Homonegativity as a barrier to HIV testing intention: A qualitative study of Asian American Men Who Have Sex with Men  

Homonegativity as a barrier to HIV testing intention: A qualitative study of Asian American Men Who Have Sex with Men | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Homonegativity as a barrier to HIV testing intention: A qualitative study of Asian American Men Who Have Sex with Men Minh Luu, Eric Nehl, Wenting Huang, Regine Haardörfer, Cam Escoffery, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6580037/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Members of sexual minority groups often receive HIV diagnosis at later stages and are less likely to get tested. However, little is known about how HIV testing intention is shaped among Asian American men who have sex with men (MSM). This study explored socio-psychological factors that can influence the intention of HIV testing in this population. Using convenience sampling, we conducted three focus group discussions among Asian American MSM, regardless of their HIV testing history and HIV status. Data were analyzed employing a thematic analysis approach. We found divergent perspectives around factors influencing participants’ HIV testing intention. Facilitators of HIV testing intention included high levels of approval of testing by sex partners and health care providers. Homonegativity (negative attitudes towards homosexuality) and concerns about confidentiality of testing services were discussed as barriers to HIV testing intention among this population group. Social norms about HIV testing among general Asian community were reported to be less positive relative to among gay men groups. These findings will inform targeted programs promoting positive social views towards HIV testing and mitigating prejudices towards homosexuality in Asian American community. Asian American MSM homonegativity thematic analysis INTRODUCTION HIV testing has been widely acknowledged as an effective gateway linking HIV diagnosis to timely care and treatment for HIV, subsequently reducing the spread of HIV infection (CDC, 2018). Globally, gay, bisexual, transgender men and other men who have sex with men (MSM) are of heightened risk for HIV infection (Beyrer et al., 2013; WHO, 2016). The CDC recommends MSM should be tested for HIV annually; however, MSM at increased risk of HIV infection should be tested more frequently (3 to 6 months) (CDC, 2023). Asian American MSM, while generally found to be less aware of their HIV status due to a history of low HIV testing (Sen et al., 2017), are as likely as other racial or ethnic groups to engage in HIV-related risk behaviors (Adih et al., 2011; Wong FY. et al., 2004). It is reported that Asian Americans had the highest rate of undiagnosed HIV (22%) than any other racial and ethnic group in the U.S. (CDC, 2017). Furthermore, Asian American MSM are more likely than other racial groups to experience delayed HIV or testing due to multiple socio-psychological factors such as social norms about HIV testing, homonegativity, attitude, subjective norms, perceived behavioral control about HIV testing, and perceived HIV risk (Chng et al., 2003; Salud et al., 2014; Sen et al., 2017; Stephenson et al., 2015). However, knowledge about drivers of HIV testing intention among Asian Americans, especially Asian American MSM, has been very modest (Lee & Zhou, 2019). The limited research investigating HIV testing practices among Asian Americans MSM in the U.S. suggest that communities with stronger approval of homosexuality do positively influence HIV testing uptake (Do et al., 2006). Other psychological factors such as perceived HIV risk, attitudes , subjective norms , and perceived behavioral control about HIV testing have been widely documented as directly associated with intention of HIV testing among MSM overall (Stephenson et al., 2015) and Asian American MSM specifically (Kyung-Hee C. et al., 1998; Nemoto et al., 1998) . Nevertheless, there has been a lack of understanding about the collective influence of these socio-psychological factors on HIV testing intention among the population of Asian Americans MSM. To fill the gap, this study used qualitative methods, informed by constructs of the theory of planned behavior (TPB), to investigate how social norms about HIV testing, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control about HIV testing relate to HIV testing intention in this population. Social norms about HIV testing Social norms are “the informal rules that govern behavior in groups or societies” [p.1] (Bicchieri, 2018). In Asian cultures, it is perceived that social norms are largely influenced and shaped by social roles (Carteret, 2011; Chng et al., 2003). Individuals with higher social standing influence the shared interpretations and behaviors of others in their sociocultural circles (Chou, 2001). While research has suggested that social support and acceptance of homosexuality could be a facilitator to HIV testing among Asian American MSM (Do et al., 2006), no studies have examined the context of social norms about HIV testing and HIV testing intention in this population. It is, therefore, important to develop a better understanding of how social norms about HIV testing shape HIV testing intention among the population of Asian American MSM. Homonegativity Homonegativity is commonly defined as negative attitudes toward homosexuality (Morrison et al., 2005), and has been found to be a barrier to HIV testing among MSM communities (Goldenberg et al., 2018). However, it is unknown how this psychological factor may influence HIV testing intention among the Asian American MSM population. In behavioral research, the concept can be operationalized in two forms: external sources of homonegativity (prejudices from others towards someone’s homosexuality) and internalized homonegativity (negative feelings toward oneself when recognizing their own non-heterosexual identities) (Berg et al., 2016). This study focuses on the external homonegativity to better understand the impact of societal prejudice towards homosexuality on HIV testing intention among Asian American MSM. This construct consists of variables measuring people’s reactions to certain activities or social rights that gay men should or should not hold (Morrison & Morrison, 2003). Current literature documents no study examining homonegativity among Asian American MSM; however, the relationship between homonegativity and HIV testing has been studied among general MSM community (Ross M., 2018; Wei et al., 2016). A better understanding of the context about how homonegativity relates to HIV testing intention among Asian American MSM would be crucial for future efforts aiming at mitigating social barriers to HIV testing in this high-risk group. Perceived Risk of HIV The way people think and feel about their risk of HIV infection can influence testing behavior (Evangeli et al., 2018). Research has indicated that a higher level of perceived HIV risk is associated with stronger HIV testing intention (Grover & Miller, 2014; Salud et al., 2014). Examining the relationships between perceived HIV risk and HIV testing among populations at high risk for HIV transmission, including young MSM, has been a major focus among research (Clifton et al., 2016). However, the literature has mainly documented the relationships of sexual risks and risk perception with HIV testing among non-Asians, and Asians living in Asia (Lorenc et al., 2011) and very little is known among Asian Americans. We aim to fill this gap by exploring how perceived HIV risk might play a role in shaping Asian American MSMs’ HIV testing intentions. Other psychological factors influencing HIV testing intention The theory of planned behavior (TPB) has played an important role in guiding research on HIV testing (Evangeli et al., 2018). It offers theoretical underpinnings to investigate psychological factors driving HIV testing intentions (Abamecha et al., 2013). Research employing the TPB has suggested that positive testing attitudes, stronger beliefs in social pressure to test, and greater perceived behavioral control towards testing are associated with greater HIV testing intention in general population (Evangeli et al., 2016; Mirkuzie, 2011). Among young American MSM, the TPB has been found useful in examining predictors of HIV testing, especially when taking into consideration other factors, such as exposure to HIV information, self-rated HIV knowledge, and use of information to make HIV-testing decisions (Meadowbrooke et al., 2014). It was suggested that the TPB’s constructs with the added direct effects of other information-related factors explained 41.9% of the testing intention – better than the TPB framework solely (18.1%) (Meadowbrooke et al., 2014). However, across existing literature on HIV testing, there is a gap in the application of the TPB in assessing HIV testing among Asian Americans. In the absence of similar studies using the TPB to specifically assess HIV testing behavior among Asian Americans, evidence of the utility of the TPB to HIV testing research has implications for advancing our knowledge about theory-informed determinants of HIV testing intention among Asian American MSM. Altogether, this qualitative study seeks to deepen our insights of socio-psychological factors (social norms, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control) relating to the HIV testing intentions of Asian American MSM. Findings will be used to inform future interventions that promote HIV testing in this racial and sexual minority group. METHODS Participants and Data Collection This study is a part of a larger mixed-methods research program focusing on understanding socio- psychological factors influencing HIV testing intentions among Asian American men. From September to December 2021, we conducted three online focus groups using a convenience sample of 18 Asian American MSM living all over the U.S. The eligibility for participants included: 1) self-identified Asian American MSM; 2) aged 18 years and older; and 3) being a resident in the U.S. for a minimum of 6 months. Participants were recruited from several channels: 1) participants from a previous quantitative component (first phase) of the research program; 2) a community organization serving Asian Americans with a focus on health, education, and legal services; and 3) a self-help group of Asian American gay men. The sample size of 18 participants, divided into 3 groups of 6 participants, was determined following recommendations for qualitative sample size needed to achieve code and meaning saturation (Hennink et al., 2010; Maxwell, 2012; Onwuegbuzie et al., 2009). Prior to each focus group discussion, participants were sent an email with information about potential meeting dates and times for their selection, as well as a consent form for them to review and confirm participation. Among 25 invited participants, 19 responded including 18 who agreed to participate in the focus groups (72% response rate), one initially expressed interest but later withdrew due to personal reasons. Focus group discussions were organized by the first author, a Vietnamese female doctoral-level researcher with advanced training and experience in qualitative research, and a research assistant, serving as moderator, who has substantial knowledge and community connections with the population of Asian American MSM. The first author also served as assistant moderator, as needed, and note taker during the focus groups. All discussions were held in English and via the Zoom online meeting platform. Each discussion session lasted between 90 and 100 minutes and was audio-recorded. Participants received a $30 Amazon gift card to compensate for their time and study participation. The study protocol was approved by the Institutional Review Board at xxxx University. The focus group discussion guide was developed based on techniques recommended by Nyumba and colleagues that outlined key steps in qualitative research design using focus group discussion methods (O.Nyumba et al., 2018). First, we identified the main aim of the study being to explore how the proposed socio-psychological factors influence HIV testing intention among Asian American