Preventing occupational exposure to bloodborne pathogens among rural South African traditional healers

Vanderbilt Institute for Global Health (VIGH) and collaborators at the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) at the University of the Witwatersrand in South Africa have received a new research development grant from the National Institute of Allergy and Infectious Diseases to compare novel implementation strategies to reduce the risk of HIV acquisition among traditional healers in South Africa.

This $400,000 award will tailor a personal protective equipment (PPE) training program for use by traditional healers and test two implementation strategies to increase PPE use during procedures when exposure to blood occurs.

There are an estimated two million traditional healers in sub-Saharan Africa (SSA), with more than 200,000 working in South Africa. Traditional healers in SSA are frequently exposed to bloodborne pathogens (hepatitis B virus [HBV], hepatitis C virus [HCV], and human immunodeficiency virus [HIV]) through the widespread practice of traditional “injections.” Healers perform dozens of subcutaneous incisions across the chest, back, and arms using a razor blade to rub herbs directly into the bloodied tissue using their hands.

To understand the risk of HIV acquisition among this key population, researchers conducted a cross-sectional survey that included a rapid HIV test. They reported in the journal AIDS, HIV prevalence of 30% among tested healers with 98% having performed traditional skin incisions.

An average healer in Agincourt, Mpumalanga located in rural South Africa experiences approximately 1,500 occupational blood exposures over the course of their lifetime. Healers have an HIV prevalence of 30% compared to 19% in the general population in Mpumalanga.  

Healers who reported exposure to patient blood had an adjusted two-fold higher risk of being HIV-positive than those with no exposure after other exposure risks were taken into consideration (e.g. polygamous relationships, gender, age). With 231,000 new HIV infections in South Africa in 2017, healers represent an unrecognized high-risk population.

“Regular use and safe disposal of appropriate personal protective equipment is urgently needed to protect this high-risk group,” said Carolyn Audet, Ph.D., Assistant Professor in the Department of Health Policy at Vanderbilt University Medical Center and the project’s principal investigator. “Healers provide an essential health service to those living in rural communities. Now that we understand the risk they face, we have an obligation to protect their health.” 

While the use of PPE by healers during treatments is inconsistent, a small proportion of healers do use PPE regularly and appropriately. The presence of “early adopter” healers suggest a sustainable model of PPE use can be sustained in rural Africa.

The study compares the following implementation strategies to increase PPE use and proper disposal during procedures:

  1. Health care worker (HCW)-led education on blood exposure risk and PPE use through a week-long training, followed by three educational outreach visits.
  2. “Early adopter” healer and HCW co-led training followed by three educational outreach visits.

“We theorize “early adopter” healer messaging and delivery will have greater impact given their membership within the healer community,” says Audet.

If the study finds a significant decrease in blood exposure, researchers will propose a definitive randomized controlled trial to assess the impact of PPE interventions on HIV seroconversion among healers living in South Africa to determine if PPE training can reduce HIV incidence among healers.

Source: NIH Reporter Grant Number 1R21AI150302-01

Carolyn M. Audet, PhD, MSci
Assistant Professor, Departments of Health Policy and Epidemiology
Assistant Director, Community-based Implementation Science
Center for Clinical Quality
and Implementation Research
Vanderbilt University Medical Center