Transportation, administrative burden, and COVID-19: A structural intersectional analysis of barriers to HIV care among Black sexual minority men living with HIV in the US South

Abstract

While much research has focused on individual (e.g., mental health, substance use) and structural factors (e.g., stigma, institutional racism) driving HIV inequities, less studied are the macro-structural factors like policies governing healthcare and transportation. Using the framework of structural intersectionality, we explore how transportation barriers and administrative burden – the experience of accessing safety net services as burdensome – interfered with sustained HIV care engagement among Black sexual minority men living with HIV (BSMM+) in the US South. Between July 2022 and September 2023, we conducted qualitative interviews with 27 BSMM+. Interviews averaged 60 min, and data were analyzed using codebook thematic analysis. Transportation barriers included limited bus routes, reduced capacity during COVID-19, and long travel times. Administrative burden included: not knowing how to access benefits; inconsistent benefit eligibility, required frequent renewals of public insurance; and waiting in long lines for services. Most barriers existed prior to, and were exacerbated by, COVID-related restrictions. Further, barriers intersected such as when reduced capacity on public transit overlapped with changing clinic hours. Individual-level factors have long been the focus of HIV prevention and care interventions. Our findings offer important insights into how macro-structural barriers influence HIV care engagement. Importantly, macro-structural barriers do not impact all people equally. The need for, and access to transportation and safety net services vary by factors such as race, class, and geography, with the most marginalized being the most likely to face these hurdles. Additional research and policy changes are needed to address macro-structural factors and achieve equitable HIV outcomes.

1. Introduction

There is a robust body of knowledge about individual level factors (e. g., substance use, poor mental health, experiences of violence, childhood abuse) that contribute to reduced care engagement and poor medication adherence among BSMM living with HIV (BSMM+) (e.g., Blashill et al., 2015; Brown et al., 2018; Quinn et al., 2018; Quinn & Voisin, 2020; Ramos et al., 2023; Shubber et al., 2016; Tan et al., 2018). Further evidence illustrates how societal barriers such as HIV stigma, structural racism, heterosexism, and violence each contribute to worse HIV treatment outcomes, and other negative impacts on the well-being of BSMM+ (Boroughs et al., 2015; Campbell, 2021; Quinn et al., 2021; Quinn & Voisin, 2020; Storholm et al., 2023). Black sexual minority men (BSMM) continue to bear a disproportionate burden of HIV, with the highest prevalence in the US South (Centers for Disease Control and Prevention, 2023), and BSMM + report less than optimal antiretroviral treatment (ART) adherence and viral suppression rates (Buchacz et al., 2018; Centers for Disease Control and Prevention, 2021; Fedonni et al.,2021). To more fully understand and address these disparities, it is essential to examine how macro-structural forces (e.g., healthcare policy, transportation) intersect to shape the lived experiences of BSMM+.

Structural intersectionality posits that intersecting structural oppressions (e.g., structural racism, structural heterosexism, economic oppression) create qualitatively different experiences for those who are located at particular intersections and social locations (Crenshaw, 1991; Homan et al., 2021). Importantly, it is a fundamental tenet of intersectional analyses that focus be placed on the structural level and not on individual identities themselves (Bowleg, 2023; Crenshaw, 1989). Indeed, BSMM + exist at the intersections of several marginalized identities, and such structural positioning has been shown to contribute to greater vulnerability to HIV, worse HIV outcomes, and to an overall negative experiences of living with HIV for BSMM+ (Bowleg et al., 2013; Campbell, 2021, 2022; Gwadz et al., 2018; Parker et al., 2017; Quinn et al., 2019). However, it is not the race, gender, sexual identity, HIV status, or socioeconomic position of BSMM + that inherently leads to HIV-related inequities. Rather, it is the oppressive structural conditions they face as a result of existing at the intersection of these marginalized identities. Structural intersectionality offers a valuable framework for illuminating how overlapping systems of oppression create and reinforce barriers to care that disproportionately impact BSMM+. Two critical structural barriers to sustained HIV care engagement are lacking reliable transportation and the administrative burdens associated with utilizing health-supporting social safety net programs. While these barriers are not specific to BSMM+, it is worth while to explore how these influence care engagement among this group of men who continue to be disproportionately affected by HIV, and who have less than optimal HIV care engagement and clinical outcomes.

