Poverty, Power and Prejudice: How Structural Forces Shape HIV Risk for Black Women in Baltimore

A new qualitative study published in the Archives of Sexual Behavior argues that HIV prevention efforts aimed at Black cisgender women in the United States are failing to account for the layered social and structural conditions that actually shape their risk. Researchers led by Deja Knight of the Johns Hopkins Bloomberg School of Public Health conducted in-depth interviews with 26 Black cisgender women in Baltimore between October 2021 and April 2023, all aged 18 to 44, all of whom reported inconsistent condom use and vaginal or anal sex with a male partner within the previous six months. Their analysis, which combined inductive and deductive coding, reveals a web of intersecting vulnerabilities—poverty, housing instability, unequal gender power dynamics, stigma, and healthcare discrimination—that individual-level prevention strategies were never designed to address.

The epidemiological backdrop gives the findings urgency. Baltimore has long carried one of the heaviest HIV burdens in the United States, and Black women bear a disproportionate share of new diagnoses relative to their population size. Nationally, the federal Ending the HIV Epidemic initiative has set ambitious reduction targets, yet progress among Black cisgender women has lagged behind other groups. Prior research, including systematic reviews and scoping analyses cited by the study team, has repeatedly documented low uptake of pre-exposure prophylaxis, or PrEP, among Black women despite demonstrated interest and eligibility. The new study asks a deceptively simple question: why do prevention tools that work in clinical trials so often fail to translate into protection in women’s everyday lives?

The answer, according to the participants’ accounts, begins with economic precarity. Women described how poverty, limited employment opportunities, and unstable housing pushed them into circumstances that elevated their exposure to HIV, including engagement in sex work and substance use. These were not framed as free choices among equally available options but as survival strategies negotiated under constraint. The study’s authors, drawing on intersectionality theory rooted in the work of Kimberlé Crenshaw and Patricia Hill Collins, emphasize that these conditions do not operate in isolation. Economic marginalization compounds gendered power imbalances, which in turn interact with racialized stigma in healthcare settings, producing a cumulative vulnerability that no single-axis intervention can dismantle.

Gendered power dynamics emerged as a central theme in the interviews. Participants described unequal sexual relationships in which male partners held disproportionate control over condom use, and in which coercive sexual dynamics made negotiation difficult or dangerous. The theory of gender and power, developed by sociologist R.W. Connell and later applied to HIV research by Gina Wingood and Ralph DiClemente, provides the analytical scaffolding here: when women lack economic independence and face the threat of violence or abandonment, their ability to insist on condoms or refuse unprotected sex is structurally constrained. Perceived monogamy also played a protective role in women’s decision-making—many relied on the belief that they and their partners were faithful rather than on barrier methods—but the researchers note that this strategy is only as reliable as the information women have about their partners’ other relationships, information that unequal power dynamics often make impossible to obtain.

The interviews also documented how stigma and misinformation operate as barriers to prevention services. Women reported experiencing discrimination in healthcare settings and described widespread misconceptions about HIV and about PrEP specifically. Prior work by several of the same authors, including studies of PrEP initiation and adherence among Black cisgender women in Mississippi, has shown that HIV and PrEP stigma, combined with limited social support, significantly impede movement along the PrEP care continuum. The Baltimore study extends this picture by situating those barriers within women’s broader lived realities: a woman who fears judgment from providers, who cannot take time off work, who lacks stable housing for storing and taking a daily medication, and who doubts she will be treated respectfully is unlikely to initiate or sustain PrEP regardless of her actual epidemiological risk.

Methodologically, the study is notable for its scale and rigor within the qualitative tradition. Twenty-six participants is a substantial sample for in-depth interviewing, consistent with editorial guidance published in the Archives of Sexual Behavior on qualitative sample sizes. The team analyzed transcripts using MAXQDA software, applying both deductive codes derived from established frameworks and inductive codes that emerged from the data itself, and presented illustrative themes that they argue hold across the group of Black women interviewed. The research was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, and verbal informed consent was used deliberately, since requiring written signatures for sensitive interviews could itself have increased risk for participants. The qualitative data are not publicly available, a restriction the authors justify on privacy and consent grounds.

The findings arrive at a moment when the prevention landscape offers more biomedical options than ever before. Long-acting injectable PrEP, the dapivirine ring, and oral antiretroviral regimens have expanded the toolkit, and studies cited in the paper—including a randomized trial of a culturally tailored intervention among Black women who use drugs in New York City community supervision programs—show that appropriately designed programs can improve PrEP engagement. Yet the Baltimore interviews suggest that biomedical advances alone will not close the gap. If a woman’s primary constraint is not knowledge or motivation but housing instability, an abusive partner, or a clinic where she has been demeaned, then offering her a pill or an injection without addressing those conditions treats the symptom while leaving the disease of structural inequity untouched.

The authors are explicit about the policy implications. They call for HIV prevention approaches that extend beyond individual behavior change to address economic precarity, gendered power imbalances, and healthcare discrimination directly. In practice, that could mean integrating HIV services with housing support, employment programs, and intimate partner violence services; training providers to deliver trauma-informed, non-stigmatizing care; and designing PrEP delivery models that accommodate the schedules and circumstances of women juggling survival demands. Related research from the same group on service delivery preferences among Black women in Baltimore, published in BMC Public Health, indicates that women want flexible, respectful options—a finding consistent with the broader implementation science literature on differentiated service delivery.

What makes the study resonate beyond Baltimore is its theoretical framing. By treating intersectionality not as a buzzword but as an analytical method, the researchers demonstrate how race, gender, class, and housing status interact multiplicatively rather than additively. A Black woman facing poverty is not simply a Black person at risk plus a poor person at risk; she occupies a social position with its own distinct exposures and constraints, many of which are invisible to risk calculators and individual counseling models. Earlier work by LaVeist and colleagues in Southwest Baltimore showed that racial health disparities dissipate when Black and white residents live under similar conditions—evidence that place and material circumstance, not biology, drive much of the observed inequity. The new study adds the sexual health dimension to that argument.

For a field still dominated by interventions targeting knowledge, attitudes, and condom negotiation skills, the message is uncomfortable but clear: the women interviewed in this study already understood their risk better than any pamphlet could teach them. What they lacked was the structural power to act on that understanding. As the United States pursues its goal of ending the HIV epidemic, the Baltimore findings suggest that success among Black cisgender women will depend less on persuading individuals to change behavior and more on changing the economic, relational, and institutional environments in which those behaviors occur. Until prevention science takes that mandate seriously, the study implies, the same women will continue to be counted in the same statistics—year after year, city after city.

Subject of Research: Intersectional structural determinants of HIV vulnerability among Black cisgender women in Baltimore

Article Title: Beyond Individual Risk: A Qualitative Exploration of Intersectional HIV Vulnerabilities Among Black Cisgender Women in Baltimore

Article References: Knight, D., Willie, T. C., Baral, S., German, D., Ekambi, S., Prince, J., & Saleem, H. T. (2026). Beyond Individual Risk: A Qualitative Exploration of Intersectional HIV Vulnerabilities Among Black Cisgender Women in Baltimore. Archives of Sexual Behavior, 55(6), 2689-2699. https://doi.org/10.1007/s10508-026-03502-5

Image Credits: AI Generated

DOI: 10.1007/s10508-026-03502-5

Keywords: HIV, Black women, intersectionality, Baltimore, PrEP, structural determinants, gender and power, healthcare discrimination, poverty, sex work, stigma, qualitative research