The Appalachian Access Project was a community-based participatory research initiative designed to address persistent inequities in HIV, sexually transmitted infections, hepatitis C, and mpox prevention and care among gay, bisexual, queer, and other men who have sex with men, as well as transgender and nonbinary persons living in Appalachia. The bilingual peer navigation and mHealth intervention also aimed to support access to medically supervised gender-affirming hormone therapy for those who desired it, responding to well-documented barriers related to stigma, geographic isolation, limited service availability, and structural inequalities in the region.
Developed through a long-standing partnership among community members, service organizations, health departments, and academic institutions, the intervention combined peer navigation with mobile health strategies. Trained community health leaders worked within their existing social networks to share information, provide support, and help peers navigate prevention and care services using both in-person interactions and digital platforms. The approach was grounded in social cognitive theory, empowerment education, and social support, with the goal of increasing knowledge, self-efficacy, and service uptake while reducing stigma and strengthening community connection.
The randomized controlled trial demonstrated improvements in some intermediate outcomes, such as knowledge related to HIV and sexually transmitted infections. However, the intervention did not achieve statistically significant increases in key behavioral outcomes, including HIV testing, pre-exposure prophylaxis use, HIV care engagement, or uptake of gender-affirming hormone therapy, although positive trends were observed. These findings prompted a deeper examination of implementation processes to better understand factors influencing effectiveness.
Through systematic analysis of implementation data and collaborative reflection among partners, the research team identified critical lessons that help contextualize the trial results. These insights highlighted the importance of frequent and meaningful contact between study teams and peer navigators, clearer expectations around intervention intensity, stronger social ties within peer networks, and a more focused set of prioritized health outcomes. The findings also underscored the challenges posed by large geographic catchment areas, limited local availability of affirming services, and broader contextual factors such as the COVID-19 pandemic and ongoing resource constraints in rural Appalachia.
The analysis further revealed that individual- and network-level interventions may be insufficient on their own in settings where health systems lack capacity to provide welcoming, culturally responsive care. Strengthening provider and organizational readiness, improving local service infrastructure, and addressing stigma at multiple levels emerged as essential complements to peer-led strategies. The study suggests that future interventions may benefit from narrower geographic focus, more structured group activities, clearer minimum engagement thresholds, and stronger integration with health systems and community organizations.
Overall, the lessons learned from the Appalachian Access Project offer valuable guidance for designing more effective peer navigation and mHealth interventions in rural and underserved settings. By refining implementation strategies and addressing structural barriers alongside individual and social factors, future efforts can be better positioned to reduce health disparities and improve access to prevention and care for LGBTQ+ communities in Appalachia and beyond.