1.1. Transportation

Transportation barriers have well-documented impacts on access to healthcare in general and for people living with HIV (PLWH) specifically. Patients with HIV who were not retained in care have identified expensive and unreliable transportation as a primary barrier (Yehia et al., 2015). Other studies have shown that having to travel longer distances for care is a major barrier leading PLWH to miss or be late for appointments and to be unable to see HIV providers (Harrison et al., 2025; Sarnquist et al., 2011). For some, navigating complex transportation systems, and delays on public transportation can be a barrier (Dutta et al., 2024). Further, transportation barriers may intersect with HIV stigma to further limit access to care. For example, Black women in the Deep South reported worrying about disclosure if they utilized vans or shuttles provided by clinics or community based organizations (Evans & Williams, 2013).

The likelihood of having one’s HIV care disrupted by transportation barriers is shaped by existing racial and economic inequities. According to the National Equity Atlas, 17 % of Black households do not have a car compared to only 6 % of white households (Policy Link & USC Equity Research Institute, 2025). Transportation policies in major urban areas tend to reinforce racial and socio-economic segregation, indirectly restricting access to education, employment, and housing, and leading to health inequities (Sanchez et al., 2004). Across 16 southern states and DC, in the highest prevalence counties for non-Hispanic Blacks and Hispanics, travel time to comprehensive HIV care was significantly higher than in counties where the highest prevalence was among non-Hispanic whites (Kimmel et al., 2018). Reliable and affordable transportation is a key facilitator of healthcare access as well as accessing needed safety net services.

1.2. Administrative burden

Administrative burden is defined as “an individual’s experience of policy implementation as onerous” (Burden et al., 2012). The challenges described as administrative burden can be organized into three categories: learning costs, compliance costs, and psychological costs (Herd et al., 2023; Herd & Moynihan, 2019, 2020). Learning costs describe the burden of having to learn about a program and its eligibility requirements and then navigate the application process. Compliance costs involve the work required to document one’s own eligibility, and engaging in onerous bureaucratic processes to maintain one’s access to services. Psychological costs refer to the frustrations, anxiety, and feelings of dehumanization associated with these processes and the stigma and shame that some experience because they need to access safety net services. These different types of administrative burden limit access to health promoting social benefits leading to health harming effects (Bell et al., 2023). Importantly, existing economic inequities determine who is more likely to confront administrative burden. Put simply, those who have the limited economic resources are more likely to need safety net services and are, therefore, more likely to be subjected to the burdens associated with obtaining and retaining benefits that they are eligible for (Herd & Moynihan, 2019).

Indeed, publicly funded benefits that people with HIV may need to access, such as the Ryan White HIV/AIDS Program, a federally-funded program which provides HIV primary medical care and medications, as well as other related services to low-income people with HIV, the AIDS Drug Assistance Programs (ADAP), and others are no exception to administrative burden. For example, ADAP requires eligibility recertification every 6 months. An analysis conducted in the state of Washington found that failure to recertify was the most common reason why people lost ADAP, and those most likely to lose the program were Black, young, and uninsured (Erly et al., 2022). In Alabama, PLWH reported ADAP recertification as a barrier to sustained care engagement (Olson et al., 2014), and PLWH with comorbidities or who are also managing mental health challenges and substance use may have an especially difficult time maintaining safety net services that support their health (Wohl et al., 2017).

1.3. Impact of COVID-19 on structural barriers

The COVID-19 pandemic presented novel challenges to public health efforts, broadly, and to the sustained engagement in care for PLWH. In a number of studies, authors have documented PLWH losing access to their providers, cancelled appointments, difficulty refilling medications, and limited availability of clinic appointments during the COVID-19 pandemic (Kim et al., 2023; Meyer et al., 2023; Santos et al., 2021). In large part, vulnerability to each of these is determined by intersecting oppressions and preexisting social inequities (Santos et al., 2021), leading to worse health outcomes for the most marginalized communities. Importantly, the COVID-19 pandemic provides an opportunity to learn from its impact and better prepare our public health and health care systems to prevent disruptions in healthcare in the case of another acute moment of societal stress. The present study qualitatively explores how inconsistent access to transportation and administrative burden served as barriers to HIV care for BSMM+ in Houston and Dallas, TX prior to, and were exacerbated during, the COVID-19 pandemic.

