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Perceived Facilitators and Barriers to Couples' HIV Testing and Counseling in U.S. Clinical Settings

Perspectives From U.S. Health Providers

Leblanc, Natalie M., PhD, MPH, RN*; McMahon, James, PhD

Journal of the Association of Nurses in AIDS Care: May-June 2019 - Volume 30 - Issue 3 - p 279–291
doi: 10.1097/JNC.0000000000000055
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We used a qualitative descriptive design to ascertain perceived facilitators and barriers to couples' HIV testing and counseling (CHTC) by U.S. health care providers. We recruited 22 providers from 4 health care facilities in Miami-Dade County, FL, from November 2015 to March 2016. In-depth, semistructured interviews were conducted. Content analysis categorized and contextualized provider narratives. Perceived facilitators of CHTC were provider experiences with couple-centered HIV-related care, existing patient or client demands for joint HIV screening, and a health care practice environment that fosters an interprofessional approach to addressing client needs. Perceived barriers were partner unwillingness to undergo HIV screening, provider role beliefs and preferences regarding couple-based approaches, and provider time constraints in tandem with funding and billing issues. Overall, providers endorsed CHTC and thought that current challenges and successes with couple-based efforts and HIV screening and care could influence CHTC implementation. Provider recommendations are discussed.

Natalie M. Leblanc, PhD, MPH, RN, is an Assistant Professor, School of Nursing, University of Rochester, Rochester, New York, USA. James McMahon, PhD, is an Associate Professor, School of Nursing, Associate Professor (Secondary Appointment), Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York, USA.

Corresponding author: Natalie M. Leblanc, e-mail: natalie_leblanc@urmc.rochester.edu

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Couples' HIV testing and counseling (CHTC) is a dyadic approach to address interpersonal vulnerability for HIV acquisition (Centers for Disease Control and Prevention, 2012). It has proven to be effective in reducing HIV acquisition in couples and retaining people living with HIV in care (Centers for Disease Control and Prevention, 2012; Jiwatram-Negron & El-Bassel, 2014; McMahon et al., 2015; Wall et al., 2017). The World Health Organization (2012) developed guidelines for CHTC implementation to enhance engagement of HIV-serodifferent couples in dyadic prevention interventions. The Centers for Disease Control and Prevention (2012) has further endorsed CHTC as an effective strategy for HIV prevention, developed a protocol for implementation, and recommended implementation in a variety of health care settings, including U.S. clinic-based settings. However, adoption of couple-centered HIV prevention interventions is not well established in the United States (Sullivan, Stephenson et al., 2014). Couples' HIV testing and counseling research and implementation in clinic-based settings has been conducted almost exclusively in low- to middle-income countries (Allen et al., 2003; Becker, Mlay, Schwandt, & Lyamuya, 2010; Centers for Disease Control and Prevention, 2012; Karita et al., 2016).

In the context of new biomedical approaches to HIV prevention, such as pre-exposure prophylaxis (PrEP), and advances in antiretroviral therapy (ART), in tandem with growing evidence of population willingness to engage in CHTC in high-income countries (Lee & Mitchell, 2018; Stephenson et al., 2015; Sullivan, White et al., 2014), there is a growing call for health providers to tailor sexual health promotion for intimate partners to prevent HIV transmission. The World Health Organization guidelines recognize that provider support for couple-centered HIV prevention will be critical to the success of CHTC and that provider attitudes and views must be considered when planning CHTC implementation (World Health Organization, 2012). It is also essential to gain provider perspectives on factors that might facilitate or impose barriers to couple-based HIV prevention approaches, but most research on CHTC has focused on programmatic findings or patient/client outcomes with little attention paid to U.S. health provider perspectives. The literature also does not demonstrate the role of providers in the promotion of CHTC in health care facilities in the United States (Jiwatram-Negron & El-Bassel, 2014; Jones, Stephenson, Wall, & Sullivan, 2014; McMahon et al., 2015). To address these research gaps, a larger qualitative study on provider perceptions of CHTC in an HIV epicenter was conducted (Leblanc & Mitchell, 2018). The research efforts and findings reported here focus on one aspect of the larger study—provider perceptions of factors that may enhance or impede implementation of CHTC within U.S. clinical settings. Findings will help inform integration of CHTC into existing HIV prevention and sexual health promotion services and illuminate recommendations and consideration for uptake in the United States.

