The southern United States has the highest HIV rates in the country, accounting for more than half of new HIV diagnoses nationally in 2023. This occurs despite the increasing availability of a highly effective HIV prevention medication that has enabled people to live long, healthy lives with the previously deadly disease.
This medication, called pre-exposure prophylaxis or PrEP, reduces the risk of HIV transmission by more than 99% when taken as prescribed. However, in Southern cities like Jackson, Mississippi, and Memphis, Tennessee, one of the most vulnerable populations—black men who have sex with men—rarely use it, and fewer than 1 in 5 eligible people take it.
The Trump administration previously froze and proposed further cuts to US HIV prevention programs. And while the administration has restored some of the federal web pages and data sets it deleted in January 2025, it’s unclear what information is still missing or what has changed. Southern communities already facing the greatest burden of infection will suffer the greatest effects of the shift in public health priorities.
In my work as a public health researcher, I spent years studying HIV prevention and the social determinants of health in the Deep South. Through interviews with Black health professionals and patients in major Southern cities, I learned that a strong conflict between culture and public health plays a role in why effective medical treatments still do not reach those who need them most. I call this tension the paradox of the South: where medical solutions exist, but systemic forces block access.
The stories of these Southern clinicians and patients were not simply about a pill: they were about trust, identity, family, and faith. And their words highlighted a complex web of emotions and experiences that are often not addressed in standard health messages.
Southern culture and sexual health
In my recent study, I interviewed 12 people in Jackson, Memphis, New Orleans, and Atlanta: eight black men who have sex with men, along with four health professionals. Three of these professionals also identified as men who have sex with men.
Many participants reported that physical access to PrEP was not the problem. Instead, what stood in his way was much more personal and deeply rooted in his environment.
“In church, they teach you to love your neighbor, but there’s always an asterisk when it comes to who you love,” one Jackson participant told me. “If you are gay, you are ignored or silently judged.”
Nearly all participants described the South as a place deeply marked by conservative values, especially those rooted in religion and traditional family structures. The black church emerged as both a protective factor and a challenge. While it offered vital community support, it also tended to reinforce the stigma around homosexuality and discourage open conversations about sexual health.
One participant from New Orleans shared that he heard about PrEP through his healthcare provider and friends, while another from Atlanta recalled learning about PrEP during his annual physical. Despite having received information about PrEP repeatedly, both described hesitancy about starting treatment. One worried about possible stigma if others found out he took it, while the other wondered if he “really needed it.” Ultimately, none started PrEP.
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In many of these communities, sex education in schools is still abstinence-focused and often excludes LGBTQ+ topics entirely. “You grow up not hearing anything about gay sex or HIV,” said one Memphis man. “So when you grow up, it’s like starting from scratch.”
Even decisions about condom use were heavily influenced by cultural norms. Men described relying on their partner’s trustworthiness, age, or perceived hygiene rather than research-based methods to reduce HIV risk.
This absence of comprehensive and inclusive sexuality education leaves many vulnerable to misinformation and, ultimately, preventable infections.
Trust is the real barrier
One of the most surprising findings from these conversations was the deep mistrust that many black men who have sex with men feel toward the healthcare system.
“It’s hard to find positive health care for people in the queer community,” said a Memphis health professional. Others spoke about fear of being “outed” through their insurance, especially if they still had a family health plan.
A participant from Jackson confessed, “Some people avoid taking PrEP because every prescription requires an evaluation. Some people don’t want the follow-up or screening.” Another noted how fear of judgment, both direct and subtle, during medical appointments made it easier for them to avoid medical care altogether.
Systemic racism compounds these concerns. For many Black men, historical and current experiences of discrimination, including rushed visits, lack of empathy, misdiagnoses, and even outright denial of medical care, have generated a lasting sense of wariness.
Even when resources like PrEP are available, these treatments are often inaccessible to Black men because they don’t trust the system that offers them.
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Social networks intervene
Fortunately, these conversations also revealed moments of hope.
Many participants learned about PrEP from their peers. “We talk about it regularly,” said one participant in Jackson. “I have friends who work in public health, and others who take medication.”
In the South, where community ties often serve as crucial safety nets, these social networks can sometimes provide more reliable health information than clinics or campaigns. Informal conversations in group chats, house parties, or community gatherings often serve as powerful platforms for health promotion.
One provider in Atlanta said he intentionally shared his own experiences with PrEP to reduce stigma. “I’m a little sore,” he said with a smile, referring to a recent injection. So I tell everyone, ‘Yeah, I just got mine.’ The naturalness of that comment made the difference: it made PrEP feel normal, close, something for ‘us’, not something done to ‘them’.
These social exchanges, based on trust and shared experience, often did more to change attitudes than traditional public health campaigns. As one participant put it: “I trust my friends more than I trust those ads. If they take it and it works for them, that means something to me.”
Making PrEP culturally relevant
What these conversations demonstrate is that for PrEP to work in the South, access to treatment is only part of the equation. Building trust, affirming culture, and community education are equally crucial.
Public health messages that go beyond medical data and address the emotional, spiritual, and social dimensions of health are more likely to generate lasting commitment to HIV prevention. This includes investing in Black healthcare professionals who are LGBTQ+-affirming and reflective of the communities they serve. It also means integrating conversations about sexual health into everyday conversations in hair salons, churches and community centers, not just clinics.
Public health authorities and clinicians can explore alternative treatment delivery methods that address privacy concerns, such as PrEP telehealth programs, discreet mail-order services, and community distribution points. These can facilitate access to PrEP and reduce the stigma associated with clinic visits.
Most importantly, valuing the knowledge already circulating in communities and supporting peer educators as authentic public health messengers can strengthen credibility, normalize PrEP, and empower people to take charge of their health.
In the fight against HIV in the South, culture is not just a barrier. It can also be the solution. I believe that when care is offered in a way that respects people’s identity, experiences and values, it becomes not only accessible, but also empowering.
*Brandon Nabors is Postdoctoral Research Associate in Public Health, University of Mississippi.
This text was originally published in The Conversation
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