N. Gqaleni, T. Hlongwane, C. Khondo, M. Mbatha, S. Mhlongo, M. Ngcobo, V.T. Mkhize, N. Mtshali, R. Pakade, R.A. Street *

Introduction

With an estimated 5.6 million people living with HIV in 2009, South Africa’s epidemic remains the largest in the world (UNAIDS, 2010). Before the availability of ARVs, the public health sector carried a large health burden. Numerous training programmes were and still are available to educate and empower biomedically-trained staff in the management and prevention of HIV and AIDS. It is approximated that 27 million South Africans depend on traditional medicine for their primary health care needs (Mander, 1998) and regularly visit Traditional Health Practitioners (THPs). Patients often move freely between traditional and allopathic systems of medicine. In fact, up to 90% of people living with HIV and AIDS first consult THPs before visiting practitioners of allopathic medicine (Goggin et al., 2008; Peltzer and Mngqundaniso, 2008). Thus THPs bear the brunt of the HIV and AIDS epidemic (UNAIDS 2006; Morris, 2001; Goggin et al., 2009) and represent an important health-care resource, potentially capable of escalating access to HIV education and counseling (Peltzer and Mngqundaniso, 2008).

When it comes to the origins of HIV, historically, THPs are not acquainted with the germ theory. The conceptualization of the origins of HIV for THPs is determined by their cultural values and belief (Gqaleni et al, 2011). However despite the frequent contact between THPs and HIV positive patients, education of THPs with regards to HIV and AIDS has been disregarded. No HIV and AIDS educational programmes were made available for THPs to understand the virus. This means that THPs were not enabled to make meaningful contributions to the national strategies to mitigate the impact of the virus.

There have been a few studies aimed at facilitating the collaboration with THPs in scientific and social projects in which, by and large, academics study the applications of traditional healing in communities. However the main purpose of these studies is often to gather research data with little or no translation by THPs back to communities; therefore there is little to no tangible impact (for a review, see King et al., 2004). In order to bridge the gap between THPs and public health care workers (HCWs), a novel venture was undertaken to establish a district health-based collaboration between provincial and local authority clinics and THPs with regards to HIV and AIDS prevention, testing and care in KwaZulu Natal, South Africa (KZN). Training programmes were developed to equip THPs with skills to effectively manage the epidemic within their practices and in their communities. The KZN Province is the epicenter of the HIV and AIDS epidemic in SA with an estimated prevalence rate of 39.5% in 2009 (Department of Health, 2010). The main sponsor of the project was the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and involved the University of KwaZulu-Natal (UKZN), KZN Department of Health, eThekwini Municipality Health Unit and KZN THPs. The objective of this paper is to discuss the challenges and success of this innovative endeavor and to provide insights into the lessons learned and future prospects.

Formulation of collaborative traditional and biomedical projects

Collaborative projects involving traditional and allopathic medicine are by and large conceived and planned by academics after responding to calls for proposals. In certain cases, THPs are simply requested to lay the groundwork for the implementation. However research on Indigenous Knowledge Systems (IKS) ironically, often excludes the guidance and advice from THPs. Thus the immediate needs of THPs, and in turn local communities, are not addressed.

After a call for proposals from the Center for Disease Control (CDC) under PEPFAR a novel approach to proposal writing was undertaken by developing the entire proposal with THPs, taking into account their needs, and in turn establishing the best possible route to reach the study objectives. The proposal strategy leading to the award of this funding underscored the cordial relationship between all the stakeholders. The project-writing process was preceded by extensive external consultations and involved 3 KZN districts namely eThekwini, Umgungundlovu and Ilembe. The project proposal development took place over a six-month period following the signing of the memorandum of understanding (MOU) between the University of KwaZulu-Natal and THP organisations. After workshops on proposal writing, a small team was mandated to finalize the detailed proposal for submission to CDC. This core implementation team formed the UKZN THP Project Executive Committee. The THPs were represented by a chairperson from each district which included the Chair of KZN Traditional Health Practitioners Council, the Chair of the KZN Traditional Healers Organisation, the Chair of UMgungundlovu district and the Chair of eThekwini. These Chairs were part of the decision-making process for the duration of the project. This collaboration was intended to be implemented by all stakeholders as equal partners.

