human immunodeficiency virus clinic. Clin Infect Dis. 2001;33(5):700–5.

    Article  CAS  Google Scholar 

  26. Barroso PF, Schechter M, Gupta P, Bressan C, Bomfim A, Harrison LH. Adherence to antiretroviral therapy and persistence of HIV RNA in semen. JAIDS J Acquir Immune Defic Syndr. 2003;32(4):435–40.

    Article  CAS  Google Scholar 

  27. Ammassari A, Murri R, Pezzotti P, Trotta MP, Ravasio L, De Longis P, Lo Caputo S, Narciso P, Pauluzzi S, Carosi G, Nappa S, Piano P, Izzo CM, Lichtner M, Rezza G, Monforte A, Ippolito G, d’Arminio Moroni M, Wu AW, Antinori A, AdICONA Study Group. Self-reported symptoms and medication side effects influence adherence to highly active antiretroviral therapy in persons with HIV infection. JAIDS JAIDS J Acquir Immune Defic Syndr. 2001;28(5):445–9.

    CAS  PubMed  Google Scholar 

  28. Ickovics JR, Meade CS. Adherence to HAART among patients with HIV: breakthroughs and barriers. AIDS Care. 2002;14(3):309–18.

    Article  CAS  Google Scholar 

  29. Arnsten Julia H, Demas Penelope A, Farzadegan H, Grant Richard W, Gourevitch Marc N, Chang CJ, Buono D, Eckholdt H, Howard AA, Schoenbaum EE. Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring. Clin Infect Dis. 2001;33(8):1417–23.

    Article  Google Scholar 

  30. Cohen SM, Van Handel MM, Branson DM, Blair JM, Hall I, Hu X, Koenig LJ, Skarbinski J, Tracey A, Mermin J, Valleroy LA. Vital signs: HIV prevention through care and treatment—United States. MMWR Morb Mortal Wkly Rep. 2011;60(47):1.

    Google Scholar 

  31. Hoff C, Beougher S, Chakravarty D, Darbes L, Neilands T. Relationship characteristics and motivations behind agreements among gay male couples: differences by agreement type and couple serostatus. AIDS Care. 2010;22(7):827–35. https://doi.org/10.1080/09540120903443384.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Karney BR, Hops H, Redding CA, Reis HT, Rothman AJ, Simpson JA. A framework for incorporating dyads in models of HIV-prevention. AIDS Behav. 2010. https://doi.org/10.1007/s10461-010-9802-0.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Malone J, Syvertsen JL, Johnson BE, Mimiaga MJ, Mayer KH, Bazzi AR. Negotiating sexual safety in the era of biomedical HIV prevention: relationship dynamics among male couples using pre-exposure prophylaxis. Cult Health Sex. 2018;20(6):658–72. https://doi.org/10.1080/13691058.2017.1368711.

    Article  PubMed  Google Scholar 

  34. Perry NS, Huebner DM, Baucom BR, Hoff CC, Perry NS. Relationship power, sociodemographics, and their relative influence on sexual agreements among gay male couples. AIDS Behav. 2016;20(1):1302–14. https://doi.org/10.1007/s10461-015-1196-6.

    Article  PubMed  Google Scholar 

  35. Painter T. Voluntary counseling and testing for couples: a high Leverage Intervention for HIV/AIDS prevention in sub–Saharan Africa. Soc Sci Med. 2001. https://doi.org/10.1016/S0277-9536(00)00427-5.

    Article  PubMed  Google Scholar 

  36. Stephenson R, Suarez NA, Garofalo R, Hidalgo MA, Hoehnle S, Thai J, et al. Project stronger together: protocol to test a dyadic intervention to improve engagement in HIV care among sero-discordant male couples in three US cities. JMIR Res Protoc. 2017;6(8):e170. https://doi.org/10.2196/resprot.7884.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Crawford J, Rodden P, Kippax S, Van de Ven P. Negotiated safety and other agreements between men in relationships: risk practice redefined. Int J STD AIDS. 2001;12(1):164–70.

