Adaptation of a Couple-Based HIV Intervention for Methamphetamine-Involved African American Men who have Sex with Men.

Abstract

In the U.S., incidence of HIV infection among men who have sex with men (MSM) has steadily increased since the 1990s. This points to a need for innovation to address both emerging trends as well as longer-standing disparities in HIV risk and transmission among MSM, such as the elevated rates of HIV/STIs among African American MSM and methamphetamine users. While couple-based sexual risk reduction interventions are a promising avenue to reduce HIV/STI transmission, prior research has been almost exclusively with heterosexual couples. We sought to adapt an existing, evidence-based intervention-originally developed and tested with heterosexual couples-for a new target population consisting of African American MSM in a longer-term same-sex relationship where at least one partner uses methamphetamine. The adaptation process primarily drew from data obtained from a series of focus groups with 8 couples from the target population. Attention is given to the methods used to overcome challenges faced in this adaptation process: limited time, a lead investigator who is phenotypically different from the target population, a dearth of descriptive information on the experiences and worldviews among the target population, and a concomitant lack of topical experts. We also describe a visualization tool used to ensure that the adaptation process promotes and maintains adherence to the theory that guides the intervention and behavior change. The process culminated with an intervention adapted for the new target population as well as preliminary indications that a couple-based sexual-risk reduction intervention for African American, methamphetamine-involved male couples is feasible and attractive.

Full text

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The Open AIDS Journal, 2010, 4, 123-131 123

1874-6136/10 2010 Bentham Open
Open Access
Adaptation of a Couple-Based HIV Intervention for Methamphetamine-
Involved African American Men who have Sex with Men
Elwin Wu*,1, Nabila El-Bassel1, L. Donald McVinney2, Yves-Michel Fontaine1 and Leona Hess1
1Social Intervention Group, Columbia University School of Social Work, New York, NY, USA
2Harlem United, New York, NY, USA
Abstract: In the U.S., incidence of HIV infection among men who have sex with men (MSM) has steadily increased since
the 1990s. This points to a need for innovation to address both emerging trends as well as longer-standing disparities in
HIV risk and transmission among MSM, such as the elevated rates of HIV/STIs among African American MSM and
methamphetamine users. While couple-based sexual risk reduction interventions are a promising avenue to reduce
HIV/STI transmission, prior research has been almost exclusively with heterosexual couples. We sought to adapt an
existing, evidence-based intervention—originally developed and tested with heterosexual couples—for a new target
population consisting of African American MSM in a longer-term same-sex relationship where at least one partner uses
methamphetamine. The adaptation process primarily drew from data obtained from a series of focus groups with 8
couples from the target population. Attention is given to the methods used to overcome challenges faced in this adaptation
process: limited time, a lead investigator who is phenotypically different from the target population, a dearth of
descriptive information on the experiences and worldviews among the target population, and a concomitant lack of topical
experts. We also describe a visualization tool used to ensure that the adaptation process promotes and maintains adherence
to the theory that guides the intervention and behavior change. The process culminated with an intervention adapted for
the new target population as well as preliminary indications that a couple-based sexual-risk reduction intervention for
African American, methamphetamine-involved male couples is feasible and attractive.
Keywords: HIV, prevention, adaptation, men who have sex with men, African American, methamphetamine, couples.
INTRODUCTION

the earlier decades of the epidemic, transmission has
plateaued at about 56 thousand new infections per year [1,
2]. The limited decrease in HIV incidence during recent
years highlights a need for continued vigilance as well as
novel preventive intervention programs. However, the
plateau in overall incidence belies a concern particularly for
men who have sex with men (MSM): not only does male-to-
male sexual contact continue to represent the major conduit
of HIV transmission in the U.S. (53% of all new infections
and 72% among male cases in 2006) [2], but inspection of
the data reveals that incidence rates for MSM have been
increasing steadily since the 1990s [1].
Following a decrease in HIV incidence in the U.S. during

reduction among MSM stems not only from a shared risk
behavior (e.g., sex without barrier protection), but also
because the physiological and immunological sequelae of
STIs can fuel the transmission of HIV [3]. There has been a
recent increase in incidence of STIs among MSM [4], who
are already overrepresented among STI cases. In New York
City (the locale for the current study), annual rates of major
reportable STIs have increased since 2005 [4].
The need for sexually transmitted infection (STI) risk


