Couples HIV Testing and Counseling
Couples HIV Testing and Counseling (CHTC) occurs when two or more persons who are in—or are planning to be in—a sexual relationship receive all elements of HIV testing and counseling together. This includes HIV prevention counseling, receipt of test results, and linkage to follow-up services.
CHTC has been used as an HIV testing strategy in Africa for more than 20 years and has improved HIV prevention outcomes on the continent (1-3). This approach is aligned with the goals of the National HIV/AIDS Strategy (4) and High Impact Prevention (5), and has the potential to contribute to reduced HIV incidence in the United States (3,6).
Importance of CHTC
Approximately 92 percent of new HIV diagnoses in the United States during 2010 were attributed to sexual transmission (7). In some high-risk groups, HIV transmission occurs primarily as a result of sex between main partners (8). Furthermore, although sexual transmission is the leading cause of HIV infection in the United States, few prevention efforts have focused on couples or partnered relationships. CHTC is particularly important because it:
- Reduces the burden of sharing one’s HIV-positive status by ensuring provider-assisted mutual disclosure
- Creates an opportunity for couples to discuss, establish, or revise sexual agreements for their relationship
- Allows couples to prepare a risk-reduction plan based on the HIV status of both partners
- Provides a built-in support system, which may aid in linking persons living with HIV to essential care and treatment services. This is particularly important for discordant couples (i.e., one partner is HIV-positive and the other is HIV-negative), for whom antiretroviral therapy (ART) may significantly reduce the risk of transmission
- Supports pre-exposure prophylaxis (PrEP) and condom use, which can help prevent HIV transmission
- Early diagnosis of HIV infection and linkage to care enables persons with HIV to start treatment sooner, which leads to better health outcomes and longer, healthier lives
Individual HIV Testing vs. CHTC
CHTC builds on existing models of HIV testing for individuals, but with some key differences. In CHTC:
- Individuals learn not only their own HIV status, but also the HIV status of their partner(s)
- The HIV testing provider is available to ease tension and diffuse blame so that couples are assisted in dealing with difficult issues
- Past risks are discussed in abstract terms in order to avoid blame. HIV risk discussion is focused on the present and the future
- Creating a safe space for having complex discussions about agreements with outside partners can lead to better understanding and better prevention outcomes
- Prevention messages are tailored based on the results of both partners
- Partners hear information together, enhancing the likelihood of shared understanding
- Decisions about how and when to access HIV care and treatment can be made together
Potential Negative Outcomes
CHTC requires additional skills in addition to the skills of an individual HIV testing and counseling provider. Dealing with two people—instead of just one—can be challenging, but with proper training and support, CHTC providers are able to handle the issues that may arise during a typical CHTC session. Some providers fear that CHTC will result in violence or break up of a relationship, but there is no evidence that this is the case (9,10).
CHTC services may be offered to any two or more persons in a sexual relationship—or planning to have a sexual relationship—who wish to be tested together. Because CHTC will have greater impact in geographic areas and among populations with high HIV prevalence, it may be most appropriate in high burden areas and urban centers, and specifically for men who have sex with men (MSM) and other high-risk couples.
Appropriate settings for providing CHTC services
CHTC can be delivered anywhere that individual HIV testing is conducted, if providers have been trained in CHTC. “Fixed” HIV testing sites may be most appropriate for CHTC services due to the greater availability of trained staff and the timing of CHTC sessions, but outreach and mobile sites may also be modified to provide HIV testing to couples. An abbreviated approach may be appropriate for health facility settings, especially in the context of partner testing of persons living with HIV (PLHIV). Where CHTC services are not offered in health facilities, referrals to CBOs offering CHTC can be made for PLHIV and their partners.
