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RESEARCH ARTICLE
“I’ve accepted it because at the end of the day
there is nothing,I can do about it”: A qualitative
study exploring the experiences of women
living with the HIV, intimate partner violence
and mental health syndemic in Mpumalanga,
South Africa
Mpho SilimaID
1
*, Nicola Christofides
1
, Hannabeth Franchino-OlsenID
2
, Nataly Woollett
1,3
,
Franziska MeinckID
1,4,5
*
1School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, 2Division of Health
Behavior and Health Promotion, College of Public Health, The Ohio State University, Columbus, Ohio, United
States of America, 3Department of Visual Arts, University of Johannesburg, Johannesburg, South Africa,
4School of Social and Political Sciences, University of Edinburgh, Edinburgh, United Kingdom, 5School of
Health Sciences, North-West University, Vanderbijlpark, South Africa
*mpho.silima@wits.ac.za (MS); Franziska.Meinck@ed.ac.uk (FM)
Abstract
In South Africa, Mental Health (MH), HIV, and Intimate Partner Violence (IPV) form a syn-
demic, that disproportionately affects women. These challenges are often co-occurring and
create complex adversities for women. Recognising these intersections and the broader
socio-cultural dynamics at play is crucial to understanding the layered experiences of these
women and developing effective interventions. This research explores the experiences of
the women living with at least two of the epidemics (HIV, IPV and or MH) and how they
cope. A qualitative study design was used and 20 women (22–60 years) were recruited from
Mpumalanga, South Africa. To be eligible for the study the women had to have experienced
at least two of the epidemics. Data were collected through home-based interviews, arts-
based activities, and analysed thematically using MAXQDA (2022) software. MH challenges
were prevalent among all the participants and were linked to both IPV and HIV, resulting in
symptoms such as anxiety, depression, and suicidal thoughts. In relation to the HIV-MH
link, MH challenges in this combination included feelings of denial, sadness and anxiety
related to participant’s HIV diagnosis. A bidirectional relationship also existed in the IPV-MH
group where pre-existing MH challenges among women increased their vulnerability of hav-
ing violent partners, whilst IPV also increased MH challenges. In the IPV-MH-HIV group
early childhood violence exposure was linked with MH challenges and later victimization
and vulnerability to HIV. Participants primarily used religion, acceptance, occasional alco-
hol, and family support as coping strategies. Particularly in IPV situations, alcohol use/mis-
use was the most prevalent coping strategies. The study highlights the syndemic
relationship between HIV, IPV and MH challenges among South African women living in a
peri-urban community, with a central emphasis on MH challenges. Interventions should
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OPEN ACCESS
Citation: Silima M, Christofides N, Franchino-Olsen
H, Woollett N, Meinck F (2024) “I’ve accepted it
because at the end of the day there is nothing,I can
do about it”: A qualitative study exploring the
experiences of women living with the HIV, intimate
partner violence and mental health syndemic in
Mpumalanga, South Africa. PLOS Glob Public
Health 4(5): e0002588. https://doi.org/10.1371/
journal.pgph.0002588
Editor: Marie A. Brault, NYU Grossman School of
Medicine: New York University School of Medicine,
UNITED STATES
Received: October 18, 2023
Accepted: March 8, 2024
Published: May 6, 2024
Copyright: ©2024 Silima et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and Supporting information files.
Funding: This research was supported by the
European Research Council (ERC) under the
European Union’s Horizon 2020 research and
innovation programme [852787] and the UK
Research and Innovation Global Challenges
holistically address these challenges, with particular focus on MH challenges, cultural sensi-
tivity, and promotion of healthy coping strategies.
Introduction
Women living with HIV or AIDS (hereafter referred to as HIV for brevity) and experiencing
intimate partner violence (IPV) often face various mental health (MH) challenges. Research
indicates that there is a higher prevalence of MH disorders among people living with HIV.
Specifically, conditions such as depression, post-traumatic stress disorder (PTSD), anxiety,
psychosis, and alcohol misuse are observed, which are often attributed to psychological stress,
antiretroviral medication side effects, social stigma, discrimination, and lifestyle factors [1,2].
Particularly, women living with HIV are also more likely to experience coexisting MH condi-
tions and exhibit poorer overall MH than men [3]. The increased vulnerability is highlighted
in established research which indicates existing gender disparities in MH conditions such as
depression [4] anxiety [5] and PTSD [6,7]. Furthermore, in the context of HIV these gender
disparities in MH conditions may further be exacerbated [8]. Complicating matters further,
IPV contributes to adverse MH outcomes, including anxiety, depression, PTSD, and increased
suicide risk [3]. The primary mechanism that links IPV to the latter MH outcomes is IPV-
induced traumatic stress [9,10]. Moreover research also shows that IPV and MH disorders
often have a reciprocal relationship, where one can increase the risk of occurrence of the other
[9,10]. The compromised cognitive and emotional resources that often accompanies MH dis-
orders can make individuals more vulnerable to manipulative or abusive behaviors, thereby
increasing their risk of becoming victims of IPV [11]. Previous research has also established a
reciprocal link between IPV and HIV, indicating that those subjected to IPV have a 48% higher
risk of HIV infection compared to their counterparts who haven’t faced such violence. The
heightened risk can be attributed to factors such as coercive sex by an abusive partner and
their propensity for engaging in risky sexual behaviours and reduced condom use [12].
The interconnectedness between HIV, IPV and MH disorders can be better understood
using syndemic theory as proposed by Merril Singer [13]. Singer defines a syndemic as the
complex interplay existing between different epidemics, especially in the context of social
inequality and health disparities [13]. While SAVA primarily focused on the intersection of
substance abuse, violence, and AIDS, our study expands this to encompass a broader range of
MH challenges. HIV has long been long been recognized as an epidemic globally [14,15],
however, we argue that IPV and MH conditions can also be categorized as epidemics. In South
Africa IPV is a significant public health issue, ranking as the second highest burden of disease
after HIV or AIDS. It also contributes substantially to disability adjusted years (DALYs) espe-
cially among women where IPV and child sexual abuse are common [16]. In terms of MH con-
ditions, there has been a significant global increase, with a 13% increase over the past decade.
Additionally, these conditions are now responsible for one in every five years lived with a dis-
ability [17]. These trends highlight the epidemic nature of both IPV and MH.
The emphasis of the syndemic theory is that epidemics do not exist in isolation, but rather
are often interconnected and co-occur or cluster in social groups as a result of harmful social
conditions such as poverty and stigma. These conditions often interact in ways that contribute
to an increased overall burden of disease. The Substance Abuse, Violence and AIDS (SAVA)
syndemic was first identified by Singer, he argued that contextual factors such as poverty, inad-
equate housing, family instability, drug related violence worked in conjunction to exacerbate
the conditions of SAVA simultaneously [13]. Much research has been conducted on the SAVA
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Research Fund [ES/S008101/1] to FM as principal
investigator. The funders had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
syndemic, yet there is still very limited data on the HIV, IPV and MH as a syndemic. As
shown, the intersection of HIV, IPV, and MH disorders can exacerbate the health outcomes
associated with these conditions.
