Stronger Together is an intervention that uses counseling to increase engagement in and improve the quality of HIV care available for serodiscordant male couples (i.e., only one partner has HIV). It was implemented and evaluated by three clinics, Emory University (Atlanta, Georgia), Fenway Institute (Boston, Massachusetts), and Lurie Children’s Hospital (Chicago, Illinois), from 2014 to 2017 with funding from the National Institutes of Health. Through three in-person and additional “booster” sessions over an 18-month period, Stronger Together gave couples a space to work with an HIV professional to improve treatment adherence and keep both people healthy. Stronger Together participants were more likely to adhere to antiretroviral therapy (ART) than those in a control group.
Atlanta, GA
Boston, MA
Chicago, IL
HIV prevention efforts have largely focused on addressing the risks associated with casual sex for gay, bisexual, and other men who have sex with men, with little focus on transmissions within primary partnerships. Research shows that one-third to two-thirds of new HIV diagnoses are transmitted between long-term partners, due to more frequent intercourse, especially receptive roles, and less condom usage.1 Additionally, gay, bisexual, and other men who have sex with men in long-term relationships are less likely to get routine testing for HIV, often resulting in delayed diagnoses and subsequent care.
Stronger Together uses the framework of Couples HIV Testing and Counseling (CHTC), a dyadic intervention that allows serodiscordant couples to build joint prevention plans. CHTC is a specialized approach to HIV care that involves mutual support, regular HIV testing, and shared decision making. In the Stronger Together intervention, the first CHTC session is run by a CHTC-trained interventionist with both partners present for the entire 35–45 minute in-person appointment. Conversations focus on the development of a plan to keep both parties in the relationship healthy and to reduce the possibility of HIV transmission. The interventionist presents multiple prevention plans and works with the couple to choose the strategy that best suits their relationship needs (e.g., PrEP).
Stronger Together employs the Partner STEPS method, an already existing cognitive-behavioral intervention for couples. This intervention is built on the framework of relationship-oriented theory, ART adherence interventions, and HIV care approaches for serodiscordant couples. Partner STEPS, which includes two counseling sessions, is delivered by the same CHTC counselor.
These sessions focus on strategies to improve retention to care and medication adherence in each of the 10 steps:
- Traveling to appointments
- Accessing medications
- Provider-patient communication
- Safe medication storage
- Daily medication scheduling
- Addressing medication side effects
- Relationship dynamics
- Inter-relationship communication
- Social life management
- Navigating privacy concerns
The sessions are tailored to each couple’s unique relationship needs.
From 2014 to 2017, Stronger Together recruited 159 serodiscordant couples (a total of 318 men) from three clinics. The couples were randomized into the Stronger Together intervention arm and the control arm, which received the standard of care. Couples were followed for a total of 18 months, with three follow-up assessments at 6, 12, and 18 months. People with HIV in the intervention arm were significantly more likely to be prescribed and currently taking ART than those in the control arm at 12 months and 18 months, and were significantly less likely to miss a dose of ART in the last 30 days.
| Category | Information |
|---|---|
| Evaluation data | Participating clinics collected data from participants through clinical exams and brief qualitative interviews that occurred every six months. |
| Measures |
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| Results |
* statistically significant |
Source: Stephenson R, Suarez NA, Garofalo R, et al. Project Stronger Together: Protocol to test a dyadic intervention to improve engagement in HIV care among serodiscordant male couples in three US cities. JMIR Res Protoc. 2017;6(8):e170.
Recruitment of couples. Participant recruitment efforts involved social media advertising, including dating apps, LGBTQ in-person events, and clinical appointments.
Staff qualifications and training. Counselors led the Stronger Together effort. They had at least a bachelor's degree and participated in a two-day training on CHTC, which focused on didactic learning and role playing. They were also trained in engaging both members of the couple, so problem solving and plan development were done jointly.
Stronger Together was implemented and evaluated with National Institutes of Health grant funding.
“The intervention is relatively intensive, with three in-person sessions, and further work is needed to explore whether the sessions can be provided via telehealth or some of the content provided via eHealth platforms...”
- At 18 months, 77% of couples were still engaged in the Stronger Together study. It is important to consider whether couples that did not continue in the study experienced different outcomes.
- Self-reported measurements of medication adherence may be over-estimated. It is recommended to use a measurement method that is proven to have more validity.
- For the Stronger Together intervention to be generalizable, the population needs to include a more diverse sample of couples (in terms of race and socioeconomic status). This intervention’s population was largely white and highly educated.
- Stephenson R, Suarez NA, Garofalo R, et al. Project Stronger Together: Protocol to test a dyadic intervention to improve engagement in HIV care among serodiscordant male couples in three US cities. JMIR Res Protoc. 2017;6(8). doi:10.2196/resprot.7884
- Stephenson R, Garofalo R, Sullivan PS, et al. Stronger Together: Results from a randomized controlled efficacy trial of a dyadic intervention to improve engagement in HIV care among serodiscordant male couples in three US cities. AIDS Behav. 2021;25(8):2369-2381. doi:10.1007/s10461-021-03199-8
- Bazzi AR, Kirkpatrick KB, Stephenson R, et al. A dyadic behavioral intervention to optimize same sex male couples’ engagement across the HIV care continuum: Development of and protocol for an innovative couples-based approach (Partner Steps). JMIR Res Protoc. 2016;5(3). doi:10.2196/resprot.6271
