Autonomy-supportive sexual health communication and sexual health behaviors for black and Latino MSM in the House Ball Community: Protocol for a social network analysis and exploratory structural equation model

BACKGROUND

Black and Latino men who have sex with men (MSM) have the highest risk of HIV of any group in the U.S. Prevalence could be even higher among Black and Latino MSM belonging to the House Ball Community (HBC), an understudied community comprised primarily of Black and Latino sexual and gender minorities, with HIV prevalence from non-probability samples ranging from 4% to 38%.

OBJECTIVES

Basic Psychological Needs Theory will be utilized to understand how sexual health communication (SHC) influences sexual health behaviors of HBC-MSM. The proposed study will advance this goal by describing characteristics of SHC embedded within social and sexual networks, and identifying the effects of SHC on sexual health behaviors among a sample of Black and Latino HBC-MSM.

METHODS

This study entails cross-sectional quantitative survey design with internet-based data collection to test a theory-driven model of the effects of autonomy supportive communication on sexual health behaviors. Respondent-driven sampling (RDS) and internet driven sampling (ID) will be used to recruit a sample of 200 HBC-MSM. We will utilize egocentric network analysis to describe (a) the HBC-specific social and/or sexual network members who provide SHC; (b) the degree of autonomy support provided by network members, and (c) the sexual health behaviors characterizing the sample of HBC-MSM. Structural equation modeling (SEM) will be performed to test associations between autonomy supportive sexual health communication (independent variable) and sexual health behaviors (outcome), with needs satisfaction and intrinsic motivation as intervening mediators.

DISCUSSION

Such knowledge is necessary to expand understanding of how SHC impacts sexual health behaviors for HBC-MSM. The study provides an critical perspective on sexual health behaviors and motivations as participants operate in HBC. Knowledge generated from this study will help improve current HIV prevention interventions, as well as inform the development of future interventions, tailored to HBC-MSM.

Dimensions of Sexual Health Conversations among U.S. Black Heterosexual Couples

Sexual health communication is an important feature of healthy intimate relationships; however, some couples may avoid discussing difficult matters (e.g., HIV/STI testing, sexual satisfaction) to minimize interpersonal conflict. From October 2018 to May 2019 in New York State, we conducted a multi-method descriptive pilot study to characterize Black heterosexual couples' (N = 28) sexual health conversations. Partners individually completed an online sexual health/relationship survey before engaging in-person for a joint dyadic qualitative in-depth interview. Quantitative descriptive statistics demonstrated that most absolute score differences among couple's preferences for sexual health outcomes, communal coping and sexual relationship power were mainly small, but greatest regarding extra-dyadic sexual behaviors. A qualitative descriptive approach discerned, motivation and norms for sexual health conversations, and communication patterns. Thematic and content analysis revealed two central themes: initiating and sustaining sexual health conversations, and leveraging features of the couples to promote sexual health. Integrated findings indicate that couples possess varied communication patterns that operate with motivations for sexual health conversations toward subsequent sexual health promotion. Equitable and skewed communication patterns emerged as relationship assets that can be leveraged to optimize sexual health. There is also opportunity for future work to address communication regarding extra-dyadic behavior and preferences. Asset-based considerations are discussed.

Perspectives on a Couples-Based, e-Health HIV Prevention Toolkit Intervention: A Qualitative Dyadic Study with Black, Heterosexual Couples in New York State

Web-based technology provides an unparalleled opportunity to increase access and uptake of couples-based HIV prevention interventions. e-Health HIV prevention interventions for US Black heterosexual couples have largely been understudied. To address this gap, we applied the Assessment Phase of the ADAPT-ITT Framework to investigate Black heterosexual couples' perspectives on an existing e-Health, couples-based HIV prevention intervention. Applying a qualitative descriptive approach, joint dyadic interviews were conducted with 28 Black heterosexual couples from three jurisdictions in New York State. Content dyadic analysis revealed three descriptive categories: perspectives of the toolkit intervention (sub-codes: perceived relevance, reactions to core components), recommendations to enhance intervention relevancy (sub-codes: tailoring to relationship type, adding new content), and lasting intervention considerations (sub-codes: toolkit usability and language use). Overall, couples found the toolkit intervention content and usability acceptable and reflected on its potential to build sexual and relationship health. Couples recommended to enhance toolkit adaptability for varied couple's motivation and types re-consider terms like sexual agreements, and include content to facilitate communication regarding sensitive topics (e.g., childhood sexual trauma, co-parenting, family planning) and other issues that may have more relevance to the experience of US Black persons (i.e., wealth building).