2. Methods

We conducted in-depth qualitative interviews with 27 BSMM+ in the Houston and Dallas, Texas Metropolitan Areas, between July 2022 and September 2023. Participants were recruited from an ongoing, longitudinal cohort. When they enrolled in the parent study (September 2015–November 2016), participants were between the ages of 18 and 29 and were living with HIV. Detailed descriptions of the parent study methods have been previously published (see: Ramos et al., 2023; Storholm et al., 2023; Vincent et al., 2023). For the qualitative study, we recruited participants following the fourth wave of data collection, purposively selecting for those who reported: suboptimal care engagement (e.g., missing ART doses in the past year, detectable or unknown viral load, or not currently on ART); experiencing intimate partner violence (IPV); or substance use, factors commonly found to be associated with poorer ART adherence. Participants in the parent study who met inclusion criteria according to their responses in the fourth wave of quantitative data collection were contacted and offered participation in a qualitative interview.

The first author and Principal Investigator of the qualitative substudy (CKC) conducted all interviews, which lasted approximately 60 min on average. Study domains included HIV stigma (e.g., What kinds of things do people say about HIV and people living with HIV?), experience being diagnosed and living with HIV (e.g., Please walk me through your experience of being diagnosed with HIV), HIV care engagement (e.g., What, if anything, do you think would improve your ability to stay engaged in your HIV healthcare?), COVID-19 (e.g., How has the pandemic affected your engagement in HIV care?), IPV (e.g., How has relationship violence or abuse affected how and when you engaged in HIV Care?), and substance use (e.g., In what ways, if any, has your use of alcohol or drugs had an impact on your HIV care?). All participants were sent the consent form prior to the scheduled interview time. CKC reviewed the consent form and answered any questions before proceeding with the interview. We took a number of steps to protect participant confidentiality, including getting verbal consent so that participant names were not associated with study data. We also limited access to study data to the qualitative analyst team and use pseudonyms in reporting results. Participants received $75 for their participation. All study procedures were approved by the San Diego State University Institutional Review Board.

Three analysts (CKC, KK, HR) applied a codebook thematic analysis approach to analyze the interview transcripts. Codebook thematic analysis uses a codebook, not to measure intercoder reliability, but in the service of pragmatic concerns such as meeting timelines and answering specific questions in applied research (Braun & Clarke, 2022). The analysis team first listened to the interviews and audited the transcripts, developing a deep familiarity with the data while removing identifiers, taking notes, and identifying inductive codes. During this process, the team met weekly to discuss potential codes and common narratives and themes. The team then open coded three transcripts, meeting after each to compare coding, consolidate redundant codes, and discuss potential parent codes to organize the codebook. Lastly, the team independently coded the transcripts using Dedoose (SocioCultural Research Consultants LLC, 2023), while modifying the codebook as needed throughout the process, in line with codebook thematic analysis (Braun & Clarke, 2023; King & Brooks, 2018, pp. 219–236). Discrepancies in code application were part of an ongoing process during which the team discussed codes and themes and made decisions through consensus.

3. Results

In the results that follow, we share participant narratives focused on the roles of transportation and administrative burdens – including learning, compliance, and psychological burdens – on care engagement before and during the COVID-19 pandemic. Each exemplary quote is followed by participant name (pseudonym), age, years living with HIV, and viral load as reported in their quantitative survey (e.g., [David; 30yo; 6; undetectable]).

3.1. Participants

Sample demographics are described in Table 1. The mean age of participants was 30.81 years and men had been living with HIV for approximately 10 years, on average. Most men in our qualitative sample were employed part time or unemployed, just 22 % had earned a bachelor’s degree or higher, more than a third earned less than $20,000 a year, with only 29 % reporting annual income of $40,000 or more, and a quarter reported having no health insurance at all.

Table 1.

Participant demographics (N = 27).

