‘There are so many things that can’t be answered by a 15-minute doctor’s visit. We need behavioral approaches to help increase the uptake of our biomedical interventions.’
Ah, love. So much heartache. What’s the secret to a good relationship?
More than a decade into HIV prevention work, Michael Newcomb and his colleagues found that romantic relationships among gay men were actually driving infections. Not Grindr, not MISTER, not gay bars. It seemed strange, but other researchers were finding the same thing.
Yet in his work, what gay men told Newcomb they wanted was to learn how to get and keep a boyfriend, and have a healthy relationship, not just hear about HIV.
What’s a smart researcher to do? Combine the interests of the men with the imperatives of HIV prevention and—voilà! The 2GETHER Couples Project study was born. Funded by the National Institutes of Health, the program helps men, whether HIV positive or negative, work on their relationship together, both as a couple and in a group with other male couples. It helps them learn skills for intimacy, enjoy healthy sexuality, and work through a relationship agreement to guide their future.
“We had observed in our studies that the most common predictor of whether or not someone becomes HIV positive is being in a serious romantic relationship,” said Newcomb, PhD, Assistant Professor, the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University’s Feinberg School of Medicine, in Chicago. “At first when we first started to see this it was very surprising because the predominant idea as to where most HIV infections were coming from was from hooking up; people that you met at a bar or online or something like that, people you don’t know. The truth is, our prevention message got across that if you meet somebody, if you don’t know anything about them, that you should be more careful with those partners and use condoms or other prevention methods. So, people were doing that very well.
“Our other message at the time was if you are in a relationship, then that’s a place where you can let your guard down, enjoy sex without a condom. Unfortunately, what often happens is that, particularly among young people, many if not most young people who are HIV-positive don’t know that they are HIV-positive, because they haven’t been tested recently,” explained Newcomb. “What that leads to, when they get into a relationship and they stop using condoms with their partner, is the potential for HIV transmission. So we started to think, ‘Wow, what is the prevention message here?’ It’s not easy to convince couples to use condoms, because one of the benefits of being in a relationship in terms of sexual pleasure and intimacy is having sex without a condom. That’s not a great prevention message.”
There’s a control arm to the study, providing couples in that part of the study participation in a program that’s well-established in showing improvements in people’s mental health and wellbeing. So whether couples are randomized to the 2GETHER program or its control arm, they are receiving the same amount of time and attention. Yes, the study is aimed at showing reductions in new HIV infections and STIs.
“I love the fact that these are programs that are open to anyone regardless of HIV status,” said Jim Carey, MPH, the 2GETHER lead facilitator and a Research Project Coordinator at the Institute. “A lot of RCTs [randomized controlled trials, or studies] have been focused on HIV-negative people and how to help them stay negative, which is fantastic, but I feel like that’s leaving an entire piece of the population out of the equation. So the fact that people can participate regardless of HIV status, regardless of how they identify their relationship—whether they are open or not or somewhere in-between—I think it’s a more comprehensive approach to meeting the population where they are.”
2GETHER reviews the current biomedical prevention methods used against HIV, most specifically PrEP use by men who are HIV-negative, and the use of TasP (treatment as prevention) by men living with HIV.
“We’re integrating both primary and secondary HIV prevention, so prevention for negatives and positives into the same program,” said Newcomb. “It’s so important particularly in the context of the big shift to biomedical prevention strategies. With all that we know now with the effectiveness of PrEP and also the effectiveness of viral suppression on reducing HIV transmission, we’re at the point where we can talk to everybody at the same time, rather than segmenting prevention into either prevention for negatives or prevention for positives.”
This also means they get to talk to everyone about adherence to medication, taking the pressure off of those living with the virus. “That’s really what’s the same in the HIV field as it is in every other health condition—that there’s no magic bullet to fix things,” said Newcomb. “We can’t just provide someone with a medication and assume that it will go perfectly after that. In order for medical interventions to be effective they need to be paired, for many people, with behavioral interventions as well that address those barriers. It’s about things like stigma, but it’s also addressing access to resources, access to PrEP, improving people’s knowledge about what PrEP actually does. There are so many things that can’t be answered by a 15-minute doctor’s visit. We need behavioral approaches to help increase the uptake of our biomedical interventions.”
The program finds that among other things, couples come in thinking that they know how to communicate well with one another—and then discover that they don’t.
“The truth is that people are very different in the way that they communicate. People can be effective at communicating if they are quiet, if they are very verbose—you can be effective no matter what your communication style is,” said Newcomb. “We just try to improve the manner in which each couple is communicating based on what they bring to the session. It’s the same set of skills, just applied to each couple’s individual needs.
“Ultimately, at the end of the program, we help the couples build what we call a relationship agreement. That agreement details first the conditions under which it’s acceptable to have sexual partners outside of the relationship—if at all—and then, depending on the agreement that they have with their partner, we layer on top of that specific prevention methods that are tailored to the agreement that they have,” Newcomb said. “So those prevention methods could be using PrEP. If folks are HIV positive, then reducing viral load so that people are virally suppressed, as well as things like condom use and more frequent use of HIV and STI testing and things like that.”
For whatever couples need that is outside the realm of the project, they receive referrals, such as for HIV testing or PrEP prescriptions. Study staff finds that the men are happy to receive information about PrEP and referrals for other services.
Carey recalls the day when, as an undergrad, he made a presentation on HIV prevention that included a large bin of condoms for student use. He was happy to find the bin empty the next day—until someone told him another professor had thrown the condoms away so that students wouldn’t be tempted into having sex.
“People are not having sex because they have a condom,” said Carey. “You’re giving them the option of using a condom if they do have sex. I always compare the stigma conversation around PrEP to the exact same conversation when birth control pills were released in the ’60s. The argument back then was that, It could make women promiscuous! And, It could make sex about pleasure! And that, They’re going to have more partners! It actually turned out not to be case. It just gave them more options. So I present PrEP much the same way, especially considering it’s mainly more higher-risk individuals that are likely to take it. It’s actually designed for that population. Most of the time they’re probably not using any other prevention method to begin with, so we should give them more tools to put in their toolbox. It’s like a lifejacket. You could wear a lifejacket to prevent anything from happening or you could say, ‘Oh, if you fall in the water, that’s your own problem. You’ll just have to deal with it.’ That makes no sense whatsoever.”
Added Newcomb, “So many people don’t think they’re at risk.” He knows, however, that HIV prevention education may change community standards—what people believe is acceptable and expected.
“We know norms have a big influence on people’s behavior,” Newcomb said. “It’s easier to play the blame game and point the finger at someone else. The truth is that norms have an influence on older people as well as younger people.”
National videoconferencing for love and wellness: The 2GETHER program has a national component available to gay male couples across the country, operating via videoconferencing. For more information, email the team at 2gether@northwestern.edu or text 2GETHER to 773-340-9825. Follow 2GETHER Couples Project on Facebook and on Instagram.