Associations between Home- and School-Based Violent Experiences and the Development of Sexual Behavior in Young Adolescent Girls in the Rural Southern Region of Malawi

Studies show that adolescent girls who experience violence grow up with fear and develop survival mechanisms that increase their susceptibility to sexually transmitted infections including HIV. However, the relationship between violence and the development of sexual behavior in young adolescent girls is under-investigated. We examined the Malawi Schooling and Adolescent Study data to explore the associations between home- and school-based violence and sexual behaviors in 416 young adolescent girls in rural Southern Malawi. Bivariate Logistic Regression analysis was applied to determine associations. Of 353 (84.9%) girls who had sex with a male partner, 123 (34.8%) experienced home-based violence, and 53 (15%) experienced school-based violence. The odds of girls who experienced home-based violence (OR = 2.46, 95% CI = 1.21, 5.01) and those who first experienced home-based violence between 13 and 14 years (OR = 2.78, 95% CI = 1.35, 5.74) were higher among girls who had multiple sexual partners than those with a single sexual partner. With school-based violence, sexual initiation, having multiple sexual partners, and not using protection were positively associated with experiencing teasing, sexual comments, punching, and touching in private areas in transit to school and by a teacher. These results suggest that home- and school-based violence should be essential components of research and biobehavioral interventions targeting the sexual behaviors of young adolescent girls.

The Magnetic Couples Study: protocol for a mixed methods prospective cohort study of HIV-serodifferent heterosexual couples' perspectives and use of pre-exposure prophylaxis (PrEP)

INTRODUCTION

HIV transmission within serodifferent heterosexual couples plays a key role in sustaining the global HIV pandemic. In the USA, transmission within established mixed-status couples accounts for up to half of all new HIV infections among heterosexuals. Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method, although underutilised among serodifferent couples. Moreover, there is a dearth of research on US HIV-serodifferent couples' perspectives and use of PrEP, alone or in combination with other prevention methods. In this paper, we describe the study protocol for the Magnetic Couples Study, designed to fill critical knowledge gaps regarding HIV-serodifferent heterosexual couples' perspectives, experiences and utilisation of PrEP.

METHODS AND ANALYSIS

The Magnetic Couples Study is a mixed methods prospective cohort study designed to describe temporal patterns and identify determinants at multiple levels (individual, couple, HCF) of PrEP outcomes along the care continuum (PrEP awareness, linkage, uptake, retention and medication adherence) among HIV-serodifferent heterosexual couples residing in New York City. The study will also examine clinical management of PrEP, side effects and changes in sexual-related and substance use-related behaviour. A prospective cohort of 230 mixed-status couples already on oral PrEP was recruited, with quarterly assessments over 18 months; in addition, a cross-sectional sample of 150 mixed-status couples not currently on PrEP was recruited. In-depth semistructured qualitative interviews were conducted with a subsample of 25 couples. Actor-partner interdependence modelling using multilevel analysis will be employed for the analysis of longitudinal dyadic data. Framework analysis will be used to analyse qualitative data. A parallel convergent design will be used for mixed methods integration.

ETHICS AND DISSEMINATION

The study was approved by the University of Rochester Institutional Review Board (RSRB00052766). Study findings will be disseminated to community members and providers and to researchers and policy makers.

