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Traditional healers, HIV outcomes, and mortality among people living with HIV in Senegal, West Africa

Benzekri, Noelle A.a; Sambou, Jacques F.b; Ndong, Sanouc; Tamba, Ibrahima T.d; Faye, Dominiqueb; Diallo, Mouhamadou B.c; Diatta, Jean P.b; Faye, Khadimc; Sall, Ibrahimab; Sall, Fatimac; Malomar, Jean J.b; Hawes, Stephen E.e,f; Seydi, Moussac; Gottlieb, Geoffrey S.a,f on behalf of the UW-Senegal Research Collaboration

Author Information
doi: 10.1097/QAD.0000000000002232

Abstract

Introduction

Nearly one third of the ∼940 000 global deaths due to AIDS in 2017 occurred in West and Central Africa [1]. A fundamental factor contributing to the persistently high burden of HIV-associated deaths is delayed presentation to care [2–4].

Findings from previous studies suggest that seeking care from traditional healers may contribute to delays in HIV diagnosis [5–8]. According to UNAIDS, ‘the term “traditional healer” includes herbalists, spiritualists, diviners or any other practitioner trained or gifted in these forms of healing and recognized as such by the community’ [9]. The role of traditional healers is particularly important in sub-Saharan Africa (SSA), where the majority of the population utilizes some form of traditional medicine for their health care needs [9,10].

A greater understanding of the associations between seeking care from a traditional healer, presentation with advanced disease, and mortality is needed to determine the potential impact of partnering with traditional healers to improve the HIV care cascade in SSA. The goals of this study were to determine the frequency of traditional healer use among people living with HIV (PLHIV) in Senegal, West Africa, to identify predictors of traditional healer use, and to determine if traditional healer use is associated with HIV outcomes.

Methods

Additional information about study methods can be found in the Supplemental Methods, https://links.lww.com/QAD/B479. This study was conducted at the Services des Maladies Infectieuses et Tropicales, CHNU-Fann in Dakar and the Centre de Santé de Ziguinchor, located in the Casamance region. Subjects were sequentially enrolled and followed from April 2017 to April 2018. All HIV-positive individuals initiating antiretroviral therapy (ART) through the Senegalese National AIDS Program who provided written informed consent were eligible for enrollment [11]. Study procedures were approved by the University of Washington IRB and the Senegal CNERS.

Data were collected using questionnaires, interviews, clinical evaluations, laboratory analyses, and chart review. Data were analyzed using SPSS Statistics 23 (IBM, Armonk, New York, USA). Chi-square and Fisher's exact tests were used to identify differences in baseline characteristics between individuals who previously sought care from a traditional healer compared with those who did not seek care from a traditional healer. The Mann–Whitney U test was used to identify differences in medians between groups. Logistic regression was used to identify sociodemographic predictors of seeking care from a traditional healer and associations between HIV-outcomes and traditional healer use. Kaplan–Meier survival analysis was used to compare survival curves among those who sought care from a traditional healer to those who did not seek care from a traditional healer. Individuals who were alive at last follow-up were censored. Missing data were excluded from analysis. P values less than 0.05 were considered significant.

Results

Data from 157 HIV-positive individuals, of which 110 (70%) were female, were included in this analysis (Table 1). One third (34%) of participants previously sought care from a traditional healer. The median number of days of follow-up was 224 [interquartile range (IQR) 118–339.5]. The overall loss to follow-up rate was 10.2%. There was no difference in the number of days of follow-up or follow-up rates among those who sought care from a traditional healer versus those who did not.

T1-13
Table 1:
Baseline characteristics of HIV-infected participants initiating antiretroviral therapy in Senegal, 2017–2018.

