Introduction

In 2019, the U.S. government and partners announced the initiative for Ending the HIV Epidemic: A Plan for America (EHE), a vision to use four key pillars—diagnose, treat, prevent, and respond—to reduce incident HIV in the U.S. by at least 90% by 2030 [1]. King County, WA, where the city of Seattle is located, is among 48 priority counties and two cities which accounted for over 50% of HIV diagnoses in the U.S. in 2016–2017 [2], and is therefore considered a priority jurisdiction for EHE funding and activities. King County, WA and several other EHE jurisdictions include large African immigrant populations, which are disproportionately affected by HIV. For instance, African immigrants account for 2% of the King County population but 10% of the new HIV diagnoses [3,4,5]. Overall, African immigrants represent a small but growing share of the American population, increasing 251% from 2000 to 2016 [6]. Members of African immigrant communities are more likely to have a late diagnosis than U.S.-born people throughout the U.S., including in King County, WA [7,8,9]. The HIV diagnosis rate among African immigrants in King County was fivefold that of the overall population (50 vs. 10 per 100,000 population) in 2018, multiple folds higher in African immigrants than U.S.-born Blacks, including men who have sex with men (MSM) [8]. We see that while late HIV diagnosis is common among African immigrants in King County, these communities tend to do as well or better than their U.S.-born counterparts in later stages of the HIV care continuum [8,9,10].

Therefore, the key barrier to ending the HIV epidemic for African immigrant communities is early testing, or Pillar 1 (Diagnosis) of the EHE plan. While a spectrum of individual, interpersonal, organizational, and structural barriers and facilitators exist for HIV testing among immigrant communities, stigma around HIV is a key, and often the leading, barrier identified among African immigrants [11, 12]. HIV transmission in African immigrant communities tends to be largely via heterosexual routes, with both incident local acquisitions and infections acquired in the countries of origin [13]. Thus, experiences around HIV, including HIV testing and stigma, are different for African immigrant communities than, for example, white or even Black MSM born in the U.S.

In our prior work in Harambee! 1.0 we offered free, community-based and integrated HIV testing with other preventative health services among three of the largest African immigrant communities in King County, namely the Ethiopian, Somali, and Eritrean communities [11]. Our qualitative findings identified HIV-related stigma as the largest barrier to getting tested for HIV among members of these communities. To further explore exactly how HIV-related and intersectional stigmas impact HIV testing behaviors, we conducted this formative research via qualitative methods. We also aimed to elicit community feedback on potential stigma reduction interventions to help improve uptake of early HIV testing.

Methods

Study Setting, Academic-Community Partnership, and Positionality

This research took place as part of an academic-community partnership, between the University of Washington (UW) researchers and the Ethiopian, Somali, and Eritrean health organizations and their leaders. This partnership arose from our ongoing work in addressing barriers to HIV testing amongst African immigrant communities in King County, WA. This partnership utilized principles of community-based participatory research (CBPR) [14, 15]. Specifically, we prioritized principles of equity (e.g., equitable distribution of financial resources), justice (e.g., representation of community partners in all steps of the research process), and sustainability (e.g., bidirectional capacity-building and commitment to organizational priorities) in this partnership. For an effective partnership, we incorporated practices of cultural humility, trust, a history of partnerships, shared decision-making, capacity-building, bi-directional learning, and a regular process of reflection on project progress at the partnership level. Community members were valued as equal contributors, and often leaders, to the conceptualization and implementation of study design, data analysis and interpretation of findings, intervention selection, and dissemination of findings to both scientific and community audiences. Nearly half of our study budget went directly to our community partners to support them as active members of the research team as they contributed to every step of this process. The project team, which included the academic researchers (the three primary investigators did not belong to African immigrant communities, though two belonged to South Asian immigrant communities), study staff (all members belonged to African immigrant communities, including undergraduate research assistants except for one who belonged to a Latinx immigrant community), and community partners (all belonged to the African immigrant communities) met regularly during project planning, implementation, analysis, and dissemination.

Data Collection

Overall Approach

Our overall qualitative data approach utilized both key informant interviews (KIIs) and focus group discussions (FGDs). We first conducted the KIIs so as to allow preliminary analyses to inform our discussion guides for the later FGDs. The KIIs were conducted from October 2019 through January 2020 and the FGDs were conducted from March through April 2020 in King County, WA. The KIIs, which took place prior to the COVID-19 pandemic, were conducted in-person and the FGDs, which occurred during the pandemic, were conducted entirely virtually.