Governmental and institutional support is imperative for the successful endeavor of biomedical interlaced IKS projects. The realization of the PEPFAR project was facilitated by the partnership between the Nelson R Mandela School of Medicine of the University of KwaZulu-Natal, the KwaZulu-Natal Traditional Health Practitioners, the KwaZulu-Natal Department of Health (DoH) and the eThekwini Municipality Health Unit. This relationship was strengthened by the signing of a MOU between the THPs and the Medical school in 2003 in which all these stakeholders were present. The partnership set out to build a relationship based on sound principles and aimed to become not only a model for similar partnerships in the country but the whole African continent (Gqaleni et al., 2010). The implementation of such projects has to consider numerous dynamics in achieving the goal of contributing to the development of traditional health care knowledge without compromising the intellectual property rights of the THPs (Gqaleni et al., 2010).

Implementation of the project

The project focused on the establishment of a strategic collaboration between public health clinics and THPs in the fight against HIV and AIDS with a particular focus on prevention and referral for voluntary counseling and testing (VCT) and palliative care.

The chairperson of each of the participating districts identified THPs who acted as sub-district coordinators. Overall 40 THPs actively participated as coordinators. The role of the coordinators was to recruit other THPS to attend training workshops. The workshops were co-ordinated by a THP and assisted by 3 additional THPs, 2 nurses, 3 biomedical practitioners and 3 scientists who pooled resources during the workshop. The training programme which was developed and implemented specifically for this project is described in detail in Gqaleni et al. (2010). The training manual was available in both English and isiZulu. All fundamental personal details of recruited THPs were documented which included practice details to enable the data collectors to locate the THPs for future reference. The coordinators fully explained the reasons as well as the benefits of attending the training workshop. The training was meant as a mechanism that is used to form the basis upon which a meaningful collaboration between THPs and allopathic practitioners on HIV and TB can be realized.

The coordinators formed a vital link between the monitoring and evaluation team based at UKZN and the participating THPs. They explained the purpose of the project and what was expected from the healers. Coordinators explained the benefits of the project to THPs thereby allaying fears and anxieties that they may experience. Because the district chairpersons and appointed coordinators chose the THPs who participated in the project, it was a symbolic achievement for the project in that THPs themselves drove the implementation process. The participating THPs were referred to training workshops where they were trained regardless of their education or literacy. This was made possible by the interactive training program specifically designed for the purpose of this project. Those participants who could not read or write were referred to the Adult Basic Education and Training (ABET) program run by the eThekwini municipality. They went to ABET with their training manuals and thus were able to better understand their training while at the same time learning basic reading and writing skills. It must be noted that they were very few (less than 10%) participating THPs who could not read or write. Other services offered to participating THPs included referral to public eye clinics for checkups and issuing of reading glasses. It is interesting to note that although many THPs could read, they were unaccustomed to doing so at their workplace therefore they did not have appropriate glasses to enable them with this task. The graduation ceremonies that represented the successful completion of training were characterised by the most colourful and vibrant celebration where THPs came dressed in their traditional Zulu attire (see picture 1).

Picture 1: THP graduation ceremony

Dilemma of ethics/confidentiality in creating a recording system for THPs

The practice of South African traditional medicine has a long oral history as healing knowledge was passed on from generation to generation through verbal communication and initiation. Therefore THPs are not accustomed to recording their work. However, for the purpose of monitoring and evaluation of the project, THPs were obliged to record the interactions with their patients. Patients themselves were not used to having their details and illnesses recorded by the THPs. Training workshops for participating THPs were set up to familiarize them with issues of ethical practices, confidentiality of patients and patients informed consent. This also applied to their participation in this project as THPs also gave informed consent to take part in this project and their confidentiality was guaranteed. In requesting their patients to take part in the projects, THPs were required to give patients full details of the project after which patients could consent to the recording of their details. The success of this system was measured by the high number of patients who consented to be part of the project and their subsequent return visits to the same THPs.

Most projects involving THPs adopt the strategy of academic researchers recording all the activities of THPs and their patients. This project adopted a novel strategy in which THPs directly recorded the interactions with their patients. This approach allowed for all the intricacies of South African traditional healing to be recorded by the practitioners. It is a vital approach as a research questionnaire administered by a researcher to a THP or patient might overlook seemingly unimportant details which may be a valuable part of the THP/patient consultation process. More importantly the project enabled the THPs to record their own work and create archives for subsequent visits of their patients. The participating THPs were also able to contribute to the National Health Care System through the facilitated referral system between THPs and local clinics.

Referral system between THPs and local clinics

The focus of the project was to establish a district and local government level collaboration with clinics and THPs. During training of participating THPs, biomedical knowledge of HIV and AIDS provided them an alternative perspective of the disease to complement their management and to reinforce prevention. The success of the project lay in the willingness of THPs to promote HIV prevention (health promotion) to all their patients and communities. THPs were also willing to refer their patients to local clinics for HIV Voluntary Counseling and Testing (VCT) and to offer palliative care service (home-based care). The partnership with the KZN Department of Health allowed a number of clinics and hospitals to collaborate on the project. This collaborative effort between THPs and medical staff at clinics and hospitals was not easy in the beginning because the two systems frowned upon each other. But through workshops the two systems got to learn about each others’ practices and a better understanding was eventually established. Other health NGOs (such as Khaya Afrika and New Start) also assisted in the implementation of the project.

