Elia Mmbaga

• Miltenburg, Andrea Solnes; Kiritta, Richard; Kidenya, Benson R.; Amoakoh, Hannah Brown; Schielen, Peter C.J.I. & Manyogote, Felix [Show all 15 contributors for this article] (2026). PRESHA — Preventing severe hypertensive adverse events in pregnancy and childbirth: a study protocol for establishing a prospective cohort study and biobank in urban Tanzania. Frontiers in Global Women's Health. 7. doi: 10.3389/fgwh.2026.1812275. Full text in Research Archive
• Kimambo, Asteria H.; Vuhahula, Edda; Mmbaga, Elia; Baraka, Balowa Musa; Malango, Atuganile & Illonga, Zainab [Show all 10 contributors for this article] (2026). Contextual Barriers and Facilitators to Implementing Ultrasound-Guided Fine-Needle Aspiration and Rapid Onsite Evaluation in a Resource-Limited Setting. JCO Global Oncology. 12(6), p. 1–10. doi: 10.1200/GO-25-00718. Full text in Research Archive
• Kitomary, Nuruel Robert; Metta, Emmy; Leshabari, Melkizedeck T.; Moen, Kåre & Mmbaga, Elia (2026). Prevalence and factors associated with mental distress among men at higher risk of HIV infection enrolled in an HIV pre-exposure prophylaxis program in Tanga, Tanzania. Frontiers in Psychiatry. 17. doi: 10.3389/fpsyt.2026.1605734. Full text in Research Archive
• Nyagabona, Sarah Kutika; Paciorek, Alan; Pallangyo, Angela; Pallangyo, Charles Kisali; Wang, Chia Ching Jackie & Kahesa, Crispin [Show all 10 contributors for this article] (2026). Baseline clinical and laboratory profiles at breast cancer diagnosis in Tanzania: differences by HIV status. Breast. ISSN 0960-9776. 88. doi: 10.1016/j.breast.2026.104797. Full text in Research Archive Show summary

  Background Women living with HIV (WLHIV) may present with distinct clinical and laboratory characteristics at the time of breast cancer diagnosis. While previous studies, including multi-country cohorts such as the ABC-DO study, have described baseline patient and tumor features, data on pre-treatment laboratory parameters in routine clinical settings remain limited. This study aimed to characterize baseline clinical and laboratory factors at diagnosis and assess differences by HIV status. Methods We analyzed data from women newly diagnosed with breast cancer at three tertiary hospitals in Tanzania. HIV status was obtained from medical records or provider-initiated testing. Baseline clinical and laboratory variables measured before systemic cancer therapy were evaluated. Multivariable logistic regression was used to identify factors independently associated with HIV status. Results Among 425 women with newly diagnosed breast cancer, 47 (11%) were living with HIV. Advanced disease at presentation was common across the cohort. Neutropenia (absolute neutrophil count <1.5 × 109/L) was more frequent among WLHIV than among women without HIV (15% vs 3%) and remained independently associated with HIV status (adjusted odds ratio [aOR] 3.52, 95% confidence interval [CI] 1.26–9.79). Conclusions WLHIV more frequently presented with neutropenia and advanced disease at diagnosis. By identifying clinically relevant differences in hematologic status are detectable at presentation using routinely collected data, this study addresses a key gap in real-world evidence from sub-Saharan Africa. These findings provide clinically actionable insight into baseline patient status at entry into cancer care and may inform early clinical assessment and supportive care planning in resource-constrained settings.

• Ally, Mwashungi M.; Kakoko, Deodatus Conatus; Omsland, Tone Kristin; Swai, Calvin; Metta, Emmy & Moen, Kåre [Show all 12 contributors for this article] (2025). Level of Healthcare Facility and Psychosocial Factors Influence Perceived Self-Efficacy for Appropriate Use of Hydroxyurea: Experience from Caregivers of Children with Sickle Cell Disease in Tanzania. Healthcare. 13(13), p. 1500–1500. doi: 10.3390/healthcare13131500. Full text in Research Archive Show summary

  Background: Sickle cell disease (SCD) is associated with high physical and psychosocial burden among patients and their families. Hydroxyurea (HU) improves health-related quality of life by preventing SCD complications. Despite its availability, HU is underutilised in Tanzania. Perceived self-efficacy for appropriate medication use influences medication usage among individuals with chronic illnesses. We studied factors associated with caregivers’ perceived self-efficacy for appropriate use of HU and its association with HU usage among children with SCD in Dar-es-Salaam. Methods: We conducted a cross-sectional study from May to August 2023. We enrolled 374 caregivers of children with SCD from two regional and two national hospitals. We adapted the self-efficacy for appropriate medication use scale, a multidimensional perceived social support scale, and a patient health questionnaire for assessment of self-efficacy, social support, and depressive symptoms, respectively. Results: Three-quarters of caregivers had high perceived self-efficacy scores for medication use. Attending national hospitals, high social support, and absence of depressive symptoms were positively associated with perceived self-efficacy (adjusted beta coefficient aβ 2.3, 95% CI 0.5–4.2; aβ 9, 95% CI 7.1–10.9; and aβ 5.3, 95% CI 2.8–7.8, respectively). Caregivers with high self-efficacy were 5.3 times more likely to give HU to their children compared with those with low self-efficacy (incidence rate ratio 5.3, 95% CI 3.3–8.3). Conclusions: Hospital levels and psychosocial factors influence caregivers’ perceived self-efficacy for appropriate HU use. We recommend targeted interventions to enhance psychosocial support among caregivers to increase caregivers’ perceived self-efficacy and HU utilization among children with SCD in Tanzania.

• Jonathan, Agnes; Swai, Calvin; Kakoko, Deodatus; Mmbaga, Elia; Balandya, Emmanuel & Metta, Emmy [Show all 12 contributors for this article] (2025). Caregivers´ beliefs about hydroxyurea influence its usage among children with sickle cell disease: a cross-sectional study in Dar-es-Salaam, Tanzania. Pan African Medical Journal. 52(31). doi: 10.11604/pamj.2025.52.31.45975. Full text in Research Archive Show summary

  INTRODUCTION: Hydroxyurea (HU) is a proven, safe, and effective treatment for sickle cell disease (SCD) but is underutilized in Tanzania. Caregivers´ beliefs influence medication usage in childr

• Mikomangwa, Wigilya P.; Metta, Emmy; Moen, Kåre; Mmbaga, Elia; Leshabari, Melkizedeck T. & Kibusi, Stephen M. [Show all 10 contributors for this article] (2025). “I Stopped to Prove them Wrong:” Reasons for Discontinuing Daily Oral HIV Pre-exposure Prophylaxis Among Women at High Risk of HIV in Tanzania—A Convergent Mixed Methods Study. Aids and Behavior. ISSN 1090-7165. doi: 10.1007/s10461-025-04879-5. Full text in Research Archive Show summary

  Abstract High discontinuation of pre-exposure prophylaxis (PrEP) among high-risk women undermines its effectiveness. However, there is limited evidence on the reasons for PrEP discontinuation among female sex workers in sub-Saharan Africa. Exploring population-specific reasons for PrEP discontinuation will guide the design of client-centered strategies. Thus, we explored the reasons for PrEP discontinuation among female sex workers in Tanzania using mixed methods from 2022 to 2023 in Tanga, Tanzania. Participants were recruited through respondent-driven sampling and followed up for 12 months, and quantitatively interviewed at months 1, 6, and 12. In-depth interviews were carried out alongside the 12-month survey with purposely sampled female sex workers who had discontinued PrEP. Separate descriptive (and log-binomial regression) and thematic analyses were performed, and the insights were compared and integrated. We enrolled 313 participants with a median age of 27 years (IQR: 23–32). At 6 months, 61.5% (95% CI 54.3–68.4) had stopped taking PrEP for ≥ 3months, increasing to 67.4% (95% CI 60.2–74.0) at 12 months. Self-perceiving to be at “medium” to “high” risk of HIV had a 20% lower risk of stopping PrEP for ≥ 3months compared to self-perceiving to be at low or no risk (aRR 0.8, 95% CI 0.783–0.896). Participants discontinued PrEP because of medical and pharmacological challenges; perceived negative social norms and societal pressures; perceived undesirable pill characteristics and dosing schedules; low self-assessed HIV risk; perceived low benefit of PrEP; and low self-efficacy in adhering to PrEP. Our findings highlight the need for a multi-component intervention to promote PrEP retention.

• Kionde, Faithness; Metta, Emmy; Mmbaga, Elia; Leshabari, Melkizedeck; Swai, Calvin & Mbotwa, Christopher [Show all 7 contributors for this article] (2025). Retention in HIV Pre-Exposure Prophylaxis Among Men Who Have Sex with Men in Tanga, Tanzania. HIV/AIDS. Volume 17, p. 194–194. doi: 10.2147/hiv.s527111. Full text in Research Archive
• Kitomary, Nuruel; Metta, Emmy; Leshabari, Melkizedeck; Moen, Kåre & Mmbaga, Elia (2025). Prevalence and Factors Associated with Probable Alcohol Use Disorder Among Men at Higher Risk of HIV Enrolled in the HIV Pre-Exposure Prophylaxis Program in Tanga, Tanzania. A Call for Integrated Care. Substance Abuse and Rehabilitation. Volume 16, p. 307–307. doi: 10.2147/sar.s553175. Full text in Research Archive
• Nyagabona, Sarah Kutika; Haddadi, Summaiya; Mtei, Rachel Jared; Sunguya, Bruno; Kahesa, Crispin & Pallangyo, Charles Kisali [Show all 9 contributors for this article] (2025). Paving the Way for an Integrated Care Model: Experiences of Women Living With HIV and Breast Cancer in Tanzania. JCO Global Oncology. 11, p. e2500330–e2500330. doi: 10.1200/GO-25-00330. Full text in Research Archive
• Lie, Anne Kveim; Gebremariam, Mekdes; Lichtwarck, Hanne Ochieng; Mmbaga, Elia & Miltenburg, Andrea Solnes (2024). Kortvarig hospitering må planlegges nøye. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 144(15). doi: 10.4045/tidsskr.24.0376. Full text in Research Archive
• Lichtwarck, Hanne Ochieng; Massawe, Emmanuel Peter; Mmbaga, Elia & Moen, Kåre (2024). What can PrEP do for female sex workers? Unpacking the “effectosphere” of biomedical HIV prevention in Dar es Salaam. Social Science and Medicine. ISSN 0277-9536. 358. doi: 10.1016/j.socscimed.2024.117245. Full text in Research Archive
• Ng, Dianna L.; Vuhahula, Eddah; Kimambo, Asteria; Ndayisaba, Marie; Philipo, Godfrey & Mushi, Beatrice P. [Show all 15 contributors for this article] (2024). Xpert Breast Cancer STRAT4 Assay using fine-needle aspiration biopsy samples in a resource-constrained setting: a prospective diagnostic accuracy study. The Lancet Oncology. ISSN 1470-2045. 25(11), p. 1440–1452. doi: 10.1016/S1470-2045(24)00456-X. Full text in Research Archive Show summary

  Background: Use of fine-needle aspiration biopsy (FNAB) specimens on Xpert Breast Cancer STRAT4 Assay (STRAT4; Cepheid, Sunnyvale, CA, USA), a CE-marked in-vitro diagnostic medical device, could potentially increase access to breast cancer biomarker testing in resource-constrained settings. We aimed to assess the performance of a research use-only version of STRAT4 using FNAB specimens in Tanzania. Methods: In this prospective diagnostic accuracy study, patients aged 18 years or older with palpable breast masses presenting to the FNAB Clinic at Muhimbili National Hospital (Dar es Salaam, Tanzania) were recruited consecutively. Patients who were pregnant, lactating, or had a previous diagnosis of breast cancer were excluded. STRAT4 testing was performed on off-label FNAB samples using four protocols: the 1 × protocol (using the standard lysate method) on FNAB smears (1 × FNAB), quick lysis and Maui protocols (both on FNAB smears), and the 1 × protocol on formalin-fixed paraffin-embedded (FFPE) cell block material (1 × cell block). For 1 × FNAB and 1 × cell block, tissue was processed using FFPE lysis reagent, incubated at 80°C with proteinase K, and followed by addition of 95% or higher ethanol. Quick lysis was processed using FFPE lysis reagent and 95% or higher ethanol, whereas Maui was processed using a proprietary research-use only lysis reagent. The primary outcomes were overall concordance, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of STRAT4 as compared with immunohistochemistry or immunohistochemistry plus fluorescence in-situ hybridisation performed on cell blocks using clinically validated protocols in a Clinical Laboratory Improvement Amendments-accredited laboratory at the University of California, San Francisco (San Francisco, CA, USA). Findings: Between Nov 29, 2017, and Dec 17, 2020, 208 patients were enrolled. Of 208 cases, 51 (25%) were excluded from analysis because of insufficient tissue in the cell block or absent cell blocks, leaving 157 participants (all female) for analysis. For oestrogen receptor, 1 × FNAB had the best performance, with an overall concordance of 95% (95% CI 90-100), sensitivity of 94% (85-100), specificity of 97% (90-100), and AUC of 0·96 (0·81-1·00). For progesterone receptor, 1 × cell block had the best overall performance (overall concordance 89% [95% CI 84-95], sensitivity 91% [82-99], and specificity 89% [81-97], with an AUC of 0·93 [0·89-0·99]) and 1 × FNAB performed the best among the smear protocols, with a concordance of 84% (95% CI 74-93), sensitivity of 63% (43-82), specificity of 97% (92-100), and AUC of 0·91 (0·72-0·97). For HER2, Maui had the highest agreement, with an overall concordance of 93% (95% CI 89-98), sensitivity of 96% (88-100), specificity of 92% (87-98), and AUC of 0·95 (0·98-1·00). For Ki67, Maui had the best performance of smear protocols, with a concordance of 73% (95% CI 64-82), sensitivity of 70% (58-81), specificity of 81% (66-96), and AUC of 0·80 (0·54-0·82). Interpretation: Processing FNAB samples with STRAT4 is feasible in Tanzania, and performance for the oestrogen receptor is robust. Further optimisation of STRAT4 for FNAB has the potential to improve timely access to breast cancer diagnostics in resource-constrained settings.

• Mikomangwa, Wigilya; Moen, Kåre; Mmbaga, Elia; Metta, Emmy; Kibusi, Stephen M. & Leshabari, Melkizedeck T. [Show all 8 contributors for this article] (2024). HIV pre-exposure prophylaxis use during periods of unprotected sex among female sex workers in Tanga city, Tanzania: a control arm analysis of the pragmatic quasi-experimental trial. Frontiers in Public Health. 12. doi: 10.3389/fpubh.2024.1405765. Full text in Research Archive Show summary

  Background: Pre-exposure prophylaxis (PrEP) prevention-effective adherence is of critical importance but challenging particularly among key populations where periods of high HIV risk are frequent. We assessed the use of PrEP with reference to periods of unprotected sex among female sex workers in the city of Tanga. Methods: This was part of the pragmatic quasi-experimental trial for HIV PrEP rollout in Tanzania involving a control cohort of 313 female sex workers aged ≥18 years recruited by respondent-driven sampling and followed for 12 months. PrEP use and periods of condomless or unprotected sex were assessed at the 6th and 12th month of follow-up. Prevention-effective adherence was defined as PrEP use of ≥2 pills/week and ≥6 pills/week for anal and vaginal condomless sex. Multivariable modified Poisson regression was conducted to determine factors influencing PrEP use (≥2 pills/week). Results: Overall, 59.2 and 45.9% of participants had unprotected anal and vaginal sex with a client, respectively. The prevention-effective adherence for anal sex ranged from 8.0% (months 6) to 10.0% (months 12) while that of vaginal sex was from 10.1% (month 6) to 3.8% (month 12). Participants who lived with friends were 25.5 times more likely to use ≥2 PrEP doses per week than those who lived alone (aPR = 25.5; 95%CI: 2.55-255.42, p = 0.006). Compared to self-reporting poor health status, self-reporting good health status significantly increased the use of ≥2 PrEP doses per week (aPR = 17.4; 95%CI: 3.01-101.02, p = 0.001). Refusing condomless sex with a steady partner increased the likelihood of using ≥2 PrEP doses per week than accepting condomless sex with a steady partner (aPR = 11.2; 95%CI: 1.55-80.48, p = 0.017). The prevalence of using ≥2 PrEP doses per week was less among participants accepting condomless sex at high pay than those who refused (aPR = 0.1; 95%CI: 0.03-0.26, p = 0.000). Conclusion: Use of PrEP during periods of unprotected sex was rare among female sex workers. Living with friends, self-reporting good health status, and refusing condomless sex with steady partners were associated with increased use of ≥2 PrEP doses per week. However, accepting condomless sex for increased payment was associated with reduced use of ≥2 PrEP doses per week. This calls for an in-depth study to understand the perspectives and circumstances shaping poor adherence during periods of unprotected sex among female sex workers.

