'We have to learn to cooperate with each other': a qualitative study to explore integration of traditional healers into HIV self-testing and tuberculosis activities in Eswatini

BACKGROUND: Traditional healing plays an important role in healthcare in Eswatini and innovative collaborations with traditional healers may enable hard-to-reach men to access HIV and tuberculosis diagnostic services. This study assessed the feasibility and acceptability of traditional healers distributing HIV self-testing (HIVST) kits and sputum collection containers.
METHODS: A qualitative study was conducted from September 2019 to February 2020 in Shiselweni region, Eswatini. Eight male traditional healers were trained on HIV and TB including distribution of HIVST kits and sputum collection containers. Attitudes towards the intervention were elicited through in-depth interviews with the eight traditional healers, ten of their clients, five healthcare workers and seven focus group discussions with community members. Interviews and group discussions were conducted in Siswati, audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically.
RESULTS: 81 HIVST kits and 24 sputum collection containers were distributed by the healers, with 14% of participants reporting a reactive HIVST result. The distribution of sputum containers did not result in any tuberculosis diagnoses.
Traditional healers perceived themselves as important healthcare providers, and after training, were willing and able to distribute HIV self-test kits and sputum containers to clients. Many saw themselves as peer educators who could address barriers to health-seeking among Swazi men that are influenced by hegemonic masculinities and patriarchal attitudes. Traditional healers were considered to provide consultations that were private, flexible, efficient, and non-judgemental, although some clients and community members expressed concerns over confidentiality. Attitudes among health workers were mixed, with some calling for greater collaboration with traditional healers and others expressing doubts about their potential role in promoting HIV and TB services. Specifically, some did not accept sputum samples from patients collected in this way.
CONCLUSIONS: Offering HIVST kits and sputum containers through traditional healers was feasible, leading to high HIV yields, but no TB diagnoses. The intervention was acceptable to the healers' clients, due to the cultural literacy of traditional healers and practical considerations. Scaling-up this approach could bridge HIV testing gaps if traditional healers are well supported, but referral procedures for sputum samples need to be improved to increase TB diagnoses.