‘Oh, they can prevent It?‘: a structural agency framework for understanding HIV prevention among black women in community supervision programs

Abstract

Background

Despite efforts to end the HIV epidemic, new transmissions among Black women in the U.S.’ Deep South remain disproportionately high. This study examined condomless sex experiences and PrEP non-engagement among Black women in community supervision programs (e.g., diversion, probation, parole) in Alabama.

Methods

As part of Project E-WORTH South, we used a phenomenological approach and conducted 16 semi-structured interviews to explore factors influencing condom use and PrEP engagement. Participants (n = 16) were selected through criteria-based sampling: Black or African American individuals, female at birth, aged 18 years or older, English-speaking, and current community supervision involvement. Interview transcripts were double-coded using a phenomenological coding technique to identify general themes. The codes were then grouped into themes and subthemes.

Results

Analysis revealed four distinct forms of agency that participants employ in sexual health decision-making, mapped along two dimensions: structural constraints/coercion and HIV prevention knowledge/resources. Despite 37.5% engaging in self-initiated HIV testing, 87.5% were unaware of PrEP/PEP existence, with 50% reporting condomless sex. We identified two novel agency forms: deprived agency (knowledge gaps limiting autonomy) and traversed agency (bidirectional override of initial intentions).

Conclusion

This study introduces a novel structural agency matrix framework and identifies previously unrecognized forms of sexual health agency among Black women under community supervision. The paradox of high health-seeking behaviors alongside near-zero PrEP awareness reveals systematic information dissemination failures rather than individual barriers, demonstrating need for matrix-informed interventions that simultaneously address structural constraints and knowledge gaps.

Background

Despite extensive HIV prevention campaigns promoting highly effective methods like pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) (Conley et al., 2022), the Southern region of the United States (U.S.) continues to bear the highest burden of new HIV transmissions (CDC, 2024). Nationally, Black women experience an HIV diagnosis rate of 19.2 per 100,000—ten times higher than the rate among White women (1.9 per 100,000) (Kaiser Family Foundation, 2024), while in the Southern U.S., they accounted for a striking 67% of all new HIV diagnoses among women in 2017 (CDC, 2019) and have a rate of living with HIV that is 14 times higher than that of White women (AIDSVu, 2024), underscoring the significant intersection of race, gender, and regional disparities. The U.S. South also lags behind other U.S. regions and territories in various indicators of PrEP engagement and utilization (AIDSVu, 2024). In fact, the South accounted for 53% of all new HIV diagnoses in 2022 but only 39% of PrEP users in 2024 (AIDSVu, 2024). It also had the lowest regional PrEP-to-Need Ratio (PnR) at 12, as compared with 25 in the Northeast, 19 in the West, and 18 in the Midwest (AIDSVu, 2024; Sullivan et al., 2024). The PnR, calculated as PrEP users per new HIV diagnosis, reflects the extent to which PrEP use meets prevention needs in a region or demographic group (AIDSVu, 2024; Sullivan et al., 2024). Lower PnR values indicate greater unmet prevention need, and for 2024 and 2023, these ratios were calculated using 2022 new HIV diagnoses as the denominator. Additionally, the PnR among Black or African American individuals was just 4, compared to 26 among White individuals (Sullivan et al., 2024).

The likelihood of HIV transmission is particularly pronounced in Deep South states (South Carolina, Georgia, Alabama, Mississippi, and Louisiana). State-level analyses from the region (e.g., Mississippi) suggest that PrEP uptake among Black women remains especially low relative to need, though comparable multi-state estimates across the South are limited (Arnold et al., 2022). Three out of the seven U.S. states with the highest unmet need for PrEP among Black individuals are situated in the South (Arkansas, Mississippi, and Alabama), two of which fall within the Deep South (Mississippi and Alabama) (AIDSVu, 2022). Furthermore, a recent study involving heterosexual cisgender Black women receiving medical services from a clinic in Mississippi’s Deep South (n = 20), all of whom engaged in behaviors that increased the likelihood of HIV transmission, revealed that while 80% reported having heard of PrEP, only three (or 15%) had chosen to use it (Arnold et al., 2022).

Along with noted disparities in PrEP engagement, the inconsistent use of external condoms among heterosexual Black women in the Deep South has also long been recognized as an area for additional research and intervention (Lichtenstein, 2005). In light of the predominance of heterosexual contact among women’s new HIV diagnoses nationally (KFF, 2024) and the South’s continuing disproportionate share of the epidemic, alongside comparatively lower PrEP engagement (AIDSVu, 2024; CDC, 2019), additional research has been recommended to better understand region-specific factors that may limit Black women’s ability to use condoms consistently or at all (Konkle-Parker et al., 2017).

The likelihood of HIV/STI transmission is significantly heightened for low-income, heterosexual Black women with concurrent substance use and involvement in the criminal legal system (CLS), particularly when residing in the Deep South (CDC, 2019). The intersection of race/ethnicity, gender, and community supervision program involvement (e.g., diversion, probation, parole) is associated with elevated sexual/HIV risk and prevention barriers—including inconsistent condom use and low PrEP awareness/uptake—among women; evidence from Black women in community supervision and criminal legal system involved settings underscores both the risk and the need for tailored prevention approaches (Gilbert et al., 2021; Knittel et al., 2019). Despite these concerning realities, there is limited research on PrEP knowledge, uptake, and condom use among Black women in community supervision programs (e.g., diversion, probation, parole) in the Deep South. Existing studies examine criminal legal system involved women more broadly and/or in other regions—documenting PrEP awareness, eligibility, feasibility, and linkage barriers—but do not directly address this specific subpopulation and outcome bundle (Hoff et al., 2022; Dauria et al., 2023; Meyer et al., 2022).

