This is Your Moment (TiYM): Planning for Implementation of a Novel Media Campaign to Mitigate Intersectional Stigma Among Black Sexual Minority Men Living With HIV in Atlanta, Georgia

Abstract

Objective

Black sexual minority men (SMM) in the United States experience disproportionate HIV burden and lower engagement across the HIV Continuum of Care (HIV-CoC), partly due to intersecting stigmas. Structural interventions addressing these barriers remain limited.

Methods

We developed This is Your Moment (TiYM), a culturally-grounded media campaign designed to mitigate stigma and encourage engagement in care for Black SMM in Atlanta, Georgia. To inform implementation, we conducted focus groups with 63 stakeholders from six clinics and community-based organizations (March-October 2023), guided by the Consolidated Framework for Implementation Research. Transcripts were analyzed thematically.

Results

Participants described TiYM as highly acceptable, engaging, and relatable. Facilitators included alignment with organization priorities; ease of QR code integration; potential to improve health literacy and reduce stigma. Barriers included concerns about inclusivity and unintended disclosure.

Conclusion

Key partners perceived TiYM as having strong implementation potential, while identifying barriers for refinement and implementation strategy.

Plain Language Summary

Black sexual minority men in the United States are disproportionately affected by HIV and are less likely to stay engaged in care. This is partly due to overlapping forms of stigma, including HIV-related stigma, racism, and homophobia. There is a need for practical, sustainable approaches that address these barriers and improve access to and engagement in HIV care. We developed This Is Your Moment (TiYM), a media campaign designed to reduce stigma and encourage engagement in HIV treatment and support services among Black sexual minority men in Atlanta, Georgia. The campaign features short, culturally relevant videos focused on mental health (“mind”), physical health and HIV care (“body”), and overall well-being (“soul”). To understand how best to implement this campaign, we gathered feedback from 63 staff members, healthcare providers, and administrators across six clinics and community-based organizations in Atlanta. Participants shared their perspectives through group discussions and interviews. Overall, participants responded positively to the campaign, describing it as engaging, authentic, and relatable. They noted that it aligned well with their organizations’ goals, could be easily shared using QR codes, and had potential to improve health knowledge and reduce stigma among patients. However, they also raised concerns about ensuring the campaign is inclusive of other populations served and about the risk of unintentionally revealing someone’s HIV status or sexual orientation. This study shows that key stakeholders perceive TiYM as having the potential to be a feasible and acceptable intervention. The feedback gathered will help refine the campaign and support successful implementation in real-world settings.

Introduction

In the United States (US), Black sexual minority men (SMM) are disproportionately affected by the HIV epidemic. Despite making up only 14% of the country’s population, Black Americans account for 39% of new HIV diagnoses. ¹ Black SMM account for 22% of all new cases nationally and nearly a third of new cases in the US South, where 51% of new HIV diagnoses occur. ¹ Compared to other demographic groups, Black SMM also have lower rates of engagement across the HIV Continuum of Care (HIV-CoC), including linkage to and retention in care, treatment adherence, and viral suppression. ²

These suboptimal HIV care outcomes among Black SMM can be attributed in part to intersectional stigma, which occurs when an individual simultaneously experiences multiple stigmas associated with their overlapping marginalized identities.^3-7 That is, the convergence of HIV stigma, homophobia, and racism at intrapersonal, interpersonal, and systemic levels creates barriers to care that exacerbate inequities facing Black SMM. Previous studies have shown that discrimination, homophobia and racism may serve as barriers to clinic attendance and medication adherence among people living with HIV (PLH).^4,8-10 Experiences with intersectional stigma have been described in both healthcare and community-based organization (CBO) settings,^4-6,10 which may pose particular challenges for Black SMM living with HIV who regularly attend clinics and/or CBOs to meet with staff and providers, obtain medications, and monitor bloodwork. These stigmatizing experiences can lead to increased risk of disengagement across the HIV-CoC and, as a result, lower rates of viral suppression and retention in care.

The US Ending the HIV Epidemic (EHE) initiative prioritizes the use of targeted, community-specific strategies to reduce new HIV infections by 90% by 2030. ¹¹ Most existing socio-behavioral HIV interventions focused on Black SMM have centered around improving individual-level health behaviors, such as engagement in care and adherence to medications. ¹² The National Institutes of Health have increasingly prioritized research towards development of interventions that enable service organizations to address stigma and evolve understanding of HIV-related intersectional stigma for Black SMM. ¹³ Even with this shift, however, public health interventions to date have not adequately addressed the effects of intersectional stigma faced by Black SMM on HIV-CoC outcomes. Considering the evidence connecting experiences of intersectional stigma to decreased engagement in the HIV-CoC, there is an urgent need to develop and test effective, sustainable, structural interventions to reduce stigma and its impacts among Black SMM receiving HIV-related services.

