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For Hispanic/Latino MSM (HLMSM) in the South, HIV burden remains high, and HIV elimination is a national priority. Between July and September 2016, using a strengths-based approach informed by resilience theory, we conducted qualitative interviews with HIV-negative HLMSM in five southern cities in the United States with elevated HIV prevalence. We analyzed data using a qualitative content analysis approach, assessing for interrater reliability. A brief behavioral survey was also conducted. We enrolled 51 HLMSM (mean age = 33 years, range = 15-63). HLMSM discussed the climate of fear about HIV and homosexuality impeding HIV prevention, including the impact of stigma and taboo. Three main strengths-based strategies emerged for preventing HIV: assessing partner risk, establishing boundaries for sexual interactions, and self-education. Future HIV prevention efforts may benefit from balancing risk-based approaches with those that emphasize resilience, address partner trustworthiness and safety, and focus on providing novel outlets for HIV prevention education.

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OBJECTIVE: African American (AA) women in the U.S. South experience significant HIV incidence, and efforts to support antiretroviral pre-exposure prophylaxis (PrEP) uptake and maintenance among this group have been insufficient. This study aimed to explore perceptions, attitudes, and implementation preferences surrounding PrEP use for AA women in the U.S. South. METHODS AND MEASURES: The study team conducted qualitative interviews with AA cisgender women clients (n = 21) and their providers (n = 20) in Federally Qualified Health Centers and HIV clinics in Alabama. The research team employed directed qualitative content analysis to analyze interview data. RESULTS: Five themes emerged: a) inconsistent access to PrEP and PrEP knowledge, b) need for improving low PrEP awareness, c) managing hesitancy to prescribe or use PrEP, d) perceived HIV vulnerability and inherent stigma, and e) normalizing PrEP as part of routine sexual healthcare to increase uptake and maintenance. Interviews revealed an openness towards PrEP as an HIV prevention strategy for AA, cisgender women in Alabama. CONCLUSION: Improving PrEP uptake and maintenance among AA women in the U.S. South must go beyond increasing awareness to improving PrEP access and trust through visibility of AA women's PrEP use and incorporating PrEP education and services into routine sexual healthcare.

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OBJECTIVES: We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states. STUDY DESIGN: We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation. RESULTS: Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001). CONCLUSIONS: Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction. IMPLICATIONS: Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

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Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, yet adoption among Black women, who are disproportionately impacted by HIV, is low. A nuanced understanding of the multi-level factors that contribute to elevated risk is necessary to better contextualize PrEP uptake. Qualitative data from Black women residing in the Southern U.S. who self-screened as HIV-negative, were collected via four focus groups (N = 27) to understand influences on HIV vulnerability and the potential role of PrEP in mitigating risk. Content analysis of transcribed data yielded multiple themes addressing: the pervasiveness of sexual partner sharing; lack of transparency regarding HIV status, disclosure, and testing; and social/cultural influences on HIV risk. Experiences with the health care system and providers were of particular concern. Findings demonstrate support for PrEP in this population and contribute to our understanding of individual, social, and structural factors to better inform PrEP promotion.

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There has been an increase in the literature about LGBT older adults in recent years; however, there is a need for further sociological quantitative research examining the impact of geographic region on LGBT aging. Utilizing data from a nationwide survey, this study focuses on the availability of LGBT-specific resources for LGBT aging adults living in the South. We examine the effects of community type and sociodemographics on the availability of LGBT-specific resources as well as the type of resources available. Findings reveal that in the South, community type, having a partner, household income, and education affect the LGBT-specific resources available. Of particular interest, LGBT-affirming faith organizations are identified as the resource most frequently available for LGBT aging adults in this region often referred to as the Bible Belt. Overall, this study sheds light on the LGBT-specific resources that are available to provide social support and help meet the unique needs of LGBT adults aging in the South.

