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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: Psychotherapy (Chic). 2019 Dec 19;57(1):90–96. doi: 10.1037/pst0000263

“I cannot change what happened to me, but I can learn to change how I feel”: A case study from ImpACT, an intervention for women with a history of sexual trauma who are living with HIV in Cape Town, South Africa

Brandon A Knettel 1, Corné Robertson 2, Nonceba Ciya 2, Jessica N Coleman 1,3, Shannon A Elliott 1, John A Joska 2, Kathleen J Sikkema 1,2,3
PMCID: PMC7069791  NIHMSID: NIHMS1563335  PMID: 31855042

Abstract

Sexual trauma is highly prevalent among women living with HIV in South Africa, and there is a great need for psychotherapeutic interventions to address these concerns. Improving AIDS Care after Trauma (ImpACT) is a manualized intervention, based on stress and coping theories, that builds skills for coping with sexual trauma and HIV to promote long-term HIV care engagement. Using qualitative case study methodology, we report the case of Xoliswa, a 34-year-old woman with a complex history of sexual trauma and alcohol use who was diagnosed with HIV one year prior to enrollment in ImpACT. The interventionist, a lay counselor, worked with Xoliswa in a primary care clinic to address her concerns by exploring personal values, addressing barriers to HIV care, and teaching active coping. Xoliswa’s drinking reduced, her mental health improved, and she maintained strong HIV care engagement. The interventionist experienced stress and emotional challenges in delivering ImpACT to Xoliswa and other highly traumatized women, and her skill development and support received through training and supervision are briefly discussed. The case demonstrates the feasibility of ImpACT in a resource-limited setting and highlights themes and barriers in therapy, which will inform future interventions for women living with HIV.

Keywords: antiretroviral therapy (ART) adherence, case study, transactional model of stress and coping, sexual trauma, trauma-focused cognitive behavioral therapy (TF-CBT)

Background

South Africa faces the largest HIV burden in the world (UNAIDS, 2010, 2017), while also combating an epidemic of gender-based sexual violence (Gass, Stein, Williams, & Seedat, 2011), a key contributor to disproportionate HIV risk for women (UNAIDS, 2010). Sexual trauma and HIV are syndemic and frequently co-occur due to common risk factors, including poverty, social inequality, and gender-based violence (Brief et al., 2004; Nyindo, 2005). Both trauma and HIV are impacted by gender inequity and cultural norms such as power differentials in sexual decision making, economic disempowerment among women, structural challenges, and stigma about health seeking behavior (Ramjee & Daniels, 2013). Women also face biological vulnerability to infection due to factors related to female hormones and mucosal surface area (Ramjee & Daniels, 2013). As a result of these combined risk factors, South African women are infected with HIV at double the rate of the male population (Shisana et al., 2014).

Sexual trauma and HIV are also associated with multiple adverse outcomes, including substance abuse, sexual risk behavior, depression, and anxiety (Swain, Pillay, & Kliewer, 2017). Events leading up to an HIV diagnosis and the diagnosis itself may further contribute to trauma (Whetten et al., 2013). It is common for survivors of sexual trauma to avoid stressful stimuli in an effort to prevent the activation of trauma symptoms. Women living with HIV who have survived sexual trauma often perceive interactions with medical providers as stress-inducing, which may lead to poor HIV care engagement (Watt et al., 2017). Societal factors, maladaptive coping, and avoidance all contribute to the persistent, syndemic patterns of risk for poor HIV outcomes in countries such as South Africa.

In the face of high rates of sexual trauma and comorbid emotional challenges, including depression and anxiety, South Africa’s mental health system remains fragmented and under-resourced. Historically reliant upon psychiatric hospitals, South Africa is struggling to integrate mental health care into community facilities that would improve access to services due in part to resource constraints, knowledge gaps, and lack of data on cost-effectiveness (Jack et al., 2014). Additionally, evidence for interventions focusing on sexual trauma among individuals living with HIV is limited (Sikkema & Coleman, 2019). It is therefore critical to intervene at the intersection of HIV and sexual trauma with effective, accessible, and culturally compatible treatments for low-resource settings.

