A total of 35 GBM participated in this study; demographics based on age, race, sexual orientation, and relationship length are described in Table 2. Participants described what dyadic HIV care would look like for both seroconcordant HIV-positive and serodiscordant same-sex male couples. There was variation between participants within and between FGDs when discussing preferences for dyadic care vs. individual care, with greater variation occurring among FGDs using an example of a seroconcordant HIV-positive couple. Themes in the FGDs addressed comprehensive dyadic care, relationship dynamics, strengthening relationships, and accountability and adherence; all themes were discussed in terms of dyadic care and the impact on adherence. Connections were made between themes (Fig. 1); results are summarized based on benefits and challenges of dyadic care in Table 3.
Comprehensive Dyadic Care
Participants described both comprehensive and holistic HIV care, including treatment for couples that expands beyond a biomedical focus. Participants identified other mental and physical health needs in addition to social needs that should be addressed in HIV care, both for individuals and couples living with HIV, including a variety of types of counseling (relationship counseling, spiritual counseling, stress management, peer counseling, couples support groups), case management, couples-focused educational materials, and an overall focus on staying healthy (eg, nutrition, exercise, yoga). Some of these aspects of health could be addressed on an individual level (eg, spiritual counseling); however, participants identified other aspects of care as specific to dyads, including relationship counseling, stress management, couples support groups, and couple-focused educational materials. Dyadic care that addresses mental health was perceived as especially important because it can strengthen the relationship and allow partners to provide additional levels of support to one another.
There was agreement in all 5 FGDs that HIV care should be comprehensive; however, responses varied on how this care should be provided. Some participants expressed that it is the doctor's role to provide more than simply HIV treatment:
“Let's say you have a physician that is actually a physician, but also can speak to your dietary needs, your social support needs, you're having trouble keeping your lights on. Let's try to get a multi-faceted person…a holistic person” (P21, FGD3).
Other participants felt that these components of health are beyond the scope of what an HIV doctor should provide, especially with regard to relationship counseling: “This has nothing to do with your doctor's visit. This isn't Dr. Phil. I'm not here to referee your personal love life” (P29, FGD4). Although some participants felt it was not the doctor's role to provide this additional support, participants commonly agreed that someone should provide additional support, such as a case manager, social worker, or mental health specialist. Participants described HIV care as a “spectrum of care,” which can be appropriately provided through a “care network” or a “one-stop shop.” Both options focus on the interconnectedness of services; however, the one-stop shop suggests that services be provided in one easy to access location:
“Especially since we talk about…phases of the process…do everything that they can to make sure there's a continuity…that just because the doctor's visit is over doesn't mean that the nurse can't pick up right after that and the social community can't pick up right after that, and the pharmacist picks up right after that; that it is a spectrum of care, not just discrete little chunks that you have to get over and get to every time.” (Participant, FGD1).
“I think maybe just making sure…there's some connection between groups and support groups and doctors that are actually providing treatment, making sure that everyone knows who to go to for what, the care network of are you feeling down and you need to talk to someone else that's not just a lab coat?” (P25, FGD4).
There was agreement on the value of incorporating counseling into dyadic care; however, many participants also addressed the need for individual attention in receiving HIV care. Participants specifically identified the importance of individual care because it ensures confidentiality with the provider, allows for sufficient time to address individual health needs, and provides the opportunity to address personal emotional needs before discussing them with one's partner: “I would probably need to get my ducks in a row so that I could reassure my partner what's going to happen going forward” (P5, FGD1). This was consistent for scenarios with both serodiscordant and seroconcordant HIV-positive couples; however, the need for individual attention was described differently depending on the dyadic serostatus.
Dyadic Care for HIV Serodiscordant Couples
In dyadic HIV care for serodiscordant couples, some participants described care where the negative partner would attend appointments solely to support his partner, whereas others identified unique needs specific to the HIV-negative partner that are important to address in a medical or professional setting. These needs included concerns regarding their own exposure to HIV, staying negative, concerns about their partner's health, the longevity of the relationship, and whether they want to stay committed in the relationship. This is different from the needs of the HIV-positive partner, whose priority is to address living with HIV and receiving HIV care. These different needs can create challenges in obtaining a support system within the partnership:
“So, [one partner] being negative needs…to make sure [he] stays negative, making sure that if this relationship is right for [him] that [he] want to stay in that relationship. I think those are huge support items. And then [the positive partner] though doesn't have somebody that can relate firsthand. So, he's going through the fear and the emotion and everything and his partner doesn't necessarily understand that. So I think, from his perspective, he needs that kind of intimate support with what he's going through, that [the negative partner], he just can't, I don't think, provide just because he's not in the same position” (P13, FGD3).