*Address correspondence to this author at the Social Intervention Group,
Columbia University School of Social Work, 1255 Amsterdam Avenue,
New York, NY, USA; Tel: 212.851.2397; E-mail: ew157@columbia.edu

needed to counter the aforementioned trends in HIV and STI
transmission among MSM. While MSM clearly shoulder a
large burden of the HIV epidemic, epidemiological research
strongly points to additional subpopulations of MSM with
elevated rates of HIV infection in the U.S.: African
Americans [4-6], methamphetamine users [7, 8], and men in
longer-term (vis-à-vis casual) relationships [9, 10]. That
smaller subpopulations carry a proportionally higher load of
the HIV epidemic has led to recommendations to focus
prevention efforts on populations at highest risk for infection
as a “pressing public health and humanitarian imperative”
[11]. It is possible that unique dynamics are leading to higher
rates of infection among these populations. For example, the
likelihood of unrecognized HIV infection may decrease as
main partners transition into longer-term partners (or vice
versa), but the presumably lower risk may be offset by a
higher frequency of unprotected receptive anal intercourse
and fears that introducing condom use would elicit mistrust
or suspicions/acknowledgement of extradyadic partners [9].
Another possibility is that past/current prevention (and
outreach) efforts are not resonating or consonant/compatible
with the context in which these individuals live, especially
for those at multiple risks. Altogether, these considerations
prompted formative work to develop a novel behavioral
sexual risk reduction with content tailored for those at the
nexus of populations at elevated risk for HIV and STIs:
African American men in longer-term, same sex intimate
Innovative approaches to sexual risk reduction are

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124 The Open AIDS Journal, 2010, Volume 4 Wu et al.
relationships in which at least one partner is using
methamphetamine (herein referred to as “African American,
methamphetamine-involved male couples”).
Couple-Based Interventions for Sexual Risk Reduction:
Meeting the Need for Innovation

individuals, MSM have fewer population-specific HIV
interventions with scientific evidence of efficacy reported in
the scientific literature as of 2002 compared to other major
risk categories [12, 13]; this situation does not appear to
have changed substantially if at all [14]. While a growing
body of evidence underscores the promise of a couple-based
approaches in promoting sexual risk reduction among
populations at elevated risk for HIV [15], the focus has been
almost exclusively on heterosexual couples. No couple-
based interventions specifically for MSM have been
identified in meta-analyses and systematic reviews of HIV
preventive intervention trials with stronger scientific design
(e.g., randomized clinical trial) [16, 17]. Couple-based
HIV/STI prevention directly addresses the elevated risk
among MSM in longer-term relationships as noted above and
may bring innovation to renewed reductions in HIV
transmission among MSM.
Despite being the largest group of HIV-infected

strategy for engaging individuals who have been out of reach
of the prevention outreach and health services system. A
couple-based approach can start with recruitment of the
partners of hard-to-reach individuals; in our experience, the
partners often want the difficult-to-reach individual to
engage in services and positive behavioral change, and the
partners can be very compelling in recruiting/engaging the
hard-to-reach individuals because of the conjoint delivery of
the intervention [18]. Thus, a couple-based approach can
start with recruitment of
methamphetamine users, but who may be in an intimate
relationship with a methamphetamine user who is not
currently engaged with services.
A couple-based approach may also be particularly useful
MSM who are not
A Starting Point: The Connect HIV/STI Preventive
Intervention

sexual risk-reduction for mixed-gender couples, has been
demonstrated to be efficacious at 3-months and 12-months
post-intervention [19, 20] and has been selected for inclusion
in the CDC’s Compendium of HIV Prevention Interventions
with Evidence of Effectiveness. The 6-session Connect
intervention combines content related to safer sex practices
and prevention of HIV and STIs, with an emphasis on sexual
communication and negotiation skills. The intervention
cultivates responsibility and ability to protect oneself, one’s
intimate partner, and fundamentally, one’s intimate
relationship. The process is facilitated by a focus on a
positive future orientation and risk reduction as a sign of
caring, as opposed to focusing on past risky behavior and
condom use as a sign of mistrust. The intervention also
works to empower participants to act as health advocates
who are enhancing the future well-being of communities
hardest hit by HIV/AIDS.
The Connect intervention, a couple-based HIV/STI

delivered to African American, methamphetamine-involved
male couples naturally involves scrutinizing content that
reflects an assumed relevance and/or central importance of
potentially heteronormative content (e.g., knowledge of
female anatomy, traditional gender norms); however, it may
be equally heterocentrist to assume that such information is
irrelevant for all male couples. These concerns, their
underlying considerations, and the concomitant challenges
are exacerbated by the dearth of information in the empirical
knowledge base regarding relationship and couple-dynamics
among men of color in longer-term, same-sex relationships.
HIV prevention researchers have put forth models for
rigorous, formal adaptation of existing interventions for new
target populations [21, 22]; these can be multi-stage
endeavors that impose considerable requirements on time,
resources to evaluate/compare existing evidence-based
interventions, dedicated staff to collect new information and
implement revisions, and
knowledgeable experts on the new target population.
However, communities have pressing needs that may benefit
from swifter progression
interventions. Furthermore, community-based organizations
may not have the information, technology and staffing
resources to evaluate a number of existing evidence-based
interventions, or an agency may be structured/staffed to
deliver a particular intervention [for a different target
population]. Furthermore, for hidden or disenfranchised
populations, there may be an inadequate level of existing
knowledge or few experts, especially if the problem is
emerging. These constraints were in place with respect to
sexual risk reduction
methamphetamine-involved male
endeavored to develop and implement an adaptation
procedure that seeks to maintain a high level of scientific
rigor in the face of these challenges.
Revision of the Connect intervention in order to be
existence of multiple
in developing promising
for African
couples.
American,
Thus, we
METHODS
Design

