“I believe in my ancestors, and I participate and believe:” negotiating identity, tradition, and HIV-related health among SGM communities in the Eastern Cape

Sexual and gender minority (SGM) individuals in South Africa's Eastern Cape face dual challenges navigating progressive constitutional protections alongside persistent cultural conservatism. Traditional Xhosa practices, including initiation schools (Ulwaluko) and ceremonial rituals, enforce rigid gender roles that conflict with SGM identities. With HIV prevalence reaching 49.5% among men who have sex with men yet only 25.7% achieving viral suppression, understanding how SGM individuals negotiate cultural traditions while managing HIV remains critically understudied. This qualitative study explored post-intervention experiences of 31 SGM individuals living with HIV in the Eastern Cape following participation in the SOAR (Speaking Out & Allying Relationships) intervention. Semi-structured interviews, guided by Social Cognitive Theory, were conducted in participants' preferred language by trained local interviewers. Thematic analysis through the Minority Stress Model examined four domains: traditional practices, family dynamics, community perceptions, and intervention impact. Participants demonstrated resilience through selective participation in cultural practices, balancing ancestral reverence with identity authenticity. Family acceptance was often conditional, tied to economic contributions or heteronormative expectations. Health communication barriers persisted due to stigma and traditional beliefs linking HIV to moral failing. SOAR enhanced participants' status-sharing confidence, treatment adherence, and skills for navigating cultural tensions, though community stigma remained pronounced in rural areas. SGM individuals exhibit remarkable adaptability in negotiating intersecting cultural, familial, and health challenges. While SOAR effectively builds individual resilience and HIV management skills, findings underscore the need for multi-level interventions combining skill-building with community mobilization and cultural sensitization to address structural barriers in traditional contexts. • SGM individuals employ selective participation strategies to navigate traditional practices • SGM experience complex challenges of family acceptance and support systems of sexual identity and HIV status • There is a complicated intersection of cultural practices with minority stress and HIV management • The SOAR intervention is effective in building individual resilience and health skills related to HIV disclosure and adherence • There is a need for broader structural interventions to address persistent community-level barriers