Study design

This study used a qualitative descriptive design [26] to explore sexual health promotion and HIV self-protection among cisgender Latinx SMM living across the U.S. Individual in-depth qualitative interviews were conducted to inquire about participants’ perceptions of sexual health promotion. Additionally, we inquired about socio-cultural barriers and facilitators of specific HIV and STI prevention strategies such as condom use, PrEP use, and partner negotiation.

Participants

Between October 2020 and July 2021, a purposive sample of 15 Latinx SMM was recruited. Our study specifically focuses on a sub-population of Latinx individuals, as all participants reported Latin Amsssssserican ancestry and were either Spanish- or English-speaking. The eligibility criteria included: self-identifying as being Latinx (U.S. born or foreign-born), cisgender male, English or Spanish-speaking, aged 18 and older, and living without HIV. Participants were excluded if they lived outside the United States, were living with HIV, or were not fluent in Spanish or English.

Recruitment for this study was conducted through three methods. First, participants who met our inclusion criteria were purposively sampled from an ongoing study of Latinx young adults (1R01MD012249; PI: Gonzalez-Guarda). The SER Hispano study is an ongoing study on the health of young adult immigrants (18–44 years) in the southeastern region of the US (N=391). Participants who met eligibility criteria and agreed to be contacted for future studies were provided information about this study. Eleven eligible participants were identified from The SER Hispano study and consented to be contacted regarding future research, but only three participants enrolled in this study. Second, recruitment messages were posted on Latinx Facebook groups, Reddit threads for Latinx or SMM, and Craigslist. Participants who were recruited online contacted researchers by email or phone and were screened for study eligibility. Snowball sampling techniques were also used [27]. For example, Latinx SMM who had already enrolled in the study were asked to inform friends who met study inclusion criteria. All participants were screened by one of four bicultural, bilingual researchers that were a part of this study. A total of 20 participants were screened for this study, and 15 individuals ultimately enrolled. Of the five individuals who did not enroll, two were ineligible due to living with HIV, two were ineligible because they resided outside of the U.S., and one was lost to follow-up during the recruitment process. Of the 15 enrolled participants, three were recruited from an ongoing study, 11 recruited through social media, and one recruited using snowball sampling techniques. Participants received a $30 Visa gift card for their participation.

Setting

Interviews were conducted virtually via WebEx, although four participants experienced connectivity issues and were interviewed via phone call. Interviewers and participants were in a private location during the interview.

Data collection

All interviewers participated in a training on effective interviewing strategies by the senior author. A semi-structured interview guide was used to explore the meaning of sexual health and the various strategies utilized to prevent HIV among Latinx SMM. Additionally, the interview guide explored how interpersonal-, provider-, and sociocultural-level factors influenced sexual health promotion and HIV prevention. Sample questions included: “What does Sexual health promotion mean to you”; “What types of methods or activities do you engage in to protect yourself from HIV?”; and “In what ways do you feel like your partner(s) are helpful/not helpful when making decisions about your sexual health?”. The guide was reviewed by experts in the field of HIV prevention, and gay Latinx men community members.

Interviews were conducted by bilingual, bicultural researchers (L.M., J.S., C.M., R.G.G.). Participants were encouraged to respond in whichever language felt most comfortable to them throughout the interview. Most interviews (n=8) were conducted in English. Participants were also asked to complete a brief demographic survey after the interview was completed. Each individual interview lasted between 45 and 65 minutes, with an average duration of 52 minutes, and was audio-recorded for transcription and analysis.

Study materials

All materials used in this study were initially translated from English to Spanish by a bilingual team member. To ensure accuracy and cultural and linguistic relevance, the translated materials were then backtranslated from Spanish to English by another bilingual team member who was not involved in the initial translation process. Any discrepancies between the original and back-translated versions were resolved through discussion and consensus among the research team [28].

