Traditional health practitioners’ perceptions, herbal treatment and management of HIV and related opportunistic infections

The study utilised mixed methods to explore the conceptualisations of HIV and associated OIs, and to collect and prepare voucher specimens of the medicinal plants used for treatment. This research is part of a broader study initiated by the Multi-disciplinary University Traditional Health Initiative (MUTHI) to document medicinal plants used in several African countries in the treatment of various infectious diseases.

Since THPs in Strand, Western Cape, collect or order medicinal plants mostly from Mount Frere, Eastern Cape (Figure 1), both areas were studied. A total of 36 diviners and 17 herbalists were sampled in both study sites. A meeting was held with the chair of the local Traditional Healers Association (THA) in each study site and prior informed consent was obtained stipulating the purpose for collection and use of medicinal plants. Interviews were conducted in the preferred language of the respondent (IsiXhosa and IsiZulu). Plants were collected in two fold and voucher specimens prepared according to the specifications of the herbarium at the University of the Western Cape. The chair of the THA at each site helped to identify and sample THPs for the focus group discussions (FGDs). The THPs interviewed, were selected through a non-probability “snowball” sample [29]. THPs were asked to identify other potential participants to participate in the study. Field work took place from January 2012 to October 2012. Selection criteria included THPs who had plant collection permits and belonged to a local THA.

The study was undertaken in two provinces because many of the THPs in Strand received their training in Mount Frere area (Mpoza). They also collect or “order” medicinal plants from relatives or plant gatherers in Mount Frere. Strand is an urban coastal town approximately 50 km from Cape Town, located in the Helderberg district with a total population of approximately 50 000 of which 8% is black [30]. Strand has a large area with informal housing that accounts for 16.7% of the population and unemployment rate of 25.5% [31]. Approximately 5.4% of the population is affected by HIV and TB [32]. Mpoza is a semi-rural village located in the Mount Frere district and has a total population of 7 655 of which 99% is black [33]. The average number of people per household is 7.4 [34]. Poverty and unemployment is high and is seen as contributing to the high prevalence of infectious disease [33]. Mpoza has an HIV prevalence rate of 15.2% [33].

In our sample of THPs, 73% were diviners and 27% were herbalists. The herbalists were all males and belong to the Zionist church. The diviners were all females and do not belong to any religious denomination. The THPs’ ages ranged from 32–92 years. Their level of school education at both study sites was 58.49% who completed primary education, 30.19% secondary education, and 1.06% tertiary education. Only 2.12% had no formal education. Nearly all (98.41%) of the THPs were full-time practising diviners or herbalists and were known in the areas where they lived. THPs received most of their income from their healing practices, but also supplemented their income with informal trading of food and livestock. The remaining (1.59%) were part-time THPs and employed as domestic workers, gardeners or public administrators. All of the THPs were registered with a local THA, had plant collection permits and practiced from their homes. Table 1 shows the demographic characteristics of THPs in both study areas.

Data was collected through individual semi-structured interviews and FGDs. In both cases a purposive snowball sample technique was used to approach THPs to participate in the study. All participants selected, were practising diviners or herbalists and were known as such in either Strand or Mpoza. They were all thus key informants.

The same topic schedule (see Additional file 1) for discussion was used for each FGD. This was done to enhance consistency in the conversations that emerged between participants. For the first round of FGDs, participants were not preselected. Instead, all of the participants who were interviewed and who participated in plant collection were invited to participate. Participants were informed of the date, time and location for the FGDs. Participants were offered refreshments before the FGD began. The venues for the FGDs were familiar to all of the participants and the translator was a local and well-known among them. All of which made them feel comfortable. All participants were informed of the aims, objectives ad themes of the FGD in their preferred language (IsiXhosa or IsiZulu) and signed an informed consent document. Participants then completed a register and name tags were made for them. The first and second authors acted as facilitator and moderator respectively. Both have training and experience in managing focus group discussions. The facilitator took care to direct and redirect questions to ensure participation by all. The initial discussions were started with engaging questions such as “how long have you been practising as a THP?” and “from who did you acquire this knowledge?” Then exploratory or probing questions such as “what causes HIV?” and “what is the role of the ancestors in healing?” asked. Where necessary, probing questions were used to further explore underlying thoughts and assumptions. Finally, exit questions were used to ascertain if anything had been overlooked in the discussion. The facilitator and moderator listened attentively and gave sensitive and impartial responses to participant’s input.

