The Importance of Considering Religious and Spiritual Ontologies in the Care of HIV Patients in Zimbabwe - A Scoping Literature Review

Background: HIV continues to have a major impact on morbidity and mortality in Zimbabwe. Religion/Spirituality (R/S) including traditional beliefs and practices (TP) play an important role for most people living with HIV (PLWHIV) in Zimbabwe. PLWHIV conceive and practice healing holistically, embracing not only the physical conditions, but also the spiritual, psycho-emotional, social, and ecological dimensions. Objective: This scoping review aims to systematically map the research done around R/S and TP and HIV in Zimbabwe. It intends to describe what is known about the role and influence of R/S on the experience of living with HIV in Zimbabwe in general and especially, to illustrate the influence of R/S and TP on the physical and psychological wellbeing of PLWHIV, and the access to HIV care. Design: This scoping review followed the Joanna Briggs Institute’s guidelines. The online databases Medline & ATLA were used to identify articles published between 2010–2021 about R/S and TP and HIV in Zimbabwe. The review includes textual papers, qualitative, quantitative, and mixed studies. Results: 638 records were found and screened for inclusion. 46 records were considered relevant for the qualitative and quantitative synthesis. Most articles (27) addressed the influence of traditional beliefs and practices on health and HIV and 16 records examined the influence of religious beliefs and religious groups’ attitude on HIV. The qualitative synthesis illustrates the influence of R/S and TP on physical and psychological wellbeing and on access to HIV care of PLWHIV in Zimbabwe, thus portraying the medical relevance of R/S issues and TP. Further synthesis identified three areas of conflict with biomedical practice: The bio-psycho-socio-spiritual understanding of health and illness, the notion of patriarchy, and the perception of sexuality and procreation. Here religious/spiritual ontologies may lead to compromised biomedical therapy outcomes. Conclusion: This scoping review includes papers of authors from different backgrounds (theology, medicine, sociology). The synthesis of the content of the records revealed a coherent picture of themes addressed and problems identified. Thus, this review is a fair description of the experience of living with HIV in Zimbabwe and the medical relevance of R/S and TP. The findings show that religious/spiritual ontologies need to be considered and integrated into the design of new health programs. It must be the aim to avoid compromised therapy outcome and to further a holistic support of PLWHIV. This is only possible in collaboration with religious stakeholders and traditional practitioners.