Human subject protection and data management

The Institutional Review Board of Duke University approved all study materials (IRB# Pro00106283). Prior to participation in interviews, all participants verbally provided informed consent, acknowledging their understanding of the study’s purposes and the voluntary nature of their involvement. Interviews were digitally recorded and stored on a secured folder. The audio recordings were then transcribed verbatim by a professional transcription service that complies with confidentiality agreements to further protect participant privacy. To maintain the integrity and nuanced meaning of the data, all transcripts were kept in their original language. This ensures that the cultural and linguistic contexts of participants’ responses are preserved, allowing for a more accurate analysis. Once the transcripts were prepared, they were verified for accuracy by the lead author. Access to these transcripts is restricted to authorized research team members only, who are required to adhere to strict data confidentiality protocols as outlined by the IRB-approved study guidelines.

Data analysis

NVivo 13 [29] was used for the management and analysis of interview data. Thematic analysis techniques were applied to analyze transcripts in their original language with bilingual coders fluent in both English and Spanish [30]. An initial analysis of the first five interviews was conducted by the primary researcher and two team members (J.S., C.M.). Researchers immersed themselves in the data by reading and re-reading the transcripts without coding [31]. Subsequently, they highlighted meaningful units, relevant information, and key ideas present in the data [30]. Open coding was then employed to label highlighted text that captured their interpretation of the underlying meaning of participant comments. A preliminary codebook was developed based on the first five transcripts. The codebook contained codes, their content descriptions, and a brief example for reference [32].

The remaining transcripts were independently coded by the primary researcher as interviews were completed, using the same approach as described above. Throughout the coding process, additional codes that emerged from the data were added as needed to capture the richness and complexity of the data. These newly identified codes were also applied retrospectively to the first five transcripts to ensure consistency and a comprehensive analysis across all cases. After the data were coded, the primary researcher analyzed codes to generate a list of categories, which were then grouped into themes [33]. Themes were identified based on patterns, similarities, and differences across the data. Throughout the data analysis process, the primary researcher engaged in weekly discussions with senior researcher and qualitative expert on the team (R.G.G.) to review coding refine identified themes that emerged from the data. To further assess the reliability of the coding process, 20% of the transcripts were randomly selected and independently coded by (S.J.) and (R.G.G.). Any discrepancies in coding were resolved through discussion and consensus among the research team. The major themes that are reported in this paper were areas responding to our research question where saturation was reached.

Trustworthiness of the findings were ensured using several methods. To establish credibility, peer debriefing was used at several stages of this study. Researchers conducted regular peer debriefings during the recruitment interview and analysis stages [32,34]. Member checking was conducted by having participants review and respond to the findings, confirming their accuracy and providing recommendations. To establish transferability, researchers used field notes to provide detailed accounts of their experiences during data collection [34]. Interviews were analyzed in their original language to capture the full meaning of the text, ensuring that the transcripts accurately reflected the participants’ experiences and enhanced the transferability of the findings [35,36]. To establish dependability, a researcher not involved in the study assessed the research process and outcomes, ensuring the findings, interpretations, and conclusions were accurately supported by the data [34]. To establish confirmability an audit trail was maintained to document all research processes and decisions. [34].

Reflexivity

As a research team, it was crucial for us to minimize the influence of our own biases and assumptions throughout the research process. Most of the research team identified as Latinx, cisgender females, and heterosexual. The team also included LGBTQ+ members as well as individuals who were non-Latinx White. All the interviews were conducted by the Latinx cisgender heterosexual researchers on our team. Prior to conducting the interviews, the interviewer(s) acknowledged that even though they have a shared cultural understanding with participants, they may not fully comprehend the experiences of Latinx SMM. The interviewer(s) highlighted their commitment to listening and learning from the unique perspectives and experiences of participants. This conversation was aimed at fostering mutual understanding and establishing a foundation of trust and respect between the researchers and participants. Participants were also provided with the opportunity to ask questions and share their own reflections on how the interviewer(s) positionality might impact their participation and the overall research process at the end of the interview.

Prevención es mejor que curar/prevention is better than to cure

Throughout the interviews, participants primarily described sexual health promotion as having sex responsibly (e.g., using condoms) and the prevention of STIs including HIV. Participants also described sexual health as a holistic concept beyond disease prevention and included physical, emotional, and psychological well-being. This perspective informed their approach to HIV self-protection, which was seen not as a singular task but as part of a broader commitment to health and described by both Spanish and English-speaking participants.

