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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: AIDS Care. 2020 Aug 17;33(10):1316–1320. doi: 10.1080/09540121.2020.1808568

Throwing the bones to diagnose HIV: Views of rural South African traditional healers on undertaking HIV counselling and testing

Carolyn M Audet 1,2, Elise M Clemens 1,2, Sizzy Ngobeni 1,2, Mevian Mkansi 1,2, Daniel E Sack 1,2, Ryan G Wagner 1,2
PMCID: PMC7887123  NIHMSID: NIHMS1620945  PMID: 32799661

Abstract

In 2018, nearly 800,000 HIV positive individuals in South Africa were unaware of their status. Traditional healers see patients who avoid health clinics, including those who refuse HIV testing. This manuscript details the results of a qualitative study to understand traditional healer perspectives on performing healer-initiated HIV counseling and testing HIV in rural South Africa. We conducted 30 structured in-depth, in-person interviews between April and June 2019 to elicit traditional healer attitudes towards partnering with local health services to perform HIV counseling and testing with their patients. Healers reported that while some patients are open about their HIV status, others lie about it due to stigma around the disease. This creates challenges with concurrent treatment, which healers believe leads to allopathic and/or traditional medication treatment failure. Most healers expressed both an interest and a willingness to perform HIV counseling and testing. Healers felt that by performing testing in the community, it would overcome issues related to HIV stigma, as well as a lack of confidentiality and trust with health care workers at the clinic. Trained traditional healers may be able to bridge the testing gap between “non-testers” and the allopathic health system, essentially “opening” thousands of new testing locations with little financial investment.

Introduction

In 2019, 7.97 million South Africans (22.7% of adults) were living with HIV (Darbes et al., 2019). In 2018, it was estimated that 90% of HIV-positive South Africans were aware of their status, suggesting nearly 800,000 HIV positive individuals are unaware of their status (UNAIDS, 2019). In South Africa, a substantial proportion of the population do not test regularly (Human Sciences Research Council (HSRC), 2018). Innovative campaigns aimed at testing individuals who are less likely to visit health facilities have yielded successes (Bampoe, Clancy, Sugarman, Liden, & Lansang, 2012; Doherty et al., 2016; Hershow et al., 2015; Magasana et al., 2016) (Martínez Pérez et al., 2016), still miss 12–20% of the population (Johnson et al., 2017; Smith, Wallace, & Bekker, 2016; Suthar et al., 2013; van Rooyen et al., 2013). Community members with low socioeconomic status,(Pitpitan et al., 2012; Psaros et al., 2018; Wabiri & Taffa, 2013) those who are male,(Treves-Kagan et al., 2017; Young et al., 2010) younger,(Ogunmefun, Gilbert, & Schatz, 2011; Ritchwood et al., 2019) are immigrants in South Africa,(Mee et al., 2016) do not trust allopathic medicine,(Ondenge et al., 2017) and people with higher anticipated HIV stigma(Treves-Kagan et al., 2017) are more likely to seek care from a traditional healer and have lower odds of, or delayed, HIV testing (C. M. Audet et al., 2014; Moshabela et al., 2016; Wanyenze et al., 2011).

Traditional healers are respected members of their communities and play integral roles as informal referral agents to the South African health system(C. M. Audet, Ngobeni, Graves, & Wagner, 2017; C. M. Audet, Ngobeni, & Wagner, 2017; C. M. Audet et al., 2013). Healers are willing to undergo HIV testing in the community. A recent study showed healer HIV prevalence in the region to be 30% (Carolyn M. Audet et al., 2018). Given the level of trust in the community and the numbers of healers (more than 200,000)(Government Gazette, 2008; Richter, 2003), we are interested in creating healer-initiated counseling and testing services and linkage to care (Burnett et al., 1999; Fleming, 1995; Kayombo et al., 2007; King, 2000; Liverpool et al., 2004; Madamombe, 2006; PlusNews, 2010). This manuscript details the results of a qualitative study to understand traditional healer perspectives on performing healer-initiated HIV counseling and testing HIV in rural Mpumalanga, South Africa.

