AbstractAnalysing the Impact of Stigma and Discrimination on the Linkages Across the Continuum of HIV Services for Men who have Sex with Men: A Realist ApproachBackground and Aim The world has now entered the third decade of the AIDS epidemic. Men who have sex with men (MSM) continue to be disproportionately affected by HIV/AIDS. Haiti still struggles in its response to this ongoing crisis throughout the continuum of services: disease prevention, treatment, and HIV related stigma, prejudice, and discrimination. Much of the information reported on people living with HIV has come from the general population, but only a few parts of some of those studies have focused on MSM. Therefore, the overall aim of this dissertation was to analyse the impact of stigma and discrimination on the continuum of HIV services for MSM in order to ascertain why, how and under which circumstances MSM are engaged, linked and retained along the care continuum.Methods For this dissertation, data were collected via literature review, electronic medical records, participant observations, focus groups and semi structured interviews with medical students, health care workers and MSM. Using a realist approach based on mixed methods design we sought to address the influence of HIV and sexual stigma on the continuum of HIV services and to identify key mechanisms emerging from the context and leading to the outcomes. Quantitative social and medical data were gathered and analysed to produce descriptive and analytic statistics and qualitative data were analysed thematically regarding the objectives.FindingsResults indicated that MSM experienced stigma in multiple and overlapping layers. MSM described stigmatizing experiences stemming from religious sources, communities, family and friends, and from the medical establishment. From the social construction of heteronormativity in the society, several social and cultural factors, gender norms lie behind the stigma associated with sexual orientation and HIV. Moreover, medical students and healthcare givers still carry discriminatory attitudes towards them despite tailored interventions. Our analysis showed that current service delivery models are less than optimal in linking and retaining MSM, resulting in loss to follow-up in the continuum of care and failure to fully realize the health and prevention benefits. However, multi-level, contextual-based and socially accountable interventions can produce stigma mitigation through personal, health systems’ and contextual mechanisms for better engagement, adherence and retention throughout the continuum.ConclusionsThe results within this dissertation are intended to inform health professionals in the planning and implementation of interventions for better continuum outcomes in Haiti and similar contexts. This thesis provides insight and contextual information for a socially accountable framework of adapted interventions. To end the AIDS epidemic by 2030, Haiti, the Caribbean region and the entire world urgently need to defy expectations to reach the left behind.KeywordsHIV; Continuum of HIV Services; Stigma; Discrimination; Realist Evaluation; Context-Mechanism-Outcome; Social Accountability / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished