Understanding contributions of traditional healers to the prevention , care and support in the fight against HIV and AIDS Pandemic in Kariba , Zimbabwe

The role of traditional healers in HIV management in Zimbabwe remains undocumented; thus the paper investigated the role of traditional healers in the fight against HIV and AIDS. Random sampling was used to select 80 community members who were recruited as study participants. Eight interviews were conducted with traditional healers who were conveniently sampled. The study used quantitative and qualitative techniques to allow for triangulation of data. Eighty percent (80%) of the respondents knew about HIV and AIDS issues. Fifty-six (56%) of the respondents with various medical and spiritual problems had visited a traditional healer for help. Amongst those who sought help from traditional healers, 72% improved, 23% their condition did not change and 5% deteriorated. Traditional healer’s consultation charges range from US$2 to13 for treatment which was considered as being fair by health seekers. The maximum number of clients per week ranged from 3 to 50. Health seekers indicated a range of instruments used and skin-cutting gadgets were the most frequently used. In conclusion integrating TH into the formal health sector would offer an opportunity to benefit from their useful herbs and therapies, while offering the chance to dispel practices that might exacerbate the spread of HIV.


INTRODUCTION
Although, HIV sero-prevalence has declined from 29.3% in 1997/98 to 24.6% in 2003and 15.1% in 2009(AVERT, 2009;;ILO, 2009;UNAIDS, 2009), Zimbabwe still hosts a large population of HIV positive people.Caring for the HIV positive population creates a dire challenge for the community and health delivery system characterised by shortage of manpower and resources (Amzat and Abdullahi, 2008).Traditional medicine and traditional healers have become a good alternative and they complement the formal health system.The World Health Organisation (WHO, 2001) defines traditional healing as diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness.
Statistics on the number of patients seeking help from traditional healers in Zimbabwe has not been documented.However, UNAIDS estimated that 80% of the total population in developing countries make use of traditional therapies for management and treatment of diseases including HIV and AIDS (UNAIDS, 2002).In Africa, traditional herbal medicines are often used as primary treatment for HIV and AIDS related problems *Corresponding author.E-mail: ambereko@yahoo.co.uk.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License including dermatological disorders, nausea, depression, insomnia, sexually transmitted diseases and weakness (Babb et al., 2004).Academics, politicians and HIV activists are divided over the contribution of traditional healers in the HIV and AIDS pandemic (SASI, 2006).Traditional medicine is the dominant CAM used by HIV and AIDS victims in Africa.There is therefore, need for continued research to understand the contributions that traditional healers are making in care, support of people living with or affected by HIV and AIDS as well as prevention and mitigation of HIV.
Two schools of thought have emerged on the debate around traditional medicine use, namely the pessimists and optimistic; the former oppose traditional medicine with the latter supporting it.Amzat and Abdullahi (2008) have detailed the arguments of the two schools of thought.The pessimistic school is of the view that traditional healers and their practice and therapies do more harm to the patients than good (Amzat and Abdullahi, 2008).Contrary to the belief of the pessimistic school, the optimistic school believes that traditional medicine and its practitioners have contributed very immensely to the health care needs of those who utilise their services (Erinosho, 1998;Amzat and Abdullahi, 2008).Most literature that exists on Zimbabwean traditional healers focuses on the negative practices of traditional healers such as poisoning, rape, using skin piercing and cutting objects (ZHDR, 2003;Jackson, 2002;Runganga, 2001;Hampton, 1991;Mhloyi, 1990).Therefore, some traditional healers are engaging in practices that may exacerbate HIV, hence the stigmatisation and misrepresentation by critics.Scientists have more often than not misinterpreted cultural practices and beliefs associated with traditional healers, since some are intangible while others are and are protected unconditionally by the followers (SASI, 2006); hence they label them as rigid.
The legal framework in Africa has been showing signs of shifting attitudes from pessimistic to optimism.Starting with the WHO Resolution WHA56.31which, encourages Member States to adapt, adopt and implement, as a basis for national programmes, WHO's strategy for traditional medicine (WHO, 2005).Zimbabwe launched its traditional Medicines policy and Traditional Medicine Practitioners Code of Conduct in August 2009.In Zimbabwe, the colonial government and Christian missionaries who established western medical institutions discouraged traditional healers and medicine.Waite (2000) documents the trajectory of traditional healers in fighting for legal recognition until the start of the new Mbereko and Mahlatini 137 millennium, when they were legally recognised.
The biomedical hospitals mandated with people's health charge consultation fees that range from $3 to $10 depending on the health centre.For example, Kariba Hospital charges $5 as consultation fees while Harare Hospital charges $10.Furthermore, patients pay for all medical procedures and drugs with the exception of antiretroviral (ARV) and tuberculoses (TB) drugs.HIV testing, counselling, treatment and CD4 counts are free of charge in public health institutions.This is due to resources from the government through the AIDS Levy, as well as development partners such as USAID, Global Fund, Elizabeth Glaser Pediatric AIDS Foundation, UK AID.Besides these subsidised conditions, treatments of other opportunistic infections (like sexually transmitted Infection, K. Sarcoma) are charged on the patient.Thus, traditional medicine complements and also acts as a cheaper medical care.
Today, the AIDS epidemic has challenged and changed traditional healers' role and their practices (Richter, 2003).Literature points to the fact that in Africa HIV and AIDS patients utilise both the biomedical and traditional medical systems (Green, 1994;Jackson, 2002;UNAIDS, 2006;Kaboru, 2007).Literature reviewed identified gaps on the roles of traditional healers in the fight against HIV and AIDS.It is against this background that the study investigated the role of the traditional healers in the fight against HIV and AIDS in Zimbabwe.Specific variables to be addressed include the following: exploring perceptions, attitudes and knowledge of traditional healers regarding HIV and AIDS; to explore perceptions and attitude of community to traditional healers and their practices: to identify traditional healers clientele and practices used in the care and support of HIV and AIDS victims and examine opportunities for integration of traditional and formal medicine and practice.

