Opportunities for Low-Barrier HIV Testing in the U.S. Deep South: Findings from a Survey in Alabama

The HIV epidemic remains a critical public health challenge in the Southern U.S., where barriers such as healthcare shortages, structural racism, and social determinants of health exacerbate disparities. Mobile- and self-HIV testing offer promising approaches to address these barriers. Partnering with a community-based healthcare organization in Alabama, we surveyed 181 individuals accessing facility- and community-based HIV testing from August 2022 to November 2023. Most participants were Black (92%), women (78%), and heterosexual (83%), with 73% reporting annual incomes below $50,000. While 72% felt unlikely to acquire HIV, a fifth reported forgoing healthcare due to competing financial needs like housing (23%) and food (21%). Barriers to care were rated as "very slight" to "somewhat of a problem," and medical mistrust was highest in group disparities (mean 27.2/60). Community-level HIV stigma averaged 3.45/5, while social support scored 61.1/100. Mobile-based HIV testing was favorably rated for acceptability (3.9/5), appropriateness (4/5), and feasibility (4/5). Among participants, 61% were aware of HIV self-testing, 21% had used it, and 47% expressed interest in future use. Findings reveal low perceived HIV risk and significant community stigma, though individual stigma was less of a barrier than factors like fear of a positive result and lack of knowledge about care. This study highlights the need for tailored interventions to improve HIV testing access for vulnerable populations across Alabama and other rural U.S. settings.