Improving AIDS Care after Trauma (ImpACT) is a behavioral intervention targeting sexual trauma, mental health, and HIV care engagement, based on the Transactional Model of Stress and Coping (Folkman et al., 1991). The Folkman model was initially used as part of the CDC- and SAMHSA-endorsed Living in the Face of Trauma (LIFT) intervention for people living with HIV in the U.S.A. (Sikkema et al., 2013). We adapted LIFT to ImpACT, a manualized intervention adapted for use in South African primary care clinics. The results of our pilot randomized controlled trial indicate that ImpACT has the potential to reduce trauma symptoms, enhance active coping, and improve antiretroviral therapy (ART) adherence among women in South Africa (Sikkema, Mulawa, et al., 2018).

In this manuscript, we present the case of Xoliswa, a participant from the ImpACT pilot trial, to describe the intervention, examine individual-level mechanisms of change, and inform future delivery of the ImpACT intervention. Given the importance of the counselor-patient alliance in trauma-informed care, the experiences of the non-specialist provider are also presented. This includes reflections on the provider’s skill development through training and supervision and challenges faced in delivering ImpACT to a highly traumatized population.

Methods

The pilot trial of ImpACT was conducted with women living with HIV between March 2016 and March 2017 in Cape Town, South Africa. Participants were newly initiating ART in a peri-urban clinic serving more than 2,500 patients with HIV. Participants were randomized to condition upon completion of three standard of care HIV education sessions if they met the following eligibility criteria: (1) 18 years of age or older, (2) isiXhosa-speaking, and (3) endorsed a history of sexual abuse based on the WHO CIDI screener and/or the Childhood Trauma Questionnaire (Bernstein et al., 2003; World Health Organization, 1990). The screening process was described in greater detail by Yemeke et al (2017). Thirty-one women were assigned to the experimental condition of ImpACT, which consists of four weekly sessions of manualized individual counseling followed by three group sessions (see Figure 1). The goals of the intervention are to increase awareness of personal values, understand the impact of sexual trauma, and encourage adaptive strategies for coping to promote long-term HIV care engagement. Intervention goals are achieved through activities designed and tested in earlier piloting or culturally adapted from LIFT (Sikkema, Choi, et al., 2018). For example, the “Imbiza Pot” activity is as adaptation of the “Safety, Intimacy, Power, and Self-Esteem” model from LIFT, with the components visualized as legs of a traditional South African cooking pot.

Figure 1.

Figure 1.

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ImpACT intervention components and timing

For this analysis, one case was purposively selected through a narrative review of the interventionist’s process notes and study quality assurance data. The case presented primarily describes an individual, but we have integrated some details of other cases and altered the case slightly to best represent the intervention and protect the privacy of the participant. The subject provided written informed consent prior to participating; the interventionist also provided consent to discuss her experiences and approved the final version of this manuscript. The study received ethical approval from the institutional review boards of Duke University and The University of Cape Town and the case has been deidentified and disguised to ensure participant confidentiality.

Measures

All measures were translated to isiXhosa and back translated with consideration for cultural equivalence and comprehension. PTSD symptoms were assessed using the PTSD Checklist (PCL-5), a 20-item measure with scores ranging from 0 to 80 (Blevins, Weathers, Davis, Witte, & Domino, 2015). HIV-related avoidant coping was assessed using 16 items (Hansen et al., 2013) previously used to measure coping in South Africa, with scores ranging from 16 to 64. Symptoms of depression were evaluated using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), with scores ranging from 0 to 60. ART adherence was assessed using viral load data from blood samples and self-reported adherence by asking how many days they had missed taking their medication in the past 90 days. All quantitative data are presented as raw scores to demonstrate severity of symptoms at baseline and improvement at six-month follow up.

The Case of Xoliswa

Xoliswa (pseudonym) is a 34-year-old divorced woman with three children. She and her family live in a shack near the HIV clinic and she works for a transport company. Xoliswa reported that when she was a child in a nearby rural area, her father was often absent but, when present, was frequently physically and emotionally abusive. At age 13, Xoliswa was raped by an adult cousin who threatened to “bury her alive” if she told anyone. She disclosed the incident to her mother, who subsequently suffered a stroke, which Xoliswa attributes to the shock of hearing about her rape. When asked whether the perpetrator faced any consequences for the assault, she stated, “Nothing ever came from this matter. I recently saw him again and could not even make eye contact.”