Sampling

We utilized purposive sampling to identify categories of key informants to interview or participants to include in the focus groups, and our community partners determined which participants to recruit and the manner of recruitment. For the KIIs, we sought to sample persons living with HIV (PLWH), healthcare professionals, and religious leaders belonging to East African immigrant communities. PLWH participants, who we thought could speak amply to their lived experiences with HIV stigma, were recruited from provider referrals from the UW-affiliated county hospital’s HIV clinic or case management organizations. Since our KII data indicated a strong preference to include religious leaders and institutions in any HIV-related stigma intervention, in our FGDs, we heavily sampled religious leaders, though we also included other community leaders as well as some lay community members. For the FGDs, we did not attempt to knowingly recruit any PLWH, to avoid any potential inadvertent disclosure or traumatizing conversations. An informed consent form was provided in all relevant languages (see below), and participants provided oral consent. Patient demographics (age, gender, country of birth, occupation, and religious affiliation) were collected from each participant prior to the KIIs or FGDs. Each participant was provided $50 cash reimbursement for either the KII or FGD participation. Saturation of themes within categories of participants guided our sampling numbers.

Interviewers and Facilitators

Our community partners selected the interviewers and facilitators from their respective communities. Interviewers/facilitators were first generation Americans and were bi- or trilingual, speaking at least two of the following languages: English, Amharic, Tigrinya, Somali, or Kiswahili. We conducted centralized trainings for interviewers in October 2019 and facilitators in February 2020; some of the interviewers had marked prior experience conducting KIIs or FGDs and all of the facilitators had significant prior experience conducting FGDs. The interviews were conducted to match the interviewer’s language with the native-speaking participant whenever feasible. Of note, due to potential disclosure concerns for PLWH participants [16], we offered them options to undergo the interview with project members not belonging to any of the African immigrant communities, and two such participants chose such interviewers; these interviews and consents were conducted in English. For each FGD, the facilitator led the discussion while a second team member belonging to the community served as the note taker. While three of the study team members (RCP, RPK, and FM), joined at the beginning of each FGD to welcome and thank the participants with live translations by the facilitator, the remainder of the FGDs took place in the native language and included only members of each respective community.

Interview/Discussion Procedures

KIIs were conducted at various locations within the metropolitan Seattle area, such as ethnic community centers or health organization offices, dependent on the preferences of the interviewee and interviewer. The FGDs were conducted virtually via Zoom. Interviews and discussions were audio recorded and translated and transcribed directly into English by the same interviewer/facilitator or a second member of the same community partnership team. If the transcriptionist was not the interviewer, the interviewer reviewed the English transcription for accuracy, and any discrepancies were resolved via consensus.

Interview/Discussion Guides

The KII guide focused on the following five main domains: (1) interactions with the U.S. healthcare system; (2) barriers to health screenings; (3) stigma around health screenings and HIV-related stigma, including for HIV testing; (4) intersectional stigma and influence on HIV testing; and (5) how to reduce stigma around health screenings, including HIV testing. The FGD guide focused on the following three main domains: (1) stigma around health screenings and HIV-related stigma, including for HIV testing; (2) intersectional stigma and influence on HIV testing; and (3) intervention development for stigma reduction around HIV, with emphasis on the role of religious leaders and institutions. With the goal of providing direction for an intervention choice, during the FGDs, three HIV stigma reduction intervention prototypes, one of which was faith-based, were discussed [17,18,19,20]. Of note, when interrogating intersectional stigma, our team was drawn to Earnshaw’s Stigma and HIV Disparities Model as a framework for building out probes for our guides [21]. The Stigma and HIV Disparities Model developed by Earnshaw and colleagues describes the concurrent impact of coexisting marginalized identities and explains the negative impact that intersectional stigma has on HIV outcomes. In this model, multiple stigmas interact to affect both structural and individual-level processes. Stigmas may interact through multiple pathways, such as reduced access to health care (a structural-level manifestation of anti-immigrant stigma) and anticipated stigma related to a positive HIV test (the result of HIV-related stigma and/or homonegativity), to negatively impact HIV testing. A second model component pivots around resilience resources at the individual and community levels. However, we did not restrict ourselves to only the Earnshaw model in developing our guides and probes; we also borrowed from Rao et al.’s multilevel stigma model [22] and the socioecological model [23]. The KII and FDG guides can be found in supplementary text.

