Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums—BSGH-005

Gamji Rabiu Abu-Ba’are; Osman Wumpini Shamrock; Edem Yaw Zigah; Adedotun Ogunbajo; Henry Delali Dakpui; George Rudolph Kofi Agbemedu; Donte T Boyd; Oliver C Ezechi; LaRon E Nelson; Kwasi Torpey

doi:10.1371/journal.pone.0289905

. 2024 Jun 5;19(6):e0289905. doi: 10.1371/journal.pone.0289905

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums—BSGH-005

Gamji Rabiu Abu-Ba’are ^1,^2,^3,^4,^5,⁶, Osman Wumpini Shamrock ^1,^2,^*, Edem Yaw Zigah ^1,², Adedotun Ogunbajo ⁷, Henry Delali Dakpui ^1,², George Rudolph Kofi Agbemedu ^1,², Donte T Boyd ⁸, Oliver C Ezechi ⁵, LaRon E Nelson ^4,⁹, Kwasi Torpey ⁶

Editor: Moses Kelly Kumwenda¹⁰

¹Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America

²Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana

³Department of Public Health Sciences, University of Rochester, Rochester, New York, United States of America

⁴School of Nursing, Yale University, New Haven, Connecticut, United States of America

⁵Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria

⁶Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana

⁷Us Helping Us People into Living, Washington, DC, United States of America

⁸College of Social Work, Ohio State University, Columbus, Ohio, United States of America

⁹Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, United States of America

¹⁰Kamuzu University of Health Sciences: University of Malawi College of Medicine, MALAWI

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: osmanwumpini_shamrock@urmc.rochester.edu

Roles

Gamji Rabiu Abu-Ba’are: Conceptualization, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft, Writing – review & editing

Osman Wumpini Shamrock: Conceptualization, Methodology, Visualization, Writing – original draft, Writing – review & editing

Edem Yaw Zigah: Conceptualization, Investigation, Writing – original draft, Writing – review & editing

Adedotun Ogunbajo: Methodology, Writing – original draft, Writing – review & editing

Henry Delali Dakpui: Conceptualization, Methodology, Visualization, Writing – original draft

George Rudolph Kofi Agbemedu: Conceptualization, Investigation, Methodology, Visualization, Writing – original draft

Donte T Boyd: Formal analysis, Writing – original draft, Writing – review & editing

Oliver C Ezechi: Methodology, Visualization, Writing – original draft, Writing – review & editing

LaRon E Nelson: Investigation, Visualization, Writing – original draft, Writing – review & editing

Kwasi Torpey: Supervision, Writing – original draft, Writing – review & editing

Moses Kelly Kumwenda: Editor

PMCID: PMC11152275 PMID: 38837972

Abstract

Despite significant progress in Ghana’s HIV response, disparities in HIV prevalence persist among different populations. Gays, bisexuals, and other men who have sex with men (GBMSM) in the country remain vulnerable to HIV infection due to high levels of stigma and discrimination, limited access to healthcare services, and low HIV knowledge levels. While limited studies focus on HIV prevention and care in the Ghanaian GBMSM context, we did not find studies on GBMSM in slums. We, therefore, explored stigma and motivations of HIV testing among GBMSM in slums. In collaboration with our community partners, we recruited and conducted face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi, Ghana. Our multiple-reviewer summative content analysis identified the following: under HIV stigma, we identified two categories, avoidance of GBMSM living with HIV and fear of testing positive for HIV. Under motivations for HIV testing, we identified three categories; HIV vulnerability, knowing one’s HIV status, and positive messaging about HIV. Our findings provide valuable insights into stigma and motivations for HIV testing among GBMSM in Ghanaian slums. They also highlight the importance of targeted HIV education interventions to empower GBMSM to take responsibility for their sexual health and address the unique challenges they face accessing HIV testing services.

Introduction

Sub-Saharan Africa (SSA) carries over two-thirds of the world’s burden of HIV, yet, HIV testing and related services remain underutilized due to several factors such as insufficient knowledge, low-risk perception, and increased stigma [1,2]. Despite programmatic efforts in SSA, the burden of HIV and the factors (e.g., stigma) that hinder access to HIV testing remain a significant obstacle to HIV testing among HIV key populations such as gays, bisexuals, and men who have sex with men (GBMSM) [3–6].

Although Ghana has made significant strides in its HIV response, disparities persist in HIV prevalence between different populations, with GBMSM carrying a disproportionate burden, 18% compared to that of the general population, 1.7%% [7–9]. Efforts to increase HIV testing and prevention among GBMSM continue, yet reports indicate suboptimal testing rates in this group in the country due to individual, interpersonal, and environmental barriers [6–8,10,11]. At the individual level, such factors include low-risk perception, low HIV knowledge, and fear of rejection [3,12]. At the environmental level, factors include healthcare facility-level stigma, inadequate access to testing, and community stigma among others [12–15]. At the peer level, interpersonal HIV stigma affects interest in testing as some GBMSM discriminate against their peers living with HIV [3,12].

While limited studies explore stigma and testing practices among GBMSM in Ghana, no known studies have focused explicitly on GBMSM in Ghanaian slum communities. However, in SSA, studies have highlighted the association of low HIV knowledge and low HIV testing to persons with low socioeconomic status [16,17]. Slums also remain associated with high-risk behaviors such as transactional sex, inconsistent condom use, and increased HIV prevalence [18–20]. Emerging findings as from 2010 in eastern Africa show that GBMSM in slums have low-risk perception, increased risk behaviors, and low access to HIV testing and prevention services [21,22]. In 2012, HIV rates among slum residents in Kenya were notably higher at 12%, compared to 5% among non-slum urban residents and 6% among rural residents [22]. Also, out of 4028 youth sampled in Kenyan slums, only 27% had ever tested for HIV, and over 90% had low HIV risk perception. Of those who tested, over 90% reported being required to take the test [21].