risk and protective factors and dynamics among African
American, methamphetamine-involved male couples was
accomplished using qualitative methods, i.e., focus groups.,
with couples from the target population. Given the very
limited existing research on couple-based HIV prevention
with male same-sex couples, especially MSM of color, we
felt that holding a series of focus groups with the same
couples would be more efficient at covering a large number
of issues/topics in greater depth than the alternative of
multiple focus groups with different couples. Thus, couples
were asked to return and participate in up to six focus
groups. Earlier focus groups were designed to elicit
participants’ worldviews and experiences about the
challenges African American, methamphetamine-involved
male couples experience regarding general well-being,
methamphetamine use, and HIV risk/protection. Later focus
groups presented existing intervention activities and study
protocols in order to solicit and elicit participant feedback
and ideas on how to enhance the relevance, engagement, and
Obtaining in-depth, contextual information regarding the

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Adapting an HIV Intervention for Male Couples The Open AIDS Journal, 2010, Volume 4 125
safety for risk reduction behavior change among African
American, methamphetamine-involved male couples.

and the investigative team’s institution approved all
protocols, materials, and information used in this study. All
participants provided full informed consent prior to the focus
groups.
The Institutional Review Boards of the funding agency
Sample

in the focus group if they both met the following eligibility
criteria:
Individuals and their partners were eligible to participate
(1) Be male identified;
(2) At least 18 years old;
(3) Report having a “primary main male partner”
operationalized as:
(a) a male with whom he has had an ongoing sexual
relationship over the prior 6 months,
(b) a male with whom he has the intention to remain
together with for at least 12 months, and
(c) a male with whom the participant has an
emotional relationship/bond more than any
person;
(4) Self-identify as African American and/or Black, or
identify having a main partner who self-identifies in
this manner (Note: for multiracial participants, they
must state their primary race/ethnicity is “African
American” or “Black” to be eligible);
(5) Have had unprotected anal sex with a man who is a
non-main partner in the past 2 months (or, regardless
of awareness, has a main partner who meets this
criterion);
(6) Report using methamphetamines at least once in the
past 60 days (or, regardless of awareness, has a main
partner who meets this criterion);
(7) Reports not being either in or seeking drug treatment
(in-patient, out-patient, support groups, AA, etc); and
(8) Identifies each other as their main partner.

analogous to the investigative team’s prior HIV intervention
research studies with [heterosexual] couples, drug-involved
couples, and African American couples [19, 23] except for
the following: eligibility criteria 3c and 7 were agreed upon
and used by all of the sites participating in the Cooperative
Agreement that provided funding for this study. Since the
intervention is designed to be delivered conjointly to both
members of a couple, an additional requirement was that
both partners had to be willing to attend the focus group
together.
Many of these criteria have been used and/or are
Procedures
Recruitment

“Active” methods included study staff conducting outreach
Recruitment was conducted in a variety of manners.
and recruitment activities at local service agencies, bars,
clubs, commercial and public sex environments, and
community events frequented by MSM and located in the
multiple neighborhoods and boroughs of New York City.
“Passive” referral was also used, whereby referrals were
made through local agencies and organizations that provide
programs and services for methamphetamine-involved,
minority MSM (e.g., AIDS service organizations, health
clinics, dental clinics), project community advisory board
members, current participants, and individuals/couples who
screen out of other ongoing studies but who may be eligible
for this study.

couple who may be eligible, that individual was asked to
invite his main [male] partner to participate. Potential
participants were given a letter addressed to their partners
that introduces the study, describes its purpose, describes
reimbursement for participation, and contains a contact
telephone number. Only after a partner contacted study staff
would any recruitment, screening, or enrollment procedures
be initiated with that partner. In no case did study staff share
any information provided by the first individual to his
partner.
If study staff recruited/contacted only one member of a
Focus Groups

research institution. The co-facilitators—the lead author who
is the Principal Investigator of the study and the Project
Director who was an African American MSM—followed a
semi-structured interview guide constructed for each of the
six focus groups. Focus groups were held weekly and lasted
90-120 minutes. They were audio recorded and one or two
note-takers from the study staff were also present. Each
participant was compensated $40 (i.e., $80/couple) for his
time and information.
All focus groups were held in a private room at the

qualitative data and themes presented in this article have
been selected based on their relevance to the adaptation
process. Space constraints prohibit providing verbatim or
detailed description of qualitative data related to more
general matters regarding the experiences of African
American, methamphetamine-involved MSM in longer
relationships; we have endeavored to present such
information in other venues [24, 25] as well as in a separate,
forthcoming manuscript.
Since this report is focused on the adaptation process,
RESULTS
Characteristics of the Study Sample

groups with the target population. Two of the couples were
recruited via referral from local service providers; the
remaining couples were recruited by outreach staff over six
recruitment outings conducted in the evenings and lasting
about 3-4 hours each. The age of participants ranged from 29
to 48 years old (mean = 42.3 years). All but three of the
participants identified as African American/Black; one
interracial relationship was with a Caucasian (European-
American) and the other two interracial relationships
A total of eight couples participated throughout the focus