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To better understand utilization of HIV prevention, care, and treatment services by young men who have sex with men (YMSM) and young transgender persons (YTG), of Black race or Hispanic/Latino/Latina ethnicity in the U.S. South, we conducted semi-structured interviews with 127 clients at one of four community based organizations (CBOs) in Miami, Atlanta, New Orleans/Baton Rouge, or Columbia, South Carolina. Across sites, the service that most commonly drew respondents into the CBO was HIV and STD testing. Other services commonly used included HIV/STI treatment, counseling services/support groups, and PrEP services. Social/organizational/structural facilitators of service utilization include the welcoming climate/culture of the CBOs, ease of access to the services, and transportation services to reach the CBOs. Suggested service enhancements include broader range of comprehensive, navigational-type services beyond HIV testing and service co-location. Research on how to reduce stigma in the surrounding communities may help reduce health disparities experienced by these populations.

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Black adolescent girls and young women (AGYW) are disproportionately affected by HIV in the southern U.S.; however, PrEP prescriptions to Black AGYW remain scarce. We conducted in-depth interviews (IDIs) with Black AGYW ages 14-24 in Alabama to explore opportunities for and barriers to sexual health care including PrEP prescription. Twelve AGYW participated in IDIs with median age 20 (range 19-24). All reported condomless sex, 1-3 sexual partners in the past 3 months, and 6 reported prior STI. Themes included: 1) Stigma related to sex contributes to inadequate discussions with educators, healthcare providers, and parents about sexual health; 2) Intersecting stigmas around race and gender impact Black women's care-seeking behavior; 3) Many AGYW are aware of PrEP but don't perceive it as an option for them. Multifaceted interventions utilizing the perspectives, voices, and experiences of Black cisgender AGYW are needed to curb the HIV epidemic in Alabama and the U.S. South.

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In US states that have foregone Medicaid expansion, a disinvestment in general assistance programs has meant that disability benefits remain one of the few sources of cash assistance ostensibly available to uninsured working poor Americans. Yet among impoverished South Carolinians, economic hardship and ill-health often compound during the long, uncertain waits for a disability determination. Here I explore the peculiar vulnerabilities of working poor disability seekers living in an insurance gap of a state that has foregone Medicaid expansion; individuals that risk the protracted, injurious waiting for a chance at meaningful healthcare.

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This article examines an instructive moment in the archive of Feminary, a periodical that began in 1969 as a local feminist newsletter for the Triangle region of North Carolina. In 1979, the editorial collective announced a shift in focus toward "a feminist journal for the South emphasizing the lesbian vision." I argue that through this turn, the Feminary Collective experiments with lesbian and southern as discursive laboratories for shaping what I refer to as backward-onward community-formation-a praxis that requires confronting and acknowledging historical specificity and experiential limits while also imagining new possibilities for social movement. Instead of framing southernness and lesbianism as fixed identities, the Collective treats them as multivalent, slippery markers that resist closure, produce ambivalence, and contain vast relational and political potential. Moreover, this article discusses the Collective's configuration of the U.S. South as a spatial and temporal avenue for confronting the experiential and institutionalized afterlives of slavery and for critiquing the white-washed classism of literary conventions. The article's methodology includes close readings of material from the Collective's nationally-circulated journal, as well as discussions of excerpts from the oral histories of two former members of the Collective, one of which was conducted for the purposes of this project.

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HIV-related stigma is pervasive in the U.S. South and has potential negative effects on health outcomes and emotional well-being, and may act as a barrier to HIV-related advocacy among people living with HIV (PLWH). This article reports on the preliminary outcomes associated with participation in an HIV advocacy training for PLWH, LEAD, that included education and skills building for reducing HIV-related stigma. Fifty-seven PLWH at four sites in the U.S. South participated in the retreat-style training and completed a survey measuring stigma and comfort engaging in advocacy prior to and after the worshop. Participation was associated with statistically significant reduction in internalized HIV stigma and increase in comfort with participation in advocacy; however, participants reported a need for ongoing training and support to further increase comfort with advocacy participation. Although more research is needed on the LEAD Workshop, it shows promise as an option for reducing HIV-related stigma among PLWH.

