AIDS and Behavior

, Volume 23, Issue 6, pp 1518–1529 | Cite as

Syndemic Classes, Stigma, and Sexual Risk Among Transgender Women in India

  • Venkatesan ChakrapaniEmail author
  • Tiara C. Willie
  • Murali Shunmugam
  • Trace S. Kershaw
Original Paper


Syndemic theory could explain the elevated HIV risk among transgender women (TGW) in India. Using cross-sectional data of 300 TGW in India, we aimed to: identify latent classes of four syndemic conditions (Depression-D, Alcohol use-A, Violence victimization-V, HIV-positive status), test whether syndemic classes mediate the association between stigma and sexual risk, and test whether social support and resilient coping moderate the association between syndemic classes and sexual risk. Four distinct classes emerged: (1) DAV Syndemic, (2) AV Syndemic, (3) DV Syndemic, and (4) No Syndemic. TGW in the DAV Syndemic (OR 9.80, 95% CI 3.45, 27.85, p < 0.001) and AV Syndemic classes (OR 2.74, 95% CI 1.19, 6.32, p < 0.01) had higher odds of inconsistent condom use in the past month than the No Syndemic class. Social support significantly moderated the effect of DAV Syndemic class on inconsistent condom use. DAV Syndemic was found to be a significant mediator of the effect of transgender identity stigma on sexual risk. HIV prevention programs among TGW need to: (a) incorporate multi-level multi-component interventions to address syndemic conditions, tailored to the nature of syndemic classes; (b) reduce societal stigma against TGW; and (c) improve social support to buffer the impact of syndemics on sexual risk.


Syndemics Transgender women Social support Resilience Stigma HIV/AIDS 



Venkatesan Chakrapani was supported, in part, by senior fellowship from the Wellcome Trust/DBT India Alliance. Tiara C. Willie was supported, in part, by grants from the National Institute of Mental Health (T32MH02003118 and F31MH11350801A1). For successful implementation of this study, we thank our study partner agencies: The Humsafar Trust, Social Welfare Association for Men, Lotus Integrated AIDS Awareness Sangam, Mooknayak, Pahal Foundation, and Solidarity and Action Against The HIV Infection in India. 


This research study was funded by Indian Council of Medical Research (RHN/Adhoc/21/2010–11).

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Humsafar Trust, Mumbai, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Public HealthPostgraduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  2. 2.Centre for Sexuality and Health Research and Policy (C-SHaRP)ChennaiIndia
  3. 3.Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenUSA
  4. 4.Yale Center for Interdisciplinary Research on AIDSNew HavenUSA

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