Associated material
Related literature
Other articles by authors
Related articles/pages
Download to ...
Share this article
SpringerOpen Newsletter
Receive periodic news and updates relating to SpringerOpen.
for this article has been published in SpringerPlus
Case study
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
Patrick S Sullivan*†, Rob Stephenson†, Beau Grazter, Gina Wingood, Ralph Diclemente, Susan Allen, Colleen Hoff, Laura Salazar, Lamont Scales, Jeanne Montgomery, Ann Schwartz, Jasper Barnes and Kristina Grabbe
Corresponding author:
Patrick S Sullivan
† Equal contributors
Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322, USA
Hubert Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322, USA
Howard Brown Health Center, 4025 N Sheridan Rd, Chicago, IL 60613, USA
Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322, USA
Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322, USA
Center for Research and Education on Gender and Sexuality, San Francisco State University, 835 Market Street, Suites 523-525, San Francisco, CA 94103, USA
Institute for Public Health, Georgia State University, One Park Place, Suite 700, 30303 Atlanta, GA, USA
Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333, USA
Licensed Family and Martial Therapist, 2200 Century Pkwy NE Suite 200, Atlanta, GA 30345, USA
Center for Health and Behavioral Training, University of Rochester Medical Center, Rochester, NY, USA
For all author emails, please .
SpringerPlus 2014, 3:249&
doi:10.01-3-249
The electronic version of this article is the complete one and can be found online at:
Received:25 February 2014
Accepted:6 May 2014
Published:16 May 2014
& 2014 Sullivan et al.; licensee Springer.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.
To respond to the need for new HIV prevention services for men who have sex with men
(MSM) in the United States, and to respond to new data on the key role of main partnerships
in US MSM epidemics, we sought to develop a new service for joint HIV testing of male
couples. We used the ADAPT-ITT framework to guide our work. From May 2009 to July
2013, a multiphase process was undertaken to identify an appropriate service as the
basis for adaptation, collect data to inform the adaptation, adapt the testing service,
develop training materials, test the adapted service, and scale up and evaluate the
initial version of the service. We chose to base our adaptation on an African couples
HIV testing service that was developed in the 1980s and has been widely disseminated
in low- and middle-income countries. Our adaptation was informed by qualitative data
collections from MSM and HIV counselors, multiple online surveys of MSM, information
gathering from key stakeholders, and theater testing of the adapted service with MSM
and HIV counselors. Results of initial testing indicate that the adapted service is
highly acceptable to MSM and to HIV counselors, that there are no evident harms (e.g.,
intimate partner violence, relationship dissolution) associated with the service,
and that the service identifies a substantial number of HIV serodiscordant male couples.
The story of the development and scale-up of the adapted service illustrates how multiple
public and foundation funding sources can collaborate to bring a prevention adaptation
from concept to public health application, touching on research, program evaluation,
implementation science, and public health program delivery. The result of this process
is an adapted couples HIV testing approach, with training materials and handoff from
academic partners to public health for assessment of effectiveness and consideration
of the potential benefi further work is needed to optimally adapt
the African couples testing service for use with male–female couples in the United
Keywords: HIV; AIDS; P T C MSM; C A ADAPT-ITTBackground
Since the earliest reports of AIDS in the United States, men who have sex with men
(MSM) have been, and continue to be, the most adversely affected risk group in the
US HIV epidemic (Sullivan and Wolitski ). Male couples represent a high-priority group for HIV prevention interventions,
because primary partners have been identified as the source of approximately one-third
(Goodreau et al. ) to two-thirds (Sullivan et al. ) of HIV infections among MSM. Many MSM have high rates of sexual risk behavior for
HIV with main and casual partners. Potentially risky episodes with casual partners
are often not disclosed to main partners (Gomez et al. ; Hoff et al. ; Gass et al. ). Each of these factors highlights the need for targeted HIV prevention services
for male couples. The Office of the Global AIDS Coordinator, through dissemination
of prevention guidelines for MSM in countries supported by the President’s Emergency
Plan for AIDS Relief (PEPFAR), has recommended couples testing for male couples based
on the strength of evidence from observational studies of heterosexual couples (PEPFAR
HIV testing is an important component of the National AIDS Strategy (The White House
Office of National AIDS Policy ), but reported rates of HIV testing among partnered MSM are low (Chakravarty et al.
Mitchell and P Phillips et al. ). Among a large cohort of male couples, only 23% of men who had unprotected anal
intercourse with an outside partner of HIV-positive or unknown status reported testing
for HIV in the past 3 months (Chakravarty et al. ). In the same sample, 47% of those who had not tested for HIV in the past 6 months
chose the response “I am in a relationship” as the reason for their not having tested in the past year, although less than half
of these couples reported that their relationship was monogamous (Chakravarty et al.
). Clearly, innovative approaches are needed to increase rates of testing for male
couples, to increase the success of primary prevention and to improve the rates of
early identification of new HIV infection and early treatment engagement (Sullivan
Couples HIV Testing and Counseling (CHTC) has been used as an HIV prevention strategy
in Africa for over 20 years and is considered by the US Centers for Disease Control
and Prevention (CDC) to be a “high leverage HIV prevention intervention” (Painter
). The critical difference between the CHTC model and the conventional model of individual
testing or Voluntary HIV Counseling and Testing is that CHTC provides HIV testing
and counseling to the couple: Couples receive different HIV counseling and prevention
messaging based on the characteristics of their relationships and their joint HIV
status. CHTC has demonstrated success in reducing sexual risk behavior and promoting
mutual disclosure of HIV status among heterosexual serodiscordant couples (i.e., couples
in which one is HIV negative and one is HIV positive) (Allen et al. ; Allen et al. ). In a non-randomized prospective study of heterosexual couples, HIV-negative women
whose male partners had not participated in CHTC had a small reduction in HIV incidence,
from 4.1/100 person-years (PY) to 3.4/100 PY. In contrast, the HIV incidence rate
among women whose partners had participated in CHTC was about half as high (1.8/100
PY, p&0.04) (Allen et al. ). Previous studies have also demonstrated CHTC to be effective in increasing and
sustaining condom use within primary couples and reducing sexual risk-taking within
heterosexual serodiscordant couples who receive CHTC (Allen et al. ; Allen et al. ; P Roth et al. ). CHTC has received significant support through PEPFAR, has been adopted widely in
sub-Saharan African countries with high adult HIV prevalence, and has been recommended
by the World Health Organization as part of an integrated testing and biomedical prevention
strategy (World Health Organization ).
