Health & Place 83 (2023) 103076 Contents lists available at ScienceDirect Health and Place journal homepage: www.elsevier.com/locate/healthplace “For my safety and wellbeing, I always travel to seek health care in a distant facility”—the role of place and stigma in HIV testing decisions among GBMSM – BSGH 002 Edem Yaw Zigah a,*, Gamji Rabiu Abu-Ba’are a,b,c,g, Osman Wumpini Shamrock b,c, Henry Delali Dakpui a, Amos Apreku d, Donte T. Boyd e, LaRon E. Nelson f,g, Kwasi Torpey d a Behavioral, Sexual, and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana b Behavioral, Sexual, and Global Health Lab, School of Nursing, University of Rochester, Rochester, NY, USA c School of Nursing, University of Rochester, Rochester, NY, USA d School of Public Health, University of Ghana, Accra, Ghana e College of Social Work, Ohio State University, Columbus, OH, USA f School of Nursing, Yale University, New Haven, CT, USA g Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, USA A R T I C L E I N F O A B S T R A C T Keywords: Gays, bisexuals, and all other men who have sex with men (GBMSM) are heavily impacted by HIV in Ghana HIV testing compared to the general population. In addition to HIV and same-sex intercourse stigma, barriers such as GBMSM reduced privacy, lower-income status and limited health care facilities (HCF) affect HIV testing decisions among Stigma GBMSM. We employed a phenomenological research design to understand the role of place and stigma in HIV Slums Ghana testing among GBMSM in slums. GBMSM (n = 12) from slums in Accra and Kumasi, Ghana, were recruited and engaged in face-to-face interviews. We used a multiple reviewer summative content analysis to analyze and organize our key findings. The HIV testing options we identified include 1. Government HCF, 2. NGO and community outreach 3. Peer-educated services. Factors influencing GBMSM to test for HIV at HCF outside their areas included 1. The location of HCF 2. HIV and sexual stigma from slum areas 3. Positive HCW attitudes at distant HCF. 4. Negative Healthcare worker (HCW) attitudes towards GBMSM. These findings highlighted how stigma from slums and HCW influence HIV testing decisions and the need for place-based interventions to address stigma among HCW in slums to improve testing among GBMSM. The Human Immunodeficiency Virus (HIV) remains a significant compared to the 1.7% prevalence among the adult population (Ali et al., public health issue globally. In sub-Saharan Africa (SSA), gay, bisexual, 2019). and other men who have sex with men (GBMSM) carry a higher burden Additionally, there are regional disparities in Ghana, with the of HIV and remain at higher risk of contracting HIV than heterosexual highest rates of HIV among GBMSM found in the Greater Accra region men (Lane et al., 2016; Sandfort et al., 2019; Wirtz et al., 2017). While (34.3%) and the Ashanti Metropolitan region (13.7%) (Ghana AIDS most SSA countries have generalized HIV epidemic statistics, HIV Commission). prevalence among GBMSM is significantly higher, estimated at an 18% Despite significant efforts to end the HIV epidemic, many nations overall, with an odds ratio of 3.8 compared to the general adult popu- have difficulty meeting the United Nations’ Millennium Development lation. (Beyrer et al., 2010, 2012). The range of HIV prevalence among Goals to decrease the number of new HIV cases and deaths from ac- GBMSM in SSA countries varies greatly, with rates as low as 7.8% in quired immunodeficiency syndrome (AIDS). One reason for this diffi- Khartoum, Sudan, and as high as 49.5% in Johannesburg, South Africa culty is the HIV testing target, which is a crucial part of HIV prevention (Kunzweiler et al., 2017; Lane et al., 2011; Mmbaga et al., 2018; and treatment plans, is not being met in many developing countries. HIV Sandfort et al., 2019; Wirtz et al., 2017). Ghana is not an exception; HIV testing practices, especially among GBMSM, remain low, as they often prevalence among GBMSM is estimated at 17.5%, which is much higher experience additional obstacles in accessing HIV testing and care, * Corresponding author. E-mail address: Edemzigah3@gmail.com (E.Y. Zigah). https://doi.org/10.1016/j.healthplace.2023.103076 Received 9 March 2023; Received in revised form 19 June 2023; Accepted 20 June 2023 Available online 7 July 2023 1353-8292/© 2023 Elsevier Ltd. All rights reserved. E.Y. Zigah et al. H e a l t h a n d P l a c e 83 (2023) 103076 including stigma and discrimination (Abubakari et al., 2021a; Abuba- the way for the development of interventions to address HIV testing in kari et al., 2021b; Nelson et al., 2021). Existing social and legal barriers, slums in Ghana and elsewhere. such as criminalization, social isolation, and financial exclusion of GBMSM and persons living with HIV, intersect and negatively impact 3. Design and methods their physical and mental well-being (Abubakari et al., 2021c; Alessi et al., 2013; Nelson et al., 2022; Poku et al., 2005; Scheibe