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Method

We used a qualitative descriptive design for the study (Sandelowski, 2010). Two-tiered purposive sampling was used to recruit providers with at least 1 year of experience engaging people in the HIV care continuum. In-depth, semistructured interviews were conducted with health providers (N = 22) recruited from 4 health care facilities (2 federally qualified health centers and 2 hospital-affiliated HIV specialty clinics) in Miami-Dade County, FL, between November 2015 and March 2016. Approximately half of the sample were clinicians (n = 13), with nurse practitioners (n = 8) constituting the largest group of clinicians. Clinician, in this study, is defined as practitioners who are licensed as advanced practice nurses or physicians. Other providers represented those in psychology, social work, health counseling/education, program management, and health administration. The majority of the sample were women (n = 13). Most of the sample had more than 5 years of work experience in their professions.

Data collection involved use of an interview guide that was informed by the literature on provider-level factors that influence patient engagement in the HIV care continuum and allowed open-ended responses (Table 1). The interview guide was updated after the first three interviews to add discussion points that consistently emerged (i.e., PrEP utilization). Details on data collection and analysis procedures have been published elsewhere (Leblanc & Mitchell, 2018). Interviews were audio recorded, conducted by the first author in-person or by phone, and lasted 30 to 90 minutes. Data collection and analysis occurred simultaneously, and MAXqDA (VERBI Software GmbH, Berlin, Germany) was used for data management and assistance with data analysis. Directed content analysis was used for code development and the typology of the findings (Hsieh & Shannon, 2005; Vaismoradi, Turunen, & Bondas, 2013). Analysis involved peer debriefings between the lead author and 2 other nursing health science researchers, including one who had more than 20 years of clinical expertise in HIV treatment and care. Peer debriefings involved a series of discussions of the transcripts, the coding schema developed, and integration of findings. Further details on the data collection and analysis procedures have been documented elsewhere (Leblanc & Mitchell, 2018). The Institutional Review Board at the University of Miami approved the study.

Table 1

Table 1

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Results

Participants

Of the 22 participants, three clinicians were versed in the global literature on CHTC. Of the remaining providers, seven had undergone CDC CHTC training hosted by the local health department unrelated to the implementation of our study. Of these seven providers, none were clinicians, and three reported some experience implementing CHTC. Therefore, the narratives presented were based primarily on the response to a general description of the CHTC CDC guidelines at the time of our study. During the consenting process, providers were briefed on the origins of CHTC in sub-Saharan Africa, and the development of the CDC CHTC protocol for the U.S. male same-sex couple population, which was the focus of the protocol at the time of our study.

Providers were recruited from four different health service settings in Miami-Dade County, FL. Two of the settings were hospital-based HIV care clinics within two separate hospitals, and the other two settings were community-based, federally qualified, multiservice health facilities. Patients in these facilities were a mix of insured, underinsured, or uninsured people in Miami-Dade County. They were also a mix of U.S. and foreign-born individuals representing a variety of ethnoracial identities. Patients who were foreign born varied in immigrant status; most were from Caribbean and Latin American countries with varied English-speaking abilities. Patients also had varied sexual orientations and gender identities.

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Analytical Framework

Content analysis revealed that perceived facilitators and barriers to CHTC manifested in two perspectives: the holistic perspective and the particularistic perspective (Kim, 2010). The holistic perspective has an explicit focus on global aspects of the phenomenon (i.e., individual HIV screening, one's general perception of sexual health). A particularistic perspective focuses on a specific element of a phenomenon, in this case, CHTC. Here, we focus on providers' particularistic perspectives regarding barriers and facilitators to CHTC using the following conceptual typology: (a) the patient/client domain (clients, patients, partners, or couples); (b) the practice (provider) domain, and (c) the environment domain (Fawcett, 1984; Kim, 2010).

