Improving PrEP adherence by leveraging the strengths of male couples’ relationships: the “Couples PrEP” Study

Male Couple

Men who have sex with men continue to be the highest risk group for HIV transmission in the United States.1 A large proportion of new HIV infections among men who have sex with men (between one- and two-thirds) are attributed to sexual contact with primary or main partners.2,3 Understanding the contexts of men’s sexual and intimate relationships may help improve the efficacy of prevention interventions.4-6

While antiretroviral pre-exposure prophylaxis (PrEP) has been shown to be a promising biomedical HIV prevention strategy for many men, the efficacy of oral PrEP regimens depends on taking the medication consistently, often referred to as adherence.7-11 Although some individual- and structural-level barriers to PrEP adherence have been identified, limited research has examined the experience of using PrEP—including barriers to and facilitators of adherence—within the context of male-male couples’ intimate and sexual relationships. A new research study funded by the Harvard University Center for AIDS Research was designed to identify relationship factors among male-male couples that could be leveraged to optimize PrEP adherence.

Conducted at Fenway Health, the “Couples PrEP” study is seeking to conduct qualitative interviews with approximately 20 male-male couples in which at least one partner has used PrEP in order to learn about PrEP experiences within the context of a relationship. Couples PrEP is also interviewing some couples in which at least one partner is interested in starting PrEP. These qualitative interviews will be conducted with both partners together in the same room to allow partners to share their experiences together. A small number of individuals (not in couples) may also be recruited separately (without their partner) if they have experience using PrEP in a previous relationship context.

All of the qualitative interviews for Couples PrEP will explore couples’ attitudes toward and experiences using PrEP, including any barriers to PrEP adherence (things that got in the way of consistent use) and facilitators of PrEP use (reminders, communication within relationships).  These data will be used to develop and pilot test the first-ever couples-based PrEP adherence intervention with approximately 10 male-male couples.

Existing studies of PrEP attitudes, acceptability, and use among men who have sex with men have focused almost exclusively on individual-level factors.12 By conducting in-depth qualitative research into the relationship dynamics that may influence PrEP acceptability, uptake, and adherence, data resulting from Couples PrEP may provide useful insights into how to improve PrEP adherence among high risk men who have sex with men. Furthermore, few studies have explored male-male couples’ relationship dynamics or contexts with the objective of developing a culturally relevant behavioral intervention. Couples PrEP findings will inform the adaptation of Life-Steps13,14 an existing, efficacious HIV treatment adherence intervention developed by Fenway Health’s Dr. Steven A. Safren for HIV-infected individuals. Couples-based interventions to improve PrEP adherence among MSM have not been developed; thus, this study will be the first to explore and pilot test this approach.

Men who may be eligible to participate in the Couples PrEP research study must meet the following criteria (other criteria may apply):

  • 18 years or older;
  • Born biologically male and identify as male;
  • Involved in a committed relationship with another man for at least 3 months (OR an individual in a previous committed relationship that lasted 3 months or more); and
  • At least one partner must have experience using PrEP, be currently prescribed or using PrEP, or strongly interested in using PrEP.

Couples may be either sero-discordant (each partner has a different HIV serostatus) or concordant negative (both partners are HIV uninfected) in order to participate. All interested couples are encouraged to request more information about Couples PrEP by emailing Jowanna Malone at jmalone@fenwayhealth.org or calling 617-927-6436.

These research efforts are being conducted at Fenway Health in Boston and led by Principle Investigator Angela Robertson, PhD, MPH, with co-investigators Matthew Mimiaga, ScD, and Ken Mayer, MD, and Research Assistant Jowanna Malone.


References

1.    Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One. / 2011;6(8).

2.    Goodreau SM, Carnegie NB, Vittinghoff E, et al. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS One. / 2012;7(11).

3.    Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 06/01 2009;23(9):1153-1162.

4.    Beyrer C, Sullivan PS, Sanchez J, et al. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 07/28 2012;380(9839):424-438.

5.    Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet. Aug 23 2008;372(9639):669-684.

6.    Sullivan PS, Carballo-Dieguez A, Coates T, et al. Successes and challenges of HIV prevention in men who have sex with men. Lancet. 07/28 2012;380(9839):388-399.

7.    Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. Dec 30 2010;363(27):2587-2599.

8.    Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science (New York, N.Y.). Sep 3 2010;329(5996):1168-1174.

9.    Karim SS, Kashuba AD, Werner L, Karim QA. Drug concentrations after topical and oral antiretroviral pre-exposure prophylaxis: implications for HIV prevention in women. Lancet. Jul 16 2011;378(9787):279-281.

10.  Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA. Aug 9 2006;296(6):679-690.

11.  Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection among African women. The New England journal of medicine. Aug 2 2012;367(5):411-422.

12.  Young I, McDaid L. How acceptable are antiretrovirals for the prevention of sexually transmitted HIV?: A review of research on the acceptability of oral pre-exposure prophylaxis and treatment as prevention. AIDS Behav. Jul 30 2013.

13.  Safren SA, Otto MW, Worth JL. Life-steps: applying cognitive behavioral therapy to HIV medication adherence. Cognitive and Behavioral Practice. //Autumn 1999;6(4):332-341.

14.  Safren SA, Otto MW, Worth JL, et al. Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring. Behaviour research and therapy. Oct 2001;39(10):1151-1162.

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