Evidence indicates that various socio-structural factors prevalent in the Deep South individually and collectively drive HIV transmission (Crosby et al., 2011). Alabama in particular, is noted to be the 7th poorest state in the U.S., and the most religious (Poverty Rate by State, 2023; Most Religious States, 2023). Criminal legal system involvement in Alabama is also disproportionately high relative to other places across the nation. While male jail admissions have seen a reduction of 26% since 2008, there has been an upward trajectory in the total number of women’s admissions and their proportion within overall jail admissions nationwide (Vera, 2019). At present, women make up nearly a quarter of all jail admissions, up from less than 10% in 1983 (Vera, 2019). Between 1970 and 2013, the count of women confined in U.S. jails has surged by a factor of 14, escalating from under 8,000 to nearly 110,000 (Vera, 2019). As a result, women in jail currently constitute approximately half of the total female incarcerated population across the nation (Vera, 2019). These trends are even more pronounced in Alabama, where the number of incarcerated women in jail has witnessed a remarkable increase of 711% since 1980, alongside a 583% rise in the number of women in prison (Vera, 2019), a high percentage of whom have a history of substance use (Alabama Department of Corrections, 2018).

Alabama is also one of only 10 states that have not expanded Medicaid significantly limiting access to care (Kaiser Family Foundation, 2025) and ranks 10th highest in the nation for states with the most hospital closures in rural areas over the last 20 years (Stacker, 2021). Further exacerbating this challenge, over 43% of Alabamians live in suburban and rural areas with significantly limited access to WIFI, transportation, and healthcare (Alabama Department of Public Health, 2015). Together, these system-level conditions reduce routine primary-care touchpoints and specialty access where PrEP is typically discussed and initiated, plausibly contributing to the South’s lower PrEP engagement and PnR despite higher HIV burden (KFF, 2023; Stacker, 2021; Alabama Department of Public Health, 2015; AIDSVu, 2024). Collectively, these socio-structural factors disproportionately impact Black women in the state and may contribute to limited condom usage and decreased PrEP awareness, access, and agency (Lima et al., 2018). The influence of these factors on agency associated with condom usage and PrEP uptake among heterosexual, cisgender Black women in community supervision programs in Alabama and the broader Deep South remains far less studied however, resulting in significant research and practice gaps. Considering the aforementioned factors, there is a growing recognition of the need to better understand how the interplay of race/ethnicity, gender, criminal legal involvement, and residence in the Deep South may constrain agency related to PrEP and/or condom use—contributing to higher HIV transmission rates among populations disproportionately affected by adverse socio-structural conditions (Konkle-Parker et al., 2017; Gilbert et al., 2021; Dauria et al., 2023).

This paper addresses this challenge by developing a novel theoretical framework for understanding sexual health agency among Black women in community supervision programs with high rates of substance use residing in Alabama. Using phenomenological methodology (Husserl, 1900-01; Grossoehme, 2014), we examine how structural constraints and prevention knowledge access intersect to shape decision-making regarding PrEP and condom usage. Phenomenology’s focus on lived experience (Van Manen, 1990; Manen, 2006) enables identification of previously unrecognized forms of agency that emerge when women navigate competing pressures and information gaps within constrained circumstances.

Through in-depth qualitative interviews, we analyze participants’ narratives to reveal how personal, interpersonal, and socio-structural factors influence sexual health autonomy and HIV prevention behaviors. This analysis contributes to agency theory by mapping decision-making along two critical dimensions while identifying novel mechanisms through which structural violence operates in sexual health contexts.

This qualitative study was conducted within Project E-WORTH South—a parent study examining the acceptability of implementing the evidence-based E-WORTH intervention (Johnson et al., 2018) in the U.S. South and whether Southern-specific tailoring is needed for Black women under community supervision. The current qualitative component was designed to inform adaptation decision making and implementation priorities for the region by characterizing overall HIV/STI prevention knowledge, PrEP/PEP awareness, condom use decision-making, agency, and service navigation among Black women in Alabama.

Methods

This qualitative study adhered to the consolidated criteria for reporting qualitative research (Tong et al., 2007). The methodological approach was as follows:

Recruitment

The study sample consisted of 16 participants, chosen through a criterion-based sampling method. Inclusion criteria required participants be Black or African American and currently involved in the community supervision system. All participants were under criminal-legal supervision through diversion, probation, or parole. In this study, diversion programs refer to pre-trial or post-charge alternatives to prosecution or incarceration that provide supervision and services in the community (e.g., treatment/“drug” courts). Community supervision refers to non-custodial, post-plea or post-conviction supervision such as probation or parole administered through county community supervision offices. Individuals residing in jail or prison were not recruited and were not eligible for participation.

While the study protocol required that individuals experiencing mental health distress be excluded from the study, no potential participants met this exclusion criterion, so no individuals were excluded from participation. To protect agency and participant confidentiality in a small catchment area, partner agencies are not identified by name. Participating sites included county-operated community supervision offices in West Central Alabama that provide supervision, reporting, and case management to adults under criminal-legal supervision.

For participant recruitment, we utilized the extensive connections of faculty members from The University of Alabama School of Social Work and criminal legal system (CLS) providers catering to this population. The recruitment process took place at community supervision sites in West Central Alabama through the distribution of fliers posted in designated reporting locations. Additionally, study personnel distributed fliers in front of community supervision reporting sites. Potential study participants were also referred to the study by community supervision personnel. As an incentive for their participation, participants were given $50 Visa gift cards.

Data collection

Data collection commenced on October 10, 2019, and concluded on February 3, 2021 (IRB Protocol ID: 19-05-2366). To maintain the safety and confidentiality of study data, the following precautions were implemented: all study information and materials were labeled with individual participant code numbers only; all study materials were stored in locked file drawers in the principal investigator’s office; participants had the option to request the research team to destroy their research data at any time by contacting the study’s principal investigator; and all information shared during interviews was kept confidential and not shared with the court, community supervision, or any other CLS personnel. Funding for this study was provided by The University of Alabama RGC pilot funding, Dr. Karen A. Johnson, PI, The University of Alabama, Alabama Hillcrest Endowment funding (PI: Dr. David L. Albright), the National Institutes of Health via the UAB Center for AIDS Research (P30AI027767), and the National Institutes of Health via the National Center for Advancing Translational Sciences (1K12TR004769-01).