• Mbotwa, Christopher H; Kazaura, Method Rwelengera; Moen, Kåre; Sudfeld, Christopher R; Metta, Emmy & Leshabari, Melkizedeck T. [Show all 8 contributors for this article] (2024). Trial of an mHealth intervention to improve HIV prophylaxis for female sex workers, United Republic of Tanzania. Bulletin of the World Health Organization. ISSN 0042-9686. 102(12), p. 852–860. doi: 10.2471/BLT.24.291516. Full text in Research Archive Show summary

  Objective: To evaluate the effect of a mobile health (mHealth) intervention on early retention of female sex workers in human immunodeficiency virus (HIV) pre-exposure prophylaxis services in the United Republic of Tanzania. Methods: The study involved 783 female sex workers: 470 from Dar es Salaam who were given the Jichunge mHealth application (app) in addition to standard HIV pre-exposure prophylaxis (intervention arm), and 313 from Tanga who received pre-exposure prophylaxis alone (control arm). Participants were recruited using respondent-driven sampling and followed up for 12 months. Early retention was defined as attending a pre-exposure prophylaxis follow-up clinic within 28 days of an appointment scheduled for 1 month after starting treatment. To assess if the Jichunge app led to higher retention, we conducted intention-to-treat and per-protocol analyses using a regression model adjusted by inverse probability weighting. Findings: Early retention in HIV pre-exposure prophylaxis care was observed in 27.6% (130/470) of participants in the intervention arm and 20.1% (63/313) in the control arm. In the adjusted, intention-to-treat analysis, early retention was observed in 29.4% in the intervention arm and 17.7% in the control arm (risk difference: 11.8 percentage points; 95% confidence interval: 5.3-18.3). Conclusion: Early retention in HIV pre-exposure prophylaxis care was significantly greater among female sex workers in the United Republic of Tanzania who used the Jichunge app than in those who did not. Nevertheless, more than two thirds of sex workers using the application did not attend follow-up services after 1 month, suggesting that additional interventions are needed.

• Habiba, Um E; Khan, Amjad; Mmbaga, Elia; Green, Ivan Robert & Asaduzzaman, Muhammad (2023). Use of antibiotics in poultry and poultry farmers- a cross-sectional survey in Pakistan. Frontiers in Public Health. 11. doi: 10.3389/fpubh.2023.1154668. Full text in Research Archive Show summary

  Background Antimicrobial resistance (AMR) which has been ascribed to be due to community carriage of antibiotic-resistant bacteria is highly prevalent in the WHO South-East Asia region. One of the major reasons for this is the misuse of antibiotics in animal farming practices and at the community level, which threatens both human and animal health. However, this problem of antibiotic misuse in poultry farms and in respective farmers is not well studied in countries like Pakistan. Methods We conducted a cross-sectional study in rural Punjab to explore the current practices of antibiotic use in poultry and poultry farmers, associated factors, their healthcare-seeking behavior and biosecurity practices. Results In the context of antibiotic use for poultry, 60% comprised of Colistin sulfate and Amoxicillin trihydrate whereas Colistin is considered as the last resort antibiotic. In addition, the significant consumption of antibiotics in poultry farms (60%) and poultry farmers (50%) was without prescription by either human health physicians or veterinarians. Most of the farms (85%) had no wastewater drainage system, which resulted in the direct shedding of poultry waste and antibiotic residue into the surrounding environment. The lack of farmers’ education, professional farm training and farming experience were the most significant factors associated with antibiotic use and knowledge of AMR. Conclusion Our study findings show that it is necessary for an integrated AMR policy with the inclusion of all poultry farmers to be educated, a mass awareness program to be undertaken and that strict antibiotic usage guidelines be available to them. Such initiatives are also important to ensure food safety and farm biosecurity practices.

• Muya, Sikudhani; Ndumbalo, Jerry; Nyagabona, Sarah; Shaid, Yusuf; Rhee, Dong & Mushi, Beatrice [Show all 15 contributors for this article] (2023). Feasibility and Clinical Acceptability of Automation-Assisted 3D Conformal Radiotherapy Planning for Patients With Cervical Cancer in a Resource-Constrained Setting. JCO Global Oncology. 9. doi: 10.1200/GO.23.00050. Full text in Research Archive Show summary

  Purpose: The Ocean Road Cancer Institute (ORCI) in Tanzania began offering 3D conformal radiation therapy (3DCRT) in 2018. Steep learning curves, high patient volume, and a limited workforce resulted in long radiation therapy (RT) planning workflows. We aimed to establish the feasibility of implementing an automation-assisted cervical cancer 3DCRT planning system. Materials and methods: We performed chart abstractions on 30 patients with cervical cancer treated with 3DCRT at ORCI. The Radiation Planning Assistant (RPA) generated a new automated set of contours and plans on the basis of anonymized computed tomography images. Each were assessed for edit time requirements, dose-volume safety metrics, and clinical acceptability by two ORCI physician investigators. Dice similarity coefficient (DSC) agreement analysis was conducted between original and new contour sets. Results: The average time to manually develop treatment plans was 7 days. Applying RPA, automated same-day contours and plans were developed for 29 of 30 patients (97%). Of the 29 evaluable contours, all were approved with <2 minutes of edit time. Agreement between clinical and RPA contours was highest for the rectum (median DSC, 0.72) and bladder (DSC, 0.90). Agreement was lower with the primary tumor clinical target volume (CTVp; DSC, 0.69) and elective nodal clinical target volume (CTVn; DSC, 0.63). All RPA plans were approved with <4 minutes of edit time. RPA target coverage was excellent, covering the CTVp with median V45 Gy 100% and CTVn with median V45 Gy 99.9%. Conclusion: Automation-assisted 3DCRT contouring yielded high levels of agreement for normal structures. The RPA met all planning safety metrics and sustained high levels of clinical acceptability with minimal edit times. This tool offers the potential to significantly decrease RT planning timelines while maintaining high-quality RT delivery in resource-constrained settings.

• Kimambo, Asteria; Vuhahula, Edda; Philipo, Godfrey; Mushi, Beatrice; Mmbaga, Elia & Loon, Katherine van [Show all 7 contributors for this article] (2023). Rapid Onsite Evaluation for Specimen Adequacy and Triage of Breast Masses in a Low-Resource Setting. Archives of Pathology & Laboratory Medicine. ISSN 0003-9985. 148(1). doi: 10.5858/arpa.2022-0398-OA. Full text in Research Archive Show summary

  Context.—: Rapid onsite evaluation (ROSE) is critical in determining sample adequacy and triaging cytology samples. Although fine-needle aspiration biopsy (FNAB) is the primary method of initial tissue sampling in Tanzania, ROSE is not practiced. Objective.—: To investigate the performance of ROSE in determining cellular adequacy and providing preliminary diagnoses in breast FNAB in a low-resource setting. Design.—: Patients with breast masses were recruited prospectively from the FNAB clinic at Muhimbili National Hospital. Each FNAB was evaluated by ROSE for overall specimen adequacy, cellularity, and preliminary diagnosis. The preliminary interpretation was compared to the final cytologic diagnosis and histologic diagnosis, when available. Results.—: Fifty FNAB cases were evaluated, and all were adequate for diagnosis on ROSE and final interpretation. Overall percentage of agreement (OPA) between preliminary and final cytologic diagnosis was 86%, positive percentage of agreement (PPA) was 36%, and negative percentage of agreement (NPA) was 100% (κ = 0.5, P < .001). Twenty-one cases had correlating surgical resections. OPA between preliminary cytologic and histologic diagnoses was 67%, PPA was 22%, and NPA was 100% (κ = 0.2, P = .09). OPA between final cytologic and histologic diagnoses was 95%, PPA of 89%, and NPA of 100% (κ = 0.9, P = <.001). Conclusions.—: False positive rates of ROSE diagnoses for breast FNAB are low. While preliminary cytologic diagnoses had a high false negative rate, final cytologic diagnoses had overall high concordance with histologic diagnoses. Therefore, the role of ROSE for preliminary diagnosis should be considered carefully in low-resource settings and may need to be paired with additional interventions to improve pathologic diagnosis.

• Lichtwarck, Hanne Ochieng; Mbotwa, Christopher Hariri; Kazaura, Method Rwelengera; Moen, Kåre & Mmbaga, Elia (2023). Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: A socioecological approach. BMJ Global Health. 8(12). doi: 10.1136/bmjgh-2023-013662. Full text in Research Archive
• Upreti, Ramesh; Mmbaga, Elia; Haugnes, Hege Sagstuen; Kiserud, Cecilie E. & Kollerud, Ruby del Risco (2023). Most common health problems in general practice among adolescents, and young adults’ survivors of lymphoma: a register-based cohort study in Norway. Acta Oncologica. ISSN 0284-186X. 62(12), p. 1607–1615. doi: 10.1080/0284186X.2023.2273894. Full text in Research Archive Show summary

  Background - The aim was to investigate the distribution of health problems in general practice (GP) among adolescent and young adult (AYA) survivors of lymphoma and to compare problem rates with the general population.<p> <p>Methods - All GP consultations between 2006 and 2020 were identified from the national GP claims register. Diseases and complaints presented 3–10 years after the cancer diagnosis were identified using the International Classification of Primary Care codes (ICPC-2) and compared by applying logistic regression models, presented with odds ratio (OR) and 95%CI.<p> <p>Results - A total of 2,500,557 AYAs, of whom 1105 were diagnosed with lymphoma, and over 50 million GP consultations were included. The most common causes of consultation among AYA survivors of lymphoma were related to Hodgkin’s disease (13%), pregnancy (11%), respiratory diseases (9%), psychological problems (8%), musculoskeletal system (6%) and fatigue (4%). Almost all these problems were significantly higher among AYA lymphoma survivors compared to the general population (OR ranging from 1.1 to 1.5).<p> <p>Conclusion - Compared to the general population, young lymphoma survivors have increased contact with the GP for a considerable number of health problems for up to 10 years post-diagnosis. This emphasizes the importance of robust follow-up and a good flow of information between hospital and primary care.

• Ishungisa, Alexander Mwijage; Mmbaga, Elia; Leshabari, Melkizedeck Thomas; Tersbøl, Britt Pinkowski & Moen, Kåre (2023). Five different ways of reasoning: Tanzanian healthcare workers’ ideas about how to improve HIV prevention among same-sex attracted men. BMC Health Services Research. 23(1). doi: 10.1186/s12913-023-09771-3. Full text in Research Archive Show summary

  Background Same-sex attracted men in Tanzania and globally carry a disproportionate burden of HIV. Drawing on qualitative research, this article explores healthcare providers’ ideas and recommendations regarding how to improve HIV prevention among same-sex attracted men. Methods We carried out a qualitative study among healthcare workers in the cities of Dar es Salaam and Tanga in Tanzania between August 2018 and October 2019. Data were collected using qualitative methods of data collection, specifically in-depth interviews, focus group discussions, and participant observation. Study participants were recruited through a purposive sampling strategy that aimed to ensure variation in age, education, and work experience. Forty-eight interviews with 24 healthcare workers, six focus group discussions, and participant observation were conducted. A total of 64 persons participated in the study. Results This paper describes five different “ways of reasoning” that were identified among healthcare workers regarding how to strengthen HIV prevention among same-sex attracted men. One held that punitive measures should be taken to prevent HIV transmission, another that health services needed to become more friendly towards men who have sex with men, a third that healthcare workers should reach out to provide more education to this population, a fourth called for strengthened collaboration between healthcare providers and same-sex attracted men in healthcare delivery, and the fifth proposed that activistic efforts be taken to remove structural barriers for same-sex attracted men to access healthcare. Conclusion When reflecting on what is needed to strengthen HIV prevention among men who have sex with men, healthcare workers described six different ideas. One was that restrictive and punitive measures ought to be taken to prevent HIV transmission through same-sex sex. The remaining five promoted understanding of and support for same-sex attracted men. They prescribed more healthcare education, measures to improve attitudes among healthcare workers, healthcare delivery with user involvement, and political action to achieve law reform. Finally, some study participants raised concerns about the implementation of the national comprehensive package for key populations.

• Mbotwa, Christopher H; Kazaura, Method Rwelengera; Moen, Kåre; Lichtwarck, Hanne Ochieng; Leshabari, Melkizedeck T & Metta, Emmy [Show all 7 contributors for this article] (2023). 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. Digital Health. 9. doi: 10.1177/20552076231170507. Full text in Research Archive Show summary

  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.

• Mbotwa, Christopher H; Kazaura, Method Rwelengera; Moen, Kåre; Leshabari, Melkizedeck Thomas; Metta, Emmy & Mmbaga, Elia (2023). 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 and uhealth. 11. doi: 10.2196/46853. Full text in Research Archive Show summary

  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. Keywords: Africa; HIV; PrEP; engagement; mHealth; mobile health; pre-exposure prophylaxis; retention; sex workers.

