During the past decade, the proportion of people infected with HIV in the general population in Tanzania decreased by half (from 8.3% to 4.7%). However, the proportion of men who have sex with men (MSM) and female sex workers (FSW) living with HIV is almost 5 times higher. Preventive use of antiretroviral drugs (pre-exposure prophylaxis; PrEP) holds the potential to significantly lower the rate of HIV infection in these populations. The Tanzania Ministry of Health has now started to provide these medicines, however, low adherence to the daily dose of the treatment could seriously reduce the anticipated benefits. This study aims to study whether increased adherence can be achieved through the use of a mobile application that provides PrEP information, medication reminders, discussion with peers, and two-way interaction with peer educators and health personnel. A broad range of issues related to the understanding and use of PrEP are being studied in the course of qualitative and quantitative research. The project is implemented in collaboration between University of Oslo (UiO), Norway, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania and the Tanzania National AIDS Control Programme (NACP). This project is funded by GLOBVAC and is part of the EDCTP2-Program supported by the European Union.
Three PhD students (2 at UiO and 1 at MUHAS) were recruited and continued with their studies during the year 2023. Both PhD students at UiO have successfully completed their mid-term evaluation and the one at MUHAS completed mid-term defense. All PhD students are expecting to compete their PhDs before the end of the project in July 2024. To ensure that data emanating from the project are utilized and contribute in capacity building and informing policy and practice, three additional PhD students funded by a Norad-funded project (DOCEHTA) enrolled at MUHAS in Tanzania will be using data emanating from this project for their PhD. One master student graduated in 2022.
Progress in Research work
The Jichunge mobile application (mHealth) was developed, pilot tested and provided to MSM and FSW in the intervention region of Dar es Salaam. Baseline qualitative and quantitative data collection were completed both in the intervention region (Dar es Salaam) and Control region (Tanga). A total of 471 FSW and 419 MSM were recruited in the intervention region and 315 MSM and 396 FSW were recruited in the control region. Six-month and 12-month follow up data collections have been completed both in Dar es Salaam and in Tanga regions. The project has therefore completed planned quantitative data collection. Data cleaning for baseline and six mot h follow up has been completed and 12 months follow up data collection will be completed by 31 January 2024. Data analysis and publication/dissemination is ongoing.
Overall, the project has made Eighteen (18) different conference presentations and published seven (7) articles in international peer-reviewed journals. The conferences in which presentations were made include the MUHAS Scientific Conference in Dar es Salaam, Tanzania, NIMR 6th International Scientific Conference, Tanzania, the International AIDS Conference, and the European Conference on Tropical Medicine and International Health. Results from the project demonstrate how user involvement in mobile phone application development processes may be effective in identifying useful features and eliciting enthusiasm for future use (Mauka et al, 2021). We learnt how research involving mobile applications may be complex and entail challenges related to hardware, software and users (Mbotwa et al, 2021). The Jichunge mHealth application developed and tested in this project was acceptable among the users and about half (47%) of the participants optimally used the Jichunge app during the first month of the project (Mauka et al, 2021; Mbotwa et al, 2022). About half (54%) of the FSW were retained in PrEP services during the first 6-month of follow up. Use of the Jichunge mHealth application was significantly associated with retention in PrEP services (Mbotwa et al, 2022, 2023). While sex workers reported good health ( Litchwarck et al, 2023) with relatively low levels of societal stigma (Lichtwarck et al, 2021), individual perceived stigma was common (Lichtwarck et al, 2022). PrEP taking required that users engage in carrying out many types of (frequently overlooked) work (Haaland et at, 2021, 2023).
While the HIV prevalence in the general adult population in Tanzania has dropped to 4.7%, recent studies carried out by the group behind this proposal found that the prevalence remain high among men who have sex with men (MSM; 22.3%) and female sex workers (FSW; 30%). PrEP holds the potential to make a significant contribution to lowering HIV incidence in these populations, but has not as of yet been made available in Tanzania. Among issues that have delayed PrEP being made available to MSM and FSW, are concerns about acceptability, uptake and adherence among potential clients, as well as high levels of stigmatization and discrimination of these groups in public health facilities. In order to study the potential uptake and impact of PrEP among MSM and FSW, an innovative PrEP implementation model will be developed and tested in this project. It will use an interactive m-Health platform to establish and maintain contact between health providers and clients, as well as a Peer-to-Peer Mentoring (PPM) approach. The project will take a stepwise phased approach. In work package (WP) 1, a mixed method formative assessment will be conducted to assess the understanding of PrEP among MSM and FSW, their willingness to use this medication, and their opinions on the mobile platform and PPM approach. Factors associated with access to mainstream health services will also be assessed. In WP II, the mobile intervention platform will be developed and peers recruited and trained in collaboration with the at risk populations. Finally, WP III will use a pragmatic quasi-experimental design to assess the effectiveness of the proposed intervention by comparing it to a control group elsewhere in Tanzania (Tanga) where PrEP will be introduced without either the m-Health platform nor PPM. This project will be implemented in collaboration between the University of Oslo, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania and the Tanzania National AIDS Control Programme.