Each participant completed a single interview that lasted between 60 and 90 min. Throughout each interview, participants were asked questions regarding their knowledge of and experience with pre- or post-exposure prophylaxis (PrEP or PEP) (e.g., “Have you ever heard of PrEP or PEP, medications to prevent HIV?“; ), and condom usage (e.g., “Have you ever had an experience where you wanted to use a condom with a sexual partner and were not able to?“). In addition, interviews elicited participants’ narratives relating to current and recent substance use and sale (e.g., “Have you ever had an experience in which you used controlled drugs to cope, or prescription drugs differently than intended?“), and sexual behaviors currently and recently engaged in (e.g., “Have you ever had an experience in which you received money, drugs, a safe place to stay or other things in exchange for sex?“). Although interviews elicited narratives about current and recent substance use and sale, the guide did not systematically capture route of administration (e.g., injection versus non-injection), frequency of injection, or injection equipment sharing, because the primary focus was on sexual HIV prevention (PrEP/PEP) and condom use among women under community supervision. Participants were also asked to respond to questions related to socio-structural experiences such as CLS involvement (e.g., “Can you tell me how you came to participate in the diversion program? probation? parole?“) and lack of housing / safe and stable housing (e.g., “Was there a time in your life where you felt that you were homeless?“).

The semi-structured interview guide employed a combination of open and closed-ended questions. Out of the 16 interviews conducted, five took place in person at the University of Alabama School of Social Work in a private setting. Due to COVID-19, the remaining eleven interviews were conducted remotely using platforms like Zoom or telephone calls. These interviews were carried out by a team of trained social work researchers affiliated with the study. The team included three master’s in social work students, two Doctoral in social work students, and the study’s Principal Investigator (PI), who holds both a master’s and a PhD in social work. Three Project E-WORTH South study personnel, including the study’s PI, were Black women, all of whom emigrated from African diasporic countries. The remaining three personnel were White women, born in the U.S.

Data analysis

Interview transcriptions were analyzed using Nvivo software (v.12) by two researchers. The data analysis followed a phenomenological coding technique to uncover the essential themes and patterns embedded within participants’ narratives (Polkinghorne, 1989; Husserl, E. 2001). The analysis was carried out in five discrete steps: (1) Transcription: All interview recordings were transcribed verbatim to ensure accurate representation of participants’ responses and statements. (2) Familiarization: The researchers immersed themselves in the data by reading and re-reading the transcripts to gain a comprehensive understanding of the content. (3) Coding: Phenomenological coding, incorporating both deductive and inductive approaches, was employed. Initially, a set of a priori codes was developed based on existing literature and research questions (deductive coding).

As data analysis progressed, additional codes emerged from the data (inductive coding). Researchers used thematic content analysis to identify and label relevant codes. 4) Grouping into themes: Codes were organized into themes and subthemes based on similarities and relationships. A lead researcher further facilitated team discussions to explore emerging themes and alternative explanations arising from the data analysis. 5) Validation: The lead researcher initially coded all 16 interviews. A second researcher coded 30% of the interviews to ensure inter-rater reliability, with a kappa value of ≥ 0.80. Additionally, validation approaches to enhance the rigor of the study included weekly team discussions during the coding and data analytic phases of the study to ensure consensus and agreement on the thematic framework and investigator triangulation. Researchers also cross-checked the findings against existing literature.

To synthesize these codes, we organized agency expressions along a conceptual continuum from deprived to realized agency. Two dimensions guided placement: (1) the degree of external constraint or coercion versus independent choice, and (2) access to and use of HIV-prevention knowledge/resources (e.g., PrEP awareness, testing, condom negotiation). For each transcript, coders identified exemplar segments, drafted analytic memos justifying placement, and reached consensus in team meetings; discrepancies were adjudicated by the PI. The continuum is qualitative and interpretive (not quantitative), and the same participant could occupy different positions across partners, settings, or time. Using quantization techniques (Sandelowski et al., 2009), the study identifies and reports rates of substance use, reasons for CLS involvement, and what we term ‘self-initiated HIV prevention efforts’—proactive health-seeking behaviors participants undertook on their own initiative, including requesting HIV/STI testing, PrEP/PEP awareness, PrEP/PEP utilization, and condomless sex.

Results

Participants

As noted in Table 1, study participants’ age ranged from 22 to 52, with an average age of 35. Six were currently under supervision by a division program and the remaining 10 (or 62.5%) were currently being supervised by community corrections (probation: n = 6 or 37.5%; parole: n = 4 or 25%). All participants identified as heterosexual cisgender women. Additionally, 11 out of 16 participants (or 68.75%) reported recent or current substance or polysubstance use of substances (e.g., marijuana/synthetic marijuana, cocaine [crack or powder], stimulants [crystal methamphetamine], opiates [heroin], and/or ecstasy).

Table 1.

Socio-structural and HIV/STI transmission factors, testing and prep/pep Awareness / Knowledge

