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Objective: We evaluated married couples’ perspectives on the quality of their marital relationships after participating in a counselor-led couple education and counseling intervention aimed at improving the quality of marital relationships and reducing high HIV risk sexual behaviors. Design: This qualitative endline survey was part of a prospective study to assess the effect of a counselor-led couple education and counseling intervention on improving the quality of marital relationships. Settings: Fishing communities along Lake Victoria in Kisumu County, Kenya. Participants: We conducted dyad in-depth interviews with a sub-sample of six married couples three months following a 5-session Waya (local language word for paternal aunt) intervention Outcome measures: Perspectives on the effect of in a counselor-led couple education and counseling on quality of marital relationships.Results: The couples perceived that the intervention resulted in enhanced quality of their marital relationships. Specifically, the couples reported improved intimacy, joint financial planning, partner support, enhanced communication, conflict-solving abilities, and sexual behavior change. Couples also reported improved knowledge of sexual and reproductive health issues and services available to support safer sex practices. Conclusion: Married couples perceived the Waya intervention to have improved their marital relationships. Given the potential to reduce HIV transmission, there is a need to test this intervention with a rigorous trial design for efficacy. [ABSTRACT FROM AUTHOR]

Decision-making on childbearing and safer conception use in HIV sero-different couples involves an intricate balance of individual desires and perceived HIV acquisition risk. This paper addresses an important knowledge gap regarding HIV sero-different couples' considerations and the relationship and power dynamics involved when deciding to use a safer conception method. Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples, who exited the SAFER study - a pilot study assessing the feasibility, acceptability and cost-effectiveness of a safer conception programme for HIV sero-different couples in Zimbabwe. All couples in SAFER were provided with a choice of safer conception methods and were followed for up to 12 months of pregnancy attempts and 3 months following pregnancy. While couples generally perceived their safer conception discussions to be easy and consensus-driven, the decision-making process also involved complex gender dynamics and trade-offs in relationship power, which resulted in differing interpretations of what constituted a joint or shared couple decision. Participants regarded effective couple communication as an essential component of and precursor to good safer conception conversations and requested additional training in couple communication. Couples relied on information from healthcare providers to kickstart their safer conception discussions. Safer conception programmes should address relationship power imbalances, promote effective couple communication and offer healthcare provider support to enable HIV sero-different couples to make informed choices about conception in a manner that upholds their safety and reproductive autonomy.

Background: Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples' actual experiences using safer conception methods, and why some couples switch safer conception methods., Methods: Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods., Results: We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely., Conclusions: The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals., (© 2024. The Author(s).)

Safer conception services are needed to minimize HIV transmission among HIV sero-different couples desiring pregnancy. Few studies have evaluated the choices couples make when offered multiple safer conception methods or real-world method acceptability and effectiveness. We piloted a comprehensive safer conception program (Clintrials.gov identifier: NCT03049176) for HIV sero-different couples planning pregnancy in Zimbabwe to measure feasibility, method uptake, acceptability, pregnancy outcome, and HIV transmission. This study was not designed to compare rates of HIV transmission by safer conception method choice but rather to understand choices couples make when seeking to minimize risk of HIV transmission and maximize likelihood of pregnancy. Couples in this prospective, non-randomized study were given a choice of one or more currently available safer conception methods: antiretroviral therapy (ART) with monthly viral load (VL) monitoring for the HIV-positive partner (ART/VL), pre-exposure prophylaxis (PrEP) for the HIV-negative partner, vaginal insemination (VI) for couples with an HIV-positive woman, and semen washing (SW) for couples with an HIV-positive man. Couples were followed monthly for up to 12 months of pregnancy attempts, quarterly during pregnancy, and 12 weeks post-partum. At each visit, data on method use, urine for pregnancy testing, and blood for HIV antibody testing, or viral load if HIV-positive, were obtained. Infants born to HIV-positive women were tested for HIV at 6 and 12 weeks. Between March 2017 and June 2019, 46 individuals from 23 HIV sero-different partnerships were enrolled and followed. At enrollment, all couples chose ART/VL, and all couples chose at least one additional method; 74% chose PrEP, 36% chose SW, and 25% chose VI. During pre-pregnancy follow-up visits, three couples discontinued SW, and one couple discontinued VI; all four of these couples opted for ART/VL plus PrEP. Satisfaction with safer conception methods was high among those who chose ART/VL and PrEP. Twelve couples achieved pregnancy. There were no cases of HIV transmission to partners, and no infants tested positive for HIV. This safer conception program is feasible and acceptable, allowing sero-different couples to safely achieve pregnancy. Sero-different couples in Zimbabwe seek a combination of HIV prevention methods, particularly ART/VL plus PrEP. Trial Registration: Clintrials.gov, NCT03049176., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Brown et al. 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 author and source are credited.)

