Patient and Service Provider Perspectives of Barriers and Facilitators to HIV Care in North Carolina.

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Published in final edited form as: AIDS Patient Care STDS. 2026 May 6;40(8):307–320. doi: 10.1177/10872914261448349 Patient and Service provider perspectives of barriers and facilitators to HIV care in North Carolina Meagan Zarwell 1 , Sebastian Marin-Cespedes 1 , Jordyn McCrimmon 3, 7 , Marielle Indyg 1 , Ian Dale 2 , Eunice Okumu 3 , Alicia Diggs 3 , Jesse Strunk Elkins 1 , Maria Esposito 3 , Ujunwa Onyeama 3 , Grace Galphin 3 , Carol Golin 3, 4, 5 , Matthew Zinck 3 , Travis Barnes 8 , Keenan Phillips 1 , Patrick Robinson 6 , Ann Dennis 2 Author information Article notes Copyright and License information 1. Department of Epidemiology and Community Health, College of Health and Human Services, UNC Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA 2. Division of Infectious Diseases, Department of Medicine, UNC-Chapel Hill School of Medicine, UNC Chapel Hill Bioinformatics Building, CB 7030, 130 Mason Farm Rd, Chapel Hill, NC 27514 3. Center for AIDS Research, UNC-Chapel Hill, Lineberger Building, 450 West Dr, Chapel Hill, NC 27599, USA 4. Department of Health Behavior, UNC-Chapel Hill, Gillings School of Global Public, CB 7440, 135 Dauer Road, Chapel Hill, NC 27599, USA 5. Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, UNC-Chapel Hill School of Medicine, UNC-Chapel Hill, 5034 Old Clinic Building, CB#7110, Chapel Hill, NC 27599, USA 6. Department of Health Policy and Management, College of Health and Human Services, UNC Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA 7. Department of Psychology, College of Humanities and Social Sciences, North Carolina State University, Poe Hall, 2310 Stinson Dr, Raleigh NC 27607, USA 8. Central Piedmont Community College, 1201 Elizabeth Ave, Charlotte, NC 28204 ✉ Corresponding Author : ann_dennis@med.unc.edu AUTHOR CONTRIBUTIONS Ann M. Dennis, Meagan Zarwell, Carol Golin, and Eunice Okumu contributed to the study conception and design. All authors contributed to the material preparation, data collection, and analyses. The first draft of the manuscript was written by Meagan Zarwell, Jordyn McCrimmon, and Sebastian Marin-Cespedes and all authors commented on previous versions of the manuscript. All authors read and approved of the final manuscript. Issue date 2026 Jul. PMC Copyright notice PMCID: PMC13222102  NIHMSID: NIHMS2174287  PMID: 42087676 The publisher's version of this article is available at AIDS Patient Care STDS Abstract Barriers to initiating and maintaining HIV care continue to impede efforts to ‘End the HIV Epidemic’ in the United States, particularly among members of Black sexual and gender minoritized groups (BSGM) in the US South. Evidence-informed social network-based interventions may improve engagement in HIV care services among BSGM; however, understanding and addressing context-specific barriers and facilitators to HIV service use are critical for intervention effectiveness. We explored barriers to HIV care engagement to inform the adaptation of a social network strategy to increase participation in HIV prevention and care services in Charlotte, NC. We interviewed BSGM individuals with HIV who were in treatment; local health department officials, clinicians, and community-based organization leaders; and held four focus groups with HIV public health services staff. Transcripts were iteratively coded and analyzed thematically. We identified two themes across all focus groups and in-depth interviews. Two additional themes were identified specifically from in-depth interviews with BSGM. Across data sources, participants described multi-level stigma, competing priorities, and logistical hurdles that impede BSGM engagement in HIV care. BSGM with HIV indicated that supportive social networks enhanced HIV treatment adherence and described how their personal agency and self-efficacy evolved after receiving an HIV diagnosis. Interventions to improve HIV care engagement among BSGM with HIV must address inequities, leverage social support networks, and enhance self-efficacy. Keywords: HIV Care, social network strategy, HIV care and treatment, sexual and gender minorities, peers INTRODUCTION The United States (US) Ending the HIV Epidemic (EHE) initiative aims to improve HIV care continuum outcomes in regions with elevated HIV diagnoses 1 , 2 . The care continuum describes stages of engagement with care services: newly diagnosed people with CD4 or viral load tests within one month of diagnosis (linkage); one or more CD4 or viral load tests per year (receiving care); two or more CD4 or viral load tests at least three months apart per year (retention); and a recent viral load under 200 copies of HIV per milliliter of blood (viral suppression) 3 . In 2022, approximately 80% of people diagnosed with HIV (PWH) were linked to care within one month, defined as having a CD4 or viral load tests within one month of diagnosis. However, in 2022, only 76% of people diagnosed received some HIV care (at least one CD4 or viral load), 54% were retained in care, and 65% achieved viral suppression 4 . Most new HIV diagnoses occur in the South among Black sexual and gender minoritized individuals (BSGM), including men who have sex with men and transgender (trans) women 2 , 5 - 9 . Despite advancements in treatment and prevention methods, BSGM are substantially more likely to present late for care and experience higher morbidity and mortality than other population groups 10 . The disproportionate outcomes across the HIV care continuum among BSGM are influenced by many factors 11 - 13 and interventions should address structural racism, poverty, housing instability, cultural responsiveness, social support, and medical distrust within healthcare systems to improve linkage, retention and viral suppression 7 , 14 , 15 . Social network approaches may effectively reduce HIV among BSGM and often include strategies such as peer-led recruitment, counseling and treatment, and navigation support 16 . One evidence-informed intervention, the CDC’s Social Network Strategy (SNS), uses peer networking to increase HIV testing, which may also address social and structural barriers to HIV and care and retention among BSGM 17 , 18 . During the formative phase of a larger study to develop an enhanced social network strategy (eSNS) intervention in the Southern US that will expand beyond HIV testing to increase both HIV prevention and treatment services 19 , we explored factors that influence HIV care engagement among BSGM. METHODS Study Design and Setting This qualitative study explores factors influencing HIV care engagement among BSGM from the perspectives of PWH and HIV service providers. The study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill. Recruitment We purposively recruited two groups of participants: 1) BSGM living with HIV (potential eSNS intervention recipients); and 2) people who provide, manage, or lead HIV prevention and care services (“HIV service providers”). Although we also interviewed four BSGM without HIV as part of the larger study, we exclusively explored experiences among PWH in this analysis. We recruited BSGM via staff at the local health department and community-based organizations (CBOs) who shared cards and flyers to share with clients; we also advertised on dating apps. HIV service providers were recruited through health department personnel and clinicians identified by the research team. All BSGM participants completed a brief screening survey prior to informed consent. Reflexivity Members of the research team are infectious disease doctors, social scientists, and public health professionals and students in training for health services and practice. The research team consisted of ten researchers from UNC Chapel Hill and six researchers at UNC Charlotte. Gender representation consists of eight cisgender women, six cisgender men, and