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126 The Open AIDS Journal, 2010, Volume 4 Wu et al.
consisted of an African American and a partner who
identified as biracial (African American/Latino). Six of the
couples consisted of only one partner who met the
methamphetamine use criterion, though it became apparent
that the other partner in many of these couples had used
methamphetamine in the past. Only 1 of the couples had
accessed/received any services together as a couple (couples
therapy).

missed a single meeting. Of those two meetings where an
entire couple was missing, one was planned due to a prior
engagement and only one was an unanticipated “no show.”
In one other instance, one participant attended while his
partner could not due to a planned prior engagement. All
other couples were willing and succeeded in attending
scheduled sessions [together].
Across the six focus group meetings, only two couples
Adaptation Process
Eliciting Information Needed for Adaptation

guide that contained a series of open-ended questions
designed to elicit participants' worldviews, experiences, and
understanding/insights in four primary areas: (1) influence of
methamphetamine on sexual risk behavior; (2) core
components of the intervention; (3) barriers to participation
in an HIV preventive intervention study; and (4) ethical
issues. A separate guide was created for each focus group
such that earlier group meetings tended to have a greater
proportion of questions designed to elicit data on experiences
and worldviews among the couples, and later groups focused
more on obtaining feedback on intervention activities/
content. Table 1 presents some example interview guide
questions for each of the four areas. In addition to sharing
their experiences and perceptions, participants were
prompted to respond to each other’s comments and/or
indicate agreement/differing opinions. Finally, as a topic was
concluding, participants were often asked, “What about other
couples you may know?”
The focus group co-facilitators followed an interview
Capturing Lived Experiences of African American,
Methamphetamine-Involved Male Couples

longer-term same-sex relationships, combined with the
recognition that literature on methamphetamine use among
African American MSM is limited compared to other
populations, prompted a significant amount of focus group
questions and time to be dedicated to collecting background
and contextual information about the lives of African
American, methamphetamine-involved male couples. The
process of eliciting, analysis, and inference about the
experiences and worldviews was guided by a relationship-
oriented ecological perspective [26]. This couple-based,
multi-level framework organizes the broad range of proximal
and distal factors that shape human behavior and
interpersonal relationships. Furthermore, by characterizing
the different analytic levels of organization as nested, the

The paucity of research on African American MSM in

relationship-oriented ecological perspective acknowledges
that factors reciprocally interact and influence each other
both within and across analytic levels. Table 2 lists the
analytic levels and examples of specific factors within each
analytic level posited to shape the lives—including HIV/STI
risk and protective behaviors—among African American,
methamphetamine-involved male couples.
Table 1. Sample Questions from the Focus Group Interview
Guide

Methamphetamine and Sexual Risk Behavior
• What are some of the challenges that African American/Black men
who have sex with men face in having healthier, longer-term
intimate relationships?
• How does the use of methamphetamine interfere with safer sex
practices?
• In what ways does this differ with your main partner versus casual
or outside partners?
• In what situations do you engage in unprotected sex? Could you
describe the event? Were you under the influence of
methamphetamine and/or other drugs?
Core Components of the Intervention
• What do you think about the [activity/content presented or
demonstrated]?
• What aspects of the activity/intervention would you like to see
different when considering this is specifically for African
Americans? For men in
methamphetamine use is an issue?
• How comfortable do you feel with the content, homework
assignments, etc.?
same-sex relationships where
Barriers to Study and Intervention Participation
• What might prevent you from attending the intervention sessions?
From completing the “homework” assignments?
• What are ways that we could help you to overcome these issues?
Ethical Issues
• Would you feel comfortable bringing intervention materials home?
• What concerns do you have related to participating in the
intervention? In a study?
• How can we best address these concerns?


are unique to one’s developmental history and experiences.
One prominent theme was how the level of comfort with
identity, sexuality, and presentation were shaped by earlier
life experiences, particularly rejection or acceptance of non-
heteronomativity among one’s family of origin. Several
participants described growing up with families located in
southern regions of the U.S. and more heavily involved with
religion as negative experiences themselves. Another topic
noted by many focus group participants was the sexualizing
and sexual stereotyping of African American men. When
asked to discuss methamphetamine use, the psychological
disinhibition, cognitive dissociation, and physiological
effects were thought to reflect a means of coping with
prevalence of sexual difficulties (both psychological and
physiological) that arose and/or varied depending upon the
different levels of accepting/rejecting experiences.
The ontogenetic level refers to the personal factors that

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Adapting an HIV Intervention for Male Couples The Open AIDS Journal, 2010, Volume 4 127
Table 2. A Relationship-Oriented Ecological Framework
Applied to Sexual Risk Behavior Among African
American, Methamphetamine-Involved
Couples
Male