The ADAPT-ITT framework, developed by Wingood and DiClemente (), provides a guide for systematically adapting HIV prevention interventions with
proven efficacy to new target audiences. The framework grew from recognition of a
lack of theoretical frameworks available for the adaptation of evidence-based interventions
(EBIs). ADAPT-ITT consists of 8 sequential phases that offer HIV prevention providers
and researchers a prescriptive method for adapting EBIs. It has been applied successfully
to the adaptation of several HIV prevention interventions, including those for incarcerated
populations (Latham et al. ), faith-based HIV interventions (Wingood et al. ) and a community-recruited sample of Latina women (Wingood et al. ). This report describes the use of the ADAPT-ITT framework to modify the original
CHTC approach for use with male couples in the United States. We also discuss our
critical path from concept to scale-up of the adapted intervention, which was different
than the traditional approach to intervention development and testing.
Methods and results
We applied the ADAPT-ITT framework using a mixed-methods approach: qualitative methods,
quantitative surveys, key informant interviews, theater testing, a randomized prevention
study, and an expanded program evaluation. Throughout the process, multiple funders,
including government and private sector foundation funders, played key roles in supporting
the adaptation. Our process followed the phases of adaptation specified in the ADAPT-ITT
framework (Wingood and DiClemente ).
Phase 1: assessment
The assessment phase typically involves data collection (focus groups, interviews
and surveys) with members of the target population and target service providers, to
determine the prevention needs of the risk population and to assess the capacity of
an agency to adapt an intervention and implement it.
Data collection
We conducted 4 focus groups with a total of 39 MSM in Atlanta, Chicago, and Seattle
between September and October of 2009 (Stephenson et al. ). We conducted 2 online surveys of a total of 6,640 MSM to assess willingness to
use a couples’ testing service and reasons for willingness or lack of willingness
to use such a service. We conducted key informant interviews with staff from 2 community-based
organizations (CBOs) that provide HIV testing services to MSM. We also incorporated
feedback from health department staff in the City of Chicago, the State of Georgia,
and the District of Columbia. Trainings were conducted for health department staff
in the District of Columbia and City of Chicago, and trainers received feedback from
participants about the trainings’ content. We received critical feedback from an NIH
study section that reviewed an initial submission of an R34 proposal. Finally, we
conducted a site visit to a CHTC provider in Lusaka, Zambia, with representatives
of 2 community-based organizations (LS and BG) and a licensed marriage and family
therapist (JM), and recorded their their observations about provision of the African
CHTC service.
Major findings
The results of focus groups with MSM have been previously reported (Stephenson et
al. ). Major findings that influenced the assessment phase were an overall enthusiasm
for using CHTC, and some important misconceptions about couples testing. The common
misconceptions were that couples testing violated privacy laws, and that a counselor
would elicit individual sexual histories from both partners in the joint CHTC session.
HIV-positive men also reported using individual HIV testing as a way to disclose their
HIV status to new sex partners. HIV-negative men across groups stated that they would
use CHTC to learn one another’s status, so that they could discontinue condom use
with their main partner if both were HIV-negative.
The results of the online internet survey relating to willingness to use CHTC have
also been previously reported (Wagenaar et al. ). Major findings that influenced the assessment phase were a high (82%) overall intention
of MSM to test with a male sex partner in the coming year (conditioned on the availability
of a CHTC service in the United States); there was higher intention to use CHTC among
men of color, younger men, and men with main sex partners. Main reasons for wanting
to use CHTC among those who intended to use the service were learning one another’s
HIV status, supporting their partner, and strengthening the relationship. Main reasons
for not wanting to use CHTC among those who did not intend to use the service were
wanting to learn one’s own status before testing with a partner, concern about a counselor
asking questions about sexual history in front of the partner, and fear of being HIV-positive.
The results of a separate online survey reporting the prevalence and nature of sexual
agreements have also been recently reported (Gass et al. ). The principal findings of these analyses were that agreements about whether or
not outside sexual partners are allowed are nearly ubiquitous (91% of men with a main
partner had some kind of agreement). Most of these agreements (64% of men) were agreements
of monogamy, but over a quarter of men reported agreements that allowed outside sex
partners with (24%) or without (3%) conditions. About a sixth of men reported breaking
their agreement, and of those, over three-quarters of men did not tell their partner
about breaking the agreement right away(Gass et al. ).
Feedback from community-based organization (CBO) staff and health department staff
indicated some key concerns about implementing a couples testing service. First, both
CBO and health department staff felt that a CHTC service would be feasible to implement
only if it were time-neutral, i.e., if the time required were approximately the length
of 2 individual voluntary counseling and testing sessions. Second, both groups were
concerned about clarifying state laws regarding testing of partners together and developing
appropriate models of informed consent. Other considerations raised by these groups
were the need to consider service flow within service provision settings and how data
elements for administrative reporting of provision of testing services would be provided.
Participants in the training using the African training materials suggested removing
some language that was perceived as value-laden, especially the recommendations to
couples for monogamy and recommendations for disclosing HIV status to clergy.
An NIH study section raised concerns that intimate partner violence (IPV) was a possible
negative outcome of the service and asked that plans be developed to evaluate this
concern. CBO representatives and the licensed marriage and family therapist who observed
the service provided in Africa expressed concerns that the group-informed consent
and group delivery of pre-test information used in that program would be inappropriate
for use in the United States.
Modifications
Based on the findings in the Assessment phase, we made a number of modifications to
the existing training materials, service flow, and marketing plan. First, our overall
finding revealing a high intention to use the service encouraged us to continue the
adaptation. The specific motivations to use or not use a CHTC service informed “frequently
asked questions” for a public website ( ), which refuted misconceptions about confidentiality and elicitation of sexual histories
as part of the CHTC session.
The data on the high prevalence of agreements and breaking of agreements, coupled
with men’s intention to discontinue condom use if both were HIV-negative, led us to
add a new component to the CHTC service. Our reasoning was as follows: if a couple
received concordant HIV-negative results and decided to discontinue condom use, they
could actually be at increased risk of HIV transmission if one partner was exposed
to HIV outside the relationship and came back into a relationship where condom use
had been discontinued. Therefore, we felt it important to add an element to the CHTC
service that established the existing agreement about outside partners, and provided
skill-building to the couple around how to disclose violations of the agreement should
they occur.
Based on the feedback from CBO providers, we aimed to limit the length of a CHTC session
to no more than 45 minutes, the typical duration of 2 individual HIV testing sessions
in many CBOs at the time. This duration was consistent with the length of service
observed in many African couples testing programs. We also decided that consent and
pre-test counseling should be conducted with the couple privately, rather than using
the model of group consent and pre-test information observed in Africa.
