Prevention in Focus

Fall 2014 

Views from the front lines: Couples testing and counselling

We spoke to three service providers to find their views on couples HIV testing and counselling:

  • Holly MacLean, HIV/STI Testing Nurse, Nine Circles Community Health Centre, Winnipeg, Manitoba
  • Ted Town, Counsellor, Options Clinic, London InterCommunity Health Centre, London, Ontario
  • Geoffrey Ford, RN, Nurse Educator, STOP Outreach Team, Vancouver Coastal Health, Vancouver, British Columbia

Holly MacLean

What do you think the potential benefits are of couples testing and counselling? What are the potential drawbacks?

Most clinics and testing sites in Canada recognize that some visits can be more difficult than others, and are happy to accommodate for a partner or support person to be present during the visit. The idea of couples testing and counselling is interesting and would definitely be appealing to some clients who I see in a clinical setting for HIV/STI testing.

There are a number of benefits to couples testing and counselling. Many partners find strength in the support of one another. For many people, testing for HIV can be a difficult thing to do. The familiarity and support of a partner, and the act of offering support can help clients feel more engaged in the care they receive. Another reason people may like getting tested together is the opportunity for clear communication. They may find that testing together and having questions answered together helps with communication around sex and risk.

A third reason to consider couples testing and counselling may be that clients feel better about returning to a health provider or clinic if they were first introduced to it as partners. They may feel that the provider has a better understanding of their particular relationship or situation. Support and couples counselling is offered to people living with HIV and their partners at our clinic. Couples testing and counselling may be a natural way to transition some couples to this support if it is required.

One of the drawbacks of offering this type of testing and counselling is that it requires more skill from the provider in educating clients, especially about testing. Clients may be hesitant to ask questions, or may not be as forthcoming with information as they would be if they had a private visit.

I am concerned about people in abusive or controlling relationships who may come to the clinic with their partner for couples testing and counselling. There is the potential that a testing session may put one partner in greater danger of harm.

Do you think couples testing and counselling has a role to play in Canada? Who do you think would most benefit from this approach to testing? Tell us why.

I believe couples testing and counselling has value for some patients. When offered in a setting where individual follow-up is made possible, and clients feel supported as individuals and in their partnerships, couples testing and counselling may help to facilitate access to information and services.

Couples testing and counselling may be most beneficial for partners who have many questions and concerns. Partners who have very different knowledge/comfort levels around HIV may also benefit the most from this approach to testing. People in open relationships, polyamorous relationships, and fluid-bonded couples (couples that exchange bodily fluids) may appreciate the opportunity to have a discussion in the presence of a tester to discuss risks and concerns.

People for whom language presents a barrier to care may also appreciate the opportunity to test with their partner(s) for many of the reasons discussed above. Access to an interpreter would be important in these cases.

What steps need to be taken in Canada to make couples testing and counseling a reality in more testing sites?

I think it would be key to have a discussion about confidentiality of health information as a top priority in couples testing. Testing in Canada occurs in a variety of settings, by testers with different skill sets. There is the potential that information that a client wants to keep private is shared. That said, I definitely see a movement in health care toward holistic care of person and family. Recognizing that some clients live in partnership with others is an important part of providing holistic care.

Sites in Canada may want to carefully consider how they offer testing to clients. The skill and comfort level of a tester, and the appropriateness of the testing technologies used are important factors in planning how to offer the best service to clients. For instance, are there couples for whom rapid point-of-care testing may not be appropriate, due to window periods or the hesitation to test of one partner? Can a tester facilitate an effective visit if rapid point-of-care testing is used and one or both (or more) partners test positive? Does it make a difference if no rapid point-of-care testing is offered, or if rapid point-of-care testing is performed in front of clients versus in a separate room?

How clinicians document a session also needs to be considered. Where charting is done for client visits, each person in the counselling and testing session would need a separate chart, with care taken not to identify or share partners’ health information. Programs may also need to look at how statistics for these visits are recorded: as one or as two patient interactions? If a doctor provides the care, how do they bill? Do provincial targets for number of patients seen change?

Finally, it may also be important (and I’d be interested to see) research on what clients have to say about the experience of testing with partners.

Ted Town

What do you think the potential benefits are of couples testing and counselling? What are the potential drawbacks?

One of the potential benefits of couples testing and counselling is that this may be a good approach for couples who are knowledgeable about HIV issues, and are comfortable knowing that what happened in the past (unknown external partners, for example) may be an issue.

When there is that level of openness, it seems somewhat paternalistic for counsellors to say no, you can’t have testing and counselling together. An HIV-positive diagnosis can be a bombshell, but if both partners trust each other enough to hear the news at the same time, who are we to say they need to test separately?

