Despite overall improvement in HIV prevention and treatment outcomes and reduction of HIV incidence and mortality across the United States, Hispanic/Latino persons, persons who live in the U.S. South, and men who have sex with men (MSM) continue to experience a disproportionate burden of HIV [1–5]. For Hispanic/Latino MSM (HLMSM), intersectionality and minority stress theory explain how having a “dual minority status” can further elevate HIV risk and thus exacerbate disparities in HIV trends among HLMSM as compared with trends seen in other racial/ethnic and sexual orientation groups. In addition, HLMSM living in the southern United States must contend with socioeconomic factors like poverty and unemployment or cultural factors such as HIV stigma that have been found to affect HIV prevention and treatment in the region [3, 6–10]. Studies have also identified behavioral factors such as higher rates of condomless sex, not using pre-exposure prophylaxis (PrEP), and lower PrEP awareness (as compared to White MSM) [1, 11]. Qualitative interviews with HLMSM identified low knowledge about HIV prevention, transmission, and treatment [12] [1], increased likelihood of engaging in sexual behaviors associated with HIV acquisition, and low-risk perception [13, 14] as contributors to disparities among HLMSM.

Our research questions were guided by a strengths-based approach in which we posited that individual and community strengths and assets contribute to HLMSM remaining HIV negative, and these self-identified protective factors provide unique opportunities for preventing HIV. We used resilience theory [15–18] to understand how experiences of adversity (increased likelihood of exposure to HIV) might result in protective health outcomes (prioritizing behaviors that prevent HIV transmission) for sexual minority men [19–21].

To meet the goals of the Department of Health and Human Services’ multi-agency national initiative, Ending the HIV Epidemic (EHE) [22], prevention efforts must focus on the Hispanic/Latino community [23, 24], specifically HLMSM vulnerable to HIV infection [25]. To eliminate HIV disparities among HLMSM, it is imperative to understand how HIV-negative HLMSM who reside in high HIV burden areas, such as the U.S. South, remain HIV negative despite challenges that increase exposure to HIV [19], and perceptions of what is considered a transmission risk among HLMSM who engage in behaviors associated with HIV acquisition [26]. The purpose of this study was to understand how HLMSM not living with HIV who reside in the southern U.S. understand and prevent HIV, and to identify factors HLMSM attribute to remaining HIV negative.

Between July and September 2016, we conducted in-depth interviews with 150 HIV-negative adolescent and adult cisgender Black/African American (N = 99) and Hispanic/Latino MSM (N = 51) in five cities in the southern U.S. with elevated HIV prevalence among racial/ethnic minority MSM at the time of data collection: Atlanta, GA; New Orleans, LA; Baton Rouge, LA; Jackson, MS; and Miami, FL [2, 27, 28]. Eligibility criteria were 13–17 years of age for adolescents, and ≥ 18 years of age for adults; evidence of an HIV-negative test result in the past 6 months [self-reported negative/unknown status accepted for those < 18 years of age]; self-identify as cisgender male; self-identify as Black/African American or Hispanic/Latino; reside in one of the five cities listed above; report oral or anal sex with another man at least once in the past 6 months or (if a minor) indicate physical attraction to other males; and be proficient in either English or Spanish. Respondents were screened by phone or in person. Participants were recruited through referrals from local community–based organizations, health departments, clinics, HIV testing sites, and via word-of-mouth referrals and flyers from local service–providing agencies. Respondents were screened for eligibility and provided a $40 cash incentive for participation. A purposive sampling strategy was used to ensure that quotas were met based on city, race/ethnicity, and age group to achieve qualitative data saturation for subgroups. Study procedures were approved by the Emory University Institutional Review Board (#IRB00077517).

Interviewers were trained social scientists diverse in gender, race/ethnicity, age, and ability to speak Spanish with experience conducting interviews with MSM, including HLMSM and Spanish-speaking MSM. Participants were recruited through community sites and interviews conducted at the community-based venue or at a private location convenient to the participant. Participants provided voluntary informed consent (those aged 13–17 provided voluntary informed assent and parental consent was waived by the IRB due to potential risk to minors of disclosure of sexual attraction or behaviors to parents or guardians). For this analysis, we focused only on data collected from HLMSM participants. Findings from this study specific to Black/African American MSM participants are published elsewhere [27].