Xoliswa reported that after her mother’s stroke, her father decided to move into the home permanently and his abusive behavior quickly worsened. At the age of 14, Xoliswa ran away from home. She initially lived with an aunt who was emotionally abusive. Xoliswa reported that she became pregnant at the age of 16, and when she informed her boyfriend, he accused her of infidelity and they never spoke again. After delivery, the baby became ill and soon passed away. Xoliswa reports she never received counseling and describes the support received from family and friends as, “almost nothing.”

Xoliswa reported that one year after the death of her baby, she met someone new and married. She says they “had a good relationship” for approximately 10 years and had 3 children together. However, over time, Xoliswa reported that the husband started to physically abuse and rape her. She started to drink heavily, believing that it was her only way of coping with the abuse. Finally, during a fight with her husband, she retaliated by throwing boiling water over him, and he left the marriage. Xoliswa reports she was diagnosed with HIV one year prior to enrolling in the ImpACT study and says she was initially shocked by the test result, but suspects it was due to her ex-husband’s infidelity.

Notable intperersonal and environmental strengths that Xoliswa entered treatment with include having close, open relationships with her coworkers and having disclosed her HIV status to her boss at work. She is also involved in her church community and feels it is a safe space and source of support.

Symptoms at Baseline

At her baseline survey, Xoliswa indicated severe symptomatology for traumatic stress on the PCL-5 (score of 66 out of 80) and that she relied on avoidant coping strategies (score of 46 out of 64). She also displayed severe symptoms of depression on the CES-D (score of 52 out of 60). Xoliswa reported feeling overwhelmed and distressed, and the research assistant noted that she seemed worried, sad, and often broke down in tears. Her speech was soft and low. She looked physically frail, thin, and pale. She was referred to the clinic doctor who in turn referred her for admission to a psychiatric hospital. Upon her return to the HIV clinic five weeks later, she indicated to the study team that she was still interested in the intervention and was enrolled at that time.

Understanding the Influence of Sexual Trauma

In the first session of ImpACT, participants get acquainted with the therapist and share their histories, including past trauma to the extent that they feel comfortable. Participants also discuss the process of being diagnosed with HIV and initiating ART. During this session, Xoliswa described mixed feelings about ART; she felt relief knowing her health would improve, but worried about how she would get to medical appointments. She noted that it was difficult to discuss her trauma, yet she felt a “great sense of relief” after sharing her memories: “Just talking about the sexual trauma made me feel better.” She expressed that she had never had a supportive setting to discuss her trauma history, and that the burden of keeping it to herself had become “intolerable and agonizing.” With the assistance of the interventionist, Xoliswa shared the devastating ways that multiple traumas had impacted her behavior, mental health, and relationships. Xoliswa stated that she was often angry, irritable, and that she could not stand being around people. She had little appetite and became physically frail and socially isolated: “I felt angry all the time and everything I did I would say that I was protecting myself.”

To build upon these disclosures, participants engage in the Head, Heart, Hands (3H) activity, a cultural adaptation of the cognitive behavioral therapy ‘cognitive triangle’, where they reflect on the impact trauma has had on their thoughts, emotions, and behavior over time. Xoliswa identified multiple symptoms of sexual trauma and explored their influence on her life. She acknowledged that trauma had negatively affected her relationships and contributed to her drinking. She battled with trust issues and felt she was always in the wrong. She explained how her abusive relationship with her husband activated past trauma and kept her constantly on edge, even when she was around people who cared for her.

Values that Motivate Care Engagement

During the Values Bridge exercise, participants describe their personal values and relate them to the importance of ART adherence. During this exercise, Xoliswa said that her personal health and love for family were the key values motivating her treatment adherence: “If I don’t take my ART, I’ll get sick and die, leaving my family behind. I will die without peace.” She expressed a desire to meet her children’s needs and support them, as well as concern for their long-term well-being. She also had the desire to maintain her position at work. With minimal guidance, Xoliswa effectively connected each of her values to the importance of care engagement. She indicated that she liked the Values Bridge as it aided her in understanding the role that ART played in bringing her closer to the things that mattered to her and planning for her children’s futures.

