Management of the Oral Manifestations of Hiv/aids by Traditional Healers and Care Givers

Curationis 30(1): 56-61 In many communities of South Africa, traditional healers are often the only means of health care delivery available. The level of knowledge and ability to recognize oral lesions of 32 traditional healers and 17 care-givers were assessed after a two-day workshop. The data collection instrument was a structured questionnaire, complimented by enlarged clinical photographs of the common oral manifestations of HIV/AIDS. Prior to the workshop, 46 (93.9%) of the 49 respondents had never had any formal information on oral health and 43 (87.8%) were unfamiliar with the symptoms of oral diseases. Thirty-five (71.4%) recognized bleeding gums from A4-size photographs and 11 (22.4%) recognized oral thrush. The recognition of other oral manifestations of HIV/AIDS were; oral hairy leukoplakia (41.0%), angular cheilitis (43.6%), herpes virus infection (56.4%), oral ulcerations (56.8%), and in children, parotid enlargement (27.3%), and moluscum contagiosum (56.8%). Traditional healers and caregivers constitute an untapped resource with enormous potential. A positive bridge should be built to link traditional healing with modem medicine in the struggle against HIV/AIDS. Abstrak Tradisionele genesers is gewoonlik die enigste gesondheidsverskaffers in baie Suid Afrikaanse gemeenskappe. Die gehalte van kennis en vermoe om orale wonde te erken was gedurende n 2 dae berraad van 32 tradisionele genesers en 17 versorgers ondersoek. Die dataversam elingsinstrum ent was n gestruktureerde vraestel, geklomplimenteer deur vergrote kliniese fotograwe van gewone orale manifestasies in H1V/VIGS. Voormalige statistieke het gewys dat 46 (93.9%) van die 49 deelnemers het geen formele inligting oor orale gesondheid bekom nie, en die simptome van orale siektes was onbekend tussen 43 (87.3%) van die deelnemers. 35(71.4%) kon bloeiende tandvleis erken deur die gebruik van A4-groottee fotograwe en 11 (22.4%) kon mondsproei erken. Die erkenning van ander orale manifestasies was soos gevolg: orale harige leukoplakie (41%), angulere cheilitis (43.6%), herpesvirusinfeksie (56.4%) en mondsere (56.8%) en in kinders, parotiede vergroting (27.3%) and moluscum contiagiosum (56.8%). Tradisionele genesers en versorges is dus ook 'n enorme enbekende potensiaal. 'n Positive verband moet dus tussen tradisionele en moderne geneeskunde gebring word in die stryd teen HI V/VIGS.


Introduction
The WHO has delineated a working definition o f traditional medicine as " including diverse health practices, approaches, know ledge and beliefs incorporating plant, anim al, and/or m ineral based m edicines, spiritual th erap ies, m anual techniques and ex ercises ap p lied sin g u larly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness" (World Health Organisation, 2002).T rad itio n al healers (the practitioners of traditional medicine) are deeply interwoven into the fabric of cultural and spiritual life o f a large proportion of South Africans and they are easily accessible in urban, peri-urban and remote areas where other health services are lacking (Dlamini, 2000;Mills, Singh, Wilson, Peters, Onia & Kanfer, 2006).
They are recognized and acknowledged by the community in which they live and p ractice as com petent health practitioners.Some traditional healers have a multifaceted role, which includes training, leadership and participation in a number of medico-religious functions (Kellemian & Thindisa, 1998).All over the world, there is growing interest in traditional healers as a resource for health care delivery (Nevin, 2000).
In Zambia, traditional healers played an influential role in the promotion of the h ealing process in the com m unity (Ndubani & Hoer, 1999).Many patients seek help concurrently from traditional healers and formal health services.Another study from Zambia found that 68% of 1000 patients attending a formal centre for HIV counseling and testing had seen a traditional healer (Baggaley, Sulwe, Burnett & Ndovi, 1996).Studies from Tanzania also indicate that approxim ately 80% o f HIV patients receive their medical attention from a traditional healer rather than from a hospital or primary health care facility (Editor, 1996).N gilisho, M osha & Poulsen (1994) interviewed 73 traditional healers and 408 villagers in Tanzania.Sixty per cent of the traditional healers claimed that they treated dental patients with an average o f three patients per month.A large variety of local herbs was used and about 40% of them claimed that they would refer the client to a modem health facility if their treatment did not work.Half of the villagers interviewed had experienced toothache and 60 per cent of those who had experienced toothache within the last two years were treated with local herbs from traditional healers.Relief was obtained for more than six months for 40 per cent of the patients, who sought this service.An additional finding was that the establishment of modem emergency oral care in rural health centres and dispensaries did not influence the villagers' use of the traditional healers.Similar reports have come from other countries in Africa (Oyebola, 1986;Zachariah et al, 2002).In a report from Nigeria, traditional healers were the only means of health care delivery available to over 80% o f the rural population (Oyebola, 1986).
It is im portant that orthodox and traditional practitioners work closely if the H IV /A ID S pandem ic is to be combated.Traditional healers are in close proxim ity to patients and are respected in th eir com m unities.A dditionally, H IV /A ID S patients sometimes seek the help o f traditional healers because they have no alternative for care.In regions with high prevalence rates, hospitals admit only acute cases o f AIDS and p atien ts are thus encouraged to seek traditional help.
C hipfakacha (1997) in v estig ated know ledge, b eliefs, p ractices and experiences o f traditional healers in relation to sexually transmitted infections, HIV and AIDS.The author found that the advent o f H IV /A ID S and the introduction of home-based care in most African countries have increased the case-load of many traditional healers.Most of the patients who are discharged from hospitals on hom e-based care usually end up at the traditional healer as relatives seek a second opinion or simply because they disagree with the diagnosis o f incurable disease.This exposes traditional healers to HIV/AIDS.
To protect themselves and their clients, trad itio n al h ealers need the right inform ation on H IV /A ID S. M ost traditional healers use their bare hands (ungloved) to apply topical medicine.Many also utilize their mouths to suck blood from their patient's body as part of disease management (Chipfakacha, 1997).Neequaye, Neequaye & Biggar (1991) examined factors related to the spread of HIV infection, including knowledge about AIDS and found among others that skin piercing, including scarification, was done using unsterile instrument by 39% of 74 rural traditional healers, many of whom had more than one patient per day.Cooperation between traditional healers and scientific m edical personnel is essential for an effective and successful HIV/AIDS prevention and infection control programme.
Traditional healers and home care-givers constitute an untapped resource with enormous potential to help address the HIV/AIDS epidemic.Care-givers in the community counsel the physical, spiritual and mentally ill, engage in regular home visits, give support and love to victims and maintain confidentiality.
An exploratory study by Lewis, Daya & Rudolph (2004) in Zonkizizwe and Dube in the Gauteng province of South Africa demonstrated that about 50% of patients who visited healers presented with oral lesions.
The objectives of the present study were; to assess the knowledge and practical ability o f traditional healers and care givers with regard to tooth cleaning, and to evaluate their post-workshop ability to recognize and differentiate between the common oral lesions of HIV/AIDS in adults and children.

