Medical pluralism predicts non-ART use among parents in need of ART: a community survey in KwaZulu-Natal, South Africa

Reasons for using traditional and complementary care by people living with HIV on antiretroviral therapy and association with interrupted care: a mixed methods study in Eswatini

The use of traditional, complementary, and alternative medicine (TCAM) can lead to delays and interruptions in the HIV continuum of care. This study explores reasons for TCAM use in people living with HIV on antiretroviral therapy (ART) in Eswatini and compares interrupted care between different types of TCAM users. Data were collected using surveys in the MaxART study (a test-and-treat trial) between 2014 and 2017 to assess the exposure, namely visiting a TCAM provider. Additionally, visit dates were retrieved from clinic records to assess the outcome, interrupted care. Open-ended questions were analysed with qualitative content analysis (n = 602) and closed questions with bivariable and multivariable analysis (n = 202). Out of 202 participants, 145 (72%) never used TCAM, 40 (20%) ever used, and 17 (8%) is currently using TCAM (diviners, herbalists, and religious healers). No differences in interrupted care were found comparing never (reference category), past (Odds Ratio: 1.31, 95% confidence interval: 0.63-2.72), and current users (1.34, 0.47-3.77), while adjusting for gender, time since HIV diagnosis, and time on ART. Contextual factors affecting the choice for TCAM were the influence of family, advice from the health facility, and religious beliefs. Individual factors include trust in biomedical care, type of illness, no need for additional care, and practical reasons such as financial means. In conclusion, individual and contextual factors influence the choice for TCAM. Interrupted care does not differ between never, past, and current users.

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.

"Sex is supposed to be naturally more pleasurable": Healers as providers of holistic sexual and reproductive healthcare in Uganda

Global health researchers often approach Traditional, Complementary, and Alternative Medicine (TCAM) from a health efficacy perspective, asking whether the presence of plural medical systems helps or hinders the uptake of biomedicine. Medical anthropologists, by contrast, typically emphasize how plural medical systems encourage us to rethink health ontologies-that is, who and what comes to constitute the experience of health and illness, and through which practices. Building on both approaches, we explore the role of "healers," a term we use to encompass several different kinds of TCAM providers, in the sexual and reproductive healthcare (SRH) of young people from southcentral Uganda, a region well known as an HIV/AIDS epicenter. Drawing from ethnographic data, we describe three reasons that young people seek SRH from healers. First, they associate stigma, scarcity, and high costs with biomedical SRH. Second, healers work across biomedical and non-biomedical therapeutic divides, prescribing herbs for sexually transmitted infections while simultaneously referring clients to biomedical HIV clinics. Third, healers provide counseling focused on pleasurable and economically-motivated sex. Because these therapies diverge from international and national HIV prevention messaging that frames non-marital and transactional sex in terms of danger and disease, healers' holistic approach to SRH may help to reconstitute the meaning, practice, and experience of "sexual health" in contemporary Uganda. This has important implications for improving global SRH programs and for understanding the continued appeal of TCAM more generally.

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.

The Impact of Immediate Initiation of Antiretroviral Therapy on Patients' Healthcare Expenditures: A Stepped-Wedge Randomized Trial in Eswatini

Immediate initiation of antiretroviral therapy (ART) for all people living with HIV has important health benefits but implications for the economic aspects of patients' lives are still largely unknown. This stepped-wedge cluster-randomized controlled trial aimed to determine the causal impact of immediate ART initiation on patients’ healthcare expenditures in Eswatini. Fourteen healthcare facilities were randomly assigned to transition at one of seven time points from the standard of care (ART eligibility below a CD4 count threshold) to the immediate ART for all intervention (EAAA). 2261 patients living with HIV were interviewed over the study period to capture their past-year out-of-pocket healthcare expenditures. In mixed-effects regression models, we found a 49% decrease (RR 0.51, 95% CI 0.36, 0.72, p < 0.001) in past-year total healthcare expenditures in the EAAA group compared to the standard of care, and a 98% (RR 0.02, 95% CI 0.00, 0.02, p < 0.001) decrease in spending on private and traditional healthcare. Despite a higher frequency of HIV care visits for newly initiated ART patients, immediate ART initiation appears to have lowered patients’ healthcare expenditures because they sought less care from alternative healthcare providers. This study adds an important economic argument to the World Health Organization’s recommendation to abolish CD4-count-based eligibility thresholds for ART.

Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa

Introduction

Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components.