Coping strategies of women with the HIV, MH and IPV syndemic
Understanding how women living with the HIV-IPV-MH syndemic cope in the face of these
intertwined epidemics is critical. Research has shown that the coping strategies used by people
living with HIV and those experiencing IPV have a link to the emergence of MH consequences
[18,19]. Therefore, exploring the coping strategies of these women could highlight important
strategies that have the potential to protect their psychological and physical wellbeing.
Research shows that psychological reframing of negative events and social support have
proven essential for women experiencing MH and HIV management, while acceptance and
hope serve as a popular coping strategies for all three epidemics [20–23]. Furthermore, adher-
ing to HIV treatment has been found to be a key coping strategy for women living with HIV,
largely driven by their sense of responsibility to their family and in particular their children
[21]. In the IPV context, coping strategies are more diverse, according to a systematic review
of US studies, it was found that religious or spiritual reliance and active abuse resistance were
common whilst self-criticism and substance misuse were less common [24]. Contrary to this, a
systematic review of South African studies found that many of the women who had experi-
enced IPV used avoidance and distraction as a way to cope and this included substance abuse/
misuse [25]. Seeking help has also been found to be a coping strategy among some IPV survi-
vors, however this varies and is dependent on the severity of the victimization as well as
resources available to the woman [24]. A comprehensive understanding of the root causes that
lead to specific coping strategies, can help us in developing interventions that can target spe-
cific issues so as to activate more adaptive coping strategies. Identifying coping strategies of
people living with HIV, IPV and MH syndemic has important implications for healthcare pro-
viders and can lead to a more holistic approach to managing the epidemics.
Present study
The primary objective of the present study was to explore the experiences of women navigating
life with the intersections of HIV, IPV and MH challenges in a peri-urban community in Mpu-
malanga South Africa. We aimed to analyse the interplay of the epidemics and better under-
stand the coping strategies used by the women. Furthermore, we sought to identify variations
in coping strategies based on the different combinations of the epidemics experienced by the
women.
Methods
Study design
To answer the study objectives a qualitative study design was used. The use of this approach
was important in that it helped in exploring the research aims in more depth. We were able to
have a deeper understanding of the participants experiences, perspectives and attitudes in rela-
tion to living with the HIV, IPV and MH syndemic. Furthermore, using a narrative approach
helped to emphasize the personal experiences of the participants which in turn allowed for
their individual stories to take centre stage. By focusing on these narratives, we were able to
attain rich, detailed data and as a result enhance the depth of the research findings. A narrative
inquiry is a type of qualitative research method that uses the stories of the participants as the
primary source of data [26]. The methodology has been used across various fields to explore
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culture, history, identity and people’s lifestyles through the narrators’ experiences [27]. In par-
ticular the approach includes investigating human experiences through narratives or produc-
ing the data in a narrative format [28].
Study setting
The current study was conducted in a peri-urban area within the Enhlanzeni District Munici-
pality of Mpumalanga Province, South Africa from October 2022 to February 2023. Mpuma-
langa province has an estimated population of approximately 4 million people [29], with the
primary languages being spoken being siSwati, isiZulu, Xitsonga and isiNdebele [30]. The
study site is often categorized as a township, and primarily consists of brick houses. Common
challenges in the community include inconsistent supply of basic services such as water and
electricity with much of the infrastructure being informal. Unemployment is also rife, with the
most common forms employment being domestic work, bricklaying and farming. The HIV
prevalence in the district is reported to be 19.% among the adult population [29,31]. In terms
of IPV, 28% of women in Mpumalanga have reported experiencing physical abuse from their
current partner at some point in their lives [32]. Moreover, a national study found that 29,2%
of adults in Mpumalanga indicated that they had experienced common mental disorders at
some point in their lives lifetime [33].
Sample
Twenty participants were purposively selected for the study. Selection of the participants was
based on their responses to specific questionnaire items from the Interrupt_Violence Study
[34]. Participants were between the ages of 20–60 years and had to screen positive for HIV,
IPV and/or MH challenges. Participants did not have to have experienced all three epidemics
to be included in the study; any combination of the two epidemics was sufficient for inclusion.
During the quantitative interview, there were automatic referral flags that were produced if
a participant disclosed behaviours, thoughts, or feelings of concern (S1 Table). The Flags were
used to create voluntary and mandatory referrals to the study social worker. To identify partic-
ipants who had experienced at least two of the epidemics, we noted participants with two or
more flags for the epidemics of interest, indicating they had self-reported some combination
of MH, IPV, and HIV. Thereafter we did a detailed analysis of the participants’ responses to
the individual items for MH, IPV and HIV in the questionnaire. The participants were catego-
rised into groups based on their questionnaire responses. In terms of MH challenges partici-
pants answered questions in the following screening tools: National Institute for Mental
Health’s Ask Suicide Screening Questions (ASQ) for suicidality risk [35], Generalized Anxiety
Disorder Screener for adult for anxiety [36], Patient Health Questionnaire for depression [37]
and Post Traumatic Stress Disorder-8 (PTSD-8) for PTSD [38]. For IPV experience, partici-
pants needed to have answered yes to any of the questions in the WHO instrument for physical
and sexual violence experience [39]. HIV status was determined either through self-reporting
or identified during the voluntary HIV test administered by the interviewer.
Furthermore, the participants in the study were either mothers or primary caregivers for a
child or children aged 17 or younger at the time of enrolment. This was because the data from
the current study stems from a larger study which focussed on the experiences of parenting a
child under the age of 17.
Data collection tools and procedure
The lead author alongside two research assistants conducted in-depth interviews which lasted
between 60 to 90 minutes with each participant during October 2022-February 2023. The
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interviews were conducted in the participants’ preferred languages of SiSwati or Xitsonga and
took place face-to-face in a private space at a time convenient for the participants. The inter-
views allowed for probing into participants’ experiences with IPV, living with HIV, and navi-
gating MH challenges. We explored their past and current experiences with IPV, the impacts
of HIV diagnosis and its disclosure, and the community’s potential stigma towards HIV. Fur-
thermore, their MH journey was explored in the context of these intersecting epidemics. For
more details on the interview guide see S1 Text.