Background
With a prevalence of about 12.7% [1] among adults aged 15 to 49 years, human immunodeficiency viruses (HIV) continues to have a major impact on morbidity and mortality in Zimbabwe. Although 85% of PLWHIV are on ART, only 73% have a suppressed viral load [1]. Thus, attrition from antiretroviral therapy (ART) remains a serious challenge [2]. Therefore, new methods of care are needed that address risk factors and protective factors to ART adherence that have not been considered sufficiently.
In Zimbabwe religion/spirituality (R/S) plays a major role in daily life, substantially influencing people's health behaviour. Research by Shoko et al explain that in the Shona understanding, healing is conceived and practiced holistically, it includes not only the physical condition, but also spiritual, psycho-emotional, social and ecological dimensions [3]. As health is often seen as a gift from God, R/S and healing are intrinsically intertwined [4]. Ten percent of the respondents of a demographic health survey conducted in 2012 indicated that they thought it was possible to contract HIV from witchcraft or other supernatural means [5]. O'Brien and Broom rightly point out that if the origin of a disease is not framed biomedically, then biomedical treatment is less likely to be appreciated or enacted [6].
In Harare it has been observed that religious affiliation influenced women's readiness for cervical cancer screening [7]. According to the demographic health survey, most Zimbabweans would call themselves 'Christian' [5]. Many different types of Christianity and many Christian sects exist in Zimbabwe. Studies have highlighted that church affiliation is an important factor to the response to HIV [8]. While some churches advocate antiretroviral therapy (ART) of HIV infection as a gift from God, others do not allow biomedical aid, some stigmatize people living with HIV/AIDS (PLWHA), and some emphasize prayer healing [9]. During Africaid/Zvandiri's most recent study in 2016-2017 among adolescents with HIV in Zimbabwe, up to 73% of deaths were due to cessation of ART sanctioned by caregivers, probably motivated by faith healing [10]. The World Council of Churches (WCC) recognizes faith healings as a major obstacle in HIV care [9]. In 2002, the WCC highlighted "harmful cultural practices and theological and ethical fault lines in the practice of ministry in the churches and theological institutions" [11].
Local researchers [12] published a paper last year stating that people living with HIV (PLWHIV) in Gweru Zimbabwe defaulted medications because they believed in faith healing, alternative medicines, perceived spirituality as the main cause of HIV and AIDS. Furthermore, they had an allegiance to church values. They showed the need to provide HIV and AIDS education to leaders of religious organizations so as to harmonize religion and HIV and AIDS treatment [12]. The importance of finding ways to engage R/S stakeholders in HIV care is also highlighted by Becker & Geissler who argue that religious groupings are instrumental in, instrumentalised by, and instrumentalising the organisation of HIV-related interventions [13]. There is at least one example where a church in Zimbabwe successfully initiated a rural community program to support PLWHIV in a tripartite partnership consisting of the Mission Hospital staff, the Church, and the community (including schools, villages, local chiefs, and a village headmen) [14].
Stigma, violence and intimate partner violence (IPV) are very important factors that have been shown to increase risk of HIV infection and lower medication adherence. [15] While such insight is important, it is crucial not only to identify the factors influencing adherence, but also to learn about the underlying root causes (beliefs, norms and attitudes behind the factors) leading to stigma and IPV. One discriminating name for HIV/AIDS in Zimbabwe is 'chirwere chepfambi' meaning 'disease of prostitutes'. It was suggested that the stigmatisation of prostitutes as carriers of the virus, as opposed to their clients, may signal a general belief about women whose sexuality is not under the control of male partners, fathers or elders [16]. Blaming and stigmatisation is very common. In Zimbabwe Homosexuals are not only stigmatized, but also criminalized [17].
In addition to religion as an influence, many Zimbabweans consult Traditional Practitioners (TP) for health-related issues and spiritual problems. The choice to consult TP and to use herbal medicines is usually based on various factors; the primary ones being inaccessibility and unaffordability of western medicine coupled with a strong belief in herbs as effective, affordable and accessible [18]. People readily combine Christian beliefs and rituals with aspects of traditional culture and religion [19]. Western medicine, traditional practices, herbal medicine, as well as faith healings are often used simultaneously. A recent exploratory qualitative study in six eastern and Southern African countries has shown that medical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributes to delays and interruptions of care along the HIV cascade, as well as mistrust between health providers. It is argued that the role of sociocultural beliefs necessitates the adoption of culture-sensitive approaches, intervention designs and policy reforms [20].
Integrating TP into the HIV care could be an opportunity to benefit from their useful herbs and therapies, while offering the chance to dispel practices that might exacerbate the spread of HIV. While herbal medicine has the potential to reduce adverse drug reactions to ART, some herbal formulations have been identified as having pharmacokinetic interactions with antiretroviral drugs [21]. Also, some traditional healing methods, like the frequent use of skin cutting gadgets, might further the spread of HIV [22]. Batisai argues that integration of the western and traditional medical systems might be complementary in their merits and achieve what neither would alone [18]. biomedical approach in Zimbabwe. TP and religious stakeholders are not officially integrated into the HIV care. A preliminary search for existing scoping reviews on the topic of R/S and HIV in Zimbabwe was conducted on the 18 th of January 2021 in Epistemonikos and Pubmed without result. There are several individual, mainly qualitative, studies with relevant results. Many of these studies have been known by the authors of this study and are included in the introduction. However, the body of literature has not yet been comprehensively reviewed and thus it seems these results stand alone. Therefore, a scoping review was conducted to systematically map the research done in this area and to summarize and synthetize the findings of the different authors of various fields of expertise (theology, medicine, sociology). The findings allowed a fair description of the influence and medical relevance of R/S and TP for PLWHIV in Zimbabwe that should be recognized by the stakeholders of all three health sectors (religious, traditional and biomedical).

Review Question
What is the role/influence of religion/spirituality (R/S) and traditional practice (TP on people living with HIV (PLWHIV) in Zimbabwe? Sub questions: What are enhancing or deterring R/S and TP factors affecting HIV therapy and related health outcomes? What are the religious/spiritual ontologies that are foundational of specific beliefs and social norms (=underlying root causes beliefs, norms and attitudes)? What are the challenges and opportunities for engaging R/S and TP stakeholders in HIV care?

