Table 5 Joint display summary to integrate and interpret findings

Both protective and challenging contexts were common. Challenging contexts experienced by some (approximately half the cohort) included temporary housing and unemployment. Most experienced financial hardship. These factors were not associated with engagement in care or HIV viral suppression, with the exception of income from federal benefits, as described below.

Challenging contexts were more commonly described than stable contexts. Factors that reduced stable housing including difficult family relationships, financial difficulties, and immigration (not having documentation/paperwork). These factors were described as having direct and indirect relationships to HIV viral suppression. HIV care was not typically seen as difficult to manage and relationships with providers were positive.

Housing was assessed in the quantitative survey but the qualitative data highlighted that housing is a very prominent and ongoing challenge in participants’ lives, and critical to wellbeing.

Participants were generally in a fairly stable place at the time of the interview but reflected on times of instability in the past.

Qualitative results emphasized mainly unstable contexts and the mechanisms by which they affect HIV management, mainly in the past, compared to quantitative results which highlighted both protective and challenging contexts.

Receiving income from welfare, public assistance, social security, disability, or workers compensation negatively related to engagement in HIV care, a counter-intuitive finding.

Benefits were generally seen as positive, particularly housing benefits. Participants often received their financial assistance and other benefits through a central NYC system which we refer to as the HIV social services administration. This large bureaucracy was challenging to navigate for these younger people.

Immigrant participants who did not have proper paperwork had challenges getting benefits, and this created housing instability and financial precarity.

Quantitative and qualitative findings are discrepant. Receiving public benefits may be a proxy for extreme financial need, which can reduce engagement in HIV care.

Half of participants worked in the street economy.

Street economy involvement was driven by challenges finding work the formal economy, for example, because of transgender gender identity, or the inability to work because of a lack of documentation. Some participants sold or heard about others selling HIV medication, which can be considered a type of street economic activity that was not assessed in the quantitative measure.

Qualitative data uncovered the reasons why participants engage in the street economy, and added to the types of street economic activities (selling HIV medication).

Immigration: Half were born outside the US/Puerto Rico, only approximately half were US citizens, a third had refugee, asylum, or temporary protected immigrant status, and approximately a third spoke Spanish as their primary language.

Descriptive data indicate 36% of those with HIV viral suppression spoke Spanish as their primary language compared to 19% among those not suppressed (Table 1)

Those whose primary language was Spanish were more likely to be well-engaged in HIV care than English-speakers (Table 3)

Immigrant participants generally left their home countries to obtain better HIV care and/or avoid persecution for, primarily, their sexual orientation and gender identity, and secondarily, their HIV status.

Immigrant participants faced challenges such as being unable to work in the formal economy or receive public assistance benefits and difficulties managing complex bureaucracies.

Immigrant participants appeared to be coping well and managing life challenges, including HIV, with a constellation of personal resilience, support from family in the home country, and support from Latine-focused CBOs in the US.

Given the challenges immigrant participants face, including the lack of English proficiency among many, their successful HIV management is notable and warrants further study.

These findings also suggest the challenges inherent in growing up in/living in the US as an AABL sexual and/or gender minority person living with HIV (e.g., structural racism, structural barriers to health, internalized stigma), compared to immigrants.

More data on the length of time immigrant participants have lived in the US and their adaptation to the US are needed.

Number of adverse childhood experiences (ACES) negatively related to engagement in in HIV care but not HIV viral suppression.

We did not examine ACEs in the qualitative component of the present study in detail. In the transcripts, participants did not generally volunteer or describe experiences that reflect the 14 specific ACEs domains. However, experiences of discrimination and trauma were common. The type of trauma was generally not specified.

Quantitative data highlight the prevalence and importance of ACEs. More qualitative exploration is needed to understand the direct and indirect effects of specific ACEs and factors that buffer or exacerbate the negative effects of ACEs.

Community resources were not assessed.

Participants’ experiences with community resources, including LGBTQ community-based organizations, were mixed. Some found community-based organizations and/or the larger LGBTQ community supportive and others did not.

Qualitative findings addressed a gap in the quantitative assessment battery. The substantial lack of engagement in the LGBTQ community was an unexpected finding and may reflect changing norms in this age group.

A number of factors were related to engagement in HIV care in the logistic regression, but did not predict HIV viral suppression at statistically significant levels. HIV care and viral suppression are strongly related, however.

Participants had relatively little to say about engagement in HIV care, but HIV medication adherence was an important and ever-present factor in their lives, whether they were currently taking HIV medication or not.

It is possible that these background and contextual factors interact with variables at other levels of influence to predict HIV viral suppression. In the present study, the qualitative findings enhance quantitative results, even when discrepant, and point the way to new research questions.