Couple-Centered HIV Prevention and Treatment: It's Time for Uptake in US Health Settings

In a renewed urgency to end the epidemic the Joint United Nations Programme on HIV/AIDS developed the 90-90-90 global treatment targets - benchmarks aimed toward galvanizing global public health efforts to eliminate HIV transmission.¹ In selected US jurisdictions, campaigns to end the epidemic (EtE) have incorporated the concept that sustained engagement in HIV care in tandem with consistent viral suppression allows people living with HIV to live a prolonged healthy life and to be incapable of transmitting HIV to others.² The concept embodies the belief that those with an undetectable HIV viral load are untransmittable (U=U) to others.³ The U=U campaign is specific to sex-based transmission and not modes (i.e. intravenous drug use) however certain HIV screening and care modalities can be a mechanism that encourages the concept of U=U to extend beyond those limitations.

Couple-centered HIV prevention and treatment is a dyadic approach to facilitate a couple’s engagement in HIV prevention and treatment together.⁴ It involves health providers’ provision of HIV/STD preventative services, joint consultation to self-defined couples with the intention of facilitating joint serostatus disclosure and integrating HIV prevention and treatment for a dyad. Couple-centered HIV prevention and treatment interventions have been shown to be effective and efficient in reducing HIV transmission and engaging people into the HIV care continuum (HCC)⁵ and have been instrumental in reducing both vertical and horizontal transmission.⁶ More recently couple-centered research in HIV prevention demonstrated the efficacy of pre-exposure prophylaxis for HIV (PrEP) as a biomedical intervention and the concept of U=U as a mechanism for understanding the importance of sustained engagement in treatment as prevention.^7,8 Longitudinal studies have further demonstrated that engagement in couples HIV testing and counseling (CHTC), a couple-centered HIV prevention and treatment strategy has resulted in significant decreases in extra-dyadic partners and STI incidence, facilitates entry into the HCC and sustained engagement in HIV care and treatment.⁶

Couple-centered HIV prevention and treatment optimizes the availability of advances in HIV testing technology and biomedical options for HIV prevention and treatment. ^{9 10} It also addresses the psycho-socio-behavioral elements of HIV transmission and support for people living with HIV. ^11,12 Despite the evidence, universal uptake of couple-centered HIV prevention and treatment in the United States has been slow. ^9,16-19

Specific recommendations brought forth by the EtE campaign calls for adopting innovative strategies to engage people into the HIV care continuum (HCC). In this report, we are calling for a concentrated effort to include within this renewed efforts to end the epidemic the availability and practice of couple-centered HIV prevention and treatment in the U.S. in order to address the current gaps in the HIV care continuum (HCC) and to achieve national and local HIV prevention and treatment goals. This concentrated effort would: 1) optimize current bio-medical and socio-behavioral interventions; 2) address the interpersonal nature of HIV acquisition and cultivate the positive role of social support for people living with HIV within couple-based care; and 3) offer considerations for couple-centered HIV prevention and treatment. The effort is informed by biomedical and psycho-socio-behavioral strategies and interventions²⁰ demonstrated to reduce HIV infection and supported by the literature, as well as existing frameworks^16,21 in HIV prevention and treatment.^12,16,22 We have outlined 4 main components to an integrated couple-centered HIV prevention and treatment effort: 1) Initiation of couple-centered HIV prevention and treatment either by a self-defined couple seeking joint HIV screening or a providers as part of routine practice or following a patient assessment; 2) Couples and provider awareness of couple-centered HIV prevention and treatment approaches, 3) Through a shared decision making process between the provider and couple an assessment would be made to determine the uptake of an appropriate joint sexual health strategy conducive to the couples needs or which may be clinically indicated, and 4) Depending on the joint sexual health strategy providers would monitor and evaluate the couple's adherence to the strategy.

Currently couples who seek joint HIV screening are denied services and therefore patient’s demands are not met. Health settings with these restrictions may want to re-consider their policies to allow couples seeking joint integrated HIV screening and treatment services, particularly settings that are located in jurisdictions with relatively high seroprevalence or whose clientele are, from an epidemiological perspective, the most affected by HIV infection. Therefore we conclude with considerations for translation of couple-centered HIV prevention and treatment in the US health settings at the couple, provider, and health setting levels.