Age			Insurance Status
Mean	30.81		Yes	19	70 %
Median	31		No	7	26 %
Range	26–35		Unknown	1	4 %
Time Since HIV Dx (Years)			Employment
Mean	10.85		Full Time	12	44 %
Median	10		Part-Time	4	15 %
Range	6–17		Unemployed	11	41 %
	n	%	HIV Viral Load
Education			Undetectable	21	78 %
High school diploma or GED	7	26 %	Detectable	5	19 %
Some college, Associate degree	14	52 %	Don’t Know	1	4 %
Bachelor’s degree	4	15 %
Any graduate studies	2	7 %	Currently On ART?
			Yes	23	85 %
Sexual Identity			No	4	15 %
Gay	21	78 %
Bisexual	6	22 %	On ART for past 60 days	22	81 %
Gender Identity			# Of Days Missed ART Dose - Past 60 Days a
Man	27	100%	Never	6	22 %
			Less than once a week	4	15 %
Income			Once a week	2	7 %
less than $10,000	6	22 %	2–3 days a week	6	22 %
$10,000–19,999	4	15 %	4–6 days a week	1	4 %
$20,000–39,999	6	22 %	Every day	3	11 %
$40,000–59,999	6	22 %
$60,000–79,999	2	7 %	Missed ART 7 Or More Consecutive Days In Past 12 Months? b
Decline to Answer	1	4 %	Yes	6	26 %
Don’t know	2	7 %	No	17	74 %

^aOf those on ART for past 60 days (n = 22).

^bOf those currently on ART (n = 23).

3.2. Location of care sites requires transportation and long travel times

A number of participants described having to travel long-distances to see their healthcare provider. This was a greater burden for those without the economic resources to live close to neighborhoods in the city center where services were concentrated. When asked what he thought would improve his engagement in HIV care, Jamar responded:

I feel like if there were more clinics available that were not just in the centralized metropolitan Houston area. Because most of the clinics, I have to drive out an hour to get over there [because of traffic]. So, if there was more clinics in my area, that would be helpful and my medication and everything.

(Jamar; 26 yo; 10; Undetectable)

For others, long commutes on public transportation served as obstacles to getting to their care providers. Phillip, who suffers with a number of health conditions including extreme fatigue – which at the time of the interview remained unexplained – described how taking his medicine on days when he has to see his doctor is a challenge.

I know it’s important to take it, and then sometimes when I get up, I’m rushing, I forget, and then, you know, I’ll be on the bus line. So, when I do have to go to a doctor’s appointment, I have to leave two and half, three hours earlier, you hear me, because I live way on the other side of town … So, I have to catch the bus into town, and then by the time I get into town I’m like, “’Shit, I forgot.’ Then, by the time I go to the appointments, do what I need to do, and I get back home, you know, it’s like, oh, ‘I’m free to go to sleep.’ Just like, ‘Damn, you forgot to take your medicine.’”

(Phillip; 35 yo; 13; Detectable)

The burden of public transportation was just “too much” for others. As Paul explained:

I don’t want anybody in my business or nothing like that, so long as I have my own means to get where I need to go, to get to doc, to get to pick up my medicine, if I can’t ship it out, or get to the doctor myself, then that’s where I be out of care. Public transportation is kinda, I’m sorry. It’s 2022, and I have a lot of patience, but I just don’t got the patience for public transportation anymore. Especially in Dallas. It’s just too much.

(Paul; 29 yo; 13; Detectable)

Importantly, as Paul mentions, he doesn’t want others to know about his doctor appointments, highlighting the overlap between HIV stigma and the structural barrier of not having his own transportation.

Some participants also noted that limited availability of public transportation made it difficult to attend their medical appointments. For Mason, a very limited bus schedule was the norm pre- and post-COVID restrictions:

I wish they would make that much more easier and the transportation issue like trying to have a charter [bus] because in Dallas where I live at, there’s a bus, but that bus cut off at a certain time. If I have an appointment at 11:30, I’m not going to get to my appointment because that bus cuts off at 9:00 in the morning, which is stupid … don’t understand how they do that. I wish there was a way they can work around that transportation issue …. [The bus] runs 5:30 in the morning till 9:00 in the morning. It cuts off from 9:00 until 1:00 in the afternoon.

(Mason; 31 yo; 8; Undetectable)

Similarly, Darius described how COVID-restrictions affected his transportation options, and how limitations on public transit overlapped with COVID-related clinic changes.

Yeah, [COVID] made it a struggle, because the bus only allowed certain amount of people on. And when you’re standing on the train, everybody don’t want to stand there. You six feet [apart], so you have to wait till the next two trains come and get there. And then about time you get to the place, you can’t go in there. You have to make an appointment. The appointment is two weeks away. It was always something …

(Darius; 32 yo; 7; Undetectable)

As each of these men described, the location of services combined with long commutes by car or public transportation added significant burdens their effort to stay engaged in care before, and during, the COVID-19 pandemic.

