Throwing the bones to diagnose HIV: Views of rural South African traditional healers on undertaking HIV counselling and testing

A individually randomized controlled trial comparing Healer-led vs. clinician- led training to improve personal protective equipment use among traditional healers in South Africa

Like allopathic healthcare workers, healers are also exposed to patients' blood and body fluids. A widespread practice is the traditional "injection," in which the healer performs subcutaneous incisions to rub herbs directly into the bloodied skin, resulting in 1,500 blood exposures over their lifetime. We tested the impact of healer-led PPE training, staffed by trained traditional healers who reported using PPE during each risky clinical encounter vs. healthcare worker (HCW)-led PPE training sessions. We randomized 136 healers into one of the two study arms (67 in the healer-led group, 69 in the HCW-led group) and assessed the impact of trainer on PPE skills and use over a six-month period. All healers received one in-person day of didactic and practical training followed by three sessions at the healers' home. Participants were largely female (80%), averaged 51 years old, and practiced as a healer for an average of 17 years. Almost 44% either disclosed themselves as HIV+ or received a positive HIV test result at study initiation. Healers in the HCW arm showed equivalent PPE scores as those trained by traditional healers at baseline and at seven months. Healers in both arms self-reported high levels of glove use during"injections," with no statistical difference of use by study arm. When we assessed actual gloves and razor blades disposed of each month, a similar trend emerged. No one seroconverted during the study period. The need for PPE support among traditional healers cannot be ignored. Traditional healers can be trained to effectively disseminate PPE knowledge and skills to other traditional healers. With an estimated 200,000 traditional healers in South Africa, it is imperative that all of them have access to PPE training and supplies to prevent HIV, HCV, or HBV infections. Trial registration: ClinicalTrials.gov, NCT04440813. Registered 17 June 2020, https://clinicaltrials.gov/ct2/show/NCT04440813.

A Qualitative Study Exploring Motivators and Barriers to COVID-19 Vaccine Uptake among Adults in South Africa and Zimbabwe

While vaccines are a well-established method of controlling the spread of infectious diseases, vaccine hesitancy jeopardizes curbing the spread of COVID-19. Through the Vaccine Information Network (VIN), this study explored barriers and motivators to COVID-19 vaccine uptake. We conducted 18 focus group discussions with male and female community members, stratified by country, age group, and—for Zimbabwe only—by HIV status. Participants’ median age across both countries was 40 years (interquartile range of 22–40), and most (65.9%) were female. We conceptualized the key themes within the World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) 3C (convenience, confidence, complacency) vaccine hesitancy model. Barriers to vaccine uptake—lack of convenience, low confidence, and high complacency—included inaccessibility of vaccines and vaccination sites, vaccine safety and development concerns, and disbelief in COVID-19’s existence. Motivators to vaccine uptake—convenience, confidence, and low complacency—included accessibility of vaccination sites, user-friendly registration processes, trust in governments and vaccines, fear of dying from COVID-19, and knowing someone who had died from or become infected with COVID-19. Overall, vaccine hesitancy in South Africa and Zimbabwe was influenced by inconvenience, a lack of confidence, and high complacency around COVID-19 vaccines.

Pulmonary tuberculosis vs. Tindzhaka and Mafularha: A mixed methods inquiry of traditional healers' perceptions of tuberculosis in rural South Africa

Although awareness of tuberculosis (TB) is high in South Africa, delays in TB testing or treatment persist. Even those with symptoms of TB often delay testing, with one study in Mpumalanga revealing a median allopathic care-seeking delay of four weeks. We sought to understand how traditional healers perceived TB symptoms among their patients, if they treated the disease, and what (if any) illnesses they defined as being traditional may have overlapping presentation with TB in South Africa. Nineteen traditional healers completed an in-depth interview (IDIs); 133 completed a quantitative survey about their treatment practices. IDIs focused on lung diseases treated, disease causation, treatment, and prognosis. Survey questions investigated diagnosis of lung ailments, including those treated by the allopathic health system and those by traditional healers. Traditional healers reported that they could differentiate between TB and traditional illnesses, like Tindzhaka and Mafularha, that presented with similar symptoms. Few (7.5%) believed they could treat TB, but the majority (72.9%) believed they could successfully treat Tindzhaka and Mafularha. Tindzhaka and Mafularha are interconnected illnesses that are reportedly caused by breaking social rules around death, sex and using the belongings of someone who recently passed away. Both, if not treated, are considered fatal. While we have no definitive data, traditional healers may be contributing to delays in the diagnosis and treatment for people with active TB by incorrectly diagnosing TB as Tindzhaka or Mafularha. Overcoming issues of trust and compensation, while respecting different forms of knowledge, are some of the challenges we face in successfully engaging with healers.