Ontogenic Level
• HIV/STI knowledge
• Perceived threat of HIV/STIs
• Race/ethnicity: HIV, sexual identity
• Condom use self-efficacy
• Condom use outcome expectancies
• Condom use intentions
• Methamphetamine use outcome expectations
• Methamphetamine use outcome expectancies
Microlevel
• Couple condom negotiation-efficacy
• Couple sexual communication skills
• Couple sexual satisfaction
• Couple sexual decision-making power
• Race/ethnicity and the relationship w/MSM partner
• Impact of methamphetamine use and sexual risk on relationship
Exolevel
• Social support for risk reduction
• Peers/community treatment regarding race/ethnicity and sexual
identity
• Peer norms about the threat of HIV
• Peer norms about safer sex/condom use
• Peer norms about methamphetamine
Macrosystem
• Sex and methamphetamine/drug use culture among MSM
• Anti-racism: e.g., race-based oppression, disenfranchisement, and
stigma
• Anti-heterocentrism: e.g., sexuality-based oppression, disenfran-
chisement, stigma, and invisibility


factors that are part of the immediate intimate relationship
context in which sexual activity and risk and protective
behaviors take place. By far the most noted and discussed
were the impact of differences between partners. Frequently
mentioned areas of differences between partners included:
experiences of being accepted/rejected by family (e.g., “We
are constantly comparing our childhood.”); level of comfort
being “out” as an individual and in an intimate relationship
with each other; past sexual experiences; and use of drugs
and or stage of recovery. While these differences were often
focal points of difficulties/disputes in the relationship,
participants noted how methamphetamine use and sexual
behaviors [that increase HIV risk] could be a means to cope
or address the differences. For example, attending or
arranging a methamphetamine and sex party was noted as a
solution to the desire to connect sexually with one another,
despite being fully aware of risk of disease transmission
and/or the potential paradox arising from sexual non-
monogamy. The microlevel also encompasses a noted
dynamic of how a partner who is not HIV-positive nor using
drugs/methamphetamine is “left out while he [the HIV-
The microlevel consists of the interactional and structural
positive/methamphetamine using partner] gets the attention
[of service providers and programs].”

relationship and likelihood of engaging in risky behavior. A
common theme was how intimacy and interaction with one’s
partner was impacted and often undermined by social
settings and community-level factors, most of which could
threaten the quality and sustainability of the relationship
itself. For example, many participants noted or described a
hypervigilance about being seen as non-heterosexual and not
being able to show affection towards their partners in public,
mostly mentioning places around their residence and work
(e.g., “I would want to give him [partner] a kiss, but he
would lean away and say ‘No, this is where I live.’”). Of
particular note was several participants noting that African
Americans may be less likely to live in historically gay-
friendlier sections of New York City. Methamphetamine use
was noted to be a means to connect with other MSM as well
as a occurring in safer places/venues where they could be
intimate with their partner. Interestingly, one participant did
note that in contrast to seeing gay-friendlier neighborhoods
as predominantly white, there was a more recent trend of
African American non-heterosexual youth congregating in
such areas presenting an image they did not want to be
associated with (e.g., “Those homothugs you see in Chelsea,
I can’t stand that.” “Those homothugs aint ever going to
amount to nothing.”). The same participant suggested that
this provided an answer when his associates would ask,
“Why you use that white boys’ drug?”
The exolevel refers external stressors or buffers on the

and belief systems that shape and interact with all of the
other analytical levels. Participants noted that the centrality
of family and religion they felt was prominent among
African Americans often exacerbated the rejection and
stigma originating from their family members. The spectrum
of responses to such dynamics among focus group
participants varied: some felt they had reconciled, many
were still struggling, others accommodated (selective
passing, “don’t ask, don’t tell”), and some rejected and/or
disenfranchised themselves from those social institutions.
The macrosystem encompasses the broad cultural values

the investigative team’s deliberate choice to use of an anti-
racist framework in considering macrosystem factors. The
anti-racist ideology rejects “race-” or “color-blind” rhetoric;
instead, the approach is to recognize, acknowledge, and
address the varied lived experiences and perceptions among
different races/ethnicities [27]. The anti-racist framework
may be optimal for the following reasons. First, rather than
needing to achieve expert understanding of African
American/Black experiences, the approach is to foster
participants to understand, analyze, and share the impact of
race for themselves. Second, it does not seek to impose or
presume a unifying framework upon African Americans
(e.g., the Afrocentric paradigm or Afrocentricity [28]);
because African American
disenfranchisement from families of origin (e.g., “Being gay,
my mother and father hated me.”) and/or the African
American communities (e.g., “We [gay men] are not
This range of responses underscores the importance of
MSM may experience