Phase 2: decision
The decision phase involves identifying candidate interventions and deciding whether
to adopt or adapt the chosen intervention. ADAPT-ITT proposes a relatively narrow
criterion for selection, identifying “starting point” EBIs for adaptation and specifying
that an EBI should be selected through review of articles and publications written
Data collection
We used data from the focus group discussions (FGDs) described above, data from the
internet survey of men in main partnerships described above, and information gathering
from African couples testing trainers. We also systematically reviewed the HIV prevention
literature to identify alternative couples HIV testing models that were not represented
in CDC’s inventory of EBIs.
Conclusions
We chose to work with the existing African couples HIV testing and counseling approach
because there was no CDC-endorsed HIV testing or counseling EBI for male couples on
, because of the robust training materials available for the African couples’ approach,
and because of the substantial evidence for the prevention value of the African couples’
approach. CDC’s African CHTC training curriculum was developed with a broad range
of academic and community stakeholders, is promoted and disseminated by CDC, and has
been used extensively in Africa and Asia for nearly a decade in its current form.
Although CDC had not formally reviewed the evidence base for CHTC in the US, CDC had
stated that CHTC was a “high leverage HIV prevention intervention” in the African
context (Painter ).
Despite the strengths of the CDC CHTC curriculum, we decided that adaptation was more
appropriate than adoption. The primary reasons for this judgment were (1) the need
to add a service component to address sexual agreements and (2) the need to make many
of the examples and role-plays more culturally relevant to male couples than those
in the original materials.
Phase 3: adaptation
The adaptation phase involves pre-testing the intervention with the target audience
to examine attitudes towards the format and content of the intervention and to receive
feedback and recommendations for improving the acceptability of the intervention among
the target audience. This is classically done with the o in our
implementation we pre-tested CHTC with some modifications, such as with the use of
non-group consent and with the addition of the agreements discussion.
Data collection
We conducted theater testing-based FGD with MSM, HIV counselors, and clinic managers
in Atlanta and Chicago. Theater testing is a pre-testing methodology adapted from
social marketing. To facilitate an accurate assessment of reactions to the service,
videos of the service are shown to groups of the intended audience and practitioners.
Participants view an example of how the service is delivered to and experienced by
the target population. In total 8 theater testing focus groups were conducted: 4 in
Atlanta and 4 in Chicago. In each city, an FGD was conducted with each of 4 groups:
black/African American MSM, white MSM, HIV counselors, and HIV testing clinic managers.
Men in the MSM focus groups did not attend as couples, and HIV status was not an eligibility
in most MSM groups, one or more men identified themselves as living with
HIV during the discussion. Each FGD followed the same format. Participants were shown
a video detailing the entire CHTC process, including the couple arriving at the testing
site, signing consent forms, and receiving the CHTC service. Three separate endings
were shown, illustrating the 3 possible HIV results that could be delivered in a CHTC
session (serodiscordant, concordant negative, concordant positive). The films were
stopped periodically to allow the participants to provide feedback on each stage of
the service. At the end of the film participants provided feedback and recommendations
on the service and discussed their willingness to use the service.
Major findings
Table& illustrates key findings from the theater testing FGD. In agreement with the survey
data presented for Phase 1, there was universally high acceptance and willingness
to utilize CHTC among MSM in all groups. Providers and Clinic Managers also reported
high levels of willingness to provide CHTC, and no supply-side barriers (e.g., limited
space or counselor capacity) were identified to the successful integration of CHTC
into existing testing sites. Participants in all groups reported that they were not
aware of the availability of CHTC in their locales (CHTC was not currently available
in either city at the time of the focus group discussions). The video showed a couple
being screened for eligibility for CHTC: they were ineligible for CHTC if they had
not been together for at least 3 months, if either of them reported recent (&12 months)
IPV or if either reported feeling coerced to attend CHTC. All participants felt that
the screening for IPV and coercion were important and reacted favorably to clients
completing their intake and consent forms separately. However, participants in all
groups did not agree with the 3-month relationship duration e
participants felt that this would prevent couples from using the service before they
had sex, and would reinforce stigma against MSM by suggesting that early stage relationships
were not “valid”.
Summary of results of theater testing of an adapted couples HIV testing service, by
focus group participant type, Atlanta, Chicago and Seattle, October 2010
In terms of the flow of the CHTC service, MSM participants felt that reminding the
couple of the need for confidentiality at the beginning of the counseling session,
establishing clear ground rules, and reminding the couple that they would hear each
other’s results immediately before the delivery of results would improve comfort with
the service.
In the video of a CHTC session, couples talked about their sexual agreements and role-played
disclosure of breaking the agreements. Participants in all groups responded well to
this element of the service, noting that it was an opportunity for couples to discuss
the realities of sex and HIV in their relationships. Importantly, MSM reported they
would be willing to participate in this element of the service and providers felt
able to facilitate these discussions. In terms of how results should be delivered
in a CHTC session (i.e., verbally, or on a written form, as is done in some Africa
settings), all participants felt that results should be delivered verbally, and that
the positive individual in a serodiscordant couple should be told first. For concordant
results, participants liked the phrase “your results are the same” as a precursor to the delivery of the results.
Modifications
Several minor modifications to the CHTC service were made as a result of the theater
testing. The requirement for couples to be in a relationship for 3
instead, instructions for the delivery of CHTC were changed to state that it was at
the discretion of the individual organization to establish relationship duration criteria,
but that the service was recommended for couples at all relationship durations. In
the original African service, the session opened with a description of the benefits
of CHTC that included a history of CHTC; most participants reacted negatively to this
and it was subsequently removed from the pre-testing steps of the service. Recommendations
that the results be delivered verbally (to the positive individual first) and language
around the delivery of concordant results were incorporated.
Other suggestions were not adopted. For example, several MSM and provider participants
suggested that only male counselors should deliver the service. This recommendation
was not taken as it was not universally reported by MSM and providers, and there was
no precedent for it in the delivery of individual HIV testing and counseling. Restricting
the delivery to male providers would also place an unnecessary burden on HIV testing
sites already working with limited resources and skilled female counselors.
Phase 4: production
In the production phase — i.e., the production of the service and related training
materials — authors must balance the need to maintain fidelity to the core elements,
underlying theory, and internal logic of the original approach with the realities
of service delivery, which may include assessing the capacity of testing sites to
provide services and the resources available for successful service delivery and integration.