Participants who sought care from a traditional healer were older than those who did not seek care from a traditional healer, a greater percentage were receiving care in Ziguinchor (66% versus 45%, P = 0.01), and the prevalence of severe food insecurity was greater (39% versus 23%, P = 0.03). Among HIV-1-infected individuals who sought care from a traditional healer, the median CD4+ cell count was lower (104 versus 208 cells/μl; P = 0.02), and a greater percentage presented with advanced disease (85% versus 62%; P = 0.01) compared with those who did not seek care from a traditional healer. The median number of days from HIV diagnosis to enrollment was 9 days (IQR 5–28). The median ART delay was 11 days; 81% of participants initiated ART 4 weeks or less after HIV confirmation. There was no difference in ART delay among those who sought care from a traditional healer versus those who did not seek care from a traditional healer. The median BMI was lower among individuals who sought care from a traditional healer (17.9 versus 20.3; P = 0.01) and the prevalence of malnutrition was greater (56% versus 30%; P < 0.01). Overall, 10 individuals (6.4%) died during follow-up. A greater percentage of those who sought care from a traditional healer died compared with those who did not seek care from a traditional healer (13.2% versus 2.9%; P = 0.03).

Participants age 35–54 [odds ratio (OR) 2.87, 95% confidence interval (CI) 1.28–6.43] and age at least 55 (OR 4.45, 95% CI 1.05–18.84) were more likely to have sought care from a traditional healer compared with those less than 35 years of age and individuals enrolled at the Ziguinchor study site (located in the Casamance region) were more likely to use a traditional healer compared with those enrolled in Dakar (OR 2.33, 95% CI 1.08–4.99) (sTable 1, https://links.lww.com/QAD/B479). Severe food insecurity was predictive in the simple regression model (OR 2.19, 95% CI 1.06–4.54). Sex, country of birth, education, and unemployment were not predictive.

Among HIV-1-infected individuals, when controlling for age and study site, those with WHO defined advanced disease (OR 3.58, 95% CI 1.18–10.82), those who were malnourished at enrollment (OR 3.79, 95% CI 1.63–8.83), and those who died during follow-up (OR 7.26, 95% CI 1.34–39.37), were more likely to have sought care from a traditional healer (sTable 2, https://links.lww.com/QAD/B479). Seeking care from a traditional healer was predictive of death even when controlling for WHO defined advanced disease (OR 6.86, 95% CI 1.17–40.16; P value = 0.03) (sTable 3, https://links.lww.com/QAD/B479). The probability of survival was lower among those who sought care from a traditional healer compared with those who did not seek care from a traditional healer (log rank P value = 0.01) (Fig. 1). All deaths occurred within the first 200 days of follow-up.

F1-13
Fig. 1:
Kaplan–Meier survival curves for time until death in those who sought care from a traditional healer versus those who did not seek care from a traditional healer (log rank P value = 0.01).

Discussion

We found that seeking care from traditional healers is common among PLHIV in Senegal, and occurs more frequently than has been reported in most other countries in SSA [5,6,12–15]. This was especially true in the Casamance region. The Casamance has been the most severely affected by the HIV epidemic and has the highest prevalence of HIV in Senegal [16]. It is home to a diverse population, including individuals of differing nationalities, ethnicities, religions, and customs. Christianity and Islam exist alongside, and are integrated within, traditional animist religions [17]. The region is predominantly rural and the economy is largely dependent on agriculture; household incomes are among the lowest in the country [18]. Furthermore, the region is emerging from a decades long war for independence that disrupted social structures and economic development. Our findings suggest that training traditional healers and integrating them into HIV strategies should be prioritized in the Casamance region.

In our study, those who sought care from a traditional healer were more likely to present with advanced HIV disease. Numerous factors contribute to delayed HIV diagnosis and treatment in SSA, including individual, health-systems, and community-level factors [19]. However, relatively few studies have explored the association between delayed diagnosis and seeking care from a traditional healer [5–7,12]. Among 150 HIV-positive adults interviewed in Gabon, 26% reported consulting a traditional healer. Traditional healer use was associated with an increase in the number of days between symptoms and HIV diagnosis [5]. In a study of 530 newly diagnosed, symptomatic, HIV-positive adults in Mozambique, 62% reported consulting a traditional healer prior to presentation [7]. Traditional healer use was associated with an increase in the number of days between symptoms and diagnosis, and the diagnostic delay increased with increasing numbers of traditional healer consulted. In a study conducted in Uganda among 612 HIV-positive adults, 7.8% reported ever being treated by a traditional healer [6]. Among those who had been treated by a traditional healer, a greater percentage had a CD4+ cell count 250 cells/μl or less; however, in the multivariate model of predictors of lower CD4+ cell count, traditional healer use was merged with receiving care in any nonmedical setting, including home or the pharmacy, and the predictive value of traditional healer use alone was not reported. In a subsequent study involving 457 HIV-positive adults in Uganda, among whom 17% reported visiting a traditional healer, an association between traditional healer use and CD4+ cell count was not found [12].

Importantly, we found that once individuals were diagnosed with HIV, traditional healer use was not associated with delays in initiating ART. Although adherence data following ART initiation were not available for this analysis, prior studies have evaluated the association between traditional healer use and adherence to ART. In a study involving 4489 HIV-positive adults on ART in Tanzania, Uganda, and Zambia, 5.6% reported ever having visited a traditional healer [13]. Using multiple measures of adherence, including self-report, provider report, and pharmacy refill data, traditional healer use was associated with incomplete adherence, defined as having missed at least 48 consecutive hours of ART during the past 3 months. In Cameroon, in a cross-sectional study of 1885 HIV-positive adults on ART, 5.2% consulted a traditional healer [14]. Having ever consulted a traditional healer was associated with increased risk of self-reported treatment interruption lasting more than 2 consecutive days. Two additional studies, one conducted in Zambia [15] and the other in French Guiana [20], reported that HIV-positive pregnant women who consulted a traditional healer were less likely to adhere to ART as part of a strategy to prevent maternal to child transmission.

The majority of individuals in our study who sought care from a traditional healer were severely ill, as indicated by low CD4+ cell counts, WHO stage 3 or 4 disease, malnutrition and anemia. These findings support the possibility that more severely ill individuals may be more likely to seek care from traditional healers, and raises the question of whether perceived psychospiritual benefits drive critically ill patients towards traditional healers. Furthermore, more than a third of those who sought care from a traditional healer were severely food insecure. Our previous work among PLHIV in Senegal has shown that severe food insecurity is associated with lower household income and indicators of poverty [21]. In a region where HIV-positive individuals can spend up to 4 h traveling to and from clinic, and the cost of clinic transportation exceeds 50% of daily food costs [22], traditional healers may represent the only easily accessible option for health care and the first encounter with any form of healthcare provider.

This is the first study to demonstrate that seeking care from a traditional healer is associated with increased mortality and WHO defined advanced disease among PLHIV in SSA. We do not suggest that the association between traditional healer use and increased mortality is causative. Rather, our findings support the hypothesis that seeking care from a traditional healer contributes to delays in HIV diagnosis and ART, therefore increasing the risk of opportunistic infections and AIDS-associated mortality. Training traditional healers to function as sentinels in the community, and to identify and refer individuals with signs or symptoms of severe disease, could provide an opportunity to target severely ill individuals who escape modern healthcare systems.

A strength of our study was that we included enrollment sites in two different regions of the country to capture a sample that is representative of the HIV-positive population in Senegal. We used a combination of data sources, including in-depth enrollment interviews conducted by social workers, to explore a diversity of factors that we hypothesized could contribute to poor HIV-outcomes. Our study was limited by sample size, follow-up time, specific timeframe of traditional healer use, data regarding cause of death, ART adherence, and viral suppression.

Conclusions

Seeking care from traditional healers is common among PLHIV in Senegal and is associated with WHO defined advanced disease, malnutrition, and increased mortality. Our findings suggest that partnering with traditional healers could provide a high-impact approach to improving the HIV care cascade and decreasing mortality in Senegal.

Acknowledgements

The authors would like to thank the study participants and the staff of the Services des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Fann and the Centre de Santé de Ziguinchor. We would also like to thank Ousseynou Cissé, Noël Magloire Manga, Cheikh T. Ndour, Papa Salif Sow, Robert A. Smith, Dana N. Raugi, and the members of the University of Washington-Senegal Research Collaboration (http://www.uwsenegalresearch.com). This study was supported by the following grants: NIH-NIAID K23 AI120761 to N.A.B. G.S.G. has received research grants and support from the US National Institutes of Health, University of Washington, Bill and Melinda Gates Foundation, Gilead Sciences, Alere Technologies, Merck & Co., Inc., Janssen Pharmaceuticals, Cerus Corporation, ViiV Healthcare, Bristol-Myers Squibb, and Abbott Molecular Diagnostics. All other authors have nothing to declare.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

African medicine; alternative medicine; herbalist; marabout; spiritual healer; traditional medicine; traditional practitioner

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