Provider reflections about their experiences and certain patient/client attributes shaped provider narratives about whether CHTC could be considered for implementation. Overall, key facilitators to CHTC were provider experiences with couples, couples' requests to be seen together, and the ability of health settings to provide couple-based HIV-related services without regard to whether these couples are serodifferent. Noted barriers to CHTC included (a) provider practice preferences, (b) partners within couples who were either unwilling to engage in couple-based HIV prevention or did not understand couple-based vulnerability to HIV acquisition, and (c) health setting characteristics that impeded provider scope of practice for couple-based HIV prevention approaches.

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Patient/Client Domain: Provider Experiences With Couples and HIV Screening

Experience with maternal HIV care

Providers who worked in maternal HIV reported efforts to ensure that expectant couples were mutually aware of the couple's joint HIV serostatus to facilitate engagement in the HIV care continuum and prevent horizontal and vertical transmission. These efforts were made especially before delivery to avoid unplanned maternal disclosure during delivery or pediatric HIV follow-up. Therefore, the predelivery period afforded an opportunity for joint serostatus awareness … “because the woman is all excited about the pregnancy most of the time, the partner is also happy about the pregnancy, sometimes they [the partner] come with the woman” (Clinician, 16 years of experience).

Due to the nature and focus of the maternal visit, these providers may have had a stronger relationship with the expectant mother than the male partner, which may challenge relationship building with the partner. Providers reported that male partners did not always accompany the expectant mother or may have accompanied the index patient but refused HIV screening. Occasionally, even when the maternal patient had disclosed her seropositivity, the male partner might still refuse HIV screening. These challenges with male partners were recognized, by extension, to be a potential barrier to CHTC. Despite these challenges, providers reported persistent efforts to encourage the partner to screen for HIV infection.

… my relationship is more with the woman, sometimes I see one time the partner but if I see more than one time and I have more of a relationship with the partner, I reinforce, you know, it is good to have the test every 6 months or every year. (Clinician, >20 years)

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Experience with male partners

Experiences with male partners of nonexpectant women seeking HIV/sexually transmitted disease (STD) screening were also deemed to influence CHTC implementation. Providers disclosed that “testing by proxy” was not uncommon among men, implying a sense of HIV vulnerability in men to be solely endorsed through the relationship with the female partner without regard for one's personal behavior. This kept men from screening for HIV infection and engaging in HIV care even when presenting with potential HIV symptoms. “…because the woman get tested, she is negative, he feel he don't have to get tested because she's negative” (Nonclinician, 15 years).

… more times than not the [male] partner is the one that gave it to them [women] and they have refused to acknowledge that they have the disease … and of course the male feelings of invincibility and denial that they can't get it. (Clinician, > 20 years)

Certain providers believed that male partner refusal to screen for HIV infection was attributable to gender-based experiences in the clinical setting and current health seeking behaviors among men. Participants thought that client perceptions of health in general and vulnerability to HIV infection specifically may have been gender influenced and had bearing on male partner engagement in CHTC. “… the woman goes more often to the doctor because of pregnancy or GYN or other reasons, but men sometimes they do not go that often to the medical provider” (Clinician, 16 years).

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Experience with client perceptions of HIV acquisition

Providers reported that the communities they served possessed varied understandings of interpersonal vulnerability to HIV acquisition and that this comprehension would influence CHTC uptake. Providers reported that client perceptions may be shaped by relationship dynamics and couples' goals. Not screening for HIV infection may have more to do with levels of intimacy and trust already developed within the relationship than a disregard for joint health attainment.

I think they understand it [HIV risk vis a vis partner risk] to a certain level … I am seeing [that] if you have been in a relationship for a while with somebody, you feel like you don't need to get tested … (Nonclinician, > 20 years)

Providers also reported that some patients may have an understanding of the interpersonal vulnerability to HIV, which may disallow partners to disclose. Therefore, this understanding may engender a fear of relationship dissolution, which may further prevent joint HIV screening. “I don't think they understand that there's always a risk … I see that every day there is always a risk, somebody can be unfaithful or some kind of behavior … and they don't express that to their partners” (Clinician, 13 years).

Juxtaposing male partner refusal to engage in couple-centered HIV prevention approaches in heterosexual couples, providers reported that male couples appeared more willing to engage in joint HIV screening. This difference was potentially due to community awareness of HIV prevalence and the absence of gender power differences.