To stimulate rich conversation, we used arts-based techniques such as the Kinetic Family
Drawing (KFD), River of Life, and Sandbox [40–42]. Based on the depth of data obtained from
the interview, some participants were asked to participate in more than one activity, which
contributed to the data’s richness. The probes used for the arts-based techniques can be found
in S2 Text. The decision regarding which participants engaged in more than one activity was
participant driven, in some cases where a participant had challenges with an activity, we
switched to another activity. Conversely if a participant engaged well with one activity and this
provided rich data, a second activity was used to help organize the story more effectively and
to explore deeper into specific events.
With the KFD, participants drew two pictures representing their family of origin and cur-
rent family dynamics, helping them to recall memories and build rapport with the interviewer
[40,43]. In the River of Life activity, participants visually drew their life journey, showing sig-
nificant positive and negative events [41]. The Sandbox activity, inspired by sandplay therapy,
provided participants a with medium to create three-dimensional scenes, that facilitated an
artistic narrative of their experiences [42,44]. To capture the story, multiple photos were taken
of the participants’ sandbox from various angles and at different times especially when partici-
pants changed the positioning of the figures during the interviews. The participants were also
audio recorded while they were describing the scenes in the sandbox. This allowed us to cap-
ture the story as it unfolded.
Ethical considerations
The study received ethical clearance from the Human Research Ethics Committee (HREC) of
the University of the Witwatersrand (M220526), ensuring adherence to recognized ethical
standards for research. The main Interrupt Violence study was also ethically approved
(M190949) by HREC, University of Edinburgh (No: 264227) and Provincial Department of
Health Mpumalanga (MP-202012–003). All participants provided voluntarily written
informed consent to participate and to have the interview audio recorded. The consent forms
were distributed and explained to the participant prior to data collection in their preferred lan-
guage, and they clearly outlined the objectives of the study, the nature of the participant’s
involvement, and how the collected data would be used and stored to maintain confidentiality.
Participants were also informed of their right to withdraw from the study at any time without
any repercussions. To protect participants’ confidentiality, unique, non-personally identifying
ID numbers and pseudonyms replaced participants’ real names in all research materials. Pho-
tographs were taken of participants’ artwork, with their explicit consent, to supplement data
analysis. All data, including these photographs, were securely stored. Recognizing the sensitive
nature of the study and the potential for psychological risk, we implemented a distress proto-
col. This protocol guided the interviewer in responding sensitively to a participants’ emotions
during and after the interview, ensuring timely provision of follow-up resources and support.
A full-time social worker from the Interrupt_Violence study was also readily available for nec-
essary or mandated referrals. We had 10 mandatory referrals; 5 non mandatory referrals and 5
participants did not require a referral. Mandatory referrals included cases such as participants
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experiences of domestic violence including a weapon, suicidality symptomology especially in
situations where there was a child in the home. Non- mandatory referrals included any
instances where the participant felt that they would benefit from speaking to the social worker,
this ranged from issues regarding accessing their social grants, accessing psychological assis-
tance for their MH challenges and challenges of food insecurities.
Data management and analysis
All interviews were translated, transcribed, and analysed using Braun & Clarke’s six-step the-
matic analysis [45]. The initial coding framework was deductively developed based on the
study’s objectives and an early review of transcripts [46]. Subsequently, a codebook was devel-
oped, which included the coding structure used to represent different themes and patterns
found in the data.
The research team then applied the codes using several transcripts, ensuring they were rele-
vant and appropriate to capture the data and that they captured the study’s focus. For this anal-
ysis, we used MaxQDA 2022 software. Furthermore, an initial six transcripts were reviewed
collectively by the research team to ensure the collected data’s depth and richness. This exer-
cise helped us to fine-tune our exploration areas, identify points requiring clarity, and identify
any emerging themes [47,48].
Findings
Characteristics of participants
The participants in the study were grouped into three categories based on their experiences
with HIV, IPV and MH challenges. The first group consisted of seven participants, whose ages
ranged from 24 to 45 years. Each participant in this group had experienced or were living with
all three of the epidemics as disclosed in the questionnaire (HIV-IPV-MH syndemic). The sec-
ond category included eight participants between the ages of 23 and 57. These individuals had
experienced the HIV-MH syndemic. Lastly, the third group had five participants, aged
between 22 and 49, who were living with the IPV-MH syndemic. For more detailed specifics
on each of the participants refer to Table 1 below. Pseudonyms have been used to conceal the
identities of the participants.
Intersecting epidemics and participant’s experiences
Our study found that the interaction between the epidemics often created a mutually reinforc-
ing dynamic that escalated the overall burden on the individuals affected.
Experiences of living with HIV-MH syndemic
Our findings highlighted a significant relationship between MH challenges and HIV. An
exploration of the women’s experiences revealed that an HIV diagnosis often triggered feelings
of denial and a struggle with accepting their status for instance, when Nono (41) was asked to
share how she felt when she was first diagnosed with HIV, she responded:
“It was very painful to even accept it,but I had to accept it and let it pass.But to be honest I
only really started to accept and get healing maybe six years after I was diagnosed.You know
it’s hard when you know all the sexual partners you have had in your life,for me it was only
two people so it hurt for this to happen to me.But it was only after I was positive that people
told me about his history,it was then that I heard of all his past sexual partners who had died
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Table 1. Participant characteristics and epidemic combinations.
Participant Age Number of
Children
Relationship
Status
Education Level Employment
Status
Additional Information
Epidemic combination: HIV, MH and IPV
Noxolo 28 Three In a
relationship
Grade 7 Unemployed Noxolo is currently experiencing violence with the current partner. She
shared MH challenges, with symptoms linked to depression and anxiety
Diana 43 One In a
relationship
Grade 1 Unemployed Diana experienced IPV in the past with the current partner, although at
the time of the interview the violence had ceased. She shared MH
challenges with symptoms linked to depression.
Silindile 38 One In a
relationship
Grade 10 Part-time
employment
Silindile’s experiences of IPV were from a previous partner. She shared
MH challenges with symptoms linked to suicidality.
Nokuthula 26 Two In a
relationship
Grade 11 Unemployed Nokuthula’s experiences of IPV were from a previous partner, the father
of her first child. She shared MH challenges with symptoms linked to
depression.
Sphe 28 Two In a
relationship
Grade 12 Unemployed Sphe’s was in a violent relationship at the time of the interview. She
shared MH challenges with symptoms linked to depression.
Lerato 24 One In a
relationship
Grade 8 Unemployed Lerato’s experience of IPV is with her previous partner. She shared MH
challenges with symptoms linked to suicidality and depression.
Paula 45 Three In a
relationship
Grade 6 Unemployed Paula has a history of violence with the current partner However, at the
time of interview the violence had ceased. She shared MH challenges
with symptoms linked to depression
Epidemic combination: HIV and MH
Nono (CG
7379)
41 Four Widowed and
single
No schooling Part-Time
Employment
Nono shared MH challenges with symptoms linked to anxiety and
suicidality.