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The United States lags in life expectancy compared to most of the world's similarly wealthy nations, driven by pronounced regional disparities particularly between the South and the rest of the country. The U.S. South has a violent history of lynchings of Black Americans by White mobs after the ending of slavery and up to the Civil Rights Era. Building on critical race scholarship, the objective of this study was to determine whether there exists an association between historical lynchings and overall life expectancies in the U.S. South. We created a cross-sectional county-level data set with 1221 data points utilizing data from the Equal Justice Initiative and Robert Wood Johnson Foundation Country Health Rankings. The average life expectancy for 2019-2020 was 76.1 years, ranging from 68.2 years to 90.2 years. Overall life expectancy was found to be highest (76.6) in counties with no recorded lynchings, and lowest (75.5) in counties with the most lynchings (p < .001). In the spatially enabled regression model, the history of lynching along with other covariates explained 57.1% of the variance in life expectancies across the study area. Counties with a history of lynchings also score lower compared to the reference group in various socioeconomic indicators, including median household incomes and high school graduation rates. The findings suggest that lynchings were pivotal in creating the social and physical environment affecting health outcomes in the U.S. South today. We call for further public health research which acknowledges and explores this form of violent and institutional anti-Black racism as foundational to the nation's regional health disparities.

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Rural-urban differences in morbidity and mortality across the United States have been well documented and termed the "rural mortality penalty". However, research studies frequently treat rural areas as homogeneous and often do not account for geospatial variability in rural health risks by both county, state, region, race, and sex within the United States. Additionally, people living in the rural South of the US have higher rates of morbidity and mortality compared to both their urban counterparts and other rural areas. Of those living in southern rural communities, people of color experience higher rates of death and disease compared to white populations. Although there is a wealth of research that uses individual-level behaviors to explain rural-urban health disparities, there is less focus on how community and structural factors influence these differences. This review focuses on the "southern rural health penalty", a term coined by the authors, which refers to the high rate of mortality and morbidity in southern rural areas in the USA compared to both urban areas and non-southern rural places. We use macrosocial determinants of health to explain possible reasons for the "southern rural health penalty". This review can guide future research on rural health between southern and non-southern populations in the US and examine if macrosocial determinants of health can explain health disparities within southern rural populations.

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Minnie Bruce Pratt (1946-) and Mab Segrest (1949-) are white middle-class lesbians that both came of age during the classical phase of the Civil Rights Movement in rural Alabama. Today, they are considered influential figures in feminist and lesbian, gay, bisexual, transgender, and queer (LGBTQ) literary movements and recognized as important activists in late twentieth-century feminist, LGBTQ, and anti-racist political struggles. Examining Pratt's Rebellion: Essays, 1980-1991 (1991) and Segrest's Memoir of a Race Traitor (1994), I argue that both texts deconstruct the sociopolitical dynamics and ideologies that inform the inculcation of white middle-class southern womanhood specifically and hegemonic white southern culture generally through performing a form of anti-racist praxis that I call geospatial critique. This term addresses how Pratt and Segrest mine spaces that they occupy for histories of struggle, paying specific attention to how white settler-colonialism and chattel slavery produced particular epistemologies of race, class, gender, and sexuality that continue to influence social identities and practices in the present. Initially developed during Pratt and Segrest's collaboration on Feminary, a lesbian-feminist journal located in Durham, North Carolina, between 1978 and 1982, geospatial critique, I suggest, is a direct response to or a way of undoing the racial training that was part of the production of whiteness in the south from the turn to the first half of the twentieth century.

