Barriers and facilitators to targeted intervention service utilisation among transgender women enrolled in a community-based organisation in Puducherry, India: a convergent mixed-methods study

Transgender women experience disproportionate HIV risk because of social and structural inequities that limit access to respectful and confidential healthcare. Targeted Interventions (TIs) under India's National AIDS Control Programme are community-based service platforms that provide peer outreach, HIV and sexually transmitted infection (STI) education, condom and lubricant distribution, counselling, testing and referral linkages. Puducherry, India with an established Community Based Organization (CBO)-led TI programme and high reported service coverage, provides an opportunity to examine whether frequent programme contact translates into acceptable and equitable access to broader healthcare. This convergent mixed-methods study assessed utilisation of TI service components and explored barriers and facilitators influencing service use among transgender women enrolled in a CBO-led TI programme in Puducherry, India. Between November 2023 and January 2024, 99 of 130 active programme beneficiaries completed an interviewer-administered structured questionnaire. Qualitative data were collected through two focus group discussions, two in-depth interviews with transgender women and eight key informant interviews with programme and health-system stakeholders. Quantitative data were analysed descriptively, while qualitative data underwent inductive-deductive thematic content analysis and were mapped to the socio-ecological framework. Most participants received HIV/STI information from peer educators or outreach workers (96.9%), condom-use demonstrations (96.9%), STI check-up and counselling (98.9%), condoms (94.9%), lubricants (92.9%) and had visited the drop-in centre (98.9%). HIV testing had been undertaken by 97.9% of participants, with a median of two tests in the preceding year. Peer-led communication, trust and confidentiality within the CBO, transgender representation among staff, repeated outreach contacts, digital communication, and support for social and legal concerns facilitated service use. However, anticipated stigma, fear of disclosure, gender-binary registration systems and queues, insensitive behaviour by non-clinical staff, privacy concerns at local facilities, inconvenient clinic timings, condom-quality concerns, factional exclusion within community networks, and staff workload and low remuneration constrained access. High TI utilisation among enrolled beneficiaries did not ensure equitable access to routine healthcare. Strengthening gender-inclusive public health services, confidential and flexible referral pathways, commodity quality, social-support linkages and CBO staffing is needed to improve comprehensive care for transgender women.