Transportation, administrative burden, and COVID-19: A structural intersectional analysis of barriers to HIV care among Black sexual minority men living with HIV in the US South.

While much research has focused on individual (e.g., mental health, substance use) and structural factors (e.g., stigma, institutional racism) driving HIV inequities, less studied are the macro-structural factors like policies governing healthcare and transportation. Using the framework of structural intersectionality, we explore how transportation barriers and administrative burden - the experience of accessing safety net services as burdensome - interfered with sustained HIV care engagement among Black sexual minority men living with HIV (BSMM+) in the US South. Between July 2022 and September 2023, we conducted qualitative interviews with 27 BSMM+. Interviews averaged 60 min, and data were analyzed using codebook thematic analysis. Transportation barriers included limited bus routes, reduced capacity during COVID-19, and long travel times. Administrative burden included: not knowing how to access benefits; inconsistent benefit eligibility, required frequent renewals of public insurance; and waiting in long lines for services. Most barriers existed prior to, and were exacerbated by, COVID-related restrictions. Further, barriers intersected such as when reduced capacity on public transit overlapped with changing clinic hours. Individual-level factors have long been the focus of HIV prevention and care interventions. Our findings offer important insights into how macro-structural barriers influence HIV care engagement. Importantly, macro-structural barriers do not impact all people equally. The need for, and access to transportation and safety net services vary by factors such as race, class, and geography, with the most marginalized being the most likely to face these hurdles. Additional research and policy changes are needed to address macro-structural factors and achieve equitable HIV outcomes.