What contributions can LGBT activists make to eliminating the inequities that drive the HIV epidemic in countries that are hostile to sexual and gender minority rights? In Breaking Barriers: Sexual and Gender Minority-led Advocacy to End AIDS in Africa and the Caribbean, Robin Lin Miller and George Ayala tell the story of a transnational partnership among community activists from eight countries to address the entrenched stigma and discrimination that blocks sexual and gender minority people from accessing affirming HIV care. Through their extended case study of Project ACT, they demonstrate how activists contributed to social progress within their country environments, despite great obstacles. Documenting the project from its inception through to its untimely demise due to the Covid pandemic, Miller and Ayala highlight the many ups and downs endured by activists and their allies as they tried to promote access to health care in politically and culturally hostile national contexts and with limited financial resources. They raise questions about the role of donors and partners from the Global North in supporting progress on the ground in Global South countries. They also consider effective strategies for evaluating human rights-focused HIV advocacy in these fraught environments. Ultimately, Miller and Ayala provide readers guidance on principles of practice for human rights advocacy and for planning, carrying out, and evaluating projects that aspire to create structural change to improve access to affirming HIV care for sexual and gender minority people.