et al., 2014; 3.1. Research design Ulasi et al., 2009; Zahn et al., 2016). Such barriers also affect the ability of GBMSM to access and utilize sexual health services, such as those The study employed a qualitative phenomenological research design related to sexually transmitted infections and HIV (Fay et al., 2011; to understand the lived experiences of GBMSM around HIV testing in Schwartz et al., 2015; Semugoma et al., 2012). These adverse effects slum communities and to understand if their location impacts testing may manifest in various ways, including reluctance to seek testing and decisions. This design is best for collecting first-hand information on the treatment, difficulty finding and trusting healthcare providers, and lived experiences of individuals regarding a particular phenomenon (e. increased risk of physical harm (Abubakari et al., 2021c; Gu et al., g., stigma experiences, testing experiences). 2021). These societal attitudes and actions can create significant barriers to achieving improved health outcomes for GBMSM (Gyamerah et al., 3.2. Sampling and recruitment procedure 2020; Saalim et al., 2023). Research assistants from two GBMSM-led community organizations 1. Why slum communities? in Kumasi—Priorities on Rights and Sexual Health (PORSH) and Youth Alliance on Health and Human Rights (YAHR)—sampled participants An estimated 37.4% of the Ghanaian population lives in slum com- through a time-location sampling technique in the cities of Accra and munities, with a projected 5.5 million people living in urban slum Kumasi. All participants were engaged in an in-depth interview during communities (Abubakar and Kucukmehmetoglu, 2021) With this pop- one of the organizations’ activities. PORSH and YAHR have a long his- ulation steadily increasing over the years, it is imperative to understand tory of working with GBMSM in these study locations, ensuring that how GBMSM living in slum communities are affected when seeking sampled participants were the appropriate fit for the study. The study HIV-related care and what might inform their decisions to seek care initially targeted 19 GBMSM for interview sessions. However, research outside their communities (Kabiru et al., 2011; Madise et al., 2012; Sclar assistants in charge of interview sessions reached saturation in responses et al., 2005; Swahn et al., 2016). Slums are informally planned settle- by the eighth interview. To ensure complete saturation, research assis- ments that remain associated with unfavorable factors, such as high tants continued interviewing an additional 4 GBMSM, totaling 12 crime, low income, poor housing, unsanitary conditions, and lack of participants. proper health care and educational facilities (UN-Habitat, 2004; Amuyunzu-Nyamongo et al., 2007; Kabiru et al., 2011; Madise et al., 3.3. Inclusion criteria 2012; Oti et al., 2013; Sclar et al., 2005). The conditions in slums significantly increase the risk of contracting HIV (Adedimeji et al., 2007; All participants included in the study had attained the age of 18 years Greif and Dodoo, 2011; Madise et al., 2012). Poverty and lack of eco- and lived in a slum community within the Greater Accra Metropolitan nomic opportunities can push individuals into risky behaviors (e.g., Area and Kumasi Metropolitan Area. These cities, which are the most transactional sex, sex without condoms), further increasing their populated in Ghana, also have the highest prevalence of HIV among vulnerability to HIV (Pellowski et al., 2013). In addition, people who GBMSM. All participants self-identified as cisgender and members of a live in slums have congested and intimate units affecting privacy GBMSM category (gay, bisexual, or have sex with other cisgender men (Mahabir et al., 2016; McDonald and Forte, 2022; Morgan, 2020). For for reasons other than sexual orientation). Participants were expected to vulnerable populations such as GBMSM, being unable to stay anony- be sexually active and have had sexual intercourse with another cis- mous could affect various aspects of their lives, including HIV-related gender man in the year preceding this study. care and expression of sexual orientation or behavior, which leads them to seek HIV care elsewhere (Iott et al., 2022; Kutner et al., 2021). 