Increasing Opportunities for Spiritual and Religious Supports to Improve HIV-Related Outcomes for Black Sexual Minority Men

Abstract

Given the importance of spirituality and religion in the lives of many Black gay, bisexual, and other Black sexual minority men (SMM) and the need for additional resources to improve HIV outcomes within this population, research on how spiritual and religious support can promote HIV prevention and treatment among Black SMM is greatly needed. We conducted nine focus groups with 52 spiritual and religious Black SMM in Baltimore, Maryland, to explore opportunities for HIV-related programming that incorporates spiritual and/or religious supports. Thematic analysis of the focus group transcripts was conducted using an iterative constant comparison coding process. Participants expressed a desire for more spiritual/religious support in non-church-based settings and identified the use of peer supports, inclusion of prayer and gospel music, and messaging related to the ideas that God is love, the Bible says to treat yourself preciously, and taking care of your health can strengthen your relationship with God as ways in which this could be incorporated into HIV-related programming. Participants living with HIV identified the message of “keeping the faith” as important for maintaining their HIV treatment plans. Participants also expressed a need for parental supports to improve HIV-related outcomes for Black SMM and potentially expand opportunities for spiritual and religious support to Black SMM within the church. Spirituality and religion can influence HIV outcomes for Black SMM, and the strategies identified by Black SMM in this study could aid in designing culturally congruent HIV prevention and treatment programs situated in the community.

In the U.S., Black gay, bisexual, and other Black sexual minority men who have sex with men (SMM) are disproportionately affected by HIV. Although they account for less than 1% of the U.S. population, Black SMM accounted for 26.1% of all HIV diagnoses and 59.9% of diagnoses among Blacks/African Americans in 2015 [1]. HIV prevalence among Black SMM is estimated to be 30% compared to 15% for Hispanic/Latino sexual minority men and 14% for non-Hispanic White sexual minority men [2]. At current trends in prevention and treatment, Black SMM have an estimated 50% lifetime risk of HIV infection [3].

It is well-established that among Black SMM, HIV infection and outcomes along the HIV care continuum are impacted by a complex syndemic affect of behavioral (i.e., condomless sex) and structural (i.e., stigma, discrimination, racism, access to healthcare services) factors [4–8]. Despite great attention given to this population to curb the epidemic, intervention strategies that address and mitigate these factors remain urgently needed. Incorporating spiritual and religious elements into these intervention strategies could increase coping strategies and help circumvent these structural barriers among Black SMM [9].

Spirituality and religion are salient among Black SMM [10, 11]. Black SMM are more likely to report spirituality and religion as very important to them compared to other racial/ethnic groups of sexual minority men [12]. The literature shows that spirituality and religion influence health through several pathways, including (but not limited to) (1) the regulation of lifestyles and health behaviors, (2) access to social resources such as social ties and social support, (3) promotion of positive self-perception, (4) methods of coping resources (i.e., for stress, sadness), and (5) promotion of health beliefs [13–15]. Among Black SMM, spiritual and religious supports foster cultural bonds within their community and among other sexual minority men and serve to aid in coping with homonegativity and illness [16–18].

However, studies have demonstrated a paradox of spirituality and religiosity being associated with both risk for and protection against HIV among Black SMM [11, 19–22]. Spirituality and religiosity have been associated with HIV and other sexually transmitted infections [21, 23, 24], lower gay affirmation [25], and with high-risk behaviors such as illicit drug use and increased number of partners [21, 22]. However, spirituality and religiosity have also been associated with protective factors against condomless anal intercourse [11, 21, 26]. As a result of the negative attitudes of many Black churches towards homosexuality [27–29], some Black SMM experience conflict with and rejection from organized religious communities [27, 30–32], which may in turn lead to a disconnection between their religious identity and sexual identity and behaviors [11, 20, 33]. Alternatively, as a result of this conflict and rejection, some Black SMM reinterpret church teachings and prioritize their personal faith in God over religious institutions and their espoused beliefs on homosexuality [32, 34]. The ways in which Black SMM resolve these conflicts could influence HIV vulnerability [21, 35].

Given the importance of spirituality and religion in many Black SMM’s lives and the need for additional resources and interventions to address vulnerability and promote resilience to HIV within this population, additional research identifying ways to optimize spiritual and religious concepts in HIV prevention and treatment programs for Black SMM is greatly needed. Therefore, this study aimed to identify opportunities for spiritual and religious supports to promote HIV prevention and treatment and inform local HIV intervention efforts for Black SMM. Since spirituality and religiosity are salient among this population and disparities in the HIV care continuum persist, incorporating spiritual and religious supports into HIV interventions and programs may promote improved HIV outcomes.

