title: Symptomatic HIV-positive persons in rural Mozambique who first consult a traditional healer have delays in HIV testing: a cross-sectional study.
abstract: OBJECTIVE
  Delays in HIV diagnosis and initiation of antiretroviral therapy are common even among symptomatic individuals in Africa. We hypothesized that antiretroviral therapy delays might be more common if traditional healers (THs) were the first practitioners consulted.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  We interviewed 530 newly diagnosed HIV-infected adults (≥18 years of age) who were clinically symptomatic at the time of HIV testing in 2 rural districts in Zambézia Province, Mozambique. We ascertained their previous health care seeking behavior, duration of their symptoms, CD4 cell counts at the time of entry into care, and treatment provided by TH(s).
  
  
  RESULTS
  Of 517 patients (97.5%) with complete histories, 62% sought care from a healer before presenting to the local health facility. The median time to first health facility visit from first relevant symptom was 2 months [interquartile range (IQR): 1-4.5] for persons who had not visited a healer, 3 months (IQR: 2-6) for persons visiting 1 healer, and 9 months (IQR: 5-12) for persons visiting >1 healer (P < 0.001). Healers diagnosed 56% of patients with a social or ancestral curse and treated 66% with subcutaneous herbal remedies. A nonsignificant trend toward lower CD4 cells for persons who had seen multiple healers was noted.
  
  
  CONCLUSIONS
  Seeking initial care from healers was associated with delays in HIV testing among symptomatic HIV-seropositive persons. We had no CD4 evidence that sicker patients bypass THs, a potential inferential bias. Engaging THs in a therapeutic alliance may facilitate the earlier diagnosis of HIV/AIDS.
authors.affiliation: *Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN; Departments of †Preventive Medicine; ‡Biostatistics, Vanderbilt University School of Medicine, Nashville, TN; §Peace Corps, Mozambique, Quelimane and Maputo, Mozambique; ‖Friends in Global Health, Quelimane and Maputo, Mozambique; and ¶Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Carolyn M
authors.initials: CM
authors.lastname: Audet
authors.forename: Meridith
authors.initials: M
authors.lastname: Blevins
authors.forename: Caitlin
authors.initials: C
authors.lastname: Rosenberg
authors.forename: Sarah
authors.initials: S
authors.lastname: Farnsworth
authors.forename: José
authors.initials: J
authors.lastname: Salato
authors.forename: Jorge
authors.initials: J
authors.lastname: Fernandez
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D006801:Humans; D008297:Male; D016488:Medicine, African Traditional; D008875:Middle Aged; D009073:Mozambique / Q000453:epidemiology; D012424:Rural Population; D013997:Time Factors; D055815:Young Adult