… we always encourage them [patients/clients] to bring the partner. Some of them are open to tell the partner, especially the gay people. Most of the time it's almost like normal to bring the partner and I think they understand each other, but the man in the [heterosexual] couple, it's always like a big secret, they don't want to bring in [the partner] and discuss. (Nonclinician, 12 years)

Generally, participants did not report providing on-demand joint HIV screening services specifically if their facility was not implementing CHTC. Instead, some providers offered to address couples' questions following individualized HIV/STI screening if requested. Therefore, current community demands for joint HIV/STD screening indicated that certain patients possessed an awareness of, and made efforts to receive, joint health attainment via joint HIV screening. As one provider reported on his organization's eventual uptake of the CHTC protocol as part of the facility's HIV prevention program, existing patient demand was the sole motivation to adopt the strategy.

I think that we would probably not be as open to it [CHTC] or receptive … if we did not see a demand, because we had people coming in asking for it [to be tested together] … so our motivation was to be able to respond to the demand. (Nonclinician, 3 years)

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Practice Domain: Provider Couple-Oriented Practice Norms, Preferences, and Beliefs

Perceived provider capabilities

Some providers incorporated couples into care delivery or used a couple-based approach in their practices. Providers reported experience engaging couples in a general wellness visit or in some other health-related capacity. Therefore, engaging a couple in HIV screening could be incorporated into existing HIV prevention and treatment practice. “… So I'll be in the room with like both of them and I'll do one and then do the other …that kind of thing, nothing official” (Clinician, 6 years). Although most clinicians reported a willingness to engage couples in CHTC; they noted that some colleagues might not be capable due to the lack of knowledge training needs, practice preferences, and, ultimately, an inability to manage a couple. Providers further reported that certain colleagues might be unwilling due to the prospect of a seropositive patient or a serodifferent couple: “… the testing is the easy part if you will, but if it is where somebody becomes positive … that may be a little bit more of a challenge for the clinician” (Clinician, > 20 years).

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Perceived provider preferences

Providers acknowledged that colleagues' preferences for working with individuals rather than families or couples would be a potential barrier to CHTC. “I know there are some clinicians who do not like having other people in the room when they are seeing one particular patient. So that may be an issue, but for me personally, it is not” (Clinician, 6 years).

Providers also reported that despite a willingness to engage couples, others might prefer to engage couples in which there is not an established patient–provider relationship. They believed that engaging new patient–partner dyads would eliminate bias toward either member of the couple and allow an unbiased interaction, which was believed to be important in the event of HIV serodifference.

… a client that I see on a weekly basis, that would be a barrier because I feel like it is a conflict of interest only because if I am doing individual testing with one of the persons and now I have to bring another, I don't know if I would be comfortable. (Nonclinician, 5 years)

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Provider role beliefs

Two providers expressed ambivalence about clinician involvement in CHTC implementation. This ambivalence was related to the perceived provider role in CHTC, specifically that CHTC was more about relationship building and that the clinician might not be the appropriate person to initiate interpersonal sexual health conversations. “Never have I told a patient to bring your partner in because I think that is very personal and to some degree a bit invasive” (Clinician, 3 years). Despite this ambivalence, most providers discerned that all provider types could facilitate and/or implement CHTC. Overall, study participants thought that the provider role was influential in the adoption of CHTC and that all provider types were positioned to adopt and implement CHTC. These perceptions were influenced by current practices that employed couple-oriented efforts in the areas of STD treatment, reproductive health, mental health, and drug addiction issues.

… you want to make [the client] feel comfortable and once they feel comfortable you can take it from there and [have discussions about CHTC] it won't be on that same visit … say, “Well, next time since you are in a pretty serious relationship, you may want to bring your partner with you and at first we will talk to your partner and then you both can get tested for everything, okay? And then if you want, you both can share results.” (Clinician, 10 years)

Providers further reported that nurses, nurse practitioners, and physicians garnered respect from clients due to the nature of their professions and the interpersonal relationships with providers. The interactions with health providers and clients' reverence for certain provider types were deemed facilitators of CHTC because clients would be more apt to follow a clinician's recommendations for CHTC. “Many people already see [clinical] providers on a different level and may be more inclined to participate if they are offering [CHTC]” (Nonclinician, 3 years).

