Abstract
The prevalence of HIV among transgender women (TGW) in India is disproportionately high, estimated at 4% to 8% in comparison with the national average of 0.2%. Despite free antiretroviral therapy (ART) provided by the government, TGW encounter multilevel barriers-including stigma, poverty, and lack of gender-affirming care-that hinder HIV care access and retention. Existing behavioral frameworks fail to address the compounded effects of systemic oppression on the health of TGW with HIV in India. We present a conceptual framework integrating syndemic theory and intersectionality to examine structural and syndemic factors shaping HIV care barriers. Informed by key informants-including TGW with HIV, community leaders, health providers, and Indian researchers-the framework highlights how systemic marginalization, particularly through discriminatory policies, shapes social position and exacerbates inequities in HIV care outcomes. It also underscores the role of community mobilization and collective action in overcoming these barriers. The framework provides a foundation for interventions tailored to the needs of TGW. By centering community-driven strategies and addressing structural inequities, it offers a pathway to improve HIV care engagement and health outcomes among TGW in India. (Am J Public Health. 2025;115(8):1245-1253. https://doi.org/10.2105/AJPH.2025.308046).