Rejoice 25 One In a
relationship
Grade 12 Casual Work Rejoice shared MH challenges with symptoms linked to depression and
anxiety.
Xoli 23 Three Single Grade 11 Unemployed Xoli shared MH challenges with symptoms linked to depression and
anxiety.
Ntombi 26 One In a
relationship
Grade 12 Part-time
employment
Ntombi shared MH Challenges with symptoms linked to depression, she
was also clinically diagnosed with Trichophagia
Phindi 48 Five Married Grade 12 Unemployed Phindi shared MH challenges with symptoms linked to suicidality.
Pauline 42 Three In a
relationship
Grade 8 Full-time
employment
Pauline shared MH challenges with symptoms linked to depression
Nelly 57 Two Single Grade 6 Unemployed Nelly shared MH challenges with symptoms linked to depression and
anxiety
Adelaide 46 Five Married Grade 7 Part-time work Adelaide shared MH challenges with symptoms linked to suicidality and
anxiety.
Epidemic combination: IPV and MH
Palesa 22 Two Single Engineering
Diploma
Unemployed Palesa is caregiving for her sister’s children. At the time of the interview,
she was not in a violent relationship, her history of IPV is from previous
partners. She shared MH challenges with symptoms linked to
depression.
Nomie 28 Two In a
relationship
Grade 5 Unemployed Nomie was in a violent relationship at the time of the interview. She
shared MH symptoms linked to depression.
Cindy 49 Two Married Grade 8 Unemployed Cindy has a history of violence with her current partner, however at the
time of the interviewer the violence had ceased. She shared MH
symptoms linked to depression and anxiety
Londiwe 42 Three Married No schooling Part-time
employment
Londiwe has a history of violence with her current partner, however at
the time of the interviewer the violence had ceased. She shared MH
challenges with symptoms linked to suicidality and depression.
Ntomfuthi 28 One Single Grade 12 Part-time
employment
Ntomfuthi has a history of violence with her previous partner, however
at the time of the interview she was single. She shared MH challenges
with symptoms linked to depression.
https://doi.org/10.1371/journal.pgph.0002588.t001
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from HIV.When I found out I was always crying,constantly crying.Asking myself for how
long I will I have to suffer like this.”.
Furthermore, for many of these women, an HIV diagnosis triggered symptoms linked to
depression, anxiety, and in extreme cases, suicidal ideation. Ntombi, (26), conveyed the anxi-
eties accompanying her HIV positive status,
“It stresses me when,I think of what will happen when he [son] is grown up.I worry a lot espe-
cially when I think of times when I will not be around anymore.My heart is sore and I’m con-
stantly scared."
For those participants who reported suicidal ideation, it was often in situations where their
children had also acquired HIV. Silindile’s (38) son, for example, was born with HIV, when
asked which of all of the challenges, she had encountered is the most difficult for her to accept,
she responded:
“I would say the most difficult for me is the HIV status because it directly affects my son.I
don’t even know where to begin with solving that situation.How will I ever tell my son,he
won’t even understand how he contracted this virus.This is the thing that breaks my heart the
most,even now,sometimes I just have these feelings of wishing I could kill myself.Every time I
think about his father,I just wish I had never met that man,if it were up to me,I would have
never even walked in the same direction as that man.”
Additionally, the perceived burden and the accompanied denial of an HIV diagnosis often
significantly impacted their decision-making regarding treatment initiation. Paula, (45),
shared how her HIV status and the emotional toll it took delayed her initiation of treatment:
“I wasn’t ready to accept. . . so I waited five years after being diagnosed,I felt I needed to coun-
sel myself before I could start taking treatment.There was a time where I did something. . . I
would go fetch pills at the clinic and throw them away afterwards,then I fell sick.Interviewer:
“What happened afterwards?”Paula:“I do not remember exactly who it was,maybe it was
the nurse,they told me not to stop taking the pills.They asked me who I want to leave my chil-
dren with.I went back to the clinic and I never stopped taking them.”
Experiences of living with IPV-MH syndemic
For the participants who had experienced IPV, we found that many of them also reported
symptoms indicative of anxiety and depression. Cindy (49) had been in an abusive relationship
with the father of her children for many years, she shared how being in this relationship put
her in a constant state of fear and worry:
Interviewer:“So,were there other times in your life where you felt constantly scared or wor-
ried?”Cindy:“Yes,it was during that time of the abuse.I would worry all the time about
what will happen to my children if I leave.I would look around at other people’s lives and feel
like I was the only one going through this and I didn’t understand why my life was the way
that it was.I was so afraid of this man; I thought one day he will kill me.”
Furthermore, Palesa (22), detailed how her abusive relationship created a constant state of
anger in her, which she unconsciously directed towards her son. She shared:
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"It was difficult,I won’t lie,I was angry,I was an angry mother,very angry.Even when he
[son] would try and speak to me,I would just insult him to the point that I would even regret
it afterwards.I would get pissed off by my partner and take it out on the closest person to me
and usually,it was my son he would do a small thing,like spill water,and I would overreact.
Like,I realised that the way I was hitting him was not normal.I would take out a lot of pain
on him,but I learned that he doesn’t know anything,he is a baby”.
On the other hand, some participants reported the relationship between MH and IPV as
bidirectional where they felt that their MH challenges also lead to violence in their relation-
ship. Nomie (28) shared how her challenges with anger which spurred from her childhood
trauma often impacted on her intimate relationships at times leading to violence:
“I’m one person who is quick to anger.I’ve always been an angry person.I have serious anger
issues especially when I think about how my parents can just abandon me like that as a child.
If someone does something to me,I get very angry and I want us to hit each other”.Inter-
viewer:“Oh,and have you ever hit each other?Nomie:“With this one [current partner],no it
hasn’t happened.I’ve noticed that he holds back even when I try to provoke him so that we
can fight he holds back a lot.So,I tend to push him so that he can get to the point where he
hits me so that I can also hit him back.But he holds back and doesn’t hit me.[laughs].But
with the others?like my ex.We used to fight a lot.When we would start fighting everything
would be all over the place,you’d see this table turned upside down.Ah we would beat each
other.”
Experiences of women living with HIV-IPV-MH syndemic
In our study, the women among the group who had experienced all three intersecting epidem-
ics, spontaneously shared their experiences of childhood sexual abuse (CSA), which appears to
have contributed to MH challenges in adulthood especially in situations where they disclosed
to caregivers and were not believed. It must be noted however, that the lack of disclosure in the
other groups, does not preclude the existence of CSA in the histories of the other women who
did not disclose. Although we did ask participants about experiences of violence during child-
hood, we did not explicitly ask about sexual abuse. This could mean that some participants
may have chosen not to disclose such experiences. Nonetheless we did find that the MH chal-
lenges amongst this group were very severe. Lerato (24), reported:
“When I was living with my uncle and aunt it was not good.They used to abuse me.My uncle
used to force me to have sex with him.He was abusing me.This river is where I used to go to
be alone and wish that I could die.And in terms of the railway,I tried to tie myself with a
rope and kill myself on the railway.But I didn’t manage.And even now there are times when
I still feel like this.Recently I even tried to kill myself.”