Although some participants felt that this lack of empathy and understanding would make it impossible for a partner to provide support, other participants saw this as a challenge that could be addressed through dyadic HIV care. Across all FGDs, relationship counseling and stress management were perceived as more necessary in serodiscordant relationships than in seroconcordant HIV-positive ones to increase empathy and prevent HIV transmission. Participants suggested that individual counseling, dyadic relationship counseling, and community-based organizations can help address these emotional and educational needs:
“I need to know what is safe and what's not. I think I need to have more education…I think I would be looking for [CBOs in Atlanta], a professional that can actually tell me what is safe, what is not, what treatments are there. I'd be reaching out to professional associations that could give me information…So that the negative partner does not become positive” (P5, FGD1).
“I would want some sort of sex plan and maybe also meet with a counselor [together]…It would depend on the sexual rules of each partner and how that would impact the sex life. And then maybe some education and guidance through that…But I also would want [the negative partner] to seek his own individual counseling on the issue” (P7, FGD2).
Additional components of HIV care can also provide an additional purpose for the HIV-negative partner to be present for his partner's HIV care:
“I also think that structure…providing [the negative partner] with something that he should be doing every three to six months as well, or adding some sort of component…separately from [the positive partner], sort of engage him with the process individually as well” (P8, FGD2).
This concept was discussed across all FGDs and both scenarios; however, it was perceived as especially important in serodiscordant relationships because it allows for the space to focus on the needs of the HIV-negative partner as well.
Dyadic Care for Seroconcordant HIV-Positive Couples
Participants described dyadic care for seroconcordant HIV-positive couples as 2 separate scheduled appointments, 1 for each partner with both partners present at these appointments. These appointments would preferably be scheduled consecutively, with the same doctor at the same facility; however, scheduling challenges and differences in insurance and ability to pay for care may not allow for that.
In this scenario, although both partners are HIV positive, their needs will still vary. Partners can differ based on the stage of the HIV infection, reaction to medications, and mental health status. Some participants felt that these dyadic differences would not allow for dyadic care to be successful for seroconcordant HIV-positive couples because it would not provide enough individual attention:
“I would rather go by myself, period…When you go to see your doctor, you need that attention just for yourself and how can you get that attention that you need if it's two of y'all in the room? And you're not going to be able to get that quality time that you need to understand things for you because y'all bodies are different. So, y'all might be on different retros and that's a whole lot of explaining there, which gets you confused to…what he done saying to you. Then you want to know why he on this and why I'm on that” (P27, FGD4).
Other participants recommended that dyadic differences be addressed by incorporating individual time with the doctor into dyadic care. Even if both participants receive the necessary individual attention from the doctor, an additional challenge is that differences in experiences with HIV may result in “resentment” or poor “morale”:
P15: “There may be some sort of feelings or resentment in the event that one partner is doing better in terms of his health care…just faring better in terms of his health and then another partner is not doing well in terms of his health. There may be a sense of resentment on one of the party's behalves. So that could be a challenge.”
P20: “Absolutely. Well even if you don't resent your partner, then I think just the morale…for you to see that your partner's responding and you’re not. So even if you don't resent…you may just start feeling badly about yourself” (FGD3).
The resentment and “discouragement” that results from different reactions to HIV treatment and stages of HIV infection could also negatively impact the dynamics of the relationship:
“On this particular subject, I can speak from experience because on my regimen, I didn't have any side effects. So, I was comfortable. It was like taking a multivitamin. I was fine from there. However, my partner, he had very negative reactions to the medication and so stopped taking the medications. And of course, that created a lot of tension in the relationship. So, I think that that can definitely create a unique dynamic where one individual is discouraged because of the other individual's response to their medications” (P29, FGD4).