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Environment Domain: Attributes of the Health Care Environment

The environment domain is concerned with the saliency of proximal and distal ecological structures and contexts that sustain, impede, or enhance health promotion and attainment. Narratives regarding the environment domain embodied sentiments about the physical, social, and policy environment where one practices and the health care system in general. From the particularistic perspective, environmental characteristics included interpersonal attributes within the environment, expectations of and constraints on provider scope of practice, and organizational and institutional norms of health care delivery that could influence CHTC.

… as far as the logistics are concerned we already have the capability to schedule patients at the same time, we really just need to do that. I think we also need clinician buy-in because a lot of times people get a little nervous when they have a double-booked schedule. (Nonclinician, 8 years)

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Space and timing of HIV services within the health care setting

Some providers reported that they had the physical space to accommodate another person in a consultation room to jointly screen and counsel couples, and therefore, they could implement CHTC in the clinical space. “… it would be pretty easy to do it here actually because we have the people, we have plenty of people. We have room here and there is space and we encourage testing anyway … especially if there is a couple” (Clinician, 6 years).

Temporal characteristics in the health care environment that providers reported could facilitate CHTC included routinization of health promotion practices within the health facility. Some providers reported that their workplace had adopted a model of care that incorporated routinized HIV screening as part of an existing patient's annual visit or within wellness health services for newly enrolled patients. Participants reported that this model welcomed partners in health care visits. Providers also reported comfort with consulting and addressing couple-based issues during these visits, thus providing an opportunity for CHTC.

… it's [CHTC] not that big of a deal … it will probably have to do with how our scheduling works because we usually book people separately …. So there might be some scheduling issues if it was within our clinic, but as far as doing the [CHTC] that's not a problem at all. It would be more of an issue of scheduling more than anything else. (Clinician, 6 years)

Provider role beliefs also manifested in narratives regarding the perceived length of time typically allocated for consultations by certain provider types and the estimated time commitment CHTC would require. Existing consultation time limits were perceived to impact CHTC provision for certain provider types.

… I think you need more time than 15 minutes …. I would say you would need someone who's more like doing treatment modalities, whose spending like 45 minutes, like a psychologist, like a substance abuse counselor or a licensed social worker. (Nonclinician, 12 years)

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Structural and logistical constraints on couples' HIV testing and counseling uptake

Certain clinicians were unable to conduct HIV testing within an HIV care clinic or for the partner of an index patient due to structural barriers that would impede provider scope of practice. The structural barriers were perceived to be part economical and legal in nature and warranted consideration. One provider specifically pointed out that much of her client population were women who were coupled with low-income and/or unemployed men. The lack of health insurance for male partners was identified as a potential structural barrier to CHTC. Another participant reported potential challenges in CHTC uptake in designating who is the actual patient, in tandem with the provider's ability to bill for services and client insurance coverage.

The provider can't see a patient without financial screening, accessibility, insurance approval …. Before they even make the appointment they need to say, “they're both there for couples testing” … it is not a matter of paying, it is a matter of me as a clinician. I am not allowed to probably discuss anything of health in my office if you are not my patient. So it is not just who was going to pay for it, it is more regulation. (Clinician, 12 years)

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Model of care influences on couples' HIV testing and counseling uptake

Some providers reported that the model of care in their facilities would allow partners to screen for STDs, including HIV infection, and hence could logistically facilitate CHTC. Certain providers noted that in the event a couple wanted to be screened for HIV infection, non–clinical providers were available to do so. The availability of an alternative funding stream for health promotion services for underinsured/uninsured patients was thought to potentially facilitate CHTC. Also, the availability of varying provider types (including nonclinicians) would produce an option for billing couple-centered HIV services for the underinsured/uninsured client. The utilization of diverse health providers in HIV prevention and care demonstrated a model of care that implemented a team-based patient-centered practice approach to meet client needs. The availability of such services was perceived to be necessary and best suited to implement CHTC.