Poor marital satisfaction is associated with high-risk sexual behavior and HIV transmission. We tested whether a counselor-led couple education and counseling intervention dubbed Waya (paternal aunt) would improve marital satisfaction and reduce HIV risk behavior among married couples in Kisumu County, western Kenya. In a pre-post design, we enrolled 60 heterosexual married couples at high risk for HIV to undergo five 1-h couple education and counseling sessions over 56 days. We collected self-reported data on marital satisfaction, the number of sex partners, and condom use with extramarital partners at pre- and post-intervention visits. We used Wilcoxon and McNemar tests to examine the association of our intervention with marital relationship satisfaction and reduction in HIV risk sexual behavior. The intervention was associated with marital relationship satisfaction score improvement from a median of 5 (interquartile range [IQR], 4-5) to 6 (IQR, 6-7) among men and 4 (IQR, 3-5) to 6 (IQR, 5-6) among women (p < .01). The intervention was also associated with reducing HIV risk sexual behaviors depicted by a reduction in the number of sex partners in the past one month and an increase in consistent extramarital condom use. The number of sex partners reduced from a median of 2 (IQR, 1-2) to 1 (IQR, 1-2) and consistent extramarital condom use increased from 4% at baseline to 56% among men. Our intervention was associated with improvements in marital relationship satisfaction and reductions in HIV high-risk behaviors necessary for achieving epidemic control in HIV hotspots such as fishing communities in western Kenya., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Involving both partners of a couple in HIV prevention can improve maternal and child health outcomes in sub-Saharan Africa. Using data from 96 couples, we explored the actor and partner effects of perceived relationship dynamics on a couple's confidence and ability to reduce HIV risk together. Perceived relationship quality altered perceived confidence and ability to reduce HIV threat. One's own ability to confidently act together with their spouse appeared to be stronger for husbands than wives with respect to relationship commitment. A partner's confidence to communicate with their spouse about HIV risk reduction appeared to be stronger from husbands to wives for relationship satisfaction and trust. Gender differences in perceived relationship quality and effects on communal coping may exist and requires further study for applicability in intervention development in this setting. Efficacious couple-oriented interventions for HIV prevention should incorporate evidence on how partners mutually influence each other's health beliefs and behaviors., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Interpersonal support can promote positive outcomes among people living with HIV. In order to develop an acceptable psychoeducational couples-based intervention aimed at strengthening the relationship context and improving HIV outcomes before and after pregnancy, we conducted qualitative interviews with pregnant women living with HIV and their male partners., Methods: We interviewed a convenience clinic-based sample of pregnant women living with HIV (n = 30) and male partners (n = 18) in Lusaka, Zambia. Interviews included pile sorting relationship topics in order of perceived priority. Interviews also focused on family health concerns. Interviews were audio-recorded, translated, transcribed, and thematically analyzed. Pile sorting data was analyzed using descriptive statistics., Results: All female participants were living with HIV; 61% of the male partners interviewed were additionally living with HIV. The most prioritized relationship topic among both genders was communication between couples. Honesty and respect were important relationship topics but prioritized differently based on gender. Female participants considered emotional and instrumental support from male partners critical for their physical and mental health; men did not prioritize support. Intimate partner violence was discussed often by both genders. Family health priorities included good nutrition during pregnancy, preventing infant HIV infection, safe infant feeding, sexual health, and men's alcohol use., Conclusions: A major contribution of this study is a better understanding of the dyad-level factors pregnant women living with HIV and their male partners perceive to be the most important for a healthy, well-functioning relationship. This study additionally identified gaps in antenatal health education and the specific family health issues most prioritized by pregnant women living with HIV and their male partners. The findings of this study will inform the development of an acceptable couples-based intervention with greater likelihood of efficacy in strengthening the relationship context and promoting family health during and after pregnancies that are affected by HIV., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Rates of sexually transmitted infections and unintended pregnancies are disproportionately high among African American adolescents and young adults (AYA). New media platforms such as social networking sites, microblogs, online video sites, and mobile phone applications may be a promising approach in promoting safe sex and preventing sexually transmitted infections., Objective: The purpose of this scoping review was to address promising approaches in new media that may serve as valuable tools in health promotion, prevention, education, and intervention development aimed at African American AYA., Methods: An electronic search was conducted using Google Scholar, Scopus, Cumulative Index to Nursing and Allied Health (CINHAL), and PubMed online databases. Concept blocks and MeSH terminology were used to identify articles around African American youth and new media., Results: The search yielded 1169 articles, and 16 publications met the criteria. Studies from the review found themes in new media that included feasibility, changing attitudes, and improving knowledge related to sexual health behavior among youth of color., Conclusions: New media is a promising and feasible platform for improving the sexual health of African American AYA. Further research is suggested to better understand the benefits of new media as a sexual health promotion tool among this specific population., (©Sierra Teadt, Jade C Burns, Tiffany M Montgomery, Lynae Darbes. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 05.10.2020.)

