Exploring the Space Between Healers: A Narrative Approach to Understanding the Relationship Between Traditional Healers and Biomedical Practitioners in Kwazulu-natal

Despite playing essential and parallel roles in the lives of patients, there exists a frictional, imbalanced relationship between traditional healers and Western doctors in South Africa. While national policy encourages a seamless system rooted in both Western science and indigenous knowledge, biomedical institutions are hesitant to accept traditional medical practices, which are based on less tangible and more spiritually-oriented elements. This research project turns to these two ideologically different entities to assess their perspectives on the roles of themselves and the other within the context of the South African health system. Responses from semi-structured interviews with seven health practitioners from KwaZulu-Natal – izangoma and doctors—were the primary sources used for the knowledge acquisition process. Given that I was the lens through which these participant stories were told, my own narrative and perspectives on the subject were interwoven throughout this report. Participant narratives suggest that there is no consensus within either biomedical or traditional health domains about perceptions of the other, save for the agreement that the South African health system is disconnected with both modalities working in parallel. However, there are five overarching points of engagement throughout the practitioner-patient healing process through which the modalities directly or indirectly interact with one another and form cross-disciplinary opinions. These serve as points of discussion in this report. Elements keeping the domains separated include miscommunication, suspicion, and adherence to cultural paradigms. However, doctors and traditional healers alike expressed varying degrees of interest in facilitating a working a working relationship, since the South African public healthcare system relies extensively on both domains of healing. These findings have reinforced my personal sentiments about the importance of medical pluralism in systems operating under two distinct healing paradigms

Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings

BackgroundHigh, sustained adherence is critical for achieving the individual and public health benefits of HIV antiretroviral therapy (ART). Electronic monitors provide detailed adherence information and can enable real-time interventions; however, their use to date has largely been confined to research. This pilot study (NCT03825952) sought to understand feasibility and acceptability a relatively low-cost version of this technology and associated interventions for routine ART delivery in sub-Saharan Africa.MethodsWe provided two ART clinics in rural, southwestern Uganda with electronic adherence monitors for data-informed counseling as well as optional SMS messages to clients and/or social supporters (daily or triggered by missed or delayed doses) and/or an alarm. Clinic and ART client experiences were observed for 3 months per client, including time and motion studies. Qualitative interviews among clients, clinicians, and healthcare administrators were informed by the Consolidated Framework for Implementation Research.ResultsFifty-one ART clients were enrolled; 57% were male and the median age was 34 years. Choice of associated intervention varied among participants. The median number of visits during follow-up was two per client. Counselors reviewed the adherence data with 90% of clients at least once; 67% reviewed data at all visits. Average adherence was 94%; four clients had adherence gaps >1 week. Acceptability was high; all but one client found the monitor "very useful” and all found SMS “very useful.” Clinic visits among clients with the intervention lasted 4 min longer on average than those in standard care. The monitors and daily SMS generally functioned well, although excess SMS were triggered, primarily due to cellular network delays. Overall, participants felt the technology improved adherence, clinic experiences, and clinician-client relationships. Few worried about stigma and privacy. Cost was a concern for implementation, particularly at scale.ConclusionWe successfully implemented a relatively low-cost electronic ART adherence monitor and associated interventions for routine care in rural Uganda. Feasibility and acceptability were generally high, and individuals were identified who could benefit from adherence support. Future work should involve longitudinal follow-up of diverse populations, clinical outcomes, and detailed cost-effectiveness analysis to help drive policy decisions around the uptake of this technology for routine clinical care.Clinical Trial Registrationidentifier: NCT03825952