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Lichtwarck HO, Mbotwa CH, Kazaura MR, Moen K, Mmbaga EJ. Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: a socioecological approach. BMJ Glob Health 2023; 8:e013662. [PMID: 38154811 PMCID: PMC10759139 DOI: 10.1136/bmjgh-2023-013662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/25/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool when taken as prescribed. However, suboptimal use may challenge its real-life impact. To support female sex workers in their efforts to prevent themselves from HIV, it is essential to identify factors that contribute to early disengagement from PrEP care. In this study, we aimed to estimate the risk of early disengagement from PrEP services among female sex workers in Tanzania and associated factors using a socioecological model as a guiding framework. METHODS The study was conducted as part of a pragmatic mHealth trial for PrEP roll-out in Dar es Salaam in 2021. We estimated the risk of early disengagement, defined as not presenting for the first follow-up visit (within 56 days of enrolment), and its associations with individual, social, behavioural and structural factors (age, self-perceived HIV risk, mental distress, harmful alcohol use, condom use, number of sex work clients, female sex worker stigma and mobility) using multivariable logistic regression models, with marginal standardisation to obtain adjusted relative risks (aRR). RESULTS Of the 470 female sex workers enrolled in the study, 340 (74.6%) did not attend the first follow-up visit (disengaged). Mental distress (aRR=1.14; 95% CI 1.01 to 1.27) was associated with increased risk of disengagement. Participants who reported a higher number of clients per month (10-29 partners: aRR=0.87; 95% CI 0.76 to 0.98 and ≥30 partners: aRR=0.80; 95% CI 0.68 to 0.91) and older participants (≥35 years) (RR=0.75; 95% CI 0.56 to 0.95) had a lower risk of disengagement. CONCLUSIONS AND RECOMMENDATIONS Early disengagement with the PrEP programme was high. Mental distress, younger age and having fewer clients were risk factors for disengagement. We argue that PrEP programmes could benefit from including mental health screening and treatment, as well as directing attention to younger sex workers and those reporting fewer clients.
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Affiliation(s)
- Hanne Ochieng Lichtwarck
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Christopher Hariri Mbotwa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Mbeya, Tanzania
| | | | - Kåre Moen
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Elia John Mmbaga
- Department of Community Medicine and Global Health, University of Oslo, Faculty of Medicine, Oslo, Norway
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Mbotwa CH, Kazaura MR, Moen K, Leshabari MT, Metta E, Mmbaga EJ. Retention in an mHealth App Aiming to Promote the Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers in Dar es Salaam, Tanzania: Prospective Cohort Study. JMIR Mhealth Uhealth 2023; 11:e46853. [PMID: 37855221 PMCID: PMC10595516 DOI: 10.2196/46853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/17/2023] [Accepted: 08/04/2023] [Indexed: 10/20/2023] Open
Abstract
Background Increasing access to smartphones in sub-Saharan Africa offers an opportunity to leverage mobile health (mHealth) technology to improve access to health care in underserved populations. In the domain of HIV prevention, mHealth interventions can potentially contribute to solving the challenges of suboptimal adherence to pre-exposure prophylaxis (PrEP) and low retention in PrEP services among populations most vulnerable to HIV acquisition. However, there is a gap in the knowledge about the use of such interventions in sub-Saharan Africa. Objective This study aims to evaluate the extent and predictors of retention in an mHealth app (Jichunge) that aims to promote adherence to PrEP and retention in PrEP care among female sex workers in Dar es Salaam, Tanzania. Methods A prospective cohort of female sex workers residing in Dar es Salaam were recruited, using respondent-driven sampling. All participants were provided with the Jichunge app as they started PrEP. A questionnaire was used to collect data on sociodemographics and other structural factors, while app use data for the 60-day period following the first 150 days of being in the intervention arm were extracted from the app's back end. A multivariable log-binomial model was used to determine predictors of 6-month retention in the Jichunge app. Results A total of 470 female sex workers were recruited. Nearly three-quarters of participants (206/284, 72.5%) who came to the 6-month follow-up interview no longer had the Jichunge app on their phones. The majority of these participants (193/206, 93.7%) no longer had access to the app because of issues related to their phones. Data extracted from the back end of the app showed that the use of the app declined over time, and only 13.4% (63/470) of the participants were retained (continued to use the app) after 6 months of intervention. At 6 months, women aged ≥35 years were >2 times more likely to use the app than women aged 18 to 24 years (adjusted risk ratio [aRR] 2.2, 95% CI 1.2-4.1; P=.01). Furthermore, retention in the app was higher among participants who demonstrated high PrEP awareness at baseline (aRR 1.8, 95% CI 1.1-3; P=.01) and among those who had experienced financial difficulties due to health care spending (aRR 1.9, 95% CI 1.2-3.2; P=.01). Conclusions Most female sex workers (206/284, 72.5%) who were enrolled in PrEP care in Tanzania no longer used the Jichunge app after 6 months. Retention in the app at 6 months was predicted by older age, high PrEP awareness, and financial difficulties due to health care spending. Strategies for the long-term retention of participants in mHealth apps, such as systems for reinstallations of apps, should be considered during the design phase.
