Everyone has heard of the different ways that HIV can spread: unprotected sex, sharing needles and childbirth to name a few. But, there is another dangerous perpetrator of HIV that is less obvious: violence against women.
Violence against women is a social structure that helps spread HIV infection. It works by affecting women’s ability to negotiate when they have sex, what HIV prevention tools they use, and can even cause them to suffer social stigma if they insist on HIV prevention. Until these power structures are eliminated, HIV will never be beaten.
How can we promote healthy relationships and reduce inter-partner violence? These are the aims of CHARISMA (Community Health Clinic Model for Agency in Relationships and Safer Microbicide Adherence), a pilot study funded by PEPFAR and USAID to assess relationships in two locations in Johannesburg with high HIV burdens, aims to answer.
The three aims of the study were to identify ways to measure and address the impacts of violence on HIV prevention use, to develop the clinic- and community-based CHARISMA intervention and to disseminate best practices. They have finished the pilot and need more testing before the release of the project as a whole.
Hartmann explained that CHARISMA focuses on gender and intimate-partner violence because “Inequitable gender norms put women at a greater risk of HIV.”
Over six months, the current cohort of 77 women was invited for a counselling at enrollment in the HOPE open-label vaginal ring study, then again after one month. Enrollment is rolling and the final number is expected to be 100. These consultations ascertained the concerns in each relationship and helped women address them with different counselling approaches. Women can be more empowered to use HIV prevention effectively when their relationship challenges are acknowledged and addressed.
For example, some women are unable to refuse sex with their partner and would benefit from strategies for discrete product use. In the CHARISMA study, Hartmann explains that their approach is to provide skills regardless of relationship dynamics so even women who say they can talk openly with their partner are offer skill-building around communication and conflict negotiation.
The counselling worked on inter-partner violence, vaginal ring disclosure and partner communication. A vaginal ring is a soft, silicone ring infused with an HIV-prevention drug, called Pre Exposure Prophylaxis (PrEP) that can be inserted in the vagina comfortably. During the course of a month, the ring releases the HIV-prevention drug, protecting the woman from HIV infection discretely. This option is not available in clinics yet, but it is coming and knowledge of the product is growing.
Not every woman needed all of the counselling options, but over half needed counselling for intimate-partner violence. This emphasizes how many women are in a relationship where they receive abuse. Over the course of the study, the number of women taking up external referral resources for violence was low, but Hartmann thinks that “This is often the first recognition that psychological abuse and control constitutes something that’s unhealthy” in a relationship. If these counselling sessions are the first time that women are realising the extent of abuse in their relationships, then they may not be ready for the next steps. This is an area they want to explore further.
From the women who have reached their month 3 visit, around 40% reported improvements in relationship abuse. Generally, the women reported that the counselling was useful, with positive outcomes such as thinking about relationships, feeling empowered, having safety plans and even leaving an abusive partner in some cases.
The Other Half
Empowering women to recognise abuse in relationships is only half the battle against intimate partner violence. Where the counselling sessions Hartmann described are sometimes the first time women realise that their situation is not normal, the same may be true for men.
There is a community component of the study which starts with a two to three day workshop. 14 men at a time are invited to talk about HIV risk perception and norms about PrEP and microbicides (a gel with an HIV prevention drug that a woman can apply to her vagina before sex). Gender stereotypes were addressed, for example, a woman who uses HIV prevention tools is not automatically promiscuous.
These workshops are a great way to find the committed participants and make them community action team members (CATS). These men then design how to impart the issues they’ve discussed into their community. For example: painting a mural, talking on the radio or hosting a tavern dialogue.
Over 9000 men and 1500 women have been accessed during this study. From pre and post-dialogue questionnaires, there has been an increase in HIV prevention knowledge and gender attitudes and participants are generally interested in learning about HIV prevention tools. Clinics report that the results are acceptable and feasible, and women comment that these interventions are positively impacting their relationships. At least one CAT member was reportedly a former abuser.
The next plan is to test CHARISMA counselling within a PrEP demonstration program to understand how the intervention may work in a more real-world setting.
Written by Caroline Reid