Relationship skills can reduce the risk of HIV in young male couples

An online HIV prevention and relationship education programme developed by Dr Michael Newcomb and colleagues from Northwestern University is proving effective in reducing the risk of HIV in young male couples in the United States, a group disproportionately affected by HIV.

Using group sessions and couple coaching to teach relationship and sexual health skills to young male couples, 2GETHER improved relationship agreements, reduced rates of rectal STIs and reduced risk-taking behaviour in participants, as presented by the researchers in the Journal of Consulting and Clinical Psychology. 

Young men in ongoing same-sex relationships may stop using condoms or PrEP, be unaware of their HIV status, switch sexual positions and have non-monogamy agreements – all factors that can put them at risk of getting HIV. Binge-drinking and drug use are also linked with HIV-related risk-taking behaviour, including breaking relationship agreements and having condomless sex with external partners.

As a result, many new HIV transmissions occur within primary partnerships of men from sexual minorities, who may struggle to navigate relationships and engage with HIV prevention due to sexuality-related stigma, discrimination, and other personal challenges. Young gay, bisexual and queer men may have had fewer opportunities to develop relationship skills due to the unavailability of partners in traditional settings during their adolescence. Hence the importance of a couple-based programme that moves beyond addressing individual risk behaviours and addresses their needs as couples.

Between 2018 and 2020, the 2GETHER study recruited 200 couples of cisgender males between 18-29 years of age, who consider one another their ‘main’ partner. To be eligible, couples had to have oral or anal sex with each other, have condomless anal sex with other casual partners (or with a serious partner who had a different HIV status) and at least one of them reported binge-drinking or using illicit drugs. Their mean age was 26 years with most participants being White (56%), followed by Hispanic/Latinx (24%), most identifying as gay (81%) and the majority being HIV negative (68%).

Couples were split into two groups in a random process, based on chance alone. The 100 couples taking part in 2GETHER watched three 20-minute videos that addressed communication skills, coping with stress, relationship sexual satisfaction, and HIV transmission risk. To reinforce key concepts, they also completed three online group sessions on skills building led by a gender-diverse facilitator of 18-29 years of age, with a degree and experience in research or working with young people. Following group sessions, each couple completed two individual online coaching sessions aimed at implementing skills: one on communication and problem-solving skills, and the other on sexual health in relationships, adding to a total of around ten hours of online content.

The 100 couples in the control group had a single counselling session of existing public health content that varied depending on the HIV status of the partners. Those couples with negative or unknown HIV status received the CDC-endorsed Testing Together session, those living with HIV went through a medication adherence and risk reduction session, and serodiscordant couples received both protocols in a single session. Participants in both interventions completed surveys and took their own samples for chlamydia and gonorrhoea testing at baseline, with follow-up for different outcomes at 3, 6 and 12 months.

Before the interventions, 9.8% of couples in 2GETHER had a rectal STI compared with 8.9% in the other group. After 12 months, 0.0% of participants in 2GETHER tested positive for rectal chlamydia and gonorrhoea, whilst the control group remained at a 7.3% rate. Couples in 2GETHER also had significantly fewer condomless anal sex acts and partners at different points in time and were significantly more likely to have a relationship agreement (although they were also more likely to report breaking that agreement). The study showed no significant difference in HIV testing or PrEP use, no significant difference in relationship satisfaction or communication, and no significant difference in alcohol-related problems, but fewer marijuana-related problems.

Online programmes have the potential to reach sexual and gender minorities and reduce HIV risk, as proven by 2GETHER offering better outcomes than already effective public health interventions. However, future iterations of the online programme would benefit from a more diverse group of couples both in the demographics of the individuals and the nature of their relationships, as well as a greater focus on measuring the impact of communication on sexual behaviour and on teaching skills to reduce substance use.

2GETHER effectively combined relationship education and HIV prevention by teaching and creating space for young male couples to engage in conversations and make more nuanced decisions regarding their risk-taking behaviour and relationship agreements. The programme may have reduced the risk of HIV by providing the space and time for participants to learn, talk and reflect on their adaptive behaviours as a couple and the prevention tools that might work for them. This couple-learning approach may be beneficial in clinical and community settings where gay, bisexual and queer men engage in testing, treatment and care.