The Relationship Between Sexual Trauma and HIV

During the second session, Xoliswa began connecting her history of sexual trauma to her coping with HIV. She described with clarity the similarities between being diagnosed with HIV and the “emotional chaos” of other traumatic experiences throughout her life. She compared the moments awaiting the results of her HIV test to the fear she felt when her ex-husband was angry and threatening violence. She shared the feelings of “shock and numbness” upon hearing her positive result, remembering that she was unable to process the nurse’s words and hardly remembers the counseling she received. During her participation in ImpACT, with the help of the interventionist, Xoliswa connected her trauma history to challenges of facing life with HIV:

Therapist: You mentioned that with each experience of sexual trauma, you noticed thinking negative things about yourself. Do you ever feel or think this way about your HIV also?

Xoliswa: After that first experience (of trauma), I thought of myself as a disgrace and as a useless somebody with no life. The HIV diagnosis brought up the same thoughts and feelings like sadness and regret. I also had fear of becoming very sick. I felt angry about this circumstance because I did not go looking for this, and I felt anger toward my partner for resisting to get tested.

Therapist: It sounds like you noticed similarities between these experiences in all three areas: your ‘head’ (thoughts), your ‘heart’ (emotions) and your ‘hands’ (behavior in relationships). Would you say that’s true?

Xoliswa: I noticed that after both the sexual trauma and the HIV diagnosis, I was nervous to trust others and my relationships were damaged.

Therapist: Can you think of an example of what that looked like?

Xoliswa: I would keep to myself and lock myself in my room, and would only come out when my kids got back from school. I drank so often. I really think that I came to hate myself.

Therapist: I’m so sorry that you came to feel that way. Yes, thoughts and feelings related to a trauma can impact how we relate to others and ourselves. Noticing the relationship between your ‘head’, ‘heart’, and ‘hands’ is important and will help to understand their impact so you can choose what to do with those reactions and cope with them. We will spend more time later coming up with specific ways you could cope with what goes on in your ‘head’, ‘heart’, and ‘hands’.

In this second session of ImpACT, Xoliswa had established trust with the interventionist that led to openness in disclosing her personal history with trauma and HIV. At this point, she was readily connecting her reactions to sexual trauma and HIV, which set the stage for introducing new strategies for coping in the remaining individual sessions and group sessions.

Strategies for Effective Coping

During the Coping Pebbles activity in Session 2, the interventionist uses a small bag of pebbles to represent a global feeling of stress, and then removes pebbles from the bag to explore individual stressors. Together, the interventionist and participant label stressors as changeable (pointing to problem-focused coping) or unchangeable (pointing to emotion-focused coping) and propose new, adaptive strategies for coping. In completing the activity, Xoliswa identified using avoidant coping strategies such as the abuse of alcohol, even when a more active approach would have served her better. “I changed my behavior (because of the trauma). I became a drunkard. I used alcohol to forget. I would drink so that I was able to speak up for myself. I would drink so that I could have the courage to fight back.” Xoliswa mentioned that through this session she also became more aware of the consequences of her past drinking, including conflict in her relationships, risky sexual behavior, and feelings of guilt. She identified aspects of her drinking that felt unchangeable, such as regret about past behaviors while drinking. She determined the amount she drank was changeable, so she set the goal of drinking less. Xoliswa worked with the interventionist to identify triggers and they defined specific, practical objectives related to reducing her drinking (e.g., goals for number of days each week that she would drink and number of drinks per day) and followed up on these goals in subsequent sessions. With her gradual transition away from avoidant coping to more problem-focused and emotion-focused strategies, Xoliswa began to cope more effectively with stressors that previously led her to drink and to feel more empowered in controlling her urges to drink.

Start Strong, Stay Strong

The motto “Start Strong, Stay Strong” is used throughout ImpACT and becomes a touchpoint to motivate women to stay in HIV care. Motivation is rooted in personal values and goals, and the participant is encouraged in sessions to discuss her “journey” toward long-term ART maintenance, successes along the path, and barriers she faces due to challenges in her life. Realistic acknowledgement of the difficult contexts of women’s’ lives promotes cooperative problem solving with the interventionist and encourages the participant to build a healthy support network. After being introduced to coping model in Sessions 2 and 3, Xoliswa set the goal of improving her social support. Prior to session 4, she made an important stride in her care engagement journey by disclosing her HIV status to her two older sisters, who she found to be warm and accepting. In Session 4, Xoliswa revisited the 3H activity and described her progress through the intervention:

“I had a problem of thinking a lot about my trauma. I used to get deep into thoughts, negative thoughts about the experience and myself. I would then go and sit in the shebeen (tavern) and drink the whole day to run away from my thoughts. Being in the intervention has helped me to understand my pain and to think better thoughts about myself.”