3.3. “Well, they said that you didn’t qualify”: Administrative burden and access to care

3.3.1. Learning costs

A number of men described the difficulties they experienced in accessing publicly funded healthcare services. When Gerald was first diagnosed, he was given a temporary prescription for ART, but he did not have insurance and didn’t know how to access the benefits he would need to continue taking the medication.

I think I was about 20, maybe, 18 or maybe 20, I can’t remember, but I ended up going to the health department to try to get some type of treatment because I did want to live. So, I went to the health department. I think they did a blood test, whatever. They figured out I was positive, and they put me on medication. They gave me three months’ worth of medication … I couldn’t continue the medication because I think they didn’t have the resources, and they wanted me to get on Social Security, and I just wasn’t prepared or didn’t even have the knowledge and know how to do all of that.

(Gerald; 32 yo; 16; Undetectable)

Similarly, Jamal moved from a rural part of Texas and was not prepared to navigate the healthcare system in a large urban city.

… moving out to Dallas, it was, like, you’re one of a thousand and, like, I just lost touch with services at that point in time. And it was, like, I would go – I remember when I would run out of medicine or, like, with my Ryan White would expire and I needed to get it renewed, I would purposefully go to the ER and tell them, “Hey, you know, I’m positive and I don’t have any meds and I don’t know where to go here” … And I would purposely say these things thinking, “Y’all are going to get a social worker up here or tell me where to go.” And it was like, three years before somebody finally was like, “Wait, wait, what, what’s going on?”

(Jamal; 35 yo; 13; Detectable)

Gerald and Jamal illustrate the learning costs category of administrative burden, which include learning how to apply for benefits, where to go, and what forms need to be filled out. There were resources available to Gerald. However, he was unaware of some and didn’t know how to access those that were recommended to him. Jamal went to the ER repeatedly hoping someone would guide him in the right direction to get the support he needed, which didn’t happen for three years.

3.3.2. Compliance costs

For others who were able to navigate initially qualifying for the resources they needed, challenges to maintaining eligibility were exacerbated during COVID and interfered with their consistent engagement in care. Craig needed to renew his eligibility for Ryan White and was met with COVID-related restrictions.

Yeah, they wouldn’t even let me in the building to go, and sit down, and have a meeting. And they weren’t doing Zoom calls … It was at least going on a month. I don’t if it was a month exactly, but it took that long. I was out [of medication]. That’s what I had to renew when I tried to put in a prescription. They told me my insurance was out, so, I had to renew it. And that’s what the whole situation was.

Interviewer: So, how long did you have to go without your medications?

I’d say about two and a half weeks.

(Craig; 30 yo; 6; Undetectable)

Similarly, when asked about his experiences with HIV care, Philip described:

It was good. It was good so far up until the pandemic started. The pandemic started; I have had nothing but pure hell trying to get my medicine. I’d get my medicine one month then the next month I wouldn’t get it. Then I wouldn’t get it for, like, two or three months and then I’d get it again. And they’re like, “Oh, well, they said that you didn’t qualify.” Well, I just did all the paperwork and how can I qualify now and then next month I don’t qualify, and then the following month I do qualify? And it was just shit. And then, I couldn’t go in and talk to anybody … it was pure hell. To this day they’re still sending my medicine so much – they’ll say, “Oh, we sent your medicine.” “I never got the damn medicine, you hear me.” Then I have to go in and sign paperwork to get new medication. Then I’m sitting at home waiting and I’m like, “Well, my medicine never came again.” But then, they have no – “Well, we reordered your medicine.” It’s like, “well, it still hasn’t came yet.” So, I’ve gone two or three months without medication, then I’ll get the medicine for a month, you hear me, then the medicine might not come the next month, and then it’s just ridiculous.

(Philip; 35 yo; 13; Detectable)

Gerald’s, Craig’s, and Phillip’s narratives illustrate how those who rely on safety net services for health care access are required to engage in additional labor to maintain their health.