Several media-based and narrative interventions have been developed to address HIV-related stigma, increase HIV and sexually transmitted infection (STI) testing, and improve engagement in HIV prevention and care. These approaches have included waiting-room videos, educational programs, digital media interventions, and social marketing campaigns targeting SMM and other populations affected by HIV. For example, Safe in the City was a video-based HIV/STI prevention intervention delivered in STI clinic waiting rooms that was found to be cost-beneficial and effective in reducing STI incidence.^14,15 Similarly, Taking Care of Me was a video-based intervention developed in collaboration with people living with HIV that was created for HIV clinic waiting rooms in order to improve medication adherence. ¹⁶ Other studies have shown that digital media interventions targeting men who have sex with men have demonstrated improvements in HIV disclosure, testing, and prevention-related behaviors.^17,18 Additionally, “entertainment-education” and narrative video interventions such as 90 DAYS showed improvement in HIV disclosure beliefs and attitudes among Black women living with HIV. ¹⁹ National campaigns such as CDC’s Let’s Stop HIV Together have also used storytelling and inclusion of people living with HIV in the intervention to address HIV stigma through mass media messaging including public service announcements. ²⁰ While these media-based interventions have focused on the HIV-CoC, many have focused on individual-level behavior change, such as HIV/STI testing, disclosure, HIV pre-exposure prophylaxis (PrEP) uptake, or medication adherence, rather than addressing intersectional stigma. Furthermore, few interventions have been developed and led by Black SMM living with HIV or designed specifically for implementation within HIV care settings as a structural intervention. While one evidence-based intervention, Many Men, Many Voices (3MV), was developed by CBOs in collaboration with Black SMM to address behavioral and social determinants including racism and homophobia to prevent HIV/STI transmission, the intervention required multi-session in-person attendance and intensive organization resources to implement. ²¹ Sustainable, community-driven media interventions that address intersectional stigma while simultaneously promoting engagement across the HIV-CoC remain limited.

People who are living with HIV and facing intersectional stigma are best positioned to create effective anti-stigma interventions based on their lived experiences. Moreover, the National HIV/AIDS Strategy (NHAS) stresses the importance of leadership opportunities for PLH and addressing HIV-related stigma and discrimination. ²² However, few media-based interventions involve PLH in the design and implementation phases of stigma-specific research, and Black SMM living with HIV, in particular, are generally underrepresented in traditional academic research. Seeking to address these gaps, three leading activists in Atlanta’s community of Black SMM living with HIV founded a community-based organization in 2021 called the This is Your Moment (TiYM) Network. The goal of TiYM Network is to create innovative media content centering the voices and narratives of Black SMM living with HIV, with the express purpose of sharing this content in clinic and CBO waiting rooms as a structural, organization-level intervention for reducing intersectional stigma and concomitant barriers to care. Reflecting on their own lived experiences with HIV and previous research on intersectional stigma, the TiYM founding members identified waiting rooms in HIV-specialty clinics and CBOs as a prime, missed opportunity for content dissemination for several reasons: (1) PLH often feel anxious and/or self-conscious about their HIV diagnosis when visiting clinics/CBOS ²³ ; (2) PLH have idle time while in waiting rooms and would likely be more amenable to engaging with media content than at other busier times in their day^24,25; (3) provision of this content, which reflects the community and counters HIV stigma, may also have the effect of making the overall clinic/CBO environment less stigmatizing and more welcoming for Black SMM and other PLH.^26,27

Unlike prior HIV media campaigns and educational interventions, TiYM Network developed a novel structural intervention led by Black SMM living with HIV designed to mitigate stigma and promote engagement in care through culturally grounded media segments targeting HIV care continuum outcomes (body), mental health (mind), and health-related quality of life (soul) intended for implementation within HIV clinic and CBO waiting rooms. We conducted a pre-implementation assessment of this TiYM media intervention guided by the Consolidated Framework for Implementation Research (CFIR) to explore clinic/CBO stakeholder perspectives on the barriers and facilitators to implementing the intervention. ²⁸ CFIR outlines constructs from multiple existing theories to provide a comprehensive framework of factors that may influence implementation outcomes. The original CFIR constructs are categorized into five main domains: 1) Intervention Characteristics (features of the intervention that may shape implementation); 2) Outer Setting (external influences on an organization that may affect implementation); 3) Inner Setting (organizational culture, structure, and processes that impact implementation); 4) Characteristics of Individuals (the attitudes and beliefs of an organization’s staff and leaders that may impact implementation); and 5) Implementation Process (the activities involved in planning, engaging,and executing implementation). ²⁸ As part of ongoing development and refinement of TiYM, and to prepare for future feasibility and efficacy testing, we conducted a qualitative study to examine implementation determinants as well as service provider, staff, and administrator perceptions of potential feasibility and utility of the intervention.