Background: Social media platforms such as Facebook, Instagram, and Twitter, which have millions of users who interact and communicate every day, have been effective in promoting sexual health interventions and in disseminating reproductive health education. They have also been shown to be useful in health promotion and have been used to track several key metrics (eg, comments, posts) among users of all demographics. However, there is a lack of research on the impact and reach of these social media platforms as a community-based tool for disseminating sexual health information and for increasing engagement among Black adolescents and young adults, which is a targeted high-risk population., Objective: The purpose of this study was to determine the social media platforms and banner advertisements that affected engagement among Black male adolescents and young adults in participating in web-based health surveys., Methods: A web-based survey was conducted from March 2019 to July 2019 to assess sexual health and health behaviors in a convenience sample of Black male adolescents and young adults in the age range of 18-24 years (N=170). Social media metrics from Facebook, Instagram, and Twitter were monitored. This cross-sectional survey comprised several categories, including basic personal information, drug-related risk behaviors, health care, sexual reproductive health questions, attitudes, norms, and perceived control, mental health, violence-related risk behaviors, and social media preferences., Results: Social media advertisements on the Black Male Opinion survey reached approximately 146,412 individuals. Our primary finding of the web-based survey engagement was that referral (eg, group chat, indirect social media sharing) led to as the greatest proportion of recruitment, with Twitter and YouTube as the preferred sites to receive sexual health information., Conclusions: Recognizing the variety of technologies being used among Black male young adults and adolescents can help the community, researchers, and health care providers understand the web-based engagement of this high-risk population. This information may also promote culturally sensitive, customized marketing on sexual health information for this population., (©Jade Burns, Keith Johnstone, Tanaka Chavanduka, Cornelius Jamison, Valery Pena, Rob Stephenson, Lynae Darbes. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 22.09.2020.)

Background: Efforts to promote male partner involvement in the prevention of mother-to-child transmission (PMTCT) may inadvertently exploit gender power differentials to achieve programme targets., Methods: We explored women's relative power and perceptions of male partner involvement through interviews with postpartum Zambian women living with HIV (n = 32) using a critical discourse analysis., Results: Women living with HIV reported far-reaching gender power imbalances, including low participation in household decision-making, economic reliance on husbands, and oppressive gendered sexual norms, which hindered their autonomy and prevented optimal mental and physical health during and after their pregnancy. When the husband was HIV-negative, sero-discordance exacerbated women's low power in these heterosexual couples. Male involvement in HIV care was both helpful and hurtful, and often walked a fine line between support for the woman and controlling behaviours over her. Inequities in the sexual divisions of power and labour and gender norms, combined with HIV stigma created challenging circumstances for women navigating the PMTCT cascade., Conclusions: Future programmes should consider the benefits and risks of male partner involvement within specific relationships and according to women's needs, rather than advocating for universal male involvement in PMTCT. This work highlights the persistent need for gender transformative approaches alongside PMTCT efforts., Competing Interests: The authors have declared that no competing interests exist.