Alternatively, participants discussed how differences in responses to medication could help partners remain optimistic. The partner experiencing more negative side effects may see evidence in their partner that it is possible to find a regimen that works better. Participants also stated that one partner could help the other in managing those side effects.
Participants identified that dyadic care is impacted by the dynamics of a partnership; for dyadic care to be successful, the partners must show serious commitment, open communication, and honesty. According to participants, showing commitment in a relationship after becoming aware that one or both partners are HIV positive is an act of love: “if you really love the person, you decide to stay” (P13, FGD3).
Participants stated that dishonest relationships would not benefit from dyadic care due to concerns regarding privacy and confidentiality. Honesty is required to allow for both partners to be completely candid with the doctor in the other's presence; participants described dyadic care as involving “no secrets” and increased “transparency.” In relationships that lack open communication outside of the doctor's office, participants stated that one partner may “have some questions and things that he might not be comfortable asking if his partner is sitting there” (P24, FGD4).
Commitment was also identified as an important factor when considering privacy. If there are “doubts” and “second thoughts” in the relationship that cannot be expressed, there is an extra level of tension in openly sharing with one's doctor. Participants were also concerned that if partners are not committed to each other, then there may be repercussions if the relationship ends after the couple had already started dyadic care. When discussing privacy concerns, one participant asked, “what if the relationship doesn't make it?” (P23, FGD4). So, if partners share together in an appointment with a doctor and then the relationship ends, one or both partners could feel like their privacy was breeched.
However, in committed relationships that have open communication, participants described dyadic care as leading to increased honesty with both the partner and the doctor:
“I actually went through the process going with a partner to the doctor and I think I was more candid with the doctor because all parties were there. I was able to put things on the table and I think the doctor was challenged at being able to see the sincerity of what was coming out the conversation of three of us being there together because a lot of times we sugarcoat things…but when I had the partner there it was nothing to hide…There is nothing to hide to them and there's nothing to hide to the doctor. So we going to let it all out. Maybe they might want to say something that I didn't even know. My own partner might say something, and that did come out, my partner said, shared something and I was like, oh, you know…And the doctor shared back said ‘yeah, this is blah, blah, blah’ so it kind of brought more to the table when there was both of us being there” (P28, FGD4).
If the dynamics between partners are positive, that will enable both partners to build rapport with the doctor, thus improving the relationships and the exchange of information.
The connection between comprehensive dyadic HIV care and positive relationship dynamics is reciprocal; although positive relationship dynamics work to improve dyadic care, dyadic care can also improve the dynamics in a relationship and strengthen support systems:
“I just personally believe that going together would just make their relationship more stronger. That's just the bottom line…because now they both know that they’re not alone in it…I think that personally it would make their relationship so much more stronger. I think there will be longevity” (P30, FGD5).
One way that participants explained how dyadic care strengthens partnerships is through the establishment of empathy:
“If one partner goes, you establish only sympathy because the other partner doesn't understand what the doctor said. But if both partners go, you established empathy where would the one who is effected be like, oh my gosh, I understand that you can go through this and I understand the trauma you're going to go through so I actually understand rather than like, oh yeah, sorry you feel bad today just because. No. Having that doctor there and speaking to both parties will establish the connection between those two and so that it will help strengthen the bonds of the relationship” (P6, FGD1).
Dyadic care creates an understanding between partners and allows them to “work together to reach a goal” (P18, FGD3). Participants agreed that dyadic care allows for collaboration across all relationships; however, the goals vary based on dyadic HIV serostatus. In serodiscordant relationships, both partners work toward a goal of maintaining a healthy relationship, preventing HIV transmission, and ensuring that the HIV-positive partner adheres to care and reduces his viral load. In seroconcordant HIV-positive relationships, both partners go through the process of accepting their HIV status together, they incorporate HIV care into their lives together, and if adherence is accomplished and viral loads reduced, the relationship is strengthened because both partners can celebrate together:
“It would strengthen the relationship because it would become such a part of their lives that, OK, we're going, today's the appointment; let's meet and go. So…the information they're getting and how things are progressing, it really is going to be integrated into their life. Now there really is going to develop an acceptance of what they're going through. So they would become stronger as a couple hopefully” (P35, FGD5).
