Traditional Healer-initiated HIV Counseling and Testing in South Africa
Phase: NA
Conditions: HIV Infection
Sponsor: Vanderbilt University Medical Center

Tr a diti o n al  h e aler -initi at e d HI V  co u n s eli n g a n d  t e sti n g i n r ur al So ut h  Afri c a
N C T 0 5 0 7 9 3 4 7 
O ct o b er 2 0, 2 0 2 2
C ar ol y n M.  Au d et,  Ph D,  M S c 
A s si st a nt Pr of e s s or 
D e p art m e nt  of He alt h P oli c y 
I n stit ut e f or Gl o b al H e alt h 
V a n d er bilt  U ni v er sit y, N as h vill e  U SA 
R y a n G.  Wa g n er,  P h D,  M S c( M e d) 
R e s e ar c h F ell o w  & Tri al s Ma n a g er 
M R C/ Wit s - Agi n c o urt  Re s e ar c h U nit 
U ni v er sit y  of  th e Wit w at er sr a n d,  J o h a n n e s b ur g 

 
2 
1. Introduction 
In 2019, 7.97 million South Africans (22.7% of adults) were living with HIV. Uptake of HIV testing 
has been undermined by a combination of factors, including HIV stigma, distrust in the health 
system, skepticism toward allopathic medicine, a preference for traditional medicine, and distance 
to the nearest health facility.1-9 The unique sociocultural identities and generalized HIV epidemic 
in South Africa may require a focus on different socially stigmatized categories. Community 
members with low socioeconomic status (SES),10-12 as well as those who are male,13,14 
younger,15,16 immigrants,17 harbor distrust toward allopathic medicine,18 and those with higher 
anticipated HIV stigma14 are more likely to seek care from a traditional healer and have lower 
odds of, or delayed, HIV testing.19-21 Innovative campaigns aimed at testing individuals who are 
less likely to visit health facilities include: home-based testing,22 testing in bars,23,24 testing at 
sports events,25 and distribution of self-testing kits.26 All are available in many parts of rural South 
Africa. These interventions, while yielding successes, still miss 12-20% of the population.27-30 
South Africa has made progress towards their 90-90-90 targets, yet a substantial proportion of 
the population do not test regularly;31 only 33.9% of adults in rural Agincourt, Mpumalanga 
province (our study population, and the province with the second highest HIV prevalence in the 
country32) received an HIV test in the past year.33 Interventions that engage those with one or 
more of the above overlapping demographics/characteristics are needed to maximize HIV 
prevention. 
Annual community-based HIV testing, mobile testing, self-testing and clinic-based testing 
opportunities are available to people living in Agincourt, South Africa. Despite these ongoing 
efforts, testing uptake remains low. People with low SES, high levels of HIV stigma, immigrants, 
men, and those who distrust the allopathic health system are less likely to receive regular HIV 
testing and more likely to visit a traditional healer. In 2019, 7.97 million South Africans (22.7% of 
adults) were living with HIV32 with women bearing a disproportionate burden (26.6% among 
females vs. 14.8% among males).31 Though women bear a larger HIV burden, rural South Africa’s 
“hidden HIV population” comprises patients that the allopathic health system fails to reach. In 
Mpumalanga province, only 33.9% of adults aged 15-59 received an HIV test in the past year.33 
Undiagnosed HIV infection is highest among men, those with low SES, those with high perceived 
HIV stigma, and those who believe a traditional healer can cure HIV or deny the existence of the 
disease.1-3,11,14,34-37 Fear of stigma and discrimination, harmful gender norms, confidentiality fears, 
and a lack of policies supporting these populations render them reluctant to utilize clinic-based 
testing.21,38-43 We propose to create a new testing option to test those individuals for whom other 
testing mechanisms fail.   
While extremely successful, community-based HIV testing is still refused by 12-20% of the 
population. In a rigorous systematic review of 117 community-based testing strategies in 16 
African countries, index, self, mobile, and door-to-door testing achieved the highest uptake (88%, 
87%, 87% and 80%, respectively).27 While we have eliminated the need for people to travel for 
their test (e.g. mobile testing), ensured confidentiality (self-testing), and targeted those at high-
risk (index testing), South Africa still has a testing and linkage to care gap among difficult to reach 
subpopulations.28-30 People who perceive, experience or internalize stigma or other forms of 
marginalization are more likely to utilize traditional healers, less likely to seek care at a health 
facility, and less likely to undergo HIV testing. 20,44-49 
Stigma continues to impact HIV testing uptake but needs to be addressed in a broader context. 
A review by Musheke of qualitative factors impacting uptake of HIV testing in sub-Saharan Africa 
(SSA) found structural (health care organizations, delivery, and costs), social (HIV stigma), and 
individual belief (trust, health belief) factors all served as barriers to HIV testing (Figure 1).50 It 
further concluded that HIV stigma is “inextricably linked” with gender, reproductive norms and 
economic support, suggesting that in SSA, where much of the HIV epidemic remains generalized, 
a broad assessment of HIV stigma in the context of gender norms and SES is needed. Individuals 

 
3 
who are already marginalized from society or the health care system (low SES, immigrants, men) 
may be even more vulnerable to the negative impact of HIV stigma. Yet few studies have 
addressed this broader context of stigma.  
In Nigeria, Babalola et al.51 found that among women, individual-level HIV stigma was negatively 
associated with willingness to test for HIV, while among men, community-level HIV stigma was 
negatively associated with a willingness to test. More recently in South Africa, and in contrast to 
Babalola et al., Treves-Kagan et al.14 found that community-level HIV stigma was negatively 
associated with HIV testing among women, while individual-level stigma was associated with low 
HIV testing among men. These studies highlight the complex nature of stigma and the large gap 
that exists in our understanding of its impact on testing. Given low levels of testing among some 
subgroups, interventions should simultaneously address this confluence of factors (stigma, 
gender, SES, health care system barriers, mistrust) to maximize HIV prevention interventions.  
Traditional healers see patients who avoid allopathic health services, including those who refuse 
HIV testing. Patients report a general preference for traditional healers, given their fluency in local 
language, the length of time they spend with patients, the respect they show patients, the cultural 
congruity to their diagnosis, and their proximity to the patients.38,47,48,52-55 Reports of poor treatment 
by health care providers are common in SSA, often resulting in patients refusing or delaying 
allopathic health services and/or seeking alternative health services.18,20,39  Men, immigrants, and 
those with low SES most frequently report poor treatment at the health facility or report that the 
health system is not designed for their needs.14,15,56  People who first visit a traditional healer for 
HIV-associated symptoms before seeking an HIV test are delayed 2.4 times longer in seeking 
health services than those who do not.21 Among patients enrolled in HIV care and treatment, a 
preference for traditional medicine impacts their treatment decisions: patients who report use of 
both traditional and allopathic services are 45% less likely to enroll in antiretroviral therapy (ART) 
services.54    
Healers are respected members of their communities, play an integral role as informal referral 
agents to the South African health system,47,48,57 and act as supportive providers to patients living 
with chronic disease, if effectively engaged.58-61 In rural South Africa, traditional healers provide 

 
4  
p h y si c al a n d p s y c h ol o gi c al s er vi c e s t o > 8 0 % of t h e p o p ul ati o n. 6 2  T h er e  ar e m or e t h a n 2 0 0, 0 0 0 
tr a diti o n al h e al er s i n S o ut h Afri c a, b ut o nl y 4 6, 0 0 0 r e gi st er e d p h y si ci a n s   (> 2 0: 1 r ati o )6 3  w h o 
pr o vi d e  s er vi c e s  f or  a  m yri a d  of  di s e a s e  c o n diti o n s,  i n cl u di n g  HI V,  T B,  m al ari a,  e pil e p s y,  
s c hi z o p hr e ni a, a n d d e pr e s si o n. 4 8 ,5 2 ,5 3 ,5 7  Gi v e n t h e l e v el of tr u st i n t h e c o m m u nit y a n d t h e n u m b er s 
of h e al er s, 6 4 ,6 5  p art n er s hi p s  m a y f a cilit at e di a g n o si s a n d li n k a g e t o c ar e vi a t h e cr e ati o n of u ni q u e 
t e sti n g l o c ati o n s.6 2 ,6 6 -7 1  It i s u p t o r e s e ar c h er s a n d h e alt h c ar e pr o vi d er s t o o v er c o m e o ur o w n 
bi a s e s a n d/ or pr ej u di c e s a g ai n st t hi s w or kf or c e t o d e v el o p a n eff e cti v e str at e g y t o i n cr e a s e t e sti n g 
u pt a k e.  
Tr a diti o n al h e al er s c a n bri d g e t h e t e sti n g g a p b et w e e n “ n o n -t e st er s” a n d t h e all o p at hi c h e alt h 
s y st e m.  Tr a diti o n al h e al er s h a v e b e e n s u c c e s sf ull y e n g a g e d i n h e alt h s y st e m s t o pr o m ot e c ar e 
li n k a g e a m o n g p e o pl e li vi n g wit h di a b et e s, T B, HI V, m al ari a, a n d m e nt al ill n e s s- m a n y of w h o m 
i niti all y  di d  n ot  b eli e v e  i n  t h eir  all o p at hi c  di a g n o si s  u ntil  a  h e al er  c o n vi n c e d  t h e m  t h at  t h eir  
c o n diti o n w a s n ot c a u s e d b y a c ur s e. 4 ,5 8 ,6 1 ,7 2 -8 4  T h o s e w h o ar e h e sit a nt t o t e st n e e d a tr u st e d a n d 
c ult ur all y c o n c or d a nt 8 5 -8 7  pr o vi d er (tr a diti o n al h e al er) t o b ot h v o u c h f or a n d d eli v er t h e HI V t e st, 
a n d t h e s a m e pr o vi d er t o cr e at e a bri d g e t o t h e all o p at hi c h e alt h f a cilit y, pr o vi di n g a m et a p h ori c al 
“ s af e s p a c e” f or t h e p ati e nt w hil e t h e y tr a n siti o n t o HI V c ar e. Tr a diti o n al h e al er s ar e str o n gl y 
m oti v at e d  t o  pl a y  t hi s  r ol e  f or  t w o  r e a s o n s:  ( 1)  B ett er  p ati e nt  h e alt h  o ut c o m e s  ar e  str o n gl y  
c orr el at e d wit h p er c ei v e d q u alit y of tr a diti o n al h e al er c ar e. H e al er s d o n ot w a nt t o b e a s s o ci at e d 
wit h hi g h l e v el s of m or bi dit y or m ort alit y, a s it i s b a d f or b u si n e s s; 8 8  a n d ( 2) H e al er s ar e e x cit e d at  
e x p a n di n g t h eir p u bli c h e alt h s er vi c e s . A s all o p at hi c m e di c al k n o wl e d g e  i s di s s e mi n at e d , h e al er 
vi e w s o n di s e a s e c a u s ati o n ar e e x p a n di n g t o i n cl u d e t h e g er m t h e or y of di s e a s e. 8 9 ,9 0  P ati e nt s ar e 
o p e n t o t hi s p art n er s hi p, gi v e n t h eir i n cli n ati o n t o pi n g -p o n g b et w e e n t h e t w o s y st e m s d e p e n di n g 
o n t h eir n e e d s. 4 7 ,8 8  
 
2. O bj e cti v e s  
T h e o bj e cti v e of t hi s pr o p o s al i s t o c o n d u ct a pil ot t e st of a pr o gr a m ai m e d at tr ai ni n g tr a diti o n al 
h e al er s  t o  c o n d u ct  HI V  t e sti n g  a n d  i m pl e m e nti n g  HI V  t e sti n g  a m o n g  p e o pl e  li vi n g  i n  
B u s h b u c kri d g e, S o ut h Afri c a .  
Pil ot H e al er -i niti at e d HI V t e sti n g u pt a k e a n d li n k a g e t o pr e v e nti o n s er vi c e s. Tr u st  i n all o p at hi c 
h e alt h c ar e a n d HI V sti g m a will b e m e a s ur e d a m o n g p arti ci p a nt s at st u d y e nr oll m e nt a n d at m o nt h 
s e v e n.  
H y p ot h e si s : HI C T will i n cr e a s e tr u st i n all o p at hi c h e alt h c ar e a n d r e d u c e HI V sti g m a.  
 