Inclusion Criteria
Religious, cultural, and economic landscapes are dynamic and diverse. This is especially true for Zimbabwe's economic situation. To get a meaningful result, this scoping review focusses on Zimbabwe only. There are various descriptions, interpretations and meanings for the terms "religion" and "spirituality". In this paper the term "religion" refers to organised and/or shared faith practice or belief and the term "spirituality" refers to the way people relate to the transcendent, including traditional practices and beliefs.
HIV/AIDS remains a primary concern in Zimbabwe. Therefore, the paper focusses on HIV/AIDS. The nationwide rollout of ART in Zimbabwe in 2008-2012 has changed the perception of HIV/AIDS from being a death sentence. This might influence the role of R/S for HIV patients. Consequently, the review only includes papers published after 2009.

Review Objective
The objective of this scoping review is to systematically map the research published in this area, to describe what is known about the role and influence of R/S on the experience of living with HIV in Zimbabwe in general, and especially to illustrate the influence of R/S and TP on the physical and psychological wellbeing of HIV patients and the access to HIV care. The review further seeks to identify religious/spiritual ontologies that are foundational of specific beliefs and social norms that have a negative impact on PLWHIV in Zimbabwe and to show ways of how to mitigate this.

Methodology
This section documents how the reviewers searched for relevant sources of information for inclusion in the scoping review. It describes the individual research strategies for the two databases, documented in the Appendix.

Search Strategy
The preliminary search for existing scoping reviews on the topic of R/S and HIV in Zimbabwe in Epistemonikos and Pubmed yielded no result.
Reasons for choosing MEDLINE and ATLA databases: For the initial search, Pubmed database was chosen because it contains citations not only from the biomedicine and health fields, but also from related disciplines. The final search was then done in MEDLINE because of the added value of using the National Library of Medicine (NLM) controlled vocabulary, Medical Subject Headings (MeSH®), to index citations. This allowed for a more focused search, avoiding citations that are out of scope. ATLA religious database was chosen because it is believed to be the premier index for literature in all fields of religion and theology.
Composing of search strings: The first step was an initial limited search in Pubmed and ATLA for papers including religion or faith or belief or tradition and HIV or Aids and within Zimbabwe. This initial search was then followed by an analysis of the text words contained in the title and abstract of the retrieved papers, and of the index terms used to describe the articles. Yale MeSH analyzer (https://mesh.med.yale.edu/) and (cgi-bin/miner/miner2.cgi) were used to find additional relevant MeSh terms. All identified words and terms were then combined in the search string to use for the search in the Medline database (Appendix: Doku Suchstring). The search identified 616 records. An information specialist of Basel University translated the search string for the search in ATLA (Appendix: Doku Suchstring) and the search in the ATLA database identified 22 records. There were no duplicates. The search in both databases was conducted on the 8th of February 2021.

Study Screening and Selection
All 638 records were screened for the source of evidence. Only primary studies, population survey studies, textual papers and reviews were included. Further criteria were: 1. Record needed to be relevant for Zimbabwean context (study population from Zimbabwe, or text about Zimbabwe) 2. The title or abstract needed to address one or more of the following themes: Discrepancies were discussed using the selection criteria. Out of the 92 references that met the selection criteria, 43 references were considered to be only widely or indirectly connected and therefore excluded and 49 references were selected as directly relevant for full text screening.
Four additional records were found by searching the reference list of identified articles. There were no additional records through contact with authors.
Seven records were dismissed because they did not directly relate to HIV, the data was too old, or the approach did not meet the scientific requirements (due to the small case load and the conduct of interviews with closed questions).

Analysis and Presentation of Results
46 records were used for the qualitative and quantitative synthesis.

Quantitative Synthesis
Firstly, we mapped the records according to the characteristics. Four records were textual papers and all others were studies. Table 1 groups the studies into qualitative studies, mixed studies and quantitative studies, and also indicates the individual case load and the means of data generation.
Study Type: Most of the studies, namely 24, were qualitative studies, followed by 13 studies with a mixed approach and 4 quantitative studies out of which, 3 were population-based studies.
Means of data collection: The main data source were interviews, followed by Focus Group Discussions (FGD). Semi-structured interviews (SSI), in-depth interviews (IDI) and key informant interviews (KII) were used in 34 studies (=74%). This is not surprising, as religion/spirituality (R/S) and traditional practice (TP) are a social phenomenon, and of a personal nature. Focus Group Discussions were used in more than a third of the studies.
Population: The people interviewed were predominantly Zimbabwean, people living with HIV (PLWHIV) and key informants (KII). Key informants are people who are affected by HIV (for example, parents, religious leaders, teachers and traditional practitioners). The respondents were adolescents and adults, including men and women as well as a few transgender participants.
First author R/S and TP are shaped by local context. Comprehensibly most of the first authors (more than two thirds) have an African background and some were able to conduct the interviews in the local language.
Setting: All studies included were done in Zimbabwe or used statistical data from Zimbabwe.    Figure 2 shows the records according to their content. The majority of records (25) addressed the influence of traditional beliefs and practices regarding health and HIV. Due to the fact that this study is interested in the medical relevance of R/S and TP, the two records investigate the effect and use of herbal medicine are listed separately. Sixteen records examined the influence of religious beliefs and religious groups' attitude on HIV (=Churches/Sects).