3.4. Data collection procedure Stigma and discrimination against GBMSM are pervasive in slums, where these individuals often have limited social support and face 3.4.1. Procedure discrimination from their communities (Riley et al., 2007). Due to the phenomenological nature of this study, researchers employed a face-to-face interview technique to collect data from par- 2. The current study ticipants. Before data collection, qualified participants were presented with consent forms, which they were required to sign. Research assis- Despite the HIV risk and difficulty in seeking care in slums, we did tants provided further clarification and reminders about the key ele- not find a study that examines the role of place and stigma in the HIV ments of the consent documents during the data collection process. The testing decisions of GBMSM. The limited studies that exist on HIV and researchers overseeing the data collection ensured that participants’ full GBMSM in Ghana focus on the general GBMSM population, but even for consent was obtained through the signed forms. All interviews were held them, the physical and social environment plays an essential role in in secured locations of the community partners (PORSH and YAHR). shaping HIV testing decisions (Nelson et al., 2021; Nyblade et al., 2022; Four out of eight interviews were conducted in Twi (a local Ghanaian Saalim et al., 2023). The research on health facilities in Ghana shows language) because some participants indicated they could only express that the distribution and type of health facilities could significantly themselves effectively in Twi instead of English. affect HIV-related treatment and care, especially in slum communities (Dako-Gyeke and Kofie, 2015; Nyblade et al., 2022; Saeed et al., 2016). 3.4.2. Nature of questions Anticipated, experienced, and vicarious stigmas continue to deter Researchers were trained in qualitative interviews using a checklist. GBMSM from seeking HIV testing services in HCFs near them (Nyblade The study’s checklist allowed participants to express themselves freely et al., 2022). Therefore, this study aims to fill the gap in research around and encouraged a free and open conversation style rather than solely HIV testing among GBMSM in slums by examining how place and stigma relying on a question-and-respond format. The interviewers asked par- influence HIV testing decisions among GBMSM living in Ghanaian ticipants to describe their experiences with HIV testing within their slums. The findings provide insights into GBMSM experiences with HIV communities, stigma experiences, gender relations, coping strategies, testing and challenges associated with testing in slums, thereby paving and sexual behavior. Participants were also asked about factors that 2 E.Y. Zigah et al. H e a l t h a n d P l a c e 83 (2023) 103076 contribute to their decision to test or not for HIV. slum areas. Sample participant quotes: 3.5. Analytical strategy “I visit any available government hospital for HIV testing.” (GBMSM Participant) Data collected from participants were audio recorded and tran- scribed verbatim by research assistants. The interviews conducted in “I go to [NAME] polyclinic for HIV testing.” (GBMSM Participant) Twi were translated into English by more experienced research assis- tants who had translated such transcripts in our previous study (Saalim 4.3.2. NGO activities and community outreach et al., 2023). Transcribing audio records involved de-identifying infor- GBMSM reported using community outreach programs and other mation to ensure that vital information that could be used to link par- NGO facilities for HIV testing and other medical care. Some GBMSM ticipants to the data was removed. Analyzing participants’ responses involved multiple reviewers in a summative content analysis process. indicated having their first HIV test in an NGO facility. Community outreaches from NGOs provided GBMSM with a convenient opportunity Each transcript was shared with two reviewers who identified the salient factors raised by the participants and reported them using 100 to 200 and space to get tested for HIV. Periodic community outreaches enabled GBMSM who could not access HIV testing facilities in their slum areas to words. The lead author organized these reports into a summarized and get an HIV test. organized data spreadsheet and identified clusters frequently appearing Sample participant quotes: in the transcripts. We successfully used this process in our previous study (Abubakari et al., 2021b). “I had my first test at an NGO’s office in Kumasi, and that was a few months ago when I tested at their facility.” (GBMSM participant) 3.6. Ethical considerations “We have community outreaches where we normally go for HIV testing.” (GBMSM participant). Approval from the Institutional Review Board Committee at Yale University, Connecticut, USA (approval number: IRES IRB #RNI00002010) and the Ghana Health Service Ethics Committee, 4.3.3. Peer educators services Ghana (approval number: GHS-ERC 001/10/21) was obtained before GBMSM who were unable to find HIV testing facilities within slum the implementation of the study. The interviewers in this study ensured areas were greatly assisted by peer educators. Peer educators and some all participants fully understood the content in the informed consent friends of GBMSM referred them to GBMSM-friendly HIV testing facil- form and received written approval before conducting interviews. ities, which were located outside their slum area. Peer educators also encouraged GBMSM in slum areas to regularly test for HIV and some- 4. Results times also offered HIV testing services. This encouraged some of