Identifying factors influencing HIV testing behavior among high-risk elderly men: a mixed-methods study incorporating structural equation modeling and thematic framework

Abstract Background Population ageing has been accompanied by increasing HIV risk among older adults. Timely diagnosis and treatment are essential for improving health outcomes. However, over 65% of HIV cases among older men at elevated risk in China are diagnosed at an advanced stage, largely due to delayed testing. Understanding the factors associated with prior HIV testing among this population is therefore important for promoting earlier diagnosis and developing targeted interventions. Methods An explanatory sequential mixed-methods study was conducted in Dehong Prefecture between 2024 and 2025. The quantitative phase comprised a cross-sectional survey. Descriptive analyses were used to summarize participant characteristics, and structural equation modeling (SEM) was performed to examine the direct, indirect, and total associations between psychosocial factors and ever-tested status. In the subsequent qualitative phase, in-depth interview data were analyzed using thematic framework analysis to explain and contextualize the quantitative findings. Results A total of 300 participants were included in the quantitative survey, and 30 participated in qualitative interviews. Among the 300 participants, the mean age was 57.2 years, and 57.7% had ever been tested for HIV. Risky sexual behaviors, particularly inconsistent condom use, were common, with reduced sexual pleasure being the main reported reason for condom non-use. In the final SEM, threat perception showed the strongest positive total association with ever-tested status (0.349; p = 0.001), followed by subjective norms (0.295; p = 0.003) and self-efficacy (0.199; p < 0.001). Testing belief had a positive indirect association (0.042; p < 0.001), whereas HIV-related information and behavioral skills showed negative total associations (-0.175; p = 0.009; -0.211; p = 0.015, respectively). Qualitative findings suggested that the negative association with HIV-related information reflected participants’ distrust of conflicting information, its limited perceived relevance, and fear-oriented messaging. They also highlighted insufficient knowledge of testing procedures, low confidence in accessing services, and age-related perceptions of HIV risk. Conclusion Prior HIV testing among older men at elevated risk was associated with threat perception, subjective norms, self-efficacy, testing belief, the interpretation of HIV-related information, and practical testing barriers. Age-sensitive interventions should provide credible and personally relevant information, strengthen social support and self-efficacy, and offer clear, practical guidance on how and where to obtain HIV testing.