Survival, Trust, and Compassion: Persistent HIV prevention concerns faced by Black sexual and gender minority communities in the US South – A qualitative study

Jesse Strunk Elkins¹Ian Dale²Eunice Okumu³Matthew Zinck³Carol Golin^3,4,5Jordyn McCrimmon^3,6Maria Esposito³Isabelle T. Duguid²Dalton Craven²Ujunwa Onyeama²Sebastian Marin-Cespedes¹Alicia Diggs²Marielle Indyg¹Ann M. Dennis²Meagan Zarwell^1,7*

• ¹Department of Epidemiology and Community Health, College of Health and Human Services, UNC Charlotte, Charlotte, United States
• ²Division of Infectious Diseases, Department of Medicine, UNC-Chapel Hill School of Medicine, UNC Chapel Hill Bioinformatics Building, Chapel Hill, United States
• ³Center for AIDS Research, UNC-Chapel Hill, Lineberger Building, Chapel Hill, United States
• ⁴Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, UNC-Chapel Hill School of Medicine, UNC-Chapel Hill,, Chapel Hill, United States
• ⁵Department of Health Behavior, UNC-Chapel Hill, Gillings School of Global Public, Chapel Hill, United States
• ⁶Department of Psychology, College of Humanities and Social Sciences, North Carolina State University, Raleigh, United States
• ⁷Violence Prevention Center, UNC Charlotte, Charlotte, United States

Background: Members of Black sexual and gender minority (BSGM) groups in the Southern US experience disparities across all pillars of the HIV prevention continuum. Social network strategy (SNS) is an intervention that trains people with reasons to test for HIV to reach out to peers to increase HIV testing and may improve uptake of pre-exposure prophylaxis (PrEP). We conducted formative research to design an enhanced SNS to implement within partner services. Methods: In 2022-2024, we conducted four focus groups among HIV public health services staff and 12 in-depth interviews with local health department officials, clinicians, and community-based organization leaders. In addition, we interviewed four BSGM community members who recently used prevention services (i.e., testing or PrEP). Focus groups and interviews were transcribed and iteratively coded. Themes included salient barriers and facilitators to HIV services and mapped to a modified socio-ecological model after analysis. Narratives from the four BSGM were integrated with the summary analyses from HIV service providers. Results: Service providers and community members identified persistent barriers to HIV prevention services: (1) basic human needs for survival and (2) lack of compassion within the healthcare system. Inadequate living necessities (e.g., housing and transportation), education, mistrust, stigma, and discrimination limit HIV prevention service use. Conversely, wrap-around services, transparency, representation, and compassionate care facilitate service access. Conclusions: Enhancing HIV prevention services for BSGM groups necessitates reducing healthcare access barriers and leveraging facilitators. Our findings informed an enhanced SNS intervention to increase HIV testing, prevention, and care linkage among BSGM in the Southern US.