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128 The Open AIDS Journal, 2010, Volume 4 Wu et al.
accepted in the Black community.”), we felt was important
to provide for a wider range of worldviews to be expressed,
explored, and acknowledged. The anti-racist perspective
expands upon notions of cultural competence and cultural
humility [29] by explicitly paying attention to race-based
power, privilege, and oppression. Such issues can not be
ignored as they underlie the social and structural factors that
drive the health disparities, such as HIV, shouldered by
African Americans. Finally, the anti-racist perspective also
accommodates the varied phenotypes that may be
represented among partners as well as the service providers
and researchers working with the target population.
Paralleling the anti-racist perspective, we pose and employ
an anti-heterocentrist ideology; this perspective affirms and
accepts different sexual identities and labels (especially those
beyond gay and bisexual), which is particularly relevant
given the attention paid to non-gay identities and labels for
same-sex behaviors (e.g, “down-low”) among African
American MSM. Some participants stated they identify as
gay and/or homosexual, some embraced subverting the
derogatory nature of the term “faggot,” and others noted
referring to themselves or others as a “snow queen” or
“Carlton.”

experiences to explore possible candidate “scenarios” used in
intervention activities. Scenarios thought to have high relevance
by participants regarding couple conflict/communication/
problem-solving include: “the call”—whereby an individual
does not follow through on a promise or agreement to calling
his partner if he was staying out/coming home late, going to
drink or use drugs, etc.; not following through on abstaining
or refraining from drug/methamphetamine use; and drugs/
methamphetamine during sex with each other. Participants
also endorsed activities that encourage/enhance communi-
cation about sex, sexual desires, inhibitions, and their
possible origins (e.g., “the baggage makes free-flowing
discussion about sex difficult”). Participants shared about
conflicts about sex arising from [lack of] top/bottom
versatility, whether sex is spontaneous or planned, watching
pornography, and being intimate without intercourse. These
types of information were incorporated into role-plays and
areas for intervention facilitators to explore during sessions.
Participants were also asked to reflect on lived
Applying a Theory of Behavior Change

group data needed to focus on how to enact risk reduction,
specifically putative mediators of behavior change targeted
by the intervention. The original Connect intervention was
guided by Social Cognitive Theory (SCT) [30]. Thus,
intervention activities are designed to increase the following
among participants in order to enact risk reduction behavior:
information and knowledge that underlie accurate appraisal
of risks and risk behavior; outcome expectancies, which are
perceived costs and benefits of certain behaviors; social and
self-regulatory skills to recognize triggers of risk and enact
risk reduction, including reinforcement of health-promoting
behaviors; self efficacy, which is belief in one’s ability to
implement desired or chosen behaviors; and social support,
which refers to reciprocal interpersonal influences that
Beyond experiences and worldviews, analysis of focus
increase, decrease, or sustain certain behavior and behavior
patterns. Table 3 presents examples of how these SCT
mediators are targeted in the context of couple-based HIV
risk reduction for methamphetamine-involved couples.
Table 3. Social Cognitive Theory Constructs in the Context
of Couple-Based Intervention for Behavioral HIV
Risk Reduction

Information/Knowledge
• HIV/STI knowledge
• Psychopharmacological effects of methamphetamine use
• Physiological and neuropsychological effects of methamphetamine
use
• Correct condom use
Outcome Expectancies
• Cost/benefit of sexual risk behaviors
• Cost/benefit of methamphetamine use
• Impact of methamphetamine use on the relationship
Social and Self-Regulatory Skills
• Recognize triggers for risk behaviors and ability to enact risk
reduction
• Recognize triggers for methamphetamine use and ability to avoid
use
• Reinforcement of health-promoting decisions and behaviors
• Relationship-based regulatory skills (e.g., couple communication,
joint problem-solving/reinforcement)
Self-Efficacy
• Perceived ability to refrain from risk and/or enact risk reduction
• Perceived ability to abstain from methamphetamine use
• Belief in ability to assist [or resist] partner’s influence on
behavior(s)
Social Support
• Increasing number and strength of contacts who promote and/or
reinforce risk reduction and abstaining from methamphetamine use
• Increasing number and strength of contacts who promote and/or
reinforce risk reduction and abstaining from methamphetamine use
• Increasing number and strength of contacts who nurture the well-
being of African American MSM and their intimate relationships.

Deconstruction and Reconstruction of the Intervention

whereby each session also contains multiple exercises,
presents a challenge due to the sheer number of activities
that must be systematically and strategically revised. We
developed a visualization
Reconstruction Matrix—that captures the essence of
adapting a theory-driven intervention. One dimension of the
tool’s matrix is the session number, while the other
dimension is the theoretically posited mediators targeted by
the intervention. Each activity/element in a session is then
placed in the matrix based on the session during which the
activity takes place as well as the mediator targeted by that
activity. Fig. (1) depicts the essential structure and sample
elements for the Deconstruction/Reconstruction Matrix for
the original Connect intervention.
Adapting an existing intervention with multiple sessions,
tool—the Deconstruction/

enhances identification and tracking of all intervention
The Deconstruction/Reconstruction Matrix not only

