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CHARISMA:'To empower women to be safe while using the vaginal ring' A photo story about implementing the CHARISMA intervention pilot in Johannesburg, South Africa

The CHARISMA intervention pilot integrated delivery of HIV prevention with relationship skills building and intimate partner violence (IPV) counseling for women at the Wits Reproductive Health & HIV Institute (Wits RHI) in Johannesburg, South Africa. Beginning in June 2016, CHARISMA lay counselors conducted relationship assessments with women using the vaginal dapivirine ring for HIV prevention in the MTN-025 (HOPE) study.

“I think what we are trying to accomplish by counseling these women is to empower them...we want to see our participants being safe while using the vaginal ring that is being used in the HOPE study, that’s our main objective.”—Flo, CHARISMA clinic counseling mentor

CHARISMA lay counselors used the Healthy Relationship Assessment Tool (HEART), which was developed specifically for CHARISMA, to assess women's relationships and IPV risk. Based on each woman’s responses to HEART and selected measures from the HOPE study, CHARISMA lay counselors provided counseling tailored to meet each woman’s needs by empowering her with skills to 1) decide whether and how to disclose ring use to male partners; 2) communicate and negotiate conflict with partners; and 3) respond to experiences of IPV.

“CHARISMA intervention is about women who don’t speak up—or bottle up—about their relationships. For instance, most of the participants don’t talk much about their relationships and some of them are in abusive relationships...CHARISMA helps them to be opened up with their relationships…[HEART] asks questions regarding [participants'] relationships. So, it depends with the participant: if she answered that maybe she’s experiencing abuse we refer that participant, but we counsel her first...”—Promise, CHARISMA clinic counselor
"When you give a woman… the skills [to discuss HIV prevention with her partner]… she will think about the skills that you gave her then she will make her own decision [about ring uptake and disclosure] at her own time.”—Angeline, CHARISMA clinic counselor

In addition to tailored empowerment counseling, lay counselors provided referrals to local violence response services and other social support services as needed. Women received additional counseling at their one-month follow up visit and as needed during their participation in the HOPE study, such as when she had a new sexual partner.

“What I’m trying to accomplish when conducting counseling is...for the participants to be able to better communicate with their partners. To communicate freely. To be open with their relationships and their feelings."—Portia, CHARISMA clinic counselor
"When I’m counseling participants, or women in CHARISMA, I want to see the change, especially in their relationships…the [women] that are in an abusive relationship, I want to see them not in an abusive relationship. I want to see them bringing their partners in the study so that you can counsel both of them, and then they are happy.” —Angeline, CHARISMA clinic counselor
“I’ve learned [from working on CHARISMA] that violence comes in so many ways. Because me…I was thinking you need to be beaten by your partner in order to say ‘me, I’m in a violent relationship.’ I didn’t know that controlling is also a kind of violence. If your partner tells you what to do and what not to do, it’s a kind of violence.”—Portia, CHARISMA clinic counselor

In addition to clinic counseling, CHARISMA included intensive community outreach. The community component of CHARISMA was led by Sonke Gender Justice (Sonke) and included two-day workshops and focused outreach in taverns and other meeting places, soccer tournaments, community murals, and door-to-door outreach. This outreach focused primarily on men and male community leaders to increase their awareness and acceptance of new HIV prevention methods for women.

“CHARISMA intervention … [had] a particular focus on intimate partner violence prevention… taking in account that intimate partner violence is a contributing factor to HIV and AIDS…[and] to say ‘how can we reach men?’”–Thomas, CHARISMA community education and mobilization trainer
"The work with CHARISMA has created a space where we were able to educate communities around HIV and HIV prevention. But also, you know, break this barrier in relationships where men feel it is not appropriate for them to discuss sexual issues with their partners. And, also, to be able to understand that women are sexual beings and be able to understand that women have rights, you know, to decide about their sexuality and what they would like to use as methods of prevention… And, the partners must respect the woman’s decisions…CHARISMA for me, it’s really dealing with gender and HIV, it has created that space.”—Nonhlanhla, CHARISMA community education and mobilization manager

Sonke staff were supported by Community Action Teams (CATs), comprised of volunteer community members who were passionate about addressing HIV prevention, gender equality, and gender-based violence in their communities.

"Community action teams are a group of people who are volunteers. We volunteer to work within our community to empower the community on HIV prevention, HIV related issues, gender-based violence, intimate partner violence...it’s just a group of people who volunteer their time and they love what they are doing. They love to uplift the community.”—Cindi, CHARISMA CAT member

The CHARISMA intervention was found to be acceptable and feasible to providers and participants in the pilot study and will be further tested in an oral PrEP demonstration project starting in mid-2018.

“What I will take from CHARISMA going forward is that we have to open our hands to allow people to share their experiences, it’s very important. As researchers, we cannot assume that we know everything...and I think CHARISMA has opened those doors for participants, just to talk…to create a platform for women to talk about their relationships [and to talk about HIV prevention and disclosure of ring use to their partners].”—Flo, CHARISMA clinic counseling mentor

Find more information about CHARISMA at: https://www.prepwatch.org/usaid-supported-initiatives/ and remember to sign-up to the email list to receive project updates.

Developed by Tara Miller with contributions from Michele Lanham and CHARISMA team members at Wits RHI and Sonke Gender Justice

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