The Risk of HIV Acquisition among Traditional Healers in South Africa: Implementing Novel Strategies to improve protective Behaviors

项目概要：在南非，估计有20万名传统治疗师提供保健服务。 像对抗疗法的卫生保健工作者（HCW）一样，传统治疗师通过接触血液传播的病原体， 传统的“注射”的广泛实践，其中治疗师执行数十个皮下切口， 把草药直接注射进流血的皮肤里百分之九十八的治疗师进行这些治疗;他们经历 在他们的一生中，平均有1,500次血液接触。如此高频率的血液接触， 再加上治疗高风险患者，可能会导致患者对治疗者传播疾病的风险增加， 没有使用个人防护设备。南非的治疗师报告说， 接触过他们的皮肤的人比没有接触过的人感染艾滋病毒的风险高2.59倍（59%比2.59倍）。 总的来说，治疗者的艾滋病毒感染率（30%）大大高于普通人群（19%）。 当地卫生设施提供免费的个人防护设备，但大多数治疗师识字水平低，能力有限， 评估血液暴露风险，没有PPE培训。鉴于这些局限性，治疗期间使用PPE 不一致。一小部分治疗师在每次治疗期间适当使用个人防护设备;这些 “早期采用者”治疗师建议，如果治疗师具备以下条件， 必要的技能、风险评估培训和鼓励。我们的建议比较了两种实现方式 在手术过程中增加PPE使用并减少注射次数的策略：（1）HCW 通过一周的时间，领导关于血液接触风险的教育，并培养个人防护设备的穿戴、使用和脱下技能- 长期培训，然后在治疗师的执业地点进行3次教育外展访问，与之相比，（2）“早期采用者” 治疗师和保健妇女共同领导了为期一周的培训，随后进行了3次教育外展访问。我们假设 让“早期采用者”治疗师担任培训员的战略将导致更准确的参与者风险评估， 增加参与者自我效能，并导致在治疗期间更一致地使用PPE。 本研究的具体目的是： (1)使用ADAPT-ITT模型调整PPE培训; (2)比较仅使用HCW的团队与治疗者+ HCW团队之间PPE培训的保真度; (3)比较我们的两种实施策略对治疗者接触患者血液的影响。 这一潜在的高影响干预措施非常适合R21机制。虽然一些对抗疗法提供者 尽管可能会建议彻底禁止这种手术，但病人和治疗者都坚信这种手术的疗效。 这些治疗方法已经有几百年的历史了--它们不太可能在我们的建议下停止。我们必须 克服我们自己的偏见，制定有效的战略，以防止艾滋病毒血清转换。我们的南方团队 非洲和美国的研究人员在艾滋病毒研究方面有着成功的记录和成功的具体经验。 让传统治疗师参与、艾滋病毒预防研究以及传播和实施研究。

Project Summary: In South Africa there are an estimated 200,000 traditional healers providing health services. Like allopathic health care workers (HCW), traditional healers are exposed to bloodborne pathogens through the widespread practice of traditional “injections”, where healers perform dozens of subcutaneous incisions to rub herbs directly into the bloodied skin. Ninety-eight percent of healers perform these treatments; they experience an average of 1,500 blood exposures over the course of their lifetime. This high frequency of blood exposure, coupled with treating high risk patients, can result in increased risk of patient-to-healer disease transmission if personal protective equipment (PPE) are not used. Healers in South Africa who reported patient blood touched their skin had 2.59 times higher risk of being HIV-positive than those with no exposure (59% vs. 25%); overall healers have a substantially higher HIV prevalence (30%) than the general population (19%). Free PPE are made available at local health facilities, but most healers have low levels of literacy, limited ability to assess blood exposure risk, and have no PPE training. Given these limitations, use of PPE during treatments is inconsistent. A small proportion of healers employ PPE appropriately during each treatment; these “early adopter” healers suggest PPE use is sustainable in rural sub-Saharan Africa if a healer has the necessary skills, risk assessment training, and encouragement. Our proposal compares two implementation strategies to increase PPE use during procedures and decrease the number of injections performed: (1) HCW led education on risk of blood exposure and development of PPE donning, use and doffing skills though a week- long training followed by 3 educational outreach visits at the healer's place of practice vs. (2) “Early adopter” healer and HCW co-led week-long training followed by 3 educational outreach visits. We hypothesize that the strategy of engaging “early adopter” healers as trainers will lead to more accurate participant risk assessments, increase participant self-efficacy, and lead to more consistent use of PPE during treatments. The Specific Aims of this study are to: (1) Adapt PPE training using the ADAPT-ITT model; (2) Compare fidelity of PPE training between the HCW-only team versus the healer + HCW team; (3) Compare the effects of our two implementation strategies on healer exposure to patient blood. This potentially high-impact intervention is well-suited to the R21 mechanism. While some allopathic providers may recommend an outright ban on the procedure, patients and healers have strongly believed in the efficacy of these treatments for hundreds of years- they are not likely to stop at our recommendation. It is up us to overcome our own biases to develop an effective strategy to prevent HIV seroconversion. Our team of South African and U.S. investigators has a proven record of HIV research success and specific experience successfully engaging traditional healers, HIV prevention studies, as well as, dissemination and implementation research.