Methods

Participants and Recruitment

Details of the study participants and recruitment activities have been previously published [36]. Briefly, nine focus groups were conducted among Black SMM in Baltimore, Maryland, between December 2017 and April 2018. Participants were recruited from a combination of active and passive strategies. Passive recruitment included distributing fliers at community-based organizations and events that Black SMM were known to frequent. Separate flyers were developed to appeal to HIV-negative men and HIV-positive men. For active recruitment, research staff approached individuals at random from community-based venues such as local coffee shops, nightclubs, and community-based organizations frequented by Black SMM to inform them of the study. Participants were also recruited using snowball sampling, whereby participants were asked to refer up to two other individuals to the study.

Men were eligible to participate in the focus groups based upon the following criteria: (1) between ages 18 and 45, (2) self-identified as Black/African American, (3) had sexual or romantic contact with a man in the previous 6 months, and (4) self-identified as spiritual or religious. Participants were stratified by age and self-reported HIV status and included three groups of HIV-negative men ages 18–29, two HIV-negative groups ages 30–45, two HIV-positive groups of men ages 18–29, and two groups of HIV-positive men ages 30–45. Two experienced qualitative investigators facilitated the groups. Facilitators used a semi-structured focus group guide developed in consultation with key informants from local community-based organizations that had strong ties to the target population (Table 1). Separate focus group guides were developed for HIV-negative and HIV-positive men. Each focus group lasted approximately 1.5 hours and was audio-recorded with participant permission. Participants were compensated $40 and provided refreshments before the focus group discussion. Participants who referred others were compensated $10 for each eligible participant they referred who participated in a focus group. The Johns Hopkins University School of Medicine Institutional Review Board (IRB) approved all protocols, and all participants provided written consent.

Table 1.

Focus group guide domains and example research questions among HIV-negative and HIV-positive Black sexual minority men (SMM)

Focus group	Focus group domains	Example research questions
HIV-negative and HIV-positive Black SMM	Religion and spirituality	How do you incorporate religion and spirituality in your life? How does your religion/spirituality help you during difficult periods?
	Religion, spirituality, and same-sex attraction	How do your religious and spiritual views about sex and sexuality influence your romantic or sexual experiences? How does your sexuality influence your religious/spiritual practices?
	Religion, spirituality, and health	How do your religious and/or spiritual beliefs influence your sexual health? How do your religious and/or spiritual beliefs influence how you think about HIV and people living with HIV?
HIV-negative Black SMM	Religious and spiritual support programs for HIV prevention	What additional religious or spiritual programs or support would you be interested in to help you reduce your risk of getting HIV?
HIV-positive Black SMM	Religious and spiritual support programs for HIV treatment and care	What religious or spiritual programs or supports are available to Black SMM to help manage HIV? What about the programs or supports are liked/disliked? What additional religious or spiritual programs or supports would you be interested in?

Qualitative Data Analysis

The audio recording of each focus group was transcribed verbatim, cleaned of identifiable information, and reviewed for accuracy by the investigative team. Thematic analysis was conducted using an iterative, constant comparison coding process [37, 38]. Specifically, two coders (first and last author) read all transcripts to identify overarching themes, looked for repetitions across interviews, and developed a codebook listing each theme. Themes were identified either by patterns that were associated with specific questions or expressions that provided examples of concepts [38]. Areas of text related to each theme for the first three focus groups were coded independently by the two coders; inter-rater reliability was measured to ensure consistency between transcript coding (Kappa ≥ 0.70). Inter-rater reliability was measured twice to confirm coding consistency; inconsistencies were reviewed and showed minor differences in the lengths of quoted text but not in the overall quality of the text. The remaining transcripts were then independently coded by one of the coders using Atlas.ti 7.0 software (Scientific Software Development GmbH, Berlin, Germany). Thematic codes were compared within a single focus group and between focus groups; variability was considered based on the age group and HIV status [37].

