Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention in Atlanta, GA.

BACKGROUND: HIV-focused organizations, care providers and research programs often hire Black gay, bisexual and other men who have sex with men (GBMSM) in their efforts to reach highly affected communities. Due to their unique social position within and outside of organizations, Black GBMSM are ideally situated to contribute to HIV care and prevention programming targeting their own communities, but may also be at risk for stress and burnout in these settings. Despite this critical role for Black GBMSM in efforts to end the epidemic, little is known about subjective experiences of Black GBMSM who work in the HIV field.
METHODS: We conducted qualitative interviews with 19 Black GBMSM who were identified as key informants. All were working in community-based organizations, clinical or academic settings in the area of HIV prevention and treatment in Atlanta, Georgia. We used a thematic analysis approach to identify salient themes with respect to the workplace experiences of Black GBMSM as well as the role of their identities in their work in the field.
RESULTS: Participants discussed: (1) Shared experiences and growth; (2) Work-related stressors; (3) Worker burnout; and (4) Commitment to continue working in the HIV field. On the whole, Black GBMSM derived meaning from their work, and found their intersectional identities to be a strength in fulfilling job duties. At the same time, Black GBMSM described multiple stresses faced as they balanced their personal and professional connections to this work, while also dealing with their own challenges related to discrimination, socioeconomic status, and health. Participants repeatedly described sacrificing their own well-being for the greater good of their communities, highlighting contributors to burnout within and outside of the workplace.
CONCLUSIONS: Our participants derived meaning from their work in the HIV field and were affirmed by professional interactions with other Black GBMSM. At the same time, they also faced work-related and other psychosocial stressors that predisposed them to frustration and burnout. To promote workplace equity and wellness for Black GBMSM, we share recommendations for HIV-focused organizations that employ and serve men in this demographic.

Background

In the United States (US), Black gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV. In 2018, Black GBMSM accounted for 37% of new HIV diagnoses among gay and bisexual men in 2018, despite only making up approximately 12% of the GBMSM population [1]. It is estimated that if current HIV incidence rates persist, one in two Black GBMSM will be diagnosed with HIV in their lifetime, compared with one in eleven White GBMSM [2]. In response to these striking disparities, HIV-focused initiatives have increasingly directed their efforts towards engaging Black GBMSM in prevention, treatment, and research. To increase effectiveness, cultural relevance, and community participation in these efforts, Black GBMSM are often hired as employees to work for community-based organizations (CBOs), healthcare organizations, academic research institutions, and government entities (e.g., public health departments) implementing HIV-related programming.

Although the importance of employing Black GBMSM to work in HIV treatment and prevention is generally accepted [3], the experiences of these men while working in the HIV field are under-explored to date. Intersectionality theory posits that Black GBMSM occupy a unique social position, shaped simultaneously by systemic racism, homonegativity, and other related social structures [4-6]. Black GBMSM may be brought to work in the HIV field in large part because of their intersectional identity, which may be seen as a strength at the hiring phase (e.g., for relatability to clients/patients, which in turn could improve recruitment and retention metrics for organizations). At the same time, Black GBMSM working in HIV-focused environments remain susceptible to discrimination and stress within and outside of the workplace, as a result of multiple oppressive forces that they face [7-11]. Black GBMSM working in HIV are therefore likely to have experiences distinct from their colleagues of other racial, gender and sexual orientation backgrounds.

Adding another potential layer of complexity, due to the epidemiology described above, Black GBMSM working in the field are more likely to be either living with HIV themselves, or having been affected by HIV impacting their friends or loved ones. Similar to race and sexual orientation, HIV serostatus can facilitate relatability with clients. At the same time, there is also reason to believe that those living with HIV might experience unique stress while working in this field. Although not previously explored specifically among Black GBMSM living with HIV in the US, research conducted in Malawi and Zambia demonstrated high rates of attrition, increases in personal illnesses, and even death among healthcare workers living with HIV [12, 13].

Workplace stress among multi-disciplinary professionals in healthcare and related fields is often framed in terms of burnout [14]. Burnout can be defined as a syndrome of “emotional exhaustion and cynicism” and a “tendency to evaluate oneself negatively, particularly with regard to one’s work” [15]. Individuals providing service for people living with HIV (PLWH) may be at high risk for burnout due to the complex psychosocial needs and trauma experienced among this group [16, 17]. This is a critically important dynamic to explore, as burnout among service providers has the potential to adversely impact not only the well-being of those providers, but also the patients and clients who they serve. In addition to concerns for job turnover, several studies have suggested suboptimal job performance due to burnout can lead to adverse outcomes for patients/clients [12, 18].

Although not focused exclusively on Black GBMSM, several studies have documented job-related stressors among HIV workers, especially those hired in a peer capacity. For example, Hidalgo et al. examined the experiences of clinic-based outreach workers within a multi-site study aiming to engage young GBMSM of color across the HIV care continuum [19]. Eight sites hired outreach workers, most of whom identified as gay and/or living with HIV, to help engage the target population who shared those characteristics. Over the three-year study period, 57% of the outreach workers resigned or were terminated. Study staff described outreach workers’ challenges adjusting to workplace environment, barriers with their own health, and difficulty maintaining professional boundaries while interacting with participants [19]. In another study focused on peers working in evaluation and data collection, peers took pride in their rapport with clients, but also struggled to ensure self-care and meet their clients’ needs [20].

Relatively underexplored to date is the question of how burnout may be shaped by the identities and lived experiences of the workers in question. A related study conducted among a group of Latino GBMSM HIV/AIDS volunteers, showed that burnout was shaped by experiences within the volunteer environment, motivations for volunteering, and sense of LGBT community [21]. Those who volunteered because of their own personal experiences with HIV and/or who had a higher sense of community were less likely to burn out, while those with negative experiences volunteering were more likely to burn out. These findings highlight the need to examine experiences and motivations as a first step towards mitigating potential stress and burnout.

It is notable that much of the above literature on the HIV workforce is separate from work focused on Black GBMSM’s intersectional identities. One exception is the HIV Prevention Trials Network (HPTN) 073 study, a demonstration study of HIV pre-exposure prophylaxis (PrEP) that strategically aimed to increase representation of Black GBMSM researchers in leadership roles, with a goal of increasing access to Black GBMSM communities and organizations [22]. This study, which included comprehensive cultural competency components developed by a group of Black researchers and community members, achieved a 92% retention rate for participants at 12-month follow-up. However, little is known about the personal and professional experiences of Black GBMSM investigators and staff in conducting such work. This study and others initiated important discussions around leadership and meaningful inclusivity of Black GBMSM as a way of advancing HIV prevention efforts within the Black gay community at-large, but little work has examined the duality of not only engaging, but also being self-identified members of this population of interest.

In the US, meaningful involvement of Black GBMSM is critically important to efforts such as those outlined in “Ending the HIV Epidemic: A Plan for America” [23]. Given high risk for burnout among HIV care and service providers more generally (particularly peers); as well as the multiple barriers faced by Black GBMSM more generally, it is imperative that Black GBMSM in this field are given adequate support within organizations. In order to inform such efforts, the current study sought to explore the experiences of Black GBMSM working in HIV treatment and prevention, with a focus on understanding the role of their intersectional identities in their work.

Methods

This paper represents a secondary analysis of data from qualitative interviews conducted to inform development of an intervention to increase social capital among young Black GBMSM (YB-GBMSM) living with HIV in Atlanta, Georgia. A full description of the study methods and the development of intervention program has been published previously (6). We conducted 28 in-depth interviews with community key informants as part of the intervention development process. Key informants were HIV service and care providers in Atlanta who were either known to the study team or recommended by our youth advisory board (YAB) based on a reputation for expertise in working with YB-GBMSM. We utilized purposive sampling strategies to recruit a diverse sample participants in terms of age, race, gender, sexual orientation, educational background, and occupation. We developed a semi-structured interview guide which assessed seven domains: (1) the participants’ professional and personal interactions with YB-GBMSM; (2) the strengths of, and challenges facing YB-GBMSM in general; (3) ways in which participants’ own personal identities influenced their work with YB-GBMSM; (4) diversity among YB-GBMSM; (5) collaboration among CBOs; (6) cultural competence related to services provided to YB-GBMSM; and (7) ways in which social network connections might influence engagement in care.

