Impact of motivational interviewing training for lay counsellors on HIV care outcomes in South Africa: a cluster-randomized pilot trial

BACKGROUND: Retention in HIV care remains challenging in sub-Saharan Africa. We evaluated whether training lay counsellors in Motivational Interviewing (MI) could improve outcomes among newly diagnosed people living with HIV (PLHIV) in South Africa. METHODS: We conducted a cluster-randomized pilot trial in eight Johannesburg primary healthcare clinics, randomized 1:1 to Thusa-Thuso intervention (7-day MI training plus 12-month mentorship) or standard-of-care (SOC). Adults PLHIV (≥18 years) were enrolled and followed for 12 months. The primary outcome was 12-month retention. The secondary outcome was HIV viral suppression (VL <50 copies/mL). We assessed dose-response associations between counsellor MI skills and outcomes. RESULTS: Between March 2020 and August 2021, 548 PLHIV were enrolled (n = 291 intervention; n = 257 SOC). The intervention significantly increased 12-month viral suppression (39.86% vs 28.40%; risk differences (RD): 11.12%; P = .007). Improvements occurred for ART initiation (88.3% vs 74.7%; RD: P = .085) and 12-month retention (51.9% vs 40.5%; P = .067). Patient retention increased with counsellor proficiency in cultivating change talk (RR: 1.47; P = .016), showing empathy (RR: 1.30; P = .020) and partnership (RR: 1.37; P = .010). CONCLUSION: MI training and mentorship for lay counsellors improved 12-month viral suppression among newly diagnosed PLHIV. Training existing cadres in MI skills is a high-leverage strategy to achieve UNAIDS 95-95-95 targets.