Leaving No Man Behind: How Differentiated Service Delivery Models Increase Men’s Engagement in HIV Care

Document Type : Original Article

Author

1 South African Medical Research Council, Cape Town, South Africa

2 School of Public Health, University of the Western Cape, Cape Town, South Africa

Abstract

Background
Men demonstrate disproportionately poor uptake and engagement in HIV services with strong evidence linking men’s disinclination to engage in HIV services to their masculinity, necessitating adaptive programming to accommodate HIV-positive men. Differentiated service delivery models (DSDMs) – streamlined patient-centred antiretroviral treatment (ART) delivery services – have demonstrated the potential to improve men’s engagement in HIV services. However, it is unclear how and why these models contribute to men’s reframing of ART-friendly masculinities – a set of attributes, behaviours and roles associated with boys and men that favour the uptake and use of ART. We sought to unveil how and why DSDMs support the formation of ART-friendly masculinities to enhance men’s participation in HIV-related services.

 
Methods
A theory-driven qualitative approach underpinned by critical realism was conducted with 30 adult men using 3 types of DSDMs: facility-based adherence clubs (FACs), community-based adherence clubs (CACs) and quick pharmacy pick-ups (QPUPs). Focus group discussions (FGDs) (6) and in-depth interviews (IDIs) (20) were used to elicit information from purposively selected participants based on their potential contribution to the theory development – theoretical sampling. Recordings were transcribed verbatim in isiXhosa, then translated to English and analysed thematically. Theoretical constructs (themes) related to programme context and generative mechanisms were distilled and linked by retroduction and abductive thinking to formulate explanatory theories.
 
Results
Three bundles of mechanisms driving the adoption of ART-friendly masculinities by men using DSDMs were identified. (1) DSDMs instil a sense of cohesion (social support and feeling of connectedness), which enhances their reputational masculinity – having the know-how and being knowledgeable. (2) DSDMs provide a sense of assurance by providing reliable, convenient, stigma-free services, which makes men feel strong and resilient (respectability identity). (3) Through perceived usefulness, the extent to which an individual believes the model enhances their disease management, DSDMs enhance men’s ability to be economically productive and take care of their family (responsibility identity). 
 
Conclusion
DSDMs enhance the refashioning of ART-friendly versions of masculinity, thus improving men’s engagement in HIV services. Their effectiveness in refashioning men’s masculinities to ART friendly masculinities can be improved by ensuring conducive conditions for group interactions and including gender-transformative education to their existing modalities.

