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Published in final edited form as: AIDS Care. 2020 Nov 27;33(7):943–951. doi: 10.1080/09540121.2020.1852161

Deterrents and motivators of HIV Testing among Young Black Men Who Have Sex with Men in North Carolina

Megan Threats a,e,*, Donte T Boyd b,e, José E Diaz c,e, Oluwamuyiwa Winifred Adebayo d,e
PMCID: PMC8155091  NIHMSID: NIHMS1648218  PMID: 33244990

Abstract

In the United States (US), young, Black men who have sex with men (YBMSM) are disproportionately affected by HIV. Delayed and infrequent HIV testing has been associated with the increased likelihood of YBMSM to be infected, yet unaware. Despite increased efforts to provide HIV testing to Black men who have sex with men (MSM) in the US, HIV testing remains underutilized by YBMSM in the South. To develop strategies to increase HIV testing, this study sought to understand the factors that affect HIV testing utilization among those at highest risk for infection. Twenty-two HIV-positive and HIV-negative YBMSM aged 18-34 in North Carolina participated in semistructured interviews. Qualitative thematic analysis revealed that deterrents and motivators to HIV testing spanned individual, social, and structural levels. Deterrents included a low perceived risk of HIV, fear of receiving an HIV-positive test result, lack of HIV testing locations, healthcare provider mistreatment and privacy concerns due to intersectional stigma. Motivators of HIV testing included health maintenance, social support, and increased access to HIV testing. The findings from this study contribute to ongoing research efforts that seek to address inconsistent HIV testing and late HIV diagnosis among YBMSM. Interventions to address intersectional stigma in community and healthcare settings can enhance utilization of HIV prevention services.

Keywords: HIV testing, late testing, men who have sex with men, Black/African-American, intersectional stigma

Introduction

Black men who have sex with men (MSM) experience a disproportionate burden of HIV in the US. Black MSM have a one in two chance of becoming infected with HIV during their lifetime compared to one in five among Latinx MSM, and one in eleven among White MSM (Hess et al, 2017). In 2017, 75% of Black MSM who received an HIV diagnosis were aged 13-34 (Centers for Disease Control and Prevention, 2019a). Between 2014 to 2018, HIV diagnoses remained stable, but increased by 12% among YBMSM aged 25-34 (Centers for Disease Control and Prevention, 2019a). In the US, southern states account for an estimated 51% of new HIV diagnoses despite making up roughly one-third (38%) of the population (Centers for Disease Control and Prevention, 2019b). YBMSM account for six out of every ten new HIV diagnoses among Black Americans living in the South, and have the highest rates of new HIV diagnoses among MSM of all ethnicities (Centers for Disease Control and Prevention, 2019b; North Carolina HIV/STD/Hepatitis Surveillance Unit, 2019). An analysis of CDC-funded HIV testing data revealed that Black MSM living in the South only received 6% of HIV tests provided but accounted for 36% of new HIV diagnoses in non-healthcare facilities (Marano et al., 2016).

HIV testing is a critical entry point to the HIV prevention and care continua. YBMSM are more likely to have undiagnosed HIV infection, and to be diagnosed with AIDS when they are screened compared to their Latinx and White counterparts (Mannheimer et al., 2014; Oster et al., 2011). It is imperative for YBMSM living with HIV to receive timely medical care following HIV diagnosis, including immediate initiation of antiretroviral therapy (ART), and, consequently, viral suppression to undetectable levels. These actions contribute to significant lower risk of HIV transmission to sexual partners who are not HIV-infected (Cohen et al., 2016). Thus, timely diagnosis, linkage and retention in HIV care is essential for reducing HIV transmission risk among YBMSM.

Despite increased efforts to provide HIV testing to Black MSM in the US, HIV testing remains underutilized among YBMSM in the south (Marano et al, 2018). There is a growing body of literature which examines deterrents (e.g., stigma and discrimination, difficulty accessing HIV testing) and motivators (e.g., peer support) of HIV testing among Black MSM in non-Southern states (Arnold et al., 2014; Frye et al., 2018; Nanín et al., 2009; Levy et al, 2014; Mimiaga et al., 2009; St. Lawrence et al., 2015). The limited work among YBMSM in the South found that experiences of racism and homophobia separately predict delayed HIV testing, while peer social support works as a protective factor (Scott et al., 2014). To date, few studies have simultaneously examined the multidimensional factors (e.g., structural, social, and individual) that affect HIV testing uptake among YBMSM (Arnold et al., 2014; Frye et al., 2018).

