Descriptive Epidemiology of Factors Associated with HIV Infections Among Men and Transgender Women Who Have Sex with Men in South India

From policy to practice: syndemic and intersectional challenges to ART adherence for transgender women under India's post-test and treat policy

Transgender women (TGW) in India face one of the highest HIV prevalence rates among key populations in India, yet data on their engagement in the HIV care cascade is limited. This study investigates barriers and supportive factors for adhering to antiretroviral therapy (ART), which is vital for achieving viral suppression, reducing transmission risk to nearly zero (i.e. undetectable = utransmittable; U = U), and enhancing the quality of life for TGW living with HIV. Between July and September 2023, trained community recruiters recruited 30 TGW living with HIV in Mumbai and New Delhi, India. Using intersectionality and syndemic theory as guiding frameworks, we purposively sampled and conducted semi-structured qualitative interviews. The interviews revealed four main themes - two barriers and two supportive factors influencing ART adherence: the impact of poverty on syndemic factors, intersectional stigma and discrimination, empowerment to overcome barriers, and the influence of inclusive government programmes and policies in improving TGW's access to ART. Despite the availability of free ART immediately after diagnosis under India's 'test and treat' policy, economic instability and intersecting stigma hinder adherence. Our findings reveal that holistic interventions focusing on economic support, stigma reduction, and personal and collective empowerment might improve ART adherence among TGW in India.

Transgender Women in India: A Syndemic and Intersectional Framework Addressing HIV Care Gaps

The prevalence of HIV among transgender women (TGW) in India is disproportionately high, estimated at 4% to 8% in comparison with the national average of 0.2%. Despite free antiretroviral therapy (ART) provided by the government, TGW encounter multilevel barriers-including stigma, poverty, and lack of gender-affirming care-that hinder HIV care access and retention. Existing behavioral frameworks fail to address the compounded effects of systemic oppression on the health of TGW with HIV in India. We present a conceptual framework integrating syndemic theory and intersectionality to examine structural and syndemic factors shaping HIV care barriers. Informed by key informants-including TGW with HIV, community leaders, health providers, and Indian researchers-the framework highlights how systemic marginalization, particularly through discriminatory policies, shapes social position and exacerbates inequities in HIV care outcomes. It also underscores the role of community mobilization and collective action in overcoming these barriers. The framework provides a foundation for interventions tailored to the needs of TGW. By centering community-driven strategies and addressing structural inequities, it offers a pathway to improve HIV care engagement and health outcomes among TGW in India. (Am J Public Health. Published online ahead of print May 1, 2025:e1-e9. https://doi.org/10.2105/AJPH.2025.308046).

A scoping review of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people's health in India

Amid incremental progress in establishing an enabling legal and policy environment for lesbian, gay, bisexual, transgender and queer-identified people, and people with intersex variations (LGBTQI+) in India, evidence gaps on LGBTQI+ health are of increasing concern. To that end, we conducted a scoping review to map and synthesize the current evidence base, identify research gaps, and provide recommendations for future research. We conducted a scoping review using the Joanna Briggs Institute methodology. We systematically searched 14 databases to identify peer-reviewed journal articles published in English language between January 1, 2010 and November 20, 2021, that reported empirical qualitative, quantitative or mixed methods data on LGBTQI+ people's health in India. Out of 3,003 results in total, we identified 177 eligible articles; 62% used quantitative, 31% qualitative, and 7% mixed methods. The majority (55%) focused on gay and other men who have sex with men (MSM), 16% transgender women, and 14% both of these populations; 4% focused on lesbian and bisexual women, and 2% on transmasculine people. Overall, studies reported high prevalence of HIV and sexually transmitted infections; multilevel risk factors for HIV; high levels of mental health burden linked to stigma, discrimination, and violence victimization; and non-availability of gender-affirmative medical care in government hospitals. Few longitudinal studies and intervention studies were identified. Findings suggest that LGBTQI+ health research in India needs to move beyond the predominant focus on HIV, and gay men/MSM and transgender women, to include mental health and non-communicable diseases, and individuals across the LGBTQI+ spectrum. Future research should build on largely descriptive studies to include explanatory and intervention studies, beyond urban to rural sites, and examine healthcare and service needs among LGBTQI+ people across the life course. Increased Indian government funding for LGBTQI+ health research, including dedicated support and training for early career researchers, is crucial to building a comprehensive and sustainable evidence base to inform targeted health policies and programs moving forward.