Results

Nine focus groups were conducted with 52 men (21 of whom were living with HIV), and all of whom identified as a sexual minority. Although recruitment was not targeted by religious affiliation, all participants reporting a religious affiliation identified their affiliation as a Christian denomination, and participants had an overwhelming preference for traditional churches rather than LGBTQ-affirming churches. Almost half (48.1%) of the participants reported attending religious activities (e.g., church services, prayer meetings) once a month or more, although only 40.4% believed they could be open about their sexuality with their faith community (Table 2).

Table 2.

Socio-demographic characteristics and religious beliefs and practices of focus group participants (N = 52)

	HIV-negative men n (%)	Men living with HIV n (%)	Total n (%)
Age (mean, sd)	30.0 (7.6)	29.8 (7.9)	29.9 (7.7)
Sexual orientation
Homosexual, gay, or same gender-loving	21 (72.4%)	16 (69.6%)	37 (71.2%)
Bisexual	8 (27.6%)	5 (21.7%)	13 (25.0%)
Queer	0 (0.0%)	1 (4.3%)	1 (1.9%)
Other	0 (0.0%)	1 (4.3%)	1 (1.9%)
Education
Less than high school degree/GED	0 (0.0%)	1 (4.3%)	1 (1.9%)
High school diploma/GED	6 (20.7%)	10 (43.5%)	16 (30.8%)
Some college	9 (31.0%)	11 (47.8%)	20 (38.5%)
Technical degree	2 (6.9%)	1 (4.3%)	3 (5.8%)
Bachelor’s degree	9 (31.0%)	0 (0.0%)	9 (17.3%)
Graduate degree	3 (10.3%)	0 (0.0%)	3 (5.8%)
Religious affiliation
Catholic	1 (3.4%)	0 (0.0%)	1 (1.9%)
Evangelical or Protestant	2 (6.9%)	1 (4.3%)	3 (5.8%)
Baptist	8 (27.6%)	9 (39.1%)	17 (32.7%)
Christian-other	13 (44.8%)	7 (30.4%)	20 (38.5%)
No religious affiliation	2 (6.9%)	4 (17.4%)	6 (11.5%)
Other	2 (6.9%)	2 (8.7%)	4 (7.7%)
Missing	1 (3.4%)	0 (0.0%)	1 (1.9%)
Attendance at religious activities
Never	4 (13.8%)	4 (17.4%)	8 (15.4%)
Once a year or rarely	10 (34.5%)	6 (26.1%)	16 (30.8%)
Once a month or more	14 (48.3%)	11 (47.8%)	25 (48.1%)
Missing	1 (3.4%)	2 (8.7%)	3 (5.8%)
I believe I can be open about my sexuality with my faith community
Strongly agree/agree	10 (34.5%)	11 (47.8%)	21 (40.4%)
No opinion/unsure	8 (27.6%)	1 (4.3%)	9 (17.3%)
Strongly disagree/disagree	7 (24.1%)	5 (21.7%)	12 (23.1%)
I do not have a faith community	2 (6.9%)	4 (17.4%)	6 (11.5%)
Missing	2 (6.9%)	2 (8.7%)	4 (7.7%)

Thematic Findings

Within their daily lives, participants regularly evoked their spirituality and religiosity as a way of coping with daily struggles, such as limited resources or tenuous relationships in their lives. Overall, participants felt a strong desire for more spiritual and/or religious support, acknowledging that fulfilling this need through the church setting and community remains challenging due to the homonegativity experienced. Across focus groups, participants believed that spiritual and religious supports could be incorporated within HIV prevention and treatment programming for Black SMM. Evoking elements of their spiritual and religious beliefs and practices that they independently utilized to help navigate daily struggles, they provided ideas for incorporating spiritual and religious support into HIV programs and activities and identified messages that may be utilized within these programs or supports to promote sexual health among Black SMM. These ideas were largely focused on opportunities for programs and supports outside of the church setting. Along with these supports targeting Black SMM and the messages that may be incorporated into them, participants identified the need for parental support programs within the church. Participants believed that parental support programs within the church may indirectly improve HIV-related outcomes for Black SMM and open opportunities for church-based spiritual and religious supports as a result of addressing homonegativity within the church setting.

Incorporating Spiritual and Religious Supports into Non-church-Based HIV Programs

Recognizing that many of their peers felt a desire for more spiritual and/or religious supports just as they did, participants discussed focusing on spirituality, which would enable the inclusion of more people, as opposed to focusing on denomination-specific religious beliefs and practices. For example, one younger participant said:

Because, everybody, like…is very, separated on, you know, their connection to the church, you know, and Christianity specifically. I know a lot of people…have this kind of antagonism towards the church, and I feel like if you incorporate something that’s not specifically geared towards [a specific domination] of Christianity, and helps everybody kind of, you know, have some sort of like, spirituality in that, you know, program, it would be easier to get more people up.