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Adapting an HIV Intervention for Male Couples The Open AIDS Journal, 2010, Volume 4 129
activities, but also helps ensure adherence to the theory
behind how the intervention enacts behavior change. To
adapt the Connect intervention, the matrix helped to make
sure that the revised activity hit the same targets/mediators,
with changes to information, content, and presentation that
was more appropriate and compelling. For example, focus
group participants’ suggestion of using direct language for
sexual orientation (e.g., “gay”) instead of using a “generic”
phrase like “men who have sex with men.” This was further
refined by the anti-heterocentrist macrosystem understan-
ding, culminating with the intervention having facilitators
asking for and using the identity label that the participants
prefer.

times in the same column of the matrix, indicating that some
activities target multiple mediators. By intentional design,
some sessions also do not have activities that target certain
mediators. We also acknowledge that there may be activities
that do not fit into the matrix (e.g., welcoming activities,
graduation ceremony). Such activities may be related to
clinically important issues such as engagement and
termination; however, if the target of an activity is not or can
not be determined, this may indicate that the purpose may
need to be clarified, offering another opportunity to
strengthen the intervention via revision or deletion.
Of note is that some activities may show up multiple

population may be strengthened by the addition of new
activities into the intervention. New activities might be focus
on issues and dynamics that have been overlooked or not
play as significant an impact for the original target
population compared to the new target population. For
example, focus group participants suggested that sexual
Adaptation of an existing intervention for a new target
histories figured prominently in shaping sexual behaviors
and communication among African American MSM. Thus,
we added an activity—the “Couple Timeline”—designed to
elicit more detailed sexual histories from participants and
provide an interactive, visual presentation of the temporal
sequence of event. Participants stated that this new activity
allowed both partners to gain a greater appreciation and
awareness of the impact of each of their personal histories in
a more meaningful, interactive manner than the activities in
the original intervention. Placing new activities into the
Deconstruction/Reconstruction Matrix helps ensure that
new/added activities are consistent with the theory that
guided the original intervention, which is SCT for the
Connect intervention. We then examined other intervention
activities originally constructed before/without the Couple
Timeline, and incorporated revisions that could leverage the
information elicited or presented in the Couple Timeline
activity (e.g., aligning drug use history with sexual history to
foster insight on outcome expectances related to drug use
and sexual [risk] behavior). Thus, additional passes through
the matrix are possible and were performed as activities are
added and consequently revised. The visualization tool also
minimizes the chance that some mediators may inadvertently
receive insufficient attention due to accommodating new
activities or revisions.

deconstructing the original intervention into component
activities, each activity revised in a manner that adheres and
promotes theoretical rigor,
Comparing the matrix for the original intervention versus the
matrix for the revised intervention provides a quick means to
visualize the adaptation.
Altogether, the adaptation process involved
and then reconstructed.


Intervention Session #
1 2 3 …
6
Information/
Knowledge
• Introduce purpose of the
intervention/study
• Review of last session
• HIV/STI 101
• Personal vulnerability
• Speaker/listener intro
• Goal-setting
• Review of last session
• Myth/facts about
HIV/STIs
• Alternatives to unsafe sex
…
• Recap & review
• Social support network
map

Outcome
Expectancies
• Pros/cons of participating • Protecting ourselves and
protecting our
relationship
• Speaker/listener review
• Condom use skills
• Goal-setting
…
• Relapse prevention &
contingency planning
Social & Self-
Regulatory Skills
• Commitment contract • Speaker/listener practice
• Goal-setting

…
• Relapse prevention &
contingency planning
• Rewarding behaviors,
ourselves, & relationship
Self-Efficacy
• Overcoming barriers to
participating
• Taking control of life
• Communicating about sex
…
• Relapse prevention &
contingency planning
Social Cognitive Theory Construct
Social Support
• Couple-based approach • Speaker/listener intro
• Speaker/listener practice
• Communicating about sex
• Commitment to
relationship
…
• Social support network
map
• Relapse prevention &
contingency planning

Fig. (1). Example of a Deconstruction/Reconstruction Matrix used for the adaptation of the Connect intervention. Bulleted items represent
activities conducted during the indicated session.

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130 The Open AIDS Journal, 2010, Volume 4 Wu et al.
Ancillary Activities

and revising materials used for engagement, recruitment, and
retention. Participants were also uniformly enthusiastic about
the appeal and potential promise of a couple-based
intervention for African American, methamphetamine-
involved male couples. A prominent theme involved
countering the experience of invisibility and isolation of
African American MSM couples (e.g., “We’re an
endangered species…Show two Black men as a couple [on a
flyer], that indicates ‘We do exist.’”). Additional suggestions
included leveraging African American MSM in the popular
media such as the Noah’s Arc television miniseries.
Participants noted that positive experiences could be
generated/facilitated by ensuring all intervention-related
activities were “a safe place to be honest” and to “be
welcoming no matter what [his sexual orientation and
dis/comfort with non-heterosexual identity].” Finally,
participants were also uniformly enthusiastic about the
appeal and potential promise of a couple-based intervention
for African American, methamphetamine-involved male
couples (e.g., “Couples [intervention] stimulates new
thoughts and ways of seeing things…we are not alone with
these problems, and it is real.”, “Participation shows others
like ourselves that we really care about these issues and the
community.”).
Additional developmental activities focused on adapting
DISCUSSION

