Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique

Abstract

BackgroundSystematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system.MethodsAdaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients.ResultsTraditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted.ConclusionsSystematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers—an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.

Exploring adaptations and successful implementation of Traditional Healers as adherence partners for people living with HIV in rural Mozambique: A qualitative assessment

“…Healers were trained in identifying factors to bring to the attention of a health care provider and health care providers at the clinic were included throughout the creation of the program to increase acceptability towards the intervention. 42 Despite these efforts, sociocultural norms, including dismissive attitudes towards healers from health care providers, made advocacy di cult. Patients' interviews highlighted the challenges they encountered with disrespectful health care providers and poorly implemented clinical services.…”

“…The evidence-based intervention was originally designed for use by community health workers. The program was tailored for use by traditional healers using the ADAPT-ITT framework 54 in 2017, 43 and to allow for patients to select the healer of their choice. Traditional healers who were selected for the program were given two weeks of counseling and clinical training, six hours of contact time with local health care providers to facilitate relationship building, and a structural change at the health system that allowed healers to "jump the queue" with their patients.…”

“…41 Healers provide care that is socially acceptable, are wellrespected, and already have an existing relationship with people in their community. 21,42 Moreover, healers have been shown to in uence patients' attitudes and behaviors towards HIV care utilization. 22,43−45 Thus, our intervention aimed to leverage this established relationship by training healers as treatment partners to promote and facilitate ART uptake and maintenance.…”

Contributions des tradipraticiens de santé au traitement antirétroviral : Étude de cas à Nampula, Mozambique

“…21 La formation des TPS avec une procédure intégrée a déjà été recommandée par d’autres auteurs 22 : (1) les TPS collaborent avec les services de santé modernes, (2) des structures locales sont créées pour faciliter l’accès aux services de santé, (3) les TPS participent à des études et des recherches avec les professionnels de santé 23 , (4) le succès de cette démarche dépend d’une bonne identification des TPS avec connaissance et disponibilité, ainsi que de l’établissement d’une relation solide avec les professionnels, en manifestant de l’intérêt, du respect professionnel, et de la confiance; il faudra aussi assurer la garantie d’un prix juste en échange de leur temps et de leurs plantes, ainsi que les droits de propriété intellectuelle personnels et collectifs. 24 , 25 , 26 …”

Traditional health practitioners’ management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy

“…While some studies have indicated that THPs lack the biomedical skills and knowledge to diagnose and treat HIV [34,35,44], THPs who are trained in HIV/AIDS have been used to educate patients about the causes and consequences of HIV, and have provided physical and psychosocial community-based HIV care [19,45–47]. A quantitative study conducted among patients consulting THPs in the context of HIV/AIDS found that PLHIV did so owing to several complex health situations [28].…”