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Cognitive-psychosocial and other factors may affect participation in HIV testing, particularly by Hispanic/Latino gay, bisexual, and other men who have sex with men (MSM) in the U.S. South, a region hard-hit by HIV. We used univariate and multivariable logistic regression analyses to examine the association between social support and other cognitive-psychosocial factors; sociodemographic characteristics; risk behaviors; and self-reported HIV testing in a sample of 304 Hispanic/Latino MSM in North Carolina. In the multivariable logistic regression analysis, general and HIV-related social support and HIV-related knowledge were associated with greater odds of testing; speaking only Spanish was associated with reduced odds of testing. Social support and aspects of social connectedness may constitute community-based resources for use in HIV prevention efforts with Hispanic/Latino MSM. However, harnessing these resources for HIV prevention will require a better understanding of how social support relationships and processes shape HIV risks and protective actions by these vulnerable MSM.

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Building on research that has identified community characteristics associated with child maltreatment, this study investigates the adequacy and equity of the child welfare response at the county level. The study focuses on states in the U.S. south with demographic characteristics that make it possible to disentangle county racial composition from county rurality. County-level child maltreatment data were merged with data from the U.S. Census and other publicly-available sources for the 354 counties in four southern states. Results from multiple regression models indicated that, despite a greater preponderance of risk factors typically associated with child maltreatment, rural, majority African-American counties had lower rates of reported and substantiated child maltreatment compared to other southern counties. Cross-sectional results were consistent across three years: 2012, 2013, and 2014. The findings suggest that children and families in rural, majority African-American counties in the South may not be receiving adequate or equitable responses from the formal child welfare system.

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Relying on a close reading of more than 4,000 medicals student theses, this essay explores the evolving medical approaches to race and environment in the early national and antebellum United States and highlights the role that medical school pedagogy played in disseminating and elaborating racial theory. Specifically, it considers the influence of racial science on medical concepts of the relationship of bodies to climates. At their core, monogenesis-belief in a single, unified human race-and polygenesis-the belief that each race was created separately-were theories about the human body's connections to the natural world. As polygenesis became influential in Atlantic medical thought, physicians saw environmental treatments as a matter of matching bodies to their natural ecology. In the first decades of the nineteenth century, Atlantic physicians understood bodies and places as in constant states of flux. Through proper treatment, people and environments could suffer either degradation or improvement. Practitioners saw African Americans and whites as the same species with their differences being largely superficial and produced by climate. However, by the 1830s and 1840s medical students were learning that each race was inherently different and unalterable by time or temperature. In this paradigm, medical students articulated a vision of racial health rooted in organic relationships between bodies and climates.

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Justice-involved HIV-positive women have poor health outcomes that constitute health inequities. Researchers have yet to embrace the range of qualitative methods to elucidate how psychosocial histories are connected to pathways of vulnerability to HIV and incarceration for this key population. We used life course narratives and intersubjectivity-predicated on interview dialogue-to investigate how familial and social settings established their social patterning of HIV, incarceration risk, and poor health. Working with two Alabama community-based organizations, we recruited and interviewed 24 HIV-positive cisgender women with cyclical incarceration. We analyzed the data by charting women's life histories and conducting iterative content analyses. Participants described chaotic home environments, marked by exposure to trauma in childhood. The majority experienced repeated sexual and physical abuse that went undiagnosed and untreated until adulthood. Adolescence and young adulthood were characterized by onset of substance use, violent intimate partnerships, and subsequent behavioral and mental health problems. In adulthood, risk behaviors persisted for decades and women lacked mental health treatment and social support. Life course narratives and intersubjectivity contributed to knowledge by affording agency to marginalized participants to reflect on and narrate their life stories; instilling needed trust for researchers to investigate the complex risk pathways and psychosocial histories with this population; illuminating the nature, timing, sequence, and frequency of events underlying women's vulnerability and exposure to HIV and incarceration; and clarifying that early shaping events in childhood are connected to later risk environments and behaviors in adolescence and adulthood, suggesting the need for earlier interventions than are typically proposed.

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