Whereas no specific studies exist among GBMSM in Ghana’s slums, previous studies among slum communities in Ghana report increased HIV risk behaviors and higher HIV prevalence among slum residents [19,23,24]. Communities with increased HIV prevalence and risk also have poorly resourced infrastructure and health facilities which contributes to poor health outcomes [25,26]. Urban areas such as the Accra and Kumasi larger regions present the highest prevalence rates of HIV, 2.47% and 1.98%, respectively, compared to the other 16 regions [9]. These two cities and their surrounding areas also record high prevalence among GBMSM, Accra (42%) and Kumasi (25%), compared to the national GBMSM rate of 17.5% [7]. Thus, placing GBMSM living in urban slums at increased risk of HIV infection than other populations.

The current study seeks to understand GBMSM slum-specific HIV stigma manifestation and motivation for testing in Accra and Kumasi, Ghana. Understanding stigma and motivations for HIV testing is critical to reducing HIV transmission and improving health outcomes for this population.

Self Determination Theory (SDT)

The Self Determination Theory (SDT) explains, individuals’ innate psychological needs inform their wellbeing and quality of life within a social context [27,28]. The various components of SDT (the basic psychological need for autonomy, competence, and relatedness) could help explain the importance of HIV testing motivations among GBMSM in slums. Per the psychological need for autonomy, the barriers faced by GBMSM in slums can undermine the autonomy and restrict their ability to make informed HIV testing [12,13,29–31]. On the psychological need for competence, the low levels of HIV knowledge can affect GBMSM’s proficiency to make informed decisions regarding HIV testing [29,32].

The theory also offers insight into HIV stigma by GBMSM. Being stigmatized can affect the autonomy GBMSM have over their ability to test for HIV due to the potential threat of disclosure of their sexual orientation without their consent. This perceived threat may lead to the reluctance of GBMSM to seek HIV testing. GBMSM may be affected by negative stereotypes and misconceptions about homosexuals and HIV. These misconceptions may lead to situations where GBMSM feel ashamed, have self-doubts, or have low self-esteem, affecting their chances of testing for HIV. The stigma and discrimination faced by GBMSM can also negatively impact the relatedness aspect of SDT, which emphasizes the need for individuals to feel connected and supported in their social environments. Creating supportive and inclusive environments, reducing stigma, and improving access to healthcare services are crucial for promoting relatedness and encouraging GBMSM to seek HIV testing [33–35].

Methodology

Study design

The study used a qualitative interview [36] to collect data from GBMSM living in slum communities in Ghana. This approach allowed researcher in this study gather firsthand experiences of GBMSM around HIV stigma and motivations for HIV testing for those living in slum communities within the Accra, and Kumasi cities in Ghana.

Sampling and recruitment procedure

Using the time location sampling (TLs) technique, we reached and recruited GBMSM in slum communities in collaboration with our community partners in Accra and Kumasi. Research assistants working with our community partner organizations in Accra. community partner organizations screened and invited GBMSM to take part in interviews sessions during one of the organizations’ activities when GBMSM visited the site. We have worked with these community partners in previous studies [10,11]. Although we originally intended to purposively include 19 participants in this study, we reached saturation of information after the eight interviews. When responses from study participants were found to be consistent by the research assistants, an additional four transcripts were included to ensure complete information saturation, bringing the total number of transcripts to twelve.

Study setting

Ghana is a country located in West Africa and the main religions practiced are Christianity (71%), Islam (18%), and African Traditional Religion (5%) [37]. The education statistics show that the majority of children (71%) complete primary education, but the percentages decrease (47%) for lower secondary school, and upper secondary school (35%) [38]. A study conducted on MSM (transgender, gay, bisexual, and straight) in Ghana revealed that over half (52.2%) of them are educated, with around 16.8% of them having tertiary or higher educational qualifications [7]. Additionally, the study highlighted that nearly half (44.1%) of the MSM were employed and had never been married [7]. The official language spoken in Ghana is English, but there are several indigenous languages such as Twi, Ewe, and Fante that are spoken more frequently [39].

Inclusion criteria

Participants in the study had to be at least 18 years old and live in a slum community in Accra, Ghana’s Greater Accra regional capital, or Kumasi, Ghana’s Ashanti regional capital. Additionally, the individual identity had to be a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation. The person must have been sexually active during engagement and must have had sexual intercourse with another cis-gender man within the previous six months.

Data collection procedure

Procedure

To gather information from the participants, we conducted in-depth face-to-face interviews. Following the screening, participants were given consent forms by the research assistants to review. Research assistants (EYZ, OWS) engaged in data collection had prior and extensive research training from working with these populations in the past. We also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants [23,24,40–44]. The research assistants also read the consent forms out loud and provided extra explanations to ensure everything was understood. They answered the participants’ queries before the interviews started, collected signatures confirming GBMSM’s agreement to participate in the study, and allow for audio recording. The community partners’ private spaces were used for all interviews. All but four interviews were in English, the other four in Twi, a local Ghanaian language that some participants found more conversant. Data collected in Twi were translated and transcribed into the English Language. Data were collected from participants in January 2022, and lasted for 10 days.

Nature of questions

The research assistants were trained to conduct qualitative interviews using the study’s checklist as a guide in collecting information on HIV stigma and motivations for testing among GBMSM living in Ghanaian slum communities. In line with our design, the checklist allowed a more transparent and open discussion rather than the traditional question-and-answer interview structure. Participants were asked to share their experiences of HIV testing, their knowledge, and what motivated or affected their interest in testing.

Analytical strategy

Trained research assistants deidentified the transcripts after translating the audio interview recordings verbatim. We performed a summative content analysis on the transcripts with multiple reviewers [11]. Our team has successfully used this analytical method to comprehend crucial components in participant accounts [11]. Each transcript received at least two reviewers. Each reviewer independently read the transcripts to identify the most statements made by the participants. They then reported these statements in between 100 and 200 words. The principal authors reviewed each summary to find clusters and recorded the elements frequently appearing in transcripts and summaries in a data spreadsheet. We identified several clusters and classified them under categories that outlined participant experiences, perceptions, and motivations for HIV testing. Each area that was reported appeared in both peer reviewers’ summaries.