METHODOLOGY Study context and setting
The study was conducted in Nyamhunga high-density suburb of Kariba.Kariba town is situated in the North-western border of Zimbabwe and Zambia.The town is situated in a national parks area.The town developed into an urban area after the construction of Kariba Dam wall across the Zambezi River in the late 1950s.The main purpose for constructing the dam was hydroelectric power generation.Kariba town is the capital of Kariba District, which stretches along the shorelines of Lake Kariba.In addition to hydroelectricity generation, other uses of the reservoir developed like fisheries, boating, game industry and supply of drinking water.The majority of people employed in Kariba are engaged in natural resources and wildlife related activities such as fisheries (including aqua-culture), fish farming, hunting, tourism, crocodile farming and tertiary service firms (shops, banks e.t.c).
Kariba has a population of +/-80 000.Nyamhunga suburb was estimated to have about 1 400 households, subdivided into three locations, namely Nyamhunga 1, 2 and 3. Kariba is a multi-cultural society including the Tonga, Shona, Chewa and Ndebele ethnic groups.Like the rest of the country, it has the traditional health system made up of traditional and herbal healers and the formal health system.The burden of HIV and AIDS is high with a prevalence of 23% in 2008.

Sampling
The study target population included local authorities, leaders of faith-based organisations, Zimbabwe National Traditional Healers Association (ZINATHA), community members and organisations that deal with HIV and AIDS issues.Due to constraints in resources, one suburb was selected using random sampling.Random sampling was done in Nyamhunga 1 to select 80 households out of 601, which participated in the household survey.Kariba household municipal records were used to create the sampling frame.The Statistical Package for Social Scientists (SPSS) was used to draw a randomised group of respondents.The most senior member of the household was the respondent disregarding sex.The most senior was preferred since the questions asked for experiences with traditional healers, which were more than 10 years ago.Mostly elders are the ones who visit traditional healers on behalf of the minors or family, hence their experiences were preferred.Females constituted 73% of the respondents because men were at work at time of interview, others had travelled for work in other towns or neighbouring countries and others were deceased.One representative from each of the five organisations (including ZINATHA) that deal with HIV and AIDS were purposively selected to be an interview respondent.The study recruited 8 traditional healers using convenience sampling.Convenience sampling was used for the following three reasons: there were no registers; lack of funds to enumerate the traditional healers; and the traditional healers stay in scattered locations and travel frequently travel to patients homes which are outside Kariba.

