The Connect intervention, a couple-based HIV/STI 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.

Revision of the Connect intervention in order to be 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 existence of multiple knowledgeable experts on the new target population. However, communities have pressing needs that may benefit from swifter progression in developing promising 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 for African American, methamphetamine-involved male couples. Thus, we endeavored to develop and implement an adaptation procedure that seeks to maintain a high level of scientific rigor in the face of these challenges.

Recruitment was conducted in a variety of manners. “Active” methods included study staff conducting outreach 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.

If study staff recruited/contacted only one member of a 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.

All focus groups were held in a private room at the 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.

Since this report is focused on the adaptation process, 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.

The focus group co-facilitators followed an interview 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 paucity of research on African American MSM in 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 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.

The ontogenetic level refers to the personal factors that 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 microlevel consists of the interactional and structural 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-positive/methamphetamine using partner] gets the attention [of service providers and programs].”

The exolevel refers external stressors or buffers on the 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 macrosystem encompasses the broad cultural values 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.

This range of responses underscores the importance of 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 MSM may experience 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 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.”

Participants were also asked to reflect on lived 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 communication 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.

Beyond experiences and worldviews, analysis of focus 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 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.

Adapting an existing intervention with multiple sessions, 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 tool—the Deconstruction/ 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.

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.

The Deconstruction/Reconstruction Matrix not only enhances identification and tracking of all intervention 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 understanding, culminating with the intervention having facilitators asking for and using the identity label that the participants prefer.

Of note is that some activities may show up multiple 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.

Adaptation of an existing intervention for a new target 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 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.

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

Additional developmental activities focused on adapting 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.”).