Sexual agreements between same-sex practising men facilitate communication about health promotion activities, including HIV prevention. In African contexts, male couples negotiate their sexual agreements in relation to rigid cultural prescriptions about male power and privilege, intense hostility towards same-sex sexualities and persistent heterogendered socio-cultural norms. Yet the impact of such norms on relationship practices and HIV risk among male couples remains inadequately explored. This qualitative study examined the role of gendered power disparities in establishing sexual agreements among male couples in two Southern African contexts. Eighteen male couples completed in-depth interviews focused on relationship practices, including sexual agreements. The research employed critical social theory to analyse power relations and socio-cultural norms shaping male couples' explicit and implicit sexual agreements, with a focus on implications for HIV risk. The findings outline different types of and motivations for sexual agreements among male couples, including qualified non-monogamy with female partners only. The study illustrates how Southern African male-male sexual practices remain embedded in a cultural context favouring the replication of heteronormative sexual behaviours and relationship practices. These heterogendered norms impact negatively on the process of establishing explicit, mutually agreed-upon sexual agreements, and thus place male couples at increased risk for HIV.

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

We sought to understand whether women's empowerment and male partner engagement were associated with use of antenatal care (ANC). Women presenting for ANC in Nyanza province of Kenya between June 2015 and May 2016, were approached for participation. A total of 137 pregnant women and 96 male partners completed baseline assessments. Women's empowerment was measured using the modified Sexual Relationship Power Scale. ANC use measures included timing of the first ANC visit and number of visits. Male engagement was based on whether a husband reported accompanying his wife to one or more antenatal visits during the pregnancy. Multiple linear and logistic regression analyses were used to identify factors independently related to use and timing of ANC. Women with higher mean empowerment scores were likely to have more than one ANC visit in the index pregnancy [Adjusted Odds Ratio (AOR) = 2.8, 95% Confidence Interval (CI): 1.1-7.3], but empowerment was not associated with early ANC use. Women who were more empowered were less likely to have a husband who reported attending an ANC visit with his wife (AOR = 0.1, 95% CI: 0.03-0.8). Women's empowerment is important and may be related to ANC use and engagement of male partners in complex ways.

Purpose: Despite indications that lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients have unique needs when seeking healthcare, the experiences of LGBTQ patients in the context of cancer care have not been fully explored. This qualitative study investigated recommendations offered by LGBTQ patients with cancer for improving cancer care., Methods: Two hundred seventy-three LGBTQ people across the USA who had been diagnosed with cancer completed an online survey that included open-ended questions. Using responses to these questions, two researchers independently conducted open coding. A code book was generated collaboratively and the data were coded independently. Codes were clustered and refined and the data were independently re-coded., Results: Five themes emerged. LGBTQ patients with cancer: (1) are affected by providers' LGBTQ-specific knowledge and skills, assumptions, and mistreatment; (2) negotiate disclosure of identities based on safety of clinical encounters; (3) have differing experiences based on multiple intersecting identities; (4) receive more effective care when members of their support networks are included; and (5) are self-advocates and undergo transformative experiences in the face of morbidity and marginalization., Conclusions: LGBTQ cancer survivors report challenges accessing competent cancer treatment. To address this, cancer care providers should provide safe clinical encounters, inquire about and respond professionally to patients' identities and identifiers, include chosen support people, provide care relevant to patients' gender identities, and address treatments' effects on sexuality. Training providers about diverse LGBTQ communities and acknowledging the strengths of LGBTQ patients with cancer may improve provider/patient relationships. Provider training could be created based on these principles.

Sexual agreements are ubiquitous among male couples, yet little is known about motivations behind agreements and their association with sexual risk for human immunodeficiency virus (HIV). Qualitative interviews with 39 couples informed the development of the items in the Motivations Behind Agreement (MBA) scale. The scale was validated via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) using quantitative data from two (790 and 882 men) independent samples of couples. The EFA yielded two factors: relationship quality enhancement motive (RQEM) and sex life enhancement motive (SLEM). The CFA indicated satisfactory global model data fit. Finally, in predicting sexual risk, RQEM and SLEM showed significant interactions with agreement type. For men with monogamous agreements, higher RQEM was associated with less condomless anal sex (CAS) with an outside partner of discordant or unknown serostatus (aOR = 0.15; 95% CI = 0.05, 0.46). For men with nonmonogamous agreements, higher RQEM was associated with less CAS (aOR = 0.76; 95% CI = 0.60, 0.97) while higher SLEM was associated with greater odds of CAS (aOR = 1.57; 95% CI = 1.18, 2.08). Men whose agreements were highly motivated by relationship enhancement were less likely to engage in sexual risk with outside partners regardless of agreement type. HIV-prevention interventions targeting male couples will benefit from incorporating an understanding of couples' agreement motivations.