This phase also draws upon the results of the Assessment and Adaptation phases. Wingood
and DiClemente () note that authors need to decide whether the goal of adaptation is to produce a
successfully adapted intervention for a new target population or to test whether the
adapted intervention produces changes in theoretically important HIV prevention mediators
and behavioral outcomes. For CHTC the aim was to produce a successfully adapted service
for a new target population: adapting a previously successful couples’ testing model
used with heterosexual couples in Africa for male-male couples in the US. In the Assessment
phase we made changes to the content of the counseling messages (e.g., reduced emphasis
on fertility), and these changes, as well as the changes identified by the target
audience in the adaptation phase, were included in the service and related training
materials.
The production process originally suggested by Wingood and DiClemente () was used to guide Phase 4: a 7-stage plan for production is nested within this Phase.
The information for stages 1–4 of the production phase drew upon information and decisions
made earlier: (1) the aim of the adaptation: to provide couple’s HIV testing for male-male
couples in the U.S; (2) the intervention (service) to be adapted: African CHTC; (3)
the CDC publication citing the intervention as an EBI: for this we refer to the work
of Painter et al., identifying CHTC as a “high leverage intervention”, and CDC’s dissemination
of the training materials for the original A and (4) the new target
population or context: male couples in the US.
Stage 5 identifies the core elements of the original intervention. These remained
the joint testing and counseling of male couples used the same protocol
as used for heterosexual couples in Africa. Revisions to the training curriculum were
contextual, removing discussions of fertility and religion. Most new material was
produced in stages 6 and 7, which involved identifying the aim of the new materials
and/or activities for inclusion in the adapted service and developing new materials
and/or activities that may be more appropriate and relevant for the target population.
In the assessment phase we had decided to include discussions of sexual agreements,
given their relevance to male-male relationships, so we developed new content for
the training materials. This content introduced the concept of sexual agreements,
discussed the prevalence of typologies of sexual agreements, provided skills on counseling
couples to form agreements and include them in prevention planning, and described
activities that allowed providers to name types of agreements and practice counseling
skills around agreement formation and disclosure of broken agreements. Other content
included role-playing scenarios of male couples seeking CHTC, and an updated values-clarification
exercise that included issues that were more contemporary and more pertinent to MSM,
such as pre-exposure prophylaxis.
Phases 5 & 6: topical experts and integration
The topical-experts phase involves collecting feedback from content experts on the
first draft of the training materials and the flow and content of the service. The
integration phase involves integrating that feedback into the adapted service and
related training, resulting in a set of training materials suitable for pilot testing.
Data collection
Content experts were identified in several key domains: HIV testing service delivery,
couples counseling theory and practice, interventions for male-male couples, HIV risk-taking
among MSM, scale development and data collection from couples, and IPV among male
couples. Several of the content experts are authors on the current paper. The experts
were engaged early in the adaptation process for a one-day meeting to review the preliminary
materials and discuss changes. At the one-day meeting they were presented with the
data from the assessment phase on willingness to use CHTC and the role of sexual agreements
in male couples, and reviewed proposed changes to the service based on those data.
A web-based survey of MSM in main partnerships was used to validate scales for measuring
key elements of the theoretical framework.
Modifications
The expert review resulted in a number of small changes made to the first draft of
the materials. In addition to small changes in language and format, the most significant
change was the proposal to change the name under which the service was marketed. It
was felt that the “Couples” in CHTC would potentially result in self-censoring from
the service for male partners who did not see themselves as a “couple”, with connotations
of commitment and monogamy. Like the participants in the theater testing FGD, the
content experts felt that CHTC should be available for all male partnerships, including
those in which men were currently in, or intended to be in, a sexual relationship.
As a result, it was recommended to market the service as “Testing Together”. We also noted the importance of training counselors explicitly about the use of language
around identifying “couples”, to allow counselors to provide a high-quality service
to men in different types of partnerships. Experts validated the incorporation of
discussions and role playing around broken sexual agreements, and the licensed marriage
and family therapist adapted the language and key counseling skills to be used at
that stage. Experts also suggested scenarios for the role plays in the training materials.
After the expert review, scales were developed to capture domains of the Couples’
Interdependence Theory that forms the basis of the CHTC service (Lewis et al. ). The scales needed to be able to identify the impact of the service on the transformation
of key elements of male-male relationships (e.g., communal coping and shared preferences).
The development and validation of the scales is described elsewhere (Salazar et al.
); briefly, the purpose was to measure the perceived severity of HIV, preferences
for sexual health outcomes, outcome and couple efficacy to avoid HIV, and communal
coping strategies. Scale items were created based on theoretical definitions and results
from 6 focus groups with MSM (recruited through the same venue-based sampling methodology
used for FGD recruitment at other stages of the adaptation). Face and content validity
of the scales were assessed with a panel of 6 content experts in the field of HIV
prevention. Revised scales were subsequently administered to an online sample of 638
MSM who indicated being in a main partnership with another man for at least 3 months.
All scales showed
evidence for construct validity was obtained
for all scales except for perceived severity of HIV. The results indicated that these
scales are reliable and valid measures that can be used in future HIV prevention research
and practice with MSM couples (Salazar et al. ). The scales were used in Phase 8 (testing) as measures of the central concepts of
change within couples resulting from exposure to the service. The scales have since
also been used successfully in other studies examining IPV, HIV testing and relationship
dynamics among male couples.
Phase 7: training
The training process included training for current HIV counselors on how to deliver
the CHTC service to male couples, and for trainers to train the counselors. The training
of providers was based on the original CHTC training, which was a 4–5 day in-person
didactic training. Our initial adaptation reduced the training to a 3-day in-person
training, which topical experts felt was much more feasible and increased the likelihood
of uptake among resource-constrained HIV testing organizations. It was decided that
the audience for the training would be HIV counselors and testers, ideally with at
least 6 months’ experience providing individual HIV counseling and testing.
The training materials consisted of 7 modules: background and discordance, introduction
to couples counseling skills, initial session of CHTC, delivery of concordant negative
results and prevention planning, delivery of concordant positive results and prevention
planning, delivery of serodiscordant results and prevention planning, and implementation.