one genderfluid individual, with five identifying as non-heterosexual. The team includes six Black members and ten white members, and several are multilingual or have lived or worked internationally, contributing to the team’s cultural competency. While seven researchers grew up in the US South, the majority of the research team members share an outsider's perspective and understanding concerning BSGM health experiences and/or living with HIV. Five co-authors were interviewers (EO, ME, UO, GG, and MZ) and none had prior relationships with participants they recruited or interviewed, but some participants had professional connections to study team members. Participants understood the goal of the study was to understand barriers to HIV care and prevention among BSGM. The majority of team members have been trained in qualitative research methods, conducting semi-structured interviews and focus groups, and using thematic analysis. Instruments Semi-structured in-depth interview (IDI) and focus group (FG) guides explored factors at individual, community, and policy factors that may impact HIV care, from patient and provider perspectives. We used the modified socioecological model to identify and organize influences for HIV care engagement at multiple levels (i.e., individual behaviors contextualized within social network, community, and epidemic contexts) 20 . All three guides elicited perceptions about HIV care services and included specific questions tailored for Black trans women to understand their perspectives on gender-based discrimination, stigma, and gender-affirming care. All BSGM interview participants completed a separate online survey where they provided demographic information, including age, race, education, employment status, and a short health history (HIV status, time since diagnosis, and current antiretroviral therapy [ART] use). Data Collection Interview guides were piloted among the team before data collection began. IDIs and FGs were conducted by trained team members over Zoom. The FGs and IDIs with HIV service providers were conducted from December 2022 to February 2023. FGs lasted 90 minutes, and each group included 4-6 participants from the local health department or CBOs who provide direct services to clients. FGs were held during regular work hours, and participants were not compensated. Team members took notes during focus groups. Twelve IDIs were conducted among public health leaders and clinical providers and lasted approximately one hour. Participants received a $50 gift card. We also conducted thirteen IDIs lasting 60-90 minutes among BSGM living with HIV from June 2023 to February 2024; BSGM participants received a $50 electronic gift card. Data Analysis We used thematic analysis to understand HIV care engagement across the three data sources 21 . Audio recordings were transcribed verbatim by a transcription service, reviewed by team members for accuracy, and transcripts were organized in NVivo and in ATLAS.ti. An initial codebook was developed for FGs and IDIs with HIV providers, and a separate codebook was developed for IDIs with BSGM. Codebook robustness was tested by comparing two independently coded transcript sets from each data source and iterative team meetings to reach consensus until coding saturation was achieved, and no new codes were applied to data. Discrepancies were resolved through consensus among five co-authors (JM, EO, ME, UO, GG, and MZ) who coded the data, and the codebook was iteratively refined before the remaining transcripts were coded. Participants did not receive copies of the transcripts or coded data or provided feedback on findings. Patterns and themes were derived from all three data sources and organized using memos and discussions over analysis meetings by MCZ, JM, and SMC to integrate findings and identify convergent, independent, or divergent perspectives from each data source. Quotations were minimally edited for brevity and to remove pauses or redundant phrases. Larger abbreviated quotes have ellipses in brackets as noted in tables. RESULTS Sample Characteristics Demographic characteristics of the 13 BSGM with HIV are shown in Table 1 . Among the nine Black cisgender men (median age 33, range: 24-36), most were single (89%), gay/same gender loving (78%), college-educated (56%), employed (56%), and earning over $50,000 annually (44%). One was not currently taking ART, and two received their HIV diagnosis within the past 12 months. Reported recent health concerns included general health (22%), pain (33%), mental health (44%), and cardiac issues (11%). Among the four Black Trans women (median age 25, range: 21-34), most had some college or associate degrees (75%), two were employed, and two made less than $19,999 per year. All four Trans women were taking ART. Table 1. Demographic Characteristics of BSGM With HIV Characteristic Cisgender man (N = 9) Transgender woman (N = 4) N (%) N (%) Age, Median (Min, Max) 33 (24, 36) 25 (21, 34) Sexual Orientation Bisexual 1 (11) 0 (0) Gay/Same gender loving 7 (78) 0 (0) Pansexual 1 (11) 0 (0) Straight/Heterosexual 0 (0) 4 (100) Education High school grad or lower 2 (22) 1 (25) Some college or associate degree 2 (22) 3 (75) Bachelor's degree or higher 5 (56) 0 (0) Employment Employed 5 (56) 2 (50) Out of work or unable to work 2 (22) 0 (0) Student 1 (11) 2 (50) Prefer not to answer 1 (11) 0 (0) Occupation among employed participants Business owner 1 (20) 1 (50) Manager or executive 1 (20) 0 (0) Professional 3 (60) 0 (0) Service, clerical, or sales 0 (0) 1 (50) Did not indicate employment 4 2 Household income Less than $19,999 3 (33) 2 (50) $20,000 - $49,999 1 (11) 2 (50) $50,000 or more 4 (44) 0 (0) Prefer not to answer 1 (11) 0 (0) Relationship status Single/Separated/Divorced 8 (89) 3 (75) Partnered/Married/Living together 1 (11) 1 (25) Lives alone Yes 7 (78) 2 (50) No 2 (22) 2 (50) Taking ART Yes 8 (89) 4 (100) No 1 (11) 0 (0) Time since HIV diagnosis <12 months (“newly diagnosed”) 2 (22) 1 (25) >12 months ago 7 (78) 3 (75) Health Problems or Conditions 1 General health 2 (22) 1 (25) Pain 3 (33) 0 (0) Cognitive/Mental Health 4 (44) 0 (0) Cardiac 1 (11) 0 (0) No health problems 4 (44) 3 (75) Open in a new tab 1 Responses to the question “ In which areas do you feel you experience more health problems than the average person? ” Note: Response categories do not sum to 100% because multiple categories could be chosen except for 'No health problems'. IDIs with HIV service providers included staff members from public health departments (5), CBOs (4), and local clinics (3). FG participants included nine case managers, eight public health field investigators, and two supervisors of partner services and/or linkage-to-care programs. At least one CBO staff member participated in three of the four FGs (see Table 2 ). Table 2: HIV Service Provider Participant Characteristics Participants N % In-depth interviews with 12 public health leaders Gender Female 8 66.7% Male 4 33.3% Race White 7 58.3% African American/Black 5 41.6% Ethnicity Non-Hispanic/Latine 11 91.6% Hispanic/Latine 1 8.3% Position Title Executive 5 41.7% Program Manager 4 33.3% Medical Director 3 25% Practicing Clinician No 8 66.7% Yes 4 33.3% Age Median (range) 47 (28-66) Time in Current Role (years) Median (range) 3.5 (1-13) Professional Experience (years) Median (range) 18 (10-40) Four Focus Group Interviews with Partner Services Staff (n =19 participants) Position Title Case Manager 47.3% 9 Public Health Investigator 42.1% 8 Program Manager 5.3% 1 Unknown 5.3% 1 Time in Current Role (years) Median (range) 1.5 (<1-4) Professional Experience (years) Median (range) 13 (4-25) Open in a new tab We identified two themes related to HIV Care across all data sources, and two additional themes were identified specifically from IDIs with BSGM. Across data sources, participants described multi-level stigma and competing priorities and logistical hurdles that impede BSGM engagement in HIV services. BSGM