MSM. Based upon this aim, we prepared a list of primary questions and related prompts to be used as a guide in each focus group discussion session. The guide was developed drawing on existing literature about HIV testing intention among young adult men (Ayodele, 2017; Meadowbrooke et al., 2014) using the TPB (Ajzen, 2013). The guide began with general questions about knowledge of HIV testing. Primarily informed by the TPB constructs and supplemented by key findings from the previous quantitative component of our team’s research studies, we constructed specific questions that discussed how social norms about HIV testing, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control about HIV testing might influence HIV testing intention. One question at the end of the guide included probes to allow comments, ideas, and recommendations regarding strategies to promote HIV testing among Asian American MSM. Examples of questions and probes are listed in Appendix. Before conducting the focus group discussions, we pilot-tested the guide with members of our research team (the moderator and one research collaborator from a community organization) who are Asian American MSM, have substantial knowledge and understanding of the study population as well as extensive experience in conducting focus group discussions. The guide was revised and finalized based on feedback and comments from the testers. In addition to focus group discussion data, we also collected basic sociodemographic characteristics of the participants, including age, education, employment, and marital status after the completion of each focus group discussion session. The demographic survey was conducted via email after the focus groups. Response to the sociodemographic questions was optional. Recordings of the three focus group discussions were transcribed verbatim by a professional transcriber. Data Analysis We employed a mixed qualitative thematic analysis that utilized both deductive and inductive approaches (Fereday & Muir-Cochrane, 2006). First, our team of two coders (the first author and a doctoral-level research assistant specializing in behavioral science and qualitative research) developed an initial framework of codes and sub-codes from the focus group discussion guide. The team then read all three transcripts carefully and developed a codebook with code definitions, inclusion criteria, exclusion criteria and examples. Throughout the review, recurring explanatory statements were identified and classified into thematic units, including negative or divergent comments to add rigor to the results of our qualitative analysis (Stewart, 1990). With the TPB as the guiding framework and other related socio-psychological determinants of HIV testing intention, including social norms about HIV testing, homonegativity, and perceived HIV risk, we categorized emergent themes based on the key constructs. For example, quotes related to ‘negativity’ but not directly corresponding to homonegativity and HIV testing intention, we categorized as ‘negativity-within MSM group’, ‘negativity-outside MSM group’ or ‘negativity-religion related’. We then used the codebook to independently code all three transcripts in parallel. During the coding process, we regularly discussed ideas, questions, or concerns as they arose. We resolved any discrepancies through theoretically informed deliberations that involved rereading of the transcripts, reviews of notes taken from all three focus group discussions, as well as our knowledge of HIV prevention among Asian American MSM. During the analytic process, we leveraged several techniques to ensure validity in qualitative research, including analyst triangulation (two analysts to review findings), and negative case analysis (discussions of elements that would deem contradictory to normal cases) (Creswell & Miller, 2000; Golafshani, 2003). Descriptive analysis of demographic data was performed using Microsoft Excel Worksheet @ . RESULTS Sample characteristics We conducted three focus group discussions with 18 participants; each session had 6 people. Only four participants responded to the online demographic survey. Due to the low response, we could not characterize the demographics of the sample. Research findings Across the three focus groups, there were no major differences in perspectives related to how the socio- psychological factors influenced HIV testing intention among the participants. Themes emerged from each of the six constructs with sample quotes are presented in Table 1. We identified 18 themes from the topics that were present at least in two out of three focus group discussions and discussed by at least two participants in each group (Buetow, 2010; Padela et al., 2016). Stronger themes, defined as common subjects mentioned in all three focus discussions, or themes of novel and strongly relevant insights, are highlighted below. Social Norms about HIV testing and HIV testing intention. As part of this study, we explored perceptions of HIV testing behavior that Asian MSM felt represented the overall Asian community and within their groups of gay men. When talked about what they knew of the HIV testing intentions of other Asian community members, participants shared different perspectives. For the broader community of Asian Americans , participants discussed negative perceptions HIV testing intentions. For example, one participant recalled: “ So other Asians, I feel most of them, they're so reluctant to go for the tests, because they feel that they will face some stigma. And then being pointed that they are [sic], for example, if they're positive, and so people laugh at them, and they will also isolate them. ”. Another participant concurred: “ So I think most of them do not want to go for the tests because of being Asians. People maybe see it as that it is maybe [sic] embarrassing. Yeah, most of them are not comfortable .”. Negative social norms about HIV testing also were mentioned as a potential barrier to Asian MSM as it comes to personal motivation to get a HIV test. One participant described: “ As for me, I think the testing behavior of those who are surrounding me, I have come to find out that these guys are a little bit shy and reluctant to go to testing as suggested, because I've never had maybe some in a group discussing about maybe testing for HIV and AIDS ”. Another participant recalled: “ And then being pointed that they are, for example, if they're positive, and so people laugh at them, and they will also isolate them.” In contrast, within the community of MSM, participants felt positive social norms towards HIV testing from their peers and friends . One participant stated: “ There is a handful of very close friends of mine who has discussed this with me. For some reason they mention they're going to get tested or whatever .” This was further supported by another participant who recalled: “ I don't think there's any issues at all, with my immediate friends around this topic at all .” Additionally, most of participants had experienced positive influence from their peers in relation to HIV testing. A stigma-free community, positive social norms, and peer influence were discussed as facilitators of getting someone tested. One participant asserted: “ I think everyone just knows that it's something you should do if you're having open relationships or promiscuous sex or whatnot with another partner. So, I don't think there's any issues or stigmatism, within my network of friends .” Another participant added: “ As humans, I think that knowing when somebody else is doing something would also encourage you or would motivate you to do something”. Another participant voiced his own belief: “Well, so I think a lot of my friends, gay Asians or Caucasians or whatever, it doesn't matter. Yeah, I feel very confident getting it and if my peers are getting tested then why not ?”. Homonegativity and HIV Testing Intention. Homonegativity refers to prejudices or negative attitudes toward homosexual individuals (Morrison & Morrison, 2013). We explored participants’ experiences of homonegativity and how those experiences might influence their HIV testing intention. The majority of participants across all focus groups shared their thoughts and experiences being stigmatized as Asian MSMs . One participant said: “ First of all, they usually think if you’re gay, you will have AIDS and you will die. That’s one. And number two, one of my best friend’s moms actually think we are a disease and not who you are ”. Another added: “ So she told my best friend like, ‘Oh, I feel so bad that your friend is sick’, and my friend was like, ‘What are you talking about?’ And then her mom was like, ‘Because he is gay. He has an illness’ ”. The consequence of homonegativity on the first-time participants sought HIV testing services was reported as a novel thematic insight. Several comments were made in relation to their first-time testing, with their primary concern being the underlying risk of personal information leaking to their family. One exclaimed: “ It was very difficult decision the first time I went. When I was further from my family, it was easier ”. Another participant said: “ Okay, I wanted to say that, for me at first, the stereotyping of me as an MSM--as an Asian MSM. It makes you not want to go. So as time went by, I have had the courage and it no longer affects ”. This comment was supported by another participant who said: “ I remember P say that the stigmatization in school caused him to be scared about getting tested [at first] ”. Differences in the experience of homonegativity within Asian sub-cultures emerged as another strong topic of discussion. Homonegativity as the barrier to HIV testing, if any, appeared to come from family, especially those from South Asian cultures. One said: “ And I know that there are some family members of mine who are particularly sensitive to how others think and those are the people who I worry about, I suppose sometimes ”. Another participant shared: “ So far, the negative connotation, in my experience has been from my more conservative family members who, again, they just perceive sexual promiscuity, or sexual activity to be done post-marriage ”. Unique cultural dynamics of South Asian communities were also discussed as an emerging theme when it came to the societal and family approval of homosexuality and homonegativity towards gay men. To elucidate the context, one participant from South Asia reported: “ I think about that, that there's an intersectionality with religion a lot in a lot of South Asian cultures that a lot of my East Asian friends don't experience when it comes to East Asian MSMs versus South Asian MSMs and there's often a very big difference ”. Another participant shared additional views: “ But I think this is experienced a lot in other Asian cultures, which is like those, the aunties on the top of the buildings with binoculars ”. Additionally, participants voiced their concern about the relationship between homonegativity and immigration status and/or education . One participant said: “ Education is the problem with those who express homonegativity ”. Another one added: “ Yeah, I'm kind of thinking about maybe building off of K's comment about maybe older generational Asian communities may view relationships and sex more conservatively than the younger generation and also Asian Americans versus Asian-Asian, where maybe, the view of somebody who's heterosexual would be to, once they're an adult, find a partner, have children settle down, and all that ”. Perceived HIV risk and HIV testing intention. The way people perceive their own risk of HIV acquisition impacts their testing intention (Evangeli et al., 2018). In this study, we found that risk perception was strongly reported to influence Asian MSM’s intention of HIV testing, and this was primarily derived from the sexual HIV risk behaviors, including high frequencies of sexual intercourse and having multiple sex partners and. Regarding the perceived risk related to having multiple sex partners , one participant reflected: “ But for example, if I have had sex with multiple partners who I’m not aware of their status, then I definitely will be concerned and definitely I will want to know my health, or