Skip to main content


Log in

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

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript


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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code Availability

All code for data cleaning and analysis associated with the current submission is available from the corresponding author on reasonable request.


  1. Simbayi L, Zuma K, Moyo S, Marinda E, Mabaso M, Ramlagan S, et al. South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017. 2018 [cited 2021 Oct 1]; Available from:

  2. Andersson N, Cockcroft A, Shea B. Gender-based violence and HIV: Relevance for HIV prevention in hyperendemic countries of southern Africa. AIDS. 2008;22(SUPPL. 4).

  3. Strebel A, Cloete A, Dwadwa-Henda N, Crawford M, Kalichman S, Shefer T, et al. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. Sahara J. 2006;3(3):516–28.

    Article  CAS  PubMed  Google Scholar 

  4. Dunkle KL, Decker MR. Gender-Based Violence. and HIV: Reviewing the evidence for links and causal pathways in the General Population and High-risk groups. Am J Reprod Immunol. 2013;69:20–6.

    Article  PubMed  Google Scholar 

  5. World Health Organization. Violence Against Women Prevalence Estimates. 2018 Global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women WHO, on behalf of t. Geneva; 2021.

  6. Campbell JC, Lucea MB, Stockman JK, Draughon JE. Forced Sex and HIV Risk in Violent Relationships. Am J Reprod Immunol [Internet]. 2013 Feb [cited 2021 Oct 1]; 69(0 1):41. Available from: /pmc/articles/PMC3573255/

  7. Stockman JK, Lucea MB, Campbell JC. Forced sexual initiation, sexual intimate partner violence and HIV risk in women: A global review of the literature [Internet]. Vol. 17, AIDS and Behavior. AIDS Behav; 2013 [cited 2021 Oct 1]. p. 832–47. Available from:

  8. O’Malley TL, Hawk ME, Egan JE, Krier SE, Burke JG. Intimate Partner Violence and Pre-exposure Prophylaxis (PrEP): A Rapid Review of Current Evidence for Women’s HIV Prevention. AIDS Behav 2019 245 [Internet]. 2019 Nov 27 [cited 2021 Oct 1];24(5):1342–57. Available from:

  9. Devries KM, Mak JY, Bacchus LJ, Child JC, Falder G, Petzold M, et al. Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A Systematic Review of Longitudinal Studies. PLOS Med [Internet]. 2013 [cited 2021 Oct 1];10(5):e1001439. Available from:

  10. Mitchell J, Wight M, Van Heerden A, Rochat TJ. Intimate partner violence, HIV, and mental health: a triple epidemic of global proportions [Internet]. Vol. 28, International Review of Psychiatry. Int Rev Psychiatry; 2016 [cited 2021 Oct 1]. p. 452–63. Available from:

  11. Klein H, Elifson KW, Sterk CE. Depression and HIV risk behavior practices among “At Risk” women. Women Heal [Internet]. 2008 Sep [cited 2021 Oct 1];48(2):167–88. Available from: /pmc/articles/PMC6192253/.

  12. CDC. Pre-Exposure Prophylaxis (PrEP) | HIV Risk and Prevention | HIV/AIDS | CDC [Internet]. Center for Disease Control and Prevention Website. 2018 [cited 2022 Sep 22]. Available from:

  13. Ambia J. Barriers and Facilitators of Adherence in User-Dependent HIV Prevention Trials, a Systematic Review. Int STD Res Rev [Internet]. 2013 May 24 [cited 2021 Oct 1];1(1):12–29. Available from:

  14. Haberer JE, Bukusi EA, Mugo NR, Pyra M, Kiptinness C, Oware K, et al. Effect of SMS reminders on PrEP adherence in young Kenyan women (MPYA study): a randomised controlled trial. Lancet HIV [Internet]. 2021 Mar 1 [cited 2021 Oct 1];8(3):e130–7. Available from:

  15. Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-Based Preexposure Prophylaxis for HIV Infection among African Women. N Engl J Med [Internet]. 2015 Feb 4 [cited 2021 Oct 1];372(6):509–18. Available from:

  16. Cabral A, Baeten M, Ngure J, Velloza K, Odoyo J, Haberer JE. J, et al. Intimate Partner Violence and Self-Reported Pre-exposure Prophylaxis Interruptions Among HIV-Negative Partners in HIV Serodiscordant Couples in Kenya and Uganda. J Acquir Immune Defic Syndr [Internet]. 2018 Feb 1 [cited 2021 Oct 1];77(2):154–9. Available from:

  17. Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, et al. Intimate Partner Violence and Adherence to HIV Pre-exposure Prophylaxis (PrEP) in African Women in HIV Serodiscordant Relationships: A Prospective Cohort Study. J Acquir Immune Defic Syndr [Internet]. 2016 Nov 1 [cited 2021 Oct 1];73(3):313–22. Available from:

