The research was conducted as part of the broader Ending the HIV Epidemic initiative, a federal program launched in 2019 that concentrates resources on jurisdictions where transmission remains stubbornly high. Tennessee is one of the priority states, and the midsize historically Black college and university that hosted the study sits squarely within that geography. Between March and September 2022, researchers administered an electronic cross-sectional survey through the REDCap platform, recruiting students between the ages of 18 and 35. The instrument collected demographic information, details about sexual behavior and other HIV risk factors, history of HIV testing and pre-exposure prophylaxis use, perceived barriers and facilitators to prevention services, and responses on the HIV Testing Belief Inventory, a validated psychometric scale designed to measure beliefs about the benefits of testing and the weight of stigma.

Of the 240 responses received, 146 surveys met the inclusion criteria of reporting either a prior HIV test or prior PrEP use, and those formed the analytical sample. The demographic profile reflected the institution’s identity: 84.9 percent of respondents identified as Black, 58.9 percent as female, and 82.9 percent as heterosexual. Sexual activity was nearly universal in the recent past, with 93.2 percent reporting intercourse within the previous year. When the researchers applied their risk classification, 49.3 percent of the sample fell into the high-risk category, a figure that underscores how broadly HIV vulnerability is distributed even among young adults who may not perceive themselves as candidates for prevention services.

The statistical analysis revealed what the authors describe as discrepant concern for HIV risk. Being classified as high risk was not significantly associated with recent HIV testing, with a p-value of 0.138, nor with reported concern about HIV risk, with a p-value of 0.455. In practical terms, the students whose behavior placed them at greatest epidemiological risk were no more likely to seek testing or to worry about infection than their lower-risk peers. This misalignment is a well-recognized challenge in HIV prevention science, but documenting it in a young, predominantly Black, predominantly heterosexual college population adds an important data point, because much of the national conversation about HIV risk perception has historically centered on other demographic groups.

Where the psychometric measures did show signal was in distinguishing students who had been tested from those who had not. Prior HIV testing was significantly associated with lower concern about HIV-associated stigma, with a mean stigma score of 1.7 among those tested versus 2.0 among those untested, a difference that reached statistical significance at p = 0.023. Testing was also associated with greater perceived benefits of testing, with mean scores of 4.4 versus 4.0 on that subscale, significant at p = 0.002. These associations are correlational rather than causal, and the authors are careful not to overinterpret them, but they suggest that stigma and perceived benefit are meaningful levers in the psychology of testing behavior. Interventions that reduce the social cost of being seen at a testing event, or that sharpen students’ understanding of the concrete advantages of knowing their status, may shift uptake in ways that risk education alone has not.

The headline utilization numbers were sobering. Fewer than half of respondents, 46.6 percent, reported a recent HIV test, and only 6.2 percent had ever used PrEP, the daily antiretroviral regimen that reduces the risk of acquiring HIV through sexual exposure by roughly 99 percent when taken as prescribed. The gap between the half of the sample classified as high risk and the tiny fraction using PrEP represents one of the clearest illustrations of the prevention cascade failures that characterize the Southern United States. PrEP uptake among Black Americans has lagged far behind the burden of disease in the community, driven by a combination of limited awareness, access barriers, medical mistrust, and prescriber-level biases that have been documented in prior literature.

When the survey asked what would make testing easier, the most frequently cited facilitator was on-campus testing events, selected by 52.4 percent of respondents. This preference for a familiar, convenient, and institutionally sanctioned setting speaks to the practical barriers that off-campus clinics can pose, including transportation, cost, scheduling conflicts, and the fear of being recognized in a small community health setting. The campus itself, in other words, is not just a backdrop but a potential delivery platform. Consistent with that theme, when respondents interested in learning more about PrEP were asked where they would turn, the largest share, 40.7 percent, said they would rely on the HBCU for information, outranking healthcare providers and other sources.

That trust in the institution is a strategic asset. Historically Black colleges and universities occupy a distinctive position in American higher education and in Black communities more broadly, with a legacy of producing a large share of the nation’s Black professionals and a reputation for serving students whom other institutions have historically marginalized. The study’s authors argue that this positioning makes HBCUs acceptable, and potentially highly effective, avenues for delivering HIV prevention services. Embedding routine testing at campus health centers, staging regular testing events integrated into student life, and channeling PrEP education through trusted campus messengers could reach a population that conventional clinic-based outreach has struggled to engage. The finding that students themselves nominate the institution as their preferred information source strengthens the case for institution-embedded programming rather than externally imposed campaigns.