Data Analysis

English transcripts were uploaded into NVivo (version 12.0, QRS International Pty Ltd.). We utilized inductive coding, and three team members (SAH, NJ, and GB) with guidance from RCP, RPK, and FM conducted the coding. We developed an initial codebook in a group setting based on the KII and FGD guides and a read of the initial few transcripts, and iteratively adapted the codebook as coding of transcripts progressed. Initial coding was done on the first transcript with all three coders together, then 1–2 transcripts were double-coded individually by coders, and any discrepancies in coding were resolved by consensus. Thereafter, the remaining transcripts were coded individually by separate coders, with one coder (SAH) reviewing the coding for all transcripts. We used thematic analysis [24, 25] through several group meetings, to arrange the codes into three thematic domains with corresponding sub themes, both convergent and divergent, in conjunction with illustrative quotations.

Results

We conducted a total of thirty KIIs and five FGDs, with one participant from the KIIs also participating in one of the Ethiopian FGDs (n = 72 total participants; Table 1). Our Ethiopian and Somali community partners conducted sex-specific FGDs while our Eritrean partner chose to conduct one FGD with participants of both sexes. Out of the 72 total participants, 26 (36%) were born in Ethiopia, 27 (37%) in Somalia, 17 (23%) in Eritrea, and one each were born in Kenya and the U.S. (with the U.S. born individual identifying with the Eritrean community). In total, 35 (48%) of our participants identified as female. Respondent ages ranged from 22 to 67 years, with over half of participants between 30 and 49 years of age. The majority of participants worked as healthcare professionals (n = 15) or as religious leaders (n = 14). Five individuals identified as PLWH, all of whom participated in the KIIs.

Table 1 Sociodemographic characteristics of study participants

Overall, in analyzing potential influences on HIV testing behaviors among the Ethiopian, Somali, and Eritrean immigrant communities in the Seattle area, four major themes emerged: (1) culture and stigma, (2) HIV-related stigma, (3) intersectional stigma, and (4) other influences. We present these four themes in detail below, beginning with a broad understanding of culture and stigma in these communities to provide greater context for our later findings. In general, there were far more commonalities across the three communities than differences. So, when differences exist, we highlight them, otherwise the findings are applicable to all three country-of-origin communities queried in this study. Table 2 provides example quotations from the interviews and focus groups, organized by themes described below.

Table 2 Main themes, subthemes, and example quotes for factors influencing HIV testing behaviors among Ethiopian, Somali, and Eritrean immigrant communities in King County, WA

Culture and Stigma

Social Networks and Cohesion

Within each country-of-origin community, the overall orientation of the culture towards any stigma played a role in how stigma around HIV manifests, including for HIV testing. Participants routinely mentioned that the concept of stigma was tied to beliefs of shame and isolation. Importantly, these beliefs around stigma have implications not only for the individuals but went on to have marked ramifications for their extended families or tribes/clans. Therefore, there was a large emphasis on stigma affecting social cohesion of whole networks of communities. Relatedly, participants also described using secrecy to maintain social cohesion amongst their social networks, in order to maintain strong relations between themselves and their community.

Stigma Around Other Health Conditions

Multiple health-related stigmas existed, and the stigmatization of health conditions often related to cultural norms around remembering those who have died of that illness, instead of focusing on those living with it. Identifying those living with such conditions is also more challenging given that community members often do not disclose the health conditions they may be living with due to perceived stigma. Communicable diseases such as tuberculosis and COVID-19, along with non-communicable diseases such as diabetes, hypertension, mental health, and cancer, were all mentioned as stigmatized health conditions within these communities. Several participants mentioned how after they disclosed a disease diagnosis, members of their community would list, more often than not, others who passed away from it. Nonetheless, despite there being stigma around most health conditions, it appears that a hierarchy for stigma, and conversely empathy, exists, with HIV being the most stigmatizing condition among the rest. For example, although participants noted that cancer is stigmatized in their communities, they also highlighted how their communities empathize more with those with cancer than those with HIV.