… all around wraparound services … you may need a psychiatrist, psychologist, the client may end up in a depression because of the results, or the doctor because they need to read his labs and say well you need to get on these type of medicines, the counselors because they're going to need to talk about their feelings and what went on, the case manager … needs to organize all your appointments. So you would need the whole team of them, I would say something like a FQHC [federally qualified health center], like us. (Nonclinician, 12 years)

These settings were also perceived to be patient centered and family oriented, indicating a conceptual understanding that individual health incorporated healthy interpersonal relationships and that couple-centered approaches to sexual health addressed an interpersonal relationship that warranted attention. A model of care that optimized interprofessional approaches to health and varied expertise to reinforce services and address an array of couples' needs was seen as a facilitator for CHTC.

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Holistic Perspective and Recommendations

Although the focus of our inquiry was on provider perceived facilitators and barriers to CHTC (a particularistic perspective), providers also reported on broader issues in HIV prevention and the U.S. health system more generally (Table 2). These viewpoints provided a more holistic outlook that participants deemed as potentially having an influence on subsequent uptake of CHTC. Further demonstration of the holistic perspective is presented in Table 2.

Table 2

Table 2

Providers spoke to client demands for couple-based services as a facilitator for CHTC. Providers noted that patient/client dislike for existing health-related services problems in the U.S. health system, such as wait times and health costs, would be, by extension, a barrier to CHTC. Within the practice domain, providers spoke about their comfort addressing sexual health with patients/clients and that couple-based approaches would be an evolution in their practice. Participants also noted that, on the contrary, some providers were uncomfortable engaging or were not adequately trained to engage patients/clients in sexual health conversations. They noted that some providers simply refused to engage with certain patients/clients or to see certain types of patients. It was perceived that these provider attributes might be barriers to CHTC. Finally, within the environment domain, multiservice health settings that were able to provide interprofessional services were perceived to facilitate CHTC, whereas health settings that were perceived to constrain provider practice via time or resources were seen as barriers to CHTC.

In tandem with the holistic perspective, providers posed recommendations for implementation of CHTC within each domain (Table 3). Provider recommendations incorporated both particularistic and holistic perspectives. In the client domain, providers noted that CHTC should be for all couple types regardless of gender or sexual orientation and that couples were self-defined. Furthermore, CHTC required a tailored approach for each couple to meet couple-based goals for joint sexual health. Providers also stated that provider humility was essential to engage couples of varying types and to meet couples' needs. In tandem with these provider efforts, health settings must reiterate and reinforce particular provider attributes in order for CHTC to be successful.

Table 3-a

Table 3-a

Table 3-b

Table 3-b

Providers recommended that the health environment for CHTC implementation should have existing and robust HIV-related prevention and treatment policies and procedures. Finally, CHTC should be promoted by settings serving in U.S. jurisdictions and communities where the HIV seroprevalence or incidence is high. Couples' HIV testing and counseling could also be optimized in services that incorporated HIV screening as part of the delivery of services (i.e., maternal care).

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Discussion

The typology used to categorize findings in our study elucidated multilevel ecological factors perceived to influence CHTC integration in U.S. clinical settings. Findings not only revealed perceptions of potential facilitators of and barriers to CHTC but also revealed areas of need in HIV-related health promotion in U.S. clinical settings and specified organizational capacity considerations required for successful CHTC implementation. Provider recommendations for CHTC implementation based on perceived facilitators and barriers involved both the broader holistic perspective and elements specific to a couple-based practice within the three domains.

The client domain demonstrated provider knowledge of client characteristics and norms that could influence CHTC implementation. Insights within this domain demonstrated current efforts and opportunities providers used to engage couples. Such insights can inform CHTC tailoring and help ensure that education messaging required for certain couples assists with understanding the benefits of CHTC. This is needed, particularly in the context of innovative sociobiomedical approaches such as PrEP and improvements to ART.