ID	Age	Type of Legal System Involvement	Charge	Self-Reported HIV/STI Transmission Factors	HIV/STI Testing	Location of testing	PrEP / PEP Awareness / Knowledge
P001	34	Diversion	Drugs	Y (drugs)	Y (annually)	Doctors’ office (routine visit) – self initiated testing	N
P002	23	Diversion	Drugs (partner related)	Y (drugs)	Y (annually)	Doctor’s office (routine visit) --self-initiated testing	Na
P003	45	Diversion	Credit card fraud	Yes (sex trading, condomless sex)	Not Disclosed	Not Disclosed	N
P004	41	Diversion	Drugs	Y (drugs, condomless sex)	Y	University Medical Center (clinic) – self initiated testing	N
P006	28	Parole	Fled the scene of an accident	Y (sex trading, drugs, condomless sex, sexual assault)	Y (every 6 months)	Emergency Room – self initiated testing In jail (at intake)	N
P008	27	Diversion	Petty theft	Y (sex trading, drugs)	Y	Doctors’ office (pregnancy related)	Not Reported
P011	47	Probation	Petty theft	Y (sex trading, drugs, condomless sex)	Not Reported	University Medical Center (routine visit, clinic) – self initiated testing	N
P012	29	Parole	Burglary Petty theft	Y (condomless sex)	Y	Community Supervision In jail (sporadic testing)	Na
P013	30	Parole	Petty theft	Y (required condomless sex, sex trading, drugs, condomless sex)	Y (annually)	Health Department (routine visit) – self initiated testing	N
P015	30	Diversion	Petty theft	Y (drugs)	Y	Private doctor (routine visit) – self initiated testing	Nb
P016	52	Probation	Petty theft	Y (sex trading, drugs, condomless sex)	Y	In jail	N
P017	22	Probation	Child Abuse	Y (intimate partner violence, required condomless sex)	Y (with each of 3 children)	Doctor’s office (pregnancy related)	N
P018	45	Parole	Petty theft	Y (details not disclosed)	Y	In jail	N
P019	28	Probation	Declined to respond	Declined to respond	Y	Doctor’s office (routine visit) – self initiated testing	N
P020	25	Probation	Drugs	Y (drugs)	Y (every 3 months)	Doctor’s office (routine visit) – self initiated testing	N
P021	26	Probation	Drugs (partner related)	Y (drugs)	Y (during each pregnancy)	Hospital (pregnancy related)	N

Note. STI = sexually transmitted infection; PrEP = pre-exposure prophylaxis; PEP = post-exposure prophylaxis

a Saw commercials but believed it was only for men who had sex with men

b Saw commercials but did not know its intended purpose

Fifteen of the 16 participants reported at least one HIV/STI transmission factor—drug use (n = 11), condomless sex (n = 7), sex trading/transactional sex (n = 6), partner interference with condom use (prevented or required condomless sex; n = 2), intimate partner violence (n = 1), and sexual assault (n = 1); one participant reported a factor but did not specify details (n = 1), and the remaining participant declined to respond. Disclosure of such factors was not required for eligibility.

Criminal legal system involvement

Reported pathways leading to CLS involvement were solely characterized by petty crimes and/or crimes of survival (Table 1). These included the sale of illicit substances (n = 3 or 18.75%), petty theft/burglary (n = 7 or 43.75%), and credit card fraud (n = 1 or 6.25%).

Socio-structural transmission factors

Participants also recounted experiencing an array of socio-structural transmission factors such as being unhoused/housing insecurity (n = 4 or 25%); poor treatment from medical providers (n = 1 or 6.25%); racism from CLS providers (n = 6 or 37.5%); transportation barriers (n = 5 or 31.25%); and food insecurity (n = 6 or 37.5%). For example, in discussing racism experienced by CLS providers, participant 018 stated:

“The guards. The guards was like that too…Because I know when I was in Mississippi…it was a guy who just got out of prison for a murder charge or something. And they hung him. The white people hung him in a tree.”

Likewise, when describing experiences in an Alabama jail, participant 015 reported:

“So I prayed, you know, I was reaching out to the judge, I was reaching out to the lady over the jailhouse, like, cause something’s gotta give, like this is horrible. The way you have us women living is horrible. They have had the women in like a little dog kennel, where they have little dog cages at in one little, you know, little slim room.”

Of being in jail in Alabama, participant 015 also stated “They feed you roadkill, they give you dirty water, like it was horrible.” and:

“You know, I was just worried about the fact that, you know what I’m saying, anything can happen at any given time in here. I actually watched a girl I actually watched a girl try to hang herself while she was in the shower.”

In discussing unhoused status, participant 006 reported:

“I was staying in the shed. She’s really been helping me out since I’ve been homeless, see what I’m saying? It’s been hard, but at that time I was home, at least I was trying. I was staying in my car, staying in the shed. I needed help, but I couldn’t get it. I got in trouble. I was trying to do other things, like sell drugs or sell my body, and stuff like that, even though I knew it wouldn’t help, but I still—that’s what I did.”

Self-initiated HIV/STI prevention efforts

Notably, despite the high prevalence of socio-structural transmission factors experienced by participants, self-initiated prevention efforts included routine HIV testing (n = 6 or 37.5%), attending HIV prevention groups (n = 3 or 18.75%), and requiring the use of condoms when having sex with intimate and casual sexual partners (n = 4 or 25%) (Table 1). Conversely, 8 out of 16 participants (or 50%) reported engaging in condomless sex.

Among those who reported being tested for HIV (n = 13 out of 16 or 81.25%): 1 out of 16 (or 6.25%) mentioned being tested every 3 months; 1 out of 16 (or 6.25%) mentioned being tested every 6 months; 3 out of 16 (or 18.75%) reported being tested on an annual basis; and 1 out of 16 (or 6.25%) reported testing during pregnancy. The reported testing locations encompassed: public health locations (n = 2 or 12.5%); clinics (n = 2; 12.5%); doctor’s offices (n = 5 or 31.25%); jails / community corrections (n = 4 or 25%); and emergency room / hospital (n = 2; 12.5%).

For example, regarding the location and frequency of testing, participant 002 reported: “In my doctor’s office…I was just tested ‘bout two months ago…I do it every year.” Participant 013 also emphasized her commitment to routine testing:

“Nothin’ just when you go get your checkups, your yearly checkups, or your six-month checkup, I just go in, and I let her know, like, “I wanna be tested for everything.” That’ll consist of HIV, herpes, syphilis, and STDs as well. It’s just something that I’ve always said goin’ to the clinic. “I wanna be tested for everything,” so that I how I always get mine. I don’t really know about other women.”

Likewise, participant 020 reported:

“Alabama really don’t have that many places that just up and offering for you to come in…They’re not gonna just test you for it unless you tell them, like if I go to the doctor for the flu right now. You know they’re going to test me for the flu they’re going to test me for a few other viruses that might cause the flu, and then they’ll determine their, you know their diagnosis. But other than that, they’re not going to try to see if maybe you got sick because you have HIV or chlamydia or maybe gonorrhea, they’re not going to do that unless you say Hey Doc, when you run this blood test, can you make sure I don’t have any STDs…".

