People standing together in a group talking wearing red HIV awareness ribbons.

Culturally competent HIV prevention for African, Caribbean, and Black communities and Indigenous Peoples

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Questions

  • What are the best practices for delivering culturally competent HIV prevention strategies for African, Caribbean, and Black communities and Indigenous Peoples?

 Key take-home messages

  • Developing culturally sensitive approaches and materials helps ensure HIV prevention interventions are relevant, acceptable, and responsive to the needs of the intended population groups (1–3).
  • Close collaboration with target communities is essential to the development of culturally grounded and culturally safe programs (4, 5). For example, the inclusion of a community specific advisory board (such as an Indigenous advisory board) can guide the successful adaptation of an existing intervention, ensuring that its content reflects the practices, worldviews, and experiences of the service recipients (6).
  • Culturally competent interventions and strategies that affirm individuals’ racial, ethnic, and sexual identities are especially needed (7, 8). Culturally safe services that are appropriately tailored and co-developed with communities are highly valued (3).
  • The culturally informed client-centered care coordination model (C4™) for HIV pre-exposure prophylaxis (PrEP) among Black men who have sex with men is a successful example of a culturally competent HIV prevention strategy (9, 10).

The issue and why it’s important

In Canada, certain populations are disproportionately impacted by HIV due to social and structural determinants of health that drive inequities (11). The latest 2023 HIV surveillance report, published by the Public Health Agency of Canada (PHAC) notes that “Black or racialized persons, and Indigenous people face unique challenges in accessing and receiving quality care, stemming from the reality of colonialism, systemic and structural racism, and social inequities between white vs. non-white individuals, and Indigenous vs. non-Indigenous individuals in Canada” (12).

In 2023, there were 2,434 first-time HIV diagnoses in Canada; however, race and/or ethnicity data were available for only 42.9% (n=1,043) of cases (12). There are several reasons for low completeness of these data across the provinces and territories of Canada: limited collection of information, restrictions on the ability to submit these data to the national surveillance program, and variation in how race and/or ethnicity is collected (12). Of the 1,043 new cases of HIV for whom race and/or ethnicity was reported, 27.6% (n=288) were reported as Black, and 19.6% (n=204) were reported as Indigenous (12).

Ontario has provincial estimates of HIV incidence for African, Caribbean, and Black communities as well as for Indigenous Peoples (13). The Ontario HIV Epidemiology and Surveillance Initiative (OHESI) states that in Ontario in 2023, people who reported their race/ethnicity as Black accounted for the largest proportion (37.8%; n=224) of first-time HIV diagnoses (13). Indigenous Peoples accounted for 3.04% (n=18) of the first-time HIV diagnoses in the same year (13).

Although Canada’s health care systems do not routinely collect race and Indigenous identity data—a necessary step in measuring health inequities (14)—it is clear from the available data that African, Caribbean, and Black communities and Indigenous Peoples in Canada experience disproportionately higher rates of HIV incidence than other ethnic or racial groups (12, 13).

Culture plays a critical role in the design, implementation, and research of effective interventions (15). Those working in HIV research and care have repeatedly pointed out that “…the behavioral transmission of HIV occurs within a social context bound by culture…as such, cultural scripts are believed to influence the norms and attitudes that govern engagement in HIV risk behaviors” (2). Accordingly, when HIV interventions are rooted in culture, they are more likely to be appealing, acceptable, and effective for the specific populations they are designed to serve (2).

Disparities in how health interventions are implemented across different population groups can lead to unequal health outcomes (3, 16). This review identifies culturally competent HIV prevention strategies and interventionsdelivered to African, Caribbean, and Black communities and Indigenous Peoples. By adopting culturally competent strategies, public health efforts can more effectively engage diverse communities and ultimately contribute to ending the HIV epidemic.

What we found

What is cultural competency?

A 2003 study by Betancourt et al. developed a practical definition of “cultural competence” in health care based on a review of relevant academic literature, foundation reports, and government publications (17). The authors summarized that cultural competence involves:

  • understanding the importance of social and cultural influences on patients’ health beliefs and behaviours;
  • considering how these factors interact at multiple levels of the health care delivery system; and
  • devising interventions that take these issues into account to ensure quality health care delivery to diverse patient populations (17).

