IntroductionDelayed uptake of clinical services impedes favorable clinical outcomes in Mozambique. Care is delayed among patients who initiate care with traditional healers; patients with conditions like human immunodeficiency virus (HIV) or tuberculosis are rarely referred to the health system in a timely fashion.MethodsWe conducted a pre-post educational intervention with traditional healers, assessing healer referral rates and HIV knowledge in three rural districts in Zambézia Province.ResultsThe median monthly referral rate prior to the intervention was 0.25 patients (interquartile range [IQR]: 0–0.54) compared with a post-intervention rate of 0.34 patients (IQR: 0–0.71), a 35% increase (p = 0.046). A median HIV knowledge score of 67% (IQR: 59–78) was noted 4-months pre-intervention and a median score of 81% (IQR: 74–89) was recorded 2½ months post-intervention (p<0.001). One hundred and eleven healers referred 127 adults, 36 pregnant women, and 188 children to health facilities. Referred patients were most likely to be diagnosed with bronchopneumonia (20% adults; 13% children) and/or malaria (15% adults; 37% children). Of 315 non-pregnant persons referred, 3.5% were tested for HIV and 2.5% were tested for tuberculosis.DiscussionWe engaged traditional healers with some success; referral rates were low, but increased post-intervention. Once seen in the clinics, patients were rarely tested for HIV or tuberculosis, though symptoms suggested screening was indicated. We found increased referral rates through an inexpensive intervention with traditional healers, a viable, cost-effective method of directing patients to health facilities. However, quality improvement within the clinics is necessary before a substantial impact can be expected.

Objective Delays in HIV diagnosis and initiation of antiretroviral therapy (ART) are common even among symptomatic individuals in Africa. We hypothesized that ART delays might be more common if traditional healers were the first practitioners consulted. Design Cross-sectional study Methods We interviewed 530 newly diagnosed HIV-infected adults (≥18 years of age) who were clinically symptomatic at the time of HIV testing in two rural districts in Zambézia Province, Mozambique. We ascertained their prior health care seeking behavior, duration of their symptoms, CD4+ cell counts at the time of entry into care, and treatment provided by traditional healer(s). Results Of 517 patients (97.5%) with complete histories, 62% sought care from a healer before presenting to the local health facility. The median time to first health facility visit from first relevant symptom was 2 months (interquartile range [IQR]:1–4.5) for persons who had not visited a healer, 3 months [IQR:2–6] for persons visiting one healer, and 9 months [IQR: 5–12] for persons visiting >1 healer (p<0.001). Healers diagnosed 56% of patients with a social or ancestral curse and treated 66% with subcutaneous herbal remedies. A non-significant trend towards lower CD4+ cells for persons who had seen multiple healers was noted. Conclusion Seeking initial care from healers was associated with delays in HIV testing among symptomatic HIV-seropositive persons. We had no CD4 evidence that sicker patients bypass traditional healers, a potential inferential bias. Engaging traditional healers in a therapeutic alliance may facilitate the earlier diagnosis of HIV/AIDS.

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.

“Medical pluralism” is the use of multiple health systems and is common among people living with HIV/AIDS in sub Saharan Africa. Healers and traditional birth attendants (TBAs) often are a patient's first and/or preferred line of treatment; this often results in delayed, interrupted, or abandoned diagnosis and therapy. Literature from the study of medical pluralism suggests that HIV care and treatment programs are infrequently and inconsistently engaging healers around the world. Mistrust and misunderstanding among patients, clinical providers, and traditional practitioners make the development of effective partnerships difficult, particularly regarding early HIV diagnosis and antiretroviral therapy. We provide recommendations for the development of successful collaboration health workforce efforts based on both published articles and case studies from our work in rural Mozambique.

Objective Healers provide support for acute and chronic illnesses in rural Mozambique, such as socially acceptable traditional “vaccinations” (subcutaneous cuts in the skin to rub herbs directly into the bloody lesion). We aimed to document the frequency of blood exposure by traditional practitioners in Mozambique. Methods We conducted surveys with a simple random sample of 236 traditional healers in Zambézia province. Chi-square and Wilcoxon rank sum tests were used to compare “injection” behaviors across districts. Results Healers treated a median of 8 patients in the past month (IQR: 4–15). 75% conducted “injections”. These healers “injected” a median of 4 patients (IQR: 1–8), used a new razor a median of 3 times (IQR: 1–8), and almost never used gloves. Lifetime blood exposures among those who provided “injections” during treatments were estimated to be 1,758 over a healer’s career. Conclusion The majority of healers is exposed repeatedly to patient blood. Given the high prevalence of HIV, hepatitis B and C virus, and other blood-borne agents, specific healer practices are an occupational hazard and reuse of razors is risky for their clients.