Verbal informed consent was obtained prior to each interview. Interviews were conducted in mutually convenient locations deemed private and adequate for proper recording without distraction. Interviews were conducted by two Black and queer-identified study team members (MJ and SM), sometimes in conjunction with a YAB member who had been trained in qualitative interviewing. Interviews were digitally recorded and transcribed by a professional service. Interviews averaged approximately one hour in length, and participants also self-administered a brief demographic survey at the end of the interview. Upon completion of the interview, participants received a $50 gift card as a token of appreciation. Although workplace treatment was not a topic explicitly included in the original interview guide, early pilot interviews featured rich discussion about the work experiences of the Black GBMSM participants, and the duality of working with and being a part of this focus population. To explore this emerging theme, the team decided to ask additional questions specifically on workplace environment (i.e., describe your experiences working at your organization).

Ethical considerations

The study was approved by the Emory University Institutional Review Board and the Grady Research Oversight committee.

Thematic analysis

Interviews were digitally audio-recorded and transcribed verbatim by a professional agency. The research team used MaxQDA 2018 (VERBI Software, Berlin, Germany) to conduct thematic analysis using the following steps. Thematic analysis is a method for identifying, analyzing, and reporting patterns or themes within qualitative data, and provides rich detail and descriptions of the data [24]. First, we created a codebook including both structural, deductive codes derived from the interview guide (e.g., “challenges facing young Black GBMSM”) and inductive codes that emerged from the data (e.g., “workplace challenges”). The codebook was developed and refined through iterative discussions among the team. Subsets of transcripts were coded by multiple coders in parallel. Weekly team meetings were held to compare and refine codes, until consensus was achieved. The team then were given coding assignments, applying appropriate codes to each. The current analysis draws upon multiple codes, including “identity in the work”, “cultural competence”, and “challenges”. Coded text was then compared across participants, yielding the overarching themes presented.

Results

Participants spoke at length about both challenging and rewarding aspects of working in the HIV treatment and prevention fields as Black GBMSM. We categorized discussions of their experiences into four major thematic areas: (1) Shared Experiences; (2) Work-Related Stressors; (3) Worker Burnout; and (4) Commitment to Continue Working.

Participants

Of the 28 providers who participated in the parent study, 19 self-identified as Black GBMSM and are included in the current analysis. Participant ages ranged from age 22 to 62 (mean = 36.3, SD = 10.5) years. All participants had at least a high school diploma, and most had some postsecondary education as well. Over half worked at nonprofit CBOs/ASOs–the rest worked in clinical or research settings. We did not ask participants to disclose HIV status in the post-survey questionnaire, but six men (32%) disclosed that they were living with HIV during the course of their interview. See Table 1 for further demographic characteristics.

Table 1

Participant demographics.

Age                                % (n)
<30	31.6 (6)
30–39	42.1 (8)
40–49	15.8 (3)
>50	10.5 (2)
Education
Some College	21.1 (4)
Bachelor’s Degree	36.8 (7)
Advanced Degree	42.1 (8)
Organization Type
Non-Profit/CBO	63.2 (12)
Academic Institute	15.8 (3)
Clinical Setting	10.5 (2)
Other	10.5 (2)
Years in HIV related work
1–5	31.6 (6)
6–10	31.6 (6)
11–15	10.5 (2)
>16	26.3 (5)
HIV Status
HIV Positive	31.6 (6)
HIV Negative	15.8 (3)
Unknown/Did not mention	52.6 (10)

Shared experiences

Our participants described their Black and gay identities as assets, which made them more effective in their professions. Many described instances of using their own personal experiences to connect with, mentor and even inspire their clients. The value of shared identities and experiences for building such connections is illustrated by the quote below:

I am better able to meet people where they’re at because of knowing at the forefront of my mind what struggles look like and what that stress looks like, um, and how it can be expressed amongst community. We hurt the people that are closest to us when we are hurting ourselves. So being able to recognize that and see it for what it is, as someone hurting and trying to sift through that to get to the love that’s underneath, whether it’s love for themselves or love for someone else that they lost, um, and being able to heal that, is something that I’m more able to identify because I know what it looks like to be hurting and I know what it looks like to lash out. Um, and to know what it feels like to just need someone to say, ’I see you, and I’m here whenever you’re ready.’ (CBO staff member, 28 years old)

Most participants described professional interactions with Black GBMSM as mutually beneficial for both service providers and their clients. Some described their own growth and maturation through the exchange of inspiration and information with other Black GBMSM facing barriers similar to what they had previously encountered.

I guess, it’s weird to say in the work setting that I serve the role as the person’s big brother. But for the last three years I worked in a program that was just strictly designed to support Black gay men. And through that program I found a lot of, you know, learned a lot about myself and fortified myself a lot about my own HIV positivity. And because of that I was able to co-found this amazing network and…community-based organization. (CBO staff member, 38 years old)

In these cases, being a Black GBMSM working in service of other Black GBMSM within the HIV context was described in a very positive light–participants utilized their identity and lived experiences to fulfill their professional responsibilities. Furthermore, self-assurance about their own intersectional identities was fortified through repeated, affirming interactions with other Black GBMSM.

Work-Related stressors

Despite the deep and often rewarding connections that our participants felt to the work and to their clients, they discussed a range of stressors relating to work in the HIV field. The most cited stressors were a) Work-Life Imbalance, b) Tokenization and Discrimination, c) Inadequate Organizational and Professional Resources, and d) Lack of Upward Mobility.

Work-Life imbalance

Many participants lamented a lack of healthy work-life balance in their lives. Due to deep personal commitment to the work and the close connections they felt to their clients, many struggled to set boundaries with work-related tasks, leading to encroachment of these duties upon their personal time.

The line between professional and personal blend with my particular type of work, um, sometimes I’m seen as a mentor… Because working with young, Black gay men, particularly positive men, it’s not transactional, it’s not just about the linkage. … It’s about being a role model, not just on the clock but off the clock as well.” (CBO staff member, 33 years old)

As alluded to above, many voiced that the needs of Black GBMSM clients often extended beyond normal business hours. Participants would frequently make themselves readily available outside of official duty hours, to ensure that clients and community members received the information and resources they needed. Of note, participants specifically pointed to their shared Black GBMSM identity and experience as the main reasons why it was more difficult to set boundaries with clients.

I do HIV prevention counseling, emotional wellness type of counseling, motivation interviewing. We do a lot around like goal-setting and addressing barriers to care. Um, I make myself readily available. Sometimes it goes beyond intervention you know, I make myself readily available. I give out my personal cell phone number. I give my email. You know, I have clients that will ask questions in the middle of the night. Um, I make myself available because I know that there are so many barriers accessing care and then staying in the care. So I try to make myself readily available to all of my clients, particularly, my young gay Black men clients (CBO staff member, 27 years old).

One participant gave a specific example of what some of these off-hours duties could entail:

Just last night, at 2:30 in the morning, somebody told me that they were in the midst of swallowing Oxycodone pills. And I’m half, one eye asleep, one eye open, you know, I called them and they didn’t pick up, and I called them again and they text me and said they don’t want to talk, they just want to text. Okay, and I talked them down. Got them into the doctor now and was over there early this morning and made sure, you know, that they got the proper services that they need. But if anything, it’s not about the finesse that it took to talk the person down, it’s the fact that in the midst of a person actively trying to take their life, something in them made them reach out to me. (CBO staff member, 33 years old)

This quote highlights two important points that relate directly to shared identities between service providers and clients: Black GBMSM service providers are often able to connect with young Black GBMSM facing extreme psychosocial challenges, and they are also frequently willing to go above and beyond expectations for typical work responsibilities. Because this work is so personal for Black GBMSM, however, many participants were unable to protect their own time and energy due to overwhelming client needs.

Tokenism and discrimination

Participants described instances in which tokenism and discrimination within organizations negatively impacted their work experiences. Many shared feeling as though they were hired simply to promote the appearance that their organization was being culturally competent in efforts targeting Black GBMSM, a population increasingly prioritized by funders. Additionally, some participants felt that their employment was contingent upon them being knowledgeable of all Black gay experiences, without consideration of the diversity among this non-homogenous population.

So while this career has been really, really good for me, I think it is a career that tokenizes Black gay men. I think it is the career that very few are lucky to be in because people really want to see them grow. I think many of us have positions in this field because the assumption is that I’m the Black gay person that knows all Black gay things, and I’m going to hire you for this role because my grant focuses on this demographic and we feel like because you’re a part of it, you must be an expert, and that’s not true. (CBO staff member, 35 years old)

Experiences of tokenism were very common among our participants. Related to this tokenism, a few participants expressed discomfort with the commodification of certain parts of their identity, at the expense of their privacy. Because their employment was perceived as inherently tied to their identity as Black GBMSM (who, in some cases, were also living with HIV) these participants felt pressured to openly share very personal information (i.e., their sexuality and/or HIV status) as a way of engaging other Black GBMSM. A few participants were still working through their own internal processes of self-acceptance of sexuality and/or HIV status and had not disclosed widely–these participants found identity-focused aspects of the job to be particularly stressful.

Of note, some participants felt not only tokenized, but more explicitly discriminated against because of their sexuality. When such workplace discrimination occurred, participants often felt that they had no recourse, due in part to perceived alliance between human resources departments and managers, as well as state employment laws that allow for at-will termination of employees without a need to prove cause.

Like in the workplace, in the workplace like you are subjected to so much scrutiny…People will see a gay man as an easy target in the workplace…I’ve been you know “type-casted”, “Oh you can only do this because this is what you are and that’s what we feel the program’s doing." So you’re kinda pimped out there in a way, in the sense. But you’re also manipulated just for the aims of the program… for the gay community as a whole, we’re type casted, we’re stereotyped, we’re seen as easy targets. How we address that? We live in Georgia, that’s a barrier in itself right there with some of the laws that we have for employment, it’s just really antiquated and doesn’t really give credence to those individuals who are marginalized in the office community. (Healthcare Organization employee, 29 years old)

As a lower-level worker who is also a Black GBMSM, he is describing how he is forced to endure discrimination based on his sexuality because he fears losing his job. This participant illustrates how identity intersects with socioeconomic position and workplace hierarchy to cause disempowerment and discouragement.

Inadequate organizational and professional resources

Because of the close connections that they felt to their clients and communities, several participants described frustration when their desire to aid Black GBMSM was limited due to inadequate resources. Organizational limitations, often related to policies or funding, were barriers to providing the necessary level of support to clients and patients. Some participants highlighted a disconnect between funding priorities and the issues that they were directly faced with in their communities:

I’m not sure where priorities lie with, you know, federal funding, with the federal government. I’m not sure what their, what their vision is. I just know about—as a front line staff member and on the ground level, I have to, you know, look my friends and my brothers in the eye and say, you know, this program, after ten years is done, like, and because it’s grant funded, there is no, there is no kind of sun setting and it being a—and being something that we have time to really process. It’s like, it’s done. Like, once that date, once like March 31 shows up, that’s it… Um, the red tape, the red tape has me tired. There are so many stipulations to what someone can do when they’re just trying to help people, it’s really—that’s really kind of bothersome to me. (CBO staff member, 28 years old)

In addition to a lack of resources at the organizational level, several participants cited a lack of professional resources for Black GBMSM workers as an obstacle to efficiently providing services to others. Participants identified inadequate compensation, lack of benefits, and lackluster support from employers as stressors that reduced their ability to focus on their work.

We’re overworked and underpaid! You know…we deal with the same issues that the clients that we’re trying to help get through the day-to-day to deal with, you know. I gotta worry about housing. I gotta worry about my bills. I gotta worry about going to the doctor. I gotta worry about all those things and oftentimes organizations don’t give that support. (CBO staff member, 27 years old)

Several participants specifically mentioned that they did not have access to affordable physical or mental healthcare in spite of their employment, and cited a need for such services to be available to help them cope with work and life-related stressors.

Lack of upward mobility

Many of our participants highlighted limited opportunities for promotion, lack of adequate benefits (e.g., paid time off and health benefits), and lack of job security as additional examples of poor treatment in the workplace. In particular, many participants voiced resentment at a perceived lack of opportunities for training and advancement for Black GBMSM working in HIV-focused organizations. Speaking about people living with HIV being hired as peer educators or peer navigators, one participant stated the following:

I’m a firm believer, peers are great individuals but so often we overlook peers, so often we don’t promote peers. Because just because I’m living with HIV doesn’t mean I don’t have a Master’s degree. You know what I’m saying? It doesn’t mean I can’t be Executive Director. But often we say, “Oh you’re HIV-positive, you stay right here. You talk to these people.” That’s wonderful but you need, people need to hear my story of progression. (CBO staff member, 33 years old)

Several others echoed this sentiment and discussed the frustration related to being a Black GBMSM pigeonholed in certain, often front-line, roles without clear opportunities for growth. Several participants suggested this as a prime opportunity for improvement within CBOs.

Interviewer: So what do you feel that various organizations can do better?

Participant: First of, all you know, continue to hire you know, highly impactful and highly qualified young gay Black men to do this work, to work for young gay Black men–continue to do that. But foster their growth. (CBO staff member, 27 years old)

This participant and others are again referencing hierarchy within the workplace, within which Black GBMSM are typically at the bottom of the hierarchy, working in jobs that are less secure and have less opportunity for growth. This position is described in implied contrast to other people working in the organizations, who are less likely to be Black GBMSM and/or PLWH, but who may be more likely to have leadership positions and potential for advancement.

Worker burnout

When experienced in combination, the aforementioned challenges with work-life imbalance, tokenization, discrimination, and lack of career progression culminated in experiences of burnout. Participants related this burnout directly to de-prioritization of their own self-care as they completed tasks that fell outside of their official scope of work “to get the job done,” without regard to the demands such extra duties may have on their own health needs. At times, participants said that their work became so stressful that it led to participants suffering many of the same negative physical and emotional sequelae that they were working to prevent among the clients they served. Others discussed situations in which they were already beginning to impose limitations on themselves for the sake of preventing such burnout. Unfortunately, taking these types of self-care measures and setting boundaries was often accompanied with a sense of guilt.

My vocation is my occupation and vice-versa. So, on a daily basis, I’m out in the community, I’m communicating with the community, I’m a part of the community. And when I come home, sometimes that burnout from dealing with multiple people in the community or just multiple personalities in general, it kind of burns you out and then you want to do more for yourself because you represent, I represent the community I serve as well. I wish I could do more because I want to do more but I don’t because of burnout.

(Healthcare Organization employee, 29 years old)

Commitment to continue working

Despite the major challenges faced by Black GBMSM in these settings, our participants were overwhelmingly committed to continuing to work in the HIV field. Some participants stated that they would “work for free” and loved their work, while also acknowledging the unique challenges that they faced.

A lot of us will do some great work, but we’re not getting paid for it. Which granted, we’re gonna do it for the community but we also need to live and thrive as well, you know? Um, that’s one of my biggest things that I face. I don’t have enough time to give self-care because I’m working so hard.