indicated that supportive social networks enhanced HIV treatment adherence and described how their personal agency and self-efficacy evolved after they received an HIV diagnosis. Theme 1: Stigma at multiple forms and levels continues to impede engagement in HIV care Multiple forms and levels of stigma emerged as significant barriers to HIV care linkage and retention among BSGM ( Table 3 ). We identified anticipated and enacted HIV stigma at interpersonal and structural levels in alignment with Earnshaw and Chaudoir’s (2009) HIV stigma framework 22 . Table 3. Representative Quotes from Theme 1: Stigma at multiple levels continues to impede engagement in HIV services Domain Representative Quotes by Participant Group Potential eSNS Recipients Providers Interpersonal Stigma Within Social Networks Most of my family did not know. Only a select few that I feel comfortable and have shared my status with, and for the most part, they have been from my perception, they have been very helpful and non-judge-judgmental. - Gay/ same gender loving man, age 35 My biological family is—it impacted a lot. Living with my mother, it was horrible… she had just married a man. And, um, this was her third husband. And, you know, it was-it was somebody who I didn't like in general, but …. they treated me like I was a walking disease. I had to use—I couldn't use any—I had—literally had plastic plates, plastic cups, plastic cup—uh, silverware. Um, every time I used the bathroom, I used to have to clean it right after myself. I mean, I don't mind cleaning the bathroom for, of course, for the obvious reasons to clean it. But they made me clean it because they thought it was [contaminated]—just as they touched me. Um, I couldn't-I couldn't cook for myself. I couldn't even wash dishes. Like, everything that was served to me was given to me in a microwave. Of course, of course. - Trans woman, age 25 For especially the younger, um, the younger kids, um, with HIV, I worry about their lack of support and their lack of mature support systems. Uh, you know, if they’re an 18-year-old and they now have HIV, um, is the issue, you know, the, you know, did they get kicked out of the house? Are they estranged from their family? Are they estranged from their family because they have HIV or are they estranged from their family because the family just found out they were gay? So, I-I—so lack of support system is a huge one… - HIV Care Provider Truthfully, that first impression is everything. Um, one thing that stands out for me is that, you know, uh, after they start the regimen and everything seems okay, a lot of times, it’s whoever they’re living with, um, may no longer accept them, um, whether they’re living with family, or if they get into it with their partners because of diagnosis. - HIV Care Provider, FG #2 Interpersonal Stigma from Health Care Providers I think many times providers focus so much on HIV, they don't see that that's the last thing that people are worried about because they're worried about food and clothes and shelter and finances and transportation and mental health and all these other things that are going on in their lives. I think if you address those issues, then you would have a better time addressing the issue at hand, which was HIV. - Pansexual man, age 33 Before I found [Clinic A], like, I just was not—I wasn’t in care for, like, a year. Um, and someone had recommended [Clinic A] to me, so it just, like, put me in the fear of, like, going into another situation where someone was gonna pretty much judge me by [laughter] facial expression and with words behind, you know, their facial expressions. You know? - Trans Woman, age 34 Honestly, there was—yeah, so there was one time when I was in college, I was goin’ to get tested, and one of the nurses made a comment, like, “Oh. You was out there bein’ high. That’s why.” And I was like, “No. I was only sleepin’ with my boyfriend.” But she assumed because I’m comin’ to get tested that I had multiple-sex partners, and even I did have multiple-sex partners, I shouldn’t be shamed for wantin’ to come and get tested…I mean, at the end of the day, I just had to tell myself like you gotta what’s best for you. So now I’m at that point to where if I do run into a situation when I have a bad nurse or a bad medical provider, I just literally chuck it up to, “You know what? I’m doin’ what I need to do,” and just—basically just come out—I just tell myself just to ignore them or just request somebody else. - Gay / Same gender loving man, age 26 As far as my physician goes. He is a little quirky, but in a good way. Um, I wouldnť consider him a friend. I consider him my provider, but— it's-it's a relationship of trust I think we've built. I don't trust doctors whatsoever. I've had horrific experiences in the medical field. I'm very-very much apprehensive of going to the doctor, but he made it more comfortable for me where I'm not as scared or I don't feel as—I don't feel that they can't be trusted. Um, I believe what he tells me, and I go off of that. If I feel that I don't agree with him, he still takes that into account and he tries to work out a plan that's mutually beneficial. So I appreciate that. - Pansexual man, age 33 They’re grown adults. They had sex, which is healthy for an adult individual, um, and you contracted something. It’s perfectly natural. Most people contract something in their lifetime. You shouldn’t be ashamed for that. Um, it’s all about language. I think a lot of-[laughter]-a lot of individuals lack bedside manner. And that, [laughter] um, I’ll say they’re kind of, blunt. They’re not the softest touch. - Case Manager, FG #1 I mean, the-the thing that, like, immediately comes to mind, which is why we attend doctor's appointments with folks, is, um, stigma and discrimination. Right? It is I don't want to be judged, right, because I'm going in and need this service. So, like, our role there is kind of like, uh—it's advocacy, but we're just a friend to let you know you're not alone. - Organization Leader Well, for our services, I mean, I'm thinking that, uh, that the most important thing is for them to-to feel as if, you know, the-the place or the people that are delivering the services are welcoming and respectful… the people are giving the-the value that they are getting valued as the-the people that they are, and, you know, they're gonna be more likely to continue utilizing that service, um, as well as, uh, letting other people know, you know, what kind of positive experience they had […] I think, like I said I mean it's key to-to be working with individuals that, um, I mean it's been helpful for us to have individuals, you know, on staff who can identify with, uh, this population. Um, and if not, then to be working with other, you know, individuals that have a lot of, uh, respect or influence within that community. - Program Manager Stigma in Media and Public Narratives Thankfully not. No, I have not had that experience. Um, I think that people are discriminated on very quickly because of it, and even in commercials, I've noticed that most HIV medication commercials typically have a Black male. Um, I have not seen very many, and although everyone can have HIV, it's rare that you see an HIV commercial that has a woman— that has anyone that is of another ethnicity. it's typically Black men, and—even when they show Black men, a lot of time they're more feminine Black men. So it seems like the visuals are very specifically targeting—um, a demographic, which I've noticed more and more and have become more and more annoyed by it because— it just does not ever seem to look as diverse as what this, um, this illness is. - Gay/ same gender loving man, age 36 I think—if you a part of the LGBTQ community, you know of, uh, a decent amount of the services because—a lot of the people are friends with people that work in those services or, um, have heard about them through being at Pride or at one of the testing—vans