Abstract
INTRODUCTION: Transgender women (TGW) in India continue to bear disproportionate HIV burden and face persistent social, legal and structural barriers to receive gender-affirming care. METHODS: Since 2021, we established three "Mitr" (meaning: friend) clinics in Hyderabad, Pune and Thane, India, for transgender people with staffing primarily from the community. Mitr clinics provide free HIV testing and pre-exposure prophylaxis (PrEP) on site with linkage to government antiretroviral therapy (ART) centres. They also provide free consultation for gender-affirming hormone therapy (GAHT), subsidized laser hair removal and legal assistance. Client service utilization data were analysed using summary statistics to evaluate uptake of HIV and gender-affirming services; correlates of HIV testing were examined using logistic regression. Semi-structured interviews conducted at one site were used to understand barriers/facilitators of HIV testing. RESULTS: A total of 5223 unique clients registered between March 2021 and September 2024; median age was 26 years. Most (86%) self-identified as TGW, and 35% reported transactional sex. Most clients (70%) had not previously accessed public sector HIV services. The majority (75%) accessed Mitr clinics for gender-affirming care, including laser hair removal (53%), GAHT consultations (34%) and surgical referral (26%). Over half (62%) of clients eligible for HIV testing underwent screening, of whom 6% were newly diagnosed. Accessing Mitr clinics for gender-affirming surgical services was significantly associated with HIV testing receipt (aOR: 1.51; 95% CI: 1.02, 2.25). Services provided by staff from the community were a prominent facilitator for HIV testing, while stigma and disclosure concerns were notable barriers. Among 585 clients interested in and eligible for PrEP, 576 (98%) initiated PrEP, and 378 (66%) were PrEP persistent at 3 months. Of 454 clients with HIV (newly diagnosed or previously known), 392 (86%) initiated ART. As of 30 September 2024, 233 (59%) were still receiving Mitr clinic services and retained in HIV care; viral suppression was 98% among the 156 clients with data. CONCLUSIONS: The Mitr model highlights the importance of aligning programme and community priorities. The provision of gender-affirming care attracted many clients who might not otherwise have accessed HIV services; indeed, laser hair removal served as the key entry point to HIV testing, PrEP and ART.