them to continuously test for HIV, as they got more comfortable with the HIV 4.1. Description of participants testing facilities they were referred to. Sample participant quotes: Twelve participants, 18 years and above, from slum communities “I had my first test at the [NAME] hospital, and I was referred by a within the Accra and Kumasi cities in Ghana participated in the study. friend. I have been testing since, and I’ve made it my habit to test Six participants indicated they belonged to the Christian religion, four frequently” (GBMSM participant) belonged to the Muslim religion, and two practiced both. The education levels of participants ranged from junior high school (JHS) to tertiary “It’s tough in our area because I’ve never seen a place to go and test education. The education levels of participants ranged from junior high for HIV. When I even go to the pharmacy, I don’t get the test. I have school (JHS) to tertiary education. Five participants had attained to call a friend who lives in Accra to take me somewhere. I’ve been to tertiary-level education. Six had a senior high school education, and one [NAME] to test. And I’ve also been to [NAME] to test. These places had completed junior high school. are all far from my home.” (GBMSM participant) “I always visit the [NAME] hospital for HIV testing, or I sometimes 4.2. Description of significant findings have my test through peer educators. And the last time I tested was in August last year.” (GBMSM participant) External factors beyond the control of GBMSM and other personal decisions contributed to their HIV testing experiences and influenced Factors influencing GBMSM’s choice of HIV testing facilities outside GBMSM’s choice to test for HIV within the slum area or at other facil- of slum areas they reside in. ities. Under HIV testing options, we identified three main categories: 1. Government HIV testing sites, 2. NGO activities and community 4.3.4. Location of HIV testing facility informed utilization among GBMSM outreach, and 3. Peer-education services. Factors influencing GBMSM to in slum areas test for HIV at other HIV testing facilities outside their slum areas were The proximity of HIV testing facilities to the slum communities of as follows: 1. Location of HIV testing facility, 2. HIV and sexual stigma GBMSM discouraged their utilization. The participants explained that from slum areas, 3. Positive Healthcare worker (HCW) attitudes at the need to keep their sexuality and outcomes of HIV tests confidential distant HIV testing facilities, and 4. Negative HCW Attitudes and Ex- informed their decision to test at distant HIV testing facilities. They had periences in testing facilities in the slum area. reduced instances of encountering familiar persons at distant HIV testing facilities compared to facilities in the slum areas they resided in; such 4.3. Options for HIV testing among GBMSM living in slum communities experiences made them feel uncomfortable and unsafe. Sample participant quotes: 4.3.1. Government HIV testing facilities “I don’t use health facilities that are just around me because I don’t GBMSM acknowledged that there were limited HIV testing facilities want to meet a person who knows me. I don’t want to face any kind within the slum communities. However, those who expressed the need of discrimination. Because I know a lot of people talk. Even when to get tested highlighted various HIV testing options within slum areas. they don’t know why you are there. Maybe they will say, ’I found this Government HIV testing facilities were among the most utilized by person here, and he is like this and that, and he has this thing,’ when GBMSM in the slum areas. Some explained that the location of these it’s not even the truth. Maybe even the person saying that is also facilities presented an accessible option for HIV testing to GBMSM in 3 E.Y. Zigah et al. H e a l t h a n d P l a c e 83 (2023) 103076 facing the same thing but will be like, ’I saw this person here; I think necessarily guarantee its use by GBMSM in such communities due to he has HIV,’ even though he has it himself, and he will be the one to stigma experiences and negative HCW attitudes toward them accessing spread the news. So, I don’t go to facilities in my immediate sur- HIV testing facilities located in slums. Some of the positive attitudes of roundings.” (GBMSM participant) HCWs highlighted by GBMSM in the study were as follows: non- “I will have my HIV test at any available government hospital. But discriminatory and non-stigmatizing attitudes, respect and empathy not in my community. The reason why I don’t want to test in my toward GBMSM, and friendliness and patience of HCWs. Pre-counseling community is because maybe I will go and meet someone in the fa- and educative sessions received by GBMSM from HCWs before getting cility who knows me. So, I will like to go far away to go and check it.” tested created a conducive environment for them. They explained that (GBMSM