Lack of PrEP / PEP Knowledge / Awareness

Lastly, 14 of 16 (or 87.5%) women reported on their knowledge and awareness of PrEP and PEP (Table 1). Although two of the participants who responded to this question had heard of PrEP/PEP, none of the 14 who responded were aware that HIV transmission could be prevented among women using medicine like pre- and post-exposure prophylaxis (PrEP or PEP).

One of the two participants who had heard of PrEP (participant 002) stated:

“Yeah, sort of. Somewhat, yeah. I guess basically, I came across that on a show and it was a gay couple on there. One of the gay guys had HIV and the other boyfriend was taking it so he could have sex.”

Upon learning that PrEP could be taken to prevent HIV, participant 002 later stated: “Oh, and they can prevent it (HIV)?…That’s crazy.”

As noted, the remaining participants had zero awareness of PrEP/PEP or HIV prevention medicine as a whole. When Asked whether she had heard about PrEP, PEP, or a medicine that can prevent HIV transmission among women, participant 004 stated “pap smear?” In response to the same prompt, participant 017 replied: “Oh, like a text, they text you?“.

Forms of agency in sexual Decision-Making and HIV prevention

Analysis of participants’ narratives revealed four distinct forms of agency related to sexual decision-making and HIV prevention behaviors, as presented in Table 2 and illustrated in Fig. 1. These forms of agency—deprived agency, traversed agency, constrained agency, realized agency—emerged across different partner types and prevention contexts.

Table 2.

Black women in community supervision programs use of agency when navigating HIV/STI transmission

Type of Agency	Proposed Definition	When and With Whom Exercised	Representative Quotes
Constrained Agency	Agency where decision-making is influenced by socio-structural factors like poverty, money, hunger, fear of partner abandonment, fear of violence, or parental coercion. Example: Black women in community supervision programs trading sex for money and other goods	All forms of sexual partners (intimate, casual, and/or paying)	With a casual/intimate sexual partner: “It was nothing for real. It was just I had asked; can I have some money from someone I was communicating with…He was like, you get—excuse my language, he was like, “You give me some ass, I give you some cash…I did it just so I can get the money.” (Participant #008) With an intimate sexual partner: “Well, that day that, that it (physical assault) happened pretty bad. But before that he had never done anything like that he was just really emotionally like, like, he was just like, if I wanted to get out of the relationship, it’s just a lot of like, threatening stuff. And…” (Participant #017) With a paying sexual partner: “I had a situation where my lights were about to get cut off, and I didn’t have the money. I tried to get it. My mom didn’t have it. That’s usually what I do—I go to my family first, my mom and my sister first. They didn’t have it. I had to do what I had to do.” (Participant #004) With a paying sexual partner: “Yes, Ma’am, I’ve done it a lot, and still do it (have sex in exchange for money). To try to make ends meet.” (Participant #005) With a paying sexual partner: “I got friends that just give me cash, or want to see me for sex, or just want to see me to dance. I don’t like that. I want to have a regular job. I got to have a weekly job, because I’m on child support, because I signed my kids over temporary custody. I just need a lot of—I need help, you know? I don’t have it.” (Participant #006) With an intimate sexual partner: “Well, the guy that I had been dealing with for a few years, and he would help me out with stuff. He would help me out in different things. He would get mad when I asked him to use a condom.” (Participant #011)
Realized Agency	Agency where choices are made independently, free from external influences. Example: Black women in community supervision programs’ ability to control access to their own body	All forms of sexual partners (intimate, casual, and/or paying), providers	With an intimate sexual partner: “No, no, no. If I wants to use a condom, I use one, but then after a while being with that someone for so long I chose not to do it no more.” (Participant #012) With providers: “Nothing just when you go get your checkups, your yearly checkups, or your six-month checkup, I just go in, and I let her know, like, “I wanna be tested for everything.” That’ll consist of HIV, herpes, syphilis, and STDs as well. It’s just something that I’ve always said going to the clinic. “I wanna be tested for everything,” so that I how I always get mine. I don’t really know about other women.”(Participant #013) With an intimate sexual partner: “Yeah, with my ex-boyfriend when I was telling you, I was 15, and he was 31. He was just the type of person he didn’t do that (use condom). Yeah, there’s people like that. There was some reason. I don’t know. It was just something that I don’t have to go through now.” (Participant #013)
Traversed Agency	Agency that overrides original intentions, either by choice or due to external forces forcefully overriding their decision-making. Example: Black women in community supervision programs overriding their initial attempts to use condoms	All forms of sexual partners (intimate, casual, and/or paying)	With a casual/intimate sexual partner: “One boo was telling me he was [audio cuts out 16:20]. I told him I wasn’t—I didn’t want to do the activity, because we was doing it as an exchange, you know, for money…He got mad, definitely one of the situations where I got raped, but I still used—still got my money, but we didn’t use a condom, so I had to go and get checked to make sure I didn’t have a disease or anything…I hated that, but that’s what I had to go through when I need money and things.” (Participant #006)
Deprived Agency	Agency where the ability to make decisions or choices is hindered by a lack of knowledge or awareness. Example: Lack of awareness and/or knowledge of PrEP prevents Black women in community supervision programs from using it	Strangers, Providers	With strangers: “I had been using pills for years and never got in trouble and then one time I was with some people who I thought were my friends, one was supposed to be my best friend, she left me at a house alone with a man and I got sexually assaulted. And I found out she had sold me for drugs.” (Participant #005) With providers: (In response to being informed of the existence of PrEP) “Oh, and they can prevent it (HIV)?…That’s crazy.” (Participant #002)

Fig. 1.

Agency Framework for HIV Prevention Decision-Making: Structural Constraints, Knowledge Access, and Novel Forms of Sexual Autonomy Among Black Women in Community Supervision

We depict the four agency forms as a structural agency matrix (Fig. 1) organized along two key dimensions: structural constraints/coercion and HIV prevention knowledge/resources. This framework moves beyond linear conceptualizations to show how agency operates within the intersection of external forces and information access. The matrix positions deprived agency (high constraints, absent knowledge) as a distinct form of structural violence through knowledge deprivation, while traversed agency (variable constraints, some knowledge) captures the novel bidirectional nature of overridden intentions. Categories are not mutually exclusive; a given woman may occupy different positions across partners, situations, or time periods. Operational definitions and representative quotes for each form are provided in Table 2.