One of the potential drawbacks of couples testing and counselling is that individual testing and counselling is a safeguard against one person feeling coerced or pressured into testing. This allows for a more comfortable setting in which to discuss potentially uncomfortable situations. This may be lost in couples testing.

We have many couples asking to be tested together, but we’ve always tested individually. We have generally found, after both parties have left with their results, that the stories they told us were quite different. One partner disclosed an encounter that the other did not mention. This is completely understandable. People don’t want to have a session degenerate into, “What? When? At what conference? With him? And I’m finding this out now?” It’s a lot tougher to provide appropriate HIV prevention counselling when that happens.

Do you think couples testing and counselling has a role to play in Canada? Who do you think would most benefit from this approach to testing? Tell us why.

I think couples testing and counselling certainly has a role to play in Canada. At least one-third of new HIV infections among male-male couples come from the main partners.

So what do we do with that knowledge? It makes sense to view it as part of the evolving discourse around HIV prevention: people are discussing serosorting, PEP, PrEP and poz prevention. If we’re comfortable acknowledging that HIV prevention issues are complex and nuanced, then we should be able to trust our clients to choose how they want to get their HIV testing and counselling.

Couples testing and counselling is geared primarily to gay couples, and my experience as a counsellor is that these couples are generally far more up to speed on HIV issues than are heterosexual couples. I’ve heard far more heterosexual men and women state, quite emphatically, that HIV would be a deal-breaker for their relationship.

What steps need to be taken in Canada to make couples testing and counselling a reality in more testing sites?

I think the first step is to reduce the stigma around serodiscordant relationships. Using more accessible language and referring to them as “magnetic relationships,” might be one thing to do. I believe those of us who have already been providing anonymous testing and counselling to individuals are ready to offer it to couples. In other words, whenever service providers are ready.

I think we need to remember that this is not about providing relationship counselling. Our responsibility is not to keep couples together if they are unhappy with the HIV test results. Just because they came in as a couple, it doesn’t mean they will leave as one.

Naturally, there will be a learning curve with these new couples testing and counselling protocols, but even when we’ve covered all bases, even when the couple has described their relationship and discussed their plan, it is essential to keep in mind it is not our responsibility to keep them together.

Geoffrey Ford

What do you think the potential benefits are of couples testing and counselling? What are the potential drawbacks?

I think one of the potential benefits of couples testing and counselling is that it may encourage people to test who have not previously been tested. HIV testing can be a stressful thing; it’s important to have as many options as possible so that there is at least one option that clients feel comfortable using. It also gives people who test regularly another testing option.

Right now, clients who want to test with a partner sometimes face paternalism (the idea that doctors know best) from healthcare providers who say that couples can’t test together. Introducing couples testing and counselling as an option for clients seeking testing may reduce this paternalism by showing healthcare providers that, when done appropriately, couples testing and counselling may be beneficial to certain clients in relationships.

There are some drawbacks to couples testing and counselling, however. There is the risk that one or both partners may lose control over the disclosure of their HIV-positive status. Couples testing and counselling may also prevent one or both partners from disclosing important information to the tester. For example, when people test individually, they may be more likely to disclose high-risk sex to their tester. However, when testing is part of a couples session, partners may not want to share that they have had sex, high risk or not, outside of their relationship. By keeping this information from their partner and the tester, some couples may not be getting the best sexual health and HIV prevention counselling for their needs.

Do you think couples testing and counselling has a role to play in Canada? Who do you think would most benefit from this approach to testing? Tell us why.

Yes, I think couples testing and counselling has a role to play. Couples testing and counselling could be a good option for couples deciding to stop using condoms. Couples deciding to have condomless sex should get tested and have a frank conversation about risks, including sex outside their relationship. Getting tested and counselled together may facilitate this conversation for some couples by allowing them to talk to an experienced counsellor together.

It may also be a good option for male–male couples. In my work, with the gay community in Vancouver, I have seen many guys struggle with how to tell their partner they've had a high-risk exposure outside the relationship. Couples testing and counselling could provide a space for this disclosure to happen. It also offers couples the opportunity to learn how to talk to each other about risks when they happen so that they can better protect each other from HIV.

What steps need to be taken in Canada to make couples testing and counselling a reality in more testing sites?

I think there are three practical steps that need to be taken to make couples testing and counselling a reality in more testing sites:

  1. There needs to be an appropriate space for couples testing to take place. This space should be comfortable, private and safe for clients to talk to the counsellor and each other.
  2. There needs to be buy-in from testing providers. Providers should be offered adequate training. Clients will sense if testers are not comfortable with testing couples together and this may do more harm than good.
  3. Education materials targeted to couples for use during counselling sessions need to be developed. This will provide testers with the resources they need to counsel clients on HIV prevention, measuring risk, and disclosure after a potential exposure to HIV outside of the relationship.

Related article

For more detailed information on couples testing and counselling, see Couples HIV Testing and Counselling.