participant) they felt their HIV test outcomes would be kept more confidential and safer at distant HIV testing facilities. They were encouraged to test for “My experience at the HIV testing facility in my community wasn’t HIV regularly due to non-stigmatizing HCW attitudes at distant HIV good because I never liked the atmosphere. I didn’t like how people testing facilities. would be staring at me in an awkward manner.” (GBMSM Sample participant quotes: participant) “I always visit the [NAME] hospital because the nurses are friendly “It is not safe for men who have sex with men (MSM) to access health and understand us (referring to GBMSM). Even though it is far from care in my community, but they will be safe at the place where I my community, I still travel to that facility because of their services.” receive health care which is [NAME] hospital outside my commu- (GBMSM participant). nity.” (GBMSM participant) “The nurses are cool. There’s this woman there, and she is very cool. I think her name is [NAME]. When I go there, she will ask me how I’m 4.3.5. HIV and sexual stigma from slum communities discouraged the use of doing and give me condoms and lubricant. At the [NAME] hospital, HIV testing facilities within slums by GBMSM there is a male nurse there who is cool. I go there for a check-up. The participants indicated that the stigma experiences and stereo- Sometimes he will encourage me to get tested.” (GBMSM participant) typical conversations about GBMSM and persons living with HIV discouraged the use of HIV testing facilities within slum areas. Thus, “My experience at the HIV testing site was normal because the nurse they shy away from seeking HIV testing in their community facilities as in charge is a friendly nurse, and even though she knows about my they anticipate stigma around HIV and same-sex sexual behaviors. To sexuality, she doesn’t stigmatize me or discriminate against me or avoid stigma, some of them preferred to seek HIV testing services at a any other MSM.” (GBMSM participant) distant location where the impact of stigma was likely to be lessened due “I will describe the [NAME] hospital as a perfect place for people like to the reduced chance of encountering familiar individuals. In addition myself to get treatment or health care. I am saying that because of to stigma from the slum communities, GBMSM also had safety concerns. how I was treated when I visited the facility. I was informed that the They were scared of being discriminated against because of HIV or health care providers there know our situation, so they treat us with physically attacked by slum dwellers because of their sexuality or same- care and respect.” (GBMSM participant) sex sexual behaviors. To secure their safety and well-being in their communities, they preferred to take HIV testing services in facilities outside their slum areas. 4.3.7. Negative HCW Attitudes and Experiences discourage HIV testing in Sample participant quotes: slum areas The negative experiences of GBMSM at HIV testing facilities in slum “I have never seen anyone living with HIV being treated badly in my areas discouraged their use. Most participants indicated that their safety community, but comments about HIV and its related topics from my and ability to secure their anonymity within the slum areas when community people prove that they will not treat you well if they accessing HIV testing was paramount to them. They described feeling should find out that you have the virus.” (GBMSM participant) unsafe while getting tested for HIV in their communities and reported “My community members think people living with HIV have a lot of that HCWs did not maintain confidentiality. Ultimately, while govern- sex, and they are sex addicts. Because if you don’t have sex, you ment health facilities present a convenient option for HIV testing for won’t get infected. And married people usually don’t get infected in GBMSM in slums, anticipated stigma and the likelihood of being atten- my community. It’s mostly a religious area with Muslims; they al- ded to by familiar HCWs guided their choice to get tested outside of the ways think you should get married before you have sex. So, if you are slums. Participants reported experiencing negative attitudes from infected and someone gets to know you are infected, you are going to HCWs, such as disrespect toward GBMSM, which led to non-confidential be mocked or treated badly in the area.” (GBMSM participant) services in slum areas. Some participants recounted personal experi-ences to illustrate this point. “People in my slum community treat persons living with HIV very Sample participant quotes: badly because there is this lady in my community who was sick, and rumors said she had HIV. They pointed fingers at her whenever she “[NAME] hospital in my community, I know the workers there are walked around. They even refused to even sell to her when she not well-meaning. If you are MSM and go there, you won’t be