Within these programs, participants identified ways in which spiritual and/or religious supports can be incorporated into HIV-related programs. As one possibility, participants discussed incorporating peer navigators or peer supports into programs. These supports could incorporate spiritual and/or religious elements into the relationship that is simultaneously focused on issues related to HIV prevention or treatment. For example, one participant, living with HIV, discussed opportunities for case managers at HIV clinics to provide spiritual and/or religious support, while another older participant, not living with HIV, suggested mentoring younger Black SMM men as part of an HIV or sexual health program and providing spiritual and/or religious support through this process.

Additionally, participants discussed the opportunity to include prayer and gospel music into HIV-focused programming. Both prayer and gospel music were important elements of participants’ engagement with their spirituality and religion, and these are often called upon during difficult times when spiritual and/or religious support may not be available: “Mostly I pray if I’m in a real funky mood and I don’t have no guidance, sometimes I’ll listen to gospel music. That’ll help me too.” One younger participant described the role of gospel music in helping him through struggles, saying:

I love music and that's one of the biggest things I remember from church when I was a kid was the music and it was always, like, a message of salvation. You know, yeah, things are going wrong now but there is, you know, hope coming and some sort of help on the way, basically…And I mean, I carry that. Like, when I listen to a [gospel] song, like, man, I'm going through things, like money or whatever, and if you listen to the song you'll be like, all right, it's going to be all right.

Participants overwhelmingly felt that these elements could be beneficial within the context of HIV programming by providing an additional opportunity for spiritual and/or religious support while also addressing health needs within their community.

Incorporating Spiritual and Religious Messaging in HIV Programs

Across groups, participants identified of spiritual and/or religious supports within HIV-related programming as appropriate and desired the inclusion partially due to their belief that their spiritual and religious perspectives and practices were connected to their health and well-being. One younger participant, for example, stated: “For me, I just feel like because, like, I feel like the way we are made [by God], that we’re made and we have purpose and that we matter, that and you should take care of yourself.” While discussing the role of spirituality and religion in their health and well-being, participants identified four ideas or concepts that encouraged them to take care of their mental and physical health and that could be utilized within HIV-related programming. First, participants frequently stated that God is love. This belief provided participants with strength when confronted with homophobia in the church, encouraged them to be accepting and kind to themselves as same sexual minority men, and could be incorporated into HIV prevention and treatment programs to circumvent internalized homonegativity from churches.

Participants also shared the belief that you should treat yourself preciously, recognizing that this is what God wants of us. One young participant, for example, explained this, stating:

Well, the Bible or most religions tell you to treat yourself preciously and it tells you to treat yourself properly and it tells you to treat other people with respect. And if you live your life by those sets of morals and ethics, I think that is beyond, I think that's good karma. And I mean, this can segue into the conversation that we're having about STI and HIV. If you are treating yourself well, you're going to do all the things that will keep your health intact.

This idea extended, for some participants, into the belief that taking care of your health can strengthen your relationship with God. Another young participant explained this, explaining:

I feel like the fortification of my relationship with God was when I recognized heart within myself… I quit drinking and that was something that I-- that was a decision I made for myself, because I realized, like, “Okay, you’re doing this thing. This thing is not working. So, stop doing this thing and see what happens.” But I realize that the more intentionally I heal and the more intentionally I care for myself and the more intentionally I step into spaces that amplify the fact that there’s literally nothing wrong with us that we can’t fix, I recognize God in myself more and more, because I get to be a catalyst for these conversations, and for this healing, and for this process. And that is to me, that’s God moving. So, it wasn’t until I looked inward and started actually giving a f*** about me that I started feeling like there was any version of God in my life.