 
 
 
4. St u d y P o p ul ati o n  
P o p ul ati o n  
Tr a diti o n al  h e al er s,  p e o pl e  s e e ki n g  c ar e  fr o m  tr a diti o n al  h e al er s,  a n d  bi o m e di c al 
pr a ctiti o n er s  (i n cl u di n g cli ni ci a n s a n d n ur s e s) pr o vi di n g p ati e nt c ar e i n t h e B u s h b u c kri d g e ar e a.  
I n cl u si o n Crit eri a 
1. Tr a diti o n al h e al er s > 1 8  y e ar s of a g e, w h o ar e r e gi st er e d a s tr a diti o n al h e al er s wit h t h e 
g o v er n m e nt of S o ut h Afri c a, ar e c urr e ntl y pr a cti ci n g i n t h e B u s h b u c kri d g e ar e a, a n d  ar e 
tr ai n e d t o pr o vi d e HI V t e sti n g.  
2. Bi o m e di c al pr a ctiti o n er s > 1 8 y e ar s of a g e, w h o ar e c urr e ntl y pr o v i di n g  HI V-r el at e d 
h e alt h c ar e s er vi c e s t o p ati e nt s at g o v er n m e nt or pri v at e h e alt h f a ciliti e s i n B u s h b u c kri d g e.  
3. C o m m u nit y m e m b er s > 1 8 y e ar s  of a g e, w h o h a v e n ot r e c ei v e d a n HI V t e st r e s ult i n 
t h e p a st y e ar a n d  w h o c urr e ntl y li v e i n B u s h b u c kri d g e.  
 

 
5 
Exclusion Criteria 
1. Traditional healers who do not pass their HIV counseling and testing certification.  
2. Biomedical practitioners who do not interact with patients seeking treatment for HIV.   
3. Community members who are not out sound mind or body during the recruitment 
(inebriated, too sick to leave the house) and community members with a previous positive 
HIV test result.  
 
Calculation of Sample Size & Sampling Strategy  
We anticipate approximately 5%, perhaps 10%, of study participants will test positive for HIV 
and not be eligible for the analysis of health facility HIV testing within 6 months among those 
testing HIV negative or refusing testing. We further estimate that 70% will complete the 
healer-initiated HIV test, 60% will participate in additional counseling sessions, and 50% will 
attend an open house. Because study participants had no history of HIV testing in the prior year, 
we anticipate the primary endpoint of uptake of HIV testing at the health facility will be low, 
approximately 30%. Finally, given the importance of identifying sub-groups which may benefit 
the most from the intervention components, we have powered our study to detect significant 
associations within strata of potential modifiers (e.g., gender). We utilized Stata psim command 
to conduct 500 simulations each for all combinations of the parameters described above to 
estimate power to detect a range of RRs. 
 
Given our sample size of 600 study participants, with 5% testing HIV+, and for a modifying 
variable distributed 50%/50%, we have ~90% power to detect stratum-specific RRs of 2.0 for 
each intervention component (Table 1). We still retain >80% power to detect RRs of 2.25 even if 
uptake of HIV testing in control group is as low as 20%. Similarly, if the modifying variable is 
distributed 40%/60%, we retain ≥80% power to detect stratum-specific RRs of 2.0 (Table 2). 
Thus, the high power due to our sample size allows for robust assessment and identification of 
intervention associations within key subsets of participants (gender, stigma, etc.). 
 
Given that we only anticipate 10-30 participants to test HIV+, we will be underpowered to detect 
a meaningful association for how the intervention components associate with uptake of ART 
services at the health facility within three months among those testing HIV positive. However, 
the proportion testing positive, the proportion linking to ART care, and the magnitude of the RR 
for the intervention components will provide important preliminary data for whether this 
intervention improves ART care and retention, and not just linkage to HIV prevention services 
(such as follow-up HIV testing in those who are negative). 
 
Table 1.  
Stratum 
specific 
sample size* 
Baseline uptake 
of health facility 
HIV testing 
Intervention 
component 
distribution 
Power for relative increase in HIV testing 
uptake among those with the intervention 
component vs. those without 
RR=1.75 
RR=2.0 
RR=2.25 
135 
20% 
40% 
0.484 
0.702 
0.856 
50% 
0.458 
0.724 
0.868 
60% 
0.432 
0.622 
0.824 
70% 
0.346 
0.576 
0.762 
135 
25% 
40% 
0.628 
0.852 
0.954 
50% 
0.596 
0.832 
0.952 
60% 
0.604 
0.814 
0.964 
70% 
0.501 
0.708 
0.874 

 
6 
135 
30% 
40% 
0.772 
0.924 
0.994 
50% 
0.738 
0.928 
0.996 
60% 
0.726 
0.924 
0.998 
70% 
0.592 
0.850 
0.976 
135 
35% 
40% 
0.868 
0.990 
1.000 
50% 
0.832 
0.974 
1.000 
60% 
0.830 
0.980 
1.000 
70% 
0.744 
0.952 
0.996 
135 
40% 
40% 
0.922 
1.000 
1.000 
50% 
0.924 
1.000 
1.000 
60% 
0.932 
1.000 
1.000 
70% 
0.852 
0.990 
1.000 
*N=135 assumes ~10% test HIV+ and are excluded and the remaining participants are divided equally 
into two strata of a modifier (e.g., 50% female) 
Table 2. 
Stratum 
specific 
sample size* 
Baseline uptake 
of health facility 
HIV testing 
Intervention 
component 
distribution 
Power for relative increase in HIV testing 
uptake among those with the intervention 
component vs. those without 
RR=1.75 
RR=2.0 
RR=2.25 
115 
20% 
40% 
0.464 
0.660 
0.814 
50% 
0.412 
0.596 
0.802 
60% 
0.346 
0.536 
0.770 
70% 
0.298 
0.468 
0.654 
115 
25% 
40% 
0.574 
0.780 
0.928 
50% 
0.546 
0.782 
0.932 
60% 
0.536 
0.746 
0.898 
70% 
0.412 
0.624 
0.820 
115 
30% 
40% 
0.646 
0.896 
0.974 
50% 
0.676 
0.902 
0.986 
60% 
0.638 
0.852 
0.958 
70% 
0.516 
0.796 
0.934 
115 
35% 
40% 
0.796 
0.972 
0.998 
50% 
0.802 
0.972 
0.998 
60% 
0.716 
0.958 
0.998 
70% 
0.638 
0.910 
0.994 
115 
40% 
40% 
0.908 
0.992 
1.000 
50% 
0.914 
0.996 
1.000 
60% 
0.858 
0.990 
1.000 
70% 
0.794 
0.986 
1.000 
*N=115 assumes ~5% test HIV+ and are excluded and the remaining participants are divided unequally 
into two strata of a modifier (e.g., 40% female or other modifier) 
 
 
5. Methods 

 
7  
M e a s ur e m e nt of R e s ult s  
C o m m u nit y m e m b er (t h o s e off er e d HI V t e sti n g) a n d h e al er  o ut c o m e s: P arti ci p a nt s will c o m pl et e 
b ot h a b a s eli n e a n d 7 -m o nt h p o st -e nr oll m e nt q u e sti o n n air e u si n g t h e A C A SI -s y st e m o n a t a bl et. 
D at a c oll e cti o n at 7 m o nt h s will i n cl u d e t h e b a s eli n e s ur v e y a n d a d diti o n al q u e sti o n s a b o ut u pt a k e 
of HI V t e sti n g o ut si d e of t h e st u d y a n d f e e d b a c k a b o ut t h e a c c e pt a bilit y a n d s ati sf a cti o n wit h t h e 
st u d y e x p eri e n c e. T h e s e will b e c o n d u ct e d b y a st u d y a s si st a nt b a s e d i n t h e A gi n c o urt ar e a  w h o 
i s fl u e nt i n E n gli s h a n d xi-T s o n g a. T h e n u m b er of p arti ci p a nt s a p pr o a c h e d, t h e n u m b er w h o a gr e e 
t o t e sti n g a n d c o u n s eli n g (i n cl u di n g t e sti n g o ut c o m e), a n d r e p ort s o n t h e i m p a ct of p erf or mi n g 
HI V t e sti n g a n d c o u n s eli n g o n h e al er i n c o m e will b e c oll e ct e d b y t h e tr a diti o n al h e al er. H e alt h 
cli ni c r e s e ar c h st aff will c oll e ct u pt a k e of t e sti n g d uri n g o n e of t h e “ O p e n H o u s e” e v e nt s a n d d uri n g 
n o n -o p e n h o u s e d a y s (if, f or e x a m pl e a p ati e nt s e e k s t e sti n g d uri n g r e g ul ar cli ni c h o ur s ). Cli ni c al 
d at a will b e a c c e s s e d u si n g “ Cli ni c Li n k” w hi c h all o w s u s t o g ai n a c c e s s t o r el e v a nt cli ni c al d at a , 
i n cl u di n g A R T u pt a k e a n d r et e nti o n i n c ar e. D at a fr o m cli ni c al pr o vi d er s w h o p arti ci p at e i n t h e 
sti g m a r e d u cti o n i nt er v e nti o n will c o m pl et e s ur v e y s at st u d y i niti ati o n a n d i m m e di at el y aft er t h e 
st u d y h a s c o n cl u d e d.  
T a bl e 3: O ut c o m e s  
Tr a diti o n al H e al er O ut c o m e s  
A c c e pt a bilit y E n d p oi nt s :  ( 1)  P er c e nt  of  eli gi bl e  h e al er s  w h o  e nr oll  i n  t h e  tr ai ni n g  pr o gr a m  a n d  ( 2)  
A c c e pt a bilit y of t h e i nt er v e nti o n s c al e ( a s u s e d i n Ai m 2).  
F e a si bilit y E n d p oi nt s: ( 1) P er c e nt of h e al er s w h o c o m pl et e tr ai ni n g, ( 2) C h a n g e i n s elf-r e p ort e d h e al er 
i n c o me, a n d ( 3) F e a si bilit y of t h e i nt er v e nti o n ( a s u s e d i n Ai m 2).  
P ati e nt O ut c o m e s  
Pri m ar y C o nti n u u m of C ar e E n d p oi nt s:  ( 1) U pt a k e of h e alt h f a cilit y HI V -t e st at 6-m o nt h s (if pr e vi o u sl y 
n e g ati v e or r ef u s e d t e st), ( 2) U pt a k e of A R T s er vi c e s, if p o siti v e.  
S e c o n d ar y E n d p oi nt s: ( 1) Mi str u st t o w ar d s t h e all o p at hi c h e alt h s y st e m, ( 2) C h a n g e i n l e v el s of HI V-
r el at e d sti g m a a m o n g t h o s e w h o t e st n e g ati v e, ( 3) C h a n g e i n l e v el s of c o n s pir a c y b eli ef s 
F e a si bilit y O ut c o m e: ( 1) U pt a k e of h e al er -b a s e d HI V t e sti n g  
 
