Perceived HIV Risk, Barriers, and Preferences for HIV Testing in Structurally Vulnerable Communities in St. Louis: A Best-Worst Scaling Survey

Background Persistent gaps in efforts to end the HIV epidemic in the United States highlight the need for community-specific, evidence-based HIV testing strategies. This study investigated barriers and preferences around HIV testing among underserved populations, including Black, queer, and young adults in the St. Louis, Missouri area. Methods We conducted a Best-Worst Scaling (BWS) survey with adults (16+ years) recruited at community events, collecting responses electronically and providing a 25 incentive. The survey assessed the relative importance of 13 potential barriers to HIV testing such as stigma, structural barriers, and perceived HIV risk, chosen based on literature review and community input. Mean preference weights (MPWs) were derived from participants’ most and least selected barriers in a set of 13 choice tasks and rescaled using Hierarchical-Bayes estimation. We applied latent class conditional logit models to explore variability in preferences among participants. Results Among 152 participants, 53% identified as women, 39% as men, and 7% as nonbinary; 49% identified as Black, with a median age of 29 years (IQR: 23-37). Additionally, 49% identified as nonheterosexual. The most prominent barrier to testing was low perceived risk for HIV (MPW: 13. 9; 95% CI: 12. 5-15. 2). Black participants reported lack of trust in testing organizations and the absence of peer encouragement for testing as significant barriers compared to White participants (P =. 03, P =. 003). Queer participants identified stigma, limited access, and fear of a positive result as more critical barriers than their heterosexual counterparts (P <. 001, P =. 023, P =. 004). Latent class modeling identified 2 distinct groups: (1) “Low-risk perceivers” (67%) who emphasized low perceived risk of HIV (MPW: 16. 7, 95% CI: 15. 4-18. 1) and lack of healthcare provider recommendation (11. 9, 95% CI: 10. 7-13. 2), and (2) “Stigma avoiders” (33%) who were concerned about stigma (17. 1, 95% CI: 16. 0-18. 3) and fear of a positive diagnosis (16. 1, 95% CI: 14. 5-17. 8). Conclusions This BWS analysis provides insights into HIV risk perception and testing barriers among affected communities in the St. Louis region, revealing that low perceived HIV risk and social stigma are substantial deterrents. Tailored HIV testing initiatives should be developed to address these barriers and improve testing uptake across diverse community members.