or facilities. But I think in the grand scheme of things, unless you are a part of the community in particular or looking for it yourself, it is not necessarily very, um, visible. - Gay / Same Gender Loving Man, age 36 I think it’s more like a thing where need to bring— I don’t know if they do sex ed anymore in school. But it’s just like, um, the understanding of like having sex with other people…or people, peoples, just you need—you just need to understand like the risk values and like how to protect theirself. And I don’t think that a lot of people are really aware of all of all the different risk factors…or things you can do to protect yourself. I think that the education level isn’t there. - Gay / Same Gender Loving Man, age 36 And it’s not-we’re not an HIV clinic, so you can come and you sit in that waiting room and you could either be here for your diabetes, or for a check-up, or for your HIV care. So no one knows what everyone else is here for, versus going to an infectious disease clinic or an HIV-specific clinic. Like you’re-you know? It’s pretty obvious, like, you’re not there just to, like, get your prostate checked or whatever. So that’s-that was our hope in reducing barriers to care for HIV patients. - Organization Leader I’m noticing when people come in, um, and when I’m doing their intake, a lot of men will say they’re bisexual but won’t, um, claim that they have sex with men. They’ll just say, “I’m bisexual.” So they won’t do certain testing because they feel that will fall on the gay side or the LGBT side of testing, so they will be not as prone to getting the HIV test like, “Oh, well, I don’t need that because, um, I sleep with more women than I do with men,” .. it’s still more of a gay disease, um, to say, you know, even though we’ve come so far with mentioning things, so that’s something I’m noticing. Um, and those are usually men of color, and for the whole bisexual aspect of it, they don’t wanna do—they usually just do the swabbing and a urine sample and then they’re out the door… - Case Manager, FG #3 One person came over and he said that “I think you have already infected me with HIV ’cause you touched my head yesterday,” and then “this is unfair.” And he-he started to complain and he—so I think things like that may be to a certain extent may be affected the people to access services because they feel once they are known and they will be stigmatized. And I saw it right away, that guy. Everybody started shouting on him, and he—that other guy said he doesn’t want even be close to him because he has infected him deliberately. And things like that, I guess, may also have an effect. And they’re all built around the stigma. - Role not specified, FG #4 Open in a new tab At the interpersonal level, a trans woman, age 25, described experiences of enacted stigma which influence HIV disclosure and fear of judgment from family members or peers. Both BSGM and HIV providers described HIV-related stigma among BSGM, including stories about misconceptions about HIV transmission that have led to mistreatment within individuals’ social circles. At the interpersonal level, an HIV provider recounted that when patients " start the regimen and everything seems okay, a lot of times, it’s whoever they’re living with, um, may no longer accept them,” demonstrating anticipated stigma from close relationships. Among providers, one participant (gay/same gender loving man, 26) recounted enacted stigma from a provider when a nurse made a stigmatizing assumption during an HIV test when they said, " Oh, you was out there bein’ high. That’s why. " The participant felt unfairly judged, despite being in a monogamous relationship, noting that even with multiple sexual partners, he should not have been ashamed for prioritizing his health. Similarly, anticipated structural stigma emerged as BSGM reported avoiding health services due to judgment from providers, and one Trans woman recounted delaying HIV treatment for over a year to avoid further stigma from providers. Another provider described witnessing stigma in the waiting room when a patient stated that they believed someone “ ha[d]already infected [them] with HIV ’cause you touched my head yesterday,” demonstrating how community-level enacted stigma persists through myths and fear about HIV. Conversely, positive provider relationships were described as transformative, fostering trust, comfort, and adherence to care. One pansexual man, age 33, who had previously avoided medical visits due to past negative provider interactions, described how a good relationship with their provider helped to shift their perspective: “ he made it more comfortable for me where I'm not as scared or I don't feel as—I don't feel that they can't be trusted. ” BSGM with HIV discussed how anticipated and structural stigma influence care, particularly through race. Many preferred Black or Latine providers to avoid dismissal or inadequate treatment from white providers, indicating anticipated interpersonal stigma because of bias and mistrust. Providers also acknowledged the need for representation. A Program Manager noted that once patients engage in care, it is vital that “ the place or the people that are delivering the services are welcoming and respectful,” by employing “ staff who can identify with ” the population served. A case manager noted that normalizing sexual health discussions helps reduce shame during clinical encounters, while an organization leader stressed the value of advocacy and peer support, describing how he often accompanies patients to appointments to ease fears of discrimination. At community and structural levels, participants noted that prevailing public narratives and stigma in media shape how PWH are perceived. Stigma can lead to avoiding testing and concerns that people will think they are LGBTQ+, which may deter engagement in care. A case manager in FG noted that BSGM “ won’t do certain [HIV/STI] testing because they feel that will fall on the LGBT side. ” Community-level enacted stigma through media portrayals and public narratives about HIV also shape awareness, perceptions, and access to care services. Some participants were critical of HIV medication commercials that predominantly feature Black men, often with feminine gender expression, that reinforce stereotypes and potentially discourage people from seeking treatment. Even after accounting for racially targeted marketing, BSGM indicated that HIV services are not widely advertised to the public and instead are promoted to LGBTQ+ communities through social networks, Pride events, or mobile testing and outreach events. Focused marketing to BSGM may lead to information gaps “ unless you are a part of the community in particular or looking for it” (gay/same gender loving man, age 36). Theme 2: Competing priorities and logistical hurdles impede accessing and navigating HIV care Table 4 ’s BSGM and HIV service provider quotations highlight multiple barriers that impede engagement in HIV services. A pansexual man, age 33 reported facing competing priorities “ sometimes I have to decide, do I pay for gas to get to work? Do I buy a meal to eat? ” Providers noted that due to individual circumstances, delays in services may result in disengagement: one program manager emphasized that when individuals seek care, " you could lose them again” if patients are forced to wait weeks for services or miss work to attend an appointment. Providers also noted that long waiting times and limited provider availability can delay engagement in care. One case manager shared, “It could be two, three weeks out,” while another provider emphasized the importance of federal funding that allows clinics to offer copay and utility assistance. Table 4. Representative Quotes from Theme 2: Competing priorities and logistical hurdles impede accessing and navigating HIV care. Domain Representative Quotes by Participant Group Potential eSNS Recipients Providers Meeting Basic Needs