Cli ni ci a n o ut c o m e s :   
W e will a s s e s s b a s eli n e, mi dt er m ( aft er t h e fir st tr ai ni n g) a n d e n d li n e ( aft er t h e s e c o n d tr ai ni n g) 
sti g m a l e v el s a m o n g pr o vi d er s u si n g a Li k ert -st yl e s c al e t h at will a s s e s s attit u d e s t o w ar d s P L HI V, 
tr a diti o n al  h e al er s  ( a n d  h e al er s  pr o vi di n g  HI V  t e sti n g  i n  t h e  c o m m u nit y),   p e o pl e  w h o  u s e  
tr a diti o n al h e al er s, s e x w or k er s, m e n w h o h a v e s e x wit h m e n, i m mi gr a nt s, y o u n g pr e g n a nt w o m e n 
w h o ar e n ot m arri e d, a n d s e x w or k er s. W e will a s k if h e alt h c ar e w or k er s: ( 1) w o ul d pr ef er t o n ot 
pr o vi d e s er vi c e s; ( 2) b eli e v e t h at s u b -p o p ul ati o n s p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V; ( 3) 
a gr e e  t h at  s p e cifi c  p o p ul ati o n s  e n g a g e  i n  i m m or al  b e h a vi or;  a n d  ( 4)  a gr e e  t h at  s p e cifi c  
p o p ul ati o n s d e s er v e t h eir HI V di a g n o si s.  
 
St u d y Pr o c e d ur e s  
P arti ci p a nt s will b e r e cr uit e d a m o n g t h o s e w h o pr e s e nt f or h e alt h c ar e s er vi c e s fr o m o n e of o ur 
tr a diti o n al h e al er s tr ai n e d i n c o n d u cti n g HI V c o u n s eli n g a n d t e sti n g. P arti ci p a nt s will b e r e cr uit e d 
aft er t h eir h e al er c o n s ult ati o n i s c o m pl et e d t o e n s ur e w e d o n ot i m p a ct t h eir s er vi c e s. H e al er s will 
s cr e e n p ot e nti al p arti ci p a nt s f or eli gi bilit y ( n o HI V t e st i n p a st y e ar, o v er 1 8 y e ar s of a g e, li v e i n 
A gi n c o urt) a n d if t h e y ar e eli gi bl e, t h e h e al er s will a s k if t h e y ar e willi n g t o p arti ci p at e i n a r e s e ar c h 
st u d y. H e al er s will st at e cl e arl y t h at t h er e i s n o o bli g ati o n t o p arti ci p at e a n d t h at c h o o si n g n ot t o 
p arti ci p at e will i n n o w a y i m p a ct t h eir h e alt h c ar e fr o m t hi s tr a diti o n al h e al er. H e al er s will c o n s e nt 
p arti ci p a nt s vi a a n o nli n e c o n s e nt f or m vi a t a bl et, s o all c o n s e nt f or m s will b e o nli n e a n d b a c k e d 
u p t o t h e s e c ur e V a n d er bilt R E D C a p cl o u d.   
 

 
8 
Training Activities 
To enable traditional healers to acquire the skills necessary to undertake home-based HIV testing 
as well as HIV coping skills counseling, traditional healers selected to participate will enroll in a 
2-week course used with HIV counselors that includes certification to conduct HIV counselling 
and testing and basic lay counseling to develop patient coping strategies. During the testing and 
counseling course, 9 topics will be covered including: 1) epidemiology and pathophysiology of 
HIV/AIDS and disease stages, 2) attitudes and social views of HIV, an introduction to HIV 
counselling and testing, legal and ethical issues of HIV and HIV testing, 3) pre- and post- test 
counselling, 4) performing an HIV rapid test and interpretation of the results, 5) psychological 
stress as a result of a positive test, 6) identifying depressive symptoms (and how to refer a patient 
to psychological services), 7) referral and management of HIV, 8) counseling patients on primary 
and secondary prevention methods (including condom use, Pre-Exposure Prophylaxis [PrEP]) 
after HIV testing) and 9) safe disposal of HIV testing equipment. Counseling support will include 
the development of coping strategies to overcome the negative effects of HIV stigma, risk 
reduction, and linkage with appropriate community organizations.91  
The course content will be delivered in an iterative fashion and trainees will have ample 
opportunity to ask questions with facilitated discussions. Traditional healers/trainees will be asked 
to orally respond to questions posed by the trainer throughout the training to gauge 
comprehension as new concepts are introduced. More formally, both a written and practical 
assessment will be administered. The trainee will be required to pass to be considered proficient 
to undertake HIV counselling and testing. Fidelity to the intervention, including the safety of the 
intervention for those tested by the healers, will be monitored via monthly observation using a 
checklist of procedural activities. This same mechanism is currently employed with community 
health workers who are providing home-based HIV counseling and testing, to which we have not 
experienced any difficulty implementing.  
Health care providers will receive training in stigma reduction and structural changes to engage 
these previously stigmatized populations. We will focus on four essential elements identified by 
Nybalde92,93 (1) Participatory learning via the provision of information about the impact of stigma 
on health care outcomes and; (2) Skill building activities (communication, openness) with health 
care providers to develop skills to work with stigmatized populations (3) Contact with the 
stigmatized group, including healers and their patients via testimonials and (4) group activities to 
develop empathy, humanize this stigmatized group, and break down stereotypes. 
The stigma reduction training will be conducted by clinician-trainers based at the University of 
the Witwatersrand. The first part of the training will include an initial two-day training followed by 
a one-day training two months later that include the following components:  
 
Title of 
exercise/session 
Educational technique 
Intended learning outcomes  
1. Naming stigma 
through pictures 
In this session, prepared pictures based on 
personal stories of stigma are viewed. 
Then, the participants discuss and analyze 
the forms, causes, and effects of stigma.  
Participants discuss what similar 
stigma takes place in different 
contexts and start to share stories of 
what they have personally 
witnessed.  
2. Our own experiences 
of stigma 
This exercise asks participants to think 
about a time in their life when they felt 
stigmatized, share this with a partner, and 
discuss with the larger group 
Gives participants a better 
understanding of the personal 
feeling and the long0term impacts of 
stigmatization  
3. Key populations 
stigma problem tree 
Using colored cards and markers, 
participants discuss and write forms of 
stigma faced by key populations at risk of 
HIV. The cards are posted on a wall with 
the causes of stigma representing “roots” 
Helps participants to recognize the 
causes of stigma and how the 
resulting effects are manifested.  

 
9 
of a tree at the bottom, actual forms of 
stigma as the “trunk” of the tree in the 
middle, and effects of stigma as the tree’s 
leaves and branches.  
4. Value clarification 
Participants fill and individual questionnaire 
about their personal values and reflect and 
discuss how these values affect their 
judgement of others.  
Recognition of how personal 
attitudes and beliefs influence 
stigmatizing behavior.  
5. Things people say 
Group brainstorming of what people say 
about different key populations at risk of 
HIV. 
Understanding how language is 
used to stigmatize different 
population subgroups and how 
words may have harmful impacts.  
6. Traditional healers 
and HIV 
Small group discussions about different 
case studies based on health service 
experiences of traditional healers, and 
those who seek services from traditional 
healers.  
Enhanced ability to identify stigma-
related barriers for people who use 
traditional medicine and traditional 
healers to access and receive 
appropriate health services.  
7. Be the change 
Paired role playing to practice challenging 
stigma in the workplace and elsewhere.  
Increased ability to personally 
challenge or change stigmatizing 
attitudes among peers and in other 
situations  
8. Writing a charter for 
stigma-free service 
Small group work discussing ideas to 
promote stigma-free health services. Ideas 
are promoted in a larger group, and ways 
forward are discussed.  
Understanding of how to develop 
ideals for promoting stigma-free 
services when service providers 
return to their workplace.  
Table 5: Stigma Training for providers 
 
Data Collection: Participants will complete both a baseline and 7-month post-enrollment 
questionnaire using the ACASI-system on a tablet. Data collection at 7 months will include the 
baseline survey and additional questions about uptake of HIV testing outside of the study and 
feedback about the acceptability and satisfaction with the study experience. These will be 
conducted by a study assistant based in the Agincourt area who is fluent in English and xi-Tsonga. 
The number of participants approached, the number who agree to testing and counseling 
(including testing outcome), and reports on the impact of performing HIV testing and counseling 
on healer income will be collected by the traditional healer. Health clinic research staff will collect 
uptake of testing during one of the “Open House” events and during non-open house days (if, for 
example a patient seeks testing during regular clinic hours). Clinical data will be accessed using 
“Clinic Link” which allows us to gain access to relevant clinical data, including ART uptake and 
retention in care. Data from clinical providers who participate in the stigma reduction intervention 
will complete surveys at study initiation and immediately after the study has concluded.  
 
