No abstract

There are estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 10% (200,000) working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens through the widespread practice of traditional ‘injections’, in which the healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied tissue with their hands. Healers who report exposure to patient blood have a 2.2-fold higher risk of being HIV-positive than those who do not report exposure. We propose a randomized controlled trial (61 healers in the intervention group and 61 healers in the control group) in Mpumalanga Province. Healers will receive personal protective equipment (PPE) education and training, general HIV prevention education, and three educational outreach visits at the healer’s place of practice to provide advice and support for PPE use and disposal. Healers in the control arm will be trained by health care providers, while participants in the intervention arm will receive training and outreach from a team of healers who were early adopters of PPE. We will evaluate intervention implementation using data from surveys, observation, and educational assessments. Implementation outcomes of interest include acceptability and feasibility of PPE use during clinical encounters and fidelity of PPE use during treatments that involve blood exposure. We will test our two intervention strategies to identify an optimal strategy for PPE education in a region with high HIV prevalence.

Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients’ desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.

Background: Implementing evidence-based interventions to improve adherence to antiretroviral therapy (ART) is essential to controlling the HIV epidemic in sub-Saharan Africa. Evidence-based community health worker interventions address barriers to medication retention by shifting the task from overburdened health facilities and emphasizing a more patient-centered approach in a comfortable location. Methods: We employed traditional healers to implement an evidence-based community health worker program for people living with HIV (PLHIV) in rural Mozambique. Participants received support services for 2 months after their first positive test. Healers were trained to provide counseling, HIV education, support with disclosure, and advocacy at the health unit. We interviewed 23 PLHIV and conducted focus groups with 19 traditional healers to explore implementation fidelity and identify unplanned adaptations made during the program. Results: Healers and PLHIV report counseling, HIV education sessions, and support with disclosure were largely delivered with fidelity. Due to the extreme poverty in the region, healers reported the need to add additional messages to support people who needed to take medication but had no food to mitigate the side effects. Patient advocacy at the health center proved difficult to implement. Negative attitudes towards PLHIV and traditional healers led to participants reporting extremely poor treatment by health care providers; the lack of respect made it difficult for healers to assist PLHIV with issues like long wait times, lost patient identification cards, or enduring medication side effects. Healers adopted directly observed therapy as an unplanned strategy to support non-adherent PLHIV.Conclusion: Given low levels of literacy and substantially different views on disease causation, healers delivered most core components of the intervention with fidelity. Healers attempted to implement the patient advocacy component but resistance from health care providers proved challenging. Future efforts will need to develop more effective strategies to overcome negative healer-clinician dynamic. Clinical Trials Registry: Name of the registry: Traditional Healers as Adherence Partners for Persons Living with HIV in Rural Mozambique (PLHIV). Trial registration number: NCT03076359. Date of registration: 3/6/2017, retrospectively registered. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03076359?cond=Hiv&cntry=MZ&draw=2&rank=7