Medical practitioners learned that the referral system can work in favor of specific cases. Patients taking HIV antiretroviral drugs (ARVs) and tuberculosis (TB) treatment are encouraged to stick to their treatment regimes as closely as possible. Clinics and hospitals administering these kinds of treatments encourage a Directly Observed Treatment Short-course (DOTS) course strategy in which community members monitor patients and ensure that treatment drugs are taken as prescribed by medical practitioners. The DOTS system is an international recommended strategy for TB control that is recognised as both cost effective and highly efficient. Statistics have shown that patients taking either ARVs or TB treatment preferred THPs as their DOTS. This project showed that indeed THPs were willing to help encourage patients to take treatment as advised by the clinic or hospital.

Media and public perception of traditional medicine

Reports in the South African popular media usually carry negative stories regarding THPs and traditional medicine. Such negativity has only worsened with the spread of the HIV and AIDS epidemic with reports of THPs claiming to have found a cure for AIDS and unethical and unsavory stories relating to treatment of patients. These negative stories have unrightfully cast all THPs as a fraudulent group, and this has affected reputable and ethical THPs who contribute positively to South Africa’s fight against the spread of HIV (Richter, 2003). Unfortunately few positive stories are reported via the media as they lack sensationalism. The PEPFAR project aimed at changing the perception of the popular media about traditional medicine practices and recognizes the crucial role THPs can play in preventing the spread of HIV in their communities.

As THPs were part of the planning and implementation in the project, relevant IK was used to provide culturally relevant prevention messages. This information formed part of an innovative training program that provided simple but comprehensive information on the HIV & AIDS by using computer simulated medical animation (for examples see www.animate4.com) combined with graphics as well as dramatic enactment to ensure precise understanding (Gqaleni et al. 2010). During the workshops multiple methods of prevention were explored including traditional methods of prevention. Further discussions on traditional methods of prevention were facilitated by a THP facilitator and participants were encouraged to share their views on how best traditional methods of prevention can be used to promote prevention. This resulted in the development of culturally relevant abstinence, and faithfulness messages which were used firstly within the traditional healing contexts and secondly to create public awareness, thereby creating the foundation of the THP Public Awareness campaign. This was one of the project’s biggest achievements in terms of maximizing THP role and impact on HIV prevention, rebuilding the public image of traditional healing and ensuring positive contribution towards the HIV and AIDS alleviation. Throughout this campaign numerous methods were used to reach the public. Public events were held in three different districts; Ilembe, eThekwini and Umgungundlovu where a total of 35 894 people were reached. These events were used concurrently with Ukhozi FM live radio broadcast with the daily listenership of 6.8million; the TV public service Announcements in a form of multimedia massages by the THPs who distributed to an active database of 33 970 subscribers and the formation of a Prevention Song CD in a public awareness with Gagasi 99.5 FM with a listenership of 1,094,000. The public was given a chance, through the radio station, to submit lyrics for the song, consistent with the project’s theme “through our culture and unity we can prevent HIV”. There was a response rate of over 3,000 people. The project worked with its Ambassadors, who are prominent South African musicians namely Zuluboy; Busi Mhlongo and iHhashi Elimhlophe, to record a song to promote the prevention of HIV and encourage behavior change.

Table 1: The success of the public awareness campaigns in spreading the HIV prevention messages and encouraging HIV testing by THPs

Evaluation of the project by SEAD

The biomedical and traditional healing collaboration on HIV and AIDS projects underwent a tough but very useful strategic review by Strategic Evaluation, Advisory and Develoment Consulting (SEAD), a PEPFAR partner organisation funded through a conventional CDC award. The evaluation team was able to experience the cordial and close working relationship between UKZN researchers and the THPs representatives firsthand. The active participation by 40 THPs as consultants on the project and the collaboration with government ensured a good working relationship with all stakeholders. The chairpersons of each district and their appointed coordinators were able to identify suitable THPs, who were then enrolled into the programme. Although effective, SEAD evaluation team felt that it appeared that not all THPs were reached within the participating districts. Therefore the project might have benefited more from a greater marketing strategy but any expansion of programme will need significant further financial support in the future.

