• Haaland, Inga & Ogillo, Karama (2023). Self-making and gender norms: sanctions and rewards in within the context of public health and sex work in Dar es Salaam. Journal of Feminist Anthropology and Gender Studies. ISSN 1388-4840.
• Haaland, Inga; Metta, Emmy & Moen, Kåre (2023). The use of PrEP among men who have sex with men and transgender women as Biomedical Prevention Work: A conceptual framework. Social Science and Medicine. ISSN 0277-9536. 333. doi: 10.1016/j.socscimed.2023.116147.
• 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. ISSN 1438-8871. doi: 10.2196/23204. 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

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• Haaland, Inga (2023). The risk and uncertainties of using PrEP as HIV prevention: an ethnographic study among men who have sex with men and transgender women in Dar es Salaam. Show summary

  At a study site in Dar es Salaam, transgender women and men who have sex with men come to get the novel biomedical technology: Pre-exposure prophylaxis (PrEP). PrEP is a pill proven to reduce the risk of contracting HIV by up to 99%. While PrEP may reduce the risks of contracting HIV, this paper argues that PrEP can also introduce new risks and uncertainties to their users’ lives. The data draws on ethnographic fieldwork mainly located at the PrEP study site for ten months in 2021/2022—rumours and stories about PrEP users becoming HIV positive made people uncertain about the promised 99% effectiveness. Furthermore, the complexity of PrEP also brought uncertainty to people’s lives: what happens if a pill is taken at the wrong time or not at all? How would this affect the known 99% protection covered by PrEP? These concerns and worries contributed to serostatus uncertainty. Secondly, some interlocutors experienced social delay about whether their PrEP use could impose a stigma on them, as PrEP was associated with HIV positivity and promiscuity/sex work. Lastly, the projectivization of PrEP programming, local stock-out and delays in the nationwide scale-up of PrEP contributed to an uncertain provision of PrEP to its users. While PrEP has shown to be important to the interlocutors in this study, PrEP also contributes to current uncertainties about life on PrEP here and now and concerns about the risks and uncertainties of whether their future would become HIV positive or remain HIV negative.

• Haaland, Inga (2023). Negotiating gendered appearance and representation in the context of a PrEP study for transgender women and men who have sex with other men in Dar es Salaam. Show summary

  Pre-exposure prophylaxis, or PrEP, have been touted by WHO and UNAIDS as an essential tool in ‘ending AIDS’ by 2030, holding the promise of a future where HIV is no longer endemic. At a study site in Dar es Salaam, transgender women and men who have sex with men come to gain access to the novel pill, which, when taken daily, is proven to be up to 99% effective in reducing new infections of HIV. In this paper, we present the case of one PrEP user, Ibada, who performed a noticeable change in their appearance during fieldwork. Exemplified by Ibadas’ transformation and analysis of their transformation, this paper demonstrates how PrEP users may manage and negotiate gender expressions at the study site and in other areas of life, such as in sex work, dating or search for employment as a peer educator. As inclusion in the PrEP program depends on gender, sexual practices and eligibility for PrEP, discussions of the motivation for participation and appearance frequently occurred among staff at the study site. The data presented in this paper draws on a 10-month of ethnographic fieldwork between January 2021 and April 2022. Methods used were participant observation at the study site and a secondary health clinic and interviews with Ibada, research staff, health care workers and peer educators. The paper provides insight into gender discourses at a PrEP study site and how non-hetero-normative persons may navigate gender expression in creating a future for themselves.

• Haaland, Inga (2023). Anticipations of ending the HIV epidemic using Pre-exposure prophylaxis (PrEP): affective states and uncertainties among PrEP users in Dar es Salaam. Show summary

  At a study site in Dar es Salaam, 'risk subjects' (Rose, 2007), in this case, transgender women and men who have sex with men, come to gain access to Pre-exposure prophylaxis (PrEP) – a novel HIV prevention pill. The pill holds the promise to 'end HIV by 2030' according to the WHO. This paper draws on ten months of ethnographic fieldwork between 2021/2022 at a PrEP study site in Tanzania. The paper explores how some PrEP users anticipated an HIV-negative future with PrEP as a temporal possibility (Adams et al., 2009) and hope for the best possible future for themselves, their partners and their community. The paper found that using PrEP not only introduced hope for the future but PrEP also introduced novel uncertainties and affective states into their users' lives, such as rumours about the spread of PrEP as an ineffective drug and uncertainty about PrEP's effectiveness caused by stress related to HIV status. Furthermore, PrEP users were concerned about the potential stigma they could experience as PrEP users, as PrEP was associated with promiscuity, sex work and HIV positivity. Lastly, the projectivization (Prince, 2014) of PrEP and the unstable provision at the beginning of the PrEP scale-up in Tanzania caused anxiety and uncertainty to its daily users. Finally, I speculate on whether biomedical interventions, such as PrEP, can hold their promise of ending an epidemic in solitude. I anticipate a need to include social and structural perspectives in present public health interventions to 'end AIDS' sometime in the future.

• Haaland, Inga; Metta, Emmy & Moen, Kåre (2022). The role of Pre-Exposure Prophylaxis as HIV prevention for men who sell sex to other men in Dar es Salaam. Show summary

  Background: Men who sell sex to other men are twice as likely to be infected with HIV compared to other men who have sex with men. PrEP use is very effective for preventing HIV infection among at risk populations including men who sell sex to other men. PrEP is freely available to key and vulnerable populations in Tanzania. However, there is limited information on PrEP use among men who sell sex to other men in Tanzania. Aim: Explore the role of PrEP as HIV prevention among male born persons who sell sex to other men. Method: This ethnographic field work and qualitative interviews was conducted between January 2021 and April 2022 in Dar es Salaam. In this paper, we focus on the findings from interviews with 16 participants who said they did ‘Ngono Pesa’, sex for money. Results: Participants saw several benefits with PrEP, as it provided safer working conditions and could facilitate condomless sex. Sex without a condom had a higher market price and was perceived to reduce pain associated with the unlubricated condoms in receptive anal sex. PrEP thus facilitated an increased number of clients per day. Regarding challenges, some clients mistook PrEP for HIV treatment, non-adherence to PrEP and stock-outs. The lack of PrEP could lead to either unprotected sex or temporary service disruption. Conclusion: As HIV prevention, PrEP were instrumental for men who sell sex. PrEP also facilitated less painful working conditions and contributed to a higher income. PrEP also caused challenges, such as loss of income for those who were perceived to be HIV positive by their clients. Secondly, unavailability of PrEP during travels and stock-outs put participants at risk of contracting HIV.

• Haaland, Inga; Metta, Emmy & Moen, Kåre (2021). Pre-exposure prophylaxis as HIV prevention in Dar es salaam: Perceptions and experiences among men who have sex with men and transgender women .
• 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. 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. 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.

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