Methods
Questionnaire surveys and interviews were used to gather data.Surveys were conducted amongst the community members, while interviews were conducted with traditional healers and organisations representatives.The study made use of questionnaires with both open ended and closed questions.The questionnaire was preferred due to the limited resources and its ability to generate data that is easily quantifiable.The questionnaires were to gather data on knowledge, attitudes, practices, clientele, satisfaction and perceptions of respondents.Traditional healers also responded to a short questionnaire that sought to explore their knowledge levels on HIV and AIDS issues.
Face to face interviews were used in the study because they allow for rapport building and further probing on questions.According to Pons (1992), interviews have the advantage that they allow researchers to gather subjective opinions as well as factual information.A checklist was prepared covering all the variables presented above.In cases where permission was granted a Dictaphone was used to record the interviews.Face to face interviews were held with traditional healers, representative of People Living With HIV and AIDS (PLWHA), Red Cross (homebased care programme), local authorities, leaders of faith-based organisations and Zimbabwe National Traditional Healers Association (ZINATHA).Data collected by interviews covered all the above stated variables.
The research team also did participatory observations if consent was granted.Where strict confidentiality was necessary the researchers kept a reasonable distance.A member of the research team participated as a patient and received herbs to stop diarrhoea.The research team observed things like hygiene, storage facilities, condition of patients, and performance of rituals, clientele and costs.

Data analysis techniques
Field data were cleaned and coded before entering it into a computer package known as Statistical Package for Social Sciences (SPSS).Data were analysed using SPSS and the following analysis was done: Frequencies, significance tests, cross tabulation and generation of graphs.Qualitative data were grouped according to variables addressed.The thematic approach was used to analyse qualitative data.The transcribed data were fragmented and grouped into themes.The data were then entered into computer software called Nnvivo version 9. Connections across themes were established and developed into codes.Nnvivo was used to run word/phrase frequencies in order to quantify responses.The rest of the data was manually interpreted in the codes.

Ethical consideration
The Medical Research Council of Zimbabwe ethics committee approved the study.During execution of the study research ethics were observed.Objectives of the study were described to potential respondents before seeking their consent to participate.Consent was sought before participants were recruited and participants reserved the right to withdraw from the study.

Socio-demography data
Out of the 80 community respondents engaged in the study, 58 were females and 22, males.The study respondents were between 18 and 65 years of age, while most respondents (56%) were between the ages of 25 and 40.About 66% of the respondents had completed secondary school level, 13% had never attended formal school, 13% had attended school to primary level and the remainder attended high school and tertiary education.50% of the 80 respondents were from the middle socioeconomic class, while 45 and 5% were from the low and high classes, respectively.

Perceptions and knowledge levels of traditional healers of HIV and AIDS
Traditional healers were asked to narrate their understanding of HIV and AIDS.The most dominant account indicated that HIV and AIDS always existed in Zimbabwe, since humans settled in the country.
"Numerous charms were used to manage the disease and it was treatable.Today, we are failing to treat it because people mix charms and western medicine.Western medicines weaken the people's immune system.People in the past used to eat wild foods, which were in season, and some of these foods strengthen the body and diseases like AIDS could be treated."Respondent 4 One informant who is a traditional healer also argued that; The interviewed traditional healers knew about HIV and AIDS, but showed lack of adequate knowledge on issues associated with HIV (Table 1).THs were tested for knowledge on medical cure of HIV, ritual cure of HIV, modes of transmitting HIV, who can contract HIV, ARV, access to ARV and opportunistic infections.It is commendable that all the interviewed TH were aware of at least three opportunistic infections, which were considered to be good.Although 45% of THs knew about ARVs, none of them had knowledge on where and how to access them.

