HIV Risk-Reducing Behavior Interventions for Heterosexuals
HIV Risk-Reducing Behavior Interventions for Heterosexuals
Objectives The current study was conducted to synthesise evaluations of couple-based HIV prevention interventions, assess the efficacy of these interventions in reducing sexual risk, and identify moderators of intervention efficacy.
Methods A comprehensive literature search identified 29 interventions (22 reports; N=5168 couples) that met the inclusion criteria, including enrolment of both members of a heterosexual couple, measurement of condom use at baseline and follow-up, and sufficient statistical information to calculate effect sizes. Effect sizes were analysed using fixed-effects and random-effects assumptions; factors related to intervention efficacy were identified using metaregression.
Results Overall, there were significant increases in condom use from baseline to follow-up (d+=0.78, 95% CI 0.48 to 1.09) and significant decreases in partner concurrency (d+=0.37, 95% CI 0.13 to 0.60). Condom use increased to a greater extent when studies were conducted toward the beginning of the epidemic, were located in countries scoring lower on the Human Development Index, enrolled serodiscordant couples, and delivered intervention content in multiple contexts. Couples who had been together longer, reported higher incidence of sexually transmitted infection, were provided voluntary counselling and testing, and provided outcome measures during face-to-face interviews also reported larger increases in condom use.
Conclusions Couple-based interventions are efficacious in reducing unprotected sex within the context of romantic relationships. Future research should continue to improve risk reduction for couples.
According to WHO, there are 34 million people living with HIV (PLWH), nearly 70% living in sub-Saharan Africa. Within the USA, there are 1.2 million PLWH, with an estimated 48 100 new infections in 2009. Heterosexual transmission is rising, and women are roughly three times more likely to acquire HIV from a male partner than a man is from a female partner. Women now account for 52% of all HIV infections worldwide. In the USA, two-thirds of new heterosexually transmitted infections were contracted by women. Heterosexual relationships are often characterised by a sexual division of power, shared resources and shared sexual networks, which can lead to increased heterosexual transmission of HIV.
For many couples, unprotected sex can be interpreted as intimacy and trust, acting as a barrier not only to condom use, but to communication about safer sex in general. Even within HIV-serodiscordant couples, condom use is inconsistent despite the immediate threat of transmission. Individuals within relationships may perceive themselves to be less at risk for HIV and other sexually transmitted infections (STI) due to their couple status, but may also underestimate their partner's risk.
Partner concurrency can also place individuals in relationships at an increased risk for HIV. Estimates of partner concurrency vary widely (from 4% to 76%). Partner concurrency is related to increased unprotected sex in some populations; Conley and colleagues found that 'cheaters' were less likely to use condoms with their main or outside partners, get regular STI tests, and disclose outside partners to their main partner compared with individuals in consensually non-monogamous relationships. Nineteen percent of participants in a couple-focused HIV-prevention intervention reported concurrent partners at baseline, and while condom use with main partners increased over the course of the intervention, there was no change in partner concurrency or STI incidence indicating that participants had unprotected sex with concurrent partners Studies examining HIV transmission within serodiscordant couples found that between 18% and 29% of new HIV infections originated from external partners.
Despite early calls for couple-focused reproductive health interventions and recently published strategies and guidelines for the use of voluntary counselling and testing (VCT) and antiretroviral therapy to prevent transmission within serodiscordant couples, couple-based interventions are scarce. Previous meta-analytic work on VCT and interventions targeting condom use included only a handful of interventions targeting couples. A more recent meta-analysis of HIV prevention interventions for PLWH in developing countries included separate analyses for four studies comparing couple-based HIV counselling to individual-based counselling, but found no difference in risk reduction between the two formats. The only systematic review conducted to date that explicitly examined the efficacy of couple-based HIV prevention interventions included six interventions, and while the authors reported generally positive behavioural and condom use outcomes, they did not conduct a meta-analysis due to heterogeneity among studies.
The goal of the present meta-analysis was to extend previous reviews by including more recent literature, determining the efficacy of couple-based HIV interventions in increasing condom use with both main and concurrent partners, and identifying moderators of intervention efficacy. We hypothesised that couple-based HIV interventions would significantly increase condom use with study partners, and would increase condom use with concurrent partners to the extent that interventions addressed concurrent partnerships. We also explored commonly identified predictors of behaviour change as identified by past reviews (eg, provision of behavioural skills training) and included couple-specific moderators (eg, serodiscordancy).
