Recall and understanding of HIV-related counseling messages among progestin implant and injectable contraception users in Malawi

Some studies have suggested an increased risk of HIV acquisition or transmission with hormonal contraception and potential drug-antiretroviral therapy (ART) interactions. We conducted a randomized clinical trial among Malawian women with and without HIV who were initiating the levonorgestrel (LNG) implant or depot medroxyprogesterone acetate (DMPA) injectable. Women living with HIV were included to examine contraceptive use in the context of potential contraceptive-ART interactions and the effect of hormonal contraception on HIV genital shedding, and women without HIV were included because of concerns about the potential relationship between hormonal contraception and HIV acquisition. A qualitative sub-study assessed participants' recall and understanding of standardized contraceptive counseling messages.Participants for the qualitative sub-study were purposively sampled from the parent trial based on HIV status, counseling exposure, and contraceptive continuation status, and enrolled after randomization and exposure to counseling messages. Women participated in individual in-depth interviews (IDIs) and/or focus group discussions (FGDs) conducted after trial follow-up visits; interview timing varied across participants.Of 60 eligible women from the parent trial, 41 participated in IDIs and/or FGDs. Most recalled counseling messages emphasizing condom use for HIV and STI prevention among serodiscordant couples. However, none accurately recalled messages about the potential HIV acquisition risk associated with DMPA or the implant, and even when these messages were re-read, they were not accurately interpreted. In contrast, women more frequently recalled messages about potential reduced contraceptive effectiveness of the implant when used with ART. Women who continued their assigned contraceptive method were more likely to accurately recall counseling messages.Improved counseling strategies are needed to support clear communication and understanding of complex and evolving contraceptive and HIV-related risk information.