Qualitative Synthesis
To identify the information available in literature regarding the influence of Religion/Spirituality & Traditional Practice, this section presents a descriptive qualitative content analysis, including basic coding of data. As the selected studies cover different fields of expertise (sociological, theological, anthropological, medical) the Framework Method [22] was used to analyze and identify the different themes of the studies. The framework created a structure to summarize and synthetize the studies' content. The founder and director of the George Washington Institute for Spirituality and Health, explains that spirituality and religion are medically relevant, if a spiritual issue leads to distress or suffering (e.g. lack of meaning, conflicting religious beliefs, inability to forgive). The spiritual issue is the cause of a psychological or physical diagnosis (such as depression, anxiety, acute or chronic pain) or is a secondary cause, or affects the presenting psychological or physical diagnosis (e.g. refusal or delaying of therapy because of religious beliefs) [23].
Leaning on this understanding of the medical relevance of spiritual/religious issues, the themes were grouped into the following eight categories: Quotes of the 46 studies were coded (=key findings), reassembled and summarized or grouped in codes and then assigned to one of the eight categories. This process was repeated and refined until both researchers agreed with the result.  [14,35] Prophets intercede between living and Spirit world and can drive out demons that cause illness [30,36] Ultimate goal of church is spiritual health of its members [33,36] Church has a healing mandate [37] Church considered alternative health care system [25,36] metaphysical explanations for health give church control of members' health [36] Christian Hospitals and Churches cared for PLWHIV from Beginning=role model for government [25,35] Missions played important role in care of rural HIV patients [37] Codes Key Findings Studies Church did not reach out to apostolic sect members [25] Church networked with authorities -police turns a blind eye on crimes in within churches (e.g. child marriages) [38] Church silent on socio-cultural issues (intimate partner violence) [39] Churches' influence on sexual & health seeking behaviour different beliefs, teachings and practices on sexual & health seeking behaviour [32] Christian teachers required to teach abstinence [26,37] Less sexual partners among Christians [32] No teaching about contraceptive use for adolescents [38] No contraceptive use for some [30] The anti-medical approach of the Johanne Marange Church has been weakened by FBO interventions [27] Sex outside marriage is sin [26] Religion determinant of response to HIV epidemic Churches played important role in reduction of HIV risk [8,41] Number of sexual partners linked to religious affiliation [8] HIV is seen as God's punishment for fornication [12,29]  Decision making is sequential and slow [20,33] wellness is derived from the role of family, community, and the spiritual world [18] Endemic problem-solving Mechanisms Chief's granary [14] volunteerism embedded in Shona culture [14] Idiom: "do not laugh when your neighbour is in trouble" [14] cultural ethos of Ubuntu fostered social cohesion [14] Pre-colonial Africans were self-sustained [33] Utanu-refusal to accept ill health-positive philosophy of life [33] Sexual offence reparation in the form of 'mwombe nemwana wayo' [two head of cattle] serves as prophylaxis [53] proper healing is holistic=harmony and correct relationship with the spiritual worlds [18] Patriarchy central role of polygyny within Shona religion [8,26,35,53] Women cannot decide autonomously on health and sex [18,33,47,50,53,54] Women are voiceless [54] Codes Key Findings Studies Wife belongs to the husband [54] Women cannot ask for safe sex practice [35,47,50,53,54] Preserving marriage more important than safe sex [54] Economic dependence on husband [32,54] Marriage is affair of two families [54] Shona word for divorce=rejected [54] Husbands' entitlement to sex [54] Forced sex in marriage common [54] wifes face barriers to safer sex at individual, relational and community levels [32,35,47,54] Women are cause of disease [18,28,29,32,35] [25,38,45] Pregnancy is common reason for marriage [45] Loss of virginity as reason for marriage [25,45] Large age discrepancy between husband and wives is common [25,45]  Pre-marital sex is seen as prostitution [57] early sexual debut, despite the socio-cultural and economic contexts [57] Limited information of reproductive health and contraceptive