Op-ed: Couples Invite Harm When They Don't Talk About HIV

In a relationship there are myriad issues to manage. Who walks the dog? Who does the cooking? Who are we supporting to win RuPaul's Drag Race? But there is one issue that can often be harder to manage -- how do we as a couple deal with HIV?

Gay men and other men who have sex with men are the only risk group in the U.S. to be experiencing an increase in HIV infections. Throughout the four decades of the epidemic HIV has been messaged as driven by unsafe casual sex. However, recent studies show that one- to two-thirds of new infections in fact come from main partners.

When you stop to think about it, this makes sense: Instead of a hookup, you most likely are having more sex with your main partner, especially anal sex, and you are less likely to be using condoms. Due to this fact, you literally have more potential exposures to HIV from your main partner than you would in a one-night stand. Recent research by my team showed that gay men in relationships perceive themselves to be at less risk of HIV and test less frequently for HIV than single men, despite frequent non-use of condoms with their main partners.

I am fully aware that this may make me sound anti-relationship (something my partner of six years may take umbrage at). I am not. Relationships are fantastic: I have found the person who doesn't mind me watching Master Chef while knitting and shouting at the TV, and that is an awesome feeling. But what I am saying is that we need to think about how men in relationships manage HIV. Relationships are not necessarily protective of HIV.

Being in a relationship is often like being in a bubble: The constant messaging about HIV risk has been predominantly linked to casual sex, creating this myth that relationships offer a protection from HIV. Beyond messaging, the love blindness that often afflicts us in the early stages of a relationship, also known as the "honeymoon stage," can prevent us from asking questions about HIV status and from talking to our partners about condom use. As a volunteer HIV counselor and tester, I can't tell you how many times I have had a client tell me "If he was HIV-positive he would tell me, he loves me." But this assumes he knows his own status.

It's not that all men who have sex with men don't talk about sex in their relationships-- recent research, showed that 90 percent report discussing sexual agreements with their main partner and 64 percent decide to be monogamous. But given that the prevalence of HIV among gay men in the U.S. is almost as high as the prevalence among heterosexual couples in African countries with the worst epidemics, there is a high risk that men are entering relationships in which one or both are HIV-positive.

HIV is a difficult issue to talk about with anyone, especially a partner, and that is the real issue around all of this: lack of communication. But there is a solution: Couples testing that allows both partners to get counseling and learn the results together. This simple act removes the need for either partner to disclose their status, prevents risky behaviors based on assumptions and ignorance of status, and allows the couple to work together on a prevention plan built on both their HIV statuses. Since 2009 couples testing for HIV has becoming increasingly common in the U.S., and it is now available at over 70 HIV testing agencies in 25 cities.

But an innovative new HIV study, Stronger Together, is taking this a step even further. Funded by the National Institutes of Health and the MAC AIDS Fund, with research sites in Atlanta, Boston, and Chicago, Stronger Together will follow male-male couples and will be asking a very simple question: If we provide information and counseling to the couple together, do they do better at managing HIV risk than if we treat them as two individuals? Currently, HIV care is individualized. Men typically go to seek care or testing alone. But for a couple doesn't it make sense to see both men together and allow the couple to work together?

Stronger Together aims to provide couples with the opportunity to come together and make informed decisions that allow them to keep their relationship healthy. This puts the couple at the center of managing their own HIV risk. Guided by a counselor, the couple set prevention goals and will learn communication skills that allow them to discuss and manage HIV in their relationship. Receiving counseling and care as a couple may allow couples to make important decisions together about PrEP use or adjusting the conditions of their agreements around outside sexual partners.

With marriage equality continuing to spread throughout the U.S. it is imperative that we start to recognize not only the demand for couples-focused HIV services but the power of couples to work together to fight HIV. Because when we all come together, especially in the fight against HIV, we are all stronger together.

ROB STEPHENSON is an associate professor of global health in the Rollins School if Public Health at Emory University. Stronger Together is headed by Dr. Rob Stephenson (Emory University), Dr. Rob Garofalo (Ann & Robert Lurie Children's Hospital of Chicago/Northwestern University), and Dr. Matthew Mimiaga (Harvard Medical School, Harvard School of Public Health, and the Fenway Institute). For more information on the Stronger Together study visit StrongerTogether.us.