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Zissette S, Tolley EE, Martinez A, Roberts ST, Palanee-Phillips T, Montgomery ET. Measuring Effects of Counseling to Increase Pre-Exposure Prophylaxis Adherence and Partner Support in South Africa Using the Healthy Relationship Assessment Tool. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200075. [PMID: 37903586 PMCID: PMC10615234 DOI: 10.9745/ghsp-d-22-00075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/19/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION In response to the diverse roles and strong influence that male partners may have in women's decisions and ability to use HIV prevention products, we previously developed the counselor-administered Healthy Relationship Assessment Tool (HEART). This tool helps counselors tailor pre-exposure prophylaxis (PrEP) adherence support counseling to women's relationship dynamics with their sexual partners, suggesting modules for counselors to deliver. In this study, we examined the extent to which counselors used the HEART to guide the delivery of intervention modules and whether changes in subsequent HEART scores reflected the counseling module(s) received. METHODS We conducted this study during a randomized controlled trial of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence (CHARISMA) counseling intervention in Johannesburg, South Africa. Trained lay counselors administered the HEART to intervention group participants at enrollment (n=203) and at 3- and 6-month follow-up visits between October 2018 and April 2021. The HEART auto-calculated participants' response scores to recommend relevant counseling modules. We compared the mean scores for the 5 HEART scales across groups receiving different counseling modules. We also assessed changes in scale scores over time by the counseling module received. RESULTS Although counselors could override HEART counseling module recommendations based on additional knowledge of participants' cases, they consistently agreed with the HEART recommendations. The HEART also triggered the sorting of women into counseling modules that they were positioned to successfully leverage. Additionally, participants' HEART scores changed over time in predictable ways based on the type of counseling module received. CONCLUSION Overall, the tool performed as predicted and was consistent with past validation efforts of the HEART, indicating that the HEART may provide an efficient means to tailor women's counseling to address relationship-related challenges to PrEP adherence.
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Affiliation(s)
- Seth Zissette
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Elizabeth E Tolley
- Behavioral, Epidemiological, & Clinical Sciences, FHI 360, Durham, NC, USA
| | - Andres Martinez
- Behavioral, Epidemiological, & Clinical Sciences, FHI 360, Durham, NC, USA
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, School of Public Health, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
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Hartmann M, Triplett N, Roberts ST, Lanham M, Reddy K, Tenza S, Mayisela N, Mbewe D, Maboa O, Mampuru L, Tolley EE, Palanee-Phillips T, Montgomery ET. Changes in relationships, HIV risk, and feelings towards PrEP: findings from a qualitative explanatory study among participants in the CHARISMA intervention trial. BMC Womens Health 2023; 23:440. [PMID: 37608373 PMCID: PMC10464438 DOI: 10.1186/s12905-023-02603-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 08/16/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Intimate partner violence (IPV) and other relationship-based challenges have been demonstrated to reduce women's ability to use pre-exposure prophylaxis (PrEP) effectively for HIV prevention. The Community Health Clinical Model for Agency in Relationships and Safer Microbicide Adherence (CHARISMA) intervention was designed to mitigate these challenges and increase South African women's agency to use PrEP. The CHARISMA randomized controlled trial did not identify statistically significant differences in PrEP adherence or relationship dynamics between the intervention and control arms. As such, the aim of this explanatory qualitative sub-study was to understand women's experiences with the CHARISMA trial and explore reasons for the null results. METHODS Twelve CHARISMA trial participants were purposively selected to participate in serial in-depth interviews, which took place at the trial end and 3 months later. Participants represented individuals who had received each of the three counselling modules, 1) healthy communication counselling, 2) PrEP disclosure counselling, or 3) IPV counselling, as well as those in the control arm who received IPV standard-of-care counselling. RESULTS A thematic case analysis revealed numerous positive relationship outcomes among intervention participants, including identifying and ending unhealthy relationships, gaining a sense of personal empowerment, and enacting more positive behaviors and HIV risk reduction strategies in subsequent relationships. These positive shifts were occasionally described as contributing to decisions to discontinue PrEP use, which may partly explain the limited impact of the intervention on PrEP adherence. CONCLUSIONS Future investigations of counselling interventions addressing relationship-based barriers to PrEP use should account for changing risk dynamics and need for PrEP.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, California, USA.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Noah Triplett
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
| | | | - Krishnaveni Reddy
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Siyanda Tenza
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nonkululeko Mayisela
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorica Mbewe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ontathile Maboa
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lydia Mampuru
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thesla Palanee-Phillips
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
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Hartmann M, Roberts ST, Triplett N, Tenza S, Maboa O, Mampuru L, Mayisela N, Mbewe D, Tolley EE, Reddy K, Palanee-Phillips T, Montgomery ET. Development of a relationship counselling website to identify and mitigate risk of intimate partner violence in the context of women's PrEP use. PLOS DIGITAL HEALTH 2023; 2:e0000329. [PMID: 37578954 PMCID: PMC10424861 DOI: 10.1371/journal.pdig.0000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 07/18/2023] [Indexed: 08/16/2023]
Abstract
