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.