Unequal starting lines: gendered barriers to participation and outcomes in a peer-led physical activity program for adolescents living with HIV in India

Adolescents with perinatally acquired HIV carry a high burden of depression and anxiety, and where specialist mental health services are scarce, peer-led physical activity has been proposed as a low-cost supportive intervention. Whether such programs reach girls and boys equally, and whether gendered constraints shape who is able to take part, has received little attention. Treating HIV status, gender, and adolescence as intersecting rather than additive axes of disadvantage, we examined participation in the Positive Running Program, a peer-led structured physical activity intervention delivered around antiretroviral therapy centers in Karnataka and Tamil Nadu, southern India. We conducted a cross-sectional convergent mixed-methods study among 150 adolescents and young people with perinatally acquired HIV (100 boys and young men, 50 girls and young women; median age 17 years, interquartile range 15-19; 91% virally suppressed). Depressive and anxiety symptoms were screened using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 scale, a score of 5 or above on either instrument was classified as a common mental disorder. High program adherence was defined as attendance at 65% or more of scheduled sessions. Associations were estimated using logistic regression adjusted for age, with gender-stratified models and an adherence-by-gender interaction term. Four focus group discussions with 28 participants and peer facilitators were analyzed using reflexive thematic analysis, with themes generated inductively and interpreted through an intersectional lens and through self-determination theory. Quantitative and qualitative findings were integrated at the interpretive stage. Girls and young women attended fewer sessions than boys and young men (mean 61.6% versus 65.6%; p=0.025) and were less likely to reach the pre-specified [&ge;]65% adherence threshold (10/50, 20% versus 57/100, 57%; p<0.001). They also had a higher prevalence of a positive depression screen (33/50, 66% versus 43/100, 43%; p=0.009) and of any common mental disorder (36/50, 72% versus 52/100, 52%; p=0.022). Higher adherence was associated with lower odds of a common mental disorder overall (adjusted odds ratio 0.31, 95% CI 0.13-0.68) and among boys and young men (0.33, 0.14-0.75); among girls and young women, only 10 participants met the adherence threshold and the estimates were imprecise. Qualitative findings located the constraints upstream of the program, in household authority over girls' time, restrictions on mobility outside the home, care-giving obligations, and community disapproval of girls exercising in public. The central finding concerns participation rather than benefit: girls and young women were half as numerous among participants and attended less consistently, clustering just below the high-adherence threshold. This differential opportunity to participate arises where gendered household authority intersects with the constrained autonomy of adolescence and the concealment demanded by HIV status. Interpreted through self-determination theory, the program supported competence and relatedness for those who attended but did little to secure the autonomy girls needed to attend consistently. The cross-sectional design precludes causal inference, including about the direction of the association between attendance and symptoms. Peer-led physical activity programs in this setting should treat gender inequality not as background context but as a determinant of participation and a core target of design.