Discreet, accessible interventions are urgently needed to mitigate the risk of intimate-partner violence (IPV) and other relationship barriers that women encounter to using HIV prevention methods such as pre-exposure prophylaxis (PrEP). We adapted a counsellor-administered intervention, CHARISMA, into a mobile-optimized website to enhance accessibility and reduce human resources required for HIV prevention and relationship counseling. Using human-centered design and participatory methods, CHARISMA was adapted through workshops with former CHARISMA in-person intervention participants (n = 14; ages 18-45) and web development 'sprints' combined with cognitive interviews (n = 24). 'CHARISMA mobile' was then beta-tested with 81 women naïve to the in-person intervention. In beta-testing, participants used a 'think aloud' process to provide feedback on ease of use and rated design, functionality, comprehension, confidentiality, safety, and usefulness on a scale of 1 to 5 via a survey. Data were conducted in four rounds, interspersed with rapid assessment according to go/no-go criteria, and website adaptations. The updated website was pilot tested for 'real-world' feasibility and acceptability among 159 women using their own smartphones at a location of their choice. Feedback was measured via surveys and website analytics. Workshops and cognitive interviews generated insights on technology use, contextual adaptations, and confidentiality, which were integrated into the beta version. The beta version met all 'go' criteria and was further adapted for pilot testing. In pilot testing, users found the website was useful (mean rating 4.54 out of 5), safe (4.5 out of 5), and had few concerns about confidentiality (1.75, representing low concern). On average, users rated the website more than 4 stars out of 5. Beta and pilot-testing suggested the smartphone-optimized website was well-accepted, relevant, engaging, feasible to administer, discreet and safe. Results contributed to a refined website, suitable for adaptations to other contexts and further evaluation where outcomes related to PrEP use and relationships should be assessed.
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Affiliation(s)
- Miriam Hartmann
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Sarah T. Roberts
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Noah Triplett
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
| | - Siyanda Tenza
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Onthatile Maboa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lydia Mampuru
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nonkululeko Mayisela
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorica Mbewe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- University of Washington, Department of Epidemiology; School of Public Health, Seattle, United States of America
| | - Elizabeth T. Montgomery
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
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Garcia M, Roberts ST, Mayo AJ, Scheckter R, Mansoor LE, Palanee-Phillips T, Reddy K, Naidoo Y, Akello CA, Gaffoor Z, Siva S, Rushwaya C, Hlahla K, Jambaya J, Makoni R, Kachale E, Ndovie M, Zuma J, Montgomery ET. Integrating Gender-Based Violence Screening and Support into the Research Clinic Setting: Experiences from an HIV Prevention Open-Label Extension Trial in Sub-Saharan Africa. AIDS Behav 2023; 27:1277-1286. [PMID: 36178556 PMCID: PMC10036410 DOI: 10.1007/s10461-022-03864-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/24/2022]
Abstract
HIV and gender-based violence (GBV) are syndemic in sub-Saharan Africa and provision of support for participants who disclose GBV constitutes part of comprehensive care. Consequently, a process was undertaken to develop, implement, and evaluate standard operating procedures (SOPs) in MTN-025/HOPE, a study of the dapivirine vaginal ring for HIV prevention. The SOP was developed using needs assessment surveys in addition to World Health Organization (WHO) guidelines and other literature. Sites tailored and implemented the SOP through HOPE implementation. At study end, staff reported increased training 32/35 (91.43%); improved confidence (18/26; 69.23%); and improved vicarious trauma prevention onsite (17/28; 60.71%). Leadership reported increased staff competence in GBV response. Obstacles included limited referral organizations and time for follow-up, continued training needs, and cultural norms. Development and implementation of an SOP is a feasible strategy to build a GBV response to improve health systems and support sustained effective use of HIV prevention products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA.
- Global Health Population and Nutrition, FHI 360, 359 Blackwell St, Ste 200, Durham, NC, 27701, USA.
| | - Sarah T Roberts
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI 360, Durham, NC, USA
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
- University of Washington School of Public Health, Seattle, WA, USA
| | - Krishnaveni Reddy
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Yuthika Naidoo
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Carolyne Agwau Akello
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Samantha Siva
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Chenai Rushwaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Kudzai Hlahla
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Jane Jambaya
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Rujeko Makoni
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Evans Kachale
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Jabulisile Zuma
- Desmond Tutu HIV Foundation (DTHF) - Emavundleni Clinical Research Site, Cape Town, South Africa
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Triplett NS, Roberts ST, Hartmann M, Wagner D, Reddy KR, Mathebula F, Tolley EE, Baeten JM, Palanee-Phillips T, Montgomery ET. Examining Associations Between Mental Health, IPV Exposure, HIV Risk Behaviors, and PrEP Use in South African Women: An Analysis of Data from the Charisma Study. AIDS Behav 2022; 27:2030-2040. [PMID: 36459264 DOI: 10.1007/s10461-022-03936-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2022] [Indexed: 12/04/2022]
Abstract
Intimate partner violence (IPV) has been associated with poorer mental health outcomes and increased human immunodeficiency virus (HIV) risk behaviors. We examine the relations between IPV, mental health symptomology (defined as psychological distress and alcohol misuse), and engagement in HIV risk behaviors among a sample of South African women who participated in a randomized controlled trial of CHARISMA, an intervention to increase women's agency to use oral pre-exposure prophylaxis (PrEP) safely and consistently as well as mitigate relationship challenges. We also examined the impact of trial participation on women's mental health, as well as the impact of psychological distress on the effectiveness of the CHARISMA intervention. Mental health symptomology and IPV exposure were prevalent and associated with some HIV risk and protective behaviors. Trial participation reduced psychological distress. There was no evidence for mental health symptomology impacting the effectiveness of the CHARISMA intervention.