rather, my status because I do not know the status of these people ”. A different participant said: “ So, I think, when I was seeing multiple partners, or promiscuous or whatever, I did get tested on a six-month basis when I have protected sex. ” A heightened frequency of sexual activities was discussed as directly related to perceived HIV risk. Almost all participants stressed that, for them, the importance of getting tested depends on the frequency of sexual intercourses. One said: “ So to me, what can push me towards getting testing is if I have maybe many different partners and we have the sex for[sic] frequently ”. Another participant contributed: “ Right, definitely multiple [partners], especially ones you don't know, and also even the safety-ness of the sex, either wearing in a condom or not, either scenario you want to get tested, but I think the frequency, the amount of time you go get tested, would change based upon how safe you are in your sexual activities ”. Constructs of the TPB. Attitudes towards HIV testing. Participants shared detailed accounts of their thoughts and beliefs towards HIV testing. While individual perspectives varied, they centered around the positive or negative aspects of HIV testing behavior, as well as the anticipated outcomes of testing. Most participants expressed positive attitudes about HIV testing . However, different reasons emerged about why taking an HIV test was encouraging to them. Several participants indicated that knowing their HIV status would mitigate their uncertainty and subsequently help them navigate care services as appropriate. For example, one participant reflected: “ There are many benefits of getting tested for HIV. The first benefit is that the test is fast and easy. And the last benefit is that it can give you peace of mind ”. Another participant added: “ I'd say yeah, like, just the health benefits is just too many health benefits to even considering not getting one, not only for yourself to make sure that on the chance that you do, gosh, you ever do receive HIV that it's important to, to find out immediately and then just take care as soon as possible to manage the viral load ”. Aligned with these positive sentiments about HIV testing, several other participants also mentioned that seeing HIV testing as a regular health seeking behavior would help normalize the topic in public. For example, one participant brought up: “ I think, yeah socially, it's a good benefit for more people to take it more often, you know, have people talk about it, because then the taboo becomes less and less, you know ”. When expressing their behavioral beliefs or evaluation of behavioral outcomes about HIV testing, most participants agreed that HIV testing is important, convenient, and it would help people protect themselves and their sex partners, as well as providing the benefit of getting early to care if they need to. One participant emphasized that: “ And I think that's something that we've forgotten or not realized, that you having a positive test is not a death sentence like it used to be in the 80s ”. Concerns about confidentiality were reported as factors that hinder participants’ intention to get tested. One participant wondered: “ How many people will know about what your sexual activities and yeah, like it just something you want to keep very close to the chest . I'd say the costs, again, it's like, then you've got to weigh the social costs. ”. The concern was furthered by another participant: “ Yeah, because I don't--with my primary care provider, I am not I’m open about it and I think partly because that primary care provider is connected with like, it's also a provider to my family members. And so, I cannot, I don't even want to think about that ”. Subjective norms about HIV testing. In this section, we explored participants’ perception of the expectations from partners, friends, families, and other acquaintances towards their HIV testing intention (normative beliefs), as well as their motivation to respond to those expectations (motivation to comply). Overall, there was strong agreement among participants that HIV testing was a private matter and they considered sexual partners, primary health care providers, and peers being the most trusted individuals supporting their intention of HIV testing. One participant said: “Don't know about the other Asian MSM but to me and my partner we took that responsibility to go getting tested after every six months.”. Speaking of expected approval on HIV testing intention and trust in someone regarding HIV testing intention, a participant described: “ I guess if I feel like I need to get testing, I would definitely consult with my partner. So that's one. Then the other person would be my physician because that's probably where I would go get testing. ”. Another participant added: “So when it comes to my peers, and me speaking to them, they are supportive.” Not surprisingly, the majority of participants did not think it would be appropriate to discuss HIV testing with their family. A participant revealed: “ I don't usually talk to my family about this stuff. Ironically, I'm very receptive to HIV testing, but most of them aren't .” Another participant reported: “ Because I cannot afford like, I mean, I have one or two family members who know, but it's a very touchy subject and it's just even indulging the conversation on something that would relate to this is touchy. So, I've just kind of stopped it there. ” Regarding motivation to comply, all participants agreed that having themselves tested for HIV would align with the expectation of their sexual partner, advice from their health care provider, and because they cared for their health . One participant mentioned: “ So I think I would just lean on people who are on the need-to-know basis, and that's basically my sexual partner, and the physician .” Another participant added: “ It's my health and it's just all for me. And just before I get the testing, if it's at a clinic, your physician will probably be the one to give you counseling advice before and also after you get the test. ” None of the participants mentioned religious leaders or community leaders as their source of support or someone they would turn to for advice in the context of HIV testing. Perceived behavioral control of HIV testing and HIV testing intention. The majority of participants indicated that they believed in their ability to get tested for HIV . In addition to factors highlighted as facilitators to HIV testing, such as availability, affordability, and accessibility to home testing, having a primary care physician was mentioned as an important support system that enables their HIV testing plan. One participant said: “ So you know, like, when in doubt, I just go and talk to my not even go and talk to him, I just send him a message through the portal, say, ‘Hey, Doc, can you write me order for HIV test?’ and he just probably will ”. Most participants agreed that getting an HIV test was easy and at no cost at many different locations. One participant described: “ I also know that at pride events, the festivals, there's always testing freely available--free--to anyone to come in and take the test and these tests are--you get results within five to 10 minutes now ”. Another shared his experience about how easy it is for him to get tested: “ With being in an educational sort of an institution, they often have a very easy way to get it done and I recall, that's how I initially got my first one as well was through my university and their student health center ”. In addition, not having to worry about testing cost was mentioned as a positive driver of their actual HIV testing behavior. One said: “ So it's all covered, like everything is all taken care of ”. Another participant expressed his positive view about HIV testing: “ So if you do test positive, there are people there who discussed and counsel you on how to deal with those positive results ”. Participants repeatedly mentioned the convenience and accessibility of HIV testing across different venues, including clinic, home-based testing, and others. One participant shared: “ Okay, I can say that HIV testing is very easy, since you only--there are some home test kits being sold in pharmacy and convenience store ”. Another one added: “ And I know there's also nonprofit organizations such as here in Atlanta, we have AID Atlanta that provides these tests freely available to any person that would like to get tested ”. DISCUSSION This study is one of the first efforts to explore socio-psychological factors relating to HIV testing intention among Asian American MSM. Our findings are generally aligned with existing literature related to barriers and facilitators to HIV testing among the population of Asian Americans (Evangeli et al., 2016; Lorenc et al., 2011). The study also provides important insights into the cultural dynamics with regards to familial approval of homosexuality within South Asian communities. Overall, participants expressed diverse views towards the role of social norms on their HV testing intention. First, our primary results indicated that Asian American MSM perceived positive social norms about HIV testing within the gay community, but that the social norms were less supportive in their families or broader Asian American community. These results correspond with a study among Chinese MSM which found that perceived norms regarding HIV testing was strongly associated with regular HIV testing (Zhao et al., 2020). In the absence of similar evidence specific to the Asian American MSM population, this finding seems to support our observation that when individuals perceive the prevalent norms of HIV testing in their social circle, they would be more likely to engage in HIV testing behavior. On the other hand, participants reported that HIV testing was less common among those outside of their gay community, including their families. This dynamic could be explained via the context of socio-cultural norms among Asian immigrants. In many U.S. Asian communities, Asian American MSM often experience family- and community-level stigmatizing beliefs due to their homosexuality, which is considered non-conforming to traditional values such as sexual activity as a means to maintain family lineage (Bhattacharya, 2004). Seeking a HIV test may be seen to be associated with shame on family or community because it represents a deviation from the Asian cultural norms that classify homosexuality as taboo (Chng et al., 2003; Yoshikawa et al., 2003). These cultural characteristics may explain the differences in the way participants perceived HIV testing norms within their networks versus family and broader U.S. Asian communities in our study. Homonegativity was reported to be a common barrier to HIV testing, especially for those testing for their first time in this study. Additionally, it was suggested that newly immigrated Asians and individuals with lower education would hold higher level of homonegativity towards Asian American MSM. Research has suggested that perceptions of community stigma on homosexuality may have negative impacts on HIV testing intentions among American MSM (Iott et al., 2022; Lorenc et al., 2011). In our study, we focused solely on community prejudice and its impact on HIV testing intention and our results is consistent with the existing literature. Our finding of elevated homonegativity among new immigrants is supported by Bracht et al. (2014) which suggested that new immigrants to a western country would have greater disapproval of homosexuality and that would decline over time (Van der Bracht & Van de Putte, 2014). This finding is further supported by a study by Röder et al. (2015) indicating that negative prejudices towards homosexuality is stronger among the first generation of immigrants compared to the second generation (Roder A, 2015). Regarding the finding that homonegativity appeared more recognizable among individuals with low education, Oyarce-Vildósola et al. (2022) found that people with education attainment of high school or higher would have lower level of homonegativity compared to those without high school education (Oyarce-Vildósola et al., 2022). While no studies have addressed this phenomenon