• Nomburg, Jason; Bullman, Susan; Nasrollahzadeh, Dariush; Collisson, Eric; Abedi-Ardekani, Behnoush & Akoko, Larry [Show all 20 contributors for this article] (2022). An international report on bacterial communities in esophageal squamous cell carcinoma. International Journal of Cancer. ISSN 0020-7136. 151(11), p. 1947–1959. doi: 10.1002/ijc.34212. Full text in Research Archive Show summary

  The incidence of esophageal squamous cell carcinoma (ESCC) is disproportionately high in the eastern corridor of Africa and parts of Asia. Emerging research has identified a potential association between poor oral health and ESCC. One possible link between poor oral health and ESCC involves the alteration of the microbiome. We performed an integrated analysis of four independent sequencing efforts of ESCC tumors from patients from high- and low-incidence regions of the world. Using whole genome sequencing (WGS) and RNA sequencing (RNAseq) of ESCC tumors from 61 patients in Tanzania, we identified a community of bacteria, including members of the genera Fusobacterium, Selenomonas, Prevotella, Streptococcus, Porphyromonas, Veillonella, and Campylobacter, present at high abundance in ESCC tumors. We then characterized the microbiome of 238 ESCC tumor specimens collected in two additional independent sequencing efforts consisting of patients from other high-ESCC incidence regions (Tanzania, Malawi, Kenya, Iran, China). This analysis revealed similar ESCC-associated bacterial communities in these cancers. Because these genera are traditionally considered members of the oral microbiota, we next explored whether there was a relationship between the synchronous saliva and tumor microbiomes of ESCC patients in Tanzania. Comparative analyses revealed that paired saliva and tumor microbiomes were significantly similar with a specific enrichment of Fusobacterium and Prevotella in the tumor microbiome. Together, these data indicate that cancer-associated oral bacteria are associated with ESCC tumors at the time of diagnosis and support a model in which oral bacteria are present in high abundance in both saliva and tumors of some ESCC patients

• Mbotwa, Christopher; Kazaura, Method Rwelengera; Moen, Kåre; Leshabari, Melkizedeck T.; Metta, Emmy & Leyna, Germana Henry [Show all 7 contributors for this article] (2022). Predictors of mHealth use in promoting adherence to pre-exposure prophylaxis among female sex workers: an evaluation of the Jichunge intervention in Dar es Salaam, Tanzania. BMC Health Services Research. 22(1). doi: 10.1186/s12913-022-08245-2. Full text in Research Archive Show summary

  Background: There is evidence that pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission, and PrEP is recommended by the World Health organization (WHO) for use by individuals at high risk of HIV infection. However, low adherence has been reported to hamper its effectiveness. Some evidence indicates that mHealth interventions may be a promising way of promoting PrEP adherence. Nevertheless, evaluations of mHealth interventions in Africa, the region most affected by HIV, are scarce. This study aimed at identifying the extent of and predictors for use of a smartphone based mHealth application among female sex workers in Dar es Salaam, Tanzania. Methods: As part of a quasi-experimental study in Tanzania, 470 female sex workers who were eligible for PrEP and who owned a smartphone were recruited using respondent driven sampling. All participants were provided with an mHealth application called Jichunge, a smartphone-based app designed to promote adherence to PrEP by offering users information, advise and support during start-up and use of PrEP. We collected data through structured interviews at baseline and extracted user data from the app for a period of 30 days. Modified Poisson regression model with robust standard errors was used to identify predictors for the optimal use of the Jichunge app. Results: Overall, the optimal use of the Jichunge app was 46.4%. Optimal use was significantly higher among women who were older (aPR = 1.3, 95% CI: 1.10-1.65, p = 0.004 for age 25-34 years, and aPR = 1.6, 95% CI: 1.19-2.07, p = 0.001 for age at least 35 years), who had secondary education or higher (aPR = 1.8, 95% CI: 1.08-2.94, p = 0.023), who had suboptimal social support (aPR = 1.2, 95% CI: 1.02-1.48, p = 0.030), who had high awareness of PrEP (aPR = 1.3, 95% CI: 1.08-1.55, p = 0.005), and who had experience using common mainstream social media applications (aPR = 1.4, 95% CI: 1.08-1.71, p = 0.009). Conclusion: Optimal use of the Jichunge app was substantially higher among women with higher age, higher education, higher PrEP awareness, less social support, and experience using common social media applications. Individual and interpersonal factors should be considered in planning mHealth interventions. Further studies to determine predictors of longer-term mHealth engagement are needed. Trial registration: International Clinical Trials Registry Platform PACTR202003823226570 ; 04.03.2020.

• Likindikoki, Samuel; Meyrowitsch, Dan Wolf; Mizinduko, Mucho; Ishungisa, Alexander Mwijage; Tersbøl, Britt & Leyna, Germana Henry [Show all 11 contributors for this article] (2022). Socio-cognitive factors influencing access to HIV prevention services among people who inject drugs in Dar es Salaam, Tanzania: An integrated bio-behavioural survey. PLOS ONE. 17(1). doi: 10.1371/journal.pone.0261500. Full text in Research Archive Show summary

  Introduction: People who inject drugs (PWID) in Sub-Saharan Africa have limited access to comprehensive HIV services. While it is important to inform programming, knowledge about factors influencing access to comprehensive HIV services is scarce. We assessed the proportions of PWID with access to HIV prevention services and associated socio-cognitive factors in Tanzania. Methods: A cross-sectional survey was conducted among PWID between October and December 2017 in Dar es Salaam, Tanzania. Data on access to HIV prevention services, demographics and selected socio-cognitive factors were collected through structured face-to-face interviews. Weighted descriptive and forward selection multivariable logistics regression analyses were done to assess independent associations between HIV prevention services and predictors of interest. The results were two tailed and a p-value of less than 0.05 was considered statistically significant. Results: The study included 611 PWID (males: 94.4%) with a median age of 34 years (Interquartile Range (IQR), 29-38). A large majority of participants reported to have access to condoms (87.8%), sterile needles/syringes (72.8%) and ever tested for HIV (66.0%). About half (52.0%) reported to have used condoms in the past one month and about a third (28.5%) accessed a peer educator. The odds of testing for HIV decreased among participants who perceived their HIV risk to be high (aOR = 0.29; 95%CI: 0.17-0.49) and those experienced sexual violence (aOR = 0.60; 95%CI 0.37-0.98). However, the odds of testing for HIV increased among participants with secondary level of education (aOR = 2.16; 95%CI: 1.06-5.55), and those who reported having correct comprehensive HIV knowledge (CCHK) (aOR = 1.63; 95%CI 1.12-2.41). The odds of access to condoms increased among females (aOR = 2.23; 95%CI: 1.04-5.02) but decreased among participants with secondary level of education (aOR = 0.41; 95%CI: 0.19-0.84), an income of >TZS 200,000 (aOR = 0.39; 95%CI: 0.23-0.66) and those who perceived their HIV risk to be high (aOR = 0.13; 95%CI: 0.03-0.36). The odds of access to peer educators was higher among participants with primary (aOR = 1.61; 95%CI: 1.01-2.26), and secondary (aOR = 2.71; 95%CI: 1.39-5.33) levels of education. The odds of access to sterile needle and syringe decreased among participants who perceived their HIV risk to be high (aOR = 0.11;95%CI 0.05-0.22), and low-medium (aOR = 0.25;95%CI 0.11-0.52) but increased among those with primary level of education (aOR = 1.72;95%CI 1.06-2.78). Conclusion: Access to condom, HIV testing, sterile needles and syringes were relatively high among PWID. However, condom use and access to peer educators was relatively low. HIV knowledge and risk perception, gender, education, and sexual violence influenced access to HIV prevention services. There is an urgent need to address the identified socio-cognitive factors and scale up all aspects of HIV prevention services to fast-track attainment of the 2025 UNAIDS goals and ending the HIV epidemic.

• Lichtwarck, Hanne Ochieng; Kazaura, Method; Moen, Kåre & Mmbaga, Elia (2022). Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. doi: 10.3390/ijerph20010698. Full text in Research Archive Show summary

  Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.

• Buckle, Geoffrey C; Mmbaga, Elia; Paciorek, Alan; Akoko, Larry; Deardorff, Katrina & Mgisha, Willium [Show all 11 contributors for this article] (2022). Risk Factors Associated With Early-Onset Esophageal Cancer in Tanzania. JCO Global Oncology. doi: 10.1200/GO.21.00256. Full text in Research Archive Show summary

  Purpose: Eastern Africa is one of several regions affected by high incidence rates of esophageal squamous cell carcinoma (ESCC). A unique epidemiologic feature of ESCC in Eastern Africa is the high incidence in young people, with one-third of cases diagnosed at age < 45 years. This study aimed to investigate risk factors for early-onset ESCC in Tanzania through a secondary analysis of a matched case-control study. Materials and methods: From 2013 to 2015, ESCC cases were recruited at Muhimbili National Hospital and Ocean Road Cancer Institute in Dar es Salaam, Tanzania. Hospital controls were identified from patients with nonmalignant conditions and matched 1:1 for sex and age (± 10 years). Questionnaires were used to assess sociodemographic characteristics and environmental, dietary, and lifestyle risk exposures. Multivariate logistic regression models were used to estimate age-specific odds ratios of ESCC for exposures among participants age 30-44 and ≥ 45 years. Results: A total of 471 cases and 471 controls were enrolled. Among cases, 100 (21%) were < 45 years. Multiple exposures were identified as risk factors for early-onset ESCC, several of which were unique to this age group, including infrequent teeth cleaning, secondhand tobacco smoke exposure, and pest infestation of grain and/or nuts. Lower socioeconomic status, family history of ESCC, tobacco smoking, home-brewed alcohol consumption, home storage of grain and/or nuts, and use of firewood for cooking were associated in the older but not the younger age group. Hot beverage intake was associated with increased ESCC risk in both age groups. Conclusion: Our results suggest that ESCC risk factors in Tanzania vary between age groups. With the data currently available, environmental and behavioral risk factors appear to play an important role in the high incidence of ESCC among young people.

• Ishungisa, Alexander Mwijage; Meyrowitsch, Dan Wolf; Mmbaga, Elia; Leshabari, Melkizedeck Thomas & Moen, Kåre (2022). Not a Problem at All or Excluded by Oneself, Doctors and the Law? Healthcare Workers’ Perspectives on Access to HIV-Related Healthcare among Same-Sex Attracted Men in Tanzania. Journal of the International Association of Providers of AIDS Care. ISSN 2325-9574. 21. doi: 10.1177/23259582221121448. Full text in Research Archive
• Likindikoki, Samuel Lazarus; Mmbaga, Elia; Mizinduko, Mucho; Alexander, Mwijage; Adams, Lisa V. & Horsburgh, Robert [Show all 12 contributors for this article] (2022). Testing for Drug-Related Infectious Diseases and Determinants among People Who Use Drugs in a Low-Resource Setting: A Respondent-Driven Cross-Sectional Survey. Tropical Medicine and Infectious Disease. 7(9). doi: 10.3390/tropicalmed7090213. Full text in Research Archive
• Tesha, Esther-Dorice; Kishimba, Rogath Saika; Njau, Prosper; Revocatus, Baraka & Mmbaga, Elia (2022). Predictors of loss to follow up from antiretroviral therapy among adolescents with HIV/AIDS in Tanzania. PLOS ONE. 17(7), p. e0268825–e0268825. doi: 10.1371/journal.pone.0268825. Full text in Research Archive Show summary

  Access to Antiretroviral Therapy (ART) is threatened by the increased rate of loss to follow-up (LTFU) among adolescents on ART care. We investigated the rate of LTFU from HIV care and associated predictors among adolescents living with HIV/AIDS in Tanzania. A retrospective cohort analysis of adolescents on ART from January 2014 to December 2016 was performed. Kaplan-Meier method was used to determine failure probabilities and the Cox proportion hazard regression model was used to determine predictors of loss to follow up. A total of 25,484 adolescents were on ART between 2014 and 2016, of whom 78.4% were female and 42% of adolescents were lost to follow-up. Predictors associated with LTFU included; adolescents aged 15-19 years (adjusted hazard ratio (aHR): 1.57; 95% Confidence Interval (CI); 1.47-1.69), having HIV/TB co-infection (aHR: 1.58; 95% CI, 1.32-1.89), attending care at dispensaries (aHR: 1.12; 95% CI, 1.07-1.18) or health center (aHR: 1.10; 95% CI, 1.04-1.15), and being malnourished (aHR: 2.27; 95% CI,1.56-3.23). Moreover, residing in the Lake Zone and having advanced HIV disease were associated with LTFU. These findings highlight the high rate of LTFU and the need for intervention targeting older adolescents with advanced diseases and strengthening primary public facilities to achieve the 2030 goal of ending HIV as a public health threat.

• Mizinduko, Mucho; Moen, Kåre; Tersbøl, Britt; Likindikoki, Samuel; Ishungisa, Alexander Mwijage & Leyna, Germana Henry [Show all 12 contributors for this article] (2021). HIV testing and associated factors among female sex workers in Tanzania: approaching the first 90% target? AIDS Care. ISSN 0954-0121. 18, p. 1–6. doi: 10.1080/09540121.2021.2014779. Full text in Research Archive Show summary

  Use of HIV testing services among FSW in sub-Saharan Africa (SSA) is below the desired UNAIDS target of 90%. We estimated the prevalence and factors associated with HIV testing among FSW in Dar es Salaam, Tanzania. A respondent-driven sampling method was used to recruit FSW aged 18. Modified Poisson regression models were used to determine factors associated with recent HIV testing. Of 958 surveyed FSW (median age 26 years), 85.4% (95% CI: 82.3, 88.1) reported to have ever been tested for HIV and 65.3% (95% CI: 61.2, 69.3) tested in the past 12 months. Condom use on the last day worked (prevalence ratio (PR) = 1.17; 95% CI: 0.99, 1.38), no or low self-perceived risk of HIV acquisition (PR = 1.16; 95% CI: 1.02, 1.32), having never felt stigmatized as a sex worker (PR = 1.18; 95% CI: 1.04, 1.33), and having been in contact with a peer educator (PR = 1.33; 95% CI: 1.18, 1.49) during the past year preceding the survey were associated with recent HIV testing. Interventions aiming to mitigate stigma due to sex work, improve health education to address risk perception as a barrier to HIV testing, and scaling up peer educator's engagement should be given priority.

• Kamori, Doreen; Joachim, Agricola; Mizinduko, Mucho; Barabona, Godfrey; Mahiti, Macdonald & Kibwana, Upendo [Show all 12 contributors for this article] (2021). Seroprevalence of Human Herpesvirus Infections in Newly Diagnosed HIV-Infected Key Populations in Dar es Salaam, Tanzania. International Journal of Microbiology. ISSN 1687-918X. doi: 10.1155/2021/4608549. Full text in Research Archive Show summary

  Background. Human herpesvirus (HHV) infections can significantly increase the risk of human immunodeficiency virus (HIV) transmission and accelerate disease progression. In the population at high risk of HIV infection, also termed as key populations (female sex workers (FSW), men who have sex with men (MSM), and people who inject drugs (PWID)), and their sexual partners, HHV infections can potentially compromise the efforts to prevent and control HIV infection. Here, we investigated the seroprevalence of HHV infections among HIV-infected key populations in Dar es Salaam, Tanzania. Methodology. We analyzed 262 archived serum samples of HIV-infected key populations from the integrated biobehavioral surveillance (IBBS) study conducted in Dar es Salaam, Tanzania. The enzyme-linked immunosorbent assay was used to determine IgG and IgM titers for cytomegalovirus (CMV) and herpes simplex virus (HSV) types 1 and 2. Results. The overall seropositivity of HHV IgG was 92% (95% CI: 87.7–95.3%). HHV IgM was not detected in any of the samples. The most seroprevalent coinfection was CMV at 69.1% (181/262), followed by HSV-2 33.2% (87/262) and HSV-1 32.1% (84/262). HSV-2 infection differed by key population groups; it accounted for FSW (46.3%) () compared to PWID (21.6%) and MSM (22.7%). In contrast, seroprevalence for CMV and HSV-1 was comparable across the key population groups; whereby, CMV was 62%, 75.3%, and 75% and HSV-1 was 26.4%, 39.2%, and 31.8% for FSW, MSM, and PWID, respectively. We also observed that multiple coinfections with CMV-HSV-2 () and CMV-HSV-1-HSV-2 () were significantly associated with key population aged above 40 years. Conclusion. The IgG seroprevalence of CMV, HSV-1, and HSV-2 was high among HIV-positive key populations. These findings indicate that these individuals are prone to recurrence of HHV infections and may harbor replicating viruses that subsequently may affect HIV disease progression. Therefore, this warrants concerted efforts for integrated HIV and sexually transmitted infection prevention programs targeting key populations.