“Bueno, pues… estoy a punto de cumplir treinta años, y me estoy haciendo plenamente responsable de mi salud individual entonces e encontrado que. que prevenir es mejor que curar. Entonces implica en todo… en alimentación, en ejercicio, en… no solamente en el área de cuidado de salud sexual, si no en general. Sabes comiendo menos sodio, menos azucares, menos comidas procesadas. Entonces encuentro como mejor vía la prevención que el tratamiento de cualquier enfermedad. [Well, I’m about to turn thirty, and I’m becoming fully responsible for my individual health, so I’ve found that prevention is better than to cure. So, it involves everything... in terms of diet, exercise, not only in the area of sexual health care, but in general. You know, eating less sodium, less sugar, less processed foods. So, I find prevention to be a better approach than treating any disease.]” (Participant #04, 29 year-old, single)

“Being sexually healthy means taking care of yourself in every aspect, not just when it comes to HIV but all STIs, and even beyond that, making sure you’re mentally and emotionally okay too” (Participant, #13, 29 year-old, single)

Subtheme: HIV self-protection behaviors and decision-making dynamics

An important subtheme that emerged was that HIV self-protection varied with new partners compared to established partners. An established partner could be their significant other, but for some participants, this also meant someone with whom they were casually dating or hooking up with regularly. Participants reported a heightened perception of HIV risk with new partners. As these participants stated,

“Pero se que cada vez que se hace algo con otra persona osea, you know, you’re out there. You’re throwing an eight ball, you know? aver en donde cae, el que cae, pero eso que para mi importante este saber con quien estoy jugando con quien estoy haciendo las cosas [But I know that every time something is done with another person, I mean, you know, you’re out there. You’re throwing an eight ball, you know? Seeing where it lands, who it lands on, but what’s important for me is knowing who I’m playing with, who I’m doing things with” (Participant #05, age 40, open relationship).

“No te necesitas meterte con varias personas, no mas te metes con la persona equivocada. [You don’t need to get involved with multiple people, you just get involved with the wrong person] (Participant #05, age 34, single).

The “question mark” around the HIV risk introduced by new partners led participants to practice caution when selecting new sexual partners.

Participants emphasized the importance of getting to know new partners and the role of open communication in mitigating HIV risk and informing their decisions about self-protection. They actively asked new partners about their sexual history, recent HIV testing, and condom use preferences, sexual positioning preferences (e.g., top, bottom, versatile) to gain a more accurate understanding of their sexual risk. These discussions also helped determine whether potential partners shared similar attitudes regarding sexual health. As one participant expressed,

“Que yo veo que la otra persona no se interesa en usar condón no tiene no tiene interés de hacerse test eh es una mala señal una red flag y definitivamente eso no me daría la seguridad para estar con la otra persona. [If I see is that if the other person is not interested in using a condom and has no interest in getting tested, it’s a bad sign, a red flag, and definitely, that would not give me the confidence to be with that person.]” (Participant #08, age 26, open relationship)

“…that’s why we’d rather do it [have sex] with people that we already know that are like us. That have been to the doctors, you know, that are the same as us, so we don’t have to worry about that.” (Participant #14, age 40, open relationship)

After screening partners, participants felt more informed to make decisions about whether to pursue a sexual relationship with the potential partner. Depending on the perceived level of risk, some participants opted for condom use with partners considered “riskier,” while others chose to engage in lower-risk sexual activities (e.g., mutual masturbation) or abstained from sex with those individuals altogether. However, participants also expressed skepticism about the accuracy of the information provided by new partners, as there was no way to verify its truthfulness. As one participant stated, “I know what I have, and I don’t have, and I know how I am and I know you know how healthy I am. But you know people can lie, and there’s no proof or any hardcore evidence to say, hey, I don’t have this” (participant #13, age 29, single). This statement underscored the difficulties in balancing trust in a new partner and their sexual health choices. Participants also acknowledged that their decision-making process was not always straightforward; attraction to a person or certain situations (e.g., partying) could lead to unsafe encounters with unknown partners. Therefore, several participants emphasized the importance of avoiding circumstances that could lead to sexual disinhibition, such as drug or alcohol use.