Reducing HIV-related disparities among YBMSM in the South is one of the key goals of the National HIV/AIDS strategy of the United States (National HIV/AIDS Strategy Federal Interagency Working Group, 2015). Despite the growing body of research literature examining deterrents and motivators of HIV testing uptake among Black MSM, it is insufficient for identifying these factors among YBMSM in the South.

This paper utilized a social-ecological theoretical approach to contextualize the deterrents and motivators of HIV testing among YBMSM in the South (Green et al., 1996; Poundstone et al., 2004).This approach involves identifying structural (e.g., access to HIV prevention and care services), social (e.g., community norms, interpersonal relationships with friends, family, and sexual partners), and individual-level (e.g., knowledge and beliefs) factors. Examining these factors from the perspectives of YBMSM in the south may be useful for revealing underlying mechanisms of undiagnosed HIV infection, and for creating strategies for increasing HIV testing uptake. Thus, the objective of this study was to identify factors that may deter or motivate HIV testing uptake from the perspectives and previous experiences of YBMSM in the South.

Methods

The qualitative data presented in this manuscript was drawn from a larger study with two sources of data: an online, self-administered survey and semistructured interviews (Threats & Bond, 2020). The study population (N=83) of YBMSM who completed the survey included HIV-negative, HIV-positive, and HIV status unknown participants. Men were eligible to participate in the study if they: self-identified as Black or African American, were aged 18 to 34, residing in the state of North Carolina, were willing and able to provide informed consent, and self-identified as gay, bisexual, or a man who has had sex with men. Recruitment of participants was done through venues including: HIV/STI clinics, AIDS Service Organizations, LGBTQ organizations, postings on social media sites and geospatial dating applications, bars/clubs, historically black colleges and universities, and public postings. A convenience sample was also recruited from the University of North Carolina at Chapel Hill Center for AIDS Research. From this larger group, twenty-two (n=22) participants who completed the survey took part in semistructured interviews that were used for this qualitative analysis. The institutional review board at the University of North Carolina at Chapel Hill approved the study.

Participants and Procedures

Twenty-two YBMSM participated in semistructured interviews from June – July 2019. Participants were purposively sampled based on the following criteria: HIV-positive diagnosis (9), HIV-negative and using pre-exposure prophylaxis (PrEP) (7), and HIV-negative but not using PrEP (6). By including the perspectives of YBMSM living with HIV, this study contributes factors which may help to explain late testing/diagnosis among this group. Given that HIV testing is the starting point to HIV prevention and treatment tools such as PrEP and ART, YBMSM at different points of engagement along the HIV prevention and care continua were included.

The interviews were conducted by the lead author, a trained and experienced qualitative researcher, using Zoom videoconference software. Interviews averaged one hour and sixteen minutes and were guided by participant responses to survey items on topics including, but not limited to: experiences with and perceived deterrents and motivators to HIV testing, most recent testing experiences, thoughts and feelings about HIV testing venues, use of mobile devices and the Internet to locate HIV testing services, and experiences of exposure to HIV testing information while using social networking sites and geospatial dating applications. Written informed consent was obtained from all study participants. Participants who completed an interview received a $35 Amazon eGift card. Interviews were audio-recorded, transcribed verbatim, and member checked. Each participant was assigned a pseudonym.

Analysis

Thematic analysis of interview text data was conducted using Dedoose software (Version 8.0.35). Interview transcripts were analyzed thematically using grounded theory methodologies, including line-by-line and focused coding and the constant comparative method to reveal themes that might explain motivators and deterrents to HIV testing uptake among YBMSM (Charmaz, 2006; Rubin & Rubin, 2011). Each interview transcript was read, and all text related to HIV testing was highlighted. The selected text was re-read and coded line-by-line to identify initial emergent themes. Next, the most frequently reappearing initial codes were chosen to begin explaining larger sections of data, and codes were condensed based on their thematic similarity. Codes were compared within and across interview text data to yield the most significant themes and provide more detailed information about structural, social, and individual-level factors that might explain the HIV testing behaviors of YBMSM in the South.