• Mauka, Wilhellmuss; Mbotwa, Christopher; Moen, Kåre; Lichtwarck, Hanne Ochieng; Haaland, Inga & Kazaura, Method Rwelengera [Show all 9 contributors for this article] (2021). Development of a Mobile Health Application for HIV Prevention Among At-Risk Populations in Urban Settings in East Africa: A Participatory Design Approach. Journal of Medical Internet Research (JMIR). ISSN 1439-4456. doi: 10.2196/23204. Full text in Research Archive Show summary

  Background: There is limited evidence in Africa on the design and development of mobile health (mHealth) applications to guide best practices and ensure effectiveness. A pragmatic trial for HIV pre-exposure prophylaxis roll-out among key populations in Tanzania is needed. Objective: We present the results of the development of a mobile app (Jichunge) intended to promote adherence to PrEP among men who have sex with men (MSM) and female sex workers (FSW) in Tanzania. Methods: A participatory design approach was employed and guided by the information system research framework. MSM and FSW were the target populations. A total of 15 MSM and 15 FSW were engaged in the relevance and design cycles, while the piloting phase included 10 MSM and 20 FSW. Results: The relevance cycle enabled the description of the existing problem, provided the compatible app features for the target population, and identified the need to develop an mHealth app that provides health services in a stigmatizing and discriminating environment. User involvement in the app’s design and evaluation provided an opportunity to incorporate social, cultural, and community-specific features that ensured usability. In addition, the participants suggested valuable information to inform the app, text message services, medication registration, and chat platform designs. Conclusions: The participatory design approach in the development of mHealth apps is useful in identifying and validating population-specific functional features, improve usability, and ensuring future health impacts. Through this participatory process, the Jichunge app took end-user needs, perspectives, and experiences into account, eliciting enthusiasm regarding its potential role in supporting pre-exposure prophylaxis adherence for HIV and related behavioral change promotion. Trial Registration: The trial registration number is PACTR202003823226570

• Nyagabona, Sarah; Mushi, Beatrice; Musiba, Selekwa; Philipo, Godfrey; Hadaddi, Sumaiya & Khadim, Emilie [Show all 13 contributors for this article] (2021). A mixed methods needs assessment and gap analysis for establishment of a cancer research training program in East Africa. Journal of Global Health Reports (JoGHR). 5. doi: 10.29392/001c.22120. Full text in Research Archive Show summary

  Background The burden of non-communicable diseases (NCDs), including cancer, in Africa is rising. Policymakers are charged with formulating evidence-based cancer control plans; however, there is a paucity of data on cancers generated from within Africa. As part of efforts to enhance cancer research training in East Africa, we performed a needs assessment and gap analysis of cancer-related research training resources in Tanzania. Methods A mixed-methods study to evaluate existing individual, institutional, and national resources supporting cancer research training in Tanzania was conducted. Qualitative data were collected using in-depth interviews while quantitative data were collected using self-administered questionnaires and online surveys. The study also included a desk-review of policy and guidelines related to NCD research and training. Study participants were selected to represent five groups: (i) policymakers; (ii) established researchers; (iii) research support personnel; (iv) faculty members in degree training programs; and (v) post-graduate trainees. Results Our results identified challenges in four thematic areas. First, there is a need for coordination and monitoring of the cancer research agenda at the national level. Second, both faculty and trainees identified the need for incorporation of rigorous training to improve research competencies. Third, sustained mentoring and institutional investment in development of mentorship resources is critical to empowering early career investigators. Finally, academic institutions can enhance research outputs by providing adequate research infrastructure, prioritizing protected time for research, and recognizing research accomplishments by trainees and faculty. Conclusions As we look towards establishment of cancer research training programs in East Africa, investment in the development of rigorous research training, mentorship resources, and research infrastructure will be critical to empowering local health professionals to engage in cancer research activities.

• Philipo, Godfrey; Vuhahula, Eddah; Kimambo, Asteria; Mmbaga, Elia John; Loon, Katherine van & Ng, Dianna (2021). Feasibility of Fine-Needle Aspiration Biopsy and Rapid On-Site Evaluation for Immediate Triage in Breast Cancer Screening in Tanzania. JCO Global Oncology. 7, p. 146–152. doi: 10.1200/GO.20.00279. Full text in Research Archive Show summary

  Purpose: Clinical breast examination (CBE) is one of the most common methods used for early detection of breast cancer in low- and middle-income countries. CBE alone is limited by lack of specificity and may result in unnecessary diagnostic procedures. We evaluated the feasibility of integrating CBE, fine-needle aspiration biopsy (FNAB), and rapid on-site evaluation (ROSE) in triaging palpable breast masses for specialized cancer care. Materials and methods: An intensive breast cancer screening event was conducted at a national trade fair by a multidisciplinary team of care providers targeting a healthy population in Dar es Salaam, Tanzania. All adults age ≥ 18 years were invited to participate. CBE was performed by oncologists and/or pathologists. FNAB was performed by a pathologist on palpable masses that were then categorized as benign, indeterminate, or suspicious for malignancy or definitively malignant based on ROSE. Results: A total of 208 individuals (207 females, one male; median age, 36 years; range, 18-68 years) were screened. Most (90.8%, 189 of 208) had normal findings, whereas 7.2% (15 of 208), 1% (2 of 208), and 1% (2 of 208) had a palpable mass, breast pain, and nipple discharge, respectively. Two participants had lesions too small for palpation-guided biopsy and clinically consistent with fibroadenomas; the participants were counseled, and observation was recommended. FNAB was performed on 13 breast masses, with 9 of 13 (69%) categorized as benign and 4 of 13 (31%) suspicious for malignancy. Final cytopathologic review of referred patients confirmed one case to be breast adenocarcinoma, one was suggestive of fibroadenoma, and two showed inflammations. Conclusion: Integration of CBE with ROSE and FNAB was feasible in a breast cancer screening program in Tanzania. In settings with constrained resources for cancer care, this may be an effective method for triaging patients with breast masses.

• Mushi, Beatrice; Mwachiro, Michael; Buckle, Geoffrey C; Kaimila, Bongani; Mulima, Gift & Kayamba, Violet [Show all 17 contributors for this article] (2021). Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy. JCO Global Oncology. 7, p. 118–126. doi: 10.1200/GO.20.00318. Full text in Research Archive Show summary

  Purpose: The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. Methods: In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. Results: Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. Conclusion: The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.

• Nyagabona, Sarah; Luhar, Rohan; Ndumbalo, Jerry; Mvungi, Nanzoke; Ngoma, Mamsau & Meena, Steven [Show all 16 contributors for this article] (2021). Views from Multidisciplinary Oncology Clinicians on Strengthening Cancer Care Delivery Systems in Tanzania. The Oncologist. ISSN 1083-7159. doi: 10.1002/onco.13834. Full text in Research Archive Show summary

  Background: In response to the increasing burden of cancer in Tanzania, the Ministry of Health Community Development, Gender, Elderly and Children launched National Cancer Treatment Guidelines (TNCTG) in February 2020. The guidelines aimed to improve and standardize oncology care in the country. At Ocean Road Cancer Institute (ORCI), we developed a theory-informed implementation strategy to promote guideline-concordant care. As part of the situation analysis for implementation strategy development, we conducted focus group discussions to evaluate clinical systems and contextual factors that influence guideline-based practice prior to launching of TNCTG. Methods: In June 2019, three focus group discussions were conducted with a total of 21 oncology clinicians at ORCI, stratified by profession. A discussion guide was used to stimulate dialogue about facilitators and barriers to delivery of guideline concordant care. Discussions were audio recorded, transcribed, translated, and analyzed using thematic framework analysis. Results: Participants identified factors both within the inner context of ORCI clinical systems and outside of ORCI. Themes within the clinical systems included: capacity and infrastructure, information technology, communication, efficiency and quality of services provided. Contextual factors external to ORCI included: inter-institutional coordination, oncology capacity in peripheral hospitals, public awareness and beliefs, and financial barriers. Participants provided pragmatic suggestions for strengthening cancer care delivery in Tanzania. Conclusion: Our results highlight several barriers and facilitators within and outside of the clinical systems at ORCI that may affect uptake of the TNCTG. Our findings were used to inform a broader guideline implementation strategy, in effort to improve uptake of the TNCTGs at ORCI. Implications for practice: This study provides an assessment of cancer care delivery systems in a low resource setting from the unique perspectives of local multidisciplinary oncology clinicians. Situational analysis of contextual factors that are likely to influence guideline implementation outcomes is the first step of developing an implementation strategy for cancer treatment guidelines. Many of the barriers identified in this study represent actionable targets that will inform the next phases of our implementation strategy for guideline-concordant cancer care in Tanzania and comparable settings.

• Samizi, Florence; Panga, Onna Duuma; Mulugu, Senga Sembuche; Gitige, Catherine Gale & Mmbaga, Elia John (2021). Rate and predictors of HIV virological failure among adults on first-line antiretroviral treatment in Dar Es Salaam, Tanzania. Journal of Infection in Developing Countries. ISSN 2036-6590. 15(6), p. 853–860. doi: 10.3855/jidc.13603. Full text in Research Archive Show summary

  Introduction: Monitoring resistance to first line Antiretroviral therapy (ART) is crucial in preventing accumulation of viral mutations following the implementation of the World Health Organization "treat all" initiative. We estimated the rate and predictors of virological treatment failure among adults living with HIV/AIDS in Dar es Salaam, Tanzania. Methodology: A retrospective cohort study involving adults aged 18 and above receiving first line ART in Dar as Salaam between 2016 and 2018 were recruited using multistage random sampling. Clinical and laboratory data were extracted from Care and Treatment Clinic database-2 (CTC2) followed by participant's interviews. Adjusted Cox-regression modelling was used to determine independent predictors of treatment failure. Results: A total of 340 participants with mean age of 37 were recruited. Overall, 10.59% had virological failure and the rate of failure was 5.24 (95% CI:3.72; 7.27) per 100 person-months at risk with a median failure time of 18 months. Independent predictors of treatment failure were being a male (Adjusted hazard ratio (aHR) 2.78, 95%CI:1.16;6.63), having used treatment for less than two years (aHR, 12.48, 95%CI:3.64-22.71) and co-infection with Tuberculosis (aHR 2.1, 95%CI: 1.0;5.9). Conclusions: HIV virological failure occurs early during treatment in this population. Male clients, co-infected with Tuberculosis were at higher risk of ART failure within two years of treatment. Substantial stride has been made towards the achievement of the last UNAIDS 90 goal but tailored counseling and close monitoring of HIV/TB co-infected male clients following ART initiation could accelerate efforts to close the gap. Further studies on pre-treatment drug resistance mutations are called for.

• Mizinduko, Mucho; Moen, Kåre; Likindikoki, Samuel; Mwijage, Alexander; Leyna, Germana Henry & Makyao, Neema [Show all 12 contributors for this article] (2020). HIV prevalence and associated risk factors among female sex workers in Dar es Salaam, Tanzania: tracking the epidemic. International Journal of STD and AIDS. ISSN 0956-4624. 31(10), p. 950–957. doi: 10.1177/0956462420917848. Full text in Research Archive Show summary

  Since 2014, HIV care and treatment services among key populations including female sex workers (FSWs) have intensified in Tanzania. We sought to track the epidemic among FSWs in Dar es Salaam, Tanzania. We conducted a cross-sectional integrated bio-behavioral survey using respondent-driven sampling and a structured questionnaire. Blood was drawn for HIV testing. Modified Poisson regression was used to determine factors associated with HIV infection. We recruited 958 FSWs (median age 26 years) of whom 952 consented to HIV testing. The HIV prevalence was 15.3% (95%CI: 12.5-18.6). Factors associated with higher HIV prevalence included old age (25-34 years: aPR 2.38; 95%CI: 1.23, 4.60 and over 35 years: aPR = 6.08; 95%CI: 3.19, 11.58) and having experienced sexual violence in the past year (aPR = 1.94; 95%CI: 1.34, 2.82). Attaining higher education level was associated with lower HIV prevalence (aPR = 0.51; 95%CI: 0.36, 0.73 for primary school level and aPR = 0.20; 95%CI: 0.08, 0.46 for secondary school level and/or above). The HIV prevalence among FSWs in Dar es Salaam has decreased by half since 2013. Prevention strategies should target older FSWs, aim to educate young girls, and institute approaches to mitigate violence among FSWs.

• Mmbaga, Elia John; Mushi, Beatrice; Deardorff, Katrina; Mgisha, Willium; Akoko, Larry & Paciorek, Alan [Show all 11 contributors for this article] (2020). A Case-Control Study to Evaluate Environmental and Lifestyle Risk Factors for Esophageal Cancer in Tanzania. Cancer Epidemiology, Biomarkers and Prevention. ISSN 1055-9965. doi: 10.1158/1055-9965.EPI-20-0660. Full text in Research Archive Show summary

  Background East Africa is affected by a disproportionately high burden of esophageal squamous cell carcinoma (ESCC). Methods We conducted an incident case-control study in Dar es Salaam, Tanzania with 1:1 matching for gender and age. A questionnaire evaluated known and putative risk factors for ESCC. Cochran-Mantel-Haenszel and multivariable conditional logistic regression analyses were applied to evaluate associations with ESCC risk, with adjustment for geographic zone. Results Of 471 cases and 471 controls, the majority were male (69%); median ages were 59 and 55, respectively. In a multivariable logistic regression model, a low International Wealth Index (IWI) score (OR 2.57, 95% CI 1.41-4.68), former smoking (OR 2.45, 95% CI 1.46-4.13), second-hand smoke in the household (OR 1.67, 95% CI 1.01-2.77), daily spicy chilies (OR 1.62, 1.04-2.52), and daily salted foods (OR 2.02, 95% CI 1.06-3.85) were associated with increased risk of ESCC. Daily consumption of raw greens (OR, 0.36, 95% CI 0.16-0.80), fruit (OR 0.47, 95% CI 0.27-0.82), and smoked fish (OR 0.31, 95% CI 0.15-0.66) were protective. Permanent residence in the Central (OR 5.03, 95% CI 2.16-11.73), Northern-Lake (OR 2.40, 95% CI 1.46-3.94), or Southern Highlands zones (OR 3.18, 95% CI 1.56-6.50) of Tanzania were associated with increased risk compared to residence in the Eastern zone. Conclusions Low IWI score, smoke exposure(s), geographic zone, and dietary factors were associated with risk for ESCC in Tanzania. Impact These findings will inform the development of future hypothesis-driven studies to examine risk factors for the high burden of ESCC in East Africa.

• Buckle, Geoffrey C; Mahapatra, Ruchika; Mwachiro, Michael; Akoko, Larry; Mmbaga, Elia John & White, Russell [Show all 8 contributors for this article] (2020). Optimal management of esophageal cancer in Africa: A systemic review of treatment strategies. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.33299. Full text in Research Archive Show summary

  Esophageal cancer (EC) is a leading cause of cancer morbidity and mortality in Africa. Despite the high burden of disease, optimal management strategies for EC in resource-constrained settings have yet to be established. This systematic review evaluates the literature on treatments for EC throughout Africa, and compares the efficacy and safety of varying treatment strategies in this context (PROSPERO CRD42017071546). Pubmed, Embase, and African Index Medicus were searched for studies published on treatment strategies for EC in Africa from 1980-2020. Searches were supplemented by examining bibliographies of included studies and relevant conference proceedings. Methodological quality/risk of bias was assessed using the Cochrane Risk-of-Bias tool and Newcastle-Ottawa Scale. Forty-six studies were included. Case series constituted the majority of studies: thirteen were case series reporting on outcomes of esophagectomies, 17 on palliative luminal or surgical interventions, four on radiotherapy and three on concurrent chemoradiation. Nine randomized-controlled trials were identified, of which four prospectively compared different treatment modalities (one investigating radiotherapy vs. chemoradiation, three evaluating rigid plastic stents vs. other treatments). This review summarizes the research on EC treatments in Africa published over the last four decades and outlines critical gaps in knowledge related to management in this context. Areas in need of further research include: (i) evaluation of the safety and efficacy of neoadjuvant therapy in patients with locally advanced disease; (ii) strategies to improve long-term survival in patients treated with definitive chemoradiation; and (iii) the comparative effectiveness of modern palliative interventions, focusing on quality of life and survival as outcome measures.

• Ishungisa, Alexander Mwijage; Mizinduko, Mucho; Likindikoki, Samuel; Mmbaga, Elia John; Leshabari, Melkizedeck T. & Moen, Kåre (2020). Health services we can trust: how same-sex attracted men in Dar Es Salaam, Tanzania would like their HIV healthcare to be organised. Culture, Health and Sexuality. ISSN 1369-1058. doi: 10.1080/13691058.2020.1780316. Full text in Research Archive Show summary

  Drawing on qualitative research in Dar es Salaam, Tanzania, this article explores how men who engage in sex with other men perceive their interactions with healthcare providers, and how they would prefer healthcare services to be organised and delivered. The paper describes the strengths and weaknesses men associate with private and public healthcare; the advantages and disadvantages they associate with dedicated clinics for sexual minority persons; what they conceive of as good healthcare services; and how they would characterise a good healthcare worker. The paper also presents recommendations made by study participants. These include the view that health services for same-sex attracted men should be developed and delivered in collaboration with such men themselves; that health workers should receive training on the medical needs as well as the overall circumstances of same-sex attracted men; and that there should be mechanisms that make healthcare available to poorer community members. We analyse men’s views and recommendations in the light of theoretical work on trust and discuss the ways in which same sex attracted men look for signs that healthcare workers and healthcare services are trustworthy.