HIV-Related Stigma

Participants from each country-of-origin community consistently noted that HIV-related stigma was the leading influencer of HIV testing behaviors, and that HIV is a heavily stigmatized disease, often to the point that HIV is rarely even mentioned or discussed in their communities. Four main subthemes or drivers of HIV-related stigma emerged: (1) the diagnosis of HIV being a death sentence or treatability of HIV; (2) misconceptions or poor messaging around the transmissibility of HIV; (3) normative beliefs around HIV and other stigmatizing behaviors such as pre/extramarital sex; and (4) the religious belief that HIV is a punishment for such behaviors. We explore these subthemes below.

First, HIV is a heavily stigmatized condition because many community members still consider an HIV diagnosis as a condition rapidly leading to death. Participants perceived a general lack of awareness within their communities when it comes to surviving and living positively with HIV. Interestingly, a normative element existed to this belief as many participants themselves acknowledged that, with treatment, PLWH can have a “normal” lifespan. However, participants felt strongly that most community members did not know enough about HIV prevention, different modes of HIV transmission, or HIV treatment and noted that lack of culturally-appropriate information provided by their community members fuels misconceptions. Furthermore, participants noted that any misbeliefs or misinformation was further worsened by community members not personally knowing anyone living with HIV who belongs to their community.

Second, one specific belief about HIV which influences HIV testing behaviors was driven by misconceptions over "contagion" or "contagiousness" of HIV. Fear of contracting the disease via casual contact drove community members, participants thought, to wanting to physically and socially distance themselves from individuals living with HIV. Subsequently, such fear, based in misinformation, leads to social isolation of PLWH and, in turn, creates an additional negative social consequence for otherwise socially cohesive communities.

Third, HIV acquisition is associated with other highly stigmatized behaviors within these communities, and of such behaviors, pre/extramarital sex (generally in the context of cisgender sex) was one identified most commonly. Given the importance of religion in these communities, and because pre/extramarital sex is considered a sin, such behaviors are highly stigmatized. Simultaneously, pre/extramarital sex emerged as the most commonly mentioned mode of HIV transmission in these communities. Thus, a diagnosis of HIV was associated with pre/extramarital sex, compounding the stigma around both. Other stigmatizing behaviors, such as men having sex with men, intravenous drug use, or transactional sex were mentioned at times as being associated with HIV, and therefore, further contributing to HIV-related stigma, including for HIV testing. One participant in a FGD worried that PLWH might even internalize these judgements on morality and perpetuate self-stigma and self-isolation, though this concern was not directly voiced in the KIIs with any of the PLWH. The commonality amongst these behaviors were perceptions of immorality associated with these behaviors in the communities.

Fourth, in light of the above association of HIV with other highly stigmatizing behaviors, stigma around HIV was driven by strong overall religious or spiritual implications of living with HIV. For example, some participants reported community beliefs that PLWH were being punished for their immoral behaviors by God or being tested by God. Others reported community beliefs around PLWH having a curse from God or spirits.

Intersectional Identities and Stigma

As suggested above, our analysis identified intersectional stigma, a separate factor from HIV-related stigma, as an important influence on HIV testing behaviors amongst these communities. Intersectional stigma was especially important as it relates to interacting with the U.S. healthcare system more generally. Stigmas across health conditions and intersecting identities such as immigrant status, race/ethnicity, non-English language preference, gender/sex, and being from a religious minority all tie into how these communities can access and benefit from the U.S. healthcare system. Several participants mentioned that they believe their immigrant/refugee status is perceived as a burden to the general U.S. society, and many members of their communities do not feel entitled to receive healthcare services in the U.S. For example, one participant mentioned if they were to accept any benefits or care from the U.S. government, it will be seen as a burden and may negatively affect their immigration case. Another participant worried that the combined stigmas of being an immigrant and a PLWH could influence rejection of their citizenship request. Another barrier in accessing and benefiting from the U.S. healthcare system is institutionalized racism. Participants from each country-of-origin community relayed their experiences in differential treatment in healthcare settings based on their race and what language they spoke. One participant in particular noted the negative stereotypes perpetuated by U.S. society prevalent in healthcare settings, such as being Black equated to being lazy, being from an African country equated to being hungry, and being an immigrant with a non-English language preference equated to being illiterate. Additionally, having a non-English language preference makes it difficult for an individual to communicate directly with their provider and requires the use of an interpreter. The use of an interpreter, in turn, discourages HIV testing because the individual might fear stigmatization or feel uncomfortable addressing private information with an interpreter present, who is likely a member of their community. These barriers have very significant implications for all aspects of interacting with healthcare systems, with specific implications for seeking HIV testing.

