Monitoring HIV risk behaviors among heterosexual couples: Challenges and lessons learned Amy Lansky, Tricia Martin, Melissa Cribbin Behavioral Surveillance Team Behavioral and Clinical Surveillance Branch Division of HIV/AIDS Prevention, NCHHSTP, CDC Presented at APHA 135 th Annual Meeting November 5, 2007 Washington DC The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention

The Problem of No Risk Many women do not know their partner’s risk –3347 of 4149 HIV cases among women attributed to heterosexual contact were attributed to “Sex with HIV-infected person, risk factor not specified” –Another 4880 cases among women included those with no risk factor reported or identified

Partner Study Objectives Describe the risk behaviors of male sex partners of minority women Assess the extent and nature of the gap between women’s perceptions of their male sex partners’ risky behaviors and the male partner’s reported behaviors

Partner Study: Methods (1) Recruitment of women National HIV Behavioral Surveillance System among Heterosexuals At Risk Eligibility for women –Black or Hispanic women –Had >1 sex partner in past 3 months –Had HIV test as part of NHBS-HET Consent-Women –Complete an anonymous survey –Recruit 1 or 2 male sex partners

Partner Study: Methods (2) Recruitment of male partners –Women given coupons&training to recruit men –Men brought coupon to study site Eligibility for men –18 years or older –Had sex during past 3 months with female who recruited him Consent: Men –Complete an anonymous survey –Take an HIV test Sample size goal: 100 male partners per city

Formative Research Prior to implementation to identify barriers to participation HIV test Incentives Female recruitment of males Male participation Content of survey During implementation to improve response rates

NHBS Partner Study, Atlanta Ft. Lauderdale Miami Dallas Houston San Diego Los Angeles Las Vegas San Francisco Seattle Denver St. Louis Chicago Detroit Boston New Haven New York City Newark Philadelphia Baltimore Norfolk

Implementation Early Implementers 8 sites started Sept – Dec 2006 Mid-Implementers 9 sites started Jan – April 2007 Late Implementers 4 sites started June 2007 or later

Pre-Implementation Formative Research: Key Recommendations Secure community support for the study Provide women information to use to recruit their partners HIV paradox –Downplay HIV focus of study –Ensure men knew HIV test was required Some concern about violence towards women

Expected Operational Challenges (Staff) Low participation rate for women 2-partner limit HIV serodiscordance

Actual Operational Challenges Male recruitment rates Women enroll and complete survey, but male partners don’t show up Study was anonymous so cannot follow-up with women or their male partners

Recruitment Rates As of September 2007 –Women enrolled: ~ 3000 –Men enrolled: ~1200 –Most women had only 1 partner As of October 2007 –6 of 8 early implementers enrolled 100 men –4 of 9 mid-implementers enrolled 100 men

Lessons Learned/Applied Appointments for women to do survey –Asked them to give out coupons before survey –They often returned with their partner

Lessons Learned/Applied Stressed in consent that agreeing to do study meant bringing in male partners –Reduced women’s enrollment –Increased female: male ratio

Lessons Learned/Applied Extended hours for men –Evening –Weekend Same-day appointments

Lessons for Future Studies Using parent study is complex Anonymous study: reduces ability to encourage recruitment/participation of partners Do formative research before and during study to better understand reasons for participation

Acknowledgements Participants Partner Study Sites –Ethnographers –Interviewers CDC Team

What do people know about the risk behaviors of their sex partners?