• Mwijage, Alexander; Moen, Kåre; Leyna, Germana Henry; Makyao, Neema; Ramadhan, Angela & Lange, Theis [Show all 11 contributors for this article] (2020). HIV prevalence among men who have sex with men following the implementation of the HIV preventive guideline in Tanzania: respondent-driven sampling survey. BMJ Open. 10(10), p. 1–8. doi: 10.1136/bmjopen-2019-036460. Full text in Research Archive Show summary

  Objectives: To estimate HIV prevalence and associated risk factors among men who have sex with men (MSM) in Dar es Salaam, Tanzania following the implementation of the national comprehensive package of HIV interventions for key population (CHIP). Design: A cross-sectional survey using respondent-driven sampling. Setting: Dar es Salaam, Tanzania's largest city. Participants: Men who occasionally or regularly have sex with another man, aged 18 years and above and living in Dar es Salaam city at least 6 months preceding the study. Primary outcome measure: HIV prevalence was the primary outcome. Independent risk factors for HIV infection were examined using weighted logistics regression modelling. Results: A total of 777 MSM with a mean age of 26 years took part in the study. The weighted HIV prevalence was 8.3% (95% CI: 6.3%-10.9%) as compared with 22.3% (95% CI: 18.7%-26.4%) observed in a similar survey in 2014. Half of the participants had had sex with more than two partners in the month preceding the survey. Among those who had engaged in transactional sex, 80% had used a condom during last anal sex with a paying partner. Participants aged 25 and above had four times higher odds of being infected than those aged 15-19 years. HIV infection was associated with multiple sexual partnerships (adjusted OR/AOR, 3.0; 95% CI: 1.8-12.0), not having used condom during last sex with non-paying partner (AOR, 4.1; 95% CI: 1.4-7.8) and ever having engaged in group sex (AOR, 3.4; 95% CI: 1.7-3.6). Conclusion: HIV prevalence among MSM in Dar es Salaam has decreased by more than a half over the past 5 years, coinciding with implementation of the CHIP. It is nonetheless two times as high as that of men in the general population. To achieve the 2030 goal, behavioural change interventions and roll out of new intervention measures such as pre-exposure prophylaxis are urgently needed.

• Likindikoki, Samuel; Mmbaga, Elia John; Leyna, Germana Henry; Moen, Kåre; Makyao, Neema & Mizinduko, Mucho [Show all 10 contributors for this article] (2020). Prevalence and risk factors associated with HIV-1 infection among people who inject drugs in Dar es Salaam, Tanzania: a sign of successful intervention? Harm Reduction Journal. 17(1). doi: 10.1186/s12954-020-00364-5. Full text in Research Archive Show summary

  BACKGROUND: Prevalence of HIV infection among people who inject drugs (PWID) has been reported to be higher than that of the general population. The present study aimed to estimate the prevalence of HIV infection and associated risk factors among PWID in Dar es Salaam, Tanzania, following the introduction of a comprehensive HIV intervention package (CHIP) for PWID in the country in 2014. METHODS: We conducted an integrated bio-behavioral survey (IBBS) among PWID using respondent-driven sampling (RDS) in Dar es Salaam, Tanzania, between October and December 2017. Data on socio-demographic characteristics and risky behaviors were collected through face-to-face interviews. Blood samples were collected and tested for HIV infection. We accounted for weighting in the analyses, and logistic regression was performed to assess risk factors for HIV infection. RESULTS: A total of 611 PWID (94.4% males and 5.6% females) with a median age of 34 years (IQR 29-38) were recruited. The overall prevalence of HIV infection was 8.7% (95% CI 6.5-10.9). The prevalence of HIV infections for males and females were 6.8% (95% CI 4.7-8.9%) and 41.2% (95% CI 23.7-58.6%) respectively. Adjusted weighted logistic regression analysis (WLRA) showed that being a female (aOR 19.1; 95% CI 5.9-61.8), injecting drugs for more than 10 years (aOR = 7.32; 95% CI 2.1-25.5) compared to 1 year or less and being 45 years or older (aOR = 34.22; 95% CI 2.4-489.5) compared to being 25 years or younger were associated with increased odds of HIV infection. Use of a sterile needle at last injection decreased odds of HIV infection (aOR = 0.3; 95% CI 0.1-0.8). CONCLUSIONS: The present study observed a decline in prevalence of HIV infections among PWID in Dar es Salaam (8.7%) compared to a previous estimate of 15.5% from an IBBS conducted in 2013. Despite the decrease, HIV prevalence remains high among PWID compared to the general population, and women are disproportionally affected. The decline may be possibly attributed to the on-going implementation of CHIP for PWID, highlighting the need for strengthening the existing harm reduction interventions by incorporating access to sterile needle/syringe and addressing the layered risks for women.

• Deboer, Rebecca; Ndumbalo, Jerry; Meena, Steven; Ngoma, Mamsau; Mvungi, Nanzoke & Siu, Sadiq [Show all 17 contributors for this article] (2020). Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa. Implementation Science Communications. 1(24). doi: 10.1186/s43058-020-00007-7. Full text in Research Archive Show summary

  Background Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. Methods In preparation for the launch of Tanzania’s first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. Discussion We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of “proven” guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.

• Leyna, Germana Henry; Makyao, Neema; Mwijage, Alexander; Ramadhan, Angela; Likindikoki, Samuel & Mizinduko, Mucho [Show all 9 contributors for this article] (2019). HIV/HCV co-infection and associated risk factors among injecting drug users in Dar es Salaam, Tanzania: potential for HCV elimination. Harm Reduction Journal. 16(1). doi: 10.1186/s12954-019-0346-y. Full text in Research Archive Show summary

  BACKGROUND: Chronic HCV infection causes substantial morbidity and mortality and, in co-infection with HIV, may result in immunological and virological failure following antiretroviral treatment. Estimates of HCV infection, co-infection with HIV and associated risk practices among PWID are scarce in Africa. This study therefore aimed at estimating the prevalence of HCV and associated risk factors among PWID in the largest metropolitan city in Tanzania to inform WHO elimination recommendations. METHODS: An integrated bio-behavioral survey using respondent-driven sampling was used to recruit PWID residing in Dar es Salaam, Tanzania. Following face-to-face interviews, blood samples were collected for HIV and HCV testing. Weighted modified Poisson regression modeling with robust standard errors was used in the analysis. RESULTS: A total of 611 PWID with a median age of 34 years (IQR, 29-38) were recruited through 4 to 8 waves. The majority of participants (94.3%) were males, and the median age at first injection was 24 years (IQR, 19-30). Only 6.55% (40/611) of participants reported to have been enrolled in opioid treatment programs. The weighted HCV antibody prevalence was 16.2% (95%CI, 13.0-20.1). The corresponding prevalence of HIV infection was 8.7% (95%CI, 6.4-11.8). Of the 51 PWID who were infected with HIV, 22 (43.1%) were HCV seropositive. Lack of access to clean needles (adjusted prevalence ratio (APR), 1.76; 95%CI, 1.44; 12.74), sharing a needle the past month (APR, 1.72; 95%CI, 1.02; 3.00), not cleaning the needle the last time shared (APR, 2.29; 95%CI, 1.00; 6.37), and having unprotected not using a transactional sex (APR, 1.87; 95%CI, 1.00; 3.61) were associated with increased risk of HCV infection. On the other hand, not being on opioid substitution therapy was associated with 60% lower likelihood of infection. CONCLUSIONS: The HCV antibody prevalence among PWID is lower than global estimates indicating potential for elimination. Improving access to safe injecting paraphernalia, promoting safer injecting practices is the focus of prevention programing. Screening for HIV/HCV co-infection should be intensified in HIV care, opioid substitution programs, and other point of care for PWID. Use of direct-acting antiretroviral treatment would accelerate the achievement of hepatitis infection elimination goal by 2030.

• Mmbaga, Elia John; Leyna, Germana Henry; Leshabari, Melkizedeck T.; Tersbøl, Britt Pinkowsky; Lange, Theis & Makyao, Neema [Show all 8 contributors for this article] (2019). Effectiveness of health care workers and peer engagement in promoting access to health services among population at higher risk for HIV in Tanzania (KPHEALTH): study protocol for a quasi experimental trial. BMC Health Services Research. 19(1), p. 1–7. doi: 10.1186/s12913-019-4675-z. Full text in Research Archive Show summary

  BACKGROUND: While there are indications of declining HIV infection rates in the general population globally, Tanzania included, men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID), now called Key Populations (KP) for HIV epidemic have 2-20 times higher infections rates and contributes up to 30% of new HIV infection. Tanzania have developed a Comprehensive Guideline for HIV prevention among key population (CHIP) to address the epidemic among KPs. However, these populations are stigmatized and discriminated calling for innovative approaches to improve access to CHIP. This project seeks to test the effectiveness of healthcare workers and peer-to-peer engagement in promoting access to CHIP among HIV at risk populations in Tanzania. METHODS: A quasi-experimental design involving Dar es Salaam City as an intervention region and Tanga as a control region will be done. Using respondent driven sampling, 1800 at risk population (900 from Intervention site and 900 from control site) will be recruited at baseline to identify pull and push factors for health services access. Stakeholder's consultation will be done to improve training contents for CHIP among health care workers and peers. Effectiveness of healthcare workers training and peer engagement will be tested using a quasi-experimental design. DISCUSSION: The results are expected to co-create service provision and improve access to services among KPs as a human right, reverse HIV infection rates among KPs and the general population, and improve social and economic wellbeing of Tanzanian. TRIAL REGISTRATION: Retrospectively registered on 28th August, 2019 with International Standard Randomized Clinical Trial Number ( ISRCTN11126469 ). KEYWORDS: HIV; Health services access; Injecting drugs; Men who have sex with men; Sex work; Tanzania

• Magodi, Richard; Mmbaga, Elia John; Masaga, Julius; Lyimo, Dafrosa; Mfuru, Alex & Abade, Ahmed (2019). Factors associated with non-uptake of measles-rubella vaccine second dose among children under five years in Mtwara district council, Tanzania, 2017. Pan African Medical Journal. doi: 10.11604/pamj.2019.33.67.17055. Full text in Research Archive Show summary

  Introduction: in 2014, Tanzania introduced the combined measles-rubella vaccine in the routine immunization schedule. Two doses of measles-rubella vaccine (MR1 and MR2) are recommended at 9 and 18 months, respectively. In 2015, MR2 coverage among eligible 18-month-old children in Tanzania was only 57%, lower than the WHO-recommended coverage (95%). During the same period Mtwara District Council (MDC) reported a coverage of 52% which is lower than the nation average. We determined factors associated with non-uptake of MR2 among children in MDC Tanzania. Methods: we conducted a community-based cross-sectional survey using cluster sampling during January - April 2017 in MDC. Caretakers of children born during January 2014 - January 2015 and residing in MDC for the past three years were recruited. We interviewed participants and reviewed vaccination cards. Logistic regression modeling was employed to identify independent factors associated with uptake of MR2. Results: of 1,000 children assessed, 558 (55.8%) were unvaccinated with MR2. Factors independently associated with non-uptake of MR2 included the caretaker being unaware of the ages for MR1 and MR2 administration [aOR=3.50; 95%CI 1.98-6.21; p

• Rubagumya, Fidelis; Nyagabona, Sarah; Msami, Khadija; Murinakiza, A; Leyna, Germana Henry & Mmbaga, Elia John [Show all 7 contributors for this article] (2019). Attitudes and Barriers to Research Among Oncology Trainees in East Africa. The Oncologist. ISSN 1083-7159. doi: 10.1634/theoncologist.2018-0805. Full text in Research Archive Show summary

  BACKGROUND: East Africa is one of the fastest growing regions in the world and faces a rising burden of cancer; however, few people are equipped to effectively conduct research in this area. MATERIALS AND METHODS: A 31-item questionnaire was distributed to current trainees and recent graduates of the Master in Medicine in Clinical Oncology Program at Muhimbili University of Health and Allied Sciences in Tanzania. Areas that were assessed included (a) demographic information, (b) prior research training, (c) prior and current research activities, (d) attitudes toward the importance of research, and (e) supports and barriers to inclusion of research in an oncology career path. RESULTS: A total of 30 individuals responded to the survey, of whom 53% (n = 16) were male and 70% (n = 21) identified as current trainees. Among the majority of respondents, attitudes toward research were strongly favorable. Although only 37% (n = 11) reported receiving any formal training in research methodology, 87% (n = 26) reported intentions to incorporate research into their careers. The absence of protected time for research and lack of access to research funding opportunities were identified by a majority of respondents as critical barriers. CONCLUSION: A majority of current or recent oncology trainees in Tanzania desire to incorporate research into their careers, but most also lack adequate training in research methodology and longitudinal mentorship. Our future collaboration will focus on creation of appropriate research training curriculums and fostering an environment that catalyzes interprofessional development and transforms and extends context-specific cancer research in East Africa. IMPLICATIONS FOR PRACTICE: Current and recent oncology trainees in East Africa expressed a high enthusiasm for research, driven by a sense of urgency related to the burden from cancer that the region faces. This highlights the need for cancer research training and mentorship in this setting. This work hypothesizes that African principal investigators can operate effectively if proper attention is given to selection and provision of high-quality foundational didactic training to learn the theory and implementation of research as well as to the development of an environment conducive to mentoring.

• Bugoye, Fidelis Charles; Leyna, Germana Henry; Moen, Kåre & Mmbaga, Elia John (2019). Knowledge, Perceived Risk and Utilization of Prostate Cancer Screening Services among Men in Dar Es Salaam, Tanzania. Prostate Cancer. ISSN 2090-3111. doi: 10.1155/2019/2463048. Full text in Research Archive Show summary

  Background. Late diagnosis of prostate cancer is common in low and middle income countries and contributes to high morbidity and mortality of the disease. Utilization of prostate cancer screening services plays a major role in prevention of adverse outcomes. However, there is limited information on the knowledge about, the perceived risk of, and the utilization of prostate cancer screening in Tanzania. Objective. To determine knowledge and perceived risk of prostate cancer, and the utilization of prostate cancer screening services, and associated factors, among men in Dar es Salaam, Tanzania. Design. A population-based cross-sectional study involving men aged 40 years and above living in Dar es Salaam was conducted between May and August, 2018. Methodology. Participants were recruited through multistage random sampling and took part in structured face-to-face interviews. Categorical variables were summarized using proportions while continuous variables were summarized as medians and inter-quarterly range (IQR). Chi square test was used to compare differences between proportions, and logistic regression modelling was used to determine factors associated with utilization of prostate cancer screening. Both crude and adjusted odds ratios (OR), with corresponding 95% confidence intervals, are reported. All analyses were two-tailed and the significance level set at 5%. Results. A total of 388 men with a median age of 53 years (IQR 44–55) participated. Half (52.1%) had poor knowledge about prostate cancer and prostate cancer screening. A third (32.3%,) perceived the risk of prostate cancer to be low. Only 30 respondents (7.7%) had ever been screened for prostate cancer. Utilization of prostate cancer screening services was independently associated with age above 60 years [AOR = 21.46, 95% CI: 6.23, 73.93], monthly income above 305 US Dollars [AOR = 15.68, 95% CI: 4.60, 53.48], the perceived risk of prostate cancer [AOR = 16.34, 95% CI: 7.82, 14.92] and knowledge about prostate cancer [AOR = 67.71, 95% CI: 8.20, 559.57]. Conclusions. Knowledge about prostate cancer and prostate cancer screening services was low among men in Dar es Salaam with a third perceiving themselves to be at no risk for the disease. Utilization of screening services was low and associated with low income, younger age, low perceived risk of prostate cancer and low knowledge about the disease. Intervention measures aiming to increase knowledge about prostate cancer and screening services, and affordable provision of services, are urgently called for.