Results

Sample

A sociodemographic profile of the 22 interview participants is provided in Table 1. Participants were aged 22-33 with a mean age of 28.8 (SD = 3.4) and resided in nine counties across the state of North Carolina. Most participants identified as gay (77.3%), with 22.7% identifying as bisexual. Most participants were employed at least part-time (77.3%) and had an annual household income of less than $40,000 per year (77.3%). Most participants had health insurance (59.1%) with 40.9% reporting they were uninsured. The sample was comprised primarily of HIV-negative men (59.1%), and 40.9% were HIV-positive.

Table 1.

Participant Demographics

N (%)
Age, mean 28.8, range 22-34
         22-27 7 (32%)
         28-34 15 (68%)
Education
         < High school 1 (4.5%)
         High school/GED 7 (32%)
         Associate degree 3 (13.6%)
         Bachelor’s degree 6 (27.2%)
         Graduate degree 5 (22.7%)
Employment
         Employed part-time 6 (27.3%)
         Employed full-time 11 (50%)
Annual Household income (USD)
         < 20,000 9 (40.9%)
         20,000-39,000 8 (36.4%)
         40,000-69,000 5 (22.7%)
Residence
         Urban 16 (72.7%)
         Rural 4 (18.2%)
         Regional city and suburban 2 (9.1%)
Health Insurance
         Private health insurance 10 (45.5%)
         Medicaid 3 (13.6%)
         Uninsured 9 (40.9%)
Sexual Orientation
         Homosexual 17 (77.3%)
         Bisexual 5 (22.7%)
HIV Status
         Positive 9 (40.9%)
         Negative 13 (59.1%)
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Deterrents to HIV testing

We identified five main themes related to the deterrents of HIV testing among YBMSM in the South (see Table 2) that align across the different levels of the ecological model (structural, social, individual). Deterrents to HIV testing at the structural level included healthcare provider mistreatment rooted in perceived and experienced intersectional stigma and lack of HIV testing locations in close geographic proximity to participants. Deterrents at the social level included privacy and confidentiality concerns rooted in anticipated intersectional stigma. Finally, deterrents at the individual level included a low perceived risk of HIV, and the fear of receiving an HIV positive test result. Our analysis found that factors that hinder the uptake of HIV testing among YBMSM in the south are multilevel.

Table 2.

Illustrative quotations that demonstrate the structural, social, and individual level deterrents of HIV testing