Methods

TiYM Intervention

We created a preliminary version of TiYM as indicated in Table 1, using Intervention Mapping-guided processes targeting the three domains: Mind, Body, and Soul. TiYM Network identified these three constructs as key influences on the health of Black SMM living with HIV. In addition, substance use, spirituality, and gender identity were identified as additional constructs of interest based on topic expertise, lived experience, and review of the literature. The preliminary intervention comprises a 5-minute video consisting of brief segments lasting approximately 30 seconds to 1 minute each. These segments depict realistic conversations targeting certain themes (e.g., mental health, gender identity) or educational content (e.g., biomedical advances in HIV prevention and treatment), as illustrated in representative photographic stills in Figure 1.

Table 1.

Intervention Content for TiYM Media Campaign

Domains	Segment title	Themes addressed	Description
Mind	Kin	Mental health stigma Disclosure Peer support Spirituality	A soap-opera style scripted drama following Black SMM friends as they navigate relationships, HIV, mental health, and substance use, showing how friendship and community support shape healing and recovery.
	From Me, To You	Internalized stigma Gender identity	A powerful letter from a transgender man to his younger self, exploring identity, resilience, and healing while challenging stigma and celebrating self-acceptance.
Body	Queer Review	HIV/STI testing HIV/STI Prevention Linkage to/engagement in care Gender identity	A fun, game-show style conversation where Black SMM discuss HIV prevention, identity, and relationships, turning sexual health education into honest, stigma-free dialogue.
	TiYM News	Engagement in care HIV Prevention	Fresh, culturally-grounded news segments discussing cutting-edge biomedical advancements for HIV prevention and treatment.
	Community Resources	HIV Prevention HIV Testing Linkage to/engagement in care	A dynamic showcase connecting viewers to real community tools, HIV resources, and supportive services through music, storytelling, and sex-positive conversations.
Soul	Ask the Provider	HIV stigma Community/peer support	Trusted HIV providers answer real community questions, breaking down stigma and building trust through honest, culturally responsive conversations.
	TiYMless Talks	Intersectional stigma Gender identity Community/Peer support Substance use	Intergenerational conversations between Black SMM exploring identity, HIV, substance use, and healing through shared stories and community wisdom.

Figure 1.

Representative photographic stills from the TiYM pilot intervention

Setting

From March 1 to October 31 2023, we conducted a qualitative study at six HIV care centers or CBOs representing different types of implementation environments in Atlanta, Georgia, an Ending the HIV Epidemic (EHE) jurisdiction in the US South. Guided by CFIR, ²⁸ our study was comprised of focus group discussions (FGD) and in-depth interviews (IDI) with clinic/CBO staff, healthcare providers, and administrators to explore barriers and facilitators to implementing TiYM media intervention through public screening on waiting room televisions and/or posting materials with QR codes. We adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines (Supplementary File 1) for this work.

Ethics

The study was approved by the Emory University Institutional Review Board (study number 0000-4574) and the Grady Research Oversight Committee. Prior to study participation, participants were informed of the potential risks and benefits associated with their involvement in the study and oral informed consent was obtained and documented by study staff.

Study Design and Procedures

We partnered with leadership at six different HIV clinics (N=4) and CBOs (N=2) to obtain a comprehensive list of key partners, including staff (front desk receptionists, patient access representatives, and testing and linkage coordinators), HIV care providers (physicians, advanced practice providers, and nurses), social service providers (social workers and case managers), and administration (chief executive officers, nurse managers, director of practice operations, and executive directors). Inclusion criteria for participants in this study were being 18 years of age or older, and English speaking. We purposively recruited staff, providers, and administrators based on their clinical roles to participate in IDIs or FGDs through email invitation. Seven FGDs of 5-12 participants and one IDI (with an executive-level administrator) were conducted (N=63), to ensure diverse perspectives were represented. Of participants contacted, 7 were not responsive or available to be interviewed. Enrollment continued until thematic saturation was met (e.g., no new themes or codes were identified). FGDs and the IDI were conducted by trained, English-speaking, female study personnel (RNB and MHG) in a private, convenient location at the clinic/CBO site, and lasted an average of 60 minutes. The interviewer had no pre-existing relationship with the participants prior to the study and emphasized confidentiality, openness, and honesty throughout the study. The IDI was conducted over Zoom, a HIPAA-compliant video conference platform and lasted approximately 45 minutes. FGDs and IDIs were conducted using a semi-structured interview guide with open-ended questions in English (Supplementary File 2). Those who completed a FGD or IDI received $50 gift card compensation for their time. All interviews were digitally recorded and transcribed verbatim by a professional service. Our investigative and analytic teams were comprised of researchers including HIV clinicians, PhD level public health researchers, Masters of Public Health (MPH)-level staff, graduate research assistants, and members of TiYM Network.

