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

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

Background: Traditional health practitioners (THPs) have been identified as a key local resource in the fight against HIV/AIDS in South Africa. However, their approaches to the treatment of people living with HIV (PLHIV) have been met with skepticism by some biomedical practitioners amidst increasing access to antiretroviral treatment (ART). In light of this ambivalence, this study aims to document and identify treatment approaches of THPs to the management of illness among PLHIV in the current era of widespread access to ART. Methods: The study was conducted as part of a larger trial of treatment as prevention (TasP) in rural northern Kwa-Zulu Natal, intended to treat PLHIV regardless of CD4 count. Nine THPs were enrolled using purposive and snowballing techniques. Repeat group discussions, triangulated with community walks and photo-voice techniques were conducted. A thematic analysis approach was used to analyse the data. Results: Eight of the nine THPs had received training in biomedical aspects of HIV. THPs showed a multilayered decision-making process in managing illness among PLHIV, influenced by attributes and choices of the THPs. THPs assessed and managed illness among PLHIV based on THP training in HIV/AIDS, THP type, as well as knowledge and experience in the traditional healing practice. Management of illness depended on the patients’ report of their HIV status or willingness to test for HIV. Conclusions: THPs’ approaches to illness in PLHIV appear to be shifting in light of increasing exposure to HIV/AIDS-related information. Importantly, disclosure of HIV status plays a major role in THPs’ management of illness among PLHIV, as well as linkage to HIV testing and care for their patients. Therefore, THPs can potentially enhance further success of antiretroviral therapy for PLHIV when HIV status is known

“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

The role of traditional health practitioners in rural KwaZulu-Natal, South Africa: generic or mode specific?

Background Traditional health practitioners (THPs) play a vital role in the health care of the majority of the South African population and elsewhere on the African continent. However, many studies have challenged the role of THPs in health care. Concerns raised in the literature include the rationale, safety and effectiveness of traditional health practices and methods, as well as what informs them. This paper explores the processes followed in becoming a traditional healer and how these processes are related to THP roles. Methods A qualitative research design was adopted, using four repeat group discussions with nine THPs, as part of a larger qualitative study conducted within the HIV Treatment as Prevention trial in rural South Africa. THPs were sampled through the local THP association and snowballing techniques. Data collection approaches included photo-voice and community walks. The role identity theory and content analysis were used to explore the data following transcription and translation. Results In the context of rural Northern KwaZulu-Natal, three types of THPs were identified: 1) Isangoma (diviner); 2) Inyanga (one who focuses on traditional medical remedies) and 3) Umthandazi (faith healer). Findings revealed that THPs are called by ancestors to become healers and/or go through an intensive process of learning about traditional medicines including plant, animal or mineral substances to provide health care. Some THPs identified themselves primarily as one type of healer, while most occupied multiple healing categories, that is, they practiced across different healing types. Our study also demonstrates that THPs fulfil roles that are not specific to the type of healer they are, these include services that go beyond the uses of herbs for physical illnesses or divination. Conclusions THPs serve roles which include, but are not limited to, being custodians of traditional African religion and customs, educators about culture, counsellors, mediators and spiritual protectors. THPs’ mode specific roles are influenced by the processes by which they become healers. However, whichever type of healer they identified as, most THPs used similar, generic methods and practices to focus on the physical, spiritual, cultural, psychological, emotional and social elements of illness

The size, characteristics and partnership networks of the health-related non-profit sector in three regions of South Africa: implications of changing primary health care policy for community-based care

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Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross sectional study

Background: In low-resource settings, patients’ use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. Methods: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant’s clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. Results: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. Conclusion: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients’ dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.Web of Scienc

Understanding patterns of health system utilisation among people living with HIV/Aids attending rural HIV services