CHTC Diffusion in the U.S. CDC's national diffusion plan for CHTC in the U.S. was initiated in 2012. In order to maximize the HIV prevention, care, and treatment benefits of this approach, CDC is focusing initial roll-out in the 12 jurisdictions with highest HIV prevalence and number of new HIV diagnoses. They are engaging Health Departments, community-based organizations, and health care providers in New York, Los Angeles, Miami, Chicago, Washington DC, Dallas, Houston, Philadelphia, Atlanta, San Francisco, Baltimore, and Orlando, and will expand to other cities as demand rises and resources are available.
CHTC training is intended for persons who will provide HIV testing services outlined above. Because CHTC builds on the skills of individual HIV testing and counseling providers, it is recommended that CHTC trainees have been previously trained in individual HIV testing and counseling, and have been providing this service for at least 6 months or to at least 50 individuals.
To express interest in attending a CHTC training in your area, please visit the EffectiveinterInterventions Training Calendar
and select CHTC
from the drop down menu. If you are in an area other than the 12 aforementioned jurisdictions, your request will be considered as resources allow.
The training package for CHTC includes a 2-hour e-learning session, a 2-day didactic training, and follow-up support for implementation. Trainings, which are conducted by CDC and its training partners, usually occur on location in the city requesting the training, and are held with 18-24 people. The CHTC training reviews essential couple communication skills, provides detail on the CHTC protocol, and ultimately equips HIV testing providers to deliver CHTC with couples. Job aids are provided to trainees, along with useful tools and sample documents to support implementation.
Complete the CHTC pre-course training online.
The pre-course online training, An Introduction to Couples HIV Testing and Counseling in the United States, is a pre-requisite for the 2-day in-person CHTC training, but can be watched on its own to get some basic information about this approach. It is designed for HIV testing providers, program managers, and others who want an overview of CHTC. You will hear from CHTC researchers and see the approach demonstrated with different couples. This online pre-course training takes about 2 hours to complete. For optimal user experience, please use Microsoft Internet Explorer 9.0 or 10.0, Mozilla Firefox 23.0 or above, Google Chrome 34.0, or Safari 5.1.2 or above as your internet browser. To learn more, please review - How to Access the Online CHTC Pre-Course Training.
In the pre-course training, you can learn:
- How CHTC came to be such an important strategy for HIV testing in the U.S.
- Details of the CHTC approach and common terms.
- Possible test results that couples might receive, and specifically about HIV discordance.
- Sexual agreements and their role in CHTC.
- Each of the steps of the CHTC protocol.
- Next steps for the 2-day in-person training.
- Curran K, et al. HIV-1 prevention for HIV-1 serodiscordant couples. Curr HIV/AIDS Rep. 2012;9(2):160-70.
- Allen S, et al. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003;17(5):733-40.
- Dunkle, KL, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008;371(9631):2183-91.
- El-Bassel N, et al. Couple-based HIV prevention in the United States: advantages, gaps, and future directions. J Acquir Immune Defic Syndr. 2010;55 Suppl 2:S98-101.
- Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22. http://www.cdc.gov/hiv/topics/surveillance/resources/reports. Published March 2012.
- Sullivan PS, Salazar L, Buchbinder S, et al. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153-62.
- Were E, et al. A prospective study of frequency and correlates of intimate partner violence among African heterosexual HIV serodiscordant couples. AIDS. 2011;25(16):2009-18.
- Grinstead, OA et al. Positive and negative life events after counseling and testing: the Voluntary HIV-1 Counselling and Testing Efficacy Study. AIDS. 2001;15(8):1045-52.
Program Review Panel Information
The CDC requires all CDC-funded agencies using the CHTC strategy to identify, or establish, and utilize a Program Review Panel and complete Form 0.113 to document this activity. The intervention researchers and developers are not involved in this activity. This is a CDC requirement for their grantees, and all questions in this regard should be directed to your agency's CDC Project Officer or to the health department funding your agency's implementation of the intervention.
The Program Review Panel guidelines, instructions for completion of Form 0.113, and the form itself are available under the Related Links section of this website.