To explore perspectives of the planned TiYM media intervention prior to implementation, the FGD and IDI guides explored CFIR domains of intervention characteristics (e.g., intervention source, relative advantage, design), outer setting (patient needs and resources), inner setting (e.g., available resources), and implementation process (e.g., planning).

Data Analysis

Transcripts were checked for quality and identifying information was removed prior to coding and thematic analysis. ²⁹ Transcripts were then imported into MAXQDA 2020 (VERBI software, Berlin, Germany), a qualitative data analysis software program. ²⁹ A team-based coding approach was used with four analysts (MHG, RNB, TM, and ML) to enhance reliability and internal validity. ³⁰

We developed and iteratively amended a codebook that contained deductive codes corresponding to selected domains and constructs of the CFIR, as well as inductive codes emerging from the data. Analysts coded a subset of transcripts (N=3) in parallel and compared the coded text to ensure consistency. Modifications were made to the codebook through an iterative process, including discussions of transcripts, identification of recurring themes, and refinement of code definitions until consensus was reached. After the codebook was finalized, the remaining transcripts were divided and coded by members of the study team. We then wrote thick descriptions, or detailed analytic memos, to explain the depth, breadth, context, and nuance of each code. ³¹ Coding, descriptions, and memos were reviewed by the analysis team. Coded interviews were then thematically analyzed to discuss emerging patterns and relationships in the data examining factors impacting implementation of TiYM media intervention.

Results

Our findings are organized by CFIR domains and constructs below. Overall, identified facilitators and barriers to implementation were similar between six clinics and CBOs; differences for specific sites are explicitly named.

Intervention Characteristics

Intervention Source: Authenticity as a Strength

Several participants noted that HIV messaging may resonate better with patients and clients when those stories are shared by people with similar lived experiences. Due to concise, authentic, and conversational language, participants felt that TiYM content communicated information about HIV and sexual health in an engaging manner.

“When it comes to the outside community, I think it can of course be a learning lesson, but I think it could be something great. The reason why I say that is because I feel before I was truly admitting or realizing who I was, it took other individuals who was comfortable with themselves for me to finally be there or even relate in some sort. I think even if they don't fully agree and it's not their story, it's some sense that they can relate to, I would say.” – CBO FGD

Intervention Source: Concerns About Diversity of Representation

Participants shared that while the content may be received positively among many clients, some may have less favorable reactions. In particular, participants acknowledged that although the intervention was tailored towards Black SMM, they had concerns about women, transgender individuals, Black heterosexual cis-gender men, and non-Black people of color who also attend the clinic or CBO feeling underrepresented in the videos:

“I love the video and all of the messaging, but because our waiting room is inclusive of so much more than just young, Black, gay males. We have young Black males that are heterosexual, that are offended if we come in and ask them if they have sex with another male. If I had a decision to make I would add some persons in there that are a older Black woman. Those are people that we have in our waiting room. The average age on the women's side is what? 50-something to 60-something.” – Clinic FGD

A few participants cautioned that some of these individuals may even feel offended by the lack of representation for groups other than young, Black SMM:

“They don't feel represented at all. They're like, “[SMM] populations, why do they get all the advertising? Why are all the studies [about SMM]? Why are all the resources targeted towards them and I've got me and my babies. We can't get this, that and the other.” I think that's a very valid thing that happens quite a bit.” – Clinic FGD

Intervention Design: Quality of Video Content

Overall, participants at all six clinics/CBOs had positive reactions to the TiYM media campaign’s design. They voiced high satisfaction with video production quality, graphics, editing, and performances, as well as the variety of segments included. The video content itself was thought to be highly engaging, personable, and informative:

“It's like you can see yourself in one of those characters, so it's very relatable and was entertaining. If I was sitting in a doctor's office and I was waiting maybe an hour, you know how they go here. If I was sitting there and I had that type of entertainment— well, I would call it ‘edu-tainment’— on the screen in front of me, then I can learn something while getting a good laugh in. And you don't have to worry about me digging in my phone, huffing and puffing. I think that is good. I like that.” – CBO FGD

Some participants also described how the entertaining aspect of the material would ease patient’s potential anxiety when in the waiting room:

