Focus group discussions and pilot study findings provided some understanding of how the intervention could teach and strengthen couples’ relationship skills. The pilot study provided insight into effective recruiting of HIV-serodiscordant couples, and methods of maintaining collaborations with service-providing CBOs that provide referrals to the study. The pilot also assured us that the questions asked were clear and that the intervention was informative, relevant, and entertaining to both woman and men participants.
The focus groups and pilot study confirmed that a Risk Reduction Intervention for African American serodiscordant couples is needed. Couples identified a lack of resources, both for the couple as a unit and for the HIV-negative partner, which often minimized the HIV-positive partner’s motivation to seek available services. Families of mixed-status couples sometimes did not know how to respond in a positive way due to misinformation about HIV and homophobic attitudes about the possibility that HIV-positive men may have become infected by male partners. These concerns contributed to the stigma and rejection that couples faced in their relationships. The couples perceived that the community-based agencies were willing and eager to help individuals, but lacked the infrastructure and staff needed to offer appropriate services. If proven effective, the Eban intervention could assist Community Based AIDS Services Organizations to better meet the couples’ needs in their communities.
Interviews with 32 couples and focus groups with 11 couples highlighted a contradiction between the couples' love and commitment to each other, the need to practice safer sex, their desires for a satisfying sexual relationship, and the skills needed to prevent HIV/STI transmission. The Eban intervention was aimed at clarifying these contradictions, maintaining the quality of relationships and utilizing the strengths of couples while increasing HIV/STI transmission skills.
The focus group and pilot study results also highlighted a contradiction between couples' high rates of unprotected sex, their fears about HIV transmission and guilt regarding the risk of infecting their partner. These couples were concerned about protecting their partner and experienced high levels of distress because they lacked resources and skills to maintain relationships. The findings are consistent with literature suggesting that psychological distress can interfere with condom use among HIV-serodiscordant heterosexuals,34
and point to the need for services and an effective intervention that addresses these issues.
Histories of intimate partner violence and child sexual abuse were common in the pilot sample. Child sexual abuse histories were particularly common in HIV-positive women. Histories of CSA can influence risky behaviors and condom use,8, 35
and experiences of IPV can interfere with the ability to negotiate condom use.9
The main trial will examine these histories as moderators of behavior change in couples. Future analyses in the main trial will also examine how these histories in either or both partners impact condom use, self-efficacy, and psychological adjustment.
Pilot data strongly suggest that the burden of being in an HIV-serodiscordant relationship may be greater for HIV-positive women and HIV-negative men. This trend is important to investigate in the larger clinical trial. We will also examine the extent to which the Risk Reduction Intervention has an impact on these mediating vulnerabilities.
Research should assess factors that influence the emotional adjustment of positive and negative partners in HIV-serodiscordant relationships. The greater vulnerability of HIV-positive women is consistent with previous literature.36
Among HIV-positive individuals, women reported lower levels of well-being and social support than the men, despite less advanced disease status.36
Because little research has been conducted with serodiscordant couples, however, we lack information about what to anticipate regarding the adjustment of HIV-negative men in such couples. In one HIV-infected couples study, women reported more distress than men regardless of serostatus.14
However, only 15 percent of that sample was African American. In the current predominantly African American sample, both positive women and negative men reported the most distress. We will examine whether HIV-negative men, particularly those who are African American, face greater rejection and pressure from family and friends to leave the HIV-positive partner. We will also examine whether negative partners who choose to stay with positive partners experience stress due to stigma and negative social reactions in the main trial.
We will assess whether roles of masculinity are particularly important for African American men, especially given the level of departure from violations of gender norms (such as the strain of caregiving for an HIV-positive partner, or sexual difficulties resulting from HIV). Women living with HIV tended to assume more responsibilities, including greater burdens of caretaking roles.1
Chronic stress may be experienced differently by men and women and be exacerbated by role-strain in the relationship due to caregiving.1
High caregiver burden has been associated with depression and poor health among caregivers of HIV-positive individuals.37
Recent research reports that compared to cancer caregivers, AIDS caregivers reported receiving less support from their families,38
a finding consistent with focus group themes. Stigma and lack of support may contribute to the strain of caregiving and depression39
and these relationships will be further examined in the main trial.
Future research should also focus on potential differences in social support for HIV-positive and -negative partners in serodiscordant relationships. Satisfaction with social support was slightly higher for HIV-positive participants in the pilot study. This is consistent with literature suggesting that family support is more limited for HIV-negative partners in serodiscordant heterosexual relationships, particularly for African Americans.40
HIV-negative partners in the focus groups found it difficult to access services in AIDS Service Organizations. The main trial will examine how serostatus influences the ability to find support that meets the needs of both partners in HIV-serodiscordant relationships. HIV-negative partners may experience high caregiver burden and may find themselves as the providers, rather than as recipients of support. They also may find it difficult to express their needs for support, feeling that their partner's needs are paramount. Social support will be examined as a moderator of the impact of the intervention in the main trial.
Focus group trends suggested that woman partners were the initiators in support seeking by discussing their experiences with a wider array of people (i.e., friends, partner, family) than did men.41
This trend is consistent with the literature on gender differences in support seeking42
and with research reporting that women in HIV-serodiscordant relationships report more family awareness and support than men.40
The differences in men's and women's coping with the common issue of HIV is also consistent with research on couples facing other common stressors.43
These relationships will be explored in a comprehensive way.
The African American couples in the focus groups and pilot study demonstrated a commitment and resilience in the midst of life challenges. Relationship stability will be assessed in the main trial. These preliminary results suggest that Risk Reduction Intervention involving African American serodiscordant couples is feasible and considered useful by couples. By implementing Project Eban, we hope to contribute to the creation of developmentally appropriate, culturally congruent strategies to empower African Americans affected by HIV to reduce STI risks while developing skills and maintaining relationships that can help couples face challenges together.