    Article  CAS  Google Scholar 

  38. Gass K, Hoff CC, Stephenson R, Sullivan PS. Sexual agreements in the partnerships of internet-using men who have sex with men. AIDS Care. 2012;24(10):1255–63. https://doi.org/10.1080/09540121.2012.656571.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Mitchell J. Aspects of gay male couples’ sexual agreements vary by their relationship length. AIDS Care. 2014;26(9):1164–70. https://doi.org/10.1080/09540121.2014.882491.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Cuervo M, Whyte J. The effect of relationship characteristics on HIV risk behaviors and prevention strategies in young gay and bisexual men. J Assoc Nurses AIDS Care. 2015;12(3):399–410.

    Article  Google Scholar 

  41. Hoff C, Beougher S. Sexual agreements among gay male couples. Arch Sex Behav. 2010;39(3):774–87. https://doi.org/10.1007/s10508-008-9393-2.Sexual.

    Article  PubMed  Google Scholar 

  42. Prestage G, Jin F, Zablotska I, Grulich A, Imrie J, Kaldor J, et al. Trends in agreements between regular partners among gay men in Sydney, Melbourne and Brisbane, Australia. AIDS Behav. 2008;12(3):513–20. https://doi.org/10.1007/s10461-007-9351-3.

    Article  PubMed  Google Scholar 

  43. Hoff CC, Chakravarty D, Beougher SC, Neilands TB, Darbes LA. Relationship characteristics associated with sexual risk behavior among MSM in committed relationships. AIDS Patient Care. 2012;26(12):738–45. https://doi.org/10.1089/apc.2012.0198.

    Article  Google Scholar 

  44. Mitchell J. Between and within couple-level factors associated with gay male couples’ investment in a sexual agreement. AIDS Behav. 2014;18(8):1454–65. https://doi.org/10.1007/s10461-013-0673-z.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Remien RH, Stirratt MJ, Dolezal C, Dognin JS, Wagner GJ, Carballo-Dieguez A, El-Bassel N, Jung TM. Couple-focused support to improve HIV medication adherence: a randomized controlled trial. AIDS. 2005;19(8):807–14.

    Article  Google Scholar 

  46. Simoni JM, Frick PA, Huang B. A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychol. 2006;25(1):74–81.

    Article  Google Scholar 

  47. Darbes LA, Chakravarty D, Beougher SC, Neilands TB, Hoff CC. Partner-provided social support influences choice of risk reduction strategies in gay male couples. AIDS Behav. 2011;16(1):159–67.

    Article  Google Scholar 

  48. WHO. Guidance on couples HIV counseling and testing including antiretroviral therapy for treatment and prevention in serodiscordant couples. Geneva: WHO; 2012.

    Google Scholar 

  49. Bazzi AR, Fergus KB, Stephenson R, Finneran CA, Coffey-Esquivel J, Hidalgo MA, Hoehnle S, Sullivan PS, Garofalo R, Mimiaga M. Partner steps: a dyadic behavioral intervention to optimize same sex male couples’ engagement across the HIV care continuum. JMIR Res Protoc. 2016;5(3):e168. https://doi.org/10.2196/resprot.6271.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Safren SA, Otto MW, Worth JL. Life-steps: applying cognitive behavioral therapy to HIV medication adherence. Cogn Behav Pract. 1999;6:332–41.

    Article  Google Scholar 

  51. Lewis MA, McBride CM, Pollak KI, Puleo E, Butterfield RM, Emmons KM. Understanding health behavior change among couples: an interdependence and communal coping approach. Soc Sci Med. 2006;62(6):1369–80.

    Article  Google Scholar 

  52. Bellg AJ, Borrelli B, Resnick B, Treatment Fidelity Workgroup of the NIH Behavior Change Consortium, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443–51. https://doi.org/10.1037/0278-6133.23.5.443.

