The Southern United States is the epicenter of the HIV epidemic, accounting for more than half of new diagnoses despite representing only a third of the national population [1,2]. African American men who have sex with men (MSM) in the South experience a disproportionate HIV burden, attributed to intersecting individual, interpersonal, structural, and cultural factors. These disparities are compounded by longstanding racial inequities, institutional mistrust, and sociocultural norms unique to the region [3].

Pre-exposure prophylaxis (PrEP), a biomedical intervention with over 90% effectiveness in preventing HIV transmission, remains underutilized in this population [4]. While PrEP awareness among Black MSM has grown, uptake continues to lag behind other groups due to a combination of access barriers, stigma, and medical mistrust [5]. For example, a recent Mississippi-based study found that despite moderate PrEP awareness, many Black MSM underestimated their personal HIV risk and described deep-seated mistrust toward healthcare providers as a deterrent to uptake [6]. These findings echo national patterns, where perceived risk, stigma, and structural barriers remain critical impediments to PrEP adoption.

Existing literature has documented a range of barriers to PrEP, including limited access to LGBTQ-affirming providers, concerns about stigma, low perceived HIV risk, and misinformation about side effects and efficacy [7]. Prior qualitative work has shown that gay men’s decisions to use PrEP are deeply tied to identity, intimacy, and relational dynamics [8]. Adeagbo [9], using the COM-B model in Iowa, highlighted the interplay of capability, opportunity, and motivation in shaping PrEP decisions among Black MSM. This framework underscores how individual perceptions of risk and motivation to prevent HIV are deeply intertwined with structural opportunities, such as access to trusted providers and supportive community environments. However, relatively few studies have examined how regional cultural contexts particularly in the South influence perceptions and decisions around PrEP.

This study builds on prior research by exploring how African American MSM and HIV prevention stakeholders in the South interpret PrEP within a broader sociocultural context shaped by religiosity, conservative values, cultural silence around sexuality, and racialized health inequities [10]. The purpose is to identify regionally informed strategies to promote equitable PrEP uptake and inform culturally grounded interventions that can effectively address the unique needs of Black MSM in the Southern U.S.

Using a purposive sample the following research was explored:

1. What characterizes the southern culture in which African American MSM (AAMSMs) live, work, and play?
2. What perceptions do AAMSMs in the South have about PrEP?
3. What are the nurturers of PrEP uptake among AAMSMs in the South?
4. What are the enablers of PrEP uptake among AAMSMs in the South?

Design

This exploratory qualitative study employed semi-structured interviews to understand stakeholder perceptions of PrEP and HIV prevention in the Southern U.S. The study is part of a doctoral dissertation examining regional and cultural influences on HIV prevention among African American MSM [11].

Sample and recruitment

Participants were purposively sampled to include both MSM currently or formerly using PrEP and key stakeholders involved in HIV prevention efforts. Inclusion criteria for MSM included self-identifying as African American, being 18 years or older, having grew up in the South, and having knowledge or experience with PrEP. Stakeholders included healthcare providers, health educators, and community leaders with experience in HIV prevention or advocacy. Participants were recruited through community-based organizations, LGBTQ centers, and snowball sampling.

Data collection

Interviews were conducted virtually in 2023 in four Southern cities: Jackson, Memphis, New Orleans, and Atlanta. A total of 12 interviews were conducted (8 MSM, 4 stakeholders). Interviews lasted 45–60 minutes and were audio-recorded and transcribed verbatim. Interview guides explored perceptions of PrEP, barriers to uptake, influence of culture and religion, and suggestions for intervention.

Data analysis

Transcripts were coded inductively using thematic analysis. Codes were clustered into categories and major themes. To enhance rigor, multiple coders reviewed the data and discrepancies were resolved through consensus. A table summarizing final themes and representative quotes is provided in the Results.

Four major themes emerged that shaped PrEP uptake perceptions and decisions among African American MSM and HIV prevention stakeholders in the South: (1) religious and cultural conservatism as a barrier, (2) institutional distrust and limited provider cultural competency, (3) stigma and silence surrounding PrEP conversations, and (4) the role of community-based organizations in bridging the gap.

Religious and cultural conservatism as a barrier to PrEP uptake

Participants consistently emphasized that deeply rooted religious values and conservative norms stigmatized same-sex relationships and HIV prevention. Faith-based opposition to sexuality limited open conversations, leading many to avoid PrEP for fear of being judged by church or family members. For some, religious doctrine was framed as incompatible with biomedical prevention.