Performance characteristics of two new rapid HIV diagnostic assays and use of test band reader

PURPOSE

Accurate HIV diagnosis is essential for appropriate patient care. This present study evaluated the performance of two different new rapid HIV diagnostic tests; 1) TRUSTline HIV-1/2 Ab rapid test (Athenese-DxPvt. Ltd, Chennai, India)and 2) OnSite HIV 1/2 Ab Plus Combo Rapid Test (CTK Biotech Inc., San Diego, USA) and also validated ALTA Rapid Test Reader (RTR-1) (CTK Biotech Inc., San Diego, USA), the device is a user-friendly and image-analysis based qualitative/semi-quantitative tabletop reader.

METHODS

A total of n ​= ​500 characterized specimens were used for this evaluation and the results of the new test kits (TRUSTline and OnSite) were also compared with 4^th generation ELISA kit (Genescreen™Ultra HIV Ag-Ab ELISA) and 3 other commercially available rapid tests that were in the market; 1)SD Bioline™ HIV 1/2 3.0, 2) Aspen® HIV 1/2 Rapid Ab Test and 3) Diagnostic enterprises HIVTRI-DOT. The test band intensities of the TRUSTline and OnSite tests were measured in an ALTA rapid test reader and compared with the naked eye reading.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value and efficacy of TRUSTline and OnSite were 100%, 99.6%, 99.5%, 100% and 99.8% and 100%, 100%, 100%, 100% and 100% respectively.

CONCLUSIONS

The 'TRUSTline HIV-1/2' and 'OnSite HIV 1/2' kits are suitable to use in the HIV testing algorithm. Use of the ALTA rapid test reader could be user's friendly in the field level testing in resource-limited settings".

The need for targeted behavioural HIV-related interventions for transgender women in India: A scoping review

Background & objectives

Transgender women (TGW) in India are at high risk of HIV infection. Despite behavioural interventions aimed at reducing HIV risk, no literature synthesis exists so far to evaluate their potential for reducing HIV incidence in India This review was aimed to identify and evaluate HIV-focussed behaviour change interventions for TGW in India.

Methods

Literature from three databases were reviewed up to June 2, 2021, for studies describing behavioural interventions for HIV prevention among TGW in India. The inclusion criteria were studies that included TGW and reported intervention effects on HIV prevention-related behaviour. Data were analyzed descriptively.

Results

Of the 146 articles screened, only three met the inclusion criteria. All three interventions were at the open pilot trial stage and included other high-risk groups (e.g. men who have sex with men). The interventions used behavioural counselling, increased sexually transmitted infection screening and sexual healthcare visits and leveraged community-based organizations to improve the outcomes. All these interventions showed modest improvements in health-seeking behaviour and access to services. However, none specifically targeted TGW.

Interpretation & conclusions

The scoping review highlights the need for behavioural interventions for HIV prevention tailored to TGW in India. This study emphasizes the need for research to move to the next stage of intervention development and testing utilizing more rigorous evaluation methods, such as a randomized controlled trial.

Syndemic violence victimization, alcohol and drug use, and HIV transmission risk behavior among HIV-negative transgender women in India: A cross-sectional, population-based study

