Background
Only 23% of people living with HIV (PLWH) in rural Uganda are virally suppressed, which falls far short of the 95% suppression target set by UNAIDS. This illustrates the need for tailored strategies to engage PLWH in rural settings and retain them in care. Traditional healers (TH) are often the first point of contact for healthcare in rural communities, including for PLWH. In our cluster-randomized clinical trial (NCT 05943548), we trained Ugandan TH to identify PLWH receiving care at their practices who were not engaged in HIV care.
Methods
In August 2023, we trained TH in Mbarara, Uganda, to screen for adult PLWH at their practices through 1) facilitation of HIV self-testing for people who had not been tested for HIV in the past 12 months and did not have a known prior HIV diagnosis and 2) evaluation of adherence among known PLWH using the CASE Adherence Index Questionnaire (CAIQ). TH clients with a reactive HIV self-test or CAIQ score <10 underwent further screening involving measurement of HIV-1 viral load (VL). All virally unsuppressed PLWH (VL >200 copies/mL) were referred to a local HIV clinic to (re-)initiate care.
Results
Between September 2023 and September 2024, 200 PLWH were identified at participating TH practices. 106 PLWH were newly diagnosed via self-testing at the TH location; for 57% (n=60) of these PLWH, the TH-facilitated test was the first lifetime HIV test that they received. Among participants who underwent HIV self-testing, prevalence of HIV was 2% (n=96/4732). TH identified 94 known PLWH who met the criteria for ART non-adherence; among these, 56% (n=53/94) had unsuppressed HIV VL.
Conclusions
Our data highlights the untapped potential of TH in reaching rural Ugandan people living with HIV who are not engaged in HIV care. Over half of newly diagnosed individuals received their first HIV test at a TH practice, suggesting that TH can complement formal health services and play a crucial role in advancing progress toward the UNAIDS 95% testing target. We also identified many PLWH with high VL who are at high risk of HIV-related complications and contributing to onward transmission. Future research should explore how some PLWH maintain viral suppression despite disengagement, assess the long-term impact of TH interventions, and identify effective ways to support TH in delivering HIV care.