  18. Velloza J, Heffron R, Amico KR, Rowhani-Rahbar A, Hughes JP, Li M, et al. The Effect of Depression on Adherence to HIV Pre-exposure Prophylaxis Among High-Risk South African Women in HPTN 067/ADAPT. AIDS Behav [Internet]. 2020 Jul 1 [cited 2021 Oct 1];24(7):2178–87. Available from:

  19. Rehm J, Probst C, Shield KD, Shuper PA. Does alcohol use have a causal effect on HIV incidence and disease progression? A review of the literature and a modeling strategy for quantifying the effect. Popul Health Metr [Internet]. 2017 Feb 10 [cited 2022 May 2];15(1). Available from: /pmc/articles/PMC5301358/

  20. Ndirangu JW, Gichane MW, Browne FA, Bonner CP, Zule WA, Cox EN, et al. ‘We have goals but [it is difficult]’. Barriers to antiretroviral therapy adherence among women using alcohol and other drugs living with HIV in South Africa. Heal Expect [Internet]. 2022 Apr 1 [cited 2022 May 2];25(2):754–63. Available from:

  21. Colombini M, Scorgie F, Stangl A, Harvey S, Ramskin L, Khoza N, et al. Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa. BMC Public Health [Internet]. 2021 Dec 1 [cited 2021 Oct 1];21(1). Available from:

  22. Hartmann M, Otticha S, Agot K, Minnis AM, Montgomery ET, Roberts ST. Tu’washindi Na prep: Working with young women and service providers to design an intervention for prep uptake and adherence in the context of gender-based violence. AIDS Educ Prev [Internet]. 2021 [cited 2021 Oct 1];33(2):103–19. Available from:

  23. Hartmann M, Lanham M, Palanee-Phillips T, Mathebula F, Tolley EE, Peacock D, et al. Generating charisma: development of an intervention to help women build agency and safety in their relationships while using prep for HIV prevention. AIDS Educ Prev [Internet]. 2019 [cited 2021 Oct 1];31(5):433–51. Available from: /pmc/articles/PMC7082989/.

  24. Kessler RC, McLeod JD. Social support and mental health. In: Cohen S, Syme SL, editors. Social support and health. Academic Press; 1985. pp. 219–40.

  25. Montgomery ET, Roberts ST, Reddy K, Tolley EE, Hartmann M, Mathebula F, et al. The CHARISMA randomized controlled trial: a relationship-focused counseling intervention integrated within oral PrEP delivery for HIV prevention among women in Johannesburg, South Africa. JAIDS J Acquir Immune Defic Syndr [Internet]. 2022; Available from:

  26. Tolley EE, Zissette S, Martinez A, Palanee-Phillips T, Mathebula F, Tenza S, et al. Development and initial validation of a simple tool to screen for partner support or opposition to HIV prevention product use. PLoS One [Internet]. 2020 Dec 1 [cited 2021 Oct 1];15(12 December). Available from:

  27. Beusenberg M, Orley J. A user’s guide to the self reporting questionnaire. Geneva: Division of Mental Health, World Health Organization; 1994

  28. van der Westhuizen C, Wyatt G, Williams JK, Stein DJ, Sorsdahl K. Validation of the Self Reporting Questionnaire 20-Item (SRQ-20) for Use in a Low- and Middle-Income Country Emergency Centre Setting. Int J Ment Health Addict [Internet]. 2016 Feb 1 [cited 2021 Oct 1];14(1):37–48. Available from: /pmc/articles/PMC4779367/.

  29. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Intern Med [Internet]. 1998 Sep 14 [cited 2021 Oct 1];158(16):1789–95. Available from:

  30. World Health Organization. WHO multi-country study on women’s health and domestic violence against women [Internet]. WHO. Geneva: World Health Organization; 2005 [cited 2021 Oct 1]. Available from:

  31. Heise L, Hossain M. STRIVE Technical Brief: Measuring Intimate Partner Violence. London, UK; 2017.

  32. Gbadamosi IT, Henneh IT, Aluko OM, Yawson EO, Fokoua AR, Koomson A, et al. Depression in Sub-Saharan Africa. IBRO Neurosci Reports. 2022 Jun 1;12:309–22.

