Implementation of male-specific motivational interviewing in Malawi an assessment of intervention fidelity and barriers to scale-up

Introduction: Treatment interruption (TI), defined as >28 days late for antiretroviral therapy appointment, is one of the greatest challenges in controlling southern African HIV epidemics. Negative client–provider interactions remain a major reason for TI and a barrier to return to care, especially for men. Motivational interviewing (MI) facilitates client-driven counselling and improves client–provider interactions by facilitating equitable, interactive counselling that helps clients understand and develop solutions for their unique needs. Fidelity of MI counselling in resource-constrained health systems is challenging.

Methods: We developed a male-specific MI curriculum for Malawian male TI clients. Four psychosocial counsellors (PCs, a high-level Malawian counselling cadre) received a 2.5-day curriculum training and job aid to guide MI counselling approaches. PCs implemented the MI curriculum with men >15 years who were actively experiencing TI. Clients were found at home (through tracing) or at the facility (for those who returned to care on their own). MI counselling sessions were recorded, transcribed, translated into English and coded in Atlas.ti V.9. MI quality was assessed using a modified version of the validated MI Treatment Integrity tool. The tool has two measures: (1) counts of key MI behaviours throughout the session (questions, reflections, etc) and (2) overarching scores (using a 5-point scale) that characterise three MI dimensions for an entire counselling session (cultivating change talk, partnership and empathy). 

Results: 44 MI sessions were recorded and analysed between 1 April 2022 and 1 August 2022. 64% of counselling sessions focused on work and travel as the main reason for TI. 86% of sessions yielded client-driven, tailored solutions for overcoming TI. PCs implemented multiple MI behaviours very well: asking questions, giving information, simple reflections and client affirmation. Few PCs used complex reflection, emphasised autonomy or sought collaboration with clients. Among overarching MI dimensions, PCs scored high in partnership (promoting client-driven discussions) and cultivating change talk (encouraging client-driven language and behaviour change confidence) but scored suboptimal in empathy. Only five sessions had confrontational/negative PC attitudes. 

Conclusions: PCs implemented MI with fidelity and quality, resulting in tailored, actionable plans for male re-engagement in HIV treatment in Malawi.