Ethical considerations

Ethical approval was received from the Ghana Health Service Ethics Committee (GHS-ERC 011/10/21) and the Institutional Review Board Committee (IRES IRB) of Yale University (IRES IRB #RNI00002010). The interviewers in this study ensured that each participant had read and understood the informed consent form thoroughly before any data was collected, and afterward, they obtained written consent.

Findings

Description of participants

The 12 participants identified as cis-gender men and had sexual intercourse within the previous six months with another cis-gender man. Six participants identified as Christians, four as Muslims, and two as both Muslims and Christians. Five participants accomplished tertiary education, and six concluded senior high school while one didn’t complete Junior High school education.

Description of findings

Findings from the data collected and analyzed revealed two categories; 1) HIV stigma and 2) motivations for HIV testing. Under HIV stigma: avoidance of GBMSM living with HIV, and fear of testing positive for HIV. Under the category motivations for HIV testing: HIV vulnerability, sexual health decision-making, and knowing one’s HIV status.

HIV stigma

Avoidance of GBMSM living with HIV

Participants in the study indicated they were afraid and had negative feelings about people living with HIV. One person, Participant K, mentioned they were scared to be near someone because of fear of a potential HIV infection. According to the participants, this fear of HIV stemmed from simple things like eating, sleeping in the same room, and bathing with persons living with HIV. Others, such as Participant F, thought that only people who have a lot of sex are likely to get HIV. They believed that married people were less likely to get the virus because they weren’t promiscuous but had sex with only their marriage partners. However, not everyone felt this way. Some participants were well informed about how HIV is transmitted and were comfortable with being around people who have HIV. Participant E, for example, said they would do things like eat or hang out with someone who has HIV, but they wouldn’t have sex with persons living with HIV.

I’m scared of them. I will be scared to eat with the person infected with HIV. Bath with the person or even live in the same area with the person. Because I don’t want to get close to the person, maybe because my thoughts are that the person may transfer it to me at any moment, so I will neglect the person (GBMSM participant K).

They do much of sex, they are sex addicts. Because when you don’t have sex, you won’t get infected. And married people usually don’t get infected in my community (GBMSM participant F).

I wouldn’t mind eating with the person because I was told you can only get infected through sex, deep kissing and sharing sharps. So I will treat the person like an ordinary person. Sex will be the only thing I wouldn’t have with this person. I am nondiscriminatory; that’s why my friends came to me and told me they were positive (GBMSM participant E).

Fear of testing positive for HIV

Participants mentioned they were really scared about getting tested for HIV. One person, Participant B, felt nervous about telling others their HIV status and was scared at the idea of getting tested. They worried that they might test positive for HIV. Another person, Participant E, said getting tested for HIV was scary at first because they were afraid of testing positive and what would happen next. However, both participants talked about how they learned to deal with their fears. Participant B said it was important to encourage themselves and think positively about the testing process. Participant E said they used to find HIV testing scary, but now they see it as a regular thing, like other medical tests. The participants indicated the importance of clearing up any wrong ideas and stigma about HIV testing so people won’t be so scared and will be more open to getting tested.

It’s scary. I have tested for HIV, but I wouldn’t like to share my status now. Being in the house, I encourage myself to go and get tested. However, when I get there, it’s scary. What if it comes out positive? But rather, I should be thinking the other way that it should be negative (GBMSM Participant B).

It’s very scary going for HIV testing, but when you encourage yourself to do the test, you realize it’s not that scary but just like the normal tests that we do. But because of the mentality that if you test, you will come out positive and the ARV and other stuff, its scary (GBMSM Participant E).

Motivations for HIV testing among GBMSM

HIV vulnerability

Some GBMSM were motivated to test for HIV due to their HIV high-risk awareness, as being a sexually active GBMSM poses a higher risk of getting HIV because of the increased HIV prevalence compared to the general population. Participant A mentioned it was really important for MSM to get tested for HIV for these reasons. Even though they were scared, some participants understood that it was imperative to know if they had HIV to stay healthy. According to Participant D, they were scared to get tested, but they knew it was necessary to prevent getting sick. They were worried about having past unprotected sex and wanted to make sure they were safe by getting tested for HIV. Other participants indicated how they regularly get tested for HIV to stay healthy. Participant C said they never know what might happen during sex and they could catch HIV without knowing it. They wanted to be careful and make sure they stayed healthy, so they made sure to get tested regularly.

Yes, there’s the need to test for HIV…because men who have sex with men have a higher rate of getting HIV infections compared to men having sex with ladies. So, it’s very good for any MSM to get tested (GBMSM participant A).

It is very scary when I am going to test. But I feel it’s very important for me to know my status to prevent me from getting sick. So, it’s very important for me to test for HIV. I test for HIV sometimes because maybe I’ve had raw sex with someone, and I don’t trust the person (GBMSM participant D).

I do test for HIV because it’s an opportunistic infection. And you will not know when you might contract it, so I have to test for it to know my status…the sex doesn’t always go as planned…and risky behaviors. I have had some infections some time ago. And now I prefer to be extra careful (GBMSM participant C).

Knowing one’s HIV status

GBMSM participants shared their thoughts about why HIV testing was important, pointing out different reasons related to their health and wellbeing. According to Participant Z, getting tested for HIV is important for knowing one’s status and making informed decisions. They were assured that medications are available to treat HIV and allow one to live a long and healthy life if diagnosed early. Participant F emphasized the urgency of HIV testing to prevent complications and the progression to AIDS. They stressed the risks of delayed testing and the importance of acting quickly to avoid negative health outcomes. Similarly, Participant I mentioned the importance of timely HIV testing after potential exposure to HIV. They described feeling uneasy after sexual encounters and felt it was necessary to get tested promptly to address any risks.