• “In the South, if you’re gay and Black, you’re already wrong in a lot of people’s eyes. Throw PrEP into the mix, and they think you’re promoting promiscuity.” – MSM participant, Atlanta
• “They say God will handle it, so why take pills?” – MSM participant, Jackson

Subthemes included (a) faith-based silence, where HIV and sexuality were rarely discussed openly, and (b) moral framing of PrEP, where prevention was interpreted as a symbol of deviance rather than protection. This cultural conservatism created a powerful deterrent to engaging with PrEP.

Institutional distrust and limited provider cultural competency

Both MSM and stakeholders highlighted mistrust toward healthcare systems, citing historical mistreatment, ongoing racial bias, and lack of representation in medical spaces. Participants described avoiding healthcare settings unless absolutely necessary, with many fearing discrimination or moral judgments.

• “A lot of these men won’t go to the doctor unless it’s life or death. And even then, they’re afraid of being judged or mistreated.” – Stakeholder, Jackson
• “Doctors don’t understand our reality. They just see statistics, not people.” – MSM participant, Memphis

Provider cultural competency was described as inconsistent, with limited availability of LGBTQ-affirming services outside urban centers. This lack of culturally responsive care reinforced distrust, creating a cycle in which medical avoidance led to reduced PrEP access.

Stigma and silence surrounding PrEP conversations

Participants emphasized the absence of open dialogue about PrEP in families, churches, and social spaces. Internalized stigma and fear of being labeled promiscuous deterred MSM from initiating or sustaining conversations about PrEP. The silence extended into healthcare encounters, where some men avoided discussing PrEP due to anticipated stigma from providers.

• “No one talks about it. If you bring it up, people assume you’re out there wildin’. So most just stay quiet.” – MSM participant, Memphis
• “It’s a hush-hush thing. People don’t want their business out there, so they just don’t ask.” – MSM participant, New Orleans

Stigma functioned on multiple levels: (a) anticipated stigma, where participants expected negative judgments; (b) enacted stigma, reflected in discriminatory remarks or treatment; and (c) internalized stigma, where participants internalized negative community narratives about PrEP users.

The Role of community-based organizations in bridging the gap

In contrast to distrust of healthcare institutions, community-based organizations (CBOs) were described as trusted and culturally grounded spaces. CBOs employing peer educators and hosting outreach in familiar environments (e.g., clubs, barbershops, churches) were praised for tailoring services to local culture and building trust with MSM communities.

• “Our CBO understands the language, the culture, the barriers. That’s why we see more PrEP uptake through them than the health department.” – Stakeholder, New Orleans
• “They meet people where they are—not in a clinic, but in the community.” – MSM participant, Atlanta

CBOs were viewed as uniquely positioned to bridge structural and cultural gaps, offering judgment-free services, trusted information, and culturally resonant outreach. Participants noted that partnerships between CBOs and medical providers could strengthen access to PrEP while reducing stigma.

This study highlights the complex interplay of cultural, institutional, and interpersonal factors affecting PrEP uptake among African American MSM in the South. The findings align with prior literature on stigma, mistrust, and limited access to affirming care, but add new insights into how Southern religiosity, cultural silence, and reliance on community institutions shape health behaviors and prevention decisions.

Consistent with Teng et al. [6], participants expressed both awareness of PrEP and skepticism about its necessity, reflecting ongoing discrepancies between knowledge and action. Many men understood PrEP’s protective benefits but perceived themselves at low risk, particularly in the context of monogamous relationships or reduced sexual activity. This disconnect between perceived and actual HIV vulnerability has been documented across Southern populations and reinforces the importance of targeted, culturally relevant risk communication strategies. Similarly, Adeagbo [9] emphasized how motivation for PrEP use is undermined when structural opportunities (e.g., access to affirming providers, financial support for medication) and capability (e.g., accurate knowledge about PrEP and side effects) are lacking patterns echoed in our participants’ narratives.

The absence of discussion around newer biomedical options such as long-acting injectable PrEP (LAI-PrEP) was notable. While this silence may reflect gaps in awareness and availability, it also signals the urgent need to ensure equitable dissemination of biomedical innovations in Southern states, where HIV burden is greatest [12]. Provider education and community-based marketing of LAI-PrEP could address both the logistical challenges (daily pill-taking) and cultural stigma associated with oral PrEP, potentially broadening appeal among hesitant populations.

Importantly, this study reveals tensions within MSM narratives about PrEP, particularly the role of community-level stigma and cultural silence. These findings are consistent with prior research documenting how sociocultural contexts shape PrEP attitudes and reinforce stigma among MSM populations across the U.S. [13]. Some participants described PrEP as being associated with promiscuity, reinforcing negative stereotypes about Black MSM and deterring engagement. Others reported distrust toward healthcare providers, echoing historical and ongoing experiences of medical racism. These findings underscore that awareness campaigns alone are insufficient. Instead, interventions must be culturally resonant and community-driven, leveraging trusted institutions—such as faith-based organizations, barbershops, and community centers—to normalize PrEP and reduce stigma.