Open communication and sexual safety negotiating sexual safety with established partners centered around decisions made as a dyad to protect their sexual health. These topics included condom use preferences, frequency of HIV testing, PrEP use, sexual boundaries, and relationship agreements.

“I think you know, when I first start conversations you know, the conversation always goes like have you taking your prep you know regularly.” (Participant #06, age 26, single)

“It’s not necessarily putting a condom on. When people think you know safe sex; it’s just understanding like when you have sex, who you’re having it with, how you have it, and how you and the other person initiate and like understand like, what are the boundaries; how you’re going to move forward; who’s going to do what, etc.” (Participant #12, age 34, single)

Importantly, individual acts of sexual health promotion and HIV self-protection took on the meaning of being an act of mutual protection between partners, whereby each partner shares the responsibility of protecting the other. Although mutual protection of sexual health between partners was more commonly brought up by participants in relationships, single participants also expressed that their acts of sexual health promotion and HIV self-protection are to protect others as well themselves. Most participants in monogamous relationships discussed having negotiated safety agreements with their partners who were living without HIV, where mutual protection included monogamy and routine HIV testing (e.g., every 6 months or annually) and did not use condoms. Moreover, participants in open relationships exemplified the way open communication and a commitment to mutual protection between partners can facilitate HIV self-protection. For instance, when describing their transition from monogamous to open relationship agreements with their partner, two participants described engaging extensive discussion with their partners about the boundaries and rules for engaging with other sex partners. These participants also made the proactive decision to use PrEP prior to introducing new partners into their relationships. It is important to note both participants were well educated and had access to healthcare, which they recognized as a privilege that other couples may not be afforded.

Cultural and religious norms create a culture of silence around sexual health

The narratives of participants highlighted the profound influence of cultural and religious factors in shaping sexual health attitudes and behaviors. All participants grew up exposed to the social stigma associated with being a gay or bisexual man regardless of whether they grew up in the US or in Latin America. Specific cultural norms such as ‘machismo’, which emphasizes traditional male gender roles, challenged their ability to reconcile their sexual identities with societal expectations. As participant #14 (age 40, open relationship) stated, “You know from the moment you proclaim yourself gay, that the male card gets taken away.” This sentiment was echoed by others who highlighted the internal conflicts they experienced due to the clash between their sexual identities and the heteronormative standards imposed by the influence of religion in Latinx culture. One participant recounted,

“So, my whole my whole upbringing was very uncomfortable because I wanted to pray or you know, to get the gay out, because I was raised in a home where that was wrong. You know, men were to to get married and with a woman and have children and be you know, a fruitful, Christian young person.” (Participant #02, age 40, open relationship)

Similarly, another participant recalled rejecting his feelings of same-sex attraction as early as 6 years old because “[being gay] was not accepted” (Participant #09, age 32, single) in his Christian family.

These sociocultural norms constrained the healthy development of sexual identity from childhood into young adulthood and hindered sexual health promotion behaviors. One participant shed light the profound impact of societal expectations in his life,

“….well my past experience right, I was you know as a straight man that was married for 20 years to a woman, three kids, Latino, Christian growing up right so you kind of lived the monogamous relationship, a Christian monogamous relationship and I did have my encounters outside, you know, because I was obviously, I’ve always been gay. I used to have those unfortunate encounters outside just to fulfill my sexual needs that I that I had, and they were not really safe… I was always afraid and scared that I would bring something to her right, and that would have been my you know, that was actually my worst nightmare.” (Participant #14, age 40, open relationship)

This narrative of societal pressure and fear of stigma is echoed in the experience of another participant (age 32, polyamorous relationship) who shared being in committed relationships exclusively with women in his early twenties, despite knowing he was bisexual. He shared that machismo, religion, HIV stigma, and the added layer of biphobia (fear or hatred directed toward bisexual people) prevented him from coming out to his family and female partners.