Of course, it is necessary to get tested because it will help you to know your status and decision-making. If I test positive for HIV, there are medications to help me live long (GBMSM participants Z).

It’s important for me to test for HIV…because you have to know your status. Knowing your status allows you to know what to do. The more you keep on delaying, the more the thing (HIV) too gets worse. Because maybe you are HIV positive, you aren’t on drugs, and if you delay, it might turn into something else (AIDS). And that can cause your death (GBMSM participant F).

I feel it’s important to test for HIV because sometimes you feel like you’ve been exposed (to HIV). Sometimes after having sex, you feel as if you should go, and your body isn’t feeling too well. These thoughts just run through my head, so I go and test because I’m not comfortable with that. So, the earlier you get tested, the better (GBMSM participant I).

Positive messaging about HIV

Several participants shared their experiences and views on HIV testing, revealing a range of motivations and beliefs related to health. Participant O took a proactive approach to HIV testing, stressing the importance of knowing one’s status in light of growing awareness about HIV transmission. They described their decision to get tested and their relief at receiving a negative result. Participant O also showed knowledge of HIV treatment options, highlighting the potential for achieving an undetectable viral load with proper medication adherence and emphasizing the overall benefit of HIV testing for health management.

Participant D also talked about their changing understanding of HIV and the significance of everyone getting tested. They explained how learning about HIV shifted their perceptions of its severity compared to other diseases, like malaria. They also emphasized the right to life for people living with HIV and spoke out against stigma and discrimination. Participant C reechoed the idea of proactive testing and understanding treatment options. They mentioned the reassurance of treatment availability as a reason for regularly getting tested.

Lately, I have been hearing a lot about HIV and how it’s spreading. I went and took the test. And I found out I’m negative. It is always good to know your status. When I was admitted to college, I had my test before I started lectures. Even if you test positive there are treatment options for you and I learned if you take your medication well, you will achieve the undetectable stage. So, I believe is good to test for HIV (GBMSM Participant O).

I thought HIV was so deadly until I started reading about it. I learned that malaria is even more dangerous than HIV, so I think everyone should test and know their status. And I believe persons living with HIV have the right to life, and they shouldn’t be stigmatized or discriminated against… I’ve learned that there are drugs they give to them when they have HIV. And when they give it to them and take it as prescribed, you will be ok and fine (GBMSM participant D).

I was told that if I should test positive for HIV, there were treatment options and other medications which would prolong my life. So, I always test when it’s time for me to test (GBMSM participant C).

Discussion

Despite the heightened stigma, elevated vulnerability to HIV, and low rates of HIV testing among GBMSM and residents of slums, there is a lack of research exploring HIV testing among GBMSM, particularly within slum communities in Ghana [11,45–47]. The SDT theory was useful in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing. The theory sheds light on the barriers and facilitators of HIV testing that’ could affect GBMSMS living in the slum communities. The theory also improved our understanding of HIV stigma and how it impacts autonomy considering that the fear of negative stereotypes impedes uptake of testing. GBMSM stigma around HIV testing may affect testing knowledge or proficiencies. Stigma also affects relatedness, which is a crucial component of social support.

The present study qualitatively describes GBMSM level stigma and their motivations for HIV testing in Ghana’s slums. Whereas some GBMSM demonstrated an understanding and acceptance of people living with HIV, others avoided their peers living with HIV and had fears of testing for HIV. The need to test was driven by factors such as perceived HIV vulnerability, need to know one’s HIV status for sexual health reasons, and positive messaging about HIV-informed motivations for HIV testing. These findings emphasize the necessity for interventions that enhance HIV awareness and capitalize on existing motivation to enhance HIV testing rates among GBMSM residing in slum areas [4,48–51].

Although this is one of the early studies to explore GBMSM level HIV stigma in slum communities, the findings remain consistent with literature reported among GBMSM and other populations in Ghana and other SSA [4,48–53]. Consistent with previous findings and aligned with key components of autonomy and competence in the SDT, HIV stigma undermines HIV testing decisions among GBMSM as they fear testing for HIV due to the stigma associated with testing positive [10,52–54]. Thus, it remains imperative for interventions to address HIV stigma to improve testing [10,54,55]. The present study findings of participants projecting stigma towards their peers living with HIV by avoiding them, refusing them sex, and labelling them as sexually promiscuous was also reflected in our previous findings among other GBMSM. Such labeling and avoidance of others living with HIV reflect our previous findings among other GBMSM in Ghana [10,30,48,54,56]. Such behavior poses a significant challenge for testing and the willingness of GBMSM who test positive to disclose their status and even adhere to care as they will not want to be isolated by their peers [56–58]. This finding is also imperative in understanding the relatedness component of the SDT framework that explains HIV stigma from peers may lead to avoidance or social isolation leading to the reluctance to seek social support services.

Despite the stigma shown by others, findings around motivations for HIV testing provide opportunities for encouraging GBMSM in slums to improve HIV knowledge and testing among their peers [11,12,45]. As shown in the results, some GBMSM understand the basics of HIV, especially around risk behaviors, and respond to such risk by testing for HIV, which remains consistent with previous research that shows that the awareness of increased vulnerability among GBMSM encouraged them to test [13,48,59]. Consistent with the SDT and prior literature, the participants’ responses show that increased knowledge of HIV will increase their self-determination for testing. GBMSM did not only consider HIV testing as a path to knowing their HIV status but as an essential means for knowledge acquisition about their health to enable them take meaningful steps like seeking care and adopting behavior changes to ensure their wellbeing. Whereas no previous studies focused on GBMSM in slums, earlier studies among GBMSM in Ghana showed that some GBMSM acknowledged the importance of HIV testing, as it enabled them know their status and make important sexual health choices [13,45,48].