  33. Bryazka D, Reitsma MB, Griswold MG, Abate KH, Abbafati C, Abbasi-Kangevari M, et al. Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020. Lancet [Internet]. 2022 Jul 16 [cited 2022 Oct 26];400(10347):185–235. Available from:

  34. Kline T, Owens C, Bonner CP, Carney T, Browne FA, Wechsberg WM. Accuracy and Utility of the AUDIT-C with Adolescent Girls and Young Women (AGYW) Who Engage in HIV Risk Behaviors in South Africa. J Appl Meas [Internet]. 2019;20(1):112–22. Available from:

  35. Sikkema KJ, Watt MH, Drabkin AS, Meade CS, Hansen NB, Pence BW. Mental health treatment to reduce HIV transmission risk behavior: A positive prevention model. AIDS Behav [Internet]. 2010 Apr 15 [cited 2022 Apr 12];14(2):252–62. Available from:

  36. Grossman CI, Gordon CM. Mental health considerations in secondary HIV prevention. AIDS Behav [Internet]. 2010 Apr [cited 2022 Apr 12];14(2):263–71. Available from:

  37. Speizer IS, Zule WA, Carney T, Browne FA, Ndirangu J, Wechsberg WM. Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: Efficacy of an intervention on the dyad. Soc Sci Med [Internet]. 2018 Jul 1 [cited 2022 Oct 26];209:95–103. Available from:

  38. Jewkes R, Willan S, Heise L, Washington L, Shai N, Kerr-Wilson A, et al. Effective design and implementation elements in interventions to prevent violence against women and girls. What Works To Prevent VAWG? Global Programme Synthesis Product Series. South African Medical Research Council, Pretoria; 2020.

    Google Scholar 

  39. Ikeda DJ, Kidia K, Agins BD, Haberer JE, Tsai AC. Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion. BMJ Glob Heal [Internet]. 2021 Dec 1 [cited 2022 Apr 12];6(12):7212. Available from: /pmc/articles/PMC8679108/

  40. Haberer JE, Kidoguchi L, Heffron R, Mugo N, Bukusi E, Katabira E, et al. Alignment of adherence and risk for HIV acquisition in a demonstration project of pre-exposure prophylaxis among HIV serodiscordant couples in Kenya and Uganda: a prospective analysis of prevention-effective adherence. J Int AIDS Soc [Internet]. 2017 [cited 2022 Apr 12];20(1). Available from: /pmc/articles/PMC5577705/.

  41. Munodawafa M, Mall S, Lund C, Schneider M. Process evaluations of task sharing interventions for perinatal depression in low and middle income countries (LMIC): a systematic review and qualitative. BMC Health Serv Res. 2018;18(1):1–10.

    Article  Google Scholar 

  42. Chibanda D, Weiss HA, Verhey R, Simms V, Munjoma R, Rusakaniko S, et al. Effect of a Primary Care–Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe: A Randomized Clinical Trial. JAMA [Internet]. 2016 Dec 27 [cited 2021 Nov 28];316(24):2618–26. Available from:

  43. Price DM, English D, Golub SA. Parallel reductions in anxiety and HIV-related worry among pre-exposure prophylaxis (PrEP) users over time. Health Psychol [Internet]. 2022 [cited 2022 Oct 26];41(6):433–41. Available from:

  44. Willie TC, Monger M, Nunn A, Kershaw T, Stockman JK, Mayer KH, et al. “PrEP’s just to secure you like insurance”: a qualitative study on HIV pre-exposure prophylaxis (PrEP) adherence and retention among black cisgender women in Mississippi. BMC Infect Dis [Internet]. 2021 Dec 1 [cited 2022 Oct 26];21(1). Available from:

  45. Tol WA, Murray SM, Lund C, Bolton P, Murray LK, Davies T, et al. Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review. BMC Womens Health [Internet]. 2019 Feb 14 [cited 2022 Apr 12];19(1):1–15. Available from:

Download references


The CHARISMA study was funded by the United States Agency for International Development through a cooperative agreement (AID-OAA-A-14-00012). This work was made possible by the generous support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the American people through the United States Agency for International Development (USAID). Manuscript preparation was also supported in part by a National Institute of Mental Health training grant (F31 MH124328) awarded to Mr. Triplett.

Author information

Authors and Affiliations



All authors have read and approved the final manuscript. ETM, STR, KRR, EET, MH, JMB and TPP designed the research study. TPP, KRR, FM had direct oversight of data collection procedures and study conduct. LDW and MH provided ongoing management and monitoring of the study. NST analyzed the data for this study. NST led the writing of the paper, with contributions from all co-authors.

Corresponding author

Correspondence to Noah S. Triplett.

Ethics declarations

Conflicts of interest/Competing Interests

The authors report no conflicts of interest related to this work.

Ethics Approval

(include appropriate approvals or waivers)

The study was approved by the Human Research Ethics Committee at the University of Witwatersrand and overseen by the IRB at RTI International.

Consent to Participate

All study participants provided written informed consent to participate in the study through a consent process approved by local ethical review committees in all research settings.

Consent for publication

All participants were informed that any publication of this study will not use their name or identify them personally.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Triplett, N.S., Roberts, S.T., Hartmann, M. et al. 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 27, 2030–2040 (2023).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: