In sub-Saharan Africa, HIV/AIDS is among the leading causes of death among adults, next to tuberculosis, cardiovascular disease, and injuries and accidents. Yet, despite the tremendous toll, juxtaposed against recently reported increases in knowledge of status across sub-Saharan countries, HIV testing remains suboptimally implemented. In rural Uganda, for example, only 39% of sexually active adults have received an HIV test within the past 12 months.
Studies repeatedly show that finding ways to reach people earlier through testing has benefits for reducing HIV mortality and preventing HIV transmission—a key component of global efforts to end the AIDS epidemic.
Enter herbalists and spiritual healers. Radhika Sundararajan, M.D., Ph.D., an assistant professor in the Weill Cornell Department of Emergency Medicine and Center for Global Health, and her research team conducted a cluster randomized trial in rural Uganda of an HIV testing program to determine the effectiveness of traditional healers delivering HIV testing directly to adults receiving care at their practices. The trial determined that delivery of point-of-care HIV tests by traditional healers significantly increased the rate of HIV testing, diagnosis, and linkage to care.
Sundararajan introduced the study’s findings during a presentation titled, “A Cluster-Randomized Trial of Traditional Healers Delivering HIV testing in Uganda” at the 28th Conference on Retroviruses and Opportunistic Infections (CROI 2021) in early March.
Sundararajan’s research focuses on understanding the health care–seeking trajectory and identifying barriers to biomedical care for both children and adults in low-resource settings. She has conducted mixed-methods research on these topics in India, Mozambique, Uganda, and Tanzania.
Terri Wilder spoke with Sundararajan about her research on expanding access to HIV services among rural communities in eastern Africa and the importance of traditional healers—who are able to “get people into care who otherwise would not have tested”—to that work.
Who Are Traditional Healers?
Terri Wilder: Congratulations on your presentation at CROI. At the beginning of your presentation, you stated that uptake of HIV testing is suboptimal in much of sub-Saharan Africa. Why is that?
Radhika Sundararajan: Thanks for having me. I’m glad to be here to talk about our work in Uganda. One of the things about HIV testing that’s really important for people to remember is that it’s really the critical entry point into the cascade of HIV care. Without HIV testing, especially in areas that have really high prevalence of HIV, we have a lot of delays in diagnosing people living with HIV, and therefore there’s a lot of transmission that continues.
Right now, in the Ministry of Health and the CDC [Centers for Disease Control and Prevention] in Uganda, we’re recommending that people are tested for HIV every 12 months. What we’re seeing is that the vast majority of people aren’t testing for HIV every 12 months. In the rural regions where we work, the percentage of people who actually meet those guidelines is about one third. So, that’s really suboptimal—that’s the reason I use that word—in order to detect undiagnosed cases and to get those people into care.
Wilder: You work at Cornell in New York City, with the Center for Global Health. You’re part of the Department of Emergency Medicine. Can you talk about your research and why you were interested in this particular area of research, one that includes traditional healers? Who is a traditional healer? What services do they provide?
Sundararajan: One of the things that is very clear when you go to a lot of international locations, when you start actually talking to people about how they take care of themselves—What do they do for their own health maintenance? What do they do when they don’t feel well?—it becomes very obvious right away that people don’t really exclusively use biomedical or Western medicine resources. We have, in most of the world, a lot of what I call informal providers—people who provide health care services but aren’t really recognized, per se, in a formal way as being health care providers. One of those categories is traditional healers.
There’s of course a lot of diversity in terms of what they’re doing from country to country, region to region. In some countries, they’re very diverse and they do a little bit of everything. In Uganda, there are four different specialties that are somewhat mutually exclusive. Most traditional healers in Uganda are herbalists, which means that they treat illnesses with herbal medicines, with natural plants and herbs. They process different natural resources. That’s the primary way that they treat patients. Other healers are spiritual healers, so they tend to treat afflictions that are more thought to be due to spiritual disruptions or ancestral conflicts, things that are outside of the living world or the world that most people can see.
There are, of course, traditional birth attendants. Those are almost exclusively women, who are providing prenatal care. They are doing labor and delivery and postpartum care in the communities.
Then there are bonesetters. And bonesetters exclusively deal with musculoskeletal injuries. So, they actually treat people who have fractures, who are really injured. They keep them and actually do almost like a rehab in their locations and try to get them strong and provide care for the injuries that people have sustained.
Wilder: How does a person become a healer in the community? Is this something that is passed-on knowledge through a familial line? Or is there official training? And can you tell me about the healers’ experience that you worked with in your research?
Sundararajan: It varies from place to place. In general, a lot of the knowledge that you see is passed on in sort of an apprenticeship model. It’s actually pretty similar to the way that doctors and nurses and other health professionals are trained. You want to be an expert, and so you kind of watch an expert. You spend time with that expert. You watch how they take care of different problems and you train with them. So, that apprenticeship model is there. A lot of times it is passed on from family to family. We have quite a few traditional healers who practice separately, but they’re all related to each other because they’ve all learned from one another.
There are also formal organizations. In Mozambique, for example, there is actually a national union of traditional healers. They’re all represented in the Ministry of Health, so that they have a standardized menu of what services they can provide. In Uganda, it’s a little bit more piecemeal. There are multiple organizations that represent healers.
There are also training schools. I visited a school in Masaka, Uganda, where they’re teaching people the different aspects of, for example, how to harvest plants to have the greatest medicinal impact for certain health problems. So, there are various ways that people are passing on these forms of knowledge. And it really varies, but it’s sort of a combination of all the things you mentioned.
What Are the Barriers to HIV Testing in Rural Uganda?
Wilder: For the research that you presented about at CROI, was this an idea that you and your team came up with, or was this actually an NIH [National Institutes of Health] announcement?
Sundararajan: This was something that we—myself and my collaborators in Uganda—have been thinking about for a long time. We focused it in terms of HIV testing because we felt that that was the biggest need in these rural communities. But the way that we really got down to the point of the trial, which I’ll talk about in a little bit, is that we spent a lot of time talking to people.
A large amount of the work that I do is qualitative, which means that we really try to understand what’s happening on the ground by talking to people and understanding their own experiences through interviews and through focus groups. And so, we spent a lot of time talking to healers, talking to people who use traditional medicine, people who use biomedicine, and talking to HIV clinic staff, and just really getting an understanding of, what are the barriers that exist to HIV testing? What are the things that make it easy? What do the health care providers wish was happening? What do the traditional healers wish was happening? And how are the patients caught in between that?
It became clear that what we needed to at least try to do was find a system that would be able to leverage the very strong influences that traditional healers have in their communities to be able to use their influence and their natural abilities to recruit patients who have patients coming to them without us standing in the clinic saying, “Why aren’t you coming to the clinic?” Those are sort of the perspectives that are really important to remember when we’re thinking about any sort of a public health or healthier intervention: Where are people going? Why don’t we try to meet people where they are?
We know people are going to traditional healers. Standing in a hospital and saying, “Why aren’t you coming here sooner?” is really a counterproductive perspective. We just try to think, where are people going and who do people trust? I think the answer, almost everywhere you look, is that traditional healers have so much trust and social capital in their communities. So it seemed natural that we would be partnering with them.
Wilder: How did you recruit the traditional healers? How were they trained? How did you develop the trainings? What was the setting? And, most importantly, what was the outcome?
Sundararajan: This was a longitudinal study. So we had been working in this region of Southwestern Uganda since 2017. This was a four-year study, and the final thing is the trial from which we just presented the results.
Early on, what became important was that we got a sense of what was out there. This is almost a question that no one knows. How many traditional healers are there? There’s no registry. We started by doing a census. We got our study team on the ground, and we just drove around looking for traditional healers, and asking, trying to find traditional healers that were practicing. That’s initially how we made connections with these practitioners across the landscape.
Then, when we finally were ready to start doing this HIV testing trial, we selected from that group. That’s how the healers were identified.
We have strong partnerships with the district HIV clinic, which is a government-run clinic. They serve the vast majority of people living with HIV in that area. So we worked with them to develop a training program. Again, drawing back on the strength of the qualitative work, we asked people over and over again, “What would this look like for you? What would make you comfortable?
Traditional healers made it very clear they wanted to be involved in this type of work. They were a little nervous about doing things outside of the scope of their practice. For example, a lot of the rapid point-of-care HIV tests are blood-based. You do a finger prick for checking the blood. Then you put it on a reactant strip, and it gives you a result.
A lot of them were really nervous about using that because they said, “I don’t really want to. I don’t want to mess up. I don’t want to hurt someone.”
