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.