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Affiliation(s)
- Christopher H Mbotwa
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, United Republic of Tanzania
| | - Method R Kazaura
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Kåre Moen
- Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Melkizedeck T Leshabari
- Department of Behavioural sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Emmy Metta
- Department of Behavioural sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Elia J Mmbaga
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Department of Community Medicine and Global Health, Faculty of Medicine, University of Oslo, Oslo, Norway
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Haaland I, Metta E, Moen K. The use of PrEP among men who have sex with men and transgender women as Biomedical Prevention Work: A conceptual framework. Soc Sci Med 2023; 333:116147. [PMID: 37556992 DOI: 10.1016/j.socscimed.2023.116147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 06/06/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023]
Abstract
Based on ethnographic fieldwork among men who have sex with men and transgender women in Tanzania, this article explores the various types of work that may go into enrolment into PrEP programming and using pre-exposure prophylaxis (PrEP). PrEP protects against HIV acquisition and is widely touted as an essential tool in 'ending AIDS by 2030'. While taking PrEP has often been portrayed as 'just taking a pill a day' in public health campaigns, a striking observation during fieldwork was that enrolling in PrEP programming and adhering to PrEP involved a wide range of tasks. Inspired by this fieldwork experience and the literature on sociology of work, more specifically illness work and patient work, we started to think of these tasks as work. This paper identifies the range of tasks that PrEP users in Dar es Salaam had to perform as part of their enrolment and usage of PrEP. We provide a description of these tasks, organised into three categories of work that we refer to as (a) readying work, (b) user work, and (c) social navigation work that jointly make up what we propose to call biomedical prevention work. We further suggest that this analytical framework can be applicable to other biomedical prevention methods in other contexts.
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Affiliation(s)
- Inga Haaland
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway.
| | - Emmy Metta
- Department of Behavioural Sciences, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Kåre Moen
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway
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Mbotwa CH, Kazaura MR, Moen K, Lichtwarck HO, Leshabari MT, Metta E, Mmbaga EJ. Effect of an mHealth intervention on retention in HIV pre-exposure prophylaxis services among female sex workers: Preliminary evidence of the use of the Jichunge app in Dar es Salaam, Tanzania. Digit Health 2023; 9:20552076231170507. [PMID: 37113256 PMCID: PMC10126669 DOI: 10.1177/20552076231170507] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Background Mobile health (mHealth) applications have been reported to be effective in promoting access and adherence to health services. However, knowledge about their effect on retention in HIV preventive services among at-risk populations in sub-Saharan Africa is limited. Objective We aimed to evaluate the effect of the Jichunge mHealth application on retention in HIV pre-exposure prophylaxis (PrEP) services among female sex workers in Dar es Salaam, Tanzania. Methods We used respondent-driven sampling to recruit female sex workers eligible for PrEP and who owned a smartphone. All study participants were provided with a smartphone application (Jichunge app) aiming to promote PrEP use through medication reminders, easy access to PrEP information, online consultations with a doctor and/or peer educator, and online discussions between PrEP users. The effect of optimal use of the Jichunge app on retention in PrEP services at 1-month was modelled using log-binomial regression. Results A total of 470 female sex workers with a median age of 26 (interquartile range: 22-30) years were recruited. Overall, 27.7% of female sex workers were retained in PrEP services at 1 month. Retention was twice as high among optimal users of the app than among sub-optimal users (adjusted risk ratios = 2.00, 95% confidence interval (CI): 1.41-2.83, p < 0.001). Conclusion The optimal use of the Jichunge mHealth application was significantly associated with higher retention in PrEP services among female sex workers in Dar es Salaam.