Methods

This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members’ perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants’ narratives from both individual interviews and focus group discussions.

Results

Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff).

Discussion

We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.

Conceptual model for pluralistic healthcare behaviour: results from a qualitative study in southwestern Uganda

INTRODUCTION

Medical pluralism, or concurrent utilisation of multiple therapeutic modalities, is common in various international contexts, and has been characterised as a factor contributing to poor health outcomes in low-resource settings. Traditional healers are ubiquitous providers in most regions, including the study site of southwestern Uganda. Where both informal and formal healthcare services are both available, patients do not engage with both options equally. It is not well understood why patients choose to engage with one healthcare modality over the other. The goal of this study was to explain therapeutic itineraries and create a conceptual framework of pluralistic health behaviour.

METHODS

In-depth interviews were conducted from September 2017 to February 2018 with patients seeking care at traditional healers (n=30) and at an outpatient medicine clinic (n=30) in Mbarara, Uganda; the study is nested within a longitudinal project examining HIV testing engagement among traditional healer-using communities. Inclusion criteria included age ≥18 years, and ability to provide informed consent. Participants were recruited from practices representing the range of healer specialties. Following an inductive approach, interview transcripts were reviewed and coded to identify conceptual categories explaining healthcare utilisation.

RESULTS

We identified three broad categories relevant to healthcare utilisation: (1) traditional healers treat patients with 'care'; (2) biomedicine uses 'modern' technologies and (3) peer 'testimony' influences healthcare engagement. These categories describe variables at the healthcare provider, healthcare system and peer levels that interrelate to motivate individual engagement in pluralistic health resources.

CONCLUSIONS

Patients perceive clear advantages and disadvantages to biomedical and traditional care in medically pluralistic settings. We identified factors at the healthcare provider, healthcare system and peer levels which influence patients' therapeutic itineraries. Our findings provide a basis to improve health outcomes in medically pluralistic settings, and underscore the importance of recognising traditional healers as important stakeholders in community health.

Improved adherence to anti-retroviral therapy among traditionalists: reflections from rural South Africa

BACKGROUND

Medical pluralism is common place in sub-Saharan Africa. The South African pluralistic health care environment is varied and includes traditionalist beliefs relating to the efficacy of African traditional medicine. Prior research indicates that traditionalism is associated with delays in testing for HIV and treatment interruption. Despite numerous reports about this in South Africa, there is a paucity of documented strategies to counter this trend.

OBJECTIVES

To develop a strategy to reduce the impact of non-adherence to antiretroviral therapy among traditionalists in Waterberg district, Limpopo Province, South Africa.

METHODS

Qualitative information was elicited from five face-to-face, dual moderated, semi-structured homogenous group discussions. The groups comprised of 50 purposively selected, rurally based, mixed gender traditionalists living with HIV. Grounded theory was applied to analyse qualitative findings that emerged from the group discussions.

FINDINGS

Self-reported increases in adherence to anti-retroviral therapy and a reduction in internalised stigma by the respondents. Both are attributed by the respondents to disease causation differentiation from a traditional explanation to an allopathic explanation.

CONCLUSION

A nascent strategy has been developed which is contributing to improved adherence and a reduction in internalised stigma among traditionalists living with HIV in Waterberg district, South Africa.

An evaluation of the innovative potentials of a HIV pilot exploring medical pluralism in rural South Africa

This article reflects on an internal evaluation undertaken to estimate the potentials of a community-university pilot project to be developed into a bonafide innovation that can be applied at scale. The focus of the community-university partnership has been to reduce the unintended consequences of medical pluralism on the HIV and AIDS epidemic in Waterberg district, Limpopo Province, South Africa. Despite promising outputs from the partnership - including an increase in adherence to antiretroviral therapy and a reduction in stigma among traditionalists living with HIV - the partnership wished to establish whether further funding should be applied for to take the pilot from its current prototype status to a more established innovation. In order to evaluate the innovative potentials of the pilot, the opportunity vacuum model of innovation was adapted and applied. The findings indicate that (1) the application of the opportunity vacuum model of innovation to evaluate the potentials of the pilot to be developed into a bonafide innovation was fit for purpose and (2) the pilot contains the key ingredients that are associated with innovations in the making. The discussion reflects on the social potentials of the pilot to contribute to 90-90-90 from a global, national and local perspective. The reflection concludes by suggesting that the opportunity vacuum model of innovation is a versatile heuristic that could be applied in other contexts and the community-university pilot represents a nascent innovation which has sufficient potential to justify further development.