“I think about the population and when people come here a lot of time it's very daunting. Yesterday I was with a patient for three hours trying to get them to understand the reason they need to come here to get their care and take their medications and everything, but they can't get past the idea of, ‘I have to walk into this building because it's on the main street.’ You get what I'm saying? If we have stuff like this, sitting in that waiting room, because a lot of these people that come in and it's scary. If we had something like this, sitting there playing them, engaging with it, laughing and having fun, maybe that’ll break the ice.” – Clinic FGD

Relative Advantage: Waiting Room ‘Edu-Tainment’

Within the Intervention Characteristics domain, participants elaborated upon several advantages of displaying TiYM videos in their organization. Participants describe the improvement from current waiting room experiences: “[TiYM] is an improvement from the untouched stack of books in the corner [of our waiting room].” In five of the six sites, participants expressed excitement over sharing the materials with the communities they serve as they felt that the TiYM content would relieve viewers’ medical anxiety compared to current random television shows and advertisements being displayed in their waiting rooms:

“I just think the video aligns with the overall goals of what the mission is— it's just to lighten the mood of a doctor's appointment. Because regardless of what the appointment is about, some people just have that general white coat syndrome and anxiety just being in here. It definitely does create like a ‘Hey, guys, it's okay. You can get comfortable here.’” – Clinic FGD

Some participants additionally felt that playing the TiYM videos in the waiting room could help encourage self-acceptance and foster a sense of openness and greater belonging among clients. These features, along with the educational aspects of the videos, could help address stigmatized views within the organization, in addition to the fear of stigma among those who have previously experienced it.

“Everybody's going to be able to some point relate to each other, and they be like, “Oh, you were laughing at that too?” Then that's going to start a whole new dialogue. I hope, my hope is hopefully the same as yours, is that everybody will start feeling comfortable with releasing the stigma of, one, the disease, two, being who you are, and just accepting back to the very first video, “This is your moment.” Accept that this is your time to whichever way this testing goes, live in your truth. To me, that is the most important message.” – CBO FGD

In addition to facilitating organizations in achieving their overarching goals, participants pitched that the TIYM media campaign could further help the organizations by promoting their activities and events:

“Like maybe talking about some of our specific programs or highlighting when Pride is coming up, something of that nature, that we're actually doing to where it can be beneficial for us.” – CBO FGD

“Because the other thing that we're looking at for the TVs is also like, ‘hey, here is the list of all the events that are coming up with [site name] this month and next month.’” – Clinic IDI

Relative Advantage: Privacy and Unintentional Disclosure

Some participants also identified potential disadvantages to incorporating TiYM media campaign in their clinic. One perceived disadvantage was the focus on young, Black SMM living with HIV in the videos which participants felt could contribute to greater stigmatization of HIV:

“It felt like, although it's meant to be anti-stigma, it might actually be perpetuating the stigma. Especially when people who are less familiar with this community are sharing the waiting room, we don't want to further label a community that's solely based on what I saw was likely sexualized behavior versus there's so much more.” – Clinic FGD

Participants in this focus group additionally shared that their clients often elect to utilize their services due to the organization’s reputation for ensuring privacy and discreet care given nondescript waiting rooms shared with other subspecialty clinics. Potential difficulties from sharing TiYM content here included possible unintentional disclosure of HIV status or sexuality. Apart from this one site, however, the FGDs revealed that staff generally felt that TiYM videos could be an effective tool over current waiting room material for decreasing HIV stigma within their respective organizations.

Outer Setting

Patient Needs and Resources: Unmet Psychosocial Needs Among Black SMM

Participants at all sites felt that there is a need to decrease intersectional stigma among their young, Black SMM patients. Participants explained how TiYM could address the many structural inequalities that the patients/clients face that are not as easily addressed in the clinic like general HIV medical care is, including trauma, multiple overlapping stigmas, and general lack of social support:

“I think we've gotten quite good at the medical care of HIV and that's pretty easy these days. It's all the other stuff. That's very hard and challenging. We haven't gotten great at the psychosocial aspects. [TiYM] is getting at that piece that we don't have great answers to and we don't have great solutions to.” – Clinic FGD

Many participants believed that the TiYM media campaign could directly contribute to stigma reduction while also indirectly contributing to increased engagement in care and improved health outcomes by improving client health literacy. They identified content providing information on the HIV-CoC and encouraging patient-provider communication as key facilitators to improved health literacy:

“From the clinical perspective, having that specific content, I think that tie directly into like a CD4 count or something like that, a viral load. Simple terminology that's used every day in this area would be something, and it doesn't get too deep. That way they may hear something and be like, oh, I don't know what that is. I'm about to go into a doctor's appointment. Let me go ahead and look my provider and be like, ‘Hey, I heard this in the [waiting room]. What is that?’” – Clinic FGD