Materials and methods
In an earlier all-inclusive study, Lewis, Mistry, Rudolph, Marambana, Monyatsi, Ramela (2001) interviewed 63 consenting traditional healers and care givers from the townships of Zonkizizwe (close to Alberton and about 40 kilometers from Johannesburg) and Dube in Soweto (about 20 kilometers from the inner city of Johannesburg).All the 63 traditional healers and care givers interviewed by Lewis et al (2004) were invited to a 2-day workshop on oral health in Zonkizizwe.F orty-nine (77.8% ) volunteered to participate in the study.These consisted of 32 traditional healers and 17 care givers.P rior to the study, a focus group discussion was held with four randomly selected respondents.This discussion was designed to obtain the views of the participants on the principle and purpose of having an oral health workshop as well as the form at and process o f the workshop.A dental assistant who could speak the local language facilitated the discussion.Issues such as venue, dates, duration, topics and confidentiality were All data was analysed on an IBM compatible micro-computer using the SAS statistical package (Version 8.2).Simple proportion was calculated for all the variables and Chisquare test was used to assess differences.Differences were taken as significant at p<0.05.

Ethical Considerations
Ethical approval was obtained from the Ethics and Research Committee at the University of Luton (London) at Regent College (South Africa) and the University o f the Witwatersrand, Johannesburg.Permission to conduct the research was also obtained from the traditional healers themselves using consent forms.

Results
Forty-six (93.9%) of the 49 respondents had never had any formal information on oral health and 43 (87.8%) were unfamiliar with the symptoms o f oral diseases.However, the traditional healers indicated that they had been o fferin g som e treatment to their clients, mainly giving "muti" for rinsing.(Table1).
The tooth-brushing ability of most of the respondents was found to be very good.
It must be fioted however that some reported using glycerine, salt, ash or toilet soaps as teeth cleaning agents.Some also reported using pantyhose or plastic strips to "floss" or clean in-between the teeth.A few also use chewing sticks.
Thirty-five (71.4%) recognized bleeding gums from A4-size photographs and 11 (22.4%)recognized oral thrush.Both conditions were usually treated by the respondents using " m u ti" as a mouthrinse.
The recognition o f lesions based on photographs dem onstrating pseudo m em branous and erythem ato u s candidiasis, angular cheilitis, oral hairy leukoplakia and herpes in adults was assessed.A sim ilar assessm ent was conducted for oral lesions associated w ith H IV /A ID S in children using photographs of oral ulcerations, parotid enlargement and moluscum contagiosum.
The responses indicated that over 40% gave incorrect answers for all the five lesions commonly seen in adults, (Table 2) and five of the six lesions in children, (Table 3).Herpes virus infection, oral ulceration and moluscum contagiosum were the best recognized with correct responses from about 57% o f the traditional healers and care givers (Table 3).(Green, 1999).However, many orthodox practitioners are still sceptical about traditional healers caring for HIV-infected individuals as they are concerned that traditional medicine may be ineffective and that they may dissem inate inappropriate health education messages.This fear is also shared by those outside the health profession (Tembo, 1991).However, it must be realized that even orthodox medicine does not have all the answers.Kikwuluand Hiza(1997) in their study found that 60% of parents who had taken their child to hospital subsequently consulted a traditional healer because of dissatisfaction.