Furthermore, Betancourt et al. state that cultural competence interventions occur at three levels: organizational, structural, and clinical:

  • organizational cultural competence interventions (e.g. diversity initiatives within academic health centres, hospitals, and medical schools);
  • structural interventions (e.g. implementing the collection of racial and ethnic data, ensuring health education materials and prevention interventions are culturally and linguistically appropriate); and
  • clinical interventions (e.g. equipping health care providers with the knowledge, tools, and skills to  manage sociocultural issues during patient encounters) (17).

Reviews of HIV prevention interventions: African, Caribbean, and Black communities and Indigenous Peoples

We identified several review articles and evidence synthesis products summarizing HIV prevention interventions for African, Caribbean, and Black communities, and one review article focused on HIV prevention interventions for Indigenous Peoples. The findings of these review articles are summarized in Table 1. Collectively, these reviews emphasize the need for culturally competent and culturally safe HIV prevention interventions (2, 7, 8, 18, 19). These reviews found that:

  • the development of culturally sensitive approaches and materials is essential to ensure that interventions are tailored to the population of interest (1);
  • close collaboration with the target community ensures programs are “culturally grounded” (4), meaning that such programs are built on the values, behaviours, norms, and worldviews of the population they are intended to serve (20); culturally safe services that are appropriately tailored to meet the needs of, and developed in close collaboration with target communities (e.g. Indigenous communities), are highly valued (3);
  • for racialized women, interventions that are culturally grounded, group based, and delivered face-to-face and in multiple sessions are needed (19);
  • few HIV prevention interventions targeting Black communities have meaningfully integrated cultural components (2);
  • the delivery of PrEP through community-based organizations tailored to and led by Black sexual minority men may help address barriers to PrEP access and uptake (18), and culturally competent interventions that affirm an individual’s racial and sexual identities (e.g. Black men who have sex with men) are especially needed (7, 8);
  • social media campaigns with appropriate messaging have the potential to increase PrEP uptake, awareness, and adherence among young Black men who have sex with men and among women (21).

Only one identified literature review focused exclusively on Indigenous Peoples; it outlined several guiding principles to inform Indigenous-led HIV-related implementation research (3):

  1. Interventions must be developed in meaningful partnership with Indigenous Peoples, recognizing and acknowledging multiple forms of Indigenous knowing, being, and doing.
  2. Future implementation studies should strive to understand the impacts of historical and intergenerational trauma, alongside the systems of oppression, to expand the uptake and reach of HIV prevention and treatment programs.
  3. A strengths-based approach should be adopted, where the unique resources, resilience, and implementation facilitators inherent in Indigenous communities are identified.
  4. The use of Indigenous research methods should be prioritized, ensuring the research process itself is culturally congruent.
  5. Capacity building for implementation research within Indigenous communities is important.
  6. HIV implementation studies must respect and reflect diversity both within and across Indigenous communities.

The review by Kemp et al. also noted that no studies evaluated PrEP interventions for Indigenous Peoples (3). However, we did find one scoping review of 11 studies examining how Indigenous communities in Australia, Canada, and New Zealand conceptualize PrEP awareness, motivation, access, and effectiveness (22). Indigenous populations in these three jurisdictions “…share similar historical and contemporary settler-colonial relations, policies, and practices that impact health access and outcomes” (22). Across 11 included studies, authors found that Indigenous Peoples often did not identify with mainstream gay communities where PrEP promotion usually occurred (22).

A recent 2025 study examining racial disparities in PrEP uptake among White, Black, and Indigenous men in Canada also notes the necessity of PrEP interventions: “[c]ommunity-based and public health interventions are immediately needed to increase PrEP awareness, access, and uptake for Black and Indigenous communities in Canada” (5). This study also provides four recommendations to reduce racial disparities around PrEP provision in Canada:

  1. Policy makers, program implementers, and providers should use a decolonizing framework that addresses anti-Black and anti-Indigenous racism to help address the structural and systemic barriers faced by these populations when developing PrEP policy, programs, and practice.
  2. Black and Indigenous communities must be prioritized in the allocation of resources and actively included in the development of a national PrEP strategy.
  3. Collect and utilize race-based data to inform HIV prevention research, programs, and policy development.
  4. Implement effective, culturally safe, and community-driven interventions that promote PrEP awareness and uptake in Black and Indigenous communities (5).

Examples of culturally competent HIV prevention interventions

As this review mainly relies on synthesized research evidence from systematic reviews, here we provide three examples of interventions with more details describing culturally competent interventions for populations of interest (Black men who have sex with men and Indigenous Peoples).