among Asian American immigrants, these studies help explain our initial observation that Asian American MSM perceive that new immigrants and individuals of low education attainment might hold stronger homonegativity towards Asian American MSM communities, as discussed in our focus groups. Another finding indicated that HIV risk perception , based upon actual risk behaviors such as frequency of sexual activities and unprotected sexual intercourse, drove participants decisions related to HIV tested. The positive relationship between perceived risk and HIV testing intention is supported by results of previous studies. In a systematic review by Lee and colleagues, it was found that risk perception is one of the barriers to whether to get tested for HIV among Asian Americans (Lee & Zhou, 2019). Among all Americans, Spielberg and colleagues found that individual-level factors such as HIV risk perceptions and HIV knowledge were commonly reported as facilitators of HIV testing and that an acknowledged risk history was a key factor in many people’s decision to seek an HIV test (Spielberg et al., 2001). Lastly, psychological factors including attitudes, subjective norms, and perceived behavioral control towards HIV testing were found to have impacts on the HIV testing intentions of Asian American MSM. There was a strong consensus that participants cared about their health and took responsibility for protecting themselves by knowing their HIV status. Nevertheless, some expressed concern about confidentiality. Sexual partners and physicians were the biggest influencers towards HIV testing behavior among Asian American MSM and they held strong personal beliefs that they could manage a HIV test when needed. The diverse attitudinal beliefs towards HIV testing documented in this study among Asian American MSM are supported by existing literature. While MSM in general, and Asian MSM specifically generally were found to have a positive sense of responsibility to protect oneself or one’s partner, concerns related to privacy and confidentiality, especially among those of minority backgrounds and/or experiences of migration, would be specific barriers to HIV testing (Evans et al., 2016; Figueroa et al., 2015; Lee & Zhou, 2019; Lorenc et al., 2011; Nicholls et al., 2022). Additionally, our findings highlight the social cost associated with HIV testing. This was described as the fear among Asian American MSM that their deviation from the conventional sex role standards of traditional Asian society would be disclosed if they get tested for HIV. Though the research team is not aware of previous studies that have examined this aspect among Asian American MSM, studies among general MSM have indicated that perceptions of stigma, from other gay men or the general public acts as barrier to HIV testing (Lorenc et al., 2011; Solorio et al., 2013). As stigma towards homosexuality in Asian societies has been widely recognized (CPACS, 2018; Ju, 2021; Vlassoff & Ali, 2011), this could help explain the finding related to the social cost of HIV testing in this study. Related to subjective norm s about HIV testing, we found strong agreement among participants that partners and physicians offer frontline support to their HIV testing intention and that most of them do not consider their family as a source of support. While a study by Lorenc et al. suggested that desire to protect oneself or one’s partner may be a motive for HIV testing in MSM of other ethnicities (Lorenc et al., 2011), this observation appeared to support the finding from our study that Asian American MSM have a mutual desire to protect each other by supporting their partner’s intention to seek HIV testing. Conversely, the lack of support from family to MSM when it comes to HIV testing has been observed in a study by Wong et al. (2012). As it is common that Asian American MSM keep their sexual orientation undisclosed to their family, the hesitancy to confide in their family with intention for HIV testing is understandable (Wong et al., 2012). Additionally, our finding is supported by a study by Solorio and colleagues (2012), where they documented negative attitudes towards HIV testing by family members among Latino immigrant MSM and suggested this may hinder HIV testing intention within this population (Solorio et al., 2013). Our study found important observations relating to the unique familial (e.g., multi-generation family living arrangements) (Yeung et al., 2018) and cultural dynamics (e.g., family obligations and loyalty to the elders) (Shariff, 2009) towards homosexuality among those of South Asian heritages. Literature on this topic is limited (Kumar, April 2013); however, it is evident that South Asian gay men bear pressure from their parents concerning their homosexual identity (Deepak, 2005). Specifically, many South Asian parents consider homosexuality unfit to their cultural norms (Estrada & Rutter, 2006). This interplay helps explain our finding that South Asian gay men would not turn to their family for sexual matters and HIV testing discussions. Our study found strong perceived behavioral control towards HIV testing across all participants. The finding that perceived behavioral control positively influenced HIV testing intention aligns well with existing literature where TBP has been used as the underlying theoretical framework. Multiple studies have affirmed that when individuals found it easy to get HIV tested, they would be more likely to engage in HIV testing behavior (Hogben et al., 2003; Meadowbrooke et al., 2014; Mirkuzie, 2011). Altogether, findings from our study are supported by existing literature and offer important novel insights of the influence of socio-psychological factors on the HIV testing intentions of the population of Asian American MSM. LIMITATIONS Although this is one of the first studies to explore factors influencing HIV testing intention in the population of Asian American MSM, it does have limitations. First, the study was limited to participants who had access to the internet and the Zoom platform. This data collection method could have introduced selection bias because it limited participation to those who had access to the internet, thus hindering the generalizability of our findings. Second, social desirability bias may present a challenge in data quality. Topics discussed in the focus group discussions were personal and sensitive. Efforts by the research personnel to ensure research protocols, including assurance of privacy and confidentiality, were implemented. However, only four out of eighteen participants were willing to provide personal demographic information at the end of the focus group discussions. Last, the discussions were held fully in English, thus, participants who were not fluent might have not been able to articulate their thoughts comfortably. Future studies should consider these limitations in the design and implementation to facilitate broader participation and better data collection. NEW CONTRIBUTION TO THE LITERATURE Findings from this study have important implications for developing interventions to promote HIV testing among the population of Asian American MSM. Understanding the influence of social and psychological factors on HIV testing intention among this minority group would help policy-making agencies, health service providers and community organizations better mobilize resources to address underlying barriers and promoting facilitators to HIV testing intention through initiatives that are culturally relevant and appropriate, especially for the first-time testers and the community of gay men originally from South Asia. Specifically, our largest themes echoed previous research indicating that homonegativity, an underlying barrier to HIV testing, is strongly present among heterosexual male population (Herek, 1988) and underscored the association between perceived HIV testing social norms and HIV testing (Lee & Zhou, 2019). These factors should be taken into consideration in designing future intervention programs. As addressing sensitive topics such as homonegativity and HIV testing social norms may require a community-based approach through social networks (Veinot et al., 2016), HIV program implementers could adopt strategies that have been suggested elsewhere, including the captivation of network homophily (e.g. targeting groups sharing similar social and demographic characteristics) (Veinot et al., 2016) or group interventions (e.g. classroom-based, computer-based, or community-based) for younger individuals, such as college students (Burk et al., 2018; Cotten-Huston & Waite, 2000). Taken together, our results could help public health efforts in increasing HIV testing and meeting other health needs of this racial and sexual minority group – Asian American MSM. Declarations Statements and Declarations: The authors declare that they have no competing interest. 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Globally, gay, bisexual, transgender men and other men who have sex with men (MSM) are of heightened risk for HIV infection (Beyrer et al., 2013; WHO, 2016). The CDC recommends MSM should be tested for HIV annually; however, MSM at increased risk of HIV infection should be tested more frequently (3 to 6 months) (CDC, 2023). Asian American MSM, while generally found to be less aware of their HIV status due to a history of low HIV testing (Sen et al., 2017), are as likely as other racial or ethnic groups to engage in HIV-related risk behaviors (Adih et al., 2011; Wong FY. et al., 2004). \u0026nbsp;It is reported that Asian Americans had the highest rate of undiagnosed HIV (22%) than any other racial and ethnic group in the U.S. (CDC, 2017). Furthermore, Asian American MSM are more likely than other racial groups to experience delayed HIV or testing due to multiple socio-psychological factors such as social norms about HIV testing, homonegativity, attitude, subjective norms, perceived behavioral control about HIV testing, and perceived HIV risk (Chng et al., 2003; Salud et al., 2014; Sen et al., 2017; Stephenson et al., 2015). However, knowledge about drivers of HIV testing intention among Asian Americans, especially Asian American MSM, has been very modest (Lee \u0026amp; Zhou, 2019).\u003c/p\u003e\n\u003cp\u003eThe limited research investigating HIV testing practices among Asian Americans MSM in the U.S. suggest that communities with stronger approval of homosexuality do positively influence HIV testing uptake (Do et al., 2006). Other psychological factors such as \u003cem\u003eperceived HIV risk,\u003c/em\u003e \u003cem\u003eattitudes\u003c/em\u003e, \u003cem\u003esubjective norms\u003c/em\u003e, and \u003cem\u003eperceived behavioral control about HIV testing\u003c/em\u003e have been widely documented as directly associated with intention of HIV testing among MSM overall (Stephenson et al., 2015) and Asian American MSM specifically (Kyung-Hee C. et al., 1998; Nemoto et al., 1998) . Nevertheless, there has been a lack of understanding about the collective influence of these socio-psychological factors on HIV testing intention among the population of Asian Americans MSM. To fill the gap, this study used qualitative methods, informed by constructs of the theory of planned behavior (TPB), to investigate how social norms about HIV testing, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control about HIV testing relate to HIV testing intention in this population.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSocial norms about HIV testing\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eSocial norms are “the informal rules that govern behavior in groups or societies” [p.1] (Bicchieri, 2018).\u0026nbsp;In Asian cultures, it is perceived that social norms are largely influenced and shaped by social roles\u0026nbsp;(Carteret, 2011; Chng et al., 2003). Individuals with higher social standing influence the shared interpretations and behaviors of others in their sociocultural circles\u0026nbsp;(Chou, 2001). While research has suggested that social support and acceptance of homosexuality could be a facilitator to HIV testing among Asian American MSM\u0026nbsp;(Do et al., 2006), no studies have examined the context of social norms about HIV testing and HIV testing intention in this population. It is, therefore, important to develop a better understanding of how social norms about HIV testing shape HIV testing intention among the population of Asian American MSM.