Multilevel Barriers and Facilitators to HIV Care Engagement Among Virally Unsuppressed People Living With HIV in the U.S. Deep South: A Qualitative Study

Abstract The U.S. South experiences disproportionate HIV-related morbidity and persistently lower viral suppression rates. Achieving Ending the HIV Epidemic goals requires understanding multilevel influences on care engagement among virally unsuppressed people living with HIV. We conducted in-depth qualitative interviews with 30 virally unsuppressed people living with HIV receiving care across Alabama, Louisiana, and Mississippi. Guided by the Modified Social Ecological Model, we examined individual, interpersonal, clinic, community, and policy-level factors shaping engagement and antiretroviral therapy adherence. Participants described intersecting structural and psychosocial barriers, including financial insecurity, transportation challenges, depression, and internalized stigma. Social networks functioned as both support and stigma, particularly within family and faith contexts. Clinics served as critical anchors when providing confidential, holistic services addressing social needs, although inefficiencies and resource constraints disrupted continuity. Persistent discrimination, restrictive policies, funding instability, and HIV criminalization further threatened engagement, underscoring the need for multilevel interventions to improve viral suppression.