Inner Setting

Available Resources: Ease of QR Codes

Across the focus groups, participants extensively discussed the ease of playing videos and displaying QR codes in their respective organizations with current available resources. Participants at all six sites agreed that they could display QR codes in their lobbies or waiting rooms, hallways, and bathrooms, as well as in private exam rooms and pharmacy areas in clinics. Utilizing QR codes was an attractive option to participants, who liked that clients could choose whether to engage with TiYM content and have more privacy while viewing the videos, which can be done either at the organization or after leaving:

“I think it's a lot more private. I can scan a QR code and I can have that tab open in my 500 tabs that are open on my phone and just go back to it in my own time. That's an advantage because sometimes you also don't want to sit in a waiting room with a lot of different people that you don't know or you might know, and they may know something about you or think they may know something about you that you don't want that-- It's all the different things, but then if you're actively staring at a screen that is talking about one specific thing, some of our patients may not want to be seen doing that.” – Clinic IDI

Participants at numerous sites shared that they have previously used QR codes in their organizations and noted that they can be an effective means of sharing information and resources with clients. However, there was some concern over the accessibility of QR codes, which less technologically savvy individuals may have difficulty using. Participants additionally noted that QR codes would not be accessible when Wi-Fi connection is poor or to clients without phones. Even so, QR codes were generally seen as a more feasible option than physically showing the TiYM videos in organizations, which requires TV screens, in addition to more involved coordination with staff:

“That means listening to our frontline workers, listening to the staff that works in the waiting rooms, that picks people up from the waiting room, and we move some around. We would want to incorporate them on like, where should the TV be mounted? How loud is the volume? Do you like this material? Do you not like this material? Also to give them the ability to understand and see the material in advance because they are the most likely to be asked questions about it. Educating and making available to the staff that is closest to the medium to be able to respond to it.” – Clinic IDI

Despite these challenges, participants from many organizations were still interested in implementing the TiYM media campaign through both QR codes and playing content aloud on central TV screens.

Implementation Process

Planning: Organizational Complexity and Approval Hierarchies

Participants outlined the steps needed to implement the TiYM media campaign in their organization. All organizations shared that the campaign content would need to be approved by multiple levels of staff and administration prior to implementation. This was predicted to be a longer, more complicated and contentious process at the HIV clinics compared to the smaller community-based organizations:

“This would be great, probably at the smaller nonprofit level, the smaller organizations. This, I think would be perfect for those spaces. When you think about creating [our clinic], it's a lot of people that's in play here. That's what makes it really difficult. Again, as you said, I think some in our administration would be, especially as executive director, very progressive, very forward thinking. I think he would be in love with this whole thing. Then there are people under him who probably would give a little bit more pushback towards that.” – Clinic FGD

Participants at all organizations, regardless of size or structure, additionally believed that it would be significantly easier to gain approval for and implement QR codes linking clients to content compared to playing the videos aloud in common areas. Finally, to aid in the approval process, participants identified key individuals who were regarded to be leaders, changemakers, and champions of their respective organizations.

Participants shared views that the TiYM media campaign has the potential to serve as a structural, organization-level intervention, but possible accessibility issues and/or negative reception among general clientele should be considered when determining the best implementation strategy for individual organizations. Furthermore, some participants from the HIV clinics voiced concerns about potential unintended disclosure of status if playing the videos aloud or displaying QR codes on posters or flyers that emphasize the content’s focus on HIV:

“Don't have it so much where the word HIV is always written all over everything. Because if you do, patients will shy away from that paper that's on that table in the waiting room. It will have to be dressed up in a way that will make people curious. Because if I'm sitting in the waiting room and I saw you scan that QR code and then I go over there to go read it, I'm going to say, ‘[Name] got HIV.’” – Clinic FGD

Discussion

In this pre-implementation assessment of the TiYM media intervention, stakeholders across six HIV clinics and CBOs in Atlanta identified barriers and facilitators to implementation, including enthusiasm for the intervention’s community-centered design, relevance to the organization’s mission, and potential to reduce intersectional stigma among Black SMM living with HIV. Participants perceived TiYM as a culturally resonant, engaging, and potentially feasible structural intervention that could improve waiting room environments and potentially impact engagement in care. Additionally, stakeholders highlighted important considerations related to representation, privacy, technological accessibility, and organizational approval processes that may influence implementation success. These findings provide insights for tailoring implementation strategies and optimizing adoption across diverse HIV service settings.