Providing information on how HIV is transmitted, participants’ accounts show that positive messaging about HIV, instead of negative messaging can encourage HIV testing. Others informing participants about how HIV is transmitted and treated, including stages such as undetectable status motivated them to test for HIV. Previous studies reported similar findings among GBMSM [10,52,54]. In one of the studies on HIV health promotion, after attending a workshop where GBMSM peer groups discussed and learned about HIV, they observed an increase in HIV testing from 4% to 17% within a week post-intervention [10].

Taken together, the central takeaway from the findings on stigma and motivation for HIV testing lies in the importance of empowering GBMSM to take charge of their sexual health and make informed decisions about HIV testing, as this may help in reducing barriers to testing and promote self-efficacy. By enhancing their sense of competence and autonomy, tailored interventions can motivate GBMSM living in Ghanaian slums to overcome barriers to HIV testing and take control of their sexual health. A popular intervention that could help reduce HIV stigma at the individual and interpersonal level is the Many Men Many Voices (3MV) [10,54,60]. The intervention addresses stigma, HIV risk, transmission, testing, and treatment among GBMSM in Black communities. When adapted to Ghana, we found that GBMSM improved their understanding of HIV, formed community, and improved their HIV testing behaviors [54].

Conclusion

Despite the important findings, research needs to consider the study limitations when interpreting these study findings. As a qualitative study, which recruited from two regions in Ghana, the findings may not apply to all GBMSM in slums across Ghana. We therefore recommend using this study’s findings in conjunction with other studies from Ghana to draw conclusions about HIV stigma and testing among GBMSM. Future studies could include GBMSM from other regions and consider targeting specific age groups, as this formative work did not have any specific age brackets and may not fully represent people in different age groups.

In conclusion, our findings contribute to the existing knowledge and provide insights for policymakers, healthcare providers, and researchers to develop effective strategies and programs aimed at reducing HIV disparities and improving HIV testing among GBMSM in slums. While stigma can undermine HIV testing, some GBMSM are highly motivated to test for HIV as such positive messaging about HIV should be encouraged and leveraged to increase HIV self-testing among GBMSM in Ghana’s slums.

Data Availability

All data contain in the study can be found in the manuscript.

Funding Statement

GRA applied and received grant funding from the Yale university FLAGS grant. Funding agency did not play a role in the study design, data collection, and analysis, decision to publish or preparation of the manuscript. All content is solely those of the authors and does not represent that of the funding agency.

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PLoS One. doi: 10.1371/journal.pone.0289905.r001

Decision Letter 0

Vanessa Carels

4 Apr 2024

PONE-D-23-23534Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have men in Ghana's slums- BSGH-005PLOS ONE

Dear Dr. Shamrock,

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Reviewer #1: Partly

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Reviewer #1: N/A

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Reviewer #1: Yes

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Reviewer #1: General Observations

This manuscript is about HIV stigma and factors influencing HIV testing among GBMSM in slums of Accra, Ghana. The study employed qualitative data collection methods and reports several findings. On HIV stigma, the study reports that people stay away of avoids GBMSM who are living with HIV and that HIV testing is feared in this sub-population. Factors influencing uptake of HIV testing among GBMSM include perceived vulnerability to HIV, Sexual health decision making, and positive messages about HIV testing. The paper is novel as it addressed literature gaps pertaining to our understanding about the interface between GBMSM and HIV in urban slums. The

“While the study appears to be sound, most of the sections especially in the methods and results sections appear to be underdeveloped. For the methods section, I advise the authors to use the COnsolidated criteria for REporting Qualitative research (COREQ) checklist. For the results section, I suggest authors to provide a discussion or interpretation of the quotes that they have provided. For the Results section, some findings are presented in two or three sentences which suggest that the analysis process was incomplete. I advise the authors to also provide a description or interpretation of the quotes. In some case, language is unclear, making it difficult to follow. I advise the authors review the manuscript to improve the flow and readability of the text. I have provided specific comments below.

Specific Observations

Introduction

Page 3, Paragraph 1, Sentence 2: Kindly specify the context in which these pragmatic efforts occur e.g., despite pragmatic efforts in SSA... or in Ghana....

Page 3, Paragraph 2, Sentence 1: Please indicate '... compared to that of the general population ... '

Page 3, Paragraph 2, Sentence 2: Please avoid repeating the same word in a sentence. Here, GBMSM has already been used. please use the following phrase '... in this group...'

Page 3, Paragraph 2, Sentence 2: Here, only individual, and environmental barriers have been mentioned. However, in subsequent sentences, there is personal, environmental, and interpersonal barriers. Kindly include interpersonal barriers here.

Page 3, Paragraph 2, Sentence 3: Is 'individual level' the same as 'personal level'? Please be consistent in the use of the words.

Page 3, Paragraph 3, Sentence 1: Kindly provide references for these limited studies.

Page 3, Paragraph 3, Sentence 2: This sentence is not coherent with the preceding sentence. There is a disconnect between the first and the second sentences. Please revisit the sentence.

Page 3, Paragraph 3, Sentence 5: Please provide the year when these results were published. For example, in Kenya in 2024, HIV rates among slum...

Page 4, Paragraph 2, Sentence 1: Reference is needed here.

Page 4, Paragraph 2, Sentence 2: This sentence will sound better if written: 'Communities with increased HIV prevalence and risk also have poorly resourced infrastructure and health facilities which contributes to poor health outcomes’.

Page 4, Paragraph 2, Sentence 3: Delete ' where GBMSM were sampled for the study'. This information should be provided in the methodology section.

Page 4, Paragraph 3, Sentence 1: It is important to clarify the type of stigma being referred to here. Is this stigma broadly, self-stigma or other forms of stigma.

Page 4, Paragraph 3, Sentence 3: Excellent to have includes a theoretical framework.

Page 4, Paragraph 3, Sentence 4: Can the theory also explain the HIV stigma dimension that also underpin this study? The theory should be used for all dimension of your study.