At her 6-month follow up assessment, Xoliswa had also disclosed her HIV status to a neighbor so that she could receive additional support. She was motivated to adhere to her ART, noting “I have not missed any clinic appointments and I don’t see myself missing any in the future.” She shared that she had joined an ART club, a group of clinic patients identified by the clinic nurses as being stable on treatment and allowed to receive fast track medication and peer-led emotional support at club meetings.

Treatment Progress and Prognosis

Throughout ImpACT, Xoliswa was willing to discuss her HIV status as well as her experiences with trauma. She engaged in her intervention sessions with honesty and pragmatism, and she learned to see the connections between her sexual trauma history, her HIV, and her behavior. She set practical and attainable goals, regularly updating the interventionist on her progress. She reported substantial improvements, which were reflected in her six month post-intervention survey, where her PCL-5 score for post-traumatic stress improved from 66/80 at baseline to 18/80 and she reported perfect HIV medication adherence in the past 90 days, which was confirmed by her viral load. Xoliswa also reported substantial reductions in avoidant coping (from 46/64 at baseline to 28/64) and CES-D depression scores (from 52/60 to 4/60) at follow up. These improvements also translated to positive changes in Xoliswa’s daily life, including a noted reduction and eventually complete abstinence in her drinking, which improved Xoliswa’s interactions with her children and family and had financial benefits. The interventionist noted that Xoliswa also showed significant physical and emotional improvements. She reached a healthier weight and described feeling stronger, while the interventionist described her as “visibly healthy and bubbly.” Xoliswa also reported increased sense of self-esteem and empowerment in her relationships:

“Being in the intervention has helped me to understand my pain and think better thoughts about myself. Now I am able to be with other people without feeling that I am less human than them. I am a better person. It’s been three months since I stopped drinking alcohol as it used to be a way for me to escape reality and my trauma. I do not feel that it’s the end of the world anymore. Now I’m able to sit with people, laugh and chat with them without feeling angry and wanting to isolate myself. I know now that I cannot change what happened to me, but I can learn to change how I feel about my sexual trauma.”

The Interventionist

The ImpACT interventionist, Bongiwe (pseudonym), also provided her perspective on her work with Xoliswa. Prior to working with ImpACT, Bongiwe had no experience as an interventionist, but she received extensive training and weekly clinical supervision throughout the intervention. This began with face-to-face training sessions with experienced clinical psychologists, including content focused on developing counseling skills, learning the framework of the intervention, and practice sessions of the intervention content. Bongiwe described a “great learning curve,” in developing her therapeutic skillset and coming to understand the lives of the women she was counseling. She stated that she had previously been unaware of the “underlying, unexplainable pain” associated with sexual trauma, which “can crush a woman and make her feel empty inside.” Bongiwe said this new understanding inspired her to learn and provide effective treatment. At the start of the study, it was difficult for her to ask a woman about her trauma history, but her comfort level rose after she was trained and became familiar with the intervention. She sought additional support by starting to see her own therapist, which she states was integral in helping her to manage her personal reactions to the difficult stories of participants. Bongiwe and her clinical supervisor agree that her level of skill and comfort grew immensely through the course of the intervention. She states,

“The more sessions I delivered, the more I found ideas on how to handle various situations and came to develop new examples I could use to make the intervention easier to understand. Supervision also acted as a kind of motivator for me because the feedback I received was positive. My supervisor made it possible for me not to limit myself.”

By the time Bongiwe had her sessions with Xoliswa, she states she had come to understand “how to be a good counselor, naturally and without being judgmental” and had learned “how to show empathy and yet be strong for that person.” Through her work on ImpACT, Bongiwe also developed her passion for advocacy for women with sexual trauma histories and HIV and hopes to continue this work into the future: “There is so much that still needs to be done.”