The SEAD report also commended the external consultation processes that took place before the implementation of the project but identified a lack in internal consultation which led to later management conflicts. The evaluators were able to see that KZN THPs were represented in all the stages of the project and also formed part of the UKZN THP Project Executive Committee. Evaluators were able to visit the field where THPs led them to their referring clinics or health care centre and were introduced to clinic staff. In these clinics SEAD were able to experience firsthand how THPs work with health care workers and the mutual respect and recognition of each other’s area of expertise in patient care. The SEAD team also saw that the referral system was a two way process in which not only THPs referred patients to clinics but that clinics were also referring patients back to the healers when necessary. This showed that the programme was very closely integrated with national and provincial health care system programmes. Additionally, the programme had become integrated into the KZN Provincial AIDS Council and reported to its structures at district level.

In the end the SEAD team of evaluators concluded that the project performed well in a sector that has been neglected. The operating environment was challenging but the programme worked hard to achieve its outputs. The project offered value and sustainability to THPs in so far as transferring knowledge and permanently educating them. The THPs will be able to use this knowledge even if the programme stopped. SEAD recommended that this UKZN project consult with CDC and other national stakeholders in other to find a mechanism to expand to the remaining districts in KZN and in THP groups in other provinces. Mechanisms should also be found to make this a sustainable project into the future.

Achievements of the project

The collaboration on HIV and AIDS was able to bring together all interested parties, i.e. researchers, THPs, traditional leadership and national and provincial government. It is the largest project involving all these spheres of society designed to empower THPs. The mandate of the project was to restore the dignity of traditional medicine by using this vital part of the African health system to spread HIV prevention and treatment messages. The design of the project involved THPs from the beginning and who remained implementers of the whole programme while the UKZN team collected data for monitoring and evaluation purposes. For the first time, THPs taking part in the project were required to seek informed consent from their patients to record their consultation sessions. Data collected from these THPs showed that most of their patients consented to this process. This was reflected by the patient’s subsequent visits to the healer.

The project was able to establish relationships with clinics to which THPs could refer their patients for further health care needs. This referral system is a major milestone in the history of the South African national health care system because the THPs are now able to feed information to this system. Clinics are now able to refer patients to THPs who have special knowledge in certain diseases. This relationship has gone so far as clinics appointing a THP to their board of directors. This shows that the project has added value to the practice of traditional medicine and healing. Such successes have prompted the KZN Provincial AIDS Council to adopt the project and its programmes. This will ensure that the project is sustained and spread to all the 11 THP districts of the province.

Perhaps the biggest challenge of traditional medicine is the perception of the popular media to this practice. The collaboration aimed to change this view by projecting THPs as vital part of fighting the disease burden of the country. The media were invited to every function of the project, especially the public awareness campaigns where THPs were spreading HIV prevention messages. The media (print, radio and television) began to report positively about the project and the role of THPs in society. An article in Drum magazine that covered the work of the project won an award for the 2010 CNN/Multichoice African Journalist of the year on HIV reporting (Ledwaba, 2009). This reflected very positively on the project.

Pre- and post-assessment questionnaires firstly identified the shift in knowledge and attitudes particularly on understanding of HIV and AIDS, its causes, modes of transmission, signs and symptoms, and prevention and secondly determined whether the training workshop had achieved its objectives or that learning did take place. With regard to participants’ level of understanding of HIV and AIDS and signs and symptoms of AIDS, there was a significant difference in terms of pre- and post-assessments (59% and 60% respectively) and modes of transmission (39%) (Gqaleni et al., 2010).

It thus becomes necessary to develop training programmes to equip traditional health practitioners (THPs) to know how to differentiate between the two conditions and effectively manage the epidemic within their practices and in their communities (Gqaleni et al. 2010). This collaboration project is the biggest THP capacitating project in South Africa. It did not only manage to train up to 1199 THPs but also managed to integrate the virology and germ theory within the traditional healing context while ensuring enhanced traditional healing knowledge without compromising their way of practice.

Conclusion

The development and empowerment of THPS to play a meaningful role in health care service delivery in South Africa is of national strategic importance. Alliances between traditional and allopathic health care workers will benefit communities significantly. This innovative project involving THPs, health care workers and University is the first and largest of its kind. It has successfully demonstrated that collaboration between these sectors is possible. It is our hope that this will not only apply to HIV/AIDS but other conditions as well.

Acknowledgements
This work is supported by the Inter-Agency PEPFAR Annual Programme Statement: US Program Missions to South Africa - under PA 04281. This publication is supported by the CDC U62/CCU024561. The contents are solely the responsibility of the authors and do not necessarily represent the official views of PEPFAR or CDC. Professor Gqaleni is funded by the Department of Science and Technology (DST) and the National Research Foundation (NRF). The views expressed by him do not reflect the official position of DST/NRF.

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