Keywords

References

  1. Cornell M, McIntyre J, Myer L. Men and antiretroviral therapy in Africa: our blind spot. Trop Med Int Health. 2011;16(7):828-829. doi:10.1111/j.1365-3156.2011.02767.x
  2. Cornell M, Schomaker M, Garone DB, et al. Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS Med. 2012;9(9):e1001304. doi:10.1371/journal.pmed.1001304
  3. Colvin CJ. Strategies for engaging men in HIV services. Lancet HIV. 2019;6(3):e191-e200. doi:10.1016/S2352-3018(19)30032-3
  4. Siu GE, Seeley J, Wight D. Dividuality, masculine respectability and reputation: How masculinity affects men’s uptake of HIV treatment in rural eastern Uganda. Soc Sci Med. 2013;89:45-52. doi:10.1016/J.SOCSCIMED.2013.04.025
  5. Dovel K, Yeatman S, Watkins S, Poulin M. Men’s heightened risk of AIDS-related death: the legacy of gendered HIV testing and treatment strategies. AIDS. 2015;29(10):1123-1125. doi:10.1097/QAD.0000000000000655
  6. Schneider H, Govender V, Harris B, Cleary S, Moshabela M, Birch S. Gender differences in experiences of ART services in South Africa: a mixed methods study. Trop Med Int Health. 2012;17(7):820-826. doi:10.1111/j.1365-3156.2012.03009.x
  7. Topp SM, Mwamba C, Sharma A, et al. Rethinking retention: Mapping interactions between multiple factors that influence long-term engagement in HIV care. PLoS One. 2018;13(3):e0193641. doi:10.1371/journal.pone.0193641
  8. Sharma M, Barnabas R V., Celum C. Community-based strategies to strengthen men’s engagement in the HIV care cascade in sub-Saharan Africa. PLoS Med. 2017;14(4):e1002262. doi:10.1371/journal.pmed.1002262
  9. Nyamhanga TM, Muhondwa EPY, Shayo R. Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania. Glob Health Action. 2013;6(1):21812. doi:10.3402/gha.v6i0.21812
  10. Chikovore J, Gillespie N, McGrath N, Orne-Gliemann J, Zuma T, Group OB of the A 12249 TS. Men, masculinity, and engagement with treatment as prevention in KwaZulu-Natal, South Africa. AIDS Care. 2016;28(sup3):74-82. doi:10.1080/09540121.2016.1178953
  11. Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson S. Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Global Health. 2011;7:13. doi:10.1186/1744-8603-7-13
  12. Shand T, Thomson-de Boor H, van den Berg W, Peacock D, Pascoe L. The HIV Blind Spot: Men and HIV Testing, Treatment and Care in Sub-Saharan Africa. IDS Bull. 2014;45(1):53-60. doi:10.1111/1759-5436.12068
  13. Wyrod R. Masculinity and the persistence of AIDS stigma. Cult Health Sex. 2011;13(4):443-456. doi:10.1080/13691058.2010.542565
  14. Sikweyiya YM, Jewkes R, Dunkle K. Impact of HIV on and the constructions of masculinities among HIV-positive men in South Africa: Implications for secondary prevention programs. Glob Health Action. 2015;8(1). doi:10.3402/gha.v7.24631
  15. Russell S. Men’s Refashioning of Masculine Identities in Uganda and Their Self-Management of HIV Treatment. Qual Health Res. 2019;29(8):1199-1212. doi:10.1177/1049732318823717
  16. Siu GE, Wight D, Seeley J. “Dented” and “resuscitated” masculinities: the impact of HIV diagnosis and/or enrolment on antiretroviral treatment on masculine identities in rural eastern Uganda. SAHARA J. 2014;11(1):211-221. doi:10.1080/17290376.2014.986516
  17. de Visser RO, McDonnell EJ. “Man points”: Masculine capital and young men’s health. Health Psychol. 2013;32(1):5-14. doi:10.1037/a0029045
  18. Siu GE, Wight D, Seeley J. How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda. J Int AIDS Soc. 2012;15(3(Suppl 1)):1-9. doi:10.7448/IAS.15.3.17368
  19. Fleming PJ, Colvin C, Peacock D, Dworkin SL. What role can gender-transformative programming for men play in increasing men’s HIV testing and engagement in HIV care and treatment in South Africa? Cult Health Sex. 2016;18(11):1251-1264. doi:10.1080/13691058.2016.1183045
  20. Cornell M, Cox V, Wilkinson L. Public health blindness towards men in HIV programmes in Africa. Trop Med Int Health. 2015;20(12):1634-1635. doi:10.1111/tmi.12593
  21. International AIDS Society. Differentiated Care for HIV: A Decision Framework for Antiretroviral Therapy. Durban; 2016. http://www.differentiatedcare.org/Portals/0/adam/Content/yS6M-GKB5EWs_uTBHk1C1Q/File/Decision Framework.pdf.  Accessed July 6, 2017.