Amid Competing Priorities I can't always keep up with the bills 'cause going— I have to go to the doctor a lot. Um, for labs, for testing, for medications, for checkups. it's—I go—I've seen my doctor at least once a month this year. S o it's a little hard to keep up with the financial portion of that…. Well, sometimes I have to decide, do I pay for gas to get to work? Do I buy a meal to eat, or do I pay this back bill because I know if I don't, it's just gonna keep stacking up and stacking up and I'm gonna be in a hole where I can't get care because I can't afford to. […] I honestly had gotten to a point this year where I just threw my hands up and I don't even open the bills anymore. I just let them stack up and hit my credit because I know I can't afford them, and I'm not gonna let myself stress out over them, make myself sick with worry, worrying about where it's gonna come from. Um, I just—it's unfortunate that healthcare's become—or maybe it always has been. I just wasn't adulting [ laughter ] at the time. - Pansexual Man, age 33 I think it’s about the same in terms of housin’. I know in, um, especially in, like, the Black community, oftentimes we’ll have clients, who once the family finds out that, um, they’re transgender, or especially if they’re, like—um, their appearance changes from, like, male to female. Um, I—prior to this job I had a house where they were actually living together. And, um, to keep that house up-and-running, they would have to do things that would put them at risk. - HIV Care Provider, FG #4 But we also have to have a system of understanding that maybe they were too busy trying to make sure they had somewhere to sleep and now that they’re here in front of you saying, “Hey. I-I want help,” I don’t feel comfortable having to wait two, three weeks ’cause you could lose them again. So I really think that some cultural sensitivity, um, with some of these providers should be mandated because language and treatment is-is important. - Program Manager, FG #1 I think some of it is, you know, just being able to get access, so it goes back to, you know, having the time, you know, to get to an appointment or- you know, especially, you know, depending on maybe a work schedule or family responsibilities—um, or having those resources—you know, the resources to get there, so, you know, having transportation or bus fare or, you know, so all the more, kinda, socioeconomic, kinda, factors. - Organization Leader Navigating Complex Systems and Resource Gaps Work [ is a challenge ] because sometimes, you know, doctor’s appointments can only be like, you know, in the middle of the day […] But I don’t get off ’til 5:00, so I’ll have to decide whether if I’m gonna leave work early or if my supervisor will allow me to leave work early or will I have to call the clinic and see if I can reschedule, but on top of that, if I do reschedule, then that appointment could be months away from the previous appointment I was s’pose to have…You know what I mean? ’Cause when you go to a clinic that has a lotta patients, um, appointments are scarce. - Gay / Same Gender Loving Man, age 26 Sometimes they come from different states. Uh, things of that nature, and they gotta figure out what kind of programs are here. - Public Health Investigator, FG#1 He just moved, and he just didn’t know how to get back into care. He didn’t know of any organizations in the state. Um, he didn’t know, like, who to talk to, um, no one reached out to him. He didn’t reach out to anyone. Um, and then, uh, also, he was trying to find somewhere to cl-somewhere to stay— coming into the new state. Um, and-and a job, occupation, so his livelihood was on his mind first and getting into care was second. - HIV Care Provider, FG # 2 I'll tell you, specifically, about a patient that I had. It was a young, um, Black MSM. Um, he was a little bit transient and so was kind of couch surfing from one home to another, staying with different people. And a lot of that was tied back to his drug use. Um, and that did affect his ability to be in care. He had limited income because he was not working. He didn't always have the same address. He might not keep the same phone number. So, tracking him down could be a challenge sometimes. - Program Manager Program Capacity and Accessibility There are multiple clinics in the Charlotte Region that provide PrEP. Um, there are multiple clinics in the region that provide HIV, um, care and they’re—they have funding from Ryan White, the county, and the state to get those things to the people who need it. So, uh, the real issue is not that the service—the real issue is not that the services are not there. The real issue is people utilizin’ the services, being retained in the services, and for meetin’ the eligibility criteria to get the services…So to get-to get services for a person who’s HIV+, you have to [have] proof that you’re positive, so you had to—um, you had to disclose—you had to show proof of income, or if you don’t have income, you had to show proof of residency, proof that you are a Mecklenburg County resident or just a North Carolina resident, and then, um, you also need to show that you don’t—to get Ryan White, you also had to—you had to show if you have proof of insurance or not… and then the same thing for PrEP. PrEP you had to, um, basically prove that you’re HIV negative. You have to, um, show your, uh, proof of income, and then you also need to disclose, um, your status. I don’t think with PrEP you need to disclose your income. I think with PrEP it’s more about if you’re HIV negative, and if you’re—and insured or not or underinsured, and under-underinsured has become the big issue here. - Gay/ same gender loving man, age 26 I think that we’ve noticed is that, um, we need more providers [ laughter ]. You know, I find that, uh, I think some people on the panel have already talked about, uh, waiting lists to get it—appointments for people to either get first-time treatment or get reengaged at—you know, it could be two, three weeks out. - Case Manager, FG #3 And some other funding, um, like our HRSA EHE grant, we're able to provide copay assistance for some of the insurance. We're able to provide that financial assistance to some of these provider agencies that can then pick up some of that cost as well. Um, we do have resources through a HOPWA grant, where we can provide utility assistance for individuals living with HIV and that kinda thing. So, I mean it runs the gamut, just depends on what program it is and that kinda thing. So yeah, we have access and-and we are able to provide some of that support to our community partners. - Organization Leader Structural Facilitators: Funding and Partnerships So that's why I like, I'm usually, I don't have to go outside to find help if I need it. But, you know, if I don't have it, I'm always with Medicaid. I've always had Medicaid and that's always been a backup for me. 