Ecological and Syndemic Predictors of Drug Use During Sex and Transactional Sex among U.S. Black Men Who Have Sex with Men: A Secondary Data Analysis from the HPTN 061 Study

Threats to sexual health among U.S. Black men who have sex with men (MSM) may manifest in a context of social adverse experiences. Situational sex is one such context, which we characterize as sexual behaviors driven either by a desire to cultivate a specific sexual experience or attributable to social vulnerability. Two characterizations of situational sex explored in this study were drug use during sex and transactional sex. Guided by ecological and syndemic frameworks, we conducted a secondary data analysis of social conditions and sexual behaviors among a prospective cohort of Black MSM from the HIV Prevention Trial Network (HPTN) 061 study. Using structural equation modeling, this analysis examined the indirect effect of syndemic factors (substance use, depression, violence exposure) in the relationship between ecological constructs (anti-Black/homophobic stigma, childhood violence, and economic vulnerability) and situational sex (drug use during sex, transactional sex). Model fit indices, CFI (.870) and SRMR (.091), demonstrated reasonable fit. Significant indirect effects emerged via substance use for economic vulnerability (indirect effect = .181, 95% CI [.078, .294]) and anti-Black/homophobic violence and stigma (indirect effect = .061, 95% CI [.008, .121]) on drug use during sex; as well as on transactional sex (economic vulnerability indirect effect = .059, 95% CI [.018, .121] and anti-Black/homophobic stigma and violence indirect effect = .020, 95% CI [.003, .051]). Findings implicate the need for social and fiscal intervention to address upstream, ecological, and syndemic factors that influence inherent vulnerability of situational sex and overall threats to sexual health among Black MSM.

Race-Based Sexual Stereotypes, Gendered Racism, and Sexual Decision Making Among Young Black Cisgender Women

Background. Due to their intersecting racial identity and gender identity, Black women are characterized by stigmatizing race-based sexual stereotypes (RBSS) that may contribute to persistent, disproportionately high rates of adverse sexual and reproductive health outcomes. RBSS are sociocognitive structures that shape Black women's social behavior including their sexual scripts. Objective. The purpose of this study was to explore the influence of RBSS on the sexual decision making of young Black women (YBW). Methods. We conducted four focus groups with 26 YBW between the ages of 18 and 25, living in a New York City neighborhood with a high HIV prevalence. Qualitative analysis was used to identify emergent themes within the domains of sexual decision making as it relates to safer sex practices and partner selection. Results. Thematic analyses revealed that RBSS may cause women to adopt more traditional gender stereotypes and less likely to feel empowered in the sexual decision making. Participants reported that RBSS may lead Black women to being resistant to learning new information about safer sex practices, feeling less empowered within intimate relationships, and jeopardizing their sexual well-being to affirm themselves in other social areas encouraging unprotected sex and relationships with men who have multiple sex partners. Discussion and Conclusion. Future research should focus on understanding the social and cultural factors that influence Black women's power in maintaining and improving their sexual health, including the aforementioned stereotypes that have influenced how others may view them as well as how they view themselves.

The Who and Why of Consensual Nonmonogamy Among African Americans

Prevalence rates of consensual nonmonogamy (CNM) demonstrate little difference across race. Yet, not much is known about CNM among African Americans. Through an online survey study, we examined the correlates of CNM among African Americans as well as the reasons why they engage. A total of 1050 African Americans between the ages of 18-40 years participated in this study. Binomial logistic regression was utilized to determine the correlates of CNM. Sexual orientation was the only significant predictor of CNM. The following variables were nonsignificant predictors of CNM: age, gender, household income, religiosity, and education. Qualitative analysis revealed several reasons for CNM engagement: (1) belief that it is natural; (2) excitement; (3) not meant for each other; (4) scared of losing partner; (5) bisexuality; (6) does not want commitment; and (7) maintain honesty, trust, and integrity. This study adds to the sparse knowledge base of CNM among African Americans.

Movements of juvenile and sub-adult striped bass Morone saxatilis in the Saint John River, New Brunswick, Canada

Juvenile striped bass (age-1) of distinct genetic ancestry were re-discovered in the Saint John River, New Brunswick in 2014 after a 35 yr hiatus of recognition. These juveniles were determined to be highly genetically divergent from all possible source populations, hypothesized to be of Saint John River ancestry, and thus considered evidence of the continued existence of the native stock. Successful recruitment of strong year classes of striped bass within the Saint John River, however, appears to be infrequent. We acoustically tagged and tracked juvenile and sub-adult striped bass (n = 37; age 2-4) in the Saint John River in both 2015 and 2016, and identified summer feeding and overwintering habitats that established an in-river residency. Following decades of poor or no recruitment of the native striped bass stock, it is now imperative that managers quickly include monitoring of juvenile and sub-adult striped bass and protection of their habitats in the conservation and recovery efforts for Saint John River striped bass.