Findings within the client domain demonstrated the need to improve incorporation of male and men's health in primary care. Challenges to engage men in HIV prevention in general (Fleming, Colvin, Peacock, & Dworkin, 2016), and male partners specifically, have been common in partner-based HIV prevention efforts globally (Fleming, DiClemente, & Barrington, 2016; Tao et al., 2015). Couples' HIV testing and counseling requires tailoring interventions with male partners' unique challenges in mind. This consideration can help to prevent lateral and vertical HIV transmission and community and social networks, which increases vulnerability to HIV acquisition. Routinized HIV screening of male partners of expectant women or women seeking maternal HIV services may be warranted in U.S. facilities in high-seroprevalence jurisdictions. Although this approach is used in global health settings, it is not often practiced in high-prevalence U.S. settings (Lee & Mitchell, 2018). Despite these challenges, couple-based approaches have demonstrated that men are willing to engage in couple-based HIV prevention approaches in the United States (Lee & Mitchell 2018; McMahon et al., 2015; Stephenson et al., 2015). The perspectives in this domain also revealed the need to promote male sexual health in order for men to comprehend and achieve agency, irrespective of sexual orientation, to reduce vulnerability for HIV acquisition. The literature has cited the lack of HIV prevention geared toward heterosexual men, which impacts women's vulnerability (Leal, Knauth, & Couto, 2015). Our findings suggest a demand for CHTC that is currently unmet by U.S. HIV prevention services. This demand should signal the need for HIV prevention and care services to consider program enhancements that would facilitate couples' on-demand requests for CHTC and other couples-based services (integrated PrEP and ART service delivery) when warranted.

Within the practice domain, participants reported comfort and confidence with engaging couples in general and noted that they personally were able to implement CHTC. Some provider role beliefs about CHTC appeared to have more bearing on the provider type that should implement CHTC due to time constraints, billing of services, and facility mandates rather than actual provider skills. Provider training and skill was not perceived to be a barrier to CHCT in and of itself, but in tandem with the service CHTC was perceived to be (focused on relationship building rather than prevention of disease transmission) and the time required for CHTC, which might challenge a clinician to commit in certain health care settings. This finding was aligned with the existing literature that has cited perceived time constraints and other organization attributes as influencing provider perceptions and/or adoption of more holistic HIV prevention and treatment efforts (Barroso, Leblanc & Flores, 2017; Krakower & Mayer, 2016; Leblanc, Flores & Barroso, 2016). Although provider demographics such as gender or years in practice were not reported as having bearing on CHTC implementation, the literature in the United States regarding provider practice in HIV prevention and treatment has found that such demographics can be influential in patient/client engagement in health care (Earl et al., 2013; Stringer et al., 2016) and, hence, should be considered in CHTC implementation.

Narratives revealed that the health care environment could facilitate health provider efforts or restrict their scopes of practice in implementing CHTC. Provider roles in this context were, in part, related to services rendered and how they were financed, given organizational fee structures and funding streams used to support specific health promotion services. For example, providers reported that complex patients may require more than a 15-minute health visit, which was perceived as a constraint that could have bearing on couple-based consultation. This insight is consistent with the environmental features of health care settings that have been reported by providers as perceived barriers in the adoption of innovative HIV prevention interventions (Flores, Leblanc & Barroso, 2016; Krakower & Mayer, 2016; Leblanc, Flores, & Barroso, 2016). Additionally, current changes in the U.S. health insurance scheme can impact who seeks sexual health services and where sexual health services are provided (Pathela et al., 2015), which can have implications on the implementation of CHTC. The considerations providers revealed within the environment domain were pervasive in health settings and have been well documented in the health care literature (Flores, Leblanc & Barroso, 2016; Lakshmi, Beekmann, Polgreen, Rodriguez, & Alcaide, 2018; White et al., 2015). Likewise, organizational practices of routinized HIV screening, family-oriented care, and interprofessional team approaches to care were viewed as characteristics of the health care environment that would facilitate CHTC implementation. The literature on organizational factors has also supported interprofessional collaboration and the creation of new roles for health professionals to optimize HIV screening and HIV care given the complexities of health care needs in people living with HIV and other vulnerable populations (Chapman & Blash, 2017; Maina, Mill, Chaw-Kant & Caine, 2016; Malcarney, Pittman, Quigley, Horton, & Seiler, 2017).

To facilitate CHTC in clinical facilities, providers identified factors in each domain that should be considered to meet the existing demand for couple-based HIV prevention and sexual health promotion. Overall, in our study, participants endorsed a need to enhance elements of HIV prevention services that have proven beneficial in optimizing the HIV care continuum to facilitate CHTC implementation in clinical settings. As the findings suggest and the literature on HIV-related care supports, provider perceptions that support innovation and the capability to engage in the approach, in tandem with a health setting that employs an interprofessional approach, were seen as best practices and facilitators to CHTC (Maina et al., 2016).

