Imagine Me & You
Testing Together makes it safer to share serostatus, and may help prevent the spread of HIV in relationships
by Larry Buhl
Since the first HIV antibody test was licensed by the Food and Drug Administration nearly thirty years ago, HIV testing has undergone an evolution. From the two-step blood draw and second counseling session (with a fraught two weeks waiting for the results) to the availability of rapid (twenty minute) tests, it’s become easier than ever to learn one’s serostatus. HIV testing is now provided in a wide range of clinical and nontraditional settings to reach more people, and, if the CDC recommendations are followed, HIV screening will become a routine part of medical care.
But one element of testing hasn’t changed much over the lifetime of the epidemic. Testing and counseling remains a one-on-one with the counselor or medical practitioner. Bringing in your partner to learn your results is still not only discouraged, but in some cases verboten.
But the paradigm of individual-only testing is finally changing. With Testing Together, a couples testing program, gay men—and soon, straight men and women—and their partners can not only learn their serostatus together, but also have trained guides to help them assess their risk, develop sexual “agreements” and come up with strategies, together, to lower their HIV risk.
Risky business • There’s been a shift in recent years to going beyond messages about safer sex as part of HIV prevention. Part of that shift is a growing understanding that openness in sharing sexual histories and serostatus among partners in committed relationships is a crucial component in risk reduction.
One longtime proponent of what’s considered a “holistic” approach to HIV prevention is Colleen Hoff, a professor of sexual studies at San Francisco State University. In 2010 Hoff examined the relationship dynamics of gay male couples and found that couples make “sexual agreements” or rules about whether sex with outside partners is allowed. They do this primarily in order to strengthen and improve their relationship but not to protect against HIV. Hoff also found that a broken sexual agreement or one that isn’t clear to either partner could make both partners vulnerable to HIV. Her findings, she said, were “concerning,” because they suggested HIV-negative gay men in couples felt unduly protected from HIV simply because of their relationship status.
“When there isn’t consensus on what the agreement is, one partner could be involved in risky behavior outside of the relationship and the other partner may be unaware of the resulting risk of unprotected sex within the relationship,” Hoff said in the study’s summary. She added that the study suggests that knowing what motivates gay couples to make sexual agreements could help HIV prevention programs tailor their efforts to be relevant to the whole relationship.
“We in HIV prevention need to take ownership of the misunderstanding [of HIV risk in monogamous relationships]” says Patrick Sullivan, professor of epidemiology in the Rollins School of Public Health at Emory University. Sullivan spearheaded the Testing Together initiative in 2010 and is an administrator for a Testing Together site.
“For many years the belief was that HIV risk was about promiscuity,” Sullivan says. “If you’re in a monogamous relationship with a partner who has HIV and doesn’t know it, being monogamous doesn’t protect you from acquiring HIV. Yet there’s a widespread belief that in a relationship it’s not important to be tested.”
And that belief can be dangerous, Sullivan and an increasing number of HIV prevention experts say.
In an abstract from a soon-to-be published study, Sullivan’s colleague, Dr. Rob Stephenson, associate professor in the Rollins School of Public Health at Emory University, writes that male couples represent a high priority group for HIV-prevention interventions, with “primary partners identified as the source of approximately one-third to two-thirds of HIV infections among MSM.”
Sullivan points to another study conducted at Emory University in 2013 that showed men who have a primary sex partner perceive themselves to be at less risk and are less likely to get tested than single men.
Conversations and “agreements” • HIV transmissions do occur within committed partnerships. But partnered men have far lower rates of routine HIV testing. One aim of Testing Together is to make couples testing normal, routine, and safe for both partners. Beyond that, it can provide a starting point for the conversation that both parties, especially those in newer relationships, are afraid to start.
Africa, Susan Alan, was working on an NIH research project learning about HIV prevalence in Rwanda among women. When they received the results the women said, ‘thanks for helping us learn our status, now help our husbands learn their status.’”
In 2008, when Sullivan was working with sites that were providing testing services for heterosexual couples in Kigali, Rwanda, and Lusaka, Zambia—he still works with these sites—he wondered why the U.S. couldn’t do couples testing for men to reduce the spread of HIV.
He was funded by the NIH to conduct the early stages of adapting the Africa intervention to the U.S. in 2009. In 2011, Sullivan and colleagues approached MAC AIDS to scale-up the new service from its first site, Atlanta, to include two additional cities.
Now the CDC has folded the Testing Together approach into the hundreds of organizations that do HIV testing. Community-based organizations are increasingly offering Testing Together as an alternative to individual testing. Couples learn about Testing Together through word of mouth and a Web site (www.testingtogether.org).
Jasper Barnes, who was the first Testing Together counselor in the U.S. and continues to counsel couples in Atlanta, says that over four years he’s been surprised at the widespread misconceptions of the men who participate. “Many men come in believing that their partners’ negative test means they must be negative too.”