Sharing of injection drug use paraphernalia is a dyadic process linked to the transmission of HIV and hepatitis C virus (HCV). Despite this, limited research exists identifying specific dyadic interpersonal factors driving injecting partners' engagement in needle/syringe and ancillary injecting equipment sharing among young adults. Using semi-structured in-depth interview data collected between 2014 and 2015 from twenty-seven people who inject drugs (PWID), we applied an inductive approach to identify key injection drug-related interpersonal factors and developed a conceptual model integrating the findings based on interdependence theory. Interactions between injecting partners resulted in varying levels of injecting-related trust, cooperation, intimacy, and power. These factors interacted to collectively influence the type and level of risk perceived and enacted by injecting partners. The relationship between these injecting-related interpersonal factors, on the one hand, and risk perception on the other was dynamic and fluctuated between actions that protect the self (person-centered) and those that protect the partnership (partnership-centered). These findings indicate that the interpersonal context exerts substantial influence that shapes risk perception in all types of injecting partnerships. Partnership-focused prevention strategies should consider the dynamics of trust, cooperation, intimacy, and power, in characterizing dyadic risk perceptions and in understanding risky injecting practices among PWID., Competing Interests: The authors have declared that no competing interests exist.

Background: The 'Primary HIV Prevention among Pregnant and Lactating Ugandan Women' (PRIMAL) study aimed to assess the effectiveness of an enhanced HIV counseling intervention for preventing HIV acquisition among HIV-uninfected mothers during pregnancy and throughout the breastfeeding period., Methods: We conducted an unblinded randomized control trial between 22 February 2013 and 22 April 2016 to assess the effectiveness of an extended repeat HIV testing and enhanced counseling (ERHTEC) intervention aimed at preventing primary HIV infection among HIV-uninfected pregnant and lactating women in Uganda. HIV-uninfected pregnant women aged 15-49 were enrolled 1:1 individually or in couples together with their partner. Enrolled women and couples were randomized 1:1 to an intervention (ERHTEC) or control (extended repeat HIV testing and standard counseling) group and followed up to 24 months postpartum or six weeks past complete cessation of breastfeeding, whichever came first. Both groups were tested for sexually transmitted infections (STIs) and HIV at enrollment, delivery, 3 and 6 months postpartum and every 6 months thereafter until the end of follow-up. The intervention group received enhanced HIV prevention counseling every 3 months throughout follow-up. The control group received standard counseling at the time of HIV retesting. Both intervention and control couples were offered couple HIV testing and counseling at all study visits., Main Outcome Measures: Frequency of condom use and incidence of HIV, syphilis, gonorrhea, chlamydia and trichomoniasis over follow-up., Results: Between February 2013 and April 2014, we enrolled 820 HIV-uninfected pregnant women presenting for antenatal care individually (n = 410) or in couples (n = 410 women and 410 partners) in one urban and one rural public Ugandan hospital. Women's median age was 24 years (IQR 20-28 years). At baseline, participants did not differ in any socio-demographic, reproductive health, HIV testing history, sexual behavior, medical history or STI status characteristics; 96% (386/402) of couples were tested and counseled for HIV together with their partners at enrolment, 2.1% (7/329) of whom were found to be HIV-infected. Six hundred twenty-five (76%) women completed follow-up as per protocol (S1 Protocol). Women were followed for an average of 1.76 years and cumulated 1,439 women-years of follow-up or 81% of the maximum 1,779 women-years of follow-up assuming no dropouts. Men were followed for an average of 1.72 years. The frequency of consistent condom use and the proportion of women who used condoms over the last 3 months or at last vaginal sex increased substantially over follow-up in both arms, but there were no statistically significant differences in increases between the intervention and control arms. During follow-up, on average 42% (range 36%-46%) of couple partners were counseled together. Between 3.8% and 7.6% of women tested positive at any follow-up visit for any STI including syphilis, gonorrhea, C. trachomatis or T. vaginalis. Four women (two in each arm) and no enrolled men became infected with HIV, representing an overall HIV incidence rate of 0.186 per 100 person-years. Three of the women seroconverters had enrolled individually, one as a couple. At or before seroconversion, all four women reported their partners had extramarital relationships and/or had not disclosed their suspected HIV-infected status. There were no statistically significant differences between study arms for STI or HIV incidences., Conclusions: A sustained enhanced HIV prevention counseling intervention for up to 2 years postpartum among pregnant and breastfeeding women did not have a statistically significant effect on condom use or HIV incidence among these women. However, in both study arms, condom use increased over follow-up while STI and HIV incidence remained very low when compared to similar cohorts in and outside Uganda, suggesting that repeat HIV testing during breastfeeding, whether with enhanced or standard counseling, may have had an unintended HIV preventive effect among pregnant and lactating women in this setting. Further research is needed to verify this hypothesis., Trial Registration: ClinicalTrials.gov NCT01882998., Competing Interests: The authors have declared that no competing interests exist.