Methods

Study Population

This study was conducted in the rural Agincourt sub-district of Mpumalanga province, northeastern South Africa. The region has an HIV prevalence of 19% (Gomez-Olive et al., 2013). Participants in this qualitative study were all traditional healers who were members of the Kukula Organization. In 2018, we conducted HIV counseling and testing with a simple random selection of 221 traditional healers who were part of this group (out of 300 eligible).(Carolyn M. Audet et al., 2018) We identified the quartile with our most active healers– and used a random number generator to recruit participants for this study. Each healer that we successfully contacted (30 of 54; 56%) was interviewed (100% acceptance rate). All healers were over the age of 18.

Ethics, Consent and Permissions

This study was approved by the Vanderbilt Institutional Review Board (IRB #190395), the University of Witwatersrand Human Research Ethics Committee (Protocol #M160447), and the Mpumalanga Department of Health’s Research Ethics Committee. All participants provided written informed consent.

Data Collection

We conducted 30 structured in-depth, in-person interviews between April and June 2019. A trained qualitative fieldworker conducted interviews in xiTsonga using a guide developed to elicit traditional healer attitudes towards partnering with local health services to perform HIV counseling and testing with their patients. Interviews were audio-recorded, then transcribed and translated to English from xiTsonga.

Data Analysis

All interviews were transcribed within two weeks of the interview from xiTsonga and translated into English by a qualified fieldworker. English transcripts were reviewed, and thematic analysis was conducted by two researchers (EMC and CMA) using MAXQDA 12© software. Initial codes were developed deductively, guided by previous research about healer engagement in the health system and challenges implementing community-based HIV testing and counseling. In vivo (inductive) codes were generated when unique benefits or challenges to implementing HIV counseling and testing were identified. EMC and CMA met to develop, define, and compare application of codes to the transcribed interviews.

Results

Traditional Healer Demographics

The traditional healers interviewed were 70% female, had a median age of 52 (Interquartile Range [IQR] 45–59), and had low levels of formal education (median: 5 years, IQR: 0–8). Healers reported a median of 17 years in practice (IQR 7.3–22.8) and practiced in 13 villages.

Current Referral Systems

Twenty-nine healers reported that their current practice was to either refer or accompany patients they suspect of being HIV positive to the clinic for counseling and testing before initiating their own treatment. One healer noted that he refers patients “so that they can get to know their status and start the treatment while there is time.” (male 51). Those who referred patients for HIV testing used a combination of visual HIV-associated symptoms and traditional ritual when deciding who to refer. Twelve healers (40%) reported using a ritualized screening method known as throwing the bones to determine who they should refer to clinic.

…the bones reveal that the patient has HIV…. And when a patient is like that, they have to go to the clinic or the hospital to do the HIV tests because they shouldn’t believe only in traditional treatment.

(male, 76)

Traditional healers also reported wanting to know their patient’s HIV status to support medication adherence. “If the tests show that the patient is HIV positive, I need to know as a healer so that I can also support them and be able to remind them when to take their medications.” (female, 39)

Healer-Initiated Counseling and Testing

Twenty-seven healers (90%) expressed interest and a willingness to perform HIV counseling and testing. Healers felt that by performing testing in the community, it would overcome issues related to HIV stigma, as well as a lack of confidentiality and trust with health care workers at the clinic. Several healers referenced the fear that people had of going to the health facility. One healer said he was interested in providing testing “because there are many people who are dying because they are scared to go to the clinic and do the tests; it will be much easier for my patients.” (male, 47)

Healers believed many of their patients would accept healer-initiated counseling and testing because of the mutual trust between patient and traditional healer. One healer explained: Patients will like access to testing at the home of a healer “because they know that I can keep their health [HIV status] very confidential.” (female, 67) Another noted that people would prefer healer-initiated testing because:

some people are scared of going to the clinic and they don’t want to be seen by other people that they are doing the HIV tests, they want it to be confidential. There are some patients that come to me at night and I can be able to do the HIV tests and give them their results.

(female, 52)

Three healers were less convinced that their patients would appreciate the offer of an HIV test from their traditional healer. One healer stated:

No, I can’t do it because many patients don’t like to do the HIV tests…Some patients would run away while I am doing the counseling before the actual tests.”