Time point 
Activity 
Data Collection 
Baseline 
Enrollment  
Demographics, HIV Stigma, Trust in allopathic provider, belief in HIV 
test, use of traditional medicine, perceived risk of HIV 
Baseline 
Healer-initiated 
C&T, including 
stigma reduction  
Attendance, HIV status, enrollment in care and treatment if positive  
Month 6  
HIV re-test  
Attendance, HIV status, enrollment in care and treatment if positive 
Month 7 
Follow-up survey 
& qualitative 
questions 
HIV Stigma, Trust in allopathic provider, belief in HIV test, use of 
traditional medicine, perceived risk of HIV, experience with the 
healer-clinician collaborative  
Table 6: Project Activities and Data Collection Points 

 
1 0  
6. St u d y L o c ati o n  
6. 1 L o c ati o n  
T h e M R C/ Wit s A gi n c o urt R e s e ar c h U nit o v er s e e s t h e m ai nt e n a n c e a n d o p er ati o n of t h e A gi n c o urt 
H e alt h a n d D e m o gr a p hi c S ur v eill a n c e Sit e ( H D S S). R o u g hl y 5 0 0 k m n ort h e a st of J o h a n n e s b ur g, 
t h e u nit h a s b e e n e n g a g e d i n p o p ul ati o n-b a s e d h e alt h a n d d e m o gr a p hi c r e s e ar c h si n c e 1 9 9 2. 
Str o n g ti e s wit h t h e l o c al c o m m u nit y e n s ur e t h e c o nti n u al f u n cti o ni n g a n d s u st ai n a bilit y of t h e 
r e s e ar c h.     
C o n stit uti n g a s u b -di stri ct of t h e B u s h b u c kri d g e di stri ct, t h e A gi n c o urt st u d y sit e c o n si st s of 4 2 0 
k m 2  of s e mi -ari d s cr u bl a n d wit h l o w r ai nf all, p o orl y -s uit e d f or s u b si st e n c e f ar mi n g t h o u g h u s e d f or 
g a m e f ar mi n g a n d l o w - d e n sit y c attl e r e ari n g. T h e st u d y ar e a c o nt ai n s si x g o v er n m e nt r u n cli ni c s, 
a pri v at e c o m m u nit y h e alt h c e ntr e, a n d o n e l ar g er ar e a p u bli c h e alt h c e ntr e wit h p ati e nt s b ei n g 
r ef err e d t o t hr e e di stri ct h o s pit al s, e a c h l o c at e d at 2 5- 5 5 kil o m et er s fr o m t h e sit e a n d r el yi n g o n 
n a m el y p u bli c m e a n s f or tr a n s p ort.  
 
6. 2  St u d y P o p ul ati o n  
T h e A gi n c o urt H D S S p o p ul ati o n i s c o m pri s e d of r o u g hl y 1 2 0 , 0 0 0 i n di vi d u al s- m ai nl y xi T s o n g a -
s p e a ki n g - s pr e a d t h r o u g h o ut 2 0, 00 0 h o u s e h ol d s i n 3 1 r e s e ar c h  vill a g e s. R o u g hl y o n e-t hir d of t h e 
p e r m a n e nt H D S S p o p ul ati o n i s c o m pri s e d of f or m er M o z a m bi c a n r ef u g e e s, w h o i m mi gr at e d t o 
S o ut h Afri c a d uri n g t h e 1 9 8 0 s.  O ur p o p ul ati o n of f o c u s will i n cl u d e tr a diti o n al h e al er s li vi n g i n t hi s 
r e gi o n, t h eir p ati e nt s, a n d h e alt h c ar e w or k er s pr o vi di n g s er vi c e s at l o c al h e alt h f a cilit at e s.  
 
7. D at a M a n a g e m e nt a n d A n al y si s  
D at a M a n a g e m e nt  
Q u a ntit ati v e d at a:  
Q u e sti o n n air e s,  o b s er v ati o n s  of  tr ai ni n g,  a s  w ell  a s  HI V  t e sti n g  d at a  will  b e  c oll e ct e d  a n d  
u pl o a d e d t o a R E D C a p d at a b a s e w hi c h i s h o u s e d at V a n d er bilt U ni v er sit y. R E D C a p pr o vi d e s 
a ut o m at e d  e x p ort  pr o c e d ur e s  f or  s e a ml e s s  d at a  d o w nl o a d s  t o  E x c el  a n d  c o m m o n  st ati sti c al 
p a c k a g e s ( S P S S, S A S,  St at a, R), a s w ell a s a b uilt -i n pr oj e ct c al e n d ar, a s c h e d uli n g m o d ul e, a d 
h o c r e p orti n g t o ol s, a n d a d v a n c e d f e at ur e s, s u c h a s br a n c hi n g l o gi c, fil e u pl o a di n g, a n d c al c ul at e d 
fi el d s. It al s o pr o vi d e s a d diti o n al s e c urit y o pti o n s, i n cl u di n g t h e a bilit y t o re stri ct a u s er’ s a bilit y t o 
d o w nl o a d d at a t a g g e d a s i d e ntifi er s t o f urt h er pr ot e ct p arti ci p a nt pri v a c y.   
St u d y p arti ci p a nt s will b e a s si g n e d a u ni q u e, c o d e d i d e ntifi c ati o n n u m b er at t h e ti m e of st u d y 
e nr ol m e nt.  I n or d er t o m ai nt ai n p arti ci p a nt c o nfi d e nti alit y, all l a b or at or y s p e ci m e n s, st u d y c a s e 
r e p ort f or m s, a n d r e p ort s will b e i d e ntifi e d u si n g t h at c o d e d n u m b er.  O nl y r e s e ar c h st aff will h a v e 
a c c e s s t o t h e c o d e d n u m b er. K e y st u d y p er s o n n el , i n cl u di n g Dr s. A u d et a n d W a g n er, will st or e 
r e s e ar c h d at a, i n cl u di n g m e di c al a n d l a b or at or y r e c or d s, i n l o c k e d c a bi n et s a n d all e-fil e s will b e 
p a s s w or d pr ot e ct e d. D at a will b e st or e d i n p a s s w or d -pr ot e ct e d fil e s wit hi n s e c ur e b uil di n g s at t h e 
M R C/ Wit s A gi n c o urt R e s e ar c h U nit’ s r ur al fi el d offi c e s. W e h a v e a d diti o n al m e a s ur e s t o e n h a n c e 
s e c urit y w h e n d at a ar e h o u s e d at V a n d er bilt. A c c e s s t o all d at a will b e I D a n d p a s s w or d -pr ot e ct e d, 
i n cl u di n g d at a w ar e h o u s e s oft w ar e a n d c o m p ut er s m a n a gi n g a n d a n al y zi n g s ur v e y d at a. N o d at a 
will b e r el e a s e d wit h a n y i nf or m ati o n t h at  m a y  dir e ctl y or  i n dir e ctl y i d e ntif y p arti ci p a nt s,  t h eir 
cli ni c al i nf or m ati o n, or l a b or at or y r e s ult s t o o ut si d e a g e n ci e s.  
D at a A n al y si s  
Gi v e n  t h at  p arti ci p a nt s  m a y  c o m pl et e  n o n e,  o n e,  t w o,  or  all  t hr e e  of  t h e s e  i nt er v e nti o n  
c o m p o n e nt s,  w e  will  c o n si d er  f o ur  diff er e nt  i nt er v e nti o n  c o m p o n e nt  v ari a bl e s  t o  t h e  H e al er -
Cli ni ci a n HI V Pr e v e nti o n C oll a b or ati v e  i nt er v e nti o n: ( 1) U pt a k e of h e al er-i niti at e d HI V c o u n s eli n g 
a n d t e sti n g ( v s. t h o s e w h o di d n ot), ( 2) P arti ci p ati o n i n a d diti o n al c o u n s eli n g s e s si o n s ( v s. t h o s e 

 
1 1  
w h o di d n ot), ( 3) Att e n d a n c e at ≥1  O p e n H o u s e e v e nt at t h e h e alt h f a cilit y ( v s. t h o s e w h o di d n ot), 
a n d ( 4) A n i n d e x r a n gi n g fr o m 0 t o 3 i n di c ati n g t h e n u m b er i nt er v e nti o n c o m p o n e nt s c o m pl et e d.   
T h e pri m ar y o ut c o m e a m o n g t h o s e t e sti n g HI V n e g ati v e or r ef u si n g t e sti n g i s u pt a k e of h e alt h 
f a cilit y HI V t e sti n g wit hi n 6 m o nt h s. W e will o p er ati o n ali z e t h e o ut c o m e s i n t h e p o siti v e ( e. g., 
t e st e d  at  h e alt h  f a cilit y  wit hi n  6  m o nt h s)  s u c h  t h at  t h e  ri s k  r ati o s  ( R R)  f or  t h e  i nt er v e nti o n  
c o m p o n e nt s  will  b e  > 1. 0  if  eff e cti v e.  W e  will  e sti m at e  t h e  a s s o ci ati o n  of  e a c h  i nt er v e nti o n  
c o m p o n e nt i n di vi d u all y ( n u m b er s 1 -3 a b o v e) u si n g s e p ar at e r e gr e s si o n m o d el s t h at ar e e a c h 
f urt h er str atifi e d b y p ot e nti al m o difi er s s u c h a s g e n d er , a g e , s e x u alit y , i m mi gr ati o n st at u s, a n d 
ot h er  b a s e li n e  c h ar a ct eri sti c s.  W e  will  u s e  m o difi e d  P oi s s o n  r e gr e s si o n  m o d el s  f or  e a c h  
i nt er v e nti o n c o m p o n e nt t o e sti m at e ri s k r ati o s a n d 9 5 % c o nfi d e n c e i nt er v al s.  
 
8 . Ethi c al C o n si d er ati o n s  
R e cr uit m e nt a n d C o n s e nt  
P arti ci p a nt s will b e r e cr uit e d a m o n g t h o s e w h o pr e s e nt f or h e alt h c ar e s er vi c e s fr o m o n e of o ur 
tr a diti o n al h e al er s tr ai n e d i n c o n d u cti n g HI V c o u n s eli n g a n d t e sti n g. P arti ci p a nt s will b e r e cr uit e d 
aft er t h eir h e al er c o n s ult ati o n i s c o m pl et e d t o e n s ur e w e d o n ot i m p a ct t h eir s er vi c e s. H e al er s will 
s cr e e n p ot e nti al p arti ci p a nt s f or eli gi bilit y ( n o HI V t e st i n p a st y e ar, o v er 1 8 y e ar s of a g e, li v e i n 
A gi n c o urt) a n d if t h e y ar e eli gi bl e, t h e h e al er s will a s k if t h e y ar e willi n g t o p arti ci p at e i n a r e s e ar c h 
st u d y. H e al er s will st at e cl e arl y t h at t h er e i s n o o bli g ati o n t o p arti ci p at e a n d t h at c h o o si n g n ot t o 
p arti ci p at e will i n n o w a y i m p a ct t h eir h e alt h c ar e fr o m t hi s tr a diti o n al h e al er. H e al er s will c o n s e nt 
p arti ci p a nt s vi a a n o nli n e c o n s e nt f or m vi a t a bl et, s o all c o n s e nt f or m s will b e o nli n e a n d b a c k e d 
u p t o t h e s e c ur e V a n d er bilt R E D C a p cl o u d.   
 
