Traditional health practitioners are key to scaling up comprehensive care for HIV/AIDS in sub-Saharan Africa

The challenge of bringing universal access to antiretroviral therapy in sub-Saharan Africa [1] implies making comprehensive HIV care available to millions of poor people infected or affected by HIV in overcrowded slums and remote rural areas of Africa, where few if any formal quality health services are available. To date, demonstration projects to deliver preventive or highly active antiretroviral therapy (HAART) have shown that people with minimal resources and education can adhere to and benefit from antiretroviral therapy as well as affluent patients. This success has hinged on sustained drug supply, the adoption of practical treatment regimens, and sustained follow-up and support before, during and after enrolment into treatment programmes [2–6]. Comprehensive HIV care should embrace this approach, but the question is: who can deliver these essential services to millions of impoverished, hard-to-reach Africans? We and others have shown that an empowered network of traditional health practitioners (THP) linked to adequate referral facilities could effectively create an expanded HIV care system with minimal costs or delays. THP – traditional healers and traditional birth attendants – are ubiquitous throughout Africa where they represent the first line of care for 70% of the population [7]. Although their training is not homogenous and the profession is rarely regulated, THP outnumber biomedical health practitioners by a hundred-fold or more, and are regularly consulted by a wide range of clients for numerous health conditions for which modern treatments are rarely accessible [8–10]. Their ancestral community roots and intimate, direct experience of poverty, inequity and disease, including AIDS, have earned them a wide and respectful audience as well as an in-depth knowledge of the culture. They are thus highly motivated and ideally placed to promote behaviour change, and to care for, support and refer people living with HIV/AIDS [11]. Over the past decade, Traditional and Modern Health Practitioners Together against AIDS (THETA) and other organizations have involved thousands of African THP in AIDS and sexually transmitted disease prevention and care. Once equipped with adequate knowledge, skills and support, these THP have efficiently integrated biomedical information of HIV/AIDS into their practices, and have performed as well, if not better than community health workers in educating communities, promoting and distributing condoms, and counselling, treating, and referring the sick [8–15]. Similarly, traditional birth attendants have prove unavoidable links in the successful implementation of safe motherhood including the prevention of mother-to-child transmission of HIV programmes [16–19]. Over time, these practitioners have reached millions of individuals infected and affected by HIV/AIDS, and have remained actively engaged years after their initial involvement, a definite sustainability advantage over conventional community health workers [11,20,21]. In scaling up comprehensive HIV care in sub-Saharan Africa, traditional healers and traditional birth attendants could thus fulfill the triple role of complementary care providers, treatment adherence counsellors, and referral advisers. As providers, THP need to be supported to maintain acceptable standards of care, to assess the effectiveness of their herbal treatments for the management of opportunistic infections [13], and to avoid possible interactions between herbal treatments and antiretroviral drugs. THP are particularly well positioned to direct clients for routine (rather than ad hoc) voluntary counselling and testing as well as to refer those in need of evaluation and treatment for sexually transmitted diseases, opportunistic infections, the prevention of mother-to-child transmission of HIV or HAART. For this, they need to be trained in pre- and post-test counselling and to be given simple tools to monitor disease progression and antiretroviral drug side-effects. THP are experienced counsellors; their ability to promote and reinforce the adoption of safer behaviours by all clients, independent of their social, HIV or treatment status, is key to sustained prevention and care. They should now be equipped with the necessary knowledge to support antiretroviral therapy adherence and to retain HIV patients in long-term care. The selection and training of THP should involve health authorities and key community leaders, a strategy that has yielded tangible results in prevention programmes in Uganda, Tanzania and Kenya [11]. Experience has also shown that the conceptual appropriateness of methods and curricula used to mobilize and train THP, including long-term, regular support supervision, as well as the training of trainers, are critical to build the confidence of THP in their new roles, to establish a working referral system, and to sustain a functional, trustful collaboration with the modern health sector. This model has proven itself for prevention, care and support [21]. We believe it can be readily adapted to scale up access to voluntary counselling and testing, the prevention of mother-to-child transmission of HIV and HAART. Documented evidence, although scarce, is telling: for example, in Uganda and South Africa, trained traditional healers formally involved in community-based directly observed therapies for tuberculosis have helped programmes achieve compliance and cure rates of 75% or more, far above national averages and better than what has been accomplished by many standard community-based directly observed therapy programmes [12,15,22]. In conclusion, traditional healers and traditional birth attendants constitute an extensive network potentially capable of expanding and simplifying access to comprehensive HIV care through various entry points. Most THPs are eager to collaborate but few have been involved. Yet established collaboration strategies are available [23]. What is now needed is to train them to support voluntary counselling and testing, the prevention of mother-to-child transmission of HIV and HAART, to strengthen existing referral facilities, and to build a functional THP–biomedical health practitioner cross-referral system. Paramount to this endeavour, the community of individuals fighting HIV/AIDS in Africa needs to mobilize groups experienced in building such collaborations, muster political support and adequate funding to bring comprehensive care not only to people living with HIV/AIDS who qualify for HAART, but also to those who do not, and to help HIV-negative individuals remain uninfected while providing services where none is available.