Intersectional stigma and gender non-affirmation hinder HIV care engagement among transgender women living with HIV in India

ABSTRACT

Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

KEYWORDS:

• Intersectional stigma
• syndemics
• HIV care engagement
• India
• resilience
• transgender women

Acknowledgements

The authors wish to thank the transgender women site leaders and peer outreach workers in Delhi, Mumbai, and Hyderabad; India HIV/AIDS Alliance’s Gender and Sexuality team; and Vihaan Care and Support program teams for their support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the United States National Institutes of Health (NIH) grants R21MH118102 and P30AI124414, National Institute of Allergy and Infectious Diseases, National Institute of Mental Health.