Eligible MSM were invited to complete a brief sociodemographic questionnaire and a 1-h in-person in-depth interview (IDI). Sociodemographic questions covered age, race/ethnicity, sexual identity, education, employment, housing status, health insurance coverage, sex-seeking behaviors, number of sex partners, relationship status, and internet use. IDI questions included perceptions and experiences of HIV prevention, including sexual behaviors, PrEP use, and condom use. Interviewers were trained to ask probing questions to elicit greater depth and reflection in participant responses [29], especially related to perceived protective factors. Interviews were digitally audio recorded, translated, and transcribed verbatim. Transcripts were not reviewed for accuracy by participants prior to analysis. Findings were not reviewed or validated by participants but were shared with community-based organizations assisting with recruitment.

Interview transcripts were coded for themes present in the data using a qualitative content analysis approach [30]. The coding process was facilitated by Lumivero NVivo qualitative data analysis software (version 11, released 2015). An initial codebook was created based on a review of the interviews. To ensure reliability in the coding process, four study team coders independently coded the same interviews with the codebook and assessed agreement using pairwise comparisons of coders (A vs. B, A vs. C, etc.) and the coder group (A vs. combined codes of B, C, and D). Agreement was measured by calculating Cohen’s Kappa [31]. Differences in coding were resolved via consensus until final agreement reached a Kappa score of ≥ 0.8 [32, 33]. The coded data were further analyzed using NVivo’s cluster analysis tools to identify codes that frequently occur together and form a narrative to describe the experiences of HLMSM) [34, 35]. Behavioral scientists, including Spanish speakers on the team, reviewed the interviews for context related to the cultural experiences of HLMSM, including those MSM not born in the United States. This method resulted in themes frequently associated by HLMSM with remaining HIV negative. A detailed description of the analytic methods has been reported elsewhere [27].

The sample included 51 HLMSM with recent HIV-negative test results. Table 1 depicts descriptive sociodemographic characteristics of respondents. Most respondents lived in Miami, FL (73%, n = 37) or Atlanta, GA (18%, n = 9), and the mean age was 33 years (SD = 15, range: 15–63). One-fifth of respondents were < 18 years of age (20%, n = 10). Nearly half (45%, n = 23) of respondents had attended some college, and half (51%, n = 26) were employed at the time of the interview. A quarter (26%, n = 13) of respondents reported staying on the street, in a shelter, or temporarily in someone’s home because they did not have a regular place to live or stay in the 12 months prior to the interview, and 14% (n = 7) reported being homeless at the time of the interview. Over a third of respondents (35%, n = 18) were uninsured; however, 84% (n = 43) had seen a doctor or nurse for care in the past 12 months. Most respondents tested for HIV every 3–6 months (61%, n = 31), although five (10%) reported having never been tested, and only 3 (6%) respondents report using PrEP. Over half of the respondents (59%, n = 30) reported having more than 11 sexual partners in the previous 6 months, and 43% (n = 22) reported using the internet recreationally to meet other men for casual sex. However, 59% of respondents reported being in a relationship at the time of the interview (n = 30), 88% (n = 45) felt there was a community of men like them in their city, and 67% (n = 34) reported feeling somewhat or very connected to the community of HLMSM in their city. More than half of the respondents were born in the U.S. (53%, n = 27), and sixteen interviews were conducted in Spanish (31%).

For this study conducted in urban areas in the southern U.S. with high HIV prevalence among racial/ethnic minority MSM, we sought to understand the context of HIV for HLMSM and to identify perceived prevention practices. It has been widely reported that stigma and taboo impede access to and acceptance of HIV prevention tools and services among HLMSM [12, 13, 24, 26, 36–45]. HLMSM in our study perceived they were not able to openly discuss HIV and homosexuality within families and the wider Hispanic Latino community. In response to the HIV epidemic in their communities, HLMSM developed strategies they believed protected them from HIV infection in environments where homosexuality and HIV are stigmatized and tabooed, demonstrating potential resilience when faced with adversity [15–18]. We learned that HLMSM in our study use condoms, but also employ personal prevention strategies not inherently associated with traditional HIV prevention approaches, such as assessing partners for their HIV status both with and without directly asking them, engaging in sex practices based on perceptions of trustworthiness, and taking the initiative to learn about HIV. As with the cohort of Black MSM in this study [2, 27], HLMSM choose to trust each other as self-protection when familial and social/structural systems fail, possibly in pursuit of agency or control over their circumstances. Using condoms, requesting the HIV status of partners, assessing the risk of new partners, and trusting partners to be negative to reduce potential of HIV acquisition are prevention practices that were also identified in another study of HLMSM in the U.S. South [3, 46], but otherwise, are not widely noted in the literature. Few participants in this study reported PrEP use and over a third were not aware of PrEP; low PrEP awareness and uptake among HLMSM are associated with stigma, medical mistrust, and machismo [40, 45, 47], indicating a topic for further research and intervention.