The Effects of Trauma, Violence, and Stress on Sexual Health Outcomes Among Female Clinic Clients in a Small Northeastern U.S. Urban Center

Background: Threats to sexual health can emerge across one's life span and are influenced by individual and interpersonal experiences, as well as certain environmental exposures. Although previous research has recognized the importance of ecological frameworks to understand the complexity of health and behaviors in marginalized communities, there continues to be a dearth of research that truly utilizes this perspective to gain insight into the multifaceted factors that can concurrently influence threats to sexual health among women. Methods: A sample of 279 ethnoracially diverse women were recruited from a U.S. northeastern small urban center health clinic to participate in a parent study on trauma and immunity. A hierarchical block analysis was conducted to investigate associations between women's experiences of trauma, stress and violence (i.e., childhood trauma (CHT), intimate partner violence (IPV), neighborhood stressors), and sexual health outcomes and behaviors (i.e., lifetime sexually transmitted infection [STI] diagnosis, concurrent partnerships, and lifetime sex trading). Results: In the full hierarchical model, IPV and life stress trauma were associated with lifetime sex trading and partner concurrency. Also in the full model, sexual CHT was associated with lifetime STI acquisition and partner concurrency, while emotional CHT was associated with lifetime sex trading. Lastly, as neighborhood disorder increased, so did the number of lifetime sex trading partners. Conclusion: Sexual health assessments in clinical and community settings require a holistic, comprehensive, and meaningful approach to inform person-centered health promotion intervention. Prevention and treatment interventions require a focus on parents and families, and should assist adolescents and young adults to adopt therapies for healing from these experiences of trauma, violence, and stress. Interventions to enhance sexual health promotion must also include the following: advocacy for safe environments, social policy that addresses lifelong impacts of CHT, and fiscal policy that addresses economic vulnerability among women and threatens sexual health. Further recommendations are discussed.

Knowledge and Acceptability of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Ghana

In Ghana, men who have sex with men (MSM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a biomedical intervention that reduces the risk of HIV infection but is not currently available in Ghana. This paper explores knowledge and acceptability of HIV PrEP among Ghanaian MSM. Qualitative content analysis was conducted on 22 focus group discussions (N = 137) conducted between March and June 2012 in Accra, Kumasi, and Manya Krobo. Overall, participants reported low knowledge of PrEP. However, once information about PrEP was provided, there was high acceptability. The primary reason for acceptability was that PrEP provided an extra level of protection against HIV. Acceptability of PrEP was conditioned on it having minimal side effects, being affordable and efficient in preventing HIV infection. No acceptability of PrEP was attributed to limited knowledge of side effects and perceived lack of effectiveness. The reasons provided to utilize PrEP and condoms were that condoms protect against other STIs, and sexual partner factors. This is the first known study to explore PrEP knowledge and acceptability among Ghanaian MSM. It is important that key stakeholders preemptively address potential barriers to PrEP acceptability, uptake, and adherence, especially among MSM, once PrEP becomes available in Ghana.

Advancing the case for nurse practitioner-based models to accelerate scale-up of HIV pre-exposure prophylaxis

AIMS

To explore the factors that position nurse practitioners (NPs) to lead the implementation of HIV pre-exposure prophylaxis.

BACKGROUND

The HIV epidemic represents a global health crisis. Reducing new HIV infections is a public health priority, especially for Black and Latino men who have sex with men (MSM). When taken as directed, co-formulated emtricitabine and tenofovir have over 95% efficacy in preventing HIV; however, substantial gaps remain between those who would benefit from pre-exposure prophylaxis (PrEP) and current PrEP prescribing practices.

DESIGN

This is a position paper that draws on concurrent assessments of research literature and advanced practice nursing frameworks.

METHOD

The arguments in this paper are grounded in the current literature on HIV PrEP implementation and evidence of the added value of nurse-based models in promoting health outcomes. The American Association of Colleges of Nursing's advanced nursing practice competencies were also included as a source of data for identifying and cross-referencing NP assets that align with HIV PrEP care continuum outcomes.

CONCLUSIONS

There are four main evidence-based arguments that can be used to advance policy-level and practice-level changes that harness the assets of nurse practitioners in accelerating the scale-up of HIV PrEP.