P arti ci p a nt C o nfi d e nti alit y  
T h e st u d y will b e c o n d u ct e d a c c or di n g t o n ati o n al a n d i nt er n ati o n al st a n d ar d s of r e s e ar c h et hi c s, 
t o e n s ur e t h at t h e ri g ht s of all p arti ci p a nt s will b e r e s p e ct e d. Et hi c al a p pr o v al fr o m t h e Wit s H u m a n 
R e s e ar c h Et hi c s C o m mitt e e  ( M e di c al), t h e M p u m al a n g a Pr o vi n ci al R e s e ar c h C o m mitt e e, a n d of 
t h e F a c ult y of M e di ci n e at V a n d er bilt U ni v er sit y will b e o bt ai n e d b ef or e a n y d at a c oll e cti o n a cti vit y 
c o m m e n c e s .  
 
T h e  i n v ol v e m e nt  of  i n di vi d u al s  i n  t h e  i nt er vi e w s  will  b e  stri ctl y  v ol u nt ar y.  Aft er  i ntr o d u ci n g  
hi m / h ers elf, t h e i nt er vi e w er will r e a d t h e i nf or m e d c o n s e nt t o t h e p arti ci p a nt a n d a n s w er a n y 
q u e sti o n s t h e y m a y h a v e. If h e/ s h e d o e s n ot a c c e pt, t h e di s c u s si o n wit h t h e i nt er vi e w will e n d. 
T h e p arti ci p a nt s will b e a s s ur e d of t h e ut m o st c o nfi d e nti alit y o n t h e p art of t h e t e a m s i n v ol v e d i n 
t h e st u d y. 
 
I nf or m ati o n r e g ar di n g c o n s e nt will n ot b e l o g g e d a n y w h er e a n d si g n e d f or m s will b e st or e d i n a 
l o c k e d c a bi n et s e p ar at e fr o m tr a n s cri pt s a n d ot h er p ot e nti all y i d e ntif yi n g  i nf or m ati o n fr o m t h e 
st u d y. O nl y t h e pri n ci p al i n v e sti g at or s will h a v e a c c e s s si g n e d c o n s e nt f or m s. Tr a n s cri pt s will al s o 
b e m ai nt ai n e d t o e n s ur e c o nfi d e nti alit y a n d a c c e s s i s r e stri ct e d t o a ut h ori z e d i n v e sti g at or s. T h e 
c o nfi d e nti alit y of t h e i nf or m ati o n c oll e ct e d will b e stri ctl y g u ar d e d.  
 
A d v er s e E v e nt s  
T h e pr o p o s e d r e s e ar c h will e st a bli s h t h e f oll o wi n g d at a a n d s af et y m o nit ori n g pr o c e d ur e s, i n 
c o m pli a n c e  wit h  NI H  r e q uir e m e nt s,  t o  e n s ur e  p arti ci p a nt  s af et y  a n d  pr ot e ct  t h e  v ali dit y  a n d  
i nt e grit y of d at a. T h e st u d y i s l o w ri s k, wit h i nt er v e nti o n c o nt e nt f o c u si n g o n pr o vi di n g p er s o n al 
pr ot e c ti v e e q ui p m e nt t o r ur al S o ut h Afri c a n tr a diti o n al h e al er s. H o w e v er, w e a c k n o wl e d g e t h at 
t h e p arti ci p a nt p o p ul ati o n i s v ul n er a bl e a n d gi v e n t h at t h e f o c u s of t h e r e s e ar c h i s o n HI V, a 
sti g m ati z e d c o n diti o n, t h e f oll o wi n g s af et y pl a n will b e i m pl e m e nt e d.  

 
12
Dr. Audet will be primarily responsible for monitoring the proposed study. Together Drs. Audet 
and Wagner (Wits), will meet regularly with the site study coordinator and research team to 
discuss and resolve any situations arising that relate to ethics or human subjects protection. 
Together with MRC/Wits Agincourt Research Unit senior field staff, they will devise and implement 
an appropriate remedial course of action that sufficiently addresses any critical incident or adverse 
event that arises.  Dr. Audet will promptly inform the VU IRB, while Dr. Wagner will inform the 
Wits HREC and Mpumalanga Province research ethics committee of any event that occurs.  
Any time an adverse event occurs and at least once a year the investigators will conduct a data 
and safety review. During this review process, the investigators will evaluate any adverse events 
and determine whether the event changes the risk/benefit ratio of the study and whether 
modifications to the protocol or consent process are required. When necessary, they will seek 
recommendations from Vanderbilt University, Wits University and/or Mpumalanga Province 
research ethics committee. 
The VU and South African (Wits and Mpumalanga Province) IRBs will also review the study 
proposal and annual reports will be submitted as part of the continuing review process. At this 
time, they will complete the following: (1) reassess the risks and benefits to participants, the 
informed consent process, and safeguards for human subjects; (2) review participant enrollment 
and retention; (3) consider any new scientific or therapeutic developments that might impact the 
safety of participants in the study; and (4) review any adverse events. Changes to the DSMP will 
be made as needed. 
The investigators will adhere to the VU and South African IRBs’ policies on unanticipated 
problems involving risks to participants or others. The following problems would require prompt 
reporting to the IRBs. This procedure outlines the process for reporting adverse events, serious 
adverse events, and unanticipated problems involving risk to participants or others. 
Investigator Responsibilities 
A. The Investigator submits any serious adverse event that requires reporting according 
to this policy and any other adverse event that may represent an unanticipated problem involving 
risk to participants or others as follows: 
1. A “Report of Unanticipated Problem Involving Risk to Participants or Others” is submitted 
to the IRB as soon as possible, but no later than 7 calendar days after the Investigator first 
learns of the event or problem. 
This form contains the Investigator’s assessment of causality (related or not related to the 
study) and a description of the actual event; 
2. The form also contains an evaluation of whether the event meets the following criteria: 
a.  An event that suggests that the research places subjects or others at a greater risk 
of physical or psychological harm than was previously known or recognized; 
b. Unanticipated (i.e., the event was not foreseeable); and 
c. Related (i.e., likely to have been caused by the research procedures)  
3. Finally, any associated materials such as medical record notations or reports with the 
name and medical record number of the individual redacted (removed) will be included with 
the report. 

 
1 3  
4.  W h e n a p pli c a bl e,  a “ R e q u e st  f or A m e n d m e nt”  i n di c ati n g c h a n g e s a s s o ci at e d wit h t h e 
e v e nt or pr o bl e m i s s u b mitt e d.  
S eri o u s A d v er s e E v e nt ( S A E) R e p orti n g  
T h e Di vi si o n of AI D S T a bl e f or Gr a di n g t h e S e v erit y of A d ult a n d P e di atri c A d v er s e E v e nt s ( D AI D S 
A E Gr a di n g T a bl e), V er si o n 1. 0, D e c e m b er, 2 0 0 4, will b e u s e d t o d et er mi n e cli ni c al a n d l a b or at or y 
gr a d e s  of  a n y/ all  gr a d e  2  or  hi g h er  e v e nt s  (i n cl u di n g  si g n s  a n d  s y m pt o m s,  l a b or at or y  
a b n or m aliti e s, a n d di a g n o s e s).  
I n a d diti o n, a n y/ all d e at h s, di s a biliti e s, m ali g n a n ci e s, a n d/ or a n y ot h er c o n diti o n s d e e m e d s eri o u s 
a n d/ or d e bilit ati n g/i n c a p a cit ati n g b y t h e cli ni c al t e a m will b e r e p ort e d t o all i n v ol v e d et hi c al r e vi e w 
b o ar d s.  T h e  PI  will  s u b mit  S A E  i nf or m ati o n  a s  r e q uir e d  b y  l o c al  r e g ul at or y  or  ot h er  l o c a l 
a ut h oriti e s, a n d t h e r e s e ar c h t e a m will a d h er e t o t h e s e stri n g e nt r e q uir e m e nt s a n d s u b mit f ull 
r e p ort s d et aili n g a n y S A E s i n a ti m el y f a s hi o n (i. e. i n a c c or d a n c e wit h e xi sti n g st a n d ar d s). Aft er 
t h e e n d of t h e pr ot o c ol-d efi n e d S A E r e p orti n g p eri o d st at e d a b o v e, t h e sit e will r e p ort s eri o u s, 
u n e x p e ct e d, cli ni c al s u s p e ct e d a d v er s e dr u g r e a cti o n s if t h e st u d y sit e st aff b e c o m e s a w ar e of 
t h e e v e nt o n a p a s si v e b a si s, i. e., fr o m p u bli cl y  
 
B e n efit s  
Tr a diti o n al h e al er s i n t hi s st u d y c o ul d p ot e nti all y b e n efit fro m tr ai ni n g o n HI V t e sti n g pr ot o c ol s a s 
t hi s o p e n s u p a n e w a v e n u e f or p ai d e m pl o y m e nt i n t h e f ut ur e. F or c o m m u nit y m e m b er s, it pr o vi d e 
a n e w, l e s s sti g m ati z e d a v e n u e t o a c c e s s HI V c o u n s eli n g a n d t e sti n g.  
 
9 . Li mit ati o n s 
T hi s pil ot st u d y i s n ot a r a n d o mi z e d c o ntr oll e d tri al, t h u s w e c a n n ot c o m p ar e u pt a k e of h e al er -
i niti at e d t e sti n g wit h ot h er m o d aliti e s; h o w e v er, w e will c a pt ur e u pt a k e of h e al er-i niti at e d t e sti n g, 
i m p a ct of u pt a k e o n k e y p s y c h ol o gi c al o ut c o m e s, i n cl u di n g HI V sti g m a a n d mi str u st i n t h e h e alt h 
s y st e m,  a n d  o bt ai n  d at a  o n  li n k a g e  of  p arti ci p a nt s  t o  t h e  h e alt h  s y st e m  - k e y  el e m e nt s  t o  
d e v el o pi n g a n d p o w eri n g a l ar g er r a n d o mi z e d c o ntr oll e d tri al. W e h a v e fr a m e d t h e i nt er v e nti o n 
a n d  s u b s e q u e nt  a n al y si s  i n  t h e  c ult ur al  c o nt e xt  a n d  ar e  c oll e cti n g  d at a  t o  s p e cifi c all y  
i d e ntif y/i nf or m s u b gr o u p eff e ct s, i n cl u di n g s e x. W hil e w e m a y b e u n d er p o w er e d t o d et e ct s o m e 
of t h e s e eff e ct s i n s m a ll s u b gr o u p s, a l o w p-v al u e o n h et er o g e n eit y t e st s will pr o vi d e u s wit h a 
si g n al f or f urt h er i n v e sti g ati o n i n a s uffi ci e ntl y p o w er e d f ut ur e R C T.  
 