Other Factors Aside from Stigma that Influence HIV Testing Behaviors

Our analysis revealed that many of the intersecting identities directly, and independently of any stigma, influence HIV testing behaviors and uptake of preventative healthcare more generally. For example, immigration status, non-English language preference, gender differences, and navigating the US healthcare system all directly influence HIV testing behaviors outside of the role they may play in intersectional stigma within these communities. For immigration status, for instance, participants mentioned a fear of testing positive for HIV would negatively influence their immigration or residency status. Thus, staying away from HIV testing would best protect their ability to stay in the U.S. Another unique element, related to immigration, was the idea of prioritizing working and the ability to provide for families over perceptions of self-care. Furthermore, some identified a notion of “survivorship,” having survived war-torn environments, displacement or refugee camps, or lengthy immigration procedures, creating momentum to keep prioritizing provision for family over seeking HIV testing. Having a non-English language preference is a barrier they mentioned in regards to trying to utilize the U.S. healthcare system, because not being able to freely converse with a provider limits rapport, along with appointment times being shortened due to use of interpretation services. Additionally, the use of interpreters can lead to issues with anonymity, confidentiality, and inaccurate translations, and such concerns can influence HIV testing because of fears of stigma and isolation in these otherwise socially cohesive communities. Gender differences were also noted as a barrier to HIV testing in some communities. Women are perceived to have greater access to routine testing, particularly during their pregnancy care, and seeking HIV testing may better conform to their gendered care-taking roles. Masculinity norms for men, on the other hand, interfered with HIV test-seeking behaviors, particularly because self-reliance is prioritized and illness is seen as a weakness for men in these communities. Lastly, navigating the U.S. healthcare system was mentioned as a barrier, including when testing for HIV, with marked confusion around and challenges navigating insurance policies and coverage plans. Even so, these particular issues pertain to individuals who have health insurance, and some participants mentioned that obtaining insurance coverage itself is either too expensive or difficult to navigate in the first place.

Discussion

Our study has identified several dominant themes, based primarily upon cultural factors and HIV-related and intersectional stigmas, as influencing HIV testing behaviors among the Ethiopian, Somali, and Eritrean immigrant communities in King County, WA. Additional key insights from our analysis include the effect of stigma on the social cohesiveness of these communities, HIV’s unique stigmatization within a larger cultural context of stigmatization of health conditions, and how many of the community members’ intersecting identities also have direct influences on HIV test-seeking and other preventative healthcare behaviors. Collectively, these influences foster normative beliefs amongst these communities that often prevent members from seeking or undergoing HIV testing. As we have noted before, the key barrier in ending the HIV epidemic for African immigrant communities in the U.S. is early HIV testing. Thus, addressing HIV-related and intersectional stigmas should be of utmost importance to programs, public health jurisdictions, and communities attempting to end the HIV epidemic amongst African immigrant communities.

Conversations for HIV-related stigma, which invariably involve communities marginalized by minority race/ethnicity, sexual orientation, or immigration status, must shift to include an equity focus, and broadening the conversation to intersectional stigma facilitates that shift. We, as well as others, have shown that barriers to HIV testing among African immigrants include reduced access to health care, HIV-related stigma, and perceptions of low HIV risk [11, 26,27,28,29]. Generalized HIV stigma has been found to be related to lower levels of HIV testing uptake in several populations [30,31,32]. Combined with HIV-related stigma, intersectional stigmas resulting from having multiple identities devalued by society, including being black, immigrants, having a non-English language preference, and, in many cases poor or being a member of a religious minority, may also contribute to low uptake of HIV testing [31, 33,34,35]. For MSM in this population, being a member of a sexual minority may further contribute to internalized stigma [36, 37]. Intersectional stigma may interact through multiple pathways to negatively impact HIV prevention and care outcomes. The Earnshaw model of Stigma and HIV Disparities incorporates intersectional stigma and resonates with our findings, and in our future work we will be further adapting this model for East African immigrant communities. However, we note that this is not the only model to address intersectional stigma in the context of HIV prevention or care.

