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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
  1. Mosa Moshabela1,2,
  2. Dominic Bukenya3,
  3. Gabriel Darong2,
  4. Joyce Wamoyi4,
  5. Estelle McLean5,6,
  6. Morten Skovdal7,8,
  7. William Ddaaki9,
  8. Kenneth Ondeng’e10,
  9. Oliver Bonnington6,
  10. Janet Seeley2,3,6,
  11. Victoria Hosegood2,11,
  12. Alison Wringe6
  1. 1 Department of Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
  2. 2 Africa Health Research Institute, KwaZulu-Natal, South Africa
  3. 3 MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
  4. 4 Tanzanian National Institute of Medical Research, Mwanza, Tanzania
  5. 5 Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
  6. 6 London School of Hygiene and Tropical Medicine, London, UK
  7. 7 Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  8. 8 Biomedical Research and Training Institute, Harare, Zimbabwe
  9. 9 Rakai Health Sciences Program, Rakai, Uganda
  10. 10 Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
  11. 11 University of Southampton, Southampton, UK
  1. Correspondence to Dr Mosa Moshabela, University of KwaZulu-Natal, Howard College, Science Drive, Durban 4001, South Africa; moshabela{at}


Objectives There 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.

Methods We 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.

Results Medical 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.

Conclusion Medical 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.

  • Medical Pluralism
  • HIV
  • Health-seeking behaviour
  • Traditional healer
  • Faith healer
  • Antiretroviral treatment
  • Sub-Saharan Africa

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  • Contributors MM, JS, VH and AW conceived the study, MM, AW, JS, VH, DB, JW, EM, KO, WD and MS designed study protocols, GD, OB, AW, DB, JW, EM, WD and MS prepared study tools, MS, GD, DB, JW, EM, WD, KO and MM supervised data collection, MM, DB, MS and JW conducted data analysis and MM prepared the first draft of this manuscript. DB, GD, JW, EM, MS, WD, KO, OB, JS, VH and AW made significant contributions to the manuscript, and revised it for intellectual content. All authors read and approved the final manuscript. MM, JS and AW are guarantors of the paper.

  • Funding The bottlenecks study was funded by the Bill and Melinda Gates Foundation (OPP1082114). This paper was also made possible with the support of The Wellcome Trust (085477/Z/08/Z). AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. MM is a Wellcome Trust Research Fellow (105825/Z/14/Z). Research (undertaken in Kisesa and) reported in this publication was supported by the National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institute on Drug Abuse, National Cancer Institute and the National Institute of Mental Health, in accordance with the regulatory requirements of the NIH under Award Number U01AI069911 East Africa IeDEA Consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical approval was granted by the London School of Hygiene and Tropical Medicine and the relevant ethics committees at each of the study settings. These were: Malawi National Health Sciences Research Committee #15/5/1427 (Karonga); Medical Research Coordination Committee–MR/53/100/370 (Kisesa); Uganda National Council for Science and Technology–HS1857 (Kyamulibwa) and Office of the President–ADM154/212/01 (Rakai); Kenya Medical Research Institute (KEMRI) Scientific and Ethics Review Unit (SERU)–KEMRI/SERU/CGHR/018/3115(Kisumu); Medical Research Council of Zimbabwe–MRCZ/A/1990; University of KwaZulu-Natal, South Africa, UKZN/BE338/15. Informed and written consent was obtained from all participants.

  • Provenance and peer review Commissioned; externally peer reviewed.

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