Discussion

The case of Xoliswa represents the content, delivery, and potential of ImpACT in assisting women with HIV and a history of sexual trauma. Through the intervention, Xoliswa explored the parallels and interrelatedness of her sexual trauma experiences and HIV, connected her HIV care engagement to personal values, and was introduced to adaptive strategies for coping. She came to recognize that her emotional dysregulation was impacting her relationships and that drinking had become an unhealthy, avoidant coping tool. In response, Xoliswa set goals to reduce her drinking. She committed to maintaining her HIV care and sought new, healthy sources of support in her personal life.

This case also demonstrated the individual mechanisms driving change for Xoliswa, which included having a supportive venue for disclosing her trauma for the first time, reflecting on her personal values and barriers to care engagement, and engaging in problem-focused coping with the encouragement of an empathic and skilled interventionist. Future interventions may seek to replicate these components with larger samples, and also assess whether similar approaches may improve participant outcomes in other settings or for other client populations. For example, avoidant coping is a common response to many stressors, including other forms of trauma and health challenges (Cherenack et al., 2018), and future studies should assess whether the ImpACT model can encourage more active and adaptive coping strategies for these stressors.

While this case primarily focused on one participant in a structured intervention, it is also vital to acknowledge the aspects of the therapeutic relationship that contributed to Xoliswa’s success. Research on the common factors of successful psychotherapies highlight the importance of building the therapeutic alliance, imparting relevant knowledge, and facilitating productive change (Imel & Wampold, 2008). Despite her lack of prior experience, Bongiwe was an excellent and motivated interventionist. She mastered the intervention content, sought additional training on her own time, and used supervision and individual therapy to grow, improve, and manage her emotional reactions to the difficult content arising in sessions. She benefited from strong training and supervision, which she considered vital to successful implementation of the intervention. Further, the use of non-specialist providers is an opportunity to meet human resource needs where trained specialists are not available (Knettel, Slifko, Inman, & Silova, 2017), and can reduce cultural barriers between interventionist and client, leading to more positive outcomes (Nakimuli-Mpungu et al., 2017). Bongiwe’s familiarity with the context of the participants’ lives cultivated empathy that also proved critical to the success of the sessions.

Although we chose a case that was representative of the ImpACT study, case study methodology is used to provide depth of analysis on a single case and should not be generalized. Xoliswa received other forms of support during the study, including psychiatric care and peer support from the ART club, which likely improved readiness for ImpACT and contributed to her positive outcomes. Psychiatric care was ethically necessary in this case, and we cannot be sure of the causal effects of Xoliswa’s improvement, although psychiatric care would not have addressed the HIV-specific outcomes (e.g., medication adherence) nor the specific emphasis on coping with trauma. The results of the full ImpACT trial are published elsewhere (Sikkema, Mulawa, et al., 2018).

Conclusions

The dual burdens of sexual violence and HIV carry serious consequences for mental health. While in the early stages of implementation, ImpACT offers potential for relieving this combined burden in South Africa by assisting women to adopt healthy coping strategies and promoting ART adherence. Such programs will be particularly successful when adapted to the local context and delivered by effective interventionists with strong training and supervision.

Clinical Impact Statement.

Question

What are the individual mechanisms of change in ImpACT, a manualized intervention for women living with HIV and a history of sexual trauma in South Africa?

Findings

The case of Xoliswa, a 34-year-old woman living with HIV and a complex history of sexual trauma, demonstrates how a therapeutic focus on active coping informed by personal values can lead to positive mental health and HIV outcomes.

Meaning

While in the early stages of implementation, ImpACT offers potential for relieving the combined burden of HIV and sexual trauma in South Africa, by assisting women to adopt healthy coping strategies and promoting ART adherence.

Next Steps

Pilot data will be used to further adapt and refine the intervention for a larger clinical trial.

Acknowledgments

Funding: This work was supported by the National Institute of Mental Health under Grant R34 MH102001. We also acknowledge support received from the Duke Center for AIDS Research (P30 AI064518), Fogarty International Center (D43 TW009337), NIH Office of Behavioral and Social Science Research (OBSSR), and Duke Global Health Institute.

Footnotes

Conflicts of Interest: The authors have no conflicts of interest to declare.

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