Transgender women are nearly 20 times more likely to be infected with HIV than the national average in India, a country with the third largest HIV epidemic worldwide. In spite of India’s robust “test and treat” program, which offers free antiretroviral therapy (ART) after a positive test, treatment outcomes among transgender women remain disproportionately poor.

A new study published in Global Public Health “From policy to practice: syndemic and intersectional challenges to ART adherence for transgender women under India's post-test and treat policy” authored by William Lodge II, assistant professor in the Cornell Brooks School of Public Policy, suggests that a health policy approach that addresses economic barriers and social stigma and emphasizes individual and collective empowerment can be effective in expanding the adoption and success of ART among transgender women.

“We found that the complex of issues facing transgender women in India makes it much more difficult for them to participate in ART treatment at the level required for success, particularly in urban environments,” Lodge said. “But if you tailor the approach in a way that acknowledges the intersectional barriers they face and that promotes a holistic understanding of historical, structural, and social factors that directly or indirectly impact their ability to adhere to HIV medication as prescribed, then we can develop programs and policies that meet transgender women where they are and adapt to their pressing needs.”

The study is an important step towards creating more equitable outcomes in HIV treatment in India and comes against the backdrop of the 2017 implementation of the national “test and treat” policy, which has broadly been credited with transforming HIV care in India. By highlighting both the barriers and support factors that shape transgender women's experiences with HIV care in India, the study offers critical insights for developing more inclusive and effective interventions.

A recent cost-effectiveness analysis study of heterosexual cis-gender individuals living with HIV showed that the implementation of the policy averted 18,386 HIV-related deaths and 16,105 new HIV infections. However, despite these advancements, India remains far below the UNAIDS 2030 95-95-95 targets, with only 77% of individuals aware of their HIV status, 65% on treatment, and 55% achieving viral suppression. 

Lodge and his co-authors identified that a critical gap exists in understanding the HIV care cascade among transgender women living with HIV in India, a gap illustrated by ART coverage estimates, which indicate approximately 70% coverage in the general population but only 58% among transgender people, according to UNAIDS.

Between July and September 2023, the researchers worked with trained community recruiters from The Humsafar Trust, one of India’s  oldest LGBTQ + community-based organizations, to recruit  30 transgender women living with HIV in Mumbai and New Delhi, India, two major cities with robust HIV prevention and treatment programs.

The research employed a conceptual model grounded in syndemic theory and intersectionality, focusing on barriers and supportive factors influencing HIV care outcomes. Interviews with participants included open-ended questions and probes on topics such as general health, experience receiving HIV care, and barriers (e.g. intersectional stigma, psychosocial problems, unmet gender-affirming care) to ART adherence.

The research findings revealed four key themes derived from the in-depth interviews: (1) the impact of poverty on syndemic factors (i.e. mental health, substance use) influencing ART adherence (2) intersectional stigma and discrimination related to HIV, sex work, and transgender identity hindering ART adherence (3) empowerment as a means to overcome barriers to ART adherence and (4) the influence of inclusive government programmes and policies enabling transgender women to assert their right to care and enhance access to ART.

“The research found that transgender women in India face intersectional barriers linked to their social positions as sex workers, as transgender individuals, and as people living with HIV. These overlapping factors often result in poverty and stigma, creating real, co-occurring barriers that continue to limit the effectiveness of ART programs for transgender women,” said Lodge. “At the same time, the interviews emphasized how individual and collective empowerment can support better treatment outcomes. I’m deeply grateful to my co-authors, our partners at The Humsafar Trust, and especially our research participants for their dedication, generosity, and sensitivity throughout this process. I hope this work is a step forward in improving HIV care and policy and serves as an example of the importance of conducting research that centers transgender women as part of advancing health equity for all.”

The studies co-authors included: Jatin Chaudary, The Humsafar Trust, Mumbai, Maharashtra, India; Shruta Rawat, The Humsafar Trust, Mumbai, Maharashtra, India; Madina Agénor, Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA; Alpana Dange, The Humsafar Trust, Mumbai, Maharashtra, India; Vivek R. Anand, The Humsafar Trust, Mumbai, Maharashtra, India; Don Operario, Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA; Matthew J. Mimiaga, Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA; Katie B. Biello, Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA. 

The research was funded through NIH National Institute on Drug Abuse.

Giles Morris is assistant dean for communications in the Cornell Jeb E. Brooks School of Public Policy.