Adaptation of a Couple-Based HIV/STI Preventive Intervention: Moving From Heterosexual Couples to African American Same Sex Male Couples

BACKGROUND & PURPOSE: New interventions are needed to address both emerging trends as well as longer-standing disparities in HIV risk and transmission among men who have sex with men (MSM), such as the impact of methamphetamine use and the elevated rates of HIV/STIs among African American MSM respectively. While couple-based sexual risk reduction interventions have been shown to be efficacious, prior couple-based risk reduction research has been conducted almost exclusively with heterosexual couples. We sought to adapt an existing, evidence-based intervention (EBI)—originally tested with heterosexual couples—for a new target population consisting of African American MSM in a longer-term same-sex relationship where at least one partner is a methamphetamine user. The adaptation process was constrained and shaped by several challenges: limited time, a lead investigator who is phenotypically different from the target population, a dearth of information on the experiences and worldviews among the target population, and a concomitant lack of topical experts.

METHODS: A series of 6 focus groups was conducted with 8 couples from the target population. Earlier focus groups were designed to elicit worldviews and experiences, while later focus groups presented existing intervention activities and study protocols in order to solicit and elicit feedback and ideas on how to enhance the relevance, engagement, and safety for African American, methamphetamine-involved male couples. We also developed a visualization tool to ensure that the adaptation process maintained adherence to the theory and core components of the original EBI.

RESULTS: Participants shared detailed couple-based dynamics stemming from the intersection of race/ethnicity and sexual orientation/identity: sexual objectification of African American men; stigma about receptive anal sex; and a hypervigilance or persistent attention to the fluidity of racial and sexual identity within or outside white racial norms, heterosexual norms, or both, depending on social context. Participants linked these issues to methamphetamine use via psychological disinhibition, cognitive dissociation, physiological effects, and perceptions of methamphetamine as a white gay men's and/or expensive drug (i.e., a means of distancing from negative stereotypes of African American MSM for some, while others enjoyed being part of a special niche of methamphetamine users who are African American). All couples described links between methamphetamine use and HIV/STI transmission risk (e.g., unprotected sex, multiple partners, HIV-positive partners). Conflict between partners often appeared to stem from their differences with respect to methamphetamine use, recovery, physiological sequelae, and drug-driven HIV risk. Participants strongly endorsed revision of intervention activities/content that enhanced couple communication specifically on these issues, as well as and lack of visibility of healthy African American male couples.

CONCLUSIONS & IMPLICATIONS: In situations with very limited existing knowledge about a new target population, holding multiple focus groups with the same participants can explore a large number of issues/topics in greater depth than the alternative of multiple focus groups with different couples. The additional trust and rapport built over time may enhance the efficiency and ability to incorporate the worldviews and experiences throughout the adapted intervention, as well as revising content to enhance the salience of language, presentation, and individual exercises.