After each FGD, the data were reviewed to see if new themes or information had emerged. At Mpoza, two FGDs were planned and held at the district health-care facility. Each FGD involved 13 diviners (all female) and five herbalists (all male). These THPs constituted all those practising in Mpoza at the time of interview. After the second FGD, no new information, themes or insights arose from the data and saturation had been reached [35]. In Strand, where there are larger numbers of practising THPs, the first FGD included ten diviners and six herbalists. The second group involved seven diviners and five herbalists. Twelve diviners and seven herbalists participated in the third FGD. All the FGDs were held in the Broadlands Municipality office, Strand. As in Mpoza, after each FGD, the material was transcribed and reviewed. After the third FGD, no new information or themes arose. Nevertheless, to ascertain whether there were distinctions between the ways in which diviners and herbalists understood HIV, TB and OIs, one FGD was done with diviners (15) and another with herbalists (10) only. There were no distinct differences in the information received. The information generated through the FGDs was triangulated with the in-depth interviews and current literature.

The collected plant specimens were dry pressed in the field. The scientific names of the plants were located by the authors who cross-checked their vernacular names and photographs with available literature. The dry pressed plants were then taken to the herbarium at the University of the Western Cape. Several botanists at the University herbarium examined the plant pressings together with collection notes such as flora, vernacular name, locality, GPS coordinates, habitat, plant distribution when collected, plant parts used, preparation methods, administration methods and a comprehensive plant description against the herbariums’ existing database of voucher specimens. The botanist identified the plants and their names were updated by the authors using the Kew’s plant list “http://​www.​theplantlist.​org/​”. A complete set of voucher specimens were then deposited at the herbarium at the University of the Western Cape for future reference.

After the interviews and FGDs, all information was carefully scrutinised and the first open codes were linked to sets of data. When no new information was generated during data collection and analysis and codes were not changed anymore, saturation had been achieved. Such codes included, ityhefu (poison), dirt, ungcoliseko (pollution-environmental), idliso (pollution-spiritual), and witchcraft and would cohere under the theme HIV causation (emic). The prevalence of themes was determined by the number of sections of research material that were encapsulated by related codes [36].

In this way, data were analysed using a thematic content analysis approach [37]. The data underwent several stages of analyses starting with initial transcriptions and scrutiny of the material to check for coherence and saturation. Data from different respondents were compared with each other to identify patterns and themes that recurred or were common [38]. Thereafter, the transcriptions were presented to a random sample of participants in a respondent-feedback session for cross-referencing and editing where necessary. Finally, the themes were then discussed with colleagues to scrutinise its reliability and validity and to substantiate that the results were not anecdotal.

Ethical approval for the overall MUTHI project was obtained from the Senate Ethics Committee UWC. Prior informed consent was sought from the THA and village head in Mpoza and the chair of the THA in Strand. Prior informed consent was also obtained from each participant. Interviews were conducted in the preferred language of the respondent (IsiXhosa and IsiZulu).

None of the THPs in both study areas claimed to have diagnosed HIV or TB. THPs always relied on a diagnosis of a qualified health-care practitioner from a local clinic. THPs in both areas had homogenous ideas about how to treat the symptoms of OIs, which is not surprising, since many of the THPs in Strand originated from or had received their training in the Eastern Cape. Practices varied between diviners and herbalists. Diviners relied more on guidance from the ancestors when treating OIs, while herbalists generally practice with herbs only, and in some instances would consult a diviner when a client presented with an uncommon symptom. Drawing on responses from semi-structured interviews and FGDs, THPs’ conceptualisation about HIV, and especially OIs, fell across four spheres of influence as can be seen in Figures 2 and 3. While it was evident that THPs relied on a biomedical diagnosis, they also understood the symptoms with which a client presented as a combination of biomedical diagnosis and symptoms, biomedical diagnosis and ancestors; and ancestors and symptoms. These ideas about HIV and OIs are also related to THPs’ understandings of the cause of disease which were further grouped into three categories, i.e. physical, environmental and spiritual pollution. These categories were sometimes used interchangeably as causes of disease and varied among the THPs and between THPs from Strand and Mpoza (see Figures 2 and 3).