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Affiliation(s)
- Noah S Triplett
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA.
- Department of Psychology, University of Washington, Seattle, WA, USA.
| | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Miriam Hartmann
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Danielle Wagner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Krishnaveni R Reddy
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Florence Mathebula
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizabeth E Tolley
- Behavioral, Epidemiological & Clinical Sciences Unit, FHI 360, Durham, NC, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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The CHARISMA randomized controlled trial: a relationship-focused counseling intervention integrated within oral PrEP delivery for HIV prevention among women in Johannesburg, South Africa. J Acquir Immune Defic Syndr 2022; 90:425-433. [PMID: 35416797 DOI: 10.1097/qai.0000000000002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Consistent use of oral pre-exposure prophylaxis (PrEP) has been a challenge among women, particularly when in relationships with lack of partner support or intimate partner violence (IPV). Methods. We conducted a randomized controlled trial (RCT) of an empowerment counseling intervention called "CHARISMA" delivered to women within a PrEP demonstration project in Johannesburg, South Africa. The trial tested the effectiveness of CHARISMA to increase PrEP adherence; decrease social harms (SHs) and IPV; and improve partnership dynamics (e.g. communication, disclosure and support) as compared to those who received the standard of care (SOC) counselling support and referrals. 407 HIV-seronegative, non-pregnant women aged 18-45 years were enrolled for 6 months of PrEP use, with 203 randomized (1:1) to the intervention. All participants reporting IPV received counseling and referrals that followed the WHO five-step Listen, Inquire, Validate, Enhance Safety, and Support approach. Results. This RCT did not identify statistically significant differences between study arms for PrEP adherence or relationship dynamics, with the exception of an increase in PrEP disclosure among intervention arm women. In our study, we cannot determine whether the lack of detectable findings may have been due to lack of intervention effect, strength of SOC services, low risk in the study population or other factors. Conclusions: Addressing IPV and relationship dynamics remain important factors influencing HIV risk, and addressing these within the context of PrEP delivery is an important synergistic opportunity. CHARISMA was highly acceptable to participants, and further adaptation and testing of the intervention to other populations and settings will augment the evidence base.
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Evidence for use of a healthy relationships assessment tool in the CHARISMA pilot study. PLoS One 2022; 16:e0261526. [PMID: 34972141 PMCID: PMC8719706 DOI: 10.1371/journal.pone.0261526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/03/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The CHARISMA intervention, nested within the MTN-025/HOPE vaginal ring trial in Johannesburg, South Africa, seeks to facilitate women’s use of HIV prevention products by promoting partner dialogue and mitigating intimate partner violence (IPV). We developed “HEART”, a lay counselor-administered relationship assessment tool, for the CHARISMA pilot. The five-scale tool assesses participants’ endorsement of Traditional Values (TV), her HIV Prevention Readiness (HPR) and levels of partner support (PS), abuse and control (PAC), and resistance to HIV prevention (PR), guiding decisions about which of three counselling modules to offer (partner communication/A; ring disclosure/B; and IPV prevention/C). Methods We correlated baseline scores on HEART subscales with a) independent measures of relationship stability, disclosure and IPV to assess construct validity, and b) with specific modules offered to determine how HEART was used in the pilot. We examined changes in HEART scores at three and six months. Finally, we ran separate growth models for each subscale to examine changes in scores, accounting for partnership changes and counseling module(s) received. Results Baseline HEART scores correlated as predicted among subscales and with other measures. Reliabilities for four subscales were 0.75 or higher. Women who disclosed study participation and ring use scored higher on PS and lower on PR. Women experiencing IPV scored lower on PS, and higher on PAC and PR. During the pilot, 82% of women received one and 17% received two or more modules; over half received the IPV module. Women with higher PAC and PR scores were more likely to receive the IPV than the communication or disclosure modules. Over time, the TV, PAC and PR scores decreased, and PS score increased. Receiving the IPV module was associated with a decreased PAC score. Conclusions These data offer preliminary evidence for HEART construct and predictive validity and support its further evaluation to guide implementation and monitor the impact of the CHARISMA intervention in a randomized controlled evaluation.
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