When discussing her adult relationships, Lerato shared how she was in an abusive relation-
ship with the father of her child:
“Ah that one used to hit me a lot.He would come home drunk and he would beat me.He
didn’t do anything for me and my son.I had to do everything for us” Interviewer: "Is there
anyone that you told about what was happening?”Lerato: “No,I didn’t tell anyone.I’m not
used to telling people about my problems because I generally don’t trust people.”
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Sphe (28), who also had an experience of CSA, shared how the experience left her confused
and experiencing severe MH challenges, she shared:
“This is when I was raped [pointing at drawing],I lived with the effects of the rape even
though I didn’t know or understand what rape was.My family kept telling me that I hadn’t
experienced what I knew I went through and that really traumatised me.I even started
experiencing memory loss and when that happened it was like it validated them and they
started saying I am crazy that’s why I was accusing that boy of raping me.My life after that
was not okay,I was constantly scared and paranoid.”
Because of this experience Sphe was isolated from her family, which she believed made her
susceptible to dating an abusive partner. When speaking about her partner Sphe recalled:
“Things between me and my partner started changing and I think they changed because he
started learning more about my life and he found out that I am basically an orphan and I
have nobody and I rely mostly on him.And that’s when he became toxic” Interviewer:“Can
you tell me a little bit more about what you mean when you say that he was toxic?Sphe:“One
day,he asked me why he has never seen anyone in my family coming to visit me in all the
time that we had been dating and that’s when I told him about my family background.I told
him that I do have family but we aren’t close and we don’t visit each other.From there on he
started changing as he realised that I am alone and that’s when he became toxic and abusive.”
IPV-HIV syndemic
In relation to the IPV-HIV syndemic, although there was no direct link that didn’t include
MH challenges, we did find participants who made their own association, participants shared
that they believed that they had contracted HIV because of their abusive partners who had
been cheating on them incessantly, Silindile (38) expressed:
“You know,what hurt me the most when I first found out was because I felt like I didn’t
deserve to have this thing [HIV].Two sexual partners in my whole life.The reality of this
really hurt me. . . I was loyal to my partner.I mean you stay with someone and you tell your-
self that you are committed but on the other hand you are with a partner who is running the
streets.And then I discovered I was HIV positive.”
Coping strategies
Participants from the different groups had varied ways of coping with living with the syndemic
and other challenges in their lives. Some of the coping strategies included their own resilience
and having the inner belief that they could overcome any obstacle. Religion and church also
played a crucial role.
HIV-MH syndemic and coping strategies
Women living with the HIV-MH syndemic shared that a combination of self-reliance, family
support, hope, and religious faith was how they coped. In terms of self-reliance, Rejoice (25)
highlighted the significance of having to rely on herself to cope and overcome her adversities:
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“I guess the support system was mine.Yes,I had uncles and everything,but I believe that
Rejoice helped herself out of this,even though somehow that hurt me,but it is also what kept
me together to carry on.”
Furthermore, hope, coupled with a solid support system, was emphasized as a crucial com-
ponent for coping by other participants. Xoli (23), who was born with HIV, and struggled with
MH symptoms linked to depression spoke about her hope as well as the support she received
from her family in helping her survive to this point:
“Having the hope that things will get better and being able to confide in my aunt and having
her support. . . I have learned that I can overcome anything no matter how difficult it is.”
For some of the women, religious faith and their trust in a higher power were instrumental
in navigating their challenges. Their conviction provided both comfort and resilience amid
adversity. Nelly (57), who not only contracted HIV from her husband but also grappled with
the loss of a child and socio-economic challenges stemming from unemployment, leaned on
her faith for comfort She expressed:
“In everything that I do,I say,God,you are the alpha and omega in my life,you will not for-
sake me.I know in the end you will make my life better.”
IPV-MH syndemic and coping strategies
For women struggling with the IPV-MH syndemic, two primary coping strategies emerged:
the use of substances as described earlier for women living with the HIV-IPV-MH syndemic
as a means of escape and distraction and clinging to the hope of a brighter future. Londiwe
(49), who suffered severe IPV at the hands of her husband, shared that she coped by being
hopeful that things would change, she reflected,
“It was the hope that everything would eventually be fine.I hoped that one day things would
turn out okay.”
On the subject of substance use as way for mental detachment, Nomie (28) noted:
“I just drink at home; I drink and then I sleep.I usually drink if I want to distract myself and I
just don’t want to think.Interviewer:“What do you want to distract yourself from?”Nomie:
“Honestly,everything hey,relationships,life,work,everything.I sometimes feel like nothing is
going right in my life.I try do this and it doesn’t work out,then I try something else and it also
doesn’t work,so I find myself feeling discouraged.Usually if I don’t drink,I’ll end up smoking
dagga.But I like dagga because when I smoke,I don’t think about anything; I just sleep.”
IPV-MH-HIV syndemic and coping strategies
The women living with the IPV-MH-HIV syndemic, when probed on how they coped with
these intersecting epidemics, shared that acceptance, an unwavering commitment to their chil-
dren, and, for some, substance misuse as a means of temporary relief. Many participants con-
veyed that alcohol, albeit briefly, provided some form of escape from their lives. Lerato’s (24)
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narrative paints a vivid picture of her struggle with her HIV diagnosis and her journey towards
acceptance. She shared:
“I’ve accepted it because at the end of the day there is nothing,I can do about it”.
When we probed deeper into the length of her acceptance journey, she touched upon the
solace she sought in alcohol not only in relation to her diagnosis but also her childhood trauma
experiences:
“It took a very long time.And during that time all I wanted to do was be at the tavern and
drink because I didn’t want to think about what had happened.I wanted to distract myself.I
would just go to the tavern,drink and come back and pass out.If I passed out after a drunk
night it was better because I wouldn’t think about anything.”
Diana (43) also shared her story, not only about living with HIV but also grappling with a
childhood marred by abuse. The relative who fathered her first child had sexually assaulted her
during her younger years. Further complicating her life was the consistent physical and emo-
tional abuse she endured from her husband and the longstanding MH challenges that plagued
her from childhood. In search of relief, Diana turned to alcohol. She recounted:
“He would hit me when he was drunk. . . Then I came back home and decided to never go
back there.That was the time that I started drinking alcohol,I was too stressed.I gave my life
away to alcohol,it felt as though what I was doing was the right thing.I felt good when drink-
ing.I drank so much to a point that had I not stopped drinking,I would have been dead by
now”.