Most THPs from Strand had some knowledge about the physical causes of HIV, as well as the symptoms of OIs, such as red “blister-like” sores and thrush, which were the most frequently reported. In Strand, THPs had exposure to HIV education and showed a high level of biomedical knowledge of the symptoms and treatment of HIV and associated OIs. Many of these THPs (87%) had attended at least one workshop or an awareness programme around HIV, TB and OIs. They also had access to information about these diseases through public libraries, clinics and the information available in the media. In Mpoza, general knowledge of the physical causes and symptoms of TB was moderate, however, they were less knowledgeable about HIV. When these THPs treated clients with symptoms such as swelling in the armpits and neck, red ukugubhuka (blisters with fluid) on the arms, neck, around the waist (“belt”) or with amaqhakuva asemlonyeni (mouth sores) in or around the mouth and/or the genitalia, they suspected HIV infection. Overall, the THPs firstly relied on medical diagnoses. They also looked for physical symptoms such as rashes, swollen lymph nodes, mouth and genital ulcers, vaginal discharge, weight loss, diarrhoea etcetera. TB was suspected when clients had persistent coughing, bloody sputum, weight loss and on-going feverishness. THPs were simultaneously guided by their ancestors in diagnosing a client’s ailment and for treatment options. Treatment methods varied from THP to THP.

As seen above, the perceptions of THPs pertaining to disease and treatment incorporate biomedical diagnoses, physical symptoms, ancestral guidance, as well as the possible negative influences of witchcraft or pollution. Ultimately, for THPs, healing is about addressing underlying states of imbalance caused by poor physical environment, disturbed relationships with the ancestors, negative relations between people (witchcraft) and with the spiritual world (pollution).

Twenty-four per cent of the THPs from Mpoza and 63% from Strand, understood HIV as a disease which is spread through blood and through physical intercourse. HIV transmission occurs through contact with “dirty” or “poisonous” blood e.g. by using contaminated blades to do circumcisions, semen, vaginal fluids, and intercourse with a menstruating woman.

Spiritual “pollution” or (idliso- poison) can also result in HIV. Idliso is caused by the neglect of the ancestors and necessary rituals and manifests in poor social behaviour, promiscuity, adultery, drinking too much and smoking. Urbanisation was reported as the biggest threat to traditional values and ways of living. THPs suggested that in the past, their ancestors lived as agriculturalists. According to Mr Y from Mpoza:

In another interview, Mr S, from Strand reported:

As seen above, the behaviour of, especially younger people, is linked to poverty, unemployment, migration and the breaking down of traditional ways of living. According to Dickinson [39], THPs are seen as custodians of traditional values and social order. This was found to be the case in Mpoza and Strand where THPs were actively involved with self-organised awareness programmes about sexuality.

Nearly all of the THPs in Mpoza and Strand (92%) attributed TB to exposure to people infected with TB, coughing and sputum. Vulnerability to TB was reportedly heightened because of smoking, poverty and air pollution. In Strand, TB was commonly seen as deriving from “dirtiness”, poor housing, economic circumstances, poor nutrition, drinking too much, smoking and low resistance. TB infection settles in the chest and results in heavy coughing, night sweats and chest pain. TB may also be caused by the sharing of utensils, poor hygiene and coughing over people. THPs furthermore associated TB with HIV infection.

THPs most frequently used a biomedically informed explanation of TB, but they did not exclude idliso and witchcraft as causes. They accepted that their clients would visit health-care facilities and in most cases encouraged clients to be tested before treating them. There is thus a diversity of ideas about causation which overlap and may best be understood on a sliding scale from naturalistic to “personalistic” causes [40, 41]. Thus, in certain cases, THPs also see witchcraft and “spiritual pollution” as causal.

