Introduction
The U.S. South is disproportionately impacted by the HIV epidemic (Centers for Disease Control and Prevention [CDC], 2022). People residing in the South are diagnosed with HIV at higher rates (Reif et al., 2017), and once they are diagnosed, they have worse HIV outcomes than other people with HIV (PWH) nationwide (Reif et al., 2015). Rural communities in the South are areas of particular concern due to unique barriers such as lack of transportation (Douthit et al., 2015; Pellowski, 2013), low availability of healthcare services (Masiano et al., 2019), and HIV-related stigma that limits access to care (Kalichman et al., 2017; Pellowski, 2013; Wise et al., 2019). These barriers likely contribute to poor HIV outcomes in this region and undermine Ending the HIV Epidemic (EHE) initiatives in the U.S. (Adimora et al., 2014; Fauci et al., 2019).
Florida is a southern state with the third highest incidence of HIV (CDC, 2022). Rural communities in Florida have some of the highest HIV prevalence rates in the country (Gray et al., 2016). Many rural counties in Florida have been designated as primary care and mental health professional shortage areas due to low population-to-provider ratios (Health Resources and Services Administration [HRSA], 2023a; Rural Health Information Hub, n.d.), and PWH in the rural South are more likely to have a late HIV diagnosis than their urban counterparts (Gibas et al., 2024; Kiernan et al., 2024). In light of these disparities, it is important to understand and address barriers to care among PWH in the rural South as an important step toward improving HIV outcomes in this population.
The use of health technology may be a potential strategy to address barriers to care and to improve health outcomes among PWH in rural communities. Health technology for PWH refers to any digital or electronic tool that facilitates clinical care, patient engagement and support for patients and includes telehealth (synchronous audio/video visits) and mobile (mHealth) platforms (Horberg et al., 2024). Telehealth is specifically defined as the use of audio or video technology to connect patients and providers for clinical care and services (Ezenwaji et al., 2025). Health technology uptake has grown rapidly since the onset of the COVID-19 pandemic (Shaver, 2022), and has shown promise in expanding access to health care and improving health outcomes across different settings and populations (Barbosa et al., 2021). Among PWH, interventions utilizing health technology have resulted in improvements in antiretroviral treatment (ART) adherence, symptoms of depression, and quality of life across different cultural contexts and care settings (Saragih et al., 2024). Additionally, a systematic review examining health technology interventions in rural areas found that overall, these interventions reduced costs for patients and health care organizations, decreased patient travel time, and increased access to primary and specialty care (Butzner & Cuffee, 2021). Despite the clear advantage of using health technology for people living in rural areas, there are gaps in health technology use between urban and rural residents and gaps in use among PWH (Ko et al., 2023; Larson et al., 2022).
Recent studies have demonstrated that since the onset of the COVID-19 pandemic, telehealth has become an integral component of care delivery for PWH in the South. HIV providers consistently report that telehealth is highly valued for expanding access to care particularly in regions facing transportation barriers, provider shortages and limited clinical infrastructure (Ezenwaji et al., 2025; Jain et al., 2019; Salgado et al., 2021; Yelverton et al., 2023). Qualitative studies from other southern states, such as South Carolina and Alabama, indicate that most HIV providers recognize the potential of health technology to address inequities in access to care, especially in rural areas, while acknowledging that telehealth may not be suitable for all patients or visit types (Eaton et al., 2022; Yelverton et al., 2021; Yelverton et al., 2023). Key challenges identified by providers include technological limitations, digital literacy gaps, privacy concerns, reimbursement constraints, and the need for improved integration of electronic health records with telehealth platforms (Eaton et al., 2022; Salgado et al., 2021; Yelverton et al., 2021; Yelverton et al., 2025a). National guidelines from the Infectious Diseases Society of America (IDSA) endorse telehealth as a promising model for differentiated service delivery for PWH in rural and resource-limited settings, while emphasizing the importance of ongoing assessment of barriers and tailored strategies to improve access (Horberg et al., 2024).
Considering the disproportionate impact of the HIV epidemic on individuals living in the rural South (CDC, 2022; Gray et al., 2016; Reif et al., 2015, 2017), it is critical to explore the potential role of health technology in improving care delivery among PWH in this region. Using a qualitative approach, we conducted in-depth interviews with a sample of HIV care providers to determine their perspectives and experiences of health technology use to deliver HIV care in rural Florida.
Discussion
This study examined HIV care providers’ perspectives and experiences with health technology to deliver HIV and mental health care in rural Florida, a resource-limited region in the South with high HIV prevalence (Gray et al., 2016; CDC, 2022), suboptimal HIV care outcomes (Rich et al., 2021; Schafer et al., 2017), and decreased access to care (HRSA, 2023a; Rural Health Information Hub, n.d.). Providers who participated in this study discussed their health technology practices and identified drawbacks, benefits, and potential facilitators of health technology use among PWH. Health technology was found to be a frequently used and widely accessible method to deliver HIV care, with the potential to address common barriers to care faced by PWH living in rural communities. To effectively leverage the full potential of health technology to support care delivery for PWH in the rural South, key drawbacks including lack of human connection associated with virtual care, provider burden, low technological literacy, and financing constraints must be addressed.