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eHomonegativity\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eHomonegativity is commonly defined as negative attitudes toward homosexuality (Morrison et al., 2005), and has been found to be a barrier to HIV testing among MSM communities (Goldenberg et al., 2018). However, it is unknown how this psychological factor may influence HIV testing intention among the Asian American MSM population. In behavioral research, the concept can be operationalized in two forms: external sources of homonegativity (prejudices from others towards someone’s homosexuality) and internalized homonegativity (negative feelings toward oneself when recognizing their own non-heterosexual identities) (Berg et al., 2016). This study focuses on the external homonegativity to better understand the impact of societal prejudice towards homosexuality on HIV testing intention among Asian American MSM. This construct consists of variables measuring people’s reactions to certain activities or social rights that gay men should or should not hold (Morrison \u0026amp; Morrison, 2003). Current literature documents no study examining homonegativity among Asian American MSM; however, the relationship between homonegativity and HIV testing has been studied among general MSM community (Ross M., 2018; Wei et al., 2016). A better understanding of the context about how homonegativity relates to HIV testing intention among Asian American MSM would be crucial for future efforts aiming at mitigating social barriers to HIV testing in this high-risk group.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003ePerceived Risk of HIV\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe way people think and feel about their risk of HIV \u0026nbsp;infection can influence testing behavior (Evangeli et al., 2018). Research has indicated that a higher level of perceived HIV risk is associated with stronger HIV testing intention (Grover \u0026amp; Miller, 2014; Salud et al., 2014). Examining the relationships between perceived HIV risk and HIV testing among populations at high risk for HIV transmission, including young MSM, has been a major focus among research (Clifton et al., 2016). \u0026nbsp;However, the literature has mainly documented the relationships of sexual risks and risk perception with HIV testing among non-Asians, and Asians living in Asia (Lorenc et al., 2011) and very little is known among Asian Americans. We aim to fill this gap by exploring how perceived HIV risk might play a role in shaping Asian American MSMs’ HIV testing intentions.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eOther psychological factors influencing HIV testing intention\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe theory of planned behavior (TPB) has played an important role in guiding research on HIV testing (Evangeli et al., 2018). It offers theoretical underpinnings to investigate psychological factors driving HIV testing intentions (Abamecha et al., 2013). Research employing the TPB has suggested that positive testing attitudes, stronger beliefs in social pressure to test, and greater perceived behavioral control towards testing are associated with greater HIV testing intention in general population (Evangeli et al., 2016; Mirkuzie, 2011).\u003c/p\u003e\n\u003cp\u003eAmong young American MSM, the TPB has been found useful in examining predictors of HIV testing, especially when taking into consideration other factors, such as exposure to HIV information, self-rated HIV knowledge, and use of information to make HIV-testing decisions (Meadowbrooke et al., 2014). It was suggested that the TPB’s constructs with the added direct effects of other information-related factors explained 41.9% of the testing intention – better than the TPB framework solely (18.1%)\u0026nbsp;(Meadowbrooke et al., 2014). However, across existing literature on HIV testing, there is a gap in the application of the TPB in assessing HIV testing among Asian Americans. In the absence of similar studies using the TPB to specifically assess HIV testing behavior among Asian Americans, evidence of the utility of the TPB to HIV testing research has implications for advancing our knowledge about theory-informed determinants of HIV testing intention among Asian American MSM. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAltogether, this qualitative study seeks to deepen our insights of socio-psychological factors (social norms, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control) relating to the HIV testing intentions of Asian American MSM. Findings will be used to inform future interventions that promote HIV testing in this racial and sexual minority group. \u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003e\u003cstrong\u003eParticipants and Data Collection\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study is a part of a larger mixed-methods research program focusing on understanding socio- psychological factors influencing HIV testing intentions among Asian American men. From September to December 2021, we conducted three online focus groups using a convenience sample of 18 Asian American MSM living all over the U.S. The eligibility for participants included: 1) self-identified Asian American MSM; 2) aged 18 years and older; and 3) being a resident in the U.S. for a minimum of 6 months. Participants were recruited from several channels: 1) participants from a previous quantitative component (first phase) of the research program; 2) a community organization serving Asian Americans with a focus on health, education, and legal services; and 3) a self-help group of Asian American gay men. The sample size of 18 participants, divided into 3 groups of 6 participants, was determined following recommendations for qualitative sample size needed to achieve code and meaning saturation (Hennink et al., 2010; Maxwell, 2012; Onwuegbuzie et al., 2009). Prior to each focus group discussion, participants were sent an email with information about potential meeting dates and times for their selection, as well as a consent form for them to review and confirm participation. Among 25 invited participants, 19 responded including 18 who agreed to participate in the focus groups (72% response rate), one initially expressed interest but later withdrew due to personal reasons. \u0026nbsp;Focus group discussions were organized by the first author, a Vietnamese female doctoral-level researcher with advanced training and experience in qualitative research, and a research assistant, serving as moderator, who has substantial knowledge and community connections with the population of Asian American MSM. The first author also served as assistant moderator, as needed, and note taker during the focus groups. All discussions were held in English and via the Zoom online meeting platform. Each discussion session lasted between 90 and 100 minutes and was audio-recorded. Participants received a $30 Amazon gift card to compensate for their time and study participation. The study protocol was approved by the Institutional Review Board at xxxx University.\u003c/p\u003e\n\u003cp\u003eThe focus group discussion guide was developed based on techniques recommended by Nyumba and colleagues that outlined key steps in qualitative research design using focus group discussion methods (O.Nyumba et al., 2018). First, we identified the main aim of the study being to explore how the proposed socio-psychological factors influence HIV testing intention among Asian American MSM. Based upon this aim, we prepared a list of primary questions and related prompts to be used as a guide in each focus group discussion session. The guide was developed drawing on existing literature about HIV testing intention among young adult men (Ayodele, 2017; Meadowbrooke et al., 2014) using the TPB (Ajzen, 2013). The guide began with general questions about knowledge of HIV testing. Primarily informed by the TPB constructs and supplemented by key findings from the previous quantitative component of our team’s research studies, we constructed specific questions that discussed how social norms about HIV testing, homonegativity, perceived HIV risk, attitudes, subjective norms, and perceived behavioral control about HIV testing might influence HIV testing intention. One question at the end of the guide included probes to allow comments, ideas, and recommendations regarding strategies to promote HIV testing among Asian American MSM. Examples of questions and probes are listed in Appendix.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore conducting the focus group discussions, we pilot-tested the guide with members of our research team (the moderator and one research collaborator from a community organization) who are Asian American MSM, have substantial knowledge and understanding of the study population as well as extensive experience in conducting focus group discussions. The guide was revised and finalized based on feedback and comments from the testers.\u003c/p\u003e\n\u003cp\u003eIn addition to focus group discussion data, we also collected basic sociodemographic characteristics of the participants, including age, education, employment, and marital status after the completion of each focus group discussion session. The demographic survey was conducted via email after the focus groups. Response to the sociodemographic questions was optional. \u0026nbsp; Recordings of the three focus group discussions were transcribed verbatim by a professional transcriber.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe employed a mixed qualitative thematic analysis that utilized both deductive and inductive approaches (Fereday \u0026amp; Muir-Cochrane, 2006). First, our team of two coders (the first author and a doctoral-level research assistant specializing in behavioral science and qualitative research) developed an initial framework of codes and sub-codes from the focus group discussion guide. The team then read all three transcripts carefully and developed a codebook with code definitions, inclusion criteria, exclusion criteria and examples.\u0026nbsp;Throughout the review, recurring explanatory statements were identified and classified into thematic units, including negative or divergent comments to add rigor to the results of our qualitative analysis\u0026nbsp;(Stewart, 1990).\u0026nbsp;With the TPB as the guiding framework and other related socio-psychological determinants of HIV testing intention, including social norms about HIV testing, homonegativity, and perceived HIV risk, we categorized emergent themes based on the key constructs. For example, quotes related to ‘negativity’ but not directly corresponding to homonegativity and HIV testing intention, we categorized as ‘negativity-within MSM group’, ‘negativity-outside MSM group’ or ‘negativity-religion related’. We then used the codebook to independently code all three transcripts in parallel. During the coding process, we regularly discussed ideas, questions, or concerns as they arose. We resolved any discrepancies through theoretically informed deliberations that involved rereading of the transcripts, reviews of notes taken from all three focus group discussions, as well as our knowledge of HIV prevention among Asian American MSM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the analytic process, we leveraged several techniques to ensure validity in qualitative research, including analyst triangulation (two analysts to review findings), and negative case analysis (discussions of elements that would deem contradictory to normal cases) (Creswell \u0026amp; Miller, 2000; Golafshani, 2003). Descriptive analysis of demographic data was performed using Microsoft Excel Worksheet\u003csup\u003e@\u003c/sup\u003e.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003ch2\u003e\u003cstrong\u003eSample characteristics\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe conducted three focus group discussions with 18 participants; each session had 6 people. Only four participants responded to the online demographic survey. Due to the low response, we could not characterize the demographics of the sample.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eResearch findings\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAcross the three focus groups, there were no major differences in perspectives related to how the socio- psychological factors influenced HIV testing intention among the participants. Themes emerged from each of the six constructs with sample quotes are presented in Table 1. \u0026nbsp;We identified 18 themes from the topics that were present at least in two out of three focus group discussions and discussed by at least two participants in each group (Buetow, 2010; Padela et al., 2016). Stronger themes, defined as common subjects mentioned in all three focus discussions, or themes of novel and strongly relevant insights, are highlighted below.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSocial Norms about HIV testing and HIV testing intention.\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAs part of this study, we explored perceptions of HIV testing behavior that Asian MSM felt represented the overall Asian community and within their groups of gay men.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen talked about what they knew of the HIV testing intentions of other Asian community members, participants shared different perspectives. For the \u003cu\u003ebroader community of Asian Americans\u003c/u\u003e, participants discussed \u003cu\u003enegative perceptions\u003c/u\u003e HIV testing intentions. For example, one participant recalled: “\u003cem\u003eSo other Asians, I feel most of them, they're so reluctant to go for the tests, because they feel that they will face some stigma.\u003c/em\u003e\u003cem\u003eAnd then being pointed that they are [sic], for example, if they're positive, and so people laugh at them, and they will also isolate them.\u003c/em\u003e”. Another participant concurred: “\u003cem\u003eSo I think most of them do not want to go for the tests because of being Asians. People maybe see it as that it is maybe [sic] embarrassing. Yeah, most of them are not comfortable\u003c/em\u003e.”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eNegative social norms\u003c/u\u003e about HIV testing also were mentioned as a \u003cu\u003epotential barrier to Asian MSM\u003c/u\u003e as it comes to personal motivation to get a HIV test. One participant described: “\u003cem\u003eAs for me, I think the testing behavior of those who are surrounding me, I have come to find out that these guys are a little bit shy and reluctant to go to testing as suggested, because I've never had maybe some in a group discussing about maybe testing for HIV and AIDS\u003c/em\u003e”. Another participant recalled: “\u003cem\u003eAnd then being pointed that they are, for example, if they're positive, and so people laugh at them, and they will also isolate them.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast,\u0026nbsp;within the community of MSM, participants felt \u003cu\u003epositive social norms towards HIV testing from their peers and friends\u003c/u\u003e. One participant stated: “\u003cem\u003eThere is a handful of very close friends of mine who has discussed this with me. For some reason they mention they're going to get tested or whatever\u003c/em\u003e.” This was further supported by another participant who recalled: “\u003cem\u003eI don't think there's any issues at all, with my immediate friends around this topic at all\u003c/em\u003e.”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, most of participants had experienced \u003cu\u003epositive influence from their peers\u003c/u\u003e in relation to HIV testing. A stigma-free community, positive social norms, and peer influence were discussed as facilitators of getting someone tested. One participant asserted: “\u003cem\u003eI think everyone just knows that it's something you should do if you're having open relationships or promiscuous sex or whatnot with another partner.\u003c/em\u003e\u003cem\u003eSo, I don't think there's any issues or stigmatism, within my network of friends\u003c/em\u003e.” Another participant added: “\u003cem\u003eAs humans, I think that knowing when somebody else is doing something would also encourage you or would motivate you to do something”. Another participant voiced his own belief: “Well, so I think a lot of my friends, gay Asians or Caucasians or whatever, it doesn't matter.\u003c/em\u003e\u003cem\u003eYeah, I feel very confident getting it and if my peers are getting tested then why not\u003c/em\u003e?”.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eHomonegativity and HIV Testing Intention.\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eHomonegativity refers to prejudices or negative attitudes toward homosexual individuals (Morrison \u0026amp; Morrison, 2013). We explored participants’ experiences of homonegativity and how those experiences might influence their HIV testing intention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of participants across all focus groups shared their thoughts and \u003cu\u003eexperiences being stigmatized as Asian MSMs\u003c/u\u003e. One participant said: “\u003cem\u003eFirst of all, they usually think if you’re gay, you will have AIDS and you will die. That’s one. And number two, one of my best friend’s moms actually think we are a disease and not who you are\u003c/em\u003e”. Another added: “\u003cem\u003eSo she told my best friend like, ‘Oh, I feel so bad that your friend is sick’, and my friend was like, ‘What are you talking about?’ And then her mom was like, ‘Because he is gay. He has an illness’\u0026nbsp;\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe consequence of \u003cu\u003ehomonegativity on the first-time participants sought HIV testing services\u003c/u\u003e was reported as a novel thematic insight.\u0026nbsp;Several comments were made in relation to their first-time testing, with their primary concern being the underlying risk of personal information leaking to their family.\u0026nbsp;One exclaimed: “\u003cem\u003eIt was very difficult decision the first time I went. When I was further from my family, it was easier\u003c/em\u003e”.\u0026nbsp;Another participant said:\u0026nbsp;“\u003cem\u003eOkay, I wanted to say that, for me at first, the stereotyping of me as an MSM--as an Asian MSM. It makes you not want to go. So as time went by, I have had the courage and it no longer affects\u003c/em\u003e”. This comment was supported by another participant who said: “\u003cem\u003eI remember P say that the stigmatization in school caused him to be scared about getting tested [at first]\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDifferences\u003c/u\u003e \u003cu\u003ein the experience of homonegativity within\u003c/u\u003e \u003cu\u003eAsian sub-cultures emerged\u003c/u\u003e as another strong topic of discussion. Homonegativity as the barrier to HIV testing, if any, appeared to come from family, especially those from South Asian cultures. One said:\u0026nbsp;“\u003cem\u003eAnd I know that there are some family members of mine who are particularly sensitive to how others think and those are the people who I worry about, I suppose sometimes\u003c/em\u003e”. Another participant shared: “\u003cem\u003eSo far, the negative connotation, in my experience has been from my more conservative family members who, again, they just perceive sexual promiscuity, or sexual activity to be done post-marriage\u003c/em\u003e”.\u0026nbsp;Unique cultural dynamics of South Asian communities were also discussed as an emerging theme when it came to the societal and family approval of homosexuality and homonegativity towards gay men.\u0026nbsp;To elucidate the context, one participant from South Asia reported: “\u003cem\u003eI think about that, that there's an intersectionality with religion a lot in a lot of South Asian cultures that a lot of my East Asian friends don't experience when it comes to East Asian MSMs versus South Asian MSMs and there's often a very big difference\u003c/em\u003e”. Another participant shared additional views: “\u003cem\u003eBut I think this is experienced a lot in other Asian cultures, which is like those, the aunties on the top of the buildings with binoculars\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, participants voiced their concern about the relationship between \u003cu\u003ehomonegativity and immigration status and/or education\u003c/u\u003e. One participant said: “\u003cem\u003eEducation\u003c/em\u003e\u003cem\u003e\u0026nbsp;is the problem with those who express homonegativity\u003c/em\u003e”. Another one added:\u0026nbsp;“\u003cem\u003eYeah, I'm kind of thinking about maybe building off of K's comment about maybe older generational Asian communities may view relationships and sex more conservatively than the younger generation and also Asian Americans versus Asian-Asian, where maybe, the view of somebody who's heterosexual would be to, once they're an adult, find a partner, have children settle down, and all that\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePerceived HIV risk and HIV testing intention.\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe way people perceive their own risk of HIV acquisition impacts their testing intention (Evangeli et al., 2018). In this study, we found that risk perception was strongly reported to influence Asian MSM’s intention of HIV testing, and this was primarily derived from the sexual HIV risk behaviors, including high frequencies of sexual intercourse and having multiple sex partners and.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the perceived risk related to \u003cu\u003ehaving multiple sex partners\u003c/u\u003e, one participant reflected: “\u003cem\u003eBut for example, if I have had sex with multiple partners who I’m not aware of their status, then I definitely will be concerned and definitely I will want to know my health, or rather, my status because I do not know the status of these people\u003c/em\u003e”. A different participant said: “\u003cem\u003eSo, I think, when I was seeing multiple partners, or promiscuous or whatever, I did get tested on a six-month basis when I have protected sex.\u003c/em\u003e”\u003c/p\u003e\n\u003cp\u003eA \u003cu\u003eheightened frequency of sexual activities\u003c/u\u003e was discussed as directly related to perceived HIV risk. Almost all participants stressed that, for them, the importance of getting tested depends on the frequency of sexual intercourses. One said: “\u003cem\u003eSo to me, what can push me towards getting testing is if I have maybe many different partners and we have the sex for[sic] frequently\u003c/em\u003e”. Another participant contributed: “\u003cem\u003eRight, definitely multiple [partners], especially ones you don't know, and also even the safety-ness of the sex, either wearing in a condom or not, either scenario you want to get tested, but I think the frequency, the amount of time you go get tested, would change based upon how safe you are in your sexual activities\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConstructs of the TPB.\u003c/strong\u003e\u003c/h3\u003e\n\u003ch4\u003e\u003cstrong\u003eAttitudes towards HIV testing.\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eParticipants shared detailed accounts of their thoughts and beliefs towards HIV testing. While individual perspectives varied, they centered around the positive or negative aspects of HIV testing behavior, as well as the anticipated outcomes of testing.