(female, 36)

The other two other healers expressed hesitation due to concerns about their literacy and ability to learn the required skills. “Maybe I would do it if I have the kits, but I also think that one should be literate to do that because you cannot read the results if you have never been to school. For instance, I cannot even write my name; so how about the tests?”(female, 60)

Discussion

Trained traditional healers may be able to bridge the testing gap between “non-testers” and the allopathic health system. Non-testers may prefer a culturally concordant (Cuevas, O’Brien, & Saha, 2017; Pachter, 1994; Spokane, Inman, Weatherford, Davidson, & Straw, 2011) provider (traditional healer) to both vouch for and deliver the HIV test; high HIV prevalence among healers in the region give them the empathy and context to help their patients(Carolyn M. Audet et al., 2018), and create a bridge to the allopathic health facility, providing a metaphorical “safe space” for the patient while they transition to HIV care.

Traditional healers were motivated for three reasons: (1) They spend substantial time bringing patients to the health system of testing; providing testing at home would save time. (2) Better patient health outcomes are strongly correlated with perceived quality of traditional healer care (C.M. Audet, Ngobeni, & Wagner, 2016); (3) healer-initiated testing would allow healers to gauge which types (if any) traditional medicines they can provide. Healer-initiated counseling and testing would allow the health system to “open” thousands of new testing locations with little financial investment. There are 200,000 traditional healers in South Africa alone. Traditional healer HIV counseling and testing locations would greatly increase the number of testing facilities available (Jobson, 2015).

This study may not be generalizable to urban communities, where healers have less frequently partnered with the health system. Additionally, we interviewed those who were seeing the largest number of patients and conducting large numbers of traditional injections; healers with fewer patients may feel differently. While we may have inadvertently selected traditional healers particularly interested in testing their patients for HIV, we believe that training even a small cohort of healers would provide an additional source of testing for those who refuse to test with an allopathic provider.

Conclusion

Traditional healers are a potentially underutilized partner in the collective effort to reduce the spread of HIV in South Africa through timely HIV counselling and testing. To best integrate traditional healers, who are willing and eager to interface with the allopathic healthcare system to combat HIV, policy makers will need to consider how to effectively train and link traditional healers to the health system to ensure the provision of quality HIV counseling and testing.

