Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource Requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Connect¹ is a 6-session, couples-level intervention for heterosexual couples who have been together at least 6 months and who are at risk for HIV/STDs. The couple does not have to be living together. Connect can be used with couples where both partners are HIV-negative or where one or both partners are living with HIV/AIDS, regardless of HIV status. It is not intended for same-sex couples. Connect focuses on teaching communication, negotiation, and problem-solving techniques and skills to enhance the quality of the couple’s relationship and shared commitment to safety and health. Connect is not couples counseling or couples therapy.

Connect has been packaged by CDC’s Replicating Effective Programs project. An intervention package, training, and technical assistance are available through CDC’s Diffusion of Effective Interventions Project. The intervention package will be provided only to participants of the 32-hour Connect training conducted by CDC’s training partners. Registration for training as well as planning and implementation information (including the starter kit, technical assistance guide) can be found at The Diffusion of Effective Behavioral Interventions (DEBI).

Goals
Connect aims to teach couples communication techniques and HIV/STD risk-reduction knowledge and skills. It is also designed to explore with the couple the gender and power dynamics in their relationship that may be barriers to safer sex behaviors. Connect’s relationship-based approach reframes safer sex not as individual protection but rather as a way to preserve relationship and community, as an act of love, commitment, and intimacy.

How It Works
Each partner takes part in a separate orientation session to determine whether the partnership is safe enough to complete Connect. If the partnership is free of violence, the couple attends the remaining 5 sessions together. The sessions are guided by 1 facilitator. Connect’s interactive sessions create a context though which the couple examines their risks, analyzes their interpersonal behaviors, develops risk-reduction skills, improves their communication and negotiation skills, improves the quality of their relationship, removes barriers to relationship change, sets safer-sex goals, and indentifies their social support networks. In the sessions, clients view video clips of couples modeling communication and problem-solving skills. The facilitator coaches the couple as they practice developing the skills. The couple sets goals to work on between sessions.

Connect is adaptable to different populations by varying the choice of video clips and using the language used by the couple. Spanish translations of the facilitators guide, session videos, and other materials will be available at the end of 2009.

Theory Behind the Intervention
Connect is based on 2 theories. The first is the AIDS Risk Reduction Model, which organizes behavior change into three phases—recognize risk, commit to change, and act on strategies. The second is the Ecological Perspective, which emphasizes the personal, relational, and social influences on behavior. Connect also is influenced by counseling techniques used at the Ackerman Institute for the Family, which allow couples to harness their strengths and resources and  work together to solve shared problems.

Research Findings
Compared with women who received 1 session of education, couples in Connect, at 3 and 12 months after the intervention, reported a significant increase in the proportion of protected sex acts a significant increase in the rates of 100% condom use. Although the study participants were primarily African American and Latino, this intervention is applicable to couples of other races/ethnicities and subpopulations, including persons affected by HIV or by current or past drug use. The results indicate a long-term effect (up to at least 12 months) on reported risk-reduction behaviors.

Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory on which the intervention or strategy is based; they are thought to be responsible for the intervention’s effectiveness. Core elements are essential and cannot be ignored, added to, or changed.

Connect has the following 7 core elements: 

• Working with male and female partners together in 3 to 5 facilitated sessions.
• Emphasizing the relationship as the target of change, redefining sexual risk reduction from individual protection to protecting and preserving the relationship.
• Discussing ideas about relationship fidelity and the need to reduce HIV/STD risk among couples.
• Identifying how gender differences, stereotypes, and power imbalances influence safer-sex decision making and behaviors.
• Using video-based scenarios to model good communication and negotiation of safer sex to stimulate discussions and role-plays.
• Using modeling, role-play, and feedback to teach, practice, and promote mastery in couple communication, negotiation, and problem-solving and social support enhancement.
• Applying couple communication, negotiation, problem-solving, and goal-setting skills to the learning, performance, and maintenance of behaviors to reduce HIV/STD risk.

Key Characteristics
Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population.

Connect has the following key characteristics:

• Couples meet in sessions that last 90 to 120 minutes.
• Sessions are held 3 to 5 days apart so that participants can meet their goals and practice skills to build self-efficacy.
• The facilitator has experience working with couples.
• The individual orientation sessions are conducted by a facilitator who is not the same person who conducts sessions 1 to 5 with the couple.
• The same facilitator conducts sessions 1 to 5 with the same couple.
• At each session, couples receive a take-home condom packet with assorted male and female condoms and lubricants. (Contents may be locally adapted.)
• The facilitator asks couples for the terms they use for sexual behaviors and to refer to each other and uses these terms in the sessions, as appropriate.

