Table 2.

Illustrative themes on racism and White supremacy as barriers to HIV prevention across three EHE projects

	TRANSforming the Carolinas	Connecting resources for rural and urban sexual health: CRRUSH-Sacramento	Ending the HIV Epidemic: Integrated Technology Solutions
Intersectional stigma	As far as providing HIV prevention, messaging, and testing--again, the challenges are just getting people in the door…ensuring that our staff…continue to be trained and deemed competent to provide care for transgender people of any color, but especially those who are African American and Latino. Okay, poverty. Just that. You start adding other things that create intersectionality. Like race. Okay. It’s not just poverty, now it’s an impoverished Black person. Not just an impoverished Black person, it’s an impoverished Black Trans woman…any one of those issues is difficult to deal with by itself. Just being Trans, just being Trans women, just being Black persons, just being poor persons--when you combine those factors, yeah, that’s much more difficult. That increases stress, depression, poor health, suicide. So many things. [For] a transgender person of color, just walking out the door in the morning is often an act of courage. They face barriers at every turn… So it’s just not that easy to say, ‘Oh, just come to your appointments and take your pill, couldn’t be any easier.’ Well, there’s so much more going on in their lives that it can be really hard.		The intersectionality is impossible to ignore. So, with every compounding identity that you have that is marginalized, the way that you’re treated is worse exponentially. Your barriers to accessing care are greater exponentially.
Medical mistreatment of people of color & Medical mistrust		Basically, my experience [as a gay Black person] there is that they try to dismiss everything as normal. And that’s what you get. So you go in for whatever, ‘Oh, it’s normal. It will go away.’ And they send you out, within five to ten minutes you’re out of there. With like no follow-up whatsoever. They just want you out of there. By comparison, right, if you go to the more well-off areas, and you’re able to speak English, they actually pay attention to you and try to figure out what’s wrong with you, rather than saying it’s normal and it’s going to go away on its own. A lot of times [doctors] don’t take enough time to listen to their patients or take what they’re saying seriously enough. And I had a lot of pain in my stomach area for about six years and I kept complaining to the doctor and telling them that I was bleeding and in severe pain and they kept telling me that I was fine. And so I finally…I kept fighting and saying…I needed a referral to someone else. So they referred me to a gastroenterologist [who found] I have Crohn’s colitis. So like all those years of me being in pain and bleeding was an actual disease and the doctors weren’t listening to what I was saying. [My providers] would kind of shove propaganda down your throat, make you feel bad about yourself sometimes. But, you know, in all fairness, it was just to protect you from the real world.	Black and Brown folks can go to the doctor and say, ‘I’m in pain,’ or, ‘This is what’s wrong. This is what I’m feeling.’ [and the doctor says] ‘Oh, just here’s some ibuprofen. Sleep it off. Here’s some simple pain meds if it doesn’t get any better.’ … to be brushed off just makes us go back to that [old mentality of], “See, I told you I’m fine. Nothing’s wrong. I’m okay.” And then the next thing you know, somebody’s dropping. So the impact of racism when it comes – systematic racism when it comes to the medical field is so deep it’s really hard to navigate. Black and Brown folks, folks who don’t speak English…their experiences [of being] just left in the hallway, turned away, not given medicine, treated like they’re med seeking when they’re not. One of them, there was a Black trans woman [and] her friend--but their relationship was so close that she referred to her as a her sister--died in the waiting room at a hospital because the doctors would not treat her….I’ve heard horrific stories from people. There is a big distrust in the medical communication, especially as it pertains to the Black community, and so sometimes they’re not upfront with things that they’re doing, activities that they’re participating in because they think that it’s gonna go to the government, to the police, and things like that. One [of the biggest barriers] is the lack of knowledge about where to go, and the mistrust and distrust that Black and Brown folks have when accessing mental health facilities, or just connecting to providers in the community in general.
Impact of racism on HIV prevention and care experiences	Especially here in South Carolina. I feel like racism plays a bigger role than transphobia. So if you don’t know where you can get care in what you would consider a safe place culturally, then you’re going to be less likely to get the care.		Whenever someone is discriminated against simply because of the color of their skin, they disconnect [from HIV care] and a lot of times it’s a ripple effect because word of mouth travels…And so there might have been 40 or 50 people that were getting ready to come in after me. Now, you’ll never see those 40 or 50 people and maybe they need to come in, but they won’t because of that experience. There’s a…[local clinic] which is almost entirely staffed by cisgender white women…and they’re great…They’re fun but also, you’re not seeing people who look like you. How comfortable do you feel actually going there?…Are you going to go to a place to get an HIV test? Are you gonna actually get in your car and drive somewhere to go and do that? And, I think largely the answer is, ‘No, I’m not.’
Concerns for physical safety	Even though [local homeless shelters] try by law to help trans people of color, trans people of color still feel uncomfortable in those spaces. They don’t feel safe in those spaces and they’re not treated with respect and dignity.		In [large city in the South], LGBTQ+ or whatever the alphabet is accepted. There’s a whole keep [city] weird. But I’m telling, you five minutes outside of here and we have literally gun-toting, rebel flag-waving white men with AK47’s. And so there’s a lot of fear and there’s a lot of legitimate fear, especially for people of color in the queer community. [We’ve been] working with a group out of [large city in the South] with primarily Black Trans women. Their biggest concern was safety. A lot of people were getting the shit kicked out of them. People were getting murdered.
Persistent systemic racism	Systemic racism is built into how we combat these issues. So not to be trite, but there was no giant war on drugs until Becky was walking into the hood to get crack. And as long as we are talking people of color and people who aren’t feel like these issues do not affect them, we’re going to be fighting for legislation and greater funding to combat these ills. This is why community mobilization is so important. We just got to stop this mess.	The quality of care is not the same in South Sacramento [as] in the better-off areas. So, personally, you know, even though I have a hospital that is literally, like, five minutes away from my house, I do not go there because I know I’m not going to get the … quality of care that I need. I have to drive up about 20 minutes, 25 minutes, to get better quality of care. And that’s because South Sacramento is people of color, right. And in most cases, with the Latino community, and with the Asian community, there are non-English speakers, right. So they get whatever they can. But fortunately, you know, being able to speak the language, I can get out of my neighborhood, and seek quality care	If you talk housing, if you’re talking about HIV information, access to information, healthcare systems, we cannot not talk about racism. You just can’t leave [racism] out of the conversation. We basically have as close to a solution as you can come without having to cure for HIV. Since the eighties, have you removed stigma? Have you removed societal disparities? Have you removed racism? Have you removed homophobia, right? We haven’t. Those are still issues. And they’ve changed over time, but they were there then and they’re there today.
Racial inequity in organizational leadership and training opportunities	I know there are some national training [opportunities for trans care], but even some of them are not Black specifically, if that makes sense, or African-American. A lot of them, you can tell by some things that they are probably come from more predominantly White institutions and things are different.		[The] healthcare system, anything that is for-profit, in my experience, has been race-driven…the people that are part of the leadership and making decisions for the community that they’re serving, although they’re not in the community, are White people, and that’s across the board.