Level Deterrent Illustrative quotations from participants
Structural Healthcare provider mistreatment (perceived and experienced intersectional stigma) “When they see my chart, and they see what I’m in here for, it’s like ok, typical. I’m a Black man coming in here and being treated for an STD or STI. And the doctors comes in, that’s who passes judgement. She went in and looked at my past visits, and like, you’ve been here for this thing on this date, and this other thing on this date. And yea, you know I need to stop doing what I’m doing. But I’m thinking, b#### are you passing judgement on me right now? What are you doing? So I guess you can say I’m stigmatized.” (Will, age 27, HIV-negative, not using PrEP)
“It’s just like, it’s more like the feeling you’re getting is not very friendly, so like I really wouldn’t go there anymore. I just feel bad vibes in there. It’s just kind of like…I wanna say its racist…or maybe they don’t like gay people…” (Marvin, age 29, HIV positive)
Lack of HIV testing locations “There is only one place to get tested in my town, and that is the hospital. I don’t want to get tested there. I shouldn’t have to drive an hour and a half just to get the services I need. I need more options close by.” (Kenny, age 24, HIV negative, using PrEP)
Social Privacy and confidentiality concerns (anticipated intersectional stigma) “The fear of my family finding out that, uh, cause I was very big on not having a lot of people in my business at that point in time, especially being that, hey not only am I last sleeping with women, I'm sleeping with men too. So, if somebody finds that out, then it's, oh, well, at least you're getting tested, but why are you getting tested? Who have you been sleeping with this question, that question, that third question. And so, it was that kind of, that fear that set in.” (Ricky, age 22, HIV negative, not using PrEP)
“A lot of people, especially in my area, the health department is somewhat far off the highway and is fairly close to [redacted university]. However, when you’re looking at the deeper part of the community, a lot of people either don’t know where it is, don’t know what options are open, and are kind of nervous. I’ve been scared to go in the past because I may see somebody I know, I’d rather not.” (Ricky, age 22, HIV-negative, not using PrEP)
“When I was probably like 16 or 17, I had like a little scare or whatever. Because someone that I was messing with, it was actually my boyfriend at the time, they didn’t have it, but we were having unprotected sex at that point. And I wanted to get tested, but I didn’t. I didn’t go to the doctor because I didn’t want my family to know what was going on because I’m pretty sure that my doctor would end up telling my family about it.” (Nathan, age 30, HIV positive)
Individual Low perceived risk of HIV “I was just really careful. Like really careful (laughs). Prior to my diagnosis, I had only been tested one other time. I think I was maybe 17 at that time, so I wasn’t too sexually active. I always used protection. Like always. I wish I would’ve known more information.” (Jerry, age 28, HIV-positive)
“So when I got in the relationship I was in with my ex and it went on for a few years, I was not getting tested in the relationship, because in my mind we were mutually exclusive. I already knew that he was positive and that he was undetectable, so I was not getting tested. And after that relationship I didn’t have any others. So, um, I wasn’t getting tested regularly.” (Louis, age 28, HIV positive)
Fear of receiving a HIV-positive diagnosis “You have to look a certain way, you have to make a certain amount of money. They have to be a certain race. You have to be a certain height, shape, color, all of that and I don't conform to anything. I've run into a few troubles with that, like finding love or finding, sexual relations or something of that nature. Having it [HIV] would make it even harder. It's really turned me off about the gay community and I don't associate.” (Seaburn, age 30, HIV-negative, using PrEP)
“Knowing that I guess at that time scared and didn't want to know. It's like I wasn't educated and prepared for it. I was like man I don't want to know. If I did how would I deal with it, what do I do? If I did have HIV, how would I deal with it?” (Boris, age 30, HIV-negative, using PrEP)
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Structural-level deterrents to HIV testing

The first main theme was how previous experiences of mistreatment by healthcare providers; as well as anticipated mistreatment in healthcare settings were deterrents to HIV testing among participants. Participants felt they were being negatively judged for their sexual behaviors in addition to their race/ethnicity and did not want to deal with the negative tone and approach of the staff at the HIV testing locations. Some participants avoided HIV testing because they did not want to disclose their same-sex sexual behaviors. They perceived themselves to be vulnerable to mistreatment due to their race/ethnicity and did not want to add additional stigmatization by disclosing their sexual orientation and sexual behaviors. One participant described his negative treatment by a doctor who berated him for his history of contracting multiple STIs (Table 2). Another participant shared that he stopped utilizing HIV testing, because he did not like the way providers treated him. He was unsure if he was being mistreated due to his race/ethnicity or sexual orientation (Table 2). The second main structural-level theme was a lack of access to convenient HIV testing locations. Several participants reported there were few or no HIV testing locations in close geographic proximity to their homes, and the perceived costs of traveling to an HIV testing location were too high; thus, they did not obtain HIV testing.

Social-level deterrents to HIV testing

Many participants had privacy and confidentiality concerns about the physical location and set-up of HIV testing facilities. All participants expressed concerns that the location of HIV testing facilities would compromise their privacy. Testing locations were described as “too public,” and many feared that members of their social network (e.g., family, members of the gay community, and church members) would see them accessing HIV testing services. Participants were concerned that they would experience HIV-related stigma in gay communities and stigma rooted in homophobia and presumed HIV status in Black heteronormative communities if others saw them accessing testing services. Participants also feared being “outed,” and a loss of social support from the Black heteronormative community, especially family members and church members, if they were seen utilizing HIV testing services. One participant shared his experience avoiding HIV testing because of his small, rural, “bible-based community”: “So where I come from, the community was kind of close-minded when it comes to the LGBTQ community, because of it being in the country, and because of it being a bible-based state. So the community, especially our church, if they saw me at the center, they would think I’m gay, and I wouldn’t have a home. So I just tried to avoid it.” (Derrick, age 30, HIV positive) Another participant discussed avoiding HIV testing as a teenager due to fear that his physician would tell his family that he had been tested for HIV and other STIs (Table 2).

