Couples Voluntary HIV Counseling and Testing (CVCT) is a new HIV prevention intervention for men who have sex with men (MSM) in the U.S.1 CVCT is notable for several reasons: it addresses a critical deficit in HIV prevention interventions for MSM;2 it is responsive to recent data which suggest that addressing male couples may be a high-leverage approach for reducing HIV transmissions;3 and it offers an opportunity for American prevention scientists to learn from and expand upon the experiences and successes of previous models of CVCT developed in Africa.
CVCT is an HIV testing service in which two members of a couple receive all phases of the HIV counseling and testing process -- pre-test counseling, collection of specimens, return of test results, and post-test counseling -- together, in the same room. The original CVCT intervention was developed in Rwanda in the late 1980s by Dr. Susan Allen.4 Dr. Allen was implementing an HIV screening program for women in Rwanda, and recalls women who received HIV test results noting the importance of also testing their husbands. In response, the CVCT service was developed, and has since become a mainstay of HIV prevention programs in many parts of Africa.5
At first glance, CVCT may appear to run contrary to many conventions of HIV testing. Early in the epidemic, the consequences of receiving an HIV-positive test result, or perhaps of being tested for HIV at all, were dire, and many protections were put in place around the testing process. Among these protections was the right to confidentiality. These protections were needed, given the stigma of HIV which continues even today. However, now legal protections are stronger, especially in light of the Americans with Disabilities Act protections. HIV is a disease that is manageable, if not curable. And testing is now routinely recommended for Americans aged 13-64, even if no behavioral risk is identified.6
Although clients in many medical settings are allowed to be accompanied by a support person when discussing their medical test results and treatment plans with their health care provider, many HIV testing services do not extend this same opportunity to clients seeking HIV screening. This practice is unique to some HIV testing processes, which can send the message that testing is a matter so private that even intimate partners cannot observe it, and inadvertently promotes stigma associated with testing. For those who are sexually active and test HIV-positive, it also creates a further source of anxiety and obligation to tell one's sex partners about his or her diagnosis. It has long been recognized that disclosure of HIV-positive status to sex partners is a critical step in preventing sexual transmission of HIV. However, disclosure is difficult for many people living with HIV.
African studies of CVCT show a reduction in HIV transmission among serodiscordant couples by about 50% compared to testing only one partner in a couple. CVCT has been described by the Centers for Disease Control and Prevention (CDC) as a "high-leverage" intervention in African settings.7 The President's Emergency Plan for AIDS Relief (PEPFAR), a U.S. initiative to address the global AIDS epidemic, provides technical assistance for support of CVCT services in all PEPFAR-supported countries.
CVCT is effective for several reasons, all of which support the concept of testing being an effective prevention strategy. First, both members of a couple know their HIV status. This may seem an obvious point; however, the prevalence of late HIV diagnosis among the greater population,8 and the high prevalence of unrecognized HIV infection among MSM, especially MSM of color,9 underscore the importance of knowing one's serostatus. Second, disclosure of HIV status is part and parcel of the intervention, so that at the end of the session both partners know each other's statuses. This is important because our own work suggests that only about six out of ten MSM in the U.S. discuss their HIV serostatus before having sex with a new male partner.9 Third, the CVCT intervention allows the couple a space to discuss how they wish to manage the issue of HIV in their relationship, with access to a supportive and trained counselor.
For MSM in the U.S., it may be especially important to focus new HIV prevention interventions among couples. According to our analyses of CDC behavioral surveillance data, most new HIV infections in MSM were estimated to arise from main sex partners, not casual ones.10 This is because MSM tend to have sex more frequently, are more likely to have anal sex, and are less likely to use condoms, with main partners versus casual partners. Therefore, assuring correct knowledge of HIV serostatus and promoting harm reduction within male couples is a logical way to get maximal impact from an HIV testing intervention. Furthermore, this intervention allows a structured opportunity for couples to discuss and clarify their agreements about monogamy or rules about additional sex partners.11
The CVCT service is not for everyone. It should always be offered with an alternative of individual voluntary HIV counseling and testing (VCT). As part of pre-test counseling in CVCT, counselors are trained to assess the willingness of partners to agree to some basic rules, such as keeping their partners test results confidential, and making any decisions about disclosure jointly. If these conditions are not agreeable to both partners, then individual VCT is recommended.
Preliminary research conducted at Emory University Rollins School of Public Health suggests that CVCT is well received by many MSM couples. In the past 2 years, focus group discussions with MSM in Atlanta, Chicago, Pittsburgh and Seattle have produced results identifying several main themes.12 First, many MSM who learned about CVCT put the service in the context of relationship milestones, seeing testing together as an expression of commitment to the relationship. In every focus group, at least one participant likened the ritual of testing together to the ritual of marriage for male-female couples. Also, many HIV-positive participants reported having used individual VCT as a pretext to disclose their HIV-positive status to partners in the past, and expressed interest in the CVCT service as a facilitated means of disclosure in the future. Participants generally felt that the service would be most appropriate for couples who had developed a certain degree of trust, especially longer-term couples. Since August 2010, Emory University Rollins School of Public Health has offered CVCT as part of a randomized prevention study at a community-based organization, where positive reception of the interventions is consistently reported by participants.
An important aspect of the U.S. adaptation of the CVCT intervention for MSM is that the adaptation was undertaken by a diverse group of HIV prevention researchers and program experts, including representatives from community-based organizations. From its inception, priority was placed on developing a prevention service that could feasibly be integrated into existing HIV prevention practice settings. For example, the intervention was developed to be time-neutral from the HIV counselor perspective (i.e., the couple could be tested in a time no longer than the time required to test the two partners separately). The usual time for providing the CVCT intervention is between 45-60 minutes, inclusive of all testing and counseling procedures.
In the pilot work conducted at Emory University, signs in the reception area of the testing service announced the availability of services for couples. However, anecdotal evidence suggests that in other testing settings where CVCT is not available, MSM couples ask to be tested together, implying not only a demand for this service, but an expectation to be able to test as a couple. Routinely required information about demographics, risk behaviors, and testing outcomes are collected using state-administered forms, so provision of testing is documented.
Rates of new HIV diagnoses among MSM are on the rise after periods of declining HIV reports in the late 1990s. Discouragingly, only 20% of HIV prevention interventions are targeted specifically for MSM, despite the fact and MSM are estimated to comprise over half of new annual HIV infections. CVCT is an intervention that is proven to reduce HIV transmission in male-female couples, is recommended for male couples outside of the U.S., and can be provided with minimal additional training of existing counselors. CVCT also addresses HIV infection risk from main sex partners, who are a major source of new HIV infections among MSM. In short, the HIV epidemic among MSM is in critical need of effective prevention interventions, and CVCT is a promising new tool.
CVCT is also congruent with calls to reduce HIV transmission by promoting the stability of male couples, such as through laws favoring marriage equality for same-sex couples. Testing a couple together is an opportunity to validate the couples' legitimacy, and to recognize and applaud their desire to address the realities of HIV in their relationship.
In the coming year, four HIV prevention organizations in Chicago and Atlanta will roll out the CVCT service for male couples, and continue evaluation of the service for MSM. Community forums will also be hosted in Chicago, Atlanta, and other cities to share information about the service and begin a dialogue about the role of couples testing in comprehensive HIV prevention services for MSM.
Patrick Sullivan is associate professor of epidemiology, Emory University. Robert Stephenson is associate professor of global health, Emory University.