Preferences for ART adherence–focused service delivery among transfeminine individuals living with HIV in Mumbai and New Delhi, India

Background Transfeminine individuals in India face disproportionately high HIV prevalence and encounter multilevel barriers to sustained antiretroviral therapy (ART) adherence. While India’s National AIDS Control Program (NACP) has expanded outreach to transfeminine individuals, few interventions address the intersectional challenges undermining long-term optimal adherence and viral suppression. Methods We conducted 30 in-depth interviews with transfeminine individuals living with HIV in Mumbai and New Delhi between July and September 2024. Participants were recruited through community-based organizations using a maximum variation purposive sampling approach. Eligibility criteria included age ≥18, HIV diagnosis for ≥1 year, current ART prescription, and identified as a transgender woman, hijra, or other indigenous transfeminine identity. Interviews were conducted in Hindi, Marathi, or English using a semi-structured interview guide informed by syndemic and intersectional theoretical frameworks. Results Most participants were aged 25–44 years, with half from Mumbai; 36% initiated ART within six months of diagnosis. All were on ART, with 80% reporting adherence above 90% and 40% achieving perfect adherence. Our findings underscore the importance of affirming, accessible, and community-driven service delivery strategies, including peer-led counseling, technology-enabled supports, and transfeminine-led ART distribution, to address stigma and enhance adherence. Conclusion Counseling, technology, and leadership among transfeminine individuals in service delivery emerged as critical components to support sustained ART adherence. Our research identifies critical service delivery preferences that inform the design of culturally relevant, community-driven interventions to enhance ART adherence among transfeminine individuals in India and offer lessons for equity-focused ART-adherence service delivery models in other low- and middle-income countries.