1 0 . Di s s e mi n ati o n Pl a n 
R e s ult s of t hi s st u d y will b e c oll e ct e d i nt o a r e p ort a n d s h ar e d wit h t h e n ati o n al, pr o vi n ci al a n d 
l o c al D e p art m e nt s of H e alt h, tr a diti o n al h e al er s a n d bi o m e di c al pr a ctiti o n er s i n t h e B u s h b u c kri d g e  
ar e ,  a n d  r e s e ar c h er s  at  t h e  U ni v er sit y  of  Wit w at er sr a n d  a n d  V a n d er bilt  U ni v er sit y a n d  t h e  
A gi n c o urt r e s e ar c h c o m m u nit y .  R e s ult s of t hi s st u d y wil l al s o b e pr e s e nt e d i n p e er -r e vi e w e d 
j o ur n al s a n d at c o nf er e n c e s.  
 
 
 
 
 
 
 
 
 
 
 

 
1 4  
A p p e n di c e s  
 
A p p e n di x 1 : S ur v e y s f or h e alt h c ar e pr o vi d er s 
 
 
A s a h e alt h c ar e w or k er … 
 
I w o ul d pr ef er t o n ot pr o vi d e s er vi c e s  t o i m mi gr a nt s h er e ill e g all y 
  
I b eli e v e t h at ill e g al i m mi gr a nt s p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V  
 
I a gr e e t h at ill e g al i m mi gr a nt s e n g a g e i n i m m or al b e h a vi or  
 
I a gr e e t h at ill e g al i m mi gr a nt s d e s er v e t h eir HI V di a g n o si s.  
 
I w o ul d pr ef er t o n ot pr o vi d e s er vi c e s t o p ati e nt s w h o pr ef er tr a diti o n al m e di ci n e 
  
I b eli e v e t h at p e o pl e w h o u s e tr a diti o n al m e di ci n e p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V  
 
I a gr e e t h at p e o pl e w h o u s e tr a diti o n al m e di ci n e e n g a g e i n i m m or al b e h a vi or 
 
I a gr e e t h at p e o pl e w h o u s e tr a diti o n al m e di ci n e d e s er v e t h eir HI V di a g n o si s. 
 
I w o ul d pr ef er t o n ot pr o vi d e s er vi c e s t o y o u n g u n m arri e d, pr e g n a nt girl s  
  
I b eli e v e t h at y o u n g, u n m arri e d pr e g n a nt girl s  p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V  
 
I a gr e e t h at y o u n g, u n m arri e d pr e g n a nt girl s e n g a g e i n i m m or al b e h a vi or  
 
I a gr e e t hat y o u n g, u n m arri e d pr e g n a nt girl s d e s er v e t h eir HI V di a g n o si s.  
 
I w o ul d pr ef er t o n ot pr o vi d e s er vi c e s t o m e n  w h o h a v e s e x wit h o ut a c o n d o m.  
  
I b eli e v e t h at m e n w h o h a v e s e x wit h o ut c o n d o m s  p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V  
 
I a gr e e t h at m e n w h o h a v e s e x wit h o ut c o n d o m s e n g a g e i n i m m or al b e h a vi or  
 
I a gr e e t h at m e n w h o h a v e s e x wit h o ut c o n d o m s d e s er v e t h eir HI V di a g n o si s.  
 
I w o ul d pr ef er t o n ot pr o vi d e s er vi c e s t o s e x w or k er s. 
  
I b eli e v e t h at s e x w or k er s p ut cli ni ci a n s at hi g h er ri s k of a c q uiri n g HI V  
 
I a gr e e t h at s e x w or k er s e n g a g e i n i m m or al b e h a vi or 
 
I a gr e e t h at s e x w or k er s d e s er v e t h eir HI V di a g n o si s. 
 
 
A p p e n di x 2: S ur v e y s f or p arti ci p a nt s  
 
A . A d a pt e d it e m s fr o m t h e Gr o u p-B a s e d M e di c al Mi str u st S c al e ( G B M M S) It e m s  

 
15
People like me cannot trust doctors and health care workers. 
 
People like me should be suspicious of modern medicine. 
People like me should be suspicious of information from doctors and health care workers. 
 
People like me should not confide in doctors and health care workers because it will be used 
against them.  
Doctors and health care workers treat people like me like guinea pigs. 
People like me receive the same medical care from doctors and health care workers as people 
from other groups. 
 
People like me are treated the same as people of other groups by doctors and health care 
workers. 
 
In most hospitals, people of different backgrounds receive the same kind of care.  
Doctors have the best interests of people like me in mind.  
Doctors and health care workers sometimes hide information from people like me. 
I have personally been treated poorly or unfairly by doctors or health care workers because of 
who I am.  
 
B. Items from the HIV Conspiracy Belief Scale 
  
HIV is a manmade virus. 
AIDS was produced in a government laboratory. 
There is a cure for AIDS, but it is being withheld from the poor. 
AIDS is a form of genocide, or planned destruction, against Blacks. 
AIDS was created by the government to control the Black population. 
HIV was created and spread by the CIA.  
People who take the new medications for HIV are human guinea pigs for the government.  
The medicine that doctors prescribe to treat HIV is poison.  
The medication used to treat HIV causes people to get AIDS. 
 
C. Items from the Perceptions of HIV Seriousness, Risk, and Threat Survey 

 
1 6  
H o w s eri o u s f or y o u w o ul d it b e if y o u c o ntr a ct e d HI V ?   
H o w w o ul d y o u r at e y o ur ri s k f or c o ntr a cti n g HI V b a s e d o n y o ur c urr e nt b e h a vi or ?  
H o w c o nfi d e nt ar e y o u t h at y o u c a n st a y HI V -n e g ati v e i n y o ur lif eti m e ?  
 
D . It e m s fr o m t h e I nt er n ali z e d Sti g m a S c al e  
If y o u w er e t o t e st p o siti v e f or HI V a n d t ol d ot h er s y o ur st at u s … 
y o u w o ul d e x p eri e n c e a br e a k -u p of y o ur m arri a g e or r el ati o n s hi p.   
y o u w o ul d e x p eri e n c e p h y si c al a b u s e b y y o ur s p o u s e/ p art n er( s).    
y o u w o ul d l o s e y o ur j o b/ li v eli h o o d.    
y o u w o ul d b e tr e at e d b a dl y at w or k or s c h o ol.   
 
y o u w o ul d l o s e y o ur fri e n d s.    
y o u w o ul d b e di s o w n e d fr o m or n e gl e ct e d b y y o ur f a mil y.    
y o u w o ul d b e tr e at e d b a dl y b y h e alt h pr of e s si o n al s.   
y o ur  c o m m u nit y( vill a g e) w o ul d tr e at y o u li k e a s o ci al o ut c a st.   
 
y o ur f a mil y w o ul d n ot c ar e f or y o u if y o u b e c a m e si c k.  
 
E . It e m s fr o m t h e HI V sti g m a a n d Di s cri mi n ati o n S c al e  
P e o pl e li vi n g wit h HI V/ AI D S s h o ul d b e a s h a m e d   
 
P e o pl e wit h AI D S s h o ul d b e i s ol at e d fr o m ot h er p e o pl e   
 
P e o pl e w h o h a v e HI V/ AI D S ar e c ur s e d   
 
A p er s o n wit h HI V/ AI D S s h o ul d b e all o w e d t o w or k wit h ot h er p e o pl e  
P e o pl e li vi n g wit h HI V/ AI D S d e s er v e t o b e p u ni s h e d   
 
F a mili e s of p e o pl e li vi n g wit h HI V/ AI D S s h o ul d b e a s h a m e d   
 
It i s r e a s o n a bl e f or a n e m pl o y er t o fir e p e o pl e w h o h a v e HI V/ AI D S  
P e o pl e wit h HI V/ AI D S ar e di s g u sti n g   
P e o pl e w h o h a v e HI V/ AI D S d e s er v e c o m p a s si o n    

 
1 7  
P e o pl e wit h HI V s h o ul d b e all o w e d t o p arti ci p at e f ull y i n t h e s o ci al e v e nt s i n t hi s c o m m u nit y  
P e o pl e li vi n g wit h HI V/ A I D S f a c e n e gl e ct fr o m t h eir f a mil y   
P e o pl e li vi n g wit h HI V/ AI D S f a c e p h y si c al a b u s e   
 
P e o pl e w a nt t o b e fri e n d s wit h s o m e o n e w h o h a s HI V/ AI D S  
P e o pl e li vi n g wit h HI V/ AI D S f a c e ej e cti o n fr o m t h eir h o m e s b y t h eir f a mili e s   
. 
M o st p e o pl e w o ul d n ot b u y v e g et a bl e s fr o m a s h o p k e e p er or f o o d s ell er t h at t h e y k n e w h a d 
AI D S    
P e o pl e w h o ar e s u s p e ct e d of h a vi n g HI V/ AI D S l o s e r e s p e ct i n t h e c o m m u nit y   
 
P e o pl e w h o h a v e HI V/ AI D S f a c e v er b al a b u s e   
 
P e o pl e li vi n g wit h HI V/ AI D S f a c e r ej e cti o n fr o m t h eir p e er s    
P e o pl e w h o h a v e HI V/ AI D S s h o ul d b e tr e at e d t h e s a m e a s e v er y o n e el s e  
P e o pl e wit h HI V/ AI D S d o n ot d e s er v e a n y s u p p ort    
P e o pl e wit h HI V/ AI D S s h o ul d n ot h a v e t h e s a m e fr e e d o m s a s ot h er p e o pl e  
P e o pl e li vi n g wit h HI V/ AI D S s h o ul d b e tr e at e d si mil arl y b y h e alt h c ar e pr of e s si o n al s a s p e o pl e 
wit h ot h er ill n e s s e s  
 
 
A p p e n di x 3 : C o n s e nt F or m s  
 
S e e att a c h e d d o c u m e nt s.  
 
