Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa

Abstract

ObjectivesThere are concerns that medical pluralism may delay patients’ progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade.MethodsWe conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism.ResultsMedical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds.ConclusionMedical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa.

“I have to provide for another life emotionally, physically and financially”: Understanding pregnancy, motherhood and the future aspirations of adolescent mothers in KwaZulu-Natal, South Africa

“…22,14,60 Various participants described healthcare providers as disapproving and rude and they also felt mistreated by them. A study by Govender et al 14 In South Africa, attention has recently focused on the concept of medical pluralism 70 which occurs when individuals utilise more than one medical system when seeking healthcare. 70 Such healthcare systems include traditional and faith-based systems.…”

“…A study by Govender et al 14 In South Africa, attention has recently focused on the concept of medical pluralism 70 which occurs when individuals utilise more than one medical system when seeking healthcare. 70 Such healthcare systems include traditional and faith-based systems. It was evident in this study that many participants had been consulting traditional healers and using or contemplated using traditional medication.…”

A conceptual model for pluralistic healthcare behavior: results from a qualitative study in southwestern Uganda

“…They "provide health care by using plant, animal and mineral substances, and other methods based on social, cultural, and religious practices" [12]. Prior work in medically pluralistic contexts shows that initial choice of therapeutic modality is driven by patients' perceived etiology of illness, and provider trustworthiness [13][14][15][16]. Patients may switch modalities in the setting of treatment "failure", when symptoms worsen or persist despite treatment [13,17].…”

“…Medical pluralism has been characterized as a central factor contributing to poor health outcomes. For example, researchers have shown that use of traditional medicine delays HIV testing and ART initiation [18], and interrupts HIV treatment [13], for people living with HIV (PLHIV) . In Mozambique, PLHIV initially seeking care from traditional healers experienced significantly longer delays to diagnosis compared with those who did not utilize healers; this delay exponentially increased with corresponding increases in the number of healers consulted prior to receiving HIV testing [18].…”

Re-Contextualizing Medical Pluralism in South Africa: a Research Schema for Indigenous Decision Making

“…Over the last 15 years, there has been a steady flow of peer reviewed reports relating to the unintended health-related consequences associated with medical pluralism in eastern and southern Africa. In the context of HIV, medical pluralism is primarily associated with delays in testing and treatment interruption (for one of many examples, see Moshabela et al 2017).…”