Connected but Unprotected: Education Moderates the Association between LGBTQ+ Belongingness and Biomedical HIV/STI Prevention

Background and Purpose: LGBTQ+ community belongingness is a recognized health protective factor, yet its role in biomedical HIV/STI prevention remains underexamined. In the U.S. South, community networks that buffer against the deleterious impact of marginalization and discrimination may simultaneously reinforce norms discouraging biomedical prevention uptake. Grounded in minority stress theory, social capital theory, and health literacy frameworks, this study examined whether LGBTQ+ community belongingness predicted pre-exposure prophylaxis (PrEP) utilization, doxycycline post-exposure prophylaxis (doxy PEP) awareness, and doxy PEP utilization among LGBTQ+ adults in Kentucky, and whether educational attainment moderated these associations.

Methods: Data were drawn from the Queer Kentucky Survey (2025), a public health surveillance platform for LGBTQ+ adults in Kentucky. Belongingness was measured using the 18-item LGBTQ Belongingness Attainment Scale (6-point Likert; higher scores = greater belonging). PrEP use, doxy PEP awareness, and doxy PEP use were each coded as binary (0 = no; 1 = yes) outcomes. Education was dichotomized (bachelor’s degree or higher vs. less). Three moderated binary logistic regressions were estimated using Hayes’ PROCESS Model 1 in SPSS, controlling for age, race/ethnicity, and gender identity. Analytic samples ranged from 734 to 739 due to listwise deletion.

Results: All three models were significant (p < .001). For PrEP utilization (Nagelkerke R² = .199), the belongingness × education interaction was significant (B = .78, p < .001). Among respondents without a bachelor’s degree, higher belongingness was associated with lower odds of PrEP use (B = -.77, p < 001); this association was non-significant among those with a bachelor’s degree (B = .01, p = .919). For doxy PEP use (Nagelkerke R² = .181), the interaction was significant (B = .51, p = .010); belongingness predicted lower odds of use among less-educated respondents (B = -.66, p < .001) but not more-educated respondents (B = -.15, p = .289). For doxy PEP awareness (Nagelkerke R² = .112), the interaction was significant (B = .42, p = .015) with a distinct pattern: belongingness was unrelated to awareness among less-educated respondents (B = -.15, p = .206) but positively associated among more-educated respondents (B = .27, p = .034). BIPOC identity predicted higher odds across all outcomes. Nonbinary and gender fluid respondents had significantly lower odds across all three outcomes, while cisgender women had lower odds of PrEP use and doxy PEP awareness but not doxy PEP use, compared to cisgender men.

Conclusions and Implications: Findings reveal a paradox of belonging for biomedical prevention. LGBTQ+ belongingness was associated with reduced PrEP and doxy PEP utilization among less-educated adults, suggesting community norms may discourage biomedical prevention. Education neutralized this association, potentially equipping individuals to critically evaluate community norms. The awareness model clarifies this is not an information deficit—less-educated respondents with high belonging were not less aware of doxy PEP but were less likely to use it. Implications include designing community-based initiatives addressing normative resistance, in addition to information gaps, and peer health literacy programming for LGBTQ+ adults without college education in the U.S. South.