Page 4, Paragraph 3, Sentence 6: I think that these dimensions should be part of the discussion section. In the introduction, just describe what the theory is and what are its components. A description of each component is also important in the introductions section.

Methodology

Start this section with the study design. Kindly use the COREQ checklist to guide the content and structure of your methods section.

Page 5, Paragraph 2, Sentence 2: If you are talking about partner organisations, it would be necessary to also mention the main organisation that implemented this work within the methods section.

Page 5, Paragraph 2, Sentence 4: This sentence will read better if it begins like this.

Although we originally intended to purposively include 19 participants in this study, we reached saturation of information after the eighth interview.

Page 5, Paragraph 2, Sentence 4: How did you determine that saturation of information has been attained? Kindly provide examples of elements that you saw in the data to be confident that you reached information saturation.

Page 5, Paragraph 2, Sentence 3: Full stop is needed at the end of the sentence.

Page 5, Paragraph 3, Sentence 2: Kindly use past tense

Page 6, Paragraph 2, Sentence 3: Provide some background information on the qualifications of research assistants to do this work with this group of study participants. If these research assistants are part of the authors, kindly use their initials. E.g., Experienced graduate researchers (GRA and EYZ) conducted the interviews for this study.

Page 6, Paragraph 2, Sentence 5: Write interviews instead of conversations.

Page 6, Paragraph 3, Sentence 1: Please provide the number of days that this training was done and whether, protocol training was part of this training.

Page 7, Paragraph 1, Sentence 1: How was data processing done. Transcription and translation considering that some participants were interviewed in Twi.

Page 7, Paragraph 1, Sentence 1: Are these crucial points or codes?

Results

I would suggest that the authors should use the word 'Findings' instead of 'Results' which is mostly used in quantitative studies.

Page 7, Paragraph 3, Sentence 3: It would be good to include age range of the participant and their current occupation.

Page 7, Paragraph 3, Sentence 2: This sentence should be phrased 'Five participants accomplished tertiary education, six concluded senior high school while one didn't complete Junior High school education.

Page 8, Paragraph 1, Sentence 1: These groups the way this statement is written suggest that they were generated deductively based on researcher’s priori thoughts and not inductively. Kindly confirm if this observation is accurate and include a statement that these categories were deductively generated.

Page 8, Paragraph 1, Sentence 1: Are the main groups themes? Please check the language used to be consistent with language used in qualitative research methodologies.

Page 8, Paragraph 1, Sentence 2: Are the sub-categories sub-themes?

Page 8, Paragraph 2, Sentence 1: This sentence will read better if written: Our findings show that study participants feared HIV broadly and avoided being associated with PLHIV in their community. They also lacked proper information about how HIV is transmitted from one person to another.

Page 8, Paragraph 3, Sentence 1: I think that this section is underdeveloped. It needs more information. Include information about why they fear HIV positive test results. In the second quote, the participant mentions some elements of this fear. People usually are afraid of being bonded to lifetime treatment. There may be issues of HIV stigma among other factors.

Page 8, Paragraph 3, Sentence 2: This sentence is not clear and does not link well with previous sentences.

Page 9, Quotes: Some analysis or discussion of what these quotes are portraying is important. For example: The first quote demonstrates how lack of knowledge about HIV transmission precipitates fear and subsequently HIV stigma.

Page 9, Quote 2: I have noted that the authors only use the word 'GBMSM participant' for all quotes. I think that it will be good to add more information such as participant ID number and age so that we are sure that these quotes came from several participants and not just a few of them.

Page 9, Subtitle - Sexual Health Decision Making 1: I suggest that you should revise the subtitle: Knowing ones HIV status

Page 10, Quote 1: The word 'if' should begin with a capital letter.

Discussion section

Page 11, Paragraph 1; Sentence 1: This sentence is not clear. Kindly revise it.

Page 11, Paragraph 1, Sentence 4: This sentence should include the word vulnerability: 'The need to test was driven by factors such as perceived vulnerability...

Page 11, Paragraph 1, Last Sentence: The sentence is missing something. Do you mean that these findings highlight the need for interventions to ...

Page 11, Paragraph 2, Sentence 2: A phrase '...among some participants...' should be either among individuals or among people or among GBMSM.

Page 11; Paragraph 2, Sentence 4: I think that you should delete 'Such interventions remain essential considering that the participants did not only have negative misconceptions about HIV.' A revised sentence should read.

The present study findings of participants projecting stigma towards their peers living with HIV by avoiding them, refusing them sex, and labelling them as sexually promiscuous was also reflected in our previous findings among other GBMSM.

Page 12, Paragraph 1, Sentence 1: I am not clear about a phrase '...opportunities for leveraging motivated GBMSM...'

Page 12, Paragraph 1, Sentence 2: A phrase '...encouraged them to test to protect themselves and their partners.' is not clear. HIV testing does not directly provide protection from HIV infection, but knowledge of HIV status allows individuals to embrace HIV prevention or initiate treatment which also serves as prevention. I suggest that this sentence should end with '...encouraged them to test.'

Page 12, Paragraph 2; Sentence 3: please delete 'also’.

Page 12, Paragraph 2; Sentence 4: delete the word 'to’.

Page 12, Paragraph 2; Sentence 5: delete the word 'also’.

Page 12, Paragraph 2; Sentence 5: I am not sure about the meaning of '...health sexual health behaviour...'

Page 12, Paragraph 3; Sentence 1: I suggest that you should delete a phrase 'To emphasize further...' in this sentence or mention the point that is being emphasised.

Start this sentence as follows: Providing information on how HIV is transmitted...'

Page 13, Paragraph 1; Sentence 2: delete the word 'the'.

Page 13, Paragraph 2; Sentence 1: End this sentence as follows: '...when interpreting these study findings.