Most providers observed that health technology use has become increasingly common since the onset of the COVID-19 pandemic when compared to pre-pandemic levels. This expansion enabled providers to broaden their practices, maintain more regular communication with patients, and accommodate more patients. While providers noted that telehealth utilization had declined from its peak during the early stages of the COVID-19 pandemic – as noted in other studies (Yelverton et al., 2025b) – providers in our study consistently reported that telehealth services remained widely available to PWH across their organizations. The sustained presence of health technology since the onset of the COVID-19 pandemic has the potential to eliminate common and pervasive barriers to EHE initiatives in rural areas in the South. Expanded telehealth access supports earlier HIV diagnosis and linkage to care, facilitates consistent HIV treatment engagement, and enables rapid response to emerging needs – particularly in rural, underserved regions (Ezenwaji et al., 2025; Horberg et al., 2024; Krebs et al., 2025; Salgado et al., 2021). By reducing logistical and structure barriers, health technology can enhance rates of HIV care retention and viral suppression, both of which are essential to achieving EHE benchmarks in rural and other resource-limited settings in the US (Douthit et al., 2015; Fauci et al., 2019; Masiano et al., 2019; Morales et al., 2020; Pellowski, 2013; Schafer et al., 2017). However, to fully meet the needs of PWH and their providers in the rural South, it is essential that as health technology expands, the platforms that are implemented are intuitive for patient use, streamlined for providers, and integrated within existing electronic health systems. According to the providers in our study, health technology that is interoperable and easy to use is critical in reducing the burnout associated with managing multiple communication and medical record platforms and assures that services are accessible to everyone, including individuals with lower technological literacy. HIV care providers across other settings have noted concerns about the potential for health technology to increase provider workload and contribute to burnout due to increasing demands on providers’ time and blurring work-life boundaries (Chu et al., 2022; Harsono et al., 2022). Other studies have also found that low comfort with technology serves as a barrier to uptake among PWH and people living in rural areas (DeHart et al., 2022; Harsono et al., 2022; Labisi et al., 2022; Terry & Buntoro, 2021). Given the substantial potential of health technology to eliminate barriers to care among PWH in rural settings, future research is needed to address these barriers and develop health technology interventions that patients and providers find acceptable and easy to use and that are streamlined to fit into existing workflows and healthcare delivery systems.
The providers in this study also noted the potential for health technology use to reduce HIV-related stigma among PWH, especially individuals residing in rural communities. This is a key finding, as HIV-related stigma is more pronounced in rural areas (Gonzalez et al., 2009; Kalichman et al., 2017), and is associated with delays in seeking HIV treatment, low HIV care engagement, and suboptimal ART adherence (Brewer et al., 2022; Padilla et al., 2022; Rueda et al., 2016; Sweeney & Vanable, 2016). Providers shared that virtual HIV care visits help PWH in rural areas keep their HIV status private by avoiding the risk of unwanted encounters with members of the community and inadvertent status disclosure that can occur during in-person visits. The ability of health technology to promote privacy and discretion is key for PWH in rural communities, where PWH have reported heightened fear about the rapid proliferation of gossip and judgement related to their HIV status within the community (Gaskins et al., 2012; K. G. Quinn et al., 2020). Providers also spoke about the importance of digital support platforms, such as message boards and virtual support groups, as viable alternatives to in-person groups, particularly for PWH in rural areas, where it is more difficult to find in-person HIV support groups while maintaining privacy and anonymity (K. Quinn et al., 2017). Virtual peer support interventions for PWH have been shown to promote social connection and emotional support (Flickinger et al., 2017; Mo & Coulson, 2010), which serve as a buffer against the negative impacts of HIV-related stigma (Brener et al., 2020; Chan & Mak, 2021; Flickinger et al., 2018; Reif et al., 2021). Given the potential for digital support platforms to promote social connectedness and reduce HIV-related stigma, more research is needed to determine the most effective format and modes of delivery that are feasible and acceptable for PWH residing in rural communities.
Despite the consensus among providers that health technology shows great promise in expanding access to care, almost all providers in our study agreed that a major disadvantage is that it limits human connection and relationship building, which are elements they deemed vital for HIV care retention. Some providers noted that their diminished capacity to develop meaningful relationships with patients through virtual means was a major reason that they restricted or discontinued health technology for care delivery. To build patient and provider confidence in the ability of virtual encounters to preserve the element of human connection, it is critical to employ strategies that support and enhance effective communication between patients and providers (Galpin et al., 2021). Recommendations for providing a more personalized and intimate telehealth experience include training for providers that focuses on communication strategies, such as active listening, shared decision-making, and nonverbal cues (e.g., eye contact, head nods, and varied facial expressions) and elimination of distracting elements in the provider’s environment, such as background noise and clutter, to signal to patients that they are fully listening and engaged (Elliott et al., 2020; Meuter et al., 2021; White et al., 2024). Given the recent rapid increase in the availability and use of health technology, it may be helpful to incorporate training that focuses on the provision of individualized, patient-centered care via telehealth into educational curricula for healthcare providers.