Deprived agency

Deprived agency was characterized by the inability to make informed decisions or choices due to a lack of knowledge or awareness. The complete absence of PrEP/PEP awareness among study participants exemplified this form of agency, as their lack of knowledge limited their ability to add PrEP to their current repertoire of HIV prevention strategies.

As demonstrated in participant 002’s response upon learning about PrEP: “Oh, and they can prevent it (HIV)?…That’s crazy.” This reaction illustrated how lack of awareness had previously deprived her of the agency to make informed decisions about HIV prevention options.

Traversed agency

Traversed agency was defined as agency that overrides initial intentions, either by choice or due to external forces forcefully overriding decision-making. Two distinct forms of traversed agency were identified: self-initiated forms where women overrode their own initial attempts to use condoms, and forced forms where their agency was forcefully traversed by sexual partners.

Participant 006 described a situation where her initial intentions were overridden:

“One boo was telling me he was [audio cuts out 16:20]. I told him I wasn’t—I didn’t want to do the activity, because we was doing it as an exchange, you know, for money…He got mad, definitely one of the situations where I got raped, but I still used—still got my money, but we didn’t use a condom, so I had to go and get checked to make sure I didn’t have a disease or anything…I hated that, but that’s what I had to go through when I need money and things.”

On partner-mandated condomless sex, participant 017 reported, “Yes, my last relationship, that bad one, but…” Participant 017 also stated, “Well, that day that, that it (physical assault) happened pretty bad. But before that he had never done anything like that he was just really emotionally like, like, he was just like, if I wanted to get out of the relationship, it’s just a lot of like, threatening stuff.”

Results also indicated that five study participants reported experiencing forced sex as adults. All forced sex experiences were associated with an exchange for money, drugs, transportation, or a place to stay.

Similarly, participant 009 recounted being forced into sex in exchange for transportation and shelter:

“It is because I—like I said, one time, I was down, and this happened down here. Yeah, I was in a position where I accepted a ride from somebody I had met the same day, and I was not taken to my destination, but—as opposed to their home. Unfortunately, I was kept there, kept in their closet for almost three days.”

Constrained agency

Constrained agency was characterized by decision-making influenced by socio-structural factors such as poverty, fear of partner abandonment, fear of violence, or survival needs. This form of agency was observed across all three types of sexual partners (intimate, casual, and transactional) and played a role during negotiations for condomless sex.

In describing consensual sex exchanged for money, drugs, transportation, or housing, participant 004 shared:

“I had a situation where my lights were about to get cut off, and I didn’t have the money. I tried to get it. My mom didn’t have it. That’s usually what I do—I go to my family first, my mom and my sister first. They didn’t have it. I had to do what I had to do.”

Likewise, participant 005 stated, “Yes, Ma’am, I’ve done it a lot, and still do it (have sex in exchange for money). To try to make ends meet.” Similarly, participant 006 stated:

“I got friends that just give me cash, or want to see me for sex, or just want to see me to dance. I don’t like that. I want to have a regular job. I got to have a weekly job, because I’m on child support, because I signed my kids over temporary custody. I just need a lot of—I need help, you know? I don’t have it.”

Participant 008 also demonstrated constrained agency regarding a regular, committed sexual partner with whom she had a relationship:

“It was nothing for real. It was just I had asked; can I have some money from someone I was communicating with…He was like, you get—excuse my language, he was like, “You give me some ass, I give you some cash…I did it just so I can get the money.”

Regarding condomless sex undertaken to meet a partner’s demands, participant 011 stated:

“Well, the guy that I had been dealing with for a few years, and he would help me out with stuff. He would help me out in different things. He would get mad when I asked him to use a condom.”

Realized agency

Realized agency was conceptualized as the ability to control access to one’s own body and make independent decisions free from external influences. Participants showcased realized agency in their accounts of attempting to negotiate sex with and without condoms across all partner categories. They also expressed realized agency through their self-initiated HIV/STI prevention efforts with providers.

On engaging in consensual condomless sex with intimate or casual partners, participant 012 stated: “No, no, no. If I wants to use a condom, I use one, but then after a while being with that someone for so long I chose not to do it no more.”

Discussing her expectations for partner condom use, participant 013 reported that she now insists on condoms despite not doing so previously: “Yeah, with my ex-boyfriend when I was telling you, I was 15, and he was 31. He was just the type of person he didn’t do that (use condom). Yeah, there’s people like that. There was some reason. I don’t know. It was just something that I don’t have to go through now.”

Discussion

This study represents the first exploration of the lived experiences of cisgender, heterosexual, Black women in community supervision programs residing in the U.S. Deep South regarding HIV/STI transmission factor navigation. A significant majority of these women reported current or recent substance use. The findings shed light on the critical intersection of agency and health-seeking behaviors specific to HIV/STI prevention, influenced by factors such as system involvement, substance use, and trauma. The results offer a nuanced understanding of the socio-structural elements that both motivate and hinder self-initiated HIV/STI health and behavioral prevention strategies and agency among low-income Black women in community supervision programs in this region. Specifically, the study highlights women’s thoughtful and careful approach to navigating condomless sexual encounters with intimate, casual, and/or paying partners.

Intersectionality and structural vulnerabilities

Our findings highlight how the intersection of race, gender, poverty, criminal legal involvement, and regional location creates compounding vulnerabilities that shape sexual autonomy and HIV risk. The socio-structural transmission factors experienced by participants—including housing insecurity, racism from criminal legal system providers, transportation barriers, and food insecurity—create contexts where constrained and traversed agency become survival strategies rather than autonomous choices.