Clientele of Traditional healers
Kariba District only has 2 medical doctors versus a population of around 80 000, while TH are estimated to be around 250.The questionnaire survey found that 56% of the 80 respondents had sought help from a TH in the past and 44% had never sought help from a TH.In the past 5 years, only 60% of 45 respondents had sought help from TH. Low-income earners had higher visits to the TH than their counterparts with higher income (Table 2).Numerous reasons for seeking help were indicated as; medical (41%), spiritual problem (36%), barrenness (10%), divination (5%), cleansing of bad omen (5%) and good luck charm (3%).
Amongst the 8 THs interviewed the maximum number of clients per week ranged from 3 to 50.On average, the 8 TH attended to 21 patients per week.Most of these were suspected HIV and AIDS patients because of the opportunistic infections they presented.The TH clients came from Kariba, other parts of the country and from the region (Zambia, Mozambique, Botswana and other countries).Community members who sought help from TH indicated that they travelled less than one kilometre (Km) (36%), 1-10 Km (28%), 11-100 Km (18%), 101-1000 Km (15%) and more than 1001 Km (3%).

The role of traditional healers in prevention, care and support of HIV and AIDS victims
HIV and AIDS patients are increasingly seeking medical and spiritual help from traditional healers.Traditional healers were instrumental in providing care in managing illnesses associated with HIV and AIDS.One traditional healer claims to have charms that boost the immune system of HIV patients.He narrated his success story with one HIV positive patient: Case 1: A patient who had been diagnosed as having HIV visited me.I prepared some herbs for him.He had to drink 2 litres of the concoction.The patient recovered significantly and one cannot tell if he has the virus.The informant did not know if the patient had gone for CD4 re -testing.
TH ranked sexually transmitted diseases as the most common type of opportunistic infection most patients present with.TH indicated that cases of STI's reported to them are decreasing.All the 8 TH interviewed claimed that their charms were very effective in treatment of STI's especially herpes, syphilis, drop and gonorrhoea.The concoction used in the treatment of STI is locally known as guchu.When wounds dry on the skin the TH administers another charm to make sure the infection is not hibernating.If the infection is still present the charm activates it and further treatment is done.Another TH narrated this incident in an interview, Case 2: A patient went to a traditional healer for help.After having divinated-using hakata (divining bones) the TH learnt that she had an STI and that she needed to get an HIV test as the ailment was said to be natural and she was to die from it.He told her that she had wounds on her private parts and that she should consider going to the hospital for HIV and AIDS testing.According to the TH she sought for help late.However, the TH treated her for STI for a week.When she recovered from the STI's she went to hospital and was put on the ARV Programme.She looks healthy and going about her life normally.
TH claimed that herbs are very effective in the management of tuberculosis, severe headaches, diarrhea, STI's, herpes, cancer, pneumonia and HIV.TH indicated plants and animals where they extract sections to prepare medicine to manage opportunistic infections (Table 3).Traditional healers did not disclose what they considered as special medicine, as the spirits do not allow them.Such medicine can only be disclosed to a patient.They claim that at times the charms are shown in a dream where they are advised of their location and morphology and usually the TH does not know the name of the plant.Such dreams only appear when there is a patient who wants the charm.One TH claims that at times she found charms close to her pillow in the morning without her knowledge.
Amongst those who sought help from the traditional healers, 72% improved, 23% condition did not change, and 5% deteriorated.Cross tabulation of state of patient and condition after treatment shows that those who did not recover were bed ridden when they were attended to (Table 4).Community members who sought help from TH said they sought for help when patient could hardly walk (40%), could walk but ill (30%), not showing signs of illness (17%) and bed ridden (13%).According to interviews with TH most clients come to them after having been at the hospital.Most of the cases are said to seek for help when it is late and little can be done.
THs have been reported to support people on Home-Based Care (HBC) programmes.HBC patients seek the services of TH to treat some medical conditions and to help them with spiritual problems.The commonly reported were interpretation of bad dreams.TH attended to the patients in the presence of their immediate family, which improves family cohesion and also it, has psychological function.It was observed that those patients who were detained for observation and medical treatment by the traditional healers were jovial and hopeful.
THs like all medical practitioners want to prevent the spread of HIV and AIDS.All the traditional healers interviewed highlighted taking precautions like using a new razorblade per patient.It was observed that due to the high prices of razor blades THs either break the razor into four and use each piece per patient or use each of the four corners per patient.The study identified some of the tools and practices of TH and ranked their risk in spreading HIV and AIDS (Table 5).Traditional healers were also using pieces of broken glass for scarification.TH encouraged faithfulness when in a marriage and abstinence before marriage.There were mixed feelings over the use of condoms for prevention.THs appreciate that condoms are the only option now to protect the uninfected.Most of the THs claim that the gods and spirits are not happy with the throwing away of semen, as it is life.Two THs claimed that condoms are the ones that have AIDS.Further condoms have been criticised as being responsible for increased sexual activity and infidelity.Traditional healers expressed their support for the ARV and peer education programmes.