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Affiliation(s)
- Christopher H Mbotwa
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
- Mbeya College of Health and Allied
Sciences, University of Dar es Salaam, Mbeya, Tanzania
- Christopher H Mbotwa, Department of
Epidemiology and Biostatistics, Muhimbili University of Health and Allied
Sciences, P.O.Box 65015, Dar es Salaam, Tanzania.
| | - Method R Kazaura
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Kåre Moen
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Hanne O Lichtwarck
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Melkizedeck T Leshabari
- Department of Behavioural Sciences, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Emmy Metta
- Department of Behavioural Sciences, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
| | - Elia J Mmbaga
- Department of Epidemiology and
Biostatistics, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
- Department of Community Medicine and
Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Mantsios A, Muraleetharan O, Donastorg Y, Perez M, Gomez H, Shembilu C, Beckham SW, Karver TS, Davis W, Likindikoki S, Mbwambo J, Barrington C, Kerrigan D. "She is the one who knows": A qualitative exploration of oral and injectable PrEP as part of a community empowerment approach to HIV prevention among female sex workers in the Dominican Republic and Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000981. [PMID: 36712835 PMCID: PMC9880901 DOI: 10.1371/journal.pgph.0000981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite documented interest among female sex workers (FSW), uptake of oral pre-exposure prophylaxis (PrEP) for HIV prevention has been low. Recent trials and regulatory approval of long-acting injectable (LAI) PrEP offer new hope for the potential of this biomedical intervention. We examined FSW's PrEP-related interest and preferences regarding both oral and LAI PrEP situating these dynamics within their specific social and occupational realities. We conducted this work using qualitative methods across two distinct contexts by conducting 40 in-depth interviews with FSW in Tanzania and the Dominican Republic. Textual data was coded using iterative thematic content analysis. Analytic summaries were developed and reviewed to identify recurring themes. We systematically organized themes within each country and then compared across settings. Women in both settings expressed strong interest in PrEP seeing it as an important option to protect themselves in their work. Most participants preferred LAI PrEP due to expectations of reduced stigma and concerns about daily pill adherence and side effects. Occupational factors such as alcohol use, overnight dates with clients, and fear of violence from clients were identified as barriers to daily oral PrEP. LAI PrEP was seen as having the potential to reduce stress related to oral PrEP. Women who preferred pills discussed fear of needles, skepticism about the injections, and others relayed that taking a daily pill would not be challenging for them. There was a pre-dominant sentiment that women know best whether they are better suited for oral or LAI PrEP. Participants stressed the importance of FSW understanding both options to ensure informed decision-making around PrEP and described community-led peer education as key to delivering trusted information. Community empowerment approaches led by FSW which address structural and psychosocial constraints and promote safe work environments may facilitate equitable access and uptake of PrEP among FSW across settings.
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Affiliation(s)
- Andrea Mantsios
- Public Health Innovation & Action, New York, New York, United States of America
- * E-mail:
| | - Ohvia Muraleetharan
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Yeycy Donastorg
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Martha Perez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Department of Health Policy, Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Catherine Shembilu
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Tahilin Sanchez Karver
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Wendy Davis
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
| | - Samuel Likindikoki
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, George Washington University, Washington, DC, United States of America
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