Men living with HIV identified one additional message that helps them accept their HIV status and adhere to their HIV treatment plan: keep your faith in God. One young participant living with HIV stated, for example: “I wake up and I’m like, ‘God, I thank you for keeping me here. Because I could be dead.’ [laughs] Five years ago I could have been dead. So I thank him every day that I’m here…I just pray and keep my faith for him.” Several participants discussed that their focus of keeping their faith in God initially prevented them from accepting medical treatment for their HIV. These participants subsequently realized, though, that keeping their faith in God also meant having faith that God’s plan included providing knowledge to people to create the medicines that would keep them healthy. An older participant explained:

We were taught faith, you know, “Naming, claiming, believe God, and it’s going to happen.” So, when I found out I was positive for the first two years I did nothing. And-- ‘cause I was naming and claiming. And, eventually, I had to claim and name some medicine, because I got sick!... When I got [to the clinic] they took my blood and they called me back in later to say, “We need you to come in immediately,” because of what my viral load was. And at that point I knew, okay, I believe God, I trust the Creator and everything, but something’s got to be done about this from a medical perspective. Because thinking itself just in the Creator is nice, but you also need to have faith in the wisdom that He’s given Men to be able to help with medical situations. And I believe that that’s where the merger has to be, that wisdom that’s been given to men needs to be magnified.

Increasing Support to Parents of Black Sexual Minority Men within the Church

Although the participants largely focused on how spirituality and religion fostered their health and well-being directly and how these could be incorporated into HIV-related programming or services for Black SMM, younger participants felt strongly that programs were needed in the church to help parents accept children who are a sexual minority, as these relationships (or lack thereof) impact health and well-being through various means, including limiting the ability of younger men to ask questions about sexual health and safety and increasing the possibility that they may engage in behaviors that increase their risk of HIV acquisition:

Something geared towards helping our, I want to say parents, parents of youth, deal with if they're having difficulties helping their [sexual minority] child, kind of helping them navigate there. Because it's really a personal problem for them. We're kind of helping them navigate through that because essentially what's happening is when these kids are being turned away from their parents, that increases their chances of promiscuous, risk taking behavior.

To assist parents, participants discussed the need for family counseling in the church, acknowledging that the family counseling should be facilitated by a family counselor “well versed” in working with religious families to accept their sexual minority child:

But being able to not only have someone there that's knowledgeable on religion so that they can at least see why the parent feels that way and then help the parent understand, like you said. You know, it's not exactly what you may want, but what do you prefer, a dead child or a knowledgeable child that's at least being safe?

Another suggestion, made by an older participant, was a support group for mothers: “…just like, what is that name? They got the mothers together against drunk driving…You know how they say the men might be in charge, but it’s the women who always be of course be the [boss].” In addition to being a support for one another, the mothers could also lead educational activities within the church, providing information and testimonials to the congregation that challenge ideas of homophobia and promote acceptance of and love for sexual minority men and women as well as people living with HIV. Through providing this support for parents within the church, and potentially sparking a change within the congregation by challenging homophobic views, participants felt that the health and well-being of Black SMM, including their sexual health, may benefit as a result of improved family relationships and enhanced spiritual and religious support opportunities within the church.

Discussion

This study identified opportunities for spiritual and religious supports to promote HIV prevention and treatment and inform local HIV intervention efforts for Black SMM. Overall, Black SMM shared that their spiritual and religious beliefs and practices impacted their sexual health and well-being and expressed a strong desire for greater spiritual and religious supports in non-church-based settings. Participants felt that HIV-related programming for Black SMM should be considered largely as a spiritual support to welcome Black SMM of various Christian denominations and beliefs, that such programming could utilize peer navigators or peer supports, include prayer and gospel music, and incorporate specific spiritual and religious messaging. Many of these suggestions (i.e., prayer, listening to gospel music, messages) were utilized by participants independently as a way to cope with life’s daily struggles and social determinants (e.g., limited resources, low social support) that, as Black SMM, also impact HIV outcomes. Thus, participants felt that these strategies may be useful to engage Black SMM in HIV interventions and programming and encourage treatment adherence for Black SMM living with HIV.

Although research has demonstrated that spirituality and religion positively influences health, Black SMM might not be able to fully experience the social, spiritual, and health benefits associated with religious involvement due to the negative attitudes of many Black churches towards homosexuality and feelings of conflict or rejection by organized religious communities [18, 39–42]. It is possible that spiritual and/or religious supports in non-church-based settings and the use of peer support and/or peer navigators may ameliorate the negative effects of their engagement in non-affirming churches and serve as an alternative means of achieving similar benefits that others may receive through church membership.

