A realist evaluation of the continuum of HIV services for men who have sex with men

Abstract

Background Men who have Sex with Men (MSM) represent the risk group that are disproportionately most affected by the human immunodeficiency virus (HIV) and continue to drop-off from the steps of the continuum of HIV services that have been adopted to overcome poor engagement and retention in care. This realist evaluation aimed at: (1) describing the evaluation carried out in Haiti aiming to ascertain why, how and under which circumstances MSM are linked and retained along the continuum, (2) assessing the outcomes of this approach and (3) exploring the motivators and facilitators for the HIV continuum of services through mechanisms and pathways. Methods Guided by a realist approach, first, an initial program theory (IPT) was developed based on literature and frameworks review, participant observations and discussions with stakeholders. Then, the IPT was tested using a mixed method explanatory study: a quantitative phase to build the continuum from a cross-sectional analysis, and a qualitative phase to explore the motivators and facilitators related to proper linkages along the continuum. Finally, the IPT was refined by eliciting the mechanisms and pathways for outcomes improvement. Results The results showed that the current service delivery model is suboptimal in identifying, engaging, linking and retaining MSM, resulting in loss to follow-up at every step of the continuum and failure to fully realize the health and prevention benefits of antiretroviral. However, the mechanisms through which linkages across the continuum can be improved are: self-acceptance, sense of community support and sense of comprehensive and tailored HIV services. These mechanisms are based on 10 different pathways: self-esteem, awareness and pride, perception of HIV risk, pcceptance and HIV status, addressing community stigma, strengthening of MSM organizations and community networks, societal acceptation and tolerance, stigma reduction training for healthcare providers, engagement of peers as educators and navigators and, adapted services delivery through drug dispensing points and mobile technology and financial assistance. Conclusions The study findings show that engagement, adherence and retention to the continuum of HIV service for MSM are affected by a multi-layer of factors, thus highlighting the importance of taking a comprehensive approach to improve the program.

Sexual behavior stigma among cisgender gay, bisexual, and other men who have sex with men in nine NHBS cities across the United States: Burden and associations with PrEP continuum and HIV care continuum outcomes.

“…Quinn, Dickson-Gomez, et al, 2019; Sang et al, 2023; Sullivan & Eaton, 2021). These stigmas can also affect MSM living with HIV by dissuading men from accessing HIV care and treatment (Arnold et al, 2014; Dunbar et al, 2021; Haile et al, 2011). Sexuality-based anticipated health care stigma may also constrain HIV care engagement for MSM, as anticipated health care stigma related to attributes such as substance use and HIV status has been associated with decreased engagement in HIV care for this population (Batchelder et al, 2021; Camacho et al, 2020; Mitzel et al, 2015; K.…”

“…Recent research has demonstrated how sexuality-based family stigma may act as a potential barrier to PrEP awareness and uptake among MSM (Dunbar et al, 2021;Farley et al, 2022), while studies examining sexuality-based social stigma have been mixed, with both negative and positive associations with PrEP engagement being reported (Dunbar et al, 2021;Farley et al, 2022;Matacotta et al, 2020;K. Quinn, Bowleg, et al, 2019;Sang et al, 2023;Sullivan & Eaton, 2021).…”

Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti

“…For the past three decades, national HIV strategic responses have been instrumental in reducing Haiti’s HIV prevalence from 6.2% in 1993 to 1.9% in 2020 3 , 4 . As the country continues to make progress towards controlling the epidemic and expanding access to antiretroviral therapy (ART), Men who have Sex with Men and Women (MSMW), are largely left out of the discussion of key populations 5 – 7 . Yet according to a survey conducted and published by the United Nations, the HIV prevalence among MSMW was 18.2% in 2017, making them the most underserved population in terms of HIV prevention and care 4 .…”

“…As MSMW are highly stigmatized by both religious and social norms, homosexual practices are often driven underground. Perpetuated at the community level, violence toward MSMW is sometimes overlooked by the police force 7 . Moreover, access to HIV prevention and treatment services remain limited due to fear of non-voluntary disclosure and the fact that healthcare providers are perceived as judgmental and unable to respect confidentiality 5 , 12 .…”