Procedures
Procedures are detailed descriptions of some of the elements and characteristics listed above. Procedures for Connect are as follows:

Showing videos
A variety of video clips to present information for discussion or to model skills for practice are shown in the Connect sessions. Topics include the following:

• Sexually transmitted infections, including HIV/AIDS.
• Speaker/listener technique.
• Female condom demonstration.
• Risk triggers.
• Problem solving.

Signing couple agreements
The couple signs or reviews already signed contracts of commitment at each of the 5 sessions. These agreements are to attend all of the Connect sessions and to protect each other by practicing safer sex.

Conducting exercises
Each session builds communication and negotiation skills around relationship issues. In all 5 sessions clients use the speaker/listener technique to express their feelings and perspectives and to listen to and understand what their partner is saying. At each successive session, the couple picks increasingly difficult topics from their own experience to discuss with the aim of improving their relationship and reducing barriers to safer sex. The couple learns and applies additional skills, such as “I” statements, problem solving, and decision making. These skills are modeled in the videos and then practiced by the couple. The facilitator coaches the couple in the use of the techniques and provides feedback and encouragement on skill development.

Exercises related to examining risks and interpersonal behaviors are featured in every session. Identifying personal risk is conducted during 3 of the sessions. Self-identification of the couple’s position on a safer sex scale is conducted during 2 sessions. In session 2, the couple uses the scale to identify their current level of risk and to select a lower level of risk they want to achieve. In session 4, the couple uses the scale to assess their progress toward achieving their target risk level.

Setting goals
Setting goals is one of the skills taught by Connect. At the end of each session, the couple sets a goal or goals to work on. The goals can be individual, such as buying condoms or getting an HIV test, or for the couple, such as using the speaker/listener technique to discuss a certain issue or trying an unfamiliar safer sex practice. The goals are steps toward attaining the couple’s target position on the safer sex scale.

Connect can be adapted to different populations of heterosexual couples by varying the choice of video clips and using the language used by the couple. CBOs may choose to use only those video clips in which the risks or race/ethnicity of the characters match those of the clients. Connect has been used successfully with couples who use drugs or have a history of drug use. Connect can be used with couples in which one or both partners are living with HIV/AIDS. With these couples, the facilitator should emphasize preventing transmission and re-infection and effects of STDs on HIV infections as reasons to practice safer sex. Facilitators may use pictures to clarify terms and processes. In the original research, couples met once per week for 6 weeks. Connect sessions could be offered twice per week for 3 weeks if the couple has at least 3 days between sessions to complete their goals. Connect may be adapted for several settings and has been used successfully in clinical as well as community-based settings.

People
Connect needs 2 full-time or half-time, paid, experienced counselors or mental health professionals (preferably 1 man and 1 woman) and 1 part-time (25%) program coordinator for supervision, quality assurance, and evaluation. The facilitators should be skilled counselors or mental health professionals. They can be someone with bachelor’s-level training in counseling or mental health work, a psychologist, a social worker, a licensed practicing counselor, or a licensed chemical dependency counselor. The facilitators should have experience working with individuals, couples, or groups of people at risk for HIV/STDs or living with HIV/AIDS.

Each facilitator should attend the 32-hour Connect training conducted by CDC’s training partners. Program coordinators/managers, who oversee the intervention and supervise the group facilitators, are also encouraged to attend the 32-hour Connect training. Program coordinators/managers and people interested in learning more about the intervention are encouraged to read the Connect starter kit at The Diffusion of Effective Behavioral Interventions (DEBI)..

Space
Connect needs space that meets the following requirements:

• Along major transit routes, so that participants without private transportation can easily access the location.
• Large enough for the audiovisual equipment and easel to be placed near the facilitator.
• Accessible at a variety of times for flexible scheduling.
• Child care provided on the premises.
• Private and secure, so that confidentiality of clients can be ensured.
• Quiet and without interruptions (such as people entering and exiting the room or outside noise).

CBOs have taken Connect to locations convenient to clients rather than having all clients come to the agency. Some examples include borrowing an office at an outpatient clinic or community center for 2 hours per week and conducting a make-up session at the couple’s home.

Supplies
The Connect package comes with generic marketing tools, such as a video and printed promotional literature. Connect will also require the following:

• A DVD player and television or video monitor, with a remote control (or laptop computer capable of playing DVDs).
• A computer with printer.
• An easel, easel chart paper, markers, pencils.
• Penile and vaginal anatomic models for condom demonstration.
• Male and female condoms, lubricants, and latex barriers.
• Take-home packets of condoms, lubricants, and latex barriers.
• Resource manual.
• Snacks and small incentives (optional).

CBOs are encouraged to screen potential clients to determine whether they are appropriate for the intervention. The Connect package (Appendix II of the Connect implementation manual) includes the Connect readiness assessment tool, which is used to determine whether potential clients are in a relationship that is free of severe violence. 

