Syndemic violence victimization, alcohol and drug use, and HIV transmission risk behavior among transgender women in India: A cross-sectional, population-based study

IntroductionTransgender women are disproportionately burdened by HIV. Co-occurring epidemics of adverse psychosocial exposures accelerate HIV sexual risk, including among transgender women; however, studies using additive models fail to examine synergies among psychosocial conditions that define a syndemic. We examined the impact of synergistic interactions among 4 psychosocial exposures on condomless anal sex (CAS) among a national probability sample of transgender women in India. MethodsA probability-based sample of 4,607 HIV-negative transgender women completed the Indian Integrated Bio-behavioral Surveillance survey, 2014-2015. We used linear probability regression and logistic regression to assess 2-, 3-, and 4-way interactions among 4 exposures (physical and sexual violence, drug and alcohol use) on CAS. ResultsOverall, 27.3% reported physical and 22.3% sexual violence victimization (39.2% either physical or sexual violence), one-third (33.9%) reported frequent alcohol use and 11.5% illicit drug use. Physical violence was associated with twofold higher odds of CAS in the main effects model. Significant two- and three-way interactions were identified on both multiplicative and additive scales between physical violence and drug use; physical and sexual violence; physical violence, sexual violence, and alcohol use; and physical violence, alcohol and drug use. ConclusionsPhysical and sexual violence victimization, and alcohol and drug use are highly prevalent and synergistically interact to increase CAS among transgender women in India. Targeted and integrated initiatives to improve assessment of psychosocial comorbidities, to combat transphobic violence, and to provide tailored, trauma-informed alcohol and substance use treatment services may reduce HIV risk among transgender women.