Social relationships are protective against HIV for HLMSM [48]. A study of HLMSM in San Antonio found that HIV-negative HLMSM were more likely to have a prominent mother-son relationship and a strong sense of family support and acceptance, compared to those with HIV infection [37]; other studies indicate that HLMSM with a higher affinity for familismo are more likely to engage in sexual behaviors that mitigate HIV acquisition [49, 50]. Among the HLMSM in our study, more than three-quarters reported having a friend or family member they can trust to talk with about HIV, felt somewhat or very connected to other HLMSM in their community, and felt there was a community of men like them in their city. These relationships allowed men to navigate social environments otherwise perceived as restrictive and HLMSM may need more opportunities for social connectedness and relationships where conversations about HIV and other topics that might be taboo can occur. Rhodes et. al. recommend “safe spaces” for HLMSM to have supportive dialogue [12], which can be prioritized by community organizations serving HLMSM (as part of HIV prevention programming), and in online settings and other venues supporting well-being and health.

Our analysis identified that HLMSM in our study experience prevention failure when they are in environments that encourage disinhibition, especially when drugs or alcohol are used. Previous research among HLMSM regardless of HIV status found that substance abuse may be related to decreasing sexual inhibitions and social connection [38, 51–53]. PrEP can be promoted for HLMSM using substances to navigate sociocultural stressors, even when there is less than optimal uptake and barriers that impact PrEP access, use, and adherence for HLMSM [54]. Our findings related to PrEP are discussed in greater detail elsewhere [47].

Strengths-based approaches have emerged as important constructs in HIV research [19] and LGBTQ health overall [55]; however, public health messaging has prioritized a risk narrative to prevent HIV. When assessed against the backdrop of cultural and socio-political barriers to HIV care, health communication highlighting disparities may have unintended consequences for HLMSM [19, 56]. Given the reports of HIV fear and anxiety among the HLMSM in our study, and that almost all respondents know someone with HIV, HIV messaging can focus on strengths and support prevention behaviors in which MSM are already engaged, such as developing personal HIV prevention strategies based on partner trust and the desire to openly communicate about HIV with peers [27, 57].

There are important caveats and limitations to note in how participants were recruited to the study. First, the purposive sampling design used to ensure HLMSM were recruited from each of the participating cities, and the effort to include young MSM aged < 18 years introduce sampling biases. In addition, MSM were recruited from sites or agencies which conduct targeted, free HIV testing. Generalization of findings should thus be undertaken with caution; findings from this study may not be transferable to other HIV-negative HLMSM, or to other HIV-negative populations in the southern U.S. However, for a qualitative data collection effort, the large sample, and the wide range of ages of participants do provide rich data on the diversity of experience. Likewise, the cross-sectional nature of the study design does not allow us to fully identify the temporal elements for how the respondents’ vulnerability to HIV infection evolves over time. Also, as is typical with face-to-face interviews, social desirability bias may have been a factor in how participants responded to interview questions. Our analysis is not a comprehensive review of all potential factors that might affect HIV risk; for example, we did not include data on urban versus rural, community-level or societal-level economic, cultural, or political conditions that form the contextual background to the respondents’ lives and HIV exposure. Instead, our results relied on personal experiences. The self-reported nature of our data is an important strength because it allowed the respondents to provide clear reasons for how and why they were or were not utilizing HIV prevention strategies. Finally, we acknowledge the age of the data and the potential limitations to interpretation. We believe these findings are still relevant to the literature and intervention development but should be confirmed with more recent data if available.