Counselors’ acceptability of adherence counseling session recording, fidelity monitoring, and feedback in a multi-site HIV prevention study in four African countries



To retain effectiveness, evidence-based counseling interventions must be delivered with fidelity. We report on acceptability of the adherence counseling fidelity monitoring process used in MTN-025/HOPE Study, the largest biomedical HIV prevention trial to integrate fidelity monitoring using audio recordings of counseling sessions.


The MTN-025/HOPE Study, a Phase 3B open label extension trial across fourteen sub-Saharan African sites involving 1,456 women, explored safety and adherence to the dapivirine vaginal ring for HIV prevention between August 2016 and October 2018. Adherence counselors were trained to conduct Options Counseling, a Motivational Interviewing-based intervention. A sample of their audio-recorded sessions were monitored by a New York-based multilingual team, to support intervention fidelity. The rating team evaluated sessions using a fidelity monitoring tool and was itself assessed monthly for interrater reliability (IRR). To understand acceptability and feasibility of fidelity monitoring, we surveyed 42 counselors and interviewed 22 counselors, and examined spontaneous mentions of session recordings by 10 study participants among 91 interviewed. Quantitative data were analyzed using descriptive statistics. Qualitative data were coded and thematically summarized.


In total, 5,366 Options sessions were audio-recorded, of which 1,238 (23%) were reviewed for fidelity. On a scale of 1 to 7, counselors indicated that session ratings were very helpful (mean rating of 6.64). Most counselors reported progressing from apprehension to confidence about the fidelity monitoring process after conducting 25 or fewer sessions, with 88% reporting feeling confident in their abilities and 90% likely to use skills learned through Options in the future. In interviews, study participants had mixed reactions to recorded sessions; some reported receiving better counseling when sessions were monitored, and others found them time-consuming and burdensome. For raters, assessment of IRR was essential, as drift in ratings occurred over time. Furthermore, internal reviews of rating forms revealed the need for specific training to shape written feedback in a supportive, client-centered manner.


Fidelity monitoring of counseling sessions in large multi-site biomedical HIV prevention studies is acceptable and can feasibly guide and support counselors by providing structured feedback. Future international trials using behavioral interventions should include fidelity monitoring to ensure adherence to effective practices.