use for adolescents [57] No contraceptives for adolescents=high risk of HIV infection [57] Unwanted pregnancies of adolescent end in unsafe abortions [57] Adolescent sexuality is taboo no curriculum to teach reproductive health to adolescents [57] Difficult access to contraceptives for adolescents [57] double moral/standard for boys and girls [57] Limited contraceptive use among adolescents is a result of interplay of demographic, policy, socio-cultural, religious and economic factors. [57] Teachers are constrained in teaching sexual health [49] Pre-Exposure Prophylaxis linked to promiscuity [41] Men sexuality multiple and concurrent sexual partnering is accepted [27,32,50,51,58] Concurrency more acceptable in specific social contexts, including infertility and lack of a male heir [57,58] Male infertility carries overtones of failure, frustration, pain, social ostracism, stigma, marital instability, suicide [56] Infertility treatment exclusively sociocultural [56] Condoms emasculate [51,57] Pre-marital sex to display features of manhood [57] low rates of HIV testing and treatment due to reasons of stigma and the challenge to (male) identity [32,50,51] Men are tough, can defend themselves -against HIV [51] Homophobia societal homophobia as reason for lack of support [17,59] Criminalization of same sex/gender activities [17,59] Social stigma for gender minorities [59] Cultural contamination leading to disaster for family [17] No access to reproductive health services [59] Homosexuals as origin of HIV [29] Homosexuality is not African, came from abroad [29] Social isolation [17] No-disclosure [17] Pressure to get married [17] Media slanders sex-workers especially men [17] Homosexuals are abnormal and unclean [17] Sacredness of body parts infant's removed foreskin should be given to child's relations [42] Fear discarded foreskin could be used to perform witchcraft [42] Fear that sperms found it condoms could be used by witches [40] Ursula  [20] mistrust between providers operating in different health-worlds [20] Sexual education traditionally sex is not a public subject [25,26,29] Sex is sacred [26] culturally exclusive domain of aunts and uncles [57] Traditional sex education weakened, focusing on gendered sexual socialization, not promotion of sexual health [57] Risky cultural practices Cultural initiation linked to high STI prevalence in adolescents [48] adolescent pregnancies and HIV associated with cultural practices such as forced / early teenage marriage, traditional cleansing, wife pledging and HIV cleansing [26,48,52,53] risky practices were rituals surrounding open fontanelle, toning of child's sexual libido, initiation of sex after childbirth, treatment of eye & ear infections, tongue-tie and premastication sucking father's penis for open fontanelle and paternity testing [52] girl child's sexual libido is toned down through rubbing the father or maternal uncle's penis on the girl's genitals [52] Mother's milk squeezes into eyes, nose and genitals [52] baby's napkin with vaginal and seminal fluids used to rub the baby's genitals [ [17,55] Overt discrimination of sex workers/homos [17,55] Sex workers/homos find it difficult to get tested [17,55] Sex workers find it difficult to access healthcare [55] Health providers abusive even withholding treatment for sex Workers/homos [17,55] Healthcare workers blaming sex-worker/homos for illness [17,55] Mission hospitals partner with Ministry of Health [37] Economic decline and poor health systems lead to mushrooming of faith healing ministries and revival of TP [33] Difficult for working men to take medicine in time [51] Confidentiality breached by health workers [17,57] Non-conformity to social rules leads to social isolation [17,55] Little collaboration between the three health care systems [20,48] Category: Challenges for engaging R/S Stakeholders Compromising care Delays due to certain health beliefs [20] Healers claim to heal HIV and ask to stop ART [12,20] Church elders not allowed to take medication [12] No teaching of contraceptive use for adolescents [57] Sexuality is taboo subject in Churches [57] Religion forbids divorce for wife of unfaithful husbands [54] deviance-responsibility: Work hard, be good, have faith and you will be cured -individual is in control [27] Opposition to allopathic approach because procedure in health-centers lack religious aspect [43] mistrust between providers of different health-worlds [57] Demonizing of TP [33] Focus only on Evangelism no communal approach to health and healing [33] Category: Challenges for engaging TP Toxicity of herbal medicines Need of regulatory body [18] Heavy