RELEVANCE TO CLINICAL PRACTICE

Global public health goals for HIV prevention cannot be achieved without the broader adoption of PrEP as a prevention practice among healthcare providers. NPs are the best hope for closing this gap in access for the populations that are most vulnerable to HIV infection.

The Uses of Self and Space: Health Providers' Approaches to Engaging Patients into the HIV Care Continuum

In the context of HIV prevention, the provider-patient relationship has been found to profoundly impact HIV screening, patient initiation into HIV care, and adherence to medication following an HIV diagnosis. Given the importance of the provider-patient relationship, insight into provider approaches to cultivate such relationships is essential. Such insight could highlight considerations for provider engagement with patients that can address the current challenges in HIV prevention and treatment. This qualitative descriptive study sought to describe current health providers' approaches to engage patients into the HIV care continuum (HCC). Findings from the content and thematic analysis indicated that health providers (N = 22) used various approaches to engage patients/clients into HIV screening, and subsequent HIV care. Approaches were represented by an interpersonal process and a thematic analysis revealed the nuances in the approaches that manifested in the following themes: uses of self, normalizing disease, and engaging couples. This study demonstrated the importance for health providers to be aware of the specific context of patient's vulnerability to HIV infection and barriers to care. Self-awareness and the capability to self-reflect on one's personal practice also helped to ensure engagement of those vulnerable to infection or infected with HIV into the HCC.

Feasibility and acceptability of pre-exposure prophylaxis use among women in violent relationships

Intimate partner violence (IPV) is associated with a high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP), which does not require partner knowledge or consent, is a promising HIV risk reduction option for women experiencing IPV. Drawing on semi-structured interviews with 26 women experiencing IPV within the last six months, this study explored the feasibility and acceptability of PrEP use in this population. Slightly more than half of the women in this study expressed interest in taking PrEP when in a relationship with an abusive partner. Potential barriers to PrEP, discussed regardless of women's expressed interest in PrEP, included fear of side effects and long-term health concerns, low risk perceptions, potential partner interference, and prioritizing coping with the relationship over HIV prevention. When offering PrEP counseling, providers should inquire about IPV, as women in violent relationships may require tailored counseling to address barriers and concerns specific to their situation.

Providers' Perceptions of Couples' HIV Testing and Counseling (CHTC): Perspectives From a U.S. HIV Epicenter

Current epidemiology demonstrate the significance of couple-based HIV transmission among vulnerable U.S. populations and its contribution to health disparity in HIV prevalence. Couples HIV testing and counseling (CHTC) can be used to address couple-based HIV risk in the U.S. Though a globally recognized service, the literature lacks U.S.-based healthcare providers' (HCP) perspectives of CHTC. To address this research gap, a qualitative descriptive design was used to ascertain HCPs' perceptions about CHTC. Semi-structured in-depth interviews were conducted with 22 HCPs who were experienced with engaging patients or clients across the HIV care continuum. Overall, HCPs supported CHTC among different U.S.

POPULATIONS

Content and thematic analysis revealed HCPs perceived CHTC to be an evolution from current HIV testing approaches and a mechanism to screen people who may not otherwise. CHTC was perceived to have biomedical and bio-behavioral merit that warranted consideration for implementation within health service settings and among populations with heightened HIV risk. This strategy was perceived to be a mechanism for introducing PrEP and conception health into one's practice. CHTC also signaled patients reorienting perceptions of personal health as being linked to the health of another individual. Providers recognized that couples have evolved to be increasingly non-heteronormative and thought that CHTC should be offered to all couples. However, participants also noted that HCPs in the U.S. need to be comfortable with promoting sexual health among various populations for implementation of CHTC to be successful.

The Impact of Parental Reaction to Sexual Orientation on Depressive Symptoms and Sexual Risk Behavior Among Hispanic Men Who Have Sex with Men

PURPOSE

This study examined the relationship of parent reaction to sexual orientation with depressive symptoms and safer sex among Hispanic adult men who have sex with men (MSM). We also examined men's acculturation to the U.S. (Americanism) in relation with these variables.