literature regarding the adaptation of an evidence-based
intervention originally designed for heterosexual couples to
be revised specifically for male same-sex couples. Beyond
the shift from heterosexuals to MSM, the study also focused
on those residing at the nexus of several risk profiles—
African Americans, methamphetamine users, and having
longer-term intimate partners—the confluence of which
presented additional challenges and considerations: (1) the
dearth of existing research and attention paid to longer-term
couple-dynamics among African American MSM and, to
some extent, African American MSM and methamphetamine
use; (2) a lead investigator who phenotypically does not
match the target population; and (3) limitations on time,
resources, and number/availability of topical experts. Service
providers and researchers facing some or all of these
challenges as they seek to adapt existing interventions for
new target populations may benefit from the methods
employed in this study: conducting multiple focus groups
with the same participants; use of a theoretical framework
that recognizes multiple, interacting domains of influence
and accommodates different
development/use of the Deconstruction/Reconstruction
Matrix, a visualization tool that helps to ensure theoretical
rigor, that intervention targets are maintained in the revision
process, and tracking of the overall adaptation process.
To our knowledge, this is the first report in the empirical
worldviews; and

combined with the positive feedback, may signify that the
adaptation process was an attractive and feasible endeavor
for members of the target population. These conclusions are
reinforced based on subsequent review/approval from: a
High attendance rates during the series of focus groups,
panel of 8 service providers—who volunteered specifically
for this study—from local community-based agencies
serving African American MSM, methamphetamine users,
and/or HIV-affected populations; a Program Review Panel
consisting of 5 local community members who are charged
with ensuring information/materials are understandable,
accurate and appropriate; and a Community Advisory Board
that provides input across a variety of HIV-related studies
conducted at the research site.

intentional decision to rely on a small number of focus group
participants, leading to
generalizability since the range of experiences and
worldviews among the target population may not have been
fully identified. Focusing on a narrow target population
raises the concern about the generalizability and cost-
effectiveness of this approach; it remains to be answered the
extent to which these concerns are possibly countered by
increased efficacy—presumably due to the highly tailored
content—in conjunction with targeting a higher risk
population. The anti-racist and anti-heterocentrist approach
may also help temper these concerns about overspecification,
yet may increase the requisite skill level of facilitators.
Another limitation is the need to examine whether the
adaptation process preserved
effectiveness of the intervention. It is also noteworthy that
when asking focus group participants to discuss concerns
and issues of safety, they responded with information more
related to notions of psychological and social “comfort.”
Despite repeated attempts, little information appeared to be
elicited regarding participants’ views on breaches of
confidentiality (e.g., accidentally “outing” an individual) and
other possible adverse events. The extent to which this latter
issue reflects a shortcoming of the conduct of focus groups, a
selection bias among the small sample of couples
participating in the focus group (e.g., they were all
comfortable identifying as gay), and/or is truly more
generalizable to men/couples who meet the eligibility criteria
remains unclear.
A limitation of this work and the process include the
ensuring caution about
the efficacy and/or

next steps. Specifically, the revised intervention will be
pilot-tested with a small sample of African American,
methamphetamine-involved
preliminary evidence and insight regarding efficacy as well
as feasibility (e.g., recruitment, retention). The pilot test will
also include protocols for facilitators to monitor process and
record untapped areas or unanticipated information—
including adverse events—in order to make any necessary
further revisions to enhance generalizability, training of
facilitators, and participant safety. The pilot test will also
generate needed information on the means and venues for
reaching, engaging, and recruiting the target population.
Both the adaptation process and subsequent pilot testing
represent crucial first steps in the trajectory of providing
service providers with a couple-based HIV preventive
intervention backed by the highest standards of scientific
rigor for methamphetamine-involved, African American
MSM.
The aforementioned limitations inform the anticipated
male couples to obtain

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Adapting an HIV Intervention for Male Couples The Open AIDS Journal, 2010, Volume 4 131
ACKNOWLEDGEMENTS

and Prevention (CDC) grant no. UR6PS000300. We thank
Gordon Mansergh and Mahnaz Charania for their scientific
guidance throughout the study. We also would like to
acknowledge the contributions of Dale Frett and Jordan
White, as well as the participants and couples who made this
work possible. The content presented in this article is solely
the responsibility of the authors and does not necessarily
represent the official views of CDC, Harlem United, or the
Columbia University School of Social Work.
This study was supported by Centers for Disease Control
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Received: October 1, 2009

Revised: November 15, 2009 Accepted: November 25, 2009
© Wu et al.; Licensee Bentham Open.

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