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Summary: Background: HIV counselling and testing are essential to control the HIV epidemic. However, HIV testing uptake is low in sub-Saharan Africa, where many people use informal health-care resources such as traditional healers. We hypothesised that uptake of HIV tests would increase if provided by traditional healers. We aimed to determine the effectiveness of traditional healers delivering HIV testing at point of care compared with referral to local clinics for HIV testing in rural southwestern Uganda. Methods: We did a mixed-methods study that included a cluster-randomised trial followed by individual qualitative interviews among a sample of participants in Mbarara, Uganda. Traditional healers aged 18 years or older who were located within 8 km of the Mbarara District HIV clinic, were identified in the 2018 population-level census of traditional healers in Mbarara District, and delivered care to at least seven clients per week were randomly assigned (1:1) as clusters to an intervention or a control group. Healers screened their clients for eligibility, and research assistants confirmed eligibility and enrolled clients who were aged 18 years or older, were receiving care from a participating healer, were sexually active (ever had intercourse), self-reported not having received an HIV test in the previous 12 months (and therefore considered to be of unknown serostatus), and had not previously been diagnosed with HIV infection. Intervention group healers provided counselling and offered point-of-care HIV tests to adult clients. Control group healers provided referral for HIV testing at nearby clinics. The primary outcome was the individual receipt of an HIV test within 90 days of study enrolment. Safety and adverse events were recorded and defined on the basis of prespecified criteria. This study is registered with ClinicalTrials.gov, NCT03718871. Findings: Between Aug 2, 2019, and Feb 7, 2020, 17 traditional healers were randomly assigned as clusters (nine to intervention and eight to control), with 500 clients of unknown HIV serostatus enrolled (250 per group). In the intervention group, 250 clients (100%) received an HIV test compared with 57 (23%) in the control group, a 77% (95% CI 73–82) increase in testing uptake, after adjusting for the effect of clustering (p

Background: Uganda is an HIV-endemic country with prevalence of around 6%, and has yet to reach the 95–95–95 UNAIDS benchmarks for HIV epidemic control. It has previously been reported that approximately 80% of people in sub-Saharan Africa use informal health-care providers such as traditional healers. Collaboration with informal healthcare providers has been proposed as a strategy to increase testing uptake. In this study, we use data from a parent cluster-randomised trial and aim to assess acceptability and implementation of a programme that uses informal health-care providers to deliver point-of-care HIV testing. Methods: We analysed qualitative data from a parent cluster-randomised trial in which traditional healers delivered oral swab point-of care HIV tests to adults of unknown HIV serostatus (clinicaltrials.gov NCT#03718871). We invited traditional healers aged 18 years or older who were practising within 10 km of Mbarara township, southwestern Uganda, to participate in the trial. We recruited a purposive sample of trial participants to complete a qualitative interview. We included patients who had received care from participating healers, were aged 18 years or older, were sexually active, self-reported not receiving an HIV test in the previous 12 months, and had not previously been diagnosed with HIV infection. Interviews explored experiences of participating in the trial and perceptions of healers delivering HIV testing. Interviews were audio-recorded, conducted in the local language, then translated and transcribed into English. Following a content-analysis approach, transcripts were independently reviewed by two authors to develop a coding scheme and framework that explains outcomes of the parent trial. Findings: Between Nov 26, 2019, and May 14, 2020, we conducted 124 interviews with 17 traditional healers and 107 trial participants. Half the participant group were women (n=62, 50%) and approximately one-third of healers were women (n=6, 35%). Responses from patients and providers showed that the intervention programme mitigated existing barriers to HIV testing. First, healer-delivered HIV testing overcame structural barriers that impeded receiving tests at clinical facilities. Underlying impoverishment and rural locations limited use of clinical testing, as transportation costs to facilities were frequently prohibitive. Healers were located in villages, where their services were easier to access. Second, patients perceived traditional healers as trustworthy and confidential. Participant responses underscored a preference for receiving an HIV test from a healer, rather than from biomedical settings, where HIV testing was described as stigmatising. Additionally, traditional healers reported increased respect from community members for offering HIV testing and expressed a desire to continue to offer HIV testing and counselling. Interpretation: Use of informal health-care providers to administer HIV testing is not only feasible but also well accepted in an area where traditional healers are frequently used for health care. Healers should be considered key stakeholders in the effort to increase uptake of HIV testing and achieving HIV epidemic control. Further research should consider whether results are generalisable beyond rural Uganda. Funding: National Institutes of Mental Health (K23MH111409 PI: [RS]).

Background: HIV is endemic in Tanzania (prevalence 5%). However, less than half of Tanzanians are aware of their HIV status and only 75% of Tanzanian adults living with HIV are on antiretroviral therapies (ART). Informal health-care providers, such as traditional healers, frequently serve as the first line of health-care services in Tanzania. To understand gaps in HIV care, we conducted a qualitative study to understand how traditional healers interface with adults living with HIV along the cascade of care. Methods: This study was conducted in Mwanza, Tanzania between November, 2019, and May, 2020. We invited traditional healers (n=15), clients of traditional healers (n=15), biomedical health-care facility staff (n=15), and adults living with HIV (n=15) to participate in a single qualitative interview. Two community focus groups were also conducted among male participants (n=8) and female participants (n=8). All participants were aged 18 years or older. Interviews explored individual experiences with traditional healers and biomedical health-care facilities, and perceptions of traditional healers with respect to HIV care. Interviews were conducted in Kiswahili by Tanzanian research assistants, transcribed, and later translated into English for analysis. By means of a content-analysis approach, transcripts were independently reviewed by two authors (RH, RS) to develop a coding scheme. Coded data were grouped into a framework that characterised the ways through which traditional healers engage with adults living with HIV throughout the HIV treatment cascade. This study was approved by pertinent ethical review boards. Participants provided written informed consent. Findings: 60 interviews and two focus groups were conducted and analysed. Qualitative data showed that adults living with HIV frequently engaged with traditional healers throughout the HIV cascade of care, from the pre-diagnosis to the post-diagnosis stages. Traditional healers were noted, in some cases, to directly facilitate HIV testing, whereas others were described as delaying testing through continued traditional treatment. Adults living with HIV commonly used traditional medications concurrently with ARTs. There was concern that traditional healers contributed to ART non-adherence because some adults living with HIV used traditional therapies in search of a purported HIV cure. Our findings suggest that traditional healers interact with adults living with HIV throughout the HIV cascade of care and that collaboration between traditional healers and biomedical health-care facilities could improve HIV outcomes. Interpretation: Qualitative data show that traditional healers can both support and impede patient's engagement with HIV services. Our findings show that traditional healers consistently interact with adults living with HIV in both the pre-diagnosis and post-diagnosis contexts, and they should be integrated into existing health-care infrastructure to improve engagement with HIV testing and treatment. Funding: Weill Cornell Kellen Junior Faculty Fellowship Award.