There is an aetiological connection between biomedical explanations, the impact of poverty, urbanisation, the breakdown of traditional values and the overarching role of the ancestors. According to Dickinson [39] much of THPs understandings of HIV are in line with scientific explanatory models, but there are also critical differences and competing explanations of HIV and TB. Thus, biomedical and local explanatory models intermix and are not easily disentangled.

THPs follow diverse procedures in treating their patients. The scope of their practice is wide-ranging: from the collection and preparation of herbal remedies to counselling, sucking of blood from wounds, cleansing ceremonies, dealing with births, circumcision and using a range of physical and spiritual techniques. Most THPs reported that HIV was a relatively new, incurable disease and they are not trained to deal with it. Red “blister-like” sores on the neck, waist and arms or thrush on the genitalia or mouth region on the other hand were common and frequently treated. The treatment process varied between THPs. They consulted the ancestors about plants to treat their clients and performed rituals during treatment. Moreover, 89% of THPs encouraged their clients to consume TM together with ARV’s and TB medication which are available from the local clinic.

The treatment process for HIV, TB and OIs involves three stages of regenerative work depending on the symptoms and severity. These stages implement various treatments to address the body from inside out. For THPs from Mpoza and Strand, treating a client is about reinstating a state of balance which was disrupted by social behaviour, idliso or witchcraft. The healing process is consequently about expulsion of idliso “poisons”. Many of the THPs in Mpoza and Strand believe that the healing process involves a systematic support of the body’s own ability to heal itself as opposed to relieving immediate symptoms.

The first stage of treatment happens at the ancestral shrine and is aimed at cultivating strength and getting the person back on his/her feet. A THP will prepare nutritious food to “cleanse” the client from the “inside”. The client is also given a weak infusion of a plant remedy (singly or as a mixture of plants). At this stage of treatment, the client is not well enough for a strong dose of the remedy. Pregnant woman, children and infants are usually given a weaker dosage.

In the second stage of the treatment process, the client is well enough to leave the THPs shrine. He/she is given a remedy with instructions concerning the dosages. In the case of HIV and TB, the medicine is usually taken three times a day: in the morning, in the afternoon and in the evening after meals. OIs are treated with a topical herbal remedy administered thrice a day or when experiencing discomfort. This stage also includes a stronger plant remedy. The second stage of treatment spans over two weeks.

The third and final stage of treatment usually lasts four weeks or more. The most potent plant remedies are now administered. Throughout the process, the client visits the THP in follow-up sessions to examine progress. Most THPs in Mpoza and Strand reported that the symptoms of HIV and TB disappear after six weeks of successful treatment. A few THPs argued that the plants they use are “strong” and the symptoms may dissipate after a client had been treated for a week or two. Generally, treatment lasts until the symptoms disappear.

One of the most common reasons for HIV infected clients to visit THPs was when ARV’s have side effects such as throwing up, stomach cramps and headaches. THPs then provided a mixture of plants to be taken after the consumption of ARV’s to stop the reported side effects.

Plants deemed especially powerful in treating HIV and OIs are collected and dried under the guidance of ancestors. These plants may be specific for HIV or TB or are used for individual clients. According to the THPs from Mpoza and Strand, no two clients are treated in the same way.

The plants (whole or in part) are dug up. The remaining roots are covered to preserve whatever is left behind for sustainability and as a sign of respect to the ancestors and to the land. This reportedly ensures the continued growth of the plant for future use. In their shrines, THPs set about grinding or grating the plants, wholly or in part, depending on the intended application, for example as a tea, syrup, a paste applied to the skin or a powder. The plants are then stored in plastic or glass containers for later use.

THPs identified 17 plants belonging to 12 families used in the management of suspected HIV and treatment of OIs. These plants are indigenous to South Africa. Table 2 gives a list of the plants used to manage HIV and to treat OIs. The most frequently reported plants were Hypoxis hemerocallidea (48%), Asparagus densiflorus (27%) and Lessertia frutescens (L.; 25%). Figure 4 indicates the frequency of use of the different plant parts used by THPs to prepare remedies to manage and or treat HIV and OIs.