The Deep South’s geographic context adds additional layers of structural vulnerability. Alongside its status as the most religious and seventh-poorest state, with high rates of criminal legal system involvement, Alabama’s failure to expand Medicaid and high rates of rural hospital closures creates a healthcare landscape where marginalized populations face significant barriers to comprehensive care. For Black women under community supervision, these structural barriers intersect with criminal legal system involvement to create what participants described as environments characterized by racism, dehumanizing treatment, and limited support systems. These policy and infrastructure factors likely manifest as fewer opportunities to receive prevention counseling, screening, and PrEP initiation—especially for uninsured or under-insured women under community supervision. In a non-expansion state, reduced coverage narrows access to primary care and tele-PrEP; rural hospital closures and transportation/broadband barriers further limit continuity of care (KFF, 2025; Stacker, 2021; Alabama Department of Public Health, 2015). This helps explain the near-absence of PrEP awareness we observed despite frequent health-system contact.

Agency framework and sexual decision-making

Through phenomenological analysis, we developed a novel structural agency framework that maps four distinct forms of agency along two critical dimensions: structural constraints/coercion and HIV prevention knowledge/resources. This framework reveals previously unrecognized mechanisms through which structural violence operates in sexual health contexts, presented in Table 2 and illustrated in Fig. 1.

Unlike linear conceptualizations of agency, our matrix framework reveals that structural constraints and knowledge access operate independently, creating four distinct contexts for sexual health decision-making. This two-dimensional approach explains why traditional interventions targeting only individual behavior change or only structural barriers have proven insufficient. The framework provides important insights into how structural forces and information access intersect to shape sexual health autonomy in marginalized populations.

Deprived agency extends Sprague and colleagues’ (2016) notion of ‘agentic diminishment” by highlighting how information gaps—rather than just institutional restrictions—can fundamentally limit women’s ability to exercise sexual and health autonomy. This finding is particularly striking given the more than a decade of PrEP availability, and targeted outreach efforts in the Deep South. The near complete lack of awareness of PrEP (and PEP) among study participants is particularly concerning and revealing, especially when prior peer-reviewed literature has shown some knowledge of PrEP among Black women accessing various systems of care in the Deep South (Willie et al., 2021). The intersection of high structural constraints with absent prevention knowledge (deprived agency quadrant) creates what we term ‘de facto forced PrEP-less sexual encounters’—a novel form of structural violence capturing how systematic information gaps create coercive sexual health contexts where women cannot exercise true choice about HIV prevention strategies. This represents a distinct form of structural violence that operates through knowledge deprivation rather than direct coercion. The disconnect between participants’ healthcare engagement and their PrEP awareness further crystallizes systematic failures in information dissemination rather than individual-level barriers to healthcare access.

Several factors may contribute to this information gap. First, provider-level barriers may exist, including inadequate PrEP knowledge among healthcare professionals serving this population, unconscious bias affecting care quality, or conscious withholding of information due to stigma or moral judgments. Second, the intersection of HIV stigma, religiosity, and political conservatism prevalent in Alabama (Hamed et al., 2022) may create environments where comprehensive HIV prevention information is not routinely shared. Third, structural barriers within healthcare systems may limit the time and resources available for comprehensive prevention counseling, particularly for patients perceived as “high-risk” or socially marginalized.

Traversed agency, a novel theoretical contribution to agency literature, demonstrates that agency operates fluidly and contextually for Black women in community supervision programs, sometimes involving the deliberate abandonment of initial preferences under competing pressures or coercion. Our identification of traversed agency reveals two distinct pathways: self-initiated traversal (women consciously override their initial intentions) and partner-forced traversal (external coercion overrides women’s decisions). This concept reveals a previously unrecognized dimension of constrained choice—one that bridges individual decision-making and structural coercion. These interconnected theoretical contributions expand understanding of how agency operates under multiple, simultaneous constraints and have immediate implications for intervention design and healthcare provider training.

Constrained agency in our findings extends previous research by Fielding-Miller and Dunkle (2017), who identified this form of agency primarily in the context of transactional sex among low-income women. Our study demonstrates that constrained agency operates more broadly, influencing sexual decision-making across diverse relationship contexts for Black women under community supervision. These socio-structural vulnerabilities fundamentally shape sexual autonomy for this population, regardless of the type of sexual relationship.

Realized agency findings align with Mackworth-Young’s (2020) conceptualization among women living with HIV. Importantly, the narratives of study participants show that even within highly constrained circumstances, Black women in community supervision programs actively exercise agency in their efforts to prevent HIV transmission, particularly through self-initiated testing and healthcare engagement. This challenges deficit-based narratives about this population and highlights their resilience and health-seeking behaviors. Building on established agency frameworks (Fielding-Miller & Dunkle, 2017; Mackworth-Young, 2020), our framework adds new dimensions to the literature by illustrating that agency can be fluid and contextual, revealing the complex ways women navigate competing demands and coercive situations.

This structural agency matrix contributes to broader theoretical understanding of health decision-making under constraint, offering a framework applicable beyond HIV prevention to other health behaviors where both structural barriers and information access shape autonomy.

Implications for HIV prevention interventions

Our agency framework has direct implications for designing culturally responsive and structurally informed HIV prevention interventions for Black women in community supervision programs. Traditional approaches that focus primarily on individual behavior change may be insufficient given the complex interplay of structural constraints and individual agency revealed in our findings.

Provider training and healthcare system reform

In Alabama’s non-expansion context and amid rural service contraction, providers serving this population need robust training on PrEP/PEP and trauma-informed care, and systems must create low-barrier PrEP pathways (e.g., tele-PrEP, mobile clinics) to offset reduced primary-care access (KFF, 2025; Stacker, 2021). Intervention efforts should address provider bias and ensure that comprehensive HIV prevention information is routinely offered regardless of perceived patient characteristics.

Structural interventions

Effective prevention efforts must address the socio-structural factors that constrain agency, including housing instability, economic insecurity, and transportation barriers. This may require coordination between healthcare systems, community supervision programs, and social service agencies to address the root causes of vulnerability rather than just individual risk behaviors.