(CBO staff member, 27 years old)

Participants described several reasons for continuing to work in HIV treatment and prevention, with major motivating factors centering around loss of loved ones, observing the impact of HIV on their Black gay communities more broadly, and for some, personal experiences living with HIV.

I had friends who were being diagnosed, um, when I was in college, there weren’t any real places for people to go. They were still trying to figure out what was going on. So people were dying. And I took it personal, especially when I had the opportunity myself to work in this field, I made a kind of a personal promise to all of the people that I had lost that I would continue the fight for them. Since they can’t fight anymore, I’m going to fight for them to help as many people as I can not have to die to this disease. (Healthcare Organization employee, 43 years old)

Essentially all of these participants described a similar passion and deep commitment to continued service of their Black GBMSM community; work in this area was not merely an occupation but a mission. Participants also expressed pride in the depth of their commitment to the work and to their communities, in spite of the concomitant stressors that were described.

Discussion

Despite a plethora of research and programming specifically targeting Black GBMSM for HIV prevention and treatment initiatives, to our knowledge, this is the first study to specifically explore the experiences of Black GBMSM as service providers working to implement these initiatives in the field. Our participants described both advantages and disadvantages related to their Black GBMSM identity in their work. On the one hand, our participants were able to perform their jobs more effectively, and found more deeper meaning in them, as a result of shared identities with the clients they served. At the same time, experiences of workplace discrimination and resource limitations also created frustration, stress, and burnout. We found that Black GBMSM working in the HIV field are at high risk for stress and burnout, but in many cases continue to work in this area due to a strong personal commitment to their communities.

Burnout in HIV is well documented, though not previously linked before to the intersectional identities of Black GBMSM workers. Despite frequent documentation of such burnout, there is a lack of evidence-based interventions for addressing burnout specifically in this field. Burnout interventions in healthcare more generally often focus at the individual level, for example, by teaching mindfulness, cognitive behavioral therapy, or other strategies to cope with stressors. While these strategies may have some incremental benefit, we agree with other scholars that true prevention and mitigation of burnout must occur at the organizational level [25]. A meta-analysis of interventions targeting physician burnout, for example, suggested significantly improved effects of organization-directed interventions when compared to individual-level physician-directed interventions [26].

At the same time, strategies to address burnout among Black GBMSM working in HIV cannot ignore power dynamics related to these intersectional identities. Within organizations, our Black GBMSM participants experienced emotional exhaustion not only because of shared identities with their participants, but also because of stressors related directly to experiences of discrimination and perceived precarity of their employment within organizations. Additionally, studies show that Black GBMSM encounter racism within predominantly white LGBT spaces, as well as homonegativity within Black communities [7, 27]. Solutions must therefore explicitly address the identity and social position of Black GBMSM, both within and outside of these organizations.

Our findings and the above considerations lead directly to several concrete recommendations for organizations with respect to mitigating stress and burnout among Black GBMSM working in HIV. The key causes of stress that we identified included lack of material and emotional support from organizations, lack of respect or even discrimination relating to workers’ intersectional positions, and also unique stress related to the closeness of Black GBMSM to their clients and their work. To address the lack of material and emotional support, we suggest advocating for improved financial compensation and benefits for Black GBMSM working in this area. Many of our participants described job positions in which they felt that they were “only” being hired due to their Black gay identity, and that their positions were at a lower level with precarious job security–it is important that the value of these lived experiences is reflected in financial compensation as well as subsequent job opportunities and career development. To address disrespect and discrimination against Black GBMSM, organizations must examine their processes, undergo trainings to familiarize themselves with interlocking systems of oppression, and ultimately provide mechanisms for Black GBMSM to provide feedback about discrimination without fear of retaliation. Finally, to address the unique trauma and stress associated with being Black GBMSM and working in this field, it is also imperative that workers receive time and benefits (i.e., insurance) to facilitate care of their own physical and mental health. Table 2 provides a listing, based on our findings, of our recommendations for improving the experiences of Black GBMSM working in HIV with respect to workplace wellness and equity.

Table 2

Recommendations for improving the experiences of Black GBMSM working in HIV prevention and treatment.

1. Create job descriptions (and accompanying compensation and benefit packages) that reflect the value of employees’ contributions to the project and acknowledge the critical importance of knowledge and skills gained from lived experiences.2. Provide workers with appropriate flex time to acknowledge work performed outside of traditional office hours.3. Provide workers with paid time off for physical and mental health breaks given the emotional intensity of the work.4. Protect workers against implied or direct demands to self-disclose personal information regarding their sexuality, HIV status, and other aspects of their social identities and/or experiences.5. Provide workers with appropriate and affordable healthcare options and mental health resources.6. Require all employees to complete adequate cultural sensitivity trainings on a regular basis.7. Provide formalized mentoring and career development opportunities.8. Include workers in programmatic decision-making and advocate for more Black GBMSM to take on leadership roles.

Importantly, Black GBMSM are not always lower-level employees and are not always employed as peers. As one strategy for dealing with the problems described in this study, a few of our participants had started their own organizations which were therefore led and primarily populated by Black GBMSM themselves. Future studies to compare and contrast experience of Black GBMSM working in organizations with different demographic makeups and leadership structures might shed some light on the contribution of various facets of the work experience to burnout (or lack thereof).

Limitations

This study was a secondary analysis of data being collected for other purposes; our sampling strategy was therefore not designed to maximize variation around the experiences of Black GBMSM in the workplace. It therefore could be the case that our participants, who were selected due to community reputation for excellence in work with young Black GBMSM, may not represent the range of workplace experiences of Black GBMSM in the HIV field. If anything, however, we would expect that this would bias our sample towards reporting more favorable experiences–since the people we were interviewing were still working in the field and active/visible in the community. This brings up a concern that other Black GBMSM working in HIV are having experiences even more stressful than what is described here. Our study is also limited by its cross-sectional design; longitudinal interviews, had they been possible, would have provided more information about trajectory of burnout in this population over time.

Conclusions

To achieve an end to the HIV epidemic in the US, we must focus on supporting Black GBMSM, whose perspectives and leadership are vital to the development and implementation of these efforts. This study identified several factors that contribute to stress and burnout among Black GBMSM working in the field of HIV treatment and prevention. There is a need for meaningful capacity building, physical and mental health support, and improvement of workplace conditions to adequately support the Black GBMSM who work to improve the health of their own communities. Improving these organizational conditions will hopefully contribute to the overall health of Black GBMSM, and also strengthen their ability to provide the support needed to reduce HIV incidence among Black GBMSM in general.

10 Feb 2021

PONE-D-20-33257

Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention

PLOS ONE

Dear Dr. Jones,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Petros Isaakidis

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overview

It was with great interest that I read this paper, and I would like to congratulate the authors on their efforts to document a surprisingly under-explored area. I found the central focus of this manuscript to be relevant for publication, from both research and public health programming perspectives.

Prior to publication, there are a number of areas which I recommend the authors consider amendment to. These I believe these would improve the framing, content and discussion presented. I have organized these suggestions according to the main headings used throughout their paper.

Introduction

In its current form, I find that the Introduction does not adequately frame the importance of the study and is lacking a robust rationale for publication. This could be resolved through a more detailed exploration of existing research which elaborates some of the key concepts, health and social aspects that the authors seek to raise. Core concepts potentially of value to introduce include: personal identity/ies in professional/volunteer/activism work; the intersection of gender, race and HIV status; the role and importance of recognition for workforces; discrimination and tokenism in HIV work etc. Of course, the authors will need to discuss which they find most relevant to detail and illuminate for the reader.

I note that burnout is defined in the second paragraph of the Discussion, but understanding this is central to the framing of the study (Introduction), findings of the authors (Results) and exploring what these mean (Discussion).

