An estimated 25% of people living with HIV in Canada do not know they have HIV. Effective new ways to increase the uptake and frequency of testing are needed.

Recently, a new approach to testing, called couples HIV testing and counselling (couples testing), has been introduced in the U.S. for men who have sex with men (MSM). This article explores what couples HIV testing and counselling is, its advantages and disadvantages, and describes the approach being used in the U.S.

Why are we talking about testing and counselling?

In Canada an estimated 25% of people living with HIV remained undiagnosed as of 2011.¹ Reducing the number of people who are unaware of their HIV status requires effective new ways to increase the uptake and frequency of HIV testing. Testing not only increases awareness of HIV status, it is also an important gateway to prevention, care and treatment services.

A novel approach to testing and counselling – couples HIV testing and counselling

Couples HIV testing and counselling is the counselling and testing of two (or more) people together who are in, or about to start, a sexual relationship. In couples testing, partners receive pre-test counselling, are tested for HIV, learn the test results and receive post-test counselling together and are linked to care (if one or both test positive).

In addition to the diagnostic, prevention, care and treatment benefits of individual HIV testing and counselling, there are many other benefits of a couples approach to testing:^2,3,4

• Provides a venue for mutual disclosure of HIV status in an environment where support can be provided by a counsellor or health worker.
• Risk-reduction messages can be tailored depending on the outcome of the test results of both partners.
• Decisions about prevention, accessing treatment, care and support, and family planning options can be made together.

Moreover, through couples testing, the counsellor can help create a safe environment in which the couple can discuss potentially difficult issues, such as sexual agreements. Sexual agreements are mutually agreed upon conditions or limitations about sexual behaviours within and outside of the relationship. Couples HIV testing and counselling provides a forum for open discussion about sexual agreements, with the help of a counsellor. This helps both partners fully understand the agreement which may better protect them from HIV.

A few potential concerns exist with couples testing and counselling. There is concern that people could be coerced into testing. In situations where there is an unequal power dynamic within the couple, one partner may be coerced into testing against his or her will. This should be taken into consideration when designing couples testing and counselling approaches. A questionnaire could be used to screen each individual for partner violence. The use of individual consent forms for testing may also identify situations where one partner is being forced to test.

Another concern is that there may be blame within established or longer-term relationships if one or both people test HIV positive. In order to overcome this issue, counsellors should focus their discussions on present and future HIV risk behaviours not past behaviours.

Adaptation for men who have sex with men in the United States

Couples HIV testing and counselling was first used in Rwanda with heterosexual couples in the late 1980s but it has expanded into many African countries over the past 20 years. Research suggests it is an effective approach to testing and has strong HIV prevention benefits.⁵ In 2007, the U.S. Centers for Disease Control and Prevention (CDC) deemed this program a high-impact HIV prevention approach.

Based on the success in Africa, couples testing and counselling was adapted for MSM in the U.S. This population was chosen for several reasons. The U.S. has a high burden of HIV among MSM – an estimated 63% of new HIV infections were in MSM in 2010.⁶

Furthermore, many men in long-term relationships are unaware of their partner’s status^7,8 but still feel they are at low risk for HIV.⁹ This makes them less likely to test for HIV. This is problematic since between one-third to two-thirds of all new HIV infections in MSM are acquired from the main partner within a relationship.^10,11

Testing Together – Couples testing and counselling for MSM in the United States

In the U.S. a couples testing and counselling approach, called Testing Together, consists of a 30–60 minute session between a couple and a trained counsellor. The session includes a pre-test discussion of HIV risks, HIV testing of both partners, skills building around sexual agreements, results given to both partners together, and a post-test discussion of how the couple want to approach HIV prevention going forward. The sexual agreement element is an addition to the traditional couples testing approach. This future-centric aspect of couples counselling differentiates it from the individual counselling approach, which traditionally includes a risk-assessment of past behaviour.

Testing Together was piloted in several U.S. cities (Atlanta, Chicago, Boston, San Diego and Seattle) through funding from MAC AIDS, and was formally evaluated in Atlanta, Georgia. The approach was found to be very acceptable to those who used it.¹²

Testing Together was also found to be very effective at identifying new cases of HIV, with 11% of people tested being newly identified as HIV positive. This is two to three times higher than the rate of new diagnoses among MSM through conventional testing approaches.^13,14,15 In addition, 17% of all couples in the study were newly identified as serodiscordant (where one person is HIV positive and the other is HIV negative)¹⁶.

The study found that people within relationships don’t always have the same understanding of their sexual agreements, but particularly so in couples found to be serodiscordant. This can have strong implications for HIV transmission and reiterates the need for the inclusion of the development of sexual agreements with a couples testing and counselling approach. Testing Together found that almost two-thirds of the couples newly diagnosed as serodiscordant reported different understanding of their sexual agreements, compared to less than half of couples who were diagnosed as seroconcordant (both HIV negative or both HIV positive).¹²

The study also looked at whether there was more inter-partner violence or relationship breakups in people who underwent couples testing and counselling compared to those who underwent individual testing and counselling. These are potential concerns with couples approaches to testing. No evidence of increased inter-partner violence or relationship dissolution were found in those undergoing couples testing compared to those who underwent individual testing.¹²

Roll-out of couples testing and counselling in the US and Canada.