Traditional health practitioners and sustainable development: a case study in South Africa

OBJECTIVES

To highlight legal and regulatory advances relating to South African traditional health practitioners (THPs) over the past 10 years and discuss the implications for the translation of health policies into guidelines for sustainable practice supporting public health.

STUDY DESIGN

This is a rapid, structured literature review.

METHODS

A rapid, structured literature review was undertaken to identify relevant studies related to South African THPs involving a search of peer-reviewed literature from three databases and a grey literature internet search. The identified citations were screened, critically appraised, and narratively synthesized.

RESULTS

Efforts to regulate THPs in South Africa are underway; however, the lack of a regulatory framework for traditional practices is hampering progress. Several efforts to collaborate with THPs have been made over the years, many of which were not systematically evaluated and not based on principles of mutual respect. Existing collaborative examples need to be further supported by cost-effective evidence to suit the South African public health budget. Furthermore, small collaborative research efforts do not take into consideration the scale up of interventions.

CONCLUSIONS

THPs in South Africa represent an important healthcare resource. However, the current policy environment does not support indicators to describe, monitor, and/or evaluate the role of THPs in the healthcare system.

Navigating Multiple Sources of Healing in the Context of HIV/AIDS and Wide Availability of Antiretroviral Treatment: A Qualitative Study of Community Participants' Perceptions and Experiences in Rural South Africa

BACKGROUND

South Africa introduced the world's largest antiretroviral treatment (ART) program in 2004 and since 2016 the Department of Health implemented a universal Treatment as Prevention (TasP) strategy. However, some studies have shown that increasing the availability of ART is insufficient for the comprehensive treatment of HIV, since many people still use traditional health practitioners (THPs) to avoid being identified as HIV positive, and for reasons unrelated to HIV/AIDS. This qualitative study explored the factors influencing how both HIV-negative and HIV-positive people choose amongst multiple sources of healing and how they engage with them, in the context of HIV/AIDS and wide availability of ART.

METHODS

Data were collected as part of a larger TasP trial at the Africa Health Research Institute, KwaZulu-Natal. Repeat in-depth individual interviews were conducted with 10 participants. Repeat group discussions were conducted with 42 participants. Group discussion data were triangulated using community walks and photo-voice techniques to give more insight into the perceptions of community members. All data were collected over 18 months. Thematic analysis was used to analyze participants' narratives from both individual interviews and group discussions.

FINDINGS

In the context of HIV/AIDS and wide availability of ART, use of biomedical and traditional healing systems seemed to be common in this locality. People used THPs to meet family expectations, particularly those of authoritative heads of households such as parents or grandparents. Most participants believed that THPs could address specific types of illnesses, especially those understood to be spiritually caused and which could not be addressed or cured by biomedical practitioners. However, it was not easy for participants to separate some spiritually caused illnesses from biological illnesses in the context of HIV/AIDS. These data demonstrate that in this context, the use of THPs continues regardless of the wide availability of ART. To meet the health care needs of those patients requiring a health care system which combines biomedical and traditional approaches, collaboration and integration of biomedical and traditional health care should be considered.

Theorizing the complexity of HIV disclosure in vulnerable populations: a grounded theory study

Background

HIV disclosure is an important step in delivering the right care to people. However, many people with an HIV positive status choose not to disclose. This considerably complicates the delivery of adequate health care.

Methods

We conducted a grounded theory study to develop a theoretical model explaining how local contexts impact on HIV disclosure and what the mechanisms are that determine whether people choose to disclose or not. We conducted in-depth interviews among 23 people living with HIV, 8 health workers and 5 family and community members, and 1 community development worker in Achham, Nepal. Data were analysed using constant-comparative method, performing three levels of open, axial, and selective coding.

Results

Our theoretical model illustrates how two dominant systems to control HIV, namely a community self-coping and a public health system, independently or jointly, shape contexts, mechanisms and outcomes for HIV disclosure.

Conclusion

This theoretical model can be used in understanding processes of HIV disclosure in a community where HIV is concentrated in vulnerable populations and is highly stigmatized, and in determining how public health approaches would lead to reduced stigma levels and increased HIV disclosure rates.

Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa

OBJECTIVES

There are concerns that medical pluralism may delay patients' progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade.

METHODS

We conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism.

RESULTS

Medical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds.

CONCLUSION

Medical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa.

"It is better to die": experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)

The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a "test and treat" approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves.