Patient and provider perspectives of male uptake of HIV testing at selected public health facilities in Orange Farm, South Africa

2.1 Theoretical framework

This study is underpinned by the socio-ecological model (SEM) [14, 17] (see Fig. 1, Ref. [17]), which offers a multidimensional framework for understanding how individual, interpersonal, organisational, community, and policy-level factors interact to influence health behaviours. The individual level considers personal characteristics such as knowledge, attitudes, and beliefs. The interpersonal level includes social relationships that influence decision-making. The organisational level addresses institutional contexts, including health facility structures and practices. The community level reflects broader societal influences such as social norms and community mobilisation. The policy level relates to national guidelines and health system frameworks that shape access to and quality of HTS. The SEM provides a comprehensive lens to explore the structural and psychosocial, and local contextual [17, 18], dynamics shaping men’s engagement with HIV testing.

Fig. 1.The socio-ecological model (SEM). Source: McLeroy et al. [17].

2.2 Study design

The study followed a qualitative approach to gain an in-depth understanding of participants’ views on male uptake of HTS [16]. To adequately address the research problem, this study adopted an exploratory case study design [19, 20], with semi-structured interviews (SSIs) among male patients and healthcare providers.

2.3 Setting

The study was conducted at three PHC facilities in Orange Farm, a peri-urban township located in the southern periphery of the City of Johannesburg Metropolitan Municipality [21]. Based on their work on voluntary medical male circumcision, Govender et al. [22], established that there was high HIV prevalence in Orange Farm. The high HIV prevalence informed the purposive selection of this study area.

2.4 Study population and sampling strategy

The population included adult male patients attending PHC services, Nurse-Initiated Management of Antiretroviral Therapy (NIMART)-trained nurses, and lay counsellors trained in Rapid Test Counselling and Quality Improvement (RTCQI) recruited from three PHC facilities in Orange Farm. Professional nurses play a vital role in enrolling patients who test positive for HIV on ART as part of a concerted nationwide initiative to increase the uptake of HIV treatment at healthcare facilities towards attaining the second UNAIDS 95-95-95 target [23]. Additionally, the National Department of Health (NDoH) supports lay counsellors in providing HIV counselling at medical and non-medical sites [24]. Overall, a total of 12 patients (four [4] patients per PHC facility), five (5) NIMART nurses (two [2] each from Clinic A and B), and one (1) from Clinic C (one [1] declined to participate), and six (6) lay counsellors (two [2] per PHC facility) were purposively selected to participate in the study. The purpose of this sample size was to reach saturation as opposed to the generalisability of findings [25]. Data saturation was reached when no new themes or insights emerged across the different participant groups, demonstrating adequate depth and diversity of responses. Despite the small sample size, the use of structured interviews and triangulation of perspectives among patients, healthcare providers, and lay counsellors enhanced the richness and credibility of the data, thereby supporting the attainment of thematic saturation.

Patients were recruited into the study with the assistance of healthcare providers at the PHC facilities. The inclusion criteria encompassed adult men aged 18 years and older, selected due to their sexual reproductive age and higher risk of HIV contraction. Participants needed to be able to communicate effectively in English, isiZulu, or Sesotho. Efforts were made to include perspectives from young, middle-aged, and older men, as well as those who had or had not undergone PHC facility-based HTS. Patients deemed too physically ill to participate and individuals aged 17 years and younger were excluded. The inclusion criteria for healthcare providers in the study required their involvement in offering HTS. Specifically, they needed to be professional nurses with NIMART training, or lay counsellors trained in RTCQI.

2.5 Data collection

Data collection among patients and healthcare providers was undertaken from July to August 2022. The first author enlisted and trained a male assistant to interview male patients, while she interviewed the lay counsellors and nurses. Both researchers, proficient in English, Sesotho, and isiZulu, administered the informed consent procedure before commencing with the semi-structured interviews (Refer to Table 1) in the patients’ preferred language. The semi-structured interviews took 45 minutes to an hour to complete, were conducted in a private room within the PHC facilities and were audio-recorded with patients’ permission. The interviews with healthcare providers were conducted by the first author at the convenience of the healthcare providers, in a private room to maintain privacy, and lasted between 45 minutes and an hour. As with the patients’, informed consent was obtained prior to the interviews, which were audio-recorded with the healthcare providers’ permission.

2.6 Data analysis

Data were thematically analysed using the framework established by Braun and Clark [26] and expanded by Braun et al. [27], with the SEM constructs serving as a priori or pre-determined themes. The research employed data triangulation [28] to examine perspectives on barriers to and facilitators of male uptake of HTS within the three distinct participant groups: male patients, NIMART-trained professional nurses, and RTCQI-trained lay counsellors. The first author transcribed the interviews, translating vernacular responses into English. She also generated the initial codes for the sub-themes, which were subsequently reviewed by the second and third authors. All three authors collaboratively discussed and refined the sub-themes, using data triangulation to enhance credibility by comparing perspectives across different participant groups. This method contributed to a comprehensive and nuanced understanding of male uptake of HTS at PHC facilities.

3.1 Participants’ socio-demographic characteristics

The socio-demographic profile (Table 2) of the twelve male participants in this study reveals a group marked by shared ethnicity and gender, yet diverse in age, education, and employment status. All participants were African males aged 18 years and older, with ages ranging from early adulthood to over sixty years. This age range encompasses a diverse spectrum of experiences, from young men at the threshold of adulthood to older individuals who may have faced long-term social and economic challenges.

Most of the participants were unmarried, with only one reporting being married. This predominance of single status may reflect broader social patterns or personal circumstances that influence HTS access among men in these communities.

Educational backgrounds varied significantly. While some participants had only completed primary or early secondary schooling, others had reached Grade 12, and a few had pursued tertiary education or were currently enrolled in college. This variation suggests differing levels of access to educational opportunities.

More than half of the patients were unemployed. The participants were drawn equally from three clinics, Clinic A, Clinic B, and Clinic C, ensuring a balanced representation across different healthcare settings. This distribution may offer insights into how local contexts shape the experiences and needs of male patients, particularly in relation to health-seeking behaviour and access to services.

The socio-demographic profile (Table 3) of the eleven healthcare providers in this study reflects a team that is diverse in gender, age, and years of professional experience. While the group consisted predominantly of males, females were also represented across both lay counsellor and professional nurse roles, highlighting some gender balance within the cadre of HTS providers.

Participants ranged in age from their late 20s to late 50s, indicating a blend of early-career and more experienced professionals. This variation is important, as it brings together a range of perspectives—from those newer to HIV service delivery to those with extensive exposure to the evolving landscape of HIV testing and treatment practices.

The lay counsellors had, on average, spent 6.5 years in their current roles, compared to the professional nurses’ average of 3.8 years. This suggests that lay counsellors may offer more cumulative, community-facing experience in delivering HTS, which can be invaluable in understanding patient engagement, especially among hard-to-reach groups like men. Conversely, the shorter tenure among professional nurses may reflect either recent training (such as NIMART) or staff turnover in clinical roles.

Providers were distributed across all three clinics, Clinic A, Clinic B, and Clinic C, with a near-equal spread of professional nurses and lay counsellors in each facility. This balanced representation supports a comprehensive view of facility-based dynamics affecting male HTS uptake, enabling comparisons across different facility environments and team compositions.

3.2 Barriers to male uptake of HTS at PHC facilities

Table 4 provides an overview of the emerging sub-themes based on the SEM levels.

3.3 Barriers to male uptake of HTS at PHC facilities

3.4 Facilitators of male uptake of HTS at PHC facilities

Table 5 provides an overview of the emerging sub-themes based on the SEM levels.

3.5 Facilitators of male uptake of HTS at PHC facilities

4.1 Barriers to male uptake of HTS

At the individual level, participants in the current study perceived that men’s lack of comprehensive knowledge about HIV and available HIV testing methods hinders their HTS uptake at PHC facilities, which echoes findings from research among young men in the rural areas of Ladysmith, KwaZulu-Natal [29]. Other factors perceived to drive men’s reluctance to engage with HTS at PHC facilities were fear of both the testing process and potential emotional consequences, and men’s self-stigmatisation. This is consistent with a qualitative study in KwaZulu-Natal, which reported that fear related to men’s perceptions of their own HIV risk, along with stigma and discrimination, contributed to their unwillingness to access HTS [29, 30].

At the interpersonal level, the study identified several perceived barriers that hinder men’s uptake of HTS. These include a lack of family support for men, stigmatisation and discrimination, peer pressure and adherence to traditional gender norms that discourage emotional expression. These findings align with other research conducted in sub-Saharan Africa. For instance, in Uganda, Camlin et al. [10] revealed that while men were inclined to discuss HIV-related issues with close family members, such as their wives, they often found it difficult to do so. Similarly, research in Zambia found that young men’s motivation to undergo HIV testing diminished due to negative peer influence, intoxication, and the fear of reprimand from healthcare providers [31]. Furthermore, Stephenson et al. [32] reported that in communities with high tolerance for violence against women and conservative gender roles, there was greater reluctance among men to engage in HTS.

At the organisational level, the perceived barriers to male uptake of HTS included discomfort with cross-gender interactions, the negative impact of staff attitudes on patient care and experience, concerns about privacy and confidentiality, inefficiencies within the health system, and language and communication barriers. These issues are consistent with findings from other studies across sub-Saharan Africa [31, 33].

At the community level, perceived barriers to male uptake of HTS in the selected Orange Farm clinics included a lack of education and awareness about HIV. Available research on community-level barriers to male uptake of HTS generally does not emphasise lack of education and awareness as key barriers [6, 12, 34]. However, a study from Eastern Africa by Adugna and Worku [9] highlights high community illiteracy rates as a significant barrier to men’s engagement with HTS. This shows the divergence in perspectives regarding the role of community education in influencing male uptake of HTS.