Aaron described receiving a healthcare card (referred to as a “gold card”) that Harris County, TX (where Houston is located) provides. It is not traditional insurance, but allows for discounted health services on a sliding scale. He described how he was able to receive the card but was not able to use it during the pandemic.

When I got a gold card through the Houston Health Department, I guess, when I wanted to use the health card, I couldn’t because at that time they weren’t taking new patients. And so that’s something that I didn’t like, because even [post COVID restrictions] I still didn’t use it. And so now I’m wondering, “Well, do I still have that gold card? Do I need to get it renewed or what?” So that was one thing that I didn’t like, because that gold card was supposed to help me get other things done if I needed … So that was another form of insurance that was going to help me out. And because of the pandemic, I wasn’t able to use it or even figure out how I was going to be able to use it because they weren’t taking new patients.

(Aaron; 26 yo; 7; Undetectable)

Jason described having healthcare coverage and how, before the pandemic, he was able to pick up his prescriptions in person. However, policies changed during the pandemic and, because he was unhoused, he struggled to maintain his medication adherence.

Well, when they [implemented COVID restrictions], it slowed me down from getting my medicine because I was picking it up. But they stopped us from coming in and because I didn’t have an address. I didn’t have a place to send it to … I just went off of medicines for a little bit because I wasn’t able to get it … I want to say about six months, really … I had to go to a homeless shelter. Nothing, checking in as homeless for a day or two, and they got the ball rolling … Because then, you can pick it up there at the shelter.

(Jason; 35 yo; 15; Detectable)

Jason’s experience further highlights the additional burdens facing those who are experiencing poverty and a lack of stable housing. To receive the services he needed, he needed to have an address which, at the time, he did not have and was therefore not in compliance with the benefit requirements.

3.3.3. Psychological costs

In addition to the compliance burdens, those who receive public health benefits are also confronted with long waits and limited availability of services. For example, Chris described his experience with dehumanizing psychological costs associated with some public health services.

I had went through [a local healthcare] system. Their system, I do not, I did not like it at all. I felt like a cow, standing in the line with other cows, being ready to be cut up. But the only thing is, it takes a million years for you to get cut up because just takes that long to see a doctor, or this, or this, or that. I just didn’t have a good experience with it … just the visits and the referrals would be so far out. Yeah. So, I had to learn it. I just didn’t like the system. It was just not streamlined, and you have to go here, and it was a lot of other people there. I just wasn’t used to all that.

(Chris; 33 yo; 14; VL Unknown)

Similarly, a number of men discussed having to attend hours-long intake processes to get enrolled in care. Brandon described what that process entails.

Them intake things, just take too long. We have lives still, all of us aren’t disabled, or have a disability. We do work. We do have lives. So, when we have to take out a whole day for intake, that’s taken away from what we have to do, personally well for me. It’s a long process. For one, you go in early in the morning, and when I say early, I think it’s like seven o’clock in the morning. Go in early, it’s like a full shift. You don’t leave til about two or three o’clock literally, because you have to do everything in one, and then you have to wait for this person to get ready so you can go do that, then you got to go wait somewhere else for them to get ready to do that. It’s like you got to do everything in one, and to be honest, some of this stuff could be done online while you wait.

(Brandon; 29 yo; 10; Undetectable)

He went on to describe some of what is happening during those hours. Patients meet with “financial people, so in case you need coverage and stuff, and you meet with the foot doctor, you meet with the regular doctor, you meeting with everybody … The case worker.” As Herd and Moynihan (2020) describe, psychological costs include frustration, anxiety, loss of autonomy, and stigma, all of which Chris and Brandon describe in these experiences.

4. Discussion

In this study, we used the framework of structural intersectionality to explore how two structural barriers – transportation and administrative burden – influenced HIV care engagement for BSMM+ and how those barriers were exacerbated for some during the COVID-19 pandemic. Importantly, we did not specifically ask participants about transportation or administrative burdens. These narratives arose organically in response to neutral, open-ended questions about their ability to be engaged in care (e.g., “How, if at all, has the pandemic affected your HIV care?; “What, if anything, do you think would improve your ability to stay engaged in your healthcare?”). That men highlighted these, as opposed to those specific to their providers or their own personal lives, illustrates how real and consequential structural barriers are for the HIV clinical outcomes and overall well-being of the communities most disproportionately impacted by HIV. These findings build on our previous findings from this sample which focus on barriers and facilitators of care engagement at the individual, and health systems levels (Campbell et al., 2024; Kielhold et al., 2024). Findings from this analysis illustrates macro-structural barriers that are beyond the control of individual patients.