metal and microbial contamination is concern with HIV [44] Moringa samples were contaminated with bacteria and fungi [44] mistrust between providers operating in different health-worlds [20] potential of altered ART pharmaco kinetics [21] Codes Key Findings Studies Opposition to Circumcision separates circumcision from adolescent initiation [42] Involvement of women (mothers) not acceptable [42,43] Needs to be secretive cultural ritual [43] Circumcision in health-centers lack religious aspect [43] Only circumcised men should do procedure [43] Cultural practices in conflict with allopathic approach Adolescents sexual health can cause conflict [48] Practices exposing infants to bodily fluids that may contain HIV are a cause of concern [52] Use of unsterile instruments [26]  Allowing traditional and western medical systems to coexist [18,43] to supplement the care to fulfil psycho-socio-spiritual needs [18,20,53] collaboration needed to perform circumcision according to cultural and religious norms [43] great convergence between allopathic and African vernacular explanatory frameworks for infectious disease [28] STIs have moral overtone are treated well by TP [28] Indigenous term "dirt" could be used as idiom for HIV [28] TP can complement allopathic healthcare system's shortfalls [18,28] distinct cultural sensibilities of Un'anga, traditional healers provide culturally salient explanations and ritual solutions for illnesses such as HIV/AIDS, as well as the pragmatic alleviation of symptoms. [4,18] Utanu concept used in wider context [33] Collaboration with police in case of abuse possible [53] Rituals give sense of community belonging [18] Part of holistic care [18] TP and faith-healers refer patients to biomedical services [20] Subset of biomedicine practitioners refer to TP or faith healers [20] Herbal/traditional remedies Musakavakadzi & Peltoforum africanum reduce adverse drug events [21] Moringa oleifera used as nutritional supplement and immune enhancer by HIV [44] existing knowledge systems used to treat male impotence and infertility [56] Endemic problem solving mechanism These findings were further summarized and synthetized in Figure 2. The aim of this next synthesis is to illustrate the social, cultural, and religious context of the experience of living with HIV in Zimbabwe. Deterring and enhancing R/S and TP factors influencing HIV patients need to be understood and seen in this unique context. Figure 2 illustrates the influence of R/S and TP on the physical, psychological, spiritual, and social wellbeing of HIV patients and their access to reproductive health information and services, their compliance with HIV therapy and the risk of HIV infection. This  Figure 2 confirms the medical relevance of R/S issues and TP. This is not surprising to most of the individual authors of the included studies. This is what many of them have tried to show in their own studies. By giving an overview of the findings of all relevant studies published in the last 11 years, the claim of medical relevance of R/S and TP was endorsed. This scoping review allowed to go even a step further. Analyzing the data of all 46 records combined in Table 2 + Figure 2 made it possible to recognize formal relations (recurring patterns, units of social organization, as well as cause and effect relations and/or social mechanisms). This helped to identify three main areas of concern (=red flags), where R/S and TP influence and shape underlying beliefs, norms, and attitudes that conflict with the allopathic medical approach and compromise the therapy outcome (shown in Figure 3 at the end): The bio-psycho-social-spiritual understanding of health and illness is crucial to the Zimbabwean health system. The allopathic medical approach does not meet all aspects of that holistic understanding. Therefore, people use the religious and/or traditional health system to supplement allopathic therapy or choose the health system according to their perceived need. The parallel use of the three health systems can lead to concurrency, delayed access to allopathic health care, increased suffering, and compromised therapy outcome.
Patriarchal norms were long promoted as a solution to HIV. The records in this scoping review demonstrate the opposite. Patriarchal norms act as barriers to HIV care and increase the risk of becoming infected by HIV. Arguably, they are the source of much suffering for men, women, and children.
Cultural, religious, and societal norms of sexuality are very relevant in the Zimbabwean context. Sexuality is sacred, a taboo subject, moralized, and for some PLWHIV criminalized, and stigmatized.