A brief PubMed search highlighted some potentially useful titles for the authors to read, consider inclusion and use the referencing to identify other potential papers to support this research (e.g. 1) Swank & Fahs (2012) An Intersectional Analysis of Gender and Race for Sexual Minorities Who Engage in Gay and Lesbian Rights Activism or 2) Molina, Dirkes & Ramirez-Valles (2017) Burnout in HIV/AIDS Volunteers: A Socio-Cultural Analysis among Latino Gay, Bisexual Men, and Transgender People).

I suggest to conclude the Introduction section with a stronger paragraph summarizing the key gap in the literature and presenting a more detailed rationale for the study.

Methodology

Whilst the authors do reference the previously published research which details the Methodology in full, I feel that inclusion of more detail here would be useful to the reader, particularly regarding the study design, recruitment and inclusion/exclusion criteria.

Additionally, I suggest some light restructuring to improve the flow of the Methodology section. Namely, opening with an overview of the study design, detailing the study population and recruitment, description of the development and adjustments to the data collection tools, interview procedures, followed by the analysis and closing with the ethical considerations (including informed consent, remuneration/benefits and details of the protocol review).

There are conflicting opinions about where to include the overview of study participants and their demographic information. In this case I would suggest moving these five sentences at the end of the sub-section titled Participants from the Methodology to the opening section of the Results.

Results

The Results are interesting and extremely valuable. The authors have presented the four major themes in an order which is logical and understandable.

I wonder if the second theme of Work Related Stressors, warrants a minor re-ordering. The authors could consider presenting first work-life balance, second tokenism and discrimination, third organizational and professional resources, and finally upward mobility. I feel that the link between the personal identities described under work-life balance is more logically followed by tokenism and discrimination. Additionally, in the same section, I wonder if the experiences of organizations requiring/encouraging individuals to share personal information (sexuality, sexual orientation or HIV status) perhaps better illustrates inadequate organization and professional resources, rather than as currently presented as an example of tokenism and discrimination?

Whilst I am strongly supportive of the use of quotes in the Results section, bringing very human elements of this research forward, I do find the balance between the authors descriptive content and quotes to be somewhat unbalanced. Preferably, the Results section to be readable without any quotes at all, and where they are included, they complement and emphasise what has been presented by the authors. In its current form, removal of the quotes would make the Results section very challenging to follow, and there are a number of examples where the authors rely almost entirely on the quote to demonstrate the result. I would therefore strongly suggest an amended ratio, with more well elaborated paragraphs describing the authors findings, and shorter quotes of the study participants. The authors have very interesting findings to present, but I miss their voice.

Discussion

With such interesting Results, I was expecting a punchier Discussion to follow. Overall, I found that the section was challenging to navigate and lacking a coherent story. Several important issues are presented, but often in vague terms or with a strong advocacy/activist message that is not necessarily well linked to the findings and discussion presented. For example, “Burnout among service providers has important implications, not only for the well-being of those providers but also for the patients and clients who they serve.” What are these implications? Or a second example, “However, simply increasing diversity or employing Black GBMSM is clearly not sufficient to address this problem – if conditions continue as described by our participants, new EHE initiatives will continue to be faced with high rates of burnout and attrition among workers, suboptimal engagement with the most impacted communities, and ultimately, lack of progress in the fight to end HIV.” This long sentence doesn’t really get to the core of what the authors are trying to convey.

The authors have some exceptionally valuable points to raise here, and to properly present these a significant revision to the Discussion section is recommended. I would advise the authors re-consider the central points they wish to make and the logical order, then construct paragraphs/sections around these which make more tangible links between finding and the supporting/contradicting literature, arguing the relevance, and proposing the recommendation(s).

The inclusion of a table specifically detailing the authors recommendations is highly valuable. However, these recommendations need to be integrated into the relevant paragraphs of the Discussion so that clearer links between the identified results, supporting literature, discussion of relevance and the proposed recommendations can be demonstrated.

Grammar, Spelling and Formatting etc

In general I found the quality of writing to be high, and note that the authors have taken care to write this paper clearly in understandable language. There are a number of minor grammatical, spelling and formatting inconsistencies and errors that require amendment, which I expect the authors will be able to address in a revised version. In text any numbers under 10 should be written out in full (e.g. “one in two Black GBMSM will be diagnosed with…”). Stylistically, throughout the Results, the authors have a tendency towards slightly repetitive phrasing of their findings (e.g. “Most participants described…” and “Participants described…”). It might be worthwhile employing some light cosmetic editing to avoid these kinds of repetition where possible, bearing in mind that some repetition is inevitable. A few times in the paper the authors make use of a colon followed by a numbered list. Where the list is short (e.g. Results, sub-section Work-Life Imbalance) I would suggest putting this into full sentences rather than utilizing a list format.

Reviewer #2: This is an important paper, which addresses a current and important gap in the literature. I think that this paper will not only be of interest to people working in the US but also more globally. However, the paper requires major revision before it can be published. This includes good copy-editing to ensure sentence structure and readability.

A minor detail, the title should include the location and should also more closely reflect the key points of the paper.

In the introduction, the team reflect why Black gay, bisexual and other men who have sex

with men (GBMSM) are an important population in terms of the epidemiology of HIV in the US context. And in the discussion the authors try to situate this paper within the broader literature.

What is missing through the methods, and analysis and on through the discussion is a focus on the uniqueness of this of this group in relation to other people working in similar positions. What is the particular interest/ value of doing a subset analysis from within the larger study? How are the black men different or similar to the other men of colour who participated in the larger study? What in particular comes from the analysis of these data that would otherwise be missed if there was not a specific focus on the group of black men who participated. There is a discussion on "tokenism" within organizations but beyond this there is little reflection/ exploration of the interaction between being a peer, being black, being GBMSM and providing HIV services.

Did the authors explore other approaches to analysis which might allow deeper exploration of the experiences shared by the study participants? The thematic approach employed feels a bit flat - a different approach is needed to do justice to the rich and unique data that you have.

**********

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Reviewer #1: No

Reviewer #2: Yes: Sarah Jane Steele

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30 Sep 2021

Reviewer #1: Overview

It was with great interest that I read this paper, and I would like to congratulate the authors on their efforts to document a surprisingly under-explored area. I found the central focus of this manuscript to be relevant for publication, from both research and public health programming perspectives.

Prior to publication, there are a number of areas which I recommend the authors consider amendment to. These I believe these would improve the framing, content and discussion presented. I have organized these suggestions according to the main headings used throughout their paper.

Thank you for your encouragement!

Introduction

In its current form, I find that the Introduction does not adequately frame the importance of the study and is lacking a robust rationale for publication. This could be resolved through a more detailed exploration of existing research which elaborates some of the key concepts, health and social aspects that the authors seek to raise. Core concepts potentially of value to introduce include: personal identity/ies in professional/volunteer/activism work; the intersection of gender, race and HIV status; the role and importance of recognition for workforces; discrimination and tokenism in HIV work etc. Of course, the authors will need to discuss which they find most relevant to detail and illuminate for the reader.

Thank you for these very helpful suggestions. Incorporating the articles that you recommend from Swank & Fahs and Molina et al., we now situate our study within an intersectionality framework, to strengthen our justification for focusing specifically on the experiences of Black gay men as a unique group working in the HIV field.

I note that burnout is defined in the second paragraph of the Discussion, but understanding this is central to the framing of the study (Introduction), findings of the authors (Results) and exploring what these mean (Discussion).

Thank you for this suggestion – we now introduce the concept of burnout in the introduction, so as to provide context for the results and discussion.

