Key participant demography is detailed in Table 1. Twenty-three participants are between the ages of 22 and 45 and are therefore suitable for both HPV and meningococcal vaccine; the remaining two participants were over 45 years old and were only suitable for meningococcal vaccine. Most of the participants were identified as Hispanic, gay had a university or higher education level and did not live with a man. known HIV diagnosis . Seventy-two percent of all participants reported that had never been vaccinated against meningococcal disease and 68% did not recommend this vaccine by a healthcare provider. Seventy percent of the 23 participants eligible for the HPV vaccine reported that had never had this vaccine, and 57% never recommended this vaccine by a healthcare provider. Table 1 Demographic characteristics of focus group participants Full size table Barriers to vaccination Qualitative analysis revealed that the barriers to HPV and meningococcal vaccine overlap closely. These included limited awareness and information, reliance on mainstream healthcare providers for vaccine information, stigma and reluctance to disclose sexual orientation, uncertainty about health insurance coverage and vaccine costs and the distance and time required to access vaccines. We elaborate these barriers below and present sample supporting data in Table 2. Table 2 Key barriers to HPV and meningococcal vaccination and sample quotes Full-size table Limited awareness and knowledge About HPV and HPV vaccine Participants were generally aware that anyone who was sexually active could carry the HPV virus and that HPV infection could lead to anogenital warts and cancer in cisgender women of all sexes. However, few participants were aware that men could develop HPV-related cancers, or that MSM had a high risk of HPV-related anal cancer. As Miguel stated , “ Cancer is more severe in women, cancer cases caused by the virus [HPV]. And for men, there are certain types of HPV viruses that do not cause cancer. ” Assuming that HPV-related cancers only affect cisgender women, as Boots summarizes , contributed to a general lack of concern about HPV compared to other sexually transmitted infections “ Attention is drawn to sexually transmitted and more common diseases gonorrhea, chlamydia, syphilis... I don't know if this [HPV] is actually one of the diseases that are considered the same in our world. ” While most of the participants were aware that all genders were eligible for the HPV vaccine, some assumed they were "too old" to be vaccinated incorrectly. As Ailesq, who is currently eligible for the HPV vaccine, emphasizes "I was interested, but when I found out that a vaccine exists, I was old outside the vaccine range." About meningococcal disease and meningococcal vaccine Participants who were recommended a meningococcal vaccine to go to college were generally aware that meningococcal disease was transmitted through close contact and could cause inflammation in the brain and spinal cord. Many other participants, however, stated that they knew nothing about meningococcal disease or how it was transmitted. For example, in the age of Wario "What is meningitis?... When I think about it, it reminds me of something that has been eliminated as in polio days." Participants had different perceptions of which subpopulations were at high risk of meningococcal disease and only one participant accepted any ECE-specific risk. As Chuy shared "I believe that all of us, like all people, are exposed to [menengokok disease ], everyone can be gay, heterosexual without exception. They can be young or old, boy or girl. ” Multiple participants did not see themselves as candidates for the meningococcal vaccine, as they assumed they were vaccinated in childhood and were unaware of the current ACIP reinforcement guidelines. As Roy explains “ I think I had this vaccine when I was a little boy, because I didn't think much about it afterwards. 'It was like 'Oh I already have it', then when I went to college, it came out of this checklist. Relying on mainstream healthcare providers for vaccine information Participants reported that health resources for MSM were insufficient in the Inner Empire. As a result, many said that they rely on mainstream healthcare providers rather than providers identified as LGBT friends for vaccine information. Although several participants reported that they wanted to learn about recommended vaccines and related safety and efficacy from healthcare providers, most never talked to them about HPV or meningococcal vaccine. Ailesq shared "I think medical professionals should master more issues in suggesting these things [ vaccines ]. I don't even remember that I was offered a meningitis vaccine... It seems strange to get basically radio silence from my treatment providers about these important vaccines. When there was no talk with healthcare providers about HPV and meningococcal vaccine, some participants reported that they thought they were not candidates for both vaccines. As John shared , "I am a reasonable citizen. I'm going to my doctor, ‘ Is there anything I should know? ’ Stigma and reluctance to disclose sexual orientation Several participants reported previous stigmatization experiences in healthcare settings due to their sexual orientation andor HIV status. As a result, some were reluctant to seek vaccines in clinical settings. As Chuy stated “... Stigma has a lot of effect on this... The reason is that if I enter a clinic to get vaccinated, maybe everyone knows that I am positive [HIV] or they will point me out. This is of course a factor that can affect [ vaccine intake ]. ” Other participants reported that they were reluctant to disclose their sexual orientation to healthcare providers, which they thought was interfering with their ability to participate in common clinical decision-making conversations about the relevant vaccines. For example, Atlus shared “Many people are not really comfortable talking about their sexuality or really opening up. Especially to their doctors... it feels like they are not as open as a gay man or they are not really compatible with your needs... [ Keep many questions you wish to be able to ask healthcare providers ] about such things. Uncertainty regarding health insurance coverage and vaccine costs Although 88% of respondents had health insurance, many were not sure that their insurance covered the HPV or meningococcal vaccine. This uncertainty, coupled with the high out-of-pocket costs expected to obtain a vaccine, was noted as barriers to vaccination for several participants. The high cost expectation from the pocket was most obvious to get the HPV vaccine series. As Wario describes "A healthcare provider told me to get vaccinated against [HPV ]... they told me how expensive this was ... it was a really big failure ... just like 'oh, I know it's important' it seemed, however, I can't afford it right now based on how they frame it to me, so although I now have health insurance, I never really researched it. Distance and time required to reach vaccines Many participants are important to get HPV or meningococcal vaccines