'Oh, they can prevent It?': a structural agency framework for understanding HIV prevention among black women in...

Despite efforts to end the HIV epidemic, new transmissions among Black women in the U.S.' Deep South remain disproportionately high. This study examined condomless sex experiences and PrEP non-engagement among Black women in community supervision programs (e.g., diversion, probation, parole) in Alabama.

As part of Project E-WORTH South, we used a phenomenological approach and conducted 16 semi-structured interviews to explore factors influencing condom use and PrEP engagement. Participants (n = 16) were selected through criteria-based sampling: Black or African American individuals, female at birth, aged 18 years or older, English-speaking, and current community supervision involvement. Interview transcripts were double-coded using a phenomenological coding technique to identify general themes. The codes were then grouped into themes and subthemes.

Analysis revealed four distinct forms of agency that participants employ in sexual health decision-making, mapped along two dimensions: structural constraints/coercion and HIV prevention knowledge/resources. Despite 37.5% engaging in self-initiated HIV testing, 87.5% were unaware of PrEP/PEP existence, with 50% reporting condomless sex. We identified two novel agency forms: deprived agency (knowledge gaps limiting autonomy) and traversed agency (bidirectional override of initial intentions).

This study introduces a novel structural agency matrix framework and identifies previously unrecognized forms of sexual health agency among Black women under community supervision. The paradox of high health-seeking behaviors alongside near-zero PrEP awareness reveals systematic information dissemination failures rather than individual barriers, demonstrating need for matrix-informed interventions that simultaneously address structural constraints and knowledge gaps.