\u003c/p\u003e\n\u003cp\u003eMost participants expressed \u003cu\u003epositive attitudes about HIV testing\u003c/u\u003e. However, different reasons emerged about why taking an HIV test was encouraging to them. Several participants indicated that knowing their HIV status would mitigate their uncertainty and subsequently help them navigate care services as appropriate. For example, one participant reflected: “\u003cem\u003eThere are many benefits of getting tested for HIV. The first benefit is that the test is fast and easy. And the last benefit is that it can give you peace of mind\u003c/em\u003e”. Another participant added: “\u003cem\u003eI'd say yeah, like, just the health benefits is just too many health benefits to even considering not getting one, not only for yourself to make sure that on the chance that you do, gosh, you ever do receive HIV that it's important to, to find out immediately and then just take care as soon as possible to manage the viral load\u003c/em\u003e”. Aligned with these positive sentiments about HIV testing, several other participants also mentioned that seeing HIV testing as a regular health seeking behavior would help normalize the topic in public. For example, one participant brought up: “\u003cem\u003eI think, yeah socially, it's a good benefit for more people to take it more often, you know, have people talk about it, because then the taboo becomes less and less, you know\u003c/em\u003e”. When expressing their behavioral beliefs or evaluation of behavioral outcomes about HIV testing, most participants agreed that HIV testing is important, convenient, and it would help people protect themselves and their sex partners, as well as providing the benefit of getting early to care if they need to. One participant emphasized that: “\u003cem\u003eAnd I think that's something that we've forgotten or not realized, that you having a positive test is not a death sentence like it used to be in the 80s\u003c/em\u003e”.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConcerns about confidentiality\u003c/u\u003e were reported as factors that hinder participants’ intention to get tested. One participant wondered: “\u003cem\u003eHow many people will know about what your sexual activities and yeah, like it just something you want to keep very close to the chest\u003c/em\u003e. \u003cem\u003eI'd say the costs, again, it's like, then you've got to weigh the social costs.\u003c/em\u003e”. The concern was furthered by another participant: “\u003cem\u003eYeah, because I don't--with my primary care provider, I am not I’m open about it and I think partly because that primary care provider is connected with like, it's also a provider to my family members. And so, I cannot, I don't even want to think about that\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eSubjective norms about HIV testing.\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eIn this section, we explored participants’ perception of the expectations from partners, friends, families, and other acquaintances towards their HIV testing intention (normative beliefs), as well as their motivation to respond to those expectations (motivation to comply). Overall, there was strong agreement among participants that HIV testing was a private matter and they considered \u003cu\u003esexual partners, primary health care providers, and peers being the most trusted individuals\u003c/u\u003e supporting their intention of HIV testing. One participant said:\u0026nbsp;\u003cem\u003e“Don't know about the other Asian MSM but to me and my partner we took that responsibility to go getting tested after every six months.”.\u003c/em\u003eSpeaking of expected approval on HIV testing intention and trust in someone regarding HIV testing intention, a participant described:\u0026nbsp;“\u003cem\u003eI guess if I feel like I need to get testing, I would definitely consult with my partner. So that's one. Then the other person would be my physician because that's probably where I would go get testing.\u003c/em\u003e”. Another participant added: \u003cem\u003e“So when it comes to my peers, and me speaking to them, they are supportive.”\u003c/em\u003e Not surprisingly,\u0026nbsp;the majority of participants did not think it would be appropriate to discuss HIV testing with their family. A participant revealed: “\u003cem\u003eI don't usually talk to my family about this stuff. Ironically, I'm very receptive to HIV testing, but most of them aren't\u003c/em\u003e.” Another participant reported: “\u003cem\u003eBecause I cannot afford like, I mean, I have one or two family members who know, but it's a very touchy subject and it's just even indulging the conversation on something that would relate to this is touchy. So, I've just kind of stopped it there.\u003c/em\u003e”\u003c/p\u003e\n\u003cp\u003eRegarding motivation to comply, all participants agreed that having themselves tested for HIV would\u003cu\u003e\u0026nbsp;align with the expectation of their sexual partner, advice from their health care provider, and because they cared for their health\u003c/u\u003e. One participant mentioned: “\u003cem\u003eSo I think I would just lean on people who are on the need-to-know basis, and that's basically my sexual partner, and the physician\u003c/em\u003e.” Another participant added: “\u003cem\u003eIt's my health and it's just all for me. And just before I get the testing, if it's at a clinic, your physician will probably be the one to give you counseling advice before and also after you get the test.\u003c/em\u003e”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone of the participants mentioned religious leaders or community leaders as their source of support or someone they would turn to for advice in the context of HIV testing.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePerceived behavioral control of HIV testing and HIV testing intention.\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe majority of participants indicated that they \u003cu\u003ebelieved in their ability to get tested for HIV\u003c/u\u003e. In addition to factors highlighted as facilitators to HIV testing, such as \u003cu\u003eavailability, affordability, and accessibility\u003c/u\u003e to home testing, having a primary care physician was mentioned as an important support system that enables their HIV testing plan. One participant said: “\u003cem\u003eSo you know, like, when in doubt, I just go and talk to my not even go and talk to him, I just send him a message through the portal, say, ‘Hey, Doc, can you write me order for HIV test?’ and he just probably will\u003c/em\u003e”.\u0026nbsp;Most participants agreed that getting an HIV test was easy and at no cost at many different locations. One participant described: “\u003cem\u003eI also know that at pride events, the festivals, there's always testing freely available--free--to anyone to come in and take the test and these tests are--you get results within five to 10 minutes now\u003c/em\u003e”. Another shared his experience about how easy it is for him to get tested: “\u003cem\u003eWith being in an educational sort of an institution, they often have a very easy way to get it done and I recall, that's how I initially got my first one as well was through my university and their student health center\u003c/em\u003e”. In addition, not having to worry about testing cost was mentioned as a positive driver of their actual HIV testing behavior. One said: “\u003cem\u003eSo it's all covered, like everything is all taken care of\u003c/em\u003e”. Another participant expressed his positive view about HIV testing: “\u003cem\u003eSo if you do test positive, there are people there who discussed and counsel you on how to deal with those positive results\u003c/em\u003e”. Participants repeatedly mentioned the convenience and accessibility of HIV testing across different venues, including clinic, home-based testing, and others. One participant shared: “\u003cem\u003eOkay, I can say that HIV testing is very easy, since you only--there are some home test kits being sold in pharmacy and convenience store\u003c/em\u003e”. Another one added: “\u003cem\u003eAnd I know there's also nonprofit organizations such as here in Atlanta, we have AID Atlanta that provides these tests freely available to any person that would like to get tested\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study is one of the first efforts to explore socio-psychological factors relating to HIV testing intention among Asian American MSM. Our findings are generally aligned with existing literature related to barriers and facilitators to HIV testing among the population of Asian Americans (Evangeli et al., 2016; Lorenc et al., 2011). The study also provides important insights into the cultural dynamics with regards to familial approval of homosexuality within South Asian communities.\u003c/p\u003e\n\u003cp\u003eOverall, participants expressed diverse views towards the role of social norms on their HV testing intention. First, our primary results indicated that Asian American MSM perceived\u0026nbsp;\u003cstrong\u003e\u003cem\u003epositive\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u003cem\u003esocial norms\u003c/em\u003e\u003c/strong\u003e about HIV testing within the gay community, but that the social norms were less supportive in their families or broader Asian American community. These results correspond with a study among Chinese MSM which found that perceived norms regarding HIV testing was strongly associated with regular HIV testing (Zhao et al., 2020). In the absence of similar evidence specific to the Asian American MSM population, this finding seems to support our observation that when individuals perceive the prevalent norms of HIV testing in their social circle, they would be more likely to engage in HIV testing behavior.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, participants reported that HIV testing was less common among those outside of their gay community, including their families. This dynamic could be explained via the context of socio-cultural norms among Asian immigrants. In many U.S. Asian communities, Asian American MSM often experience family- and community-level stigmatizing beliefs due to their homosexuality, which is considered non-conforming to traditional values such as sexual activity as a means to maintain family lineage (Bhattacharya, 2004). Seeking a HIV test may be seen to be associated with shame on family or community because it represents a deviation from the Asian cultural norms that classify homosexuality as taboo (Chng et al., 2003; Yoshikawa et al., 2003). These cultural characteristics may explain the differences in the way participants perceived HIV testing norms within their networks versus family and broader U.S. Asian communities in our study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHomonegativity\u003c/em\u003e\u003c/strong\u003e was reported to be a common barrier to HIV testing, especially for those testing for their first time in this study. Additionally, it was suggested that newly immigrated Asians and individuals with lower education would hold higher level of homonegativity towards Asian American MSM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch has suggested that perceptions of community stigma on homosexuality may have negative impacts on HIV testing intentions among American MSM (Iott et al., 2022; Lorenc et al., 2011). In our study, we focused solely on community prejudice and its impact on HIV testing intention and our results is consistent with the existing literature. \u0026nbsp;Our finding of elevated homonegativity among new immigrants is supported by Bracht et al. (2014) which suggested that new immigrants to a western country would have greater disapproval of homosexuality and that would decline over time (Van der Bracht \u0026amp; Van de Putte, 2014). This finding is further supported by a study by R\u0026ouml;der et al. (2015) indicating that negative prejudices towards homosexuality is stronger among the first generation of immigrants compared to the second generation (Roder A, 2015). Regarding the finding that homonegativity appeared more recognizable among individuals with low education, Oyarce-Vild\u0026oacute;sola et al. (2022) found that people with education attainment of high school or higher would have lower level of homonegativity compared to those without high school education (Oyarce-Vild\u0026oacute;sola et al., 2022). While no studies have addressed this phenomenon among Asian American immigrants, these studies help explain our initial observation that Asian American MSM perceive that new immigrants and individuals of low education attainment might hold stronger homonegativity towards Asian American MSM communities, as discussed in our focus groups.