Understanding the role of traditional healers in the HIV care cascade: Findings from a qualitative study among stakeholders in Mwanza, Tanzania

Tanzania is HIV-endemic, with 5% prevalence. However, less than half of Tanzanians are aware of their HIV status, and only 75% of adult Tanzanians living with HIV are on antiretroviral therapy (ART). Informal healthcare providers, such as traditional healers, frequently serve as the first line of healthcare in Tanzania. How traditional healers interact with people living with HIV (PLWH) remains unknown. This study sought to understand gaps in HIV care and explore how traditional healers interface with PLWH along the HIV care cascade. We conducted a qualitative study in Mwanza, Tanzania, between November 2019 and May 2020. We invited 15 traditional healers, 15 clients of traditional healers, 15 biomedical healthcare facility staff, and 15 PLWH to participate in a single qualitative interview. Two community focus groups were held with eight male and eight female participants. Participants were 18 years of age or older. Individual experiences with traditional healers and biomedical healthcare facilities, as well as perceptions of traditional healers with respect to HIV care, were explored through interviews. Using a content-analysis approach, codes were grouped into a framework that characterized how traditional healers engage with PLWH throughout the HIV care cascade. PLWH engaged with traditional healers throughout the HIV care cascade, from pre- to post-HIV diagnosis. Traditional healers were described in some cases as facilitating HIV testing, while others were described as delaying testing by providing traditional treatments for HIV symptoms. Traditional medications were frequently used concurrently with ARTs by PLWH. There was concern that healers contributed to ART nonadherence as some PLWH used traditional therapies in search of a "cure" for HIV. Our findings suggest that traditional healers interact with PLWH throughout the HIV care continuum and that collaboration between traditional healers and biomedical healthcare professionals and facilities is needed to improve HIV treatment outcomes.

How informal healthcare providers improve uptake of HIV testing: qualitative results from a randomized controlled trial

OBJECTIVE

Uganda is HIV-endemic with a prevalence of 5.7%. Lack of epidemic control has been attributed to low engagement with HIV testing. Collaborating with informal healthcare providers, such as traditional healers, has been proposed as a strategy to increase testing uptake. We explored acceptability and implementation of an HIV testing program where traditional healers delivered point-of-care testing and counseling to adults of unknown serostatus (clinicaltrials.gov NCT#03718871).

METHODS

This study was conducted in rural, southwestern Uganda. We interviewed participating traditional healers ( N  = 17) and a purposive sample of trial participants ( N  = 107). Healers were practicing within 10 km of Mbarara township, and 18+ years old. Participants were 18+ years old; sexually active; had received care from participating healers; self-reported not receiving an HIV test in prior 12 months; and not previously diagnosed with HIV infection. Interviews explored perceptions of a healer-delivered HIV testing model and were analyzed following a content-analysis approach.

RESULTS

Most participants were female individuals ( N  = 68, 55%). Healer-delivered HIV testing overcame structural barriers, such as underlying poverty and rural locations that limited use, as transportation was costly and often prohibitive. Additionally, healers were located in villages and communities, which made services more accessible compared with facility-based testing. Participants also considered healers trustworthy and 'confidential'. These qualities explain some preference for healer-delivered HIV testing, in contrast to 'stigmatizing' biomedical settings.