However, amid these challenges, the women’s commitment to motherhood provided a
sense of hope for them. Silindile highlighted this sentiment, asserting:
“I think it’s my children that give me the go forward,because the last thing I want is for my
children to struggle.”Nokuthula (26) also shared the following when asked how she coped
with her challenges, “My children are the reason that makes me wake up every morning,raise
my head,and say thank God for giving me another day to live.Then in my life,the people that
I have as my priority,are my children and my brother”.
Overall, we found that acceptance was a cross-cutting coping strategy observed across all
the different epidemic combinations. Nokuthula (26), who had experienced all three epidemics
had the following to say:
“After being raped,the only thing I was scared of was a man.I did not want a man near me;
they disgusted me.So,after getting raped for a second time,they ran tests on me,and that’s
where I found out that I have HIV.It became difficult for me to accept and live with it.It was
difficult,very difficult.But as time went by,I decided and accepted that I am living with this
thing for the rest of my life and to accept what that man did to me,so why should I be misera-
ble because of it?I think I have to live with the fact that I am HIV positive and I contracted
this through rape,and I won’t change it.”
Moreover, Xoli (23) who was living with the HIV-MH syndemic, shared how she had to
accept her diagnosis,
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“It has really affected my family because my younger sister and I were born with HIV.At first
it was difficult to accept,but eventually I accepted that I have to take my medication and go
to the clinic in order to live longer.”
Finally, Cindy (49), who was living with the IPV-MH syndemic, shared that when she was
being abused by her husband, what helped her cope was hope that he would change as well as
acceptance of the situation because of her dependence on him, she reported:
“I hoped that one day things would turn out okay.I was afraid to go to social workers or the
police because I didn’t want him to get arrested because if he got arrested what would we eat.
In life you have to accept everything that happens to you.You have to accept and let it pass
and understand that this is life.”
Our findings showed that substance use was more commonly mentioned in the combina-
tions involving IPV, whilst hope, self-reliance, family support, and religious faith were promi-
nent coping strategies in the HIV-MH syndemic.
Discussion
The experiences of women living with the HIV, IPV, and MH syndemic are complex. The
study identified intersections and the synergistic interactions between HIV-MH, IPV-MH,
and the relationship between IPV-HIV-MH. Our findings suggest that HIV, IPV and MH
challenges interact in ways that exacerbate the severity and impact of each condition and we
therefore propose that the co-occurrence of these epidemics constitutes a syndemic. Notably,
beyond substance use, other MH challenges were evident among the participants, warranting
an expansion of the SAVA syndemic concept. We found that among participants living with
the HIV- MH syndemic, an HIV diagnosis was met with denial, symptoms related to depres-
sion, anxiety and suicidality and delayed treatment initiation. In the IPV-MH syndemic
group, participants reported symptoms related to anxiety and depression in relation to the
abuse they experienced, participants also reported a bi-directional relationship between IPV
and MH with IPV worsening MH and MH challenges increasing women’s vulnerability to
IPV. Participants experiencing all three epidemics reported a history of CSA, which was associ-
ated with MH challenges over their life course and experiences with IPV from past and current
partners. Participants coped with their circumstances mostly through acceptance of the situa-
tion and religion, while others used excessive substance use to help them cope and detach. In
the groups where IPV was not present, participants relied on family, friends, religion and
other social support.
The experiences of women living with the HIV-MH syndemic
In the HIV-MH interaction, the syndemic nature is evident. We found that an HIV positive
diagnosis often triggered MH symptoms linked to depression and anxiety among participants
and in many cases also exacerbated the symptoms. This was particularly apparent especially in
cases of vertical HIV transmission where maternal guilt, which was often intensified by inter-
nalized stigma significantly increased the risk of severe MH challenges such as suicidal idea-
tion. This complex interplay aligns with findings from KwaZulu Natal study which identified a
significant prevalence of suicidal ideation among pregnant women diagnosed with HIV [49].
Additionally research from Mpumalanga reported that the factors associated with suicidal ide-
ation among HIV positive pregnant women included, major depression, partner disclosure
status, stigma, age, and partner aggression [49–51]. Despite the existing research on HIV
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positive pregnant women and suicidal ideation, our study identifies a gap in the literature spe-
cifically related to maternal suicidal ideation in the context of vertical transmission.
Furthermore, the current study is unique in that it emphasizes the role of internalized
stigma within the syndemic. Our findings show that internalized stigma not only amplifies the
maternal guilt often associated with vertical transmission but it also intensifies overall MH
challenges faced by people living with HIV. Evidently despite the advancements in HIV treat-
ment as well as widespread prevalence, HIV stigma still persists. This finding is significant as it
highlights the importance of tackling the medical aspects of HIV, as well as the societal and
psychological barriers such as stigma, which significantly contribute to these complex inter-
twined epidemics.
Moreover, many participants in this group reported initial feelings of overwhelming fear of
death and denialism, which led to delays in seeking HIV treatment. Evidently the psychologi-
cal impact of an HIV diagnosis exacerbated their MH challenges, which in turn impeded them
from seeking timely medical intervention. This is in line with other research which has found
a positive relationship between poor MH and delayed medical intervention [52]. Such findings
highlight the need for psychological screenings alongside HIV testing. Incorporating psycho-
logical screenings alongside HIV testing presents multiple advantages. Firstly, it could enable
early identification and management of potential MH challenges and as result possibly avert-
ing the worsening of both mental and physical outcomes. Secondly, the screening could also
serve to address the psychological barriers such as anxiety, fear and denialism that often hinder
timely HIV treatment [52]. By implementing psychological screening as part of HIV testing,
this can mitigate the syndemic impact of these health challenges.
The experiences of women living with the IPV- MH syndemic
Women experiencing the IPV-MH syndemic often displayed symptoms indicative of anxiety
and depression. For some participants these MH challenges existed before their IPV experi-
ence. This aligns with prior research indicating that pre-existing MH challenges can predis-
pose individuals to IPV victimization [11,53,54]. Conversely for other participants IPV was a
salient trigger or exacerbated MH challenges, creating a cyclical relationship where IPV and
MH challenges intensify each other. This bidirectional relationship where each condition
aggravates the other is indicative of a syndemic. The MH repercussions of IPV have been thor-
oughly reported on in the literature, with conditions ranging from PTSD and depression to
anxiety and eating disorders [53,55,56]. Evidently the relationship between IPV and MH goes
beyond co-occurrence. When these two epidemics intersect, they also mutually exacerbate the
other, often resulting in a compound impact on the women.