happy. visited a shop to buy something. She was sacked from home, and they If you have feminine mannerisms as well, it gets worse. They will talk erected a wooden structure for her, and she was prohibited from a lot because the nurses there gossip a lot.” (GBMSM participant) coming back home.” (GBMSM participant) “I always go to [NAME] hospital because the kind of treatment I will receive in my community health care unit will be different. I will 4.3.6. Positive HCW attitudes at distant HIV testing facilities encouraged always travel to different places for health care for my safety and GBMSM to test for HIV outside their slum areas well-being. It is very far, but I don’t want to be treated differently The HCWs at distant HIV testing facilities motivated most GBMSM because of my sexuality.” (GBMSM participant) interviewed to travel far to seek HIV testing. For some of them, getting “The health care facility in my community is not safe. Because if it’s a an HIV test at other testing facilities beyond their slum communities did straight health care center, you can’t express yourself to tell them not come up as a major concern once they accessed services that were what’s really wrong with you for them to understand your situation. much more conducive and accommodating. Respondents highlighted You have to cover up with a bit of lie just for them to give you that the availability of HIV testing facilities in slum areas did not average care, but they can’t go deep because you have to cover up 4 E.Y. Zigah et al. H e a l t h a n d P l a c e 83 (2023) 103076 and hide your identity. Because I’m scared. The stigma is very high. stigma for dwelling in slums as an additional barrier to HIV testing The HCW might even sack you or won’t attend to you.” (GBMSM among GBMSM. The anticipation of HIV, gender, and sexual stigma was participant) attributed to the stigma experiences of persons living with HIV in the “I see that not every hospital is safe in my community. In some slums as well as the high prevalence of myths and misconceptions hospitals, the way they treat you is bad when you go there. I among slum dwellers. This suggests that GBMSM avoided being seen at remembered that I had an … some time ago, and they took me to HIV-related service facilities to prevent identification by slum dwellers [NAME] in my community. I spent about a week there and saw the and avoid stigma from within the slums. The social discrimination and way the nurse treated my mum rudely, telling her to walk out. Had I stigmatization of GBMSM pose a major risk for HIV infection and act as not been sick, I would have dealt with her. Seeing someone like this, deterrents to prevention efforts, as many GBMSM may avoid seeking you know she can’t keep her mouth shut for one to go there. I slept HIV testing and other related care services out of the fear of further there for about one week and learned how these HCWs talk, gossip, stigmatization or social rejection (Babel et al., 2021). and don’t respect us. So, if you go to such a hospital for HIV testing, I An important pull factor that encouraged HIV testing at distant fa- don’t think it will even be confidential.” (GBMSM participant) cilities was the positive attitude of HCWs at HIV testing facilities outside slum communities. Findings from the study suggested that GBMSM in slums are encouraged to get tested for HIV regularly due to the non- 5. Discussion stigmatizing attitudes of HCWs at distant HIV testing sites. Friendly nurses at distant HIV testing sites created a more comfortable and Despite the increased risk of HIV infection and the pervasiveness of encouraging environment for GBMSM to get an HIV test regularly. As stigma and challenges related to HIV testing and care services among established in other studies, the friendly and respectful attitude of HCWs GBMSM living in slum communities, there is a paucity of research on the and their empathy toward GBMSM motivates the latter to get an HIV test role of place and stigma in HIV testing among GBMSM in the slums of (Kushwaha et al., 2017; Nyblade et al., 2022). Using distant HIV testing Ghana and SSA (Abubakari et al., 2021c; Kushwaha et al., 2017; Nelson sites also enabled GBMSM to stay anonymous about their sexuality and et al., 2021; Nyblade et al., 2022). Therefore, this study provides qual- HIV test outcomes. For instance, some participants reported going to itative insights into how stigma and place influence decisions on where distant HIV testing sites to avoid the likelihood of meeting familiar slum to test among GBMSM. Although participants mentioned the availability dwellers or HCWs to avoid compromising the confidentiality of their of local HIV testing options, several factors contributed to the HIV test results and reduce the chances of being stigmatized by fellow non-utilization of HIV testing facilities in their slum communities and slum dwellers who may identify them within HIV testing facilities. For the subsequent