Providers in this study also emphasized that financial barriers must be overcome to ensure that PWH in rural areas can effectively access and use health technology to receive care. Concerns related to financing of health technology included high costs of equipment and cellular data/high-speed internet, inability to bill for audio-only telehealth visits, and lack of funding for health technology initiatives in rural clinics and health service organizations. Financial resources for EHE initiatives in Florida are concentrated in urban counties that receive additional Ryan White Part A funding from the Health Resources and Services Administration (CDC, 2024; Department of Health and Human Services, 2020). Counties in rural Florida, most of which are in the northern and central parts of the state, have an HIV incidence and prevalence similar to those of urban EHE counties; however, because they are rural, they do not receive EHE or Part A funding (Florida Department of Health, n.d.; Florida Department of Health, 2023). As such, the population of PWH in these regions is at a disadvantage because of funding and resource limitations. Moreover, similar to many other states in the South, Florida is a Medicaid non-expansion state. Lack of Medicaid expansion and subsequent lack of coverage for critical health care needs are associated with poor health outcomes, including HIV care outcomes (Romero & Ponomariov, 2023). Given that approximately 20% of PWH in Florida live below the federal poverty line (HRSA, 2023b), and PWH in Medicaid non-expansion are far more likely to be uninsured than PWH in Medicaid expansion states (Dawson & Kates, 2020), this may further contribute to widening HIV care disparities, particularly in under-resourced rural areas. To help eliminate disparities in resources and increase access to care for PWH living in rural communities in Florida, additional funding is needed to invest in interventions that leverage health technology and to support the needed equipment and infrastructure, such as mobile devices, high-speed internet, and reliable cellular data coverage.
While a few other studies have documented barriers and facilitators to health technology use among PWH in the South (Eaton et al., 2022; Ennis et al., 2022; Labisi et al., 2022; Salgado et al., 2021; Yelverton et al., 2021, 2023), our study offers new insights by focusing on provider perspectives from rural Florida – a region widely recognized as the epicenter of the HIV epidemic in the US, with distinct structural and policy contexts that shape care delivery for PWH (CDC, 2022; Rich et al., 2022; Sullivan et al., 2021). Providers in our study identified disparities in access to health technology among PWH in rural Florida due to inadequate financing and health technology infrastructure, HIV provider shortages and burnout, low digital literacy, and data privacy concerns. These findings align with existing literature in other Southern states such as Alabama, Georgia and South Carolina, where studies have emphasized willingness to adopt and promote telehealth services, yet concerns around staff capacity, technology literacy, data security and economic and clinical infrastructure to support technology (Eaton et al., 2022; Salgado et al., 2021; Yelverton et al., 2021, 2023). Although many challenges are shared across the region, PWH in rural Florida experience disproportionately higher rates of late diagnosis and worse health outcomes compared to other southern states (Lyons et al., 2021; Parisi et al., 2025; Rich et al., 2024; Sullivan et al., 2021; Trepka et al., 2014), highlighting the importance of addressing their unmet health technology needs to improve care outcomes. By identifying the gaps in health technology among PWH in rural Florida, this study provides actionable insights for developing tailored multi-component interventions to expand health technology use for PWH – both in rural Florida and in other similar underserved settings – to maximize progress along the HIV care continuum and strengthen EHE efforts (Daoud et al., 2025; Horberg et al., 2024).
This study has several limitations. First, the sample included only HIV care providers and did not include individuals living with HIV. Thus, the present analysis does not capture perspectives from the intended target population, and future research is needed to obtain perspectives from individuals with lived experience to ensure that recommendations are feasible and acceptable to members of the population. In addition, the categorization of rural counties in Florida was based on resource limitations among counties and populations in Florida and was not classified using other metrics. Furthermore, providers were recruited only from the north and central parts of the state. Interviewing more providers from other rural counties across the state may have yielded additional emerging themes, and it is possible that our sample cannot be generalized to all rural HIV care providers in Florida.
In conclusion, the use of health technology may address barriers to HIV and mental health care faced by PWH in the rural South, and promote higher engagement and retention in HIV care. Leveraging health technology to increase access to care and subsequently improve HIV care outcomes will accelerate progress along the HIV care continuum in the South, a region with a high HIV prevalence that possesses unique barriers to achieving EHE goals. To ensure that health technology interventions are effective in this population, drawbacks to health technology use, such as lack of human connection, limited financial resources, provider burden, and low technological literacy, must be addressed.
