A new initiative called Testing Together aims to use the power of love as an HIV prevention tool. It allows for couples to receive HIV counseling and testing together, at the same time, in the same room—even as the results are given. It's an idea whose time has come, and one that says a lot about where we are in the U.S. epidemic, as well as in the fight for LGBT equality.
Although Testing Together has focused on men who have sex with men (MSM), it is applicable to straight couples and to individuals who already know their status. People living with HIV have already used the service as a way to disclose to their partners.
As Cupid's arrows zing through the upcoming days, it is worth noting the sobering fact that falling in love and having sex with your partner can put you at a higher risk for HIV. Why is this? That's just one of the topics we covered during our interview with Patrick Sullivan, PhD, an associate professor at Emory University's Rollins School of Public Health in Atlanta, and the principal investigator behind Testing Together.
Don't just read the edited Q&A below. Think of the article as a virtual Valentine—and send it to friends and sweethearts.
|Patrick Sullivan, PhD, Emory University's Rollins School of Public Health in Atlanta|
First off, why is couples testing an important prevention tool?
Your main sex partner is the most important person in terms of your HIV risk. This makes sense because you have sex more often with your main partner. Gay men are more likely to have anal sex with their main partner than a casual partner and are less likely to use condoms [with their main partner].
If you have a main partner, knowing your own status isn't sufficient to decide how to manage your risk for HIV. You need to know his status, and you need a prevention plan. [While I was working with the U.S. Centers for Disease Control and Prevention, the CDC,] we analyzed some national data, and our estimate was that two thirds of new infections among MSM were coming from main partners. Suddenly it was looking like the situation in Africa.
Couples testing has been around for a few decades—notably among heterosexual couples in Rwanda—but, with rare exceptions, it never got traction in the United States. Why is that; are there legal hurdles to overcome?
It's not a legality as much as a way of thinking that we've developed as a prevention community. If you think about the context, early in the epidemic, people were being fired [for having HIV], and stigma was worse. So a counseling and testing system was set up and built, I think, in a shrine of privacy because the consequences were so high.
Now we have better legal protections, better education, a better outlook for people living with HIV. Don't get me wrong, there are still consequences—social and all kinds—of being diagnosed with HIV, but it's a lot different. At the same time, currently, if I am being screened for cancer or some other disease, I can say I want my friend or my wife or whomever to be in that room. So in some ways, we are coming in line with the way other issues are handled in medical settings.
Run us through the history of Testing Together and what's in store for the initiative later this year.
In 2009, we took people to see what the intervention looked like in Africa, then we came back and adapted the intervention. We did qualitative work in Chicago and Seattle and Pittsburgh to get the input of prevention counselors and men in relationships about what they wanted in this type of service.
We first did a trial with about 100 couples in Atlanta. In September, we started Testing Together in four sites: [two in Atlanta, and two in Chicago; MAC AIDS Fund is supporting the initiatives in both cities], which is really a program, not in research mode. Some places, for example Fenway Health in Boston, wanted to start providing the service, so we trained counselors there recently. I am going to do training in New York, and through a CDC initiative to expand testing among minority MSM, we'll be training counselors probably in about 10 more cities. That training will start in probably April.
[Editors note: Fenway Health in Boston expects to launch a pilot next month and to officially launch Testing Together in April. About 80 percent of Fenway's testing clients are MSM, and of those, about 60 percent report being in a relationship.]
Does the training apply only to MSM couples; can counselors also test straight couples?
The training we do is specific to male couples. Certainly the counselor skills are generally applicable, and the organizations will have to decide if their counselors feel like they're in a good place to offer the service to male-female couples.
Can a person who is HIV positive use this service as a way to disclose to a partner?
We're fine with that. A person living with HIV needs to be in control of how they want to share that news. This is an environment where, if a partner has questions, there's a third party to make sure there's right information about the risks.
HIV-positive participants in our focus groups [pointed out that when you meet someone] you don't always think, “He's going to be a boyfriend.” So things evolve, and maybe you start out having sex in a way that is very low risk, maybe only oral sex, and then [you think,] “I don't know if I'm going to be with him in a week or two, and if I tell him [my status] everyone's going to know I'm positive, so I'm going to hold that back.” [The positive guys in the focus group] then describe reaching a point maybe without a lot of planning when they're starting to have anal sex and a condom was used, but then three months into this, it becomes really awkward [that they haven't disclosed].
We're continuing to refine what parts of the service are useful to guys and looking at a broader evaluation. One of the things we were interested in was if couples break up more often after testing together versus separately. We've found no evidence that they break up more often. [We are also looking at] partner violence. That's a concern: Do the issues that come up in the session lead to intimate partner violence. We didn't find an increase in violence in partners tested together or separately.
In your research, did you find differences in testing male couples and male-female couples?
I'd say the fears and desires were similar. All the steps and processes are the same. But guys said, “If it's going to be like regular counseling, where a counselor asks about when was the last time I had unprotected sex and how many partners I've had, I don't want to answer that in front of my partner.”