Participants in our study prioritized non-church-based spiritual and religious supports for HIV-related programming; however, church-based programs may provide examples of effective health programming that incorporate spirituality and religion. Peer support groups such as Discipleship/Bible study groups, age-based groups, and grief support groups are common within church congregations (although these are generally not readily available or inclusive of sexual minorities); although not widely studied, health-focused support groups based in church settings have demonstrated positive health outcomes [43–47]. Additionally, health interventions focused on a variety of health issues and diseases that utilize peer educators in church settings have been shown to positively improve health outcomes [48–51]. Thus, in addition to the program messages identified by the participants in our study (i.e., treat yourself preciously, taking care of your health can strengthen your relationship with God), these programs can provide examples of how peer support- and/or peer navigator-led HIV-related programs for Black SMM in non-church-based settings could incorporate spiritual and/or religious elements and messages.

Additionally, these elements and messages could be utilized, as suggested by participants in our study living with HIV, by case managers or other clinical staff providing support to Black SMM living with HIV. Research has demonstrated associations between spirituality and/or religiosity among people living with HIV and reduced likelihood of severe depressive symptoms [52], slower HIV disease progression [53], and increased likelihood of returning to HIV care [54]. Incorporating spirituality and/or religion into clinical practice, clinical case management, or other peer support programs for Black SMM living with HIV could improve patient outcomes. Providers or peer support leaders should assess a person’s spiritual and/or religious views and support patients utilizing religious resources to cope. While this may include referring patients to a pastoral counselor, religious clergy, or religious support program, it may also include discussion of spiritual and religious beliefs, incorporation of messages such as those identified by the participants of this study into discussions, or prayer. Providers and peer support leaders do not need to be religious themselves to recognize that some Black SMM patients may benefit from this support, and these strategies can be incorporated into cultural competency training programs. However, examination of spiritual and/or religious interventions in healthcare settings is limited; thus, more research is needed to demonstrate whether incorporating spiritual and/or religious support in this manner can improve health outcomes for Black SMM living with HIV [55].

In addition to expressing a desire for spiritual and/or religious support in efforts to address HIV prevention and treatment in non-church-based settings and identifying important elements of these potential programs, our findings highlighted two important interventions needed within church settings in conjunction with HIV prevention and treatment interventions for Black SMM occurring elsewhere. First, participants living with HIV acknowledged that their religious beliefs—specifically, their faith in God as their healer—delayed their acceptance of HIV treatment. This belief has been found to delay medical care for numerous diseases, including cancer and diabetes [56–58]. Thus, given evidence that spirituality and religiosity may both positively and negatively impact HIV outcomes, it is important that church leaders are educated about the influence of the pulpit and promote messages and actions that support adherence to appropriate medical care. Second, participants expressed a need for parental support within the church to foster healthy relationships within religious families so that these relationships may aid in improving HIV-related outcomes for Black SMM and potentially expand opportunities for spiritual and religious support to Black SMM within the church setting. Data suggest that family plays an important role in comprehensive HIV prevention efforts for Black SMM [59–63], and that support from family can be beneficial for Black SMM living with HIV [26, 64, 65]. Providing parental support groups in the church may aid in fostering communication and closeness among religious families when a family member is a sexual minority by providing a safe space for family members to explore and process their beliefs and feelings regarding homosexuality and their faith.

This research is not without limitations. We did not quantify the level of religious or spiritual involvement of Black SMM in this study, or standardize the definitions of religiosity and spirituality. This study also recruited a convenience sample of Black SMM in Baltimore City; the findings may not be generalizable to other areas in the U.S., as research demonstrates that there are large regional differences regarding religious involvement among Black community members [66].

HIV disparities experienced by Black SMM along the HIV care continuum result from a complex syndemic affect of behavioral and structural factors; interventions to address these are urgently needed. Given the salience of spirituality and religion among Black SMM, incorporating spiritual and religious elements into these intervention strategies could help Black SMM increase coping strategies and circumvent structural barriers. Our findings add to a body of research on spirituality, religion, and health among Black SMM by identifying ways in which non-church-based HIV-related programs can incorporate spiritual and religious supports and by highlighting the need for interventions within the church setting that may indirectly improve HIV prevention and treatment among Black SMM. Spirituality and religion are important in many Black SMM’s lives, and integrating spiritual and religious elements into HIV-related programs may improve intervention outcomes. The strategies identified by Black SMM in this study could aid in designing culturally congruent HIV prevention and treatment programs in the community.

Funding Information

This project and publication was made possible with help from the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIGMS, NIDDK, and OAR. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.