“Coming from like the male side of the family and there is always a huge stigma about being gay… then my uncle who died of HIV. He’s bisexual as well so there is an even larger stigma… So that that kind of like delayed me coming out of the closet big time.” (Participant #07, age 32, polyamorous)

During this time, he was also having encounters with men outside of his relationships with women, often without protection or discussions about sexual health or HIV status.

While concealing their sexual identity protected against familial estrangement, it also led to feelings of anxiety and isolation. A poignant example is a 29-year-old, single participant recounted experiencing depression during his teenage years because he was concealing his sexual identity. After bravely coming out to his parents in high school, they reacted negatively and rejected him, which worsened his depression to the point of a suicide attempt.

“The coming out can be very traumatic, and you know, in my experience, like every other, I guess LGBT community gay person there’s always depression and the thought of ending your life then and there…. mine was a very negative experience. I have attempted suicide. I have been through depression, mom and Dad took me to rehab for it. They were traumatized and then, you know, deep down they don’t get that I’m rainbow but I am…”

He described the importance of coming out in his life not only in his relationship with his parents, but mostly in his relationship with himself,

“…when you come out and you have your support, your life just everything just blossoms and blooms. Clouds are parting with the rays of sunshine are coming down. The weight off your shoulder has officially lifted. Your head doesn’t weigh 1000 pounds. You can start focusing on other things like your career path or what you’re gonna have for lunch tomorrow and whatnot… ‘cause you do feel though the love and support afterwards, after your little like I said, you’re at rock bottom.” (Participant #13, age 29, single)

Many participants echoed similar initial reactions of rejection and disappointment from their families after coming out, but also regarded it as a difficult yet necessary experience towards greater self-acceptance. Embracing and openly owning their sexual identity provided them with the space to start prioritizing their sexual health.

Although most participants reported improved acceptance of their sexual identity by their families over time and strong family bonds, their narratives highlighted the ongoing role of families in perpetuating stigma post-coming out. For instance, some participants continued to conceal certain aspects of their sexual identity, like their dating life, to avoid negative or judgmental reactions. For example, participant #15 (age 40, single), out to his family for nearly 20 years, shared that his parents and sisters often make veiled homophobic comments, such as asking if he’s going to meet “amigos de los tuyos [friends like you]” when they suspect he’s seeing another man. Similarly, another participant recounted how his mother heightened the stigma around HIV when he came out as gay in his teens, warning him, “If you are sleeping around with these men, you’re going to get HIV “ (participant #03, age 24, single). Despite the stigmatizing nature of her comments, he recognized they came from a place of protection and credited his mother’s warnings for his diligent HIV self-protection practices. Interestingly, a few other participants described that this stigma fueled their motivation to protect themselves from HIV. Their stories illustrated how family-induced stigma influenced their self-acceptance and shaped their HIV self-protective behavior, before and after coming out.

Lack of information and misinformation leading to self-reliance for sexual health protection

Across the interviews, a recurring theme in participant narratives was the absence of comprehensive sexual health education during their formative years. Many participants did not receive any sexual health education from their parents and did not feel comfortable discussing these topics with them because of the silence around sex, including sexual identity, prevalent in Latinx communities. Importantly, participants had received limited or no formal sexual health education in school regardless of whether they went to school in the U.S. or in Latin America, which highlighted that sexual conservatism is not only a cultural manifestation but a broader societal issue. Participants felt that sexual health conversations with their parents could have potential to help them be more informed. The absence of comprehensive sexual health education led to participants engaging in sexual exploration without a full grasp of how to protect their sexual health and against HIV. This lack of knowledge often resulted in periods of increased risk, particularly during adolescence and young adulthood, as participants navigated their sexual experiences without the necessary knowledge to effectively engage in HIV self-protection. As participant #03 (age 24, single) reflected, “I think, looking back, there were times when I was definitely at higher risk because I just didn’t know any better. It’s like you’re trying to figure it all out on your own, and that can be really dangerous.” This sentiment was shared by other participants who in absence of formal sexual education, learned lessons about sexual health promotion through trial and error, such as acquiring their first STI. Unfortunately, for some participants, STI treatment was also their first opportunity to engage in a sexual health discussion with a provider.