\u003c/p\u003e\n\u003cp\u003eAnother finding indicated that\u0026nbsp;\u003cstrong\u003e\u003cem\u003eHIV risk perception\u003c/em\u003e\u003c/strong\u003e, based upon actual risk behaviors such as frequency of sexual activities and unprotected sexual intercourse, drove participants decisions related to HIV tested.\u0026nbsp;The positive relationship between perceived risk and HIV testing intention is supported by results of previous studies. In a systematic review by Lee and colleagues, it was found that risk perception is one of the barriers to whether to get tested for HIV among Asian Americans (Lee \u0026amp; Zhou, 2019). Among all Americans, Spielberg and colleagues found that individual-level factors such as HIV risk perceptions and HIV knowledge were commonly reported as facilitators of HIV testing and that an acknowledged risk history was a key factor in many people\u0026rsquo;s decision to seek an HIV test \u0026nbsp;(Spielberg et al., 2001).\u003c/p\u003e\n\u003cp\u003eLastly, psychological factors including attitudes, subjective norms, and perceived behavioral control towards HIV testing were found to have impacts on the HIV testing intentions of Asian American MSM. There was a strong consensus that participants cared about their health and took responsibility for protecting themselves by knowing their HIV status. Nevertheless, some expressed concern about confidentiality. Sexual partners and physicians were the biggest influencers towards HIV testing behavior among Asian American MSM and they held strong personal beliefs that they could manage a HIV test when needed.\u003c/p\u003e\n\u003cp\u003eThe diverse\u0026nbsp;\u003cstrong\u003e\u003cem\u003eattitudinal beliefs\u003c/em\u003e\u003c/strong\u003e towards HIV testing documented in this study among Asian American MSM are supported by existing literature. While MSM in general, and Asian MSM specifically generally were found to have a positive sense of responsibility to protect oneself or one\u0026rsquo;s partner, concerns related to privacy and confidentiality, especially among those of minority backgrounds and/or experiences of migration, would be specific barriers to HIV testing (Evans et al., 2016; Figueroa et al., 2015; Lee \u0026amp; Zhou, 2019; Lorenc et al., 2011; Nicholls et al., 2022). Additionally, our findings highlight the social cost associated with HIV testing. This was described as the fear among Asian American MSM that their deviation from the conventional\u0026nbsp;sex role standards of traditional Asian society would be disclosed if they get tested for HIV. Though the research team is not aware of previous studies that have examined this aspect among Asian American MSM, studies among general MSM have indicated that perceptions of stigma, from other gay men or the general public acts as barrier to HIV testing (Lorenc et al., 2011; Solorio et al., 2013). As stigma towards homosexuality in Asian societies has been widely recognized (CPACS, 2018; Ju, 2021; Vlassoff \u0026amp; Ali, 2011), this could help explain the finding related to the social cost of HIV testing in this study.\u003c/p\u003e\n\u003cp\u003eRelated to\u0026nbsp;\u003cstrong\u003e\u003cem\u003esubjective norm\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e about HIV testing, we found strong agreement among participants that partners and physicians offer frontline support to their HIV testing intention and that most of them do not consider their family as a source of support. While a study by Lorenc et al. suggested that desire to protect oneself or one\u0026rsquo;s partner may be a motive for HIV testing in MSM of other ethnicities (Lorenc et al., 2011), this observation appeared to support the finding from our study that Asian American MSM have a mutual desire to protect each other by supporting their partner\u0026rsquo;s intention to seek HIV testing. Conversely, the lack of support from family to MSM when it comes to HIV testing has been observed in a study by Wong et al. (2012). \u0026nbsp; As it is common that Asian American MSM keep their sexual orientation undisclosed to their family, the hesitancy to confide in their family with intention for HIV testing is understandable (Wong et al., 2012). Additionally, our finding is supported by a study by Solorio and colleagues (2012), where they documented negative attitudes towards HIV testing by family members among Latino immigrant MSM and suggested this may hinder HIV testing intention within this population (Solorio et al., 2013). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study found important observations relating to the unique familial (e.g., multi-generation family living arrangements) (Yeung et al., 2018) and cultural dynamics (e.g., family obligations and loyalty to the elders) (Shariff, 2009) towards homosexuality among those of South Asian heritages. Literature on this topic is limited (Kumar, April 2013); however, it is evident that South Asian gay men bear pressure from their parents concerning their homosexual identity (Deepak, 2005). \u0026nbsp;Specifically, many South Asian parents consider homosexuality unfit to their cultural norms (Estrada \u0026amp; Rutter, 2006). This interplay helps explain our finding that South Asian gay men would not turn to their family for sexual matters and HIV testing discussions. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study found strong\u0026nbsp;\u003cstrong\u003e\u003cem\u003eperceived behavioral control towards\u003c/em\u003e\u003c/strong\u003e HIV testing across all participants. The finding that perceived behavioral control positively influenced HIV testing intention aligns well with existing literature where TBP has been used as the underlying theoretical framework. \u0026nbsp;Multiple studies have affirmed that when individuals found it easy to get HIV tested, they would be more likely to engage in HIV testing behavior (Hogben et al., 2003; Meadowbrooke et al., 2014; Mirkuzie, 2011).\u003c/p\u003e\n\u003cp\u003eAltogether, findings from our study are supported by existing literature and offer important novel insights of the influence of socio-psychological factors on the HIV testing intentions of the population of Asian American MSM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough this is one of the first studies to explore factors influencing HIV testing intention in the population of Asian American MSM, it does have limitations. First, the study was limited to participants who had access to the internet and the Zoom platform. This data collection method could have introduced selection bias because it limited participation to those who had access to the internet, thus hindering the generalizability of our findings. Second, social desirability bias may present a challenge in data quality. Topics discussed in the focus group discussions were personal and sensitive. Efforts by the research personnel to ensure research protocols, including assurance of privacy and confidentiality, were implemented. However, only four out of eighteen participants were willing to provide personal demographic information at the end of the focus group discussions. Last, the discussions were held fully in English, thus, participants who were not fluent might have not been able to articulate their thoughts comfortably. Future studies should consider these limitations in the design and implementation to facilitate broader participation and better data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNEW CONTRIBUTION TO THE LITERATURE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings from this study have important implications for developing interventions to promote HIV testing among the population of Asian American MSM. Understanding the influence of social and psychological factors on HIV testing intention among this minority group would help policy-making agencies, health service providers and community organizations better mobilize resources to address underlying barriers and promoting facilitators to HIV testing intention through initiatives that are culturally relevant and appropriate, especially for the first-time testers and the community of gay men originally from South Asia. Specifically, our largest themes echoed previous research indicating that homonegativity, an underlying barrier to HIV testing, is strongly present among \u0026nbsp;heterosexual male population (Herek, 1988) and underscored the association between perceived HIV testing social norms \u0026nbsp;and HIV testing (Lee \u0026amp; Zhou, 2019). These factors should be taken into consideration in designing future intervention programs. As addressing sensitive topics such as homonegativity and HIV testing social norms may require a community-based approach through social networks (Veinot et al., 2016), HIV program implementers could adopt strategies that have been suggested elsewhere, including the captivation of network homophily (e.g. targeting groups sharing similar social and demographic characteristics) (Veinot et al., 2016) or group interventions (e.g. classroom-based, computer-based, or community-based) for younger individuals, such as college students\u0026nbsp;(Burk et al., 2018; Cotten-Huston \u0026amp; Waite, 2000). Taken together, our results could help public health efforts in increasing HIV testing and meeting other health needs of this racial and sexual minority group \u0026ndash; Asian American MSM.\u0026nbsp;\u003cbr\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements and Declarations:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote about the change of first author\u0026rsquo;s affiliation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first author (Minh L.) moved to a new institution after completing the research. Her new affiliation is Humana Inc.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbamecha, F., Godesso, A., \u0026amp; Girma, E. (2013). 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Factors associated with regular HIV testing behavior of MSM in China: a cross-sectional survey informed by theory of triadic influence. \u003cem\u003eInternational journal of STD \u0026amp; AIDS\u003c/em\u003e,\u003cem\u003e 31\u003c/em\u003e(14), 1340-1351. https://doi.org/10.1177/0956462420953012 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Asian American MSM, homonegativity, thematic analysis","lastPublishedDoi":"10.21203/rs.3.rs-6580037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6580037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Members of sexual minority groups often receive HIV diagnosis at later stages and are less likely to get tested. However, little is known about how HIV testing intention is shaped among Asian American men who have sex with men (MSM). This study explored socio-psychological factors that can influence the intention of HIV testing in this population. Using convenience sampling, we conducted three focus group discussions among Asian American MSM, regardless of their HIV testing history and HIV status. Data were analyzed employing a thematic analysis approach. We found divergent perspectives around factors influencing participants’ HIV testing intention. Facilitators of HIV testing intention included high levels of approval of testing by sex partners and health care providers. Homonegativity (negative attitudes towards homosexuality) and concerns about confidentiality of testing services were discussed as barriers to HIV testing intention among this population group. Social norms about HIV testing among general Asian community were reported to be less positive relative to among gay men groups. These findings will inform targeted programs promoting positive social views towards HIV testing and mitigating prejudices towards homosexuality in Asian American community.","manuscriptTitle":"Homonegativity as a barrier to HIV testing intention: A qualitative study of Asian American Men Who Have Sex with Men ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 17:34:30","doi":"10.21203/rs.3.rs-6580037/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66804d0b-90da-4851-b217-0463441c7ad5","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T00:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 17:34:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6580037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6580037","identity":"rs-6580037","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}