preference for HIV testing facilities further away. Some some GBMSM, the proximity of HIV testing facility to their slum was not of these factors were as follows: 1. Location of HIV testing facility, 2. HIV a barrier once they were assured stigma-free, confidential, and friendly and sexual stigma, 3. Positive HCW attitudes at distant HIV testing fa- HIV testing services at distant facilities. This highlights the importance cilities, and 4. Negative HCW attitudes at HIV testing facilities in slums. and impact of HCW attitudes toward HIV testing decisions of GBMSM Findings from previous studies have shown that living in slum or and the need to develop interventions that address and promote positive informal communities compromises the health of inhabitants due to HCW attitudes toward GBMSM (Abubakari et al., 2021c; Nyblade et al., limited HCFs and the general inability of residents to afford their basic 2022). healthcare needs (Aberese-Ako et al., 2022; Lungu et al., 2016; Nejad Similar to stigma from the community, we established that negative et al., 2021; Sverdlik, 2011). GBMSM, in the study, acknowledged that HCW attitudes greatly discourage the use of HIV testing sites in slums the slums have limited HIV testing sites. Nonetheless, despite the among GBMSM. HCWs’ stigmatizing attitudes toward GBMSM and availability of HIV testing facilities within the local slum, their utiliza- gender-non-conforming men and their lack of respect for the confiden- tion by GBMSM was discouraged. Consistent with previous research tiality of their data compromised the sense of safety of GBMSM who seek (Phukan, 2014), our participants acknowledged that living in slums HIV testing in the slum areas. This finding confirms that negative atti- promotes familiarization but compromises privacy. As such, GBMSM tudes of HCWs contribute to low HIV testing rates among GBMSM in who live in slums or poorer communities experiences a sense of inse- different settings (Sison et al., 2022). GBMSM in this study did not feel curity and have a strong need to maintain anonymity regarding their safe and could not trust HCWs with their HIV test outcomes. For sexuality or same-sex sexual behaviors; it is driven by their desire to instance, HCWs who continuously disrespected, stigmatized, and avoid further social rejection and discrimination (Allman et al., 2007). discriminated against GBMSM could not be trusted by them to be Stigma from the slum communities around HIV and their gender confidential about their HIV test outcomes (Ogunbajo et al., 2017). This expression and sexual behavior was highlighted as a major push factor implies that although there might be available HIV testing sites within for GBMSM to seek HIV testing outside their slum areas. While previous the slums, there is no guarantee of its utilization by GBMSM due to studies have not examined the stigma toward GBMSM in slum com- negative HCW attitudes toward GBMSM. Hence, it is essential not just to munities in Ghana, our findings align with existing research on stigma provide HIV testing facilities in slums but also to ensure a conducive and HIV testing outcomes among GBMSM; GBMSM in slums also face environment, including privacy for GBMSM, HCW professionalism, and various forms of stigma from their slum communities, which in turn a non-stigmatizing health care experience to ensure GBMSM are contributes to lower rates of HIV testing (Gyamerah et al., 2020; encouraged to take regular HIV tests (Matovu et al., 2019; van der Elst Kushwaha et al., 2017). Though very few respondents mentioned being et al., 2013). This is especially critical as Ghana has considered passing able to use HIV testing facilities within slums, the majority of GBMSM one of the harshest anti-LGBTQ + laws in West Africa. As reported by acknowledged experiencing and anticipating stigma, which negatively Abubakari et al. (2021c) and Nyblade et al. (2022), this policy has the impacts their ability to test for HIV in certain facilities. Highlighting the potential to increase stigma and discrimination among LGBT Q+ people reasons for not testing for HIV within their slum communities, some and may negatively impact healthcare delivery by HCW. For GBMSMs in GBMSM indicated that they live in a community with social norms and slum communities, this may pose a further barrier to seeking care in values that frown upon same-sex sexual behaviors. As such, GBMSM in slum communities as they may feel unsafe. slums live a closeted life and avoid instances or situations that may compromise their anonymity (Phukan, 2014). Findings from Abubakari 5.1. Limitations and future research et al. (2021a) also support our findings, which suggest that GBMSM in Ghana are faced with the intersection of HIV stigma, sexual stigma, and The study’s major limitations can be seen in the qualitative findings stigma toward gender non-conforming men, which negatively impacts that are inherently subjective to the authors. The personal bias and