A brief PubMed search highlighted some potentially useful titles for the authors to read, consider inclusion and use the referencing to identify other potential papers to support this research (e.g. 1) Swank & Fahs (2012) An Intersectional Analysis of Gender and Race for Sexual Minorities Who Engage in Gay and Lesbian Rights Activism or 2) Molina, Dirkes & Ramirez-Valles (2017) Burnout in HIV/AIDS Volunteers: A Socio-Cultural Analysis among Latino Gay, Bisexual Men, and Transgender People).

I suggest to conclude the Introduction section with a stronger paragraph summarizing the key gap in the literature and presenting a more detailed rationale for the study.

We have added these references as well as this paragraph, thank you for the suggestion.

Methodology

Whilst the authors do reference the previously published research which details the Methodology in full, I feel that inclusion of more detail here would be useful to the reader, particularly regarding the study design, recruitment and inclusion/exclusion criteria.

We have added details about recruitment as requested.

Additionally, I suggest some light restructuring to improve the flow of the Methodology section. Namely, opening with an overview of the study design, detailing the study population and recruitment, description of the development and adjustments to the data collection tools, interview procedures, followed by the analysis and closing with the ethical considerations (including informed consent, remuneration/benefits and details of the protocol review).

We have added these details about ethical considerations, study population, and data collection tools.

There are conflicting opinions about where to include the overview of study participants and their demographic information. In this case I would suggest moving these five sentences at the end of the sub-section titled Participants from the Methodology to the opening section of the Results.

We have moved the demographic descriptions to the results.

Results

The Results are interesting and extremely valuable. The authors have presented the four major themes in an order which is logical and understandable.

I wonder if the second theme of Work Related Stressors, warrants a minor re-ordering. The authors could consider presenting first work-life balance, second tokenism and discrimination, third organizational and professional resources, and finally upward mobility. I feel that the link between the personal identities described under work-life balance is more logically followed by tokenism and discrimination. Additionally, in the same section, I wonder if the experiences of organizations requiring/encouraging individuals to share personal information (sexuality, sexual orientation or HIV status) perhaps better illustrates inadequate organization and professional resources, rather than as currently presented as an example of tokenism and discrimination?

We have re-ordered the presentation of findings as suggested by the reviewer. However, to the last point – we feel that the section mentioned (about having to disclose sexuality and HIV status) does align more closely with tokenism – the participants are being “used” for their identities and therefore are forced to disclose. We have added text to clarify this connection, but left it within the same subsection as it was originally.

Whilst I am strongly supportive of the use of quotes in the Results section, bringing very human elements of this research forward, I do find the balance between the authors descriptive content and quotes to be somewhat unbalanced. Preferably, the Results section to be readable without any quotes at all, and where they are included, they complement and emphasise what has been presented by the authors. In its current form, removal of the quotes would make the Results section very challenging to follow, and there are a number of examples where the authors rely almost entirely on the quote to demonstrate the result. I would therefore strongly suggest an amended ratio, with more well elaborated paragraphs describing the authors findings, and shorter quotes of the study participants. The authors have very interesting findings to present, but I miss their voice.

Thank you for this suggestion. We have added more explanatory text to the results section and believe that it would now be understandable even without the very rich quotes.

Discussion

With such interesting Results, I was expecting a punchier Discussion to follow. Overall, I found that the section was challenging to navigate and lacking a coherent story. Several important issues are presented, but often in vague terms or with a strong advocacy/activist message that is not necessarily well linked to the findings and discussion presented. For example, “Burnout among service providers has important implications, not only for the well-being of those providers but also for the patients and clients who they serve.” What are these implications? Or a second example, “However, simply increasing diversity or employing Black GBMSM is clearly not sufficient to address this problem – if conditions continue as described by our participants, new EHE initiatives will continue to be faced with high rates of burnout and attrition among workers, suboptimal engagement with the most impacted communities, and ultimately, lack of progress in the fight to end HIV.” This long sentence doesn’t really get to the core of what the authors are trying to convey.

The authors have some exceptionally valuable points to raise here, and to properly present these a significant revision to the Discussion section is recommended. I would advise the authors re-consider the central points they wish to make and the logical order, then construct paragraphs/sections around these which make more tangible links between finding and the supporting/contradicting literature, arguing the relevance, and proposing the recommendation(s).

The inclusion of a table specifically detailing the authors recommendations is highly valuable. However, these recommendations need to be integrated into the relevant paragraphs of the Discussion so that clearer links between the identified results, supporting literature, discussion of relevance and the proposed recommendations can be demonstrated.

Thank you for this feedback. We have completely restructured the discussion section and hope that it addresses your concerns. We agree that the prior version was less focus and less aligned with the recommendations presented in Table 2. The revised discussion is much more focused on solutions to burnout for this population (as presented in the Table) and how these relate to other solutions that have been discussed in other settings. We hope you will find this more cohesive and compelling.

Grammar, Spelling and Formatting etc

In general I found the quality of writing to be high, and note that the authors have taken care to write this paper clearly in understandable language. There are a number of minor grammatical, spelling and formatting inconsistencies and errors that require amendment, which I expect the authors will be able to address in a revised version. In text any numbers under 10 should be written out in full (e.g. “one in two Black GBMSM will be diagnosed with…”). Stylistically, throughout the Results, the authors have a tendency towards slightly repetitive phrasing of their findings (e.g. “Most participants described…” and “Participants described…”). It might be worthwhile employing some light cosmetic editing to avoid these kinds of repetition where possible, bearing in mind that some repetition is inevitable. A few times in the paper the authors make use of a colon followed by a numbered list. Where the list is short (e.g. Results, sub-section Work-Life Imbalance) I would suggest putting this into full sentences rather than utilizing a list format.

Thank you for catching these – we have edited the paper accordingly.

Reviewer #2: This is an important paper, which addresses a current and important gap in the literature. I think that this paper will not only be of interest to people working in the US but also more globally. However, the paper requires major revision before it can be published. This includes good copy-editing to ensure sentence structure and readability.

A minor detail, the title should include the location and should also more closely reflect the key points of the paper.

We have added the location to the title.

In the introduction, the team reflect why Black gay, bisexual and other men who have sex

with men (GBMSM) are an important population in terms of the epidemiology of HIV in the US context. And in the discussion the authors try to situate this paper within the broader literature.

What is missing through the methods, and analysis and on through the discussion is a focus on the uniqueness of this of this group in relation to other people working in similar positions. What is the particular interest/ value of doing a subset analysis from within the larger study? How are the black men different or similar to the other men of colour who participated in the larger study? What in particular comes from the analysis of these data that would otherwise be missed if there was not a specific focus on the group of black men who participated. There is a discussion on "tokenism" within organizations but beyond this there is little reflection/ exploration of the interaction between being a peer, being black, being GBMSM and providing HIV services.

We have added a discussion of intersectionality to the introduction that we hope better frames/justifies the focus on this population. Further, we have added additional interpretation and context in the results section and tried to specifically highlight the role of the Black GBMSM identity in the different findings and in contextualizing the different quotes.

Did the authors explore other approaches to analysis which might allow deeper exploration of the experiences shared by the study participants? The thematic approach employed feels a bit flat - a different approach is needed to do justice to the rich and unique data that you have.

We hope that the additional contextualization provided with the quotes helps to make the data feel less flat.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

10 Feb 2021

PONE-D-20-33257

Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention

PLOS ONE

Dear Dr. Jones,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Petros Isaakidis

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overview

It was with great interest that I read this paper, and I would like to congratulate the authors on their efforts to document a surprisingly under-explored area. I found the central focus of this manuscript to be relevant for publication, from both research and public health programming perspectives.

Prior to publication, there are a number of areas which I recommend the authors consider amendment to. These I believe these would improve the framing, content and discussion presented. I have organized these suggestions according to the main headings used throughout their paper.