Taking that information, we looked around and we found that an oral test kit had just become Ministry of Health–approved and had been validated for self-testing. This is a noninvasive kit that we decided we could use because it has good sensitivity and specificity. It’s really equivalent, compared to the blood-based sample. It’s so easy and noninvasive, and everybody just was so excited about it.
We decided to use this oral swab test kit, and we got our partners at the HIV clinic to do a two-day training program. We trained a small group of healers. Again, we had a control arm, and we have an intervention arm. In the control arm, or the standard of care, we actually did do some training because we didn’t want just the standard of care in this trial to be nothing. We spent a day with them, just teaching them about HIV epidemiology. How is HIV transmitted? What is the benefit of testing? What is the benefit of antiretroviral therapy? Probably just so we could all have the same sort of knowledge base.
Then the intervention-arm healers had an extra day. We taught them how to use this point-of-care kit, and deliver pre-test counseling and post-test counseling. So, that is what the study encompassed; we basically trained traditional healers to offer and deliver HIV testing to patients who hadn’t had a test in the last 12 months.
Wilder: What happened after they got training and started implementing HIV testing in their practices?
Sundararajan: Well, we were really surprised to find that, in the intervention arm, every single person who was offered a test accepted a test. We had 100% uptake of testing that was delivered by traditional healers—which was way beyond what we—100% is like never what you expect when you do a study, right? We were really excited about that—especially in comparison to the control arm, which was usual care, where the healers were providing education about HIV and then referring participants to the HIV clinic, which is the normal resource that’s available. Only about 23% of people went to get a test within 90 days of being enrolled in the study.
So, what you see is, if you ask people to go get tested, which is what most HIV programs are doing—saying, “Well, go to the clinic. That’s where the testing is located”—you’re not going to get a lot of people. Twenty-three percent of people who are eligible for a test get a test. If you actually take the testing to the traditional healer, to where people are going, every single person got one, which is pretty exciting. We saw, basically, four times more people got tested as a result of the intervention.
Wilder: How many people did the traditional healers test? How many of them tested HIV positive? And how many people were linked to care?
Sundararajan: This was a trial where we enrolled 500 people overall: 250 people in the intervention and 250 people in the control. So we had, in the intervention, 250 people who were tested. Of those people who were tested, we diagnosed 10 new HIV diagnoses. That ended up being a 4% positivity rate. We found that actually that’s a pretty good screening tool. Of all the tests that we delivered, 4% were reactive. That was a total of 10 new cases.
We checked in with people at 90 days after the point-of-care test. Seven of them had linked to care within 90 days, which is a 70% linkage-to-care rate. We had two people who were newly diagnosed who we could not locate, so they were lost to follow-up. We had one participant who declined to link to care. The other seven, we did find that they were linked to care. If you look at other community-based testing programs, the linkage-to-care rate is about 50%. So, we were doing better than that, albeit with smaller numbers.
Wilder: Did the person who declined linkage to care share why they were declining?
Sundararajan: Yes. She felt that she wanted a second opinion, to be tested again. This is actually pretty common, not only in sub-Saharan Africa, but everywhere. She was also saying that her husband did not support her linking to care. There was a lot of internalized stigma in the household. She felt that without her husband’s permission she couldn’t go to the clinic.
I think it gives us a lot of information on how we could be supporting. Obviously, getting a new diagnosis is challenging. How could we be supporting people in that very vulnerable and critical period in their lives?
Wilder: It makes me think of a peer component to the traditional healers—to have people living with HIV who are out in the community to help with that process.
Sundararajan: That would really help with the stigma reduction and offering an embodied sense of support. These are all things that we are really thinking through right now. We’re in the process of designing a follow-up study. So, stay tuned.
Western Medicine or Traditional Medicine?
Wilder: It feels like Western medicine is often framed as superior, and traditional medicine as inferior. Why do you think that this is believed? And how can this narrative change so that people recognize the value of truly localized medicine that partners with whoever is providing care and services in a given community?
Sundararajan: It’s such a complicated issue. The fact that Western medicine is considered to be the gold standard, that it is considered to be superior seems really tied, especially in places like sub-Saharan Africa, to colonialism. There are a lot of anthropologists that have thought about this and written about this. Historically, as you know, germ theory, all of these advances in biomedicine became predominant, and were sort of overlapping with the peak of colonialism, especially in sub-Saharan Africa. And so much of what was happening in colonization of places like sub-Saharan Africa was replacing indigenous knowledge with Western knowledge, under the premise that Western knowledge and ways of being were better, and could be better to promote health, for example. And indigenous knowledge really became considered something that needs to be suppressed or something that should be really replaced by biomedicine.