• Mmbaga, Elia John; Leyna, Germana Henry; Leshabari, Melkizedeck T. & Moen, Kåre (2019). Early Anal Sex Experience Among Men Who Have Sex with Men in Dar Es Salaam Tanzania: Implications for HIV Prevention and Care. Archives of Sexual Behavior. ISSN 0004-0002. doi: 10.1007/s10508-019-01529-5. Full text in Research Archive Show summary

  Early age at first sex experience has been attributed to medical and psychological consequences, including practice of risk behaviors and HIV infection later in life. Studies have examined early heterosexual experience, but little is known about early anal sexual experience among men who have sex with men (MSM) in Africa. We conducted a time to event analysis to examine the extent and role of early anal sexual experience and HIV risk and infection in the largest MSM survey in Africa. A total of 753 MSM with a mean age of 26.5 years and that at first anal sexual experience of 18.3 years participated. Of those who participated, 29.0% (219/753) had their first anal sexual experience at age below 15. MSM reporting early anal sexual experience were young, had men as first sexual partner (adjusted hazard ratio—AHR, 4.75; 95%CI: 3.51–6.43), assumed receptive position during last anal sex (AHR, 3.25; 95%CI: 2.42–4.35), had anal sex as first penetrative sexual experience (AHR, 5.05, 95%CI; 3.68–6.97), had unprotected first anal sex (AHR, 1.55, 95%CI: 1.03–2.33), not preferring women for sex (AHR, 2.78; 95%CI: 2.11–3.67), had non-consensual first sex (AHR, 1.53, 95%CI: 1.10–9.41), and HIV positive (AHR, 1.75; 95%CI: 1.21–2.50). A third of MSM engaged in anal sex at an early age and were more likely to report sexual abuse, practice HIV risk behaviors, and been HIV seropositive. Roll-out of the existing Comprehensive Guideline for HIV Treatment and Care for key population in Tanzania should be implemented alongside measures addressing sexual abuse among young people.

• Joachim, Agricola; Moyo, Sabrina John; Nkinda, Lillian; Majigo, Mtebe; Rugarabamu, Sima & Mkashabani, Elizabeth G [Show all 10 contributors for this article] (2018). Nasal carriage of methicillin-resistant staphylococcus aureus among health care workers in tertiary and regional hospitals in Dar es Salam, Tanzania. International Journal of Microbiology. ISSN 1687-918X. 2018. doi: 10.1155/2018/5058390. Full text in Research Archive
• Mmbaga, Elia John; Deardorff, Katrina; Mushi, Beatrice; Mgisha, Willium; Hiatt, Robert & Loon, Katherine van (2018). Characteristics of Esophageal Cancer Cases in Tanzania. Journal of Global Oncology (JGO). doi: 10.1200/JGO.2016.006619. Full text in Research Archive Show summary

  PURPOSE: Age-standardized incidence rates for esophageal cancer (EC) in East Africa have been reported as disproportionately high compared with the worldwide incidence of nine per 100,000 population. This study aimed to characterize EC cases seen at Muhimbili National Hospital and Ocean Road Cancer Institute in Dar es Salaam, Tanzania. METHODS: Demographic, clinical, and treatment variables were abstracted from charts of patients who received care for a diagnosis of EC at one or both institutions between 2011 and 2013. Categorical data were summarized as frequency counts and percentages. Continuous data were presented as medians and ranges. To compare men and women, Pearson's χ2 and two-sample t tests were applied. RESULTS: Seven hundred thirty-eight unique cases of EC were identified, of whom 68% were men and the median age was 60 years (range, 19 to 95 years). Notably, 93 cases (13%) were ≤ 40 years old at diagnosis. Squamous cell carcinoma was the dominant histology, comprising 90% of cases with documented histopathology. However, 34% of cases with a diagnosis of EC were not pathologically confirmed. The stage was documented as locoregional in 4% of cases, locally advanced in 20% of cases, metastatic in 14% of cases, and unknown in 63% of cases. Of 430 patients who received treatment at Ocean Road Cancer Institute, 76% were treated with radiation, 44% were treated with chemotherapy, 3% underwent a cancer-related surgical procedure, and 10% of cases received no cancer-directed therapy. The median overall survival for all patients was 6.9 months (95% CI, 5.0 to 12.8), regardless of stage at presentation. CONCLUSION: Between 2011 and 2013, cases of EC represented a large clinical burden at both institutions.

• Mmbaga, Elia John; Leyna, Germana Henry; Moen, Kåre & Leshabari, M.T. (2018). HIV Prevalence and Associated Risk Factors Among Men Who Have Sex With Men in Dar es Salaam, Tanzania. Journal of Acquired Immune Deficiency Syndromes. ISSN 1525-4135. doi: 10.1097/QAI.0000000000001593. Full text in Research Archive Show summary

  INTRODUCTION: Limited studies and differential risk behaviors among men who have sex with men (MSM) in Africa calls for population-specific studies. We present results from the largest integrated biobehavioral survey among MSM in Africa to inform programming. METHODS: This was a cross-sectional study using respondent-driven sampling to recruit MSM aged 18 and above. Data on sociodemographic characteristics and HIV-related risks were collected and all participants were tested for HIV, herpes simplex virus type-2 (HSV-2), hepatitis-B virus (HBV), and syphilis RESULTS:: A total of 753 MSM with a mean age of 26.5 years participated in the study and 646 (85.7%) provided blood for biological testing. The prevalence of HIV was 22.3%, HSV-2 40.9%, syphilis 1.1%, and HBV 3.25%. Significant risk factors for HIV were age above 25, having no children [adjusted odds ratio (aOR), 2.4, 95% confidence interval (CI): 1.4 to 4.2], low HIV-risk perception (aOR, 2.6, 95% CI: 1.2 to 5.3), receptive position (aOR, 8.7, 95% CI: 1.2 to 5.3), and not using water-based lubricants (aOR, 2.6, 95% CI: 1.0 to 4.5) during the last anal sex. Also associated with HIV infection was, having sexual relationships with women (aOR, 8.0, 95% CI: 4.1 to 15.6), engaging in group sex (aOR, 3.8, 95% CI: 1.6 to 8.4), HSV-2 seropositivity (aOR, 4.1, 95% CI: 2.6 to 6.5), and history of genital ulcers (aOR, 4.1, 95% CI: 1.1 to 7.2). CONCLUSIONS: HIV infection and HSV-2 were highly prevalent among MSM. Low perceived HIV risk, practice of risk behaviors, and infection with HSV-2 were significant predictors of HIV infection. Behavioral interventions, HSV-2 suppressive therapies, and pre-exposure prophylaxis are highly needed.

• Mmbaga, Elia John; Moen, Kåre; Leyna, Germana Henry; Mpembeni, Rose & Leshabari, Melkizedeck T. (2017). HIV prevalence and associated risk factors among men who have sex with men in Dar es Salaam, Tanzania. Journal of Acquired Immune Deficiency Syndromes. ISSN 1525-4135. 77(3), p. 243–249. doi: 10.1097/QAI.0000000000001593. Full text in Research Archive Show summary

  Introduction: Limited studies and differential risk behaviours among men who have sex with men (MSM) in Africa calls for population specific studies. We present results from the largest integrated bio-behavioural survey among MSM in Africa to inform programming. Methods: This was a cross-sectional study utilizing respondent driven sampling to recruit MSM aged 18 and above. Data on socio-demographic characteristics and HIV-related risks were collected and all participants were tested for HIV, Herpes Simplex Virus Type-2 (HSV2), Hepatitis-B Virus (HBV) and Syphilis. Results: A total of 753 MSM with a mean age of 26.5 years participated in the study and 646 (85.7%) gave blood for biological testing. The prevalence of HIV was 22.3%, HSV-2 40.9%, syphilis 1.1 %, and HBV 3.25%. Significant risk factors for HIV were age above 25, having no children (aOR), 2.4, 95% CI: 1.4-4.2), low HIV-risk perception (aOR, 2.6, 95% CI: 1.2- 5.3), receptive position (aOR, 8.7; 95% CI 1.2-5.3), and not using water-based lubricants (aOR, 2.6, 95% CI: 1.0-4.5) during last anal sex. Also associated with HIV infection was, having sexual relationships with women (aOR, 8.0, 95% CI: 4.1-15.6), engaging in group sex (aOR, 3.8, 95% CI: 1.6-8.4), HSV-2 seropositivity (aOR, 4.1, 95% CI: 2.6- 6.5) and history of genital ulcers (aOR, 4.1, 95% CI: 1.1-7.2). Conclusions: HIV infection and HSV-2 were highly prevalent among MSM. Low perceived HIV risk, practice of risk behaviours and infection with HSV-2 were significant predictors of HIV infection. Behavioural interventions, HSV-2 suppressive therapies and Pre-exposure Prophylaxis are highly needed. The final version of this research has been published in Journal of Acquired Immune Deficiency Syndromes. © 2018 Lippincott, Williams & Wilkins

• Mmbaga, Elia John; Moen, Kåre; Makyao, Neema & Leshabari, Melkizedeck T. (2017). Prevalence and predictors of human immunodeficiency virus and selected sexually transmitted infections among people who inject drugs in Dar es Salaam, Tanzania: A new focus to get to zero. Sexually Transmitted Diseases. ISSN 0148-5717. 44(2), p. 79–84. doi: 10.1097/OLQ.0000000000000555. Full text in Research Archive Show summary

  Background: Previous studies in Tanzania indicated that human immunodeficiency virus (HIV) prevalence among people who inject drugs (PWIDs) could be as high as 40%. We aim to provide data on the prevalence of HIV and sexually transmitted infection among PWIDs to inform national plans to get to zero. Materials and Methods: Respondent-driven sampling was used to collect drug use, and sexual practices data among PWIDs aged 15 years and older. Blood samples were examined for HIV, herpes simplex virus type 2, syphilis, and hepatitis B. Results: A total of 620 PWIDs with a median age of 32 (interquartile range, 17–52) participated in the study. Their use of drugs had typically started during adolescence. The prevalence of HIV was found to be 15.5%, whereas that of herpes simplex type 2 was 43.3%. Associated with an increased likelihood of HIV infection was being a female (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.0–3.6), sharing of syringes (aOR, 2.4; 95% CI, 1.1–6.1), used syringes hidden in public places (aOR, 5.1; 95% CI, 1.3–10.2), and having had a genital ulcer during the last 12 months before this survey. On the other hand, being educated, use of noninjectable drugs, access (aOR, 0.5; 95% CI, 0.2–0.8), and use of clean syringes (aOR, 0.3; 95% CI, 0.1–0.6) were associated with decreased likelihood of HIV infection. Conclusions: The prevalence of HIV infection among PWIDs in Dar es Salaam is 3 times higher than that in the general population. Behavioral and biological risk factors contribute to HIV transmission and needs to be addressed to be able to get to zero. The final version of this research has been published in Sexually Transmitted Diseases. © 2017 Lippincott, Williams & Wilkins

• Mmbaga, Elia John; Moen, Kåre; Makyao, Neema; Mpembeni, Rose & Leshabari, Melkizedeck T. (2017). HIV and STIs among men who have sex with men in Dodoma municipality, Tanzania: a cross-sectional study. Sexually Transmitted Infections. ISSN 1368-4973. 93(5), p. 314–319. doi: 10.1136/sextrans-2016-052770. Full text in Research Archive Show summary

  Objectives: To determine the seroprevalence of HIV, STI and related risks among men who have sex with men (MSM) in Dodoma municipality, Tanzania. Methods: A cross-sectional study using respondent-driven sampling was employed to recruit study participants aged 18 years and above. Data on sociodemographics, HIV/STI knowledge and sexual practices were collected. Blood samples were tested for HIV and selected STIs. Results: A total of 409 participants aged from 18 to 60 years took part in this study. The median age at first anal intercourse was 15 years. At last anal intercourse, 37.5% practiced receptive, 47.5% insertive and 15.0% both insertive and receptive anal intercourse. The seroprevalence of HIV, herpes simplex virus 2 (HSV-2), syphilis, hepatitis B virus and hepatitis C virus were 17.4%, 38.5%, 0.2%, 5.4% and 3.4%, respectively. A third of MSM perceived their risk for HIV to be low and this was associated with unprotected sex (adjusted OR (AOR), 4.8, 95% CI 1.8 to 10.2). HIV seropositivity was also associated with HSV-2 (AOR, 5.0, 95% CI 3.01 to 11.21); having lived outside Dodoma (AOR 1.7, 95% CI 1.1 to 6.7); age above 25 years; (AOR 2.1, 95% CI 1.7 to 3.7); sexual relationship with a woman (AOR 5.6, 95% CI 3.9 to 12.8); assuming a receptive (AOR 7.1, 95% CI 4.8 to 17.4) or receptive and insertive (AOR 4.5, 95% CI 1.9 to 11.4) position during last anal intercourse; engaging in group sex (AOR 3.1, 95% CI 1.2 to 6.1) and the use of alcohol (AOR 3.9, 95% CI 1.1 to 9.2). Conclusions: HIV prevalence among MSM is five times higher compared with men in the general population in Dodoma. Perceived risk for HIV infection was generally low and low risk perception was associated with unprotected sex. STI, bisexuality and other behavioural risk factors played an important part in HIV transmission. The findings underscore the need for intensified HIV prevention programming addressing and involving key populations in Tanzania.

• Mmbaga, Elia John; Leyna, Germana Henry; Moen, Kåre; Dodo, MJ & Leshabari, Melkizedeck T. (2012). Sexual Practices and Perceived Susceptibility to HIV Infection among Men who have Sex with Men in Dar es Salaam, Mainland Tanzania. Journal of AIDS and Clinical Research. Full text in Research Archive
• Leyna, Germana Henry; Mmbaga, Elia John; Mnyika, Kagoma S; Hussain, Akhtar & Klepp, Knut Inge (2010). Food insecurity is associated with food consumption patterns and anthropometric measures but not serum micronutrient levels in adults in rural Tanzania. Public Health Nutrition (PHN). ISSN 1368-9800. 13(9), p. 1438–1444. doi: 10.1017/S1368980010000327. Full text in Research Archive
• Mmbaga, Elia John; Leyna, Germana Henry; Mnyika, KS; Hussain, Akhtar & Klepp, Knut Inge (2009). Prevalence and predictors of failure to return for HIV-1 post-test counseling in the era of antiretroviral therapy in rural Kilimanjaro, Tanzania: challenges and opportunities. AIDS Care. ISSN 0954-0121. 21(2), p. 160–167. doi: 10.1080/09540120801982905. Full text in Research Archive
• Mmbaga, Elia John; Leyna, Germana Henry; Hussain, Akhtar; Mnyika, KS; Sam, NE & Klepp, Knut Inge (2008). The role of in-migrants in the increasing rural HIV-1 epidemic: results from a village population survey in the Kilimanjaro region of Tanzania. International Journal of Infectious Diseases. ISSN 1201-9712. 12(5), p. 519–525. doi: 10.1016/j.ijid.2008.02.007. Full text in Research Archive
• Mmbaga, Elia John; Leyna, Germana Henry; Mnyika, KS & Klepp, Knut Inge (2008). Sexually transmitted infections knowledge and its impact in the practice of risky sexual behaviours and HIV serostatus: results from rural Kilimanjaro, Tanzania. Sexually Transmitted Infections. ISSN 1368-4973. 84. doi: 10.1136/sti.2007.029488. Full text in Research Archive
• Leyna, Germana Henry; Mmbaga, Elia John; Mnyika, KS & Klepp, Knut Inge (2008). Validation of the Radimer/Cornell food insecurity measure in rural Kilimanjaro, Tanzania. Public Health Nutrition (PHN). ISSN 1368-9800. 11, p. 684–689. doi: 10.1017/S1368980007001267. Full text in Research Archive
• Mmbaga, Elia John; Leyna, Germana Henry; Mnyika, KS; Akhtar, Hussain & Klepp, Knut Inge (2007). Education attainment and the risk of HIM infections in rural Kilimanjaro region of Tanzania, 1991-2005: A reversed association. Sexually Transmitted Diseases. ISSN 0148-5717. 34, p. 947–953. Full text in Research Archive
• Mmbaga, Elia John; Hussain, Akhtar; Leyna, Germana Henry; Mnyika, KS; Sam, NE & Klepp, Knut Inge (2007). Prevalence and risk factors for HIV-I infection in rural Kilimanjaro region of Tanzania: Implications for prevention and treatment. BMC Public Health. 7. doi: 10.1186/1471-2458-7-58. Full text in Research Archive Show summary