Introduction

In its current form, I find that the Introduction does not adequately frame the importance of the study and is lacking a robust rationale for publication. This could be resolved through a more detailed exploration of existing research which elaborates some of the key concepts, health and social aspects that the authors seek to raise. Core concepts potentially of value to introduce include: personal identity/ies in professional/volunteer/activism work; the intersection of gender, race and HIV status; the role and importance of recognition for workforces; discrimination and tokenism in HIV work etc. Of course, the authors will need to discuss which they find most relevant to detail and illuminate for the reader.

I note that burnout is defined in the second paragraph of the Discussion, but understanding this is central to the framing of the study (Introduction), findings of the authors (Results) and exploring what these mean (Discussion).

A brief PubMed search highlighted some potentially useful titles for the authors to read, consider inclusion and use the referencing to identify other potential papers to support this research (e.g. 1) Swank & Fahs (2012) An Intersectional Analysis of Gender and Race for Sexual Minorities Who Engage in Gay and Lesbian Rights Activism or 2) Molina, Dirkes & Ramirez-Valles (2017) Burnout in HIV/AIDS Volunteers: A Socio-Cultural Analysis among Latino Gay, Bisexual Men, and Transgender People).

I suggest to conclude the Introduction section with a stronger paragraph summarizing the key gap in the literature and presenting a more detailed rationale for the study.

Methodology

Whilst the authors do reference the previously published research which details the Methodology in full, I feel that inclusion of more detail here would be useful to the reader, particularly regarding the study design, recruitment and inclusion/exclusion criteria.

Additionally, I suggest some light restructuring to improve the flow of the Methodology section. Namely, opening with an overview of the study design, detailing the study population and recruitment, description of the development and adjustments to the data collection tools, interview procedures, followed by the analysis and closing with the ethical considerations (including informed consent, remuneration/benefits and details of the protocol review).

There are conflicting opinions about where to include the overview of study participants and their demographic information. In this case I would suggest moving these five sentences at the end of the sub-section titled Participants from the Methodology to the opening section of the Results.

Results

The Results are interesting and extremely valuable. The authors have presented the four major themes in an order which is logical and understandable.

I wonder if the second theme of Work Related Stressors, warrants a minor re-ordering. The authors could consider presenting first work-life balance, second tokenism and discrimination, third organizational and professional resources, and finally upward mobility. I feel that the link between the personal identities described under work-life balance is more logically followed by tokenism and discrimination. Additionally, in the same section, I wonder if the experiences of organizations requiring/encouraging individuals to share personal information (sexuality, sexual orientation or HIV status) perhaps better illustrates inadequate organization and professional resources, rather than as currently presented as an example of tokenism and discrimination?

Whilst I am strongly supportive of the use of quotes in the Results section, bringing very human elements of this research forward, I do find the balance between the authors descriptive content and quotes to be somewhat unbalanced. Preferably, the Results section to be readable without any quotes at all, and where they are included, they complement and emphasise what has been presented by the authors. In its current form, removal of the quotes would make the Results section very challenging to follow, and there are a number of examples where the authors rely almost entirely on the quote to demonstrate the result. I would therefore strongly suggest an amended ratio, with more well elaborated paragraphs describing the authors findings, and shorter quotes of the study participants. The authors have very interesting findings to present, but I miss their voice.

Discussion

With such interesting Results, I was expecting a punchier Discussion to follow. Overall, I found that the section was challenging to navigate and lacking a coherent story. Several important issues are presented, but often in vague terms or with a strong advocacy/activist message that is not necessarily well linked to the findings and discussion presented. For example, “Burnout among service providers has important implications, not only for the well-being of those providers but also for the patients and clients who they serve.” What are these implications? Or a second example, “However, simply increasing diversity or employing Black GBMSM is clearly not sufficient to address this problem – if conditions continue as described by our participants, new EHE initiatives will continue to be faced with high rates of burnout and attrition among workers, suboptimal engagement with the most impacted communities, and ultimately, lack of progress in the fight to end HIV.” This long sentence doesn’t really get to the core of what the authors are trying to convey.

The authors have some exceptionally valuable points to raise here, and to properly present these a significant revision to the Discussion section is recommended. I would advise the authors re-consider the central points they wish to make and the logical order, then construct paragraphs/sections around these which make more tangible links between finding and the supporting/contradicting literature, arguing the relevance, and proposing the recommendation(s).

The inclusion of a table specifically detailing the authors recommendations is highly valuable. However, these recommendations need to be integrated into the relevant paragraphs of the Discussion so that clearer links between the identified results, supporting literature, discussion of relevance and the proposed recommendations can be demonstrated.

Grammar, Spelling and Formatting etc

In general I found the quality of writing to be high, and note that the authors have taken care to write this paper clearly in understandable language. There are a number of minor grammatical, spelling and formatting inconsistencies and errors that require amendment, which I expect the authors will be able to address in a revised version. In text any numbers under 10 should be written out in full (e.g. “one in two Black GBMSM will be diagnosed with…”). Stylistically, throughout the Results, the authors have a tendency towards slightly repetitive phrasing of their findings (e.g. “Most participants described…” and “Participants described…”). It might be worthwhile employing some light cosmetic editing to avoid these kinds of repetition where possible, bearing in mind that some repetition is inevitable. A few times in the paper the authors make use of a colon followed by a numbered list. Where the list is short (e.g. Results, sub-section Work-Life Imbalance) I would suggest putting this into full sentences rather than utilizing a list format.

Reviewer #2: This is an important paper, which addresses a current and important gap in the literature. I think that this paper will not only be of interest to people working in the US but also more globally. However, the paper requires major revision before it can be published. This includes good copy-editing to ensure sentence structure and readability.

A minor detail, the title should include the location and should also more closely reflect the key points of the paper.

In the introduction, the team reflect why Black gay, bisexual and other men who have sex

with men (GBMSM) are an important population in terms of the epidemiology of HIV in the US context. And in the discussion the authors try to situate this paper within the broader literature.

What is missing through the methods, and analysis and on through the discussion is a focus on the uniqueness of this of this group in relation to other people working in similar positions. What is the particular interest/ value of doing a subset analysis from within the larger study? How are the black men different or similar to the other men of colour who participated in the larger study? What in particular comes from the analysis of these data that would otherwise be missed if there was not a specific focus on the group of black men who participated. There is a discussion on "tokenism" within organizations but beyond this there is little reflection/ exploration of the interaction between being a peer, being black, being GBMSM and providing HIV services.

Did the authors explore other approaches to analysis which might allow deeper exploration of the experiences shared by the study participants? The thematic approach employed feels a bit flat - a different approach is needed to do justice to the rich and unique data that you have.

**********

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19 Jan 2022

Reviewer #1: Overview

It was with great interest that I read this paper, and I would like to congratulate the authors on their efforts to document a surprisingly under-explored area. I found the central focus of this manuscript to be relevant for publication, from both research and public health programming perspectives.

Prior to publication, there are a number of areas which I recommend the authors consider amendment to. These I believe these would improve the framing, content and discussion presented. I have organized these suggestions according to the main headings used throughout their paper.

Thank you for your encouragement!

Introduction

In its current form, I find that the Introduction does not adequately frame the importance of the study and is lacking a robust rationale for publication. This could be resolved through a more detailed exploration of existing research which elaborates some of the key concepts, health and social aspects that the authors seek to raise. Core concepts potentially of value to introduce include: personal identity/ies in professional/volunteer/activism work; the intersection of gender, race and HIV status; the role and importance of recognition for workforces; discrimination and tokenism in HIV work etc. Of course, the authors will need to discuss which they find most relevant to detail and illuminate for the reader.

Thank you for these very helpful suggestions. Incorporating the articles that you recommend from Swank & Fahs and Molina et al., we now situate our study within an intersectionality framework, to strengthen our justification for focusing specifically on the experiences of Black gay men as a unique group working in the HIV field.

I note that burnout is defined in the second paragraph of the Discussion, but understanding this is central to the framing of the study (Introduction), findings of the authors (Results) and exploring what these mean (Discussion).