Discussion
Although the psychotherapeutic care provided by traditional healers could be regarded as safe and acceptable, other methods of treatment, such as sucking blood and extracting teeth, are highly suspect and constitute high-risk HIV activities (Ogunbodede, 1991;Editor, 1996).In this study one of the traditional healers "burnt incense to kill the worms in the tooth".This is based on an age long myth, and such ineffective remedies abound in current practice of traditional m edicine (Baker, M illard, M alatsi, Mkoana, Ngoatwana, Agarawal & de Valliere, 2006).However, the positive aspects of the contributions of traditional healers need to be harnessed and encouraged while attempts should be made to educate them on infection co n tro l, high risk pro cedures and appropriate referral.It is also essential that they are trained to identify and manage simple oral diseases as they are often the first to be consulted by ailing patients.Masauso et al. (1999) in Zambia found that the traditional healers had detailed co n stru cts o f the p hy siology and infective processes underlying syphilis, gonorrhea, chancroid and AIDS.The study id entified some areas o f compatibility between indigenous and biomedical models of sexually transmitted infections.Consequently, a programme was established in which traditional healers received AIDS training and learnt to counsel clients on safer sex behaviour.
Similarly, an evaluation of a South African AIDS prevention programme found that a year after training, healers were able to define and describe HIV accurately; describe three or more AIDS symptoms correctly and describe accurately three or more means of HIV transmission and prevention (Leclerc-Madlala, 2002) Since traditional healers see many clients from all works of life, they can be very powerful educators.They can influence the community, as well as other healers through their professional networks.They understand local belief systems and can explain illness and misfortune in ways with which people are familiar.They usually treat the whole person, not just the diseases and so take into account a person's mental, emotional, spiritual as well as physical well-being.
T raditional healers often see their patients together with other family m em bers and as a result can play important role in family counseling.They need to have access to correct inform ation about oral diseases and especially the oral manifestations of IIIV/ AIDS (Green, 2000).They can help to achieve the positive pattern of behaviour, beliefs and values that ultimately helps the com m unity they serve.There is however, the need for wide scale studies on the dissemination of information on HIV/AIDS prevention in South Africa.
During the workshop, the discussion revealed role conflicts am ongst the different categories of traditional healers.Thus, the concept o f 'ro le' will be particularly important if traditional healers are to function effectively as part of a larger group of health care workers.To facilitate effective cooperation with traditional healers, Green, (1999) has made the following recommendations: 1) be fair and democratic in selecting healers for training; 2) try to identify and train motivated healers who are respected in their com m unities; 3) do not make m em bership o f a traditional healer asso ciatio n a requirem ent for participation in HIV/AIDS training; and 4) encourage healers to promote sexual abstinence among youth, and fidelity within marriage among adults.
The 49 traditional healers and care-givers who participated in the present study constitute a high percentage of all the traditional healers in the study area.This suggests a willingness to learn new information and share their knowledge w ith colleagues and orthodox practitioners.This is in agreement with the finding of Baggaley et al (1996) that some traditional healers request help, from orthodox sources, in managing patients who they suspect may be HIVseropositive, especially for HIV testing.

Table 1 . Treatment offered by the traditional healers
* The total was more than the number o f respondents due to overlap of responses.raised.At the beginning of the workshop, the purpose was further explained to the participants.The participants were also informed that a questionnaire would be completed at the end of the workshop.Every effort was made to create an atmosphere of cordiality, understanding, trust, and mutual respect.The form al w orkshop presentation included the dem o n stration o f the common oral manifestations of HIV/AIDS using clinical photographs, oral hygiene m aintenance and treatm ent o f oral lesions.A discussion was held about the associated with HIV/AIDS were provided and relevant questions on these were put to the respondents.The competence of participants in the practical aspect of tooth brushing was also evaluated (by MM) on a scale of 1 (very poor) to 5 (excellent) with each participant brushing own mouth.

Table 3 . Recognition of the oral manifestations of HIV/AIDS commonly seen in children
The current health system in South Africa is based on the Primary Health Care Approach (PHCA).The District Health

Curationis March 2007 manifestations
of HIV/AIDS.A positive bridge should be built to link traditional healing with modem medicine, especially in the struggle against HIV/AIDS.National medical policies in Nigeria.The professionalisation of African medicine.Manchester: University Press.Traditional healers.In: Baron, P. (ed.).South African Health Review 1999.Durban: Health Systems Trust, Chapter 18.
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