R ef er e n c e s  
1.  
A h orl u C K, K or a m K A, A h orl u C, d e S avi g ny D, W eiss M G. S oci o -c ult ur al d et er mi n a nts of 
tr e at m e nt d el a y f or c hil d h o o d m al ari a i n s o ut h er n G h a n a. Tr o pic al m e dici n e & i nt er n ati o n al 
h e alt h : T M & I H. 2 0 0 6; 1 1( 7): 1 0 2 2 -1 0 3 1.  
2.  
v a n Dy k A C, v a n Dy k PJ. " T o k n o w or n ot t o k n o w": s er vic e -r el at e d b arri ers t o v ol u nt ar y HI V 
c o u ns eli n g a n d t esti n g ( V C T) i n S o ut h Afric a. C ur ati o nis. 2 0 0 3; 2 6( 1): 4 -1 0.  
3.  
M at o v u J K, M a k u m bi F E. Ex p a n di n g acc ess t o v ol u nt ary HI V c o u ns elli n g a n d t esti n g i n s u b -
S a h ar a n Afric a: alt er n ativ e a p pr o a c h es f or i m pr o vi n g u pt a k e, 2 0 0 1 -2 0 0 7. Tr o pic al m e dici n e & 
i nt er n ati o n al h e alt h : T M & I H. 2 0 0 7; 1 2( 1 1): 1 3 1 5 -1 3 2 2.  
4.  
B w a m b al e F, Ss ali S, By ar u h a n g a S, K al y a n g o J, K ar a m a gi C. V ol u nt ary HI V c o u ns elli n g a n d 
t esti n g a m o n g m e n i n r ur al w est er n U g a n d a: I m plic ati o ns f or HI V pr ev e nti o n. B M C P u blic 
H e alt h. 2 0 0 8; 8( 1): 2 6 3.  
5.  
G et a h u n A, D eri b e K, D eri b e w A. D et er mi n a nts of d el ay i n m al ari a tr e at m e nt -s e eki n g b e h a vi o ur 
f or u n d er-fi v e c hil dr e n i n s o ut h-w est Et hi o pi a: a c as e c o ntr ol st u dy. M al ari a j o ur n al. 2 0 1 0; 9: 3 2 0.  

 
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6. 
Njau IW, Karanja SM, Wanzala P, Omolo JO. Factors associated with late presentation of 
suspected tuberculosis cases to tuberculosis management facilities: The case in Dagoretti 
district, Nairobi, Kenya. Pan Afr Med J. 2012;12:93. 
7. 
Matseke G, Peltzer K, Mohlabane N. Clients' perceptions and satisfaction with HIV counselling 
and testing: A cross-sectional study in 56 HCT sites in South Africa. African journal of primary 
health care & family medicine. 2016;8(1):e1-7. 
8. 
Zuma T, Wight D, Rochat T, Moshabela M. Navigating Multiple Sources of Healing in the Context 
of HIV/AIDS and Wide Availability of Antiretroviral Treatment: A Qualitative Study of Community 
Participants' Perceptions and Experiences in Rural South Africa. Frontiers in public health. 
2018;6:73. 
9. 
Visser MJ, Makin JD, Vandormael A, Sikkema KJ, Forsyth BWC. HIV/AIDS stigma in a South 
African community. AIDS care. 2009;21(2):197-206. 
10. 
Psaros C, Milford C, Smit JA, et al. HIV Prevention Among Young Women in South Africa: 
Understanding Multiple Layers of Risk. Archives of sexual behavior. 2018;47(7):1969-1982. 
11. 
Wabiri N, Taffa N. Socio-economic inequality and HIV in South Africa. BMC public health. 
2013;13:1037-1037. 
12. 
Pitpitan EV, Kalichman SC, Eaton LA, et al. AIDS-related stigma, HIV testing, and transmission risk 
among patrons of informal drinking places in Cape Town, South Africa. Annals of behavioral 
medicine : a publication of the Society of Behavioral Medicine. 2012;43(3):362-371. 
13. 
Young SD, Hlavka Z, Modiba P, et al. HIV-related stigma, social norms, and HIV testing in Soweto 
and Vulindlela, South Africa: National Institutes of Mental Health Project Accept (HPTN 043). 
Journal of acquired immune deficiency syndromes (1999). 2010;55(5):620-624. 
14. 
Treves-Kagan S, El Ayadi AM, Pettifor A, et al. Gender, HIV Testing and Stigma: The Association 
of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa 
Differ for Men and Women. AIDS and behavior. 2017;21(9):2579-2588. 
15. 
Ogunmefun C, Gilbert L, Schatz E. Older female caregivers and HIV/AIDS-related secondary 
stigma in rural South Africa. Journal of cross-cultural gerontology. 2011;26(1):85-102. 
16. 
Ritchwood TD, Selin A, Pettifor A, et al. HIV self-testing: South African young adults' 
recommendations for ease of use, test kit contents, accessibility, and supportive resources. BMC 
Public Health. 2019;19(1):123. 
17. 
Mee P, Kahn K, Kabudula CW, et al. The development of a localised HIV epidemic and the 
associated excess mortality burden in a rural area of South Africa. Global health, epidemiology 
and genomics. 2016;1:e7-e7. 
18. 
Ondenge K, Renju J, Bonnington O, et al. 'I am treated well if I adhere to my HIV medication': 
putting patient-provider interactions in context through insights from qualitative research in five 
sub-Saharan African countries. Sexually transmitted infections. 2017;93(Suppl 3). 
19. 
Wanyenze RK, Kamya MR, Fatch R, et al. Missed opportunities for HIV testing and late-stage 
diagnosis among HIV-infected patients in Uganda. PloS one. 2011;6(7):e21794-e21794. 
20. 
Moshabela M, Zuma T, Orne-Gliemann J, Iwuji C, Larmarange J, McGrath N. "It is better to die": 
experiences of traditional health practitioners within the HIV treatment as prevention trial 
communities in rural South Africa (ANRS 12249 TasP trial). AIDS care. 2016;28 Suppl 3:24-32. 
21. 
Audet CM, Blevins M, Rosenberg C, et al. Symptomatic HIV-positive persons in rural 
Mozambique who first consult a traditional healer have delays in HIV testing: a cross-sectional 
study. Journal of acquired immune deficiency syndromes (1999). 2014;66(4):e80-86. 
22. 
Magasana V, Zembe W, Tabana H, et al. An assessment of quality of home-based HIV counseling 
and testing performed by lay counselors in a rural sub-district of KwaZulu-Natal, South Africa. 
SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance. 2016;13(1):188-196. 

 
19
23. 
Bampoe V, Clancy A, Sugarman M, Liden J, Lansang MA. Response from the Global Fund. Bulletin 
of the World Health Organization 2012;90:70. 
24. 
Doherty IA, Myers B, Zule WA, et al. Seek, Test and Disclose: knowledge of HIV testing and 
serostatus among high-risk couples in a South African township. Sexually transmitted infections. 
2016;92(1):5. 
25. 
Hershow R, Gannett K, Merrill J, et al. Using soccer to build confidence and increase HCT uptake 
among adolescent girls: A mixed-methods study of an HIV prevention programme in South 
Africa. Sport in society. 2015;18(8):1009-1022. 
26. 
Martínez Pérez G, Cox V, Ellman T, et al. ‘I Know that I Do Have HIV but Nobody Saw Me’: Oral 
HIV Self-Testing in an Informal Settlement in South Africa. PloS one. 2016;11(4):e0152653. 
27. 
Suthar AB, Ford N, Bachanas PJ, et al. Towards universal voluntary HIV testing and counselling: a 
systematic review and meta-analysis of community-based approaches. PLoS medicine. 
2013;10(8):e1001496. 
28. 
van Rooyen H, Barnabas RV, Baeten JM, et al. High HIV testing uptake and linkage to care in a 
novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-
Natal, South Africa. Journal of acquired immune deficiency syndromes (1999). 2013;64(1):e1-8. 
29. 
Smith P, Wallace M, Bekker L-G. Adolescents' experience of a rapid HIV self-testing device in 
youth-friendly clinic settings in Cape Town South Africa: a cross-sectional community based 
usability study. Journal of the International AIDS Society. 2016;19(1):21111-21111. 
30. 
Johnson CC, Kennedy C, Fonner V, et al. Examining the effects of HIV self-testing compared to 
standard HIV testing services: a systematic review and meta-analysis. J Int AIDS Soc. 
2017;20(1):21594. 
31. 
Human Sciences Research Council (HSRC). The Fifth South African National HIV Prevalence, 
Incidence, Behaviour and Communication Survey, 2017: HIV Impact Assessment Summary 
Report. In. Cape Town: HSRC Press; 2018. 
32. 
Darbes LA, McGrath NM, Hosegood V, et al. Results of a Couples-Based Randomized Controlled 
Trial Aimed to Increase Testing for HIV. Journal of acquired immune deficiency syndromes 
(1999). 2019;80(4):404-413. 
33. 
Massyn N, Padarath A, Peer N, Day C. The District Health Barometer 2016/17. In. Westville, 
South Africa Health Systems Trust; 2017. 
34. 
Van Dyk A, Van Dyk PJ. "What is the point of knowing?": psychosocial barriers to HIV/AIDS 
voluntary counselling and testing programmes in South Africa. South African Journal of 
Psychology. 2003;33(2):118-125. 
35. 
Advert. HIV Testing Programmes. 2017; www.avert.org/professionals/hiv-programming/testing. 
Accessed December 19, 2018. 
36. 
Staveteig S, Croft TN, Kampa KT, Head SK. Reaching the 'first 90': Gaps in coverage of HIV testing 
among people living with HIV in 16 African countries. PloS one. 2017;12(10):e0186316. 
37. 
Johnson LF, Rehle TM, Jooste S, Bekker LG. Rates of HIV testing and diagnosis in South Africa: 
successes and challenges. AIDS (London, England). 2015;29(11):1401-1409. 
38. 
Audet CM, Blevins M, Moon TD, Vergara AE, Vermund SH, Sidat M. Health Seeking Behavior in 
Zambezia Province, Mozambique. SAHARAJ. 2012;9(1):41-46. 
39. 
Audet CM, Groh KE, Moon TD, Vermund SH, Sidat M. Poor quality health services and lack of 
program support leads to low uptake of HIV testing in rural Mozambique. Journal of African AIDS 
Research. 2012;4(327-335). 
40. 
Audet CM, Y.M. C, L.M. V, et al. Barriers to Male Involvement in Antenatal Care in Rural 
Mozambique. Qualitative health research. 2015. 
41. 
Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea 
and HIV screening. Am J Public Health. 2002;92(3):378-381. 