Each module contained a combination of didactic teaching and participant activities
aimed at highlighting key messages and building or reinforcing key skills. The materials
placed a strong emphasis on developing counseling skills to enable the effective provision
of CHTC; role plays allowed participants to practice simulated CHTC sessions and receive
feedback from trainers. Several quality assurance efforts were also included: checklists
of the protocol stages and their elements for counselors to use in delivering the
service (see Figure& for an example), palm cards and posters of the protocol stages, and detailed instructions
on the continued practicing of role plays and key questions to facilitate feedback
after role plays. The implementation module was developed to address questions about
demand generation, management of service provision within different organization types,
organization-specific consent procedures, and a discussion of developing and implementing
criteria for eligibility. The issue of eligibility was a frequent concern of trainees,
and we approached this element by providing principles guiding the development of
provider-specific criteria (i.e., the importance of mechanisms to exclude couples
where one felt coerced, the importance of obtaining agreement on confidentiality and
mutual disclosure, and the different types of couples that might seek CHTC services).
Example of a training palm card with the CHTC protocol steps. Materials such as these are used in training and support of counselors being trained
to deliver the CHTC service.
The first trainings were conducted in Atlanta and Chicago, the sites for the Stage
8 (Testing) pilot tests. Over the course of 4 years (), more than 30 trainings
were conducted throughout the US Additional trainings were conducted on request for
community-based organizations and local health departments. In total, representatives
from 73 testing sites were trained, representing 17 cities and 11 states. Over 300
HIV counselors and testers were trained in the provision of CHTC through mid-2013.
The large number of trainings conducted facilitated 2 key processes: the constant
updating and refinement of the training materials, and the training of additional
trainers. The training materials evolved significantly throughout this process. They
came to include less content on the history of CHTC. They also included videos demonstrating
key counseling skills and stages of the protocol, and training on consent and IPV/coercion
screening procedures. At each revision the authors and key content experts reviewed
the materials to ensure fidelity to the service. The materials were further refined
by an expert in the production of training materials, focusing on reading level, comprehension,
format and visual presentation.
Throughout this process other facilitators were trained to provide the CHTC training.
Trainee facilitators first attended the training as participants, and then assisted
with the delivery and feedback of participant activities, building up to delivering
a single module, and eventually becoming a co-trainer. Trainings were provided by
2 co-trainers.
Another significant change to the CHTC training materials came when the service’s
authors began working with Centers for Disease Control and Prevention — through the
Division of HIV/AIDS Prevention — to include CHTC in the CDC list of effective HIV
prevention strategies. At this point it was felt that a 3-day training might not be
feasible for all testing sites. Thus the training was re-developed as a 2-day in-person
training preceded by a 2-hour online webinar. Content about the history of and introduction
to CHTC, key counseling skills, and an overview of the stages of the protocol were
moved to the pre-training webinar. The 2-day in-person training remained focused on
developing skills and practicing the delivery of the protocol. A further revision
came with the transition from the webinar into a self-paced e-learning module, allowing
the pre-training information to be viewed on the participant’s own schedule. The webinar
and e-learning module were developed in collaboration with the Center for Health and
Behavioral Training at the University of Rochester. At each stage of the training
process, evaluation data were collected from training participants measuring attitudes
towards the training format and content. In general, attitudes towards the trainings
were positive, with favorable responses to the interactive nature of the training.
The finalized CHTC training materials can now be found at
Phase 8: testing
Our testing of the adapted intervention (service) comprised 2 studies: a phase IIa
(exploratory, non-pivotal) randomized prevention trial of CHTC versus individual voluntary
counseling and testing to assess acceptability and safety (IPV and relationship dissolution)
in 1 site, and an expanded evaluation in 5 US cities to assess counselor satisfaction,
IPV, relationship dissolution, and client satisfaction in a broader setting and with
more counselors providing service. In both studies, we also assessed the prevalence
of HIV serodiscordance among male couples as an indicator of pos
based on African data, the clearest evidence of the preventive impact is with serodiscordant
Data collection
For the randomized prevention trial, we enrolled a total of 113 couples in an Atlanta
community- couples with a recent history of IPV or where one or
both partners felt coerced to test together were not randomized (Sullivan et al. ). Other couples were randomized to either be tested for HIV together with the adapted
approach, or to be tested separately. Regardless of study arm, couples were contacted
at 3 months after their original service for retesting and a follow-up survey. Main
outcomes were client satisfaction with their testing service, new IPV, and relationship
dissolution after the testing service. For the extended evaluation, we trained an
additional 7 sites, and additional counselors at the original study site. The additional
sites included an academic medical center, a youth-oriented community-based organization,
a city health department STI clinic, 2 LGBT health centers, and 2 additional community-based
AIDS service organizations. In these sites, counselors were trained, and organizations
were provided with iPod touch devices for counselor satisfaction surveys and with
iPads for client satisfaction surveys administered immediately after the service was
completed. This activity, which was considered to be a non-research evaluation project
by Emory’s Institutional Review Board, also included an optional follow-up survey
for couples 3 months after they received the testing service. The primary outcomes
of the extended evaluation were: client satisfaction, counselor satisfaction, length
of time required to deliver the service, 3-month post-service reporting of IPV and
relationship dissolution by clients, and prevalence of HIV serodiscordance.
Major findings
The results of the randomized prevention trial indicated that levels of satisfaction
with the couples testing service were very high, and were not different from the levels
of satisfaction with individual testing. (Sullivan et al. ) There was no evidence of increased IPV or relationship dissolution after couples
testing (p=0.60). In secondary exploratory analysis, no partner in a serodiscordant
partnership reported unprotected anal intercourse within the discordant partnership
in the 3 months after the service, regardless of study arm (Sullivan et al. ). The prevalence of serodiscordance among 95 couples with testing data was 17% (Sullivan
In the extended evaluation, client and counselor satisfaction data from testing encounters
with 365 couples depicted high levels of satisfaction, similar to what was observed
in the RCT. This was a key observation because nearly all of the satisfaction data
from the RCT related to the counseling services of 1 study counselor. Receiving equally
positive reports from services provided by a larger and less experienced group of
counselors makes this finding more robust. Across service settings in the expanded
evaluation, we observed prevalence of serodiscordance ranging between 1 in 7 and 1
in 10 couples. About three-quarters of CHTC sessions were completed in 45 minutes
Conclusions
Based on a re-emergent HIV epidemic among US MSM (Prejean et al. ), evidence that main sex partners play a key role in that epidemic (Sullivan et al.
Goodreau et al. ), the need for more effective prevention services (Sullivan et al. ), and a high observed prevalence of undiagnosed HIV infection (CDC ), we sought to develop a new HIV testing service for male couples in the United States.
Guided by an ADAPT-ITT framework, we selected the African HIV couples testing service
and applied a systematic, data-driven process to adapt and test the service. The outcome
of this process is an adapted service that is acceptable to MSM and HIV prevention
counselors and does not appear to cause any harms (e.g., IPV, relationship dissolution).
