Culturally-based challenges to and recommendations for delivering adherence counseling in a multicultural biomedical HIV prevention trial in four African countries

Research is needed to identify how to effectively tailor evidence-based interventions across cultures with limited resources, particularly for behavioral components in large HIV prevention trials. Through surveys and interviews with counselors of sub-Saharan African women during an openlabel microbicide trial (MTN-025), we examined language, education, and cultural barriers in delivering a motivational interviewing-based adherence counseling intervention (i.e., Options Counseling). Counselors encountered an array of barriers, most prominently that participants struggled to comprehend culturally incongruent pictorial guides, such as traffic light images, and to uphold product use when primary partners disapproved. Overwhelmingly, counselors cited the intervention’s inherent flexibility as an asset; it encouraged them to tailor language and examples to be more culturally relevant to participants. Future resource-conscious researchers may preemptively offset similar barriers by consulting with communities during intervention development. Similarly, affording counselors flexibility while delivering the chosen intervention may enable them to troubleshoot barriers that arise on the ground.