References

  1. Audet CM, Blevins M, Rosenberg C, Farnsworth S, Salato J, Fernandez J, & Vermund SH (2014). Symptomatic HIV-positive persons in rural Mozambique who first consult a traditional healer have delays in HIV testing: a cross-sectional study. J Acquir Immune Defic Syndr, 66(4), e80–86. doi: 10.1097/QAI.0000000000000194 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Audet CM, Ngobeni S, Graves E, & Wagner RG (2017). Mixed methods inquiry into traditional healers’ treatment of mental, neurological and substance abuse disorders in rural South Africa. PLoS One, 12(12), e0188433. doi: 10.1371/journal.pone.0188433 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Audet CM, Ngobeni S, Mkansi M, Wafawanaka F, Aliyu MH, Kahn K, & Wagner R (2018). Occupational hazards of traditional healers in rural South Africa: Bloodborne pathogen exposures and risk of HIV transmission. Late Breaker Poster Presentation presented at the 22nd International AIDS Conference Amsterdam, Netherlands. [Google Scholar]
  4. Audet CM, Ngobeni S, & Wagner RG (2016). Use of CD4+ cell count results to determine traditional treatment eligibility among HIV-infected patients in rural South Africa. AIDS 2016, Durban, SA. [Google Scholar]
  5. Audet CM, Ngobeni S, & Wagner RG (2017). Traditional healer treatment of HIV persists in the era of ART: a mixed methods study from rural South Africa. BMC Complement Altern Med, 17(1), 434. doi: 10.1186/s12906-017-1934-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Audet CM, Salato J, Blevins M, Amsalem D, Vermund SH, & Gaspar F (2013). Educational Intervention Increased Referrals to Allopathic Care by Traditional Healers in Three High HIV-Prevalence Rural Districts in Mozambique. PLoS One, 8(8), e70326. doi: 10.1371/journal.pone.0070326 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bampoe V, Clancy A, Sugarman M, Liden J, & Lansang MA (2012). Response from the Global Fund. Bulletin of the World Health Organization 90, 70 [Google Scholar]
  8. Burnett A, Baggaley R, Ndovi-MacMillan M, Sulwe J, Hang’omba B, & Bennett J (1999). Caring for people with HIV in Zambia: are traditional healers and formal health workers willing to work together? AIDS Care, 11(4), 481–491. doi: 10.1080/09540129947875Q34MQ0X9KND385CN [pii] [DOI] [PubMed] [Google Scholar]
  9. Cuevas AG, O’Brien K, & Saha S (2017). What is the key to culturally competent care: Reducing bias or cultural tailoring? Psychol Health, 32(4), 493–507. doi: 10.1080/08870446.2017.1284221 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Darbes LA, McGrath NM, Hosegood V, Johnson MO, Fritz K, Ngubane T, & van Rooyen H (2019). Results of a Couples-Based Randomized Controlled Trial Aimed to Increase Testing for HIV. J Acquir Immune Defic Syndr, 80(4), 404–413. doi: 10.1097/qai.0000000000001948 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Doherty IA, Myers B, Zule WA, Minnis AM, Kline TL, Parry CD, … Wechsberg WM (2016). Seek, Test and Disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township. Sexually Transmitted Infections, 92(1), 5. [DOI] [PubMed] [Google Scholar]
  12. Fleming J (1995). Mozambican healers join government in fight against AIDS. J Int Assoc Physicians AIDS Care, 1(2), 32. [PubMed] [Google Scholar]
  13. Gomez-Olive FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, … Clark SJ (2013). Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care, 25(9), 1122–1128. doi: 10.1080/09540121.2012.750710 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Gazette Government. (2008). Traditional Health Practitioners Act, 2007.Cape Town. [Google Scholar]
  15. Hershow R, Gannett K, Merrill J, Kaufman BE, Barkley C, DeCelles J, & Harrison A (2015). Using soccer to build confidence and increase HCT uptake among adolescent girls: A mixed-methods study of an HIV prevention programme in South Africa. Sport in society, 18(8), 1009–1022. doi: 10.1080/17430437.2014.997586 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Human Sciences Research Council (HSRC). (2018). The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017: HIV Impact Assessment Summary Report. Cape Town: HSRC Press. [Google Scholar]
  17. Jobson M (2015). Structure of the health system in South Africa. Johannesburg, South Africa [Google Scholar]
  18. Johnson CC, Kennedy C, Fonner V, Siegfried N, Figueroa C, Dalal S, … Baggaley R. (2017). Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis. J Int AIDS Soc, 20(1), 21594. doi: 10.7448/ias.20.1.21594 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Kayombo EJ, Uiso FC, Mbwambo ZH, Mahunnah RL, Moshi MJ, & Mgonda YH (2007). Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. J Ethnobiol Ethnomed, 3, 6.doi: 1746-4269-3-694[pii] [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. King R (2000). Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa: a literature review. UNAIDS Best Practices Collection [Google Scholar]
  21. Liverpool J, Alexander R, Johnson M, Ebba EK, Francis S, & Liverpool C (2004). Western medicine and traditional healers: partners in the fight against HIV/AIDS. J Natl Med Assoc, 96(6), 822–825 [PMC free article] [PubMed] [Google Scholar]
  22. Madamombe I (2006). Traditional healers boost primary helath care: Reaching patients missed by modern medicine. African Renewal, 19(4), 10 [Google Scholar]