The adapted service is available to the public health community for assessment of
its effectiveness and consideration by policy makers of the potential benefits of
its dissemination in the United States and elsewhere.
Although the ADAPT-ITT framework guided our process, we did depart from it. Importantly,
ADAPT-ITT specifies that the base intervention should be selected from CDC-endorsed
evidence-based interventions (Wingood and DiClemente ). In this case, there was no CDC-reviewed evidence-based testing service for couples,
so we cast a broader net to identify base prevention services. Also, we conceptualized
our work as adapting an HIV testing service, in contrast to an HIV prevention intervention. This distinction is in line with CDC’s categorization of effective interventions
( ); HIV testing by itself has inherent value as a prevention service, and we hoped
to use a couples approach to recruit more MSM to testing, to increase the extent of
disclosure of HIV-positive test results, and to improve the impact of prevention planning
by helping couples make joint plans informed by their mutual serostatus. Finally,
we note that our adaptation was not as linear and ordered as the ADAPT-ITT framework
proposes. Because we collected data when funding (from a variety of sources) was available,
we had primary data before formally deciding on adap we convened
our expert panel somewhat earlier in the process than ADAPT-ITT and we phased
out testing over a relatively long period of time.
Our critical path from concept to scale-up was also different than a classical approach
to prevention intervention development. In this case, we first developed data on willingness
of MSM to use a service and motivations for using it, and after initial adaptation
we conducted a phase IIa (exploratory, non-pivotal) randomized study with primary
endpoints of acceptability and safety. This trial was not powered for efficacy against
behavioral endpoints or new HIV infection. At the time the data collection for the
randomized study concluded, we consulted with key stakeholders at the National Institutes
of Health, the CDC, and representatives of community-based organizations. Together
we considered possible mechanisms for funding a larger, randomized prevention trial
with behavioral and HIV infection endpoints, and expectations of what data would be
needed to support CHTC either as a service or an intervention, based on the current
CDC hierarchy of evidence (Centers for Disease Control and Prevention ). Based on these consultations, we were encouraged to consider the couples testing
service as a mode of delivering HIV testing — i.e., a testing strategy. We decided
to focus on preliminary data on seropositivity rates, prevalence of serodiscordance,
acceptability and safety, the long history of the service in Africa (Painter ), and the urgent need for new prevention approaches for MSM (Sullivan et al. ) to make a case for scale up of a new prevention “service,” rather than pursuing
a phase III efficacy trial for a new “intervention” against behavioral or HIV incidence
endpoints. Importantly, couples testing is in line with CDC recommendations for at
least annual HIV testing for MSM. Providing a diverse set of options for HIV testing
congruent with the realities of men’s lives and with the data about the risks of transmission
within main partnerships, furthers the goals of public health and early detection
and treatment of HIV for men (The White House Office of National AIDS Policy ).
A strength of our process was the involvement of multiple stakeholders in the process
of assessment, adaptation, and evaluation. As described below, multiple public and
private funders contributed to the process. We also were fortunate to have input from
different prevention stakeholders: MSM, HIV counselors, management of community-based
organizations and health departments, federal prevention scientists, and foundation
grantmakers all provided input and guidance into the adaptation process. Importantly,
these collaborations allowed us to design a service that was likely to be implementable
in the kinds of service settings where we hoped it would be used. For example, we
tailored the length of the service based on CBO and health department input about
how long a service would be practical in their settings, and we asked individual HIV
prevention counselors which areas of training they would wish to have if they were
going to be counseling couples.
This process of adaptation and testing is notable for the extent to which multiple
funders, both public and private, supported different phases of the process (Figure&). Pilot data about willingness of MSM to test with their partners were collected
through an Emory Center for AIDS Research small-grant mechanism, which is designed
to support junior investigators in developing preliminary data towards developing
larger research agendas. The National Institutes of Mental Health supported the initial
research through an intervention development (R34) mechanism, allowing the initial
adaptation and data collection through the end of the randomized prevention study.
At this point, the preliminary research was complete and the adapted service held
promise, but there was not critical scientific mass, or extended evidence of more
generalizable acceptability and relevance. At this point the MAC AIDS Fund provided
a critical bridge between the end of the first phase of research and the transition
into publicly-supported packaging and rollout. Specifically, this foundation funder
supported extended evaluation, expanded training, and activities related to developing
training materials jointly with CDC partners. This support allowed the new service
to establish a broader base of credibility and implementation and to maintain momentum
following the initial randomized trial. Ultimately, sustainability requires the involvement
and support of a governmental in this case, CDC has provided
leadership and in-kind contributions to the process of developing and finalizing training
materials, and as of March 1, 2013 has taken over responsibility for the national
training program in the United States.
Timeline for activities related to the adaptation and testing of a couples HIV testing
service for by type of funding, United States, . Emory CFAR: Emory Centers for AIDS R NIH/NIMH: National Institutes of Health/National
Institute of Mental Health CDC: US Centers for Disease Control and P ECHPP:
Enhanced Comprehensive HIV Prevention Planning P RCT: Randomized Clinical Trial.
There are a number of important next steps for the implementation of this prevention
service. First, there is interest in the service, for both male couples and for male–female
couples, from countries outside the United States. Each country considering this service
must make an assessment of whether the service is appropriate as we have adapted it,
or whether further adaptation is required. The ADAPT-ITT framework anticipates and
provides a structure to answer these questions with an iterative process. On the other
hand, some countries might want to pursue a different critical path and propose a
more formal, randomized evaluation of the service against endpoints of possible harms,
behavioral risks, and/or HIV or STI incidence outcomes. An easy initial step is to
assess interest in the prevention service among male couples. For example, we have
conducted a 7-country study of willingness to use CHTC among MSM in Australia, Brazil,
Canada, South Africa, Thailand, the United Kingdom, and the United tates. The results
indicated high intent to use a couples testing service among MSM in all countries,
with a range of intent to use the service in the next year from 79-90% (Stephenson
et al. ). In Canada and the United Kingdom we have participated in initial community meetings,
where the idea of couples testing for male couples was discussed with physicians,
public health practitioners, MSM, CBO staff, and laboratorians. These discussions
are fruitful ways to bring forward the concerns and perspectives of stakeholders and
to formulate a process to evaluate if and how couples testing might be implemented
in a particular community.