Participants described TiYM’s strength as rooted in its development by Black SMM living with HIV, whose lived experience enhanced the intervention’s credibility, relatability, and engagement. This finding reinforces growing evidence that interventions co-developed with communities most affected by HIV are more likely to resonate with intended audiences and advance health equity.^32,33 Community-based participatory research (CBPR) and other participatory frameworks have demonstrated that the integration of lived experience strengthens interventions by increasing trust, relevance, and sustainability, particularly in marginalized communities disproportionately affected by HIV.^34,35 Within HIV prevention and care, community-engaged and peer-led approaches to interventions have been associated with improved testing uptake, linkage to care, and viral suppression among SMM and other marginalized populations.^36-38 Furthermore, by centering narrative storytelling and representation, TiYM moves beyond traditional didactic health messaging towards culturally grounded “edu-tainment” (e.g., the use of entertainment as an educational tool). ³⁹ Narrative-based interventions have been shown to enhance messaging, leveraging individuals’ identification with characters and emotional engagement, which in turn can reduce stigma and shift health-related attitudes and engagement in care.^40,41 Previous studies among women and SMM have shown that edu-tainment strategies in HIV contexts have demonstrated efficacy in increasing HIV knowledge, reducing stigma, and increasing safe sexual practices, particularly when narratives reflected the lived realities of the target audience.^17-19,42-44 By including authentic representation of Black SMM living with HIV, TiYM has potential to help mitigate stigma, foster self-acceptance, and strengthen peer support – mechanisms that are critical to improving engagement across the HIV-CoC.

Stakeholders also perceived clear relative advantages compared to existing décor or educational materials currently on display in waiting rooms, which were often described as generic, outdated, or unrelated to patients’ lived experiences. Participants felt that TiYM could reduce anxiety associated with clinic visits, normalize conversations about HIV and sexuality, and create opportunities for peer connection within shared spaces. These findings align with current evidence that healthcare environments, including physical space, visual cues, and institutional climate, shape patient perceptions of safety, belonging, and stigma.^10,45 Prior research has shown that individuals living with HIV frequently experience enacted and anticipated stigma within clinical settings, which can contribute to delayed care-seeking, disengagement from services, and poorer health outcomes.^46,47 Interventions that modify structural and environmental features of care settings with inclusive imagery, affirming messages, and visible representation have been associated with improved patient trust, satisfaction, and engagement, particularly among sexual and gender minority populations.^48,49 By creating welcoming, affirming spaces in waiting rooms, TiYM represents a structural, organization-level intervention aligned with the National HIV/AIDS Strategy to address stigma at multiple levels rather than solely focusing on individual behavior change. These findings suggest that embedding culturally grounded, affirming content within clinical spaces may help transform waiting rooms from passive holding areas into active sites of stigma reduction and community affirmation.

However, some participants expressed concerns about representation across diverse patient populations, underscoring the complexity of implementing targeted equity-focused interventions in clinical settings. While the intervention intentionally centers young Black SMM living with HIV– those most disproportionately affected by HIV– some stakeholders worried about the potential isolation of other populations, including women, heterosexual men, transgender individuals, and older adults. Prior research on culturally tailored interventions indicates that while focused strategies can enhance relevance and engagement for marginalized populations, they may also inadvertently cause feelings of exclusion if other identity groups are not acknowledged, potentially limiting reach and equity of impact. ⁵⁰ Studies among transgender women and Black/African American populations have shown that interventions that incorporate inclusivity when adapted and implemented in diverse clinical contexts are associated with improved engagement and psychosocial outcomes across diverse populations.^51,52 These findings suggest that implementation strategies may benefit from contextual tailoring, such as integrating additional complementary content that acknowledges and is inclusive of broader clinic demographics while maintaining the intervention’s core focus.

Privacy and unintentional disclosure emerged as critical determinants of implementation strategy, particularly in the site where the waiting room was shared with other subspecialties. Participants expressed concern that overt HIV-focused messaging or visible engagement with QR codes or video content playing out loud on TV screens could inadvertently disclose one’s HIV status or sexual identity. These findings align with existing literature documenting fear of disclosure and anticipated stigma as a barrier to engagement in care among people living with HIV.^10,46,47 Implementation strategies that emphasize subtle branding and optional engagement (e.g., QR codes versus playing on central TV screens) may mitigate these concerns. ⁴⁵ Notably, in our study we found that QR codes were widely viewed as feasible and privacy-enhancing, though stakeholders acknowledged potential digital literacy and access limitations. A hybrid dissemination approach combining both ambient video display with more status-neutral content and discreet digital access may therefore optimize reach while preserving autonomy.