Though Testing Together is technically a formal program, counselors have some flexibility in administering the services. Sometimes a couple comes in and one is previously diagnosed and wants to use this mechanism to facilitate a discussion. In other cases one partner with HIV knows he is positive but he may want to use Testing Together to be there to support his partner.
Whatever the couple decides, there is a lot of ground to cover over a thirty- to forty-five-minute session. There are eight steps according to Barnes: (1) An introduction and session overview and a chance to learn what the couple wants to get out of the session; (2) Performing the test; (3) A discussion of the relationship in general. An exploration of partners’ concerns about HIV; (4) Determining the “agreement.” Partners state whether their relationship is open, monogamous, or somewhere in between. The counselor is there to help them develop this agreement, if there isn’t one already, through role-playing; (5) Preparation for the results; (6) Delivery of the results; (7) Creating a risk reduction plan; (8) Links to follow-up services and referrals.
Coming up with the agreement takes up most of the session, Barnes says. “Many haven’t had a conversation about the boundaries of their sexual relationship. Often they’ll say they thought (monogamy) was just understood.”
When couples say they’re monogamous or think they’re monogamous, in some cases they’re actually monogam-ish, making their own rules and conditions for if and when they do stray outside the relationship. “When a couple tells us they’re monogamous, we dig a little deeper and ask what does that really mean to them,” Sullivan says. “Then we ask what would it look like if one partner stepped outside of the relationship.”
Barnes adds that there are fewer conflicts that arise than one might suspect. “Because the couples are choosing to be a part of this, they’re very open with the counselors,” Barnes says. “It’s very different than individual HIV counseling, where it’s often like pulling teeth.”
But Barnes admits that the process does have the possibility of opening up deeper issues that go beyond the parameters of the session. In those cases, the counselor will refer the couple to skilled practitioners in couples therapy, substance abuse or whatever is needed.
“In many cases couples have not always communicated their serostatus, or that was based on testing that predated the relationship,” Barnes says. “When they decide they want to stop using condoms, that’s a good time for them to talk about it.”
Sullivan says that having a counselor start a discussion about safe sex practices in and outside the relationship is liberating.
“It helps to have a facilitator to say it’s okay to discuss these issues of monogamy and it is not a sign of weakness in your relationship to do so. It is hard for a person in a relationship to start that discussion without a suspicion or starting from a place of conflict.
Conflict does happen, but it’s rare, Sullivan says. The leaders of Testing Together were sure of this from the start, when they conducted a randomized trial of 100 couples before launching the program. “We found there was no higher occurrence of break ups or violence between the group that tested separately and the group that tested apart.”
In that same study Sullivan found another striking statistic: The seropositivity rate for couples who came in to test was higher than the rate of men who came in individually. This underscored the need for a service that would help burst the bubble of perceived safety from HIV for those in committed relationships.
“One of the benefits of Testing Together is that it offers a relevant way for men to be tested in the context of a relationship, without undermining the relationship. Counselors emphasize that this is a way to strengthen the relationship, and as a result this may bring people in for testing who may think they’re not at great risk.”
Sullivan says that in addition to potentially stopping the spread of HIV within couples, services like Testing Together can play an important role for men living with HIV. That is, having a third party start the dreaded HIV conversation with a new partner.
“When we brought in focus groups of HIV men in each city, they said, ‘I knew I was positive when I met this guy but I didn’t tell him because I didn’t know it would go anywhere. One morning I woke up and said, ‘We had sex last night and how do I deal with this?’’’ They didn’t have a way to tell their partner and set the reset in the relationship. For people living with HIV, as with coming out, the disclosure is a process that never ends. It’s challenging to find the right time to tell a relationship prospect.”
Future plans • The CDC is supporting and expanding Testing Together around the country. Trainings are scheduled for El Paso, St. Louis, and Brunswick, New Jersey, and a few other cities this spring. Sullivan says it is likely that places already providing HIV testing and counseling will add Testing Together to their offerings.
Nancy Mahon, global executive director for MAC AIDS said in a prepared statement that the organization will continue to invest in Testing Together and that she is “gratified that the CDC is now bringing this program to scale to reach more people nationwide.”
Sullivan adds that there is interest in exploring the possibility that couples testing actually helps HIV-positive partners link into care, and suppress their viral load sooner. A study to be conducted in Boston, Atlanta, and Chicago this year will test this theory.
A comprehensive approach to testing gay male couples may seem like a no-brainer now. So what took it so long for the idea to gain traction? Sullivan points to the societal changes since the early eighties, and how attitudes about gay men—both by society and gay men themselves—influenced testing practices. At the start of the crisis in the eighties sex between men was criminalized in many places, and there was no Americans With Disabilities Act. HIV testing was set up with protecting confidentiality—gay sex was shameful and HIV was shameful and deadly—and it was a given that you wouldn’t test with another person present.
Sullivan hopes the increased societal recognition of male couples and their legitimacy and respect for those partnerships will encourage many more male couples, at whatever stage of whatever kind of relationship they’re in, to test together.
Larry Buhl interviewed writer, editor, and advocate Khafre Kujichagulia Abif for the February issue.