"That's not who I am": an examination of multi-level stigma as a barrier to pre-exposure prophylaxis (PrEP) use among individuals involved in the criminal legal system in the southern US.

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention for preventing HIV, yet uptake remains disproportionately low among individuals involved in the criminal legal system (CLS), particularly those under community supervision in the Southern United States. Multi-level stigma - including self, interpersonal, and structural stigma - has been identified as a significant barrier to PrEP awareness and acceptance. This study draws on in-depth, semi-structured interviews with 72 participants across three Southern states - Florida, Kentucky, and North Carolina - who were under community supervision and met clinical indications for PrEP. These findings illustrate the compounding impact of stigma across levels, and how the overlapping stigmas associated with HIV, sexuality, drug use, and incarceration can hinder engagement with preventive care. This study fills a critical gap in the literature by centering the voices of CLS-involved individuals under community supervision in the South - a population that exists in a unique space between incarceration and community reentry. Our findings underscore the need for stigma-informed interventions that address not only knowledge and access gaps but also the social and institutional conditions that shape health behavior. Future PrEP implementation efforts must be context-specific, trauma-informed, and embedded in systems that CLS-involved individuals routinely engage with.