Then we explained that the intervention is forward focused, that we don't make lists of former activities, but we're going to find out your status today and then we can make a plan to decide how you want to handle the issue of HIV in your relationship going forward. With that knowledge, guys focused on what we think is its greatest strength, which is that they wanted to be there to support each other, to say, “If one of us is infected, we want to have that built-in support.”
The one thing that's different [from male-female couples testing is that the male couples testing includes] a component that deals with agreements around outside sex partners. When we asked male couples [about this], over 90 percent of them had some kind of agreement as to whether they can have sex with an outside partner. Sixty-five percent of couples had an agreement to be monogamous. Another 35 percent said we can have sex with an outside partner in some way—and most have conditions around that. And there's 3 or 4 percent of that 35 percent who say, “We can have sex with outside partners with no conditions.”
For most men in relationships, some kind of agreement is in place. But when you sit down with them and ask them, “How did you reach that agreement, and is it an explicit arrangement or understood,” some men say: “We haven't talked about it specifically, but I'm sure we are on the same page.” So part of what we do in the couples counseling and testing intervention is to open up the discussion.
And we do find times when that may be the first time a couple explicitly [talked about] an agreement, and then we do some skills building around how a couple wants to handle that. We also know from national survey data that in those couples that have an agreement toward monogamy, about 25 percent of men will say they've stepped out of the agreement and a very small proportion of those will tell their partner about [it].
One of the reasons we heard that guys wanted to test together was so that if they're both negative they can stop using condoms. From an HIV prevention point of view, you can recover from stepping outside the relationship, but you have to talk about it.
We do a skills building piece around clarifying agreements and practicing how to handle it if someone steps outside. We ask them, “Joe, John, you guys have an agreement to monogamy. It's great you talked about this explicitly, and it's strengthened your relationship. I don't think it's going to happen, but sometimes in relationships, people do step outside that relationship. So Joe, my question is, if John does that, do you want to know about it?”
In most cases Joe doesn't want to know. [But if he does,] then we say, “How would you want to know? Text message? In person?” Not uncommonly [after the skills building exercise] guys say, “If this happened and you told me about it and we could work through it, I'd rather know and work through it.” So that's enabling for relationships to be able to manage the issue.
This sounds like it's going beyond HIV prevention and into relationship building.
We try to be really clear: The counselors are HIV prevention counselors who have additional training working with couples. There are definitely certain issues the couples may bring to a session that we have clear boundaries around, and we train counselors to make referrals to family therapy if needed.
And from a counselor's point of view, it's a really different skill set to deal with two people. Counselors are concerned that conflict may arise from issues of outside partners that they haven't discussed. If one person is positive, is that going to lead to accusations of infidelity? If both are positive, is one going to blame the other for infecting him? There are skills we teach about raising these issues in a way that doesn't lead to conflict, and how to diffuse tension and blame.
Are there specific advantages to testing as a couple?
As you know, getting diagnosed is just a first step. Then there are all these important steps that need to follow: finding a place that's a good match for care, then engaging in care and remaining engaged in care. So to the extent we can enlist, in a discordant partnership, the negative partner to help support those linkage-to-care pieces, that's a real opportunity as well.
But one of my underlying hopes in this is that we need to be telling couples that their relationships are important. My own perspective as a researcher and a member of the community is that we haven't done the best job of providing support to couples. The move toward marriage equality in several states is a positive development, but if you think about what society has said to male couples historically, there hasn't been a lot of societal support for guys to say it's normative to stay in these relationships.
Part of engaging men as a couple is saying, “Your relationship is valid, and it's great that you're dealing with HIV as a couple instead of individually.” That conveys some broader sense of support of their life as a couple.
Do you have any data regarding what motivates couples to get tested together?
When we did qualitative work, we said, “When would guys want to do this?” Men viewed this as a marker of commitment in a relationship: when you're getting serious, if you're getting exclusive, if you want to quit using condoms, if you want to buy a house or adopt a kid or get a dog—we heard all these natural milestones at which men might want to check in together about this intervention. Having said that, I think it is not a service men are used to [getting].
Do couples have to be together a specific amount of time to get tested together?
In the first study, we only worked with couples who had been together three months. In our Testing Together guidelines, it's a month. If it's less than a month, I think we would just have a longer conversation around that level of trust and whether they're really in a place to trust the other person with this information.
I see young men who are testing before they get involved sexually. And that is a sign that we are having a much more open discussion, that young couples can identify as a couple. They've grown up hearing about marriage [equality], and probably watching reruns of Will & Grace—not even the original. There's much more visibility. All that's good, and it's exciting to see this generation of young gay men stepping up and doing this in their own way and frankly in a way we didn't completely anticipate—and that's a good sign, too.
Finally, how can couples find out where to get tested together?
We have the web site TestingTogether.org. There is a ZIP code locater in there; people can find facilities as they're offered. And also, if you put in your ZIP code, we keep tally of where there's interest. In the next phase, we'll start reaching out to [those] health departments and community organizations.