1. Abstract No. WEPDD0101
Promise or Peril? The Nature of Medical Pluralism along the Cascade of Care for HIV/AIDS in Eastern and Southern Africa
Mosa Moshabela, Dominic Bukenya, Gabriel Darong, Joyce Wamoyi, Thembelihle Zuma, Jenny Renju, Constance Nyamukapa, William Ddaaki, Oliver Bonnington, Janet Seeley, Vicky Hoosegood, Alison Wringe
Greetings to everyone
Grateful to AIDS2016 for the opportunity to share these results
Acknowledge:
co-authors,
institutions,
ALPHA,
participants and
sponsors

2. Introduction Using more than one medical system
Sores, pus and pain from 2001
#Local district hospital (2001)
*Local clinic (2003)
Offered VCT but refused (2003)
*Traditional Healer: 5 months
Diagnosis was Witchcraft: 2004
*Prophet 1 (Paid R50 fee) (2004)
*Prophet 2 (Paid R90 fee) (2004)
*Chemist (Paid R45 fee) (2004)
HIV test done & diagnosed (2004)
Local district Hospital (2004)
HIV clinic (2004)
ART was initiated in 2005
# Temporary symptomatic relief
* Treatment and care ineffective
Using more than one medical system
Switching between modalities of care
Hindering progress through the cascade
PLHIV experiences across medical systems
Qualitative study in seven HDSS
uMkhanyakude
Manicaland
Karonga
Kisesa
Kisumu
Masaka
Table 1: Participants and Study Sites in six African countries
HCW
Diagnosed no ART
On ART
No longer in care
Kisesa (Tanzania) 8 6 18 5
Karonga (Malawi) 9 27 4
Rakai (Uganda) 16 14
Kyambaliwa (Uganda)
Kisumu (Kenya) 10 15
Manicaland (Zimbabwe) 13 35 11
uMkhanyakude (South Africa) 17
TOTAL 54 72
142 42
Rakai
Medical pluralism represents the notion of using more than one medical system for healthcare.
We have previously demonstrated the use of multiple sources of healthcare, including prophets and traditional healers.
We noticed at the time that medical pluralism may be responsible for delayed ART care, and we later confirmed this hypothesis. However, we were not able to draw strong conclusions on this matter because we simply could not tell whether medical pluralism was an opportunity for or a threat to ART success.
We have gone back to the drawing board, and this time involving multiple partners across eastern and southern Africa, through the ALPHA Network, to once again try to make sense of this notion given the era of widely available ART.
The work was done as part of the Study of Bottlenecks along the HIV cascade of care, involving seven demographic surveillance sites, recruiting PLHIV, HCW and Family members of people dying with known HIV status.
As you can see in the table, the sample size was quite large for a qualitative study – over 300 participants.

3. Results
“I have taken the medicine for HIV and the HIV is unrelenting. That only implies that this is witchcraft. That is why I kept going to the traditional doctors.”
Healthcare for PLHIV involves faith healers, pastors and prophets, traditional healers and herbalists, public sector clinics and hospitals, and private sector doctors, pharmacies and chemists
“Okay it’s true, there are some who are bewitched. He goes to a traditional healer and gets healed, but that disease comes in so many different ways…”
IMPLICATIONS
Treatment delays
Excessive costs
Treatment interruptions
Drug-drug interactions
Conflicting messages.
“There are some traditional healers who will tell you to stop the treatment. They say they have discovered some herbs which cure the disease.”
PLHIV engage in medical pluralism largely because of the nature of their health worlds, be it traditional or religious – based on interpretation of their illness and symptoms, as well as social influence
“…traditional healers have had an awakening…when you are infected with the virus, they will tell you to follow up with the proper medication.”
One thing that is clear is the list of providers and sources of healthcare for PLHIV in the top-left corner, please note that they represent four distinct, but occasionally overlapping, medical systems of care – biomedical, traditional, religious and complementary/alternative medicines (CAM) systems of care (happy to discuss this further)
The second thing that is clear, in the top-right corner – the implications of medical pluralism, issues of delays, interruptions and costs, as well as conflicting and false messages, and concerns regarding interactions of medicines esp. by HCWs.
The elusive parts are in the middle, right at the top we can see that people accept beliefs about illnesses occurring due to enchantment, for a lack of a better word, what we often refer to as witchcraft, as well as the complexity of HIV as an illness.
These were explained through health worlds and social support systems of PLHIV, as you can see in the bottom-left.
In the centre is the core of the problem as far as we are all concerned, ART disruptions in the quest for cure, and the curve ball at the bottom, that biomedical practitioners are recommending use of traditional medicines, due to shared health worlds.
But, with the widespread HIV information and use of ART, Traditional healers are supporting ART care services.
“The doctor said: “It is better you take her from here and go seek some traditional medicines.” I took my wife, and we went to a traditional healer.”

4. Conclusions
PLHIV across Africa use multiple sources & systems of healthcare
Explained by health worlds & social systems of support for ill-health
PLHIV compensate for aspects of healthcare needed but not received
Other PLHIV attempt to substitute ART services, in the quest for cure
Medical pluralism may act as a bottleneck along the cascade of care
May delay HIV testing & ART initiation, & interfere with adherence
Unresolved tensions between biomedical & other systems of care
Need for collaborative engagements to promote health outcomes
PLHIV across several African countries included in this study used multiple sources and systems of care, results that are not new in themselves, but reinforce the shared reality of indigenous populations in Africa, their health beliefs and practices, which should be acknowledged and perhaps respected, regardless of my own beliefs/views.
The biomedical health systems are not able to cater for all the health needs of these indigenous populations, however those needs are defined and understood.
Instead biomedical health providers of indigenous origin are also referring patients to traditional healers, whether we judge these acts to be right or wrong.
Yes, there is a real problem, in that these practices can and do delay and interfere with ART, which we currently know to be the only effective treatment for HIV, and this situation constitute a barrier to ART access, a bottleneck along the continuum of care and should be urgently remedied.
We therefore urgently need effective interventions that do not discriminate against indigenous knowledge and practices in Africa, but can help ensure that people who believe in and use traditional and religious practices for healthcare can also enjoy the benefits of biomedical advances in HIV care and treatment.
This study was supported by the Wellcome Trust (085477/Z/08/Z) and the Bill and Melinda Gates Foundation (OPP
Thank you