As a result of the Testing Together pilot, in 2013 the CDC took over responsibility for developing and providing training support¹⁷ across the United States for local HIV organizations and health departments to deliver couples testing counselling programs for MSM in cities with high HIV prevalence. As of the fall of 2013, 73 testing sites have been trained in 21 cities throughout the US.

Following the success of the U.S. Testing Together approach to couples HIV testing and counselling, four centres in Ontario (Hassle Free Clinic in Toronto, Options Clinic in London, Somerset West Community Health Centre in Ottawa, and Hamilton Public Health) will pilot the program starting in summer 2014. The program will be evaluated after 2 years with the support of the Ontario HIV Treatment Network (OHTN). Other centres in Canada do test couples together if they request it, but without the structured approach of the Testing Together model.

The Public Health Agency of Canada’s HIV Screening and Testing Guide, published in 2013, includes a recommendation for couples testing.

Can couples testing and counselling be used in other populations?

This approach could be useful in identifying new HIV infections in population or geographic areas where there is a high prevalence of HIV infection. Although there is limited research in other populations, couples testing has been found to be effective in heterosexual couples where the woman uses substances.¹⁸

To achieve maximum effectiveness, couples counselling should be adapted for specific populations and circumstances. Although all the main components of pre-and post-test counselling should be used whatever the population, the messaging around risk-reduction strategies needs to be targeted for each population.

Related article

For a discussion on couples testing and counseling, see Views from the front lines: Couples testing and counselling.

Resources

Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach – WHO

Couples HIV Testing and Counseling – CDC

Testing Together

HIV Screening and Testing Guide – Public Health Agency of Canada

HIV in Canada: A primer for service providers

References

• 1. Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011. Surveillance and Epidemiology Division, Professional Guidelines and Public Health Practice Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2012. Available at: www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.php
• 2. World Health Organization. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. 2012. Available at: http://www.who.int/hiv/pub/guidelines/9789241501972/en/
• 3. Chemaitelly H, Cremin I, Shelton J, et al. Distinct HIV discordancy patterns by epidemic size in stable sexual partnerships in sub-Saharan Africa. Sexually Transmitted Infections. 2012, 88:51–57.
• 4. Effective interventions: Couples HIV testing and counseling. Available at: https://www.effectiveinterventions.org/en/HighImpactPrevention/PublicHealthStrategies/CHTC.aspx
• 5. LaCroix JM, Pellowsk JA, Lennon CA, et al. Behavioural interventions to reduce sexual risk for HIV in heterosexual couples: a meta-analysis. Sexually Transmitted Infections. 2013;89(8):620–27.
• 6. CDC. Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012
• 7. 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(9):1153–62.
• 8. Chakravarty D, Hoff CC, Neilands TB. Rates of Testing for HIV in the presence of serodiscordant UAI among HIV-negative gay men in committed relationships. AIDS and Behavior. 2012;16(7):1944-8. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429654/)
• 9. Mitchell JW, Petroll AE. Patterns of HIV and STI testing among MSM couples in the U.S. Sexually Transmitted Diseases. 2012;39(11):871–6.
• 10. 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 Jun 1;23(9):1153–62.
• 11. Goodreau SM, Carnegie NB, Vittinghoff E, et al. What Drives the US and Peruvian HIV Epidemics in Men Who Have Sex with Men (MSM)? PLoS ONE. 2012;7(11):e50522
• 12. a. b. c. Sullivan PS, White D, Rosenberg ES, et al. Safety and Acceptability of Couples HIV Testing and Counseling for US Men Who Have Sex with Men: A Randomized Prevention Study. Journal of the International Association of Providers of AIDS Care. 2013 September 13. [Epub ahead of print]
• 13. Georgia Department of Health. Ongoing HIV Risk Behaviors in Metropolitan Atlanta: Preliminary Data from the National HIV Behavior Surveillance (NHBS) System, Men who have Sex with Men (MSM2). 2010. Available at: https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/MSM2-Ongoing%20HIV%20Risk%20Behaviors-082211.pdf
• 14. Centers for Disease Control and Prevention. Use of social networks to identify persons with undiagnosed HIV infection – Seven U.S. Cities, October 2003 – September 2004, MMWR. June 24, 2005.
• 15. Centers for Disease Control and Prevention. HIV Testing at CDC Funded Sites, United, States, Puerto Rico and the U.S. Virgin Islands, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; November, 2013
• 16. Sullivan PS, Wall KM, O'Hara B, et al. The prevalence of undiagnosed HIV serodiscordance among male couples presenting for HIV testing. Archives of Sexual Behavior. 2014;43(1):173–80.
• 17. Sullivan PS, Stephenson R, Grazter B, et al. 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. SpringerPlus. 2014;3:249. Available at: http://www.springerplus.com/content/3/1/249.
• 18. McMahon JM, Tortu S, Pouget ER, et al. Effectiveness of Couple-Based HIV Counseling and Testing for Women Substance Users and Their Primary Male Partners: A Randomized Trial. Advances in Preventive Medicine. 2013:286207. [Epub 2013 Mar 12]