  Background Variability in stages of the HIV-1 epidemic and hence HIV-1 prevalence exists in different areas in sub-Saharan Africa. The purpose of this study was to investigate the magnitude of HIV-1 infection and identify HIV-1 risk factors that may help to develop preventive strategies in rural Kilimanjaro, Tanzania. Methods A cross-sectional study was conducted between March and May of 2005 involving all individuals aged between 15–44 years having an address in Oria Village. All eligible individuals were registered and invited to participate. Participants were interviewed regarding their demographic characteristics, sexual behaviors, and medical history. Following a pre-test counseling, participants were offered an HIV test. Results Of the 2 093 eligible individuals, 1 528 (73.0%) participated. The overall age and sex adjusted HIV-1 prevalence was 5.6%. Women had 2.5 times higher prevalence (8.0% vs. 3.2%) as compared to men. The age group 25–44 years, marriage, separation and low education were associated with higher risk of HIV-1 infection for both sexes. HIV-1 infection was significantly associated with >2 sexual partners in the past 12 months (women: Adjusted odds ratio [AOR], 2.5 (95%CI: 1.3–4.7), and past 5 years, [(men: AOR, 2.2 (95%CI:1.2–5.6); women: AOR, 2.5 (95%CI: 1.4–4.0)], unprotected casual sex (men: AOR,1.8 95%CI: 1.2–5.8), bottled alcohol (Men: AOR, 5.9 (95%CI:1.7–20.1) and local brew (men: AOR, 3.7 (95%CI: 1.5–9.2). Other factors included treatment for genital ulcers and genital discharge in the past 1 month. Health-related complaints were more common among HIV-1 seropositive as compared to seronegative participants and predicted the presence of HIV-1 infection. Conclusion HIV-1 infection was highly prevalent in this population. As compared to our previous findings, a shift of the epidemic from a younger to an older age group and from educated to uneducated individuals was observed. Women and married or separated individuals remained at higher risk of infection. To prevent further escalation of the HIV epidemic, efforts to scale up HIV prevention programmes addressing females, people with low education, lower age at marriage, alcohol consumption, condom use and multiple sexual partners for all age groups remains a top priority. Care and treatment are urgently needed for those infected in rural areas.

• Mmbaga, Elia John; Hussain, Akhtar; Leyna, Germana Henry; Klouman, Elise; Masenga, Elisante J. & Sam, Noel [Show all 8 contributors for this article] (2006). Incidence of HIV-1 infection and changes in prevalence of reproductive tract infections and sexual risk behaviours: a population-based longitudinal study in rural Tanzania. African Journal of AIDS Research. ISSN 1608-5906. 5(3), p. 281–288. Full text in Research Archive

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• Ng, Dianna L.; Edelweiss, Marcia; Kimambo, Asteria Herman; Vuhahula, Edda; Mushi, Beatrice Paul & Adegoke, Omolade [Show all 13 contributors for this article] (2025). Efforts to strengthen anatomic pathology diagnostic services for cancer in sub-Saharan Africa: a scoping review protocol. doi: 10.1136/bmjopen-2024-089425. Full text in Research Archive
• Mikomangwa, Wigilya P.; Moen, Kåre; Mmbaga, Elia; Metta, Emmy; Kibusi, Stephen M. & Leshabari, Melkizedeck Thomas [Show all 8 contributors for this article] (2024). PrEP prevention-effective adherence among women at high risk of HIV: control-arm analysis of pragmatic trial. Full text in Research Archive Show summary

  Background: Prevention-effective adherence is of critical importance but challenging particularly among key populations where periods of high HIV risk are frequent. Pre-exposure prophylaxis (PrEP) prevention effective adherence involves aligning the use of PrEP pills with unprotected sex practice. PrEP Prevention-effective adherence among female sex workers is understudied globally. Objective: To determine PrEP prevention-effective adherence among female sex workers in Tanga, Tanzania. Methodology: This was part of the pragmatic quasi-experimental trial for HIV pre-exposure prophylaxis rollout in Tanzania (PREPTA) involving a control cohort of 313 female sex workers ≥18 years of age recruited using respondent-driven sampling and followed for 12 months. PrEP use and sexual behaviour were assessed at the 6th and 12th month of follow-up. Modified Poisson regression analysis was conducted to determine factors influencing PrEP at p <0.05. Results: Prevention-effective adherence among participants who had unprotected vaginal sex was 10.1% (month 6) and 3.8% (month 12). Also, the prevention-effective adherence among participants who had unprotected anal sex was 8.0% (month 6) and 10.0% (month 12). The use of ≥2 PrEP doses/week was associated with living with friends (aPR=25.5; 95%CI: 2.55-255.42, p=0.006), self-perceived health status (aPR=17.4; 95%CI: 3.01-101.02, p=0.001), refusing unprotected sex with steady partner (aPR=11.2; 95%CI: 1.55-80.48, p=0.017) and accepting unprotected sex at high pay (aPR=0.1; 95%CI: 0.03-0.26, p=0.000). Conclusion: PrEP use during unprotected sex was rare among female sex workers. Living with friends and refusing unprotected sex with steady partners were determinants of PrEP use. However, accepting unprotected sex for increased payment was significantly associated with lower PrEP use. This calls for an in-depth study to understand the circumstances shaping poor adherence during periods of unprotected sex among female sex workers.

• Mikomangwa, Wigilya P. & Mmbaga, Elia (2024). PrEP prevention-effective adherence among women at high risk of HIV: a control arm analysis of the pragmatic quasi-experimental trial. Full text in Research Archive Show summary

  Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV during periods of high risk if taken as prescribed. Prevention-effective adherence is of critical importance but challenging particularly among key population groups where periods of high HIV risk are frequent. PrEP prevention effective adherence involves aligning the use of PrEP pills with high-risk sexual behaviour such as unprotected sex. In this study we analysed data from the cohort of female sex workers who participated in the pragmatic quasi-experimental trial in city of Tanga, Tanzania. Practising condomless sex was considered a period of high-risk of HIV acquisition. The optimal use of PrEP was considered at ≥2 pills and ≥ 6 pills per week for anal and vaginal sex respectively. We found low use of PrEP pills during periods of high-risk HIV acquisition among female sex workers. Low PrEP use during periods of high risk undermines the overall benefit of PrEP intervention in Tanzania. In this paper, we analysed sociodemographic, sexual behaviours and structural factors associated with low prevention-effective adherence.

• Mikomangwa, Wigilya P. & Mmbaga, Elia (2024). Initial and long-term retention to PrEP services among women at high risk of HIV acquisition in Tanzania. Full text in Research Archive Show summary

  Introduction To realize the impact of HIV pre-exposure prophylaxis (PrEP) at the population level, retention in PrEP care among people at high risk of HIV infection is of paramount importance. Evidence is scarce on retention rates in PrEP service and their determinants in real-life settings among female sex workers in sub-Saharan Africa including Tanzania. We, therefore, evaluated retention in PrEP services and its determinants among female sex workers in the city of Tanga, Northeastern Tanzania. Methods We analyzed data from a prospective cohort of 313 female sex workers. Participants were followed up at 1, 6, 12, and 16 months. Early retention was defined as attending two or more follow-up visits at the PrEP clinic within the first six months of PrEP initiation. Long-term retention was defined as attending at least one additional visit between six and 16 months after initiation. Kaplan-Meier method was used to estimate retention rates. A multivariable logistic regression model with clustered robust standard error was used to determine factors associated with the retention in PrEP services. Results Early and long-term retention in PrEP care was 38.0% (95% CI: 33.25-43.04) and 11.0% (95% CI: 7.67-15.61) respectively. The determinants of early retention were to have sex work as the only source of income (aRR 0.58, 95%CI: 0.36-0.94, p= 0.028), to have a self-perceived “moderate” risk of acquiring HIV (aRR 1.64, 95%CI:1.12-2.41, p=0.011) and to have between 10 and 29 sexual clients per month (aRR 0.66, 95%CI: 0.47-0.92, p=0.014). Factors associated with long-term retention were self-perceived “high” PrEP stigma (aRR 0.16, 95%CI: 0.03-0.99, p=0.049) and having a self-perceived “moderate” risk of acquiring HIV (aRR 5.03, 95%CI: 1.37-18.47, p=0.015). Conclusion The retention in facility-based HIV PrEP care among female sex workers was low. Having sex work as the only source of income, having 10-30 sexual clients per month and self-perceived high PrEP stigma were determinants of low retention in PrEP services whereas self-perceived moderate HIV risk was the motivation of female sex workers to be retained in facility-based PrEP care. Approaches to addressing PrEP stigma and enhancing understanding of the HIV risk among female sex workers are crucial to optimize retention in facility-based PrEP services.

• Litchwarck, Hanne; Moen, Kåre & Mmbaga, Elia (2023). Mental health and social vulnerability among HIV negative female sex workers in Tanzania – a cross-sectional analysis of data from a female sex worker cohort. Full text in Research Archive Show summary

  Introduction: Poor mental health is closely linked to sex work and HIV risk, but has received limited attention in research among female sex workers in Sub-Saharan Africa. Inspired by syndemic framework, which recognizes that the epidemics of HIV, substance use and poor mental health are interrelated, we investigate mental health outcomes among female sex workers at high risk of HIV in Tanzania. Methods: Data from a cohort of female sex workers initiating HIV pre-exposure prophylaxis use (PrEP) in Dar es Salaam was analysed. Participants were recruited through respondent driven sampling (RDS), and interviewed about depression (PHQ-2), anxiety (GAD-2) and hazardous alcohol use (AUDIT). We conducted weighted descriptive analysis and assessed sociodemographic predictors of mental distress (positive screen for PHQ-2, GAD-2 or both) using modified Poisson regression with robust standard errors. Results: A total of 470 women with a median age of 25 years were recruited. Nearly a third (n=143; 30%) screened positive for mental distress (n=106; 25.3% for depression, n=89; 18.4%, for generalized anxiety). More than two thirds (n=360; 69.6%) were categorized with hazardous alcohol use (AUDIT≥8). Predictors of mental distress were less social support (aPR=1.37, CI: 1.05-1.79) and working outside a bar setting (aPR= 1.52 CI: 1.13-2.06). Sex work stigma showed borderline significance (aPR=1.34, 0.99-1.80). Discussion: Our findings indicate that female sex workers in Tanzania are vulnerable to poor mental health outcomes, which is related to social disadvantage. Health programs and initiatives should acknowledge the presence of syndemics by offering comprehensive interventions that meet the range of health needs of female sex workers.

• Litchwarck, Hanne; Moen, Kåre & Mmbaga, Elia (2023). Good self-reported health and associated factors among HIV negative female sex workers in Tanzania – a salutogenesis perspective. Full text in Research Archive Show summary

  Introduction: Female sex workers carry a heavy burden of HIV and are disproportionally affected by unfavourable social determinants like poverty and violence. Research among this group often have a “risk-focus”, but might end up overlooking factors that contribute to better health. Inspired by “salutogensis”: a scholarly orientation that focuses on factors supporting health, we assessed self-reported health and predictors of good self-reported health among a cohort of HIV negative female sex workers starting PrEP in Tanzania. Methods: Female sex workers were recruited by respondent driven sampling and interviewed using a standardized questionnaire. Self-perceived health was measured using a five-point scale from “excellent” to “poor” and frequencies was weighted in descriptive analysis. We assessed if sociodemographic (age, marital status, education, income), social (social support, stigma) and sex work factors (self-perceived HIV risk, number of clients, age first sold sex) were predictors of good self-reported health (merging “excellent”, “very good” or “good”) using bivariate and multivariable modified poisson regression. Results: Of 470 participants, 81 (16.2%) described their health as excellent/very good, 359 (79.0%) as good, and 30 (6.3%) as fair/poor. Being < 24 years compared to >35 (PR=1.16, 95%CI: 1.01-1.33) having higher education (PR=1.06, 95%CI: 1.00-1.11), never being married/single (PR=1.08, 95%CI: 1.01-1.16), and having high level of social support (PR=1.08, 95%CI=1.02-1.14) predicted the outcome in bivariate analysis. Social support (aPR=1.08, 95%CI: 1.02-1.14) and marital status (aPR=1.08, 95%CI: 1.01-1.16) were independently associated with good self-reported health in the final model. Discussion/Implications: Despite being a key population vulnerable to disadvantageous disease-outcomes, the majority of the female sex workers in this cohort reported good health. Introducing a perspective founded on “salutogenesis”: i.e. a stronger focus on factors that promote health among female sex workers, such as building social ties, not merely avoiding disease and individual risk, can be a welcomed addition to health programs and policy.

• Mbotwa, Christopher; Kazaura, Method Rwelengera & Mmbaga, Elia (2022). Use of mHealth to improve retention to Pre-exposure Prophylaxis for HIV prevention among female sex workers. An evaluation of the Jichunge intervention in Dar es Salaam, Tanzania. Full text in Research Archive Show summary

  Background: Female sex workers (FSW) are among groups at increased risk HIV infection. Pre-exposure prophylaxis (PrEP) has been proven to be effective in preventing HIV transmission, but low retention to services poses a challenges to its effectiveness. Innovative interventions to tackle the problem and help achieve universal health coverage goals are called for. Objective: To determine the effect of smartphone based mHealth application on retention to PrEP among female sex workers in Dar es Salaam. Methods: Using respondent driven sampling, 470 FSW eligible for PrEP and who owned a smartphone were recruited. All participants were provided with a a smartphone-based mHealth app (Jichunge app) which has multiple functionalities designed to promote PrEP use and retention among HIV at risk population. We utilized information collected during the baseline, month 1 follow-up, and data on the use of Jichunge app for a period of 30 days. Associations between PrEP retention and optimal use of different functionalities of the app was assessed using modified Poisson regression model with robust standard errors. Results: Of 470 recruited participants, 253 (53.8%) were retained to PrEP services at month 1. Retention to PrEP services was significantly higher among those who opened the Jichunge app after installation (APR=1.4, 95% CI: 1.13-1.85), used gamification functions (APR=1.5, 95% CI: 1.18-1.89), visited PrEP editorial contents (APR=1.4, 95% CI:1.16-1.67) consulted a doctor or peer educator (APR=1.5, 95% CI:1.29-1.79), or engaged in the discussion with other PrEP users (APR=1.4, 95% CI:1.17-1.62). Conclusion: The use of Jichunge mHealth application significantly increased retention to PrEP among female sex workers in Dar es Salaam. The results indicate that use of mHealth interventions hold potential to promote universal health coverage in a cascade of PrEP and other related interventions.