Structural intersectionality posits that the convergence of structural oppressions (e.g., laws, policies, segregation, economic oppression) on the basis of race, class, gender, or other marginalized identities must be addressed, as they hinder the ability of marginalized people to achieve desired outcomes (Crenshaw, 1991). An intersectional structural analysis calls for situating data in historical context such as existing laws, policies, and socioeconomic circumstances (Bowleg, 2008, 2023; Cuadraz & Uttal, 1999). To do so, Cuadraz and Uttal (1999) suggest that data include “interview accounts AND other sources of information” (p. 180). Indeed, those with multiple marginalized social statuses are “already positioned within a set of structurally deleterious social discourses” (Berger, 2010, p. 29) before they are confronted with life challenges, such as HIV or COVID-19 in this case, leading to experiences and outcomes that differ from those of people with relatively more privilege. BSMM+ in the US, and in the South, sit at the intersections of marginalized race, sexuality, and HIV status and, thus, occupy a structural position that subjects them to multiple intersecting forms of structural and institutional oppressions (Burns, 2022; Campbell, 2021; Kipke et al., 2020; Nelson, 2020; Quinn, 2022). Consequently, they BSMM + are especially likely to encounter structural barriers to HIV care engagement that mostly impact marginalized people with fewer resources.

Transportation is a well-documented facilitator and barrier to healthcare (Dutta et al., 2024; Harrison et al., 2025; Sarnquist et al., 2011; Yehia et al., 2015). Centralized HIV care services were often located far from where men could afford to live, which meant long travel times by car or public transportation. Limited bus schedules and, during COVID-19 restrictions, reduced capacity on buses made traveling to doctor appointments more difficult and, at times, these limits coincided with limited and changing hours at clinics. Segregation – a result of historical practices such as redlining and predatory lending, as well as more current trends like gentrification – is a major driver of disparities in healthcare access, health outcomes, and use of public transportation (Acolin et al., 2024; Barajas, 2021; Bassett, 2024; Ferber et al., 2024; Goldstein et al., 2023; Swope et al., 2022; Versey, 2023; Yang et al., 2020). The Dallas and Houston metropolitan areas rank 16th and 18th most segregated, respectively, out of 221 metropolitan areas with populations over 200,000, (Lichter et al., 2023), and Texas ranks above the average of all states on segregation and education disparities between Black and white residents (Siegel & Wiklund, 2023). Further, Black people are more likely than other racial or ethnic groups to lack their own form of reliable transportation (Policy Link & USC Equity Research Institute, 2025). Lastly, in line with previous research conducted more than a decade ago (Evans & Williams, 2013), we heard how stigma still remains a barrier to alternative transportation options. For example, asking for a ride to a doctor appointment can risk having other learn of one’s HIV status.

To our knowledge, this is the first study that has applied the framework of administrative burden to understand a critical structural barrier to sustained HIV care engagement and medication adherence. Some research has used the term “administrative burden” to describe some of the more complex and taxing work in which providers and staff have to engage to provide healthcare services (e.g., Emmert et al., 2025; Maulsby et al., 2017; Roland et al., 2022). Here, we use the framework developed by Herd & Moynihan that focuses on the learning, compliance, and psychological burdens facing patients as they seek to access safety net services for which they are eligible (Herd et al., 2023; Herd & Moynihan, 2019, 2020). In our study, participants described learning costs such as needing to enroll in Social Security for their care while not knowing how to do so. Jamal described repeated trips to the emergency room hoping that someone would guide him in establishing ongoing care and getting access to needed resources, clearly highlighting that being unaware of what resources are available and how to access them is a fundamental barrier to care for those who need social safety net programs to receive HIV care. Compliance costs included changing and inconsistent assessments of their eligibility, leading to unpredictable starts and stops to their, and qualifying for benefits, and then being unsure if and how they could use them. Participants also described psychological costs such as dehumanizing queues (waiting “like a cow, standing in the line with other cows”), and long intake processes at clinics that interfered with school, work or other general life obligations. Each of these types of administrative burden acted as hurdles that men had to get over to access health benefits to manage HIV and remain healthy.