Following the successful introduction of antiretroviral therapy (ART) in resource-limited settings, we have observed an unprecedented explosion in the expansion of ART programs throughout sub-Saharan Africa, resulting in a 13-fold increase in coverage since 2004. In spite of these achievements, uptake of ART remains low. The gap in treatment coverage is approximately 50% of those who need ART in South Africa, while the country boasts the largest ART program worldwide. Rural areas are particularly prone to lower ART coverage rates, largely a result of existing health care inequities. The ART coverage gap will widen given the recent introduction of new treatment guidelines, which allows for ART commencement at CD4 350 cells/mm3. Furthermore, approximately one-third of ART patients are lost to follow up after two years of treatment initiation in sub-Saharan Africa. This study explores factors associated with ART access and utilisation in a rural area, in order to reduce the gap in knowledge on patient and health system factors. Unaddressed, these factors may continue to hinder adoption of rigorous interventions to improve ART uptake and retention. This research employs the A-Framework to conceptualize access to health care, where dimensions of access include availability (physical access), affordability (financial access), and acceptability (cultural access). A data triangulation approach was adopted as very little was known on the utilization patterns of health care by HIV/AIDS patients. Quantitative research (2008-2010) employed a four-site rural-urban comparative analysis of 1266 participants, and was part of a 5-year project Researching Equity and Access to Health care (REACH).This was complemented by a more in-depth qualitative assessment (2006-2007) that followed the treatment experience of 32 patients before and after ART initiation in the rural Bushbuckridge site. We found plural utilisation of health care to be a cross-cutting theme throughout this thesis. While the movement of patients between providers at various levels within the traditional and formal health sector may be a sign of agency, it may also result in excessive health costs that threaten the livelihoods of individuals and their households. We discuss a number of strategies to improve ART initiation and adherence including the need to incorporate metrics for pluralism into routine assessments; the importance of decentralized, humane and high quality care and support services; support for efforts to enhance patient self-efficacy through education, awareness and social support interventions; the incorporation and regulation of traditional healers into the formal system; risk protection mechanisms that reduce financial barriers and consequences of HIV care including grants, subsidies and National Health Insurance, and support for wider efforts to reduce urban-rural inequalities

Improving South African medical curricula related to traditional health systems

Background. Increased co-ordination and co-operation between traditional and biomedical health systems in South Africa (SA) is a national priority. To improve care, practitioners in both systems must learn to recognise the value of their parallel counterparts, and such lessons should begin in medical school. However, there is little research regarding the way in which SA’s medical students are taught to interact with the traditional medicine (TM) system. Objectives. To explore how SA medical students perceive their curriculum as it relates to the traditional health system and to describe their suggestions for improvement. Methods. We conducted individual in-depth interviews and focus group discussions with 43 final-year medical students across 3 SA medical schools. We applied thematic analysis to improve our understanding of student-reported experiences with TM in their medical school curricula. Results. All 3 medical schools rely heavily on hidden curricula to educate students on the SA traditional health system. These hidden curricula are largely negative and learnt primarily from witnessing faculty-client interactions involving TM use. Students across the institutions agree that this problematic deficit in formal teaching contributes to their incompetence in treating patients who use TM. Their suggestions for improvement focused largely around 3 themes: (i) understanding the fundamentals of the traditional health system; (ii) empathising with patient use of TM; and (iii) promoting broader structural integration of the two health systems. Conclusion. Medical students in SA recognise the value of increased exposure to and education surrounding the traditional health system. Future curricular interventions should focus on increasing formal teaching of TM, directly addressing the hidden curriculum related to the topic, and instituting policies and initiatives that improve integration of the SA biomedical and traditional healing paradigms on a structural level

The hidden harm of home-based care: Pulmonary tuberculosis symptoms among children providing home medical care to HIV/AIDS-affected adults in South Africa

Millions of children in sub-Saharan Africa undertake personal and medical care for family members who are unwell with AIDS. To date, no research has investigated whether such care provision places children at heightened risk for pulmonary tuberculosis. This study aimed to address this gap by identifying risk factors for paediatric pulmonary tuberculosis symptomatology. In 2009–2011, 6002 children aged 10–17 years were surveyed using door-to-door household sampling of census enumeration areas. These were randomly sampled from six urban and rural sites with over 30% HIV prevalence, within South Africa's three highest tuberculosis-burden provinces. Validated scales and clinical tuberculosis symptom checklists were modelled in multivariate logistic regressions, controlling for socio-demographic co-factors.Findings showed that, among children, severe pulmonary tuberculosis symptomatology was predicted by primary caregiver HIV/AIDS-illness [odds ratio (OR): 1.63, confidence interval (CI): 1.23–2.15, p<0.001], and AIDS-orphanhood (OR: 1.44, CI: 1.04–2.00, p<0.029). Three-fold increases in severe tuberculosis symptoms were predicted by the child's exposure to body fluids through providing personal or medical care to an ill adult (OR: 3.12, CI: 1.96–4.95, p<0.001). Symptoms were also predicted by socio-economic factors of food insecurity (OR: 1.52, CI: 1.15–2.02, p<0.003) and household overcrowding (OR: 1.35, CI: 1.06–1.72, p<0.017). Percentage probability of severe tuberculosis symptoms rose from 1.4% amongst least-exposed children, to 18.1% amongst those exposed to all above-stated risk factors, independent of biological relationship of primary caregiver-child and other socio-demographics. Amongst symptomatic children, 75% had never been tested for tuberculosis. These findings identify the risk of tuberculosis among children providing home medical care to their unwell caregivers, and suggest that there are gaps in the health system to screen and detect these cases of paediatric tuberculosis. There is a need for effective interventions to reduce childhood risk, as well as further support for community-based contact-tracing, tuberculosis screening and anti-tuberculosis treatment for children caring for ill adults in contexts with a high burden of HIV and tuberculosis