HIV Testing Service Utilization Among Transgender Communities: Insights from a Respondent-Driven Sampling Survey in India.

Transgender populations in India bear a disproportionate HIV burden and systemic discrimination that limits access to prevention services. We explored psychosocial correlates of HIV testing and reasons for never testing among transgender people across three high-HIV burden states. Transgender individuals aged ≥ 18 years were recruited using respondent driven sampling for an interview-administered survey in Telangana, Maharashtra, and Uttar Pradesh, India in 2022. Summary statistics and reasons for never testing incorporated RDS-II weights. We used Poisson regression with robust variance to assess associations between psychosocial variables and prior HIV testing. Among 1,997 respondents (median age, 27 years), 37% were from Telangana, 43% from Maharashtra, 21% from Uttar Pradesh; 65% identified as transgender, 28% as Hijra, 6% as women, and 1% as men. Half (47%) had never tested for HIV. Prior testing was positively associated with higher and lower HIV risk perception, hazardous alcohol use, past experience of sexual violence, larger transgender peer networks, and past healthcare stigma; it was negatively associated with anxiety or depression. The most cited reasons for never testing were never hearing of HIV (38%), low risk perception (39%), and privacy concerns (25%). The prevalence of each reason for no prior HIV testing differed by gender, mental health status, and the network size of other transgender people in the district. Findings highlight the need for HIV testing strategies to be sensitive to gender identity and psychosocial factors in order to improve access for transgender communities. Community-partnered approaches that integrate mental health and support peer networks may improve testing uptake among transgender populations in India.