Individual-level deterrents to HIV testing

The first individual-level theme was the low perceived risk for HIV. Some participants perceived their risk for HIV to be low because they had few acts of sexual intercourse or abstained from sex. Others noted forgoing HIV testing because they were in a monogamous relationship and assumed that their romantic partner did not have additional sexual partners. Several of the HIV positive participants discussed how an inaccurate low perceived risk of HIV was a deterrent to HIV testing before their diagnosis. One participant explained that he did not utilize HIV testing because he always used condoms during sex (Table 2). The second and final individual-level deterrent to HIV testing identified was the fear of receiving an HIV positive test result. Fear of testing positive was due to concerns about the long-term management of an HIV diagnosis (e.g. costs of medication, medication adherence and side effects) and anticipated HIV-stigma in the gay community and Black heteronormative community. Participants feared rejection and isolation from both communities and noted that living with HIV would make them even more vulnerable for mistreatment and discrimination (Table 2).

Motivators of HIV testing

We identified three themes related to the motivators of HIV testing among YBMSM in the South (see Table 3). Motivators to HIV testing included increased access to HIV testing, social support, and health maintenance. Like the deterrents to testing, the motivators were multilevel. Qualitative analysis revealed that the structural and social motivators were resilience-based factors which participants noted helped to reduce or overcome deterrents to HIV testing identified in the study.

Table 3.

Illustrative quotations that demonstrate the structural, social, and individual level motivators of HIV testing

Level Motivator Illustrative Quotes from participants
Structural Increased access to HIV Testing (Convenient testing locations) “I would say location, because my location where I live is pretty much close to a clinic, so with me being so close to there it was like, aye, why not? If I’m right there, you know, this close to a clinic, why not go and make sure that I’m ok. I have no excuse. I’m literally this close. So, just go get checked.” (Antonio, age 19, HIV negative, using PrEP)
(Free or low-cost services) “I like to go to like the gay club as well on the weekends and I get a lot of that information while I’m there. That’s probably the number one source, but a lot of testing at the gay club is free as well. And I will take advantage of that free testing especially around Pride month.” (Lawrence, age 32, HIV negative, on PrEP)
Social Social Support (informational support) “My friend is a peer educator when he was in college and he worked with a HIV and AIDS program in Virginia. So a lot of the information that I have with reference to HIV and AIDS comes from him.” (Chris, age 29, HIV negative, not using PrEP)
(instrumental support) “I had a friend of mine who actually kind of showed me how to do the rapid mouth swab HIV testing, and he was very charismatic. He’s very friendly and very approachable. And even people who I had heard, oh yeah, I’d rather not know. He would test them and they would get tested just because it’s like, okay.” (Ricky, age 22, HIV-negative, not using PrEP)
Individual Health Maintenance “I just like to stay up to date on my status. I go every 3 months. Um, that’s usually what I do. I just like to stay in the know. And I like to know the community. I like to know the stats for the gay Black men. It’s so drastic, so I’m just trying to do whatever I need to do.” (Preston, age 23, HIV negative, using PrEP)
Signs and symptoms of infection “The discharge, and the sh*t burning when I pee. That was the biggest thing right there, and just knowing that I got something that’s not right. Like I got discharge going on, I need to go get tested, I need to go get treated. You know a lot of times people, I feel like ignorant people they may have discharge and they kind of just say “oh yea that’s just that.” Not realizing that you probably just contracted something and you need to go get tested. So that was my main motive.” (Will, age 27, HIV negative, not using PrEP)
High risk sexual risk behaviors “So I guess it goes back to that unsafe practices when I would probably 21 or 22. I did get tested a lot because I wasn’t having safe sex, for lack of a better word. And now I only get tested maybe once or twice a year, the twice being at those different prides or different big club events with the LBGT community where they are giving out free testing. I do it because my friend is going to be doing it. There’s just the support then.” (Tyus, age 33, HIV negative, not using PrEP)
Fear of not knowing HIV status “I get tested because of the symptoms and what it can do to your body in the future. And, uh, it would just be to prevent it. Because you know I don’t want to have any of the symptoms that come with HIV and other STDs, you know, when it comes to relationships, I don’t want to have that extra baggage. I think about the long-term rather than the short-term.”
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Structural-level motivators to HIV testing

Increased access to HIV testing including free or low-cost HIV testing services and convenient testing locations were motivators of HIV testing among this sample. Most of the participants utilized free testing offered at gay community events. One participant shared that he often obtains HIV testing at gay clubs during PRIDE month (Table 3). Other participants lauded the convenience of accessing an HIV testing location in their neighborhood as a motivator of HIV testing.