Objective: The HIV literature has largely ignored the importance of alcohol use in the quality of intimate relationships in sub-Saharan Africa (SSA), despite evidence of alcohol's role in relational behaviors that increase risk for HIV infection and other harms. The present study explored the association of alcohol use with relationship functioning among heterosexual couples from rural South Africa., Method: Dyadic analyses were conducted with 443 sexually active, heterosexual, South African couples (886 individuals) to examine the association between male partners' alcohol use (abstinent, nonhazardous, and hazardous), and male and female partners' reports of relationship intimacy, trust, mutually constructive communication, demand/withdraw communication, and satisfaction. Five structural equation models were fit using male partner alcohol use as a predictor of male and female reports of relationship quality., Results: Women with a hazardous-drinking male partner (compared to an abstainer) reported significantly higher levels of intimacy (p <.05) and significantly more demand/withdraw communication (p <.001); men who were hazardous drinkers reported significantly less trust in their relationship compared to men who were abstainers (p < .01)., Conclusions: Hazardous alcohol use among South African couples is positively correlated with women's relationship intimacy and maladaptive communication patterns, yet negatively correlated with men's perceived trust.

A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship. Sexual agreements have been central to research and programming efforts around HIV prevention, primarily for male couples. A comprehensive scoping review of the primary literature on sexual agreements, including negotiated safety, was performed to identify what is known about sexual agreements among couples (n = 66). Results indicate a wide range of prevalence of agreements and measurements used to characterize sexual agreements. Findings also report associations between sexual agreements and health and relational outcomes. Several knowledge gaps were identified; specifically, the need to expand sexual agreements research beyond MSM populations and the need to better understand agreement breaks, break disclosure, and how variation in agreement categorization may impact reported prevalence. This review demonstrates the importance of broadening the evidence-base of sexual agreements research and programmatic focus.

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

Gay, bisexual, and other men who have sex with men (GBMSM) in resource-poor settings are disproportionately affected by the HIV/AIDS epidemic. GBMSM living in these settings may face unique barriers to HIV prevention, including legal barriers and increased sexuality-based stigma. It is therefore imperative to tailor HIV prevention and care resources to recognize the lived realities of GBMSM in these settings. Central to this is the accurate measurement of sexuality-based stigma. However, there is wide inconsistency in how sexuality-based stigma is measured among GBMSM in resource-poor settings. This paper reviews recent studies of sexuality-based stigma among GBMSM in resource-poor settings, finding great variability in measurements. The results of the review call for greater attention to the development of contextually and culturally specific measures of sexuality-based stigma for GBMSM living in resource-poor settings.

Despite the important role of social relationships for health and wellbeing, little is known about how primary partners affect adherence to HIV care and treatment. We qualitatively explored how relationship dynamics and partner support influence adherence among couples from KwaZulu-Natal, South Africa. Twenty-four heterosexual couples with at least one HIV-positive partner completed semi-structured interviews on topics including relationship dynamics (intimacy or emotional closeness, communication, violence), experiences with HIV care and treatment and HIV-related social support. The majority of couples were seroconcordant HIV-positive (92%) and both on antiretroviral therapy (ART) (63%). Participants described how primary partners both interfered with and supported adherence. Negative forms of influence included relationship conflict, which resulted in forgetfulness to take pills, and men's attempt to control use of ART. However, participants were more likely to highlight positive forms of influence on adherence, which included social support (instrumental, informational and emotional), intimacy and commitment. The findings also suggest a reciprocal relationship between ART and relationships such that couple ART use may enhance relationship quality. Primary partners are important pillars of support for ART adherence, especially in contexts of high unemployment and poverty. Future interventions that encourage and leverage these supportive relationships could improve ART adherence among heterosexual couples in similar settings.