The fact that traditional healers have this bad reputation is, very recently, again, tied into the Ebola outbreak from the early 2010s in West Africa, where traditional healers were really blamed for a lot of the community bubble spread as they were taking care of sick people in villages and preparing some of the deceased for traditional rites and rituals.
I can certainly understand historically and culturally how these ways of thinking about traditional medicine are really embedded in our societies. But I think it’s important, as you said, to understand how local medicine is working, and to really understand where people are going to seek care. It’s important to change that narrative by understanding what’s best for patients, and how the patients get caught in the middle between these two systems of healing that don’t talk to each other and that, in many cases, are antagonizing each other.
My group, my research partners, and other people working in these areas have actually published a lot of data that suggest that traditional healers are very interested in working with biomedical providers, and that they actually really look to biomedicine to solve problems that they can’t solve. They get a reputation for being non-participating in biomedical treatments, but that’s not really accurate. They live in a space where biomedicine is so important, and they realize that, in some cases, biomedical care is better for whatever the illness seems to be.
But I think the converse isn’t true, where biomedical providers don’t really see traditional medicine as having a contribution. That’s the main limiting factor to really being able to change this narrative and being able to do what’s best for patients who are already going to seek traditional care.
Wilder: And as you’re talking, I can’t help thinking, can this be implemented in a place like the United States via people who I perceive as being healers, like acupuncturists, massage therapists, native healers, and herbalists, in terms of helping with HIV testing and also linkage to care?
Sundararajan: That would absolutely be a strength of any community-based program. There already have been a lot of efforts in the United States to expand HIV education and testing to non-medical spaces. Thinking about church groups and religious contexts, and barbershops—places where people are going.
I absolutely think that there is a growing tradition in the United States where people are looking outside of biomedicine for healing and for health. As health care providers, as biomedical providers, we need to be very understanding of that and really recognize that.
What I worry about, what I see as being a big difference right now between the traditional forms of healing that we work with in sub-Saharan Africa and what I see in the United States, is that there is a little bit more of the antagonism. I don’t necessarily know that the two forms want to work together. That really has to be the basis of any program, so it’s like a bidirectional sense of benefit, that you really feel like you can communicate with one another and help the patient by talking and working together.
This would be something that obviously needs to be explored. Like I said, qualitative work is the best way to do that, and just talk to people and say, “How would you perceive this as a possibility? What are the characteristics of that type of system that would work for you?”
A lot of times we need to change attitudes by supporting collaboration. Just getting people in the same room sometimes to talk to each other is so powerful. In our work in Uganda, for sure, having HIV clinical staff and traditional healers in the same room just being able to ask questions of each other was such an important way to create a basis of trust from which you can work to really help patients.
Wilder: To your point, we have other ways that we’ve done outreach and engaged with nontraditional settings, like you said, in barbershops or hair salons. It makes me think of an acupuncture or massage therapy setting and other nontraditional ways of getting health support.
Sundararajan: I totally agree. What would be important and interesting would be to get a sense of, number one, their comfort doing that—because you’re thinking about something that’s slightly outside of their scope of practice. They have to have knowledge and interest in delivering that service.
I certainly think it’s something to think about because many people are preferentially going to these alternative or complementary therapies instead of going to doctors. I could totally understand why they would want to avoid biomedicine, especially now.
Wilder: What is next for you and your team, in terms of your research and this study?
Sundararajan: We’re really excited by this pilot work. We are in the process of applying for subsequent research funds.
One of the things that became very clear from this testing program was that, number one, it was very acceptable. Healers wanted to do it, patients wanted it, and that it was effective, insofar as through the testing program we actually identified quite a few people who didn’t realize that they had been living with HIV. And that’s the whole point. We were able to get people into care who otherwise would not have tested. That to me was so demonstrative that this could actually help.
What we found from doing exit interviews with a lot of participants is that this testing program is really good, and we like it—and we would like to do more. We would like the healers to do more in supporting people in HIV care, and in helping them link to care, and in persisting in care. That’s really the emphasis that we’re trying to do. A future work is, we’re trying to implement this program, number one, on a larger scale so we can have a bigger impact in a public health sense, but also to focus on how we can support linkage to care and adherence.