Page 12, Paragraph 2; Sentence 2: I think that qualitative designs are important for their depth within the context where the study has been done and not their generalisability or applicability in contexts elsewhere. I think that this limitation does not apply to this study.

Page 12, Paragraph 2; Sentence 4: This also is not a methodological limitation for qualitative studies.

**********

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Reviewer #1: No

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PLoS One. 2024 Jun 5;19(6):e0289905. doi: 10.1371/journal.pone.0289905.r002

Author response to Decision Letter 0

16 Apr 2024

All responses to the reviewer has been attached to this submission in the file "response to reviewer".

Attachment

Submitted filename: Response to Reviewers..doc

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PLoS One. doi: 10.1371/journal.pone.0289905.r003

Decision Letter 1

Moses Kelly Kumwenda

15 May 2024

PONE-D-23-23534R1Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have men in Ghana's slums- BSGH-005PLOS ONE

Dear Dr. Shamrock,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We observed that a clean version of the manuscript did not contain the changes made in the tracked version. This suggest that the original version of the clean manuscript was resubmitted instead of a revised manuscript. In the next revision, please make sure that a clean version of the manuscript contain all changes made in the tracked version. Based on changes made in the tracked manuscript, we suggest additional changes to further improve the manuscript.

Please submit your revised manuscript by Jun 29 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Moses Kelly Kumwenda, BEd, MPhil, PhD

Guest Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

I would like to thank the authors for working on the manuscript and making appropriate revisions. I have however noted a few issues that needs to be addressed in the tracked version of the manuscript. Based on changes made in the tracked manuscript, I have made additional suggestions to further improve the manuscript. These have been outlined below.

Methods section

Sampling and Recruitment Procedure Section

Revise the sentence: ‘Although we originally intended to purposively include 19 participants in this study, we reached saturation of information after the eight interview.’ The sentence should mention ‘eight interviews’ and not ‘eight interview’.

Inclusion criteria section

Please revise this sentence: ‘Additionally, the individual must identify as a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation’ to 'Additionally, the individual identity had to be a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation.

Data Collection Procedure

Procedure

Revise this sentence: ‘Research assistants (EYZ, OWS) engaged in data collection have had prior and extensive research training from working with these populations in the past’ to ‘Research assistants (EYZ, OWS) engaged in data collection had prior and extensive research training from working with these populations in the past.’

Revise this sentence: ‘We have also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants’ to ‘We also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants.’

Ethical Considerations

Revise the word 'Participant' to 'participant' with a lower case.

Results

Description of findings

Rewrite the word 'Motivation' to 'motivation' in a sentence: ‘Findings from the data collected and analyzed revealed two categories; 1) HIV stigma and 2) Motivations for HIV testing.’

HIV Stigma: Avoidance of GBMSM living with HIV

Please revise this sentence: ‘Participant K, mentioned they were scared to be near someone with HIV because they worried, they might get infected’ to ' Participant K, mentioned they were scared to be near someone because of fear of a potential HIV infection’.

Please revise this sentence: ‘Some participants knew a lot about how HIV spreads and were ok with being around people who have HIV’ to ‘Some participants were well informed about how HIV is transmitted and were comfortable with being around people who have HIV.’

Discussion

Please revise this sentence: ‘We employ the SDT theory in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing.’ To ‘'The SDT theory was useful in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing.'

Please revise this sentence: ‘The theory also throws more light on HIV stigma and how this impacts autonomy as fears of negative stereotypes impede testing.’ To ‘The theory also improved our understanding of HIV stigma and how it impacts autonomy considering that the fear of negative stereotypes impedes uptake of testing.’

Please revise this sentence: ‘The need to test was driven by factors such as perceived HIV vulnerability, need to know one’s HIV status for sexual health reasons, and positive messaging about HIV-informed motivations for HIV Testing. Revise the word 'Testing' to 'testing’.

Reference is needed to support a sentence ‘The present study findings of participants projecting stigma towards their peers living with HIV by avoiding them, refusing them sex, and labelling them as sexually promiscuous was also reflected in our previous findings among other GBMSM.’ If the previous study has not been published, it is important to indicate '...was also reflected in our previous unpublished findings …'

References

The authors should be consistent with their referencing. They should use Plos One guidance on how to cite sources. For example, reference number 5 also has authors qualifications but other do not.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Jun 5;19(6):e0289905. doi: 10.1371/journal.pone.0289905.r004

Author response to Decision Letter 1

16 May 2024

Methods

1. Eight interview-was changed to eight interviews.

2. Additionally, the individual must identify as a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation- Has been revised to Additionally, the individual identity had to be a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation.

3. Research assistants (EYZ, OWS) engaged in data collection have had prior and extensive research training from working with these populations in the past- Has been revised to Research assistants (EYZ, OWS) engaged in data collection had prior and extensive research training from working with these populations in the past.

4. We have also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants- Has been revised to We also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants.

5. “Participants”- has been changed to “participants”.

Results

6. “Motivation”- has been changed to “motivation”.

7. Under HIV stigma, we identified two subcategories, avoidance of GBMSM living with HIV, and fear of testing positive for HIV- has been changed to Under HIV stigma: avoidance of GBMSM living with HIV, and fear of testing positive for HIV

8. Under the category motivations for HIV testing, we identified three subcategories: HIV vulnerability, sexual health decision-making, and knowing one’s HIV status - has been changed to Under the category motivations for HIV testing: HIV vulnerability, sexual health decision-making, and knowing one’s HIV status.

9. Participant K, mentioned they were scared to be near someone with HIV because they worried, they might get infected - has been changed to Participant K, mentioned they were scared to be near someone because of fear of a potential HIV infection.

10. Some participants knew a lot about how HIV spreads and were ok with being around people who have HIV - has been changed to Some participants were well informed about how HIV is transmitted and were comfortable with being around people who have HIV.

Discussion

11. We employ the SDT theory in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing. - has been changed to The SDT theory was useful in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing.'