CONCLUSION

Traditional healer-delivered HIV testing was considered more confidential and easily accessible compared with clinic-based testing. Offering services through traditional healers may improve uptake of HIV testing services in rural, medically pluralistic communities.

A Cluster-Randomized Trial of Traditional Healer-Delivered Counseling and Rapid HIV Testing in Tanzania

Collaborations with traditional healers have been proposed to improve HIV testing uptake. We hypothesized that healer-delivered HIV testing would improve HIV testing uptake, compared with referral to clinic-based HIV testing. We conducted a cluster randomized trial to determine the effectiveness of traditional healers delivering counseling and HIV testing in Mwanza, Tanzania (ClinicalTrials.gov NCT#04071873). Intervention arm healers provided counseling and offered point-of-care HIV tests to adult clients of unknown HIV serostatus. Control arm healers provided referral for clinic-based testing. Primary outcome was receipt of an HIV test within 90 days of enrollment. Secondary outcomes were new HIV diagnosis and linkage to care. In the intervention, 100 clients (100%) received an HIV test, compared with 73 (73%) of control participants (p < 0.001). Two intervention arm participants (2%) had a new diagnosis compared with zero in the control arm (p = 0.50). Engaging traditional healers might provide a culturally concordant opportunity to improve HIV testing uptake.

Traditional healer-delivered point-of-care HIV testing versus referral to clinical facilities for adults of unknown serostatus in rural Uganda: a mixed-methods, cluster-randomised trial

BACKGROUND

HIV counselling and testing are essential to control the HIV epidemic. However, HIV testing uptake is low in sub-Saharan Africa, where many people use informal health-care resources such as traditional healers. We hypothesised that uptake of HIV tests would increase if provided by traditional healers. We aimed to determine the effectiveness of traditional healers delivering HIV testing at point of care compared with referral to local clinics for HIV testing in rural southwestern Uganda.

METHODS

We did a mixed-methods study that included a cluster-randomised trial followed by individual qualitative interviews among a sample of participants in Mbarara, Uganda. Traditional healers aged 18 years or older who were located within 8 km of the Mbarara District HIV clinic, were identified in the 2018 population-level census of traditional healers in Mbarara District, and delivered care to at least seven clients per week were randomly assigned (1:1) as clusters to an intervention or a control group. Healers screened their clients for eligibility, and research assistants confirmed eligibility and enrolled clients who were aged 18 years or older, were receiving care from a participating healer, were sexually active (ever had intercourse), self-reported not having received an HIV test in the previous 12 months (and therefore considered to be of unknown serostatus), and had not previously been diagnosed with HIV infection. Intervention group healers provided counselling and offered point-of-care HIV tests to adult clients. Control group healers provided referral for HIV testing at nearby clinics. The primary outcome was the individual receipt of an HIV test within 90 days of study enrolment. Safety and adverse events were recorded and defined on the basis of prespecified criteria. This study is registered with ClinicalTrials.gov, NCT03718871.

FINDINGS

Between Aug 2, 2019, and Feb 7, 2020, 17 traditional healers were randomly assigned as clusters (nine to intervention and eight to control), with 500 clients of unknown HIV serostatus enrolled (250 per group). In the intervention group, 250 clients (100%) received an HIV test compared with 57 (23%) in the control group, a 77% (95% CI 73-82) increase in testing uptake, after adjusting for the effect of clustering (p<0·0001). Ten (4%) of 250 clients in the intervention group tested HIV positive, seven of whom self-reported linkage to HIV care. No new HIV cases were identified in the control group. Qualitative interviews revealed that HIV testing delivered by traditional healers was highly acceptable among both providers and clients. No safety or adverse events were reported.

INTERPRETATION

Delivery of point-of-care HIV tests by traditional healers to adults of unknown serostatus significantly increased rates of HIV testing in rural Uganda. Given the ubiquity of healers in Africa, this approach holds promise as a new pathway to provide community-based HIV testing, and could have a dramatic effect on uptake of HIV testing in sub-Saharan Africa.

FUNDING

US National Institute of Mental Health, National Institutes of Health.

Shortening "the Road" to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda

In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.