Black people have lower incomes and education than white Americans, making them more likely to face administrative burdens (Kyle & Frakt, 2021). Further, compared to non-LGBT Black people, Black LGBTQ persons in the US are more likely to face financial stress, poverty, housing instability, and everyday discrimination (Choi et al., 2021). The socio-economic position of participants in our study closely aligns with that of Black people in Houston, Dallas, and the state of Texas. According to the United Nation’s Sustainable Development Solutions Network, in Texas, the uninsured rate is 14.81 % for Black people and 9.77 % for Whites; the poverty rate for Blacks is 20.3 % and 18.32 % of Black people live in high poverty neighborhoods, compared to 8.7 % and 4.61 % for Whites, respectively (Lynch et al., 2021). As a result of their economic positions, men in our study needed to access public health services and confront associated administrative burdens. These economic inequities occur alongside the reality that BSMM have the highest HIV incidence and prevalence of any demographic group (Centers for Disease Control and Prevention, 2023), making them more susceptible to policy changes such as eligibility and compliance requirements for programs like Ryan White and ADAP.

4.1. Implications for research, policy, and intervention

Given the critical importance of being able to reliably travel to doctor appointments, including transportation funding (e.g., rideshare, transportation vouchers) as a central part of HIV care could help to overcome a lack of transportation, a critical barrier to HIV care engagement and improved clinical outcomes. While studies have tested and evaluated models of care that included some form of transportation support, they have largely measured the effect of the full intervention and not the specific impact of transportation support on HIV care engagement (Bove et al., 2015; Dombrowski et al., 2019; Fadul et al., 2019; Flash et al., 2015; Sohail et al., 2019). One study with women living with HIV found that providing transportation lead to a significant decrease in missed visits for those with no mental health symptoms or current heroin use. Those with mental health symptoms or active heroin use reported increased medical visits when provided transportation plus personalized care from a project nurse, but visits decreases when the nurse care ended (Andersen et al., 2007). Additional research is needed to explore transportation interventions to increase care engagement and improve clinical outcomes among people with HIV from the most marginalized communities (e.g., SMM of color, transgender women, people with few financial resources). Importantly, studies are needed across geographic locations as transportation policy, reliability, and availability differ by county, city, state and region.

In the presence of existing administrative barriers, peer navigation or comprehensive case management as a regular part of HIV care can help participants to navigate access to health supporting safety net programs. Further, participant narratives highlight a need to ensure streamlined intake processes that don’t create additional barriers such as interfering with work, school, or other personal responsibilities. Most importantly, however, policy changes that can ensure easier access to safety net programs is, ultimately, what will have the greatest positive impacts on health outcomes. Research modeling the potential effect of streamlined access to safety net programs, and testing interventions to remove administrative barriers are need to measure the impact of these specific barriers on HIV care outcomes.

4.2. Limitations

Our study is not without limitations. Men were recruited from two large metropolitan areas. Thus, the experiences of those in rural and suburban areas, and smaller cities and towns will likely have different experiences with transportation and HIV care access. Further, these cities are located in the state of Texas, the policy environment of which shaped their experiences obtaining care and benefits. For example, Texas has not participated in the Medicaid expansion afforded by the Affordable Care Act (Kaiser Family Foundation, 2025) which affects eligibility for that social safety net program. Their experiences should be understood in these contexts, as BSMM + who live in other cities, states, and regions will have different experiences dependent on their health care systems, policies governing the access of public health benefits, transportation policies and availability of public transit.

4.3. Conclusion

Our findings offer an important contribution to the growing literature highlighting the structural determinants of health. While it is, indeed, important to focus efforts on addressing individual-level health behaviors and barriers in the healthcare system, our efforts to achieve equitable health outcomes must also focus on politics and policy. As our findings show, transportation policy can directly influence one’s ability to reach medical care, and the level of difficulty people face when attempting to access needed benefits can determine whether one has insurance to cover medical expenses. These barriers are inherently outside of the control of any one individual patient, as they may be well-informed about the importance of medication and appointment adherence, and have every intention of adhering, but are confronting a number of hurdles to care that are not in their control. Additional research exploring these higher-level barriers, and policy changes are needed to increase the likelihood of achieving more equitable HIV outcomes and improved health and well-being of the most marginalized communities.