The study has limitations that the authors acknowledge and that readers should weigh. The sample came from a single midsize HBCU, and the 146 analyzed surveys represent a subset of the 240 collected, raising the possibility of selection bias toward students already engaged with health topics. Self-reported sexual behavior and testing history are subject to recall and social desirability errors, and the cross-sectional design captures a single moment in time, precluding any inference about whether reduced stigma leads to testing or whether the experience of testing reduces stigma. The authors explicitly call for future work to evaluate the drivers of the mismatch between actual and perceived risk, a question the survey was designed to document rather than resolve.

Even with those caveats, the study contributes a concrete, actionable map for a population that sits at the intersection of several high-priority public health targets: young adults, Black Americans, Southerners, and students at institutions with both elevated vulnerability and unusual community trust. The Tennessee Center for AIDS Research, funded by the National Institutes of Health, supported the work, along with an appropriation from the State of Tennessee’s Legislative Black Caucus, a signal of state-level political engagement with HIV disparities in Black communities. The research team, which spanned Vanderbilt, Meharry Medical College, St. Jude Children’s Research Hospital, LeMoyne-Owen College, and partner institutions, also drew on student health ambassadors and the Memphis Connect to Protect HIV Community Coalition in designing and disseminating the survey, a community-engaged approach that mirrors the delivery model the findings themselves endorse. The next step, the authors conclude, is implementation research: rigorously testing locally tailored HIV prevention interventions delivered through HBCUs, so that the institutional trust documented in this survey can be converted into higher testing rates, wider PrEP uptake, and measurable reductions in new infections among the young Black adults who carry the heaviest burden of the American HIV epidemic.

Subject of Research: HIV testing and pre-exposure prophylaxis uptake among young adults at a historically Black college in Tennessee

Article Title: Barriers and facilitators to HIV testing and prevention services among young adults at a historically black college in Tennessee

Article References: Moore, E. R., Wilkins, M. L., Alexander, L., Davis, B., Karris, M., Lang, L., McGee, M. L., McMorris, C., Muhammad, J., Ross, A. N., Propst, E. A., Willging, C., Rebeiro, P. F., & Pettit, A. C. (2026). Barriers and facilitators to HIV testing and prevention services among young adults at a historically black college in Tennessee. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14533-7

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14533-7

Keywords: HIV, HIV testing, PrEP, HBCU, young adults, HIV prevention, stigma, health disparities, U.S. South, Ending the HIV Epidemic, public health, cross-sectional survey

The scientific premise behind Project Adhere rests on a well-documented paradox. Oral PrEP, typically a combination of emtricitabine and tenofovir disoproxil fumarate, reduces the risk of HIV acquisition by more than 90 percent when taken as prescribed, a finding established in landmark trials such as iPrEx and PROUD. Yet the protective effect of the drug is exquisitely sensitive to adherence. Pharmacologic studies measuring intracellular tenofovir-diphosphate in dried blood spots have shown that protection drops steeply when fewer than four doses per week are taken. Black men who have sex with men, the very group facing the highest incidence of new infections, have repeatedly been shown in prior research to be less likely to initiate, adhere to, and persist on oral PrEP compared with their white counterparts.

To understand what drives this gap, the research team, led by Darren L. Whitfield of the University of Maryland School of Social Work together with colleagues at Emory University, New Mexico State University, and Vanderbilt University Medical Center, designed an observational study that tracked both behavior and psychology over time. Participants were recruited from Ending the HIV Epidemic jurisdictions, geographic areas selected by federal health agencies because they account for a majority of new HIV diagnoses in the United States. By concentrating on these hotspots, the investigators aimed to study adherence in the settings where improvements would have the greatest public health impact.

The methodological design of Project Adhere reflects a growing recognition that self-reported adherence is unreliable. Previous studies comparing self-report with pharmacologic measures have found that participants frequently overestimate the doses they take, a pattern documented among young men who have sex with men in both clinical trials and community settings. To counter this bias, Project Adhere monitored participants’ PrEP use objectively over the six-month follow-up period while simultaneously administering validated psychometric instruments. These included the Patient Health Questionnaire for depression, the Alcohol Use Disorders Identification Test for alcohol consumption, the Drug Abuse Screening Test for other substance use, and the Brief Resilience Scale for the capacity to recover from stress.

The headline finding of the study is that substance use was significantly associated with lower PrEP adherence. This result aligns with a systematic review published in AIDS and Behavior in 2023, which synthesized evidence from studies enrolling men who have sex with men and transgender women and found consistent links between substance use and diminished adherence to HIV pre-exposure prophylaxis. It also echoes earlier findings from the HPTN 073 trial, in which self-reported substance use behaviors among Black men who have sex with men were associated with both PrEP acceptance and adherence outcomes. The consistency of this association across independent cohorts strengthens the case that substance use is not a peripheral issue but a central mechanism undermining chemoprophylaxis in this population.