Achieving “goals” together as a couple allows for couples to “normalize” the experience of HIV care and experience a greater level of acceptance. Furthermore, successes in HIV care “reinforce” and strengthen the relationship, allowing for partners to celebrate achievements together as a couple.
Accountability and Adherence
Receiving care as partners rather than individually was also identified as a way to show “commitment” or “solidarity” to one's partner. Participants described commitment in a relationship as leading to increased accountability; each partner adheres to their HIV treatment not only for themselves but also for their partner. Participants described how this commitment is established in a serodiscordant relationship: “By [the positive partner] taking his drugs, he is showing the [negative partner] that he is there for him. He's invested” (P3, FGD1). As discussed in the FGDs, adhering to a treatment plan shows “investment” in serodiscordant relationships for 2 reasons: (1) it shows that the each individual cares about his partner's health, working to ensure that he stays negative by reducing his own viral load, and (2) it shows an investment in the “longevity” of the relationship because he is trying to keep himself healthy and will therefore be able to be in the relationship longer:
“I think maybe [the negative partner] would possibly need support…I know it would be self-centered in that situation but he may be fearful of losing this person, physically, from this world and…not in a commitment relationship wise but dying…but [the positive partner] maybe supporting [the negative partner] and reassuring him that he's going to do whatever he can and he's going to be OK, too” (P4, FGD1).
This concept of commitment was described similarly when both partners adhere to their treatment in a seroconcordant positive relationship:
“The objective is for us to both get treatment and for us both to be happy…live healthy lives…If you're my partner, I am invested in your long term health and longevity and vice versa. I would hope that that same sentiment is reciprocated” (P29, FGD4).
In both serodiscordant and seroconcordant HIV-positive relationships, adhering to HIV treatment is an act of commitment that represents an investment in not only one's own health but also the health of one's partner and the longevity of the relationship.
This increased sense of commitment can lead to greater accountability and adherence to an HIV treatment plan:
“I think it shows their commitment to each other, serious commitment to each other…If they do those things together, they're obviously in it together, both of them for the long haul and I think it's very positive for them. And in [the positive partner]'s general outlook on himself, he's going to feel better, he's going to work harder to try and stay healthy” (P12, FGD2).
Although most participants described that dyadic care as improving adherence because it allows for both partners to motivate, support, and hold each other accountable, some participants also identified challenges in adherence due to dyadic care. One challenge to seroconcordant HIV-positive relationships is that dyadic differences may cause a lack of motivation; when a partner is feeling unmotivated, he can bring the other down with him:
“I will say that the person's different level because the other person probably has more extreme state of mind, like my partner wanted to go ahead and die…he didn't want to go ahead and live. So you need that extra support then to push the person through…Definitely there was a mental state when they find out one wants to do this, one wants to do that. So medication adherence is kind of hard to get the other person to do when he wants to go ahead and die” (P13, FGD3).
“Another challenge could be that one of them or both them could start to regress and not want to go to their appointments…depression could set in in one and the other is affected by it and because…the one that's not depressed wants to helps his lover and get fallen into that same mood with his lover. They just say F it” (P31, FGD5).
Another challenging concept or “red flag” discussed by the participants involved dependence on one's partner. This was discussed in terms of personal responsibility versus relationship accountability. Participants explained that no matter the accountability within the relationship, the ultimate importance is one's personal accountability in adhering to their HIV treatment:
“There may be a level of dependency and codependency there…It may get to a point where maybe [the negative partner] does things for [the positive partner] that he ought to be doing for himself” (P9, FGD2)
Although relationship accountability was perceived as an important factor in increasing adherence, it functions best when it serves the purpose of increasing one's personal accountability rather than replacing it. Ultimately, an individual may feel a stronger personal accountability in adhering to treatment because they are in a committed relationship but that desire to adhere needs to come from within and not only from the partner.
Participants discussed how dyadic care and relationship dynamics can impact accountability and adherence across the continuum of care, including specific examples for linkage to care (eg, having a partner present at that first doctor's appointment shows commitment), engagement in ongoing care (eg, attending visits with a partner can increase appointment attendance), and HAART adherence (eg, partners can monitor and support each other's health behaviors and adherence to increase accountability, committing to a medication regimen is a sign of commitment).