Another challenge will be how to address issues of reimbursement for the CHTC service
in different service settings. In many ways, this issue is analogous to the challenges
of supporting individual HIV testing with prevention counseling. Currently, all CDC
grantees who receive funds to support HIV testing are permitted and encouraged to
use those funds to provide CHTC services. Costs of the service have not been estimated
across a range of organizations, but it is estimated that they do not differ greatly
from costs associated with in fact there may be cost-savings
in some settings. Anticipated costs for CHTC include the cost of the testing devices,
approximately one hour of counselor time (to include 30–45 minutes with the couple
and recordkeeping), and the costs of registration, test reporting, and administrative
costs. With respect to privately-funded healthcare providers, the laboratory costs
of routine HIV screening are covered by health insurance plans for those aged 15–25
years in light of recent US Preventive Service Task Force recommendations (Moyer ). The additional costs of prevention counseling associated with HIV testing are not
routinely reimbursable, but may be through some plans. In the future, partnerships
could be considered in which community providers trained to provide CHTC could support
medical providers by providing the CHTC service as a referred service in appropriate
Finally, there are still scientific and evaluation opportunities to better understand
the possible role of couples testing for HIV and prevention of sexually transmitted
infections among male–female couples in the United States. Based on the strength of
evidence and long history of service provision to male–female couples in Africa, CDC
has developed an integrated training approach that prepares counselors to provide
couples testing to any couple, regardless of sex of the couple members. However, it
is likely that our understanding of the best ways to provide the couples testing service
to male–female couples will evolve. For example, it is not clear whether the discussion
of sexual agreements is as relevant for male–female couples, or whether the counselor
initiating a discussion of agreements will be acceptable to male–female couples. Survey
work about willingness to test with opposite-sex partners and qualitative studies
of the intentions to use a couples testing service are needed. Incremental revisions
to service delivery can be implemented as needed from the expanding base of evidence.
Further, existing systems to monitor the provision of testing services (Centers for
Disease Control and Prevention ) should be modified to allow monitoring of the uptake and outcomes of CHTC supported
by federal resources. Finally, additional research is needed on ways in which CHTC
can be used to leverage high impact prevention strategies, including pre-exposure
prophylaxis (Grant et al. ; Baeten et al. ) and linkage to effective clinical care for persons living with HIV.
HIV couples testing is an African prevention service that has been adapted and brought
to program in the United States. It is an example of South-to-North knowledge transfer,
and its adaptation illustrates that some key principles of HIV epidemiology and prevention
transcend specific risk and geographic settings. This couples HIV prevention service
complements existing testing and counseling services, and we are hopeful that an increased
number of HIV testing options for MSM will support greater uptake of routine HIV testing.
Abbreviations
CBO: Community- CDC: Centers for disease co
CHTC: Couples HIV te EBI: Evidence- FGD: Focus
IPV: Intim LGBT: Lesbian, gay, bisexual,
MSM: Men w PY: Person-years.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
PS and RS developed the couples prevention service, conducted the studies described,
developed the training materials, and drafted the manuscript. BG, LS, and JB oversaw
the conduct of the randomized study and expanded evaluation, and reviewed and provided
input to the manuscript. BG, GW, LS, SA, CH, LS, and JM gave input into the adaptation
of the service, and reviewed and provided input to the manuscript. AS and KG provided
input into the development of training strategies and materials, and reviewed and
provided input to the manuscript. All authors read and approved the final manuscript.
Acknowledgments
This work was supported by the National Institute of Mental Health (grant number R34-MH086331),
the Emory Center for AIDS Research (grant number P30-AI050409), and the MAC AIDS Fund.
We thank AID Atlanta for providing space for the research activities, and Adam Carpenter
and Erik Schwab for editorial support. We thank Anthony McWilliams and for their contributions
to the development of the training materials, Ron Stall, PhD, for his contributions
to the expert panel, and Elizabeth Stallcup for her contributions to the management
of the Testing Together scale up. We thank Dr. Kristin Wall, Jeb Jones, Sharoda Dasgupta,
Eli Rosenberg and Darcy White for working with the study data. We thank Drs. Jono
Mermin, Rich Wolitski, and David Purcell for advice about strategy for scale-up, and
Rhondette Jones and Rashad Burgess for their support with training materials and national
Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily
represent the views of the Centers for Disease Control and Prevention.
References
Allen S, Tice J, Van de Perre P, Serufilira A, Hudes E, Nsengumuremyi F, Bogaerts J, Lindan C, Hulley S (1992) Effect of serotesting with counselling on condom use and seroconversion among HIV
discordant couples in Africa. BMJ 304(-1609
Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U, Musonda R, Kasolo F, Gao F, Haworth A (2003) Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS 17(5):733-740
doi:10.1097/01.aids..71999.ed
Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, Tappero JW, Bukusi EA, Cohen CR, Katabira E (2012) Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 367(5):399-410
CDC (2006) Human immunodeficiency virus (HIV) risk, prevention, and testing behaviors–United
States, National HIV Behavioral Surveillance System: men who have sex with men, November
2003-April 2005. MMWR Surveill Summ 55(6):1-16
Centers for Disease Control and Prevention (2007) Compendium of HIV prevention interventions with evidence of effectiveness.
Revised April 2008. Available at:
. Accessed April 17, 2008
Centers for Disease Control and Prevention (2013) HIV testing and risk behaviors among gay, bisexual, and other men who have sex with
men - United States. Mmwr 62(47):958-962
Chakravarty D, Hoff C, Neilands T, Darbes L (2012) Rates of testing for HIV in the presence of serodiscordant UAI among HIV-negative
gay men in committed relationships. AIDS Behav 16(7):
doi:10.-012-0181-6
Gass K, Hoff CC, Stephenson R, Sullivan PS (2012) Sexual agreements in the partnerships of internet-using men who have sex with men. AIDS Care 24(10):
Gomez AM, Beougher SC, Chakravarty D, Neilands TB, Mandic CG, Darbes LA, Hoff CC (2012) Relationship dynamics as predictors of broken agreements about outside sexual partners:
implications for HIV prevention among gay couples. AIDS Behav 16(6):
doi:10.-011-0074-0
Goodreau SM, Carnegie NB, Vittinghoff E, Lama JR, Sanchez J, Grinsztejn B, Koblin BA, Mayer KH, Buchbinder SP (2012) What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE 7(11):e50522
doi:10.1371/journal.pone.0050522
Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, Goicochea P, Casapia M, Guanira-Carranza JV, Ramirez-Cardich ME, Montoya-Herrera O, Fernandez T, Veloso VG, Buchbinder SP, Chariyalertsak S, Schechter M, Bekker LG, Mayer KH, Kallas EG, Amico KR, Mulligan K, Bushman LR, Hance RJ, Ganoza C, Defechereux P, Postle B, Wang F, McConnell JJ, Zheng JH, Lee J, et al. (2010) Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 363(27):
doi:10.1056/NEJMoa1011205
Hoff CC, Beougher SC, Chakravarty D, Darbes LA, Neilands TB (2010) Relationship characteristics and motivations behind agreements among gay male couples:
differences by agreement type and couple serostatus. AIDS Care 22(7):827-835
Latham TP, Sales JM, Boyce LS, Renfro TL, Wingood GM, DiClemente RJ, Rose E (2010) Application of ADAPT-ITT: adapting an evidence-based HIV prevention intervention for
incarcerated African American adolescent females. Health Promot Pract 11(3 Suppl):53S-60S
Lewis MA, McBride CM, Pollak KI, Puleo E, Butterfield RM, Emmons KM (2006) Understanding health behavior change among couples: an interdependence and communal
coping approach. Soc Sci Med 62(6):
doi:10.1016/j.socscimed.