HIV stigma-related interventions also need to adapt models for intersectional stigma, with an eye for promoting equity and justice, and interventions that leverage religious identities, leaders, and institutions is a priority among our three African immigrant communities (data not presented here). Several faith-based interventions have been developed or adapted to reduce HIV-related stigma among lay community members, including the FAITH Project [18, 19], Project Fostering AIDS Initiatives that Heal (FAITH) [38], Taking it to the Pews (TIPS) [39, 40], and Project Faith-based Anti-stigma Initiative Towards Healing HIV/AIDS (FAITHH) [41, 42]. All of these interventions were developed through community-based participatory research, and address the spiritual beliefs that influence HIV-related stigma in U.S.-born African American communities, and as such, they seem like good models for an HIV-related and intersectional stigmas reduction intervention that could be adapted for East African immigrant communities. However, none of these were developed to specifically address intersectional stigma and only one (Project FAITHH) touches on intersectional stigma by including discussion of how poverty and homelessness both contribute to HIV transmission and are both also stigmatized. Based on our findings, in the next phase of our Harambee! work, we plan to adapt Project FAITHH for use in our three partner communities; the adaptation will require changes to incorporate intersectional stigma reduction, as well as changing the materials and activities to better represent Islam alongside Christianity.

Our findings suggest more similarities than differences between the Ethiopian, Somali, and Eritrean communities. Many similarities exist in themes and subthemes, such as how their cultural and religious beliefs add to HIV-related stigma, fear of disease diagnosis, preventative care attitudes, and intersecting identities serving as barriers in navigating the U.S. healthcare system. For example, participants from all three communities acknowledged that their communities socially isolate PLWH in fear of contracting the infection themselves; messaging that is culturally appropriate and led by the African immigrant community members can easily address misconceptions. In addition, adding ways that community members, as peers, can take the role of “health navigator” may also help correct misconceptions, foster trust in the system, and link people to services [43, 44].

Some differences arose when certain themes or subthemes were emphasized more or less in certain communities. For example, gender differences in healthcare-seeking behaviors were more commonly noted in the Ethiopian and Eritrean communities, while lack of trust in interpreters arose more often in the Somali community. Concerns about confidentiality of interpretation services have been documented before [45, 46], and our participants and community partners reported known incidents of translators, specifically in the Somali community, having a history of unreliability when it comes to adhering to patient confidentiality rules. Such behaviors further erode trust in the U.S. healthcare system among immigrant communities.

Our work may have several limitations. This work is most readily transferable to other Ethiopian, Somali, and Eritrean communities in the U.S., and may be limited in applicability to other East African or African immigrant communities. However, given the marked similarities and commonalities that arose in our findings, we anticipate many of our findings will resonate with many African or even other immigrant communities in the U.S. [16, 47,48,49]. The subgroups we chose to prioritize, such as PLWH or religious leaders, may not have captured the breath of various perspectives within each community. Nonetheless, our interviews and focus groups recruited various other types of individuals, so we hope to have captured a sufficiently robust breath of perspectives. Finally, KII participants included somewhat fewer PLWH than we had anticipated recruiting, and the start of the COVID pandemic added complexity to recruitment for in-person interviews. We have previously found that African immigrant PLWH are less likely to agree to participate in research than members of other groups, likely related in part to fears around privacy and confidentiality [50]. Notwithstanding these limitations, our work is the most detailed and involving of the Ethiopian, Somali, and Eritrean communities around HIV-related and intersectional stigmas to date.

Conclusions

In summary, we have found several themes for how HIV-related and intersectional stigmas impact HIV testing behaviors among the Ethiopian, Somali, and Eritrean communities in King County, WA, which may be common to other African immigrant communities in the U.S. Amongst these communities, while cultural beliefs contribute to stigma around many health conditions, stigmatization of HIV is unique. Misconceptions or poor messaging appears to contribute to HIV-related stigma. While misconceptions might be easily remedied, some of the normative or religious/moral beliefs associated with HIV may prove more challenging to address. Intersecting identities such as immigrant status, race/ethnicity, and having a non-English language preference all interact to further influence access to the U.S. healthcare system, including for HIV testing. Given that intersectional stigmas are considerable barriers for HIV testing among African immigrant communities, future research into community-led approaches of addressing intersectional stigmas is necessary to improve access to care and health outcomes among these communities. Overall, our findings point to the likely usefulness of peer navigators and interventions rooted in community, spirituality, and culture to better link African immigrants with HIV testing services.