The following recruitment strategies can be used to reach heterosexual couples at risk for HIV/STDs:

• Recruit 1 or both partners from your existing programs and services for at-risk persons, such as comprehensive risk counseling and other evidence-based interventions.
• Invite referrals from other agencies that serve sexually active adult heterosexuals, such as outpatient substance abuse treatment programs.
• Use the generic marketing materials in the Connect package.
• Advertise in local newspapers, including alternative and Spanish-language papers.
• Send press releases to local radio and television stations.
• Post announcements on the Internet.

Choose a recruitment strategy that will work in the setting in which the CBO plans to implement Connect.

Before a CBO attempts to implement Connect, the following policies and standards should be in place to protect clients, the CBO, and the Connect intervention team. 

Confidentiality
A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which a client is referred, signed informed consent from the client must be obtained.

Cultural Competence
CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to different cultures. In addition, they should offer materials and services in the preferred language of clients, if possible, or make translation available, if appropriate. CBOs should facilitate community and client involvement in designing and implementing prevention services to ensure that cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. (Please see Ensuring Cultural Competence in the introduction of this document for standards for developing culturally and linguistically competent programs and services.)

Data Security
To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.

Informed Consent
CBOs must have a consent form that carefully and clearly explains (in appropriate language) the CBO’s responsibility and the clients’ rights. Individual state laws apply to consent procedures for minors; but at a minimum, consent should be obtained from each client. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client’s record.

Legal and Ethical Policies
By virtue of participation in Connect, clients living with HIV/AIDS may learn of or disclose their HIV status. CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization’s responsibilities if a client receives a positive HIV test result and the organization’s potential duty to warn. CBOs also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.

Referrals
CBOs must be prepared to refer clients as needed. For clients who need additional assistance in decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as comprehensive risk counseling and services, partner counseling and referral services, and other health department and CBO prevention programs. For potential clients who are experiencing severe violence in their relationship, providers must be prepared to refer them to intimate partner violence help.

Volunteers
If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker’s compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

The following quality assurance activities should be in place when implementing Connect.

Facilitators
Training
Facilitators should complete a training workshop, including review of the intervention theory and materials, and participate in practice sessions.

Session review
CBOs should have in place a mechanism to ensure that all session protocols are followed as written. Quality assurance activities can include observation and review of sessions by key staff and supervisors involved with the activity. This review should focus on adherence to session content, use of correct videos with adequate facilitation of discussions, accessibility and responsiveness to expressed client needs, and important process elements (e.g., time allocation, clarity).

Record review
Selected intervention record reviews should focus on assuring that consent forms (signed by the clients) are included for all participants and that session notes are of sufficient detail to document that clients are participating actively.

Clients
Clients’ satisfaction with the intervention and their comfort should be assessed at each session.

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures.  Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting.  PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements.  Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

CDC. Draft CDC Technical assistance guidelines for CBO HIV prevention program performance indicators. Atlanta, GA: US Department of Health and Human Services; November 2003.

Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: US Department of Health and Human Services; 2001.

An intervention package, training, and technical assistance on the Connect intervention is available from CDC.

References

1. El-Bassel N, Witte SS, Gilbert L, Wu E, Chang M, Hill J, Steinglass P. The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. American Journal of Public Health.2003; 93:963–969.
2. El-Bassel N, Witte SS, Gilbert L, Wu E, Chang M, Hill J, Steinglass P. Long term effects of an HIV/STI sexual risk reduction intervention for heterosexual couples. AIDS and Behavior.2005;9(1):1–13.
3. El-Bassel N, Witte SS, Gilbert L, Sormanti M, Moreno C, Pereira L, Elam E, Steinglass P. HIV prevention for intimate couples: a relationship-based model. Families, Systems and Health. 2001;19(4):379–395.
4. Schiff M, Witte SS, El-Bassel N. Client satisfaction and perceived helping components of an HIV/AIDS preventive intervention for urban couples. Research on Social Work Practice. 2003;13(4):468–492.
5. Sormanti M, Pereira L, El-Bassel N, Witte SS, Gilbert L. The role of community consultants in designing an HIV prevention intervention. AIDS Education and Prevention. 2001;13(4):311–328.
6. Witte SS, El-Bassel N, Gilbert L, Wu E, Chang M, Steinglass P. Recruitment of minority women and their main sexual partners in an HIV/STI prevention trial. Journal of Women’s Health. 2004;13(10):1137–1147.
7. Wu E, El-Bassel N, Witte SS, Gilbert L, Chang M, Morse P. Enrollment of minority women and their main sexual partners in an HIV/STI prevention trial. AIDS Education & Prevention. 2005;17(1):41–52.

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