Exploring the factors influencing peer-recommended HIV testing in men who have sex with men (MSM): A qualitative study based on the theory of planned behavior

OBJECTIVES: This study explored the factors influencing peer-recommended HIV testing in men who have sex with men (MSM), using the Theory of Planned Behavior (TPB), to inform strategies that promote peer engagement in HIV testing. STUDY DESIGN: Qualitative study. METHODS: We recruited MSM participants through the Tongxing Community-based Organization (CBO) in Shijiazhuang City in September 2024. Semi-structured interviews were conducted using a TPB-based guide, and thematic analysis was performed. RESULTS: Twenty-four MSM were interviewed (median age = 34.5 years; Q1- Q3: 23-43.5). Most were college-educated, unmarried, and employed. Nineteen (79.2 %) expressed willingness to recommend HIV testing to peers. Three key themes emerged: (1) Attitudes - Participants with positive attitudes generally viewed testing recommendation as a beneficial health practice, whereas negative attitudes reflected concerns about creating discomfort or imposing a social burden on peers. (2) Subjective Norms - Influencing factors included supportive peer environments, limited social networks, and the normative role of CBOs. (3) Perceived Behavioral Control - Facilitators included risk awareness, trust in CBOs, prior experience of being recommended for testing, and access to tools such as HIV self-test kits and social media platforms. Barriers included inadequate HIV testing promotion, privacy concerns. CONCLUSIONS: In summary, this study uses the TPB to conceptualize peer-recommended HIV testing among Chinese MSM as a social behavior that combines pathway navigation and transfer of trust in services. The findings suggest that HIV testing promotion programs should more deliberately integrate peer recommendation into existing services by strengthening norms that frame "recommending testing as caring for peers" and by providing simple scripts and clear pathway information to support potential referrers.