  23. Magasana V, Zembe W, Tabana H, Naik R, Jackson D, Swanevelder S, & Doherty T (2016). An assessment of quality of home-based HIV counseling and testing performed by lay counselors in a rural sub-district of KwaZulu-Natal, South Africa. SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance, 13(1), 188–196. doi: 10.1080/17290376.2016.1248477 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Martínez Pérez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, … Ibeto M. (2016). ‘I Know that I Do Have HIV but Nobody Saw Me’: Oral HIV Self-Testing in an Informal Settlement in South Africa. PLOS ONE, 11(4), e0152653. doi: 10.1371/journal.pone.0152653 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Mee P, Kahn K, Kabudula CW, Wagner RG, Gómez-Olivé FX, Madhavan S, … Byass P. (2016). The development of a localised HIV epidemic and the associated excess mortality burden in a rural area of South Africa. Global health, epidemiology and genomics, 1, e7–e7. doi: 10.1017/gheg.2016.3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Moshabela M, Zuma T, Orne-Gliemann J, Iwuji C, Larmarange J, & McGrath N (2016). “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). AIDS Care, 28 Suppl 3, 24–32. doi: 10.1080/09540121.2016.1181296 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Ogunmefun C, Gilbert L, & Schatz E (2011). Older female caregivers and HIV/AIDS-related secondary stigma in rural South Africa. J Cross Cult Gerontol, 26(1), 85–102. doi: 10.1007/s10823-010-9129-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Ondenge K, Renju J, Bonnington O, Moshabela M, Wamoyi J, Nyamukapa C, … Skovdal M. (2017). ‘I am treated well if I adhere to my HIV medication’: putting patient-provider interactions in context through insights from qualitative research in five sub-Saharan African countries. Sex Transm Infect, 93(Suppl 3). doi: 10.1136/sextrans-2016-052973 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Pachter LM (1994). Culture and clinical care. Folk illness beliefs and behaviors and their implications for health care delivery. JAMA, 271(9), 690–694 [DOI] [PubMed] [Google Scholar]
  30. Pitpitan EV, Kalichman SC, Eaton LA, Cain D, Sikkema KJ, Skinner D, … Pieterse D. (2012). AIDS-related stigma, HIV testing, and transmission risk among patrons of informal drinking places in Cape Town, South Africa. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 43(3), 362–371. doi: 10.1007/s12160-012-9346-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. PlusNews. (2010). South Africa: Traditional healers extend healthcare. IRIN: humanitarian news and analysis, [Google Scholar]
  32. Psaros C, Milford C, Smit JA, Greener L, Mosery N, Matthews LT, … Safren SA. (2018). HIV Prevention Among Young Women in South Africa: Understanding Multiple Layers of Risk. Arch Sex Behav, 47(7), 1969–1982. doi: 10.1007/s10508-017-1056-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Richter M (2003). Traditional Medicines and Traditional Healers in South Africa. Retrieved from http://www.tac.org.za/Documents/ResearchPapers/Traditional_Medicine_briefing.pdf
  34. Ritchwood TD, Selin A, Pettifor A, Lippman SA, Gilmore H, Kimaru L, … Kahn K. (2019). HIV self-testing: South African young adults’ recommendations for ease of use, test kit contents, accessibility, and supportive resources. BMC Public Health, 19(1), 123. doi: 10.1186/s12889-019-6402-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Smith P, Wallace M, & Bekker L-G (2016). Adolescents’ experience of a rapid HIV self-testing device in youth-friendly clinic settings in Cape Town South Africa: a cross-sectional community based usability study. Journal of the International AIDS Society, 19(1), 21111–21111. doi: 10.7448/IAS.19.1.21111 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Spokane AR, Inman AG, Weatherford RD, Davidson AK, & Straw R (2011). Ecologically Based, Culturally Concordant Responding Following Disasters:The Counseling Psychologist’s Role. The Counseling Psychologist, 39(8), 1128–1159. doi: 10.1177/0011000010397933 [DOI] [Google Scholar]
  37. Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, Saltzman AK, … Baggaley RC. (2013). Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med, 10(8), e1001496. doi: 10.1371/journal.pmed.1001496 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Treves-Kagan S, El Ayadi AM, Pettifor A, MacPhail C, Twine R, Maman S, … Lippman SA. (2017). Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women. AIDS Behav, 21(9), 2579–2588. doi: 10.1007/s10461-016-1671-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. UNAIDS. (2019). Country: South Africa. Retrieved from https://www.unaids.org/en/regionscountries/countries/southafrica
  40. van Rooyen H, Barnabas RV, Baeten JM, Phakathi Z, Joseph P, Krows M, … Celum C. (2013). High HIV testing uptake and linkage to care in a novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr, 64(1), e1–8. doi: 10.1097/QAI.0b013e31829b567d [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Wabiri N, & Taffa N (2013). Socio-economic inequality and HIV in South Africa. BMC public health, 13, 1037–1037. doi: 10.1186/1471-2458-13-1037 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, Sawires S, … Hahn JA. (2011). Missed opportunities for HIV testing and late-stage diagnosis among HIV-infected patients in Uganda. PloS one, 6(7), e21794–e21794. doi: 10.1371/journal.pone.0021794 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Young SD, Hlavka Z, Modiba P, Gray G, Van Rooyen H, Richter L, … Coates T (2010). HIV-related stigma, social norms, and HIV testing in Soweto and Vulindlela, South Africa: National Institutes of Mental Health Project Accept (HPTN 043). J Acquir Immune Defic Syndr, 55(5), 620–624. doi: 10.1097/QAI.0b013e3181fc6429 [DOI] [PMC free article] [PubMed] [Google Scholar]

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