The HIV-IPV intersection
In the present study, we didn’t find an exclusive overlap between IPV and HIV, as all partici-
pants reported concurrent MH challenges. It appeared that any existing IPV-HIV connection
was invariably connected with MH challenges. Research indicates that an HIV diagnosis can
increase stress at both the individual and relationship level. This heightened stress can
adversely impact women’s mental health, potentially increasing their vulnerability to becom-
ing involved in an abusive relationship [9,57]. Other studies indicate that the influence of HIV
on IPV is notably accentuated in women already struggling with IPV in their relationships, as
their partners, often with a heightened antisocial disposition, might react more aggressively to
an HIV diagnosis disclosure [12].
While we did not find evidence of a standalone IPV-HIV overlap, the data consistently
highlighted the omnipresence of MH challenges, intersecting with the other two epidemics. A
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deeper look at the experiences of women living with the IPV-HIV-MH syndemic is critical at
this point.
The experiences of women living with IPV-HIV-MH syndemic
Among this group of women with the IPV-HIV-MH syndemic, a prominent shared experi-
ence was the history of CSA. The trauma from CSA has been identified as a potential precursor
to adult MH challenges, given its long-lasting detrimental effects on psychological well-being
[58–60]. Many of the participants reported symptoms indicative of depression, anxiety, and
suicidality, which align with previous findings on the profound impact of CSA on survivors’
psychosocial development [58,61].
Furthermore, research indicates that CSA survivors face an elevated risk of sexual revictimi-
zation in later life, including within stable relationships [62]. This revictimization can manifest
as various forms of IPV, such as psychological and physical abuse [59]. The latter indicates a
cyclical pattern where early trauma can lead to MH challenges which in turn increase vulnera-
bility to IPV [54].
Regarding the HIV component, while none of the participants directly linked their HIV
diagnosis to violence, some believed that their acquisition resulted from their abusive partners’
extramarital affairs. This perspective underscores the intersectionality of these epidemics: the
compounded vulnerabilities from CSA and MH challenges potentially leading to relationships
characterised by IPV, and within these relationships, an increased risk of contracting HIV.
It must be noted, however, that these relationships are not strictly linear but bidirectional.
For instance, while CSA can predispose individuals to MH challenges [61], which might then
lead to violent relationships and an elevated HIV risk [12,59], the reverse can also hold true.
MH challenges might manifest first, making the child more susceptible to CSA. Similarly, an
HIV diagnosis might precipitate or exacerbate violence in relationships [12]. Recognizing this
intricate web of bidirectional influences underscores the need for a nuanced and multifaceted
approach to understanding and addressing the overlapping epidemics faced by these women.
Coping strategies
According to Lazarus and Folkman (1984) two primary coping modalities can exist: problem-
focused and emotion-focused coping [63]. The former encompasses efforts to alter the envi-
ronment or the problem itself, while the latter aims to alleviate emotional distress [63]. Most of
our participants leaned towards emotion-focused coping strategies. The coping strategies used
by women living with different combinations of the IPV, HIV and MH syndemic revealed sev-
eral patterns and similarities. Acceptance emerged as a cross-cutting coping strategy observed
across all combinations. Participants in the HIV-MH group expressed religion and belief in
God as important in coping with challenges. Additionally, substance use was commonly men-
tioned in combinations involving IPV. Furthermore, the reliance of social support to cope was
found in the groups who did not experience IPV. Research focusing on coping strategies
among women dealing with IPV revealed that victims found their families, friends, and neigh-
bours to be supportive and reliable resources for assistance [25]. Our study, however, did not
find that participants experiencing IPV relied on family and social support structures as a way
of coping, in such situations. Some theories have posited that the reason for this could be that
often in IPV situations the perpetrator is likely to isolate their partner from their friends and
family [64].
The notion of acceptance although cross-cutting across the groups, its manifestation dif-
fered based on the unique combination of adversities each participant faced. When consider-
ing HIV and acceptance, our findings resonate with prior research in the field. For example, a
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study by Sreelekshmi (2015) involving 150 HIV-positive individuals highlighted the prevalent
use of emotion-focused coping techniques [23]. A significant 65.7% of participants identified
acceptance as their primary coping approach. However, for some participants who had experi-
enced IPV, the acceptance conveyed often leaned towards resignation. This type of acceptance
was deeply entrenched in feelings of desolation and helplessness. Moreover, in the literature,
acceptance in the face of IPV has also been characterised as a form of denial or avoidance
which is often linked to PTSD symptomology [65–67]. On the other hand, there were some
participants that seemed to have accepted and normalized the violence. In relation to the latter,
research has also found that in some contexts young women may perceive violent men as
more desirable partners and as being real men, in such situations, IPV is not only normalized
but is also seen as a necessary component in romantic relationship [68,69].
As mentioned, substance misuse, especially in the context of IPV was a recurrent theme
amongst participants. This observation is echoed by Mehr et al. (2023), who define substance
misuse as the consumption of substances in high quantities or inappropriate contexts [70].
Their research highlights that those subjected to IPV frequently resort to substance misuse as a
way to manage the emotional and physical trauma they endure and as a form of self-medica-
tion. Our findings are in line with this, particularly among women who had experienced the
combinations including IPV. Our findings add and expand to the literature on coping strate-
gies among women living with the different combinations of HIV, IPV and MH epidemics, as
we not only identified which strategies were more prevalent but also how their manifestations
differed based on the unique combinations of epidemics each woman faced.
Understanding how women cope with these often-co-occurring epidemics is imperative as
it provides an opportunity to better inform clinical practice, as well as contribute to the devel-
opment of comprehensive, evidence-based strategies for prevention, support, and treatment.
Furthermore, our findings also highlight the significance of considering the impact at the com-
munity and interpersonal levels in IPV research. They also affirm the perspective that IPV
should be treated as a communal issue rather than an individual problem.
Limitations
Although the current study provides valuable insights, it is not without its shortcomings and
limitations. The first limitation is related to translation of the interviews. Some researchers
argue that translation during the research process has the potential to introduce a level of bias
as translation involves some subjective interpretation [71]. It includes cultural interpretation
and an understanding of the context, and herein is where the bias is often introduced [72]. It is
thus critical to incorporate ethical translation practices in research to limit such biases. These
include using translators who are not only proficient in the language but are also familiar with
the context and the environment [73]. For the current research, interviews were conducted in
Siswati and Xitsonga and subsequently transcribed and translated into English. Though this
posed a potential limitation as some nuances may have been lost in translation, efforts were
made to ensure accuracy and preserve the essence of the participants’ responses. The measures
included, having transcribers who were fluent in the language the interview was conducted in
as well as English. Secondly the interviewers were also familiar with the community, with two
of the interviewers having worked in the area for over a decade on various other research proj-
ects. Finally, in cases where there was no direct translation for a particular word or phrase, an
explanation in English was provided in brackets.