id- HIV testing outcomes. Our study further highlights the inclusion of iosyncrasies of researchers could have affected data collection and 5 E.Y. Zigah et al. H e a l t h a n d P l a c e 83 (2023) 103076 analysis in this study. Future research could explore other forms of Allman, D., Adebajo, S., Myers, T., Odumuye, O., Ogunsola, S., 2007. Challenges for the research design, such as employing a quantitative or mixed approach to sexual health and social acceptance of men who have sex with men in Nigeria. Cult. Health Sex. 9 (2), 153–168. reduce the likelihood of bias in data collection and analysis. Researchers Amuyunzu-Nyamongo, M., Okeng’o, L., Wagura, A., Mwenzwa, E., 2007. Putting on a also realize a limitation connected to the sampling of 12 GBMSM in the brave face: the experiences of women living with HIV and AIDS in informal study. Although in-depth interviews conducted by researchers reached a settlements of Nairobi, Kenya. AIDS Care 19 (Suppl. 1), S25–S34. Babel, R.A., Wang, P., Alessi, E.J., Raymond, H.F., Wei, C., 2021. Stigma, HIV risk, and saturation in responses, the authors strongly believe expanding the access to HIV prevention and treatment services among men who have sex with men study context to include GBMSM in other regions of Ghana could lead to (MSM) in the United States: a scoping review. AIDS Behav. 25 (11), 3574–3604. new findings not realized in this study. The study also did not target a Beyrer, C., Baral, S.D., Walker, D., Wirtz, A.L., Johns, B., Sifakis, F., 2010. The expanding specific age group, as GBMSM had to be 18 years or older to qualify for epidemics of HIV type 1 among men who have sex with men in low-and middle- income countries: diversity and consistency. Epidemiol. Rev. 32 (1), 137–151. the study. Future studies could target more specific age brackets, such as Beyrer, C., Baral, S.D., Van Griensven, F., Goodreau, S.M., Chariyalertsak, S., Wirtz, A.L., young adults, to better understand the dynamics of study outcomes. Brookmeyer, R., 2012. Global epidemiology of HIV infection in men who have sex with men. Lancet 380 (9839), 367–377. Dako-Gyeke, M., Kofie, H.M., 2015. Factors influencing prevention and control of 6. Conclusion malaria among pregnant women resident in urban slums, southern Ghana. Afr. J. Reprod. Health/La Revue Africaine de La Santé Reproductive 19 (1), 44–53. http:// The study results call for the need for stakeholders and scholars to www.jstor.org/stable/45239736. Fay, H., Baral, S.D., Trapence, G., Motimedi, F., Umar, E., Iipinge, S., Dausab, F., employ a place-based approach to HIV research and intervention de- Wirtz, A., Beyrer, C., 2011. Stigma, health care access, and HIV knowledge among livery, particularly regarding the availability of HCFs, improved HIV men who have sex with men in Malawi, Namibia, and Botswana. AIDS Behav. 15 (6), testing and care services, and sensitization campaigns targeted at 1088–1097. Ghana AIDS Commission, President’s Emergency Fund for AIDS Relief, US. reducing the stigma associated with HIV in slums. This study highlights Greif, M.J., Dodoo, F.N.-A., 2011. Internal migration to Nairobi’s slums: linking migrant the critical need to develop HCW interventions to sensitize and educate streams to sexual risk behavior. Health Place 17 (1), 86–93. them on more appropriate service delivery to GBMSM living in slum Gu, L.Y., Zhang, N., Mayer, K.H., McMahon, J.M., Nam, S., Conserve, D.F., Moskow, M., Brasch, J., Adu-Sarkodie, Y., Agyarko-Poku, T., 2021. Autonomy-supportive communities to encourage HIV testing. The study also contributes to healthcare climate and HIV-related stigma predict linkage to HIV care in men who existing knowledge for stakeholders striving to achieve universal HIV/ have sex with men in Ghana, West Africa. J. Int. Assoc. Phys. AIDS Care 20, AIDs related targets, such as the United Nations Program on HIV/AIDS 2325958220978113. (UNAID) 90-90-90 treatment target to end the AIDS epidemic and the Gyamerah, A.O., Taylor, K.D., Atuahene, K., Anarfi, J.K., Fletcher, M., Raymond, H.F., McFarland, W., Dodoo, F.N.-A., 2020. Stigma, discrimination, violence, and HIV goals stipulated in the United States President’s Emergency Plan for testing among men who have sex with men in four major cities in Ghana. AIDS Care AIDS Relief (PEPFAR) (a United States government initiative program 32 (8), 1036–1044. adopted in Ghana to achieve epidemic control). These targets aim to end Hagopian, A., Rao, D., Katz, A., Sanford, S., Barnhart, S., 2017. Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of the AIDS epidemic, increase HIV testing, ensure sustained antiretroviral PEPFAR? Glob. Health Action 10 (1), 1306391. treatment, and reduce new HIV infections in Ghana (Ali et al., 2019; Iott, B.E., Loveluck, J., Benton, A., Golson, L., Kahle, E., Lam, J., Bauermeister, J.A., Hagopian et al., 2017; Marum et al., 2012). Lastly, to achieve ending the Veinot, T.C., 2022. 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