The lack of sexual health education made it difficult for Latinx SMM to parse through the misinformation that exists around sexual health. As one participant described,

“Oh, pues siento que, al principio bueno, desde el primer momento en que empecé a hacer activo sexualmente, pienso que la protección que uno más tiene es el miedo.¿Por qué? La desinformación; entonces al principio, pues no es mucha la información que uno recibe de pronto más en el país del que yo vengo, como que en las escuelas no se habla de mucha educación sexual; de pronto se viene más de la familia, pero a veces es como muy limitada la información. Entonces, pues al principio es como el miedo en cuanto a muchas cosas,¿no? Entonces pienso que es una manera de cuidarte es bueno sintiendo miedo. [Oh, well I feel that, at first, well, from the first moment I started being sexually active, I think the greatest protection one has is fear. Why? Because of misinformation; so at the beginning, there isn’t much information, especially in the country I come from, where there isn’t much talk of sexual education in schools; it often comes more from the family, but sometimes the information is very limited. So, at the beginning, it’s like fear about many things, right? So, I think that one way to take care of yourself is by feeling fear.]” – (Participant #10, age 26, monogamous relationship)

Despite this lack of sexual health education, many participants had taken a proactive approach to become educated about sexual health and HIV in adulthood by actively seeking out reliable sources of information. Even though this process was often described as intimidating, they sought information from various sources including from healthcare providers, online resources, or community organizations. For example, one participant shared his personal experience seeking sexual health care for the first time,

“My father never talked to me about, you know, sexually transmitted diseases or anything like that. My mom was a little open, in the sense that, you know, you got to practice abstinence, but, you know, never did they give me a condom, or did they give me anything like that. And since a very young age that I was in [city name] at 21, I did go to like, the human services to make sure I got tested for HIV, or any, you know, anything like that. And it’s a little intimidating when you don’t know exactly what you want, you know, what you’re going into, but at the same time, you know, it broke me. And they’re like, here’s your condoms, here’s what you need, and move forward.” (Participant #02, age 40, open relationship)

The proactive efforts in seeking reliable sexual health information taken by participants reflected their resilience in overcoming educational deficiencies and in taking ownership of their sexual health.

Growing wiser: maturity’s impact on sexual health and relationships

Participants’ narratives revealed a core theme of maturity, reflecting their journeys toward more self-protective behaviors, and overcoming challenges related to limited awareness and stigma. As individuals navigated the complexities of accepting their sexual identity and establishing themselves professionally within their communities, participants described a stronger sense of self-worth with these milestones, which gave them the confidence to take ownership of their sexual health.

“Just like being out to like my parents and communities and just overall, like coworkers and I feel like there’s a sense of maturity from when I first came out to like where I am now, and so I think quote, unquote, being an adult like now, I think I’m able to, you know, take that accountability and take that confidence in saying, you know, like if you if you can’t respect to my values and my control of my sexual health and you know, like maybe, I shouldn’t be you know interacting with you or like speaking on this action that shouldn’t be taken lightly.” (Participant #06, age 27, single)

This included setting healthy boundaries with partners, choosing partners whose values align with their own, and thinking beyond physical desires when making decisions about partners.

Latinx SMM also discussed how sexual experiences and previous relationships influenced them to take better care for their sexual health. A participant described that sexual experiences made him wiser, allowing him to detect “red flags” from partners, which he perceived as giving him more control over his sexual health.

“As you become more, I guess mature in age you start... things start clicking in your mind. You know what’s a pinpoint suspicious attitude or I guess energies and personalities like ooh no just that right there was... that’s a big red flag and red is not a super color, and you only get more wiser with experience or with stories.” (Participant #13, age 29 single)

With wisdom and maturity, participants reported becoming more selective in their engagement with potential partners, favoring “quality” over “quantity” in their relationships. This selectiveness was driven by a better understanding of their own needs and their ability to communicate those needs with partners. Several participants described a notable shift towards valuing deeper emotional connections over purely physical or superficial attractions.