12. The theory also throws more light on HIV stigma and how this impacts autonomy as fears of negative stereotypes impede testing. - has been changed to The theory also improved our understanding of HIV stigma and how it impacts autonomy considering that the fear of negative stereotypes impedes uptake of testing.

13. Testing - has been changed to testing

14. Reference has been provided for “The present study findings of participants projecting stigma towards their peers living with HIV by avoiding them, refusing them sex, and labelling them as sexually promiscuous was also reflected in our previous findings among other GBMSM in Ghana.”

References

15. Number (5) reference has been updated to Price MA, Rida W, Mwangome M, Mutua G, Middelkoop K, Roux S, et al. Identifying at-risk populations in kenya and south africa: HIV incidence in cohorts of menwho report sex with men, sex workers, and youth. J Acquir Immune Defic Syndr (1988). 2012;59(2). doi:10.1097/QAI.0b013e31823d8693

16. Added reference: 31. Dakpui HD, Shamrock OW, Aidoo-Frimpong G, Zigah EY, Agbemedu GR, Ahmed A, et al. A qualitative description of HIV testing and healthcare experiences among trans women in Ghanaian urban slums BSGH-011. 2024. doi:https://doi.org/10.21203/rs.3.rs-4390892/v1

17. Added reference: 6. Abu-Ba’are GR, Torpey K, Nelson L, Conserve D, Jeon S, McMahon J, et al. Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums–A clustered pre-post pilot trial protocol. 2024. Available from: doi: 10.21203/rs.3.rs-4313437/v1

18. Added reference: 20. Osman Wumpini Shamrock, Henry Delali Dakpui, George Rudolph Kofi Agbemedu, Donte T Boyd, Kharul Islam, Ibrahim Wunpini Mashoud, et al. “I’m scared of the nurses telling other people I am a transwoman”: Disclosure and nondisclosure of gender identity among trans women in Ghana’s urban slums– BSGH010 [Internet]. 2024 Apr [cited 2024 Apr 19]. Available from: https://doi.org/10.21203/rs.3.rs-4243840/v1

19. All other references have been adjusted to fit the journal’s specifications.

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PLoS One. doi: 10.1371/journal.pone.0289905.r005

Decision Letter 2

Moses Kelly Kumwenda

21 May 2024

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have men in Ghana's slums- BSGH-005

PONE-D-23-23534R2

Dear Dr. Osman Wumpini Shamrock,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Moses Kelly Kumwenda, BEd, MPhil, PhD

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

There are several formatting issues that needs addressing.

1. References should be in square brackets [].

2. There should be consistency in placing of citations. In some cases, there is space between the last word and the reference bracket (e.g. ...participants (24,25). In others, there is no space (e.g. ...community stigma among others(12–15).

3. In a sentence 'Sub-Saharan Africa (SSA) carries over two-thirds of the world's burden of HIV, yet, HIV testing and related services remain underutilized due to several factors such as insufficient

knowledge, low-risk perception, and increased stigma. (1,2).' there is a full stop between the word 'stigma' and the reference '(1,2)'. This is different from how most of the references have been presented.

4. In a sentence 'Emerging findings as from 2010 in eastern Africa show that GBMSM in slums have low-risk perception, increased risk behaviors, and low access to HIV testing and prevention services.(21,22).' there is also a full stop between the last word and the reference.

5. Authors should be consistent in their presentation of the participants information for quotes. In some cases, there is a full stop between the quote and participants information {e.g. and told me they were positive. (GBMSM participant E)} in some cases there is no full stop {e.g. '...I've had raw sex with someone, and I don't trust the person (GBMSM participant D)}. In the same manner, other quotes have a full stop at the end of participant information {e.g. (GBMSM participant A).}, while others do not have the full stop {e.g. '...so I will neglect the person. (GBMSM participant K)}

Conclusion should have a separate sub-title 'Conclusion' in bold

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0289905.r006

Acceptance letter

Moses Kelly Kumwenda

27 May 2024

PONE-D-23-23534R2

PLOS ONE

Dear Dr. Shamrock,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Moses Kelly Kumwenda

Guest Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Attachment

Submitted filename: Plos One Review_300324.docx

pone.0289905.s001.docx^{(18.3KB, docx)}

Attachment

Submitted filename: PONE-D-23-23534_Reviewer.pdf

pone.0289905.s002.pdf^{(653.8KB, pdf)}

Attachment

Submitted filename: Response to Reviewers..doc

pone.0289905.s003.doc^{(248KB, doc)}

Attachment

Submitted filename: Response to Reviewers (2).doc

pone.0289905.s004.doc^{(230KB, doc)}

Data Availability Statement

All data contain in the study can be found in the manuscript.

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PERMALINK

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums—BSGH-005

Gamji Rabiu Abu-Ba’are

Osman Wumpini Shamrock

Edem Yaw Zigah

Adedotun Ogunbajo

Henry Delali Dakpui

George Rudolph Kofi Agbemedu

Donte T Boyd

Oliver C Ezechi

LaRon E Nelson

Kwasi Torpey

Roles

Abstract

Introduction

Self Determination Theory (SDT)

Methodology

Study design

Sampling and recruitment procedure

Study setting

Inclusion criteria

Data collection procedure

Procedure

Nature of questions

Analytical strategy

Ethical considerations

Findings

Description of participants

Description of findings

HIV stigma

Avoidance of GBMSM living with HIV

Fear of testing positive for HIV

Motivations for HIV testing among GBMSM

HIV vulnerability

Knowing one’s HIV status

Positive messaging about HIV

Discussion

Conclusion

Data Availability

Funding Statement

References

Decision Letter 0

Vanessa Carels

Roles

Author response to Decision Letter 0

Decision Letter 1

Moses Kelly Kumwenda

Roles

Author response to Decision Letter 1

Decision Letter 2

Moses Kelly Kumwenda

Roles

Acceptance letter

Moses Kelly Kumwenda

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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