PrEP messaging

IMPACT is a public health program developed by the Baltimore City Health Department (BCHD) to create a PrEP awareness campaign to effectively engage Black sexual minority individuals and was developed in response to previous advertisements that had failed to reach this community because it reinforced stereotypes about gay men (23). The goal of the IMPACT campaign was to produce messaging that would resonate more effectively with Black sexual minority communities. Notably, this particular campaign was not included in the Kudrati et al. review (Table 1) that examined communication campaigns to increase PrEP uptake among young Black and Latinx men who have sex with men and women (23).

Qualitative methods were used to inform the PrEP campaign: 80 individuals participated in 13 unstructured, one-hour focus groups on reducing stigma and increasing the visibility of Black sexual minority individuals in Baltimore (23). Of the 80 participants, 64 (80%) identified as sexual or gender minorities, and 70 (88%) identified as Black or African American (23). Four key themes informed the development of campaign messaging (23):

  1. Public health messaging should be culturally competent, community-informed, and locally relevant to effectively reach and engage the target population.
  2. Avoiding stigmatizing language and messages: language should not alienate or further stigmatize people, especially in the context of HIV and STI prevention where behaviour and sexuality are already stigmatized.
  3. Limit the inaccessibility of clinical language: messaging in some public health campaigns is not accessible to lay audiences; terms like PrEP or U=U (i.e. undetectable equals untransmittable) need to be defined to avoid misinterpretation.
  4. Using identity labels representing local communities and their diversity. For instance, the use of acronyms to describe sexual and gender minorities was seen as problematic.

Authors concluded that “…PrEP campaigns need to be developed through community-informed processes to engage and avoid stigmatizing priority populations” (23). This finding aligns with the conclusions of the previously mentioned literature review on Indigenous Peoples’ conceptualizations of PrEP, which found that mainstream PrEP messaging often failed to resonate with Indigenous individuals at HIV risk (22).

PrEP counselling

A randomized controlled trial included in Turpin et al.’s review in Table 1 found that delivering PrEP services in a culturally competent setting improved uptake among young Black men who have sex with men (9). The intervention was modeled on the client-centered care coordination (C4™) model, which was developed and successfully implemented to optimize PrEP use among Black men who have sex with men in the HTPN 073 trial (10, 24). Using an integrative anti-racism lens, the C4™ model is grounded in self-determination theory and HIV prevention case management (i.e. comprehensive risk counselling and services) (24).

In this study, conducted in Washington, D.C., participants were randomized to either the intervention group (n=25) or the control group (n=25) (9). Participants in the control group received PrEP education and supplies from a health care provider that included: information on how PrEP works, indications for starting PrEP, dosing, efficacy, side effects and importance of compliance, HIV risk reduction counselling, signs and symptoms of seroconversion, printed educational materials, a list of local PrEP providers, copay assistance cards, pill case keychains, and condoms with lubricant (9). Those in the intervention group received all the services provided to the control group, plus a personalized counselling session at baseline (9). Counselling was delivered by an individual who self-identified as a Black man who has sex with men and who had extensive outreach and counselling experience related to PrEP (9). During the session, potential barriers to PrEP initiation were explored and addressed, and participants were referred to appropriate community resources, when necessary (9). Optional text- or phone-based follow-up support was provided by the PrEP counsellor (9).

The authors found that more participants in the intervention group initiated PrEP, suggesting that the low-resource, culturally tailored counselling and community support services addressed key barriers and improved PrEP utilization (9).

Education and behavioural skills training

Becoming A Responsible Teen (BART), an evidence-based HIV prevention intervention, was culturally adapted in the U.S. for urban Native American (Indigenous) adolescents (6). Culturally adapted interventions can increase participant engagement, effectiveness, and sustainability (25). BART consists of eight 1.5–2 hour sessions, conducted weekly over two months (6, 26). Youth learn accurate information about HIV/AIDS; clarify their values around sexual decision-making; and develop skills in condom use, assertive communication, risk-reduction, and problem-solving (6, 26). Originally developed for African-American youth aged 14–18, BART increased HIV knowledge, delayed sexual debut, and reduced sexual activity frequency among participants (6, 26).

