Identifying Factors Influencing HIV Testing Behavior Among High- Risk Elderly Men: A Mixed-Methods Study Incorporating Structural Equation Modeling and Thematic Framework

Background High-risk elderly constitute a vulnerable group for HIV infection. Age-specific barriers impede voluntary testing among elderly and limit the reach of traditional interventions. Existing models often oversimplify motivation and overlook older adults’ unique psychological and contextual challenges. This study addresses this gap by extending the dimension of motivation, and using a mixed-methods design to generate actionable insights for improving HIV testing among high-risk elderly men in China. Methods This mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in Dehong Prefecture from 2024 to 2025. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Chi-square test was employed to compare demographic characteristics. And multivariable logistic regression was used to identify independent predictors of HIV testing behavior. Finally, structural equation modeling (SEM) was utilized to decompose and quantify both direct and indirect effects of the predictors within a comprehensive framework. Results There were 300 and 15 participants included in quantitative and qualitative study respectively, achieving an HIV testing rate of 57.7% and a mean age of 57.2 years. Among participants, non-commercial sex with non-regular partners was reported by 56.0%, 31.0% of these forwent condoms due to reduced pleasure (42.3%). Commercial sex was reported by 85.3%—44.4% of non-condom users cited the same reason. Multivariate logistic regression identified older age (≥ 70 years), ethnicity, education level, occupation, and urban residency as significant predictors of HIV testing uptake. SEM analysis identified self-efficacy as the strongest positive predictor (total effect = 0.32, p < 0.05), while behavioral skills (-0.21, p < 0.05) and HIV information (-0.20, p < 0.05) exhibited significant negative effects. The model fit was acceptable (RMSEA = 0.073, CFI = 0.94). Qualitative data revealed that peer success stories bolstered self-efficacy, whereas stigma eroded it; testing was also hindered by procedural complexity, low-information transparency, and misaligned messaging and media channels among older adults. Conclusion Self-efficacy facilitates HIV testing among high-risk elderly men, whereas usability issues, ineffective messaging strategies, and cultural perceptions suppress testing behavior. Interventions should focus on enhancing self-efficacy, optimizing age-friendly self-testing tools, adopting non-fear-based messaging strategies, and integrating HIV screening into chronic disease check-ups to break cultural biases.