HIV risk among transgender women has been attributed to condomless sex with primary male partners. This study pilot tested a couples-focused HIV intervention program for transgender women and their primary male partners. We analyzed data from 56 transgender women and their male partners (n = 112 participants) who were randomized as a couple to one of two groups. Participants in the intervention group (27 couples) received 3 counseling sessions: 2 couples-focused sessions, which discussed relationship dynamics, communication, and HIV risk, and 1 individual-focused session on HIV prevention concerns. Participants in the control group (29 couples) received 1 session on general HIV prevention information delivered to both partners together. At 3-month follow-up, participants in the intervention reported lower odds of condomless sex with primary partners (OR 0.5, 95 % CI 0.3-1.0), reduced odds of engaging in sex with a casual partner (OR 0.3, 95 % CI 0.1-1.0), and reduction in the number of casual partners (B = -1.45, SE = 0.4) compared with the control group. Findings provide support for the feasibility and promise of a couples-focused HIV prevention intervention for transgender women and their primary male partners.

Participation in romantic relationships during adolescence and young adulthood provides opportunities to explore one's sexuality, yet may also cause distress once these relationships dissolve. Although researchers have asserted that participation in same-sex relationships may be beneficial for young gay and bisexual men's (YGBM) psychosocial well-being, less is known about YGBM appraisals of breakups after participating in same-sex relationships. We examined the association between self-reported psychological well-being (e.g., symptoms of depression and anxiety; self-esteem, sense of personal competency) and YGBM's negative and positive appraisals of breakups within a sample of single YGBM (N=1,040; ages 18-24) who reported prior serious same-sex relationships. Negative appraisals were associated with lower psychological well-being. Positive appraisals were associated with greater anxiety symptoms, self-esteem and sense of personal competency. Our findings highlight the need to acknowledge how YGBM's differential responses to breakups may be associated with their psychological well-being.

Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).

Hegemonic masculine norms (HMN), which promote sexual risk-taking among males and the subordination of women, are believed to play a key role in the HIV epidemic among heterosexual couples in South Africa (SA). Sexual communication self-efficacy (SCSE) (i.e., a couple's confidence in their ability to communicate about HIV prevention) may be a key leverage point for increasing HIV prevention behaviors among this population. We interviewed 163 sexually active heterosexual couples in Soweto, SA to investigate the association between SCSE, HMN, and consistent condom use. We collected information on demographics, relationship dynamics, and sexual activity. We utilized the SCSE scale to measure couples' SCSE, and a subscale of the Gender Equitable Men scale to measure HMN among males. We performed bivariate and multivariable analyses to determine the association of consistent condom use with couples' SCSE as well as the male partner's endorsement of HMN. We found that couples with higher SCSE have greater odds of consistent condom use (adjusted odds ratio [AOR] = 1.30, 95% CI: 1.15-1.47). Furthermore, male endorsement of HMN was found to be negatively associated with consistent condom use among couples (AOR = 0.47, 95% CI: 0.24-0.89). Joint HIV serostatus was not significantly associated with the outcome. Future interventions that equip heterosexual couples with sexual communication skills, while simultaneously promoting more gender equitable norms, may increase consistent condom use and thereby reduce the transmission of HIV among this at-risk population.

Reproduction is important to many HIV-affected individuals and couples and healthcare providers (HCPs) are responsible for providing resources to help them safely conceive while minimizing the risk of sexual and perinatal HIV transmission. In order to fulfill their reproductive goals, HIV-affected individuals and their partners need access to information regarding safer methods of conception. The objective of this qualitative study was to develop a Safer Conception Counseling Toolkit that can be used to train HCPs and counsel HIV-affected individuals and couples in HIV care and treatment clinics in Kenya. We conducted a two-phased qualitative study among HCPs and HIV-affected individuals and couples from eight HIV care and treatment sites in Kisumu, Kenya. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) to assess the perspectives of HCPs and HIV-affected individuals and couples in order to develop and refine the content of the Toolkit. Subsequently, IDIs were conducted among HCPs who were trained using the Toolkit and FGDs among HIV-affected individuals and couples who were counseled with the Toolkit. HIV-related stigma, fears, and recommendations for delivery of safer conception counseling were assessed during the discussions. One hundred and six individuals participated in FGDs and IDIs; 29 HCPs, 49 HIV-affected women and men, and 14 HIV-serodiscordant couples. Participants indicated that a safer conception counseling and training program for HCPs is needed and that routine provision of safer conception counseling may promote maternal and child health by enhancing reproductive autonomy among HIV-affected couples. They also reported that the Toolkit may help dispel the stigma and fears associated with reproduction in HIV-affected couples, while supporting them in achieving their reproductive goals. Additional research is needed to evaluate the Safer Conception Toolkit in order to support its implementation and use in HIV care and treatment programs in Kenya and other HIV endemic regions of sub-Saharan Africa.