  22. Bemelmans M, Baert S, Goemaere E, et al. Community-supported models of care for people on HIV treatment in sub-Saharan Africa. Trop Med Int Health. 2014;19(8):968-977. doi:10.1111/tmi.12332
  23. Kwarisiima D, Kamya MR, Owaraganise A, et al. High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya. J Int AIDS Soc. 2017;20:21673. doi:10.7448/IAS.20.5.21673
  24. Luque-fernandez MA, Cutsem G Van, Goemaere E, et al. Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PloS One. 2013;8(2):e56088. doi:10.1371/journal.pone.0056088
  25. Tsondai PR, Wilkinson LS, Grimsrud A, Mdlalo PT, Ullauri A, Boulle A. High rates of retention and viral suppression in the scale-up of antiretroviral therapy adherence clubs in Cape Town, South Africa. J Int AIDS Soc. 2017;20(Suppl 4):21649. doi:10.7448/IAS.20.5.21649
  26. Grimsrud A, Lesosky M, Kalombo C, Bekker LG, Myer L. Community-based adherence clubs for the management of stable antiretroviral therapy patients in Cape Town, South Africa: a cohort study. J Acquir Immune Defic Syndr. 2016;71(1):e16-e23. doi:10.1097/QAI.0000000000000863
  27. Fox MP, Pascoe S, Huber AN, et al. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: results from a cluster randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med. 2019;16(7):e1002874. doi:10.1371/journal.pmed.1002874
  28. Nsanzimana S, Remera E, Ribakare M, et al. Phased implementation of spaced clinic visits for stable HIV-positive patients in Rwanda to support treat all. J Int AIDS Soc. 2017;20(Suppl 4):21635. doi:10.7448/IAS.20.5.21635
  29. Mukumbang FC, S  van B, Marchal B, et al. Towards developing an initial programme theory: Programme designers and managers assumptions on the antiretroviral treatment adherence club programme in primary health care facilities in the metropolitan area of western cape province, South Africa. PLoS One. 2016;11(8):e0161790. doi:10.1371/journal.pone.0161790
  30. Grimsrud A, Bygrave H, Doherty M, et al. Reimagining HIV service delivery: the role of differentiated care from prevention to suppression. J Int AIDS Soc. 2016;19(1):21484. doi:10.7448/IAS.19.1.21484
  31. Mukumbang FC, Marchal B, Belle S Van, Wyk B Van. A realist approach to eliciting the initial Programme theory of the antiretroviral treatment adherence Club intervention in the western Cape Province , South Africa. BMC Med Res Methodol. 2018;18(1):47. doi:10.1186/s12874-018-0503-0
  32. Mukumbang FC, Orth Z, Van Wyk B. What do the implementation outcome variables tell us about the scaling-up of the antiretroviral treatment adherence clubs in South Africa? A document review. Health Res Policy Syst. 2019;17(1):1-12. doi:10.1186/s12961-019-0428-z
  33. MSF. Art Adherence Club Report and Toolkit. https://samumsf.org/sites/default/files/2017-07/ART-Adherence-Club-REPORT-and-TOOLKIT_OCT2014.pdf.  Updated October 2014.
  34. Rasschaert F. Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique. BMC Public Health. 2014;14:364. doi:10.1186/1471-2458-14-364
  35. International AIDS Society (IAS). A decision framework for antiretroviral therapy delivery. Durban; 2016. http://www.differentiatedcare.org/Portals/0/adam/Content/yS6M-GKB5EWs_uTBHk1C1Q/File/Decision%20Framework.pdf.    Accessed January 13, 2017.
  36. Wynn D, Williams CK. Principles for conducting critical realist case study research in information systems. MIS Q. 2012;36(3):787-810. doi:10.1016/j.ijproman.2012.11.012
  37. Scott D. Ontology, epistemology, strategy and method in educational research. A critical realist approach. Rev Int Investig Educ. 2014;7(14):29-38. doi:10.11144/Javeriana.M7-14.OESM
  38. Danermark B, Ekstrom M, Jakobsen L, ChKarlsson J. Explaining Society: Critical Realism in the Social Sciences. 1st ed. London: Routledge Taylor & Francis; 2002.
  39. Bygstad B, Munkvold BE. In search of mechanisms. Conducting a critical Realist data analysis. In: Thirty Second International Conference on Information Systems; Shanghai; 2011:1-15. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.690.4006&rep=rep1&type=pdf.  Accessed June 18, 2019.
  40. Yin RK. Case Study Research: Design and Methods. Sage; 2013.
  41. Sobh R, Perry C. Research design and data analysis in realism research. Eur J Mark. 2006;40(11-12):1194-1209. doi:10.1108/03090560610702777
