TABLE 3.

CHARISMA Intervention Components and Activities

COMMUNITY COMPONENT
Formation of Community Action Teams (CATs)	Recruitment of community leaders to participate in 2–3-day workshops, particularly targeting men Activities focused on methods to increase awareness of men’s role in preventing violence against women and supporting HIV prevention, including microbicide and PrEP use Identified champions within the workshops to join the “Community Action Team” (CAT) who then undertook outreach activities described below
Outreach activities and topics	CAT members and intervention staff: Conduct community dialogues, door-to-door canvassing, tavern dialogues, soccer tournaments, and radio shows to reach men in the community Provide men with educational materials and information related to IPV, gender equality, HIV, human rights, and sexual and reproductive health Provide men with information about vaginal ring and oral PrEP and address men’s misperceptions about these products Ask men to commit to prevention of IPV and HIV in their communities Target certain geographic areas to increase the chances of reaching male partners of clinic-component participants Send WhatsApp messages to female clinic-component participants about male engagement events so they can tell their male partners about the events (WhatsApp messages are opt-in)
CLINIC COMPONENT
HEART screening tool	Screening tool comprised of 42 items, organized into five subscales, which assesses relationship dynamics within a woman’s primary partnership Administered by lay counselors on a tablet. Initially administered at enrollment, the tool guides recommendations about which counseling module to administer to participants. The tool is re-administered at month three and month six visits to monitor changes in relationship dynamics, as well as at other times when a new partner is reported in order to inform the potential need for additional counseling.
Empowerment counseling	Based on responses to HEART and reports of IPV and ring disclosure, one of three counseling modules is administered by a trained lay counselor at enrollment visit, month 1 visit, and as needed (including when a woman changes partners) Counseling modules: Partner communication, including elements of communication (verbal and nonverbal), the use of “I” statements, and conflict de-escalation and resolution skills Ring disclosure and partner support, including assessing male partner attitudes towards ring use, decisions around disclosure or non-disclosure, and principles of improved disclosure Responding to IPV, including sections on the cycle of violence, safety planning, supportive referrals, and legal action Counseling is skills-based and interactive, following a detailed counseling manual with laminated table-top flipcharts Development of action plans for all women at the end of enrollment counseling to take forward skills into their lives Counseling emphasizes empathetic listening and nonjudgment, treating the woman as an expert in her relationship
Referral network and process	Relationship building activities and information gathering with local referral agencies Enhanced linkages to referral services, including mental health services, shelters, legal resources, child protection, police, and legal services, provided by counselors as needed Follow-up on quality of care received and adjustment of referrals offered, as needed Modifications to the supportive referral network and staff support system to meet geographical context of participants and staff Offer of referrals of male partners to outreach events for men
Training	5-day training for counselors and study coordinators Combined presentations, participatory activities, readings, reflections, and role-play exercises Topics included microbicides as a new HIV prevention option; sexual relationships dynamics, including partner communication and conflict; improving knowledge of IPV and how it links to HIV; clarifying values and perceptions of gender norms and IPV; understanding legal rights of women experiencing IPV; promoting mental health among intervention participants; awareness of previous and current trauma in women’s lives; understanding the forms and cycle of violence; community resources and services for IPV; dealing with vicarious trauma; ethical and safety issues; and understanding the specific CHARISMA counseling modules and approach Development of core counseling skills around listening, support, and empowerment of the client, assessing women’s readiness to change, and safety planning One-day training for all clinic staff, covering: Concepts of gender and IPV Providers’ roles in supporting women experiencing IPV The overall components of the CHARISMA intervention
Ongoing support for counselors	Weekly debriefing sessions to discuss and process client interactions, give feedback to counselors on how to give standardized yet tailored counseling, provide mental and emotional support to counselors Psychological support given as needed by clinical psychologist and social worker Counseling supervisor to provide ongoing monitoring, feedback, and support to counselors Counseling certification process and regular observation to ensure high quality counseling