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

Abstract

BackgroundImplementing 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.MethodsWe 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.ResultsHealers 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.ConclusionGiven 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 RegistryName 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