At the policy level, healthcare providers identified non-adherence to health policy as a significant barrier, underscoring the importance of stricter compliance with established health policies at PHC facilities. Inconsistencies were noted in the application of the NDoH’s HTS Policy and the Standard Operating Procedures for HIV Index Testing Services [24, 35]. Evidence from Cartagena, Colombia, similarly shows that the implementation of the HIV and AIDS-health-related policies often fails at the local level due to poor contextual alignment and barriers such as limited collaboration, stigma, resource shortages, and unstable leadership [36]. Across sub-Saharan Africa, health policies have for many years predominantly focused on women, often overlooking the engagement of men in HTS [37]. Although non-adherence to health policies is not widely identified in the literature as a barrier to men’s use of HTS in PHC facilities, strengthening policy implementation within healthcare settings may help address this challenge and improve men’s access to HTS.

4.2 Facilitators of male uptake of HTS

At the interpersonal level, both the patients and healthcare providers in this study identified that supportive family and friend networks, along with promoting health education within families, could significantly facilitate male uptake of HTS. Various stakeholders have underscored the crucial role of family dynamics and peer support in influencing men’s decisions to access HTS, highlighting the importance of targeted interventions [3, 6, 38]. However, existing literature lacks robust evidence on the promotion of HIV health education within families as a facilitator of male uptake of HTS, suggesting a need for further exploration.

The suggested facilitators at the organisational level included reducing the negative impact of stigma within healthcare facilities, improving privacy, and prioritising health outreach and education. In previous research, similar interventions were suggested, such as implementing measures to improve gender-sensitive healthcare provision, training to foster positive staff attitudes, and the creation of male-friendly environments within healthcare facilities [6, 3038]. Additionally, Mabuto et al. [39] recommended interventions to improve HTS delivery efficiently within the limitations of existing human resources, such as abbreviated pre- and post-test counselling, the integration of HIV self-testing options into facility-based HTS, and triaging methods to exclude HIV-negative patients.

At the community level, participants proposed leveraging community gatherings as platforms to educate men on health issues. Improving community education and awareness, specifically initiatives tailored to address men’s unique challenges, has been emphasised as crucial for promoting HTS uptake among men in Eastern Africa [9]. A study conducted by DiCarlo et al. [40] in Lesotho found that educational initiatives led by men themselves can be especially effective. Similarly, the South African DoH underscores the importance of community-driven approaches in engaging men in HTS [3]. Community-based education can help to dispel myths, challenge negative perceptions, and reduce stigma, thereby empowering men to take control of their own health. Collaborative efforts with local leaders and community organisations are essential in developing effective strategies to enhance HTS uptake.

At the policy level, participants identified increasing the number of male healthcare providers, reinforcement of HTS policy adherence and extended clinic hours as key facilitators to improving men’s uptake of HTS. These findings align with Shand et al. [37], who emphasise the need for a unified policy agenda that engages men and boys, while also noting the lack of prioritisation of men’s participation in HTS within existing African HIV policies. In 2022, the UNAIDS endorsed a policy framework aimed at actively involving men in HTS, particularly in Eastern and Southern Africa—regions disproportionately affected by the HIV epidemic [41]. This was followed by the identification of men as a priority population for HTS intervention in South Africa’s National Strategic Plan for HIV, TB and STIs 2023–2028 [3]. Nevertheless, current literature seldom recognises policy adherence and the presence of male providers as enablers of HTS, indicating a gap that warrants further research and policy attention.

The findings highlight interactions across the SEM levels that shape men’s HIV testing behaviours. At the community-level, stigma and misconceptions about HIV reinforce individual self-stigmatisation, discouraging men from seeking testing or disclosing their status. Interpersonal level factors, such as a fear of judgment from family members or peers, can further exacerbate these barriers. Conversely, supportive family and peer networks can buffer the negative effects of stigma, highlighting the critical role of interpersonal relationships in shaping health behaviours. At the organisational level, male-friendly health spaces, improved privacy, and positive staff attitudes can mitigate both individual self-stigmatisation and community-level stigma by creating supportive environments. Policy-level interventions such as consistent implementation of HTS policies, targeted recruitment of male healthcare providers, and extended clinic hours can reinforce these efforts and promote positive behavioural change across all levels.

4.3 Limitations of the study

The limitations of this qualitative case study should be acknowledged. Non-probability sampling and a small sample size may restrict the application of the results to other clinics or broader male populations. Social desirability bias may have influenced the responses from both healthcare providers and male participants. Not quantifying the actual prevalence of barriers and facilitators may weaken the study’s conclusions. Therefore, future research incorporating objective measures to validate these perceptions is recommended. Another limitation of the study concerns the multi-level approach used, which, although it provides a thorough look at the factors influencing male uptake of HTS, inevitably also introduces complexity, making it difficult to determine which interventions should be prioritised first. Additionally, the sample comprised participants with varied educational backgrounds and high levels of unemployment, which may have influenced their perspectives and experiences related to healthcare access and HIV testing. Despite these challenges, the study contributes insights into the specific factors that either deter or encourage men to take up HTS, as seen from both the users’ and healthcare providers’ perspectives.