myHIN Blog

March 20, 2013

The Need for Couple-based HIV Interventions to Empower African American Women in Monogamous Relation

African American women continue to be disproportionately affected by HIV/AIDS. According to the CDC (2012), African Americans represent approximately 14 percent of the U.S. population, but they account for almost half of people living with HIV (44 percent, or an estimated 510,600 persons), and of new infections each year (44 percent, or an estimated 21,200 infections). African American women account for 30 percent of the estimated new HIV infections among all African Americans and 57 percent of all new HIV infections among women. The estimated rate of new HIV infections for African American women are more than 15 times as high as the rate for white women, and more than three times as high as that of Latina women. Perhaps most disturbingly, the CDC (2012) estimates that one in every 32 Black women will be diagnosed with HIV during their lifetime.

Most of these African American women (85%) will be infected through sex with a male partner.

While conducting focus groups with African American women undergraduate students, I’ve found that many desired information about HIV prevention while in committed, monogamous relationships with men. Much of the HIV prevention discourse places the burden on the woman to convince her partner to use condoms. However, this is extremely difficult even when the woman and her steady sexual partner want to mutually protect each other. How can we lessen this burden and keep our young women protected?

My suggestion is that we create more interventions that focus exclusively on heterosexual African American couples. The Eban HIV/STD Risk Reduction Intervention (2009) is an example of a project that was designed to address individual, interpersonal and community level factors that contribute to HIV/STD transmission risk behaviors among heterosexual African American couples. The project used both couples and group discussion sessions. The intervention included modules that focused on culture and race, and used African American co-facilitators. These factors helped couples feel more comfortable disclosing risky behaviors and facilitated learning prevention strategies that were consistent with the couples’ cultural values.

Other HIV prevention studies have found that voluntary counseling and HIV testing provided to couples was more effective at increasing condom use than was individual counseling and testing. In one of the first studies to evaluate a couple-based voluntary counseling and HIV testing studies in the US, Padain and colleagues (1993) report that couple counseling in combination with social support appears to be an effective means to promote and sustain behavior change among HIV-infected individuals and their heterosexual partners. Nearly half (49%) of the couples reported consistent condom use before the intervention, but 88% reported consistent condom use at the first follow-up. Unfortunately, consistent condom use was not maintained at this high level during follow up meetings with the couples. El-Bassell and colleagues (2003) were among the first to conduct a study to test the efficacy of a relationship-based HIV/STD prevention intervention with low-income urban couples in the US. They found that couples meetings helped to reduce unprotected sex at both the 3-month and 12-month follow-up assessments.

Taken together, studies such as these suggest that couple-based interventions may be an effective means for reducing African American women’s risk of contracting HIV. The Eban HIV/STD Risk Reduction Intervention (2009) and similar studies report that couples-based counseling is an effective means for increasing commitment in a relationship to protecting each other from HIV/STDs; reducing gender power imbalances that influence condom use; and increasing sexual communication and negotiation skills.

There are also strong arguments for focusing on heterosexually active women, especially when 85% of African American women are infected through sex with male partners. HIV is also “more efficiently” transmitted from men to women, and issues of gender and power make it very difficult for women to negotiate condom use easily with heterosexual partners.

Couple-based interventions are also important for showing how gender and power frameworks advance our understanding African American men’s HIV risk. Dr. Bowleg (2011) correctly asks: where are the heterosexually active men in HIV prevention theory, research and interventions? “While same-sex behavior is salient for men in the HIV/AIDS epidemic, a similar focus on men’s heterosexual behaviors is pretty much nonexistent. In the context of the HIV/AIDS epidemic, maleness and heterosexuality, two otherwise powerful statuses, intersect to confer the dubious privilege of invisibility.” To render heterosexual African American men visible and to lessen the burden currently placed on their female partners to negotiate condom use, public health professionals should develop couple-based interventions.