Risks of exacerbating HIV and AIDS associated with traditional healers
Practices and instruments used by traditional healers have frequently been blamed for exacerbating HIV and AIDS.This study explored the instruments and practices of TH in order to identify possible risks posed.The traditional healers use a wide range of instruments that aid them perform certain practices (Table 5).The 45 community members who had sought help from Patients are asked to wash in charms mixed with the water In the case of mamhepo/munyama a client washes with charms and the remaining water is poured at cross roads or in the river.
To contain vomits where it has been induced

Hot ash To burn charms
The practice is called kufukira in shona, it's were by charms are put on hot ash and the patient has to breath the smoke while covered by a blanket.In cases of STI's the nánga (even male ones) examines the wounds on vagina or vice versa a female nánga examine a penis.

Induce pregnancy
Sex is at times used in treatment or diagnosis of infertility Sperms are necessary in treating infertility as they are mixed with charms and have to be inserted into the vagina channel.were blamed for lying or giving false hope, using sharp objects irresponsibly, giving charms for luck or wealth and using human parts in rituals (Table 6).

High
Interviews with TH showed that 75% (n=8) have never referred any patient to the hospital.The traditional healers would administer charms before referring to hospital (see case two).Three have however referred patients to other THs for treatment.Those who have never referred anyone said they have not met conditions that they have failed to deal with that needed the hospital.Twenty six percent of the respondents who went to TH were referred to another practitioner.Out of those referred 46% were referred to another TH, 36% to hospital and 18% to faith healer.One traditional healer said a patient or the family will move their patient from one TH to another until they get one who can treat the illness or until the patient dies.