• Mbotwa, Christopher; Kazaura, Method Rwelengera; Moen, Kåre & Mmbaga, Elia (2022). Preliminary effect of mHealth intervention on PrEP engagement among female sex workers in Dar es Salaam, Tanzania. Full text in Research Archive Show summary

  Background: Female sex workers are among groups at increased risk of HIV infection. In Tanzania, HIV prevalence among FSW is more than twice as high as other women in the general population. Pre-exposure prophylaxis (PrEP) has been proven to be effective in preventing HIV transmission, but low retention to services poses a challenge to its effectiveness. Innovative interventions to tackle the problem and help achieve universal health coverage goals are called for. Objective: To determine the preliminary effect of mHealth application on PrEP services engagement among female sex workers in Dar es Salaam. Methods: Using respondent driven sampling, 470 female sex workers eligible for PrEP and who owned a smartphone were recruited. All participants were provided with a smartphone-based mHealth app (Jichunge app) designed to promote PrEP use and retention among HIV at risk population. We utilized information collected during the baseline, follow-up, and data on the use of Jichunge app for a period of 30 days. The effect of Jichunge intervention on PrEP services engagement was assessed using generalized Poisson regression model. Results: Of 470 recruited participants, 253 (53.8%) were engaged in PrEP services in 6 months following the initiation of PrEP. Engagement in PrEP services was significantly higher among those who opened the Jichunge app after installation (APR=1.4, 95% CI: 1.13-1.85), used gamification functions (APR=1.5, 95% CI: 1.18-1.89), visited PrEP editorial contents (APR=1.4, 95% CI:1.16-1.67), consulted a doctor or peer educator (APR=1.5, 95% CI:1.29-1.79), or engaged in the discussion with other PrEP users (APR=1.4, 95% CI:1.17-1.62). Conclusion: The use of Jichunge mHealth application significantly increased PrEP services engagement among female sex workers in Dar es Salaam. The results indicate that use of mHealth interventions hold potential to promote universal health coverage in a cascade of PrEP and other related interventions. Recommendations: mHealth interventions should be incorporated in implementation of the PrEP roll-out to promote utilization of PrEP services among the targeted populations. Studies that compare between intervention and control, as well as specific PrEP cascade such as retention in clinical care and adherence to PrEP are needed for further evidence.

• Litchwarck, Hanne; Moen, Kåre & Mmbaga, Elia (2022). Perceived pre-exposure prophylaxis stigma among female sex workers: A potential barrier for intervention effectiveness. Full text in Research Archive Show summary

  Introduction: The antiretroviral medication pre-exposure prophylaxis (PrEP) provides 99% protection against HIV infection if taken daily. While PrEP is being rolled-out in Tanzania to female sex workers, uptake and adherence has proven to be a challenge during the demonstration trial in the country and beyond. Perceived PrEP stigma, the idea that people may come to stigmatize you because of taking PrEP, has been identified as a potential barrier to intervention effectiveness. Objectives/Aims: To assess perceived PrEP stigma and associated predictors among female sex workers initiating PrEP in Dar es Salaam. Methodology: Using respondent driven sampling, female sex workers in Dar es Salaam were recruited to a study in collaboration with a health clinic offering PrEP. We used a 5-point 10 item Likert scale to assess perceived PrEP stigma at baseline, with Cronbach’s alpha of 0.84. The stigma scale was dichotomized at score > 3 reflecting “higher perceived stigma”. We conducted bivariate analysis to assess for predictors, with confidence level at 5%. Results: A total of 470 female sex workers with a median age of 26 years (IQR:22-30) were recruited. More than half (58.9%, 95% CI: 36.7-45.6) had some secondary education. The median stigma score was 2.4 (IQR 2-3). A quarter (24.3%, 95% CI: 20.6-28.4) experienced “higher perceived stigma”. Factors associated with higher levels of perceived stigma were low social support (OR: 1.8, 95% CI: 1.2-2.8), limited access to condoms (OR 1.8, 95% CI:1.1-3.1) and having fewer clients per month (p-value 0.01). Conclusion: Higher perceived PrEP stigma was present among a quarter of female sex workers initiating PrEP in Dar es Salaam, with low social support, limited access to condoms, and having few clients being associated factors. We have not found any study of female sex workers that have examined this construct using a comparable scale limiting the opportunity for cross-context comparisons. Recommendation: Findings suggests that addressing socio-structural factors alongside PrEP provision can be important for the PrEP continuum of care.

• Mbotwa, Christopher; Kazaura, Method Rwelengera & Mmbaga, Elia (2022). Acceptability of an mHealth intervention to promote the use of pre-exposure prophylaxis among individuals at increased risk of HIV. The case of the Jichunge smartphone app in Dar es Salaam, Tanzania. Full text in Research Archive Show summary

  Background: Reducing HIV infection rates among at-risk populations is more likely to contribute to achieving the 2030 goal of ending the epidemic. Countries in sub-Saharan Africa, including Tanzania, have started rolling out pre-exposure prophylaxis (PrEP), but adherence to the daily pills poses a challenge. Evidence indicates that mHealth is a promising solution for promoting uptake, retention, and adherence to PrEP. However, evaluation data of its implementation in Africa settings are scarce. This study aimed at assessing acceptability and initial use of mHealth in promoting PrEP use among female sex workers (FSW) and men who have sex with men (MSM) in Dar es Salaam, Tanzania. Methods: FSW and MSM residing in Dar es Salaam who owned smartphones and were eligible for PrEP were recruited using respondent-driven sampling and provided with the Jichunge, a smartphone-based application designed to promote adherence to PrEP and retention in PrEP services. The app offers users information about HIV and PrEP, reminds them to take their daily pill, allows them to consult a doctor and peer educator, and includes an online forum where may engage in discussions with other PrEP users. Results: A total of 885 participants (470 FSW and 415 MSM) with a median age of 26 and 21 years, respectively, were recruited. Most (559; 63.2%) opened the app and registered pill-taking (523; 59.1%) at least once. About a third of the participants accessed the app’s PrEP and HIV editorial contents (348; 39.3%) and participated in the discussion forum (277; 31.3%). A total of 172(19.4%) consulted a doctor or peer educator via the app. FSW were significantly more likely than MSM to open the app (FSW:74%; MSM: 50.8%; p<0.001), register daily pill use (FSW:71.7%; MSM: 44.8%; p<0.001), access editorial contents (FSW:47.0%; MSM: 30.6%; p<0.001), and engage in the discussion forum (FSW:34.3%; MSM: 27.9%; p=0.044). Online consultation was not statistically significant different between the two populations (FSW:20.1%; MSM: 18.1%; p=0.336). Conclusion: The use of different services of Jichunge was significantly high. This suggests that mHealth is acceptable and can be a valuable platform to promote the use of PrEP and other services among HIV at-risk populations in Tanzania.

• Litchwarck, Hanne; Mmbaga, Elia & Moen, Kåre (2022). Unprotected sex among female sex workers in Dar es Salaam: support for the ongoing scale up of pre-exposure prophylaxis in Tanzania. Full text in Research Archive Show summary

  Background: The HIV epidemic disproportionally affects female sex workers in Tanzania with 15% of female sex workers living with HIV in Dar es Salaam. Condoms is one important prevention tool, while Pre-exposure prophylaxis (PrEP), antiretroviral daily medication used as HIV prevention, currently is being introduced. We reflect on the need to scale-up this biomedical intervention based on estimated rates of unprotected sex prior to PrEP initiation. Methods: We collected data from a cohort of 470 FSW initiating PrEP in Dar es Salaam from March-July 2021 using respondent driven sampling. Weighted prevalence for sexual practices were calculated using STATA/SE 16.0. Results: Half (50.7%) reported to have had unprotected sex at last vaginal sex with clients. Of the 28.2 % who reported ever having had anal sex with clients, half (50.4%) did not use condom during last anal sex. The majority had steady partner(s) (64.4 %), and 85.2 % reported not using condom at last vaginal sex with this partner(s). For the 10.7 % of women reporting to have anal sex with a steady partner, 81.4% did not use condom last anal sex. Only 45.4 % agreed with the statement “using a condom every time during anal sex reduces the risk of HIV transmission”. Reasons for not obtaining a condom when needed were cost, stockout, not knowing where to obtain it, being drunk and things happening too fast. Close to half reported to have accepted condomless sex for more pay (46.9 %), while 48.0 % reported to have refused sex with a partner who opposed condom use. Discussion: Unprotected sex was common among female sex workers initiating PrEP in Dar es Salaam. Non-use was related to individual, social and structural constraints, highlighting the obstacles to condom use well known from previous research. The need for access to additional ways of protecting oneself from HIV infection seems clear, and this is among the reasons why the ongoing scale-up of PrEP in Tanzania may be of considerable importance.

• Mbotwa, Christopher; Mauka, Wilhellmuss; Lichtwarck, Hanne; Haaland, Inga; Kazaura, Method Rwelengera & Metta, Emmy [Show all 9 contributors for this article] (2021). mHealth interventions to enhance adherence to PrEP among Female Sex Workers in Tanzania: Lessons from the field. Full text in Research Archive Show summary

  Background: Pre-Exposure Prophylaxis (PrEP) is a recent biomedical tool recommended for HIV prevention among populations at increased risk. PrEP effectiveness largely depends on users’ adherence to medication but it has been a challenge in most trials. In Tanzania, the plan for roll-out are ongoing. However, poor adherence is one of the anticipated challenges. mHealth has emerged as one of the ways of promoting adherence in different medications. Aim: The aim is to highlight various challenges we experienced when implementing research on mHealth among female sex workers (FSW) in Tanzania. Methodology: This is pragmatic quasi-experimental study being implemented in Dar es Salaam (intervention) and Tanga (control). Respondent driven sampling was used to recruit 471 FSW in Dar es Salaam. All participants recruited were an mHealth app, a smartphone-based application called Jichunge. A subset of the sample was also invited to take part in qualitative interview. The findings for this study are based on the qualitative interviews and participant observation. Results: We experienced several challenges relating to phones and the app itself when enrolling participants to the Jichunge app. The lessons we learned includes the importance of having site equipped with all facilities for charging phones, strengthening screening for the ownership of phone as some participants could borrow phones, considering mHealth interventions accessible to both user and non-users of smartphone as well as online and offline services. Conclusions: Some prospective participants who did not had own smartphone wanted to take part in Jichunge intervention. In our case, to get access to PrEP was considerably more important to some people than to be straight forward about their phone ownership. We assume that many of the points we raise will be of relevance to consider also in other mHealth studies. Recommendations: To maximize usability of mHealth interventions in Tanzania and other developing countries, services accessible via non-smartphone and offline should be put forward. Early and continuously follow-up on people who stop using the mHealth is useful in mapping some issues relating to the app.

• Mauka, Wilhellmuss; Litchwarck, Hanne; Mbotwa, Christopher; Haaland, Inga; Kazaura, Method Rwelengera & Metta, Emmy [Show all 9 contributors for this article] (2021). The use of Jichunge app on Pre-exposure Prophylaxis adherence Among Men Who Have Sex With Men in Dar es Salaam Tanzania. Full text in Research Archive Show summary

  Background: Jichunge app is a mHealth intervention in a quasi-experimental study introduced to support PrEP adherence among Men who have Sex with Men (MSM) in Dar es Salaam Tanzania. Hence, this preliminary analysis aims to determine the Jichunge app use among MSM. Methods: A respondent-driven sampling (RDS) was used to recruit MSM between 23rd March 2021 and 17th July 2021. Through their mobile phones, the intervention group was installed with the Jichunge app and had access to register their daily PrEP, editorial & health educational content, a chatting forum with their peers, and online consultation with a doctor or peer educator expected to be followed for 12 months. The descriptive analysis was carried out to describe user status, accessing the app’s features, and drug registration. Results: A total of 422 MSM were involved in this analysis, whereby observation time was from 23rd March - 23rd July 2021, contributing 2073 days of data. MSM ever used the app overall, first and the third month from recruitment were 56.2%, 56.7%, and 89.8%, respectively; 51% ever visited editorial & health educational contents, 57.6% ever used chat forum, and 26.8% ever used online consultation. Overall, eighty-three percent (83%) ever registered their PrEP at least once into the app. Conclusion: The use of the Jichunge app and its features are optimum and may improve over time.

• Lichtwarck, Hanne Ochieng; Kazaura, Method Rwelengera; Mmbaga, Elia & Moen, Kåre (2021). Sex worker stigma among female sex workers initiating PrEP in Dar es Salaam Preliminary analysis from baseline data collection in the PREPTA study. Full text in Research Archive Show summary

  Introduction: Female sex worker stigma is an understudied social determinant of health. In the context of HIV/AIDS studies have found that FSW stigma can pose a barrier both to access prevention and treatment services. Methods: We did a baseline survey of 471 FSW in Dar es Salaam initiating pre-exposure prophylaxis (PrEP). The participants were recruited using respondent driven sampling. Interviews covered several topics of relevance to PrEP, including a 13 point item 4 item validated FSW stigma scale where statements reflected perceptions and experiences of being a FSW. Additionally we did qualitative interviews with 25 FSW. Results: Median stigma scale score was 30 (IQR 27-35), a lower score compared to another study conducted in a different region of Tanzania. A majority of respondents expressed agreement with four of the five positively phrased statements such as “You like your job as a sex worker” (73.4% either agreed or completely agreed). Additionally a majority indicated disagreement with seven of eight negative phrased statements such as “Working as a sex worker makes you feel like a bad person” (66.6% either disagreed or completely disagreed). Qualitative data indicated that several of the women had experienced or felt stigma related to their profession and one participant explained that this could for instance impede participation in research. However, several expressed that they saw sex work as any other work and had become self-assured as people able to sustain themselves and in many cases their family members. Discussion: These preliminary findings shows a nuanced picture of these sex workers own perspectives related to their work, stigma and themselves, and opposes a view of FSW as victims devoid of agency and self-assurance.

• Mauka, Wilhellmus; Moen, Kåre; Mbotwa, Christopher & Mmbaga, Elia John (2020). Jichunge mobile application: Key population group orientation and piloting. Full text in Research Archive
• Mmbaga, Elia John; Leshabari, Melkizedeck T.; Leyna, Germana Henry; Kazaura, Method Rwelengera & Moen, Kåre (2019). Presentation of the PREPTA project in a kick-off seminar. Full text in Research Archive
• Lichtwarck, Hanne Ochieng; Moen, Kåre & Mmbaga, Elia (2024). Pre-Exposure Prophylaxis Use among Female Sex Workers in Dar es Salaam, Tanzania: a Mixed-Methods Study. Universitetet i Oslo. ISSN 9788234804564. Full text in Research Archive Show summary

  Sex-workers in low-and middle income countries, including in Tanzania, are at increased risk of HIV. Pre-exposure prophylaxis (PrEP) taken as a daily oral drug is efficacious in preventing HIV. However, studies have shown suboptimal engagement with services providing PrEP. This thesis aimed to provide some of the first evidence on PrEP usage among female sex workers in Tanzania, including perceptions and experiences with PrEP and estimate disengagement with services and potential influencing factors, including harmful alcohol use. A total of 470 HIV negative female sex workers (≥18 years) living in Dar es Salaam were recruited through respondent-driven sampling. They were surveyed at baseline when initiating PrEP and their attendance was registered at first clinical follow-up (month 1). Qualitative interviews were also conducted with 40 female sex workers who were former or current PrEP users or who intended to start PrEP. Almost three quarters (74.6%) of the women did not attend the first follow-up appointment, and this was independently associated with mental distress. Older age and having more clients were protective factors for disengagement with PrEP services. Harmful alcohol use was prevalent (37.3%) and independently associated with experiences of arrest, gender-based violence and mobility. Harmful alcohol use was not associated with disengagement. PrEP had multiple and diverse effects, referred to as the “effectosphere” of PrEP. Despite high disengagement, PrEP could lead to empowerment and human flourishing by enabling a sense of freedom and confidence which could promote health, economic opportunities and social relations. However, PrEP could also expose sensitive information leading to stigma, arguments, create fear of harms and medicalize aspects of life. The findings indicate that PrEP is relevant for female sex workers, but PrEP needs to be integrated into holistic HIV prevention strategies that takes into account their complex social circumstances.

• Mmbaga, Elia (2024). Effectiveness of a Mobile Health Intervention in Promoting the Use of Pre-exposure prophylaxis for HIV prevention among female sex workers in Tanzania: A pragmatic Quasi-Experimental Trial. Muhimbili University of Health and Allied Sciences. Full text in Research Archive
• Cavallo, Simon; Lichtwarck, Hanne Ochieng; Moen, Kåre & Mmbaga, Elia (2022). Prevalence of substance use and its association with sexual behaviours among men who have sex with men in Dar es Salaam, Tanzania. Universitetet i Oslo. Full text in Research Archive

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