'cause you know, I'm on family planning and at that certain age, you get family planning with Medicaid…So, and that just takes care of like, you know, uh, your regular checkups and, um, STD treatments and/or stuff like that. Um, but other than that, you know, I also get healthcare with my job, so I have both of those. So it's like I'm covered where one thing doesn't cover, I'm covered with the other. Um, my HIV is currently paid—my HIV medicine is currently paid for Ryan White through the, uh— Yes, ma'am. For the services [ provider visits ], yes. it's, uh, same Ryan White. - Trans woman, age 25 We ourselves don't have a mobile clinic. But we are afforded the opportunity with some funding to provide that opportunity to one of our partner agencies. So we received a grant, and what we did, we broke into the grant funding to allow our partner agency to purchase a mobile unit that they could then use in collaboration with some of our other community partners to create a mobile clinic that could then be taken out in the community to provide certain services. - Organization Leader I think being able to extend the clinic hours would be ideal, if I had unlimited amount of funds, to meet those individuals who work third shift, to meet those individuals who need a 6:00 a.m. clinic appointment. - HIV Care Provider, FG #2 My own one-stop-shop—everything right here. You get mental health, you get transportation. You get housing, you get clothes, showers, wash your clothes, educational purposes. You get your, um, the—your full panel for testing. You get results. Um, even if you aren’t too sure about results coming too soon, you still get the treatment for it for, like, PrEP, PEP, uh, gonorrhea, penicillin shots, uh, Truvada, Biktarvy, whatever it may be, but yeah, I would do everything ’cause you-you know, we’re nonprofit, [ laughter ] but if the funds were there um, yeah. I definitely would do everything, like, right here for us, one-stop-shop. - HIV Care Provider, FG #3 Open in a new tab Many BSGM emphasized that basic needs (e.g., housing, employment, and food security) are not always prioritized over HIV care and would prefer HIV care to be integrated with other health services. Providers also highlighted that integrated care “one-stop shop” models can address competing priorities, meet individual needs, and reduce stigma by making HIV care part of routine services. Providers also noted that while organizations may lack some resources, external funding does enable collaborative partnerships to fill service gaps. For example, one agency that secured funding to purchase a mobile unit collaborated with another to overcome transportation barriers. Both groups of participants noted that complicated systems lead to disengagement from care. Some providers acknowledged bureaucratic hurdles, such as proof of residency, income, and status requirements, and scheduling challenges, especially among individuals who recently relocated or are transient. In addition, limited appointment availability and rigid scheduling within overburdened clinics can delay follow-up care. A 26-year-old gay/same gender loving man explained “appointments are often midday, but I don’t get off until 5, […] if I do reschedule, then that appointment could be months away from the previous appointment.” BSGM and HIV providers explained that access to HIV services in the region is shaped by the complexity of navigating available resources. One gay/same-gender-loving man (age 26) described, “The real issue is people utilizin’ the services, being retained in the services, and meeting the eligibility criteria to get the services.” He explained that patients must provide extensive documentation to qualify for programs like Ryan White or PrEP assistance. Several participants also described how supportive clinic staff and caseworkers eased enrollment processes. Theme 3: Supportive networks enhanced treatment adherence BSGM described how supportive networks improved adherence to care. Participants noted how their social networks affect care engagement, particularly as some of them work in healthcare or can share recommendations for local providers or services ( Table 5 ). Lacking supportive networks at diagnosis can lead to emotional distress, with one trans woman, age 25, describing feeling neglected or abandoned. A pansexual man, age 33, emphasized that " the stress of [an HIV diagnosis] without support is horrific ". Supportive relationships also encourage individuals to adhere to treatment, which one trans woman explained helped her to stay motivated to care for herself. BSGM participants described their friends as credible sources of healthcare information due to their occupations (i.e., nurse, outreach workers, etc.), while others stated their friends played an essential role by sharing lived experiences and helpful resources, such as links to health websites and clinics they recommended. Although most participants emphasized supportive networks, there were differences in support sources as some reported familial rejection of post-diagnosis. Some BSGM reported being more receptive to friends than family or feeling more inclined to rely on themselves to stay motivated. Table 5. Representative Quotes from Theme 3: Supportive networks enhanced treatment adherence Well, I can say it affects you in a positive way because a lot of people don't have the support when they find out that they get HIV. A lot of people are neglected, abandoned, but I felt I was lucky to have that because, you know, a lot of people are lucky to have that. But it-it helps me take care of myself better and helps me, you know, stay motivated to taking care of myself because the people who love me wanna see me do better and be better. So why not be better? [Laughter]. - Trans woman, age 25 Very much so, um, if anything, my [HIV-related] job makes me unhealthy mentally and physically. Um, but it's the stress of it without support is horrific. Um, I had the conversation today with my boss, actually, um, with my family, they very much need—want me to be healthy. They know I struggle sometimes and they try their best in their own way to tell me that they want me to be healthy. But it—again, it's not in a way that I'm receptive to. So I really lean on my friends to push me. They push me to go to the doctor. They push me to go to therapists. They push me to eat better and to eat more. […] - Pansexual man, age 33 Um, like I said, I do have friends who do work in the healthcare service. Um, and so, when I, you know, feel the need to reach out to them, then um, it's nice to know that somebody's very knowledgeable on the topic and that they experienced or what they know. - Gay / Same Gender Loving Man, age 33 So, work and family dinner, a dead end. But friends, they actually regularly send me things. They'll send me links to Psychology Today to different counseling. They'll send me, "Oh, I—I had—you know, when I used to live in Charlotte, I went to this clinic. You should try it out." They'll send me, "Have you ever heard of this-this dentist? I've used them before when I had an emergency. You can work it out." Um, they'll send me links, they'll send me pamphlets send , they'll give me pamphlets. They'll, uh, like text me, they'll call me. My friends are very, I don't know the word for it. I'm-I'm blanking right now. But they're—they're very much on top of my healthcare. They-they want me to be-be mentally and physically, and they don't play with it at all. - Pansexual man, age 23 Open in a new tab Theme 4. Personal Agency and Self-Efficacy Evolved After Receiving an HIV Diagnosis for BSGM with HIV Although public narratives linking HIV testing to LGBTQ+ identity were described as barriers to care engagement, and some BSGM described initially avoiding testing to distance themselves from stigmatized identities, many BSGM described a shift in personal agency and self-efficacy after their diagnoses. Several BSGM explained how their view of HIV, sense of control, and personal agency evolved after their HIV diagnosis ( Table 6 ). For example, one Trans woman, age 34, reported “ being depressed ” and feeling as if she was never “ gonna be able to live again ” after her initial diagnosis. However, she now feels as “ healthy as an ox ” and able to live “ life to the fullest .” A gay man, age 26, who once perceived his status as a “ death sentence,” now describes it as a manageable condition. For some participants, stigma and discrimination catalyzed self-advocacy and activism. One Trans woman stated that a stigmatizing comment about her HIV status initially left her feeling distressed but ultimately motivated her to challenge misconceptions, asserting that having HIV does not make her undeserving of love. Table 6. Representative Quotes from Theme 4. Personal Agency and Self-Efficacy Evolved After Receiving an HIV Diagnosis for BSGM with HIV Domain Representative Quotes Evolving Perceptions of HIV after Receiving a Diagnosis Growing up in my household and with my father and how