Abstract and Introduction
Abstract
Objectives The current study was conducted to synthesise evaluations of couple-based HIV prevention interventions, assess the efficacy of these interventions in reducing sexual risk, and identify moderators of intervention efficacy.
Methods A comprehensive literature search identified 29 interventions (22 reports; N=5168 couples) that met the inclusion criteria, including enrolment of both members of a heterosexual couple, measurement of condom use at baseline and follow-up, and sufficient statistical information to calculate effect sizes. Effect sizes were analysed using fixed-effects and random-effects assumptions; factors related to intervention efficacy were identified using metaregression.
Results Overall, there were significant increases in condom use from baseline to follow-up (d+=0.78, 95% CI 0.48 to 1.09) and significant decreases in partner concurrency (d+=0.37, 95% CI 0.13 to 0.60). Condom use increased to a greater extent when studies were conducted toward the beginning of the epidemic, were located in countries scoring lower on the Human Development Index, enrolled serodiscordant couples, and delivered intervention content in multiple contexts. Couples who had been together longer, reported higher incidence of sexually transmitted infection, were provided voluntary counselling and testing, and provided outcome measures during face-to-face interviews also reported larger increases in condom use.
Conclusions Couple-based interventions are efficacious in reducing unprotected sex within the context of romantic relationships. Future research should continue to improve risk reduction for couples.
Introduction
According to WHO, there are 34 million people living with HIV (PLWH), nearly 70% living in sub-Saharan Africa. Within the USA, there are 1.2 million PLWH, with an estimated 48 100 new infections in 2009. Heterosexual transmission is rising, and women are roughly three times more likely to acquire HIV from a male partner than a man is from a female partner. Women now account for 52% of all HIV infections worldwide. In the USA, two-thirds of new heterosexually transmitted infections were contracted by women. Heterosexual relationships are often characterised by a sexual division of power, shared resources and shared sexual networks, which can lead to increased heterosexual transmission of HIV.
For many couples, unprotected sex can be interpreted as intimacy and trust, acting as a barrier not only to condom use, but to communication about safer sex in general. Even within HIV-serodiscordant couples, condom use is inconsistent despite the immediate threat of transmission. Individuals within relationships may perceive themselves to be less at risk for HIV and other sexually transmitted infections (STI) due to their couple status, but may also underestimate their partner's risk.
Partner concurrency can also place individuals in relationships at an increased risk for HIV. Estimates of partner concurrency vary widely (from 4% to 76%). Partner concurrency is related to increased unprotected sex in some populations; Conley and colleagues found that 'cheaters' were less likely to use condoms with their main or outside partners, get regular STI tests, and disclose outside partners to their main partner compared with individuals in consensually non-monogamous relationships. Nineteen percent of participants in a couple-focused HIV-prevention intervention reported concurrent partners at baseline, and while condom use with main partners increased over the course of the intervention, there was no change in partner concurrency or STI incidence indicating that participants had unprotected sex with concurrent partners Studies examining HIV transmission within serodiscordant couples found that between 18% and 29% of new HIV infections originated from external partners.
Despite early calls for couple-focused reproductive health interventions and recently published strategies and guidelines for the use of voluntary counselling and testing (VCT) and antiretroviral therapy to prevent transmission within serodiscordant couples, couple-based interventions are scarce. Previous meta-analytic work on VCT and interventions targeting condom use included only a handful of interventions targeting couples. A more recent meta-analysis of HIV prevention interventions for PLWH in developing countries included separate analyses for four studies comparing couple-based HIV counselling to individual-based counselling, but found no difference in risk reduction between the two formats. The only systematic review conducted to date that explicitly examined the efficacy of couple-based HIV prevention interventions included six interventions, and while the authors reported generally positive behavioural and condom use outcomes, they did not conduct a meta-analysis due to heterogeneity among studies.
The goal of the present meta-analysis was to extend previous reviews by including more recent literature, determining the efficacy of couple-based HIV interventions in increasing condom use with both main and concurrent partners, and identifying moderators of intervention efficacy. We hypothesised that couple-based HIV interventions would significantly increase condom use with study partners, and would increase condom use with concurrent partners to the extent that interventions addressed concurrent partnerships. We also explored commonly identified predictors of behaviour change as identified by past reviews (eg, provision of behavioural skills training) and included couple-specific moderators (eg, serodiscordancy).