To adapt the intervention, authors conducted a literature review and obtained input from an advisory board of Native American health and education professionals (6). Advisors reviewed the intervention’s activities for cultural appropriateness, and recommended additional activities they deemed culturally safe (6). Both the literature review and input from the advisory board informed culturally relevant content and activities for the adaptation (6). The advisory board recommended including:

  • matrilineal tribe social structures and their associated cultural stories and teachings;
  • Native puberty ceremonies and their cultural significance;
  • Native philosophy and teachings, including their relation to holistic worldviews, daily practices, and shared roles/responsibility between youth, family, and community;
  • the impact of colonization and historical trauma to contextualize health and social disparities within Native communities; and
  • Native American terms, such as Mother Earth and Father Sky (6).

The authors also described major structural adaptations, including the addition of multiple Native American historical and cultural stories, inclusion of the Medicine Wheel, and Native American videos conveying accurate HIV risk information and culturally specific methods of partner communication (6). Guest speakers were invited to pray, speak, or conduct culturally safe activities (6). These adaptations led to modification of original sessions and the development of new sessions (6). An opening prayer was conducted by a Native American elder; and a participant led a closing prayer (6).

To determine if the intervention was acceptable to Native American adolescents, researchers conducted a pilot study with male and female participants, aged 14–18, who were members of different Native American tribes (6). All participants received an adapted workbook, USD 75 honorarium for completing the pilot work, and an additional USD 25 for participation in a post-intervention focus group to discuss the strengths and the weaknesses of the adapted curriculum (6).

Pre-pilot and post-pilot surveys found that HIV knowledge scores significantly increased post-intervention (6). Additionally, a session satisfaction survey indicated that participants found the adapted sessions in the intervention to be highly culturally safe (6). The inclusion of Native American cultural stories was found to be beneficial, as it enhanced or offered participants new perspectives on making responsible decisions (6). An activity that interconnected past, present, and future on an individual and social level was adapted, and facilitated a meaningful sense of personal identity (6).

Factors that may impact local applicability

While this review focuses on two of the five population groups in Ontario most impacted by HIV (African, Caribbean, and Black communities and Indigenous Peoples), it is important to acknowledge that individuals may belong to more than one population group. Not all interventions described may be suitable for every individual. Moreover, African, Caribbean, and Black communities as well as Indigenous Peoples are not homogeneous; culturally competent interventions should be tailored to reflect the diversity within these populations.

While cultural competence focuses on provider knowledge and skills, cultural safety (particularly within Indigenous contexts) centres power, self-determination, and the lived experience of service recipients (29). Cultural safety requires health practitioners to consider the impact of their own culture in clinical interactions, including biases, attitudes, assumptions, stereotypes, and prejudices (29). Advancing health equity requires recognizing and addressing power differentials in clinical interactions and across health care systems (29).

Racism has shaped the social and structural conditions that influence HIV vulnerability, acquisition, and engagement across the HIV prevention and care cascade (30). HIV stigma and discrimination in health care settings has created barriers to HIV prevention, care, and treatment across the HIV cascade, especially among marginalized populations, resulting in disproportionate rates of HIV across certain populations (30). These factors are essential for a proper contextualization of the findings of this Rapid Response.

AMSTAR 2 assessment (Table 1) revealed low or critically low overall confidence in the results of most included systematic reviews. Therefore, findings from these reviews should be viewed with caution.

What we did

We searched Medline (including Ovid MEDLINE® and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations) using text term HIV AND term cultural* in titles or abstracts AND terms (prevent* OR pre-exposure prophylaxis OR preexposure prophylaxis OR PrEP) in titles or abstracts AND terms ([Black* OR African American* OR ACB* OR Indigenous OR Aboriginal* OR Metis OR First Nation* OR Inuit* OR American Indian*] in titles or abstracts OR MeSH terms [American Indian or Alaska Native OR Indians, North American]). We also searched the Prevention Research Synthesis HIV Compendium of Best Practices of the U.S. Centers for Disease Control and Prevention. Searches were conducted on July 17, 2025 and results were limited to articles published in English since 2015. The literature search was restricted to research conducted in high-income countries. Reference lists of identified articles were also searched. The searches yielded 313 references, of which 30 were included.

Reference list

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Suggested citation

The Ontario HIV Treatment Network (OHTN). Rapid Response Service. Culturally competent HIV prevention for African, Caribbean, and Black communities and Indigenous Peoples. Toronto, ON. March 2026.

Prepared by

Danielle Giliauskas & David Gogolishvili