Another limitation concerns the method used for categorizing participants into different
epidemic combinations. While this approach initially provided a structured framework for
analysis, it might have introduced some degree of arbitrariness, where in some cases some
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participants may not have met the criteria of the questionnaire leading them to not being cate-
gorized as experiencing a particular MH challenge. However, to refine this categorization, we
re-categorized the groups, based on the information gathered from the qualitative interviews.
For example, participants not initially flagged for MH challenges in the questionnaire but who
later revealed symptoms indicative of such during the interviews were re-categorized accord-
ingly. This additional layer of categorization aimed to capture more accurately the complexi-
ties of each participant’s experiences.
Although there is much debate about what constitutes as sensitive research, according to
Lee and Renzetti, any topic can be deemed as sensitive, however there are some topics that are
likely to cause more distress in individuals than others such as HIV/AIDS, MH issues, death
and bereavement [74,75]. Research on personal experiences of violence and childhood trauma
can be classified as sensitive [76]. The sensitive nature of the topics discussed in the interviews
may have influenced the participant’s willingness to fully share and be open, thus leading to
potential underreporting due to discomfort or fear of stigma. To address this, interviewers
assured participants of the confidentiality of their responses, and assurance that they would
receive help if they felt distressed during the interview. Ensuring participants anonymity and
confidentiality increased the likelihood of participants providing more truthful and genuine
responses [77].
Reflexivity in qualitative research is imperative, this involves the ongoing, cooperative and
multifaceted activities where researchers actively critique and assess the ways in which their
personal perspectives and backgrounds can potentially affect the research [78]. We acknowl-
edge that our personal beliefs, cultural understanding, and personal experiences may have
shaped our interpretation as well as the presentation of the participants’ stories and as a result
potentially introducing subjective biases. As an attempt to mitigate this, the research team had
regular debriefing sessions throughout the study, where we discussed and challenged each oth-
er’s viewpoints, which helped in ensuring a more balanced perspective on the data. Further-
more, the interviewers also kept detailed field notes after the interviews which were reflective
accounts of the interviews including the interviewer thoughts and reactions to the interview.
Furthermore, the potential for response bias due to the interview-led nature of the inter-
views was another limitation. However, to mitigate this, experienced qualitative interviewers
were used and trained to maintain neutrality and foster a non-judgmental and supportive
environment.
Finally, while the study’s focus on the South African peri-urban and rural context provides
in-depth and context specific insights especially due to the limited data in such settings, this
also implies that the findings may not be directly transferable to other settings. The experience
of women in this specific context are shaped by unique socio-cultural, economic, and environ-
mental factors which may differ significantly from those in other provinces or countries.
Despite the limitations outlined, the study holds substantial value, particularly in under-
standing the experiences of women in South African peri-urban and rural contexts. It also lays
a foundation for further research, suggesting the need for more studies with diverse samples to
broaden the understanding of these complex experiences in varied settings.
Implications of the research and next steps
The findings of the current study highlight the importance of addressing the interconnected
epidemics of HIV, IPV and MH in a comprehensive and integrated manner. A key implication
is the need for holistic care approaches that are geared towards tackling these interlinked epi-
demics rather than treating them in isolation. A holistic approach has the potential to improve
prevention and response strategies, ultimately contributing to beneficial outcomes in public
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health [79]. A good example of this is the SHARE multicomponent intervention in Uganda
which has effectively managed to reduce HIV incidence and IPV in women [80].
Furthermore, taking into consideration the diversity in coping strategies observed in the
participants, there is a need to support positive coping strategies while providing targeted
interventions for harmful coping strategies such as substance misuse among women living
with the syndemic. An example is the coping strategies intervention implemented at the ART
clinic of the All-India Institute of Medical Science in New Delhi. The intervention aimed to
enhance positive coping mechanisms and quality of life among people living with HIV through
informational support, adaptive coping strategies, social support, and positive living [81].
Furthermore, our study highlights the importance of considering the unique contexts and
backgrounds of individuals when designing and implementing public health interventions. In
particular, the role of cultural and socio-economic factors in shaping the experiences of HIV,
IPV and MH epidemics requires context-specific strategies.
Moreover, the high prevalence of MH challenges identified in the current sample highlights
a need for enhancement of MH care especially in peri-urban and rural areas, where MH ser-
vices are close to non-existent [70]. Strengthening MH services in these areas would serve as a
critical aspect in addressing the syndemic effectively. Research highlights the importance of
community-based MH interventions as pivotal especially in low-resource communities. For
instance, Malawi has integrated their Health Surveillance Assistants to deliver MH interven-
tions into the community’s already existing social and cultural structures [82]. Similarly, in
South Africa there is an ongoing effort through the Mental Health integration program aimed
at enhancing integration of MH services in the primary health care system. However, despite
the innovativeness of this program, the effectiveness is significantly hindered by inadequate
funding, poor administrative coordination and low MH awareness among officials and the
general population. [83].
Future research should focus on the development of interventions that can address the co-
occurrence and the multi-faceted nature of these epidemics. This includes the exploration of
the efficacy of integrated care models and the potential of Mobile-health solutions in increas-
ing accessibility to MH and support services, especially in resource limited settings. There is
also a need for more qualitative research on the IPV, MH and HIV syndemic. Whilst there is
an abundance of quantitative research in this area [84–87], qualitative research is critical in
providing a deeper and more nuanced understanding of the syndemic.
Conclusion
Our study highlights the intricate hardships faced by women navigating combinations of HIV,
IPV, and MH epidemics and how the combination of epidemics worsens each of these. MH
challenges were a consistent factor, whether associated with HIV, or IPV. A deeper under-
standing into these women’s multifaceted experiences is vital for developing targeted strategies
that address their specific needs, thus enhancing their overall quality of life.
Supporting information
S1 Table. Referral flags and categories.
(DOCX)
S1 Text. Interview guide.
(DOCX)
S2 Text. Art-based method prompts.
(DOCX)
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Women living with the HIV, IPV and mental health syndemic in South Africa
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S1 Checklist. STROBE statement—Checklist of items that should be included in reports of
observational studies.
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S2 Checklist. Inclusivity in global research.
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Author Contributions
Conceptualization: Mpho Silima, Nicola Christofides, Hannabeth Franchino-Olsen, Nataly
Woollett.
Formal analysis: Mpho Silima, Nicola Christofides.
Funding acquisition: Franziska Meinck.
Investigation: Mpho Silima.
Methodology: Mpho Silima.
Software: Franziska Meinck.
Supervision: Mpho Silima, Nicola Christofides, Hannabeth Franchino-Olsen, Nataly Wool-
lett, Franziska Meinck.
Writing – original draft: Mpho Silima.
Writing – review & editing: Mpho Silima, Nicola Christofides, Hannabeth Franchino-Olsen,
Nataly Woollett, Franziska Meinck.
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