Social-level motivators of HIV testing

Social support was a motivator for obtaining HIV testing among participants. The quotes in Table 3 illustrate the power of support within YBMSM social networks to serve as a motivator for testing and to overcome the structural deterrents such as intersectional stigma that may prevent YBMSM from engaging in HIV testing. Social support encompassed informational, instrumental, and appraisal support received from friends, family members, and romantic partners. Informational support included receiving information about HIV testing locations, HIV testing options (e.g., self-testing kit), and health care provider recommendations. Informational support exchanged within serodiscordant relationships (e.g., romantic and/or sexual partners) was commonly discussed by participants living with HIV, and participants who were HIV-negative. Appraisal support involved the encouragement to get tested for HIV, particularly by other Black MSM, especially Black MSM living with HIV. Instrumental support included getting tested with a romantic partner or friends, being transported to an HIV testing location by a romantic partner or friend and being shown how to conduct a rapid HIV self-test. One participant who was uncomfortable utilizing HIV testing at a local venue describes how his friend showed him how to use an HIV self-testing kit (Table 3). The quotes in Table 3 illustrate the power of support within YBMSM social networks to serve as a motivator for testing and to overcome the structural barriers such as intersectional stigma that may prevent YBMSM from engaging in HIV testing.

Individual-level motivators of HIV testing

Health maintenance was an individual-level motivator of HIV testing revealed in this study. Health maintenance refers to HIV testing motivated by the signs and symptoms of an HIV infection, and to minimize concerns about health due to engagement in high-risk sexual behaviors and knowledge of HIV epidemic among YBMSM in the U.S. A participant who is HIV-negative and using PrEP describes his experience of HIV testing as part of his routine general health care, and based on his knowledge of HIV incidence among Black gay communities in North Carolina (Table 3). Another participant described being motivated to be tested for HIV because he frequently had sex without a condom. The final individual-level motivator of HIV testing was the fear of not knowing HIV status. A participant shared “The fear motivated me to get tested because of the fear that I have HIV. But I overcome the fear that I have about being tested because I know that in the end, if I don’t get tested, I need to know that I’m in the clear. And not just being worried and being tested and getting the results is like a big stress reliever.” (John, age 26, HIV negative, using PrEP)

Discussion

The goal of this study was to provide insight into the multidimensional factors that may deter or motivate the utilization of HIV testing among YBMSM in the South from the perspective and experiences of YBMSM living in North Carolina, a state with HIV epidemiology similar to the greater southern US. The analysis reflects the experiences of YBMSM at different points of engagement along the HIV prevention and care continua, including those living with HIV, and HIV negative individuals. Although other studies have examined factors influencing HIV testing among Black MSM, few have included participants living with HIV (Arnold et al., 2014). By including YBMSM living with HIV, the findings from this study contribute to our knowledge of the multi-level factors that deterred HIV testing among YBMSM who are now living with HIV. These findings also provide insight into factors that may be an underlying mechanism for late HIV diagnosis among this population.