Within the Inner Setting and Implementation Process domains, organizational complexity and approval hierarchies were identified as potential barriers, particularly in larger clinical systems or national organizations. Participants emphasized the need for multi-level buy-in and identified internal champions as essential facilitators for implementation. The involvement of engaged opinion leaders and champions has been associated with successful adoption and sustainment of evidence-based HIV interventions, particularly in complex healthcare systems.^53,54 These findings highlight the importance of early stakeholder engagement and leadership alignment when implementing structural stigma-reduction interventions in clinical settings. Interestingly, all sites felt that it would be both faster and easier to get flyers with QR codes approved by administration compared to displaying videos on centralized waiting room screens. This aligns with prior studies that showed that implementation strategies requiring fewer workflow disruptions and less organizational coordination are more likely to be adopted in early phases. ⁵⁵ We found that smaller CBOs and clinics were perceived as more flexible and as potential early adopters, suggesting that a phased implementation beginning in community-based settings and/or starting with QR codes may be a pragmatic strategy to enhance feasibility while building momentum for broader structural integration in larger institutions.

Across sites, stakeholders consistently described unmet psychosocial needs among Black SMM living with HIV, noting that biomedical HIV care had advanced substantially while stigma, trauma, and social support remain insufficiently addressed. While the scale up of antiretroviral therapy and treatment-as-prevention strategies have improved life expectancy and reduced HIV transmission, disparities in engagement and viral suppression persist among Black SMM, driven in part by structural racism, intersectional stigma, and co-occurring psychosocial conditions (e.g., depression, trauma exposure, substance use).^47,56-58 Participants perceived TiYM as having the potential to fill this gap by addressing mental health, affirmative representation of Black SMM, and health literacy in ways that complement clinical care. Interventions that integrate psychosocial support and stigma reduction into HIV care settings have been associated with improved patient-provider communication, medication adherence, and retention in care.^59-61 By promoting dialogue around these topics within clinical settings, TiYM may improve engagement along the HIV Continuum of Care. Future effectiveness studies should examine whether exposure to TiYM is associated with measurable changes in stigma perceptions, patient-provider communication, retention in care, and viral suppression.

This study has several limitations. First, findings reflect perspectives from stakeholders in one metropolitan area in the US South and may not be generalizable to other geographic contexts. Additionally, we assessed anticipated barriers and facilitators prior to implementation; actual implementation strategies may differ. Although participants represented diverse roles within clinics and CBOs, we did not directly assess patient/client perspectives in this phase of the study. Future research should incorporate patient-level evaluations to assess acceptability, perceived impact, and potential barriers to implementation among diverse populations. It should also be noted that this study, given the exploratory phase of research, did not directly examine efficacy or feasibility of the intervention; these represent important directions for future research. Despite these limitations, this study contributes to the limited literature on structural, media-based stigma-reduction interventions co-developed with Black SMM living with HIV. By leveraging waiting rooms, an underutilized but universal touchpoint in HIV care, TiYM offers a scalable and sustainable approach aligned with national HIV priorities. Our findings, guided by CFIR, provide a roadmap for tailoring implementation strategies, addressing privacy concerns, engaging organizational champions, and maintaining fidelity to the intervention’s equity-driven core.

Conclusions

In conclusion, stakeholders across HIV clinics and CBOs in Atlanta, Georgia expressed strong support for implementing TiYM as an innovative, community-driven strategy to mitigate intersectional stigma and enhance engagement in care among Black SMM living with HIV. We identified important barriers and facilitators to implementation, including diverse representation, inclusion of status-neutral content, privacy concerns, and organizational processes that will be critical to successful implementation. Future implementation and effectiveness studies are needed to evaluate intervention uptake, feasibility, and acceptability among patients, as well as its impact on stigma and HIV-CoC outcomes. Structural interventions such as TiYM are urgently needed to complement current HIV care and ensure that progress towards Ending the HIV Epidemic is both equitable and community-driven.

ORCID iDs

Madeleine H. Goldstein https://orcid.org/0000-0002-5389-2597

Tigest F. Mekonnen https://orcid.org/0009-0003-8428-7351

Antonio Newman https://orcid.org/0009-0005-6557-5790

Ethical Considerations

The study was approved by the Emory University Institutional Review Board (study number 0000-4574) and the Grady Research Oversight Committee.

Consent to Participate

Prior to study participation, participants were provided an overview of study procedures, potential risks and benefits, and confidentiality associated with their involvement in the study. Oral informed consent was obtained from each participant before any study activities were initiated and all questions from participants were answered completely. Consent was documented at the time it was obtained by trained study staff using an IRB-approved consent documentation form, which included the date and confirmation of participant agreement. The use of oral consent and the procedures for its documentation were reviewed and explicitly approved by the Institutional Review Board.

Data Availability Statement

De-identified transcripts can be available upon request by emailing the corresponding author.*