Transgender women globally are disproportionately burdened by HIV. Co-occurring epidemics of adverse psychosocial exposures accelerate HIV sexual risk, including among transgender women; however, studies using additive models fail to examine synergies among psychosocial conditions that define a syndemic. We examined the impact of synergistic interactions among 4 psychosocial exposures on condomless anal sex (CAS) among transgender women in India. A national probability-based sample of 4,607 HIV-negative transgender women completed the Indian Integrated Biological and Behavioural Surveillance survey, 2014-2015. We used linear probability regression and logistic regression to assess 2-, 3-, and 4-way interactions among 4 psychosocial exposures (physical violence, sexual violence, drug use, and alcohol use) on CAS. Overall, 27.3% reported physical and 22.3% sexual violence victimization (39.2% either physical or sexual violence), one-third (33.9%) reported frequent alcohol use and 11.5% illicit drug use. Physical violence was associated with twofold higher odds of CAS in the main effects model. Statistically significant two- and three-way interactions were identified, on both the multiplicative and the additive scales, between physical violence and drug use; physical and sexual violence; physical violence, sexual violence, and alcohol use; and physical violence, alcohol use and drug use. Physical and sexual violence victimization, and alcohol and drug use are highly prevalent and synergistically interact to increase CAS among HIV-negative transgender women in India. Targeted and integrated multilevel initiatives to improve the assessment of psychosocial comorbidities, to combat systemic transphobic violence, and to provide tailored, trauma-informed alcohol and substance use treatment services may reduce HIV risk among transgender women.

The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis

Introduction

Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals.

Methods

We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP).

Results

Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4–84.8) for trans feminine individuals and 6.8 (95% CI 3.6–13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established.

Conclusion

Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.

HIV/AIDS-Related risk behaviors, HIV prevalence, and determinants for HIV prevalence among hijra/transgender people in India: Findings from the 2014-2015 integrated biological and behavioural surveillance

Background

Hijra or transgender (H/TG) people are significantly affected by HIV in India. HIV prevalence among H/TG is the second highest after people who inject drugs. Effective interventions require understanding about various risk behaviors and associated factors for high prevalence.

Objectives

This study analyzes the known risk behaviors and vulnerabilities of HIV-positive and HIV-negative H/TG people to identify the determinants of HIV seropositivity in this high-risk group.

Methods

Using secondary data from India's 2014 to 2015 Integrated Biological and Behavioural Surveillance survey, this analysis was conducted among 3325 H/TG people across seven states. Probability-based sampling methods were used to recruit H/TG people. Informed consent was obtained for the collection of behavioral information and blood samples for HIV testing. Multivariable binary logistic regression analysis was undertaken to identify the determinants of HIV seropositivity.

Results

HIV prevalence for this group of respondents was 9.5%. Multivariable analysis of survey data revealed higher odds of HIV infection if H/TG had regular male partners (adjusted odds ratio [AOR]: 1.81, confidence interval [CI]: 1.07-3.06), were living in the states of Maharashtra (AOR: 6.08, CI: 3.02-12.22) and Odisha (AOR: 2.91, CI: 1.05-8.06), and were members of self-help groups (AOR: 2.08, CI: 1.04-4.14). None of the demographic or behavioral correlates of risk were found to be associated with HIV infection.

Conclusion

The findings suggest that community and structural factors, which are inadequately covered in surveys such as IBBS, play a more important role than individual behavioral factors.

Syndemic Classes, Stigma, and Sexual Risk Among Transgender Women in India

Syndemic theory could explain the elevated HIV risk among transgender women (TGW) in India. Using cross-sectional data of 300 TGW in India, we aimed to: identify latent classes of four syndemic conditions (Depression-D, Alcohol use-A, Violence victimization-V, HIV-positive status), test whether syndemic classes mediate the association between stigma and sexual risk, and test whether social support and resilient coping moderate the association between syndemic classes and sexual risk. Four distinct classes emerged: (1) DAV Syndemic, (2) AV Syndemic, (3) DV Syndemic, and (4) No Syndemic. TGW in the DAV Syndemic (OR 9.80, 95% CI 3.45, 27.85, p < 0.001) and AV Syndemic classes (OR 2.74, 95% CI 1.19, 6.32, p < 0.01) had higher odds of inconsistent condom use in the past month than the No Syndemic class. Social support significantly moderated the effect of DAV Syndemic class on inconsistent condom use. DAV Syndemic was found to be a significant mediator of the effect of transgender identity stigma on sexual risk. HIV prevention programs among TGW need to: (a) incorporate multi-level multi-component interventions to address syndemic conditions, tailored to the nature of syndemic classes; (b) reduce societal stigma against TGW; and (c) improve social support to buffer the impact of syndemics on sexual risk.