Thank you for this suggestion – we now introduce the concept of burnout in the introduction, so as to provide context for the results and discussion.

A brief PubMed search highlighted some potentially useful titles for the authors to read, consider inclusion and use the referencing to identify other potential papers to support this research (e.g. 1) Swank & Fahs (2012) An Intersectional Analysis of Gender and Race for Sexual Minorities Who Engage in Gay and Lesbian Rights Activism or 2) Molina, Dirkes & Ramirez-Valles (2017) Burnout in HIV/AIDS Volunteers: A Socio-Cultural Analysis among Latino Gay, Bisexual Men, and Transgender People).

I suggest to conclude the Introduction section with a stronger paragraph summarizing the key gap in the literature and presenting a more detailed rationale for the study.

We have added these references as well as this paragraph, thank you for the suggestion.

Methodology

Whilst the authors do reference the previously published research which details the Methodology in full, I feel that inclusion of more detail here would be useful to the reader, particularly regarding the study design, recruitment and inclusion/exclusion criteria.

We have added details about recruitment as requested.

Additionally, I suggest some light restructuring to improve the flow of the Methodology section. Namely, opening with an overview of the study design, detailing the study population and recruitment, description of the development and adjustments to the data collection tools, interview procedures, followed by the analysis and closing with the ethical considerations (including informed consent, remuneration/benefits and details of the protocol review).

We have added these details about ethical considerations, study population, and data collection tools.

There are conflicting opinions about where to include the overview of study participants and their demographic information. In this case I would suggest moving these five sentences at the end of the sub-section titled Participants from the Methodology to the opening section of the Results.

We have moved the demographic descriptions to the results.

Results

The Results are interesting and extremely valuable. The authors have presented the four major themes in an order which is logical and understandable.

I wonder if the second theme of Work Related Stressors, warrants a minor re-ordering. The authors could consider presenting first work-life balance, second tokenism and discrimination, third organizational and professional resources, and finally upward mobility. I feel that the link between the personal identities described under work-life balance is more logically followed by tokenism and discrimination. Additionally, in the same section, I wonder if the experiences of organizations requiring/encouraging individuals to share personal information (sexuality, sexual orientation or HIV status) perhaps better illustrates inadequate organization and professional resources, rather than as currently presented as an example of tokenism and discrimination?

We have re-ordered the presentation of findings as suggested by the reviewer. However, to the last point – we feel that the section mentioned (about having to disclose sexuality and HIV status) does align more closely with tokenism – the participants are being “used” for their identities and therefore are forced to disclose. We have added text to clarify this connection, but left it within the same subsection as it was originally.

Whilst I am strongly supportive of the use of quotes in the Results section, bringing very human elements of this research forward, I do find the balance between the authors descriptive content and quotes to be somewhat unbalanced. Preferably, the Results section to be readable without any quotes at all, and where they are included, they complement and emphasise what has been presented by the authors. In its current form, removal of the quotes would make the Results section very challenging to follow, and there are a number of examples where the authors rely almost entirely on the quote to demonstrate the result. I would therefore strongly suggest an amended ratio, with more well elaborated paragraphs describing the authors findings, and shorter quotes of the study participants. The authors have very interesting findings to present, but I miss their voice.

Thank you for this suggestion. We have added more explanatory text to the results section and believe that it would now be understandable even without the very rich quotes.

Discussion

With such interesting Results, I was expecting a punchier Discussion to follow. Overall, I found that the section was challenging to navigate and lacking a coherent story. Several important issues are presented, but often in vague terms or with a strong advocacy/activist message that is not necessarily well linked to the findings and discussion presented. For example, “Burnout among service providers has important implications, not only for the well-being of those providers but also for the patients and clients who they serve.” What are these implications? Or a second example, “However, simply increasing diversity or employing Black GBMSM is clearly not sufficient to address this problem – if conditions continue as described by our participants, new EHE initiatives will continue to be faced with high rates of burnout and attrition among workers, suboptimal engagement with the most impacted communities, and ultimately, lack of progress in the fight to end HIV.” This long sentence doesn’t really get to the core of what the authors are trying to convey.

The authors have some exceptionally valuable points to raise here, and to properly present these a significant revision to the Discussion section is recommended. I would advise the authors re-consider the central points they wish to make and the logical order, then construct paragraphs/sections around these which make more tangible links between finding and the supporting/contradicting literature, arguing the relevance, and proposing the recommendation(s).

The inclusion of a table specifically detailing the authors recommendations is highly valuable. However, these recommendations need to be integrated into the relevant paragraphs of the Discussion so that clearer links between the identified results, supporting literature, discussion of relevance and the proposed recommendations can be demonstrated.

Thank you for this feedback. We have completely restructured the discussion section and hope that it addresses your concerns. We agree that the prior version was less focus and less aligned with the recommendations presented in Table 2. The revised discussion is much more focused on solutions to burnout for this population (as presented in the Table) and how these relate to other solutions that have been discussed in other settings. We hope you will find this more cohesive and compelling.

Grammar, Spelling and Formatting etc

In general I found the quality of writing to be high, and note that the authors have taken care to write this paper clearly in understandable language. There are a number of minor grammatical, spelling and formatting inconsistencies and errors that require amendment, which I expect the authors will be able to address in a revised version. In text any numbers under 10 should be written out in full (e.g. “one in two Black GBMSM will be diagnosed with…”). Stylistically, throughout the Results, the authors have a tendency towards slightly repetitive phrasing of their findings (e.g. “Most participants described…” and “Participants described…”). It might be worthwhile employing some light cosmetic editing to avoid these kinds of repetition where possible, bearing in mind that some repetition is inevitable. A few times in the paper the authors make use of a colon followed by a numbered list. Where the list is short (e.g. Results, sub-section Work-Life Imbalance) I would suggest putting this into full sentences rather than utilizing a list format.

Thank you for catching these – we have edited the paper accordingly.

Reviewer #2: This is an important paper, which addresses a current and important gap in the literature. I think that this paper will not only be of interest to people working in the US but also more globally. However, the paper requires major revision before it can be published. This includes good copy-editing to ensure sentence structure and readability.

A minor detail, the title should include the location and should also more closely reflect the key points of the paper.

We have added the location to the title.

In the introduction, the team reflect why Black gay, bisexual and other men who have sex

with men (GBMSM) are an important population in terms of the epidemiology of HIV in the US context. And in the discussion the authors try to situate this paper within the broader literature.

What is missing through the methods, and analysis and on through the discussion is a focus on the uniqueness of this of this group in relation to other people working in similar positions. What is the particular interest/ value of doing a subset analysis from within the larger study? How are the black men different or similar to the other men of colour who participated in the larger study? What in particular comes from the analysis of these data that would otherwise be missed if there was not a specific focus on the group of black men who participated. There is a discussion on "tokenism" within organizations but beyond this there is little reflection/ exploration of the interaction between being a peer, being black, being GBMSM and providing HIV services.

We have added a discussion of intersectionality to the introduction that we hope better frames/justifies the focus on this population. Further, we have added additional interpretation and context in the results section and tried to specifically highlight the role of the Black GBMSM identity in the different findings and in contextualizing the different quotes.

Did the authors explore other approaches to analysis which might allow deeper exploration of the experiences shared by the study participants? The thematic approach employed feels a bit flat - a different approach is needed to do justice to the rich and unique data that you have.

We hope that the additional contextualization provided with the quotes helps to make the data feel less flat.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

16 Feb 2022

Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention in Atlanta, GA.

PONE-D-20-33257R2

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23 Feb 2022

PONE-D-20-33257R2

Passion, commitment, and burnout: Experiences of Black gay men working in HIV/AIDS treatment and prevention in Atlanta, GA.

Dear Dr. Jones:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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