Discussion
Puchalski's argument of the medical relevance of R/S in case it is the cause or secondary cause of a disease, increases the suffering, or interferes with the treatment [23] and the claim of Kendrick's recently published systematic Literature review of studies in the USA that R/S can be a barrier or a facilitator to treatment for HIV, [60] were used to code and group the content of the 46 records ( Table 2). The synthesis of these findings enabled to take out the influence of R/S on the experience of living with HIV in Zimbabwe in general, and especially to illustrate the influence of R/S and TP on the physical and psychological wellbeing of HIV patients and the access to HIV care ( Figure 2). Figure 2 describes the socio, cultural and religious context of PLWHIV in Zimbabwe and illustrates how R/S and TP play a role as facilitator and/or barrier to HIV care and wellbeing of PLWHIV and so are medically relevant.
Further synthesis of the content of the 46 records by authors from different disciplines (sociology, theology, and medicine) revealed great coherence. It was possible to recognize social relations which helped to identify three key areas where underlying beliefs, norms and attitudes directly conflict with the biomedical approach, and potentially compromise the therapy outcome ( Figure 3). Thus, religious, and spiritual ontological concepts are accentuated in the identified three key areas: understanding of health, the notion of patriarchy, and sexuality. To mitigate the negative impact of specific beliefs, attitudes, and social norms, religious and spiritual ontologies need to be considered, integrated, and valued equally to secular ontologies when designing health development programs. The importance of the role of religion in health development has also been pointed out by Dijik and other anthropologists, who explain that the relationship between religion and religious responses to HIV and the biomedical approach to HIV is complex, diverse, and ever changing [61].
The focus of the synthesis of this scoping review was based on Puchalski's criteria of medical relevance of R/S. This led to a one-sided emphasis on negative health impacts. However, the enhancing factors and opportunities of the contribution of R/S and TP for PLWHIV in Zimbabwe shown in Figure 2 are equally important: R/S and TP supplement the biomedical treatment by responding to the psycho, social, and spiritual needs of PLWHIV. Spirituality plays a key role in coping. Mutambara has already shown this in one of her previous publications [62]. The importance of religious coping is widely acknowledged and was also pointed out in a recently published study from a Brazilian context [63]. Furthermore, Simmons explains that there is a great convergence between biomedical and African vernacular explanatory frameworks for infectious disease [28]. Thus, secular, and religious/spiritual ontologies do not need to clash but may together form a common basis for future health development. Figure 2 also shows that religious, spiritual, and traditional communities and practices provide a sense of belonging and mutual support. They are often the most accessible, culturally relevant, and affordable way of getting help. Such positive impacts of R/S on PLWHIV have also been shown in other studies, like in a recently published scoping review by Vigliotti and others. They found that more than half of the studies in their review documented a positive/protective association between religion, faith, spirituality, and HIV prevention activities [64].
Hence, the findings of this scoping review demonstrate that R/S and TP influence PLWHIV in positive and negative ways and that religious and spiritual ontologies are to be taken seriously. This is in line with, Pool's and other anthropologists' call for equal appreciation and consideration of religious and secular ontologies in health development projects. They see an urgent need for a development dialogue that draws on various ontologies and that understands religion as an integral part of such a meta-ontology [65].
The WHO Bangkok Charter for Health Promotion in a Globalized World declared in 2005 that health promotion should offer an inclusive concept of health, encompassing emotional and spiritual well-being. The WHO traditional medicine strategy 2014-2023 acknowledges the importance of traditional medical practice and its contribution to health and wellbeing and a people centred healthcare [67]. The findings of this scoping review should be interpreted in this context.
By portraying the importance of Religion/Spirituality including traditional beliefs and practices in the context of HIV in Zimbabwe, they underline the importance of an inclusive, value-driven approach to health development that duly respects an integral part of religious and spiritual ontologies and so becomes more people centred.

Conclusion
Religion and spirituality (including traditional practice) play an important role in the life of PLWHIV in Zimbabwe. R/S and TP influence the health, wellbeing, and access to care in positive and negative ways. The findings of this scoping review ask for twofold action: Firstly, future health development programs should consider and integrate religious/spiritual ontologies alongside secular ontologies to avoid competitive approaches and compromised therapy outcomes. Secondly, religious stakeholders, traditional practitioners, and biomedical experts need to evaluate their own approach and teaching individually and in their communities. The three health-systems (religious, traditional, biomedical) in Zimbabwe have the potential to compliment and/or supplement each other's shortfalls. Together they can form a holistic system of care for people living with HIV in Zimbabwe. Collaboration between the three systems is needed to reduce concurrency, mistrust, and compromised therapy outcomes. Together they can achieve what neither could alone: Ending the AIDS epidemic as a public health threat by 2030 (third Sustainable Development Goal).