METHOD

Cross-sectional data collected from July 2011 to December 2012, from 125 MSM with a mean age of 43.02years. Instruments included the Perceived Parent Reaction Scale, the Centers for Epidemiological Studies Depression Scale, the Safer Sex Behavior Questionnaire and the Bidimensional Acculturation Scale. Data was analyzed using Hierarchical generalized linear models (GZLM).

RESULTS

Among men whose parents knew of their sexual orientation, rejection of son's sexual orientation from mother (p=0.032) and from father (p=0.004) was related to higher number of depressive symptoms. Parent reactions were not directly related to safer sex behaviors. Americanism was associated with lower depressive symptoms (p=0.001) but was not related to safer sex behaviors.

CONCLUSIONS

Current parent attitudes about their sons' sexual orientation had an effect on the sons' emotional wellbeing and acculturation may play a protective role. Mental health and primary care clinicians working with Hispanic MSM should assess for level of family support and provide resources to assist with disclosure and family acceptance of sexual orientation as indicated, particularly among recently immigrated men who may be at higher risk.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Negotiated safety - components, context and use: an integrative literature review

AIM

The aim of this study was to examine the components and use of negotiated safety in the context of HIV prevention and to identify reported factors associated with the concept.

BACKGROUND

There is an emerging interest in dyadic approaches to address HIV transmission. Although there are theoretical foundations for how interpersonal relationships influence individual behaviour, how these dyadic processes influence on health is still not wholly understood.

DESIGN

Integrative review of empirical and theoretical literature.

DATA SOURCES

The Cumulative Index for Nursing and Allied Health Literature (CINAHL) MEDLINE and PsychINFO electronic databases were accessed.

REVIEW METHODS

Articles were read to gain a historical context of the term and identify varying interpretations of the concept. Factors warranting consideration in association with NS were identified and clinical and public health implications were noted.

RESULTS

Forty-eight studies were reviewed. Negotiated safety included the following components: (i) HIV sero-negative concordant men within a primary relationship; (ii) joint HIV screening and mutual disclosure of their HIV status; (iii) explicit relationship boundaries which establish either nonexclusively that allows for the dispensing of condoms within the primary relationship and consistent condom use for extra-dyadic sex; or dispensing of condoms within a primary partnership and exclusivity; and (iv) a breach clause that allows communication to re-establish the agreement if needed.

CONCLUSION

Negotiated safety is a prescriptive approach to HIV risk reduction among couples. Researchers and practitioners could benefit from promoting this approach to HIV prevention.

Facilitators and Barriers to HIV Screening: A Qualitative Meta-Synthesis

Accomplishments in biomedical research and technology, combined with innovative community and clinically based interventions, have expanded HIV testing globally. However, HIV screening and receipt of results remains a challenge in some areas. To optimize the benefits of HIV screening, it is imperative that there is a better understanding of the barriers to and motivators of testing for HIV infection. This study is a meta-synthesis of the qualitative literature on HIV screening and receipt of results; 128 unique publications had implications for HIV screening and receipt of results. A socioecological perspective provided an appropriate approach for synthesizing the literature. Three levels of influence emerged: individual attributes, interpersonal attributes, and broader patterns of influence. Findings were reviewed and found to have implications for continued engagement in the HIV treatment cascade. Recommendations to enhance HIV screening and to ensure receipt of results are proposed and discussed.

An exploration of men's knowledge, attitudes, and perceptions of HIV, HIV risk, and willingness to test for HIV in Yendi District, Northern Ghana

We explored men's HIV knowledge, perceptions of HIV risk, and willingness to test for HIV in preparation for the initiation of formalized voluntary counseling and testing (VCT) services at Yendi Hospital in Yendi District, Ghana. A multi-method approach was used, including surveys of 129 male hospital patrons, three men-only focus group discussions, and eight interviews with clinical staff at the hospital. History of condom use, perception of risk, paying for an HIV test, and age were all significantly associated (p < .05) with willingness to test. An aversion to the hospital was the most prominent theme among participants. Aversion was due to perceived lack of confidentiality, preference for traditional healers, perceived costs, and fear of testing. Our participants (a) expressed the need for VCT services, (b) recommended that VCT target men for HIV prevention and VCT patronage, and (c) thought locations outside of hospitals should provide testing services.