Patients Lost to Follow-Up: Research into the Tradition of Holy Water and Implications for Patient Adherence to Antiretroviral Therapy in Ethiopia
Background
In an I-TECH outreach project at antiretroviral therapy (ART) clinics of four Ethiopian public hospitals, patients on ART who did not return for routine HIV care were identified as "lost to followup" (LTFU). After phone calls and visits to individuals LTFU, investigators revealed that some LTFU patients had discontinued ART, opting instead for the sole use of clergy-blessed "holy water" to fight their symptoms of HIV. The objective of this study was to conduct formative research to create stronger adherence for HIV education messages (targeting pre-ART patients) about the importance of continuing on ART or the importance of continuing care (pre-ART) in addition to holy water.
Methods
Data was gathered through observations, field note descriptions, and in-depth key informant interviews.
Findings
Key informants interviewed attributed their HIV-positive status to "God's rage" or "the devil's work." Unprotected sexual intercourse with multiple partners and substance use were seen as transgressions of God's laws. It was felt that holy water intake purged illness, restored the self-image as being worthy of love, and provided the possibility of a cure. Patients who chose to use holy water to treat HIV engaged in an iterative process wherein they reassessed their options between clinical treatment and holy water, based on their positive or negative health outcomes. Patients' social influences, their experiences with illness, health care, and treatment, and their religious beliefs contributed to their decision-making process. Most importantly, the patients believed that holy water was more likely than ART to lead to a cure. Hearing testimonies from others and stories from friends and family about such cures fostered this perception. For patients attempting to concurrently use holy water and ART, the conflicting regimen requirements of each—particularly when fasting—posed a significant challenge to ART adherence. Love demonstrated through the persuasion of "spiritual friends," family members, and health care workers, the absence of respite from illness, and the incompatibility of holy water intake with their daily routine brought patients back to ART.
Recommendations
Retaining patients who have treatment dilemmas requires HIV clinical personnel to work with religious personnel to provide a model of faith and healing that precludes an "either/or" situation between ART and holy water. Focus should also be placed on sensitizing spiritual leaders to the need for patient adherence to ART concomitant to any faith-based healing practices. This can be done by bringing spiritual leaders into adherence discussions as stakeholders, and also asking spiritual leaders to provide training to medical personnel so they can better understand patient treatment requirements.