Intersectional stigma was a multi-level deterrent to HIV testing. The fear of receiving a diagnosis of HIV was rooted in anticipated stigma, and concerns about navigating HIV treatment and care long-term. The findings point to a need to communicate HIV treatment information (in addition to HIV prevention) to YBMSM, and promoting the message that YBMSM can live long, health lives with HIV. Anticipated intersectional stigma was also the root of confidentiality and privacy concerns about the physical location and setup of HIV testing facilities, particularly among participants in rural areas of North Carolina. Participants feared rejection and loss of social support from family, romantic partners, church members, and further ostracization from Black communities and gay communities if they were seen in HIV testing facilities. These findings support other studies that found heteronormativity and homophobia in Black communities and religious institutions have an impact on the HIV prevention activities of Black Americans (Nelson et al., 2017; Ransome et al., 2018; Vigliotti et al., 2020). Future HIV prevention programs and interventions which aim to increase HIV testing uptake among YBMSM in the South may benefit from collaboration with faith institutions in Black communities (Coleman et al., 2012; Ransome et al., 2018; Stewart, 2015). The findings of this study corroborate research that found the intersecting or multiple streams of stigma function as deterrents to HIV testing uptake among YBMSM (Arnold et al., 2014; Scott et al., 2014). Together, these findings suggest that interventions which target the multi-level influence of intersectional stigma may help increase HIV testing utilization among YBMSM in the South (Barry et al., 2018; Bauermeister et al., 2018; Bowleg et al., 2017; Taylor et al., 2019).

In the current study, some of deterrents to HIV testing included a low perceived risk of HIV, lack of HIV testing locations in close geographic proximity to where participants live, and fear of receiving an HIV positive test result. These findings are consistent with other studies conducted among Black MSM in non-Southern states and the Caribbean (Levy et al., 2014; St. Lawrence et al., 2015; Washington et al., 2015). Many participants who shared that their low perceived risk of HIV was a deterrent to HIV testing, discussed being in serodiscordant relationships. This finding suggests that YBMSM need targeted HIV prevention education to help them accurately assess their HIV risk, and HIV prevention and treatment information tailored to serodiscordant couples.

Our findings noted several vital motivators of HIV testing among YBMSM, including health maintenance and social support. Several participants discussed health maintenance as a motivator of HIV testing among those who utilized HIV testing as a protective measure. Importantly, many of the HIV-negative participants used HIV testing as a protective measure, because they engaged in high-risk sexual behaviors and were not using PrEP. These findings support recent calls to tackle the structural and social barriers to increasing PrEP uptake in the South, including the financial cost and provider PrEP knowledge, in efforts to reduce the HIV diagnoses among YBMSM (Lockard et al., 2019; Sullivan et al., 2019). For instance, post-HIV testing counselling should provide information about PrEP and provide linkages to clinics or providers who can enhance access to PrEP among YBMSM who engage in high-risk sexual behaviors (Khosropour et al, 2020; Nelson et al, 2019). Consistent with the existing literature, we also found that peer support acts as a motivator of HIV testing among YBMSM in the South (Scott et al., 2019). Among our sample, informational support exchanged between YBMSM in serodiscordant relationships was especially cognizant. Most existing stigma-reduction interventions include either HIV-negative or HIV-positive MSM (Bauermeister et al., 2018; Adam et al., 2011). Given the importance of informational social support exchanged within serodiscordant relationships, future interventions should include YBMSM of varying HIV status.

Limitations and Conclusion

Despite the impactful findings of this study, there are some limitations. The conclusions drawn from this study are limited by the participants’ demographic and geographic characteristics and may not fully account for the experiences of YBMSM in other Southern US states. Therefore, subsequent studies may need to explore geographic differences that may exist in the experiences of YBMSM in other Southern US states. Additionally, the deterrents and motivators identified would benefit from further statistical exploration that will identify relationships between variables and different levels of influence that were beyond the scope of a qualitative method. To continue efforts that reduce the HIV-related disparities among YBMSM living in the South, future studies would benefit from exploring the identified motivators and deterrents using a larger sample composed of a more geographically diverse sample. Nevertheless, this study uniquely contributes to research on YBMSM at varying stages of engagement along the HIV prevention and care continua, and factors that influence HIV testing uptake at multidimensional levels. Future research exploring strategies to improve engagement in HIV prevention and care should address intersectional stigma, and leverage motivators of care engagement (e.g., social support, health maintenance). Furthermore, highlighting deterrents and motivators at the individual, social, and structural levels can guide healthcare institutions, community-based organizations, government institutions, and other stakeholders in designing programs and tailoring interventions that address YBMSM’s experiences accessing and engaging with HIV testing and care more holistically.

Acknowledgments

Funding Details

The authors are supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R25MH087217. Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R25MH080665. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

Footnotes

Disclosure Statement

No competing financial interests exist.

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