 
20
42. 
Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and 
testing in a black township in Cape Town, South Africa. Sexually transmitted infections. 
2003;79(6):442-447. 
43. 
Kalichman SC, Simbayi L. Traditional beliefs about the cause of AIDS and AIDS-related stigma in 
South Africa. AIDS care. 2004;16(5):572-580. 
44. 
Okome-Nkoumou M, Okome-Miame F, Kendjo E, et al. Delay between first HIV-related 
symptoms and diagnosis of HIV infection in patients attending the internal medicine department 
of the Fondation Jeanne Ebori (FJE), Libreville, Gabon. HIV Clin Trials. 2005;6(1):38-42. 
45. 
Peltzer K. Utilization and practice of traditional/complementary/alternative medicine (TM/CAM) 
in South Africa. Afr J Tradit Complement Altern Med. 2009;6(2):175-185. 
46. 
Labhardt ND, Aboa SM, Manga E, Bensing JM, Langewitz W. Bridging the gap: how traditional 
healers interact with their patients. A comparative study in Cameroon. Tropical Medicine & 
International Health. 2010;15(9):1099-1108. 
47. 
Audet CM, Salato J, Blevins M, Amsalem D, Vermund SH, Gaspar F. Educational Intervention 
Increased Referrals to Allopathic Care by Traditional Healers in Three High HIV-Prevalence Rural 
Districts in Mozambique. PloS one. 2013;8(8):e70326. 
48. 
Audet CM, Ngobeni S, Wagner RG. Traditional healer treatment of HIV persists in the era of ART: 
a mixed methods study from rural South Africa. BMC complementary and alternative medicine. 
2017;17(1):434. 
49. 
Zuma T, Wight D, Rochat T, Moshabela M. Navigating Multiple Sources of Healing in the Context 
of HIV/AIDS and Wide Availability of Antiretroviral Treatment: A Qualitative Study of Community 
Participants' Perceptions and Experiences in Rural South Africa. Frontiers in public health. 
2018;6:73-73. 
50. 
Musheke M, Ntalasha H, Gari S, et al. A systematic review of qualitative findings on factors 
enabling and deterring uptake of HIV testing in Sub-Saharan Africa. Vol 132013. 
51. 
Babalola S. Readiness for HIV testing among young people in northern Nigeria: the roles of social 
norm and perceived stigma. AIDS and behavior. 2007;11(5):759-769. 
52. 
Moshabela M, Bukenya D, Darong G, et al. Traditional healers, faith healers and medical 
practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for 
HIV/AIDS in Eastern and Southern Africa. Sexually transmitted infections. 2017;93(Suppl 3). 
53. 
Moshabela M, Pronyk P, Williams N, Schneider H, Lurie M. Patterns and implications of medical 
pluralism among HIV/AIDS patients in rural South Africa. AIDS and behavior. 2011;15(4):842-
852. 
54. 
Pantelic M, Cluver L, Boyes M, Toska E, Kuo C, Moshabela M. Medical pluralism predicts non-
ART use among parents in need of ART: a community survey in KwaZulu-Natal, South Africa. 
AIDS and behavior. 2015;19(1):137-144. 
55. 
Audet CM, Hamilton E, Hughart L, Salato J. Engagement of Traditional Healers and Birth 
Attendants as a Controversial Proposal to Extend the HIV Health Workforce. Curr HIV/AIDS Rep. 
2015. 
56. 
Hullur N, D'Ambruoso L, Edin K, et al. Community perspectives on HIV, violence and health 
surveillance in rural South Africa: a participatory pilot study. Journal of global health. 
2016;6(1):010406-010406. 
57. 
Audet CM, Ngobeni S, Graves E, Wagner RG. Mixed methods inquiry into traditional healers' 
treatment of mental, neurological and substance abuse disorders in rural South Africa. PloS one. 
2017;12(12):e0188433. 
58. 
Furin J. The role of traditional healers in community-based HIV care in rural Lesotho. J 
Community Health. 2011;36(5):849-856. 

 
21
59. 
Green EC. Traditional healers, mothers and childhood diarrheal disease in Swaziland: the 
interface of anthropology and health education. Social science & medicine (1982). 
1985;20(3):277-285. 
60. 
Hindley G, Kissima J, L LO, et al. The role of traditional and faith healers in the treatment of 
dementia in Tanzania and the potential for collaboration with allopathic healthcare services. 
Age and ageing. 2017;46(1):130-137. 
61. 
Mbeh GN, Edwards R, Ngufor G, Assah F, Fezeu L, Mbanya JC. Traditional healers and diabetes: 
results from a pilot project to train traditional healers to provide health education and 
appropriate health care practices for diabetes patients in Cameroon. Glob Health Promot. 
2010;17(2 Suppl):17-26. 
62. 
King R. Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan 
Africa: a literature review. UNAIDS Best Practices Collection 2000. 
http://data.unaids.org/Publications/IRC-pub01/jc299-tradheal_en.pdf. Accessed August 19, 
2013. 
63. 
Health Professions Council of South Africa. Statistics 2018; 
https://www.hpcsa.co.za/Publications/Statistics. Accessed April 18, 2019. 
64. 
Richter M. Traditional Medicines and Traditional Healers in South Africa. 2003; 
http://www.tac.org.za/Documents/ResearchPapers/Traditional_Medicine_briefing.pdf. 
Accessed January 12, 2011. 
65. 
Government Gazette. Traditional Health Practitioners Act, 2007. In. Vol 511. Cape Town2008. 
66. 
Burnett A, Baggaley R, Ndovi-MacMillan M, Sulwe J, Hang'omba B, Bennett J. Caring for people 
with HIV in Zambia: are traditional healers and formal health workers willing to work together? 
AIDS care. 1999;11(4):481-491. 
67. 
Fleming J. Mozambican healers join government in fight against AIDS. J Int Assoc Physicians AIDS 
Care. 1995;1(2):32. 
68. 
Kayombo EJ, Uiso FC, Mbwambo ZH, Mahunnah RL, Moshi MJ, Mgonda YH. Experience of 
initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. J Ethnobiol 
Ethnomed. 2007;3:6. 
69. 
Liverpool J, Alexander R, Johnson M, Ebba EK, Francis S, Liverpool C. Western medicine and 
traditional healers: partners in the fight against HIV/AIDS. J Natl Med Assoc. 2004;96(6):822-825. 
70. 
Madamombe I. Traditional healers boost primary helath care: Reaching patients missed by 
modern medicine. African Renewal. 2006;19(4):10. 
71. 
PlusNews. South Africa: Traditional healers extend healthcare. IRIN: humanitarian news and 
analysis. 2010. http://www.irinnews.org/report.aspx?ReportId=88655. Accessed November 9, 
2010. 
72. 
McMillen H. The adapting healer: pioneering through shifting epidemiological and sociocultural 
landscapes. Social science & medicine (1982). 2004;59(5):889-902. 
73. 
Rudolph MJ, Ogunbodede EO, Mistry M. Management of the oral manifestations of HIV/AIDS by 
traditional healers and care givers. Curationis. 2007;30(1):56-61. 
74. 
Colvin M, Gumede L, Grimwade K, Maher D, Wilkinson D. Contribution of traditional healers to a 
rural tuberculosis control programme in Hlabisa, South Africa. The international journal of 
tuberculosis and lung disease : the official journal of the International Union against Tuberculosis 
and Lung Disease. 2003;7(9 Suppl 1):S86-91. 
75. 
Green EC. AIDS and STDs in Africa: bridging the gap between traditional healing and modern 
medicine. . Boulder: Westview Press; 1994. 
76. 
Poudel KC, Jimba M, Joshi AB, Poudel-Tandukar K, Sharma M, Wakai S. Retention and 
effectiveness of HIV/AIDS training of traditional healers in far western Nepal. Tropical medicine 
& international health : TM & IH. 2005;10(7):640-646. 

 
22
77. 
Kambo IP, Gupta RN, Kundu AS, Dhillon BS, Saxena HM, Saxena BN. Use of traditional medical 
practitioners to delivery family planning services in Uttar Pradesh. Studies in family planning. 
1994;25(1):32-40. 
78. 
Harper ME, Hill PC, Bah AH, Manneh K, McAdam KP, Lienhardt C. Traditional healers participate 
in tuberculosis control in The Gambia. The international journal of tuberculosis and lung disease 
: the official journal of the International Union against Tuberculosis and Lung Disease. 
2004;8(10):1266-1268. 
79. 
Nations MK, De Souza MA. Umbanda healers as effective AIDS educators: Case-control study in 
Brazilian urban slums (favelas). Tropical Doctor. 1997;27(Suppl 1):60-66. 
80. 
Somse P, Chapko MK, Wata JB, et al. Evaluation of an AIDS training program for traditional 
healers in the Central African Republic. AIDS education and prevention : official publication of 
the International Society for AIDS Education. 1998;10(6):558-564. 
81. 
Warren DM, Bova GS, Tregoning MA, Kliewer M. Ghanaian national policy toward indigenous 
healers. The case of the primary health training for indigenous healers (PRHETIH) program. 
Social science & medicine (1982). 1982;16(21):1873-1881. 
82. 
Berger RA, Porter L, Mekisini G, Courtright P. Traditional healers in AIDS control. AIDS (London, 
England). 1994;8(10):1511-1512. 
83. 
Oswald IH. Are traditional healers the solution to the failures of primary health care in rural 
Nepal? Social science & medicine (1982). 1983;17(5):255-257. 
84. 
Ssali A, Butler LM, Kabatesi D, et al. Traditional healers for HIV/AIDS prevention and family 
planning, Kiboga District, Uganda: evaluation of a program to improve practices. AIDS and 
behavior. 2005;9(4):485-493. 
85. 
Cuevas AG, O'Brien K, Saha S. What is the key to culturally competent care: Reducing bias or 
cultural tailoring? Psychology & health. 2017;32(4):493-507. 
86. 
Pachter LM. Culture and clinical care. Folk illness beliefs and behaviors and their implications for 
health care delivery. Jama. 1994;271(9):690-694. 
87. 
Spokane AR, Inman AG, Weatherford RD, Davidson AK, Straw R. Ecologically Based, Culturally 
Concordant Responding Following Disasters:The Counseling Psychologist’s Role. The Counseling 
Psychologist. 2011;39(8):1128-1159. 
88. 
Audet CM, Ngobeni S, Wagner RG. Use of CD4+ cell count results to determine traditional 
treatment eligibility among HIV-infected patients in rural South Africa. AIDS 2016; 2016; Durban, 
SA. 
89. 
Audet CM, Ngobeni S, Wagner R. Claims of a cure: use of CD4 cell count results to guide 
traditional treatment in Bushbuckridge, South Africa. AIDS 2016; July 17, 2016, 2016; Durban, 
South Africa. 
90. 
Audet CM, Ngobeni S, Mkansi M, et al. Occupational hazards of traditional healers in rural South 
Africa: Bloodborne pathogen exposures and risk of HIV transmission. Late Breaker Poster 
Presentation presented at 22nd International AIDS Conference July 23-27, 2018, 2018; 
Amsterdam, Netherlands. 
91. 
Wu L, Li X. Community-based HIV/AIDS interventions to promote psychosocial well-being among 
people living with HIV/AIDS: a literature review. Health Psychology and Behavioral Medicine. 
2013;1(1):31-46. 
92. 
Nyblade LC. Measuring HIV stigma: existing knowledge and gaps. Psychol Health Med. 
2006;11(3):335-345. 
93. 
Nyblade L, Stockton MA, Giger K, et al. Stigma in health facilities: why it matters and how we can 
change it. BMC Medicine. 2019;17(1):25. 
 

 
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