Multilevel Syndemic Profiles Impacting Optimal ART Adherence among Trans Women Living with HIV in Mumbai and New Delhi, India: A Latent Class Analysis.

Background: Antiretroviral therapy (ART) adherence is essential for maintaining viral suppression and reducing HIV transmission risk. However, data on adherence rates among trans women living with HIV in India are scarce, hindering effective intervention efforts. Understanding multilevel syndemic factors, including harmful drinking, depressive symptoms, HIV, and trans women-related stigma, and access to gender-affirmative care, is crucial for improving HIV treatment outcomes in this population.

Methods: Trans women living with HIV (N=150) in Mumbai and New Delhi, India, completed a one-time self-reported assessment of sociodemographic and psychosocial factors and ART adherence and provided recent viral load test results in the ART booklet. Latent class analysis (LCA) identified multilevel syndemic classes. Then, in logistic regression models, we assessed the relationship between syndemic classes and optimal ART adherence (defined as 90% or higher adherence as prescribed).

Results: Optimal ART adherence (defined as 90% or higher adherence to prescribed doses) was reported by 63% of participants. Among those with suboptimal adherence (n=93), common barriers included lack of medication while traveling, forgetting, and alcohol use. The LCA identified two syndemic classes: Class 1, characterized by unidimensional stigma and moderate multilevel syndemic barriers, and Class 2, characterized by intersectional stigma and high multilevel syndemic barriers. In the bivariate analysis, participants in Class 2 had significantly lower odds of optimal ART adherence [OR: 0.27 (95% CI: 0.11 - 0.61), p = 0.003]. After controlling for potential confounders (i.e., city, monthly income, stable housing, and history of sex work), participants in Class 2 still had significantly lower odds of optimal ART adherence [aOR: 0.26 (95% CI: 0.09 - 0.64), p = 0.009].

Conclusion: Findings highlight substantial disparities in ART adherence among trans women living with HIV in India, driven by intersectional stigma and multilevel syndemic barriers. Addressing these factors, particularly HIV and trans women-related stigma, is critical for improving ART adherence and HIV treatment outcomes in this population.