Future research should further investigate regionally grounded approaches that integrate biomedical HIV prevention into broader conversations on health equity, mental health, and community resilience. In addition, strategies to engage primary care physicians, mental health providers, and non-LGBTQ–specific service providers are necessary to expand access beyond urban centers and specialized clinics [14]. Exploring community receptiveness to emerging PrEP modalities, including LAI-PrEP, will also be critical for expanding the HIV prevention toolkit in the South.

Strengths of the study

This study is among the first to explore and characterize the perceptions, enablers, and barriers of PrEP uptake among African American MSM in the South. It uniquely integrates the perspectives of both MSM and HIV prevention stakeholders, providing a multi-level view of the cultural and institutional factors shaping PrEP use. By situating biomedical prevention within the broader context of Southern religiosity, cultural silence, and institutional mistrust, the study contributes important insights that go beyond individual-level explanations for PrEP underutilization.

Limitations

Several limitations should be noted. First, the small sample size limits generalizability, and although stakeholders were included, most represented organizations or roles directly connected to MSM-focused HIV prevention. Perspectives from broader provider groups—such as primary care physicians, pharmacists, and mental health professionals—were not included, despite their growing role in PrEP education and delivery.

Second, all participants were English-speaking and recruited from urban centers, restricting applicability to rural, non-English-speaking, and immigrant populations. Rural Black MSM may face heightened stigma, fewer affirming providers, and limited healthcare infrastructure, making their experiences distinct and underexplored.

Third, while this study identified religiosity and cultural silence as significant contextual influences, it did not directly engage faith leaders, church communities, or other regionally influential institutions. Considering the central role that faith-based organizations play in shaping norms and behaviors in the South, future research should explicitly examine their influence on PrEP perceptions, both as potential sources of stigma and as vehicles for intervention.

Finally, the cross-sectional design limits examination of how PrEP awareness and uptake evolve over time, particularly as newer modalities such as LAI-PrEP become available. Longitudinal and community-engaged designs could provide deeper insights into how perceptions shift in response to biomedical innovations, evolving cultural narratives, and changes in healthcare infrastructure.

Implications for future research and practice

The findings of this study underscore the importance of culturally grounded, regionally specific HIV prevention strategies. Interventions should:

• Leverage trusted community institutions such as faith-based organizations, barbershops, and cultural networks to normalize PrEP and reduce stigma.
• Address provider gaps by training primary care physicians, pharmacists, and mental health professionals to discuss PrEP with cultural sensitivity, expanding access beyond HIV-specific clinics.
• Tailor messaging to perceived risk by designing communication campaigns that bridge the gap between self-perceived and actual HIV vulnerability, particularly for men in monogamous relationships or those with low perceived risk.
• Promote emerging modalities by educating both providers and communities about LAI-PrEP and other biomedical innovations that may reduce stigma associated with daily oral pill use.
• Research should prioritize rural populations, non-English-speaking groups, and faith leaders to capture perspectives that remain underrepresented in the current literature. In addition, longitudinal studies are needed to assess how attitudes and behaviors shift as new prevention technologies are introduced and as cultural narratives evolve.

This study provides timely and regionally specific insights into PrEP uptake among African American MSM in the Southern United States. By situating participants’ narratives within the sociocultural and institutional contexts of the South, the findings highlight the persistent influence of stigma, mistrust, religiosity, and cultural silence in shaping HIV prevention behaviors. While awareness of PrEP has increased, uptake remains constrained by these intersecting barriers.

Addressing these challenges will require more than conventional awareness campaigns; it will demand community-driven, culturally resonant strategies that bridge the gap between biomedical innovation and lived realities. By illuminating these dynamics, this study lays critical groundwork for interventions that are equity-driven, culturally grounded, and responsive to the unique contexts of Black MSM in the South.

The authors wish to thank the community health workers, providers, and participants who contributed their insights to this research. We also appreciate the guidance and mentorship provided by colleagues in the field of HIV prevention and cultural health equity.

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This research was supported by internal research development funds from the Jackson State University College of Health Sciences.

The study was approved by the Institutional Review Board (IRB) at Jackson State University. Informed consent was obtained from all individual participants included in the study.

The data that support the findings of this study are available from the corresponding author upon reasonable request. To preserve confidentiality and ethical standards, only de-identified transcripts and aggregate data may be shared.

Brandon Nabors completed this research while a Doctor of Public Health student with Jackson State University. Any future correspondence should be directed to the email listed above.