he was, it was very much always [HIV diagnosis is] gonna happen because you're gay or that's you know, it was always one of those very scary PTSD trauma things. So in my situation, with me getting comfortable with a guy and it happening to me, it was, kinda, like, it was so, like, it was so-so bad. It was so bad. Like— Um, it was so bad. But I'm in such, like, a better place, and I never once, like, stopped to smell, like, the flowers, like, ever. I was always, like, in la-la land… And ever since I've been, like, forced to, like, kind of, like, take a break from all of that because I was getting myself back together from what happened, and I'm still getting myself back together. I mean, I'm good and I'm, like, happy and in a couple, but, like, I'm still—there's things that I—goals that I wanna reach and things that I wanna do. So it's like—I've been able to stop and smell the flowers. Like, I've been able to like, find myself a little more. I've been able to calm down a little bit and find, like, figure out who I am. And— it's been a very interesting-it's been very interesting. So now it's, like-it's like there's no, um, like, there's no—like, how do I say this? Like, my health comes first. Like, all this—like, no matter what. - Trans Woman, age 25, recently diagnosed So I view [HIV] as—you know what? [Laughter]. That’s a good question. I’ve never had to answer that. I und—I don’t view it any type of way. Um, for me, like, at first, when I was diagnosed, of course, you know, I went down the whole downward spiral of being depressed, and you know, feeling like I never was gonna be able to live again. However, where I am today, it’s like, I’m still as healthy as an ox. And I just live my life to the fullest. So when you asked how do you I view it—I just—I don’t view it. I live as if I’m perfectly healthy […Participant described experiencing discrimination from close relationships, including her ex-husband.] Um, it really caused me to have a lot of resentment towards him. Um, I still don’t deal with him to this day because he just does not—he’s very closeminded. And I feel sorry for him ‘cause he’s really living in a small jewelry box. And he has to break out of that on his terms. Um, I can’t force him to grow, so, by all means it did—it was very disheartening for me to hear that he had called, and was, like, being very messy like that. - Trans Woman, age 34 Honestly, I did—I view it as just any—just like any other virus or any other, like—any-any other, like, symptoms or—what's it called? Like, any other, um—what's it called? Any other condition—that's what it is—that someone can have. Like, people can have cancer. People can have HIV. Like, it's-it's okay. We, uh, have something. As long as you can, like, maintain it and keep it under control that's the thing that matters. - Gay / Same Gender Loving Man, age 26, recently diagnosed I view [HIV] as somethin’ that becomes part of your life, but it’s not something that—it’s not a death sentence. It’s something that happened to you, but you’re able to live a healthy life with it and also, too, as long as you’re undetectable, you’re untransmittable. So you won’t-you won’t pass the illness to any of your partners you’ve chosen, but you have to do the work to be undetectable. - Gay/ same gender loving man, age 26 Self-reliance, Advocacy, and Determination for HIV Care Managemen t Nothin' really. Nothin' [ gets in the way of HIV appointments ]. I, um, try to stay on top of things. I try to stay ahead of the curve in all aspects. So if there is something that does goes wrong, there's a plan B, you know. So for most of the times, there-there's not—there's no issue—which I'm thankful for. - Bisexual Man, age 24, recently diagnosed Nothin’ affects my [ laughter ]— my decision when it comes to stuff like [ medication adherence ]. Because that’s a decision I’ve already made to you know— be a part of. So nothin’ affects my—only thing that’s gonna affect my decision to, uh, not take my medicine on time or somethin’ like that is because I’m-I’m drunk or somethin’. But other than, I’m gonna take it. […] I was just letting you know like you know that that’s not something that I’m like—for me personally, I don’t—I can’t think of anything that will affect me from like goin’ to my doctors appointments or takin’ my medication on time. - Gay / Same Gender Loving man, age 34 I work for everything I have… just because I have [HIV], it doesn't crutch. Just because, you know, I have HIV doesn't mean it crutches me to, or it hinders me from living my life. Like I said, that's a self—that's more of a self, um, accountability thing, situation. You have to want it for yourself, and so a part of wanting for yourself is living for yourself. - Trans Woman, age 25 Sometimes when people are unknowing about anyone’s status, a lot of times, you know, it’s a—for me, it’s a ice breaker. Because I’ve heard, like, people say, “Well, you know, I don’t ever think I could date someone that is positive.” And, like, they kind of frown upon it and stuff. But, like, for me, sometimes that when I just go ahead a break the ice. And I just like, “You know, I don’t think it’s fair that you say that.” Um, and then I disclose my status, and I let them know, “You know, I was positive. I’m-I’m positive. You know, I didn’t ask to be positive. But had I, like, continued to, uh, use protection, I wouldn’t be in the situation I’m into.”… just being able to take accountability and just being around people that will take the time to innerstand and understand what-what, you know, you’re educating them on. Like, ‘cause a lot of people are ignorant because they aren’t truly educated. And you’d be surprised how many people are not educated on this. …So when I say ‘innerstand’, for me, innerstanding is literally putting yourself in someone else’s shoes. Um, acknowledgin’ that just like this has happened to me, it can happen to you. And it only takes once. It takes one time to get pregnant. It takes one time to get an STD. […] I was triggered. It kind of made me very stressed at that person because it’s like, of course, you don’t know my status. But the fact that you said that, again, it made me break the ice and say, “Hey. You know, I don’t agree with the comment that you made because I’m positive. And I just feel like anybody deserves love.” - Trans Woman, age 34 Open in a new tab DISCUSSION We describe experiences of BSGM living with HIV and HIV service providers in the Southern US to extend recent literature indicating HIV care efforts must address complex and intersecting factors across structural, community, social network, and individual levels that influence transmission and care engagement 7 , 14 , 23 , 24 . Findings highlight the need for multifaceted approaches to foster BSGM engagement in HIV care, which should include reducing stigma in the health care services by increasing social support, improving availability and assistance with integrating service navigation, and enhancing self-efficacy to engage in care 25 , 26 . Increased support from social networks, providers, and within systems is needed to improve engagement in HIV care among BSGM. Participants in our study described fear of judgment by health care providers combined with obstacles accessing available services that perpetuate mistrust in the healthcare system and delay care engagement and disclosure. Moreover, participants described competing priorities as identified in other studies, such as the need to meet basic needs and challenges with scheduling appointments 27 . Discrimination in care settings, including stigmatizing language and interpersonal interactions with providers, continue to hinder HIV care engagement and may be addressed through provider-level interventions that promote patient autonomy and agency 14 , 28 . Previous studies have identified strategies to reduce stigma via patient-provider communication, training, non-clinical resources, and diversifying teams and services 