We used a descriptive qualitative design to allow perspectives to emerge not only as prompted by research questions but also as warranted by what participants deemed necessary to report. Efforts were made to ensure that a rigorous approach was used to address study aims and illuminate the findings pertinent to the research question. Despite these efforts and the approach used, there may have been limitations to the study that deserve mentioning. The first limitation was that most participants required a briefing about CHTC and narratives were, therefore, a result of participant subjective interpretations of a health service they generally lacked experience using. However, this was offset by providers reporting experience using a nonformal approach to engage couples in general health or HIV-related care and possessing substantial experience engaging people in the HIV care continuum. Second, the providers who agreed to participate in our study were independently forthcoming, and the sampling of providers was from facilities in which there was some routinization of HIV testing, treatment, and/or care. Our recruitment approach may have produced a biased perspective on the topic, but insights from study participants with expertise and with diversity in provider types offered holistic and nuanced perspectives on potential facilitators and challenges in U.S. clinical settings that may prove salient in other facilities and jurisdictions.

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Conclusion

The benefits of CHTC have long been established and endorsed (Centers for Disease Control and Prevention, 2012; World Health Organization, 2012). Couples' HIV testing and counseling is an opportunity to maximize innovations in HIV prevention and treatment for all couple types, has the ability to address current gaps in each phase of the HIV care continuum (Wall et al., 2017), and serves as an opportunity to facilitate PrEP uptake among those who are eligible (Morton et al., 2017). As with individual engagement in the HIV care continuum and PREP uptake, provider buy-in, provider practice, and health setting factors will be influential to CHTC implementation, thus warranting research in this area. Provider perceptions are important to ascertain for the success of health promotion strategies because their insight commonly gives purview to the processes and the environment of the health setting that can facilitate translation of health strategies into health settings. Findings from our study aimed to address the gap in CHTC research, document U.S.-based health provider perspectives on facilitators and barriers to CHTC, and inform CHTC implementation in U.S. health settings. Provider reports entailed reflection on personal experiences engaging partners in the HIV care continuum. Narratives suggested that current U.S.-specific health system facilitators and challenges will have bearing on CHTC uptake in the United States. The perspectives provided in our study not only shaped the problem of couple-based HIV vulnerability but also identified elements to promote CHTC. Overall, the findings suggested that implementation of CHTC in a U.S. clinical setting was feasible and that recommendations for implementation require broader considerations for HIV prevention service delivery in the larger U.S. health care system.

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Key Considerations

  • Couples' HIV testing and counseling (CHTC) is a dyadic approach that is effective in reducing HIV acquisition in couples and retaining people living with HIV in care. However, adoption of couple-centered HIV prevention interventions are not well established in the United States.
  • Routinized HIV screening of male partners of pregnant women or women seeking maternal HIV and/or STD services may be warranted in U.S. facilities in high seroprevalence jurisdictions.
  • Organizational practices of routinized HIV screening, family-oriented care, and interprofessional team approaches to care would facilitate CHTC implementation.
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Disclosures

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

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Acknowledgments

We would like to acknowledge Drs. Joseph DeSantis and Victoria Mitrani at the University of Miami School of Nursing, Dr. Rosa Gonzalez-Guarda at the Duke University School of Nursing, and Dr. Julie Barroso at the Medical University of South Carolina School of Nursing. We would like to acknowledge the health providers who lent their perspectives and participated in this study and the patient populations they served. We would also like to acknowledge the School of Nursing University of Rochester Qualitative Research and INSHHR Groups. Dr. Leblanc would like to acknowledge the Florida Educational Fund McKnight Program for their support. This manuscript's development was supported by a postdoctoral fellowship to the first author from the University of Rochester, School of Nursing and by the University of Rochester Center for AIDS Research (NIH P30AI078498; PI: Stephen Dewhurst).

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Keywords:

content analysis; couples HIV testing and counseling; health care providers; qualitative descriptive design

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