Results point to a mutual relationship between positive relationship dynamics and dyadic HIV care among same-sex male partnerships, which can lead to an increased sense of “solidarity,” allowing both partners to “work together to reach a goal.” Data from the FGDs suggest that relationship dynamics are an important factor on HAART adherence; these data expand upon previous research13,19–21,23,24 by examining how dyadic HIV treatment may increase accountability through an increased sense of “togetherness.” When GBM adhere to care, they are actively showing commitment to their partners; this sense of commitment also holds GBM accountable to adherence. These findings show that it may be useful to promote commitment and positive relationship dynamics as a measure for improving HIV care; messaging around HIV care for MSM may benefit if it shifts to a dyadic focus that addresses same-sex male couples.
These symbiotic and complex relationships were discussed as a source of increased retention throughout the continuum of care. These findings are especially valuable in the context of a shift for HIV interventions to a test-and-treat framework that focuses on the continuum of care.5 An executive order released by President Obama in July 2013 created the HIV Care Continuum Initiative, which calls for HIV strategies to prioritize the continuum of care to focus on prevention and treatment simultaneously and to address gaps in receiving optimal treatment.39 Within this context, it is important to understand how dyadic strategies could potentially improve services at each stage in the continuum of care. Findings from this study suggest that there may be many benefits to a dyadic focus for linkage to care, engagement in care, and HAART adherence; the possibility for comprehensive dyadic care to strengthen relationships and increase accountability and adherence can work to increase motivations for care at each stage across the continuum.
There were some limitations in this study. These data are not generalizable beyond this specific cohort; however, these data are able to explain complexities in the relationship between same-sex male partner dynamics and dyadic HIV care. Because FGDs were meant to capture general perceptions of dyadic care, they used scenarios to allow GBM in same-sex relationships to discuss dyadic care, despite dyadic serostatus. We did not collect data on HIV status, therefore data cannot be stratified by individual or dyadic serostatus; however, participants had a wide range of knowledge of how HIV care works and discussed a wide range of experiences in the FGDs, whether based on personal experience with HIV or experience from others in their community. The moderator clearly explained the continuum of care, including descriptions and questions at each step, to ensure that all participants understood how care is generally provided.
Despite limitations, these data indicate a need for comprehensive care that focuses on more than just medication and allows space for patients to interact with more than just “a lab coat.” The experience of living with HIV expands beyond reducing a virological load, and when other aspects of health, especially mental health, are incorporated into care, it is easier to focus on a patient's medical needs. Furthermore, a focus on dyadic mental and physical health improves overall health and HIV care for both the individual and couple by increasing support for HAART adherence and focusing on preventing seroconversion in discordant dyads. Participants also recommended that comprehensive treatment occur at a “one-stop shop”; this concept is similar to the patient-centered medical home legislation addressed in the Obama administration's Affordable Care Act. The medical home model describes an organization of the medical system that includes “coordinated, comprehensive, efficient, and personalized” care.39 A “one-stop shop” or medical home model for HIV treatment would establish one location where patients have a primary provider but also where care is coordinated across practitioners, including infectious disease doctors, mental health specialists, nutritionists, etc.
For medical homes to provide dyadic care, they need to be accessible to couples; this includes the capacity to schedule appointments for couples and increased awareness about the availability of dyadic care. Dyadic care should also focus on improving communication between partners; participants in multiple FGDs suggested having both partners “make a plan” before attending each appointment. This “plan” should incorporate a discussion of each partner's informational needs, including any questions or concerns that they have for the provider. Tools, such as paper forms or electronic applications, that allow partners to identify talking points and needs for HIV care appointments could ensure open communication between both partners and with the care provider.
Despite decades of programmatic focus and intervention, MSM continue to be the only risk group in the United States in which HIV incidence is increasing. Evidence indicating high rates of HIV transmission within main partnerships demonstrates the need to create novel dyadic interventions for MSM. Dyadic HIV care that is comprehensive, focuses on both individual and dyadic needs, and promotes positive relationship dynamics among same-sex male couples could improve HIV treatment across the continuum of care.
The authors thank Whitney Williams at Emory University who assisted with this research.
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Keywords:© 2013 by Lippincott Williams & Wilkins
MSM; dyadic HIV care; same-sex male relationships; HAART adherence