24 . BSGM described a dynamic process navigating their HIV diagnoses involving an internal shift from initial fear to acceptance of living with a chronic condition. Participants also noted that their social support networks played a critical role in their HIV care by serving as sources of healthcare information and emotional encouragement. However, providers indicated that many BSGM lack access to supportive networks due to reluctance to disclose their identities and HIV status in healthcare and social settings. Both groups acknowledged patient difficulty navigating healthcare systems due to challenges of scheduling appointments, availability of programs, and understanding eligibility requirements for local resources. Additionally, both providers and BSGM described how HIV-related stigma shapes patients’ ability to remain in care. Our findings align with previous studies 29 , wherein providers have noted issues with navigation (e.g., clinic accessibility; availability of appointments), stigma, and provider sensitivity to BSGM health issues (including lack of provider training as barriers to care for trans women). These findings highlight the provider-level and system-level barriers, including understaffing and administrative burden, which can reduce engagement in HIV care 30 . Providers who are culturally responsive, flexible, and offer patient-centered services are needed. Although BSGM advocated for co-located care services to increase engagement, providers emphasized the importance of building coalitions and leveraging financial assistance to sustain essential services. HIV service providers highlighted sustainable program funding as essential to expand access to HIV care and support services, which often remain fragmented. Although BSGM and providers both indicated persistent challenges that impact the HIV continuum of care, perspectives of specific HIV care barriers differed. Many providers highlighted systemic barriers, including housing instability and financial obstacles, whereas BSGM participants indicated basic needs and relationship challenges before prioritizing HIV care, such as the fear and emotional burden of disclosing their HIV status. Some BSGM shared negative experiences with providers with varying experiences based upon types (primary care, HIV care, health departments, emergency rooms, etc.). In addition, providers did not as frequently indicate how peer social network dynamics may influence adherence to treatment among BSGM with HIV. This sentiment aligns with previous work, in which patients cited relational issues, including a lack of support from providers, as impediments to care 31 . Our findings align with prior studies that identified structural drivers, provider-level stigma, and limited social support among Latine populations, justifying the need for culturally responsive provider training to improve HIV care and patient communication 32 . Educating general healthcare providers’ understanding of their role in shaping patient experiences, particularly through everyday interactions, may be a key step toward improving care outcomes. Implications for Social Network Strategies: BSGM in this study framed stigma as an advocacy tool. Although many had negative experiences following diagnosis, they also described transforming adversity into opportunities to educate and empower their communities, which in turn strengthened their commitment to treatment adherence. BSGM also described a tension between healthcare system barriers and patient self-efficacy, noting that self-efficacy may improve when HIV care and related services are easier to access. First, providers should engage in anti-bias training to increase nonjudgmental communication styles to better support patient self-efficacy in interactions. Second, community programs and campaigns are critical to counteract the societal misconceptions concerning HIV transmission and stigma for PWH, particularly among people of color. These findings align with prior intervention literature indicating that flexible, client-centered, and trauma-informed strategies are essential for increasing HIV care engagement among key populations 33 . Third, strengthening social support systems that offer peer support to PWH may reduce stigma-related concerns about disclosure within relationships and families. Finally, streamlining both system and provider processes may improve access to Ryan White and other programs, which are crucial to circumvent structural barriers to care. Many of these structural barriers identified by participants may worsen under the current federal funding landscape and amid growing fears among BSGM that seeking services could lead to discrimination or other negative consequences. We support calls for strength-based, community-led intervention approaches to improve multilevel resilience through social support that are adapted to the local context ( 31 , 34 , 35 ) . This qualitative study purposively sampled BSGM individuals who recently engaged in HIV/STI services and local providers in one EHE jurisdiction, which limits generalizability. Our findings may be transferable to other EHE jurisdictions, particularly in the Southern US, with similar challenges in HIV care engagement among BSGM. Although interviews and focus groups are subject to recall and social desirability bias, our interviewers were trained to develop rapport and foster open dialogue with participants. Additionally, we note that HIV care providers did not all identify as members of the BSGM community, and their perspectives of facilitators and barriers to care for this community may be somewhat influenced by their identities and experiences. However, providers all noted experience serving these communities at their respective organizations. Enhancing the HIV continuum of care for BSGM populations requires an integrated approach involving social, systemic, and individual-level interventions. Social stigma and organizational obstacles delay engagement with HIV care services and result in strained experiences in healthcare settings for BSGM 7 . Findings highlight complex care systems that are challenging to navigate and reinforce medical mistrust. Future studies should prioritize empowering patients, training providers, and creating equitable healthcare systems to improve outcomes for BSGM with HIV. ACKNOWLEDGEMENTS We express our gratitude to all participants in this study, members of the community advisory group, and additional study contributors including staff at Mecklenburg County Public Health Department, NC DHHS, and Sable Watson who assisted with FG moderation. Funding: This study was supported by the NIH through Grant Award Number R01AI169602, the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410), and the Eunice Kennedy Shriver National Institute of Child Health & Human Development (F31HD114366 to Jordyn McCrimmon). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Footnotes Statements and Declarations Ethical considerations: The study was approved by the UNC Chapel Hill Institutional Review Board (#22-1988). Consent to participate: Participants provided written informed consent. Conflicts of Interest: The authors have no relevant financial or non-financial interests to disclose. Data, Materials and/or Code availability: Data supporting this study will be available in the UNC Dataverse repository at https://doi.org/10.15139/S3/XS6NJH . Due to the sensitive nature of qualitative interview data and the small sample size, full transcripts cannot be shared to protect participant confidentiality. The following materials are publicly available: interview guides, the codebook, and summary analysis tables. Additional details regarding the analytic approach are available from the corresponding author upon reasonable request. REFERENCES 1. Department of Health and Human Services, Office of Infectious Disease and HIV/AIDS Policy. HIV.gov . 2025. 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