Mitchell JW, Petroll AE (2012) Patterns of HIV and sexually transmitted infection testing among men who have sex
with men couples in the United States. Sex Transm Dis 39(11):871-876
doi:10.1097/OLQ.0b013e
Moyer VA (2013) Screening for HIV: U.S. Preventive services task force recommendation statement. Ann Intern Med.
doi:10.19-159-1-645
Painter TM (2001) Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS
prevention in sub-Saharan Africa. Soc Sci Med 53(11):
Phillips G II, Hightow-Weidman L, Arya M, Fields S, Halpern-Felsher B, Outlaw A, Wohl A, Hidalgo J (2012) HIV testing behaviors of a cohort of HIV-positive Racial/Ethnic minority YMSM. AIDS Behav 16(7):
doi:10.-012-0193-2
Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker F, Lin LS, An Q, Mermin J, Lansky A, Hall HI (2011) Estimated HIV incidence in the United States, . PLoS ONE 6(8):e17502
doi:10.1371/journal.pone.0017502
Roth DL, Stewart KE, Clay OJ, van Der Straten A, Karita E, Allen S (2001) Sexual practices of HIV discordant and concordant couples in Rwanda: effects of a
testing and counselling programme for men. Int J STD AIDS 12(3):181-188
Salazar LF, Stephenson RB, Sullivan PS, Tarver R (2011) Development and validation of HIV-related dyadic measures for men who have sex with
men. J Sex Res.
Stephenson R, Sullivan PS, Salazar LF, Gratzer B, Allen S, Seelbach E (2011) Attitudes towards couples-based HIV testing among MSM in three US cities. AIDS Behav 15(Suppl 1):S80-S87
doi:10.-011-9893-2
Stephenson R, Chard A, Finneran C, Sullivan P (2013) Willingness to use couples voluntary counseling and testing services among men who
have sex with men in seven countries. AIDS Care.
Sullivan PS, Wolitski RJ (2007) HIV infection among gay and bisexual men. In: Wolitski RJ, Stall R, Valdiserri RO (eds) Unequal Oppportunity: Health Disparities Affecting Gay and Bisexual Men in the United
States, New York: Oxford University Press. pp 220-247
Sullivan PS, Zapata A, Benbow N (2008) New U.S. HIV incidence numbers: heeding their message. Focus 23(4):5-7
Sullivan PS, Salazar L, Buchbinder S, Sanchez TH (2009) Estimating the proportion of HIV transmissions from main sex partners among men who
have sex with men in five US cities. AIDS 23(9):
doi:10.1097/QAD.0b013e32832baa34
Sullivan PS, Carballo-Dieguez A, Coates T, Goodreau SM, McGowan I, Sanders EJ, Smith A, Goswami P, Sanchez J (2012) Successes and challenges of HIV prevention in men who have sex with men. Lancet 380(9
doi:10.-55-6
Sullivan PS, White D, Rosenberg ES, Barnes J, Jones J, Dasgupta S, O’Hara B, Scales L, Salazar LF, Wingood G, DiClemente R, Wall KM, Hoff C, Grazter B, Allen S, Stephenson R (2014a) Safety and acceptability of couples HIV testing and counseling for US men who have
sex with men: a randomized prevention study. JIAPAC 13(2):135-144
Sullivan PS, Wall KM, O’Hara B, Jones J, Barnes J, DiClemente R, Hoff C, Scales L, Salazar LF, Sanchez T, White D, Wingood G, Allen S, Stephenson R (2014b) The prevalence of undiagnosed HIV serodiscordance among male couples presenting for
HIV testing. Arch Sex Behav 43(1):173-180
doi:10.-013-0214-x
The White House Office of National AIDS Policy (2010) National HIV/AIDS Strategy for the United States [online policy document].
Available at:
. Last accessed: October 4, 2012
Wagenaar BH, Christiansen-Lindquist L, Khosropour C, Salazar LF, Benbow N, Prachand N, Sineath RC, Stephenson R, Sullivan PS (2012) Willingness of US men who have sex with men (MSM) to participate in couples HIV voluntary
counseling and testing (CVCT). PLoS ONE 7(8):e42953
doi:10.1371/journal.pone.0042953
Wingood GM, DiClemente RJ (2008) The ADAPT-ITT model: a novel method of adapting evidence-based HIV Interventions. J Acquir Immune Defic Syndr 47(Suppl 1):S40-S46
doi:10.1097/QAI.0b013e
Wingood GM, DiClemente RJ, Villamizar K, Er DL, DeVarona M, Taveras J, Painter TM, Lang DL, Hardin JW, Ullah E, Stallworth J, Purcell DW, Jean R (2011) Efficacy of a health educator-delivered HIV prevention intervention for Latina women:
a randomized controlled trial. Am J Public Health 101(12):
doi:10.2105/AJPH.
Wingood GM, Simpson-Robinson L, Braxton ND, Raiford JL (2011) Design of a faith-based HIV intervention: successful collaboration between a university
and a church. Health Promot Pract 12(6):823-831
World Health Organization (2012) Guidance on couples HIV testing and counselling including antiretroviral therapy for
treatment and prevention in serodiscordant couples: recommendations for a public health
approach. [online prevention gudiance document].
Available at:
. Last accessed October 4, 2012
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (2011) Technical Guidance on Combination HIV Prevention for Men who Have Sex with Men [online
technical guidance].
Available at:
. Last accessed: October 4, 2012
Sign up to receive new article alerts from SpringerPlus