“… like other things are important to me. You know, looks very important in my 20s and there still are, you know you definitely want a good-looking partner; But to me I think what’s most important now is how someone makes me feel, what they bring to the table. No matter what they look like but am I at risk...? …When I lived in New York, the first like of the first three or four years, I would basically hook up like multiple times on a week…” (Participant #12, age 34, single)

These narratives reflected not just a change in sexual behaviors, but a deeper understanding of what truly fulfills them in interpersonal connections.

Humanizing unjust sexual health care

Participants provided descriptions of unjust and dehumanizing healthcare experiences, but they also provided glimpses of hope for a more human experience. Healthcare provider attitudes and the healthcare environment had an impact on how participants accessed sexual healthcare. A common thread across participant experiences was feeling judged or stigmatized by healthcare providers. This stigma was often related to their sexual orientation, sexual behavior, or their health concerns, such as STI testing or treatment. A participant felt he had been reprimanded and ‘scolded’ by the nurses when seeking care at his local health department after being exposed to syphilis. Latinx SMM also anticipated and experienced stigma from healthcare providers related to PrEP use. Some healthcare providers have limited familiarity with PrEP and even suggested discouraged the use of PrEP. One participant, shared his experience,

“I’ve had difficulty with doctors and putting their own opinion or even initiating the conversation. Just the stigma of like of the sexual behaviors and the doctor is not feeling comfortable with like prescribing the drug because they feel like it could be preventable if you just don’t engage in those activities.” (Participant #06, age 27, single).

These negative experiences with healthcare providers led some Latinx SMM to feel reluctant to access sexual healthcare and discouraged open communication about sexual health.

In contrast, providers who were LGBTQ+ affirming, non-judgmental, and knowledgeable facilitated sexual health promotion for Latinx SMM and were actively sought out by participants.

“I would always look for. Like a younger female Doctor who is like more like him to meet with the gay world, right? Or like. Or a doctor that says they’re gay, friendly and like advertises on like gay websites you know, or gay directories and stuff like that. Just because you know we want to be 100% completely open with your health care practice, right?” (Participant #07, age 32, polyamorous)

Several participants articulated positive experiences of engaging in shared decision-making with their healthcare providers because they approached sexual healthcare in a respectful and understanding manner. Providers were also helpful in helping participants address any concerns about beginning PrEP, by providing information about side effects and reassurance about benefits of PrEP use. Additionally, healthcare providers who delivered kind and compassionate care helped to mitigate negative aspects of the healthcare environment for Latinx SMM.

“Sometimes I feel that if you don’t go to like these public places for service, they dehumanize you, you know? They make you like, ugh you can’t afford it and look at you, you’re, you’re insecure. I don’t know, I felt dehumanized by others. But she humanized me. She was very nice, no matter when I had a call whatever. She was always, she was always like, how’s the prep, um, let’s go get your blood work, you know, she was always on top of things, making sure that I was okay.” (Participant #02, age 40, open relationship)

Regardless of whether participants had an established relationship with a healthcare provider, they consistently cited providers as trusted sources of sexual health information and recognized the role they play in sexual health promotion. Normalizing sexual health care through advertising on social media and in the community as well as increasing visibility of sexual health clinics was described as important for stigma reduction and increasing access to care among Latinx SMM.

Financial barriers and lack of health insurance were also significant structural barriers to accessing care for Latinx SMM. Participants in this study revealed that financial barriers had impeded their access to sexual health care at some point in their lives and cited high costs of healthcare visits as a deterrent to seeking healthcare. Additionally, participants identified the lack of health insurance as a critical barrier to accessing sexual health care, particularly among self-employed individuals. The high costs of PrEP were cited by participants as a significant obstacle to its use, irrespective of their health insurance status. These narratives highlighted several structural barriers that are known to limit Latinx SMM’s access to sexual healthcare and HIV self-protection options.