    Article  PubMed  Google Scholar 

  53. Finitsis DJ, Pellowski JA, Huedo-Medina TB, Fox MC, Kalichman SC. Visual analogue scale (VAS) measurement of antiretroviral adherence in people living with HIV (PLWH): a meta-analysis. J Behav Med. 2016;39(6):1043–55.

    Article  Google Scholar 

  54. Stephenson R, Grabbe KL, Sidibe T, McWilliams A, Sullivan PS. Technical assistance needs for successful implementation of Couples HIV Testing and Counseling (CHTC) intervention for male couples at U.S. HIV testing sites. AIDS Behav. 2016;20(4):841–7. https://doi.org/10.1007/s10461-015-1150-7.

    Article  PubMed  Google Scholar 

  55. Neme S, Goldenberg T, Stekler JD, Sullivan PS, Stephenson R. Attitudes towards couples’ HIV testing and counseling among Latino men who have sex with men in the Seattle area. AIDS Care. 2015;27(10):1354–9. https://doi.org/10.1080/09540121.2015.1058894.

    Article  PubMed  Google Scholar 

  56. Sullivan PS, Stephenson R, Gratzer B, Wingood G, DiClemente R, Allen S, Hoff C, Salazar L, Scales L, Montgomery J, Schwartz A, Barnes J, Grabbe K. Adaptation of the African couples’ HIV testing and counseling model for men who have sex with men in the United States: an application of the ADAPT-ITT framework. Springer Plus. 2014;3:249. https://doi.org/10.1186/2193-1801-3-249.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Wall K, Sullivan P, Kleinbaum D, Stephenson R. Actor-partner effects associated with experiencing intimate partner violence or coercion among male couples enrolled in an HIV prevention trial. BMC Public Health. 2014;14:209. https://doi.org/10.1186/1471-2458-14-209.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Amico RK, Fisher WA, Cornman DH, Shuper PA, Redding CG, Konkle-Parker DJ, Barta W, Fisher JD. Visual analog scale of ART adherence: association with 3-day self-report and adherence barriers. JAIDS J Acquir Immune Defic Syndr. 2006;42(4):455–9. https://doi.org/10.1097/01.qai.0000225020.73760.c2.

    Article  PubMed  Google Scholar 

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Funding

The funding was supported by National Institutes of Health (Grant No. R01HD075655).

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Authors and Affiliations

  1. Department of Systems, Population and Leadership & The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, 400 North Ingalls, Ann Arbor, MI, 48109, USA

    Rob Stephenson

  2. Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA

    Robert Garofalo & Samuel Hoehnle

  3. Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Robert Garofalo & Samuel Hoehnle

  4. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA

    Patrick S. Sullivan

  5. Division of Adolescent and Young Adult Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA

    Marco A. Hidalgo

  6. Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Marco A. Hidalgo

  7. Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA

    Angela R. Bazzi

  8. Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA

    Anna Bratcher

  9. School of Medicine, Emory University, Atlanta, GA, USA

    Catherine A. Finneran

  10. Center for LGBTQ Advocacy, Research, and Health, UCLA, Los Angeles, CA, USA

    Matthew J. Mimiaga

  11. Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA

    Matthew J. Mimiaga

  12. Department of Psychiatry & Biobehavioral Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, USA

    Matthew J. Mimiaga

  13. The Fenway Institute, Fenway Health, Boston, MA, USA

    Matthew J. Mimiaga

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  1. Rob Stephenson
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Correspondence to Rob Stephenson.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval for this study was obtained from the Institutional Review Boards of Emory University (IRB #00065111), Lurie Children’s Hospital (IRB #2014-15896) and The Fenway Institute (IRB #FWA00000145). The authors declare no conflicts of interest. Informed consent was obtained from all participants via an electronic consent form.

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Stephenson, R., Garofalo, R., Sullivan, P.S. et al. Stronger Together: Results from a Randomized Controlled Efficacy Trial of a Dyadic Intervention to Improve Engagement in HIV Care Among Serodiscordant Male Couples in Three US Cities. AIDS Behav 25, 2369–2381 (2021). https://doi.org/10.1007/s10461-021-03199-8

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