DISCUSSION
HIV and AIDS haves caused havoc in Africa; the potential of traditional medicine and therapies in the fight against the pandemic is under-utilised (Sekagya et al., 2006).Previous studies in Zimbabwe on traditional therapies have focused on toxicity (Kasilo and Nhachi, 1992), efficacy of herbs and general practices (Gelfand et al., 1985).The present study examined the role of traditional therapists in the fight against HIV and AIDS.Results of this study agree with others before it in that urban communities particularly the poor utilize TH for primary health care, treatment of opportunistic infections and management of HIV (Mhame et al., 2005).The numbers of patients attended to by TH in Kariba are significant.The respondents highlighted a number of reasons why they sought for help from TH, which include medical, spiritual, rituals, good luck charms and divination.The formal health system is often avoided because it cannot take a holistic approach to health (including spiritual problems), it is too expensive and payment terms are not flexible.The numbers of PLWHA seeking for help from TH will probably increase due to cultural acceptability, desperation created by the Home Based Care programme, efficacy of some herbs and the deepening poverty levels.
Traditional healers play an important role in palliative care for people living with HIV/AIDS by caring for patients as complete persons within their family and community context.According to Sekagya et al. (2006), most traditional healers use herbal medication, though they may also use psychosocial therapies, cosmic and meta/parapsychic interactions, simple surgical procedures, rituals, and symbolism.Psychosocial support, rituals and symbol-lism have been shown to have a positive impact on the patients.The language and symbols used are usually common to the patients and their cultural setting.High satisfaction was noted amongst study participants who had sought for help from traditional healers, despite indicating poor quality of service environment.This study has proved that although THs might not be able to cure illnesses, but they make their patients believe in recovering health and it helps them psychologically.Some patients welcomed family counselling.Guidance and counselling is an area Zimbabwean HIV and AIDS behaviour change framework can tap from the THs.However, currently very little is being done to involve TH in such situations in areas that they can be useful in the health delivery system.Furthermore, it is important to recognize the role of herbal therapies in management of sexual transmitted diseases (STD's), diarrhea and charms that increase CD4 counts.The study encountered people who had improved from STD's and diarrhea by using traditional therapies.The results demonstrate that none of those who sought for help early deteriorated, unlike those who sought for help late.About 50% of patients who sought for help from TH when bed ridden, improved to the extent of going about their normal life duties.Only 5% of the patients taken to TH for treatment deteriorated their conditions.Similar trends, where patients improve from taking traditional therapies have been noticed in Tanzania (Kayombo, 1999) and South Africa (Viall, 2005).
In conclusion, this study argues for the 'optimists' view point that traditional healers are playing a positive role in fighting HIV and AIDS as shown by accounts of patients whose conditions improved and their claimed role in treatment of STI's.Furthermore, traditional healers are important for palliative health, psychosocial support and spiritual health especially for HIV and AIDS infected and affected people.This study has explored the role of traditional healers in fighting HIV and AIDS in Kariba.Their herbs and counselling sessions have been said to be very helpful to the patient and their families.On the other hand, the study results showed practices and instruments used by traditional healers that could exacerbate the pandemic.
Further wrong perceptions and low knowledge of HIV could disqualify the traditional healers as key stakeholders in the fight against HIV and AIDS.However, if the two sides are weighed there is more credit in believing that traditional healers are playing a much positive role in care and supporting HIV and AIDS infected and affected households.

POLICY RECOMMENDATIONS
It should be acknowledged that the study was small but it brought out important policy issues.The study makes the following recommendations to policy makers: Collaboration between traditional medicine and biomedical practices in health issues in general and HIV in particular can be of great benefit to the patients.However, Kaboru (2007) argues that colliding views of these two worldviews complicates collaboration.Traditional healers can be involved in counselling and some of their potent medicines can be used in the management of opportunistic infections.
Trainings and campaigns aimed at discouraging use of toxic herbs/ charms and HIV and AIDS high-risk practices should be prioritised.Zimbabwe could benefit from the experiences of South Africa, Zambia Tanzania and others where THs have been trained and collaborated with formal health systems (Kayombo et al., 2007).
More research is needed in the area of traditional medicine.Kanyombo et al. (2007) have cautioned that collaboration models need to be improved because the concept is easier said than done.

Table 1 .
Knowledge levels of Traditional healers on HIV related issues.

Table 2 .
Cross tabulation of socio-economic class and seeking for help from TH.Not all traditional healers agree with the notion that HIV always existed in Zimbabwe.It was alleged that HIV came with the white men.When the whites came into Zimbabwe they introduced a lot of diseases to the local population.HIV was not spread at this time because of the absence of cross-racial sex, prior to 1980.More African people die from HIV than Whites because their bodies have become accustomed to the virus (Respondent 8).

Table 3 .
Diseases identified by community and TH and constitution of herbs used in their management.

Table 4 .
Cross tabulation of conditions of patient after treatment and the state of the patient before treatment.

Table 5 .
Ranking risks to HIV transmission associated with instruments and practices of TH.

Table 6 .
TH practices to be encouraged and to be discouraged.