  42. Thompson C. Qualitative research into nurse decision making: factors for consideration in theoretical sampling. Qual Health Res. 1999;9(6):815-828. doi:10.1177/104973239900900609
  43. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies. Qual Health Res. 2016;26(13):1753-1760. doi:10.1177/1049732315617444
  44. Pawson R. Theorizing the interview. Br J Sociol. 1996;47(2):295-314.
  45. Coyne IT. Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? J Adv Nurs. 1997;26(3):623-630. doi:10.1046/j.1365-2648.1997.t01-25-00999.x
  46. Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148. doi:10.1186/s12874-018-0594-7
  47. Crinson I. A Realist Approach to the Analysis of Focus Group Data. London; 2001. http://www.criticalrealism.com/archive/iacr_conference_2001/icrinson_raafgd.pdf.  Accessed June 2, 2019.
  48. Mukumbang FC, Van Belle S, Marchal B, van Wyk B. An exploration of group-based HIV/AIDS treatment and care models in Sub-Saharan Africa using a realist evaluation (Intervention-Context-Actor-Mechanism-Outcome) heuristic tool: A systematic review. Implement Sci. 2017;12(1). doi:10.1186/s13012-017-0638-0
  49. Corbin J, Strauss A. Formulation development and evaluation of Silymarin gel. Qual Sociol. 1990;13(1):3-21.
  50. Gilmore B, McAuliffe E, Power J, Vallières F. Data analysis and synthesis within a realist evaluation: toward more transparent methodological approaches. Int J Qual Methods. 2019;18:1-11. doi:10.1177/1609406919859754
  51. Zachariadis M, Scott S, Barrett M. Methodological implications of Critical Realism for mixed-methods research. MIS Q. 2013;37(3):855-880. doi:10.25300/MISQ/2013/37.3.09
  52. Attride-Stirling J. Thematic networks: An analytic tool for qualitative research. Qual Res. 2001;1(3):385-405.
  53. Fletcher AJ. Applying critical realism in qualitative research: methodology meets method. Int J Soc Res Methodol. 2017;20(2):181-194. doi:10.1080/13645579.2016.1144401
  54. Mukumbang FC, Marchal B, Van Belle S, van Wyk B. Using the realist interview approach to maintain theoretical awareness in realist studies. Qual Res. 2019. doi:10.1177/1468794119881985
  55. Eshun-Wilson I, Mukumbwa-Mwenechanya M, Kim H-Y, et al. Differentiated care preferences of stable patients on ART in Zambia. J Acquir Immune Defic Syndr. 2019;81(5):1. doi:10.1097/qai.0000000000002070
  56. Mukumbang FC, Marchal B, Van Belle S, Van Wyk B. Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach. BMC Health Serv Res. 2018;18(1):343. doi:10.1186/s12913-018-3150-6
  57. Mukumbang FC, Wyk B Van, Belle S Van, Marchal B. Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study. PLoS One. 2019:1-26. doi:10.1371/journal.pone.0210565
  58. Dudhia R, Kagee A. Experiences of participating in an antiretroviral treatment adherence club. Psychol Health Med. 2015;20(4):488-494. doi:10.1080/13548506.2014.953962
  59. Russell S, Namukwaya S, Zalwango F, Seeley J. The framing and fashioning of therapeutic citizenship among people living with HIV taking antiretroviral therapy in Uganda. Qual Health Res. 2016;26(11):1447-1458. doi:10.1177/1049732315597654
  60. Mukumbang FC, Marchal B, Van Belle S, van Wyk B. “Patients are not following the [adherence] club rules anymore”: a realist case study of the antiretroviral treatment adherence club, South Africa. Qual Health Res. 2018:28(12):1839-1857. doi:10.1177/1049732318784883
  61. Baatiema L, Skovdal M, Rifkin S, Campbell C. Assessing participation in a community-based health planning and services programme in Ghana. BMC Health Serv Res. 2013;13(1):233. doi:10.1186/1472-6963-13-233
  62. Sileo KM, Reed E, Kizito W, et al. Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda. Cult Health Sex. 2019;21(7):774-788. doi:10.1080/13691058.2018.1516299
  63. Mantell JE, Masvawure TB, Mapingure M, et al. Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe. J Int AIDS Soc. 2019;22(10):e25403. doi:10.1002/jia2.25403
International Journal of Health Policy and Management
Volume 10, Issue 3
March 2021
Pages 129-140

Files

History

  • Receive Date: 21 August 2019
  • Revise Date: 24 February 2020
  • Accept Date: 25 February 2020
  • First Publish Date: 01 March 2021

Share

How to cite

Statistics