Matrix-informed interventions

Our framework suggests interventions must simultaneously address both dimensions—reducing structural constraints while ensuring comprehensive prevention knowledge access. Rather than viewing women under community supervision as passive recipients of services, programs should recognize and amplify their existing health-seeking behaviors while addressing information gaps and structural barriers.

Community supervision integration

Given the regular contact between women and community supervision systems, these touchpoints represent opportunities for HIV prevention education and linkage to care. However, such integration must be carefully designed to avoid further stigmatization or coercion.

Although additional research is needed that examines the reasons for participants’ lack of PrEP/PEP knowledge, this information gap could be linked to a conscious or subconscious withholding of PrEP/PEP/HIV/STI prevention information by providers given the high levels of HIV stigma, religiosity, and political conservatism in the state, all of which are believed to be interrelated (Hamed et al., 2022). Conversely, it could also be possible that some medical providers and HIV testing sites frequented by the women in this study were themselves unaware of the existence of PrEP/PEP. We therefore recommend that additional research be conducted to examine the awareness level of medical providers in Alabama and other Deep South regions regarding PrEP/PEP, and their ability to effectively engage Black women in community supervision programs in HIV/STI prevention. Future studies should also investigate the possibility of treatment withholding behaviors among medical providers, a term used previously to examine the influence of religiosity in medical decision making among children (Brierley et al., 2013).

Future research should examine provider knowledge and attitudes regarding PrEP for women under community supervision, investigate the possibility of conscious or unconscious treatment withholding behaviors, and explore how different forms of agency may be simultaneously enacted across various contexts. Additionally, research should investigate optimal integration points between community supervision systems and HIV prevention services, examine the effectiveness of agency-centered intervention approaches, and test this matrix framework across diverse populations and settings to establish its generalizability and refine intervention targeting. Finally, we recommend that research be conducted to examine how women may simultaneously enact various forms of agency as they navigate personal, interpersonal, provider level, and system level transmission factors.

Limitations

These important findings must be considered through the lens of several limitations that also point toward future research directions. First, our exclusive focus on women’s perspectives, while providing rich insight into lived experiences, limited our ability to examine the provider-side factors contributing to the near-complete PrEP/PEP knowledge gap we observed. Future research should examine healthcare provider knowledge, attitudes, and potential information withholding behaviors to fully understand the mechanisms creating deprived agency. Second, the study relied on self-reported data, which may be subject to potential biases. However, phenomenological approaches are particularly well-suited for capturing sensitive experiences, and our in-depth interviews provided rich insights into agency dynamics that quantitative measures might miss. Third, while our framework identifies structural constraints as a key dimension, we did not systematically collect detailed measures of specific structural barriers (e.g., housing stability scales, transportation access indices) that could provide more granular understanding of how different constraint types influence agency forms.

Fourth, the study did not include a structured assessment of injection drug use; therefore, we cannot characterize injection-specific risk behaviors (e.g., syringe sharing) that may contribute to HIV risk. Future research should incorporate validated measures of injection practices and related harm-reduction access to more fully assess these risks among women under community supervision in the Deep South. Fifth, we did not collect insurance coverage or clinic access measures (e.g., usual source of care), which limits our ability to directly test access-mediated pathways between Alabama’s policy context and PrEP knowledge. Our matrix framework requires validation across diverse populations and geographic contexts to establish generalizability beyond Black women in community supervision in the Deep South. Additionally, the framework’s two-dimensional structure may not capture all relevant dimensions of agency in sexual health decision-making. We did not test intervention approaches based on our agency framework, limiting our ability to assess the practical effectiveness of matrix-informed prevention strategies. We do not name partner agencies to preserve confidentiality; instead, we describe site characteristics (type, function, and region). While this limits site-level specificity, it aligns with IRB requirements associated with participant protections. Despite these limitations, our phenomenological approach successfully captured the complex interplay of structural constraints and knowledge access in shaping sexual health agency. The theoretical framework developed provides a foundation for future quantitative validation studies and intervention development that can address these methodological gaps while building on our qualitative insights.

Conclusions

This phenomenological study contributes significantly to understanding sexual health agency among marginalized populations through development of a novel structural agency matrix. Our framework maps decision-making along two critical dimensions—structural constraints/coercion and HIV prevention knowledge/resources—introducing two previously unidentified forms: deprived and traversed agency. Our findings demonstrate that traditional interventions targeting only individual behavior change or only structural barriers are insufficient. The structural agency matrix provides a generalizable framework applicable beyond HIV prevention to other health behaviors where structural forces and information access shape autonomy. Ending the HIV epidemic requires matrix-informed interventions that simultaneously address structural constraints and knowledge gaps, recognizing that prevention autonomy emerges only when comprehensive knowledge access meets reduced structural coercion.

Author contributions

All authors on this paper meet the four criteria for authorship as identified by the International Committee of Medical Journal Editors (ICMJE); all authors have contributed to the conception and design of the study, drafted or have been involved in revising this manuscript, reviewed the final version of this manuscript before submission, and agree to be accountable for all aspects of the work. Specifically, using the CRediT taxonomy, the specific contributions of each author is as follows: Conceptualization & Methodology: [KAJ, AP, KO]; Formal Analysis: [KAJ, SB]; Funding acquisition: [KAJ; DLA]; Project administration: [KAJ, AP, KO]; Writing – original draft: [KAJ, SB, MB]; Writing/Revising – [KAJ, MB, SB, AP, KO, SW, DLA, PPF, SC, GM, TH, DGE, LG, NE].

Funding sources

Dr. Johnson’s work was supported by funding from The University of Alabama RGC pilot funding, Dr. Karen A. Johnson, PI; The University of Alabama Hillcrest Endowment funding (PI: Dr. David L. Albright); the National Institutes of Health via the UAB Center for AIDS Research (P30AI027767); and the National Institutes of Health via the National Center for Advancing Translational Sciences (1K12TR004769-01).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This research was conducted in accordance with the Declaration of Helsinki. All study procedures were approved by The University of Alabama Institutional Review Board (IRB Protocol ID: 19-05-2366). Written informed consent to participate in this study was provided by the participants.

Competing interests

The authors declare no competing interests.