Background
For a little more than a decade, considerable attention has been focused on the sexual health needs of sexual minority men (SMM) in same-sex relationships (including gay, bisexual and other men who have sex with men). The impetus for much of this work was provided by groundbreaking research that estimated 35-68% of new HIV infections among SMM were transmitted between main – or primary – relationship partners rather than casual sex partners [
2,
3,
32]. Risk for main partner HIV infection was particularly high among younger SMM, with estimates as high as 79% among those aged 18-29 years [
32]. These studies suggested that main partner HIV transmission risk may arise from the fact that SMM have sex with their main partners more frequently and are less likely to use condoms when having sex with their main partner. More recently, Starks et al. [
28] identified that partnered SMM are more likely to have sex with casual partners on days they also have sex with their main partners. The co-occurrence of these behaviors may also enhance shared risk for HIV.
In response to the observed need for dyadic sexual health interventions for this population, couples HIV testing and counseling (CHTC) – originally developed for heterosexual couples in African nations with generalized epidemics – was adapted for use with male couples in the United States [
4,
30]. CHTC is an 8-step intervention during which couples receive an HIV test together and learn their status together. The HIV tester also engages the couple in a discussion that reviews their current HIV prevention practices, clarifies their sexual agreement – and expectations around communication if the agreement were broken – and develops a shared HIV prevention plan with the couple.
More recent research supports the need for ongoing attention to this population. Evidence suggests that single SMM and those in non-monogamous relationships (where sex with casual partners is in some way permitted) engage in condomless anal sex (CAS) with casual partners at comparable rates [
22,
26]. Furthermore, there are indications that SMM in monogamous relationships (wherein partners have agreed to forego sex with partners outside their relationship) who break their agreement and engage in CAS with casual partners may actually do so more frequently than non-monogamous and single men [
22].
The use of illicit drugs has been consistently linked to sexual risk taking among SMM. In particular, the use of a number of illicit drugs (i.e., cocaine or crack, methamphetamine, ecstasy, ketamine, gamma-hydroxybuterate – GHB) has been associated with either the occurrence or frequency of CAS with casual partners across a range of studies (e.g., [
1,
15,
16,
22,
23]). In their recent paper, Starks et al. examined data from a sample of more than 65,000 SMM and found that this association was significant across relationship status and sexual agreements, though it was significantly stronger among single and non-monogamous men compared to those in monogamous relationships [
22]. Separately, Starks et al. [
28] have since observed an association between illicit drug use and CAS with casual partners in day-level data obtained from male couples.
Starks et al. [
20] posited that CHTC – which in its standard form involves the negotiation of a sexual agreement and joint HIV prevention planning – might provide an opportunity for male couples to develop consensus related to rules or limitations on drug use. Furthermore, they hypothesized that augmenting CHTC with supplemental communication skills training might also enhance its efficacy. The team developed a communication training (CT) video to deliver dyadic skills training following a standard Cognitive Behavioral modeling paradigm. They also developed a substance use module (SUM) wherein partners create a calendar feedback tool, which is subsequently debriefed using a brief dose of Motivational Interviewing (MI). The MI component is delivered following the framework for couples MI derived by Starks et al. [
24,
27].
Initial pilot results [
20] indicated that completion of the SUM alone was associated with statistically significant decreases in the odds of drug use (
B = − 3.62;
p = .03) and drug use related problems as measured by the Drug Abuse Screening Test (DAST-10) [
17] (
B = − 0.75;
p = .02) at 1-month post-intervention. While CT videos were not independently associated with reductions in drug use or DAST-10 scores; they significantly enhanced the long-term benefits of SUM completion. At 3-month and 6-month follow-up the SUM was only associated with significant decreases in the odds of drug use (
B = − 2.79;
p = .013 and
B = − 3.93;
p = .014 respectively) and DAST-10 scores (
B = − 0.64;
p = .01 and
B = − 0.79;
p = .003 respectively) among men who viewed the CT videos. In a direct comparison between the CHTC as usual condition and those participants who received both
We Test adjunct components (CHTC+SUM+CT video), the combined condition had significantly lower odds of drug use at 1- and 3-month follow up and significantly lower DAST-10 scores at all follow-up time-points.
While promising, the results of Starks et al. [
20] were limited in several ways. First, their study did not include biological markers for drug use and sexual risk taking to validate self-report responses. Second, the most distal follow-up was 6-months post-intervention. This was not sufficiently long enough to observe decay in the treatment effect for substance use outcomes. This limited the development of guidance or recommendations on the timing of CHTC-retesting with
We Test module delivery. The next step in this program of research is to conduct a full scale efficacy trial that incorporates the use of biological markers in addition to self-reported behavioral data and a more extensive follow-up period with an expanded potential to observe decay in the intervention effect.