All couples face challenges to the development and maintenance of their relationship. When helping a couple address their relationship difficulties, therapists have found that it is extremely important to work with the couple as a unit, rather than with each individual in isolation. This is especially true when helping couples of mixed HIV status (couples with one HIV-positive partner and one HIV-negative partner, also called HIV "serodiscordant" relationships).
In couples of mixed HIV status, barriers to open communication that may confront any kind of relationship are often exacerbated due to fears of HIV transmission, illness progression, and future loss. Our research indicates that many members of mixed-status couples avoid discussing their mutual HIV-related concerns in order to "protect" their partner from these potentially troubling thoughts and feelings. This can compound difficulties associated with current or anticipated illness, care-taking, future planning, fears of abandonment, sexual spontaneity and satisfaction, and decisions about pregnancy and child-rearing.
In addition to these relationship concerns, adherence to medical care and medications presents another challenge for mixed-status couples. Adherence is critical for the health and well-being of people living with HIV, but strict adherence to medications can be challenging and difficult to maintain. Poor or inconsistent adherence to combination antiretroviral therapy can lead to the development of drug-resistant virus, which can compromise the health and treatment of the HIV-positive partner. The drug resistant virus could also potentially be transmitted to the uninfected partner through risky sexual practices.
These challenges cannot be easily divided into the "concerns of the HIV-positive partner" and the "concerns of the HIV-negative partner." Our research has found that both members of mixed-status couples are equally concerned about issues such as medical care adherence and potential HIV transmission within the relationship. Researchers and service providers must therefore find ways to help members of mixed-status couples work together as a couple to address their common challenges, rather than dealing with each member of the couple individually or in separate groups. Our research team has begun to do that through a series of research projects with mixed-status couples.
Our research team first conducted a descriptive study of male couples of mixed HIV status. The study aimed to identify the challenges couples faced and the role of sex and sexual risk in the relationship. In addition to the difficulties and challenges described above, we also learned that many men in mixed-status relationships were experiencing levels of distress and stress that were higher than what was being experienced by single men or men in "seroconcordant" relationships (in which both partners are either HIV negative or HIV positive). The primary domains of life that were associated with this distress included sex and intimacy, concerns about illness and care-taking issues, and difficulties planning for the future particularly making long-term plans. Many of the couples also spoke of social isolation and a lack of support for their coupling.
Regarding sex and sexual risk-taking, we learned that sexual intimacy and satisfaction were seen as important in the relationships, but that fears of HIV transmission raised a number of challenges. Sexual risk-taking often occurred in contexts where relationship partners desired closeness and intimacy, wanted to express love and trust, and sought pleasure for oneself and one's partner. There were also some misconceptions about what is and isn't risky. Men were generally seeking ways to increase their expressions of intimacy and experience of satisfaction while at the same time protecting each other.
The Couples Project
This early research led to the development of a program for mixed-status male couples that was carried out as a collaboration between Body Positive and our research team at the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute/Columbia University. The program brought couples together in groups co-facilitated by two people trained and supervised by personnel from both of these organizations. The program, which was titled "The Couples Project," was described as a series of workshops held over eight weeks. The goals of the program were to reduce feelings of isolation, reduce feelings of distress, improve communication and coping within the relationship, and increase sexual satisfaction while reducing risk for the transmission of HIV within the couples.
This program was evaluated through a randomized clinical trial. This meant that all participating couples completed extensive interviews, but half of the couples were randomly chosen to receive the program immediately, while the other couples had to wait until after follow-up interviews were conducted to participate in the program. Couples who took part in the group program reported many positive effects in their relationship. Many couples stated that the program:
helped "validate" their relationship;
made them feel less isolated and alone by meeting other couples in their situation;
improved the way they communicate with each other;
facilitated more effective problem-solving to help meet the challenges they faced;
assisted them in discussing topics that were otherwise difficult to talk about, such as expressing their true fears, concerns, wishes, and desires; and
helped them develop strategies for more satisfying sex that they felt comfortable with.
Despite such comments, along with study results that showed improvements regarding most of the program's stated goals, there were not significant differences between the couples who were randomized into the "immediate treatment" arm of the study and those who were in the "delayed treatment" condition. We believe that this occurred, in part, because of the lengthy interviews that couples experienced (which many described as "therapeutic" for them), as well as the fact that the program was conducted during the time of successful treatment advances associated with the advent of combination antiretroviral therapy which led to improvements in many of the men's lives.
Ongoing Study: The SMART Couples Project
These earlier studies demonstrated the importance of working together with both members of mixed-status couples to help them face challenges in their relationship. This understanding is consistent with other research that suggests that social support can play an important role in helping establish and maintain good health-behavior habits, such as adherence to medical care and medications. Unfortunately, standard medical care does not usually include the patient's "significant other" in doctor and nurse visits and in health education programs. We believe that involving a supportive partner in health education visits with health-care professionals can help improve healthy behaviors and health outcomes for people living with HIV. We are testing this idea through our new study, the SMART Couples Project.
The SMART Couples Project is an ongoing research study for heterosexual, gay, and lesbian couples of mixed HIV status. The study aims to better understand the role that supportive relationships can play in helping people living with HIV keep up with their medical treatments. The study is being administered in collaboration with the Center for Comprehensive Care at St. Luke's-Roosevelt Hospital.
An important part of the SMART Couples Project is the opportunity to collect research data about the health care practices and concerns of couples of mixed HIV status. The study therefore includes a series of confidential, paid interviews with each relationship partner. The information obtained through the study interviews will provide valuable data for doctors, psychologists, social workers, policy makers, and others who have mixed-status couples as clients. Participating couples will therefore make a significant contribution to other people in their situation.
In addition to the interviews, participants in the SMART Couples Project will have a chance to enter a brief program designed to help mixed-status couples deal with medical issues and other HIV-related concerns, including sex and intimacy. Couples participating in the study may be randomly assigned to take part in this program, which is designed to supplement the existing health services that are currently accessed by the couple. The program involves four meetings with a nurse practitioner to discuss how the couple can work together to protect one another's health. This includes helping the HIV-positive partner stay on top of his or her treatments and discussing mutual protection from HIV and other sexually transmitted diseases.
Participants receive payments for each study appointment, and an eligible couple can collectively earn $250 or more over the course of the study. If you are interested in learning more about the SMART Couples Project, or are interested in participating in the study, please contact our research team at 212-740-3204.
Robert H. Remien, Ph.D. and Michael Stirratt, M.A. are from the HIV Center for Clinical and Behavioral Studies.