Male couples represent a high priority group for HIV prevention interventions because primary partners have been identified as the source of one-third to two-thirds of HIV infections among men who have sex with men (MSM). HIV testing is an important component of the U.S. National AIDS Strategy. In previous research rates of HIV testing among partnered MSM have been found to be lower compared to other MSM. In this paper, we use a sample of 906 MSM recruited through internet advertisements to contrast HIV testing behavior, perceived risk of HIV infection and confidence in remaining HIV sero-negative between single MSM and MSM who report having a main partner. We also examine associations between sexual agreements and HIV testing and perceived risk among partnered MSM. Although results were marginally significant, men with a main partner had significantly higher odds of perceiving zero risk of HIV infection, higher odds of being very confident they will remain HIV-negative, and lower odds of testing for HIV in the past 6 months. Partnered men who reported they were in an open relationship had higher odds of recent HIV testing, lower odds of perceiving zero risk, and lower odds of being very confident in remaining HIV-negative, relative to those who reported monogamy. The results point to the need for dyadic interventions to tackle the underestimation of potential risk associated low HIV testing among partnered MSM. Couples HIV Testing and Counseling-CHTC-affords male couples the opportunity to learn their sero-status together and discuss the realities of their agreement and relationship and should be considered a priority intervention for male couples in the U.S.

Objective: Building a successful combination prevention program requires understanding the community's local epidemiological profile, the social community norms that shape vulnerability to HIV and access to care, and the available community resources. We carried out a situational analysis in order to shape a comprehensive HIV prevention program that address local barriers to care at multiple contextual levels in the North West Province of South Africa., Method: The situational analysis was conducted in two sub-districts in 2012 and guided by an adaptation of WHO's Strategic Approach, a predominantly qualitative method, including observation of service delivery points and in-depth interviews and focus groups with local leaders, providers, and community members, in order to recommend context-specific HIV prevention strategies. Analysis began during fieldwork with nightly discussions of findings and continued with coding original textual data from the fieldwork notebooks and a select number of recorded interviews., Results: We conducted over 200 individual and group interviews and gleaned four principal social barriers to HIV prevention and care, including: HIV fatalism, traditional gender norms, HIV-related stigma, and challenges with communication around HIV, all of which fuel the HIV epidemic. At the different levels of response needed to stem the epidemic, we found evidence of national policies and programs that are mitigating the social risk factors but little community-based responses that address social risk factors to HIV., Conclusions: Understanding social and structural barriers to care helped shape our comprehensive HIV prevention program, which address the four 'themes' identified into each component of the program. Activities are underway to engage communities, offer community-based testing in high transmission areas, community stigma reduction, and a positive health, dignity and prevention program for stigma reduction and improve communication skills. The situational analysis process successfully shaped key programmatic decisions and cultivated a deeper collaboration with local stakeholders to support program implementation.

Objective: To conduct a meta-analytic review of HIV interventions for heterosexual African Americans to determine the overall efficacy in reducing HIV-risk sex behaviors and incident sexually transmitted diseases and identify intervention characteristics associated with efficacy., Methods: Comprehensive searches included electronic databases from 1988 to 2005, handsearches of journals, reference lists of articles, and contacts with researchers. Thirty-eight randomized controlled trials met the selection criteria. Random-effects models were used to aggregate data., Results: Interventions significantly reduced unprotected sex (odds ratio = 0.75; 95% confidence interval = 0.67, 0.84; 35 trials; N = 14 682) and marginally significantly decreased incident sexually transmitted diseases (odds ratio = 0.88; 95% confidence interval = 0.72, 1.07; 10 trials; N = 10 944). Intervention characteristics associated with efficacy include cultural tailoring, aiming to influence social norms in promoting safe sex behavior, utilizing peer education, providing skills training on correct use of condoms and communication skills needed for negotiating safer sex, and multiple sessions and opportunities to practice learned skills., Conclusion: Interventions targeting heterosexual African Americans are efficacious in reducing HIV-risk sex behaviors. Efficacious intervention components identified in this study should be incorporated into the development of future interventions and further evaluated for effectiveness.