The mechanisms linking substance use to missed doses are plausibly multifactorial. Alcohol and drug use can disrupt daily routines that anchor medication-taking habits, impair memory and executive function during intoxication, and increase the perceived burden of a daily pill. Qualitative work with PrEP-prescribed gay and bisexual men has documented that participants themselves perceive alcohol consumption and substance use as direct obstacles to consistent adherence, sometimes describing complete lapses in their medication routines during periods of heavy use. There is also the phenomenon of interactive toxicity beliefs, the concern that combining PrEP with alcohol or drugs could harm the body, which prior research has linked to stigma, substance use, and reduced PrEP uptake.

What makes the Project Adhere findings notable is that substance use emerged as the significant correlate while other psychosocial factors did not reach statistical significance in this sample. Depression, anxiety, stigma, resilience, and self-efficacy have all been implicated in prior literature as barriers or facilitators of PrEP adherence. A syndemic perspective, which holds that clustered psychosocial epidemics such as depression, substance use, and violence exposure interact synergistically to elevate HIV risk, has been widely applied to young Black gay and bisexual men. The Project Adhere results do not invalidate this framework, but they do suggest that within a six-month observational window in this cohort, substance use was the factor with the clearest measurable signal, and that the effects of other psychosocial and structural variables require further study with larger samples.

The study’s limitations are important for calibrating interpretation. With 69 participants, the sample size constrains statistical power, meaning that modest but real associations between other psychosocial factors and adherence may have gone undetected. Observational designs cannot establish causation; it is possible that unmeasured confounders influence both substance use and adherence. Nevertheless, the authors argue that the findings point toward a practical intervention target. Screening for substance use in PrEP clinics serving Black men who have sex with men, and integrating substance use support into HIV prevention services, could address a modifiable behavior that directly compromises the pharmacologic protection the medication is meant to provide.

The structural context surrounding these individual-level findings cannot be ignored. Black men who have sex with men navigate layered stigma related to race, sexuality, and PrEP use itself, along with medical mistrust rooted in historical and contemporary discrimination. Studies in Jackson, Mississippi and Boston documented how stigma, mistrust, and perceived racism suppress PrEP awareness and uptake. Research in Harlem and Atlanta has shown high discontinuation rates even among those who initiate the regimen. Structural racism and racial trauma have been proposed as upstream determinants that shape both mental health burdens and engagement with prevention services. Within this landscape, a daily pill demands a stability of routine, trust, and access that structural inequities actively erode.

The federal Ending the HIV Epidemic initiative has set the goal of reducing new infections by at least 90 percent by 2030, and mathematical modeling suggests that PrEP could substantially reduce incidence among Black sexual minority men if coverage and adherence were equitable. Population-based analyses of the first decade of PrEP use in the United States, however, have documented persistent disparities in uptake by race and ethnicity, with Black men who have sex with men remaining underrepresented among PrEP users relative to their share of new infections. Project Adhere adds a granular, longitudinal, and methodologically careful data point to this national picture, indicating that closing the gap will require more than expanding prescriptions. It will require interventions that meet Black men where the evidence now points: at the intersection of substance use, daily routine, and the social conditions that shape both. The authors call for further research to determine the full impacts of psychosocial and structural factors on adherence and persistence, and for interventions designed to assess and assist Black men who use substances, so that the promise of PrEP can finally be delivered equitably to the communities that need it most.

Subject of Research: Psychosocial and structural factors influencing PrEP adherence among Black men who have sex with men

Article Title: Associations Between Psychosocial Factors and Pre-exposure Prophylaxis (PrEP) Adherence Among Black Men Who Have Sex with Men in Ending the HIV Epidemic Jurisdictions: Findings from Project Adhere

Article References: Whitfield, D. L., Caldwell, J., Edwards, O. W., Mammadli, T., Chandler, C. J., Sullivan, P., & Jones, J. (2026). Associations Between Psychosocial Factors and Pre-exposure Prophylaxis (PrEP) Adherence Among Black Men Who Have Sex with Men in Ending the HIV Epidemic Jurisdictions: Findings from Project Adhere. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-026-03433-1

Image Credits: AI Generated

DOI: 10.1007/s10508-026-03433-1

Keywords: PrEP, HIV prevention, Black men who have sex with men, medication adherence, substance use, Ending the HIV Epidemic, psychosocial factors, health disparities, Archives of Sexual Behavior, Project Adhere, Associations, Between